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Urge Incontinence / Overactive Bladder

Definition:
Overactive bladder is a problem with bladder function resulting in a sudden urge to urinate that is difficult to suppress. It may also cause incontinence, the involuntary loss of urine.

Overactive bladder, sometimes called an irritable bladder, affects about one in six men and women in the United States. Most men with overactive bladder are 65 and older. But women tend to be affected earlier — the prevalence rate begins to climb among women when they reach their mid-40s.

If you have overactive bladder, you may feel embarrassed, isolate yourself or limit your work and social life. A combination of treatments may greatly alleviate symptoms of overactive bladder and help you manage their impact on your daily life.

Causes:
Filling and emptying your bladder is a complex interplay of nerve signals and muscle activity. A problem anywhere throughout this system can contribute to overactive bladder and urge incontinence.

Normal bladder function
Your kidneys produce urine, which travels down a pair of long tubes from your kidneys to your bladder. Urine drains from your bladder through an opening at the bottom (neck) and flows out a short tube called the urethra (u-RE-thruh). In women, the urethral opening is located just above the vagina. In men, the urethral opening is at the tip of the penis.

Your bladder expands like a balloon to accommodate the flow of urine. When it's reached about half its capacity, nerve signals alert your brain, and you sense that your bladder is "full." By the time it's three-quarters full, you feel the need to urinate (void). When you urinate, nerve signals coordinate the relaxation of the pelvic floor muscles and the muscles surrounding the neck of the bladder and upper portion of the urethra (urinary sphincter muscles). The muscles of the bladder contract, forcing urine out.

Involuntary bladder contractions
The symptoms of overactive bladder occur in most cases because the muscles of the bladder involuntarily contract when it's still filling and only about half full. This contraction creates the urgent need to urinate. The urinary sphincter may remain constricted and prevent the bladder from emptying. If not, then a person experiences urge incontinence.

Causal or contributing factors
In many cases doctors can't exactly identify overactive bladder causes. Neurological disorders, such as Parkinson's disease or strokes, are often associated with overactive bladder.

Several factors may cause or contribute to symptoms similar to those of overactive bladder and your doctor will try to rule out these during an evaluation, because these require other specialized treatments. These include:
  • Urinary tract infection
  • Inflammation of tissues near the urinary tract
  • Abnormalities in the bladder, such as tumors
  • Factors that obstruct bladder outflow (enlarged prostate, constipation, bladder stones, or previous operations to treat other forms of incontinence)
  • Diabetes, which can cause excess urine production
  • Excess consumption of caffeine or alcohol
  • Medications that cause a rapid increase in urine production

Risk Factor:

As you grow older, you're at increased risk of developing overactive bladder, and you're also more susceptible to diseases and disorders that can contribute to problems with bladder function, such as enlarged prostate, inflammation of vaginal tissues and diabetes. Although common among older adults, overactive bladder and urge incontinence shouldn't be considered a normal part of aging.

When to seek medical advice:
Talk to your doctor if you experience urge incontinence or if other symptoms of overactive bladder disrupt your work schedule, social interactions and everyday activities. Don't avoid an evaluation and simply deal with the condition by wearing absorbent undergarments or pads. An overactive bladder and urge incontinence may occur because of a serious underlying problem, such as a bladder infection or a cancerous tumor.

Symptoms:

Overactive bladder symptoms may mean you:
  • Feel a strong, sudden urge to urinate
  • Experience urge incontinence, the unintended loss of urine immediately following an urgent need to urinate
  • Urinate frequently, usually eight or more times in 24 hours
  • Awaken two or more times in the night to urinate (nocturia)
You may be able to get to the toilet in time when you sense an urge to urinate and not suffer any leakage. Nonetheless, frequent and nighttime urination, as well as the need to suddenly "drop everything," can significantly disrupt your life.

Overactive bladder without urge incontinence — often called overactive bladder, dry — affects about two-thirds of the people with the disorder. When symptoms include urge incontinence, it's often referred to as overactive bladder, wet.

Dignosis:
Common clinical assessments
Your doctor may use an overactive bladder screening questionnaire to make a preliminary assessment of your symptoms. You may also be asked to keep a voiding diary for a few days. You'll record when, how much and what kind of fluids you consume; when you urinate; whether you feel an urge to urinate; and whether you experience incontinence. Your diary may reveal patterns that help your doctor understand your symptoms and identify contributing factors.

