NORMAL URINATION:
The ability to hold urine and maintain continence is dependent on normal function of the lower urinary tract, the kidneys, and the nervous system. Additionally, the person must possess the physical and psychological ability to recognize and appropriately respond to the urge to urinate.

The process of urination involves two phases: 1) the filling and storage phase, and 2) the emptying phase. Normally during the filling and storage phase, the bladder begins to fill with urine from the kidneys. The bladder stretches to accommodate the increasing amounts of urine.

The first sensation of the need to urinate occurs when approximately 200 ml of urine is stored. The healthy nervous system will respond to this stretching sensation by alerting you to the need to urinate while also allowing the bladder to continue to fill. The average person can hold approximately 350 to 550 ml of urine.

The ability to fill and store urine properly requires a functional sphincter (muscle controlling output of urine from bladder) and a stable bladder wallmuscle (detrusor).

The emptying phase requires the ability of the detrusor muscle to appropriately contract to force urine out of the bladder. Additionally, the body must also be able to simultaneously relax the sphincter to allow the urine to pass out of the body.

During infancy, the bladder contracts automatically when a certain volume of urine is reached within its walls. As an individual learns to control urination, bladder muscle contraction is prevented by constant inhibition from the brain (cerebral cortex) as the individual consciously delays urination.

Undesired bladder muscle contraction may occur as the result of a break in the neurological pathway from the brain to the bladder. It can also occur if the bladder is so irritable that the normal inhibitory neurological impulses (messages that slow down or prevent an action) are insufficient to keep the bladder muscle relaxed as urine fills the bladder.

URGE INCONTINENCE:
Urge incontinence is basically a storage problem in which the bladder muscle contracts inappropriately. Often these contractions occur regardless of the amount of urine that is in the bladder. Urge incontinence may result from neurological injuries (such as spinal cord injury or stroke), neurological diseases (such as multiple sclerosis), infection, bladder cancer, bladder stones, bladder inflammation, or bladder outlet obstruction (enlarged prostate). However, the majority of cases are classified as idiopathic--a specific cause cannot be identified.

Irritable bladder may occur in either males or females at any age, however it is more common in women and the elderly. It is second only to stress incontinence as the most common cause of urinary incontinence (involuntary loss of urine). Approximately 1 to 2% of adult females are affected by the problem.

Early initiation of bladder retraining techniques may be useful in reducing the severity of symptoms.

• sudden and urgent need to urinate (urinary urgency)
• frequent urination, in the daytime and at night
• abdominal distention or discomfort
• involuntary loss of urine (urinary incontinence)

Physical examination will include exam of the abdomen, rectal exam, genital exam in men, and pelvic exam in women.In most cases the physical exam is normal. If there are neurologic causes of the urge incontinence, other neurologic abnormalities may be found.

Tests include:

• post void residual (PVR) to measure amount of urine left after urination
• urinalysis/urine culture to rule out urinary tract infection
• urinary stress test (the patient is asked to stand with a full bladder, and then cough)
• pad test (after placement of a pre-weighed sanitary pad, patient asked to exercise; following exercise, the pad is re-weighed to determine the degree of urine loss)
• a pelvic or abdominal ultrasound
• X-rays with contrast dye
• cystoscopy (inspection of the inside of the bladder)
• urodynamic studies (tests to measure pressure and urine flow)
• rarely, an EMG (myogram) is performed

Further tests will be performed to rule out other types of incontinence. These tests may include the measurement of the change in the angle of the urethra when it is at rest and when it is straining (Q-tip test). An angle change of greater than 30 degrees often indicates significant weakness of the muscles and tendons that support the bladder, as in stress incontinence.

There are several different approaches that may be used in managing and treating urge incontinence. Kegel exercises (tightening the pelvic floor musculature 150 to 200 times per day) may be beneficial self-care.

If evidence of infection is found in urine culture, antibiotics will be prescribed. Bladder retraining exercises can be used, having the individual urinate on a predetermined schedule or gradually increasing the interval between urinations. Biofeedback techniques may prove useful.

Medications that relax the bladder muscles such as anticholinergics, bladder muscle relaxants or antispasmodic medications.

The choice and location of a specific treatment will depend on the severity of the symptoms and the extent that the symptoms interfere with your life style. There are three major categories of treatment for urge incontinence; bladder retraining therapy, medications to relax bladder contractions, and surgery.

MEDICATIONS:
Medications used to treat urge incontinence are aimed at relaxing the involuntary contraction of the bladder and improving bladder function. There are several types of medication that may be used, including anticholinergic agents, oxybutynin, tricyclic antidepressants, calcium channel blocking agents, flavoxate and terbutaline. Medications may be used alone or in a combination.

Oxybutynin and tolterodine are antispasmodic medications that relax the smooth muscle of the bladder. These are the most commonly used medications for urge incontinence. Side effects of these drugs are minimal, with the most commonly occurring side effects being dry mouth and constipation.

Both of these drugs have a once-a-day formulation that makes dosing easy and effective. These medications are contraindicated in patients with narrow angle glaucoma.

Propantheline and dicyclomine are anticholinergic medications that block the inappropriate contractions in the bladder. These medications has been widely used in the past to treat urge incontinence because they are relatively inexpensive yet effective.

Oxybutynin and tolterodine have virtually replaced the use of these medications. Dicyclomine also has the ability to function as a bladder muscle relaxant. Side effects, including dry mouth, dizziness, drowsiness, increased heart rate, and difficulty urinating, are reported in about half of the people who are taking these medications.

