Urgency and urge incontinence

You may also hear the terms “unstable bladder”, “irritable bladder” or overactive bladder” being used to describe this problem. You may have very sudden urges to go to the lavatory: this is called “urgency”.

Sometimes you may not make it in time and have an accident, which is called “urge incontinence”. You may also have to go to the lavatory very often (this is called “frequency”) and even several times at night (which is called “nocturia”).At night you may not wake up in time and will wet the bed.

This happens because the muscles around the bladder, which are there to squeeze the bladder to make it empty, do so at the wrong times - even when you are trying hard to hold on. There is a complicated arrangement of nerves and muscles which is meant to control the bladder, allowing you to hold on until you find a suitable time and place to pass water. It only takes a tiny fault in this complicated arrangement for its co-ordination to go wrong. You may start to feel an urgent need to pass water more and more suddenly. Sometimes the bladder may empty with very little warning at all.It is easy to understand that anyone with this sort of problem will get into the habit of rushing to the nearest toilet at the first hint of their bladder filling. Unfortunately, because the bladder is always slowly filling, a vicious circle of frequency and greater urgency can develop.

Fear of not reaching the toilet in time and having another accident creates tension, which can add to the problem further. The cause of urge incontinence is very often not known. People who have diabetes or prostate problems can develop an unstable bladder. Also people with damage to the nervous system caused by stroke or injury or diseases such as Multiple Sclerosis or Parkinsons Disease - these people may also have problems getting to a toilet quickly which adds to the problem of urgency. It can also occur because of an infection in the bladder such as cystitis - your doctor can test for this very easily. However, for many people with urge incontinence the cause is never found, and they may have no other health problems. It can be a relief to be assured that there is no serious health problem causing your incontinence - but it can also feel frustrating and confusing not having a reason for such a problem.

Urgency and frequency of passing water and urge incontinence can be worsened by worrying about where the nearest toilet is and by the fear of having an accident. You must try not to get into the habit of going to the toilet "just in case" or of dashing to the toilet at the very slightest hint that you may need to. Doing so will mean that gradually your bladder will be able to hold less and less urine and the problem will become worse.

Bladder retraining can be useful in treating urge incontinence, but this should be decided upon by a healthcare professional who has investigated your case. It takes time and determination. A cure does not happen overnight, but it can be very successful. Bladder retraining involves training your bladder to be able to "hold on" for a few minutes longer than you normally would each time you feel that you need to go to the toilet. Doing exercises to strengthen your pelvic floor muscles for a few months before beginning bladder retraining can help you to be able to hold on. Gradually you should be able to wait longer and longer between each visit to the toilet and your bladder will be able to hold more urine.

Drugs

There are also drugs, which can help to reduce instability in the bladder muscles. These drugs can be very effective, although like all drugs they sometimes have side effects, which can be troublesome to some people.

Irritants

Avoiding tea, coffee and alcohol can help because all these can irritate your bladder and make the problem worse. By avoiding various drinks for a while in turn and paying attention to any changes in your urge incontinence you may be able to find out which ones have this effect on you. It is quite common for someone to have symptoms of both urge incontinence and stress incontinence - this is called mixed incontinence.

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Bladder control and prostate problems

The prostate gland is about the same size as a walnut and lies just below the bladder. The tube through which urine passes from the bladder (the urethra) passes through it. The prostate gland’s job is to make a fluid, which forms part of the semen.

Enlargement of the prostate
The prostate gland becomes enlarged in most men over a certain age. In the vast majority of cases this is NOT prostate cancer. More than half of all men over the age of 60 and 80% of all men over 80 have enlarged prostate glands, which are NOT cancerous.

This is called "benign prostatic hyperplasia". Whether treatment is needed depends on how enlarged the gland becomes and what symptoms occur.

When the prostate becomes enlarged it begins to squeeze the urethra and when this happens you might find that you have difficulty passing water.

You may also have to go to the toilet more often (called "frequency"). Because your bladder has difficulty squeezing the urine out,it seldom empties completely - and because it is never completely empty it takes a much shorter time for it to fill up again.

Over time other symptoms can start to occur.Because of the extra work which the bladder muscles are having to do, the bladder’s muscular wall can become thicker and less flexible and it can also become overactive and irritable. This can cause you to need to pass water urgently and on occasion you may not make it to the toilet in time ("urge incontinence"). If this takes place at night it can lead to bedwetting ("nocturnal enuresis").

The enlarged prostate itself also contains more muscle tissue than previously. Any muscles can sometimes contract involuntarily as a result of the cold or of nervousness and such involuntary contractions can cause further difficulties in passing water.

Treatment

Treatments are available, all aiming either to reduce the size of the gland or to reduce the blockage of the urethra which it is causing. Choosing which treatment to try is a matter of weighing up the seriousness of the condition and the effect it is having on your quality of life on the one hand with the possible side effects of treatment on the other. The symptoms of a slightly enlarged prostate gland are inconvenient to say the least, but not life threatening: difficulties passing water, frequency, perhaps an irritable bladder, which can cause occasional incontinence.

The condition becomes more serious if the gland continues to grow, so that treatment becomes more necessary - but this does not happen in every case. The increasing pressure in a bladder which cannot easily empty can cause damage to the bladder or may force urine back up to the kidneys ("reflux"). Because the bladder is never properly emptied, urinary infections can develop. Bladder stones can form and these can cause bleeding and can even block the bladder outlet.

