"Spend a few extra minutes to learn about emotions and voiding in your patient," writes Gopal H. Badlani, MD.
Badlani, professor and vice chair of urology at Wake Forest Baptist Health High Point Medical Center, Winston-Salem, North Carolina, is a coeditor-in-chief for Urology Times®.
Actress Lorna Luft once said, “I choose not to think of my life as surviving but coping.” I often see patients “living around their bladder.” In a recent paper, Reynolds et al1 studied responses from 5 items from the Overactive Bladder (OAB)-q Quality-of-Life scale asking about OAB symptoms and compensatory coping behaviors to generate a total coping score. They report that higher body mass index, lower education, use of OAB medication, and urgency incontinence as well as urinary symptom severity were all associated with higher coping scores. Furthermore, coping was associated with greater urinary symptom severity and higher anxiety and stress.
Emotions and voiding have an intimate relationship. In an exquisite treatise, The Art and Science of Piddling; Voiding Habits of Man and Beast,2 Frank Hinman Jr describes the evolution of defensive voiding by animals so as not to wet their fur and be marked. He further describes the effects of anxiety on frequency, hesitancy, and the effect of voiding in public.
Women carry a significant burden affecting voiding behavior, from genetic/familial effect on the pelvic support mechanism, anatomy of the outlet, childbearing, and hormonal influence to the cultural effects of clothing/posture for voiding. If you add bladder dysfunction or a weak outlet, the problem and fear of being discovered are reflected in coping behavior from knowing where every toilet is to restricting or avoiding activity altogether. The circle is complete with anxiety causing even more defensive frequency, perceived difficulty in voiding because there is hardly any urine in the bladder, and pelvic pain from excessive guarding.
Allowing women to build confidence and assurance that they are not going to leak requires a multimodal approach. A voiding diary and knowing functional capacity at home allows one to assess the scope of a bladder training program. An individual who sleeps 4 to 5 hours at night without leaking but goes frequently during the day in small volumes is an ideal candidate for bladder training, whereas one who leaks with urgency several times around the clock needs more involved assessment and treatment.
Part of coping is making the patient more knowledgeable about their condition and appealing to their logic. It is quicker to write a prescription than to spend time understanding the nuances of their OAB. We have learned that not all OABs are equal. Quality of life improvement is a better goal than perfect dryness. Situational symptoms such as “garage door syndrome” or change of position leaking and increased frequency with lifestyle stress require special education in addition to the fluid management. Use of Kegel exercises before getting up, using support to avoid overt Valsalva pressure are examples of mechanically dealing with situational leaking. Immediate-release sublingual medication that prevents bladder overactivity can be used by the patient when necessary in a situation known to trigger urgency/frequency.
Spend a few extra minutes to learn about emotions and voiding in your patient. Urologyhealth.org is a great patient resource to learn about voiding dysfunction and simple measures to improve the condition.
1. Reynolds WS, Kaufman MR, Bruehl S, Dmochowski RR, McKernan LC. Compensatory bladder behaviors (“coping”) in women with overactive bladder. Neurourol Urodyn. Published online September 15, 2021. doi:10.1002/nau.24788
2. Hinman F Jr. The Art and Science of Piddling; Voiding Habits of Man and Beast. Vespasian Press; 1999.