Bladder

Urge Incontinence

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Urge Incontinence, Detrussor Instability, Overactive Bladder, Bladder Irritability

  • Epidemiology
  1. Most common Urinary Incontinence in elderly (represents 70% of cases)
    1. Prevalence age 40: 9%
    2. Prevalence age 70: 31%
  • Mechanism
  1. Detrussor overactivity
    1. PVC: "Premature Vesicular Contraction"
    2. Dial (2003) AAFP Board Review, Seattle
  2. Overly sensitive Bladder
    1. Urge to void is perceived
  3. Inhibition of detrussor contraction is ineffective
    1. Detrussor hyperactivity
  • Causes
  1. Neurologic
    1. Stroke
    2. Demyelinating disease
  2. Local Irritation
    1. Urinary Tract Infection
    2. Bladder tumor
  3. Idiopathic (most common)
  4. Medications
    1. See Medication Causes of Urinary Incontinence
    2. Alcohol
    3. Caffeine
    4. Diuretics
  • Findings
  • Signs and Symptoms
  1. Urinary Frequency
  2. Irresistable urge to void
  3. Urinary Urgency preceeded by various stimulation
    1. Posture change
    2. Hear or feel water
    3. Laugh or cough
  4. Urine Volume lost
    1. Few drops to entire Bladder contents
  5. Urine loss timing
    1. Begins seconds after trigger
    2. Continues beyond trigger while detrussor contracts
    3. Often occurs while on the way to the toilet
  6. Low FSV and low Bladder capacity
    1. See Bladder Stress Test
  • Diagnostics
  1. Post-Void Residual normal (<100 cc)
    1. Sterile in-out catheterization or
    2. Ultrasound measurement of post-void residual
  2. Cystoscopy indications
    1. Hematuria
    2. Recurrent Urinary Tract Infection
    3. Bladder Cancer risk factors
  • Associated Conditions
  • Overactive Bladder
  1. Urinary urgency, frequency, Nocturia and Incontinence
  2. May be caused by Benign Prostatic Hyperplasia
  3. Treatment is similar to Urge Incontinence below
  4. Ouslander (2004) N Engl J Med 350:786-99 [PubMed]
  • Diagnosis
  1. Exclude other symptoms causes with a minimum of careful history, exam and Urinalysis
  2. Consider adjunctive diagnostic tools (e.g. Urine Culture, post-void residual, Bladder diary)
  3. Urodynamics, cystoscopy and renal/Bladder Ultrasound should be limited to second-line tests only when indicated
  • Management
  • General
  1. Background
    1. Overactive Bladder is a symptom complex rather than a disease, and a reasonable strategy is "no treatment"
    2. Educate patients on findings, diagnosis and treatment options
  2. General measures
    1. Avoid Diuretics including Caffeine
    2. Avoid Constipation
    3. Plan fluid intake earlier in the day to prevent sleep interruption
    4. Weight loss
  3. Behavioral measures (first-line treatment)
    1. See Bladder Retraining Drills
    2. See Kegel Exercises
    3. Scheduled voiding every 2-3 hours
    4. Prompted voiding and habit training
      1. Indicated in cognitive Impairment
      2. Give reminders to void every 2-3 hours
      3. Check for wetness at scheduled intervals to determine timing of voids
        1. Schedule prompted voids at shorter intervals
    5. Behavioral therapy is more effective then medication
      1. Burgio (2002) JAMA 288:2293-9 [PubMed]
      2. Wyman (1991) Urol Nurs 11:11-7 [PubMed]
  • Management
  • Medications
  1. General
    1. Medications are only an adjunct to behavioral therapy (see above)
    2. Urge Incontinence and mixed Incontinence are rarely controlled with medications alone
  2. Bladder Relaxants (M2/M3 antimuscarinics)
    1. See Bladder Antispasmodics
    2. Preferred pharmacologic agents in Urge Incontinence
