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Overactive Bladder

Wake Forest Baptist Approach Stress and urge incontinence are often experienced together and Wake Forest Baptist urologists conduct a thorough evaluation to determine the presence and severity of both. A voiding diary is recorded to determine the number and frequency of urine loss and voiding habits. In addition, urodynamics may be performed to help guide the diagnosis and whether surgery is appropriate or not. Pure urge incontinence, or overactive bladder, is treated medically and not by surgery.  When medications aren’t successful, injections of botulinum toxin, or Botox®, is an option. The treatment has been shown to be effective in approximately 70 percent of cases, according to Gopal Badlani, M.D., co-director of the Continence Center. In an outpatient procedure, Botox injections are delivered through a small scope that is inserted into the urethra, the canal leading to the bladder. For severe cases of overactive bladder that aren’t helped with other therapies, Wake Forest Baptist is part of a national study to evaluate laboratory-engineered bladders. The technology, developed by Anthony Atala, M.D., chairman of the Department of Urology, has already been successfully used in children with spina bifida and dysfunctional bladders. In cases of combined stress and urge incontinence, treatment can include placement of mesh tape to support the tube leading from the bladder and keep it closed during stressful movements. Our practice has many years of experience with mesh slings for stress urinary incontinence. Our five-year results (Journal of Urology 2003; 170:849) show high sustained success rates over the long term (81% completely dry at 5 years) without any mesh infections. Close to 1 million procedures have been done worldwide. Operative time is usually 30 minutes or less. Reported complications are low, and time to return to daily activities is relative short. Other treatment options include a pacemaker for the bladder that can be used when more conservative treatments, such as medications or behavioral modification, are not effective. The device, which is implanted during an outpatient procedure, is used to treat three major types of urinary incontinence: urge, urgency-frequency and urinary retention, said John Smith, M.D., co-director of the Continence Center. The device emits short, painless bursts of electrical current to stimulate the sacral serves, which influence the bladder. In some patients, the stimulation has been shown to eliminate or reduce bladder control systems.         Urge incontinence Female urinary tract Male urinary tract Definition: Urge incontinence is the strong, sudden need to urinate due to bladder spasms or contractions. Alternative Names: Overactive bladder; Detrusor instability; Detrusor hyperreflexia; Irritable bladder; Spasmodic bladder; Unstable bladder; Incontinence - urge; Bladder spasms Causes, incidence, and risk factors: A person's ability to hold urine depends on normal function of the lower urinary tract, kidneys, and nervous system. The person must also have the physical and mental ability to recognize and respond to the urge to urinate. The bladder's ability to fill and store urine requires a working sphincter muscle (which controls the flow of urine out of the body) and a stable bladder wall muscle (detrusor). The process of urination involves two phases: Filling and storage Emptying During the filling and storage phase, the bladder stretches so it can hold the increasing amount of urine. The bladder of an average person can hold 350 ml to 550 ml of urine. Generally, a person feels like they need to urinate when there is approximately 200 ml of urine in the bladder. The nervous system tells you that you need to urinate. It also allows the bladder to continue to fill. The emptying phase requires the detrusor muscle to contract, forcing urine out of the bladder. The sphincter muscle must relax at the same time, so that urine can flow out of the body. The bladder of an infant automatically contracts when a certain volume of urine is collected in the bladder. As the child grows older and learns to control urination, part of the brain (cerebral cortex) helps prevent bladder muscle contraction. This allows urination to be delayed until the person is ready to use the bathroom. Undesired bladder muscle contractions may occur from nervous system (neurological) problems and bladder irritation. URGE INCONTINENCE Urge incontinence is leakage of urine due to bladder muscles that contract inappropriately. Often these contractions occur regardless of the amount of urine that is in the bladder. Urge incontinence may result from: Bladder cancer Bladder inflammation Bladder outlet obstruction Bladder stones Infection Neurological diseases (such as multiple sclerosis) Neurological