Incontinence

Updated 10 June 2016

Urge incontinence

Urge incontinence is the leakage of urine associated with the frequent passage of urine.

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Summary

  • Urge incontinence is the leakage of urine associated with a great desire to urinate that cannot be suppressed.
  • Urge incontinence may occur in anyone at any age, but is more common in women and the elderly.
  • Although incontinence is not detrimental to the physical well-being of the patient, it impacts negatively on their social, sexual, recreational and working lives.
  • There are several different approaches that may be used in managing and treating urge incontinence.

Alternative names

Overactive bladder; detrusor instability; detrusor hyperreflexia; irritable bladder; spasmodic bladder; unstable bladder; incontinence - urge

What is urge incontinence?

Urge incontinence is the leakage of urine associated with a great desire to urinate that cannot be suppressed. It is invariably associated with symptoms of urgency and frequency. The bladder is incapable of storing adequate amounts of urine, because it is either too small or unstable.

What causes urge incontinence?

Urge incontinence can be caused by:

  • Bladder muscle (detrusor) instability due to:
    • old age
    • unknown cause (idiopathic)
    • cystitis
    • radiation
    • bladder stones
    • bladder tumours
  • Small capacity bladder due to:
    • interstitial cystitis
    • tuberculosis of the bladder
    • schistosomiasis (bilharzia) of the bladder
    • radiation
    • neuropathic bladder

The most common cause of urge incontinence is a spasm or contraction of the bladder muscle, which squeezes at the wrong time, and causes leaks.

Neurological injuries or diseases, such as spinal cord injury, a stroke or multiple sclerosis, may also result in urge incontinence.

Other causes include:

  • infection
  • bladder cancer
  • bladder stones
  • bladder inflammation
  • bladder outlet obstruction

What are the symptoms of urge incontinence?

Urge incontinence is caused by the inability of the bladder to store adequate amounts of urine for long enough between voiding. The bladder is either too small or unstable. The classic symptom is a great desire to urinate that cannot be suppressed and the patient leaks urine before getting to a toilet.

Urge incontinence is associated with the frequent passage of urine during the day (frequency) and night (nocturia). Bladder instability caused by pathology in the bladder, such as infection, stones or tumour, is often associated with burning urine (dysuria) and blood in the urine (haematuria). Bladder pain is common with infections, stones and interstitial cystitis.

How is urge incontinence diagnosed?

The diagnosis of urinary incontinence is made based on a medical history, a physical examination and some confirmatory special tests. The health professional has to identify the types and severity of the incontinence, as well as the possible underlying causes.

A careful history will often indicate the type of incontinence. The amount of protection (such as pads) needed will give some indication of the severity of the problem. The voiding pattern is noted, and direct questions are asked regarding other urinary tract symptoms such as frequency or dysuria. Any concurrent or previous medical, surgical or obstetric history is noted.

The bladder is examined to see if it is full or empty, and whether it is tender or not. A basic neurological examination is performed to rule out neurological causes for the incontinence. The underwear and pads are examined for evidence of wetness. The genital skin is inspected for evidence of urine-induced dermatitis. The urethra and vagina are examined next, usually with a speculum in place. The health professional specifically looks for atrophy of the tissues and for evidence of leaking with coughing. An assessment is made of the integrity of the bladder and urethral support.

A urine sample is tested for evidence of infection or underlying bladder pathology (stone, tumour, and so forth). If there is an underlying cause of bladder instability this should be diagnosed and treated first. In the absence of an underlying cause the diagnosis is confirmed by urodynamic testing - which tests the functionality of the bladder and the bladder outlet.

The suspected findings are that of a small capacity bladder or an unstable bladder that contracts involuntarily at low volumes.

How is urge incontinence treated?

The treatment of incontinence will vary according to the cause, type and severity of the problem.

Non-medical treatment

  • Bladder training - voiding the bladder on a time schedule.
  • Biofeedback - a method of positive reinforcement in which electrodes are placed on the abdomen and the anal area.
  • Pelvic floor exercises - such as Kegel exercises, strengthen the muscles of the pelvic floor, thereby improving the urethral sphincter function.

Medical treatment

  • oxybutynin
  • tolterodine
  • imipramine

Drug therapy forms the mainstay of treatment for patients with urge incontinence due to bladder instability. These anticholinergic agents relax the bladder muscle and increase bladder capacity.

Surgical treatment

When bladders are small because of radiation or tuberculosis, they can be enlarged with an augmentation cystoplasty, where a segment of intestine is patched onto the opened bladder, thereby increasing the capacity.

What is the prognosis?

How well a patient recovers depends on his/her symptoms, an accurate diagnosis, and proper treatment. Many patients must try different therapies to reduce symptoms.

Instant improvement is unusual. Perseverance and patience are usually required to see improvement.

When to call your doctor

All but the most minor degrees of incontinence tend to be extremely inconvenient for the patient. Although incontinence per se is not detrimental to the physical well-being of the patient, it has a negative impact on the social, sexual, recreational and working lives of people. Thus anybody with a degree of incontinence that affects his or her lifestyle should see a health professional.

How can urge incontinence be prevented?

It is not possible to avoid all the potential causes of urinary incontinence. Regular pelvic floor exercises reduce the incidence of incontinence. Bladder training can be very effective in patients with urgency and frequency. One hopes that this will arrest the symptoms before urge incontinence develops.

 

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Incontinence Expert

Prenevin Govender completed his MBChB at the University of Cape Town in 2001. He obtained his Fellowship of the College of Urologists in 2009 and graduated with distinction for a Masters in Medicine from the University of Cape Town in 2010. His special interests include laparoscopic, pelvic organ prolapse and urinary incontinence surgery. He consults full-time at Life Kingsbury Hospital in Claremont.

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