Urge Incontinence

Background:

Urge incontinence involves a strong, sudden need to urinate, then the bladder contracts, leading to urine leakage.

Causes:

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 a 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 approximately 200 ml of urine fills up 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 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 diseases (such as multiple sclerosis)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:

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

Exams and Tests

During a physical examination, the health care provider will look at the abdomen and rectum and perform a pelvic exam.
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)
• 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)

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 agents (oxybutynin, tolterodine, enablex, sanctura, vesicare, oxytrol)
• Antispasmodic medications (flavoxate)
• Tricyclic antidepressants (imipramine, doxepin)

Oxybutynin (Ditropan) and tolterodine (Detrol) are medications to relax the smooth muscle of the bladder. 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 anticholinergic 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 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

Estrogen vaginal therapy (preferably with estriol vaginal crème or suppositories) can be used to improve urinary frequency, urgency, and burning in postmenopausal women. It also can improve the tone and blood supply of the urethral sphincter muscles.

Diet

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. 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.

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.
Our therapists place a sensor in the vagina (for women) 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.
About 85% of people who use biofeedback for Kegel exercises report symptom improvement.
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 is performed in the clinic. Treatment sessions usually last 45 minutes and may be performed every 4 to 7 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.

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

• Blood clots
• Bowel obstruction
• Infection
• Pneumonia

There is a risk of developing abnormal tube-like 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.