Tricyclic antidepressants, such as imipramine or doxepin, have been used to treat urge incontinence because of their ability to inhibit or "paralyze" the bladder smooth muscle. Possible side effects include fatigue, dry mouth, dizziness, blurred vision, nausea, and insomnia.

Flavoxate is also used to treat urge incontinence. This medication may have the ability to relax the smooth muscle of the bladder. However, studies have shown inconsistent benefit in controlling symptoms of urge incontinence.

SURGERY:
Surgery is reserved for patients that are severely debilitated by their incontinence. Urge incontinencemay result from inappropriate bladder contraction or decreased ability of the bladder to store urine.

Surgery may be advised for people who have an unstable bladder (severe inappropriate contraction) and poor ability to store urine. Thus, the goal of any surgery to treat urge incontinence is aimed at increasing the storage ability of the bladder, while decreasing the pressure within the bladder.

• AUGMENTATION CYSTOPLASTY

Augmentation cystoplasty is the most frequently performed surgical procedure for severe urge incontinence. This is basically a reconstructive surgery in which a segment of the bowel is removed and used to replace a portion of the diseased bladder.

Possible complications include the usual complications resulting from a major abdominal surgery, bowel obstruction, blood clots, infection, and pneumonia.

Also, there is a risk of developing urinary fistulae (abnormal tubelike passage resulting in abnormal urine drainage), urinary tract infection, difficulty urinating, and a rare possibility of increased risk of developing tumors.

DIET:
Some experts recommend a regimen of controlled fluid intake as a supplement to other therapies in the management of urge incontinence. The goal of this program is to distribute the intake of fluids throughout the course of the day so that the bladder does not need to handle a large volume of urine at one time.

Do not drink large quantities of fluids with meals, limit your intake to less than 8 ounces at one time. Sip small amounts of fluids between meals. Stop drinking fluids approximately two hours before going to bed.

Additionally, it may be helpful to eliminate your intake of foods that may irritate the bladder, such as caffeine, spiced foods, carbonated drinks, and highly acidic foods.

BLADDER RETRAINING:
People with urge incontinence are initially managed with a program of bladder retraining. Occasionally, electrical stimulation and biofeedback therapy may be used in conjunction with bladder retraining. A program of bladder retraining involves becoming aware of patterns of incontinence episodes, and relearning skills necessary for storage and proper emptying of the bladder. Bladder retraining alone was successful in 75% of people treated for urge incontinence.

Bladder retraining consists of developing a schedule of times when you should try to urinate, while trying to consciously delay urination in between these times. One method is to force yourself to try to urinate every 1 to 11/2 hours , despite any leakage or urge to urinate in between these times. As you become skilled at waiting this long between urination episodes, gradually increase the time intervals by 1/2 hour until you are urinating every 3 to 4 hours.

KEGEL EXERCISES:
Pelvic muscle training exercises called Kegel exercises are primarily used to treat people with stress incontinence. However, these exercises may also be beneficial in relieving the symptoms of urge incontinence. The principle behind Kegel exercises is to strengthen the muscles of the pelvic floor, thereby improving the urethral sphincter function. The success of Kegel exercises depends on proper technique and adherence to a regular exercise program.

Some women may use vaginal cones to strengthen the muscles of pelvic floor. A vaginal cone is a weighted device that is inserted into the vagina. The women should then try to contract the pelvic floor muscles in an effort to hold the device the place. The contraction should be held for up to 15 minutes. This procedure should be performed twice daily. Within 4 to 6 weeks, about 70% of the women had some improvement in their symptoms.

BIOFEEDBACK AND ELECTRICAL STIMULATION:
For those people who are unsure if they are performing the procedure correctly, biofeedback and electrical stimulation may be used to help you identify the correct muscle group to work. Biofeedback is a method of positive reinforcement. Electrodes are placed on your abdomen and along the anal area.

Some therapists place a sensor in the vagina in women or anus in men, to monitor contraction of the pelvic floor muscles. A monitor will display a graph showing which muscles are contracting and which are at rest. The therapist can help you identify the correct muscles for performing Kegel exercises.

Of the people who used biofeedback to enhance performance of Kegel exercises, about 75% have reported improvement of their symptoms, and 15% were cured.

Electrical stimulation involves using low-voltage electric current to stimulate the correct group of muscles. The current may be delivered using an anal or vaginal probe. The electrical stimulation therapy may be performed in the clinic or at home. Treatment sessions usually last 20 minutes and may be performed every 1 to 4 days.

Some clinical studies have shown promising results in treating urge incontinence with electrical stimulation.

ACTIVITY:
People who have urge incontinence may find it helpful to avoid activities that irritate the bladder and thus worsen symptoms. One such activity is bubble baths and use of some caustic soaps in the genital area, as they may have a potentially irritant effect on the urethra or bladder.

MONITORING:
Urinary incontinence is a chronic (long-term) problem. Although some people may be cured by various treatments, you should continue to see your health care provider to evaluate the progress of your symptoms and monitor for possible complications of treatment.

Symptoms can usually be alleviated with accurate diagnosis and adequate treatment regimens. Many patients require trials of multiple therapies or multiple simultaneous therapies to alleviate symptoms. This requires a good working relationship with your doctor. Instantaneous improvement is unusual and perseverance and patience is usually required to see improvement. A small number of patients are not helped by conservative and medical therapies and require surgical intervention.

Physical complications are rare, but psychosocial problems may arise, particularly if incontinence results from an inability to get to the bathroom when urgency arises.

If symptoms are moderate or severe (incontinence occurs more often than rare occasions, or if pelvic discomfort or burning with urination occurs), or if symptoms occur daily, call for an appointment with your health care provider.