Overactive bladder and/or urinary incontinence are common problems after a brain injury and spinal cord injury.  Approximately 63% of people with a brain injury and 70-84% of people with a spinal cord injury, struggle with one or both of these conditions. 1, 2, 3  Bladder dysfunction can also occur in 11-40% of the general population, due to hormonal changes, urinary tract infections and/or side effects of medication. 4 , 5

Normally, sensors in the bladder wall are designed to send information to the brain indicating how full the bladder is.  This helps the brain decide when it’s time to empty the bladder.  However, after a brain injury or spinal cord injury, these signals between the bladder and the brain can become disrupted.  This is sometimes labelled “neurogenic bladder.”  In a spinal cord injury, damage to the nerves can stop or hinder signalling between the bladder and the brain. In a brain injury, sometimes the nerves are functioning as they should, but the brain is unable to interpret the signals that are being sent.

Regardless of the reason, bladder dysfunction can interfere with sleep, cause people to avoid exercise and socialisation (due to fear of having “accidents” when out) and generally have a negative impact on quality of life.

Symptoms of overactive bladder: (4, 6)

• A sudden, uncontrolled urge to urinate that cannot be ignored.
• Leaking urine after feeling a sudden need to empty the bladder. The involuntary leaking of urine is called “incontinence.”  Overactive bladder can occur with and without incontinence.
• Urinating at least eight times during the day.
• Urinating at least twice during the night.

Case managers can use the Overactive Bladder Assessment Tool to screen clients for this condition.

Ensure that clients see a GP or urologist to get an accurate diagnosis for any type of bladder dysfunction. For example, overactive bladder, stress urinary incontinence, interstitial cystitis and bladder pain are all different conditions that require different forms of treatment.  For more information go to the Urology Care Foundation website.

While clients with overactive bladder and urinary incontinence are often prescribed medication such as solifenacin, oxybutynin, or mirabegron to help manage bladder dysfunction, the symptoms sometimes persist.  In spinal cord injuries, sometimes clients will end up using indwelling or intermittent catheterisation to manage the condition.  In other cases, bladder botox may be recommended.

Top 5 diet and lifestyle tips for reducing overactive bladder & urinary incontinence (5, 7, 8, 9)

There are several dietary and lifestyle triggers which can actually “irritate” (or stimulate) the bladder and/or otherwise worsen overactive bladder and urinary incontinence.  Reducing or avoiding these triggers can help.  The list below outlines the most common advice with the greatest amount of research.  People are affected by dietary and lifestyle factors to varying degrees, so some people may benefit greatly by the suggestions below and others may not experience much benefit. However, considering these are low-cost strategies with no side effects, it’s worth at least trialling the suggestions below to see if they provide any symptom relief.  Keeping a bladder symptom diary before and after making any changes can help to identify what works and what doesn’t.

1. Drink enough fluid (but not too much)

Most clients with bladder dysfunction try to manage symptoms by just drinking less overall.  However, dehydration makes urine more concentrated and acidic which then “irritates” the bladder and can actually make symptoms worse.  Dehydration can also increase the risk of urinary tract infections and constipation, both of which worsen bladder dysfunction.  The trick is to find the balance between enough fluid, but not too much.  An excessive fluid intake will obviously make symptoms worse as well.

Options for setting fluid targets include:

a) consuming a set 1500mL of fluid per 24 hours;

b) calculating 30mL fluid/kg body weight per 24 hours; OR

c) reducing “usual” fluid intake by 25%.

Fluid intake also needs to be carefully timed to avoid waking in the night (e.g. limiting fluid 3-4 hours before bed).

2. Reduce or avoid ingredients known to increase urination and/or increase the frequency and intensity of bladder contractions.

Examples include:

• Caffeine (e.g. in coffee, tea, energy drinks, cola soft drinks & chocolate).
• Artificial sweeteners (specifically acesulfame K, aspartame & saccharin).
• Carbonated soft drinks. These contain ascorbic acid, citric acid, phenylalanine and colourants which all enhance bladder muscle contractions.  The artificial sweeteners in diet soft drinks will have an additional effect (see above).
• Citrus fruit/juice
• Vitamin C supplements

It’s also worth noting that grapefruit juice can interact with certain medications and should be avoided in people taking oxybutynin and solifenacin.10

3. Prevent or manage constipation

Constipation can increase pressure on the bladder and trigger more frequent urination.  Chronic constipation can also result in permanent damage to the nerves of the pelvic region.  Ensuring a sufficient fibre intake (about 30 grams per day) can help reduce constipation.