In a basic diagnostic workup, your doctor will look for clues that may also indicate contributing factors. The exam will include:
  • A medical history
  • A complete physical examination with particular focus on your abdomen and genitals
  • A urine sample to test for infection, traces of blood or other abnormalities
  • A neurological exam to identify sensory problems
Specialized tests
Your doctor may order urodynamic tests, which are used to assess the function of your bladder and its ability to empty itself steadily and completely. These tests usually require a referral to a specialist in urinary disorders (urologist) or urinary disorders in women (urogynecologist).
  • Measurements of postvoid residual urine. When you urinate or experience urinary incontinence, your bladder may not empty completely. The remaining urine volume (postvoid residual urine) may exacerbate symptoms of overactive bladder. To measure residual urine after you have voided, a thin tube (catheter) is passed through the urethra and into your bladder. The catheter drains the remaining urine, which can then be measured. Alternatively, a specialist may use an ultrasound scan, which translates sound waves into an image of your bladder and its contents.
  • Uroflowmetry. A uroflowmeter is a device into which you urinate to measure the volume and speed of your voiding. This device translates the data into a graph of changes in your flow rate.
  • Cystometry. Cystometry measures bladder pressure during filling. A catheter is used to fill your bladder slowly with warm water. Another catheter with a pressure-measuring sensor device will be placed in your rectum. This procedure can identify any involuntary muscle contractions, indicate the level of pressure at which you feel an urge or experience leakage, and measure pressure needed to empty your bladder.
  • Electromyography. Electromyography assesses the coordination of nerve impulses in the muscles of the bladder and the urinary sphincter. Sensors are placed either on the skin in your abdominal region or on catheters inserted into the urethra or rectum.
  • Video urodynamics. These procedures use either X-ray or ultrasound waves to create pictures of your bladder as it's filling and emptying. Your bladder is filled with the use of a catheter, and you urinate to empty your bladder. The fluid may contain a special dye that can be detected by X-ray technology. This test is often combined with cystometry.
  • Cystoscopy. A cystoscope, a thin tube with a tiny lens, enables your doctor to see the inside of your urethra and bladder. With the aid of this device, your doctor can check for abnormalities in your lower urinary tract, such as bladder stones or tumors.
Your doctor will review the results of these tests with you and suggest a treatment strategy.

Complication:
As might be expected, urge incontinence detracts from your overall quality of life, but frequent urination and nocturia can also be detrimental to your well-being. People with significant disruption from an overactive bladder are more susceptible to:
  • Depression
  • Low self-esteem
  • Anxiety
  • Fatigue
  • Poor attention or concentration
Some people may also have a disorder called mixed incontinence. This is usually the presence of both urge incontinence and stress incontinence. Stress incontinence is the loss of urine when you exert pressure on your bladder, as when you cough or laugh.

Treatment:
Your doctor is likely to recommend a combination of overactive bladder treatment strategies to alleviate your symptoms.

Behavioral interventions
Behavioral interventions can help you manage overactive bladder. If you experience urge incontinence, these interventions alone aren't likely to result in complete dryness, but they will reduce the number of incontinence episodes. The interventions your doctor will recommend may cover the following areas:
  • Fluid consumption. Your doctor may recommend the amount and timing of fluid consumption during the day. You should also determine whether dietary irritants, particularly caffeinated and alcoholic beverages, cause or worsen your symptoms.
  • Fiber intake. Eat a diet rich in fiber, or take fiber supplements if instructed by your doctor, to avoid constipation.
  • Bladder training. Your doctor may recommend a strategy to train yourself to delay voiding when you feel an urge to urinate. You'll begin with very small delays, such as 10 minutes, and gradually work your way up to urinating every two to four hours.
  • Double voiding. If you have problems with residual urine, your doctor may recommend double voiding. After urinating, you wait a few minutes and then try again to empty your bladder completely.
  • Scheduled toilet trips. Your doctor may recommend a schedule for toileting so that you urinate at the same time every day — every two to four hours as recommended — rather than when you feel the urge to urinate.
  • Pelvic floor muscle exercises. Exercises called Kegels strengthen your pelvic floor muscles and urinary sphincter — muscles that are critical for holding urine even if your bladder muscles involuntarily contract. Kegels are then used to suppress the bladder's involuntary contractions. Your doctor or a physical therapist can help you learn how to do these exercises correctly.
  • Absorbent pads. You can wear absorbent pads or undergarments to protect your clothing and avoid embarrassing incidents if you do experience incontinence.
Medications
Clinical trial evidence shows that medications called anticholinergics (antispasmodics) are the most effective for alleviating symptoms of overactive bladder and reducing episodes of urge incontinence. These drugs include tolterodine (Detrol), oxybutynin (Ditropan), an oxybutynin skin patch (Oxytrol), trospium (Sanctura) and solifenacin (Vesicare).

The most common side effect of these drugs is dry mouth, but drinking water to alleviate thirst can exacerbate symptoms of overactive bladder. Your doctor may recommend that you suck on a piece of sugar-free candy or chew sugar-free gum to alleviate dry mouth. Extended-release forms of oxybutynin (Ditropan XL) and tolterodine (Detrol LA), the oxybutynin skin patch (Oxytrol), trospium (Sanctura) and solifenacin (Vesicare) tend to result in fewer side effects.

Surgery
Surgery to treat overactive bladder is reserved for people with severe cases who don't respond to other treatments. The goal is to improve the bladder's storing ability and reduce pressure in the bladder. Surgical interventions include :
  • Sacral nerve stimulator. In this procedure a small device, which resembles a pacemaker, is placed under the skin of your abdomen and is connected to a small wire placed near the sacral nerves near your tailbone. The sacral nerves are a primary link between the spinal cord and nerves in the bladder's tissues. Modulation of these nerve impulses can improve overactive bladder symptoms.
  • Augmentation cystoplasty. This reconstructive procedure, intended to increase the capacity of your bladder, uses pieces of your bowel to replace a portion of your bladder. If you undergo this procedure, you may need to use a catheter to empty your bladder.
Prevention:
As most causes of overactive bladder are unknown, prevention strategies are somewhat limited. Healthy lifestyle choices that may reduce your risk of overactive bladder include a regular exercise routine, a high-fiber diet, and limited consumption of caffeine and alcohol.
 
Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.
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