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Diane Newman: Welcome. I'm Diane Newman. I'm a nurse practitioner, incontinence nurse specialist. I have over 35 years practicing in the field of urinary incontinence and treatment of lower urinary tract symptoms. My practice is behavioral interventions for low urinary tract symptoms. And this is one of several presentations on these very effective interventions.

I'm going to go over ways to regain bladder control, urinary incontinence, urgency, frequency, by lifestyle modifications. So that's what this presentation is about.

This is a list of all the lifestyle changes that if women and men practice, they can regain bladder control. I'm going to go over each one specifically and discuss what can be done, how to educate and work with the patient on making this lifestyle change. And also where's the evidence as far as its effectiveness?

So basically healthy bladder habits is really a lot of discussion now, especially since I'm part of the PLUS, Prevention of Lower Urinary Tract Symptoms Consortium, which is seven sites that is looking at bladder health in women across the lifespan, starting with teenage girls, adolescents, 'til whatever age, because we're looking at how to prevent these problems.

So one of the things we're real interested in is what are the bladder habits of women and girls? Okay, what are healthy bladder habits? And there's a little bit of research on this. Basically it's thought that if you urinate frequently, it can contribute to reduced bladder capacity.

Does that make sense? Yes. Because your bladder is a muscle and it should fill up to about 450 MLs. If you're going to the bathroom every hour, you're going to shrink that bladder to be a one-hour bladder. It's going to give you those messages to urinate much more frequently. So basically, it can, if you go frequently, contribute to decreased bladder capacity.

It may become overactive, become more irritated by things like caffeine, that we'll talk about. And then also it can lead to urgency and urgency incontinence. So it can lead to lower urinary tract symptoms.

So what are good toilet habits? Okay, let's talk with the fact that you should empty your bladder in a relaxed and private place. This is especially true for women. We are socialized in western cultures to go into a stall, enclosed, no one sees you and to urinate. We should also sit to urinate. Although some of my research that I have done over the years and is currently doing shows that most women, when they're away from home, hover, they crouch over the toilet to pee.

If you're listening and you're a woman, how many times have you gone into the bathroom and you've noticed urine on the toilet seat and you knew that woman stood to urinate? So we probably should make sure that we're able to relax and void, because in order to relax your urinary sphincter and relax your pelvic floor, you have to be in a relaxed environment.

So if someone's tense always they tell the issue as far as if you hear someone knocking on the door, you stop peeing. So if you tense up, you're not able to empty properly.

Women should see comfortably on the toilet seat, their feet should be supported. One of the things that we see with children is if their feet can't reach the floor and they're dangling, they can't relax their pelvic floor. So actually we tell mothers to put the child's feet on a stool so that they're in a comfortable position to urinate. Man should stand. Man use abdominal force so they stand to void. But again, they can sit and you see older gentlemen do that. That's fine.

And I just show you a picture of what probably is the correct toileting position to urinate. Again, we don't think hovering is what should be done or standing over the toilet. But we do know that in research, current research that I'm actually doing, is that in focus groups, qualitative research as part of the PLUS NIH network, is that we are finding that women are so worried about the cleanliness of especially public bathrooms, that when they're away from home they actually hover or stand over the toilet.

We don't know whether that leads to urinary symptoms, because what we do know is that you should compress your bladder to empty well. That's how women urinate properly.

So other good toilet habits is just don't go the toilet every time you see a bathroom sign, run in there to urinate. That's probably not good, just in case. You should try to go only when you feel the bladder's filled and you really need to go. And you should really empty your bladder when you wake up in the morning and before you go to bed. Okay, so that's a good habit too. And before and after sex is also a good habit to get into.

There are ways to make sure your bladder's completely emptying. A lot of women will tell me, "Well, I don't think I empty my bladder." And when I do, say, a bladder scan, it's empty, but they still feel they're not.

Well, there's ways that you can teach them. They should change the position of the upper body, they can rock forward and really try to compress more of the bladder to make sure they're empty. One stopped, they can do double voiding. Which means that when you feel the you're done voiding, you stand up and sit back down and go some more.

Remember, the bladder never empties to zero, there's always about an ounce or two. It can be as much as 75 CCs left in the bladder. So you always go a little bit more if you want to make sure you're totally empty, you can double void.

And also people say to help with double voiding is that you can actually exhale through the mouth like with a straw, that actually helps open up that sphincter to make sure that all the urine's out of the bladder.

Nighttime. Nighttime is a difficult problem. So nocturia is reported a lot by older adults, and that's awakening at night to urinate. And basically from the age of 50 onward we see more patients with this problem. About 40% will experience incontinence at night, when they wake up to walk to the bathroom. 40% will, that's a large amount.

And what are you thinking of, I hope whenever I'm talking about this, are they going to fall? That's the biggest issue at night as far as broken bones in the older adult is falling during the night as they're walking to the bathroom.

