Urinary Incontinence and Biofeedback

Christine Alquisira

Introduction

Conservative estimates indicate that at least 11 million 
adults living in the community suffer from urinary 
incontinence [UI] (Agency for Health Care Policy and 
Research, 1992).  Furthermore, more than 50% of all 
residents in nursing homes are incontinent.  Direct medical 
costs of caring for people with UI in the community are 
more than 7 billion dollars annually plus 3.3 billion 
dollars for nursing home residents.  It is difficult to 
estimate other, indirect costs such as costs for protective 
garments, loss of income resulting from an inability to 
work with incontinence, or costs for caring for an 
incontinent person in the house.  In addition to monetary 
costs, the psychosocial impact of UI ranges from 
embarrassment to depression and social isolation  
(Schwartz, 1995).  
 
Urinary incontinence is a commonly underreported and 
underdiagnosed condition.   When people do report it, 
health care providers often do not treat the problem 
comprehensively (Agency for Health Care Policy and 
Research, 1992).  Many people with urinary incontinence may 
refuse to report their condition due to feelings of 
embarrassment.  The underreports of UI are very unfortunate 
because this is an issue that has many treatments and 
cures.  Behavioral treatments that include biofeedback are 
usually suggested first as treatments versus more invasive 
treatments such as surgery (Schwartz, 1995).  

Causes and Treatments

Urinary incontinence can be caused by a number of factors 
that affect the nervous system, the bladder itself, or the 
muscle tissues that support the bladder and pelvic organs.  
Likewise, there are a number of different treatment 
modalities that are effective for treating incontinence, 
including behavioral interventions, medications, surgery, 
electrical stimulation, and intra urethral injections.  
With the array of treatments available today, most cases of 
incontinence can be cured or significantly improved.  
Behavioral interventions, in particular, are a group of 
therapies that include bladder training, habit training, 
pelvic muscle training, and biofeedback assisted behavioral 
training.  These treatments have shown to improve bladder 
control significantly by teaching patients to adopt new 
skills or to change old habits.  
   
Types of Incontinence

There are three different types of urinary incontinence 
that are characterized by the symptoms associated with each 
group.  Categories can be intermixed.  Presenting symptoms 
and etiologies often overlap within the same individual.  
The first type of incontinence is stress incontinence.  
Genuine stress incontinence occurs when intra abdominal 
pressure exceeds urethral pressure, as with coughing or 
sneezing.  The striated pelvic floor muscles normally 
support the bladder neck and exert a closing force on the 
urethra during conditions of heightened intra abdominal 
pressure.  Weakness or laxity of these muscles usually 
results in stress incontinence.  Stress incontinence is 
more prevalent in women.  This is often the result of 
frequent pelvic floor denervation that occurs during 
childbirth.  However, it is also seen after prostatectomy 
following damage to the urethral sphincter or its nerve 
supply.  

The second type of UI is urge incontinence.  Urge 
incontinence occurs with a sudden, intense, and urgent need 
to urinate that the person cannot inhibit.  Associated 
symptoms include urinary frequency and low volume 
urination.  Urge incontinence can stem from detrusor 
hyperreflexia, a neurogenic condition marked by uninhibited 
bladder contractions occurring at subnormal volumes.  In 
contrast, the term "unstable bladder" denotes a condition 
where uninhibited bladder contractions occur without a 
neurogenic etiology.  

One also sees urge incontinence without uninhibited bladder 
contractions.  This condition is sensory urge incontinence.  
The causes of both unstable bladder and sensory urge 
incontinence are not well understood.  One predisposing 
factor for unstable bladder is the pattern of voiding 
against urethral obstruction.  This occurs with an enlarged 
prostate or a contracted sphincter.  Voiding against 
urethral resistance advances the development of detrusor 
muscle thickening, or bladder trabeculation.  In turn, that 
decreases the bladder's compliance and lowers its threshold 
for contraction.  The habit of frequent, low volume voiding 
may lower the sensory threshold for the need to void.  This 
contributes to the development of sensory urgency.

The third type of incontinence is overflow incontinence.  
Overflow incontinence occurs when the bladder cannot empty 
efficiently.  The bladder becomes overly distended and 
incontinence occurs as bladder pressure overcomes urethral 
pressure.  Overflow incontinence can develop in any 
condition that limits bladder emptying.  This includes 
urethral obstruction caused by prostatic hyperplasia.  It 
also occurs in conditions that impair sensations that cue 
the need to void and when there is compromised bladder 
contractility (e.g., bladder denervation resulting from 
diabetic neuropathy).  

A variant of both urge and overflow incontinence is 
detrusor hyperactivity combined with impaired bladder 
contractility.  Patients with this condition have urgency 
and frequency but have elevated postvoid residual volumes 
characteristic of overflow incontinence (Agency for Health 
Care Policy and Research, 1992). 

