urge incontinence

Introduction

The involuntary loss of urine associated with an abrupt & strong desire to void (urgency).

Etiology

• detrusor contractions too strong (detrusor overactivity)
• hypersensitive bladder
• chronic cystitis
• infiltrative diseases of the bladder
  • tumor
  • urinary stones
• prostatic hypertrophy
• fecal impactation
• decreased cortical inhibitions of detrusor contractions
  • stroke
  • brain tumor
  • dementia
    • normal pressure hydrocephalus
  • multiple sclerosis
  • Parkinson's disease
  • lesions of the spinal cord above sacral level
    • lumbar spinal stenosis
• poor bladder compliance (radiation cystitis)
• deconditioning of voiding reflexes
  • frequent voiding at low bladder volumes
• diabetic neuropathy
• parasympathomimetics including cholinesterase inhibitors
• also see disorders contributing to overactive bladder & urge incontinence

Epidemiology

• common in men & women over age 75
• accounts for 2/3 of geriatric incontinence in both sexes
• 30-40% of men after prostate surgery

Pathology

• uninhibited detrusor muscle contractions overcome urethral resistance, resulting in a sudden urge to void & leakage of moderate to large amounts of urine

Clinical manifestations

• incontinence proceded by an urge to void
• frequency & nocturia with small to moderate volumes
• large volumes of urine may be lost
• pain on urination if acute inflammation present
• incontinence similar to stress incontinence delayed 10-20 seconds

Laboratory

• urinalysis
• basic metabolic panel

Diagnostic procedures

• postvoid residual volume (PVR) in men (prior to discontuing medication)
• urodynamic testing:
  • indications
    • failure of initial therapy
    • planning of surgery
  • can identify involuntary detrusor contractions or detrusor overactivity
• cystoscopy as indicated

Complications

• higher risk of falls & fractures in the elderly resulting from frequent need to rush to the bathroom

• disease interaction(s) of mobility impairmtne with functional incontnence & urge incontinence
• disease interaction(s) of cervical spinal stenosis with urge incontinence
• disease interaction(s) of rheumatoid arthritis with urinary incontinence

Management

• general
  • see urinary incontinence for general measures
    • taper or discontinue offending medications (cholinesterase inhibitors)
  • behavioral measures better than anticholinergic agents
    • ask patient to complete voiding diary even if diagnosis is obvious
  • acute or subacute onset, check urinalysis even in the absence of dysuria
  • stable symptoms
    • no benefit of treating bacteriuria even with pyuria
• scheduling regimens:
  • bladder retraining: (cognitively intact patients)
    • patient gradually lengthens time between voidings
  • prompted voiding (cognitively impaired patients)
    • patient prompted about need to void at regular intervals
    • mobility-impaired patients
    • cognitively impaired patients
• behavioral measures
  • manage urgency by staying very still & repeatedly contracting the pelvic floor muscles until the urgency is gone
    • only then proceed to the bathroom
    • if urgency returns enroute to the bathroom, again 'freeze & squeeze'
  • pelvic muscle exercises not helpful
  • pelvic yoga no better than Kegel exercises
• pharmacologic agents if refractory to bladder retraining or prompted voiding
  • antimuscarinic agents inhibit involuntary detrusor contractions
    • oxybutynin (Ditropan) 2.5-5 mg BID/TID
      • extended release 5-30 mg QD
      • transdermal 3.9 mg over 4 days (96 hours)
      • now OTC for women >= 18 years of age
      • higher rate of discontuation than tolterodine
        • mean 68 vs 128 days
      • oxybutynin seems to have highest discontinuation rate due to adverse effects [23[
    • tolterodine (Detrol) 1-2 mg PO BID
      • extended release 2-4 mg QD
    • fesoterodine
      • highest success in achieving continence in women (13%)
      • improves both urge incontinence & sleep quality
    • trospium (Sanctura) 20 mg PO BID
    • darifenacin (Enablex) 7.5-15 mg PO QD
      • improves urinary incontinence & quality of life*
      • rate of discontinuation similar to placebo*
    • solifenacin (Vesicare) 5-10 mg PO QD
    • continence achieved in < 15% of women
    • see ref for comparison of different agents
  • other anticholinergic agents
    • propantheline (Pro-Banthine) 15-30 mg QID
    • imipramine (Tofranil) 25-100 mg QHS
    • flavoxate (Urispas) 100-200 mg TID-QID
    • dicyclomine (Bentyl) 20 mg QID
  • calcium channel antagonists
    • inhibit bladder contractions
    • nifedipine (Procardia) 10 mg TID
    • efficacy not proven
    • may be useful for patient with hypertension or cardiac arrhythmia
  • beta-3 adrenergic receptor agonist
    • mirabegron (Myrbetriq) 25-50 mg PO QD
  • estrogen replacement therapy
    • alleviates sensory problems in postmenopausal women
      • urgency, frequency, dysuria, nocturia
    • systemic estrogen-progestin may worsen urinary incontinence (MKSAP19)
    • ultra low-dose estradiol vaginal ring is as effective as oxybutynin
  • combination therapy
    • alpha-adrenergic receptor antagonist (tamsulosin)
    • antimuscarinic agent (tolterodine)
  • botulinum toxin A (Botox) FDA-approved
    • single injection every 6 months
      • cystoscopic intra-detrusor injection of 200 U of onabotulinumtoxinA
    • as effective as oral antimuscarinic agents
    • potentially better than neuromodulation
    • adverse effects include urinary retention & cystitis
• biofeedback
• behavioral therapy combined with antimuscarinic therapy is often better than either alone
  • behavioral therapy (pelvic muscle exercises plus scheduling regimen) alone as effective as antimuscarinic therapy alone
• surgery
  • reserved for refractory cases
  • procedures
    • neuromodulation
      • denervation
      • posterior tibial nerve stimulation
      • sacral neuromodulation
        • slightly less effective, but with fewer adverse effects than cystoscopic intra-detrussor Botox injections
    • augmentation cystoplasty
    • removal of irritating lesions

More general terms

• urinary incontinence (UI)
• chronic urogenital disease

More specific terms

• overactive bladder (OAB)

Additional terms

• detrusor instability (unstable bladder, hyperactive bladder, irritable bladder)
• detrusor muscle (musculi detrusor vesicae)
• dicyclomine (Bentyl)
• disorders contributing to overactive bladder & urge incontinence
• flavoxate (Urispas, Bladderon)
• imipramine (Tofranil, Janimine)
• nifedipine (Procardia, Adalat)
• oxybutynin (Ditropan, Oxytrol, Gelnique)
• propantheline (Pro-Banthine)
• sensory urgency
• tolterodine (Detrol, Detrol LA)
• urodynamic testing