II. Epidemiology

  1. Most common Urinary Incontinence in elderly (represents 70% of cases)
    1. Prevalence age 40: 9%
    2. Prevalence age 70: 31%

III. 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

IV. 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

V. 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

VI. 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

VII. 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]

VIII. 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

IX. 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]

X. 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
      3. Reduces the number of urgent voids from 6 to 2-3 per day
    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-3 Adrenergic Agonists (detrussor relaxants, expensive)
      1. Mirabegron (Myrbetriq)
        1. Reduces Incontinence by 1-2 episodes per day
        2. Risk of increased Blood Pressure and Heart Rate (do not use in Uncontrolled Hypertension)
        3. Sacco (2012) Ther adv urol 4(6): 315-24 [PubMed]
      2. Vibegron (Gemtesa)
        1. Similar to Mirabegron without the effects on Heart Rate, Blood Pressure or Drug Interactions
    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

XI. 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]

XII. 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

Images: Related links to external sites (from Bing)

Related Studies

Ontology: Urge Incontinence (C0150045)

Definition (CCC) Involuntary passage of urine following a sense of urgency to void
Definition (NAN) Involuntary passage of urine occurring soon after a strong sense of urgency to void
Definition (MSH) Involuntary discharge of URINE that is associated with an abrupt and strong desire to void. It is usually related to the involuntary contractions of the detrusor muscle of the bladder (detrusor hyperreflexia or detrusor instability).
Concepts Sign or Symptom (T184)
MSH D053202
ICD9 788.31
ICD10 N39.41
SnomedCT 207173003, 87557004, 129854001, 236658007
LNC MTHU013458
English Urge incontinence, Lack blad contrl desire resist, Lack blad control desire urgnt, [D] Urge incontinence (context-dependent category), Incontinence, Urge, Incontinence, Urinary Reflex, Urinary Incontinence, Urge, Urinary Reflex Incontinence, Urinary Urge Incontinence, [D] Urge incontinence, urge incontinence of urine (diagnosis), urge incontinence of urine, Urge incontinence syndrome, rndx urge urinary incontinence, rndx urge urinary incontinence (diagnosis), Urinary Incontinence, Urge [Disease/Finding], incontinence urge, urge urinary incontinence, urge incontinence, urinary urge incontinence, [D] Urge incontinence (situation), Urge urinary incontinence (finding), Urge Urinary Incontinence, Lack of bladder control if desire resisted, Lack of bladder control if desire urgent, Must urinate at once with urge, Urge incontinence of urine, Urge incontinence of urine (finding), Urge urinary incontinence, URGE URINARY INCONTINENCE, incontinence; urge, incontinence; urinary, urge, urge; incontinence, urine; incontinence, urge, Urge Incontinence
Italian Incontinenza da urgenza allo stimolo, Sindrome da incontinenza urinaria da sforzo, Incontinenza urinaria da urgenza, Incontinenza urinaria riflessa, Incontinenza da urgenza
Dutch urge-incontinentiesyndroom, incontinentie; urge, incontinentie; urine, urge, urge; incontinentie, urine; incontinentie, urge, urge-incontinentie
German Dranginkontinenzsyndrom, Drangurininkontinenz, Drangharninkontinenz, Dranginkontinenz
Portuguese Síndrome de incontinência de stress, Incontinência Urinária de Urgência, Incontinência de Urgência, Incontinência de urgência
Spanish Síndrome de incontinencia, Incontinencia Urinaria de Urgencia, [D]incontinencia de urgencia (categoría dependiente del contexto), [D]incontinencia de urgencia (situación), [D]incontinencia de urgencia, incontinencia urinaria por tenesmo vesical, incontinencia urinaria por tenesmo vesical (hallazgo), incontinencia por tenesmo vesical (hallazgo), incontinencia por tenesmo vesical, Incontinencia por tenesmo vesical
Japanese 切迫性尿失禁症候群, セッパクセイニョウシッキンショウコウグン, セッパクセイニョウシッキン, 切迫失禁, 逼迫性尿失禁, 急迫尿失禁, 失禁-急迫, 尿失禁-急迫性, 急迫性尿失禁, 切迫尿失禁, 尿失禁-切迫性, 失禁-切迫, 急迫失禁, 切迫性尿失禁
Swedish Trängningsinkontinens
French Syndrome d'incontinence impérieuse, Miction impérieuse incontrôlable, Incontinence urinaire par impériosité, Incontinence urinaire par urgenturie, Incontinence aiguë
Finnish Ylivuotoinkontinenssi
Czech moč - inkontinence reflexní, moč - inkontinence nutkavá, Syndrom urgentní inkontinence, Urgentní inkontinence, reflexní inkontinence moči, urgentní inkontinence, urgentní inkontinence moči, moč - inkontinence urgentní
Polish Nietrzymanie moczu wywołane naglącym parciem, Nietrzymanie moczu naglące, Nietrzymanie moczu odruchowe spowodowane naglącym parciem, Odruchowe nietrzymanie moczu spowodowane naglącym parciem
Hungarian urgens incontinentia, Urgens incontinentia syndroma
Norwegian Urgeinkontinens

