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Page 1
Literature Review
Interventions for Overactive Bladder: Review
of Pelvic Floor Muscle Training and Urgency
Control Strategies
Rebecca  Reisch ,  PT, DPT, PhD
ABSTRACT
Background:  Overactive bladder (OAB) is a common condition
with a negative impact on quality of life. Physical therapists utilize
multiple treatments for OAB, including behavioral training such
as pelvic foor muscle training and urgency control strategies.
Objectives: The purposes of this narrative literature review
were to describe the rationale and theory for behavioral
training techniques for OAB, review published evidence for
these techniques, and discuss additional questions pro
voked by the review as well as future research directions.
Study Design:  Narrative literature review.
Methods: A 2018 review of PubMed, CINAHL, the
Cochrane database, and the Trip database yielded 12
articles appropriate for evidence analysis.
Review of Literature: Pelvic foor muscle training for OAB has
been studied by multiple authors. Most outcomes are favor
able, but there is inadequate evidence to support any specifc
training protocol. Similarly, modalities to aid pelvic foor muscle
training and/or reduce urinary urgency generally have positive
results but published studies are diffcult to compare and
ideal treatment parameters are unclear. Cognitive strategies
as a component of treatment for OAB, while commonly used
clinically, are understudied at this time. Overall, while there is
evidence to support behavioral training, the currently available
literature on this subject leaves many unanswered questions.
Conclusion: Behavioral treatment for OAB is well sup
ported by solid theoretical rationales, but evidence for the
treatment is equivocal and leaves practitioners with many
unanswered questions. Studies on the details of behavioral
therapy for OAB are strongly needed.
Key Words: overactive bladder, pelvic foor muscle train
ing,  physical therapy
INTRODUCTION
Overactive bladder (OAB) is a common condition
that negatively impacts health-related quality of life
Pacifc University School of Physical Therapy and Athletic
Training, Hillsboro, Oregon .
The author is an associate editor for the Journal of
Women's Health Physical Therapy.
The author declares no conficts of interest .
 Corresponding Author : Rebecca Reisch, PT, DPT, PhD, 222
SE 8th Ave., Hillsboro, OR 97123 (reischra@pacifcu.edu ).
 DOI: 10.1097/JWH.0000000000000148
(HRQoL). It is a clinical diagnosis of exclusion,
defned as urinary urgency, usually accompanied by
frequency and nocturia with or without urgency
urinary incontinence (UUI), in the absence of uri
nary tract infection or other obvious pathology. 1
The prevalence of OAB varies widely depending on
the sample studied and how a diagnosis is made but
has been reported between 20% and 40% in young
women (younger than 40 years)2,3 and increases with
age.4,5 Overactive bladder has a substantial impact on
HRQoL, with social, professional, recreational, health
(eg, sleeping, exercising), and sexual activities all
negatively impacted.2,3,6,7 In addition, OAB, especially
OAB with UUI, presents a signifcant economic bur
den, with direct costs for OAB with UUI in the United
States estimated to reach $82.6 billion in 2020,5 and
is associated with increased risk of urinary tract infec
tion, falls, and fractures. 8 Approximately one-third of
patients with OAB have UUI.9 Urgency urinary incon
tinence is also termed OAB-wet, while OAB without
UUI is called OAB-dry. 1
While the mechanisms underlying OAB remain
unclear, 10 several interventions for OAB have been
explored. Pharmacologic treatments such as anticho
linergic therapy (eg, Detrol, Ditropan), botulinum
toxin (Botox), and mirabegron (Myrbetric) are suc
cessful for treating OAB symptoms in many patients
but have a high rate of negative side effects.11-13 For
example, anticholinergic medications reduce urgency
but also cause dry mouth, constipation, and nausea.10
Behavioral interventions are the frst-line nonphar
macologic approach for treating OAB.14-16 These
interventions can be divided into 2 general categories:
(a) behavioral training, which emphasizes pelvic foor
muscle training (PFMT) to improve bladder control, as
well as techniques to suppress urgency, and ( b ) bladder
training (BT) and lifestyle modifcations, such as fol
lowing a voiding schedule, modifying fuid intake, and
