Urge Urinary Incontinence

DEFINITION:

Frequent, spasmotic contractions of the detrusor muscle (overactive bladder), resulting in an urgent need to urinate, accompanied by an uninhibitable loss of urine.

ETIOLOGY:

Overactive Bladder (OAB) apprears to be the result of increased excitability and morphologic changes that promote spontaneous detrusor contraction. "Increased excitability and greater connectivity of the smooth muscle create foci of electrical activity that could propagate and generate an uninhibited contraction." *

• Idiopathic OAB occurs when afferent bladder nerves properly signal the brain that the bladder has filled, but the central nervous system (CNS) is unable to suppress detrusor muscle contraction.
• Neurogenic OAB occurs when a known neurologic problem impairs the signaling systems between the bladder and the CNS, rendering the brain unable to inhibit detrusor contraction. "Neurologic diseases can often damage the central or peripheral pathways that are involved in the central control of the lower urinary tract." *
  Some conditions known to be associated with neurogenic OAB include:
  • spinal cord injury
  • strokes
  • Parkinson's disease
  • dementia
  • multiple sclerosis
  • diabetic neuropathy.

SIGNS & SYMPTOMS:

Frequent and abrupt desire to void with subsequent leakage of urine; loss of urine often occurs on the way to the bathroom. Patients may need to void more than 8 times per day, including 2 or more times per night. Urge incontinence that occurs only at night is called nocturnal enuresis.

MANAGEMENT OPTIONS:

Management of urge incontinence depends upon the underlying pathologies.

• Neurogenic OAB may be amenable to pharmacotherapy, including antimuscarinics and experimental drugs like: Capsaicin, Resiniferatoxin and Botulinum Toxin. *
• Idiopathic OAB management often begins with bladder and pelvic floor retraining coupled with medication. Biofeedback and pelvic floor electrical stimulation may be added as adjunctive therapy. When urge incontinence is resistant to conservative therapy sacral neurostimulation or augmentation cystoplasty may provide relief.

• Conservative
• Bladder training implements urge suppression techniques with the goal of extending the interval between voiding and increasing bladder capacity prior to leakage.
• Avoidance of bladder irritants: caffeine, tobacco, alcohol, spicy food, citrus, carbonated drinks and excess fluid intake.
• Avoidance of constipation and straining at stool
• Weight management
• Pelvic floor muscle exercise increases the tone of the urethral sphincter and the muscles supporting the lower urinary tract.
• Biofeedback includes a group of training technologies that can monitor physical response of pelvic floor muscles during exercise in realtime.
• Vaginal cone training promotes pelvic floor muscle strength by enhancing the ability to retain weights within the vagina.
• Pelvic floor electrical stimulation via electrodes in the vagina or anus to painlessly contract the pelvic floor muscles and diminish the urge to urinate by acting on the nerves that cause unwanted bladder contractions.
• Medical
  • Anticholinergic/antimuscarinics medications vary more in side effects then effectiveness. All must be used with caution in the elderly.
    • Oxybutynin FDA clinical pharmacology data for Ditropan®
    • Tolterodine FDA clinical pharmacology data for Detrol®
    • Darifenacin FDA clinical pharmacology data for Enablex®
    • Fesoterodine FDA clinical pharmacology data for Toviaz®
    • Solifenacin FDA clinical pharmacology data for Vesicare®
    • Trospium FDA clinical pharmacology data for Sanctura®
  • Tricylic antidepressant Imipramine Tofranil® may be used to treat mixed — urge and stress — incontinence.
• Surgical (rarely)
  • Sacral neuromodulation involves passage of an electrode through a sacral foramen for placement near sacral nerves. Mild electrical stimulation of the sacral nerves is believed to overide the nerve activity generated by overactive bladder (OAB)
  • Augmentation cystoplasty involves adding a segment of bowel to the bladder to increase bladder storage capacity.

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