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Neurourology and Urodynamics 32:43–47 (2013)

The Relationship Between Urinary Bladder Control

and Gait in Women
Joanne Booth,1* Lorna Paul,2 Danny Rafferty,1 and Carolyn MacInnes3
1
School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
2
Nursing & Healthcare, School of Medicine, University of Glasgow, Glasgow, UK
3
NHS Greater Glasgow & Clyde, Glasgow, UK

Aims: Urinary incontinence and OAB are associated with increased falls risk in older people suggesting a potential
relationship between bladder functioning and control of gait. To begin to understand the possible interaction between
gait and bladder control this exploratory study aimed to examine the effects of controlling the bladder on gait param-
eters in healthy adult women. Methods: Thirty-six continent women (mean age 50.8
15.8 years), participated in
this observational cohort study. Subjects walked three times along an electronic walkway under three different bladder
conditions; first desire to void (FDV), strong desire to void (SDV), and post void (PV). Spatial and temporal parameters
of gait and continence status were recorded for each condition. Results: A significant reduction in gait velocity
(P < 0.025) was found at the SDV compared with the PV condition. Stride length decreased significantly (P < 0.001) at
the SDV compared with the FDV and PV conditions. No significant differences were found between FDV and PV
conditions. In addition, the variability of gait increased significantly with respect to cadence (P < 0.05) and stride times
(P < 0.05) at the SDV compared to the PV condition. This was not observed between the FDV and the PV conditions,
nor the FDV and the SDV. Conclusion: In healthy continent women, speed and rhythmicity of gait are different
when a strong desire to void is experienced. This suggests an interaction may exist between urinary bladder control
and control of gait. Further investigation is necessary to understand this relationship and begin to explain the
increased risk of falls associated with urinary bladder functioning. Neurourol. Urodynam. 32:43–47, 2013.
ß 2012 Wiley Periodicals, Inc.

Key words: attention; falls; gait; gait changes; urinary bladder control; urinary incontinence; variability

BACKGROUND There is a known increased risk of falls among community

In the healthy person, urinary continence involves success-
ful storage of urine, urethral sphincter regulation, and bladder
emptying. Unconscious sub-cortical and reflex control is
continuously modulated by higher cortical centers, allowing
voluntary control of bladder functioning.1 The processes of
bladder filling and voiding are separate activities and the
intensity of the sensation of bladder filling escalates as
the bladder distends,2 increasing awareness and thus the
perceived need to gain relief through voiding.3–5 A significant
contribution to continence is made by the biomechanical
contribution of the pelvic floor muscles which actively
support the pelvic organs including the bladder, rectum,
uterus, and vagina (in women). The anterior and cephalad
contraction of these muscles helps to close and maintain
closure of the pelvic openings. The motor cortex is crucial to
the voluntary control of these pelvic floor muscles and their
activities.6 Maintaining control of the bladder and voiding
behavior involves complex cognitive and sensory processes,
not yet fully understood, involving various components and
levels of the nervous system.
Previous beliefs that walking is solely an automatic activity
controlled by central pattern generators within the spinal
cord have been modified and more recent work has confirmed
that maintaining safe gait involves both cognitive and
sensori-motor processes.7,8 Therefore like bladder control,
control of gait is a complex neurological process involving
multiple levels and components of the nervous system and
evidence from clinical practice suggests there may be a
relationship between the two although to date this has not
been investigated.
dwelling older people with all types of urinary inconti-
nence9,10 those rising at night to use the toilet11 and those
with urinary incontinence associated with an urgent desire to
void (urgency urinary incontinence).12 This suggests a poten-
tial association between continence control, postural stability,
and gait. Our group were interested in investigating this
relationship and sought to determine whether maintaining
urinary continence, with a strong desire to void affects gait.
As this is a novel concept, the aim of this exploratory study
was to examine the influence of controlling the bladder on
gait parameters (measurable factors that define gait and
determine its qualities) of healthy adult women. The study
hypothesized that, in healthy, continent women, spatial and
temporal gait parameters assessed with a strong desire to
Mickey Karram led the peer-review process as the Associate Editor responsible for
the paper.
Conflict of interest: none.
Authors’ contributions: JB conceived, designed and coordinated the study, con-
tributed to data collection, analysis and interpretation, prepared the manuscript;
LP conceived and designed the study, contributed to data collection, analysis, in-
terpretation and manuscript preparation; DR collected data, performed the statis-
tical analysis, interpreted findings and helped prepare the manuscript; CM
collected data and contributed to interpretation and manuscript preparation. All
authors read and approved the final manuscript.
*Correspondence to: Joanne Booth, School of Health and Life Sciences, Glasgow
Caledonian University, Cowcaddens Road, Glasgow G4 0BA, UK.
E-mail: jo.booth@gcu.ac.uk
Received 7 November 2011; Accepted 23 April 2012
Published online 12 June 2012 in Wiley Online Library
(wileyonlinelibrary.com).
DOI 10.1002/nau.22272

