As comorbidities continue to rise and we continue to live with COVID-19, recent studies have explored the potential increased susceptibility and fatality rates from COVID-19 of people living with obesity or neurological conditions such as Parkinson's disease (Artusi et al, 2021; Zhou et al, 2021). However, living with such conditions can also increase a person's risk of other less serious conditions that can nonetheless affect their daily life and, importantly, their quality of life.
One such example is urge incontinence, also known as the ‘overactive bladder’. The British Medical Journal (BMJ, 2020) defines urge incontinence as ‘involuntary, spontaneous urine loss that is associated with an uncontrollable sense of urgency.’ It is caused by overly active or irritated bladder muscles, with the most common symptom being the frequent and sudden urge to urinate, with occasional leakage of urine. Mixed incontinence can occur when there is muscle weakness and an uncontrollable need to void the bladder.
Some key diagnostic factors include the presence of risk factors, involuntary urine leakage on effort, exertion, sneezing or coughing, involuntary urine leakage accompanied by or immediately preceded by urgency and the frequency of urination (BMJ, 2020). Other diagnostic factors are the presence of nocturia, abnormal bulbocavernosus and wink reflexes, weakened sphincter tone and chronic heart failure (BMJ, 2020). In addition to obesity and neurological conditions, other risk factors include older age and white ethnicity (BMJ, 2020).
What causes it?
The BMJ (2020) states that this type of urinary incontinence may be caused by changes in anatomical support and/or neuromuscular function of the pelvic floor, or it may be idiopathic. There is a high incidence of stress and urge incontinence in women with chronic lower back pain, caused by poor motor control in the local lower back and pelvic floor muscles responsible for continence while also supporting the spine. Both problems are therefore often treatable with transversus abdominis exercises, known as core stabilising exercises (Australian Menopause Society, 2013).
The National Institute for Health and Care Excellence (NICE) (2019a) points out that urge incontinence is often associated with overactive bladder syndrome, the symptoms of which are thought to be caused by involuntary contractions of the detrusor muscle during the filling phase of the micturition cycle. As a result of the over activity of the detrusor muscles, urgency and frequency of micturition can be caused, with or without incontinence. Urge incontinence is idiopathic in most women and, in some cases, it can be associated with systemic neurological conditions such as Parkinson's disease, multiple sclerosis, or injury to the pelvic floor or spinal nerves (NICE, 2019a). There are various comorbidities that increase urgency symptoms such as obesity, type 2 diabetes and chronic urinary tract infection.
Adverse effects of some medications may also cause detrusor overactivity, such as parasympathomimetics, antidepressants and hormone replacement therapy. Diuretics increase urinary frequency as well. On top of this, urinary urgency can be increased significantly by caffeinated, acidic or alcoholic beverages.
How is it treated?
The NICE (2019b) guidelines indicate that treatment of urinary incontinence should begin with conservative treatment, and surgical treatment should be used when conservative treatment is not able to achieve positive results (Kolodynska et al, 2019). Conservative treatment would involve pharmacotherapy, physiotherapy and behavioural therapy.
Where it is a case that does not require referral, and symptoms require managing, alongside any medicated treatment, the patient should be counselled in the following way, according to the NICE (2019a) clinical knowledge summary on the topic:
- Treatable causes of overactive bladder syndrome should be treated or managed
- Advice should be given on fluid intake and lifestyle measures
- Self-help advice and resources should be given
- Absorbent containment products, hand-held urinals, and toileting aids as treatments for urinary incontinence should not routinely be offered but they may be able to be considered in certain circumstances.
- Offer referral for bladder training, which lasts for at least 6 weeks, available from the local continence nurse, continence physiotherapist or urology clinic
- If symptoms persist despite bladder training and frequency is a troublesome symptom, encourage the woman to continue bladder training and consider medication (an antimuscarinic, ie oxybutynin). Also consider other conditions such as dementia, heart failure (requiring diuretics) and so on and how to manage these appropriately. See the CKS by NICE (2019a) for all details on medication to give
- Ensure appropriate counselling on the therapeutic agents is given, i.e. time to work, adverse effects, long term effects of anticholinergics on cognitive function remain uncertain, likelihood of treatment success
- Review the woman after 4 weeks of drug treatment (sooner if drug adverse effects are intolerable, then consider secondary care referral, dose change, alternative medication)
- Where treatment is effective and the woman wishes to continue treatment, review every 12 months. If the woman is older than 75 years of age, then review every 6 months.
Physical therapy
One of the primary physical therapies to offer is pelvic floor muscle training. A supervised trial should be offered of this intervention for at least 3 months as a first-line treatment for women who experience stress or mixed urinary incontinence, with the pelvic floor training programme consisting of at least eight contractions three times daily (NICE, 2019b). NICE (2019b) do not recommend the use of perineometry or pelvic floor electromyography as biofeedback as a routine part of pelvic floor exercise programmes. If found to be beneficial, the pelvic floor muscle training should be continued.
Another option is electrical stimulation, which should not be routinely used in the treatment of women with an overactive bladder, and it should also not be used routinely in combination with pelvic floor muscle training. NICE (2019b) explain that this intervention should be offered to women who are not physically able to contract their pelvic floor muscles, and should be provided in order to aid motivation and adherence to therapy.
Behavioural therapy
In term of behavioural therapy, NICE (2019b) recommends bladder training lasting for a minimum of 6 weeks as a first-line treatment for women with urgency or mixed incontinence, and that where there is no satisfactory benefit from this, a combination of medication for the overactive bladder in combination with bladder training should be considered where frequency may be a troubling symptom.
Neurostimulation is another physical therapy to consider, but transcutaneous sacral nerve stimulation or transcutaneous or posterior tibial nerve stimulation should not be offered for an overactive bladder (NICE, 2019b). Percutaneous posterior tibial nerve stimulation should also not routinely be offered, except if there has been a local MDT review as well as ensuring the patient already tried non-surgical management including overactive bladder medication but this has not worked adequately, and on top of these two factors also where the woman has been offered but does not want botulinum toxin type A or percutaneous sacral nerve stimulation (NICE, 2019b).
Other medicated treatments
The NICE (2019a) CKS states that if the woman with urge incontinence is post-menopausal and has vaginal atrophy, consider intravaginal oestrogen therapy. This should then be reviewed at least annually to re-assess the need for continued treatment and for the monitoring of symptoms of endometrial hyperplasia or carcinoma in women with a uterus.
If the woman has troublesome nocturia, desmopressin can be considered as an off-label indication, but this should be avoided in women over the age of 65 with cardiovascular disease or hypertension.
Where conservative treatment options fail, a referral for specialist urological assessment and management should be considered (NICE, 2019a). The treatment options in secondary care include injection of botulinum toxin type A into the bladder wall, percutaneous sacral nerve stimulation, augmentation cystoplasty and urinary diversion (NICE, 2019a).
Containment aids
NICE (2019b) makes it clear to not offer any absorbent containment products, hand-held urinals or toileting aids for the treatment of urinary incontinence, unless only as a coping strategy while waiting for their actual treatment for the condition, or as an adjunct to ongoing therapy, or for long term management of urinary incontinence but only after treatment options have been looked at properly. Women who do use such products should be reviewed every year, and have their skin assessed alongside a routine assessment of continence, and an evaluation of the efficacy of the product to ensure it is meeting the patient's unique needs (NICE, 2019b).