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ladder training, sometimes referred to as bladder reeducation or bladder retraining, teaches the patient to restore a normal pattern of voiding by setting mandatory scheduled voidings that help the patient adopt longer time intervals between voiding. The ultimate goal of this program of behavioral therapy is to return the patient to a normal bladder function. Emphasis is placed on the importance of the brain’s control over the lower urinary tract. Bladder training corrects faulty habit patterns of frequent voiding, increases bladder capacity, teaches control of strong bladder urges, and eliminates the desire for frequent voiding. A main goal of bladder training is for the patient to void no more than every three or four hours. To help the patient get to four hours, teach the patient how to distract him or herself by concentrating on an idea or image and by practicing relaxation techniques. The patient will learn how to control the urge.
       There has been much research on bladder retraining in middle-aged women. It can be successful in persons with urge incontinence and those who have frequent urination. Research indicates that 75 percent of women with stress and urge incontinence who follow a bladder retraining program have at least a 50-percent reduction in the number of incontinent episodes. The research also shows that bladder retraining can lead to increased bladder volume. The bladder begins to hold more urine, and therefore, the patient will not feel as though he or she needs to go to the bathroom as often. It has also been shown to help individuals who have stress incontinence.
       The urinary urge is a message from the bladder telling the patient it is time to empty the bladder. The urinary urge is simply a signal telling the patient it is necessary to empty the bladder—not that emptying must occur immediately. The urinary urge follows a wave pattern.
       The key to controlling the urinary urge is for the patient not to respond as though he or she has received an emergency message: “I must go now and I must go quickly.”
• Rushing jiggles the bladder and increases the awareness of how full it feels, making urgency worse.
• Rushing can stimulate the bladder to contract more forcefully, making it more difficult to hold back urine leakage.
• Rushing puts extra downward pressure on the bladder, which tends to push the urine out.
• Rushing interferes with the ability to concentrate on controlling the urge.
       Your patient may benefit from a six-week bladder retraining program. There are usually five components to such a program:
1. Determining voiding pattern by having the individual first keep a seven-day bladder diary.
2. Developing a fixed scheduled voiding protocol, which is adjusted on a weekly basis.
3. Teaching strategies for controlling urinary urgency.
4. Self-monitoring of voiding behavior by having the patient keep a bladder diary.
5. Positive reinforcement for achieving set goals.
       Bladder retraining requires the development of a relationship between the patient with the bladder problem and a clinician who understands behavioral training. An entire bladder retraining program takes at least six to eight weeks before success is achieved. The voiding schedule is followed during the day; no schedule is expected to be followed during sleeping hours. The clinician must take into account the patient’s lifestyle and preferences. Once a voiding schedule has been identified, the patient should make every effort to stick to the schedule exactly as prescribed and not to veer off schedule even if he or she gets bladder urgency. If the patient gets the urge to void and it’s not time according to the schedule, have the patient practice strategies for controlling urgency. Teach the patient how to relax!

Relax, Relax
       Learning to relax lessens the strong urge sensation and allows the patient to wait longer before using the toilet. The urge sensation is a feeling, nothing more. The patient will then stop the bad habit of frequent voiding, improve his or her ability to stop urinary incontinence, and cut down on urinary urgency.
       To help the patient control the urge to void, have him or her concentrate on another body sensation, such as slow, deep breathing.
       By practicing deep breathing, the patient will find that the urgency lessens or even disappears. Deep breathing is a distraction method to interrupt the bladder urgency message from the bladder control center in the brain. The patient will be more successful if he or she practices these relaxation techniques when near the bathroom so he or she does not worry about having an accident. The patient can also distract him or herself by playing mind games—counting backwards from 100 by 7s, listing the birthdays of brothers, sisters, and other close family members, remembering all the words to a favorite song or nursery rhyme. Have the patient note how long he or she is able to keep the urge away.
       Once the urge is gone, or not as strong, the patient should try not to void until the next scheduled time. If the patient gets a strong urge and it is not the scheduled time, have the patient practice deep breathing and make every effort to wait until the assigned hour. If the patient is concerned about having an incontinent episode, have him or her void but then return to the schedule. If this occurs often, perhaps the schedule needs adjustment. You may have to schedule less time between voidings. Always have the patient try to lessen strong urge sensations before toileting. Once the urge has lessened or disappeared, then have the patient walk, unhurriedly, to the bathroom to void. In order to reduce the chances of awakening during the night to urinate, the patient should empty his or her bladder immediately before going to sleep. Tell the patient not to be discouraged by setbacks. Sometimes during periods of increased stress, such as attending an important social event where a restroom is inaccessible, the patient may revert back to old habits. Just pick up the schedule again once the stress has been resolved.
       How do you know if the patient is successful? Have the patient keep a bladder diary throughout the retraining process to monitor if he or she is voiding less often during the day and if he or she is having less incontinence. Have the patient bring these records when you return for treatment visits.

Excerpted and adapted with permission from Diane Kaschak Newman. Newman DK. Nonsurgical techniques: Behavior modification. The Urinary Incontinence Sourcebook. Los Angeles, CA: Lowell House, 1997:143–73. Copyright © 1997 Diane Kaschak Newman.