Urgency incontinence
The second most common type of incontinence is urgency incontinence. Urgency is the sudden and uncontrollable desire to pass urine; if a toilet is not reached in time there may be leakage. This is the ‘I want to go . . . oops I’ve leaked’ situation. Occasional urgency is normal and it is only a problem if you feel that the symptoms are affecting your lifestyle or you have recurrent infections.
In most cases, urgency incontinence results from an instability of the muscle in the bladder wall (the detrusor muscle). The condition is known as urodynamic detrusor overactivity. The detrusor muscle contracts to force urine out through the bladder neck when you pass urine. Normally it does not contract until there is an appropriate time for passing urine. But if it is unstable or overactive, it may contract involuntarily, resulting in the sensation of urgency and the need to void more often than normal (frequency).
Incontinence can result from urodynamic detrusor overactivity if the bladder neck is weak or is opened by the force of the contraction. The problem tends to wax and wane, often being worse during the winter months.
The involuntary contractions can be triggered by a variety of things. Coughing is one of them, and thus a woman with urodynamic detrusor overactivity can go to their doctor with the symptoms of stress incontinence (because she leaks when she coughs). Things such as the sight and sound of running water can also be a trigger. The fuller the bladder, the more likely it is that involuntary contractions will occur.
The two major types of urgency are urodynamic detrusor overactivity (motor urgency) with involuntary contractions and sensory urgency, in which the bladder feels very uncomfortable but there is no actual leaking. The differentiation of these two types of problem requires a variety of tests called urodynamics, although there are other features to suggest what the problem may be.
What causes it?
In most cases we do not know. Urodynamic detrusor overactivity may be related to loss of normal control of the bladder-emptying reflex or relative overactivity of one of the nerves supplying the bladder. Nerve damage and neurological conditions such as a stroke or multiple sclerosis can cause the bladder to contract in an unstable way. If there is a known neurological cause for the instability, the condition is known as detrusor hyperreflexia.
Often people who develop the condition have a history of bedwetting as children or have always had a ‘weak bladder’. This may be a result of poorly learned bladder training as children. Quite often other members of the family have had problems as well.
Women who have had previous incontinence surgery may also be prone to the condition. The original surgery may have partially blocked the bladder neck to stop leakage. The bladder’s response is to cause the muscle to thicken, and in some cases the normal control mechanism is lost, resulting in an unstable bladder.
Treatment options
Treatment of urodynamic detrusor overactivity is based on trying to stop the bladder contracting. This may be achieved by behavioural therapy with or without the use of medication. Both these approaches tackle the symptoms rather than the cause of the problem and neither offers a cure.
Behavioural therapy
Behavioural therapy works by re-educating the brain to control the bladder more effectively, in particular by suppressing the involuntary contractions that cause urgency incontinence.
The mainstay of behavioural therapy is bladder drill. First the bladder is emptied. A target time is then set, usually an hour, during which the woman is not allowed to use the toilet (even if this means leaking). After the hour has passed the woman must pass urine. This is then repeated so that a pattern of regular toileting is established. The time is slowly increased as each target is repeatedly met. The aim is to achieve three-hourly voiding.
Bladder drill has been shown to be highly effective in treating urgency incontinence when taught as an in-patient in hospital, with up to 85 per cent of women showing dramatic improvement. It does, however, require a very high level of motivation and commitment, along with encouragement from staff.
Consequently, on leaving hospital there is a very high relapse rate as women return to their normal lifestyle, which does not always allow for a strict toilet regimen.
There is usually less encouragement and support outside a hospital, although bladder drill is also taught and supervised in the community by physiotherapists, continence advisers and nurses. Despite the problems with maintaining progress, bladder drill remains an important tool in the management of an unstable bladder.
Biofeedback can be used to help with bladder drill. Electrical sensors can be used to detect bladder activity, which will help the patient to learn what the sensation of the bladder contraction is, so that she can more easily learn to suppress it.
The same principle of bladder drill can be applied to bedwetting. In this case it involves knowing when the bedwetting occurs and setting an alarm clock to ring before this time. When incontinence is regularly avoided the time can be gradually increased.
Drug treatment
The most common type of medication used for the treatment of an unstable bladder is the anticholinergic drugs. These preparations act by blocking the impulses between the nerves controlling the bladder and those controlling the bladder muscle. In this way the response of the muscle to stimulation is damped down, and the drugs act almost like a shock absorber. As this treats the symptoms rather than the cause of the problem, treatment may need to be long term or even for life.
