This programme takes about three (3) months to completely alter your bladder function even though some people get considerable benefit within the first week or two. Your attitude of mind and willingness and determination to succeed are important ingredients in the curative process. Once you have learnt to keep control of your bladder and once again become the master of it instead of a slave to it and have practiced this skill repeatedly, you will never again have your bladder problem.
Although success cannot be guaranteed, there is every chance, that three months of hard work will improve you significantly. The programme is designed to help people with this problem, but not everyone is the same and not everyone tries as hard.
Your unstable bladder contracts inappropriately in response to filling (often to only low volume) or to provocation (such as change of posture – i.e. standing from a lying position, running water, exercise or intercourse). When it does contract, it pulls open the neck of the bladder, which is normally closed and watertight exactly as it does when you are about to pass water. When this happens, you naturally try and hold on using the muscles around the urethra (the water pipe which runs from the bladder to the outside). Whether you leak or not depends upon two factors:
How strong the muscles are.
How strongly the bladder is contracting.
Obviously, the duration of that unstable bladder contraction may affect whether control can be maintained or not, as does your motivation to remain dry.
You may be aware already of some of the things that make your bladder worse: cold, wet days, winter, running water, anxiety and stress or period time are often mentioned. Similarly, you may have found some things which help you control the bladder and get to the toilet in time: crossing the legs and pressure on the perineum (the area between the legs or saddle area). It is important to try and learn more about your bladder and the way it works while you are on the programme. It is especially important for you to quickly find out what you can and cannot do with safety. Once you have determined for yourself your own limits, you can learn to stay in control of your bladder and slowly improve what you can do.
The aim of the training programme is to increase your bladder capacity until it can hold the normal amount of between 400 and 500 milliliters (mls). In achieving this, you will learn how to suppress your bladder contractions by using various techniques, which you will be taught and then practice over and over again until they become second nature to you.
In addition, the muscles around the bladder outlet and in the floor of the pelvis will slowly be strengthened by exercises. It is however, important to realise, that the art of bladder control lies in learning to control the pressure inside the bladder from the brain rather than by learning to run faster! Sometimes, problems at home or at work can not only make the bladder behave badly, but also make it difficult to concentrate on the programmes (set out below). We are aware of this and can help to overcome them.
How to start
The Bladder Diary (Time and Volume Chart)
You are asked to keep a record of how your bladder works on a time and volume chart. On this, you should record:
The volume of urine that you pass in mls.
The time of day when you do so.
The time interval since you last passed urine.
You are also requested to record in the appropriate column, whether you have leaked during the interval and the circumstances of urine loss. For example, you may have leaked with coughing or sneezing (stress incontinence) when unable to get to the toilet in time (urge incontinence), when laughing or even when asleep. Do not be too bashful or ashamed to write down what is happening to you. If you aren’t honest about the extent of your problem, it makes it difficult to help you.
Once your pattern of bladder behaviour has been determined, a regime of treatment exercises will be given to you and this will vary from one person to the next. This may involve simple deferment exercises, in which you will be taught how to put off going to the toilet. You may be given a minimum voiding time programme or receive additional help from drug therapy.
In filling out the chart, be honest, be accurate, be consistent and be intelligent. Try to compare the volume you measure with the volume you thought was in the bladder when it signaled it was full. You may notice that the bladder can sometimes feel fuller with a small volume than with a large one. Notice that the urine is often more irritant when it is a darker colour than when it is paler. Notice how often your bladder tells lies about how full it is. Try to relate small volume voids to specific incidents or events that provoked them: for example – showering, having bowels open, anxiety or whatever. Find out by trial and error whether coffee or tea or alcohol provoke your bladder to misbehave.
Timed Deferment Programme
This technique of training involves trying to increase the effective capacity of the bladder by “stretching” it. Instead of rushing to the toilet as soon as you get the “call of nature”, you are asked to wait for 5 minutes before going, each and every time you get the desire to pass urine.
You will be asked to increase your fluid intake to at least 2 litres a day. It is sensible to do the majority of this drinking in the morning and afternoon, wisely drinking little liquid after the evening meal if you want to have a quiet night! You may find it difficult to drink this quantity at first but do try. People who say they cannot do it are just not trying and have the wrong mental attitude. It can be done. It may be, that over the years, your stomach has got used to dealing with small quantities of liquid in just the same way that your bladder has. With effort and determination you can change both just give it time and keep on trying.
You may not at first be able to defer micturition (passing urine) by 5 minutes every time you want to go. Perhaps you can only manage 2 or 3 minutes. That doesn’t matter. Each person has to start somewhere. What does matter is that you try and do it every time you get the urge to empty the bladder and record on the time and volume chart the number of minutes that you managed to hold on.
A word or two of warning is appropriate at this time. Firstly, don’t try to hold on too long at first. It is better to hold on for 3 minutes and get to the toilet dry, than to hold on for 6 and get wet. You must learn to walk before you can run! And talking about running, the watchword is don’t. Get yourself out of the habit of running to the toilet. Most of the time it doesn’t help, because you cannot concentrate on keeping your bladder under control and you therefore get wet anyway. It is much better to try and get your bladder under control and then glide to the toilet like a lady.
You will need to learn some of the deferment techniques. As you proceed, you will be asked to slowly increase the period of deferment from 5 to 10 minutes each time and then from 20 to 30 minutes. During the time you are putting off going to the toilet you are learning how to suppress the bladder contractions and by filling the bladder with urine, stretching the wall so it will hold more.
