Bladder urgency and Overactive Bladder (OAB)

Causes of bladder urgency

There can be many different causes of bladder urgency. Sometimes the bladder can become very sensitive and begin to tell you that it is full, when really there is very little urine in it. The bladder sends the brain a false signal of bladder fullness, which feels like an urgent need to pass urine, before the bladder is properly filled. This is often referred to as a hyper-sensitive bladder.

The bladder can also become overactive (OAB). This means that instead of the bladder being relaxed as it fills up, it starts squeezing (contracting) without any warning during filling, causing the sudden urge to pass urine. This is called urinary urgency. This need to pass urine can be so strong that it can lead to a urine leakage called urgency urinary incontinence.

Other causes of bladder urgency:

• Bladder or urinary infection
• Prostate infection
• Enlarged prostate
• Pregnancy
• Hormone changes
• Stressful situations
• Medication side effects
• Taking high dosages of water tablets/diuretics
• Neurological conditions

Often no cause can be identified.

What can I do to help the problem?

Whatever the cause, there are certain steps to follow to help control and improve your symptoms:

• Make sure that you drink a balanced amount of fluid for your weight, on average it is advised to drink 8 cups or 2 litres of fluid per day. Advice on how much fluid you should drink can be found in the information leaflet GHPI0533 ‘Fluid and caffeine intake for bladder and bowel health’. Please ask a member of staff for a copy.
• Drink fluids that are known not to irritate the bladder, such as, water, herbal and fruit teas, decaffeinated drinks, milk and diluted squash/fruit juices.
• Do not reduce the amount that you drink as this will cause your urine to become more concentrated, making the bladder irritable.
• Avoid constipation as this can put extra pressure on the bladder, increasing the urge to void, making the problem much worse
• Try to avoid drinks containing caffeine, which is found in tea, coffee, chocolate and cola, as caffeine can make the bladder more sensitive.
• Stop drinking fizzy (carbonated) drinks as the fizz can aggravate the bladder, particularly fizzy alcoholic drinks - these stimulate the bladder even more.
• Avoid foods and drinks that contain artificial sweeteners containing aspartame as this can irritate your bladder, for example, diet drinks and foods replacing natural sugars.
• Avoid high energy drinks as these contain high dosages of caffeine and sugars.
• Reduce your alcohol intake as this can increase urine production and disrupt the signals to your brain that make you aware of bladder filling and make your symptoms worse.
• Try to avoid spices such as chilli and chocolate as this is known to irritate the bladder lining.
• Try to avoid high acidic drinks such as fruit juices, blackcurrant juice and foods such as citric fruits and tomatoes as they can irritate the bladder.
• Avoid passing urine ‘just in case’ as this causes the bladder to get use to emptying small volumes of urine.
• Try to increase the amount of time between daytime visits to the toilet to increase your bladder capacity.
• Reduce your fluid intake before going to bed; this will help to lessen the number of times you get up in the night.
• Do not try to hold on at night, as this will only keep you awake.
• Do not try to hold on if you think you have a urinary tract infection (UTI), seek medical attention if you feel you have an infection. Please ask a member of staff for a copy of leaflet GHPI1662 Urinary Tract Infection.
• Practicing holding on in the daytime will slowly help any night time problem as it helps increase your bladder capacity.
• If you have been given water tablets (diuretics), you must continue to take them. Discuss your bladder urgency with your GP or nurse to see if any changes to your medication can be made. For example, taking your prescribed dose at different times i.e. 8:00am and 12:00 noon. This may help reduce your urgency.
• If you are overweight, try to lose a few pounds as this will help your symptoms by reducing the weight on your pelvic floor muscle.
• Learn how to do pelvic floor exercises (your specialist nurse can advise you). When these exercises are done correctly, they will build up and strengthen the muscles that help you hold urine. Please ask a member of staff for a copy of leaflet GHPI0259 Pelvic floor exercises for women or GHPI0322 Pelvic floor exercises for men.

How will I be assessed?