weight loss.17 These approaches require a high level of
patient motivation and encouragement, but the clear
advantages are the absence of adverse drug reactions
and the potential for long-term beneft. 10,15,18
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Literature Review

Physical therapists specialized in women's health
or pelvic foor physical therapy regularly treat
patients with OAB using behavioral training strate
gies. Anecdotally, success rates with PT are high, and
the medical literature indicates that regular treatment
supervised by a health care professional produces
better outcomes for urinary issues than unsupervised
techniques.19 Given that the most effective interven
tions are those tailored to the unique needs of indi
vidual patients,15 physical therapists are ideally posi
tioned within the health care system for delivering
interventions for OAB. The purposes of this narrative
literature review were to (a) describe the rationale and
theory for behavioral training techniques utilized by
physical therapists for treating OAB, (b) review pub
lished evidence for these techniques, and (c) discuss
additional questions provoked by the review as well
as future research directions. The focus of the review
is on PFMT, modalities to assist with PFMT, and
cognitive techniques to address urgency; details of
BT and lifestyle modifcations such as diet and fuid
intake are extensively described elsewhere.13,16,17,20
 METHODS
A review of PubMed, CINAHL, the Cochrane
database, and the Trip database was completed in
August and September, 2018, using the following
search terms alone and in various combinations
to identify articles on PFMT, modalities to assist
with PFMT, and cognitive techniques to address
urgency: OAB, physical therapy, physiotherapy,
behavioral therapy, behavioral interventions, pelvic
foor muscle exercise, PFMT, vaginal cones, vaginal
weights, surface electromyography, and electrical
stimulation. Studies were chosen for inclusion in
the evidence components of this article if they were
randomized controlled trials (RCTs) or systematic
reviews (SRs) published in English since 2002; 1
description of a protocol for a future RCT and 1
long-term follow-up of a previously published RCT
were also deemed appropriate for evidence analy
sis based on their relevance to the topics. Studies
performed on women with neurological disorders
such as multiple sclerosis were excluded. The search
produced 3 SRs and 7 RCTs deemed appropriate
for analysis as well as the long-term follow-up study
and protocol of a previously published RCT men
tioned earlier. All article reviews were performed by
the author.
 REVIEW OF LITERATURE
Pelvic Floor Muscle Training
Urinary urgency, a sudden, compelling desire to
void that is diffcult to defer, 1 is the dominant
feature of OAB and is what produces the other
OAB symptoms of urinary frequency, nocturia, and
UUI.21 Urgency is a multidimensional sensation that
is different than the normal desire to void, as people
with OAB perceive the sensation of desire to void as
more sudden, intense, and unpleasant than people
without OAB.22 Given that urgency is the key fea
ture of OAB, training the pelvic foor muscles to (1)
contract and strongly hold in order to occlude or
compress the urethra, thereby preventing urgency
UI, and (2) contract quickly and in a coordinated
fashion to help inhibit urgency-producing blad
der (detrusor) contractions can be considered the
cornerstone of physical therapy for OAB. Strong
sustained urethral compression works to prevent
urine loss via physical block, while quick contrac
tions work to refexively inhibit detrusor contrac
tion and prevent internal sphincter relaxation . 23,24
Quick contractions for controlling urinary urgency,
clinically referred to as "quick ficks," frst appeared
in the medical literature as a treatment strategy in
the 1980s.25
Pelvic foor muscle training as a treatment for
OAB or its components has been explored both in
RCTs and SRs, which are summarized here and in
the Table . Kaya et al 26 compared 6 weeks of high-
intensity PFMT (initially 100 contractions per day,
increasing to 600 contractions per day in fnal week)
plus BT, with BT alone for women with UUI. Their
results indicated that PFMT + BT was superior to BT
alone for improved quality of life but did not result
in a statistically signifcant improvement in inconti
nence severity, HRQoL, or bladder diary parameters
