How to cite: Fleischmann, N. Guarding Reflex Inhibition Training (GRIT) Reduces Postoperative Urinary Retention (POUR) After Urethral Bulking for Stress Urinary Incontinence (SUI). December 10, 2025 Accessed Apr 2026. https://grandroundsinurology.com/guarding-reflex-inhibition-training-grit-reduces-postoperative-urinary-retention-pour-after-urethral-bulking-for-stress-urinary-incontinence-sui/
Summary
Diane K. Newman, DNP, ANP-BC, FAAN, FAUNA, BCB-PMD, Urology and Pelvic Floor Nurse Specialist, University of Pennsylvania; Adjunct Professor of Surgery, Perelman School of Medicine, Emerita, University of Pennsylvania, Philadelphia, Pennsylvania, introduces Nicole Fleischmann, MD, URPS, Urologist, White Plains Hospital Physician Associates, White Plains, New York. Dr. Fleischmann reviews the concept of guarding reflex inhibition training (GRIT) and its association with reduced postoperative urinary retention following urethral bulking for stress urinary incontinence.
Dr. Fleischmann begins by describing the guarding reflex as a normal, involuntary neuromuscular response that develops early in life and contributes to continence by activating the pelvic floor muscles. She explains that this reflex operates largely below conscious awareness and can persist into adulthood, interfering with coordinated voiding. She notes that many individuals rely on clenching or straining rather than pelvic floor release to initiate urination.
Dr. Fleischmann reframes postoperative urinary retention as a failure of release rather than solely an anatomic obstruction. She discusses how stress urinary incontinence and postoperative urinary retention may reflect impaired sensory-motor coordination and difficulty downregulating pelvic floor activity during voiding.
GRIT is described as a structured sensory-motor protocol designed to inhibit involuntary pelvic floor guarding. The training focuses on teaching patients how to hold continence without clenching and how to void without pushing. Dr. Fleischmann explains that the technique utilizes sniff-enhanced respiration, combined with postural sequencing, to activate conscious neural pathways that facilitate relaxation of the pelvic floor.
She then reviews a retrospective cohort study conducted at White Plains Hospital involving women undergoing distal urethral bulking for stress urinary incontinence. Patients who received GRIT training before the procedure were compared to those who did not. Dr. Fleischmann reports that postoperative urinary retention was eliminated in the GRIT group, while it occurred in a proportion of patients who did not receive training.
Dr. Fleischmann and Dr. Newman further discuss the implications for the management of stress urinary incontinence. They emphasize behavioral training as a complement to procedural interventions, highlighting the need for further study.
ABOUT THE AUTHOR
Nicole B. Fleischmann, MD, URPS, is a Urologist with White Plains Hospital Physician Associates in New York. Dr. Fleischmann specializes in women's health, the diagnosis and treatment of urinary incontinence, surgical procedures for incontinence, and pelvic floor prolapse. Her research interests focus on the etiology and treatment of incontinence and female bladder outlet obstruction. She uses minimally invasive techniques, implementing the DaVinci robot to perform complex pelvic floor reconstructions, and runs a program in sacral nerve modulation for incontinence.
Dr. Diane K. Newman is an Adjunct Professor of Surgery at the Perelman School of Medicine at the University of Pennsylvania. She is the former Co-Director of the Penn Center for Continence and Pelvic Health, Division of Urology, Penn Medicine, in Philadelphia. She is a Fellow of the American Academy of Nursing and the Academy of Urologic Nurses and Associates. She is certified as an adult nurse practitioner by the American Nurses Credentialing Center and Board Certified in Biofeedback for Pelvic Muscle Dysfunction by the Biofeedback Certification Institute of America.
Dr. Newman has 35+ years of experience practicing as a urology advanced practice provider and continence nurse specialist. Her clinical expertise involves the evaluation, treatment, and management of urinary incontinence, bladder dysfunction, and related problems, including the use of catheters and other devices in the management of bladder and pelvic floor conditions. Throughout her career, she has evaluated and treated men and women with urologic disorders in multiple settings: acute care, long-term, and home care, with 23 years in an ambulatory practice at the Division of Urology at the University of Pennsylvania.
