Prevention of Urinary Incontinence by Behavioral Modification Program: A Randomized, Controlled Trial Among Older Women in the Community

0022-5347/04/1713-1165/0 THE JOURNAL OF UROLOGY® Copyright © 2004 by AMERICAN UROLOGICAL ASSOCIATION

Vol. 171, 1165–1171, March 2004 Printed in U.S.A.

DOI: 10.1097/01.ju.0000111503.73803.c2

PREVENTION OF URINARY INCONTINENCE BY BEHAVIORAL MODIFICATION PROGRAM: A RANDOMIZED, CONTROLLED TRIAL AMONG OLDER WOMEN IN THE COMMUNITY ANANIAS C. DIOKNO,* CAROLYN M. SAMPSELLE, A. REGULA HERZOG, T. E. RAGHUNATHAN, SANDRA HINES, KASSANDRA L. MESSER, CINDY KARL AND MARIA CLAUDIA A. LEITE From the Department of Urology, William Beaumont Hospital (ACD, CK), Royal Oak and School of Nursing (CMS, SH) and Institute for Social Research (ARH, TER, KLM, MCAL), University of Michigan, Ann Arbor, Michigan

ABSTRACT

Purpose: We determined whether a behavioral modification program (BMP) taught to groups of continent older women would decrease the incidence of urinary incontinence, increase pelvic muscle strength and improve voiding control. Materials and Methods: We performed a randomized, controlled trial comparing a BMP treatment group to a control, no treatment group in ambulatory, postmenopausal, continent women (0 to 5 days of incontinent episodes in the previous year) 55 years and older who were followed for 12 months. Qualified volunteers from 4 Michigan counties were randomly assigned to a control or a treatment group, consisting of a 2-hour classroom presentation on BMP followed 2 to 4 weeks later with individualized evaluation to test knowledge, adherence and skills in behavioral techniques, and brief reinforcement of the technique as needed. Followup was done by telephone and mail every 3 months except month 12, when all participants underwent final clinical evaluation. Outcome measures were continence status, pelvic floor muscle strength and voiding frequency/intervoid interval. Results: A total of 195 control and 164 treated participants completed the study. Baseline data on the 2 groups were not statistically different. At 12 months the treatment group was statistically significantly better than the control group in continence status (p ⫽ 0.01), pelvic muscle strength (pressure score p ⫽ 0.0003 and displacement score p ⬍0.0001), improved voiding frequency (p ⬍0.0001) and intervoid interval (p ⬍0.0001). Conclusions: To our knowledge we report the first randomized, controlled trial of BMP for preventing urinary incontinence in older women. It demonstrated feasibility and efficacy in improving continence status, pelvic muscle strength and voiding control as long as a year after treatment. KEY WORDS: urinary incontinence, bladder, behavior therapy, aged

Behavioral techniques, including pelvic floor muscle training (PMT) and bladder training (BT), have been found to be safe and effective for stress, urge and mixed urinary incontinence (UI).1– 4 Patient learning occurs during individual contact with the provider, followed by several visits for reinforcement and maintenance.5, 6 Group instruction could obviate the disadvantage of time-consuming individualized teaching and be more attractive for consumers and caregivers. Randomized controlled trials (RCTs) of a behavioral modification program (BMP) for prevention have been limited to pregnant and postpartum women. None of the 7 RCTs previously reported7 or the RCT reported by Morkved and Bo8 tested the preventive effects of BT or PMT in older women. We initiated a study to determine whether BMP provided to groups of ambulatory, postmenopausal, continent women 55 to 80 years old living in a community would decrease the incidence of UI, increase pelvic floor muscle strength and improve voiding control. We combined PMT, BT and education into a 2-hour session and called it the behavioral modification program. We report the results of an RCT to test the preventive effects of BMP in older women.

