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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 diffi cult to transfer to everyday experiences. There is therefore a need to explore what does infl uence 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 fi nal decision to void is an awareness of bladder volume. The concepts of ‘ cognitive voiding ’ informed by ‘ bladder awareness ’ are introduced and, if correct, will infl uence 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 fi ve 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 fi lled 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 infl uencing the cognitive processes of considering when and where to void. • A sub-group of subjects reported little awareness as their bladder fi lled, experiencing only sudden strong sensations that needed immediate action for fear of leakage.

CONCLUSIONS

• The decision to void is primarily a cognitive process infl uenced by multiple elements of which bladder awareness is only one. • Mechanisms generating awareness may be intensifi ed or lost refl ecting possible different pathological states. The importance of these observations in relation to current views of normal and abnormal voiding is discussed.

KEYWORDS

voiding pattern , bladder awareness , cognitive voiding , sensation

Study Type – Aetiology (case series) Level of Evidence 4

The relationship between cognition and sensation in determining when and where to void: the concept of cognitive voiding Joan Harvey , Steven Finney * , Laurence Stewart † and James Gillespie ‡ School of Psychology, Newcastle University, Newcastle upon Tyne , * Urology Department, Blackpool Victoria Hospital, Blackpool , † Department of Urology, Western General Hospital, Edinburgh , and ‡ Urophysiology Research Group, The Medical and Dental School, Newcastle University, Newcastle upon Tyne, UK

INTRODUCTION

The decision to void involves considerations of time and place followed by activation of the voiding refl exes. Normally, little thought is given to these processes, but, for some, this is not the case. These individuals report an increased voiding

frequency and intense sensations that need immediate action to avoid leakage: the overactive bladder symptom complex (OABSC) [ 1 ] .

Investigations into the origin of the OABSC are now focusing on the mechanisms underlying sensation. Many studies have

attempted to measure sensation using simple numerical scoring systems during cystometric investigation [ 2,3 ] or as part of a voiding diary [ 4 – 7 ] . Such scoring schemes are widely used and form the basis of many investigations and clinical trials. However, the basic concepts underpinning this approach have recently been criticised [ 8 ] . It

Accepted for publication 20 December 2011

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was argued that the methodology may not be appropriate, causing a degree of bias that refl ects more the expectation of the observer than the true experiences of the subject [ 8 ] .

The present study is an attempt to circumvent these problems. The objectives of this preliminary investigation were: to identify, directly from asymptomatic subjects, the key factors when deciding to ‘ go to the toilet ’ and to identify the importance of bladder sensation in this decision-making process.

SUBJECTS AND METHODS

The study used iterative focus group discussions involving a small random sample of the females with informed consent. None reported any underlying urinary problem. As exploration into perceived sensation is intrusive, the interview focus group method was used to circumnavigate the potential problems of imposing concepts and language. A semi-structured questioning technique was used to minimise interviewer

bias with the greatest opportunity for participants to generate ideas freely and in their own words. The focus group interviews comprised of: introduction, discussions on ‘ going to the toilet ’ , frequencies/timings, perceived sensation related to the bladder, rationale for going to the toilet, relevance of place and time of day, role of fl uid intake, apparent ‘ suppression ’ of sensation inter alia . Once ideas were formulated, basic urological terms and defi nitions, e.g. ‘ voiding ’ were introduced. Focus group information was recorded and used for thematic analysis.

In all, 25 women took part: mean (range) 60 (21 – 90) years. The sample was chosen opportunistically aiming to have a broad socio-economic background. Participants met in groups of one to fi ve on up to four separate occasions. Each session lasted for 40 – 60 min and was held in an neutral, non-clinical/laboratory, environment. In the fi rst two sessions, subjects were asked about voiding frequency, voiding considerations and associated sensation. From the responses, a thematic analysis was carried

out and key common factors identifi ed. At subsequent sessions, groups were presented with the key elements of the thematic analysis and asked to discuss, confi rm and develop emerging concepts. It was as a consequence of these discussions that enabled a distillation and focus to be made on the major themes in relation to voiding behaviour. The acceptance and refi nement of these areas were the topics of subsequent sessions. It was clear from the outset that an association existed between bladder volume and/or time from last void and bladder sensation. From this, the concept of a volume/time – sensation curve was introduced and its validity discussed.

RESULTS

Based on transcripts from the initial focus group sessions several issues relating to voiding behaviour were noted ( Table 1 ). Thematic analysis yielded six major themes relating to voiding behaviour: temporal and cognitive maps, risk issues, habituation, opportunistic behaviour and bladder awareness .

