Urge Incontinence

What is Urge Incontinence?

Urinary incontinence refers to any unwanted leakage of urine, which usually happens without the person intending it. The three most common types are ‘urgency’ or ‘urge’ incontinence, ‘stress’ incontinence, and ‘overflow’ incontinence. Some people might experience symptoms of more than one type (mixed), whereas others might have functional symptoms.

People suffering from urge incontinence typically describe a sudden, strong need to urinate that is hard to control. This often results in leaking urine without intending to.

Stress incontinence is when you lose control of your urine due to a sudden increase in pressure on your abdomen. On the contrary, overflow incontinence generally involves a bladder that is too full (either because the muscle that controls the release of urine, or ‘detrusor’, isn’t contracting properly, or because there is a blockage at the outlet of the bladder), leading to unwanted urine leakage.

This article will summarize ‘urgency’ or ‘urge’ urinary incontinence.

What Causes Urge Incontinence?

Urge incontinence often involves problems with the detrusor muscle, which is a special muscle in the bladder wall. Problems can arise from the muscle being too active, not working well with the detrusor, or the bladder being too sensitive.

When the detrusor muscle is “overactive,” it means it contracts more than it should while your bladder is filling up. This could be due to nerve problems from a spinal cord injury, abnormalities in your bladder, or changes in the mix of microorganisms in your bladder. Sometimes, there is no clear reason for the overactivity.

If your bladder doesn’t stretch the way it should, it is described as having “poor detrusor compliance.” This can cause discomfort while your bladder is filling up and limit its capacity. Treatments like pelvic radiotherapy or using a catheter for a long period of time can sometimes cause this.

Lastly, your bladder may be hypersensitive. This is closely linked with the sensory role of the urothelium, which is a tissue layer in your bladder. This tissue is crucial in controlling how your bladder functions. Any inflammation or infection of this tissue can cause an overactive bladder with or without urgency. A change in the balance of microorganisms in your urine can also affect the sensitivity and function of your bladder, which could potentially result in urge incontinence.

Risk Factors and Frequency for Urge Incontinence

The issue of urinary incontinence (the loss of bladder control) appears to be influenced by several factors. Age and obesity are the main ones, while things like previous pelvic surgery, having children, lung diseases, diabetes, dementia, and living in a nursing home can also contribute.

However, it’s difficult to know the actual prevalence rates of the different kinds of bladder weakness due to factors like social stigma, lack of self-reporting, and varying criteria in research studies. This is especially true in developing countries. Although more robust data is available from the United States and some European and Asian countries, these figures still vary widely (from 5%-72%). Yet, an estimated 30% seems fairly consistent according to several studies.

It’s well recognized that urinary incontinence tends to be more common with advancing age. Stress incontinence (caused by pressure on the bladder) is often found to be the most common type. However, urgency and mixed incontinence (a combination of stress and urge incontinence) tend to increase with age. While men do experience these issues, severe incontinence is typically half as common in men compared to women, particularly in older age groups.

Looking at urge incontinence specifically, it’s worth noting that while it’s perhaps less common than stress incontinence among postmenopausal women, it can be very distressing and often leads to treatment. The prevalence of any urinary incontinence in men across all ages is considerably lower than in women. However, among men who do experience these problems, urge incontinence tends to be the most common type, affecting around 40% to 80% of those affected.

Urinary incontinence is mostly influenced by age and obesity, but other factors like pelvic surgery and diabetes can also contribute.
The actual prevalence rates of different kinds of incontinence is hard to determine because of factors like social stigma and lack of self-reporting.
Data from the United States and some European and Asian countries suggest that urinary incontinence affects approximately 30% of people.
Urinary incontinence is recognized to be more common with advancing age and tends to increase further in advanced age.
Even though men do experience incontinence, severe levels are typically half as common in men compared to women.
While postmenopausal women more commonly experience stress incontinence, urge incontinence is particularly distressing and often needs treatment.
In men, urge incontinence tends to be the most common among those affected, accounting for 40% to 80% of cases.

Signs and Symptoms of Urge Incontinence

When dealing with urinary incontinence, the conversation typically starts with your primary healthcare provider. Many people with this condition may hesitate to bring it up because it’s an uncomfortable topic. However, it’s essential for your doctor to get a complete understanding of the situation. They should know about your usual patterns of urination, how long you’ve been experiencing incontinence, whether it bothers you, and what factors might be contributing to it. This could include your daily fluid intake and bladder irritants like caffeine, fizzy drinks, artificial sweeteners, and alcohol.

Your doctor should also learn about the things that make your incontinence worse. For instance, it could be urgency, coughing, sneezing, the sound of running water, lifting, bending, movement, changes in position, or sexual activity. They need to know if leakage is constant or comes and goes, and if you have any relevant health conditions like diabetes, cancer related to female reproductive organs, lung diseases, chronic cough, dementia, confusion, urinary tract infection, obesity, or sleep apnea.

