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Behavioral Therapy for Urinary Incontinence

Behavioral therapy offers low-risk, low-cost noninvasive options for overactive bladder (OAB), urgency urinary incontinence (UUI) and mixed urinary incontinence; selected lifestyle measures also apply to stress urinary incontinence (SUI). The 2024 AUA/SUFU OAB guideline offers behavioral options without requiring a fixed treatment sequence.[1] The 2024 AUA/SUFU OAB guideline recommends that clinicians offer bladder training to all patients with OAB and offer behavioral therapies to all patients with OAB .[1] It also recommends discussing incontinence management strategies such as pads and barrier creams with all patients who have urgency urinary incontinence .[1] For SUI, the 2023 AUA/SUFU guideline directs counseling on observation, pelvic floor muscle training with or without biofeedback, other non-surgical options such as a continence pessary, and surgery .[15]

Phenotype-specific emphasis. Bladder training and urge suppression have the strongest evidence in OAB and UUI. For SUI, pelvic floor muscle training is a key active conservative option; weight loss, fluid or caffeine management, and constipation care are adjuncts when indicated. Bladder training has a less direct role.[15] The components below are used selectively by phenotype.

This page is the behavioral-treatment companion to the Female Stress Incontinence Database, OAB & UUI treatment database, Pelvic Floor Physical Therapy, Weight Loss for Urinary Incontinence, anticholinergic / antimuscarinic agents, and β3-adrenergic receptor agonists.

Practice Guideline Position​

The AUA/SUFU guideline separates behavioral therapy from broader non-invasive therapies.[1]

CategoryExamplesPractical interpretation
Behavioral therapiesBladder training, fluid management, caffeine reduction, physical activity / exercise, dietary modification, mindfulnessOffer to all patients with OAB; few adverse effects; success depends on acceptance, coaching and adherence
Select non-invasive therapiesPelvic floor muscle therapy, transcutaneous tibial nerve stimulation, transvaginal electrical stimulation, yogaMay offer; safety is favorable, but efficacy and evidence certainty vary by modality
UUI management strategiesPads, briefs, barrier creams, skin care, bedside commode / urinal accessDiscuss with all patients with urgency urinary incontinence

Bladder training has the strongest evidence base of the behavioral therapies.[1][2] The EAU 2026 guideline recommends bladder training as first-line therapy for adults with OAB/UUI and prompted voiding for cognitively impaired adults with OAB ; its evidence summary states that bladder-training efficacy for UUI in women appears lower than pharmacotherapy (level 1b).[21] PFMT overlaps with behavioral care when the goal is urge suppression and learned detrusor inhibition. It is best delivered as a formal pelvic-floor intervention when tone, strength, coordination or pain needs assessment.

Components​

Behavioral therapy comprises several components.[2][3][4]

ComponentHow it is deliveredClinic target
Bladder training / bladder drillEducation, fixed voiding interval, diary review, gradual interval lengthening, positive reinforcementIndividualized, comfortable interval; 3-4 hours may be a goal for selected patients
Scheduled voiding / timed voidingVoids occur by clock rather than urgencyFrailty, cognitive impairment, caregiver-dependent toileting, high-volume urgency
Urge suppressionStop moving, sit or stand still, relax abdomen / thighs / jaw, use rapid pelvic-floor contractions if appropriate, breathe, distract, then walk calmly once urgency fadesBreak the urgency-rushing-leak loop
Fluid managementAvoid large boluses; distribute intake; reduce evening fluid when nocturia is diary-linkedReduce frequency without causing dehydration
Caffeine / alcohol / dietary trigger trialTime-limited elimination and rechallenge based on diaryIdentify patient-specific urgency triggers
Constipation managementStool softening strategy, fiber / osmotic laxative when needed, defecatory mechanicsReduce rectal loading and pelvic-floor guarding
Weight loss and activityStructured program when BMI is elevated; realistic exercise prescriptionReduce incontinence burden and improve mobility
Mindfulness / CBT-informed strategiesUrgency exposure, attention shifting, catastrophizing reduction, coping skillsReduce fear-driven urgency amplification

Bladder Training Protocol​

The following bladder-training example is adjustable.

  1. Start with a 3-day bladder diary to identify the shortest safe interval.
  2. Set the initial voiding interval just below the usual urgency interval.
  3. Void by the clock while awake; avoid "just in case" voiding outside the plan.
  4. When urgency arrives early, use urge suppression until the scheduled time.
  5. Increase the interval by about 15 minutes after several successful days.
  6. For women with urgency or mixed urinary incontinence, continue bladder training for at least 6 weeks as recommended by NICE NG123, reassessing symptoms and safety.[1][2][14] An 8-12-week course and a 3-4-hour interval may suit some patients.[1][2][14]

Progress is easiest to sustain when the patient can see it in diary data: fewer urgency episodes, fewer leaks, longer intervals and fewer rushed bathroom trips.

