Urge Incontinence

Introduction

Urge incontinence is usually associated with urinary frequency, urgency, or a complaint such as “I’m unable to make it to the bathroom on time.” At times, urine loss is massive and sudden, occurring with little or no warning at all.

This is caused by an overactive detrusor. It is either idiopathic or secondary to bladder outlet obstruction (detrusor instability), urinary tract infection or bladder cancer. An overactive detrusor with a known neurological disorder is termed as detrusor hyperreflexia (see below).

The urgency experienced by the patient may be associated with sensory urgency (hypersensitivity) or it may be associated with the overactive function of the detrusor, also referred to as motor urgency. An example of sensory urgency is the strong desire to void associated with intense emotional excitation or nervousness.

An example of motor urgency is when a person has uninhbited detrusor contractions of sufficient magnitude to cause urine to empty from the bladder.

A person with urge incontinence is aware of the need to void, but is unable to prevent the bladder from emptying its contents until toilet facilities are reached. Two related terms defined by the ICS are unstable detrusor and detrusor hyperflexia.

This term is to be used when there is a relevant neurological disorder.

One term related to urge incontinence found in older literature was unstable bladder, which had been used to describe motor urge incontinence. Another term previously used was uninhibited neurogenic bladder. This term was formerly used to describe incontinence resulting from a lesion in the cerebral cortex in which sensation of bladder fullness was intact but inhibitory control was absent.

Incontinence Opens in new window was characterized by the sensation of the need to void followed almost immediately by the uncontrolled contraction of the detrusor.

Treatment of Urinary Incontinence

The three major forms of treating UI are

1. Behavioral.
2. Pharmacologic.
3. Surgical

Before implementing behavioral therapy, patients should have the basic evaluation completed. Treatment options including their risks, benefits, and outcomes should be discussed with the patient so that informed choices can be made.

1. Behavioral techniques

Behavioral techniques are proven to decrease the frequency of UI in most individuals when provided by knowledgeable health care providers, have no reported side effects, and do not limit future treatment options. Behavioral therapies can be divided into

1. caregiver-dependent techniques for patients with cognitive and motor deficitis and
2. those requiring active rehabilitation and education techniques.

These distinctions are arbitrary, however, and any individual’s ability to actively participate varies on a continuum from complete dependence to full participation in the most complex behavioral therapies. For example, physically impaired patients who are cognitively intact may benefit from bladder training, pelvic muscle exercises (PMEs), and biofeedback therapy, but may depend on caregivers for assistance to the toilet.

Behavioral techniques are listed below in the order of those requiring passive involvement to those requiring active participation:

• Toileting assistance—routine/scheduled toileting, habit training, and prompted voiding.
• Bladder retraining.
• Pelvic muscle rehabilitation—PMEs, PMEs and bladder inhibition augmented by biofeedback therapy, PMEs augmented with vaginal weight training, and pelvic floor electrical stimulation.

To effective these behavioral techniques require educating the patient, the caregiver, or both, and provide positive reinforcement for effort and progress.

2. Pharmacology

Detrusor Instability: Prevailing Cause of Urge Incontinence

The following pharmacologic agents are reportedly useful in treating detrusor instability as observed in clinical practice. (Strength of Evidence = B.)

• Anticholinergic agents: oxybutynin, dicyclomine hydrochloride, and propantheline.
  
  Anticholinergic agents are the first-line pharmacologic therapy for patients experiencing urge incontinence caused by detrusor instability (DI). When pharmacologic therapy is to be used for patients with DI, oxybutynin is the anticholinergic agent of choice. The recommended dosage is 2.5–5 mg taken orally three or four times per day. (Strength of Evidence = A.)
  
  Propantheline is the second-line anticholinergic agent in the treatment of patients with DI who can tolerate the full dosage. The recommended dosages are 7.5–30 mg administered three to five times per day; higher dosages (15–60 mg qid) may be required. (Strength of Evidence = B.)
• Tricyclic antidepressants: imipramine, doxepin, desipramine, and nortriptyline.
  
  The use of tricyclic agents (TCAs) should be reserved for carefully evaluated patients. The usual oral dosages are 10–25 mg initially administered one to three times per day, but less frequent administration is usually possible because of the long half-life of these drugs. The daily total dosage is usually 25&ndsh;100 mg. (Strength of Evidence = B.)

• Other Drugs of Possible Benefit. Other drugs used for detrusor instability include a beta-adrenergic agonist (terbutaline) (Lindholm and Lose, 1986) and a spinal synaptic inhibitor (baclofen) (Taylor and Bates, 1979). Limited studies and clinical experience with these agents suggest that further studies must be done before they can be recommended for general use.

3. Surgical Treatment for Detrusor Instability

Use of surgical procedures in the management of urge incontinence is uncommon. Surgical treatment is usually considered only in highly symptomatic patients in whom nonoperative management has failed repeatedly. The surgical procedures reviewed for the treatment of overactive bladder include:

• Augmentation intestinocystoplasty or urinary diversion.
  
  Various surgical procedures have been proposed for treating intractable, severe bladder instability and poor compliance.
  
  Augmentation cystoplasty with a patch of detubularized intestine is usually considered the procedure or choice. Urinary diversion with a urostomy or continent urinary diversion may be utilized as a last resort. The risks of augmentation cystoplasty, in addition to those of any bowel surgery, include voiding difficulties that may require catheterization, mucus or stone formation, metabolic decompensation, and the rare long-range possibility of tumor formation. Contraindications for augmentation cystoplasty include renal insufficiency, bowel disease, intractable urethral disease, and inability to perform self-catheterization.

• Bladder denervation procedures.
  
  Subtrigonal phenol injections and bladder denervation are not presently recommended because the “cure” rates are low, and therefore the risk-to-benefit ratio is too great.