Behavioral Treatments:

With the exception of functional incontinence, most cases of incontinence will almost always improve with behavioral techniques. There are a variety of methods, but the focus is usually on strengthening or retraining the bladder. Studies indicate that such exercises are very effective, even for men recovering from surgery for prostate cancer.

To enhance bladder training for incontinent patients who are in nursing rooms, nurses may need to check patients for dryness and regularly remind them to urinate. As an extra tip for older people with severe incontinence, keeping a pan or portable commode near the bed may prevent injuries from falling as well as improve general convenience.

Combination of Kegel Exercises and Bladder Training

Perhaps the best first-line approach for any form of incontinence is a combination of Kegel exercises and bladder training.

Studies also report that 50 - 75% of patients who perform only Kegel exercises have a substantial improvement in their symptoms, including elderly people who have had the problem for years. Kegel exercises may be especially helpful for women in their 40s and 50s who suffer from stress incontinence.

Pelvic Floor Muscle (Kegel) Exercises. Kegel exercises are designed to strengthen the muscles of the pelvic floor that support the bladder and close the sphincters.

Stress incontinence is an involuntary loss of control of urine that occurs at the same time abdominal pressure is increased as in coughing or sneezing. It develops when the muscles of the pelvic floor have become weak.

Dr. Kegel first developed these exercises to assist women before and after childbirth, but they are very useful in helping to improve continence for both men and women.

The general approach for learning and practicing Kegel exercises is as follows:

• Since the muscles are sometimes difficult to isolate, the best method is to first learn while urinating. The patient begins to urinate and then contracts the muscle in the pelvic area with intention of slowing or stopping the flow of urine. Women should contract the vaginal muscles as well. They can detect this by inserting a finger inside the vagina. When the vaginal walls tighten, the pelvic muscles are being correctly contracted. Patients should place their hands on their abdomen, thighs, and buttocks to make sure there is no movement in these areas while exercising.
• An alternate approach is to isolate the muscles used in Kegel contractions by sensing then squeezing and lifting the muscles in the rectum that are used in passing gas. (Again, women should contract the vaginal muscles as well.)
• The first method is used for strengthening the pelvic floor muscles. The patient slowly contracts and lifts the muscles and holds for 5 seconds, then releases them. There is a rest of 10 seconds between contractions.
• The second method is simply a quick contraction and release. The object of this exercise is to learn to shut off the urine flow rapidly.
• In general, patients should perform 5 - 15 contractions, three to five times daily.

Some notes of caution:

• Once learned, Kegel exercises should not be performed while urinating more than about twice a month, since this practice may eventually weaken the muscles.
• In women, incorrect or overly vigorous exercises may cause vaginal muscles to tighten excessively, resulting in pain during sexual intercourse.
• Overexercise can tire muscles and cause more leakage.
• Incontinence will return to its original severity if these exercises are discontinued.
• It may be several months before the patient sees significant improvement.

Bladder Training. Bladder training involves a specific and graduated schedule for increasing the time between urinations:

• Patients start by planning short intervals between urinations, then gradually progressing with a goal of voiding every 3 - 4 hours.
• If the urge to urinate arises between scheduled voidings, patients should remain in place until the urge subsides. At the time, the patient moves slowly to a bathroom.

Vaginal Cones

This system uses a set of weights to improve pelvic floor muscle control. The cones are inexpensive, relatively simple to use, and may be as effective as Kegel exercises or electrostimulation:

• The typical set includes five cones of graduated weights ranging from 20 grams (less than 1 ounce) to 65 grams (slightly over 2 ounces).
• Starting with the lightest, the woman places the cone in her vagina while standing and attempts to prevent the cone from falling out. The muscles used to hold the cone are the same ones needed to improve continence.

As with standard Kegel exercises, frequent repetition is required, but most women will eventually be able to use the heavier weights and build up the ability to prevent stress and urge incontinence.

Biofeedback Devices

Women who are unable to learn Kegel muscle contraction and release with verbal instructions may be helped with the use of biofeedback:

• Biofeedback uses a vaginal or rectal probe inserted by the patient that relays information to monitoring equipment.
• The patient isolates the pelvic floor and bladder muscles and performs Kegel exercises.
• The monitor emits auditory or visual signals that indicate how strongly the patient is contracting the proper pelvic floor muscles and how effectively the bladder muscles are being released.
• The apparatus is designed for home use.

As with any Kegel exercise regimen, biofeedback must be used for several months before it is effective. Biofeedback that teaches control of pelvic muscles may also be helpful for children who have daytime wetting, frequent urinary tract infections, or both.

Electrical Stimulation of the Pelvic Floor

Electrical stimulation of the pelvic floor muscles has been a common treatment for years. The procedure uses a probe inserted into the anus or vagina, which produces a contraction in the pelvic floor muscles. Studies evaluating this procedureâ ' s effectiveness have been mixed. Many insurance companies consider this procedure investigational and will not pay for it.