Urinary Incontinence: Urge

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Chapter 63 Urinary Incontinence: Urge

INTRODUCTION

Description: Urinary incontinence is a sign, a symptom, and a disease all at the same time. Urge incontinence is the involuntary loss of urine accompanied by a sense of urgency or impending loss and is associated with increased bladder activity.
Prevalence: Urge incontinence accounts for 35% of patients with incontinence.
Predominant Age: Mid-reproductive age and onward. Urge incontinence becomes more common during the 40s and beyond and is most common after menopause.
Genetics: No genetic pattern.

ETIOLOGY AND PATHOGENESIS

Causes: Allergy, bladder stone, bladder tumor, caffeinism, central nervous system tumors, detrusor muscle instability, interstitial cystitis, multiple sclerosis, Parkinson’s disease, radiation cystitis, radical pelvic surgery, spinal cord injury, urinary tract infections (Urinary tract infections [UTI]; acute or chronic).
Risk Factors: Frequent UTIs.

CLINICAL CHARACTERISTICS

Signs and Symptoms

• Reduced bladder capacity and early, intense sensations of bladder fullness
• Spontaneous and uninhibitable contractions of the bladder muscles, resulting in large-volume, uncontrolled urine loss
• Loss possibly provoked by activities such as hand washing or a change in position or posture or after (not during) changes in intra-abdominal pressure such as a cough or sneeze

DIAGNOSTIC APPROACH

Differential Diagnosis

• Mixed incontinence (stress and urge)
• Stress incontinence
• UTI
• Urinary tract fistula
• Interstitial cystitis
• Urethritis

Associated Conditions: Vulvitis, vaginitis, nocturia, enuresis (bed-wetting).

Workup and Evaluation

Laboratory: No evaluation indicated. Urinalysis is generally recommended, although results are nonspecific. Abrupt-onset incontinence in older patients should suggest infection, which may be confirmed through urinalysis or culture.
Imaging: Radiographic studies are sometimes performed as a part of complex urodynamics studies but are generally of limited utility.
Special Tests: Measurement of postvoid urinary residual volume.
Diagnostic Procedures: History and physical examination, urodynamics testing (simple or complex), and evaluation of sphincter tone and function (as an indication of neurologic function) are the best ways to establish the diagnosis of urge incontinence.

Pathologic Findings

Based on cause. Patients with urge incontinence have a reduced bladder capacity, early first sensation, and uninhibited bladder contractions.

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MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: Treatment of any UTI present, timed voiding.
Specific Measures: Medical therapy; limited role for surgical repair.
Diet: No specific dietary changes indicated. Reduction in caffeine use and other bladder irritants may help some patients with symptoms of urgency incontinence.
Activity: No restriction.
Patient Education: Reassurance; American College of Obstetricians and Gynecologists Patient Education Pamphlet AP081 (Urinary Incontinence).

Drug(s) of Choice

Flavoxate hydrochloride (Urispas) 100 to 200 mg PO three times a day to four times a day (fewer side effects, more expensive than some).
Imipramine hydrochloride (Tofranil) 25 to 50 mg PO twice a day to three times a day (good for mixed incontinence and enuresis, 60% to 75% effective).
Oxybutynin hydrochloride (Ditropan) 5 to 10 mg PO three times a day to four times a day (side effects common [75%], 60% to 80% effective).
Phenylpropanolamine hydrochloride (Propadrine) 50 mg PO twice a day (α-adrenergic sympathomimetic).
Propantheline bromide (Pro-Banthine) 15 to 30 mg PO three times a day to four times a day (few side effects, variable absorption, 60% to 80% effective).
Darifenacin (Enablex) 7.5 mg PO daily (works by blocking the M3 muscarinic acetylcholine receptor, which is primarily responsible for bladder muscle contractions).
Solifenacin (Vesicare) 5 mg PO daily (urinary antispasmodic of the anticholinergic class).
Contraindications: Most agents are contraindicated in patients with urinary retention, narrow-angle glaucoma, or known or suspected hypersensitivity.
Precautions: Anticholinergic drugs must be used with caution in patients with obstructive gastrointestinal disease or tachycardia. Dry mouth is experienced by 40% to 50% of patients. Darifenacin and solifenacin are contraindicated in urinary retention, gastric retention, or uncontrolled narrow-angle glaucoma and are pregnancy category C.
Interactions: Patients taking cytochrome P450 3A4 inhibitors (macrolide antibiotics or antifungal agents) must reduce their doses of tolterodine tartrate.
Alternate Therapies: Tolterodine tartrate (Detrol) 1 to 2 mg PO twice a day, dicyclomine hydrochloride (Bentyl) 20 mg IM four times a day (requires parenteral use), terodiline hydrochloride (Micturin) 12.5 to 25 mg PO twice a day (available outside of United States, carries some risk of esophageal and gastric erosions).

