Urge incontinence

Answer 1

Definition

Urge incontinence is the strong, sudden need to urinate due to bladder spasms or contractions.

Alternative Names

Overactive bladder; Detrusor instability; Detrusor hyperreflexia; Irritable bladder; Spasmodic bladder; Unstable bladder; Incontinence - urge; Bladder spasms

Causes, incidence, and risk factors

A person's ability to hold urine depends on normal function of the lower urinary tract, kidneys, and nervous system. The person must also have the physical and mental ability to recognize and respond to the urge to urinate.

The bladder's ability to fill and store urine requires a working sphincter muscle (which controls the flow of urine out of the body) and a stable bladder wall muscle (detrusor).

The process of urination involves two phases:

• Filling and storage
• Emptying

During the filling and storage phase, the bladder stretches so it can hold the increasing amount of urine. The bladder of an average person can hold 350 ml to 550 ml of urine. Generally, a person feels like they need to urinate when there is approximately 200 ml of urine in the bladder.

The nervous system tells you that you need to urinate. It also allows the bladder to continue to fill.

The emptying phase requires the detrusor muscle to contract, forcing urine out of the bladder. The sphincter muscle must relax at the same time, so that urine can flow out of the body.

The bladder of an infant automatically contracts when a certain volume of urine is collected in the bladder. As the child grows older and learns to control urination, part of the brain (cerebral cortex) helps prevent bladder muscle contraction. This allows urination to be delayed until the person is ready to use the bathroom.

Undesired bladder muscle contractions may occur from nervous system (neurological) problems and bladder irritation.

URGE INCONTINENCE

Urge incontinence is leakage of urine due to bladder muscles that contract inappropriately. Often these contractions occur regardless of the amount of urine that is in the bladder.

Urge incontinence may result from:

• Bladder cancer
• Bladder inflammation
• Bladder outlet obstruction
• Bladder stones
• Infection
• Neurological diseases (such as multiple sclerosis)
• Neurological injuries (such as spinal cord injury or stroke)

In men, urge incontinence also may be due to:

• Bladder changes caused by benign prostatic hypertrophy (BPH)
• Bladder outlet obstruction from an enlarged prostate

In most cases of urge incontinence, no specific cause can be identified.

Although urge incontinence may occur in anyone at any age, it is more common in women and the elderly.

Symptoms

• Frequent urination, in the daytime and at night
• Involuntary loss of urine
• Sudden and urgent need to urinate (urinary urgency)

Signs and tests

During a physical examination, the health care provider will look at the abdomen and rectum. Women will also have a pelvic exam. Men will also have a genital exam. In most cases the physical exam reveals nothing abnormal.

If there are nervous system (neurologic) causes, other abnormalities may be found.

Tests include the following:

• EMG (myogram) - rarely needed
• Inspection of the inside of the bladder (cystoscopy)
• Pad test (after placement of a previously weighed sanitary pad, the patient exercises, then the pad is weighed to determine urine loss)
• Pelvic or abdominal ultrasound
• Post-void residual volume (PVR) to measure amount of urine left after urination
• Urinalysis or urine culture to rule out urinary tract infection
• Urinary stress test (the patient stands with a full bladder and coughs)
• Urodynamic studies (measurement of pressure and urine flow)
• X-rays with contrast dye

Further tests will be performed to rule out other types of incontinence. The "Q-tip test" measures the change in the angle of the urethra at rest and when straining. An angle change of greater than 30 degrees often is a sign that the muscles supporting the bladder are weak. This is common in stress incontinence.

Treatment

The choice of treatment will depend on how severe the symptoms are, and how much they interfere with your lifestyle. There are three main treatment approaches for urge incontinence: medication, retraining, and surgery.

MEDICATION

If evidence of infection is found in a urine culture, your doctor will prescribe antibiotics.

