Urge Incontinence

Urge incontinence is a common form of incontinence. Urge incontinence is when you get an urgent desire to pass urine and sometimes urine leaks before you have time to get to the toilet. It is usually due to an overactive bladder. Treatment with bladder retraining often cures the problem. Medication may also be advised to relax the bladder. Advice from a continence advisor is also usually helpful.

Understanding urine and the bladder

The kidneys make urine continuously. A trickle of urine is constantly passing to the bladder down the ureters (the tubes from the kidneys to the bladder). You make different amounts of urine depending on how much you drink, eat and sweat.

The bladder is made of muscle and stores the urine. It expands like a balloon as it fills with urine. The outlet for urine (the urethra) is normally kept closed. This is helped by the pelvic floor muscles beneath the bladder that surround and support the urethra.

When a certain amount of urine is in the bladder, you become aware that the bladder is getting full. When you go to the toilet to pass urine, the bladder muscle contracts (squeezes), and the urethra and pelvic floor muscles relax to allow the urine to flow out.

Complex nerve messages are sent between the brain, the bladder, and the pelvic floor muscles. These tell you how full your bladder is, and tell the correct muscles to contract or relax at the right time.

What is urge incontinence?

  • Urgency is a symptom where you get a sudden urgent desire to pass urine. You are not able to put off going to the toilet.
  • Urge incontinence is when urine leaks before you get to the toilet when you have urgency.

Urgency and urge incontinence are sometimes called an unstable or overactive bladder, or detrusor instability. (The detrusor muscle is the medical name for the bladder muscle.)

If you have urgency or urge incontinence, you also tend to pass urine more often than normal (this is called frequency). Sometimes this is several times during the night as well as many times during the day. Some women also find that they leak urine during sex, especially during orgasm.

How common is urge incontinence?

Urge incontinence is the second most common cause of incontinence. About 3 in 10 cases of incontinence are due to urge incontinence. It can occur at any age, but commonly first starts in early adult life. Women are more commonly affected than men.

Other types of incontinence

The most common type of incontinence is stress incontinence, which is dealt with in a separate leaflet. Very briefly, stress incontinence occurs when the pressure in the bladder becomes too great for the bladder outlet to withstand. This is usually caused by weak pelvic floor muscles. Urine tends to leak most when you cough, laugh, sneeze or when you exercise. Pelvic floor muscles are often weakened by childbirth.

Some people have mixed incontinence, which is both stress incontinence and urge incontinence.

There are other less common types of incontinence.

Note: you should always see your doctor if you develop incontinence. Each type has different treatments. Your doctor will assess you to determine the type of incontinence that you have and advise on possible treatment options.

See the separate leaflet called 'Urinary Incontinence' for a general overview and to understand what is likely to happen during the assessment by your doctor. The rest of this leaflet is only about urge incontinence.

What causes urge incontinence?

The cause is not fully understood. The bladder muscle seems to become overactive and contract (squeeze) when you don't want it to.

Normally, the bladder muscle (detrusor) is relaxed as the bladder gradually fills up. As the bladder is gradually stretched, we get a feeling of wanting to pass urine. This normally occurs when the bladder is about half full. Most people can hold on quite easily for some time after this initial feeling, until a convenient time to go to the toilet arises. However, in people with overactive bladder and urge incontinence, the bladder muscle seems to give wrong messages to the brain. The bladder may feel fuller than it actually is. This means that the bladder contracts too early when it is not very full, and not when you want it to. You are unable to wait to pass urine so suddenly you need the toilet. In effect, you have much less control over when your bladder contracts to pass urine.

In most cases, the reason why an overactive bladder develops is not known. This is called overactive bladder syndrome or idiopathic urge incontinence. Symptoms may get worse at times of stress. Symptoms may also be made worse by caffeine in tea, coffee, cola, etc, and by alcohol (see below).

In some cases, symptoms of an overactive bladder develop as a complication of a nerve- or brain-related disease such as following a stroke or spinal cord damage, or with illnesses such as Parkinson's disease or multiple sclerosis (MS). Similar symptoms may occur if there is irritation in the bladder. Bladder irritation can occur when you have a urinary tract infection (UTI) or stones in your bladder.

What are the treatments for urge incontinence?

Treatments include:

  • Some general lifestyle measures may help.
  • Bladder retraining is a common treatment. This can work well in up to half of cases.
  • Medication may be advised in addition to bladder retraining.
  • Pelvic floor exercises may also be advised in some cases.
  • Surgery is a last resort and rarely used to treat urge incontinence.