Ontology: Overactive Bladder (C0878773)

Definition (MEDLINEPLUS)

Overactive bladder is a condition in which the bladder squeezes urine out at the wrong time. You may have overactive bladder if you have two or more of these symptoms:

  • You urinate eight or more times a day or two or more times at night
  • You have the sudden, strong need to urinate immediately
  • You leak urine after a sudden, strong urge to urinate

You also may have incontinence, a loss of bladder control. Nerve problems, too much fluid, or too much caffeine can cause it. Often the cause is unknown.

Your doctor may prescribe a medicine that can calm muscles and nerves. The medicine may come as a pill, a liquid, or a patch. The medicines can cause your eyes to become dry. They can also cause dry mouth and constipation. To deal with these effects, use eye drops to keep your eyes moist, chew sugarless gum or suck on sugarless hard candy if dry mouth bothers you, and take small sips of water throughout the day.

NIH: National Institute of Diabetes and Digestive and Kidney Diseases

Definition (MSH) Symptom of overactive detrusor muscle of the URINARY BLADDER that contracts with abnormally high frequency and urgency. Overactive bladder is characterized by the frequent feeling of needing to urinate during the day, during the night, or both. URINARY INCONTINENCE may or may not be present.
Concepts Disease or Syndrome (T047)
MSH D053201
ICD9 596.51
ICD10 N32.81
SnomedCT 9009001, 314717001, 236633002
English Hypertonicity of bladder, Overactive Bladder, Bladder, Overactive, Overactive Urinary Bladder, Urinary Bladder, Overactive, hyperactivity of bladder, hypertonicity of bladder, hyperactivity of bladder (diagnosis), hypertonicity of bladder (diagnosis), bladder hypertonicity, bladder hyperactivity, Urinary Bladder, Overactive [Disease/Finding], bladder hyperactive, overactive bladder, bladders overactive, bladder overactive, hyperactive bladder, hypertonic bladder, hyperactivity bladder, Hypertonic bladder (disorder), Hypertonic bladder, bladder; overactive, overactive; bladder, Hyperactivity of bladder, Overactive bladder, Hyperactive bladder
Italian Vescica ipertonica, Ipertonicità vescicale, Vescica iperattiva, Vescica urinaria iperattiva
Dutch hypertoniciteit van de blaas, hyperactieve blaas, overactieve blaas, blaas; overactief, overactief; blaas, hypertonische blaas
French Hypertonicité de la vessie, Vessie hyperactive, Vessie hypertonique
German hyperaktive Blase, Überaktive Harnblase, OAB-Syndrom, Harnblase, überaktive, Harnblase, instabile, Harnblasenüberaktivität, Überaktive Blase, Instabile Harnblase, ueberaktive Blase, Hypertonus der Blase
Portuguese Bexiga superactiva, Bexiga hiperactiva, Hipertonicidade vesical, Bexiga Urinária Hiperativa, Bexiga hipertónica
Spanish Vejiga urinaria hiperreactiva, Vejiga urinaria hiperactiva, Hipertonía de la vejiga, Vejiga Urinaria Hiperactiva, hipertonicidad de la vejiga, hipertonicidad vesical, vejiga hipertónica (trastorno), vejiga hipertónica, Vejiga hipertónica
Japanese 過活動性膀胱, 緊張性膀胱, カカツドウセイボウコウ, キンチョウセイボウコウ, OAB症候群, 尿意切迫-頻尿症候群, 過活動膀胱, 膀胱-過活動, 膀胱過活動, 過活動膀胱症候群
Swedish Överaktiv blåsa
Finnish Yliaktiivinen virtsarakko
Czech močový měchýř hyperaktivní, Hypertonie močového měchýře, Hypertonický močový měchýř, Hyperaktivní močový měchýř
Polish Zespół pęcherza nadreaktywnego, Pęcherz moczowy nadreaktywny, Nadreaktywny pęcherz moczowy
Hungarian hypertoniás húgyhólyag, Húgyhólyag hypertonus, Hyperactiv húgyhólyag, Hyperactiv hólyag
Norwegian Urinblære, overaktiv, Overaktiv blære, Overaktiv urinblære, Blære, overaktiv

