MEDICAL MANAGEMENT OF URGE INCONTINENCE

Karny Jacoby, MD
Northwest Hospital (Seattle, WA)

What is urge incontinence?

Urge Incontinence as defined by the International Continence Society is “the complaint of involuntary leakage (of urine) accompanied by or immediately proceeded by urgency”. Other terms used to describe this condition are Overactive Bladder and LUTS or Lower Urinary Tract Symptoms. Some patients experience urgency without leakage and sometimes this is described as “Overactive Bladder, Dry”. When the sensation of urgency spills into the night we use the term Nocturia, “the complaint that the individual has to wake at night one or more times to void”. Nocturia can be accompanied with Urge Incontinence.

Urge and Urge Incontinence are quite prevalent. Up to 16% of the population may be affected and it’s more common in women than men by about 3 to 1. Men tend to be affected later in life than women. We’re not sure what causes urge incontinence but it may have something to do with the nerves to and from the bladder or even nerves in the bladder itself. It may also have to do with the elasticity of the bladder muscle itself, which decreases with age.

How to make the diagnosis?

A good history is a start. Patients will usually complain of not making it to the bathroom on time, or leaking a few drops or more of urine when the “key is in the door”. When patients complain of leaking “all the time” or also leaking with activities that put stress on the bladder such as coughing or sneezing then they might have “Mixed Incontinence”. Stress Incontinence is described in more detail elsewhere, but 30% of patients might leak for both reasons, making the history difficult to interpret. Constipation, diarrhea or excessive fluid intake can all contribute to Overactive Bladder. A bladder diary can be helpful in capturing triggering events and documenting severity of incontinence.

Physical exam helps to evaluate the pelvic floor. Sometimes urine leaks out with a cough, clinching a diagnosis of Stress Incontinence. If the patient is elderly, then vaginal atrophy from hormonal changes can contribute to bladder irritation. A check for residual urine is performed to make sure the patient doesn’t have Overflow Incontinence, where the urine leaks out all the time because the bladder doesn’t empty properly.

A urinalysis is checked to make sure a urinary tract infection is not causing irritation.

If examination doesn’t reveal the reason for incontinence more advanced testing of the nerves of the bladder may be necessary. This is called Urodynamics.

In addition to some of the reversible causes of Overactive Bladder mentioned, some irreversible causes should be ruled out such as bladder cancer, BPH (Benign Prostatic Hyperplasia) or prostate cancer in men, and Interstitial Cystitis.

Medical Treatment…

Goals of treatment should be discussed with your doctor. Some patients may want to attain total dryness whereas others may want to reduce the urge sensation or the number of times they void at night. Usually it’s important to employ several strategies to achieve these goals and the timing of behavior changes or drug dosing may be affected. Patients with Urge incontinence have a better response with drug therapy than patients with Overactive bladder who are dry.

Behavioral modification

Dietary modification such as avoidance of foods high in acid can be helpful. The addition of urinary alkanizing agents such as Prelief or Coffee Tamer can help reduce the acidity of foods like coffee or citrus fruits. Reducing fluid intake is important. How many glasses of water per day is enough? For some patients 3-4 eight once glasses are plenty. Reducing fluids after dinner can decrease nocturia. Timed voiding or urinating every 2-3 hours by the clock rather than by bladder signals can help the patient gain control over their bladder. Combination therapy utilizing timed voiding with training in Kegel exercises, or pelvic floor strengthening can be helpful. For patients with lower extremity swelling, elevation of the legs in the afternoon can reduce mobilization of fluid later at night and may reduce nocturia. Those patients may also benefit from support stockings.

Medications

Classic treatment involves using a class of drugs called anticholinergics. These drugs relax the bladder by interfering with the nerve signal to the bladder muscle thereby reducing the bladder’s ability to contract. There is also evidence that these drugs interfere with the sensory nerves thus also reducing the sensation of urgency. Examples of these drugs are Oxybutynin (Ditropan), Tolterodine (Detrol), Trospium (Sanctura), Solfenacin (Vesicare) and Darifenacin (Enablex). Transdermal application with Oxytrol (Oxybutynin) patches can ameliorate the side effects of dry mouth, constipation and drowsiness, although transdermal dosing may not be high enough to reach therapeutic levels for some patients.

Other drugs used for LUTS symptoms are tricyclic antidepressants such as Imipramine or Amitriptyline. These drugs have anticholinergic effects as well as central effects on the brain. Sometimes they are superior if the patient has pain along with their urge incontinence.

Alpha blockers such as Tamsalosin (Flomax) are helpful in some cases. Especially patients with LUTS related to neurologic causes.

Modifying the dosing schedule of diuretics can ameliorate nocturia. For example, taking the diuretic earlier in the day and accounting for a typical 6-8 hour half life of the drug can reduce its effect at night.

Conclusion

Urge incontinence is a condition that can be modified and improved by utilizing a number of strategies. Clearly defining the goals of treatment with your doctor should help in furthering a workable solution to the problem. A combination of therapies is usually employed such as dietary modification, pelvic floor strengthening exercises and medications.

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