MATERIALS AND METHODS

A pilot study was initially done to determine the feasibility of group instruction in older continent women living in the community.9 Results showed that participants were interested, cooperative and able to grasp the knowledge imparted during the session, in contrast to the prevailing notion that verbal instruction alone is insufficient in providing the appropriate skill to perform PMT and establish BT.10, 11 A 2-pronged recruitment approach included 1) phased mass mailings into targeted community zip codes and 2) referral from the University of Michigan geriatric program. Four counties served by the 2 centers were selected. Initial screening was done by telephone (Appendix 1). Sufficient continent volunteers who qualified at telephone screening were recruited and randomly assigned to a BMP treatment group or to a no treatment group (control). Randomization was done via random ordering in blocks of 16 women to provide balanced recruitment between groups. A block size of 16 subjects was chosen to minimize the chance of prior recruiter knowledge of the subject assignment. Each group underwent baseline clinic evaluation (Appendixes 1 and 2). The control group underwent all baseline evaluation at 1 clinic visit. For the treatment group the questionnaires and diary were collected prior to the group session, and vaginal examination and stress tests were performed 2 to 4 weeks later. Clinic inclusion criteria were applied equally to

Accepted for publication October 24, 2003. * Correspondence: William Beaumont Hospital, 3535 West 13 Mile Rd, Suite 438, Royal Oak, Michigan 48073 (telephone: 248-551-0387; FAX: 248-551-8107; e-mail: [email protected]). 1165

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the 2 groups. Each group underwent quarterly followup by telephone and mail, and final clinical evaluation at 12 months. The control group was offered group BMP after the exit evaluation. The group BMP treatment protocol consisted of slides and handouts (Appendix 3). The urologist presented the first hour lecture and the nurse specialist presented the second hour lecture. The sessions, which were done Saturday mornings or early evening weeknights in Ann Arbor or Royal Oak, Michigan, included 5 to 25 participants. Each participant

was provided an audiotape on PMT instructions, suggesting practicing PMT with the tape daily and BT if the intervoid interval was less than 3.5 hours. A nurse specialist assessed participant knowledge, adherence and skills to perform PMT and BT 2 to 4 weeks later. The nurse instructed those who had not completely acquired the correct skill of PMT and corrected misunderstandings about BT. A nurse specialist at each site collected the data. They were periodically evaluated for interrater agreement in the assessment of pelvic floor muscle strength. During the exit evalu-

FIG. 1. Pelvic floor muscle strength scores in treatment and control groups. A, proportion at each strength level. At 12-month exit treatment group had higher digital pressure scores than controls, suggesting stronger pelvic floor muscles. B, changes in pressure scores at 12-month exit vs baseline. More treatment than control participants had improved score at exit compared with baseline. C, displacement scores at exit were higher in treatment group than in control group. D, changes in displacement scores at exit vs baseline. More participants in treatment vs control group had improved score at exit compared with baseline. Values in parentheses represent control vs treatment p values.

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PREVENTION OF URINARY INCONTINENCE TABLE 1. Subject exclusion at baseline assessment Total No. Subjects

No. Control

No. Treatment

38 5 3 15 3 3 1

18 4 2 7 1 2 0

20 1 1 8 2 1 1

Totals 15 Failed screen 2 (part of 68 exclusions): Invalid cough test Clinicians unable to assess digitally pelvic floor muscle strength Invalid cough test ⫹ clinicians unable to assess digitally pelvic floor muscle strength

68

34

34

6 8 1

4 3 0

3 5 1

Totals 23 Exclusions at baseline physical examination due to missing data: Missing last year data on UI ⫹ passed screen 2 Missing last year data on UI ⫹ failed screen 2 Missing stress test data ⫹ failed screen 2†

15

7

9

1 2 20

1 0 3

0 2 17

Exclusion Variable 68 Exclusions after clinic examination (screen 2):* Passed stress test ⫹ UI frequency 6 or greater Failed stress test ⫹ UI frequency less than 6 Failed stress test ⫹ UI frequency 6 or greater Passed stress test, UI frequency less than 6 ⫹ failed screen 2 Passed stress test, UI frequency failed screen 2 or greater ⫹ 6 Failed stress test, UI frequency less than 6 ⫹ failed screen 2 Failed stress test, UI frequency failed screen 2 or greater ⫹ 6

Totals 23 4 19 * Invalid cough test, grade 4 uterine prolapse, inability to contract voluntarily pelvic floor muscles or clinician not able to digitally assess pelvic floor muscle strength. † Subject withdrew prior to physical assessment.