The doctor or specialist nurse will ask you questions about your bladder problem(s) and your general health. An examination may be needed; this may be an internal examination for female patients.

A urine sample will be sent for testing to rule out infection and you will be asked to complete a 3 day frequency/ volume chart to record the time of passing urine and the amount you pass.

If your symptoms do not respond to basic medical treatment and self-help you have been advised to try before, you may need to have an urodynamic test. This is a test to find out if there is a problem in the bladder. It will measure the pressure inside the bladder as it is filled with sterile water and emptied. Please ask for a copy of leaflet GHPI0622 Urodynamic investigation.

What is bladder retraining?

Bladder retraining should help you to take control of your bladder urgency. Instead of rushing to the toilet as soon as you get the urge to pass urine, it is important to try to hold on and delay the toilet visit.

If you have difficulty doing this, try to distract yourself by doing something else such as a pelvic floor squeeze, breathing techniques, sitting straight on a hard seat, sitting on a rolled-up towel or counting backwards from 100. However, if you choose to distract yourself, stay calm and avoid moving around and wait for the urge to die down. Then walk at a normal pace to the toilet.

Other alternative calming techniques that may help are:

• Toe curling exercises – curl your toes downwards as if you were making a fist. Hold this position for as long as the bladder is feeling urgent. Be careful if you experience cramp – try instead alternating between one foot and the other until the urge subsides.
• Sacral tapping –gently tap or rub over the sacrum at the bony base of your spine, keep this movement up until the urge passes.

Bladder retraining this way will gradually increase the time between your visits to the toilet, so that slowly the bladder will be able to hold on to a larger amount of urine more comfortably.

Bladder retraining is of no help to people who go frequently or urgently because of a urine infection (such as cystitis). If you have a urine infection you may experience a burning sensation when you pass urine and your urine may be cloudy.

Bladder retraining will make this worse, so it is important to get treatment for the urine infection from your GP.

Start by keeping a frequency/volume record of:

• The number of times you pass urine, measuring the amount of urine you pass each time.
• The number of times you have any leakage.
• The amount and type of fluid you drink.
• Keep this record for 3 days.

This record will give you an idea of how much your bladder can hold and how long you can hold on between toilet visits. It can also inform you if you are under drinking or over drinking.

There are 2 ways of retraining your bladder. Both ways have the same result of ‘stretching’ your bladder and making it hold a greater amount of urine more comfortably. Doing regular pelvic floor exercises will help by strengthening the muscles which you use to ‘hold on’. Please ask a member of staff for a copy of the pelvic floor exercise leaflet as stated previously.

You should notice some change or improvement in your toilet visits within 6 to 8 weeks of starting the retraining programme. Permanent improvement however, may not be seen for 3 to 6 months or even longer, so do continue with the retraining. It takes patience, perseverance and determination on your part for bladder retraining to succeed.

Bladder retraining methods

1. Delay after urge

This involves waiting for the urge to pass urine, then holding on/waiting before going to the toilet and gradually increasing the time you wait.

First of all, decide on the length of time you will delay going to the toilet. If you know you are able to hold on for 1 minute before passing urine, do this for 1 week every time the urge comes.

When you are more confident, increase the time delay for 3 to 5 minutes each time and practise this for another week. As you get more confident, the time delay can be increased and you should be able to overcome the first urge and hold on for 30 minutes to 1 hour. It would be helpful if you record your progress for the first 1 or 2 months.

When you feel the urge to go, remember to focus your attention away from your bladder by reading a book, sitting down, recite a poem or write out a shopping list. When you are holding on, it may be useful to do your pelvic floor exercises which may help in controlling the urge. Do not worry about your night time retraining until you are in more control of your bladder function during the day.

2. Pre-set toilet times

This involves setting fixed times to visit the toilet and not giving in to the urges that come before that time.

First set a realistic target time for passing urine. Decide on practical time intervals based on your 3 day record. Keep motivated. You will need to be determined to succeed.