Urge Suppression Script​

The patient is taught a short script:

  • Stop. Do not rush to the toilet.
  • Still. Sit or stand quietly, because rushing intensifies the urge and the risk of leakage.
  • Soften. Relax abdomen, gluteals, thighs, shoulders, and jaw.
  • Squeeze only if appropriate. Use several quick pelvic-floor contractions when the patient can contract without pain or guarding.
  • Shift attention. Use slow breathing, counting backward, or another distraction until the urgency wave falls.
  • Walk calmly. Go to the bathroom after the urge recedes.

For patients with pelvic-floor tenderness, pain, or guarding, route to Pelvic Floor Physical Therapy; repeated strengthening can worsen a high-tone phenotype.

Evidence Snapshot​

In a randomized trial of 123 noninstitutionalized women aged 55 years and older, urodynamically classified as urethral sphincteric incompetence (n = 88) or detrusor instability with or without sphincteric incompetence (n = 35), bladder training reduced incontinent episodes by 57%, with a similar effect in both urodynamic groups, and reduced fluid loss by 54%.[19]

Behavioral therapy vs. oxybutynin​

In a randomized trial of 197 older women with urge or mixed incontinence, Burgio and colleagues compared biofeedback-assisted behavioral training, oxybutynin and placebo. In the trial’s analysis of 190 of 197 randomized women with at least one follow-up bladder diary, mean reductions in incontinence episodes were 80.7% with behavioral therapy, 68.5% with oxybutynin (P = .04, behavioral vs drug), and 39.4% with placebo.[7]

A urodynamic companion analysis of 105 women reported mean reductions in incontinence frequency of 82.3% with behavioral training, 78.3% with oxybutynin and 51.5% with placebo. Bladder capacity rose by 68.9 mL with oxybutynin and 17.3 mL with behavioral training. Volume at strong desire to void rose by 69.9 mL with oxybutynin and 40.5 mL with behavioral training.[6]

Systematic reviews​

Evidence sourceFinding
Balk 2019 network meta-analysisFor urgency UI, behavioral therapy was significantly more effective than anticholinergics for cure or improvement (high strength of evidence)[8]
Cochrane bladder training 2023Immediately after treatment, bladder training may be more effective than anticholinergics for participant-reported cure or improvement (RR 1.37, 95% CI 1.10 to 1.70; 4 studies, 258 participants; low certainty). A separate adverse-event analysis found fewer events with bladder training (RR 0.03, 95% CI 0.01 to 0.17; 3 studies, 187 participants; very low certainty)[2]
Cochrane conservative-interventions overview 2022For urgency UI, PFMT with feedback or biofeedback, electrical stimulation and bladder training were each more beneficial than control for cure or improvement (moderate to high certainty). Across all UI types, PFMT with bladder training was more beneficial than bladder training alone[9]

Combining Behavioral and Drug Therapy​

Behavioral therapy can be used as the first step, as a combination partner or as a rescue strategy when medications are stopped because of adverse effects.

PopulationTrial signalPractical use
OAB (75% women): tolterodine + simplified bladder trainingIn 501 evaluable patients at 24 weeks, median voiding frequency fell 33% with the combination vs 25% with tolterodine alone (P < 0.001); median percentage reduction in incontinence episodes was 87% vs 81% (not significant)[5]—
Women: optimized oxybutynin ± behavioral therapyAt 8 weeks, intent-to-treat analysis of 64 women found mean incontinence episode reductions of 88.5% with drug alone and 78.3% with combined therapy (P = 0.16); the trial stopped early for futility[10]—
Men: behavioral vs drug vs combinationAt 6 weeks, combined therapy reduced voiding frequency more than drug therapy alone, but not more than behavioral therapy alone[4]—

Medication partners are covered in anticholinergic / antimuscarinic agents, β3-adrenergic receptor agonists, and the OAB & UUI treatment database.