TABLE 1 Summary of the topics arising from the initial focus-group sessions. Column 1 indicates initial subsets that identifi ed some initial common themes. Column 2 describes and categorises the different points and factors identifi ed in relation to the thought processes when subjects considered the time and place of voiding. From these descriptions and categorisations the thematic analysis was constructed (see results). Column 3 summarises the comments made in relation to sensations noted or experienced by subjects who were voiding in response to the other considerations. Column 4 shows the collected and paraphrased comments of the subjects in relation to their ability to control the time of voiding and its implications for their general life considerations

1 Themes 2 Voiding behaviour 3 Sensation 4 Implications1.1 Precise times for voiding: e.g. before going out, before

the start of an eventNone or very little Temporal and cognitive maps, retain

control1.2 Opportunistic voiding: geographical: e.g. nice toilet

conveniently situated geographicallyNone or little Defers later stronger urge

1.3 Opportunistic voiding: temporal nice toilet, well placed temporally

None or little Defers later stronger urge

2.1 Opportunistic but aware of bladder, convenient local: e.g. already going to vicinity of toilet

Some, middling Defers later urge

2.2 Opportunistic but aware of bladder, planned: e.g. plan to go during intermission

Some, ‘ controllable ’ Retains control of situation

3.1 Strong sensation, predictable: e.g. 2 h after drinking and watching television, toilet near

Strong Will tolerate intensity longer

3.2 Strong sensation predictable, toilet not known Strong, exacerbated by worry Stress can increase perceived intensity3.3 Sudden strong sensation unpredictable when it will

occurStrong and intense, requires

rapid responseUrge incontinence

4.1 Strong sensation and potential leak worry, sudden onset Strong to painful Urge incontinence – learn to manage4.2 Strong sensation and potential leak worry, slow onset:

e.g. lying in bedStrong, slowly becoming painful Can tolerate extreme intensity

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From the initial focus group discussions it was clear that subjects had diffi culty describing sensations associated with the bladder. However, ‘ fullness of their bladder ’ was a common theme, but such feelings were indistinct and diffi cult to describe. On introspection most described changes with time. Initially, after a void, there was little or no sensation. This was followed by a period of increasing ‘ awareness ’ that eventually developed into a strong, dominant and persistent sensation. Several subjects described these strong sensations as unchanging. If they did not void then the strong sensations became painful. Over a wide range of intensities, the sensations were described in terms of a progressively intensifying ‘ awareness ’ . In this range, no subjects related sensations to ‘ a

desire to void ’ . Awareness was used primarily to inform decision making about voiding. It was only with strong sensations did subjects agree that these could be described as the defi nite ‘ need to go ’ to the toilet.

Thematic analyses of these sessions were used to construct a graphical representation of changing awareness and distil the language used.

Figure 1A , shows a graphical representation of the pattern of awareness. This analysis was then presented to the subjects during the next focus group session. Most subjects (17/25) agreed with the general form of an ‘ awareness curve ’ . However, some (4/25) disagreed suggesting that the period of ‘ no sensation ’ was short or absent

and that progressively increasing and signifi cant sensations were there all the time. The remainder (4/25) reported that they had only weak sensations of awareness that increased imperceptibly if they postponed voiding. However, this group described a rapid development of an intense sensation and desire to go to the toilet.

Figure 1A was then re-drawn to incorporate this feedback. In the fi nal focus group session subjects were then asked to choose from one of three broad patterns of awareness as their bladder fi lled (a – c: Fig. 1B ). Each subject had little diffi culty in choosing a curve that they thought fi tted the pattern of their individual developing awareness. The consensus was also that words relating to a progressive increase in awareness were appropriate. Stronger sensations of awareness were accepted as sensations linked to predictions of time to void (sensation that will need action, sensations needing action and sensations needing immediate action). Sensations greater than this were accepted to occur but rarely and described as pain. When the progressive language was incorporated into these fi nal graphical representations all subjects related to the terminology and reported that it was informative in relating their personal experience. It is interesting to note that ‘ urge ’ terminology was not prevalent in the subjects own descriptions.

Once each subject had identifi ed their preferred curve they were asked to mark on their own curve when they thought they would normally void. They were asked to use up to 10 marks representing different voids during several days. The resulting patterns of voiding correlate well with the analysis of the initial focus group sessions, where most voids were reported to occur with little or only moderate sensations of bladder awareness. Some subjects voided at almost any sensation up to and including strong sensations. Those subjects who described little sensation but then sudden strong sensations, voided frequently with little sensation trying to avoid the extreme sensations.

DISCUSSION

Clearly, sensation plays a role in determining when and where to void. Many studies

• Temporal maps, defi ned as voiding behaviour based on a subjects experience and calculation of time, were evident in all participants. Relating to strong anticipatory notions of when the next need to void would be they were based on knowledge of liquids consumed and personal experience. Voiding strategy was also anticipatory in that voiding at one time was used to defer the need to void at some point in the near future. In most cases temporal maps represented a personal strategy for voiding and were usually not informed or infl uenced by bladder sensation.