injuries (such as spinal cord injury or stroke) In men, urge incontinence also may be due to: Bladder changes caused by benign prostatic hypertrophy (BPH) Bladder outlet obstruction from an enlarged prostate In most cases of urge incontinence, no specific cause can be identified. Although urge incontinence may occur in anyone at any age, it is more common in women and the elderly. Symptoms: Frequent urination, in the daytime and at night Involuntary loss of urine Sudden and urgent need to urinate (urinary urgency) Signs and tests: During a physical examination, the health care provider will look at the abdomen and rectum. Women will also have a pelvic exam. Men will also have a genital exam. In most cases the physical exam reveals nothing abnormal. If there are nervous system (neurologic) causes, other abnormalities may be found. Tests include the following: EMG (myogram) - rarely needed Inspection of the inside of the bladder (cystoscopy) Pad test (after placement of a previously weighed sanitary pad, the patient exercises, then the pad is weighed to determine urine loss) Pelvic or abdominal ultrasound Post-void residual volume (PVR) to measure amount of urine left after urination Urinalysis or urine culture to rule out urinary tract infection Urinary stress test (the patient stands with a full bladder and coughs) Urodynamic studies (measurement of pressure and urine flow) X-rays with contrast dye Further tests will be performed to rule out other types of incontinence. The "Q-tip test" measures the change in the angle of the urethra at rest and when straining. An angle change of greater than 30 degrees often is a sign that the muscles supporting the bladder are weak. This is common in stress incontinence. Treatment: The choice of treatment will depend on how severe the symptoms are, and how much they interfere with your lifestyle. There are three main treatment approaches for urge incontinence: medication, retraining, and surgery. MEDICATION If evidence of infection is found in a urine culture, your doctor will prescribe antibiotics. Medications used to treat urge incontinence relax the involuntary bladder contractions and help improve bladder function. There are several types of medications that may be used alone or in combination: Anticholinergic medicines help relax the muscles of the bladder. They include oxybutynin (Oxytrol, Ditropan), tolterodine (Detrol), darifenacin (Enablex), trospium (Sanctura), solifenacin (Vesicare) These are the most commonly used medications for urge incontinence and are available in a once-a-day formula that makes dosing easy and effective. The most common side effects of these medicines are dry mouth and constipation. The medications cannot be used by patients with narrow angle glaucoma. Flavoxate (Urispas) is an antispasmodic drug. However, studies have shown that it is not always effective at controlling symptoms of urge incontinence. Tricyclic antidepressants (imipramine, doxepin) have also been used to treat urge incontinence because of their ability to "paralyze" the bladder smooth muscle. Possible side effects include: Blurred vision Dizziness Dry mouth Fatigue Insomnia Nausea DIET Some experts recommend controlling fluid intake in addition to other therapies for managing urge incontinence. The goal of this program is to distribute fluids throughout the course of the day, so the bladder does not need to handle a large volume of urine at one time. Do not drink large quantities of fluids with meals. Limit your intake to less than 8 ounces at one time. Sip small amounts of fluids between meals. Stop drinking fluids approximately 2 hours before bedtime. It also may be helpful to eliminate foods that may irritate the bladder, such as: Caffeine Carbonated drinks Highly acidic foods such as citrus fruits and juices Spicy foods BLADDER RETRAINING Managing urge incontinence usually begins with a program of bladder retraining. Occasionally, electrical stimulation and biofeedback therapy may be used with bladder retraining. A program of bladder retraining involves becoming aware of patterns of incontinence episodes. Then you relearn skills necessary for bladder storage and proper emptying. Bladder retraining consists of developing a schedule of times when you should try to urinate. You try to consciously delay urination between these times. One method is to force yourself to wait 1 to 1 1/2 hours between trips to the bathroom, despite any leakage or urge to urinate in between these times. As you become skilled at waiting, gradually increase the time intervals by 1/2 hour until you are urinating every 3 - 4 hours. KEGEL EXERCISES Pelvic muscle training exercises called Kegel exercises are primarily used to treat people with stress incontinence. However, these exercises may also be beneficial in relieving the symptoms of urge incontinence. The principle