ß 2012 Wiley Periodicals, Inc.


44 Booth et al.
void would be different to the same gait parameters assessed
with no desire to void.
METHODS
Subjects
This cross sectional study recruited a convenience sample of
healthy women volunteers. To be included in the study, the
women had to be adults aged 18 and above with no medical
conditions which would affect their gait, including lower limb
dysfunction or neurological impairment. They were also re-
quired to be continent (defined as no urinary leakage reported
in the previous 3 months), or no or minimal known urinary
storage symptoms (frequency, urgency, nocturia) or voiding
symptoms (slow stream, intermittency, straining) or post-
micturition symptoms (feeling of incomplete emptying) as de-
termined by a score of 0–7 (indicating mild symptoms) when
screened using the American Urological Association
International Prostate Symptom Score (IPSS).13 The study was
approved by the University Ethics Committee. All subjects
gave written, informed consent.
Measures
The temporal and spatial parameters of gait were assessed
using the GAITRite walkway. The GAITRite Gold (CIR systems,
Inc., USA) has been shown to be a valid and reliable device.14
The GAITRite system was used to measure step (the heel con-
tact of the current footfall to the heel contact location of the
next footfall on the opposite foot) and stride length (the dis-
tance between the heel contact of two consecutive footfalls of
the same foot) and time; swing time (the period of time when
the foot is not in contact with the ground), duration of single
support (the period of time when only one foot is in contact
with the ground) and double support (the period of time
when both feet are in contact with the ground); velocity (the
total distance walked divided by the time taken to walk it)
and cadence (the number of steps the person would take in
1 min). Taped marks were made on the floor 1.5 m beyond
each end of the walkway to allow an additional length for
acceleration and deceleration (thus each ‘‘walk’’ was over
6.5 m/21 feet). Each subject walked at their self-selected walk-
ing pace, three times for each of the three conditions. The
three bladder conditions were: first desire to void (FDV) de-
fined as ‘‘the feeling that would lead you to pass urine at the
next convenient moment but voiding can be delayed if neces-
sary;’’15 strong desire to void (SDV) defined as ‘‘the volume at
which you feel you can no longer delay micturition and have
a strong and persistent desire to void’’15 and post void (PV)
defined as ‘‘the immediate period after passing urine and sub-
jectively emptying the bladder.’’ All three bladder conditions
are subjective sensations for which there are no reliable meas-
ures as yet.16
Procedures
Testing took place on one occasion. On attending the labora-
tory, the study was fully explained to the subjects and each
was provided with, and encouraged to drink, non-alcoholic
fluid of their choice (water, juice, tea, coffee). Gait assessment
was undertaken when the subject indicated their FDV, follow-
ing which they were asked to postpone voiding, controlling
their bladder and maintaining continence as long as possible
to the point of SDV. At the point of SDV subjects completed
further gait assessment. Distraction techniques including
Neurourology and Urodynamics DOI 10.1002/nau
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activities such as individual and group conversations were ap-
plied, to ensure that the point of SDV was reached. As some
subjects were concerned at the outset that they might experi-
ence an episode of urinary incontinence, absorbent pads were
provided and used if required. The walkway was positioned
along the direct route to the bathroom. When they had emp-
tied their bladder (PV) subjects were asked to walk along the
