Urge Urinary Incontinence
Many terms are used around urinary urgency and it can be rather confusing. You may hear any of the following:
OAB (overactive bladder) wet and dry
DO (detrusor overactivity)
According to the International Continence Society (ICS), "Detrusor Overactivity (DO) is defined as a urodynamic observation characterized by involuntary detrusor contractions during the filling phase that may be spontaneous or provoked"
OAB, as defined by ICS 2002, " is a symptomatic diagnosis. OAB is defined as urgency, with or without urge incontinence, and usually with frequency and nocturia." It refers to urgency as "a sudden, compelling desire to void which is difficult to defer"
This is the sensation that would make you leave your trolley in the supermarket and rush off to the loo! It comes on suddenly. 0-100 in a few seconds.
Compare that to the feeling of a very strong urge to urinate. Your bladder is very full and feels firm, maybe a strong pressure feeling. You could, however hold on longer if caught in traffic for example, even though it is uncomfortable. This feeling builds up over time as the bladder gradually fills.
Sudden urgency is not normal.
A strong urge to urinate is normal.
So you can have urgency without leaking. It is only termed urge urinary incontinence (UUI) if you leak when the bladder urgency hits you.
Many people can 'hold on' when they experience sudden urgency.
Any of these symptoms, however, can lead to frequency of urination. This can become a habit because you run to the loo every time an urge hits. The frequency of the urges will dictate how often you go to the loo.
Also, many people go to the loo either 'just in case' or every time they feel the slightest sensation in their bladder in order to keep it as empty as possible in an effort to avoid leaks or urges.
Unfortunately, this very behaviour can actually increase the urgency as you and your bladder stop communicating!
Often various things will trigger an episode of urgency.
For example : does a bladder urge hit you every time you put the key in the front door or turn on a tap ?
These are examples of a conditioned response - your body produces the same response to the same stimulus because it has been conditioned to do so.
It all becomes a vicious circle, but one that can be broken free from with the right treatments.
How is urinary urgency treated?
Firstly a check up with your GP is needed to rule out any medical conditions that may be contributing. This is very important because moving straight to bladder training can be very detrimental if there is an underlying medical problem. This MUST be addressed first.
Some medical conditions that may have urgency and frequency as symptoms are diabetes, UTI's (urinary tract infections) cystitis, menopause and high blood pressure. There can also be neurological reasons for bladder urgency such as stroke, MS, Parkinsons disease. So it is very important to have a medical assessment first. These are just a few of the more common ones, there are many more.
Once medical causes have been ruled out, or successfully treated, and if bladder urgency persists, the next step is usually to do a detailed sensation-based bladder diary. This should be done under the guidance of a health professional with training in continence management.
Bladder training can be started based on the results of the bladder diary.
Lifestyle changes are often suggested:
- manage constipation which can be a big driver of an overactive bladder
- monitor fluid intake. Too much or too little can both cause urgency. If you are consuming more fluid than you need, your kidneys will just turn it into urine and you will need to go more often. If you reduce your input significantly thinking that if you drink less = less urine then you are in fact doing the opposite because your urine will become more concentrated. Concentrated urine can irritate the bladder and an irritated bladder wants to empty more often
- some people are sensitive to the rate at which their bladder fills. If it fills quickly, the bladder wall stretches quickly to accomodate and may be uncomfortable, setting off a bladder contraction resulting in a sudden sense of urgency. You may be better taking fluid in slowly over a period of time if this is the case
- reduce caffeine intake IF it irritates your bladder. For some people it does, for some it doesn't cause irritation but alwasy worth trialling a reduction
- other common bladder irritants can be acidic foods, spicy foods, artifical sweeteners, carbonated drinks and alcohol
- stop smoking - yet another health reason to do so as it contributes to OAB
- method will depend on outcome of bladder diary
- the two main types are :
→bladder drills - going at regular intervals so you don't reach the point of sudden urges, this does mean you are going when you don't always feel any urge but gradually the time between voids is increased
→ deferment techniques - help you to settle the bladder urge down without rushing to the loo and ultimately become the boss of your bladder again rather than it being the boss of you
- some commonly used deferment techniques which all have an inhibitory or quietening effect on the bladder are:
✓ contract your pelvic floor
✓ curl your toes
✓ rub the back of your thigh
✓ if standing, go up/ down on your toes
✓ pressure on your perineum with hands 'hold onto yourself' or sit on a rolled towel or the edge of a chair
✓ at the same time you need to distract your brain from alerting attention to the bladder. Try reciting the alphabet backwards in your head.
- once the sense of urgency passes, you can then either calmy walk to the loo or, if comfortable, keep doing what you were until your bladder fills a bit more.
- the reason these deferment techniques can help is that they all target the same sensory nerve pathways as the bladder. ie the nerves that make your toes curl, activate your calf muscles and give you sensation on the back of the leg branch off the spinal cord at the same level as some of those to the bladder. So, in effect, you are causing a traffic jam of sensory input up to the brain so instead of it focusing just on the bladder it focuses on all of the information it is receiving.