behind Kegel exercises is to strengthen the muscles of the pelvic floor to improve the function of the urethral sphincter. The success of Kegel exercises depends on proper technique and sticking to a regular exercise program. Another approach is to use vaginal cones to strengthen the muscles of the pelvic floor. A vaginal cone is a weighted device that is inserted into the vagina. The woman contracts the pelvic floor muscles in an effort to hold the device the place. The contraction should be held for up to 15 minutes and should be performed twice daily. Within 4 - 6 weeks, about 70% of women trying this method had some improvement in symptoms. BIOFEEDBACK AND ELECTRICAL STIMULATION Biofeedback and electrical stimulation can help identify the correct muscle group to work, to make sure you are performing Kegel exercises correctly. Some therapists place a sensor in the vagina (for women) or the anus (for men) to assess contraction of the pelvic floor muscles. A monitor will display a graph showing which muscles are contracting and which are at rest. The therapist can help you identify the correct muscles for performing Kegel exercises. Electrical stimulation involves using low-voltage electric current to stimulate the correct group of muscles. The current may be delivered using an anal or vaginal probe. The electrical stimulation therapy may be performed in the clinic or at home. Treatment sessions usually last 20 minutes and may be performed every 1 - 4 days. SURGERY Surgery can increase the storage ability of the bladder and decrease the pressure within the bladder. It is reserved for patients who are severely affected by their incontinence and have an unstable bladder (severe inappropriate contraction) and a poor ability to store urine. Augmentation cystoplasty is the most often performed surgical procedure for severe urge incontinence. In this surgery, a segment of the bowel is added to the bladder to increase bladder size and allow the bladder to store more urine. Possible complications are those of any major abdominal surgery, including: Blood clots Bowel obstruction Infection Pneumonia There is a risk of developing abnormal tubelike passages (urinary fistulae) that result in abnormal urine drainage, urinary tract infection, and difficulty urinating. Augmentation cystoplasty is also linked to a slightly increased risk of developing tumors. Sacral nerve stimulation is a newer surgical option that consists of an implanted unit that sends small electrical pulses to the sacral nerve. The electrical pulses can be adjusted to each patient's symptoms. ACTIVITY People with urge incontinence may find it helpful to avoid activities that irritate the urethra and bladder, such as taking bubble baths or using harsh soaps in the genital area. MONITORING Urinary incontinence is a long-term (chronic) problem. Although you may be considered cured by treatment, you should continue to see your health care provider to evaluate the progress of your symptoms and monitor for possible treatment complications. Expectations (prognosis): How well you do depends on your symptoms, an accurate diagnosis, and proper treatment. Many patients must try different therapies (some at the same time) to reduce symptoms. Instant improvement is unusual. Perseverance and patience are usually required to see improvement. A small number of patients need surgery to control their symptoms. Complications: Physical complications are rare. However, psychological and social problems may arise, particularly if you are unable to get to the bathroom when you feel the urge. Calling your health care provider: Call your health care provider for an appointment if: Your symptoms are causing you problems You have pelvic discomfort or burning with urination Your symptoms occur daily Prevention: Starting bladder retraining techniques early may help reduce the severity of symptoms. References: Gerber GS, Brendler CB. Evaluation of the urologic patient: History, physical examination, and urinalysis. In: Wein AJ, ed. Campbell-Walsh Urology. 9th ed. Philadelphia, Pa: Sauders Elsevier; 2007: chap 3. Rogers RG. Clinical practice: urinary stress incontinence in women. N Engl J Med. 2008;358:1029-1036. Shamliyan TA, Kane RL, Wyman J, Wilt TJ. Systematic review: randomized, controlled trials of nonsurgical treatments for urinary incontinence in women. Ann Intern Med. 2008;148:459-473. van Kerrebroeck PE, van Voskuilen AC, Heesakkers JP, Lycklama a Nijholt AA, Siegel S, Jonas U, et al. Results of sacral neuromodulation therapy for urinary voiding dysfunction: outcomes of a prospective, worldwide clinical study. J Urol. 2007;178:2029-2034.

Review Date:8/30/2009 Reviewed By:Louis S. Liou, MD, PhD, Assistant Professor of Urology, Department of Surgery, Boston University School of Medicine. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.