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) affects more than 30% of men and 40% of women in the U.S appears to result from 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) cannot 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 and symptoms:

Frequent and abrupt desire to void with subsequent urine leakage; 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.
  • First-line of treatment
    • Bladder training implements urge suppression techniques intending to extend the interval between voiding and increasing bladder capacity prior to leakage.
    • Avoid 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 the physical response of pelvic floor muscles during exercise in real time.
    • 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.
  • Second-line of treatment
    • Anticholinergics. These medications can calm an overactive bladder and may be helpful for urge incontinence. Examples include oxybutynin (Ditropan XL), tolterodine (Detrol), darifenacin (Enablex), fesoterodine (Toviaz), solifenacin (Vesicare) and trospium chloride.
    • Mirabegron (Myrbetriq). Used to treat urge incontinence, this medication relaxes the bladder muscle and can increase the amount of urine your bladder can hold. It may also increase the amount you are able to urinate at one time, helping to empty your bladder more completely.
    • Alpha blockers. In men who have urge incontinence or overflow incontinence, these medications relax bladder neck muscles and muscle fibers in the prostate and make it easier to empty the bladder. Examples include tamsulosin (Flomax), alfuzosin (Uroxatral), silodosin (Rapaflo), and doxazosin (Cardura).
    • Topical estrogen. Applying low-dose, topical estrogen in the form of a vaginal cream, ring or patch may help tone and rejuvenate tissues in the urethra and vaginal areas.
    • Tricylic antidepressant Imipramine Tofranil® may be used to treat mixed — urge and stress — incontinence.
  • Third-line of treatment
    • Temporary chemical denervation of the bladder detrusor muscle with intravesical botulinum toxin A. Cystoscopic injection of Botulinum toxin A (BTA) into the posterior wall of the detrusor muscle blocks acetylcholine release from parasympathetic nerves. BTA inhibits detrusor contraction by preventing the activation of muscarinic receptors on the detrusor muscle fibers.
    • 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)
  • Fourth-line of treatment
    • Augmentation cystoplasty involves adding a segment of mesentary perfused bowel to the bladder to increase the volume of bladder storage capacity.
      (See Bladder augmentation graphic on Wikipedia )

Scarneciu, I., Lupu, S., Bratu, O. G., Teodorescu, A., Maxim, L. S., Brinza, A., Laculiceanu, A. G., Rotaru, R. M., Lupu, A. M., & Scarneciu, C. C. (2021). Overactive bladder: A review and update. Experimental and therapeutic medicine, 22(6), 1444. https://doi.org/10.3892/etm.2021.10879

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