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Urge IncontinenceAka: Detrussor Instability, Overactive Bladder

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  1. Mechanism
    1. PVC: "Premature Vesicular Contraction"
      1. Dial (2003) AAFP Board Review, Seattle
    2. Overly sensitive bladder
      1. Urge to void is perceived
    3. Inhibition of detrussor contraction is ineffective
      1. Detrussor hyperactivity
  2. Epidemiology
    1. Most common Urinary Incontinence in elderly (70%)
  3. Etiologies:
    1. Neurologic
      1. Stroke
      2. Demyelinating disease
    2. Local Irritation
      1. Urinary Tract Infection
      2. Bladder tumor
    3. Idiopathic (most common)
  4. Signs and Symptoms
    1. Irresistable urge to void
    2. Urge preceeded by various stimulation
      1. Posture change
      2. Hear or feel water
      3. Laugh or cough
    3. Urine volume lost
      1. Few drops to entire bladder contents
    4. Urine loss timing
      1. Begins seconds after trigger
      2. Continues beyond trigger while detrussor contracts
    5. Low FSV and low bladder capacity
      1. See Bladder Stress Test
  5. Diagnostics
    1. Post-Void Residual normal (<100 cc)
      1. Sterile in-out catheterization or
      2. Ultrasound measurement of post-void residual
    2. Cystoscopy indications
      1. Hematuria
      2. Recurrent Urinary Tract Infection
      3. Bladder Cancer risk factors
  6. Associated Conditions: Overactive Bladder
    1. Urinary urgency, frequency, nocturia and Incontinence
    2. May be caused by Benign Prostatic Hyperplasia
    3. Treatment is similar to urge Incontinence below
    4. Ouslander (2004) N Engl J Med 350:786
  7. Management: General
    1. General measures
      1. Avoid Diuretics including caffeine
      2. Avoid Constipation
      3. Plan fluid intake to prevent sleep interruption
    2. Behavioral measures (first-line treatment)
      1. See Bladder Retraining Drills
      2. See Kegel Exercises
      3. Behavioral therapy is more effective then medication
        1. Burgio (2002) JAMA 288:2293
        2. Wyman (1991) Urol Nurs 11:11
  8. Management: Medications
    1. General
      1. Medications are only an adjunct to behavioral therapy
    2. Anticholinergic (Propantheline, Imipramine)
      1. Inhibits detrussor contraction
      2. Increases bladder capacity
    3. Bladder Relaxants (antimuscarinics)
      1. See Bladder Antispasmodics
      2. Inhibits involuntary detrusor contractions
      3. Medications (long-acting agents are preferred)
        1. Oxybutinin XR reduces Incontinence episodes 28%
        2. Tolterodine XR offers similar benefit to Oxybutinin
        3. Oxytrol (transdermal antispasmodic patch)
        4. M3 Specific antimuscarinics (Vesicare, Enablex)
    4. Consider alpha-blocker medications if BPH present
      1. Example: Terazosin (Hytrin)
    5. Estrogen not recommended
      1. Oral Estrogen Replacement may exacerbate Incontinence
      2. Intravaginal preparations lack evidence to support
  9. Management: Implanted Electrical Stimulation Device
    1. Severe and refractory urge Incontinence
    2. Generator implanted in buttocks or low back
    3. Lead placed in sacral foramen into S3 Nerve
    4. Inhibits detrusor muscle contractions
    5. Expensive: $10,000 for device; $10,000 for surgery
    6. Highly effective
      1. Amundsen (2002) Am J Obstet Gynecol 187:1462
  10. References
    1. Appell (2001) Mayo Clin Proc 76:358
    2. Weiss (2005) Am Fam Physician 71:315

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