Urgency Urinary Incontinence/ Overactive Bladder

Welcome to the NAFC Web site section devoted to overactive bladder (OAB) and urgency incontinence. The International Continence Society (ICS) defines overactive bladder (OAB) as "urgency, with or without urgency incontinence, usually with frequency and nocturia."

Typical symptoms of overactive bladder include:

  • urinating more than eight times per day or more than once at night (urinary frequency)

  • and a strong and sudden desire to urinate (urinary urgency).

If the urge to urinate cannot be controlled before reaching the toilet in time, overactive bladder can result in urgency urinary incontinence (involuntarily emptying the contents of the bladder). If you have symptoms of overactive bladder, such as urinary urgency and/or frequency, test your knowledge by taking a quiz on overactive bladder.

Overview

Read answers to common questions about overactive bladder, in NAFC's Q&A session with Dr. Ross A. Rames. He is an Associate Professor at the Medical University of South Carolina whose specialties include Female Urology, Incontinence, Urodynamics, Nephrolithiasis, Laparoscopy, Kidney disease / Stones, Infertility / Impotence and Vasectomies. His MD was awarded by Vanderbilt University in 1987.

Anatomy of the Urinary System
The urinary system is composed of two kidneys, two ureters, a bladder, and a urethra. The kidneys remove waste products from the blood and continuously produce urine. The muscular, tube-like ureters move urine from the kidneys to the bladder, where it is stored until it flows out of the body through the tube-like urethra. A circular muscle, called the sphincter, controls the activity of the urethra and keeps urine in the bladder until it is time to urinate.

In a normal person without overactive bladder, the bladder wall is relaxed while storing (or filling with) urine and the urethra is closed off by the sphincter. Muscles of the pelvic floor also make a contribution to keeping the bladder outlet closed during filling by supporting the urethra.

When the bladder is properly under control, we pass urine by a process which starts with a deliberate decision. Signals first move from the bladder up the spinal cord to the brain and inform us first subconsciously and then consciously about how full the bladder is. At the same time during storage, messages pass from the brain down the spinal cord and out through nerves that run through the pelvis to activate the sphincters and keep them closed and prevent the bladder muscle from contracting.

When the bladder is full, we assess the social appropriateness of passing urine (a complicated neurological process in itself!) and consider if the time and place are right. If so, we switch on a program of activity which causes the pelvic floor as well as muscles at the outlet of the bladder to relax and open up. As this occurs, the muscle in the wall of the bladder (detrusor muscle) begins to contract and continues contracting until the bladder is completely emptied.

The process of bladder filling and emptying is very complex. When any part of the urinary system or pelvic floor does not work correctly, incontinence can result.

Definitions

What is an overactive bladder (OAB)?
The International Continence Society (ICS) defines overactive bladder as "urgency, with or without urgency incontinence, usually with frequency and nocturia."

Typical symptoms of overactive bladder include:

  • urinating more than eight times per day or more than once at night (urinary frequency)
  • and a strong and sudden desire to urinate (urinary urgency).

Urgency urinary incontinence (UUI) is defined as the unwanted urine loss that happens shortly after the sudden, intense desire to urinate.

Urgency UI is caused by involuntary bladder contractions that occur as your bladder fills with urine continually flowing from the kidneys via tiny tubes, or ureters. With urgency UI, a person may be suddenly aware of the urgency sensation but is unable to get to the toilet before losing control of his or her urine. Urine loss can be in large amounts that soak underwear and even outer clothing. Sometimes an event will "trigger" the urine leakage. Some common triggers include hearing running water or what is known as the "key-in-the-door" syndrome. The anticipation of urinating can trigger a bladder spasm. In some cases, people who have physical limitations, such as arthritis, may not be able to reach the toilet in time, causing an accident. This may not be due to urgency incontinence or even the result of OAB.