Medications used to treat urge incontinence relax the involuntary bladder contractions and help improve bladder function. There are several types of medications that may be used alone or in combination:

• Anticholinergic medicines help relax the muscles of the bladder. They include oxybutynin (Oxytrol, Ditropan), tolterodine (Detrol), darifenacin (Enablex), trospium (Sanctura), solifenacin (Vesicare)
• These are the most commonly used medications for urge incontinence and are available in a once-a-day formula that makes dosing easy and effective.
• The most common side effects of these medicines are dry mouth and constipation. The medications cannot be used by patients with narrow angle glaucoma.

Flavoxate (Urispas) is an antispasmodic drug. However, studies have shown that it is not always effective at controlling symptoms of urge incontinence.

Tricyclic antidepressants (imipramine, doxepin) have also been used to treat urge incontinence because of their ability to "paralyze" the bladder smooth muscle. Possible side effects include:

• Blurred vision
• Dizziness
• Dry mouth
• Fatigue
• Insomnia
• Nausea

DIET

Drink plenty of water:

• Drinking enough water will help keep odors away.
• Drinking more water may even help reduce leakage.

Some experts recommend controlling fluid intake in addition to other therapies for managing urge incontinence. The goal of this program is to distribute fluids throughout the course of the day, so the bladder does not need to handle a large volume of urine at one time.

Do not drink large quantities of fluids with meals. Limit your intake to less than 8 ounces at one time. Sip small amounts of fluids between meals. Stop drinking fluids approximately 2 hours before bedtime.

It also may be helpful to eliminate foods that may irritate the bladder, such as:

• Caffeine
• Carbonated drinks
• Highly acidic foods such as citrus fruits and juices
• Spicy foods

BLADDER RETRAINING

Managing urge incontinence usually begins with a program of bladder retraining. Occasionally, electrical stimulation and biofeedback therapy may be used with bladder retraining.

A program of bladder retraining involves becoming aware of patterns of incontinence episodes. Then you relearn skills necessary for bladder storage and proper emptying.

Bladder retraining consists of developing a schedule of times when you should try to urinate. You try to consciously delay urination between these times.

One method is to force yourself to wait 1 to 1 1/2 hours between trips to the bathroom, despite any leakage or urge to urinate in between these times. As you become skilled at waiting, gradually increase the time intervals by 1/2 hour until you are urinating every 3 - 4 hours.

KEGEL EXERCISES

Pelvic muscle training exercises called Kegel exercises are primarily used to treat people with stress incontinence. However, these exercises may also be beneficial in relieving the symptoms of urge incontinence.

The principle behind Kegel exercises is to strengthen the muscles of the pelvic floor to improve the function of the urethral sphincter. The success of Kegel exercises depends on proper technique and sticking to a regular exercise program.

Another approach is to use vaginal cones to strengthen the muscles of the pelvic floor. A vaginal cone is a weighted device that is inserted into the vagina. The woman contracts the pelvic floor muscles in an effort to hold the device the place. The contraction should be held for up to 15 minutes and should be performed twice daily. Within 4 - 6 weeks, about 70% of women trying this method had some improvement in symptoms.

BIOFEEDBACK AND ELECTRICAL STIMULATION

Biofeedback and electrical stimulation can help identify the correct muscle group to work, to make sure you are performing Kegel exercises correctly.

Some therapists place a sensor in the vagina (for women) or the anus (for men) to assess contraction of the pelvic floor muscles. A monitor will display a graph showing which muscles are contracting and which are at rest. The therapist can help you identify the correct muscles for performing Kegel exercises.

Electrical stimulation involves using low-voltage electric current to stimulate the correct group of muscles. The current may be delivered using an anal or vaginal probe. The electrical stimulation therapy may be performed in the clinic or at home. Treatment sessions usually last 20 minutes and may be performed every 1 - 4 days.

SURGERY

Surgery can increase the storage ability of the bladder and decrease the pressure within the bladder. It is reserved for patients who are severely affected by their incontinence and have an unstable bladder (severe inappropriate contraction) and a poor ability to store urine.

Augmentation cystoplasty is the most often performed surgical procedure for severe urge incontinence. In this surgery, a segment of the bowel is added to the bladder to increase bladder size and allow the bladder to store more urine.

