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urge incontinence

The involuntary loss of urine associated with an abrupt & strong desire to void (urgency). Etiology: 1) detrusor contractions too strong (detrusor overactivity) 2) hypersensitive bladder 3) chronic cystitis 4) infiltrative diseases of the bladder a) tumor b) urinary stones 5) prostatic hypertrophy 6) fecal impactation 7) decreased cortical inhibitions of detrusor contractions a) stroke b) brain tumor c) dementia - normal pressure hydrocephalus d) multiple sclerosis e) Parkinson's disease f) lesions of the spinal cord above sacral level - lumbar spinal stenosis 8) poor bladder compliance (radiation cystitis) 9) deconditioning of voiding reflexes - frequent voiding at low bladder volumes 10) diabetic neuropathy [16] 11) parasympathomimetics including cholinesterase inhibitors 12) also see disorders contributing to overactive bladder & urge incontinence Epidemiology: 1) common in men & women over age 75 2) accounts for 2/3 of geriatric incontinence in both sexes 3) 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: 1) incontinence proceded by an urge to void 2) frequency & nocturia with small to moderate volumes 3) large volumes of urine may be lost [4] 4) pain on urination if acute inflammation present 5) incontinence similar to stress incontinence delayed 10-20 seconds Laboratory: - urinalysis - basic metabolic panel Special laboratory: 1) postvoid residual volume (PVR) in men (prior to discontuing medication) [16] 2) urodynamic testing: a) indications [15] - failure of initial therapy - planning of surgery b) can identify involuntary detrusor contractions or detrusor overactivity 3) cystoscopy as indicated Complications: - higher risk of falls & fractures in the elderly resulting from frequent need to rush to the bathroom [5] Management: 1) general a) see urinary incontinence for general measures - taper or discontinue offending medications (cholinesterase inhibitors) b) behavioral measures better than anticholinergic agents [32] - ask patient to complete voiding diary [34] even if diagnosis is obvious c) acute or subacute onset, check urinalysis even in the absence of dysuria [4] d) stable symptoms - no benefit of treating bacteriuria even with pyuria [18] 2) scheduling regimens: a) bladder retraining: (cognitively intact patients) - patient gradually lengthens time between voidings [4,25] b) prompted voiding (cognitively impaired patients) - patient prompted about need to void at regular intervals - mobility-impaired patients - cognitively impaired patients 3) behavioral measures a) manage urgency by staying very still & repeatedly contracting the pelvic floor muscles until the urgency is gone [7] - only then proceed to the bathroom - if urgency returns enroute to the bathroom, again 'freeze & squeeze' [7] b) pelvic muscle exercises not helpful [25] c) pelvic yoga no better than Kegel exercises [35] 4) pharmacologic agents if refractory to bladder retraining or prompted voiding [25] a) antimuscarinic agents inhibit involuntary detrusor contractions [7] - oxybutynin (Ditropan) 2.5-5 mg BID/TID - extended release 5-30 mg QD [11] - transdermal 3.9 mg over 4 days (96 hours) [11] - now OTC for women >= 18 years of age [21] - higher rate of discontuation than tolterodine [24] - 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 [11] - fesoterodine - highest success in achieving continence in women (13%) [19] - improves both urge incontinence & sleep quality [29] - 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 [19] - see ref [25] for comparison of different agents b) 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 c) calcium channel antagonists - inhibit bladder contractions - nifedipine (Procardia) 10 mg TID - efficacy not proven - may be useful for patient with hypertension or cardiac arrhythmia d) beta-3 adrenergic receptor agonist - mirabegron (Myrbetriq) 25-50 mg PO QD e) estrogen replacement therapy - alleviates sensory problems in postmenopausal women - urgency, frequency, dysuria, nocturia - systemic estrogen-progestin may worsen urinary incontinence (MKSAP19) [4,9] - ultra low-dose estradiol vaginal ring is as effective as oxybutynin [14] f) combination therapy [12] - alpha-adrenergic receptor antagonist (tamsulosin) - antimuscarinic agent (tolterodine) g) botulinum toxin A (Botox) FDA-approved - single injection every 6 months - cystoscopic intra-detrusor injection of 200 U of onabotulinumtoxinA [28] - as effective as oral antimuscarinic agents [13,20,26,27] - potentially better than neuromodulation [32] - adverse effects include urinary retention & cystitis 5) biofeedback 6) behavioral therapy combined with antimuscarinic therapy is often better than either alone [16] - behavioral therapy (pelvic muscle exercises plus scheduling regimen) alone as effective as antimuscarinic therapy alone [17] 7) surgery a) reserved for refractory cases b) procedures - neuromodulation - denervation - posterior tibial nerve stimulation [26,30,31] - sacral neuromodulation [26,28,31] - slightly less effective, but with fewer adverse effects than cystoscopic intra-detrussor Botox injections [28] - augmentation cystoplasty - removal of irritating lesions

