What is Urge Incontinence?
Urge incontinence is the involuntary loss of urine associated with a strong urge to urinate. Large volumes of urine can be expelled as the bladder contracts involuntarily. This condition can begin a urinary urgency (strong urges to urinate) or frequency (having to void more often that desired) and progress to urine loss with urgency before making it to the bathroom.
What are the Causes of Urge Incontinence?
The bladder detrusor muscle can become irritable and contract involuntarily due to reasons such as:
- Childbirth, especially a vaginal delivery
- Pelvic surgery or radiation
- Lower back injuries or surgery
- Neurologic conditions such as stroke, Parkinsons or Multiple Sclerosis
- Bladder outlet obstruction such as with vaginal prolapse
- Bladder stones or tumors
What are the Symptoms of Urge Incontinence?
Urge incontinence is characterized by a sudden loss of urine associated with a strong urge to urinate, and involve loss of large volumes of urine. It can be associated with:
- Need to urinate more frequently than normal
- Frequent strong urges to urinate
- Need to get up multiple times during the night to urinate
- Leaking before reaching the toilet when an urge strikes
How is Urge Incontinence Diagnosed?
Your doctor will review your medical history and perform a physical exam, which may include a pelvic exam and a rectal exam. The other diagnostic tests include:
- Urine sample to detect traces of blood, infection, and other abnormalities
- Urinary stress test where your doctor observes urine loss when you cough or bend downwards
Bladder function tests may include:
- Pelvic ultrasound scan to measure the amount of residual urine in your bladder after you urinate.
- Multichannel Urodynamics: Pressures are measured as the bladder fills and empties by administering a sterile fluid into the bladder. During the test, bladder, urethral and abdominal pressures are measured on a computer and the obtained tracings will help achieve an accurate diagnosis.
- Cystoscopy: In this test, a scope is inserted into your bladder to detect any blockages or other abnormalities in the bladder and urethra.
What are the Treatment Options for Urge Incontinence?
Urge incontinence is best treated through a combination of approaches. These include:
Lifestyle Changes/Behavioral and Physical Therapy
Behavioral therapy or lifestyle changes include:
- Voiding on a regular schedule and not waiting for an urge to occur. The interval between voids can be increased until an acceptable interval is reached.
- Regular Kegel exercises to strengthen pelvic floor muscles and urinary sphincter
- If you are unable to perform effective Kegel exercises, you may be referred to a trained Women’s Health Physical Therapist who has an expertise in teaching women how to perform proper pelvic floor muscle contractions.
- Consume a fiber-rich diet to avoid constipation
- Regulate your fluid consumption in terms of volume, frequency, and the time of consumption
- Avoid carbonated, caffeinated, and alcoholic beverages as they may irritate and affect the bladder function
- Quit smoking, shed excess weight, and treat chronic coughing
Medications
There are multiple specific FDA approved drug to treat urge incontinence in the United States. Most of the older medications are called anti-cholinergic medications which relax the bladder muscle, but can cause significant side effects such as dry mouth, constipation and may affect memory and cognition. These include oxybutynin (Ditropan), toleterodine (Detrol), fesoterodine (Toviaz), and solifenacin (Vesicare). Trospium (Sanctura) has similar properties, but is a larger molecule which does not cross into the brain and affect cognition, and may be preferable in elderly women.
Newer medications affect the receptors in the bladder wall directly and have less side effects. The main medication in this class is Mirabegron (Myrbetriq). This medication does not affect brain function or cognition and thus is preferable in elderly women.
If initial therapy with behavioral modification (scheduled voiding), Pelvic Floor exercises (Kegel exercises) and medications do not improve a patient’s symptoms sufficiently, referral to a Women’s Health Physical Therapist can be helpful in enhancing Pelvic Floor strength and efficient utilization of the Pelvic Floor muscles such that strong urges can be dissipated.
Many patients will not respond satisfactorily to first line therapies as above. Additional approved therapies are available to reduced involuntary bladder contractions. These include:
Botox injection therapy: Botulinum toxin has many applications in medicine. Blocking involuntary nerve impulses that result in bladder contractions can be achieved by injecting Botox into the bladder muscle via a cystoscopy procedure in the office or ambulatory surgery. Botox injections can be very effective and are covered by insurance companies, but have to be repeated every 6 months, and if too much is injected can result in retention of urine which may require catheterization until the effect of the injections wears off. Finding the right dosage of Botox can thus take a few injections.
Neuromodulation: Reducing involuntary bladder contractions by altering the nerve impulses that reach the bladder can be achieved by electrical stimulation of nerve fibers. This can be performed either peripherally (along an extremity) or centrally (near the spine).
- PTNS (Posterior tibial nerve stimulation) - involves stimulation of a nerve located behind the ankle with a little needle. The impulse travels back to the spine and leads to stimulation of the nerves going to the bladder. This procedure is performed in the office and requires weekly 30 minute visits for a period of 12 weeks. If a satisfactory response is achieved, maintenance therapy is continued with monthly sessions.
- Sacral Nerve Stimulation (SNS) - involves stimulation of the nerve fibers that exit the spine and go directly to the bladder. This procedure is typically performed in two steps. Step or Phase 1 involved placing a small electrode very near the nerve that exists the sacral (tail bone) spine. This is done under light anesthesia and fluoroscopic (x-ray) guidance. The electrode is then connected to an external battery. After a 1-2 week trial stimulation during which the therapy is tested for clinical response, the permanent battery can be implanted at a second Step (Phase 2) – also under light anesthesia. The battery is only placed if a successful trial period is demonstrated. Current technology includes a rechargeable battery and the ability to adjust stimulation parameters in order to optimize reduction of bladder symptoms. SNS can also be performed for Urinary Retention and Fecal Incontinence (See section on Sacral Neuromodulation).
Surgery
Surgery is not recommended for advanced Urge Incontinence symptoms unless all other proven therapies have failed. Available surgeries involve enlarging bladder capacity, and have not been submitted to large clinical trials with long term follow up. Thus, any surgery for Urge Incontinence will only be considered under individualized circumstances.