Possible complications are those of any major abdominal surgery, including:

• Blood clots
• Bowel obstruction
• Infection
• Pneumonia

There is a risk of developing abnormal tubelike passages (urinary fistulae) that result in abnormal urine drainage, urinary tract infection, and difficulty urinating. Augmentation cystoplasty is also linked to a slightly increased risk of developing tumors.

Sacral nerve stimulation is a newer surgical option that consists of an implanted unit that sends small electrical pulses to the sacral nerve. The electrical pulses can be adjusted to each patient's symptoms.

ACTIVITY

People with urge incontinence may find it helpful to avoid activities that irritate the urethra and bladder, such as taking bubble baths or using harsh soaps in the genital area.

MONITORING

Urinary incontinence is a long-term (chronic) problem. Although you may be considered cured by treatment, you should continue to see your health care provider to evaluate the progress of your symptoms and monitor for possible treatment complications.

Expectations (prognosis)

How well you do depends on your symptoms, an accurate diagnosis, and proper treatment. Many patients must try different therapies (some at the same time) to reduce symptoms.

Instant improvement is unusual. Perseverance and patience are usually required to see improvement. A small number of patients need surgery to control their symptoms.

Complications

Physical complications are rare. However, psychological and social problems may arise, particularly if you are unable to get to the bathroom when you feel the urge.

Calling your health care provider

Call your health care provider for an appointment if:

• Your symptoms are causing you problems
• You have pelvic discomfort or burning with urination
• Your symptoms occur daily

Prevention

Starting bladder retraining techniques early may help reduce the severity of symptoms.

References

Gerber GS, Brendler CB. Evaluation of the urologic patient: History, physical examination, and urinalysis. In: Wein AJ, ed. Campbell-Walsh Urology. 9th ed. Philadelphia, Pa: Sauders Elsevier; 2007: chap 3.

Rogers RG. Clinical practice: urinary stress incontinence in women. N Engl J Med. 2008;358:1029-1036.

Shamliyan TA, Kane RL, Wyman J, Wilt TJ. Systematic review: randomized, controlled trials of nonsurgical treatments for urinary incontinence in women. Ann Intern Med. 2008;148:459-473.

van Kerrebroeck PE, van Voskuilen AC, Heesakkers JP, Lycklama a Nijholt AA, Siegel S, Jonas U, et al. Results of sacral neuromodulation therapy for urinary voiding dysfunction: outcomes of a prospective, worldwide clinical study. J Urol. 2007;178:2029-2034.

Answer 2

Definition

Urge incontinence is the strong, sudden need to urinate due to bladder spasms or contractions.

Alternative Names

Overactive bladder; Detrusor instability; Detrusor hyperreflexia; Irritable bladder; Spasmodic bladder; Unstable bladder; Incontinence - urge; Bladder spasms

Causes, incidence, and risk factors

To hold urine, the lower urinary tract and nervous system must work properly. You must also be able to feel and respond to the urge to urinate.

For the bladder to fill and store urine, the sphincter muscle (which controls the flow of urine out of the body) and bladder wall muscle (detrusor) must be working.

The process of urination involves two parts:

• Filling and storage
• Emptying

During the filling and storage phase, the bladder stretches so it can hold more urine. An average person's bladder can hold 350 milliliters (ml) to 550 ml of urine. Most people will feel like they need to urinate when there is about 200 ml of urine in the bladder.

The nervous system tells you that you need to urinate. It also allows your bladder to keep filling.

During the emptying phase, the detrusor muscle must contract, forcing urine out of the bladder. The sphincter muscle must relax at the same time, so that urine can flow out of the body.

An infant's bladder automatically contracts when a certain amount of urine has collected in the bladder. As the child grows older and learns to control urination, part of the brain (cerebral cortex) helps prevent bladder muscle contractions. This allows urination to be delayed until the person is ready to use the bathroom.

The bladder may contract too often from nervous system (neurological) problems or bladder irritation.

URGE INCONTINENCE

With urge incontinence, you leak urine because the bladder muscles contract at the wrong times. Often these contractions occur no matter how much urine is in the bladder.