CBT, Mindfulness, and Weight Loss​

Structured cognitive behavioral therapy (CBT) is an emerging adjunct for urgency incontinence. A systematic review of 12 papers reported a high level of evidence for improved symptom severity and a moderate level for quality-of-life, psychological and satisfaction outcomes; effects on clinical signs were conflicting.[11] In a 2024 randomized trial of 79 women with moderate-to-severe OAB, a multicomponent intervention incorporating CBT principles and exposure-based bladder training improved OAB questionnaire quality-of-life scores by 23.9 points versus 11.3 with a waiting list at 13 weeks. Urgency-incontinence frequency did not differ significantly between groups.[12]

Weight loss is a lifestyle intervention when excess weight contributes to incontinence. In the PRIDE randomized trial of 338 overweight or obese women, a 6-month weight-loss program reduced weekly incontinence episodes by 47%, compared with 28% with a structured education program (P = 0.01). Stress-incontinence episodes fell more in the intervention group (P = 0.02); urge-incontinence episodes did not differ significantly in frequency (P = 0.14).[13]

Patient Selection and Delivery​

Behavioral therapy is broadly appropriate. The delivery model is matched to the patient:

Patient patternBest delivery model
Motivated, cognitively intact, mild-moderate OABDiary-guided bladder training with nurse / clinician follow-up
OAB with pelvic pain, dyspareunia, guarding, constipation, or poor muscle awarenessPelvic health PT; avoid strengthening-first instructions until phenotype is known
Frailty, dementia, limited mobility, caregiver-dependent toiletingTimed voiding, prompted voiding, bedside commode access, clothing simplification, skin care
Heavy caffeine / evening fluid / edema-driven nocturiaDiary-driven trigger correction and nocturnal polyuria workup
Mixed UIPair bladder training and urge suppression with SUI-directed PFMT or SUI procedural counseling

Adherence limits success, and the AUA/SUFU guideline notes that outcomes depend on patient acceptance and adherence.[1] Follow-up is built around reviewable data: diary intervals, leak counts, urgency scores, pad use, fluid timing, stool pattern and patient-defined goals.

Group, Telehealth, and Digital Delivery​

Group classes and digital programs can extend access beyond individually supervised clinic visits. In the GLADIOLUS trial, 463 community-dwelling women 55 years or older were randomized to a one-time, 2-hour group bladder-health class with written materials and an audio CD or to a no-treatment control; the class was modestly effective, with ICIQ-SF score differences of about 1.0-2.1 points favoring the intervention across 3-12 months of follow-up, and was judged cost-effective.[16] In a 12-week randomized trial of 41 women with OAB, an online self-management program with an embedded avatar coach improved OAB-related quality of life and urgency/frequency symptoms compared with an identical voice-only version of the same program.[17] An 8-week mobile telehealth program for women veterans (MyHealtheBladder) remains in early development: an uncontrolled pilot of 29 participants reported an ICIQ-SF improvement exceeding the minimal clinically important difference, without a comparison group.[18] In the industry-funded, 12-week DINKS trial, 194 women with stress, urgency or mixed incontinence were randomized to a multicomponent app plus usual care or usual care alone.[20] Mean relative reductions in daily incontinence episodes were 60.95% and 1.69%, respectively.[20]

Operative and Clinic Pearls​

  • Offer behavioral therapy even when procedural treatment is likely; it improves baseline control and gives patients a non-drug rescue skill.
  • Do not label every pelvic-floor intervention "Kegels"; urge suppression, relaxation, and coordination may matter more than strengthening.
  • Use a bladder diary to avoid treating nocturnal polyuria, polydipsia, or edema as refractory OAB.
  • In UUI, discuss pads, barrier creams and skin care early.
  • If symptoms worsen during bladder training, check PVR, UTI, constipation, pain, and whether the starting interval was too ambitious.

Videos​

Non-Invasive Therapies for Tier 1 OAB
Dr. Janine Oliver, Grand Rounds in Urology (2025)

References​

1. Cameron AP, Chung DE, Dielubanza EJ, et al. "The AUA/SUFU Guideline on the Diagnosis and Treatment of Idiopathic Overactive Bladder." J Urol. 2024;212(1):11-20. doi:10.1097/JU.0000000000003985

2. Funada S, Yoshioka T, Luo Y, et al. "Bladder Training for Treating Overactive Bladder in Adults." Cochrane Database Syst Rev. 2023;10:CD013571. doi:10.1002/14651858.CD013571.pub2

3. Goode PS, Burgio KL, Richter HE, Markland AD. "Incontinence in Older Women." JAMA. 2010;303(21):2172-2181. doi:10.1001/jama.2010.749

4. Burgio KL, Kraus SR, Johnson TM, et al. "Effectiveness of Combined Behavioral and Drug Therapy for Overactive Bladder Symptoms in Men: A Randomized Clinical Trial." JAMA Intern Med. 2020;180(3):411-419. doi:10.1001/jamainternmed.2019.6398

