Urge Incontinence: Symptoms, Causes, and Treatment of Urge Incontinence in Women and Men

Urge incontinence is a typical symptom of bladder dysfunction. It is also described as an “overactive bladder.” These terms refer to a sudden urge to urinate that occurs without warning and can be so strong that it leads to involuntary urine leakage.

A typical description from patients with urge incontinence is, for example: “When I’m standing at the front door, already feeling the urge to urinate, and still have to look for my keys, the urge gets stronger and stronger, and then it happens: I can’t hold it anymore—I wet my pants—before the door is even open.”

Most of the time, these people have to urinate much more frequently than normal. Urge incontinence is defined as urinating more than eight times in 24 hours. In addition, their sleep is significantly disrupted, as they also have to get up multiple times at night to go to the bathroom.

With urge incontinence, those affected must urinate very suddenly and without warning © doucefleur | AdobeStock

The causes of this form of urinary incontinence, which severely limits quality of life, lie

• directly at the site of the problem—the bladder in the pelvis—and/or
• in the central nervous system.

In the bladder, a dysfunction of the inner mucosal lining (urothelium) and the bladder wall muscles can trigger “overactivity.” In this process, an increased number of urinary urge signals (stimulating nerve impulses) flow from the bladder via the spinal cord to the brain. The balance between the stimuli that stimulate and those that inhibit the bladder is then disrupted, resulting in an increased urge to urinate. An example of such a temporary dysfunction of the urothelium is bacterial cystitis.

However, the disorder may also originate in the spinal cord or even in the brain itself. In such cases, the cause may be other conditions, such as

• a stroke,
• injuries, and many others.

In this case, the inhibition of the impulses that stimulate the bladder is generally too weak. Urge incontinence thus occurs even though the bladder itself is still healthy.

If these “centrally” triggered symptoms persist for months or years, the bladder can suffer severe damage. Ultimately, this can also lead to kidney disease, and severe kidney failure may develop.

Urge incontinence must be thoroughly evaluated. It is sometimes quite difficult to distinguish from (generally non-urgent) stress incontinence (formerly known as stress incontinence). Furthermore, both conditions often occur together. Treatment methods are very diverse but vary completely depending on the type of incontinence.

Therefore, a thorough and accurate analysis of the symptoms and identification of the underlying causes (diagnosis) is particularly important. Understandably, patients with urge incontinence often want a quick resolution to this very distressing problem. However, patience on the part of both the doctor and the patient is required, particularly during the diagnostic process, and is crucial to the success of treatment.

Key steps in the diagnosis of urge incontinence are:

• Taking a medical history (anamnesis),
• Keeping a diary of fluid intake and urination (voiding diary),
• A physical, targeted examination,
• Urinalysis (and possibly blood tests),
• Imaging studies,
• Invasive diagnostics as part of minor procedures.

Taking a medical history (anamnesis)

During the medical history interview, the doctor will ask, among other things, about:

• Onset, duration, and severity of symptoms,
• frequency of urination (micturition frequency),
• sudden urge to urinate,
• urinary and/or fecal incontinence,
• fluid intake and urine output,
• blood in the urine,
• urogenital infections,
• Number of births and obstetric interventions,
• Pelvic floor prolapse or uterine prolapse,
• gynecological conditions,
• surgery or radiation therapy in the abdominal or pelvic area,
• spinal disorders,
• neurological conditions such as multiple sclerosis (MS) and stroke,
• injuries,
• inflammatory bowel diseases such as ulcerative colitis and Crohn’s disease,
• height and weight,
• medication use,
• metabolic disorders, such as diabetes.

Keeping a diary of fluid intake and urination (voiding diary)

The patient records the following information over several days in a special diary provided by their doctor, along with the time

• the amount consumed,
• urine volume,
• symptoms of urinary urgency,
• pain,
• the weight of the (wet) pads in grams, etc.,

This data collection is often extremely informative on its own. It represents a very important (and painless) diagnostic method, the significance of which is, unfortunately, often underestimated and neglected.

Physical, Targeted Examination

The physical examination is performed by a gynecologist or urologist. It includes, in particular, an examination of the external genitalia and, in women, an examination of the vagina. A brief neurological examination is also performed.

Imaging Diagnostics

As part of imaging diagnostics, an ultrasound examination (sonography) is performed

• of the bladder (with residual urine measurement),
• the kidneys, and
• the perineum.

For women, an ultrasound of the vagina (intravaginal ultrasound) is performed. In men, however, an ultrasound via the rectum (transrectal ultrasound) may be used. In addition, an X-ray examination with contrast medium, e.g., of the bladder (cystogram), may be performed.

Invasive Diagnostics

These include, for example, urethroscopy and cystoscopy, as well as bladder pressure measurement (cystometry and urodynamics).

Treatment for urge incontinence is carried out in accordance with published recommendations (guidelines). These are individually tailored to the patient’s specific circumstances and preferences.

Typically, the physician follows a stepwise treatment approach: if one treatment step does not produce sufficient results, they move on to the next step. The most important modern treatment options are briefly described below.

Non-surgical (conservative) treatment of urge incontinence

One of the first steps in stepwise therapy is behavioral training. To this end, the doctor first evaluates the voiding diary and then recommends voiding and toilet training.

