Physical Exercise and Bladder Training Program for Urinary Incontinence

Over 40% women age 65 and older or an estimated million women in the US suffer from urgency
urinary incontinence (UUI), a condition characterized by urgency to urinate. UUI is a
well-known marker for frailty and older women with UUI are at two fold higher risk for falls.
According to the biopsycho- ecological paradigm, UUI and its associated falls are the result
of interaction of the patients physical abilities (bladder urgency and reduced balance and
strength to reach the toilet), mental attitudes (anxiety related to urgency, shame and stigma
of leakage), social expectations (life demand and roles that limit access to bathroom), and
physical environment (physical barriers to reach the toilet).

Anti-muscarinic medications, the most common treatment for UUI, address only bladder urgency
and their side-effects may exacerbate falls. We plan an innovative treatment approach that
will integrate each of the bio-psycho-ecological levels implicated in UUI and falls. Strength
and balance exercises improve functional mobility and have been shown to reduce both fall
risk as well as UUI in high risk frail older adults. Behavioral urge suppression reduces
anxiety related to urgency and improves mental abilities to handle life demands and roles.
Simple home improvements can reduce environmental barriers. Adherence is an important barrier
in the implementation of exercise and behavior modification. Prior studies, including our
own, have shown that preferred treatments are associated with improved adherence,
satisfaction and outcomes in women with UUI. We hypothesize that an integrated exercise and
urge suppression program targeted to improving physical performance relevant to continence
behavior will reduce the risk of falls in appropriately selected community dwelling women
with urinary incontinence. In this pilot study, we plan to develop, validate and test a home
based integrated exercise and urge suppression intervention that targets functional mobility,
reduces anxiety urgency and physical barriers and is implemented in partnership with all
stakeholders. The proposed pilot study for a planned submission in June 2014 fulfills PCORIs
national priorities and research agenda through improving patient centered outcome measures,
informed decision making based on risks and benefits, innovative Page 9 of 17 community based
delivery of the intervention, addressing barriers to care, and engaging all stakeholders
involved in the care of older women with UUI including patients, providers, and community
advocates.

The overall objective of this project is to reduce the risk of falls in elderly frail
community dwelling women with urgency urinary incontinence (UUI). Our specific aim is: To
determine the feasibility of enrollment and randomization of a comparative effectiveness
trial of integrated exercise and urge suppression program versus usual care in older
community dwelling women with urge urinary incontinence. Hypothesis: Older women with UUI who
receive their preferred treatment option, exercises and urge suppression, will have better
objective (fewer functional limitations, falls risk and urinary incontinence) and subjective
(HRQOL, satisfaction with care, and psychological wellbeing) outcomes than women who receive
usual care.

Inclusion Criteria:

1. female

2. age 60+ years

3. community dwelling

4. Moderate to severe UUI (as measured by International Consultation on Incontinence
Questionnaire Short Form)

5. low physical activity (Physical Activity Staging questionnaire)

6. cognitively able to complete the study (in opinion of the referring provider) Women
currently on anti-cholinergic medication for urinary incontinence will be allowed if
they meet the above criteria.

Exclusion Criteria:

1. cognitive impairment (in opinion of the referring provider)

2. unable to provide informed consent or communicate in English

3. desire for surgical management

4. osteoporosis

5. lack of medical clearance from the physician.