How often you urinate
Urgency
Pain when your bladder is full
Obstetric, gynecological history (such as childbirth, history of pelvic organ collapse, weakened sphincter muscle in the anus, menopause, problems with sex)
Previous surgeries in your pelvis or on your central nervous system/spine
Drugs you’re taking that might worsen incontinence

It’s important to note that just knowing what symptoms you have may not be enough to guide your treatment. Your doctor should conduct a comprehensive physical exam that will look at your pelvis, genital and urinary organs, your brain and nerves, walking, mental state, and body weight. The exam could also reveal if kidney problems are causing your incontinence or might shed light on urinating difficulties due to neurological diseases. In the later scenario, an ultrasound will provide the most accurate and least invasive information.

The examination may help identify whether you have weak pelvic muscles or nerve damage. An internal examination can show if the muscle within your vagina or rectum is unusually stiff or floppy, or if there’s a problem with your bladder or urethra.

Your doctor should also pay attention to your mind, reflexes in your groin and knee, walking, and general movement. Other important points include a full cardiovascular check, as well as ruling out heart failur.

Unfortunately, there’s no single test to confirm if you have a particular type of urinary incontinence. Your doctor might evaluate you with a variety of tests. For example, you might undergo a test that looks for immediate leakage of urine when you cough. To establish a diagnosis of stress incontinence, they might also check the movement of your urethra when you strain or cough using a cotton swab test.

Testing for Urge Incontinence

Understanding the cause of urgent or frequent urination involves a series of steps. First, your doctor will have an in-depth chat with you about your symptoms and perform a physical examination. You may be asked to fill out questionnaires related to your symptoms and how they affect your daily life and social interactions. These questionnaires can help your doctor determine the severity of your condition and how it’s affecting you.

The next step could involve testing your urine to check for abnormal levels of sugar, blood, or signs of infection. Your doctor might also perform some simple office-based tests and ask you to keep a record of your fluid intake and when your symptoms occur. This can help paint a clearer picture of what’s going on.

During this process, your doctor will also be looking for any causes of incontinence that can be reversed. There are several potential causes of incontinence that can be remembered with the acronym DIPPERS: Delirium, Infection, Pharmaceutical, Psychological problems, Excess fluid intake, Restricted mobility, and Stool impaction. If any of these issues are causing your incontinence, your doctor will treat them and reassess your symptoms. If your symptoms are severe or complicated, a specialist may be needed to provide further evaluation and treatment.

Based on the information gathered, the third step is to determine the likely type of urinary incontinence you may have. If your symptoms include urgency, frequent urination, waking up to urinate at night, and you don’t lose control of your urine when you cough, sneeze, lift heavy objects or change position, then you might have urge incontinence. Urge incontinence can also be characterized by inconsistent amounts of urine loss and a small amount of urine left in the bladder after urinating.

The last step involves the use of special tests called urodynamic studies. These tests measure the pressure and flow of urine in your bladder and urethra, and provide extensive details on how well your lower urinary system is working. They can be essential in accurately diagnosing mixed incontinence (a combination of stress and urge incontinence) and urge incontinence. These tests are usually done by a specialist and might be necessary for patients who have had or are planning to undergo surgery, those with blood in their urine, those with neurological conditions like multiple sclerosis, those with organ prolapse, those with a history of surgery for incontinence, or those with a high volume of urine left in the bladder after urinating.

Treatment Options for Urge Incontinence

The treatment plan for urge urinary incontinence, which is an overwhelming need to urinate, aims to reduce bladder spasms, increase bladder size, and lessen the bladder’s sensitivity. There are three levels of treatment recommended by the American Urological Association.

First, doctors can suggest lifestyle and behavior changes. These could include things like improving voiding routines, modifying diet, avoiding things that can irritate the bladder such as caffeine or smoking, and exercises to strengthen the pelvic floor muscles. A tool like a voiding diary, which is a record of fluid intake and frequency and amount of urination, can also be useful.

If lifestyle and behavioral changes aren’t enough, medication might be the next step. There are two types of drugs regularly prescribed – antimuscarinics and beta-3 adrenoreceptor agonists.
Antimuscarinic drugs, like oxybutynin or solifenacin, help calm involuntary muscle movements in the bladder. These might have some side effects such as dry mouth, blurred vision, rapid heartbeat, inability to urinate, or cognitive issues. To reduce these side effects, versions of these drugs that work over an extended period (extended-release) could be prescribed.

Beta-3 adrenoreceptor agonists help to relax the muscle that controls the bladder. Mirabegron is one such example. This class of drugs is particularly used if the patient cannot tolerate or experiences no relief from antimuscarinic drugs. The use of mirabegron could lead to an increase in cardiovascular events, particularly hypertension, and headaches, so patients need to be monitored closely.