compared with BT alone. However, the authors noted
that their analysis may have been underpowered due
to small sample size. Kafri et al27 compared drug
therapy, BT, PFMT, and a combination treatment
consisting of BT, PFMT, and behavioral advice in
165 women with UUI. The PFMT intervention con
sisted of 3 sets of 8 to 12 slow maximum contrac
tions of 6 to 8 seconds of duration, performed in a
variety of positions over 3 months. Results showed
all 4 groups showing statistically signifcant improve
ments in voids per 24 hours, UUI episodes per week,
dry rates, and HRQoL over the 3-month treatment
and maintained at 1 year, but there was no difference
between groups. However, the combination treatment
group that received the intervention most like what
patients with OAB would often receive in physical
therapy was the only one to show a clinically impor
tant reduction in number of voids per 24 hours.28
The same research group performed a 4-year follow
up (n = 120) and found that all groups still were
statistically signifcantly improved compared with
baseline for all outcome measures and that there were
no statistically signifcant differences between groups;
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Literature Review

Table.  Summary of Studies
Authors
Program Details
Results and Comments
Pelvic foor muscle training
Kaya et al26
P: 16 women with UUI
I: 6-wk program of high-intensity (up to 600 reps/day ) PFMT
+ BT
C: BT without PFMT
O: Self-reported improvement, UI severity, bladder diary
measures (voids/d, episodes of UI, etc), UDI-6, IIQ-7,
pelvic foor strength and endurance
Improved IIQ scores in PFMT + BT group compared with
BT (P = .045); no statistically signifcant between-group
differences in other parameters
No long-term follow-up
Did not include participants with OAB-dry
Possibly statistically underpowered to show differences in
other parameters
Kafri et al27
P: 165 women with UUI
I: 3-mo daily PFMT program, 3 sets of eight to twelve 6- to
8-s contractions
C: Drug therapy, bladder training, or combination
O: Bladder diary measures, I-QOL, several other QOL measures
No statistically signifcant difference between groups on any
parameters
Combination group had clinically important reduction in
frequency
Did not include participants with OAB-dry
Azuri et al9
4-y follow-up of 120 women from the study by Kafri et al27
Groups that included PFMT had higher but nonsignifcant
self-reported "dry" rates than non-PFMT groups (40.67%
vs 28.8%, P = .616)
Bo et al29
8-study systematic review on PFMT vs controls for OAB
symptoms in women; addressed all components of OAB
(frequency, urgency, nocturia, UUI), PFMT duration and
intensity varied among studies
Some evidence that PFMT reduces OAB symptoms, but
authors noted high variability among interventions, con
flicting results, and a need for high-quality RCTs on the
topic
Olivera et al13
Large systematic review on all nonmuscarinic treatments for
OAB; included 4 studies on PFMT for OAB symptoms,
PFMT duration and intensity varied among studies
PFMT recommended for subjective improvement of OAB
symptoms
Authors noted low methodological quality of some studies
Greer et al30
Systematic review on multiple physical therapy interventions
for UUI; included 4 studies on PFMT, PFMT duration and
intensity varied among studies
PFMT improved UUI symptoms but was not superior to
inactive control or other physical therapy techniques
Overall quality of studies deemed moderate (PEDro scores:
4-7/10)
Did not include studies on OAB-dry
Modalities
Yuce et al33
P: 39 women with OAB
I: 8-wk program of twice-daily 10-min sessions of ADLs with
weighted vaginal cone; weight progressed when able to
retain for > 10 min
C: tolterodine, 4 mg daily
O: bladder diary measures, 24-h pad test, UDI-6, IIQ-7
Frequency, nocturia, UUI, and QoL improved in both groups,
with no statistically signifcant difference between groups
Data on adverse events not reported
Voorham et al 34
P: 58 women with OAB
I: 9-wk program of EMG biofeedback-assisted PFMT +
toilet behavior, urgency suppression strategies, and life
style instruction
C: Toilet behavior and lifestyle instruction
O: Bladder diary, PeLFIs, KHQ, 24-h pad test, EMG
measurements
11 participants initially could not perform correct contraction
and so were given 1 session of electrical stimulation
EMG biofeedback group had statistically signifcant improve
ment in QOL, number of participants completely dry, and
