Urge Incontinence

See Also

Mechanism

PVC: "Premature Vesicular Contraction"
1. Dial (2003) AAFP Board Review, Seattle
Overly sensitive Bladder
1. Urge to void is perceived
Inhibition of detrussor contraction is ineffective
1. Detrussor hyperactivity

Epidemiology

Most common Urinary Incontinence in elderly (70%)

Etiologies

Neurologic
1. Stroke
2. Demyelinating disease
Local Irritation
1. Urinary Tract Infection
2. Bladder tumor
Idiopathic (most common)

Signs and Symptoms

Irresistable urge to void
Urge preceeded by various stimulation
1. Posture change
2. Hear or feel water
3. Laugh or cough
Urine Volume lost
1. Few drops to entire Bladder contents
Urine loss timing
1. Begins seconds after trigger
2. Continues beyond trigger while detrussor contracts
Low FSV and low Bladder capacity
1. See Bladder Stress Test

Diagnostics

Post-Void Residual normal (<100 cc)
1. Sterile in-out catheterization or
2. Ultrasound measurement of post-void residual
Cystoscopy indications
1. Hematuria
2. Recurrent Urinary Tract Infection
3. 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
General

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
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
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

General
1. Medications are only an adjunct to behavioral therapy (see above)
2. Urge Incontinence and mixed Incontinence are rarely controlled with medications alone
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)
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)
Agents that are not recommended
1. Indwelling catheters are not recommended (except as a last resort in refractory, severe cases)
2. Estrogen not recommended
  1. Oral Estrogen Replacement may exacerbate Incontinence
  2. Intravaginal preparations lack evidence to support

Management
Procedures (Refractory cases)

Indicated when first and second-line therapies fail to control significant symptoms (see above)
OnabotulinumtoxinA (Botox)
1. Office-based procedure with injection into detrussor muscle
2. Indicated for refractory Urge Incontinence
3. Symptoms improve for 3-6 months following injection
4. Duthie (2011) Cochrane Database Syst Rev (12): CD005493
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]
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
7. 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
1. http://www.auanet.org/common/pdf/education/clinical-guidance/Overactive-Bladder.pdf

References