walkway again three times to complete the study. Each sub-
ject was asked if they had experienced any urinary leakage
during the testing procedure.
Statistical Analysis
For each gait parameter, at each of the three time points,
averages and standard deviations of the three ‘‘walks’’ were
calculated. The temporal and spatial parameters and variation
in these parameters as calculated by coefficient of variation
(CoV; standard deviation/average) were analyzed. The tempo-
ral and spatial parameters of gait were found to be normally
distributed and thus a two way ANOVA (subject/condition)
followed by Tukey post hoc analysis with Bonferroni correc-
tion to adjust for multiple comparisons was employed to iden-
tify where the differences lay. All coefficient of variations
were not normally distributed thus these were analyzed using
Signed Wilcoxon tests. Significance was taken as P < 0.05.
RESULTS
Initially 39 women were recruited to the study; three wom-
en were subsequently excluded as their IPSS scores were
above 7. Thirty-six women were thus included (mean age
50.8 þ 15.8 years; range 25–85 years). The median IPSS score
was 2. All women reported complete continence throughout
testing and there were no indications of urinary leakage by
any subject at any of the three assessment points, including
SDV.
Table I presents the results of the spatial and temporal
parameters of gait, the velocity and the cadence. There were
no statistically significant differences between FDV and PV for
any of the variables however at SDV (i.e., with full bladder)
gait velocity was found to be significantly reduced compared
to PV. Stride length for both sides at SDV was significantly
reduced in comparison to both PV and FDV conditions. The
temporal parameter of stride time showed no change attribut-
able to bladder condition (Table I). Similarly, no change in the
temporal parameters of step time, single and double support
time, swing time, and cadence were observed between condi-
tions (data not shown).
In terms of the variability of each of the gait parameters, as
determined by the CoV, no statistically significant changes
were observed for step length, single support, double support
and swing times (data not shown). Similarly, stride lengths
showed no change in variability across the three testing con-
ditions (Table II). However, cadence and left/right stride times
showed significantly increased variability at SDV in compari-
son to PV.
DISCUSSION
This study sought to establish whether maintaining urinary
continence with a strong desire to void affects gait in healthy
adult women by comparing the effects of three physiological
bladder conditions (PV, FDV, and SDV) on parameters of gait.
The findings that gait velocity and stride length were signifi-
cantly reduced between the SDV and the PV, but not the PV
and FDV, suggests that the experience of a strong desire to
 15206777, 2013, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/nau.22272 by INASP/HINARI - ALGERIA, Wiley Online Library on [08/12/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Urinary Bladder Control and Gait 45
TABLE I. Velocity, Cadence, Spatial, and Temporal Gait Parameters Under the Three Tested Bladder Conditions

Value average (SD) Tukey post hoc comparison P-values

Variable PV FDV SDV ANOVA P-value SDV vs. PV SDV vs. FDV FDV vs. PV

Velocity (ms1) 1.37 (0.18) 1.39 (0.19) 1.32 (0.19) 0.006a 0.008a 0.030 0.857
Cadence (steps per minute) 118 (7) 119 (8) 119 (9) 0.658 — — —
Spatial data
Stride length (L) (m) 1.40 (0.14) 1.40 (0.15) 1.32 (0.14) <0.001a <0.001a <0.001a 0.89
Stride length(R) (m) 1.39 (0.14) 1.40 (0.15) 1.33 (0.14) <0.001a <0.001a <0.001a 0.98
Temporal data
Stride time (L) (s) 1.02 (0.06) 1.01 (0.07) 1.02 (0.08) 0.909 — — —
Stride time (R) (s) 1.02 (0.06) 1.01 (0.07) 1.01 (0.08) 0.823 — — —

