Bladder
Urge Incontinence
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Urge Incontinence
, Detrussor Instability, Overactive Bladder, Bladder Irritability
See Also
Incontinence
Low Pressure Urethra
(Type 3)
Overflow Incontinence
Urge Incontinence
Stress Incontinence
Functional Incontinence
Medication Causes of
Incontinence
Three Incontinence Questions
Enuresis
Epidemiology
Most common
Urinary Incontinence
in elderly (represents 70% of cases)
Prevalence
age 40: 9%
Prevalence
age 70: 31%
Mechanism
Detrussor overactivity
PVC: "Premature Vesicular Contraction"
Dial (2003) AAFP Board Review, Seattle
Overly sensitive
Bladder
Urge to void is perceived
Inhibition of detrussor contraction is ineffective
Detrussor hyperactivity
Causes
Neurologic
Stroke
Demyelinating disease
Local Irritation
Urinary Tract Infection
Bladder
tumor
Idiopathic (most common)
Medications
See
Medication Causes of Urinary Incontinence
Alcohol
Caffeine
Diuretic
s
Findings
Signs and Symptoms
Urinary Frequency
Irresistable urge to void
Urinary Urgency preceeded by various stimulation
Posture
change
Hear or feel water
Laugh or cough
Urine Volume
lost
Few drops to entire
Bladder
contents
Urine loss timing
Begins seconds after trigger
Continues beyond trigger while detrussor contracts
Often occurs while on the way to the toilet
Low FSV and low
Bladder
capacity
See
Bladder Stress Test
Diagnostics
Post-Void Residual normal (<100 cc)
Sterile in-out catheterization or
Ultrasound
measurement of post-void residual
Cyst
oscopy indications
Hematuria
Recurrent Urinary Tract Infection
Bladder Cancer
risk factors
Associated Conditions
Overactive Bladder
Urinary urgency, frequency,
Nocturia
and
Incontinence
May be caused by
Benign Prostatic Hyperplasia
Treatment is similar to Urge Incontinence below
Ouslander (2004) N Engl J Med 350:786-99 [PubMed]
Diagnosis
Exclude other symptoms causes with a minimum of careful history, exam and
Urinalysis
Consider adjunctive diagnostic tools (e.g.
Urine Culture
, post-void residual,
Bladder
diary)
Urodynamics, cystoscopy and renal/
Bladder Ultrasound
should be limited to second-line tests only when indicated
Management
Gene
ral
Background
Overactive Bladder is a symptom complex rather than a disease, and a reasonable strategy is "no treatment"
Educate patients on findings, diagnosis and treatment options
Gene
ral measures
Avoid
Diuretic
s including
Caffeine
Avoid
Constipation
Plan fluid intake earlier in the day to prevent sleep interruption
Weight loss
Behavioral measures (first-line treatment)
See
Bladder Retraining Drill
s
See
Kegel Exercise
s
Scheduled voiding every 2-3 hours
Prompted voiding and habit training
Indicated in cognitive
Impairment
Give reminders to void every 2-3 hours
Check for wetness at scheduled intervals to determine timing of voids
Schedule prompted voids at shorter intervals
Behavioral therapy is more effective then medication
Burgio (2002) JAMA 288:2293-9 [PubMed]
Wyman (1991) Urol Nurs 11:11-7 [PubMed]
Management
Medications
Gene
ral
Medications are only an adjunct to behavioral therapy (see above)
Urge Incontinence and mixed
Incontinence
are rarely controlled with medications alone
Bladder Relaxant
s (M2/M3 antimuscarinics)
See
Bladder Antispasmodic
s
Preferred pharmacologic agents in Urge Incontinence
Use with caution and after refractory to other methods in elderly
Avoid in
Dementia
,
Intestinal Obstruction
and
Narrow Angle Glaucoma
Use with caution in
Urinary Retention
,
Delayed Gastric Emptying
and with other