Pharmacological and surgical treatments are traditionally 
and still the most often used interventions for urinary 
incontinence yet these treatments have risks and side 
effects.  They often do little to alter the basic 
underlying problem.  Behavior techniques such as 
biofeedback training have shown to be effective in treating 
urinary incontinence as well as giving individuals an 
overall understanding of their problem that could help 
prevent relapses.

Early Biofeedback Treatment for Incontinence

Biofeedback treatment for incontinence aims to alter 
pathophysiologiclal responses of both smooth and striated 
muscles related to bladder control.  The use of biofeedback 
as a treatment for UI started with Kegel in 1948.  He 
reported on the use of a structured exercise regimen for 
lax pelvic floor muscles.  Nowadays, many people refer to 
these exercises as "Kegels".  Kegel posited that 
strengthening exercises designed to improve pelvic floor 
muscle tone would, in turn, enhance support to the pelvic 
structures and thereby reduce incontinence.  He invented 
the pressure perineometer in 1948 that measured the 
contractile force of the muscles in the vagina and 
displayed the associated pressure changes on a pressure 
gauge (Schwartz, 1995).

Research Studies Using Biofeedback

An early study done by Cardozo, Abrams, Stanton & Feneley 
in 1978 used cystometric biofeedback with 32 female 
subjects with detrusor instability and urge incontinence.  
The subjects watched a polygraph tracing of their detrusor 
contractions with instructions to inhibit them.  
Instructions to subjects were to use the same strategies 
developed in the office sessions with biofeedback to 
control urgency and extend intervoiding intervals between 
sessions.    The authors reported 40% of the patients were 
cured based on patients' subjective report with 44% of 
these cured measured by the objective criteria of 
posttreatment cystometrogrmas.  Another 40% reported 
subjective improvement confirmed in 14% with the objective 
criteria.

Susset et al. (1990) used intravaginal pressure biofeedback 
to improve prevaginal contractions in 15 female patients 
with stress and urge incontinence.  The treatment protocol 
included weekly clinic visits and biofeedback practice 
twice a day using a home-training instrument.  80% of the 
subjects reported 100% improvement, and the others reported 
25 to 75% subjective improvement.  This study reported 
objective improvement in 87% of the subjects.  The 
objective criterion was a negative pad test.  This test 
estimates urine leakage by weighing a protective pad of 
known weight after performing maneuvers known to cause 
urine leakage.  

In a study published in the Research Journal in Nursing and 
Health (2002), behavioral management for incontinence was 
tested using a sample of older rural women.  The 
intervention involved self monitoring, bladder training, 
and pelvic muscle exercise with biofeedback.  The primary 
outcome variable (severity of urine loss) was evaluated by 
pad test.  Secondary variables were episodes of urine loss, 
micturition frequency, voiding interval, quality of life, 
and subjective report of severity.  Reports of the study 
show a 61% decrease in the severity of incontinence.

Another study using a sample of older women reported a 
significant bladder capacity increase in patients.  
Intervention that was used was four sessions of biofeedback 
assisted behavioral training and drug treatment with 
individually titrated oxybutynin chloride (Good et al., 
2002).

Conclusion

Urinary incontinence is a problem that is often 
underreported and not taken seriously even though it 
affects millions of people's lives everyday.  While there 
exists many different types of treatment for UI, 
biofeedback proves to be an effective and less invasive 
treatment over many other types such as surgery.  Overall 
research on biofeedback for urinary incontinence 
incorporates patient education, daily pelvic floor 
exercises, and behavioral techniques designed to inhibit 
urgency and has shown that different techniques using 
biofeedback does treat many different types of 
incontinence.  

References

Agency for Health Care Policy and Research, Public Health 
Service, U.S. Department of Health and Human Services.  
(1992, March).  

Cardozo, L.D. et al. (1978).  Biofeedback in the Treatment 
of Detrusor Instability.  British Journal of Urology, Vol. 
50: 250-254.

Dougherty, Molly C. et al.  A Randomized Trial of 
Behavioral Management for Continence with Older Rural 
Women.  Research in Nursing and Health Vol. 25, February 
2002;1:3-13.

Goode, Patricia S. et al. Urodynamic Changes Associated 
with Behavioral and Drug Treatment of Urge Incontinence in 
Older Women.  Journal of the American Geriatrics Society 
Vol. 50, May 2002;5: 808-815.
 
Schwartz, Mark S. and Associates.  Biofeedback: A 
Practitioner's Guide, 2nd edition.  The Guilford Press: New 
York, 1995.

Susset, J. G., et al. (1990).  Biofeedback Therapy for 
Female Incontinence Due to Low Urethral Resistance.  
Journal of Urology Vol. 143: 1205-1208.

Copyright © 2003, Dr. John M. Morgan, All rights reserved - This page last edited May 13, 2003
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