Interactions

disease interactions

Related

detrusor instability (unstable bladder, hyperactive bladder, irritable bladder) detrusor muscle (musculi detrusor vesicae) disorders contributing to overactive bladder & urge incontinence sensory urgency urodynamic testing

Useful

dicyclomine (Bentyl) flavoxate (Urispas, Bladderon) imipramine (Tofranil, Janimine) nifedipine (Procardia, Adalat) oxybutynin (Ditropan, Oxytrol, Gelnique) propantheline (Pro-Banthine) tolterodine (Detrol, Detrol LA)

Specific

overactive bladder (OAB)

General

urinary incontinence (UI) chronic urogenital disease

References

  1. nlmpubs.nlm.nih.gov/hstat/ahcpr/
  2. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 528-30
  3. Guide to Physical Examination & History Taking, 6th edition, Bates B, JB Lippincott, Philadelphia, 1995, pg 82-83
  4. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2006, 2015, 2018, 2021. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  5. Journal Watch 20(17):140, 2000 Brown JS et al Urinary incontinence: does it increase risk for falls and fractures? Study of Osteoporotic Fractures Research Group. J Am Geriatr Soc 48:721, 2000 PMID: 10894308
  6. Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 41
  7. Geriatrics Review Syllabus, American Geriatrics Society, 5th edition, 2002-2004 - Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022
  8. Prescriber's Letter 12(2): 2005 Antimuscarinic Medications for Overactive Bladder Detail-Document#: 210209 (subscription needed) http://www.prescribersletter.com
  9. Prescriber's Letter 12(4): 2005 Hormone Therapy for Urinary Incontinence Detail-Document#: 210412 (subscription needed) http://www.prescribersletter.com
  10. Journal Watch 25(8):57, 2005 Hendrix SL, Cochrane BB, Nygaard IE, Handa VL, Barnabei VM, Iglesia C, Aragaki A, Naughton MJ, Wallace RB, McNeeley SG. Effects of estrogen with and without progestin on urinary incontinence. JAMA. 2005 Feb 23;293(8):935-48. PMID: 15728164 - DuBeau CE. Estrogen treatment for urinary incontinence: never, now, or in the future? JAMA. 2005 Feb 23;293(8):998-1001. No abstract available. PMID: 15728171
  11. Erdem M & Chu FM Management of overactive bladder and urge urinary incontinence in the elderly patient. Am J Med 2006;119(3A):295
  12. Kaplan SA et al, Tolterodine and tamsulosin for treatment of men with lower urinary tract symptoms and overactive bladder. A randomized controlled trial. JAMA 2006, 296:2319 PMID: 17105794
  13. Dmochowski R et al. Efficacy and safety of onabotulinumtoxinA for idiopathic overactive bladder: A double-blind, placebo controlled, randomized, dose ranging trial. J Urol 2010 Dec; 184:2416. PMID: 20952013
  14. Nelken RS et al. Randomized trial of estradiol vaginal ring versus oral oxybutynin for the treatment of overactive bladder. Menopause 2011 Sep; 18:962. PMID: 21532512 - Eckler K. More treatment options for overactive bladder in postmenopausal women. Menopause 2011 Sep; 18:941. PMID: 21869637
  15. Nygaard I. Idiopathic urgency urinary incontinence. N Engl J Med 2010; 363:1156-1162 PMID: 20843250
  16. Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010 - Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013
  17. Burgio KL et al. Behavioral versus drug treatment for overactive bladder in men: The Male Overactive Bladder Treatment in Veterans (MOTIVE) trial. J Am Geriatr Soc 2011 Dec; 59:2209 PMID: 22092152
  18. Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010
  19. Shamliyan T et al Systematic Review: Benefits and Harms of Pharmacologic Treatment for Urinary Incontinence in Women Annals of Internal Medicine April 9, 2012 PMID: 22492633 http://www.annals.org/content/early/2012/04/09/0003-4819-156-12-201206190-00436.full