Ontology: Detrusor instability (C1261562)

Concepts Pathologic Function (T046)
SnomedCT 197878007, 197879004, 155889009, 61033006
English Irritable bladder, Unstable bladder, Bladder instability, detrusor instability (diagnosis), detrusor instability, bladder detrusor instability, bladder irritability, bladder instability, detrusor dyssynergia, bladder irritable, irritable bladder, unstable bladder, detrusor bladder instability, bladder irritation, irritation bladder, Detrusor instability (disorder), Detrusor dyssynergia, Detrusor instability of bladder, Detrusor instability of bladder (disorder), DI - Detrusor instability, Detrusor instability
Dutch detrusorinstabiliteit
French Instabilité du détrusor
German Instabilitaet des Detrusors
Italian Instabilità del detrusore
Portuguese Instabilidade da musculatura vesical
Spanish Inestabilidad del detrusor, disinergia del detrusor, inestabilidad del detrusor de la vejiga (trastorno), inestabilidad del detrusor de la vejiga
Japanese 排尿筋不安定, ハイニョウキンフアンテイ
Czech Nestabilita detruzoru
Hungarian Detrusor instabilitás

Ontology: Bladder irritability (C2945586)

Concepts Pathologic Function (T046)
SnomedCT 102833004, 404220000
Dutch blaasinstabiliteit, instabiele blaas, blaasprikkeling, blaasirritabiliteit, geprikkelde blaas, blaas; irritatie, blaas; prikkelbaarheid, irritatie; blaas, prikkelbaarheid; blaas
French Instabilité de la vessie, Vessie instable, INSTABILITE VESICALE, Vessie irritable, Irritation vésicale
German Instabilitaet der Blase, instabile Blase, BLASENINSTABILITAET, Reizblase, Blasenreizung
Italian Instabilità vescicale, Vescica instabile, Vescica irritabile, Irritazione vescicale, Irritabilità vescicale
Portuguese Bexiga instável, Instabilidade vesical, INSTABILIDADE VESICAL, Irritação da bexiga, Irritabilidade da bexiga, Bexiga irritável
Spanish Vejiga inestable, Inestabilidad vesical, Vejiga irritable, Irritación vesical, Irritabilidad vesical, vejiga irritable, irritabilidad de la vejiga, irritabilidad vesical (hallazgo), irritabilidad vesical
Japanese 不安定膀胱, フアンテイボウコウ, ボウコウシゲキショウジョウ, ボウコウカビン, 膀胱過敏, 膀胱刺激症状
English BLADDER INSTABILITY, Bladder irritation, Bladder irritability, Irritable;bladder, bladder irritability (diagnosis), Detrusor instability, DI - Detrusor instability, Irritable bladder, Unstable bladder, Bladder instability, Bladder irritability (finding), bladder; irritable, bladder; irritation, irritability; bladder, irritation; bladder, irritable bladder, Instability;bladder, instability of the bladder, bladder instability
Czech Nestabilní močový měchýř, Nestabilita močového měchýře, Dráždivý močový měchýř
Hungarian Irritabilis húgyhólyag, Húgyhólyag instabilitás, Húgyhólyag irritabilitas, instabil húgyhólyag, Húgyhólyag irritatio