Urge incontinence may result from:

• Bladder cancer
• Bladder inflammation
• Bladder outlet obstruction
• Bladder stones
• Infection
• Nervous system diseases (such as multiple sclerosis)
• Nervous system injuries (such as spinal cord injury or stroke)

In men, urge incontinence also may be due to:

• Bladder changes caused by benign prostatic hypertrophy (BPH)
• Bladder outlet obstruction from an enlarged prostate

In most cases of urge incontinence, no cause can be found.

Although urge incontinence may occur in anyone at any age, it is more common in women and the elderly.

Symptoms

• Frequent urination, in the daytime and at night
• Loss of urine without meaning to urinate
• Sudden and urgent need to urinate (urinary urgency)

Signs and tests

During a physical examination, the health care provider will look at the abdomen and rectum. Women will have a pelvic exam. Men will have a genital exam. In most cases the physical exam will not show anything abnormal.

If there are nervous system (neurologic) causes, other problems may be found.

Tests include the following:

• EMG (myogram) - rarely needed
• Examination of the inside of the bladder (cystoscopy)
• Pad test (you exercise while wearing a sanitary pad, then the pad is weighed to find out how much urine you have lost)
• Pelvic or abdominal ultrasound
• Post-void residual volume (PVR) to measure the amount of urine left after you urinate
• Urinalysis or urine culture to rule out urinary tract infection
• Urinary stress test (you stand with a full bladder and cough)
• Urodynamic studies (which measure pressure and urine flow)
• X-rays with contrast dye

Treatment

The choice of treatment will depend on how severe the symptoms are, and how much they interfere with your lifestyle. There are three main treatment approaches for urge incontinence: medication, retraining, and surgery.

See also: When you have urinary incontinence

MEDICATION

If you have an infection, your health care provider will prescribe antibiotics.

Medications used to treat urge incontinence relax bladder contractions and help improve bladder function. There are several types of medications that may be used alone or together:

• Anticholinergic medicines help relax the muscles of the bladder. They include oxybutynin (Oxytrol, Ditropan), tolterodine (Detrol), darifenacin (Enablex), trospium (Sanctura), and solifenacin (Vesicare).
  • These are the most commonly used medications for urge incontinence. They are available in a once-a-day formula that makes dosing easy and effective.
  • The most common side effects of these medicines are dry mouth and constipation. People with narrow-angle glaucoma cannot use these medications.
• Flavoxate (Urispas) is a drug that calms muscle spasms. However, studies have shown that it is not always effective at controlling symptoms of urge incontinence.
• Tricyclic antidepressants (imipramine, doxepin) have also been used to treat urge incontinence because of their ability to "paralyze" the smooth muscle of the bladder. Possible side effects include:
  • Blurred vision
  • Dizziness
  • Dry mouth
  • Fatigue
  • Insomnia
  • Nausea

DIET

Drink plenty of water:

• Drinking enough water will help keep odors away.
• Drinking more water may even help reduce leakage.

Some experts recommend controlling how much fluid you drink and using other therapies to manage urge incontinence. The goal of this program is to drink a little bit of fluid at a time throughout the day, so your bladder does not need to handle a large volume of urine at one time.

Do not drink large amounts of fluids with meals. Drink less than 8 ounces at one time. Sip small amounts of fluids between meals. Stop drinking fluids about 2 hours before bedtime. Avoid carbonated drinks

It also may help to stop eating foods that may irritate the bladder, such as:

• Caffeine
• Highly acidic foods, such as citrus fruits and juices
• Spicy foods

BLADDER RETRAINING

Managing urge incontinence usually begins with a program of bladder retraining. Sometimes, electrical stimulation and biofeedback may be used with bladder retraining.

During bladder retraining, you become aware of patterns in your incontinence episodes. Then you relearn the skills you need to hold and release urine.

In bladder retraining, you set a schedule of times when you should try to urinate. You try to hold in urination between these times.

One method is to force yourself to wait 1 to 1 1/2 hours between trips to the bathroom, even if you have any leakage or an urge to urinate in between these times. As you become better at waiting, gradually increase the time by 1/2 hour until you are urinating every 3 - 4 hours.