Treatment options

The following are some of the methods used in treating an enlarged prostate, starting with the least invasive:

"Watchful waiting" - if the problems caused by your enlarged prostate are slight, it may be best not to start any treatment. However, your doctor will explain some warning signs to look out for which might indicate that the condition is worsening. This sounds like simply "doing nothing" but it is actually not a bad position to be in: having a condition which is not troubling you too much and no treatments to undergo - and yet you are already under the care of a specialist so that should any problems occur you can be seen promptly.

Drugs - several different kinds of drugs can be used. Some of these are intended to prevent hormones from causing the gland to enlarge and eventually to make it shrink, while others are intended to relax the muscular element of the prostate and reduce the pressure on the urethra, so making urination easier.

Surgery - various procedures are regularly employed in treating an enlarged prostate and many of these are now performed using "keyhole surgery" technology so that although they are performed under general anaesthetic, they are short operations and no large incision is made. The idea behind surgery is to cut or to remove part of the enlarged prostate so that the urethra is no longer obstructed and urine can flow without difficulty from the bladder. Several newer techniques are becoming available which involve the use of heat and laser technology to destroy or shrink prostate tissue and achieve the same results.

Prostate cancer

Unfortunately, in a minority of cases of prostate problems it is found that cancer is present. A cancerous tumour grows within the prostate gland, causing enlargement of the gland and symptoms, which can be similar to non-cancerous prostate enlargement.

If cancer is detected it is best dealt with before it has a chance to spread to nearby tissues. While it is confined to the prostate gland it is easier to "target". The two main treatments are radiotherapy and surgery.

Radiotherapy - where the cancer is confined to the prostate, beams of radiation can be targeted very accurately at the tumour in an attempt to kill the cancerous cells.

Surgery - the most common surgery performed when cancer is confined to the prostate is called a "radical prostatectomy", in which the whole gland is removed along with the tumour. This operation will involve a hospital stay of a week or so and a couple of months convalescence.

Bladder problems following prostate surgery

After surgery on your prostate a catheter will be left in place for a while. A catheter is a thin flexible tube which is passed through the urethra and into your bladder, where it is kept in place by a small balloon at its tip inflated with water. Its job is to drain urine into a collection bag, normally worn on the leg, in order to keep your bladder empty. The catheter may only be in place for a day or two following some procedures, while for others it may remain in place for several weeks.

After the catheter is removed it may take several more weeks for things to "settle down" before your bladder control returns to normal. During these weeks, or maybe months, it might be a good idea to use some form of absorbent pad or other collection device in case of leakage. Separate information sheets are available about products, which might be suitable. You can help your recovery by slowly returning to a normal diet and by making sure you are drinking enough fluids. It may be best not to drink too much tea, coffee or alcohol as these can all irritate the bladder. Over three or four weeks you can gradually return to normal, gentle exercise. However, you should avoid lifting during this time.

Constipation should also be avoided, as this can cause straining which would be bad for the area, which has been operated upon. It is not unusual for traces of blood to be present in the urine for a week or so after surgery on the prostate, or for the urine to appear a little cloudy. However, if you experience burning or pain when passing water or if your urine is very cloudy or smells strongly it is possible that you have a urinary infection and you should consult your doctor, who will probably prescribe an antibiotic.

Longer term incontinence

For a small percentage of men problems with bladder control may last longer. The urinary system is a complex one and it can be affected by many factors. Any surgery on or near the bladder can result in bladder control problems. These problems can happen as the result of the surgery itself, which may alter the way the bladder works.

Sometimes, however, slight changes in the way the bladder works may have been caused by the illness, which lead to the surgery - but they may not have been apparent until now because they were hidden by the more serious symptoms, which the surgery addressed. Before deciding what to do to treat an ongoing incontinence problem, your doctor must assess what the exact nature of the problem is. There are a few types of incontinence, which typically might occur following prostate surgery:

Stress incontinence - you may experience a leakage of urine when you cough, laugh or move suddenly. This happens because the sphincter and other muscles which keep your bladder from leaking have become weakened and they are unable to cope when coughing and other sudden movements put pressure on the bladder. This problem can often be cured by pelvic floor exercises although in rare cases further surgery may be necessary.

Urgency / urge incontinence - before your operation the muscles of your bladder had to struggle to force urine past the enlarged prostate. Now that the obstruction has been removed it may take months for your bladder muscles to get used to the new situation. The muscles can be overactive, resulting in sudden urges to pass water, and they can contract suddenly without warning, resulting in incontinence and bedwetting. This problem usually disappears after a number of months, but in the meantime pelvic floor exercises, bladder retraining and "anticholinergic" drugs, which calm overactivity of the bladder muscles, can help.

Mixed incontinence - this is a combination of stress and urge incontinence.

Total incontinence - occasionally the sphincter that keeps your bladder outlet closed no longer functions at all, so that urine continually leaks in a steady, slow flow. Your bladder is always empty and there is no way for you to control it. This is NOT a common problem. It usually occurs only where the more extensive surgeries have been performed - and even then only rarely.

A further operation my be necessary to correct the problem, or a permanent system of management might be considered.

Management

If you have to manage incontinence for any period of time or if it is found that your incontinence cannot be cured, then you must consider what methods are available for managing the problem. You should take advice from a nurse or doctor trained in continence care. Separate information sheets are available on a variety of management techniques: absorbent pads, catheters, sheaths, leg bags, bed protection, traveling tips.

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