pad test results compared with lifestyle group
Urinary frequency, urgency, and nocturia not specifcally
assessed
Wang et al 35
P: 103 women with OAB
I: 12-wk program; participants divided into 3 intervention
groups-PFMT with EMG biofeedback, electrical stimulation,
and PFMT with no modalities. Intensity of intervention based
on participant's initial strength; home program also given
O: KHQ, patient perception of improvement, bladder diary,
1-h pad test, PFM strength
No statistically signifcant differences among groups for
urgency (P = .172), frequency (P = .214), or nocturia
(P = .056), but all groups showed improvement
Subjective rating of "cured" or "improved" equal among
groups after treatment
Arruda et al36
P: 64 women with urodynamically diagnosed DO
I: 12-wk program; participants divided into 3 intervention
groups-electrical stimulation biweekly with a physical
therapist, oxybutynin 5 mg twice/d, or PFMT biweekly with
a physical therapist + home program
O: urgency, UUI, urodynamic evaluation
All treatments reduced UUI and urgency, no statistically sig
nifcant difference among groups
72% of participants in oxybutynin group reported at least 1
negative side effect; 0% in other groups had negative side
effects
Narrow participant pool (limited to women with DO) limits
applicability of results
(continues)
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Literature Review

Table.  Summary of Studies (Continued)
Greer et al30
Systematic review on multiple physical therapy interven
tions for UUI; included 3 studies on EMG biofeedback
and 5 studies on electrical stimulation (1 study on WVC
was included but participants primarily had stress urinary
incontinence)
EMG results: (1) No pooled analysis possible due to signif
cant variability in outcome measures and follow-up time
periods. (2) Reduction in UUI shown in all studies; not
able to address frequency or nocturia. (3) PEDro scores:
5-6/10
Electrical stimulation results: (1) All studies reported reduc
tion in UUI. (2) PEDro scores: 5-6/10
No inclusion of studies on participants with OAB-dry
Authors
Description of Cognitive Technique
Comments
Cognitive techniques
Kaya et al26
Mental imagery and motivational statements such as "I can
wait"; mental distractions such as performing mathemati
cal calculations
Emphasis on distraction from bladder sensation, not
mindfulness
Voorham et al 34
As part of an urgency suppression strategy, participants were
asked to relax at the onset of urgency
Unclear what was included in instructions to relax, as
authors used the term "relax" in relation to decreasing
activity in the pelvic foor muscles  and as a cognitive tech
nique for urgency suppression
Newman et al38
Participants instructed to distract themselves with a non
physical tasks such as playing a computer game, reciting
a poem, or working on a puzzle, as well as to use self-
affrming statements such as "I am in control" or "I can
wait"
Emphasis on distraction from bladder sensation, not mind
fulness
Described as part of a protocol for an upcoming study
(results not yet published)
Baker et al43
8-wk traditional protocol of MBSR, including meditation,
nonjudgmental nonreactive awareness, mindful yoga, and
education on the interrelatedness of stress and health
Small pilot study (n = 7) on women with UUI
No specifc education on urgency suppression techniques or
any other aspect of bladder control
Baker et al44
8-wk traditional protocol of MBSR, including meditation,
nonjudgmental nonreactive awareness, mindful yoga, and
education on the interrelatedness of stress and health
n = 30 study comparing MBSR with yoga for UUI
No specifc education on urgency suppression techniques or
any other aspect of bladder control
Abbreviations: ADLs, activities of daily living; BT, bladder training; C, comparison; DO, detrusor overactivity; EMG, electromyography; I, interven
tion; I-QOL: Incontinence Quality of Life; IIQ-7, Incontinence Impact Questionnaire; KHQ, King's Health Questionnaire; MBSR, mindfulness-based
stress reduction; O, outcome; OAB, overactive bladder; P, population; PEDro, Physiotherapy Evidence Database; PeLFIs, Pelvic Floor Inventories;
PFM, pelvic floor muscle; PFMT, pelvic floor muscle training; QOL, quality of life; RCTs, randomized controlled trials; reps/day, repetitions per
day; UDI-6, Urogenital Distress Inventory; UI, urinary incontinence; UUI, urgency urinary incontinence; WVC, weighted vaginal cones.