In many cases, the underlying cause of an overactive bladder - why the bladder muscle malfunctions in this way - remains unclear. It is known that in men, prostate problems (BPH) can contribute to OAB. In women, a "dropped" (prolapsed) bladder may result in difficulty emptying the bladder due to blockage of the pathway. This can cause women to feel the sensation that they need to go to the bathroom often, but the problem is prolapse, not OAB. For others, there may be a neurological obstacle (such as multiple sclerosis) that interferes with the signals running from the brain to the bladder, causing what is called neurogenic overactive bladder. This can occur in stroke survivors. There are ill-defined aspects of the aging process itself that may cause deterioration of the body's network of nerves. Whatever the cause, it is important for those with an overactive bladder to know that the condition can and should be addressed. Identifiable underlying causes include the following:

  • Drug side effects (e.g., frequency of urination from diuretics, including caffeine-containing, over-the-counter drugs)
  • Neurological disease (e.g., multiple sclerosis, Parkinson's disease, stroke, spinal cord lesions)
  • Bladder stones, polyps, or tumor
  • Bladder infection

An additional symptom of overactive bladder seen very often - especially in the older people - is nocturia, awakening more than once at night to urinate, which will often disrupt sleep. Nocturia affects men and women of all ages, although its incidence increases significantly with age.

Please note: If you are experiencing symptoms of overactive bladder (urgency and frequency), be sure to go to your doctor to investigate the cause of your symptoms because urinary tract infections (UTIs) can produce the same symptoms as overactive bladder. Older individuals are especially susceptible to UTIs because of chronic diseases, medication, and increased residual urine (urine left in the bladder after voiding) as a result of the bladder’s decreased ability to contract with the aging process. Other groups of individuals at risk for UTIs include women with diabetes and/or who are pregnant, persons with HIV/AIDS, neurological diseases or injury, and individuals who have indwelling catheters. While an uncomplicated UTI is usually viewed to be a benign condition, more severe infections can require hospitalization.

If you have recurring symptoms such as severe bladder pain, burning, urgency, pain during sexual intercourse, and frequency, but your physician cannot verify the presence of a urinary tract infection, you may have interstitial cystitis. People who have been diagnosed with interstitial cystitis have to take great care with their diet and daily habits to manage this chronic condition. The information we provide is not intended for people with interstitial cystitis (IC), therefore for individuals who (may) have IC, the advice of a specialist should be sought. You may also wish to contact The Interstitial Cystitis Association, a vital and dynamic national organization offering information and support to IC patients and their families, educating the medical community about IC, and promoting research to find effective treatments and, ultimately, a cure for IC. View the Association's recent radio broadcast about living with the chronic pain of IC.

Stress urinary incontinence (SUI), the other main type of bladder control problem, may occur in addition to overactive bladder and urgency incontinence. SUI involves involuntary urine leakage while engaging in activities that exert pressure on the bladder, such as lifting, coughing, sneezing, or running. The leakage occurs is usually the result of a weakening of the pelvic floor muscles or connective tissue. Risk factors for SUI include childbirth, menopause, obesity, and chronic coughing/smoking. SUI in men most commonly results from prostate surgery, which can damage the sphincter muscle, leaving it too weak to function properly. The combination of both urgency incontinence and stress incontinence is referred to as mixed incontinence. The treatment of mixed incontinence involves a combination of both the treatments for urgency and stress incontinence.

Many people who experience problems with both urgency and frequency will eventually experience an episode of urgency incontinence or wetting accident. Urgency incontinence is less unpredictable and often results in a larger amount of urine loss than the typical leakage associated with stress incontinence. While you may be able to “brace” yourself when you are about to laugh or cough and leakage from stress incontinence, there tends to be little warning with urgency incontinence.

Prevalence

An estimated 33 million people in the United States suffer from an overactive bladder and an estimated 12.2 million of these adults have urgency incontinence.1 Although overactive bladder is most common among older adults and women, it does not discriminate. In fact, starting at age 60, men who report symptoms of overactive bladder begin to outnumber women who do so, with about 42% of men over age 74 reporting symptoms compared with 32% of women in the same age group.2 Anyone, at any age, can suffer from the symptoms of this problem.

