The relationship between cognition and sensation in determining when and where to void: the concept of cognitive voiding

Abstract

Study Type – Aetiology (case series) Level of Evidence 4 What's known on the subject? and What does the study add? The factors taken into consideration when determining when and where to void are poorly understood. Studies on bladder sensations, obtained during cystometry of from voiding diaries, are proving difficult to transfer to everyday experiences. There is therefore a need to explore what does influence when and where to void. This study, using focus groups, highlights the fact that many voids are driven by behavioural factors not by sensations of desire or need to void. It is further noted that a key factor in the final decision to void is an awareness of bladder volume. The concepts of ‘cognitive voiding’ informed by ‘bladder awareness’ are introduced and, if correct, will influence the way studies are devised and interpreted to explore lower urinary tract dysfunction and pharmacotherapy. OBJECTIVE To investigate the inter‐relationship between conscious decision‐making processes and bladder sensation in determining the need, time and place to void SUBJECTS AND METHODS The approach used interview focus groups and qualitative thematic analysis. In this preliminary study, 25 women were included (aged 21–90 years) meeting in groups of one to five on four occasions. RESULTS The thematic analysis yielded six themes: temporal and cognitive maps, risk issues, habituation and opportunistic behaviour and awareness of the bladder. For most voids, the decision to void was not based on sensation but determined by multiple factors: personal knowledge of time of last void, anticipated time to next void, proximity of toilets, a risk assessment or habituated behaviour. As the bladder filled the subjects described an increasing awareness of their bladder. Such sensations were not immediately associated with desire to void. Rather, these sensations were described as influencing the cognitive processes of considering when and where to void. A sub‐group of subjects reported little awareness as their bladder filled, experiencing only sudden strong sensations that needed immediate action for fear of leakage. CONCLUSIONS The decision to void is primarily a cognitive process influenced by multiple elements of which bladder awareness is only one. Mechanisms generating awareness may be intensified or lost reflecting possible different pathological states. The importance of these observations in relation to current views of normal and abnormal voiding is discussed.

The concept of peripheral modulation of bladder sensation

“…This afferent outflow does not appear to be part of the autonomic reflexes involved in the control of the coordination of micturition (Barrington’s reflexes). For reasons that will be argued below, it is possible that this system is a reasonable candidate to contribute to the sensations of “awareness” as the bladder fills 4 , 6 . It is also a candidate for modulation.…”

“…These sensations alone do not trigger a reflex void. Rather the information appears to be used in a complex decision making process 4 . The sensation of bladder “awareness” during filling has been shown to increase progressively as the bladder is filled at a constant rate 5 , 6 .…”

Influence of cognitive rehabilitation on pelvic floor muscle contraction: A randomized controlled trial

“…Urinary continence results from a complex mechanism which involves PFM contraction but also cognitive integration. Harvey et al developed the concept of cognitive voiding. They showed that urinary continence is under the influence of many key factors including conscious (temporal map, voiding behavior, habituation…) and unconscious orders (bladder filling, urinary continence sympathetic reflex…).…”

Assessing multiple dimensions of urgency sensation: The University of South Australia Urinary Sensation Assessment (USA2)

“…Participants in the current study were requested to rate their average sensation over a month. In daily life, it is likely that people choose to void for a variety of reasons, with different bladder volumes and levels of sensation . It is possible that if “tingling” is associated with a full bladder, it may be rarely experienced in a day‐to‐day context.…”