Some general lifestyle measures which may help

  • Getting to the toilet. Make this as easy as possible. If you have difficulty getting about, consider special adaptations like a handrail or a raised seat in your toilet. Sometimes a commode in the bedroom makes life much easier.
  • Caffeine. This is in tea, coffee, cola, and is part of some painkiller tablets. Caffeine has a diuretic effect. This means that the kidneys increase their urine production. Caffeine may also directly stimulate the bladder to make urgency symptoms worse. A trial of avoiding caffeine for a week or so to see if symptoms improve is definitely worth doing. If symptoms do improve, you may not want to give up caffeine completely. However, you may wish to limit the times that you have a caffeine-containing drink. Also, you will know to be near to a toilet whenever you have caffeine.
  • Alcohol. In some people, alcohol may make symptoms worse. The same advice applies as with caffeine-containing drinks.
  • Drink normal quantities of fluids. It may seem sensible to cut back on the amount that you drink so that the bladder does not fill so quickly. However, this can make symptoms worse as the urine becomes more concentrated which may irritate the bladder muscle. However, if you drink excessively, moderation may improve your symptoms. 6-8 glasses of water per day are recommended by the NHS, but there is no scientific evidence we should drink that much. In practical terms, it is best to drink when we need to, to quench our thirst. Remember that about one fifth of the water we take every day is hidden in food and that other drinks contain water. You may need to drink more than normal in hot weather.
  • Go to the toilet only when you need to. Some people get into the habit of going to the toilet more often than they need ("just in case"). They may go when their bladder only has a small amount of urine so as "not to be caught short". Again, this sounds sensible, as you might think that symptoms of urgency and urge incontinence will not develop if the bladder is emptied regularly and does not fill very much. However, this can actually make symptoms worse in the long-run. If you go to the toilet too often, the bladder becomes used to holding less urine. The bladder may then become even more sensitive and overactive at times when it is stretched a little. So, you may find that when you need to hold on a bit longer (for example, if you go out), symptoms are worse than ever.
  • Try to lose weight if you are overweight. It has been shown that losing a modest amount of weight can improve urinary incontinence in overweight and obese women. Even just 5-10% weight loss can help symptoms. If you are overweight and incontinent then you should first try to lose weight in conjunction with any other treatments. This applies to people with both stress and urge incontinence.

Bladder training (sometimes called bladder drill)

The aim is to stretch the bladder slowly so that it can hold larger and larger volumes of urine. In time, the bladder muscle should become less overactive and you should become more in control of your bladder. This means that more time can elapse between feeling the desire to pass urine and having to get to a toilet. Leaks of urine are then less likely. A doctor, nurse, or continence advisor will explain how to do bladder training. The advice you are given is likely to cover the following:

You will need to keep a diary. On the diary make a note of the times you pass urine, and the amount (volume) that you pass each time. Also, make a note of the times you leak urine (are incontinent). Your doctor or nurse may have some pre-printed diary charts for this purpose to give you. Keep an old measuring jug by the toilet (you will need to pass urine directly into this) so that you can measure the amount of urine you pass each time you go to the toilet.

When you first start the diary, go to the toilet as usual for 2-3 days at first. This is to get a baseline idea of how often you go to the toilet and how much urine you normally pass each time. If you have an overactive bladder you may be going to the toilet every hour or so, and only passing less than 100-200 ml each time. This will be recorded on the diary.

After the 2-3 days of finding your baseline, the aim is then to hold on for as long as possible before you go to the toilet. This will seem difficult at first. If you normally go to the toilet every hour, it may seem quite a struggle to last just five minutes longer between toilet trips. When trying to hold on, try distracting yourself. For example:

  • Sitting straight on a hard seat may help.
  • Try counting backwards from 100.
  • Try doing some pelvic floor exercises (see below).

With time, it should become easier as the bladder becomes used (trained) to holding larger amounts of urine. The idea is to gradually extend the time between toilet trips and to train your bladder to stretch more easily. It may take several weeks, but the aim is to pass urine only 5-6 times in 24 hours (about every 3-4 hours). Also, each time you pass urine you should pass much more than your baseline diary readings. (On average, people without an overactive bladder normally pass 250-350 ml each time they go to the toilet.) After several months you may find that you just get the normal feelings of needing the toilet which you can easily put off for a reasonable time until it is convenient to go.

Whilst doing bladder training, perhaps fill in the diary for a 24-hour period every week or so. This will record your progress over the months of the training period. Bladder training can be difficult, but becomes easier with time and perseverance. It works best if combined with advice and support from a continence advisor, nurse, or doctor. Make sure you drink normal amounts of fluids when you do bladder training (see above).

Medication

If there is not enough improvement with bladder training alone, medicines may also help. These medications are in the class of medicines called antimuscarinics (also called anticholinergics). There are several different types and many different brand names. They include:

  • Oxybutynin (brand names Cystrin®, Ditropan®, Lyrinel® XL and Kentera®).
  • Solifenacin (brand name Vesicare®).
  • Tolterodine (brand name Detrusitol®).
  • Trospium chloride (brand name Regurin®).
  • Propiverine (brand name Detrunorm®).
  • Flavoxate hydrochloride (brand name Urispas 200®).
  • Darifenacin (brand name Emselex®).
  • Fesoterodine fumarate (brand name Toviaz®).

