Overactive bladder is a problem with bladder storage function that causes a sudden urge to urinate. The urge may be difficult to suppress, and overactive bladder can lead to the involuntary loss of urine (incontinence).
If you have overactive bladder, you may feel embarrassed, isolate yourself, or limit your work and social life. The good news is that after a brief evaluation to determine the cause of overactive bladder, you can receive treatments that may greatly reduce or eliminate the symptoms of overactive bladder and help you manage their effect on your daily life.
Signs and symptoms of overactive bladder may mean you:
- Feel a strong, sudden urge to urinate
- Experience urge incontinence, the involuntary loss of urine immediately following an urgent need to urinate
- Urinate frequently, usually eight or more times in 24 hours
- Awaken two or more times in the night to urinate (nocturia)
Although you may be able to get to the toilet in time when you sense an urge to urinate, frequent and nighttime urination, as well as the need to suddenly "drop everything," can disrupt your life.
When to see a doctor
Many people never talk to their doctors about their overactive bladder symptoms. Although it can sometimes be difficult to discuss such a normally private matter with your doctor, it's important that you do, especially if you experience urge incontinence or if other symptoms of overactive bladder disrupt your work schedule, social interactions and everyday activities.
Sometimes, people assume that an overactive bladder or urinary incontinence is just a normal part of aging, and simply deal with the condition by wearing absorbent undergarments or pads. But, symptoms of urgency and incontinence aren't an inevitable part of getting older, and treatments are available that might help you. Additionally, it's important to talk to your doctor because an overactive bladder and urge incontinence may occur as a result of a serious underlying problem, such as a cancerous tumor
Normal bladder function
Filling and emptying your bladder is a complex interplay of kidney function, nerve signals and muscle activity. A problem anywhere in this system can contribute to overactive bladder and urge incontinence.
It all starts with your kidneys, which produce urine. Urine leaves the kidneys and travels down a pair of long tubes to your bladder. Urine drains from your bladder through an opening at the bottom (neck) and flows out a short tube called the urethra. In women, the urethral opening is located just above the vagina. In men, the urethral opening is at the tip of the penis.
Your bladder expands like a balloon to accommodate urine from the kidneys. When it's reached about a third of its capacity, nerve signals alert your brain, and you sense that your bladder is starting to fill. As it fills more, you'll feel the need to urinate (void). When you urinate, nerve signals coordinate the relaxation of the pelvic floor muscles and the muscles surrounding the neck of the bladder and upper portion of the urethra (urinary sphincter muscles). The muscles of the bladder contract, forcing urine out.
Involuntary bladder contractions
The symptoms of overactive bladder occur in most cases because the muscles of the bladder involuntarily contract. This contraction creates the urgent need to urinate. However, in some people, this urge is purely sensory, meaning that you might feel the need to void even though the muscles aren't contracting.
Several factors may cause or contribute to signs and symptoms similar to those of overactive bladder. Your doctor may try to rule them out during an evaluation because they require other specialized treatments. These factors include:
- Neurological disorders, such as Parkinson's disease, strokes and multiple sclerosis, are often associated with an overactive bladder.
- High urine production as might occur with high fluid intake, poor kidney function or diabetes
- Acute urinary tract infections that can cause symptoms very similar to an overactive bladder
- Abnormalities in the bladder, such as tumors or bladder stones
- Factors that obstruct bladder outflow — enlarged prostate, constipation or previous operations to treat other forms of incontinence
- Excess consumption of caffeine or alcohol
- Medications that cause a rapid increase in urine production or require that you take them with lots of fluids
In some cases, doctors can't identify the specific cause of your overactive bladder.
As might be expected, urge and any urge-associated incontinence can affect your overall quality of life, and can also be detrimental to your well-being. People with significant disruption from an overactive bladder are more susceptible to:
- Emotional distress
- Sleep disturbances and interrupted sleep cycles
Some people may also have a disorder called mixed incontinence, when both urge incontinence and stress incontinence occur. Stress incontinence is the loss of urine when you exert physical stressors or pressure on your bladder, as when you cough or laugh.
Tests and diagnosis
In a basic diagnostic work-up, your doctor will look for clues that may also indicate contributing factors. The exam will likely include:
- A medical history
- A physical examination with particular focus on your abdomen and genitals
- A urine sample to test for infection, traces of blood or other abnormalities
- A focused neurological exam that may identify sensory problems or abnormal reflexes
Your doctor may order urodynamic tests, which are used to assess the function of your bladder and its ability to empty itself steadily and completely. Tests include:
- Measuring urine left in the bladder. When you urinate or experience urinary incontinence, your bladder may not empty completely. The remaining urine (postvoid residual urine) may cause symptoms identical to an overactive bladder. To measure residual urine after you have voided, a thin tube (catheter) is passed through the urethra and into your bladder. The catheter drains the remaining urine, which can then be measured. Alternatively, a specialist may use an ultrasound scan, which translates sound waves into a measurement of the amount of urine remaining in your bladder.
- Measuring urine flow rate. A uroflowmeter is a device into which you urinate to measure the volume and speed of your voiding. This device translates the data into a graph of changes in your flow rate.
- Testing bladder pressure. Cystometry measures bladder pressure during filling. Pressure-flow studies measure the amount of pressure needed to urinate and the speed of the urine flow. A catheter is used to fill your bladder slowly with water. Another catheter with a pressure-measuring sensor is placed in your rectum or for women, in your vagina. This procedure can identify involuntary muscle contractions, indicate the level of pressure at which you feel an urge or experience leakage, and measure pressure used to empty your bladder.