Research indicates that most people believe the symptoms of an overactive bladder (urgency, frequency, and/or urgency incontinence) are an inevitable and normal part of growing older, rather than a treatable medical problem. They do not mention their symptoms to a doctor, assuming nothing can be done about the condition. Fewer than half of individuals with incontinence actually consult a healthcare provider about their problem. Furthermore, healthcare providers often don’t ask patients about these symptoms. In fact, NAFC research revealed that 9 out of 10 patients who discussed their OAB symptoms with their doctor disclosed that they were the party initiating the discussion, as opposed to the physician.2

Impact

In addition to the physical symptoms experienced, the real impact for people with an overactive bladder and/or urgency urinary incontinence is felt in the decline of quality of life. If left untreated, an overactive bladder can prevent normal living 24 hours a day. In severe cases, the effect of OAB on people's lives can be dramatic. The fear of having a wetting accident may lead people to alter their lifestyle and adopt preventive mechanisms, so they don’t have another accident. Rather than face their doctor, many people with OAB and/or urgency UI develop elaborate ways of coping, few of which address the real problem. Based on NAFC’s national epidemiological surveys of consumers, common examples of coping mechanisms are:

  • Wearing absorbent products in case of an accident and baggy/dark clothing to hide the undergarments or urine loss
  • Restricting fluids and urinating according to a timed schedule
  • Always carrying a spare set of clothing
  • Constantly emptying the bladder (defensive or preventative urination)
  • Only shopping in stores or going places with good toilet facilities
  • Inventing excuses to avoid social gatherings with friends and family
  • Limiting car trips and vacations
  • Only sitting in the aisle seat at the theater or at the movies or avoiding the theatre, public events, etc all together.
  • Weight gain, overeating, and lack of exercise

Other areas of impact:
Job Security Endangered

  • Regular absences from work
  • Frequent breaks while at work
  • Having to make unplanned toilet trips while driving
  • Inability to concentrate

Vitality Fatigue

  • Disturbed sleep due to regular nighttime trips to the bathroom, resulting in constant tiredness

Psychological Problems, Psychological well-being damaged

  • Depression, loss of self-confidence, guilt and fear of being a burden
  • Anxiety of over the potential of a public accident
  • Embarrassment and concern of public disclosure

Living this way is not only unnecessary, but can cause physical and emotional problems. Untreated overactive bladder can take a toll on almost every aspect of life: relationships, fitness and recreational activities, social life, work productivity and career prospects. Overactive bladder is a common problem, but it should not be accepted as a normal part of anyone's life. It is important to remember that if you or someone you know has overactive bladder, you are not alone.

OAB in Children

While the majority of children have voluntary control of bladder fullness between 2 and 4 years old, children of all ages can experience symptoms of overactive bladder. OAB in children is most prevalent in children ages 5 to 7, and is most commonly observed in girls.

Clinical evaluation of childhood OAB and urgency incontinence is unique from adult OAB because a couple of factors must first be considered:

  • whether the parent or child is most concerned by the symptoms of OAB,
  • and whether the child’s symptoms are medically or socially related. A mental health assessment may be needed to eliminate psychological problems as the basis for symptoms (ie., divorce, family death, stress at school, etc.)

And, similarly to evaluating OAB in adults, a doctor must determine whether or not symptoms are present during the day, during the night, or during both day and night. Additionally, doctors need to assess the child’s bowel health, as constipation can cause overactive bladder. If the child is not having daily bowel movements of a reasonable size, then treating constipation needs to be a part of the initial treatment.

If a child is diagnosed with OAB, treatment may involve a combination of behavioral and pharmacologic therapy. First, dietary changes may be needed, such as minimizing caffeine intake to reduce any stimulatory effect that it might have on the bladder. In general, behavioral approaches that include parental involvement and focus on rewards and/or goals often work well in children. For example, a parent may reward a child with a prize for each day that he or she voids every three hours, in an effort to establish a regular voiding routine. Additionally, doctors may prescribe medication for children. Some medications used in adults have been shown to be both effective and safe in children. One anticholinergic medication used in adults, oxybutynin, is available in liquid form for children who have trouble swallowing pills.

If children are not successful with either behavioral therapy and/or medication, more aggressive therapy may be recommended, such as intermittent catheterization, urethral dilatation, and augmentation.

