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    Urge incontinence

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

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

    Causes

    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)

    Exams 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.

    Outlook (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.

    Possible 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.

    When to Contact a Medical Professional

    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.

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    • Female urinary tract

      illustration

    • Male urinary tract

      illustration

      • Female urinary tract

        illustration

      • Male urinary tract

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      A Closer Look

        Talking to your MD

          Self Care

            Tests for Urge incontinence

              Review Date: 9/16/2011

              Reviewed By: 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.

              The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. © 1997- A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.
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