Retention Control Training

Description of the Strategy

Retention control training (RCT) is a daytime treatment procedure for nocturnal enuresis (i.e., bed-wetting) designed to increase functional bladder capacity (e.g., how much urine an individual can retain before voiding). Often described as an operant procedure, RCT involves encouraging increased fluid intake while reinforcing urine retention for successively longer periods of time. The procedure is based on findings that enuretic children urinate more frequently during the day, demonstrate strong urges to urinate at low bladder pressures, and possess functionally smaller bladder capacities than nonenuretic children. RCT attempts to modify this lack of bladder control by instructing enuretics to systematically refrain from urination under increasing bladder dilation cues.

RCT typically commences following an initial baseline assessment. Common baseline measures employed during this phase include bed-wetting frequency, maximum functional bladder capacity (MBC), and average length of urine retention. Bed-wetting frequency is recorded by having the parent check for nighttime wetting on an hourly or nightly basis. MBC and average length of urine retention are obtained by [Page 1008]instructing parents to use what is known as a waterloading procedure on a daily or weekly basis. This procedure consists of four primary steps. First, the child is sent to the toilet and instructed to urinate, if possible. Upon return, the child is giving a large quantity of fluid to drink (up to 500 ml) and asked to report when the initial urge to void occurs. Following this initial urge, the child is instructed to refrain from voiding until it becomes uncomfortable. At that time, the child is sent to the toilet with a measuring jug or graduated glass beaker. Parents are instructed to record the total time that voiding was postponed (i.e., from the initial urge to void to the indication that the urge to void was uncomfortable) and the amount of urine voided into the jug or beaker. MBC is obtained by dividing the total amount of urine voided by the number of the water-loading procedures conducted, while the average length of urine retention is calculated by averaging the total postponement time.

Following this formal assessment of enuretic behaviors, treatment begins by instructing parents to encourage increased fluid intake and to reinforce urine postponement. Urine retention is typically reinforced through tangible rewards, such as toys and candy, or parental attention, such as praise or games. Using these reinforcers, the child's retention period is gradually shaped by systematically increasing the length of retention necessary for reinforcement. Depending on the child's baseline measures, the retention criteria may start as low as a few minutes, increasing in 1to 5-minute blocks. Maximum retention length is typically determined based on the child's reaction to the treatment (e.g., persistence of enuretic behaviors), with documented retention intervals reaching as high as 45 minutes. In addition to retention, RCT may also incorporate physical exercises aimed at increasing the child's control over actual urine flow. Such exercises typically require the child to practice stop-and-go patterns of urination, during which the child ceases and resumes voiding a number of times.

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