TABLE 2. Sociodemographic characteristics of study participants at baseline Variable

Control

Age: No. 55–80 195 Mean ⫾ SD 65.4 ⫾ 6.7 No. race/white 192/81 No. education/greater than high 189/78 school No. family income ($): 168 Less than 20,000 13 20,000–50,000 41 Greater than 50,000 45 No. baseline health: 192 Excellent 18 Very good 49 Good 32 Fair 1 No. baseline continence status (IU 195 days/12 mos): 0 39 1–5 61 Minimental at entrance (1–32):* No. 190 Mean ⫾ SD 31.3 ⫾ 1.3 Differences between groups were not significant. * Modified score with 2 items added to allow for 32 points.

Treatment 164 66.2 ⫾ 6.4 162/84 162/82

Two-sample t tests were used to compare the means of continuous outcome variables for each group and 2-sample binomial tests were used for dichotomous outcome variables. To adjust for differences in background characteristics linear and logistic regression models were used for continuous and dichotomous variables, respectively. RESULTS

140 14 31 56 158 23 49 27 1 160 39 61 159 31.1 ⫾ 1.3

ation the nurse examiner was blinded to the baseline digital examination results obtained 1 year earlier. The biostatistician arranged randomization, supervised and performed the data analysis. Randomization codes were opened after the last participant completed the exit evaluation. The primary outcome measure was the number of days that UI occurred using the standardized Medical Epidemiologic and Social Aspects of Aging (MESA) questionnaire (Appendix 2).1 We adopted the MESA definition of continent, namely anyone who reported no UI episodes (absolute continence) and those who reported UI episodes no more than 5 days in the last 12 months.1, 12 A 3-day voiding diary provided data on voiding frequency and intervoid interval. The validated digital test for pelvic floor muscle strength, which measures pressure and displacement applied by the contracting pelvic muscles against fingers in the vaginal canal, was performed at baseline and at 12 months.13 Figure 1, A and C shows pressure and displacement codes. The MESA questionnaire and 3-day diary were completed at baseline and quarterly for 1 year.

Recruitment. From the phased mailings (approximately 47,400) and the University of Michigan geriatric program (179 subjects) 639 volunteers qualified at the telephone screening interview (569 mailing and 43 clinic), of whom 480 (75%) consented and were randomized to the treatment (238) or control (242) group. Nine control and 21 treated subjects elected not to participate, leaving 217 BMP and 233 control participants prior to the clinic visit. Of the 450 clinic screened participants 38 control and 53 treated participants (total 91) were eliminated, including 68 without eligibility criteria and 23 who refused or had missing data, leaving 164 BMP and 195 control participants (table 1). Of the 359 participants who passed the screening tests and completed all baseline measures 318 completed the study with data on outcome measures. A total of 18 of 195 control (9%) and 23 of 164 treated (14%) subjects were lost to followup. They did not return communication, relocated or experienced changes in personal health or the health of a family member. Demographics and medical history. The sociodemographic characteristics of the participants at baseline showed no significant difference between the control and treatment groups (table 2). Likewise medical history findings, including parity, sexual activity, hormone use, diuretics, smoking, diabetes, hypertension, heart attack, urinary infections and constipation, between the 2 groups were not significantly different. Group lesson knowledge and skills. The multiple choice questionnaire completed 2 to 4 weeks after the group session revealed that 87% of PMT and 89% of BT knowledge items were answered correctly. Vaginal examination identified that 68% of subjects correctly performed the technique, 32% (61) required further instructions, 89% (56) were ultimately successful and 11% (7) who were unsuccessful were excluded from study (3% of the total treatment group). To measure interrater agreement between the 2 nurse specialists Cohen’s ␬ was calculated using Stata, version 6. The ␬ values of 0.72 (p ⫽ 0.0000) for displacement and 0.70 (p ⫽ 0.000) for pres-

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FIG. 2. Continence in control and treatment groups at 12-month exit. At baseline 2 groups reported identical 39% absolute continence and zero UI days with 61% of participants reporting 1 to 5 UI episodes in year. A, absolute continence. B, same (zero or 1 to 5 IU days) or improved continence. Bars represent percent of participants. Values in parentheses represent control vs treatment p values.