Both OAB and urgency incontinence are treatable in children and efforts made to address both conditions should always be positive and encouraging. Children should never be blamed or ridiculed for their symptoms. To read about pediatric bedwetting, click here.

How to Prepare for a Doctor's Appointment

If you have a bladder control problem, a variety of medical professionals can assist you in addressing the problem. You can seek help from a urologist, primary care physician, geriatrician, urogynecologist, gynecologist, pediatrician, nurse practitioner, physician’s assistant, neurologist, occupational therapist, physical therapist, or continence nurse specialist. All of these medical professionals can recommend or perform tests to decide the best way to improve your condition. Not all, however, will necessarily be well versed in treatment options or trained in how to deliver the best treatments. In many instances, you may benefit most from a team of experts.

If you would like to search for a continence care specialist in your area, visit the NAFC homepage and search our Find An Expert database by your zip code. We encourage you to make an appointment so you can get on a path to treatment.
Once you make an appointment, please review the six tips we’ve listed for you to prepare for your doctor’s appointment.

#1. Fill out the Overactive Bladder Awareness Tool and NAFC’s bladder diary to take with you to your appointment.
In preparation for your appointment, download the PDF below, answer the questions, and give it to your doctor when you see him/her for your first visit.

Overactive Bladder - Validated 8-question Awareness Tool (Pfizer Inc, New York, NY.)
Also download and fill out NAFC's bladder diary for about 2 days before your appointment so that you can record your symptoms.

#2 – Make a list of all of your doctors and medical conditions.
Take a list of all your doctors, medical conditions, such as diabetes, sleep disorders, or heart problems, to your appointment.

  • If you suspect you may be experiencing mixed incontinence (both stress and urgency incontinence) be sure to communicate both of these symptoms.
  • For men, be sure to ask your healthcare provider if an enlarged prostate may be the cause of your urinary urgency and/or frequency.
  • For women, talk to your provider about the possibility of pelvic organ prolapse contributing to your symptoms.
  • If constipation may be a factor, speak to your doctor about possible remedies.

#3 – Complete a list of any operations or procedures you have had.
Take a list of any operations or procedures you have had (at least in the past 10 years) and when you had them.

Women should list their:

  • number of pregnancies,
  • number of deliveries,
  • weight of their babies, and whether they were delivered vaginally or by Caesarean section.

#4 - Show the doctor all your medications.
We suggest you get three food-storage size bags. In one, put all the prescription medicines you are taking that have been prescribed or refilled during the last 30 days. In the second bag, put all the prescriptions that you keep in the house but that you don't take regularly. In the third, put all the over-the-counter medicines, vitamins, and other supplements that you take.

#5 - Be prepared to describe how incontinence affects your daily life. 
Make a list of the most bothersome aspects related to your incontinence.

#6 – Be prepared for your appointment.
On the day of your appointment, expect to be asked for a urine specimen. Talk with the doctor's receptionist when you make the appointment and when you arrive, to see if there are tests, or preparations for tests, that you should know about, eg. fasting after midnight.

Treatment

Overactive bladder and urgency urinary incontinence are generally treated with one or a combination of two or more approaches:

  • Behavioral modifications: dietary changes, fluid management, pelvic muscle exercises, biofeedback, and/or bladder retraining
  • Drug therapy
  • Percutaneous tibial nerve stimulation
  • Sacral nerve stimulation

Dietary Changes

There is no “diet” to cure incontinence. However, diet can have a profound effect on your voiding patterns. There are symptoms you may be able to manage just by altering your diet. You may want to complete a bladder diary and monitor your food and fluid intake to see if you are able to find any relationship between your intake and urination.

Remember that certain “natural” or “energy” supplements may also contain ingredients that irritate the bladder, so read labels carefully. You may want to see if eliminating one or all of the items discussed in this section improves your bladder control.