Finally, if the above treatments are not effective, third-line treatments could be suggested. These could include invasive procedures such as nerve stimulation, chemical injections to paralyze the bladder muscle temporarily, or implants to stimulate nerves. These treatments are reserved for cases that don’t respond to other measures and for people who cannot tolerate the side effects of medications.

The goal is always to find the most effective treatment plan with the least amount of side effects to help you manage the symptoms of urge urinary incontinence effectively.

When a doctor is trying to diagnose urge incontinence, they also need to consider other conditions that might cause similar symptoms. However, classifying and characterizing urinary incontinence can be a challenge. It’s generally based on conversations with the patient and their symptoms due to inconsistencies in medical history and physical examination procedures. As a result, symptoms of urge incontinence could also indicate:

Stress incontinence (leakage of urine during physical activity)
Mixed-type incontinence (a mix of stress and urge incontinence)

Another condition that can often be mixed up with urge incontinence is overactive bladder syndrome (OAB). Despite their similarities, most people with OAB don’t actually experience urge incontinence symptoms. Furthermore, conditions such as diabetes, frequent urinary tract infections, and diseases that affect the nervous system can also mimic the symptoms of urge incontinence, making the diagnosis process more complex.

What to expect with Urge Incontinence

The outcome of urge incontinence, or the sudden need to urinate, will vary from person to person. Ideally, each person should have an individual treatment plan discussed with their doctor.

In younger patients, behavior therapy and medication often show good results. On the other hand, for older patients, neuromodulation options (methods that change nerve activity) should be considered in the early stages of treatment.

According to the American Urological Association, the success of urge urinary incontinence treatment depends on several factors such as the patient’s age and other associated medical conditions. The patient’s resilience, mental functioning, family support, as well as other diseases, are all essential in determining the patient’s participation in behavioural therapies. Compared to older individuals, younger ones tend to have a higher success rate and improved quality of life with behaviour therapies, either used alone or combined with medication.

However, for elderly patients suffering from cognitive impairment and dementia, using antimuscarinic agents (medications that block a certain type of nerve activity) may worsen their condition. Other medications with anticholinergic properties, which are designed to block certain types of nerve impulses, including drugs for Parkinson’s disease, nausea, and sedatives, could lead to an unfavorable outcome. So, options such as PTNS (posterior tibial nerve stimulation, a form of neuromodulation) might need to be included in the early phase of the treatment discussion for older or affected populations.

A baseline mini-mental status exam score, which assesses cognitive function, can be crucial in judging quality of life improvement. Evaluating the riskiness of antimuscarinic drugs can be key for older people, while for younger people, managing the side effects can lead to better treatment outcome.

Furthermore, when considering third-line treatment options, assessing cognitive function is crucial to predict the outcome. If left untreated or unattended, the outcome of urge urinary incontinence can be poor. It can significantly affect a person’s social life and result in substantial health problems.

Possible Complications When Diagnosed with Urge Incontinence

Urge urinary incontinence complications can arise from the condition itself, the medications used for its treatment, or from surgical procedures. The persisting problem of urinary incontinence may lead to several issues, including:

Skin conditions like dermatitis, rashes, and bedsores because of long stages of damp skin
Repeated urinary tract infections
Gradual cognitive decline resulting from the use of various antimuscarinic drugs
Significant decrease in life quality and loss of independence in carrying out daily activities

Moreover, surgical or bladder nerve stimulation treatments can contribute to other complications, such as:

Injury to the reproductive and urinary system
Long-term use of a catheter
Continuing or repeated urinary incontinence

Preventing Urge Incontinence

Urge incontinence, which causes a sudden and strong need to urinate, is quite common. However, many people who experience it just assume that they must learn to live with it, and they hesitate to seek help. It’s crucial for doctors to ask about urinary problems like urge incontinence during patients’ check-ups. Many people might feel uncomfortable raising this issue on their own.

If you are showing signs of urge incontinence, there are some lifestyle changes that could help. For instance, try to cut down on caffeine, alcohol, and artificial sweeteners. These substances make you urinate more often, and it can be especially helpful to avoid them before going to bed. Ensure you’re not constipated, another factor that can worsen urge incontinence. One way to prevent constipation is to increase the amount of fiber in your diet.

Even though you probably have heard about exercises for the pelvic floor (the group of muscles that supports the bladder) and bladder retraining, these techniques can be complicated. You might be doing them inaccurately. That’s why it’s important for your doctor to explain these exercises correctly, or alternatively, refer you to a physical therapist who specializes in them.

