Two best practices to regain bladder control after stroke stand out, according to Jo Booth, Professor of Rehabilitative Nursing at Glasgow Caledonian University. Those two are;
- Re-train the bladder
- Do pelvic floor muscle exercises
Prior to that, a trained healthcare professional should re-assess two weeks after its onset to identify the cause of incontinence according to the standard guidelines.
Re-train the bladder to regain bladder control
According to Jo Booth, we can rehabilitate the bladder as we do with our arms and legs after a stroke.
The stroke-affected bladder can be rehabilitated.
Jo Booth, Professor of Rehabilitative Nursing at Glasgow Caledonian University
Her argument is clear. “Under normal conditions, we can control peeing. We do this by controlling the bladder’s external gate. The pelvic floor muscles regulate this gate. We can improve the bladder gate’s job by training those muscles via exercises.
Furthermore, bladder re-training should be the first line of intervention to deal with bladder problems after stroke according to the Royal College of Physician’s 2016 National Guidelines.
How to re-train the bladder
Initial assessment
The re-training begins with an initial assessment two weeks after the stroke event. A trained healthcare professional first assesses the bladder problems, including types of incontinence according to the NICE guidelines.
It also includes maintaining a three-day bladder diary to understand the bladder’s current behaviour. Then the following methods are considered per page 90 of the above guideline.
- Timed voiding: Peeing at a fixed schedule
- Prompted voiding: Urging to pee at a fixed schedule even if there is no urge.
- Review of caffeine intake
Steps of bladder re-training
The UCSF website provides detailed, simple, and clear instructions for bladder training. The following is the summary.
- Begin with a diary
- Empty your bladder as soon as you rise in the morning.
- Fix the voiding schedule in consultation with the carer/family member if you need assistance to void urine; otherwise, fix the time for the next void by yourself
- When you feel the urge, use urge suppression and relaxation methods; if possible, sit until the urge disappears.
- Increase the interval by 15-minute increments weekly, or earlier if possible, until you reach a 3-4 hour voiding interval.
- It should take 6-12 weeks to achieve the goal; there will be good days and bad days in between.
- Do pelvic muscle exercises every day.
Other methods including medications also exist to improve continence effectively as the second line of interventions.
Do pelvic floor muscle exercises to regain bladder control
The 2018 Cochrane review evidence reveals pelvic floor muscle exercises help to regain bladder control. Especially, those exercises improve urinary incontinence: stress, urge, and mixed. In these exercises, one has to squeeze, lift, and then relax those muscles repetitively -ideally 30 – in a row, up to three times a day. Research reveals this type of training improves muscle strength, the endurance (making muscle tiring less), and improves the coordination (muscle squeezes hardest in a cough or a sneeze).
How to do pelvic muscle exercises
According to UCSF Health, pelvic muscle exercises, also called Kegels, can improve continence; it also helps to suppress the urge. Its website suggests the following steps to achieve better results.
- Locate the pelvic muscles; they suggest two methods. In one method, one needs to tighten the anus as if not to pass gas. The other method suggests inserting a finger into the vagina and then squeezing it. Both methods require not tensing the abdomen, buttock, and thigh muscles while attempting to locate those muscles.
- Set a timetable for the exercises: at breakfast, lunch, dinner, and before bed. Make it a habit.
- Squeeze the muscles for a slow count of three; then relax in the same way. Repeat 15 times in one set. Do three complete sets each day.
- Increase the count gradually.
- Maintain a bladder diary (you can download a copy from their website)
You can also find a very useful set of instructions from the University Health Network through this link: https://www.uhn.ca/PatientsFamilies/Health_Information/Health_Topics/Documents/Pelvic_Floor_Kegel_Exercises_for_women.pdf.
Feedback or biofeedback to improve the effectiveness of the pelvic muscle exercises
Experts have developed some feedback and biofeedback methods to facilitate recognising the correct pelvic floor muscles to contract and to monitor progress. This is deemed necessary because many find it difficult to recognize and contract the correct muscles. Instead, they contract abdominal and buttock muscles.
Common feedback and biofeedback methods
- One-finger palpation of the muscles through the vagina among women
- Using two small sensors with a sticky pad placed under loose clothing on either side of the anus and across the abdomen to measure muscle strength while doing exercise. The sensors can be connected to a computer screen to monitor the response.
- Using a perineometer
- Using vaginal weights/cones
The 2011 Cochrane review concluded these methods may provide benefit, but further research is necessary. In contrast, the 2020 UK Multicenter Randomized Controlled Trial could not find any added benefit of using a sensor-mediated biofeedback method in comparison to conducting pelvic floor muscle training alone. However, the researchers excluded those who had urge incontinence and those who could not contract the pelvic muscles as per the finger palpation.
Address functional difficulties to regain bladder control
Assess toileting ability
Assessment tools exist to assess the toileting ability of individuals with stroke. These serve a useful purpose to improve continence problems due to difficulties with arm and leg movements. One such tool is the Toileting Task Assessment Form. However, this tool helps to assess those with a one-side weakness and using a wheelchair. This could be used by others to develop their own customised tool, I believe.
Manage constipation to regain bladder control
The 2016 National Guidelines for Stroke published by the Royal College of Physicians recommend the following to deal with constipation.
- Advice on diet, fluid intake, and exercise
- A regulated routine for toileting
- oral laxatives
- A review to reduce the number of constipation-causing medications by a physician
- A structured bowel management program by a trained nurse
Educate the stroke carers
Educating the stroke carers plays a very big role in ensuring the success of the whole effort. All standard guidelines and published research emphasise that stroke carers need to be educated about how the bladder functions and how bladder re-training and pelvic muscle training resolve bladder problems after stroke.