  • Caffeine is a powerful substance that can increase bladder activity. It is naturally present in coffee beans, tea leaves, and cocoa beans. Drinking sodas, coffee, tea, eating foods, or consuming over-the-counter medications that contain caffeine may result in urgency, frequency, and/or incontinence. Studies have demonstrated that individuals with bladder symptoms who have reduced caffeine intake to less than 100mg/day noted improvement in symptoms. If you choose to limit products containing caffeine, do so slowly over a period of several weeks, as strong headaches may result during the withdrawal period.
  • Alcohol has also been shown clinically to act as a bladder stimulant, triggering symptoms of urgency. In addition, it acts as a diuretic and may induce greater frequency of urination.
  • Artificial sweeteners (sodium saccharine, acesulfame K, and to a lesser degree aspartame) have been shown in limited studies to negatively affect bladder function. In research, episodes ofIdaytime frequency of urination, urgency, and nocturia all increased with the consumption of dietary beverages compared to drinks with sugar or unsweetened.

While not demonstrated scientifically, other foods and beverages are thought to contribute to bladder control problems in some, but not all, people. Their effect on the bladder is not always understood, but you may want to see if eliminating one or all of the following items mentioned can improve your bladder control. You should broadly consider categories of foods and beverages that have a high acid (citrus juices or citrus fruits) or high sugar content or are highly spicy as being potential culprits. Elimination of these may decrease symptoms of frequency and urgency. Again, we remind you to make one change at a time and allow yourself time to evaluate the effect. In this way, you can determine if the change you made had an impact on your symptoms.

The best beverage for your bladder is water, so drink plenty of it. A very thin slice of lemon (not enough citrus to irritate the bladder) may improve the taste of water enough that you will find it more enjoyable. Many people who have bladder control problems reduce the amount of liquids they drink in the hope that they will need to urinate less often. While less liquid through the mouth does result in less liquid in the form of urine, the smaller amount of urine may be more highly concentrated and, thus, irritating to the bladder surface. Highly concentrated (dark yellow, strong-smelling) urine may cause you to go to the bathroom more frequently, and it encourages growth of bacteria. It is recommended that you drink a total of six to eight 8-ounce glasses of fluid throughout the day. A rule of thumb is 30 mls for every kilo of body weight. Do not restrict fluids to control incontinence without the advice of your physician and always follow their instructions.

Some foods cause urine to smell bad or peculiar. The most notable of these foods is asparagus. Another cause of foul-smelling urine, and the most dangerous cause, is a urinary tract infection. If you notice that your urine has a strong odor, and you have not eaten any foods that would cause this, you should have a specimen of your urine tested for infection. Cranberry juice (or cranberry tablets that can be purchased in most pharmacies) and cherry juice may help control urine odor, and there is strong evidence for using cranberry to prevent urinary tract infections. Some medicines may also cause your urine to have an unusual odor or be discolored such as those you may take for bladder inflammation or urine tests. If your urine has a peculiar odor or color, consult your physician.

In addition to diet, constipation may also contribute to or cause OAB, so be sure to talk to your doctor if you are not having regular bowel movements. Increasing fluids and dietary fiber can help. Click here to read more about bowel health.

Pelvic Muscle Exercises

Pelvic muscle exercises are a central element of the behavioral treatment techniques that help increase bladder control and decrease bladder leakage. While these exercises are often practiced to prevent or alleviate symptoms of stress incontinence since they strengthen the pelvic floor, they can also be helpful if you have overactive bladder and urgency incontinence. PMEs send a signal to the bladder to relax and resume filling.These techniques can be very effective, but they require your conscious effort and consistent participation.

Pelvic muscle exercises, also called pelvic floor muscle (or Kegel exercises – after Dr. Arnold Kegel) have been shown to improve mild to moderate urgency and stress incontinence. When performed correctly, these exercises help strengthen the muscles that support your bladder.  Through regular exercise you can build strength and endurance to help improve, regain, or maintain bladder and bowel control. If you are considering Kegel exercises, it is wise to get proper instructions from a healthcare professional before you invest the time in the program.

Visit the Pelvic Muscle Exercise page for details on how to perform pelvic muscle exercises.

Helpful Hints:

  • If you feel the urge to urinate, practice a strong pelvic muscle contraction. Pelvic muscle exercises actually send a message to relax the bladder, which in turn helps to suppress a strong urge to urinate until you can locate an appropriate place to empty your bladder.
  • Pelvic muscle exercises should be incorporated into a regular exercise program for enduring sexual vitality as well as pelvic organ support.

