Urge incontinence

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

As your bladder fills with urine from the kidneys, it stretches to make room for the urine. You should feel the first urge to urinate when there is a bit less than 1 cup (240 milliliters) of urine in your bladder. Most people can hold more than 2 cups (480 milliliters) of urine in the bladder.

Two muscles help prevent the flow of urine:

• The sphincter is a muscle around the opening of the bladder. It squeezes to prevent urine from leaking into the urethra. This is the tube that urine passes through from your bladder to the outside.
• The bladder wall muscle relaxes so the bladder can expand.

When you urinate, the bladder wall muscle squeezes to force urine out of the bladder. As this happens, the sphincter muscle relaxes to allow the urine to pass through.

All of these systems must work together to control urination:

• Your bladder muscles and other parts of your urinary tract
• The nerves controlling your urinary system
• Your ability to feel and respond to the urge to urinate

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

URGE INCONTINENCE

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

Urge incontinence may result from:

• Bladder cancer
• Bladder inflammation
• Something blocking urine from leaving the bladder
• Bladder stones
• Infection
• Brain or nerve problems, such as multiple sclerosis or stroke
• Nerve injury, such as from a spinal cord injury

In men, urge incontinence also may be due to:

• Bladder changes caused by an enlarged prostate, called benign prostatic hyperplasia (BPH)
• An enlarged prostate blocking urine from flowing from the bladder

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 older adults.

Symptoms include:

• Not being able to control when you pass urine
• Having to urinate often during the day and night
• Needing to urinate suddenly and urgently

During a physical exam, your health care provider will look at your belly and rectum.

• Women will have a pelvic exam.
• Men will have a genital exam.

In most cases, the physical exam will not find any problems. If there are nervous system causes, other problems also may be found.

Tests include the following:

• Cystoscopy to view the inside of your bladder.
• Pad test. You exercise while wearing a sanitary pad. Then the pad is weighed to find out how much urine you lost.
• Pelvic or abdominal ultrasound.
• Post void residual to measure the amount of urine left after you urinate.
• Urinalysis to check for infection.
• Urinary stress test (you stand with a full bladder and cough).
• Urine cytology to rule out bladder cancer.
• Urodynamic studies to measure pressure and urine flow.
• X-rays with contrast dye to look at your kidneys and bladder.
• Voiding diary to assess your fluid intake, urine output, and urination frequency.

Treatment depends on how bad your symptoms are and how they affect your life.

There are four main treatment approaches for urge incontinence:

• Bladder and pelvic floor muscle training
• Lifestyle changes
• Medication
• Surgery

BLADDER RETRAINING

Managing urge incontinence most often begins with bladder retraining. This helps you become aware of when you lose urine because of bladder spasms. Then you relearn the skills you need to hold and release urine.

• You set a schedule of times when you should try to urinate. You try to avoid 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 to 4 hours.

PELVIC FLOOR MUSCLE TRAINING

Sometimes, Kegel exercises, biofeedback, or electrical stimulation may be used with bladder retraining. These methods help strengthen the muscles of your pelvic floor:

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

• You squeeze your pelvic floor muscles like you are trying to stop the flow of urine.
• Do this for 10 seconds, and then relax for 10 seconds.
• Repeat 10 times, three times a day.

Vaginal cones. This is a weighted cone that is inserted into the vagina to strengthen the pelvic floor muscles.

• You place the cone into the vagina.
• Then you try to squeeze your pelvic floor muscles to hold the cone in place.
• You can wear the cone for up to 15 minutes at a time, 2 times a day.

Biofeedback. This method can help you learn to identify and control your pelvic floor muscles.

• 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. This uses a gentle electrical current to contract your bladder muscles.

• The current is delivered using an anal or vaginal probe.
• This therapy may be done at the health care provider's office or at home.
• Treatment sessions usually last 20 minutes and may be done every 1 to 4 days.

Percutaneous tibial nerve stimulation (PTNS). This treatment may help some women with overactive bladder.

• An acupuncture needle is placed behind the ankle, and electrical stimulation is used for 30 minutes.
• Most often, treatments will occur weekly for around 12 weeks, and perhaps monthly after that.

LIFESTYLE CHANGES

Pay attention to how much water you drink and when you drink.

• Drinking enough water will help keep odors away.
• Drink a little bit of fluid at a time throughout the day, so your bladder does not need to handle a large amount of urine at one time. Drink less than 8 ounces (240 milliliters) at one time.
• Do not drink large amounts of fluids with meals.
• 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
• Artificial sweeteners

Avoid activities that irritate the urethra and bladder. This includes taking bubble baths or using harsh soaps.

MEDICATION

Medicines used to treat urge incontinence relax bladder contractions and help improve bladder function. There are several types of medicines 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).
• Beta agonist drugs can also help relax the muscles of the bladder. The only medicine of this type currently is mirabegron (Myrbetriq).
• 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) help "paralyze" the smooth muscle of the bladder.
• Botox injections are commonly used to treat overactive bladder. The medicine is injected into the bladder through a cystoscope. The procedure is most often done in the health care provider's office.

These medicines may have side effects such as dizziness or dry mouth. Talk with your health care provider if you notice bothersome side effects.

If you have an infection, your health care provider will prescribe antibiotics. Be sure to take the entire amount as directed.

SURGERY

Surgery can help your bladder store more urine. It can also help relieve the pressure on your bladder. Surgery is only used for people who have too many spasms and are not able to store much urine.

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

Possible complications include:

• Blood clots
• Bowel blockage
• Infection
• Pneumonia
• Slightly increased risk of tumors
• Not being able to empty your bladder

There is a risk of forming tube-like passages from the bladder to other organs or your skin. These are called urinary fistulae. They can lead to:

• Urine draining out in an unusual way, such as from your vagina
• Urinary tract infection
• Difficulty urinating

Sacral nerve stimulation. A small unit is implanted under your skin. This sends small electrical pulses to the sacral nerve (one of the nerves that comes out at the base of your spine). The electrical pulses can be adjusted to help relieve your symptoms.

Urinary incontinence is a long-term (chronic) problem. While treatments can cure your condition, you should still to see your health care provider to make sure you are doing well and check for possible problems.

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.

Getting better takes time, so try to be patient. A small number of people need surgery to control their symptoms.

Physical complications are rare. The condition may get in the way of social activities, careers, and relationships. It can also make you feel bad about yourself.

Rarely, this condition can cause severe increases in bladder pressure, which can lead to kidney damage.

Call your health care provider if:

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

Starting bladder retraining techniques early may help relieve your symptoms.