Biofeedback for Urinary Incontinence 

Prevalence
Types of Incontinence
Psychological Issues
Evaluation
Treatment
Further Information
What About Men and Incontinence?
A Word About Fecal Incontinence and Other Pelvic Floor Muscle  Conditions

  • Do you sometimes lose urine before you can reach the toilet?
  • Have you started planning your life around having quick access to a toilet?
  • Do you stay home more often for fear of losing bladder control when you’re out?
  • Do you bring a change of underwear with you when you go out?
  • Do you have to wear a pad or a “continence diaper”?

If you answer “Yes” to one or more of these questions, you already know that you have urinary, or bladder, incontinence. But do you know that over 13 million women and men of all ages in the U.S. experience incontinence? Do you know that, in most cases, it is highly treatable? If you’re an older adult, do you know that incontinence is NOT an inevitable fact of life and that it can be overcome? Many people keep their incontinence a secret and consequently never learn of the help that is out there.

Here I will be discussing incontinence that occurs because of problems with the muscles that expel or hold back urine. There are other causes of incontinence, such as nerve damage, infections, cystocele (fallen bladder), etc. We refer to these as medical or organic conditions. (These are beyond the scope of this article, but you may visit the National Institutes of Health site, www.kidney.niddk.nih.gov to learn more about them. However, even medical conditions can sometimes be helped with the techniques described below.)


Types of urinary incontinence not usually due to medical conditions:

  • Stress Incontinence
  • Urge Incontinence, or Hyperactive Bladder
  • Mixed Incontinence
  • Overflow Incontinence
  • Functional Incontinence
  • Enuresis, or Bedwetting or Nighttime wetting
  • Transient Incontinence, or acute incontinence

Stress Incontinence is the involuntary loss of urine when pressure, or stress, is put on the bladder. “Stress”, as used in this term, doesn’t refer to emotional stress, but to physical stress. If you lose urine when you sneeze, cough, laugh hard, run or lift something, you probably have stress incontinence. Leakage occurs because the pelvic floor muscles are too weak to hold back the urine being pushed out of the bladder. It is a common form of incontinence in women and is highly treatable.

Urge Incontinence refers to a sense of an uncontrollable urge to get to the toilet. Pure urge incontinence usually doesn’t result in the loss of urine unless a toilet is not available. There are several different kinds of urge incontinence, such as urinary frequency, sensory urge and motor urge, but all can respond to appropriate retraining of habits or muscles.

Mixed Incontinence. If the descriptions of both stress and urge incontinence fit your experience, then you have mixed incontinence. Most incontinence in women is actually mixed incontinence.

Overflow Incontinence occurs when the bladder is always too full and urine leaks out. This is a type of incontinence seen much more in men than in women. It may be a simple matter of weak bladder muscles that can be strengthened, or it may be much more complex medically.

Functional Incontinence is loss of urine because of obstacles in getting to a toilet, such as lack of wheelchair accessibility, inability to communicate the need, or difficulty in thinking and planning. It is not a bladder or pelvic floor problem, but incontinence is nevertheless the result.

Enuresis, or bedwetting, or nighttime loss of urine, usually occurs in childhood, but sometimes extends into adulthood. Children sometimes sleep so deeply that signals from their bladder fail to awaken them. The neuromuscular connection between the brain and bladder is insufficiently strong to accomplish this. Pelvic floor muscles may also be too weak. Psychological concerns may sometimes play a role in enuresis.

Transient Incontinence or acute incontinence occurs in response to a trigger that is temporary. Certain medications, infections, injury, temporary immobility or even constipation, where stool pushes against the urethra, can cause a period of incontinence that resolves when the cause is gone.


Psychological Issues in Incontinence

Psychological or emotional problems may not play any role in the onset or continuation of your incontinence, although psychologically-minded women may search for such problems. However, once incontinence is chronically present in your life, it is very difficult not to be affected psychologically and socially. Incontinence limits your activities, your planning for the future and your sense of yourself. I have known many women and men who organize their careers and their lives around their need to be close to a bathroom at all times.

Socializing and, especially, intimacy often suffer. You are out of control of your bladder and this may lead you to feel out of control of your life. Some women suffer extreme embarrassment and keep their incontinence a secret from everyone, perhaps even their doctor. Older women, especially, fear that revealing their incontinence will cause others to think that they have become cognitively impaired. Sadly, this is sometimes the response they get – quite mistakenly. The truly impaired person is usually not overly concerned about her incontinence. The tragedy is that staying silent keeps people from getting the help that is out there.

In some women and men, psychological issues may play a role in the origin of their incontinence. This is more frequently the case in pelvic pain, but can sometimes be the case in incontinence. Keeping pelvic muscles chronically tense can occur after a trauma involving the pelvic area. The trauma may be past sexual abuse or some other trauma or pain affecting the pelvic area. Holding tension in these muscles is a protective mechanism that has become unconscious and outlives its usefulness. Because of the high tension level in the muscles, the small sensations that indicate that the bladder is full cannot be perceived. Only when these sensations are extreme and very urgent can the person take note of them. By then, it may be too late to reach a toilet.

