Overactive bladder: symptoms, causes, treatment and what helps

Bladder & Bowel Community lists the most common symptoms of overactive bladder: a sudden urge to go to the toilet to pass urine (urgency), not getting to the toilet in time (urge incontinence), needing to go very often, which it gives as more than 7 times a day (frequency), getting up to pass urine during the night (nocturia) and wetting the bed (nocturnal enuresis). It describes the condition as being sometimes called an unstable or irritable bladder or detrusor overactivity.

The NHS describes urge incontinence as feeling a sudden and very intense need to pass urine and being unable to delay going, often with only a few seconds between the urge and release. The urge can be triggered by a sudden change of position, or even by the sound of running water. Some people also leak during sex.

It can coexist with stress incontinence, where urine leaks when you cough, laugh, sneeze or exercise. The NHS calls this mixed incontinence. NICE CKS lists psychological effects, sexual problems, social isolation and physical problems such as skin breakdown, recurrent infections and falls among the complications of urinary incontinence generally, which is why treating it matters beyond comfort.

Conservative treatments come first, according to the NHS. Lifestyle changes include reducing caffeine, adjusting how much fluid you drink, and losing weight if overweight. NICE guidance for women advises weight loss for those with a BMI over 30 and a minimum of 6 weeks of bladder training as first-line treatment for urgency or mixed incontinence. Bladder training teaches ways to lengthen the time between feeling the need to go and passing urine.

Pelvic floor muscle training is recommended when stress incontinence is part of the picture, with at least 8 contractions 3 times a day for at least 3 months. NHS continence services staffed by specialist nurses and physiotherapists can assess and treat, and in some cases you may be able to refer yourself. Absorbent pads and similar products are not a treatment, but the NHS says they may help while waiting for assessment or for treatment to work; NICE advises they are offered as a coping strategy rather than first-line treatment and reviewed at least annually.

The NHS says bladder training usually lasts at least 6 weeks, so improvement is judged over weeks, not days. If medicine is started, the NHS says you will be assessed after 4 weeks to see if it is helping, and every 6 to 12 months afterwards if it continues to be effective.

If bladder training is not effective, the NHS says a GP may prescribe an antimuscarinic (anticholinergic) such as oxybutynin, tolterodine or darifenacin, usually as tablets, though oxybutynin also comes as a patch. Dry mouth, constipation, blurred vision and tiredness are possible side effects, and in rare cases antimuscarinics can cause angle closure glaucoma. Review is advised after 4 weeks and then every 6 to 12 months while the medicine works.

NICE guidance for women adds that the choice should take account of other conditions and the total anticholinergic load of other medicines, including the risk of cognitive impairment, and advises against immediate-release oxybutynin in older women at higher risk of a sudden deterioration in physical or mental health. If antimuscarinics are not suitable, do not work or cause unpleasant side effects, the NHS says mirabegron or vibegron may be offered. Vaginal oestrogen is advised for women with overactive bladder and menopausal genitourinary symptoms, desmopressin may be considered for troublesome night-time urination (with caution in some people), and a transdermal option is available for those who cannot tolerate oral medicine.

The NHS says a GP may suggest simple lifestyle changes whatever type of urinary incontinence you have: reducing caffeine, found in tea, coffee and cola, as it can increase the amount of urine your body makes; altering how much you drink each day, as drinking too much or too little can make incontinence worse; and losing weight if you are overweight or obese.

Bladder & Bowel Community adds that caffeine and alcohol may irritate the bladder and cause urgency and frequency, and that some fizzy drinks and fruit teas containing hibiscus can also irritate it. It also points out the opposite problem: some people do not drink enough, their urine becomes very concentrated and this can irritate the bladder. Constipation is another contributor listed by the NHS.

A bladder diary kept for at least 3 days, which the NHS describes in its assessment, is a practical way to see which drinks and times of day make a difference.

The NHS lists possible reasons for the detrusor muscles to contract too often, though in many people the cause stays unclear:

• drinking too much alcohol or caffeine

• not drinking enough: strong, concentrated urine can irritate the bladder and cause symptoms of overactivity

• constipation

• conditions of the lower urinary tract, such as urinary tract infections or tumours in the bladder

• neurological conditions

• certain medicines, including ACE inhibitors, diuretics, some antidepressants, HRT and sedatives (the NHS says stopping these, if a doctor advises it, may help resolve incontinence)

The NHS explains that the bladder wall contains detrusor muscles that relax to let the bladder fill and contract when you go to the toilet. If they contract too often, you feel an urgent need to go; this is known as having an overactive bladder. The reason may not be clear.

NICE Clinical Knowledge Summaries define overactive bladder as a symptom complex of urgency, with or without urgency incontinence, and usually with frequency and nocturia (waking at night to pass urine). The NHS notes it can mean needing to pass urine very frequently, including several times a night, and sometimes leaking when the urge is overwhelming.

The NHS says urinary incontinence can usually be diagnosed after a consultation with a GP, who asks about symptoms, medicines, and how much fluid, alcohol and caffeine you drink. A bladder diary kept for at least 3 days records fluid intake, how often you pass urine, how much, episodes of leaking and urgent urges. A pelvic examination (or prostate and rectal examination for people with a penis) and a urine dipstick test for infection, blood or protein may follow. NICE CKS adds that kidney function may be checked because acute kidney injury can be present with obstruction.

If a cause is not clear, or treatment does not work, further tests such as cystoscopy, which uses a thin camera to look inside the bladder, or urodynamic tests, which measure bladder pressure and flow, may be arranged.

NICE says women who have tried medicine without success should be referred to secondary care, and that, after discussion by a specialist team, urodynamic investigation may be offered. Bladder wall injections of botulinum toxin type A can be offered for overactive bladder caused by detrusor overactivity that has not responded to non-surgical management. People must be willing to learn clean intermittent self-catheterisation if they develop difficulty emptying the bladder, and the risk of urinary tract infection is higher. A review within 12 weeks assesses the response.

Percutaneous sacral nerve stimulation is another option for women whose symptoms have not responded to medicines and either did not respond to botulinum toxin or who do not want the catheterisation risk. NICE says percutaneous posterior tibial nerve stimulation should only be offered in limited circumstances, and that transcutaneous (surface) stimulation should not be offered. Larger operations such as bladder augmentation or urinary diversion are reserved for those in whom all else has failed. These recommendations are written for women; the NHS describes the same stepwise principle for everyone.