however, participants in the 2 groups that included
PFMT had a higher dry rate than those in the groups
that did not include PFMT. 9
Several SRs have addressed PFMT for OAB. Bo
et al29 analyzed 8 RCTs and concluded that PFMT
might reduce OAB symptoms compared with control
interventions, but that the effect of PFMT on OAB
symptoms could not clearly be determined. Four
of the 8 studies showed a reduction in symptoms
with PFMT, and the other 4 showed no effect. The
duration of PFMT interventions and the number of
contractions performed were highly variable among
the studies. The authors did not report whether any
of the study outcomes reached clinical importance.
In addition, 5 of the 8 studies were on women with
UUI; women with non-UUI OAB symptoms were
not included. An SR by Olivera et al13 on nonphar
maceutical interventions for OAB included 4 studies
on OAB and recommended pelvic foor exercise for
patients with OAB but noted that most of the stud
ies had signifcant methodological problems. Also,
many of the participants in the studies reviewed had
urinary complaints other than OAB, making it dif
fcult to clearly apply to conclusions of the review to
women with OAB. 13 Greer et al 30 reviewed PFMT for
the treatment of UUI as part of a larger SR and con
cluded, based on 4 studies of moderate quality, that
PFMT was not better than inactive controls for UUI
reduction. The authors of the SR assessed episodes of
UUI, urinary frequency, and nocturia; OAB-dry was
absent from their analysis.
Regarding the specifcs of what type of PFMT
program is best for women with OAB, the variety
of approaches described in the literature highlights
that there is not adequate evidence to support any
particular protocol. This is consistent with the ambi
guity surrounding ideal PFMT programs for urinary
complaints reported elsewhere. 19,31 The literature
supports supervised treatment, with at least 2 sessions
per month recommended for urinary incontinence,19
and the treatment should be delivered in the most
intensively clinician-supervised program possible, as
this generates better outcomes than programs with
less supervision.32 Therefore, while the theoretical
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Literature Review

rationale for PFMT for OAB is strong and there is
some evidence to support its use, clearly there is a
need for studies examining the ideal PFMT program
for women with OAB to help guide clinicians in treat
ing this population.
Modalities to Assist PFMT and/or Control Urgency
There is some evidence for using physical therapy
modalities, including weighted vaginal cones (WVC),
electromyographic (EMG) biofeedback, and electrical
stimulation for either aiding PFMT during treatment
of OAB or helping to control urgency. Regarding
WVC, Yuce et al33 compared tolterodine with PFMT
with WVC in 39 women. Women in the WVC group
exercised with the cones daily for 8 weeks. Both
groups had statistically signifcant improvements on
all outcome measures, but there was no difference
between the groups. Interestingly, all of the women
in the WVC group were able to hold the cones with
out them falling out at the initial evaluation, and all
progressed to the heaviest weight (68 g) by the end of
the intervention, indicating that this sample may have
had better pelvic foor muscle strength and coordina
tion than many women seeking care for pelvic foor
muscle dysfunction.
Voorham et al34 compared EMG biofeedback-
assisted PFMT with lifestyle instructions in women
(n = 58) with OAB during a 9-week RCT. Women
in the biofeedback group received physical therapist-
supervised 30-minute sessions that included perfor
mance of 10 maximum contractions and 3 endurance
contractions while receiving visual feedback of the
EMG signal. Participants were taught urgency sup
pression strategies and performed a home exercise
program, which was not described in detail. Correct
performance of a pelvic foor muscle contraction was
a prerequisite for treatment; women unable to ini
tially perform a contraction were treated with electri
cal stimulation for 1 or 2 sessions. At the end of the
intervention, the EMG biofeedback group had statis
tically signifcantly better outcomes for quality of life,
urinary incontinence episodes, and EMG output than
the lifestyle instructions group.