During this time you must stop going to the toilet “just in case”. This practice encourages your bladder to hold only small quantities. The only time you are to void is when your bladder is full and after you have done your hold-on exercise. The exception to this rule is last thing at night before going to bed.
Get out of the habit of blaming your bladder and of telling yourself that you can’t do it. Your bladder is simply a muscular bag designed to hold urine. It does not have a mind of its own despite what you may think. It does what you will let it do or what you tell it to do. The more you give in to it and tell yourself there is nothing you can do about it, the longer you will have trouble. Never say you can’t - say you’ll try. You may be surprised by what you will achieve given time and determination.
Minimum Voiding Time Programme
This type of bladder training relies upon stretching the bladder by going to the toilet only at rigidly fixed intervals. After you have filled out a time and volume chart as a baseline, you will be given a time interval to aim at. You may for example be asked to void every 2 hours to start with. You then should void every 2 hours but never before that time interval. As your bladder expands, the time interval is increased.
Obviously, it is easy to cheat during this programme by not drinking and managing to hold on for 4 hours by having a small quantity in the bladder. The aim of this programme is exactly the same as that of the timed deferment programme above, namely to stretch the bladder in a progressive manner. You should read the above section again and remember the advice it contains.
This section deals with some of the deferment techniques that can be used to control the bladder. Not every method will help everybody and only practice with a number of them will teach any particular person what will work for them.
Pelvic Floor Contraction
This is what you almost instinctively do to prevent urinary leakage when you get the urgent call to void. It has several effects.
Firstly, it elevates the base of the bladder and closes the sphincter muscles around the urethra and anus. It is the closure of the muscles around the urethra that prevents urine leakage during unstable contractions (or not as the case may be).
Secondly, the contraction of the pelvic floor and sphincter muscles suppresses the bladder contraction by a reflex in the spinal cord. It does this more quickly if the pelvic floor contraction is vigorously applied very early on in the course of an unstable bladder contraction before very high pressures are reached. The reflex inhibition of the bladder contraction is also better if the urine never flows and if the “brake” can be applied with persistence. Obviously, if the pelvic floor and sphincter muscles can be relaxed before the bladder contraction has gone away, leakage will occur.
With practice, you will find that the bladder contractions do go away if they meet sufficiently determined resistance. Once the bladder contraction has been suppressed in this way there is no longer any danger of leakage on the way to the toilet. In fact, at a later stage, you will find that it may be 20 or 30 minutes before you get another desire to void.
This technique may already be known to you. At least you will be familiar with the fact, that the bladder is easier to control when you are sitting, than when you’re standing. Pressure on the perineum, especially the area between the vagina and rectum (or the scrotum and rectum in males) reflexly suppresses unwanted bladder contractions.
This is not always easy to achieve in daily life however. In practice, try sitting on the arm of a chair when you get the desire to void, getting the pressure right in the midline and also between the rectum and vagina. Augment this by also contracting the pelvic floor muscles and concentrate on suppressing the bladder contraction. Sitting on your heel or on the edge of a firm chair may be equally helpful.
Don’t give up until you feel the bladder contraction has gone and even then keep the brake on by contracting the pelvic floor and sphincter muscles while you stand up.
This technique is an extension of what little boys do the world over when they are learning to control their bladders. Girls of all ages find it impossible! The penis is squeezed between thumb and forefinger just behind the glans (tip). The grip should be firm and applied front to back not side to side. This squeeze technique is used to increase the bladder suppression achieved by central control and pelvic floor contraction. It can be applied via the trouser pocket to avoid embarrassment. Don’t let go until it is safe to do so. (A similar technique is useful in males to avoid premature ejaculation. The same reflex mechanism is involved).
This is vital to the success of all techniques and fundamental to the whole training programme. When the bladder contracts under inappropriate circumstances, the urgent desire to void brings the toilet to mind inevitably. It is important to get the mental image of the W.C. out of mind by concentrating on something else, such as mental arithmetic. Attempt to take 9’s or 7’s away from 100 – 93, 86, 79, 72 and so on.
Often, by the time you have finished, the bladder contraction has gone away. Alternatively, try controlled breathing (below), word games, reciting poetry or whatever you find easy and helpful. Just keep you mind off that toilet!
Controlled respiration is just another form of mental distraction. There are two techniques: shallow panting or controlled slow inspiration and expiration to your maximum lung capacity. The important point is to concentrate hard on the breathing instead of the bladder (or toilet). Of course, you will have to put the brake on by contracting the pelvic floor and sphincter muscles and keep them on until the bladder contraction dies away.
Any or all of the techniques can be used. It is really a matter of trying them all to see what suits each individual. Repetition and determination are the keys to success. At first you may find it safer to run to the toilet and then practice the deferment techniques. This is not a good idea and you should try to learn how to control the bladder wherever you are, rather than giving way to it. The sooner you start to get back in control the better. Stand or sit still when you get that desire to void and get your bladder under control. If you are in the street, stop and look in a shop window or at a garden, do your deferment exercise, then walk on dry and triumphant.
Try not get discouraged by setbacks, which not uncommonly occur. If you have a bad day, don’t give up and make it a bad week. Start each day afresh with a positive attitude. Your bladder will not give up without a fight, after all, the chances are, that you have had the problem for years. Note down any problems on the way and discuss with your therapist at the next opportunity.