  20. Visco AG et al Anticholinergic Therapy vs OnabotulinumtoxinA for Urgency Urinary Incontenence N Engl J Med Oct 5, 2012 PMID: 23036134 http://www.nejm.org/doi/pdf/10.1056/NEJMoa1208872 - FDA News Release: August 25, 2011 FDA approves Botox to treat specific form of urinary incontinence http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm269509.htm
  21. FDA News Release: Jan. 25, 2013 FDA approves over-the-counter Oxytrol for Women to treat overactive bladder http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm336815.htm
  22. Burgio KL, Kraus SR, Menefee S et al Behavioral therapy to enable women with urge incontinence to discontinue drug treatment: a randomized trial. Ann Intern Med. 2008 Aug 5;149(3):161-9. PMID: 18678843
  23. Madhuvrata P, Cody JD, Ellis G, Herbison GP, Hay-Smith EJ. Which anticholinergic drug for overactive bladder symptoms in adults. Cochrane Database Syst Rev. 2012 Jan 18;1:CD005429. PMID: 22258963
  24. Gomes T1, Juurlink DN, Mamdani MM. Comparative adherence to oxybutynin or tolterodine among older patients. Eur J Clin Pharmacol. 2012 Jan;68(1):97-9. PMID: 21710237
  25. Qaseem A, Dallas P, Forciea MA et al Nonsurgical Management of Urinary Incontinence in Women: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2014;161(6):429-440 PMID: 25222388 http://annals.org/article.aspx?articleid=1905131
  26. Wood LN, Anger JT. Urinary incontinence in women. BMJ. 2014;349:g4531. PMID: 25225003
  27. Anger JT, Weinberg A, Suttorp MJ et al. Outcomes of intravesical botulinum toxin for idiopathic overactive bladder symptoms: a systematic review of the literature. J Urol. 2010 Jun;183(6):2258-2264. PMID: 20400142
  28. Amundsen CL, Richter HE, Menefee SA et al OnabotulinumtoxinA vs Sacral Neuromodulation on Refractory Urgency Urinary Incontinence in Women. A Randomized Clinical Trial JAMA. 2016;316(13):1366-1374. PMID: 27701661 http://jama.jamanetwork.com/article.aspx?articleid=2565290
  29. Warsi QA, Huang AJ, Hess R et al. Association of pharmacologic treatment of urgency urinary incontinence with sleep quality and daytime sleepiness. Obstet Gynecol 2018 Feb; 131:204 PMID: 29324595
  30. Nambiar AK, Bosch R, Cruz F et al EAU Guidelines on Assessment and Nonsurgical Management of Urinary Incontinence. Eur Urol. 2018 Feb 2. PMID: 29398262 http://www.europeanurology.com/article/S0302-2838(18)30002-2/fulltext
  31. Judge DE Urinary Incontinence: Yes, It Can Be Treated. NEJM Journal Watch. Jan 22, 2019 Massachusetts Medical Society (subscription needed) http://www.jwatch.org https://www.jwatch.org/na48165/2019/01/22/urinary-incontinence-yes-it-can-be-treated
  32. Balk EM, Rofeberg VN, Adam GP et al Pharmacologic and Nonpharmacologic Treatments for Urinary Incontinence in Women: A Systematic Review and Network Meta-analysis of Clinical Outcomes Ann Intern Med. 2019. Marhc 19. PMID: 30884526 https://annals.org/aim/article-abstract/2728712/pharmacologic-nonpharmacologic-treatments-urinary-incontinence-women-systematic-review-network-meta
  33. Eustice S, Roe B, Paterson J. Prompted voiding for the management of urinary incontinence in adults. Cochrane Database Syst Rev. 2000;2000(2):CD002113 PMID: 10796861 PMCID: PMC7017853 Free PMC article https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD002113/full
  34. NEJM Knowledge+ Nephrology/Urology
  35. Huang AJ, Chesney M, Schembri M et al Efficacy of a Therapeutic Pelvic Yoga Program Versus a Physical Conditioning Program on Urinary Incontinence in Women: A Randomized Trial. Ann Intern Med. 2024 Aug 27. PMID: 39186785 https://www.acpjournals.org/doi/10.7326/M23-3051