Anticholinergic Agent
s
Inhibits involuntary detrusor contractions
Bladder Relaxant
efficacy is modest
Reduce
Incontinence
episodes from 3 to 1-2 per day in women
Reduces the number of voids from 11 to 9-10 per day in women
Reduces the number of urgent voids from 6 to 2-3 per day
Expect
Dry Mouth
and
Constipation
and treat symptomatically
See
Xerostomia
See
Functional Constipation
Medications (long-acting agents are preferred)
Non-selective antimuscarinics (block M1 in addition to M2/M3 - risk of cognitive
Impairment
)
Oxybutinin XR (
Ditropan
XR)
Reduces
Incontinence
episodes 28%
Tolterodine
XR (
Detrol
LA)
Offers similar benefit to Oxybutinin with less
Anticholinergic
side effects
Oxytrol (transdermal antispasmodic patch)
M3 Selective antimuscarinics (may be preferred where cognition effects are of concern)
Solifenacin
(
Vesicare
)
Darifenacin
(
Enablex
)
Other agents used in Urge Incontinence
Anticholinergic
(Propantheline,
Imipramine
)
Inhibits detrussor contraction
Increases
Bladder
capacity
Beta-3 Adrenergic Agonist
s (detrussor relaxants, expensive)
Mirabegron
(
Myrbetriq
)
Reduces
Incontinence
by 1-2 episodes per day
Risk of increased
Blood Pressure
and
Heart Rate
(do not use in
Uncontrolled Hypertension
)
Sacco (2012) Ther adv urol 4(6): 315-24 [PubMed]
Vibegron
(
Gemtesa
)
Similar to
Mirabegron
without the effects on
Heart Rate
,
Blood Pressure
or
Drug Interaction
s
Alpha-blocker medications if BPH present
Examples:
Terazosin
(
Hytrin
),
Tamsulosin
(
Flomax
)
Intravaginal
Estrogen
May improve
Urinary Incontinence
urge symptoms (limited evidence)
Agents that are not recommended
Indwelling catheters are not recommended (except as a last resort in refractory, severe cases)
Systemic
Estrogen
not recommended
Oral
Estrogen Replacement
may exacerbate
Incontinence
Management
Procedures (Refractory cases)
Indicated when first and second-line therapies fail to control significant symptoms (see above)
OnabotulinumtoxinA (
Botox
)
Office-based procedure with injection into detrussor
Muscle
via cystoscopy
Indicated for refractory Urge Incontinence
Symptoms improve for 3-6 months following injection
May be repeated every 6 months as needed for recurrent symptoms
Duthie (2011) Cochrane Database Syst Rev (12): CD005493
Posterior tibial nerve stimulation, or PTNS (office procedure)
Needle electrode applied at posterior tibial nerve near medial meniscus of ankle
Current administered in 30 minute sessions
Reduces Urge Incontinence in up to 75% of patients
Peters (2009) J Urol 182(3): 1055-61 [PubMed]
Implanted Electrical Stimulation Device or Sacral Neuromodulation, SNS (Surgically implanted)
Severe and refractory Urge Incontinence
Gene
rator implanted in buttocks or low back
Lead placed in sacral foramen into S3 Nerve or to
Inhibits detrusor
Muscle Contraction
s
Expensive: $10,000 for device; $10,000 for surgery
Highly effective (improvement in 60-90% of patients)
Amundsen (2002) Am J Obstet Gynecol 187:1462-5 [PubMed]
Resources
Gomley (2014) Diagnosis and treatment of Overactive Bladder (non-neurogenic) in adults: AUA/SUFU Guideline
http://www.auanet.org/common/pdf/education/clinical-guidance/Overactive-Bladder.pdf
References
(2017) Presc Lett 24(5): 28
Appell (2001) Mayo Clin Proc 76:358-63 [PubMed]
Hersh (2013) Am Fam Physician 87(9): 634-40 [PubMed]
Hu (2019) Am Fam Physician 100(6): 339-48 [PubMed]
Khadelwal (2013) Am Fam Physician 87(8): 543-50 [PubMed]
Weiss (2005) Am Fam Physician 71:315-22 [PubMed]
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