Assisted Pelvic Muscle Exercises

Various devices and techniques have been developed to help you locate, exercise, and rehabilitate the correct muscles. These include biofeedback training and, for women, vaginal weights and wands.

Biofeedback can be done with a healthcare professional or with a home device.  It helps to locate the right muscles by sending a signal (feedback) when you perform the correct contraction. Pelvic muscle exercises performed with biofeedback equipment are highly effective because PFM activity is isolated with an immediate audio or visual indication of successful exercises.

Different training aids, such as vaginal weights, have also been known to add discipline to a Kegel program – helping people stick with a routine. Talk to your healthcare provider about biofeedback and other ways to assist your pelvic muscle- strengthening program.

Bladder Retraining and Bladder Diary

Controlling the bladder and sphincter muscle is hard to do and may get more difficult as we grow older. But there is good news! Many studies over the years have supported the success of bladder retraining programs for urgency incontinence and overactive bladder for both women and men. While you should consult your doctor before trying any therapy mentioned in our literature, please note that bladder retraining can be done at home and without the help of a physician.

The goal of bladder retraining is to slowly increase the time between voids, therefore decreasing the number of trips you must make to the bathroom during the day. NAFC has published a 6-week nurse-authored Bladder Retraining Program, which has been fully researched for effectiveness. This program involves recording bathroom habits in a daily diary and learning to control the urge to urinate. Patients must be functional, highly motivated, and persistent for bladder retraining to be effective. If you are interested, visit our online store to order the program:

In addition to bladder retraining, there are several tips for “good toileting”:

  • Use the toilet regularly - every 2½ to 3½ hours. For women, sitting comfortably on the toilet seat rather than squatting over the seat will allow for more complete bladder emptying because the pelvic floor muscles are able to fully relax and let the urethral sphincter open for better flow.
  • Wear clothes that are easy to get open or removed to use the toilet.
  • Don't rush when toileting. In the case of women, remain on the toilet until your bladder is empty. If you feel there is still some urine in the bladder, stand up and then sit back down again and lean forward slightly over the knees. This is called “double voiding” and may help you empty your bladder.
  • Make the toilet facilities convenient and safe. This may mean a bedside commode, bedpan, or urinal placed conveniently near or in the bed.
  • Empty your bladder before you start on a journey of an hour or more. Don’t try to “wait until I get home to my own bathroom.” Map out the public toilets in advance of visiting a new destination to avoid anxiety about finding one.
  • Avoid rushing or running to the toilet. This actually increases the likelihood of an accident and puts you at risk of falling.

Combination Therapy

Research demonstrates that combining behavioral therapies, such as pelvic muscle exercises and bladder retraining, with medication for OAB is more effective in treating OAB and urgency incontinence than either behavioral therapy or taking medication alone.3 Click hereto read the abstract of a study in which women who received a combination of both behavioral and pharmacological treatments experienced a larger reduction in urgency incontinent episodes than women who received only one type of treatment.

It is easy to understand that two treatment options that are often successful at treating urgency incontinence alone could help a patient more when combined. It is more difficult, however, to stay motivated to continue behavioral treatment despite research in support of its benefits. It is important to develop a long-term treatment plan with your provider which may include these therapies, either in a step-wise fashion or together.

Medications

Click here to view a list of the currently approved medications for treating overactive bladder. Drugs with anticholinergic and direct bladder muscle relaxant effects are often prescribed to relieve symptoms of urgency and frequency. These drugs may have side-effects including dry mouth, constipation, blurred vision, gastroesophageal reflux, and urinary retention. To minimize side-effects, extended-release formulations and non-oral alternatives for drug delivery have been developed.