This is often supported by

• accompanying physical therapy with pelvic floor exercises and biofeedback training, as well as
• electrostimulation therapy, which can be performed as an adjunct.

Medication for urge incontinence

The second stage involves medication. Options include topical medications or oral tablets. Women with age-related estrogen deficiency, for example, can benefit greatly from topical medications such as a local estrogen ointment or vaginal suppositories. Hormones can also be administered in tablet form.

Medications designed to reduce bladder overactivity (anticholinergics) are also administered in tablet form or as patches. Long-term use is required here. If the medication is paused or discontinued, the symptoms return.

These medications have been continuously refined and improved. Newer-generation medications, which now primarily exert their effect directly on the bladder, have significantly fewer side effects. They do not additionally affect the central nervous system (brain).

Botulinum Toxin (A) for Urge Incontinence

Some patients are unable or unwilling to take these medications due to unwanted side effects. In such cases, the administration of botulinum toxin (A) into the bladder serves as a third-line treatment option.

The injection is performed under regional anesthesia of the lower body or under general anesthesia as part of a cystoscopy. Using a fine needle approximately 5 mm long, the doctor injects the highly diluted “Botox” into the bladder muscle at 10 to 30 sites.

Botox causes the overactive bladder muscles to relax. The full effect sets in after about one to two weeks and, based on experience, lasts for approximately nine months.

The intensity of the botulinum toxin’s effect cannot be precisely controlled. In very rare cases, it may become difficult to empty the bladder (resulting in large amounts of residual urine) or impossible to do so at all. For this reason, all patients receiving this therapy also learn how to perform self-catheterization, which is a simple procedure. This means that, if necessary, they can drain urine using a urinary catheter.

Despite this potential inconvenience, an increasing number of people with severe urge incontinence are opting for this highly effective treatment. If urge symptoms recur, Botox injections into the bladder can be repeated as often as necessary. Side effects affecting other organs or the entire body have not been reported to date.

Surgical Treatment of Urge Incontinence

If this treatment is not possible or is unsuccessful, surgical treatment options such as (sacral) neuromodulation may be considered. First, test electrodes are attached to the sacrum (lower back at hip level) directly to the nerves that supply the bladder. The effect of the low-level stimulation current delivered through these electrodes is then assessed over approximately five days.

If the urge incontinence improves significantly, the next step is taken. The surgeon permanently implants a device—about the size and shape of a pacemaker—into the subcutaneous fat tissue of the lower back.

In some patients, the bladder is severely damaged and has already undergone such structural changes that all other treatment options are ruled out. If there is a risk of serious kidney damage, bladder surgery is required as a last resort.

One option is to enlarge the bladder by suturing in “decommissioned” sections of the patient’s own tissue (bladder augmentation). These sections are primarily taken from the small intestine.

If this is also not feasible, the only remaining option is removal of the bladder. Urine flow is diverted to an artificial bladder outlet (urostomy, conduit). The artificial bladder outlet is usually placed in the right mid-abdomen.

This final stage of the treatment options listed is extremely rarely necessary. The majority of procedures are successfully performed within the first three stages of therapy. However, every therapy always requires good cooperation from the patient.

Even if symptoms improve significantly after treatment, the patient should undergo regular checkups. To this end, the patient remains under lifelong specialized urological care.

Once a severe structural change in the bladder has occurred as a long-term consequence of overactive bladder, it is irreversible. However, in most cases, it can be prevented through early detection and treatment.

What is urge incontinence?

Urge incontinence is a form of urinary incontinence in which a sudden urge to urinate leads to involuntary urine leakage. In this condition, the bladder sends signals to empty itself prematurely, even though it is not yet completely full. Urge incontinence is one of the most common forms of incontinence and can affect both men and women.

What causes urge incontinence?

The causes of urge incontinence can vary widely. It is often caused by an overactive bladder or overactivity of the bladder muscles. Other possible causes include neurological disorders such as Parkinson’s disease, multiple sclerosis, or diabetes mellitus. In sensory urge incontinence, the receptors in the bladder wall are particularly sensitive, whereas in motor urge incontinence, involuntary contractions of the bladder muscle occur.

How is urge incontinence diagnosed?

To make a diagnosis, the doctor first reviews the patient’s medical history, assesses the symptoms reported, and evaluates bladder function. The urologist examines the bladder, urethra, and surrounding structures to identify possible causes of urge incontinence. Additional tests, such as urine analysis, ultrasound, and other diagnostic procedures, may also be performed. A correct diagnosis of urge incontinence is the foundation for successful treatment.

What treatment options are available for urge incontinence?

Treatment for urge incontinence depends on the cause and the individual case. Bladder training, pelvic floor muscle exercises, and medication therapy with anticholinergics are frequently used. For women going through menopause, the local application of estrogen can alleviate symptoms. In some cases, medications are injected directly into the bladder muscle, or surgical procedures are performed if conservative measures are insufficient.

Can urge incontinence be permanently improved?

Yes, treatment for urge incontinence can often significantly alleviate symptoms. Starting treatment early improves the chances of success. Many people with this condition benefit from a combination of bladder training, lifestyle adjustments, and medication. Both men and women can develop urge incontinence at some point in their lives, but with appropriate treatment, quality of life can often be significantly improved.