Urge incontinence and overactive bladder: bladder training and treatment

The NHS defines urge (urgency) incontinence as urine leaking when you feel a sudden, intense urge to pee, or soon afterwards. NHS inform describes it as feeling a sudden and very intense need to pee and being unable to stop it. It can occur alone or together with stress incontinence, which is called mixed incontinence.

Overactive bladder syndrome, the NHS explains, is the frequent urge to urinate that can occur with or without leaking. The usual explanation is overactivity of the detrusor muscles in the bladder wall. These muscles should relax to allow the bladder to fill and contract when you go to the toilet, but sometimes they contract too often, creating an urgent need to go.

The NHS says the reason the detrusor muscles contract too often may not be clear, but possible causes include drinking too much alcohol or caffeine, not drinking enough fluids (which lets strong, concentrated urine irritate the bladder), constipation, conditions affecting the lower urinary tract such as urinary tract infections or bladder tumours, neurological conditions, and certain medicines. If the cause can be treated, this may cure the incontinence.

Because infection and bladder lining problems can cause urgency, a GP will usually check for a urinary tract infection. NHS inform notes that increasing age, being overweight and a family history can raise the chance of incontinence generally, but that it does not happen just because of ageing.

• Caffeine and alcohol.

• Drinking too little, so that urine is concentrated.

• Constipation.

• Urinary tract infection or other bladder problems.

• Neurological conditions and some medicines.

The NHS says to see a GP for any type of urinary incontinence. The GP will ask about symptoms and may suggest a bladder diary recording how much you drink and how often you pee, and may do a pelvic or rectal examination. NHS inform adds that the GP will try to rule out other causes, such as a urinary tract infection, and may refer you to a specialist, usually a physiotherapist. NHS continence services staffed by specialist nurses and physiotherapists can diagnose and start treatment, and in some cases you can refer yourself.

Tests such as urine tests and, in more complex cases, urodynamic studies (pressure testing of the bladder) or cystoscopy (a camera examination of the bladder) may be arranged by a specialist.

The NHS says conservative treatments are tried first: lifestyle changes, pelvic floor muscle training and bladder training. Suggestions include reducing caffeine, which increases the amount of urine produced; adjusting daily fluid intake because both too much and too little can worsen incontinence; and losing weight if overweight or obese.

Bladder training is one of the first treatments offered for urge incontinence. It involves learning techniques to increase the time between feeling the need to urinate and passing urine, and the course usually lasts at least 6 weeks. It can be combined with pelvic floor muscle training if you have mixed incontinence. Incontinence products such as pads or pants are not a treatment but can help while you wait for assessment or for treatment to work.

If bladder training is not effective, the NHS says a GP may prescribe an antimuscarinic (anticholinergic) such as oxybutynin, tolterodine or darifenacin, which may also be used for overactive bladder syndrome. They are usually taken as tablets 2 or 3 times a day, and oxybutynin also comes as a patch applied twice a week. A low dose is usually started to minimise side effects, which can include dry mouth, constipation, blurred vision and extreme tiredness; in rare cases they can lead to angle closure glaucoma. You are assessed after 4 weeks to see if the medicine helps, and every 6 to 12 months thereafter if it continues to work.

If antimuscarinics are unsuitable, have not helped or cause unpleasant side effects, you may be offered mirabegron or vibegron, which relax the bladder muscle to help it fill and store urine, usually as a once-daily tablet or capsule. Common side effects include constipation, diarrhoea, nausea and headache. A low-dose desmopressin or an afternoon loop diuretic may be used for night-time urination (nocturia), noting that loop diuretics are not licensed for that purpose. Your GP will consider other health conditions and medicines to choose which is suitable.

The NHS says surgery to treat urge incontinence includes enlarging the bladder or implanting a device that stimulates the nerve that controls the detrusor muscles. Specialist services may also offer other options, such as injections into the bladder wall or nerve stimulation through the leg. These options are generally considered only after bladder training and medicines have been tried, and a specialist should explain expected benefit, the possibility of needing to catheterise, and the risks.

It is reasonable to ask about the evidence for each approach, what the success rates mean for you, and what follow-up is involved.

The NHS pathway is GP review, urine testing, bladder training with continence services, medicines, then urology or urogynaecology for procedures. Waiting times for specialist services vary.

Private urologists and urogynaecologists can arrange faster assessment, urodynamics and procedures. Keep a bladder diary, because it helps either route, and ask for a clear plan about when to review medicines.