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Copyright 0 1981 Pcrgamon Press Ltd

Treatment of urinary urgency and excessive frequency: a case study*

(Receiued 21 October 1980)

Summary-A 39-year-old male presenting with a 5 year history of excessive urinary frequency and urgency was treated first with scheduling of urination, use of external urinary catheter and progressive muscular relaxation and then with a urinary retention training procedure. After the first set of procedures. urinary frequency decreased, whereas urgency increased slightly. After completion of retention training, both symptoms were alleviated. Overall, urinary frequency decreased from a baseline average of 14 urinations daily to a post-treatment average of 6.5 urinations per day. Urinary urgency decreased from a baseline average of 35 urges per day to a post-treatment average of 9.3 urges per day. Gains were maintained at 3 and 5 month follow-up.

INTRODUCTION

The behavioral treatment of excessive urinary frequency and urgency without organic causes has received relatively little attention in the literature. The prevalence of these disorders in adults has not been reliably reported. Although urinary frequency demonstrates considerable variability, parameters of ‘normal’ urinary frequency have been documented (Yates and Poole, 1972). Consequently, urinary frequency of greater than 8-10 voidings per day or consistent nocturnal voiding of more than once is considered to be significantly above average. The point at which the ‘statistical’ significance becomes of clinical importance is measured by the extent of discomfort experienced by the individual or the amount of interference with the person’s lifestyle.

Attempts to treat daytime urinary frequency typically have focused on a presumed anxiety component either alone (Taylor. 1972; Van der Ploeg, 1975) or in conjunction with urinary retention training (Jones, 1956; Cohen and Reed, 1978). However, in two cases anxiety modification was not a component of treatment. Kobayashi (1968) reported a case of a woman treated with electric shock contingent on report of urinary urges. Poole and Yates (1975) treated a male patient with a shaping procedure involving scheduling of urination with success- ively longer intervals.

The present study reports a two-phased sequential application of treatment techniques in a male patient. In phase I, relaxation training, scheduling of urinations and a rather unique approach to reducing fear of inconti- nence were introduced. In phase II, urinary retention control training was provided. Urinary urgency and frequency were analyzed concomitantly, providing an opportunity to study their interrelationship and differen- tial responses to treatment. By virtue of the sequential application of treatment techniques, the essential components on the entire package were pinpointed.

CASE HISTORY

Mr W was a 39-year-old male who was referred to the University of Pittsburgh Behavioral Medicine Clinic of the Western Psychiatric Institute because of complaints of urinary urgency (strong urges to urinate approxi-

* Reprint requests should be addressed to: Jorge Luis Figueroa Psychology Clinic, University of Georgia, Athens. GA 30602 U.S.A.

262 CASE HISTORIES AND SHORTER COMMlJNlCATIONS

mately 35 times a day) and excessive urinary frequency (as much as 18 times daily). These urinations were usually of small volume (20-70 cc), as measured during baseline, and were not painful. Mr W was employed in an upper level management position which required frequent traveling and attendance in lengthy business meetings. Both of these functions had been seriously impaired. causing a deterioration in work performance and resulting in missed opportunities for promotion.

The patient reported that the problem interfered with his daily routine: he would avoid all places which did not have easily accessible restroom facilities (e.g. parks) and make daily restroom stops while driving to and from work (a 30-minute trip). Although Mr W had never been incontinent, he reported an increasing fear of losing bladder control. most prominently when he experienced an urge to urinate.

Physical. neurological and urological examination had been performed prior to entering this treatment and found to be negative. Five years prior to this contact the patient had a urinary tract infection. It was at that time the patient experienced difficulty with frequency and urgency for the first time. The symptoms persisted. however, despite successful treatment of the infection. Since then. the patient reported having made multiple contacts with health professionals for his urinary difficulties without improvement.

METHOD

Dependent variable

In order to establish an ongoing measure of urinary frequency and urgency the patient was instructed in self-monitoring A 3 x 5” index card was utilized for recording The card was divided into four blocks of time: 6a.m.-12p.m.. 12p.m.-6p.m.. 6p.m.-12a.m. and 12a.m.-6a.m. One side of the card was utilized to monitor frequency of urination and the other for urgency. The subject was instructed to place a mark on urgency side each occasion he felt the need to urinate and to mark the other side of the card whenever he urinated. The subject was also requested to measure the output of urine at random times throughout the week to provide an estimation of the volume of urine. The subject maintained this monitoring procedure for nine days prior to treatment onset and throughout the course of treatment on a daily basis.

Treatment procedure

The treatment packages employed were applied in two sequential phases. Phase I (3 weeks) consisted of relaxation training scheduling of urinations and wearing a urinary catheter with leg bag. Phase II (6 weeks) consisted of retention control training

Phase I. Relaxation procedures were initiated because of Mr W’s complaint of anxiety and his identification of stress as sometimes resulting in increased urgency. The Bemsten and Borkovec (1973) format was followed. The patient received twice weekly sessions and was instructed to practice the procedure daily. Once the patient achieved relaxation by recall, he was instructed to utilize the procedure in those situations when anxiety was present along with urinary urgency.

In an attempt to establish a schedule for urination which would result in prevention of excessive urinations. the patient was instructed to limit his usage of bathroom facilities to the following times: 7:00-7:30a.m.. I1 :30 a.m.-12%) p.m., 4:30-5:00 p.m. and 10:30-l 1 :OO p.m. During those times, the patient was allowed free access to the bathroom. For urination at any other ‘unauthorized’ time periods. the patient was given an external (Condom) catheter with leg bag

The patient was instructed to wear the catheter beginning at 7:30a.m. every morning and keep it in place throughout the entire day. The purpose of this intervention was to increase adherence to the urination schedule and to decrease the fears of incontinence. The patient maintained usage of the external catheter throughout the treatment.