Wang et al 35 compared individualized PFMT, indi
vidualized PFMT with EMG biofeedback, and bipha
sic varying intensity electrical stimulation for women
with OAB. While there were statistically signifcant
benefts for QOL improvements for PFMT with
biofeedback compared with individualized PFMT, as
well as for electrical stimulation compared with indi
vidualized PFMT, the subjective improvement/cure
rates were the same. In addition, information on par
ticipants' ability to correctly contract the pelvic foor
musculature before initiating the interventions was
not presented; therefore, it is possible that differences
in outcomes indicating a beneft from electrical
stimulation may have been due to baseline differences
between groups.
Arruda et al36 compared oxybutynin, electrical
stimulation, and stand-alone pelvic foor muscle
exercise for women with urodynamically diagnosed
detrusor overactivity. Participants' ability to perform
a correct pelvic foor muscle contraction was assessed
by digital examination before starting the interven
tions. They found that all 3 treatments reduced
symptoms of urgency and UUI, with no statistically
signifcant difference between groups.
Finally, the SR by Greer et al 30 described previ
ously reported on several studies on the effects of
electrical stimulation or surface EMG for women
with UUI. Most of these studies reported a reduc
tion in UUI following treatment with the modali
ties, but study heterogeneity prevented pooling of
data or strong conclusions regarding the results.
Study quality was moderate, and other components
of OAB such as frequency and nocturia were not
addressed.
Results from these studies, further detailed in the
Table , indicate that treatment including modalities
may be helpful, but they provide little insight into the
specifc treatment parameters best suited for women
with OAB. The study participants and results are dif
fcult to compare, given diverse baseline characteris
tics and outcome measures. In addition, the electrodes
themselves present a variable for biofeedback and
electrical stimulation. Conventional vaginal probes
with large electrodes may contact multiple muscles
at once, whereas newer probes may have the ability
to both stimulate and register EMG activity from
individual muscles.34 Therefore, determining whether
stimulating individual muscles is truly feasible or ben
efcial, as well as identifying ideal treatment param
eters when using modalities, requires further study.
 Cognitive Techniques
Cognitive techniques to help a patient change atti
tudes, beliefs, and thought patterns about his or her
health or condition are used as a component of many
physical therapy interventions.37 Specifc to OAB,
cognitive distraction, that is, thinking of things other
than the bladder or the urgency sensation, has long
been emphasized as a strategy for controlling urinary
urgency15 and has been utilized as a component of
interventions for OAB in several studies.26,34,38,39
Strategies for distraction described in the literature
include performing mental mathematical calcula
tions, doing a puzzle, or making a to-do list.26,38,39
As part of distraction, patients often are instructed
to focus on staying still and avoiding rushing to
the bathroom when experiencing urinary urgency,
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Literature Review

as increased intra-abdominal pressure is thought to
15
worsen urgency.
Interestingly, the focus on distraction may be
misdirected, as recent evidence suggests that dis
traction techniques may lengthen reaction times for
involuntary sphincter contraction and impair the
ability to effectively contract pelvic foor muscles and
hence cause 2 commonly coprescribed strategies to
be contradictory. 40,41 Recently, a focus on mindful
ness has been proposed as an alternative to distrac
tion for urgency control. Mindfulness-based stress
reduction (MBSR), a technique developed in 1979
by Jon Kabat-Zinn, is an intervention focused on
mindfulness techniques. The emphasis is on nonjudg
mental awareness, responding rather than reacting,
and paying attention moment to moment.42 It is a
structured group intervention, typically delivered in
a class-based format of 8 weekly 2-hour sessions,
with in-class instruction augmented by regular home
practice.42
Mindfulness-based stress reduction has been used
as an intervention for urinary complaints in at least 2
studies. Baker et al43 performed a pilot study (n = 7)
to evaluate the feasibility of using MBSR as a treat
ment for UUI. Mean urinary incontinence episodes
per day decreased from 4.14 to 1.23, 5 of 7 improved
on the Patient Global Impression of Improvement,
and HRQoL improvements were noted.43 In a larger
follow-up study, MBSR was deemed superior to a
yoga intervention for decreasing symptoms of UUI.44
Further information on the cognitive techniques
reported by the above authors is given in the Table .