There's a strong relationship between evening fluid intake and how often you have to get up at night. So if a lot of your fluid is when you're home from work in the evening hours, you're going to have to get up and pee during the nighttime. So we tell people to spread it over the day and something to think about.

Sleep hygiene, I think it's really important, that it's a really hot topic right now in the press as far as help, self-help, self sleep help books out there. It should be a dark room and a cold environment, so they should have the best environment for making sure they sleep. And again, use night lights. And someone who's getting up at night that's an older adult, consider a bedside commode. So these can all impact sleep as well as any medications they're taking.

So I tell patients, I have a handout I give them, that they should stop drinking after 7:00 PM. Drink very little after dinner so there's less urine in their bladder at night. If they have swelling in their... If they have peripheral edema or swell sometimes by then the end of the day, I ask them, I tell them to buy support stockings. A lot of pharmacies will fit you with some very nice, attractive but supportive stockings. Wear those during the day. Make sure they stop drinking after 7:00 PM at night.

If there is some swelling to elevate their legs during the afternoon or maybe evening hours while they're watching TV. Do a recliner with your legs elevated so that they diurese before they go to bed.

And if they're on a diuretic, actually if it's a once a day diuretic, taking it in the late afternoon will help. Because when you take it in the morning you diurese in the morning hours and then the swelling accumulates, so fluid accumulates in extracellular places during the day. Take it around four o'clock so that you diurese from four to bedtime, and there'll be less in that as far as production of urine to that bladder during the nighttime hours. So that helps.

And they should really stop any bladder irritants in the diet. No caffeine, no alcohol in evening hours. And we'll talk about that in a minute.

Now, fluid intake. People think that a lot of women are on diets, so they're always drinking fluid. And then you hear in the elderly, they restrict their fluid intake, because they think if they don't drink they're not going to have bladder problems.

Well, the problem is both is wrong. So if you drink too much, yeah, you're going to produce more urine and you may not be able to control it if you have urgency, frequency and incontinence. But if you drink small amounts, you irritate the bladder by concentrating the bladder with that strong urine. So too much or too little is a problem.

And there's research on this and what I tell patients to do is to drink small amounts throughout the day. And actually on the internet there's a water intake calculator where you put in how much you weigh and how sedentary you are, and it comes up with how much you should be drinking. So it's a personalized water intake calculator. This actually was used in a study where they showed that if you reduce fluid intake by 25% of what you're over, you can actually improve urgency and frequency.

So again, but you should not stop, it concentrates the urine, making it more irritative.

Now your diet can affect your bladder. And there's certain foods and ingredients in foods that can actually cause bladder dysfunction and overactivity, or we used to say bladder spasms. One of the biggest culprits is caffeine. We are a caffeinated society. They're now putting caffeine in mints, in bread, herbal tea has caffeine. So I really talk a lot about that. And you're surprised, especially the patients that bring in a large container of coffee to your visit with you, they're doing a lot of caffeine.

And I am always pleasantly surprised when a patient comes back and says, "Well, you know, Diane, I was drinking at least three large cups of coffee and I love a chocolate which has caffeine. And I cut it down. And you know what? My symptoms are better." And you will hear that in your practice a lot. So caffeine can be an irritant. It's also natural diuretic.

I also see it with artificial sweeteners that have aspartame in it, like Equal, spicy or tomato-based foods can also cause it. And I give them information on how much caffeine is in different products. People think that diet soda does not have caffeine. It actually, unless it says caffeine free, the product probably has caffeine.

And I actually have a list. I tell them to slowly cut it down, because you can have withdrawal from caffeine, especially if they're drinking or eating large amounts of caffeinated foods. So it should be a gradual shift. So I actually have a handout that lists all the products with the amount of caffeine in it. Believe it or not, tea, brewed tea does have caffeine. Not as much maybe as coffee, but it does have caffeine in it.

And then there's also another list I give them, and that's the interstitial cystitis diet. Because I sometimes see patients will say they find something else. I had a woman who would go to Florida during the winter. She was a snow bird who went down and lived there during the six months of the winter. And she realized that she had this grapefruit tree out back and she ate grapefruits throughout the day the whole time. And she realized that actually was triggering a problem.

I have a friend who's a urologist in Iowa. And he says in the summer he sees more women come in because they're a big tomato producing area of the country and they eat lots of tomatoes.

So now sometimes my patients will say, "Diane, you took away everything I like." That's not the goal of this. The goal is for you to find something in the diet that might be irritating your bladder and you do an elimination, so you eliminate it and see what happens.

Or as I tell patients, "Hey, if you're going on a long car ride, then maybe don't drink all that coffee in the morning. Taper it so you're not having to stop so often." So you kind of try to work with them as far as... And that's a lifestyle change.