• Many subjects demonstrated knowledge-based cognitive maps in relation to voiding (a cognitive map representing knowledge of the location of toilets). This was not a feature of subjects at home but was extremely relevant during periods of uncertainty, e.g. when outside the domestic environment. Two aspects were noted: (i) distance and location of toilets, and, (ii) quality-based considerations (e.g. cleanliness). Voids were therefore initiated based on availability, suitability and/or geographical knowledge and typically not on sensation or need.

• Risk issues were of two broad types. Some described a personal security aspect associated with visiting certain toilets. The second issue was that of leakage, although this only occurred if subjects were away from the domestic situation or faced with an inappropriate toilet. For these the decision to void involved a temporal and geographical calculation to determine whether they could defer voiding. If the possibility of leakage persisted then using an inappropriate toilet was the only option and a coping strategy adopted. Under these circumstances more importance was placed on bladder sensations and this information was used to determine an imminent or postponable risk.

• Habituation played a major role in shaping voiding behaviour through the development of behaviours to make voiding predicable and manageable. A common example given by all participants was voiding immediately before an activity; to avoid having to void during the activity and typically were not associated with bladder sensation. Opportunism was common. Voiding was carried out when an opportunity arose, so deferring a possible situation where the need to might be problematic. Participants described this as one strategy to reduce leakage.

• All participants had some appreciation of the fullness of their bladder. Assessment of fullness was an essential component in triggering immediate behaviour or anticipating and calculating an ability to defer voiding. For most voids the decision to void was not based on sensations related to the ‘ need to go ’ . Voiding was often initiated with little sensation.

The background and rationale for the individual themes are outlined below:

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accept that sensation is the primary determinant in triggering voiding. However, the present study and a few others suggest that this is not true [ 10 – 12 ] . It now appears that the decision to void is taken after integrating multiple factors of which sensation is only one.

The present study focuses on a group of women who have no overt urological symptoms and who were not seeing or contemplating seeing a clinician for any lower urinary tract problems. The restriction of the group to women was done simply to facilitate free and open discussion within the sessions on matters often considered personal and diffi cult to discuss. Similar studies are therefore needed within a ‘ normal ’ male population.

Several elements have been identifi ed that infl uence voiding behaviour. Most voids occur as a result of behavioural and social considerations, unrelated to sensations of ‘ need ’ or ‘ desire ’ to void. The sensations are described as awareness rather than ‘ desire ’ or ‘ need ’ . If the bladder is allowed to fi ll to near capacity, only then are sensations heightened and described as ‘ need ’ or ‘ desire ’ . For this reason it may be more appropriate to describe normal voiding behaviour as ‘ cognitive voiding ’ . This implies that a decision to void is triggered as a result of multiple considerations and not driven by sensation alone. A conceptual model describing a possible interrelationship between cognitive processes and sensory inputs is proposed in Fig. 2 [ 8 ] .

The current views of bladder sensation are derived largely from urodynamic studies. In studies using healthy subjects, volunteers were asked to report their sensations during fi lling [ 2,3 ] . All subjects reported spontaneously a similar sequence of sensations: a fi rst sensation of fi lling, which was vague and weak, a sensation described as a fi rst desire to void, which could be coped with and voiding delayed; and fi nally a strong desire to void, which was an uncomfortable sensation demanding immediate voiding [ 2,3 ] . However, quite remarkably subjects whose bladder was not being fi lled could report similar patterns of sensations [ 13 – 15 ] . Consequently, the validity of such an approach and the language and concepts underpinning sensation have been questioned and argued to be erroneous [ 8 ] .

Bladder sensation at the time of voiding has also been assessed using voiding diaries and numerical scales devised to quantify this. It has always been a complication and an

enigma that some subjects recorded a few voids with no preceding desire to void: so called ‘ convenience voids ’ [ 9 – 12 ] . The observations described here are in broad

FIG. 1. Curves depicting the development of the awareness of the bladder as it fi lls. A , shows the initial curve derived from the early focus group sessions based on the subjects descriptions of their sensation. The pattern of sensation had the following elements: (i) a period with no awareness, (ii) a period where awareness increased, and (iii) a period when subjects were aware that the bladder was full where the sensations were strong and did not increase. B , shows a series of refi nements based on the curve in A as a result of subsequent group discussions. When asked which modifi ed curve described the development of awareness 17/25 agreed with the curve of Fig. 1A (green). Others (4/25) described their awareness as increasing but it was there all the time (yellow) while some (4/25) described the sensation as week with little or no awareness except when their bladder was full, where strong sensations developed very rapidly (red). Using the curve identifi ed by each subject of their own awareness pattern they were asked to mark, using up to 10 marks, at what level of awareness they typically went to the toilet. Each subject participating in this part of the focus group is identifi ed by a different symbol.