The major problems with anticholinergic medications are side effects, because they can affect other parts of the body. The most common side effects are a dry mouth, blurred vision, constipation, heartburn, palpitations and, if the drugs act too successfully, difficulty in passing urine. They can’t be used if you have closed-angle glaucoma, and some people find that the tablets make them drowsy or tired. Even so, although most people get some side effects (and to some extent these must be anticipated if the medication is to be successful) the benefits make it worth while.
If side effects are a real problem, a tricyclic antidepressant (amitriptyline or imipramine) may be tried instead. These medications also have anticholinergic effects but the side effects are not so severe. Newer anticholinergic medications, such as tolterodine tartrate, propiverine hydrochloride and trospium chloride, have become available recently and may have fewer side effects.
All these medications work in the same way but each offers slight differences that may suit one patient better than another. For example, trospium chloride potentially has fewer interactions and therefore may be better in older patients on multiple medications. Solifenacin may be more effective with nocturia. Oxybutynin hydrochloride patches may avoid many of the side effects of oral medications and darifenacin may particularly help with urgency.
Another approach to managing the condition is by using an artificial hormone called desmopressin. This hormone signals to the kidneys to slow down their urine production, which thus reduces the rate of bladder filling. This is particularly helpful for the night time because urine production should be naturally reduced, allowing sleep through the night.
The problem with this type of treatment is that it cannot be used continuously; if the kidneys produce less at night they must compensate and produce more during the day. Desmopressin is therefore used predominantly in children who wet the bed or in adults whose symptoms are worst at night. It is not usually given to people who may be at risk if they retain extra fluid, for example, people with high blood pressure or heart problems.
Oestrogens may also be used in postmenopausal women as part of a management strategy.
Botulinum toxin A (Botox)
Over the recent years there has been much written on the use of botulinum toxin A preparations which can be injected into the bladder to treat detrusor overactivity. The use of Botox has been proved in patients with ‘neurogenic problems’ (conditions that affect the nervous system) such as multiple sclerosis, spina bifida and patients who have had strokes. The use of Botox in patients who have ‘idiopathic’ detrusor overactivity – that is, patients who just have overactivity with no precipitating cause – the role has not yet been defined.
One of the potential problems with Botox is that if too much is used the patient may not be able to empty her bladder (voiding difficulties) and may well have to learn how to pass a catheter intermittently to be able to empty the bladder properly to avoid getting infections. Over the next few years the role of Botox will probably be defined more clearly.
Changes in diet and lifestyle
Smoking is known to irritate the bladder and make an unstable bladder worse. Caffeine and alcohol have a doubly bad effect, because not only do they stimulate the bladder, they also stimulate the kidneys to produce more urine. Thus, the instability of the bladder is increased and it also has to cope with a bigger workload. Caffeine is found in not only coffee but also tea and some fizzy drinks, and these can worsen symptoms.
A possible compromise with regard to alcohol is to switch from beer or other long drinks to spirits or wine, so that at least the volume of liquid passing through the bladder is reduced.
For some people, simple adjustments to their living arrangements may be sufficient. For example, a woman of reduced mobility may leak in the morning because her bladder is full and she cannot walk to the bathroom without significant effort. Supplying a commode by the bed may solve the problem.
Changes in other medication
Often patients with an overactive bladder have a number of other medical conditions. Also medications used for other conditions can sometimes precipitate bladder problems. The most common example of this is a medication called doxazosin, which is a very safe medication used for treating high blood pressure. Unfortunately one of the side effects of the medication is urinary incontinence.
There are a number of other mediations that may cause bladder problems and it is worth just checking through the data sheets of any prescriptions that you are on to check whether incontinence or bladder problems are a known side effect. In some cases it may be possible to replace these medications with one that does not cause bladder problems. Sometimes it is more important to treat the condition, such as high blood pressure, and put up with the side effect rather than risk the consequences of being off medication.
Surgery
The simplest form of surgery would be to insert a suprapubic catheter (a catheter passed through the wall of the abdomen rather than through the urethra), which allows the bladder to be kept empty but reduces the risk of infections from the catheter.
Very occasionally an operation called an augmentation (or clam) cystoplasty is performed. This is a last resort, because it can be complicated and there is a high risk of on-going problems. The operation involves stitching a patch of bowel into the bladder which can then act as a shock absorber for the bladder contractions.
KEY POINTS
- Urgency incontinence results from an instability of the muscle in the bladder wall
- In most cases the cause is unknown
- Treatment may be with behavioural therapy and medication
- These treatments tackle symptoms but do not offer a cure
- Changes in diet and lifestyle may help