Be aware that that many of the medications given to manage overactive bladder have a side effect of constipation, so additional fibre may be required to offset this.

In addition, neurological conditions can negatively affect signalling between the brain and the bowel resulting in neurogenic bowel dysfunction and associated constipation.  See our previous article on neurogenic bowel dysfunction for more information on how to manage this problem.

4. Achieve a healthy body weight

Obese people (BMI >30kg/m2) are 2-3x more likely to develop urinary incontinence and are more likely to develop overactive bladder.  This is due to an increase in intra-abdominal pressure leading to chronic stress on the pelvic floor and subsequent neurological dysfunction in this region.

5. Get enough vitamin D

Vitamin D deficiency is linked to a worsening of bladder dysfunction.  Vitamin D levels should be checked with a blood test (target is over 75nmol/L).  If levels are below target, then supplements should be taken to maintain adequate vitamin D levels.  If vitamin D levels are extremely low (under 25nmol/L), then the GP will need to prescribe a high dose vitamin D supplement to correct levels quickly.

Other self-management strategies promoted in the literature that may help: (11, 12, 13)

• Pelvic floor muscle training – with support from a pelvic floor physio if needed.
• Bladder training – this involves having a bathroom schedule and going to the bathroom at the same time each day with progressively increasing intervals.
• Nerve stimulation – examples include sacral nerve stimulation or percutaneous tibial nerve stimulation, which aim to block abnormal signals from the bladder and/or prevent bladder spasms.

Dietitians can help clients make dietary changes to help improve overactive bladder and urinary incontinence (amongst many other conditions).  To refer a case management client for a comprehensive dietetic assessment and report, please contact Specialist Nutrition Rehab at 0121 384 7087 or info@specialistnutritionrehab.co.uk.

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References:

1. Magro, C., Pereira, M. C., Torres, M., Beça, G., & Nunes, R. (2018). Urinary dysfunction in traumatic brain injury survivors–A retrospective study. Annals of Physical and Rehabilitation Medicine. 61, e231.
2. Leslie, S. W., Tadi, P., & Tayyeb, M. (2023). Neurogenic bladder and neurogenic lower urinary tract dysfunction.[Updated 2022 Nov 28]. StatPearls. Treasure Island (FL): StatPearls Publishing.
3. Finazzi Agro, Musco, D’Amico, Matteis, Ipektchi, Parisi A, Rigon, Formisano. Lower urinary tract dysfunction following traumatic brain injury. Abstract. 
4. Urology Care Foundation. Overactive bladder.
5. Wyman, J. F., Burgio, K. L., & Newman, D. K. (2009). Practical aspects of lifestyle modifications and behavioural interventions in the treatment of overactive bladder and urgency urinary incontinence. International journal of clinical practice, 63(8), 1177-1191.
6. Medical News Today. How to manage an overactive bladder after stroke.
7. Gordon, B. (2023). Nutritional considerations for bladder storage conditions in adult females. International journal of environmental research and public health, 20(19), 6879.
8. Robinson, D., Giarenis, I., & Cardozo, L. (2014). You are what you eat: the impact of diet on overactive bladder and lower urinary tract symptoms. Maturitas, 79(1), 8-13.
9. Ernst, M., Gonka, J., Povcher, O., & Kim, J. (2015). Diet modification for overactive bladder: an evidence-based review. Current Bladder Dysfunction Reports, 10(1), 25-30.
10. Paśko, P., Rodacki, T., Domagała-Rodacka, R., & Owczarek, D. (2016). A short review of drug–food interactions of medicines treating overactive bladder syndrome. International journal of clinical pharmacy, 38(6), 1350-1356.
11. Uroweb. Non-neurogenic female LUTS.
12. Sacral nerve stimulation for urge incontinence and urgency-frequency. 2004. NICE guidelines. 
13. Percutaneous posterior tibial nerve stimulation for overactive bladder syndrome. 2010. NICE guidelines.