New agents and methods of administration are currently being investigated in attempts to improve tolerability of treatments for OAB. Individuals may react differently to the medications, so if side effects from one are troubling, consult with your doctor to try a different one.
Anticholinergic drugs represent a broad category of pharmaceutical agents, including some of the drugs used for allergic reactions, diarrhea, depression, and overactive bladder.  Several recent studies have raised concerns about possible memory decline in older persons taking anticholinergic drugs over an extended period of time (years). 4 One study suggested that individuals who experienced memory decline did not recognize the change in their cognitive function. Studies are ongoing to assess the degree of risk of memory decline from drugs used for overactive bladder. Note:Click here if you would like to read what you should know about prescription drug advertising.

Several classes of medicines affect the bladder muscle and the bladder outlet muscle.  Sometimes these medicines are prescribed for conditions outside the urinary system and cause unwanted changes in bladder control.  At other times, these changes are desirable and the same class of medicine is prescribed to treat incontinence. To view a chart of medications that may affect bladder control, click here. When discussing your symptoms, be sure to mention to your doctor if you are taking other medications.

Percutaneous Tibial Nerve Stimulation, Urgent® PC Neuromodulation System

Individuals with urgency incontinence who have not responded to medication and/or behavioral treatment and who do not want to have surgery may be a candidate for percutaneous tibial nerve stimulation. Percutaneous tibial nerve stimulation (or PTNS) involves the delivery of electrical stimulation to the sacral nerve via the tibial nerve, accessed at the ankle. The treatment is called The Urgent® PC Neuromodulation System and many patients respond positively to this therapy.5

PTNS is an in-office procedure that uses a stimulator, which generates an electrical impulse that is delivered to the patient through a lead set. Using a needle electrode placed near the ankle as an entry point, the stimulator’s impulses alter the activity of the bladder by traveling along the tibial nerve to the nerves in the spine that control pelvic floor function.

Each treatment lasts approximately 30 minutes, in an initial series of 12 treatments, typically scheduled a week apart.  After the initial 12 treatments, your healthcare professional will discuss your response to the PTNS treatments and determine how often future treatments are needed to maintain results.
The Urgent® PC Neuromodulation System is designed to treat urinary urgency, urinary frequency, urgency incontinence, symptoms associated with overactive bladder, and interstitial cystitis.

Sacral Nerve Stimulation, InterStim® Therapy

For patients with symptoms caused by OAB who have not had significant success or could not tolerate conservative treatments such as behavioral treatments or medication, there is a treatment that allows the delivery of electrical stimulation directly to the sacral nerves, called sacral neuromodulation or sacral nerve stimulation. This therapy, introduced by Medtronic as InterStim® Therapy, was FDA approved in 1997 and has been implanted in over 75,000 individuals worldwide (2010). It has been shown to be successful in 4 out of 5 patients with urgency incontinence and successful in two-thirds of patients with urgency-frequency.6

Sacral neuromodulation involves two stages: a test and a permanent implant. The advantage of a single implant is that it delivers electrical stimulation without the need of repeated doctor’s office visits. Another benefit of this therapy is the test stimulation. This outpatient procedure allows patients to assess the effect of the therapy at home prior to consideration of a surgical implant procedure.

The implanted system consists of a small stimulation system that is surgically placed under the skin in the upper buttock or the abdomen. This is a minimally invasive procedure that can be performed under local anesthesia. The therapy uses mild electric pulses much like a heart pacemaker to stimulate the sacral nerve in the lower back (just above the tailbone).

Medtronic InterStim® Therapy is a reversible treatment and adjustments can be made at the doctor's office with a programming device that sends a radio signal through the skin to the neurostimulator. Another programming device is given to the patient to further adjust the level of stimulation, if necessary. Read more about the findings from a 2006 study on sacral neuromodulation.

InterStim® is indicated for the treatment of non-obstructive urinary retention and the symptoms of overactive bladder, including urinary urgency incontinence and significant symptoms of urgency-frequency alone or in combination, in patients who have failed or could not tolerate more conservative treatments. Evidence from research is supporting expanded indications for SNS, such as interstitial cystitis, chronic pelvic pain, an durinary dysfunction such as witnessed in patients living with multiple sclerosis. When considering the procedure, be sure to talk to your doctor about the risks of surgery, such as pain, discomfort, and infection.