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water used for one session of retention control training.

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CASE HISTORIES AND SHORTER COMMUNlCATlONS 263

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Fig 2. Average urinary urgency for 3 consecutive days (urges per days) during baseline, phase I and phase II of treatment, post-treatment and follow-up.

Phase II. Due to the increase in urinary urgency concomitant with the reduction in urinary frequency in Phase I. it was deemed necessary to institute an alternative intervention that would reduce both urinary frequency and urgency. To that end, a bladder loading procedure was initiated. The subject was instructed to ingest a specified amount of fluid 1 hour prior to each ‘authorized’ urination time. The amount of fluid was successively increased during treatment. The subject was still under instructions to urinate in the toilet only during authorized times and to use the external catheter for all other voidings. The subject began loading 8 ounces and then proceeded to 16 ounces. 24 ounces and finally 32 ounces of fluid, 1 hour prior to urination times. The subject progressed from each level to the next every 9 days. After completion of the 9 days of 32 ounces. loading was terminated. The subject was instructed to resume normal fluid intake.

RESULTS

The results of treatment are presented in Figs 1 and 2. Each data point represents the mean of 3 consecutive days. Changes within phases were generally conducted in 9 day blocks. During Phase II, each data point also represents three days of data with four occasions of bladder loading per day (1 hour before each authorized urination period).

Prior to the onset of treatment, baseline levels of urinary frequency indicated an average of 14 voidings a day, with an average daily baseline rate of 35 urinary urges. During Phase I, the mean frequency decreased to 9.4 urinations per day and mean urgency increased to an average of 42 urges per day. During Phase II, frequency was increased to a mean of 13.8 and urgency to 89.9 per day. At post-treatment, mean frequency dropped to 6.5 urinations per day (within normal limits) and urgency was reduced to a mean of 9.3 urges per day.

At 5 month follow-up, the subject reported a mean frequency of 4.7 urinations per day and a mean of 8 urges per day. The patient stated he no longer felt any anxiety regarding incontinence and reported having been on several international business trips (for the first time in many years) without any difficulty.

DISCUSSION

Although this study is limited in its generalizability, as is any single case study, it does present a systematic intervention into a perplexing problem. During the first phase of treatment involving scheduling of urinations, external catheter and relaxation training urinary frequency declined. The patient reported great aversion to urinating into the catheter, preferring to ‘cheat’ by using regular restroom facilities. ‘Cheating’, however, was reported by the patient to result in feelings of guilt and failure and to become quite aversive to him. Thus, in addition to reducing fear of incontinence. the catheter procedure may have enhanced self-generated aversive consequences for ‘non-authorized’ urinations.

In contrast to urinary frequency, urinary urgency did not improve during phase I of treatment. In fact, there was a small increase. This result differs from that of Poole and Yates (1975) who obtained improvement with urinary scheduling alone. However. this study employed a shaping procedure and extended over a longer time period. This slower approach may have permitted a gradual physiological readjustment leading to reduction in urinary urgency. The’lack of full treatment effect during phase I also appears to be at variance with two studies in which anxiety reduction procedures alone were employed (Van der Ploeg, 1975; Taylor, 1972). This may be related to the fact that the subjects in these studies were children and that the problem was highly specific to a particular situation (school).

Urinary urgency did not decrease until after the bladder loading procedure had been implemented. The mechanism of the treatment effect is not quite clear. The bladder loading procedure may have resulted in physiological changes leading to a decrease in urinary urges for a given level of bladder distention. Urinary urgency may be due to increased bladder pressure at low volumes, an increased sensitivity to normal bladder pressures or both. Jones (1956). who measured the bladder pressures of her female patient, found that the bladder pressure for a given volume was higher than normative data. indicating that the bladder capacity of this patient was reduced. In addition, the urge to urinate occurred at lower bladder pressures, implying an B.RT 19 S--F

364 CASE HlSTORlES AND SHORTER COMMUNICATIONS

altered sensitivity as well. Treatment by bladder loading resulted in decreased urinary urgency at a given pressure, but the abnormally high bladder pressure at low volumes persisted. In enuretic children. on the other hand, retention training has been shown to lead to an actual increase in bladder capacity (e.g. Starfield. 1972). In addition to possible physiological changes, the importance of the educational value of the patient observing the large volumes of urine at each urination, up to 600~~. during retention control training should not be underestimated. Just like the case described by Jones (1956). the patient of the present study was at the same time amazed and reassured upon realizing how large a volume of fluid his bladder could hold.

While retention control training was necessary for the success of this case. this study can not provide the answer whether it would have been sufficient to use this procedure alone. Miller (1972) found a reduction of urinary frequency during retention training of two enuretic adolescents. but excessive daytime frequency was not the target problem in these cases. The efficacy of retention control training without preceding anxiety reduction techniques should be studied in future appropriate cases. This is not to say that retention control training should be involved in the treatment of 011 cases. Anxiety reduction techniques may be sufficient when the onset of the problem is recent enough not to have lead to reduction in bladder capacity.

Finally. a word of caution seems to be in order. Urinary frequency or urgency often is due to physical abnormalities in the lower urogenital tract, such as inflammation, stones or tumors. In the present case the problem began as a result of a (subsequently cured) urinary tract infection. Behavioral treatment of urinary urgency of frequency should not be attempted before possible physical causes have been ruled out by a thorough medical and urological evaluation.

University of Pittsburgh School of Medicine. Western Psychiatric Institute and Clinic. 3811. O’Hara Street. Pittsburgh. PA 15261. U.S. A.

JORGE Lurs FIGUEROA ROLF G. JACOB

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