Even when overly tense muscles are identified as the problem, it may be difficult to release the tension without becoming frightened. After all, tension has become a way of feeling protected and safe or of warding off unwelcome sensations. It is important for the person treating you to understand this and to allow you to change at your own pace.

Whether psychological concerns play a major role or only a secondary and minor role in your incontinence, seek professional help from someone who is not only knowledgeable about treatment, but is empathic, supportive and nonjudgmental. You need to feel comfortable talking with this person and sharing the information needed to help you.

Evaluation

If you have not already done so, you should be evaluated by a physician who is experienced with women’s urinary tract conditions and incontinence. An internist, family physician or nurse practitioner is often the first person consulted. If a specialist is needed, you will probably be referred to a gynecologist, urogynecologist (a gynecologist who specializes in urinary problems in women), or urologist.

Your doctor will ask you about your symptoms, the history of the problem, your medical history and the medications you may be taking. You will get an examination to see if there are any medical conditions that are causing or contributing to the problem. Infections, cystoceles and nerve impingement are examples of such problems. The physical examination can also determine if there is serious muscle weakness. If the cause is not apparent after these things are done, you will probably be given various laboratory tests. Blood tests, ultrasound and urodynamics (the study of how the urine flows) are examples of these tests.

Treatment

An accurate diagnosis of the cause of your incontinence is necessary to determine appropriate treatment. The important thing to know is that there is something that can be done, whatever the cause may be. Don’t accept living with something that limits your life. There are two categories of treatments:

  • Behavioral Methods
  • Non-behavioral, medical methods

As a psychologist, I specialize in the behavioral treatment of incontinence, so this article will primarily address this category.

Behavioral Methods of Treating Urinary Incontinence

The Agency for Health Care Policy and Research of the U.S. Department of Health and Human Services has published guidelines for treating urinary incontinence. (The guidelines for medical treatment are outdated now, but the behavioral methods remain fairly current.) The Agency recommends behavioral methods as a first treatment of choice, in most instances, before more invasive treatments are used. “Behavioral methods” refers to such things as biofeedback and pelvic muscle exercises, bladder retraining and dietary changes — in other words, treatment that focuses on behaviors, rather than medicine or surgery.

Pelvic Muscle Retraining and Biofeedback. 
Most women experience incontinence because of pelvic floor muscle problems. These include the external muscles of the “floor” of the pelvic area and the internal sphincter muscles that control the release of urine. Examples of pelvic muscle problems are:

  • Muscle weakness
  • Lack of coordination of the involved muscles
  • Use of the wrong set of muscles when urinating or trying to hold back urine.

Often these muscle problems are the sole cause of the incontinence. However, even if another medical condition exists, pelvic floor muscle problems may contribute to its severity.

Pelvic muscle retraining consists of strengthening these muscles and helping them regain their normal pattern of use. We’re all familiar with strength training for other muscles of the body – we go to the gym or do repetitions with weights to strengthen muscles such as the biceps or the quadriceps. Pelvic muscle strength training is no different. By the use of repetitive exercises, called Kegel exercises, these muscles can be strengthened. And if the normal, coordinated pattern of use of all the muscles involved in urinating or holding back urine has been lost, then this can retrained.

It is generally very difficult to do this strengthening and retraining properly just by “thinking” and trying. Often, what feels “right” is actually the old pattern. This is where biofeedback comes in.

Biofeedback. When used for continence training, biofeedback measures muscle tension in the pelvic muscles and other muscles affecting the ability to hold back urine. To pick up the muscle signals, a tampon-shaped sensor is inserted into the vagina. Sensors are usually placed on the abdomen as well. These sensors relay information about the degree of weakness or strength in the muscles to a computer monitor for viewing.

In this way, you can become aware of what the involved muscles are doing and exactly how they respond when you try to relax or tighten them. With this awareness, and with practice, you can learn to strengthen the muscles and to use muscles in the proper pattern. You don’t have to guess whether your exercises are working or not. You can see it, and you can see the strength increasing from session to session.

Many studies have shown that biofeedback is a highly effective treatment for incontinence when the incontinence is caused by muscles that are too weak to hold back urine. The research in this area is so compelling that Medicare began reimbursing for biofeedback for incontinence in both women and men. (Because the Medicare standard is so high, many insurance companies now follow their lead and reimburse, also.)

How long it takes to achieve continence depends on just how weak your muscles are and on how diligent you are at doing the strengthening practice between sessions. Typically, only six to ten office sessions are needed. At first they are weekly, as you gain awareness of the muscles and learn how to control them. Then sessions are spaced further and further apart as you learn how to do the Kegel exercises and the muscle use patterns correctly without the visual feedback and the guidance from the therapist.