      1. Use with caution and after refractory to other methods in elderly
      2. Avoid in Dementia, Intestinal Obstruction and Narrow Angle Glaucoma
      3. Use with caution in Urinary Retention, Delayed Gastric Emptying and with other Anticholinergic Agents
    3. Inhibits involuntary detrusor contractions
    4. Bladder Relaxant efficacy is modest
      1. Reduce Incontinence episodes from 3 to 1-2 per day in women
      2. Reduces the number of voids from 11 to 9-10 per day in women
    5. Expect Dry Mouth and Constipation and treat symptomatically
      1. See Xerostomia
      2. See Functional Constipation
    6. Medications (long-acting agents are preferred)
      1. Non-selective antimuscarinics (block M1 in addition to M2/M3 - risk of cognitive Impairment)
        1. Oxybutinin XR (Ditropan XR)
          1. Reduces Incontinence episodes 28%
        2. Tolterodine XR (Detrol LA)
          1. Offers similar benefit to Oxybutinin with less Anticholinergic side effects
        3. Oxytrol (transdermal antispasmodic patch)
      2. M3 Selective antimuscarinics (may be preferred where cognition effects are of concern)
        1. Solifenacin (Vesicare)
        2. Darifenacin (Enablex)
  3. Other agents used in Urge Incontinence
    1. Anticholinergic (Propantheline, Imipramine)
      1. Inhibits detrussor contraction
      2. Increases Bladder capacity
    2. Beta-adrenergic agonists (detrussor relaxants)
      1. Mirabegron (Myrbetriq)
        1. Reduces Incontinence by 1-2 episodes per day
        2. Risk of increased Blood Pressure (do not use in Uncontrolled Hypertension)
        3. Sacco (2012) Ther adv urol 4(6): 315-24 [PubMed]
    3. Alpha-blocker medications if BPH present
      1. Examples: Terazosin (Hytrin), Tamsulosin (Flomax)
    4. Intravaginal Estrogen
      1. May improve Urinary Incontinence urge symptoms (limited evidence)
  4. Agents that are not recommended
    1. Indwelling catheters are not recommended (except as a last resort in refractory, severe cases)
    2. Systemic Estrogen not recommended
      1. Oral Estrogen Replacement may exacerbate Incontinence
  • Management
  • Procedures (Refractory cases)
  1. Indicated when first and second-line therapies fail to control significant symptoms (see above)
  2. OnabotulinumtoxinA (Botox)
    1. Office-based procedure with injection into detrussor muscle via cystoscopy
    2. Indicated for refractory Urge Incontinence
    3. Symptoms improve for 3-6 months following injection
    4. May be repeated every 6 months as needed for recurrent symptoms
    5. Duthie (2011) Cochrane Database Syst Rev (12): CD005493
  3. Posterior tibial nerve stimulation, or PTNS (office procedure)
    1. Needle electrode applied at posterior tibial nerve near medial meniscus of ankle
    2. Current administered in 30 minute sessions
    3. Reduces Urge Incontinence in up to 75% of patients
    4. Peters (2009) J Urol 182(3): 1055-61 [PubMed]
  4. Implanted Electrical Stimulation Device or Sacral Neuromodulation, SNS (Surgically implanted)
    1. Severe and refractory Urge Incontinence
    2. Generator implanted in buttocks or low back
    3. Lead placed in sacral foramen into S3 Nerve or to
    4. Inhibits detrusor muscle contractions
    5. Expensive: $10,000 for device; $10,000 for surgery
    6. Highly effective (improvement in 60-90% of patients)
    7. Amundsen (2002) Am J Obstet Gynecol 187:1462-5 [PubMed]
  • Resources
  1. Gomley (2014) Diagnosis and treatment of Overactive Bladder (non-neurogenic) in adults: AUA/SUFU Guideline
    1. http://www.auanet.org/common/pdf/education/clinical-guidance/Overactive-Bladder.pdf