FOLLOW-UP

Patient Monitoring: Normal health maintenance. Patients are at increased risk for UTIs, vaginitis, and vulvitis.
Prevention/Avoidance: Avoidance of and prompt treatment for UTIs are thought to reduce the risk of developing urgency incontinence in the future.
Possible Complications: Social isolation and vulvar and perineal irritation are common complications of any type of urinary incontinence.
Expected Outcome: Patients with urge incontinence can expect generally good results with medical therapy and timed voiding.

MISCELLANEOUS

Pregnancy Considerations: No effect on pregnancy. Pregnancy often induces frequency and urgency because of bladder compression by the fetal presenting part near term. Bethanechol, darifenacin, and solifenacin are pregnancy category C drugs.
ICD-9-CM Codes: 788.31.

REFERENCES

Level I

Green SA, Alon A, Ianus J, et al. Efficacy and safety of a neurokinin-1 receptor antagonist in postmenopausal women with overactive bladder with urge urinary incontinence. J Urol. 2006;176:2535. discussion 2540.

Level II

Freeman RM. The role of pelvic floor muscle training in urinary incontinence. BJOG. 2004;111:37.

Level III

Abrams P, Blaivas JG, Stanton SL, Andersen JT. The standardization of terminology of lower urinary tract function produced by the International Continence Society Committee on Standardization of Terminology. Scand J Urol Nephrol. 1988;114:5.

American College of Obstetricians and Gynecologists. Genitourinary tract changes. Obstet Gynecol. 2004;104:56S-61S.

American College of Obstetricians and Gynecologists. Urinary incontinence in women. Obstet Gynecol. 2005;105:1533.

American College of Obstetricians and Gynecologists. Pelvic organ prolapse. ACOG Practice Bulletin 79. Obstet Gynecol. 2007;109:461.

Consensus Conference. Urinary incontinence in adults. JAMA. 1989;261:2685.

Dubeau CE. The aging lower urinary tract. J Urol. 2006;175:S11.

Gibbs CF, Johnson TM2nd, Ouslander JG. Office management of geriatric urinary incontinence. Am J Med. 2007;120:211.

Lentz GM. Urogynecology. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, editors. Comprehensive Gynecology. 5th ed. Philadelphia: Mosby/Elsevier; 2007:559.

Norton P, Brubaker L. Urinary incontinence in women. Lancet. 2006;367:57.

Norton PA. Urinary incontinence. Clin Obstet Gynecol. 1990;33:293.

Smith PP, McCrery RJ, Appell RA. Current trends in the evaluation and management of female urinary incontinence. CMAJ. 2006;175:1233.

Sutherland SE, Goldman HB. Treatment options for female urinary incontinence. Med Clin North Am. 2004;88:345.

Urinary Incontinence Guideline Panel. Urinary incontinence in adults: Clinical Practice Guidelines. Rockville, MD: Agency for Health Care Policy and Research, U.S. Dept of Health and Human Services, 1992. AHCPR publication 92–0038.

Wagg A. Urinary incontinence—Older people: where are we now? BJOG. 2004;111:15.

Wall LL. Diagnosis and management of urinary incontinence due to detrusor instability. Obstet Gynecol Surv. 1990;45:1s.

Wein AJ, Rackley RR. Overactive bladder: a better understanding of pathophysiology, diagnosis and management. J Urol. 2006;175:S5.

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