sure reflected good to substantial agreement between raters during the study course. The ␬ 95% CI was 0.57 to 0.87 for displacement and 0.57 to 0.84 for pressure.14 Incontinence episodes. At baseline each group reported identical 39% absolute continence (zero UI days) and 61% reported 1 to 5 days of UI episodes in the last year. At 12 months based on the completed quarterly MESA questionnaires continence status outcomes were analyzed 3 ways. 1) A stringent measure of only the absolute continence rate of subjects with zero UI at the accumulated 12-month end point (those who remained with zero UI and those with 1 to 5 days of UI episodes at baseline who then reported zero UI) was 28% for the control and 37% for the treatment group. This result favored the treatment group (p ⫽ 0.09, fig. 2). 2) A less stringent criterion of successful outcome, defined as participants with absolute continence plus 1 to 5 UI days at baseline who reported the same or better results at the accumulated 12-month end point, was 41% for the control and 56% for the treatment group. Those who reported more UI episodes compared to baseline, even if it was only 1 to 5 UI days, were considered to have failure. These rates favored the treatment group (p ⫽ 0.01, fig. 1). 3) The OR was determined by each criterion using logistic regression modeling with the probability of continence status at 12 months being the same or better than baseline (table 3). The results showed that under the most stringent criterion participants in the treatment group after 12 months were twice as likely to remain or become absolutely continent than participants in the control group (OR 2.03, 95% CI 1.04 to 3.98, p ⫽ 0.04). Using the less stringent criterion participants in the treatment group were 97% more likely to have the same or better continence level after 12 months than the control group (OR 1.97, 95%, CI 1.15 to 3.38, p ⫽ 0.01). Pelvic floor muscle strength. At baseline results showed no statistically significant difference between the control and treatment groups in the distribution of pressure and displacement scores. However, at the 12-month exit physical examination the treatment group had significantly higher pressure scores than the control group (p ⫽ 0.0003, fig. 1, A). Likewise displacement scores at exit were significantly higher in the treatment than in the control group (p ⬍0.0001, fig. 1, C). Differences between exit and baseline pressure and displacement scores were analyzed. Significantly more participants in the treatment group than in the control group showed improvement in pressure and displacement (p ⫽ 0.0008 and ⬍0.0001, respectively, fig. 1, B and D).

Voiding frequency and intervoid interval. Mean voiding frequencies during 24-hour, awake and asleep periods were similar between the 2 groups at baseline. At 12-month exit compared to baseline voiding frequencies showed statistically significant decreases in the treatment group compared to control (p ⬍0.0001 for 24-hour and awake, and p ⫽ 0.004 for asleep, fig. 3, A). Intervoid interval also revealed significant improvement at 12 months for the treatment group compared to controls (p ⬍0.0001, fig. 3, B). The difference between baseline and the 12-month intervoid interval was also significantly different between the treatment and control groups (p ⬍0.0001). In a regression model assessing the difference between the 2 group 12-month intervoid interval measures and adjusting for UI at baseline and covariates, including race, age, education and income, the regression coefficient for treatment group indicator remained significant (p ⬍0.0001, table 3). In real time the intervoid interval in the treated group at 12 months increased by 33 minutes compared to the control increase of only 2 minutes. There was no statistically significant correlation between continence status (absolute or same/better) with improved pelvic floor muscle strength or improved voiding frequency/ intervoid interval at 12 months. DISCUSSION

This MESA prevention program is unique in several aspects. To our knowledge this is the first prospective RCT of UI prevention in older women living in a community demonstrating that BMP taught to this group followed by a single individualized assessment and training is feasible, well accepted and efficacious. Three studies of a single session of group education have been reported for the treatment but not the prevention of UI.15–17 Symptoms were decreased in all studies but none assessed changes in pelvic muscle strength. This program of group BMP followed by 1 short period of individualized followup instruction was able to impart knowledge and skills to perform PMT and BT. It enabled women to improve pelvic floor muscle strength, maintain or improve continence status and improve bladder control. These results could pave the way for broad based application of such a program in many communities and health care provider offices. Also, to our knowledge this is the first RCT of a BMP demonstrating strong effects in 3 parameters, namely continence, pelvic floor muscle strength and voiding control. We recognize that we are not the first group to observe a lack of correlation among these 3 parameters. Prior investigations

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⫺0.35 ⫾ 0.03 (⬍0.0001)

⫺0.39 ⫾ 0.04 (⬍0.0001)

⫺0.57 ⫾ 0.06 (⬍0.0001)

