Urge incontinence is caused by overly active or irritated bladder muscles. Its most common symptom is the frequent and sudden urge to urinate, with occasional leakage of urine. Mixed incontinence can occur when there is muscle weakness and an uncontrollable need to void the bladder.
Key diagnostic factors include the presence of risk factors, involuntary urine leakage on effort, exertion, sneezing, or coughing, involuntary urine leakage accompanied by or immediately preceded by urgency and the frequency to urinate (BMJ, 2020). Other diagnostic factors include presence of nocturia, abnormal bulbocavernosus and wink reflexes, weakened sphincter tone and chronic heart failure (BMJ, 2020). Risk factors include older age, white ethnicity and obesity (BMJ, 2020).
Causes
This type of urinary incontinence may be caused by changes in anatomical support and/or neuromuscular function of the pelvic floor, or it may be idiopathic (BMJ, 2020). There is a high incidence of stress and urge incontinence in women with chronic lower back pain, caused by poor motor control in the local lower back and pelvic floor muscles responsible for continence while also supporting the spine. Therefore, both problems are often treatable with transverses abdominus exercises, known as core stabilising exercises (Australian Menopause Society, 2013).
Urge incontinence is often associated with overactive bladder syndrome, the symptoms of which are thought to be caused by involuntary contractions of the detrusor muscle during the filling phase of the micturition cycle (National Institute for Health and Care Excellence (NICE), 2019a). As a result of the overactivity of the detrusor muscles, urgency and frequency of micturition can be caused, with or without incontinence. Urge incontinence is idiopathic in most women and, in some cases, can be associated with systemic neurological conditions, such as Parkinson's disease, multiple sclerosis, or injury to the pelvic floor or spinal nerves (NICE, 2019a). There are various comorbidities that increase the urgency symptoms. These include obesity, type 2 diabetes, and chronic urinary tract infection.
Adverse effects of some medications may also cause detrusor overactivity, such as parasympathomimetics, antidepressants, and hormone replacement therapy. Diuretics also increase urinary frequency. Urinary urgency can also be increased significantly by caffeinated, acidic, or alcoholic drinks.
Management
NICE (2019a) guidelines indicate that treatment of urinary incontinence should begin with conservative treatment, and surgical options should only be used when conservative treatment is not able to achieve positive results (Kolodynska et al, 2019). Conservative treatment would involve pharmacotherapy, physiotherapy, and behavioural therapy.
Where it is a case that does not require referral, and symptoms require managing, alongside any medicated treatment, the patient should be receiving counselling. The NICE (2019a) clinical knowledge summary on the topic provides further guidance.
Physical/behavioural treatments
One of the primary physical therapies to be offered is pelvic floor muscle training. A supervised trial should be offered of this intervention for at least 3 months as a first line-treatment for women who experience stress or missed urinary incontinence, with the pelvic floor training programme consisting of at least eight contractions three times daily (NICE, 2019b).
Another option is electrical stimulation, which should not be routinely used in the treatment of women with an overactive bladder, or in combination with pelvic floor muscle training. NICE (2019b) explain that this intervention should be offered to women who are not physically able to contract their pelvic floor muscles, and should be provided in order to aid motivation and adherence to therapy.
In terms of behavioural therapy, NICE (2019b) recommends bladder training lasting for a minimum of 6 weeks as a first-line treatment to women with urgency or mixed incontinence. Where there is no satisfactory benefit from this, a combination of medication for the overactive bladder, in combination with bladder training, should be considered in cases where frequency may be a troubling symptom.
Neurostimulation is another physical therapy to consider, but transcutaneous sacral nerve stimulation (TENS) or transcutaneous or posterior tibial nerve stimulation should not be offered for an overactive bladder (NICE, 2019b). Percutaneous posterior tibial nerve stimulation should also not routinely be offered except if there has been a local multidisciplinary team review, as well as ensuring that the patient already tried non-surgical management, including overactive bladder medication that may have not worked adequately (NICE, 2019b). It should also only be offered when the patient has declined botulinum toxin type A (Botox) or percutaneous sacral nerve stimulation (NICE, 2019b).
Special considerations
NICE (2019a) notes that, if the woman with urge incontinence is post-menopausal and has vaginal atrophy, intravaginal oestrogen therapy should be considered. This should then be reviewed at least annually to reassess the need for continued treatment and for the monitoring of symptoms of endometrial hyperplasia or carcinoma in women with a uterus.
If the woman has troublesome nocturia, desmopressin can be considered as an off-label indication, but this should be avoided in women over the age of 65 years with cardiovascular disease or hypertension.
Where conservative treatment options fail, a referral for specialist urological assessment and management should be considered (NICE, 2019a). The treatment options in secondary care include injection of Botox into the bladder wall, percutaneous sacral nerve stimulation, augmentation cystoplasty, and urinary diversion (NICE, 2019a).
Absorbent containment products
NICE (2019b) makes it clear to not offer any absorbent containment products, handheld urinals or toileting aids for the treatment of urinary incontinence, unless only as a coping strategy while waiting for their actual treatment for the condition, for use as an adjunct to ongoing therapy, or for long-term management of urinary incontinence if treatment options have been properly investigated. Women who do use such products should be reviewed annually via a skin assessment, alongside a routine assessment of continence and an evaluation of the efficacy of the product in meeting the needs of the individual patient (NICE, 2019b).