PV, post void; FDV, first desire to void; SDV, strong desire to void.
a
Significant result (P < 0.025; n ¼ 36).

void led to compensatory adjustments in these elements of
gait. Intuitively it might have been anticipated that gait veloc-
ity and stride length would have increased at SDV, especially
as the walkway was positioned so that participants gait was
assessed as part of their route to the bathroom, however this
was not found to be the case. Our study also showed increased
variability in some temporal gait parameters (cadence and
stride times) at SDV. It is possible that the strong desire to
void potentially interferes with the cortical control of gait
resulting in a concomitant deterioration in rhythmic gait
quality. As this was a cross sectional study it was not possible
to determine causality of the relationship between controlling
a full bladder and the gait changes we observed. There are,
however, a number of potential explanations for these
results.
It is possible that this experiment represents a dual task or
divided attention situation. Divided attention theory postu-
lates that attentional capacity, defined as a person’s informa-
tion processing capacity, is a finite resource and each activity
undertaken will require a proportion of the available resource.
In a dual task paradigm, if the two tasks combined require
more information processing capacity than is available then
the performance of one or both tasks will be affected through
mechanisms of prioritization of one task over the other, or a
deterioration in the performance of both. If the sensation of a
strong desire to void leads to the requirement for concentra-
tion and higher executive functioning to maintain continence
while reaching a suitable and safe place to void, then control-
ling a full bladder in this situation can be seen as an attention
demanding task. As continence was maintained by all partic-
ipants in this study, there was no deterioration in the bladder
control task, therefore, we hypothesize that the observed
changes in gait represented a prioritization of bladder control
over gait control as a consequence of a divided attention situ-
ation. A study designed to determine the effects of urge uri-
nary incontinence (UUI) on performance of voluntary
behavioral tasks that depend on cognitive processes in the
prefrontal cortex17 found that women with UUI had signifi-
cantly poorer working memory than continent women. This
suggested that UUI in this instance was attentionally
demanding resulting in an impaired ability to effectively
manage the two tasks. Divided attention is known to impact
on temporal and spatial parameters of gait18 particularly in
older people where an increased risk of falls is the result.7,19
In studies investigating divided attention the primary task is
most commonly postural control or walking and a variety of
secondary tasks have been investigated including: cognitive
tasks such as verbal memory tasks,20 arithmetic tasks,21
motor tasks such as coin transference22 or carrying trays with
full cups of water23 and visual–spatial tasks such as balancing
in a moving room.24 No study to date has focused on
controlling the urinary bladder as a secondary task, although
this is a fundamental and regularly performed human
activity. However, a recent study25 found a significant

TABLE II. Results of CoV for Velocity, Cadence, Spatial, and Temporal Gait Parameters Under the Three Tested Bladder Conditions

Value median (IQR) Signed Wilcoxon P-values

Variable PV FDV SDV SDV vs. PV SDV vs. FDV FDV vs. PV

Velocity 2.70 (1.83–4.71) 3.65 (1.82–5.92) 3.49 (1.94–6.58) 0.056 0.76 0.26
Cadence 1.59 (1.29–2.33) 1.75 (1.10–2.88) 2.28 (1.29–2.96) 0.014a 0.48 0.55
Spatial data
Stride length (L) 2.13 (1.45–2.71) 2.35 (0.87–3.46) 2.51 (1.28–4.40) 0.32 0.53 0.89
Stride length (R) 2.20 (1.45–2.71) 2.35 (0.87–3.46) 2.51 (1.28–4.40) 0.17 0.63 0.93
Temporal data
Stride time (L) 1.67 (0.89–2.59) 1.92 (1.12–3.43) 2.10 (1.39–3.39) 0.009a 0.19 0.08a
Stride time (R) 1.76 (0.94–2.45) 1.72 (1.25–3.10) 2.13 (1.40–2.94) 0.032a 0.95 0.37

PV, post void; FDV, first desire to void; SDV, strong desire to void.
a
Significant result (P < 0.05; n ¼ 36).