These medicines work by blocking certain nerve impulses to the bladder which relax the bladder muscle, so increasing the bladder capacity.

Medication may improve symptoms in some cases, but not in all. The level of improvement varies from person to person. You may have fewer toilet trips, fewer urine leaks, and less urgency. However, it is uncommon for symptoms to go completely with medication alone. A common plan is to try a course of medication for a month or so. If it is helpful, you may be advised to continue for up to six months or so and then stop the medication to see how symptoms are without the medication. Symptoms may return after you finish a course of medication. If you combine a course of medication with bladder training, the long-term outlook is better and symptoms may be less likely to return when you stop the medication.

Side-effects are quite common with these medicines, but are often minor and tolerable. Read the information sheet which comes with your medicine for a full list of possible side-effects. The most common side-effect is a dry mouth, and simply having frequent sips of water may counter this. Other common side-effects include dry eyes, constipation and blurred vision. However, the medicines have differences, and you may find that if one medicine causes troublesome side-effects, a switch to a different one may suit you better.

Pelvic floor exercises

Many people have a mixture of urge incontinence and stress incontinence. Pelvic floor exercises are the main treatment for stress incontinence. Briefly, this treatment involves exercises to strengthen the muscles that surround and support the bladder, uterus (womb) and rectum. See separate leaflets called 'Incontinence - Stress Incontinence' and 'Pelvic Floor Exercises' for more information.

It is not clear if pelvic floor exercises help if you just have urge incontinence alone. However, pelvic floor exercises may help if you are doing bladder training.

Surgery

If the above treatments are not successful, surgery is sometimes suggested to treat urge incontinence. Procedures that may be used include:

  • Sacral nerve stimulation. If your urge incontinence is caused by overactivity of the bladder muscle, this may be helped by inserting an implant into your bladder to help it contract more evenly and normally.
  • Augmentation cystoplasty. In this operation, a small piece of tissue from the intestine is added to the wall of the bladder to increase the size of the bladder. However, not all people can pass urine normally after this operation. You may need to insert a catheter (a small tube) into your bladder in order to empty it.
  • Urinary diversion. In these operations, another method is devised for urine to exit the body. The ureters (the tubes from the kidneys to the bladder) are re-routed so that urine does not flow into the bladder. There are various ways that this may be done - the urine can be directed into a portion of bowel that empties on to the surface of the skin. The opening is called a stoma, and a bag is worn to collect the urine. Other procedures involve the formation of a 'pouch' or artificial bladder.

Treatment with botulinum toxin A

Botulinum toxin A (Botox®) can be used to treat urge incontinence caused by an overactive bladder. It is an alternative when other treatments (including bladder training and medication) have failed.

Botulinum toxin is a prescription-only medication made from a toxin produced by a type of bacteria called Clostridium botulinum. This toxin can cause life-threatening food poisoning. Small doses of this toxin have numerous medical uses because of the way the toxin works. The toxin weakens and paralyses muscles and can block certain nerves. Botox® use has been popularised by the recent trend for cosmetic surgery. Such injections are commonly used to iron out wrinkles. However, botulinum toxin has been used for some time in the medical community.

With overactive bladder, the treatment involves injecting botulinum toxin A into the bladder wall. This is done by passing a special telescope (cystoscope) down the urethra. This treatment has an effect of relaxing the muscle contractions of the bladder. However, it may also damp down the normal contractions needed so that your bladder is not able to empty fully. Urinary retention (the inability to pass urine) is a common side-effect of this procedure. You will need to learn a technique called intermittent self-catheterisation if retention occurs. This means passing a catheter (small tube) through the urethra and into the bladder to empty it, several times per day. Usually, urinary retention in these cases only lasts a few weeks.

Botulinum toxin A has not been licensed (approved) for the treatment of overactive bladder syndrome in the UK. However, in certain specialist centres it is used off-licence. It is also available in some private hospitals. Make sure that you discuss this procedure fully with your doctor and understand all of its risks and benefits before you go ahead with it.

Continence adviser

Your GP may refer you to the local continence adviser. Continence advisers can give advice on treatments, especially about bladder training and pelvic floor exercises. If incontinence remains a problem, they can also give lots of advice on how to cope. For example, they may be able to supply various appliances and aids to help, such as incontinence pads, etc.

Further help and information

The Bladder and Bowel Foundation

SATRA Innovation Park, Rockingham Road, Kettering, Northants, NN16 9JH
Nurse helpline: 0845 345 0165 General enquiries: 01536 533255
Web: www.bladderandbowelfoundation.org