- Measuring bladder nerve impulses. Electromyography assesses the coordination of nerve impulses in the muscles of the bladder and the urinary sphincter. Sensors are placed either on or in the skin in your pelvic floor.
- Creating images of bladder function. Video urodynamics use either X-ray or ultrasound waves to create pictures of your bladder in combination with cystometry and a pressure-flow study as your bladder is filling and emptying. Your bladder is filled using a catheter, and you urinate to empty your bladder. The fluid contains a special dye that's detected by X-ray technology.
- Looking inside the bladder. A cystoscope, a thin tube with a tiny lens, enables your doctor to see the inside of your urethra and bladder. With the aid of this device, your doctor can check for abnormalities in your lower urinary tract, such as bladder stones or tumors.
Your doctor will review the results of these tests with you and suggest a treatment strategy.
Your doctor is likely to recommend a combination of treatment strategies to alleviate your symptoms.
Behavioral interventions are the first line in helping you manage your overactive bladder. If you experience urge incontinence, these interventions alone aren't likely to result in complete dryness, but they may significantly reduce the number of incontinence episodes. The interventions your doctor recommends may cover the following areas:
- Fluid consumption. Your doctor may recommend the amount and timing of your fluid consumption.
- Bladder training. Occasionally, your doctor may recommend a strategy to train yourself to delay voiding when you feel an urge to urinate. You'll begin with very small delays, such as 10 minutes, and gradually work your way up to urinating every three to five hours.
- Double voiding. Some people have problems with emptying their bladders. This is diagnosed by significant elevations of residual urine volumes and may be helped by double voiding. After urinating, you wait a few minutes and then try again to empty your bladder completely. Your doctor can tell you if this might help.
- Scheduled toilet trips. Your doctor may recommend a schedule for toileting so that you urinate at the same times every day — every two to four hours as recommended — rather than when you feel the urge to urinate.
- Pelvic floor muscle exercises. Exercises called Kegel exercises strengthen your pelvic floor muscles and urinary sphincter — muscles that are critical for holding urine even if your bladder muscles involuntarily contract. These strengthened muscles are then contracted when you feel urge so that you can successfully suppress the bladder's involuntary contractions. Your doctor or a physical therapist can help you learn how to do Kegel exercises correctly. It may take as long as six to eight weeks before you notice a difference in your symptoms.
- Intermittent catheterization. You can learn how to empty your bladder by passing a catheter periodically to empty it completely. Using a catheter simply helps the bladder do what it can't do itself. Your doctor can tell you if this is right for you.
- Absorbent pads. You can wear absorbent pads or undergarments to protect your clothing and avoid embarrassing incidents if you do experience incontinence. In addition, the use of pads means that you won't have to limit your activities due to your symptoms.
Medications that relax the bladder can be effective for alleviating symptoms of overactive bladder and reducing episodes of urge incontinence. These drugs include tolterodine (Detrol), oxybutynin (Ditropan), an oxybutynin skin patch (Oxytrol), trospium (Sanctura), solifenacin (Vesicare) and darifenacin (Enablex). These medications are usually used in combination with behavioral interventions.
Common side effects of these drugs include dry eyes and dry mouth, but drinking water to quench thirst can aggravate symptoms of overactive bladder. Extended-release forms of these medications, including the skin patch, may cause fewer side effects.
Your doctor may recommend that you suck on a piece of sugar-free candy or chew sugar-free gum to alleviate dry mouth, and use eyedrops to keep your eyes moist. Over-the-counter preparations, such as Biotene products, can be helpful for chronically dry mouth.
This medication is a protein from the bacteria that cause botulism illness. However, in small doses directly injected into tissues, this protein paralyzes muscles, and research has indicated that it may be useful for severe urge incontinence. But, it's not approved by the Food and Drug Administration for this purpose, and the effects are temporary, lasting only about six months. Additionally, onabotulinumtoxinA carries a risk of worsening bladder emptying in older adults and people already weakened by other health problems.
Sacral nerve stimulation
The sacral nerves carrying signals between the spinal cord and nerves in the bladder's tissues. Modulation of these nerve impulses can improve overactive bladder symptoms. In this procedure, a thin wire is placed close to the sacral nerves where they pass near your tailbone. Your doctor then uses a device connected to the wire to deliver electrical impulses to your bladder, similar to what a pacemaker does for the heart. If successful at reducing your symptoms, the wire is eventually connected to a small battery device that's placed under your skin.
Surgery to treat overactive bladder is reserved for people with severe symptoms who don't respond to other treatments. The goal is to improve the bladder's storing ability and reduce pressure in the bladder. However, these procedures won't help relieve any bladder pain you might be experiencing. Interventions include:
- Surgery to increase bladder capacity. This major surgical procedure uses pieces of your bowel to replace a portion of your bladder. If you undergo this procedure, you may need to use a catheter intermittently for the rest of your life to empty your bladder. Because this is a major surgical procedure with the potential for serious side effects, this surgery is reserved for people with severe overactive bladder that hasn't improved despite other treatments.
- Bladder removal. This procedure is used as a last resort and involves removing the bladder and surgically constructing a replacement or an opening in the body (stoma) to attach a bag on the skin to collect urine.