KEGEL EXERCISES

Pelvic muscle training exercises called Kegel exercises are mainly used to treat people with stress incontinence. However, these exercises may also help relieve the symptoms of urge incontinence.

The idea behind Kegel exercises is to strengthen the muscles of the pelvic floor to improve the function of the urethral sphincter. For Kegel exercises to work, you need to use the proper technique and stick to a regular exercise program.

Another approach is to use vaginal cones to strengthen the muscles of the pelvic floor. A vaginal cone is a weighted device that is inserted into the vagina. You tighten the pelvic floor muscles to hold the device the place. You hold the muscles for up to 15 minutes, twice daily. Within 4 - 6 weeks, about 70% of women who try this method have some symptom improvement.

BIOFEEDBACK AND ELECTRICAL STIMULATION

Biofeedback and electrical stimulation can help you find the right muscle group to work, to make sure you are performing Kegel exercises correctly.

Some therapists place a sensor in the vagina (for women) or the anus (for men) so they can tell when they are squeezing the pelvic floor muscles. A monitor will display a graph showing which muscles are squeezing and which are at rest. The therapist can help you find the right muscles for performing Kegel exercises.

Electrical stimulation uses low-voltage electric current to stimulate the correct group of muscles. The current may be delivered using an anal or vaginal probe. The electrical stimulation therapy may be performed in the clinic or at home. Treatment sessions usually last 20 minutes and may be done every 1 - 4 days.

SURGERY

Surgery can increase bladder storage and decrease pressure in the bladder. Surgery is only used for patients who are severely affected by their incontinence, and who have too many contractions and are not able to store much urine.

Augmentation cystoplasty is the surgery most often performed for severe urge incontinence. In this surgery, a segment of the bowel is added to the bladder to increase the bladder size and allow it to store more urine.

Possible complications include:

• Blood clots
• Bowel obstruction
• Infection
• Pneumonia

There is a risk of forming abnormal tube-like passages (urinary fistulae). These passages can lead to abnormal urine drainage, urinary tract infection, and difficulty urinating. Augmentation cystoplasty is also linked to a slightly increased risk of developing tumors.

Sacral nerve stimulation is a newer type of surgery. It uses an implanted unit to sends small electrical pulses to the sacral nerve. The electrical pulses can be adjusted to your symptoms.

ACTIVITY

People with urge incontinence may find it helpful to avoid activities that irritate the urethra and bladder, such as taking bubble baths or using harsh soaps in the genital area.

MONITORING

Urinary incontinence is a long-term (chronic) problem. Although you may be considered cured by treatment, continue to see your health care provider to evaluate your progress and monitor for possible treatment complications.

Expectations (prognosis)

How well you do depends on your symptoms, diagnosis, and treatment. Many patients must try different treatments (some at the same time) to reduce symptoms.

It is unusual for people to improve instantly. You will need to be patient to see improvement. A small number of patients need surgery to control their symptoms.

Complications

Physical complications are rare. However, you may have psychological and social problems if you cannot get to the bathroom when you feel the urge.

Calling your health care provider

Call your health care provider for an appointment if:

• Your symptoms are causing you problems
• You have pelvic discomfort or burning with urination
• Your symptoms occur daily

Prevention

Starting bladder retraining techniques early may help relieve the symptoms.

References

Gerber GS, Brendler CB. Evaluation of the urologic patient: History, physical examination, and urinalysis. In: Wein AJ, ed. Campbell-Walsh Urology. 9th ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 3.

Resnick NM. Incontinence. In: Goldman L, Ausiello D, eds. Cecil Medicine. 24th ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap 25.

Deng DY. Urinary incontinence in women. Med Clin North Am. 2011;95:101-109.

Reviewed By

Review Date: 09/16/2011

Linda J. Vorvick, MD, Medical Director, MEDEX Northwest Division of Physician Assistant Studies, University of Washington, School of Medicine; and Scott Miller, MD, Urologist in private practice in Atlanta, Georgia. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.