Electrical Stimulation. Another form of therapy done via a sensor in the vagina is electrical stimulation (or “e-stim”, for short). In this case, the sensor delivers a mild electrical stimulation to the muscles. This is a form of passive Kegel exercises – the sensor does the contracting and releasing for you. In my opinion, electrical stimulation is not comparable to biofeedback in effect or in results. However, it may be a good starting point for women with very, very weak muscles who have difficulty identifying and contracting the involved pelvic floor muscles without this assistance.

Bladder Retraining. Along with pelvic muscle retraining with biofeedback, many people need to learn a new schedule of urinating. You may have gotten into the habit of using the toilet very frequently, in the hope that by emptying the bladder often, you’ll be less prone to an accident. But this trains the brain and the bladder to “need to go” when there is actually very little in the bladder to empty. As the muscles get stronger, you can train your bladder to signal you only when you really need to empty it. Just as we teach our body to feel hungry or sleepy at certain times of the day by the routines we keep, we can teach it to signal us to urinate when the bladder is full.

Dietary Changes. Many foods are bladder stimulants. Caffeine is an obvious one, but so are alcohol, sugars, citrus and spicy foods. If you have a food allergy, it probably triggers bladder irritability. I have found that wheat is a culprit for some women. Each woman is affected by a different set of dietary bladder stimulants, so you must experiment with eliminating one suspect at a time. And some women do not appear to be affected by foods at all.

Exercise and smoking cessation. High impact exercise such as running is thought to increase the likelihood of weakening pelvic floor muscles. If you like this type of exercise, though, don’t quit. Just get those muscles strengthened. While they’re getting stronger, use pads, if necessary, when exercising. Low impact exercises such as walking, cycling, etc., do not have this effect. And some women find that smoking increases their symptoms. If you smoke, this can be an added incentive to stop!

Non-Behavioral Methods of Treating Urinary Incontinence

If these non-invasive, behavioral treatments don’t give satisfactory results or if your condition is clearly more organic in nature, other kinds of treatment may be considered by your doctor. Because I do not provide these treatments, I will only list some of them here.

They include medications, pessaries (a ring inserted into the vagina that helps to keep the urethra positioned correctly to reduce stress leakage), use of a catheter (a tube inserted through the urethra into the bladder to drain urine from the bladder) and several types of surgery. You can learn more about them from www.kidney.niddk.nih.gov or from www.ucsf.edu/wcc/. Obviously, the appropriate treatment for you must be determined and performed by someone who specializes in pelvic floor and incontinence disorders. Often these treatments are used along with behavioral techniques.

I hope this article has helped you realize that you are NOT alone with this problem and that the chances are very good that you can eliminate it. Usually, women don’t want to talk about this to other people. But when the topic does come up in a group of woman of any age, you would be surprised at how many have, or have had, incontinence to a greater or lesser degree. Talk about it with your health care professional and if the first thing you try doesn’t work, try something else. There IS something that will help.


Further Information

Pelvic floor muscle biofeedback is a specialized form of biofeedback requiring special sensors and training. Most biofeedback providers do not provide this type of biofeedback. To find other certified biofeedback providers who might have expertise in this area, see the Directory at www.bcia.org, the national certifying body for biofeedback.

 

What about Men and Incontinence?

Although this article is focused on incontinence in women, most of the information applies to men’s incontinence, as well. Prostatitis should be added to the list of possible causes in men. The behavioral treatments discussed above apply to men as well as to women. The non-behavioral, or medical, treatments would often differ because of the anatomical differences. Your male loved ones shouldn’t put up with incontinence any more than you should!
Fecal Incontinence

Over 5 million men, women and children experience fecal, or bowel, incontinence. If urinary incontinence is an embarrassing condition, imagine how people with fecal incontinence suffer! They often feel humiliated and their lives are often severely limited.

Just as with urinary incontinence, there are successful treatments for this condition, also. Again, a thorough medical assessment is necessary to determine the cause. As with urinary incontinence, the cause is often weak muscles of the pelvic floor, especially the sphincter muscles that hold back stool in the rectum. Pelvic muscle retraining with biofeedback is a highly successful treatment for this type of fecal incontinence. In fact, in my experience, the problem often remits even more quickly than urinary incontinence!

 

Other Pelvic Floor Muscle Conditions.

Pelvic floor muscle conditions fall into two general categories: elimination conditions and pain conditions:

Elimination conditions:

  • Urinary Incontinence
  • Fecal Incontinence
  • Urinary Hesitancy
  • Constipation

General or localized pelvic pain

  • Anal or rectal pain
  • Non-bacterial prostatitis
  • Vulvar vestibulitis, or vulvodynia (pain around the vulva, the entrance to the vagina, making penetration painful)
  • Vaginismus (involuntary tightening or spasms of the vagina, making intercourse painful and sometimes impossible)

Don’t accept any of these conditions as something you just have to live with! The new behavioral and non-behavioral (medical) treatments can help. If you are in the San Francisco Bay Area, I would be happy to be the one to help you. You may call me at (415) 331-5433 or email me.