0.41 ⫾ 0.10 (⬍0.0001) ⫺0.03 ⫾ 0.03 (0.30) ⫺0.02 ⫾ 0.01 (0.03) 0.12 ⫾ 0.14 (0.39) ⫺0.10 ⫾ 0.14 (0.51) ⫺0.06 ⫾ 0.17 (0.71) 0.01 ⫾ 0.18 (0.93) ⫺0.49 ⫾ 0.05 (⬍0.0001) 0.56 ⫾ 0.08 (⬍0.0001) ⫺0.02 ⫾ 0.02 (0.31) ⫺0.01 ⫾ 0.01 (0.31) ⫺0.08 ⫾ 0.10 (0.45) 0.03 ⫾ 0.11 (0.77) 0.21 ⫾ 0.13 (0.12) 0.06 ⫾ 0.14 (0.65) 2.03 (0.04) 0.40 (⬍0.0001) 1.05 (0.09) 0.87 (0.75) 0.68 (0.40) 1.01 (0.98) 1.53 (0.48) 1.97 (0.01) 0.86 (0.07) 1.01 (0.74) 0.81 (0.55) 0.88 (0.74) 1.11 (0.82) 1.77 (0.25)

⫺1.36 ⫾ 0.15 (⬍0.0001) 0.03 ⫾ 0.05 (0.49) 0.00 ⫾ 0.01 (0.90) 0.14 ⫾ 0.20 (0.49) ⫺0.12 ⫾ 0.22 (0.57) ⫺0.35 ⫾ 0.26 (0.19) ⫺0.26 ⫾ 0.27 (0.33)

0.51 ⫾ 0.10 (⬍0.0001) ⫺0.01 ⫾ 0.03 (0.81) ⫺0.02 ⫾ 0.01 (0.02) 0.15 ⫾ 0.13 (0.22) 0.11 ⫾ 0.13 (0.40) ⫺0.09 ⫾ 0.16 (0.58) ⫺0.03 ⫾ 0.16 (0.87)

(0.00) 0.43 ⫾ 0.11 0.51 ⫾ 0.09 (⬍0.0001)

Unadjusted treatment vs control Adjusted: Immediate vs delayed Baseline UI days Age Education/more than high school Race/white Income/middle Income/high Baseline pressure Baseline displacement Baseline intervoid interval Baseline 24-hr urinary frequency

(0.09) 1.55 1.86 (0.01)

⫺1.27 ⫾ 0.16 (⬍0.0001)

0.42 ⫾ 0.10 (⬍0.0001)

Pressure Digital Score Displacement Digital Score Intervoid Interval

Baseline Voiding Diary ⫾ SE (p value)

24-Hr Urinary Frequency Absolute Same/Better Treatment Effect

Continence Level OR (p value)

TABLE 3. Unadjusted and adjusted regression models for different outcome measures

Baseline Pelvic Floor Muscle Strength ⫾ SE (p value)

PREVENTION OF URINARY INCONTINENCE

have not found statistically significant correlations between pelvic muscle strength and self-reports of urine control or recorded voiding diary, or between behavioral techniques and urodynamic parameters.5, 18, 19 The lack of correlation between continence status and other outcome measures led Fantl to conclude that knowledge of bladder control and function, and increased awareness of healthy bladder habits are essential ingredients of a successful behavioral program.3 We further postulate that stronger pelvic floor muscles increases the awareness of pelvic muscle function, translating into greater preemptive voluntary contraction of the pelvic muscles at the onset of increased physical activity, thus, improving continence.20 3) To our knowledge this is the first documentation of group BMP prevention demonstrating effectiveness a year after treatment. Most studies measured outcomes within weeks of treatment.2, 5, 6 Studies with followup of a year or more did not use group teaching.4, 8 This study provides further evidence that treatment effects are durable for at least a year. This study has limitations. The definition of continence in this study included UI episodes on 5 or fewer days in the last 12 months. We believed that it was an extremely mild degree of UI and epidemiological rates have been established based on this definition.12 The absolute continence rate showed that significance was marginal (p ⫽ 0.09). Using this most stringent criterion suggests that the study may be under powered and the duration of followup must be longer. However, when we used the less stringent criteria of absolute continence and included mildly incontinent subjects, there was a significant positive result for the treated group (p ⫽ 0.01). The OR suggests that BMP has 97% probability that those treated could maintain or improve continence status. Nurse evaluators were not blinded to the group assignment, which may have biased their assessment of pelvic muscle strength at exit. However, the additional objective measure of intervoid interval was calculated from the voiding diary and it also demonstrated significant improvement in treated women at exit, increasing our confidence in the validity of a positive effect of intervention on these physiological measures. Likewise there could be concern that stress and pelvic strength testing performed 2 to 4 weeks after the group session could have influenced baseline test results. We do not believe that the short period of 2 to 4 weeks would have influenced the pelvic floor immediately. It is borne out by the fact that baseline measurements were similar. A total of 17 subjects in the treated group and 3 in the control group did not pursue the physical examination and were excluded due to a lack of baseline data. The larger dropout rate from the treated group could have potentially affected the outcome of the study. However, in our daily practice BMP is appropriate and successful in motivated patients. Another concern is that teachers in the study were considered expert scientists in this field and it is not known whether their teaching expertise could be transferred to other caregivers. We believe that our protocol can be easily reproduced and used by others because the content of the session represents well-known facts and established techniques, and the lesson is in a slide set for consistent presentation. We hope that our program may be tried and our results reproduced in other communities.