Bowels. I cannot tell you how many individuals who have bowel dysfunction, in the sense that they have hard stool. I recently saw a patient who has a real issue with voiding. He's a professional. He has had this problem with urination, urgency, slow stream.

And I was working with him. They've tried everything, his urodynamics, cystoscopy, everything doesn't show really any pathology. As I'm getting to do the biofeedback, I happen to mention his bowels. This man only has one bowel movement a week, so this individual has constipation. He has one bowel movement a week, it's hard stool, he says. He strains to have a bowel movement.
And one of his biggest symptoms is nocturia, he gets up seven times at night. It's really affecting his daytime function. You can imagine, if you're getting up seven times a night to urinate. He's tried everything.

And I said to him, "I want you to keep track of your bowels. Because do you find that when you have a bowel movement you have less nocturia?" Because remember at night the gastric colic reflex occurs. What that means is that you're at rest, so the stool was moving through your bowels and maybe it would be putting pressure on his bladder, causing him to wake up to with an urge.
And I said, "I really need you to work on some kind of bowel regimen." I really do see these changes, that when you hear severe constipation, if you put them on a bowel program you do see changes with their bladder function. You see improvement.

So when I see patients, I look at the pelvic floor and I kind of look sideways. In women, the bladder, the uterus, maybe they have a hysterectomy, and the rectum. Men, the bladder and the rectum. And then the outlets, the urethra, the vagina in women, the rectum in both. And the issue of the prostate. So you have to look at it as a whole.

So if they have hard stool, it could cause a problem. And they've shown in women that those who strain at stool, again a British term, which means they strain to have a bowel movement, over time prolapse, that means they have a dropped bladder or uterus. So really stool issues can be a problem.

And this picture really shows how a hard stool in that rectum that's sitting there can compress the bladder. So I give them a bowel regimen and I have a handout on that, as far as putting fiber in their diet, increasing their food intake, exercise, that type of thing. And the goal is to really have them have soft stool and they defecate without strain. That's the whole point. And if they cannot, there's an issue. I do send them for a GI referral and I talk to them about that.

The other thing that you really want them to do is if sometimes with the older individual, the rectal sphincter doesn't really work as well, they can't push a stool out. So sometimes a glycerin suppository several times a week will help with total evacuation from that rectal vault.

There's two other areas that really does impact the bladder and they're kind of what we call lifestyle changes. One is being overweight. Back in the early '90s women who had morbid obesity, they found they also had urinary symptoms, mostly stress incontinence because of the weight on the bladder. They underwent bariatric surgery, which back then was major surgery. And lo and behold, as that woman lost weight her urinary symptoms improved. So there's been more and more NIH supported research on weight reduction in women. We now also have it in men.

The most recent study that's been published is the fact that women who are moderately obese, if they lost 5% to 10% of their weight, and the last one was on Weight Watchers with fluid, liquid type of diet, their urinary symptoms totally resolved. And there's now a research on men. So this is something I talk to patients about.

And you'll hear that, "I lost weight, my symptoms improve." And I say, "Listen, if you would lose weight, really you could improve your urinary symptoms." Not that I want them to have bariatric surgery, which is more common today, but maybe just moderate weight loss. So that's something to bring up.

And we have quite a bit of evidence on this, that this has some of the highest... Actually weight loss has an A rating for evidence base as far as effectiveness. Okay?

The other area about that research is they started combining in diabetics who tend to... Diabetics tend to be overweight. And they found there's a combination, if they improved and controlled their diabetes and lost weight their urinary symptoms totally resolved.

The other area is smoking. In all the epidemiological studies on urinary symptoms, incontinence, urgency, frequency smokers have a higher prevalence. We don't know whether it's the chronic cough, because we also see higher urinary symptoms with those who have COPD, or whether it's the nicotine that works in the bladder muscle, which is probably the cause of bladder cancer.

But we have no research on whether if you stop smoking your urinary symptoms go away. So we don't have that cause and effect and what happens if you stop it?

This gives you the evidence base for lifestyle changes in relation to fluid, caffeine and bowel function. And where we have the evidence, so A is the top amount of evidence, B is really good, it's right below it. Fluid and caffeine has a lot of evidence. We don't have as much as the bowel, but we're gaining more and more research on that area.

So really, if you have symptoms, I just want to stress this, if you are a person with incontinence, urgency, frequency, please seek help from a provider. If you lose urine with a cough, sneeze or lifting, have an urgent need to pass urine and cannot hold it, and lose urine on the way to the bathroom, you stopped exercising because you're leaking urine. Don't do that, go see someone, see if they can help you.

You wet the bed, you have problems starting urine, urinating, starting to pee, that stream is not strong, it doesn't come out like you like it. If you strain, if you feel you're not emptying your bladder, and if you have any burning or pain when you urinate, these are lower urinary tract symptoms that you need to seek treatment.

Thank you very much for listening.