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INTRODUCTION

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Behavioral treatment consists of a group of interventions that actively engage the patient to change her habits or learn new skills to improve pelvic floor function. These interventions have been used for several decades to treat urinary and fecal incontinence, other lower urinary tract symptoms, and defecatory dysfunction. They have been integrated into several disciplines and are implemented in many different ways. The spectrum of behavioral treatments includes those that train pelvic floor muscles in order to improve strength and control, as well as those that modify voiding habits and life style.

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In clinical practice, behavioral intervention programs should be individualized according to the needs of the patient and her unique situation, which usually involves the use of multiple components. Behavioral programs are generally built around one of two fundamental approaches. One approach focuses on the bladder outlet, teaching skills for improving pelvic floor muscle strength, control and techniques for urge suppression. Another approach focuses on controlling bladder or bowel function by changing voiding and bowel habits, such as with bladder and bowel training and delayed voiding. Components of behavioral intervention can include self-monitoring (bladder or bowel diary), pelvic floor muscle training and exercise, active use of pelvic floor muscles for urethral occlusion (“stress strategies”), urge prevention and suppression techniques (urge strategies), urge control techniques (distraction, self-assertions), biofeedback, scheduled voiding, delayed voiding, fluid management, dietary changes, weight loss, and teaching normal voiding and defecation techniques.

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All of these behavioral techniques require the active participation of the patient and time and effort from the clinician. Most patients are not cured through behavioral intervention, but there is evidence that most patients experience significant reduction in symptoms and improved quality of life with little risk of adverse side effects. Behavioral treatments should be a mainstay in the care of women of all ages with incontinence or other pelvic floor dysfunction.

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INDICATIONS

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Behavioral interventions are well established for treating stress and urgency incontinence, fecal incontinence, and overactive bladder. Although less research has been done on voiding dysfunction and defecatory dysfunction, behavioral interventions are also appropriate conservative treatments. Most patients who are motivated and cooperative with behavioral treatment experience some degree of improvement, but there is wide variation in outcomes and little is known of the characteristics of patients who respond best to behavioral treatment. Even women with dementia can benefit from the appropriate combination of behavioral treatment components such as caffeine reduction and timed voiding.

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Most of the literature on predictors of outcome has been conducted in the treatment of urinary incontinence. Most studies have shown that outcomes are not related to the type of incontinence or urodynamic diagnosis.1-5 Patients with more severe incontinence have greater improvement following behavioral treatment than those with lesser incontinence.2,6 Other studies have shown that patients with more severe incontinence have poorer outcomes,5-7 or no relationship between severity and ...

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