For some people, with severe urgency, medication is required to help calm the bladder but should also then include some form of bladder training under the guidance of a health professional.
All drugs have side effects so you and your doctor have to decide if the benefits outweigh the side effects.
The most common side effect of drug therapy for an overactive bladder is constipation - which, in itself, can be a cause of bladder urgency. This is another reason why managing constipation is such an important part of bladder health.
Long term it has been shown that some medications for bladder urgency can have an affect on cognition so make sure you have regular check -ups and reviews with your doctor who prescribed your medication.
You will be more familiar with botox being used to reduce wrinkles on the face but when injected into the bladder it can help reduce the bladder spasms that cause severe urgency. This treatment normally has to be repeated every 6 months or so and can work well for some people.
TENS for OAB can be delivered either vaginally (for women) with an electrode, or via external adhesive electrodes (men and women) around the sacrum or on the inside of the ankle via the tibial nerve. This is known as TTNS or Transcutaneous Tibial Nerve Stimulation.
TENS is non-invasive, cheap and easy to administer and has some good research showing effectiveness.
This refers to Percutaneous Tibial Nerve Stimulation and is the same as TTNS as described above in TENS but instead of being applied through the skin, it is applied via a needle inserted into the skin near the nerve. This is more invasive and much more expensive but, for some, can be more effective.
This is Sacral Neuromodulation and involves the implantation of permanent wires into the sacral nerve region (specifically S3) which are attached to an implanted pulse generator (in the buttock cheek) , much like a pacemaker. This sounds scary but can in fact change the quality of life significantly for people with severe bladder urgency. This trreatment would only be considered if you had failed all conservative and medical treatment as described above, and a trial implant is done first before the permanent one.
How do I normally explain all this to my patients?
To be less technical I like to use analogies to explain what is happening when you have urinary urgency. It's all about the physics!
Let's look first at how your bladder works normally and then at what is happening when you expereinece bladder urgency (think of that as your bladder behaving badly)
Normal bladder function
- voiding 4-6 times a day and once a night ( although sleeping through is preferable)
- passing 300-500mls each void but able to hold more if unable to get to the toilet (eg when stuck in a traffic jam)
- urine is pale, not dark ( looks like a glass of chardy not a glass of beer)
- if urine is clear you are probably drinking too much fluid
- bladder filling and emptying is not painful
- there is no sudden urgency to go, rather a strong urge to pass urine once bladder is full
- flow is strong
Think of your bladder like a balloon which slowly fills but, as it does, the walls remain relaxed so the pressure within the bladder is low.
Whilst this is happening, the urethra stays closed ( via sphincters and pelvic floor) so the pressure in the urethra is high.
HIGH pressure always wins over LOW pressure ... those are the laws of physics.
When you decide to empty your bladder because it is feeling comfortably full, you sit on the toilet (or men will stand) the pelvic floor relaxes, some urine enters the bladder neck which triggers the micturition reflex. In other words a signal goes to the brain to say you are on the loo and ready to empty and a signal comes back to the bladder telling it to contract and empty out the urine.
At this point the pressure within the bladder is HIGH as the detrusor muscle contracts the bladder wall and the pressure in the urethra is LOW because the pelvic floor and sphincters are relaxed ...fluid flows from the high pressure zone to low pressure zone....those are the laws of physics.
BUT what happens when a sudden urge hits you?
The urethra is closed so in a state of HIGH pressure
The bladder is contracting when it shouldn't so is also in a state of HIGH pressure
The HIGHEST pressure will win = you will leak if your bladder pressure is greater than your urethral pressure. You won't leak if it is the other way round but you will be very uncomfortable and running to the loo. This in itself drives the need to go and makes it feel even more urgent.
Learning to control the urgency and gradually teaching your bladder to calm down will reduce the episodes and get you back in control of your bladder.
Think of your bladder as a kid having a tantrum - best way to deal with a tantrum is ignore it, not feed it by giving in.
Even though it feels awful, just remember there is no more urine in your bladder than there was a minute ago when you felt perfectly comfortable. It is just that now the urine is in a smaller space because the bladder has contracted and the pressure has gone up driving that sense of urgency.
If you use your calming techniques listed in deferment above, the bladder will relax and the pressure will return to normal at which point you can decide if it really is full or not and whether you need to goto the loo now or not.
So you need to ask yourself is your bladder telling you the truth?
The material presented here is intended as an information source only. The information is provided solely on the basis that readers will be responsible for making their own assessment of the matters presented herein and are advised to verify all relevant representations, statements and information. The information should not be considered complete and should not be used in place of the advice of a health care provider. Pelvic Floor Exercise does not accept liability to any person for the information or advice provided , or for loss or damages incurred as a result of reliance upon the material contained herein.
© Fiona Rogers, Pelvic Floor Exercise all rights reserved