While the studies on MBSR are promising, the
authors utilized the mindfulness techniques on women
with UUI; they did not address the other components
of OAB (frequency, urgency, nocturia, etc). Also, they
did not include any pelvic foor training techniques.
Cognitive techniques, while common in clinical prac
tice, have not been regularly included in intervention
studies for OAB, and it is not known at this point
what specifc types of techniques are most helpful.
Distraction strategies are a mainstay of physical
therapy treatment for urinary urgency, but theoretical
support for this strategy is lacking. This represents a
signifcant gap in the current knowledge base regard
ing best practice for treating OAB. Evaluation of the
effectiveness of different cognitive techniques is yet
another area for future research.
 DISCUSSION
This review describes the theoretical rationales behind
PFMT, modalities, and cognitive techniques for OAB
and provides a concise summary of the current evi
dence regarding these interventions. The long-held
theories regarding how and why these techniques
work are well founded in anatomy, physiology, and
neuroscience, but as this review shows, the evidence
for the treatment strategies is equivocal, with some
results indicating a treatment beneft, others indicat
ing no beneft, and many studies neglect to address
all aspects of OAB, a weakness not clearly identifed
in previous SRs.13,18,20,24 Also, the understanding of
urgency itself, the key component of OAB, is evolving
rapidly, which may lead to novel ways to approach
this key symptom. New evidence and ideas may chal
lenge the use of long-standing treatment approaches
to OAB.
The most compelling result of this review is that
current evidence leaves so many unanswered ques
tions, such as the following: What PFMT training
program is most effective for women with OAB?
Does it differ for women with OAB with UUI versus
OAB without UUI? Is distraction the best cognitive
approach to controlling urgency, or would patients
have better results by de-emphasizing distraction
and instead focusing on mindful awareness of blad
der sensation? When are additional modalities such
as electrical stimulation warranted, if at all? Strong
studies examining these questions are needed to guide
physical therapy intervention.
While there are multiple SRs on different types of
treatment for OAB, reviews on the specifc compo
nents of behavioral therapy for OAB are just begin
ning to emerge.29 This review summarizes the current
evidence on PFMT, modalities, and the cognitive
components of physical therapy for OAB, and high
lights that more research is warranted regarding these
therapies. In addition, it is imperative that future
studies address all components of OAB, not just UUI.
More quality primary studies will allow for stronger
SRs and, eventually, meta-analyses.
It is worth mentioning that, in addition to the
treatments reviewed in this article, various medi
cal options exist for the treatment of OAB, includ
ing anticholinergics,  -3 adrenoreceptor agonists,
botulinum toxin injections, sacral neuromodulation,
and posterior nerve stimulation.13,16,20 While these
are out of the scope of physical therapy practice, a
general awareness of these interventions is useful
for physical therapists to facilitate discussions with
referring providers and patients. Along these lines,
there are recommendations in the medical literature
for decreasing fuid intake prior to bedtime, reducing
caffeine, alcohol, and carbonated beverage consump
tion, and losing weight to reduce OAB symptoms. As
with the evidence reported in this article, evidence for
these recommendations is equivocal.17 Readers may
refer to other references for further information on
these treatment options.13,16,17,20
24
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Literature Review

19. Dumoulin C , Hay-Smith J .  Pelvic floor muscle training versus no treatment,
CONCLUSION
or inactive control treatments, for urinary incontinence in women .  Cochrane
Physical therapists are ideal practitioners to provide
behavioral therapy to women with OAB. While
behavioral treatment for OAB is commonly used
in clinical practice and is well-supported by solid
theoretical rationales, evidence for the techniques
is equivocal and leaves practitioners with many
unanswered questions. In addition, the typical focus
on distraction as a component of urgency control
deserved to be more closely examined and compared
with alternative approaches such as mindful aware
ness. Studies on the details of behavioral therapy for
OAB, including all possible components of OAB and
not just UUI, are strongly needed.
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