max

pain

very strong sensation needing immediate action

sensation needing action

sensation that will need action

clear sensation

mild sensation

nosensation

nosensation

empty

repo

rted

sen

satio

nA

B

repo

rted

sen

satio

n(b

ladd

er a

war

enes

s)

volume

maxempty

volume

aware

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agreement with this but suggest that the incidence of these voids, not driven by sensations of ‘ needing to void ’ , may be much greater and in fact the norm. In the present study, perhaps 60% of all voids appear to have resulted predominantly from cognitive processes based on the information given by the subjects on when they voided ( Fig. 1B ). Most voids appearing to be initiated with mild to clear sensations rather than sensations that would need immediate action and triggering of voids for fear of leakage.

The description of bladder sensations as ‘ awareness ’ may be helpful in interpreting neurophysiological data quantifying bladder

afferent nerve activity. It has been argued that the afferent outfl ow originates from discrete systems (pain, stretch receptors, urothelial-dependent mechanisms and a motor/sensory system) and that bladder sensations are contained within this ‘ afferent noise ’ [ 16 – 19 ] . Afferent noise increases progressively as the bladder fi lls. Therefore, there may be a direct correlation between afferent noise and awareness as the bladder fi lls.

However, sensations associated with fi lling and voiding are often described as episodic [ 2,20 ] . Afferent noise and bladder awareness are not episodic suggesting that voiding sensations are different; an idea proposed

originally > 60 years ago but largely overlooked [ 21 ] . This conclusion has major implications. Sensations reported at part of voiding diaries are linked to the sensations preceding a void. Consequently, diaries may not be reporting directly bladder sensation but the processing of this information. If this is correct then it has consequences for the interpretation of data from studies using voiding diaries with sensation at the time of void as their endpoint.

Some subjects appear to lack the progressive increase in awareness. These subjects report frequent voiding, which appears to originate from their cognitive strategies to avoid intense urge sensation and incontinence. Thus, the mechanisms generating or interpreting awareness may be depressed in pathological states. A different situation may occur in some patients who have increased sensations as the bladder fi lls. Animal models suggest that afferent outfl ow may be increased in animals with a partial BOO [ 22 ] . If this is so, then bladder awareness may play a greater role in the cognitive process underlying voiding in partial BOO. This would imply that there might be sub-types of the OABSC based on alterations in bladder awareness and cognitive strategies to cope with the respective changes.

The present study proposes a modifi ed view of the factors involved in making the decision of ‘ where ’ and ‘ when ’ to void. If this is correct then the design and interpretation of experiments with cystometry and voiding diaries, using voiding frequency and sensation, may have to be re-evaluated. A better understanding of cognitive voiding and particularly the component related to bladder awareness may lead to greater insights into the nature and underlying causes the OABSC.

CONFLICT OF INTEREST

None declared.

REFERENCES

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FIG. 2. Cartoon showing a possible scheme for considering the interactions between different elements involved in determining the decision to void. Cognitive processes appear to be the primary determinant involved in determining the time and place of voiding. Specifi c cognitive processes can be identifi ed relating to the overall behaviour. The net output of such processing is passed on to a decision-making element, a comparator, which integrates such cognitive information in relation to the desirability of initiating voiding. A key secondary input into this comparator is information from the bladder in relation to bladder volume, bladder awareness. Subjects, by virtue of introspection, can describe these sensations but do so in terms more related to ‘ awareness ’ rather than sensations, which require the activation of voiding behaviour. Most voids appear to be initiated as a result of cognitive processing with minimal drive from bladder awareness. As the bladder fi lls sensations of awareness increase and the decision-making processes take more account of bladder volume. If no action is taken, the bladder continues to fi ll and sensation increases. Normally, subjects do not wait until these strong sensations are experienced. However, when present such sensations dominate behaviour. Once a decision to void has been taken the mechanisms controlling voiding are activated. This results in a generalised arousal response focused on the voiding process. It is likely that once voiding behaviour is activated bladder sensations are amplifi ed and perceived more intensely [ 8 ] . Direct evidence has yet to be obtained for the elements associated with this stage (boxed elements). Such amplifi ed sensations, voiding sensations, are key elements, which drive voiding behaviour to completion. It is possible that it is these amplifi ed void sensations that are reported in voiding diaries. Voiding behaviour is then activated ultimately involving the coordinated activation of the voiding refl exes acting via the bladder and urethra.

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Correspondence: James I. Gillespie, Urophysiology Research Group, The Medical and Dental School, Newcastle University, Framlington Place, Newcastle upon Tyne NE2 4BW, UK. e-mail: j.i.gillespie@ncl.ac.uk

Abbreviation : OABSC , overactive bladder symptom complex .