Neurourology and Urodynamics DOI 10.1002/nau


46 Booth et al.
correlation between the severity of mixed urinary inconti-
nence and deterioration in functional performance, which
was more pronounced in older women. If actively controlling
the bladder while walking to a bathroom does represent a
dual task situation, our data suggest that maintaining urinary
continence takes precedence over achieving a rhythmic and
controlled gait.
An alternative potential explanation for our observed
results is that they may represent an altered biomechanical
situation brought about by the effects of muscle group activa-
tion on stability. Bladder filling is known to be associated
with increased trunk and abdominal muscle activity.26
Increased trunk muscle activity has been shown to negatively
affect balance in adult women because the contraction and
resultant stiffness of the muscle groups reduces the capacity
for postural correction when perturbations occur.26 Vertical
and lateral excursions of the body’s center of mass (CoM)
reduce as gait velocity decreases and gait velocity is known to
affect the kinematic (joint angles), kinetic (movement forces),
as well as the temporal and spatial parameters of gait. The
kinematic and kinetic aspects of gait are not within the scope
of this study, however, our data demonstrate a reduction in
gait velocity at SDV mediated (reduced) not by taking fewer
steps, borne out by the lack of change in cadence, but by
taking shorter steps. One possible explanation is that our
observed reduction in gait velocity and stride lengths at SDV
is a strategy adopted to control CoM excursions in order to
maintain balance. Thus, a second hypothesis is that the
observed changes in gait represented an adaptive response to
maintain stability. Given that our results show a similar
reduction in gait speed and stride times to those reported by
Orendurff et al.27 the excursions and velocity of the CoM at
SDV is worthy of further exploration, as a possible explana-
tion for the gait changes observed.
An increase in abdominal muscle activity is also associated
with bladder filling.25 This increases the pressure on the
bladder and thus the demand on the pelvic floor musculature
to avoid urinary leakage by stabilizing the bladder neck
and increasing intra-urethral pressure to maintain closure.26
Thus, a further hypothesis is that observed gait changes oc-
curred secondary to rises in intra-abdominal pressure and were
brought about by co-contraction of the pelvi-perineal muscula-
ture (bracing) to cope with the pressure on the pelvic floor.
A number of limitations have been identified in this study.
Determining the strength of the desire to void is a very subjec-
tive measure and open to error. Whilst every effort was made
to distract participants to wait until their bladder was
perceived to be as full as possible before undertaking the SDV
test it is likely that there was variation in the perceived
strength of the urge to void. In addition, it was not possible to
objectively measure the individual’s level of continence as
participants were asked to self report any leakage of urine
during the walking task Embarrassment may have influenced
the accuracy of reported continence. A further consideration is
the age range of the sample, which may be thought to poorly
represent the older population in whom gait and bladder
dysfunction are most prevalent. However, the study was
exploratory and designed to establish the possible association
between gait control and bladder control with a view to then
investigating clinical populations if and when the association
was established.
CONCLUSION
This study demonstrates an association between gait and
bladder condition, suggesting there is a relationship between
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walking speed and quality and maintenance of urinary conti-
nence when the bladder is perceived to be full and a strong
desire to void is experienced. It is important to develop this
work further to investigate the effects of a strong desire to
void on gait in older women with overactive bladder and
urinary incontinence. It is also important to conduct studies
to establish whether a strong desire to void is attentionally
demanding or not, to test the hypothesis that increased risk of
falls in older women is a consequence of divided attention
inducing deterioration in gait quality. Further studies will also
be designed to investigate the role of the CoM and co-
contraction of the pelvi-perineal muscles in explaining the
gait changes observed.
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