Gradually increase the length of time between toilet visits and aim for a 3 to 4 hourly pattern.

Points to remember

• It is important for you to drink 8 to 10 cups of fluid per day that do not contain caffeine. Drinking less than this will make things worse.
• Avoid constipation and being overweight by keeping to a healthy, high fibre diet.
• Practice pelvic floor exercises regularly.
• Keep yourself busy when trying to overcome the urge to pass urine.
• Record your progress and review your pattern after 3 to 6 months.

Medicines that may be prescribed

There are various medicines called antimuscarinics that can be prescribed if progress is not made. These medicines work by blocking certain nerve impulses to the bladder which stop it squeezing (contracting) and allows the bladder to fill. Improvement varies from person to person.

A plan often used is to try a course of medication for a month or so. If the medication is helpful, you may be advised to carry on taking it for up to 6 to 12 months and then stop the medication to see how your symptoms are without it. Your symptoms may return but if you combine a course of medication with bladder retraining, they may be less likely to return when you stop the medication.

Side effects

There are different antimuscarinic medications and you may need to be prescribed different types to find the one that works best for you.

Side-effects of antimuscarinic medication are quite common but are often minor. Please read the information sheet which comes with your medicine for a full list of possible side effects.

The most common are:

• Dry mouth
• Dry eyes
• Constipation
• Blurred vision

Ask your doctor, nurse or pharmacist for more information.

In some people the medication can work so well it causes the bladder to not empty as well. If you suspect this is happening, you need to contact your health care profession who will organise a bladder scan and assess if you need to reduce or stop the medication.

It is uncommon for symptoms to go completely with just medication. Regular follow up visits with your health care professional will help you to reach your aim of regaining bladder control.

What’s next if bladder retraining and medication has not worked?

If the above conservative treatments do not work for you, surgery is sometimes suggested to treat OAB. This will be discussed with you by your consultant and the risks and benefits of the treatments explain in detail. You may need to have a specialist test called urodynamics to try and prove bladder over activity before any treatment options are recommended.

Treatment options

Botox

This treatment involves injecting botulinum toxin (botox) into the inside of your bladder using a small telescope. Botox has the effect of reducing the squeezing (contractions) of the bladder but it can reduce the normal contractions so that your bladder is not able to empty fully. Up to 20 in every 100 patients may need to insert a catheter (a small tube) into their bladder to empty it. This treatment has to be repeated every 9 to 12 months as the effect of the botox wears off after this time.

Botox has been licensed (approved) in the United Kingdom for the treatment of OAB.

Sacral nerve stimulation

An overactive bladder can be treated by sacral nerve stimulation. This is a small device which is put under the skin of your bottom and sends a burst of electrical signals to the nerves that control the bladder, working like a pacemaker. The device does not work for everyone; all patients have to go through a test phase to see if it will work for them.

Augmentation cystoplasty

In this procedure, a small piece of bowel from the small or large intestine is added to the wall of the bladder to increase its size. Not all people can pass urine normally after this operation. You may need to insert a catheter (a small tube) into your bladder to empty it.

Urinary diversion

In this procedure, the ureters (tubes from the kidneys to the bladder) are joined to a pouch made from a piece of the small intestine that opens to the outside of your body. The urine is collected into a bag. This procedure is only done if all other options have failed to treat your overactive bladder.

Contact information

If you have any questions or concerns, please contact:

Bladder and Bowel Health Team

Oakley, 2nd floor Centre block, Cheltenham General hospital, Sandford Road, Cheltenham GL53 7AN

Tel: 0300 422 5305

Monday to Friday, 9:00am to 3:00pm

E-mail: ghn-tr.gloscontinenceservice@nhs.net

Urogynaecology Department

Tel: 0300422 6278 (answerphone)

Monday to Friday, 8:00am to 3:00pm

Further information

The following websites will give you additional information, help and advice.

Bristol Urological Institute

Website: www.bui.ac.uk

Bladder and Bowel UK

Website: www.bbuk.org.uk