Research and Future Treatments

In addition to the many behavioral and surgical treatment options currently being used to treat overactive bladder and urgency incontinence, there is exciting research on new treatments underway.

In 2009, NAFC sponsored a nationwide survey of women ages 40 to 65 with overactive bladder to learn more about why women seek treatment for OAB symptoms and what drives them to continue their treatment or discontinue it. This research was published in Annals of Urology.
Click here to read the Annals of Urology article.
Click here to download a PDF version of the article.

Studies have shown that patients with both neurogenic and non-neurogenic overactive bladder have experienced a significant decrease in their symptoms as the result of Botulinum toxin type A (BTX-A or Botox®) bladder injections. While it is clear that patients do experience improvement with BTX-A injection therapy, the number and dosage of injections, success rate, and duration of symptom relief varies between studies.

For example, one study reported that patients with neurogenic OAB treated with BTX-A experienced a 50% improvement in incontinent episodes, which lasted between 8 and 10 months.7 Another study showed an 88% improvement in urgency, frequency, and incontinence in patients with non-neurogenic OAB, lasting on average for 9 months.8 Studies on BTX-A also report an improvement in bladder capacity and in a patient’s ability to empty the bladder. These findings suggest new hope for individuals with neurogenic OAB (as the result of multiple sclerosis, for example) and patients with OAB who have not responded to medication; however, the long term effects of cumulative Botox treatments are unknown.

*If you participate in a clinical trial, it is possible that Medicare may cover routine costs but will not cover the item or service the trial is testing (Botox). Please refer to Medicare's clinical trial coverage pamphlet for more information.

Read the following abstracts from published studies regarding the effectiveness of Botulimum toxin type A in treating OAB:

There have been limited studies focused on the use of acupuncture for OAB and urgency incontinence. Read the following abstracts from published studies assessing the use of acupuncture on patients with OAB and urgency incontinence:

Other Considerations:

  • Those who are in the process of seeking treatment or who have not had success with treatment may find incontinence management devices helpful. The National Association For Continence sells a listing of all of incontinence products called the Resource Guide®. Visit our online store to order.
  • Invasive surgery is rarely used to treat urgency incontinence. However, if it is severe and refractory, augmentation cystoplasty, or bladder enlargement, can be considered. This is a surgical procedure in which a segment of the bowel is added to the bladder to increase bladder size and allow the bladder to store more urine. It is performed in adults and children who lack adequate bladder capacity or detrusor muscle compliance. Additionally, other surgical approaches, such as a urinary diversion, are used to improve or replace the function of the urinary bladder because of neurogenic bladder dysfunction and detrusor overactivity.

Conclusion

Patients with OAB and urgency incontinence should feel encouraged by the many existing treatment options that can provide meaningful and even complete relief of their symptoms. Moreover, because treatment options are continually advancing, the likelihood of finding an effective treatment is always increasing. For these reasons, be sure not only to make an appointment with a doctor, but also to revisit your doctor in the future if you are still experiencing bothersome symptoms of OAB and urgency incontinence.

References

1Stewart WR et al. Prevalence and impact of OAB in the US: results from the NOBLE program. Neurological Urodynamics. 2001; 20:406-408.

2Muller N. What Americans Understand How they Affected by Bladder Control Problems: Highlights of Recent Nationwide Consumer Research. Urologic Nursing. 2005:25(2): 109-115.

3 Burgio, K. et al. Combined Behavioral and Drug Therapy for Urge Incontinence in Older Women. J Am. Geriatr Soc 2000;48:370-374.
4 Tsao, Jack, Associate Professor of Neurology at Uniformed Services University. Bethesda, MD

5 Govier, F.E., et al. (2001). J Urol, 165, 1193-1198. Percutaneous afferent neuromodulation for the refractory overactive bladder: Results of a multicenter study.

6 http://www.medtronic.com/physician/interstim/clinical-12.html

7 Schurch, Brigitte. J Urol. 2005; 174:194-200.
8 Schmid, Daniel. J Urol. 2005; 173:149.

OAB in children section reviewed by Dr. Stuart Bauer, Pediatric Urologist, Children’s Hospital Boston