urinary urgency and urge incontinence

Introduction

urinary urgency is a sudden, compelling urge to urinate and if uncontrollable, may cause urge incontinence
changes in afferent evoked reflexes appear to be important in causing this symptom

over-active bladder (OAB)
- it has been postulated that urgency is triggered by local distortions in the bladder wall, caused by heterogenous activity in some muscle bundles
- detrusor muscle hypertrophy in chronic obstruction is also thought to cause patchy neuronal ischaemia '
- supratentorial overlay - anxiety, depression, stress, ADHD
- oestrogen and progestogens may also have a role
- alcohol intake may exacerbate it
- > 450mg/d caffeine can exacerbate OAB ¹⁾
interstitial cystitis
- lowered threshold or spontaneous firing of afferents
urinary tract infections (UTIs) / cystitis
bladder outlet obstruction eg. benign prostatic hyperplasia (BPH)
- elicits enhancement of a spinal reflex and initiates morphologic and electrophysiologic plasticity in afferents via NGF
post-TURP - urgency may take 12 weeks to resolve
spinal cord injury

consider bladder scan to check post-void residual to exclude retention
Rx any urinary tract infections (UTIs) / cystitis
timed voiding
weight loss if obese
reduce intake of caffeine (esp. if > 450mg/d - 4 cups of coffee or 10 cups of tea)
cease cigarette smoking
bladder re-training if OAB and urge incontinence
pelvic floor muscle exercises if stress incontinence is also present
- see https://www.bladderandbowel.org/wp-content/uploads/2017/05/BBC004_Bladder-control-after-prostate-op.pdf
consider anti-muscarinic anticholinergic agents if there is no outlet obstruction (otherwise these may risk urinary retention)
consider tricyclic antidepressants
beta-3 adrenoceptor agonist mirabegron causes direct relaxation of detrusor muscle, inhibition of spontaneous contractile activity in the bladder and reductions in bladder afferent activity, but may cause hypertension and migraine
severe refractive cases may require intravesical botulinum toxin and electrical stimulation using sacral neuromodulation

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