Dear Barb,

Your GP and gynecologist have done a good job with their evaluation of the common causes of urinary frequency and incontinence. There are three types of incontinence: stress incontinence, overflow incontinence and urge incontinence. Stress incontinence refers to leakage that may occur with coughing, laughing or sneezing and may be the result of damage to the pelvic floor from childbirth with the development of a cystocoele or “dropped bladder.” Overflow incontinence occurs when the bladder no longer empties completely, causing a patient to feel as if they need to urinate frequently. Overactive bladder, or OAB, is defined as urinary urgency, usually accompanied by frequency and excessive voiding at night, in the absence of urinary tract infection or other obvious pathology. As the definition implies, the cause is often idiopathic, or unknown. It can be accompanied by urinary incontinence, as you have described. Up to 43 percent of women, young and old, experience symptoms of overactive bladder.  In fact, OAB represents one of most commonly seen urologic conditions in women.

Even though the symptoms that you describe do trouble many women, I can understand your reluctance to discuss this issue with friends since wearing pads to prevent loss of urine is something that we often think is found primarily in women in nursing homes who wear Depends and other incontinence underwear. This condition often gets in the way of social activities, careers, and relationships. As you pointed out, urinary urge incontinence often affects interest in sexual activity because there may be concern that incontinence might occur during sex.  Wearing pads can cause irritation to the genital tissue from chafing, as well.

The symptoms of this condition often increase when a woman with urge incontinence becomes hypervigilant about any possibility that she might lose urine and begins to plan her life around avoiding drinking, avoiding social activities, avoiding intimacy and avoiding travel.

It is often helpful for patients to keep a voiding diary as part of the evaluation for urge incontinence or overactive bladder syndrome. The voiding diary is a daily record of fluid intake and urinary output. The diary serves as a pretreatment baseline and may identify issues with urinary frequency, urgency and incontinence episodes that may be contributing to these symptoms. This information provides details about bladder function that may direct further diagnostic testing.

As a primary care physician, I do order urine cytology, a screening test for bladder cancer. The truth is that women who smoke do have more bladder cancer so smoking cessation is an urgent matter for you, Barb. If the urinalysis, urine culture for infections and urine cytology (a test to evaluate for bladder cancer) are normal, the next noninvasive and painless test is a bladder sonogram that can rule out some bladder growths and reliably eliminate overflow incontinence as a cause of the urinary symptoms you describe if there is little or no urine visualized in the bladder by ultrasound measurement after voiding.

I recommend conservative measures, like reducing caffeine, alcohol and carbonated sodas and bladder retraining, as the first steps, often along with  pelvic floor therapy. Bladder retraining involves gradually increasing the time between the trips to the bathroom, working up to longer and longer intervals between bathroom stops. Ideally, a schedule for urinating is established and patients are trained to resist the first urge to urinate and to refrain from urinating until the scheduled time. The interval between scheduled bathroom visits is increased until patients can refrain from urinating for longer periods of time. Meditative mindfulness can be helpful in bladder retraining. If these conservative measures fail, a referral to a urogynecologist is a good idea. This specialist will have extensive experience with medications that often control the symptoms of overactive bladder but may have side effects. There are two main classes of medications for this condition: the anticholinergics (these medications interrupt the neuromuscular signals to the bladder, akin to taking your foot off the gas pedal of a car) and the beta-3 agonists (these medications interrupt the neuromuscular signals to the bladder, akin to pressing the brake of your car). Both types of medications help to calm the overactive bladder, although patients can experience side effects, particularly with the anticholinergics. There are also second- and third-line treatments, like Botox injection for the bladder (Botox functions by chemically relaxing the bladder muscle), peripheral neuromodulation, and sacral neuromodulation (both neuromodulation technologies send an electrical impulse to the nerves that control your bladder, thereby calming it down), which this specialist can discuss with you if medications fail.

Diagnostic procedures, like cystoscopy or urodynamics, may occasionally be used to further evaluate the urinary tract but are not typically first-line tests. One caveat: bladder cancer can be a cause of overactive bladder symptoms so cystoscopy is indicated when patients don’t have a timely or effective response to the first line treatments discussed in this post.

The good news is that many women do respond to many of these interventions and have a return of their normal lives. Here’s wishing you relief of your symptoms and a wonderful summer: bikini at 46 and all!

Dr. Pat