CONCLUSIONS

To our knowledge what was the first RCT of preventing UI in older women using group BMP was feasible and efficacious in 3 outcome measures, namely continence status, pelvic muscle strength and voiding control. The effect was measurable 1 year after treatment. This program has the potential

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FIG. 3. Mean voiding diary results in treatment and control groups. A, voiding frequency at 12-month exit was improved in treatment vs control group in 24-hour, awake and asleep periods. B, baseline and exit intervoid interval, and change at exit. Interval was equivalent in 2 groups at baseline but prolonged at exit in treatment vs control group. Values in parentheses represent control vs treatment p values.

for broad based application in many communities and health care provider offices. APPENDIX 1

A. INITIAL TELEPHONE INCLUSION CRITERIA 1. Female 55 years through 80 years old. 2. Postmenopausal defined as no menstrual cycle for the past 12 months, except those who are on hormone replacement therapy. 3. Continent of urine by the MESA definition which means no UI ever except UI during pregnancy and immediate postpartum period, or urine loss of no more than 1–5 days during the last 12 months, and no previous or present UI treatment with pharmacological agents, behavioral techniques or surgical therapy. 4. No neurological disease. 5. No difficulties with activities of daily living.

APPENDIX 2: BASELINE AND OUTCOME MEASURES

䡠 Demographics and Medical History 䡠 Social and Behavioral Data 䡠 Continence Status with MESA Questionnaire 䡠 Baseline—number of days UI episodes/12 months 䡠 Quarterly—number of days UI episodes/3 months 䡠 Accumulated 12-month—number of days UI episodes in 4 quarterly MESA questionnaire assessments 䡠 3-Day Voiding Diary at Baseline and Quarterly 䡠 Time of voiding 䡠 Time to sleep and wake up 䡠 UI episodes 䡠 Estimate of volume loss—small, medium, large 䡠 Description of urine loss (stress, urge, both) 䡠 Pelvic Examination With Paper Towel Cough Test 䡠 Digital Test for Pelvic Floor Muscle Strength 䡠 Pressure Score 1–4 䡠 Displacement Score 1–3

B. CLINIC INCLUSION CRITERIA 1. MESA UI questionnaire showing no UI or UI episodes of 5 days or less in the last 12 months. 2. Minimental status score of 24 or higher. 3. Negative paper towel cough stress test with bladder volume at least 150 ml. 4. No grade 4 uterine prolapse (prolapsing beyond the vaginal introitus) on pelvic examination. 5. Ability to voluntarily contract pelvic muscles.

APPENDIX 3: CONTENT OF BEHAVIORAL MODIFICATION PROGRAM SESSION

PART I: PRESENTATION 䡠 Anatomy of the lower urinary tract (LUT) and pelvis 䡠 Central and peripheral nervous system control of the LUT 䡠 Fluid intake requirement 䡠 Voiding frequency and bladder capacity

PREVENTION OF URINARY INCONTINENCE

䡠 Urinary incontinence including definition, types, therapy options 䡠 Impact of UI on lifestyle 䡠 Questions and answers PART II: PRESENTATION 䡠 Introduction to healthy habits and self-care 䡠 Identification of personal intervoid interval 䡠 Instruction and practice in BT 䡠 Instruction and practice in locating and exercising the pelvic floor muscle 䡠 Prescription for the frequency and duration of PMT 䡠 Implementation of BT and PMT into one’s daily activities 䡠 Questions and answers REFERENCES

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