We’ve all had that concern…. Where is the rest room? Didn’t I just go? I just can’t get up from this bed again to pee!
Obviously, frequency and urgency (and usually pain with urination) may be due to a bout of cystitis or urinary tract infection which most women experience at least once in their lives. But there are lots of other times when a woman may feel these symptoms minus the pain: when pregnant, after multiple cups of coffee downed to stay alert, as a result of drinking too much water (yes there is such a thing) and unfortunately, with age.
Let’s just start with definitions: We classify a bladder as being “overactive” if you void more than 8 times a day. (Some studies suggest that number is 13.) Urgency urinary incontinence is an involuntary loss of urine associated (you guessed it) with urgency … you feel you have to go but can’t make it to the bathroom and simply lose control and urinate, sometimes a lot. This accident may be instigated by the sound of running water, opening the bathroom door, turning the front door lock or just putting on layers of clothes (think skiing) and then realizing that getting them off and going to the bathroom has became an interminable task!
A “Clinical Practice” article that was just published in The New England Journal of Medicine reviewed “idiopathic” urinary urge incontinence. Idiopathic does not mean that you or your physicians are idiots … but it does mean that the actual cause is not well defined.
Having proclaimed that this type of incontinence is idiopathic, the article did list potential risks for overactive bladder and urge incontinence. These included increasing age, female sex (well we knew that!), obesity, diabetes, neurologic disorders, bladder symptoms in childhood, smoking and occasional excessive hydration. A total of 5 to 15% of women have urge urinary incontinence at least monthly. Overactive bladder is more common, affecting 10 to 15 % of women. From an anatomical point of view, it occurs as a result of hyperactivity of the bladder muscles (the detrussor muscles) or uninhibited contraction.
The author states that if a good history is obtained, the diagnosis can be made without major, invasive bladder testing. In order to get that history, doctors should ask patients to keep a voiding diary that helps answer simple questions: when do you void, how often, what factors precipitate the need to void, how much are you drinking (are you walking around and sipping designer bottles of water or drinking multiple cups of coffee or iced tea?) and when do accidents occur?
So what can be done? First, lifestyle changes…If you are overweight, try to lose those extra pounds. If you smoke, stop (for the latter there are a slew of other reasons…but don’t get me started). If you notice that caffeine or too many fluids instigate constant bathroom trips (and misfires), change your fluid consumption habits.
Then there are behavioral therapies also known as bladder training (not exactly what we did to potty train our toddlers, but similar). Try to learn ways to distract yourself when you feel the urge to void. (The article suggests you try mathematical calculations, deep breathing, or “freezing and squeezing” of the pelvic floor muscles.) Void every 2 hours so that you know your bladder can’t be that full. Slowly try to increase the interval between voids while you are awake. You can also try Kagel exercises. In order to know which muscles you have to use to properly Kagel, insert a finger into your vaginal opening and try to constrict the muscles around your finger. (I know that certain candidates are against masturbation but this is not done for sexual stimulation and therefore does not have any political implications.) You should feel a tightening without using your abdominal or gluteal muscles. Do 3 sets of 15 contractions; hold for 10 second each, every day. There are also therapies or biofeedback in which a therapist uses a mild electric stimulation to the pelvic floor muscles with the aim of causing a passive contraction.
And of course, there are medical therapies…. many of which you have seen or heard about in direct to consumer ads in magazines and on television. These medications all basically work by blocking muscle receptors in the bladder (these receptors called muscarinic receptors are also found elsewhere in the body…. hence the side effects of dry mouth, dry eyes and constipation). Six medications are currently approved in the U.S. for urge urinary incontinence. Randomized trials have not shown that one drug was definitively superior to anther although in 2 trials the decrease in the number if urgency incontinence episodes were greater with extended release forms. The generic names are: oxybutynin, tolteridine, fesoterodine, solifenacin, trospium, and darifenacin. In general, the older meds (and cheaper ones) may work…. It can take a month until an effect is apparent. If one doesn’t work then your doctor may suggest a higher dose or another.
Finally, systemic estrogen therapy does not seem to ward off this problem, indeed there are studies that show it can make it worse. However I and many of my urologist colleagues will have a patient who is not on estrogen therapy and who has atrophic vaginal changes together with overactive bladder symptoms try local estrogen vaginal therapy…it does seem to help.
Many women ignore their bladder problems, thinking that urgency is just a part of getting older. Since it is often treatable make sure you tell your doctor and discuss your options. Our lives should not include immediately adjacent toilets!