What is the process for doing bladder training?

Bladder Training: Practical Implementation Guide

Bladder training is a structured behavioral intervention that should be offered as first-line therapy for overactive bladder and urinary incontinence, involving scheduled voiding with progressive interval increases, fluid management, and urge suppression techniques. 1

Core Components of Bladder Training

Scheduled Voiding Protocol

The fundamental approach involves establishing a fixed voiding schedule based on the patient's baseline voiding pattern, then systematically increasing intervals between voids. 1

• Begin by having the patient complete a 7-day voiding diary to document baseline frequency, voided volumes, fluid intake, and incontinence episodes 2
• Establish an initial voiding interval based on the shortest interval between voids identified in the diary 1
• Instruct the patient to void by the clock at these predetermined intervals, whether or not they feel the urge 1
• For adults: offer toileting every 2 hours during waking hours and every 4 hours at night 1
• Progressively increase voiding intervals by 15-30 minutes every 1-2 weeks as tolerated, working toward a goal of voiding every 3-4 hours 1

Urge Suppression Techniques

When urgency occurs between scheduled voids, patients must learn to suppress the urge rather than immediately rushing to the bathroom. 1

• Teach patients to stop, sit down if possible, and remain still when urgency strikes 1
• Instruct patients to perform quick pelvic floor muscle contractions (5-6 rapid contractions) to inhibit detrusor activity 1
• Use distraction techniques such as deep breathing or mental tasks until the urgency subsides 1
• Only proceed to the bathroom once the urgency has diminished and the patient feels in control 1

Fluid Management Strategy

Implement structured fluid intake modifications as an integral component of bladder training. 1

• Reduce total daily fluid intake by approximately 25%, which has been shown to decrease frequency and urgency 1
• Limit fluid intake in the early evening hours to reduce nocturia 1
• Eliminate or significantly reduce caffeine intake, as this alone can reduce voiding frequency 1
• Avoid other bladder irritants including alcohol, carbonated beverages, artificial sweeteners, and spicy foods 3, 4

Implementation in Specific Populations

Children with Dysfunctional Voiding

For pediatric patients, bladder training requires additional education about proper voiding mechanics and posture. 1

• Ensure correct sitting posture that does not activate abdominal muscles or cause simultaneous pelvic floor co-contraction 1
• Teach the child proper abdominal/pelvic floor muscle interaction through a practitioner trained in muscle reeducation 1
• Incorporate voiding diaries and exercises between sessions 1
• Consider biofeedback using uroflow patterns, auditory stimulus, or noninvasive EMG for enhanced pelvic floor awareness 1
• Monitor with repeat flow rate and post-void residual measurements to ensure pelvic floor relaxation is improving 1
• Up to 20% of pediatric cases may be cured by conservative education and management alone 1

Post-Stroke Patients

Implement a stepwise behavioral approach before progressing to medications or surgical interventions. 1

• Determine the patient's premorbid bladder patterns before initiating any interventions 1
• Offer commode, bedpan, or urinal every 2 hours while awake and every 4 hours at night 1
• Limit fluids in early evening to address nocturia 1
• Progress to medication only when behavioral approaches are insufficient, with surgical intervention as a last alternative 1

Monitoring and Expected Outcomes

Treatment Duration and Assessment

Allow adequate trial periods of 8-12 weeks to determine efficacy before changing or abandoning the therapy. 3, 4

• Most patients experience significant symptom reductions and quality of life improvements, though complete symptom relief is uncommon 1
• Bladder training is as effective as antimuscarinic medications for reducing symptom levels 1
• In therapy-resistant children, 47.6% achieved complete response at 6-month follow-up 5
• Success rates with comprehensive escalating treatment approaches can reach 90-100% in pediatric populations 1

Combination with Other Therapies

Bladder training may be combined with antimuscarinic medications for enhanced efficacy in patients with inadequate response to behavioral therapy alone. 1

• Consider adding oral antimuscarinics (oxybutynin, tolterodine, solifenacin, darifenacin, fesoterodine, or trospium) as second-line therapy after 8-12 weeks of behavioral therapy if symptoms remain bothersome 1, 3, 4
• Combining bladder training with pelvic floor muscle training may improve outcomes for perception of improvement and quality of life 1

Common Pitfalls to Avoid

• Do not measure post-void residual routinely in uncomplicated patients receiving first-line behavioral interventions 1
• Avoid rushing patients to the bathroom when urgency occurs—this reinforces the urgency-frequency cycle rather than breaking it 1
• Do not discontinue therapy prematurely; effects are maintained only as long as therapy is continued 4
• In children, recognize that toilet training follows normal developmental patterns despite large urine volumes, with full continence typically reached in the second decade of life 1