Urinary Urgency, Urgency Urinary Incontinence, and Urinary Frequency
Anna is a 68-year-old woman who began to experience urgency to urinate and leakage when walking to the bathroom. This has gotten worse over the past year to the point where Anna is speed walking to the bathroom and still leaking. Emily is a 25-year-old with a “tiny bladder”. Lately, this has been more bothersome for Emily since she is having to get up every 45 minutes to pee and its negatively impacting her productivity at work. Luckily for these women, pelvic floor therapists are trained specialists to address these concerns and there are updated recommendations to support various treatments used.
The Academy of Pelvic Health Physical Therapy created a clinical practice guideline (CPG) using the current available research to determine the most supported evidence to address urinary urgency, urgency urinary incontinence (UUI) and urinary frequency. The review panel for this CPG included 10 professionals: urologists, urogynecologists, pelvic floor physical therapists, a nurse practitioner, a public health epidemiologist, a basic science researcher, and a pharmacist with expertise in the treatment of urologic conditions. I appreciate that these recommendations were reviewed by a variety of health care providers to allow for a well-rounded view of the research and recommendations.
There are different types of urinary incontinence. Stress urinary incontinence (SUI) occurs during activities that increase pressure like coughing, laughing, sneezing, and exercising. Urgency urinary incontinence (UUI) occurs where there is a sudden, intense urge to void (urinate) that results in involuntary urinary leakage. Mixed incontinence occurs when there is both stress and urgency incontinence. Urinary urgency is an intense urge to urinate, but no leakage occurs. Urinary frequency occurs when we are voiding (urinating) more frequently than 2 hours. The normal range for a healthy bladder is urinating every 2-4 hours during our waking time.
Over 20% of people worldwide as estimated to have urge or mixed incontinence with women more likely to be impacted than men. The prevalence increases with age. It is also estimated that more than 50% of all nursing home residents are incontinent and it is the second leading cause of placement in an institution. Urgency urinary incontinence (UUI) is also associated with increased fall risk and osteoporosis fractures. How wonderful would it be to stop urinary leakage and urinary urgency especially before we age and are potentially placed in a nursing home because of it? Even better if we can reduce our fall risk by addressing incontinence. I don’t know about you, but I don’t want to worry about breaking my hip because I was rushing on the way to the bathroom while peeing my pants.
Based on the clinical practice guideline recommendations, urinary urgency, urgency urinary incontinence (UUI) and urinary frequency must be addressed with behavioral interventions due to the strong research evidence. Behavioral interventions may include bladder retraining, urge suppression techniques, and dietary and fluid modifications, such as reducing caffeine intake. In fact, behavioral therapy has been found to be effective for treating UUI even up to 8 months after the end of the training. When compared to medication alone, bladder training provides longer term, more persistent results.
There is also strong evidence that pelvic floor muscle training should be prescribed when “contraction quality” is a confirmed symptom contributor of urinary urgency, urinary urgency incontinence, and urinary frequency. When behavioral techniques and pelvic floor muscle training are appropriately combined, patients demonstrate reduced voids per day, reduced nighttime frequency, and increase in function at follow up when compared to medication alone.
There is moderate evidence that electrical stimulation could be helpful to address urinary urgency, urge incontinence, and urinary frequency. The two recommended types are called transcutaneous tibial nerve electrical stimulation and transvaginal electrical stimulation. These are done at a low frequency and are relatively gentle treatments. Why can electrical stimulation be helpful? The sacral nerves at the bottom of the spine supply the pelvic floor and the bladder. Electrical stimulation has been shown to be an effective treatment for overactive bladder, UUI, urinary retention, fecal incontinence, constipation, and pelvic pain. The exact reason is still being studied but the idea is that it creates improvement in bladder sensation, filling and emptying. This type of nerve stimulation has been found to reduce urinary urgency and nighttime urination (nocturia).
Well, what if I just want to take medication? While that is completely your decision, the research finds that solely taking medication does not provide a long-term fix to symptoms. What happens if insurance coverage changes or the price of the medication skyrockets? Too often I have had patients who used a certain medication that suddenly was not covered for one reason or another. When looking at those who participated in physical therapy and those who participated in physical therapy with medication, both groups demonstrated improvement in bladder filling abilities, reduced number of voids (urination) per day, reduced number of incontinence episodes, and improved pelvic floor muscle activity of their bladder muscle activity. However, medication alone did not demonstrate as significant of an improvement. In fact, the new guidelines recommend that medication prescribing health care providers should “inform patients of the improved outcome when combined with pelvic health rehabilitation”.
The CPG found that weight loss should be considered in those with a body mass index of more than 25 kg/m2 as a reduction in weight has been shown to decrease stress and urge incontinence significantly as compared to those who did not reduce weight. Some research indicates that a loss of 5-10% can reduce stress and urinary incontinence but a weight loss of more than 10% does not result in greater improvements.
Mindfulness-based stress reduction (MBSR) may also be considered to reduce urinary. When compared to yoga, MBSR was found to have a 71% reduction in incontinence episodes compared to 27% reduction in the yoga group 6 months later.
It is considered best practice by experts to address constipation since constipation is significantly associated with urinary incontinence. For example, overactive bladder symptoms are more likely to be moderate to severe and have urinary incontinence when constipation is present.
It is also considered expert opinion and best practice to address fall risk as urinary incontinence is a risk factor for falls, especially for those who experience 2 or more nighttime voids. So, if you have balance concerns this should be addressed in addition to your incontinence concerns.
Keep in mind that there is no one size fits all approach, so an individualized treatment plan should be used to address each person’s contributing factors. This is why an initial evaluation is performed by a trained pelvic floor therapist to determine the cause of your symptoms. One person who experiences urinary urgency could have overactive pelvic floor muscles, meaning the muscles have too much tension, whereas another person with urinary urgency could have underactive pelvic floor muscles, meaning they have a lack of tension or strength. These two people would have different treatments based on their individual needs even though their symptoms of urinary urgency may be similar.
If you have urinary urgency, urinary incontinence with urgency, and urinary frequency (going less than 2 hours between bathroom trips), please reach out to a pelvic floor therapist to address these concerns! Get a treatment plan that is individualized to you for long term results versus a lifetime of medication, pads, and always worrying about where the closest bathroom is.
Written by Jordan Schmidt, PT, DPT
References
McAuley, J. Adrienne PT, DPT, MEd1; Mahoney, Amanda T. PT, DPT2; Austin, Mary M. PT, DPT3. Clinical Practice Guidelines: Rehabilitation Interventions for Urgency Urinary Incontinence, Urinary Urgency, and/or Urinary Frequency in Adult Women. Journal of Women's & Pelvic Health Physical Therapy 47(4):p 217-236, October/December 2023. | DOI: 10.1097/JWH.0000000000000286