One way to retrain the bladder involves scheduling your bathroom breaks and then gradually increasing the time between them. Start by trying to hold your urine for at least an hour. If the urge to urinate comes on before the hour is up, try to wait until the full hour has passed. Over time, you aim to train your bladder to hold urine for between 3 to 4 hours. If you feel the need to urinate before this time, it can help to sit or stand still, breathe deeply, and squeeze your pelvic floor muscles. This helps to relax and delay the need to urinate. Once the urge passes, you can then walk slowly to the bathroom.

It might also be beneficial to have educational materials that explain how to manage urge incontinence and what treatments are available. These resources can boost your confidence and make you more likely to follow through with your treatment plan. An excellent source of patient education is the American College of Obstetrics and Gynecology website.

Frequently asked questions

The prognosis for urge incontinence, or the sudden need to urinate, varies from person to person. Ideally, each person should have an individual treatment plan discussed with their doctor. In younger patients, behavior therapy and medication often show good results. For older patients, neuromodulation options should be considered in the early stages of treatment. The success of urge urinary incontinence treatment depends on several factors such as the patient's age, other associated medical conditions, resilience, mental functioning, family support, and other diseases. Younger individuals tend to have a higher success rate and improved quality of life with behavior therapies, either used alone or combined with medication. However, for elderly patients suffering from cognitive impairment and dementia, using certain medications may worsen their condition, so other treatment options like PTNS might need to be considered.

Urge incontinence can be caused by problems with the detrusor muscle in the bladder wall, such as the muscle being too active, not working well with the detrusor, or the bladder being too sensitive. It can also be caused by nerve problems from a spinal cord injury, abnormalities in the bladder, changes in the mix of microorganisms in the bladder, poor detrusor compliance, hypersensitivity of the bladder, inflammation or infection of the urothelium tissue in the bladder, and changes in the balance of microorganisms in the urine.

The key signs and symptoms of Urge Incontinence: -Frequent Urination: Urinating more often than usual. -Urgency: A sudden, strong need to urinate that may be difficult to control. -Leakage of Urine: Involuntary loss of urine, which may occur with: Coughing or sneezing (stress incontinence) Lifting, bending, or changing position Sexual activity Hearing running water or due to sudden movement -Pain or Discomfort: Discomfort when the bladder is full or during urination. -Worsening with Bladder Irritants: Symptoms may worsen with the intake of caffeine, fizzy drinks, alcohol, or artificial sweeteners. -Associated Symptoms: The condition may be associated with certain health conditions such as diabetes, lung diseases, chronic cough, dementia, obesity, sleep apnea, and urinary tract infections. -History of Pelvic Issues: Previous pelvic surgeries, childbirth-related complications, or pelvic organ prolapse may contribute. -Constant or Intermittent Leakage: Incontinence may be constant or come and go depending on triggers or circumstances. -Weak Pelvic Muscles: The incontinence may be related to weakened pelvic floor muscles. Neurological Symptoms: Difficulty controlling urination could be related to nerve damage or neurological conditions, which may also affect walking and reflexes. These symptoms help guide diagnosis and treatment, and discussing them thoroughly with a healthcare provider is crucial.

The types of tests that may be needed to diagnose urge incontinence include: - Urine testing to check for abnormal levels of sugar, blood, or signs of infection - Office-based tests, such as keeping a record of fluid intake and when symptoms occur - Urodynamic studies, which measure the pressure and flow of urine in the bladder and urethra to assess how well the lower urinary system is working These tests can help determine the severity of the condition, identify any reversible causes of incontinence, and accurately diagnose urge incontinence.

Stress incontinence, mixed-type incontinence, overactive bladder syndrome (OAB), diabetes, frequent urinary tract infections, and diseases that affect the nervous system.

The side effects when treating Urge Incontinence can include: - Dry mouth - Blurred vision - Rapid heartbeat - Inability to urinate - Cognitive issues - Increase in cardiovascular events, particularly hypertension, and headaches (with the use of mirabegron) - Side effects can be reduced by prescribing extended-release versions of antimuscarinic drugs.

Primary healthcare provider or doctor

Urinary incontinence affects approximately 30% of people.

Urge incontinence is treated through a multi-level approach. The first level involves lifestyle and behavior changes, such as improving voiding routines, modifying diet, and avoiding bladder irritants. Pelvic floor muscle exercises and keeping a voiding diary can also be helpful. If these changes are not enough, medication may be prescribed. Antimuscarinic drugs can calm involuntary muscle movements in the bladder, while beta-3 adrenoreceptor agonists relax the bladder muscle. If medication is ineffective, third-line treatments like nerve stimulation or chemical injections may be considered. The goal is to find the most effective treatment plan with the fewest side effects.

Urge incontinence refers to a sudden, strong need to urinate that is difficult to control, resulting in unintentional leakage of urine.

Bladder Hypersensitivity Detrusor Overactivity Kidney Health Urge Incontinence Urinary Urgency