5. Mattiasson A, Blaakaer J, Høye K, et al. "Simplified Bladder Training Augments the Effectiveness of Tolterodine in Patients with an Overactive Bladder." BJU Int. 2003;91(1):54-60. doi:10.1046/j.1464-410x.2003.03076.x

6. Goode PS, Burgio KL, Locher JL, et al. "Urodynamic Changes Associated With Behavioral and Drug Treatment of Urge Incontinence in Older Women." J Am Geriatr Soc. 2002;50(5):808-816. doi:10.1046/j.1532-5415.2002.50204.x

7. Burgio KL, Locher JL, Goode PS, et al. "Behavioral vs Drug Treatment for Urge Urinary Incontinence in Older Women: A Randomized Controlled Trial." JAMA. 1998;280(23):1995-2000. doi:10.1001/jama.280.23.1995

8. Balk EM, Rofeberg VN, Adam GP, et al. "Pharmacologic and Nonpharmacologic Treatments for Urinary Incontinence in Women: A Systematic Review and Network Meta-analysis of Clinical Outcomes." Ann Intern Med. 2019;170(7):465-479. doi:10.7326/M18-3227

9. Todhunter-Brown A, Hazelton C, Campbell P, et al. "Conservative Interventions for Treating Urinary Incontinence in Women: An Overview of Cochrane Systematic Reviews." Cochrane Database Syst Rev. 2022;9:CD012337. doi:10.1002/14651858.CD012337.pub2

10. Burgio KL, Goode PS, Richter HE, et al. "Combined Behavioral and Individualized Drug Therapy Versus Individualized Drug Therapy Alone for Urge Urinary Incontinence in Women." J Urol. 2010;184(2):598-603. doi:10.1016/j.juro.2010.03.141

11. Steenstrup B, Lopes F, Cornu JN, Gilliaux M. "Cognitive-behavioral Therapy and Urge Urinary Incontinence in Women. A Systematic Review." Int Urogynecol J. 2022;33(5):1091-1101. doi:10.1007/s00192-021-04989-3

12. Funada S, Luo Y, Uozumi R, et al. "Multicomponent Intervention for Overactive Bladder in Women: A Randomized Clinical Trial." JAMA Netw Open. 2024;7(3):e241784. doi:10.1001/jamanetworkopen.2024.1784

13. Subak LL, Wing R, West DS, et al. "Weight Loss to Treat Urinary Incontinence in Overweight and Obese Women." N Engl J Med. 2009;360:481-490. doi:10.1056/NEJMoa0806375

14. National Institute for Health and Care Excellence. Urinary incontinence and pelvic organ prolapse in women: management (NG123), recommendation 1.4.11 (bladder training at least 6 weeks for urgency or mixed UI). Recommendations.

15. Kobashi KC, Vasavada S, Bloschichak A, et al. "Updates to Surgical Treatment of Female Stress Urinary Incontinence (SUI): AUA/SUFU Guideline (2023)." J Urol. 2023;209(6):1091-1098. doi:10.1097/JU.0000000000003435

16. Diokno AC, Newman DK, Low LK, et al. "Effect of Group-Administered Behavioral Treatment on Urinary Incontinence in Older Women: A Randomized Clinical Trial." JAMA Intern Med. 2018;178(10):1333-1341. doi:10.1001/jamainternmed.2018.3766

17. Andrade AD, Anam R, Karanam C, Downey P, Ruiz JG. "An Overactive Bladder Online Self-Management Program With Embedded Avatars: A Randomized Controlled Trial of Efficacy." Urology. 2015;85(3):561-567. doi:10.1016/j.urology.2014.11.017

18. Goode PS, Markland AD, Echt KV, et al. "A Mobile Telehealth Program for Behavioral Treatment of Urinary Incontinence in Women Veterans: Development and Pilot Evaluation of MyHealtheBladder." Neurourol Urodyn. 2020;39(1):432-439. doi:10.1002/nau.24226

19. Fantl JA, Wyman JF, McClish DK, Harkins SW, Elswick RK, Taylor JR, et al. "Efficacy of Bladder Training in Older Women With Urinary Incontinence." JAMA. 1991;265(5):609-613. doi:10.1001/jama.1991.03460050063021

20. Haferkamp A, Frey L, Duwe G, et al. "App-based therapy for female patients with urinary incontinence in Germany (DINKS): a single-blind, randomised, controlled trial." Lancet Digit Health. 2025;7(12):100935. doi:10.1016/j.landig.2025.100935

21. European Association of Urology. EAU Guidelines on Non-neurogenic Female LUTS. 2026. Disease management, section 4.1.4.a.5.