Overactive Bladder and Urinary Incontinence: Symptoms, Causes, and When to See a Doctor

Urinary incontinence is a common problem thought to affect millions of people [1]. Help is available, and overactive bladder is not something you have to accept as just part of getting older or having children [2].

What Overactive Bladder and Urinary Incontinence Mean

Urinary incontinence is the unintentional passing of urine [1]. Overactive bladder (OAB) is a syndrome made up of a set of symptoms: you might suddenly feel a strong need to urinate, even when your bladder is not very full, and wake at least once at night to urinate, a symptom called nocturia [2]. The European Association of Urology (EAU) describes needing the bathroom many times during the day (more than 6-8 times) as one of these symptoms [2]. They can happen with or without urine leakage [2]. OAB affects 10% to 20% of people at some point, with women being the most affected [2].

The two terms overlap. Urge incontinence often occurs as part of a group of symptoms called overactive bladder syndrome, which is when the bladder muscle is more active than usual [3], and urgency incontinence is often referred to as overactive bladder [4].

The Main Types of Leaking

• Stress incontinence: urine leaks out when your bladder is under pressure, for example when you cough or laugh [1]. Sneezing, heavy lifting and exercise can do the same [3]. Despite the name, it is not related to feeling stressed [3].
• Urge incontinence: urine leaks as you feel a sudden, intense urge to pee, or soon afterwards [1].
• Mixed incontinence: having urgency and stress incontinence at the same time [4][5].
• Overflow incontinence: you are unable to fully empty your bladder, which causes frequent leaking [1].

The amount of leakage can vary and may be mild, moderate or severe [5].

Common Symptoms and Triggers

Signs and symptoms can include leaking urine during everyday activities such as lifting, bending, coughing or exercising; being unable to hold in urine after feeling a sudden, strong urge to urinate; leaking urine without any warning or urge; being unable to reach a toilet in time; wetting your bed during sleep; and leaking during sexual activity [6].

The need to pass urine may be triggered by a sudden change of position, or even by the sound of running water [3]. Drinking or touching water and being in a cold environment, such as reaching into the freezer at the grocery store, can also set off a sudden, strong urge [6]. Overactive bladder syndrome can also mean you need to pass urine very frequently, including several times during the night [3].

Why It Happens

Stress incontinence can happen when the pelvic floor muscles are weak or damaged, or when the urethral sphincter, the ring of muscle that keeps the urethra closed, is damaged, because the urethra may not be able to stay closed [7]. Problems with these muscles may be caused by damage during childbirth, particularly if your baby was born vaginally; increased pressure on your tummy, for example from pregnancy or obesity; damage during surgery such as removal of the womb or the prostate gland; neurological conditions; certain connective tissue disorders; and certain medicines [7].

In urge incontinence, the urgent and frequent need to pass urine can be caused by a problem with the detrusor muscles in the walls of your bladder [7]. Sometimes these muscles contract too often, creating an urgent need to go to the toilet, which is known as having an overactive bladder [7]. The reason may not be clear, but possible causes include drinking too much alcohol or caffeine, not drinking enough fluids (strong, concentrated urine can irritate the bladder), constipation, conditions such as urinary tract infections or tumours in the bladder, neurological conditions and certain medicines [7].

Diabetes, vaginal childbirth, surgery for prostate cancer, stroke, Parkinson's disease, multiple sclerosis, Alzheimer's disease, and brain or spinal cord injury are among the things that can damage or affect bladder nerves and muscles [6]. Radiotherapy or chemotherapy, used for some cancers, can also affect bladder function [5].

Some leaking is short-lived: a urinary tract infection or a bad cough may cause temporary incontinence [4].

Who Is More Likely to Have It

Getting older is the strongest risk factor [5]. Urinary incontinence becomes more common in middle age and is very common in people who are over 80 years old [7]. Even so, incontinence is not an inevitable part of ageing [1], and although it is common, it is not a routine part of being a woman or getting older [4].

Obesity and a family history of incontinence can also increase the chances [1]. So can lifestyle factors such as eating foods that cause constipation, drinking alcohol or caffeinated or carbonated drinks, certain medicines, physical inactivity and smoking [6].

Women. Pregnancy and vaginal birth can increase the chances of urinary incontinence [1]. Pregnancy and childbirth can weaken the pelvic floor muscles [5][6], especially in the last trimester and with vaginal delivery, and caesarean sections do not completely prevent this [5]. Trauma or injury, pelvic organ prolapse and the menopause can also weaken these muscles [6]. The Royal College of Obstetricians and Gynaecologists (RCOG) explains that if the pelvic floor muscles are strained or weakened, women can have difficulty controlling the bladder or bowel, and that symptoms can happen at any age, especially around pregnancy and childbirth and later in life [8].

Men. Men who have a history of radiation or surgery for prostate cancer may have short-term or long-term leaking [6], and prostate surgery can sometimes cause incontinence, particularly stress incontinence [5]. In men, an enlarged prostate (benign prostate enlargement, or BPE) can cause symptoms similar to OAB [2].

When to See a Doctor

• UK: The NHS says: "See a GP if you have any type of urinary incontinence. Urinary incontinence is a common problem and you should not feel embarrassed talking to them about your symptoms." [1] A GP can refer you to your local continence service, and in some cases you may be able to refer yourself [9].
• US: The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) says: "See a health care professional if you have symptoms of a bladder problem, such as trouble urinating, a loss of bladder control, waking to use the bathroom, pelvic pain, or leaking urine." [6]
• Europe: The EAU says: "It's important to talk to your doctor if you have OAB symptoms. They can check for other signs, like blood in your urine, to find out what's causing your symptoms and help you get the right treatment." [2]

Signs That Need Care Right Away

In the US, NIDDK advises seeking care right away and says: "See a health care professional if you" [6]

• "can't pass urine or empty your bladder, which is a sign of urinary retention"
• "urinate too often - eight or more bathroom visits a day - also called frequency"
• "see blood in your urine, called hematuria"
• "have bladder infection symptoms, including painful urination"

"These symptoms can signal a serious health problem, including inflammation of the bladder, also called cystitis, or even bladder cancer." [6]

What to Expect at the Appointment

A GP will ask about your symptoms and medical history, such as whether you leak urine when you cough or laugh, whether you need the toilet frequently during the day or night, whether you have any difficulty passing urine, whether you are taking any medicine, and how much fluid, alcohol or caffeine you drink [10]. You may also be asked about your family history and have a physical exam [11].

If you have a vagina, the GP will do a pelvic examination, and if you have a penis, the GP may check the health of your prostate gland [10]. You may be asked to cough to see if any urine leaks [10][11]. If an infection is suspected, a sample of your urine may be tested [10], and a urine test can also look for a kidney problem or diabetes [11]. Further tests may be needed if the cause is not clear [10].

Keeping a Bladder Diary

A bladder diary is a record of what and how much you drink, how often you pee and how much, any leaks, and any strong urges to go [10][11]. How long to keep one varies: the NHS says the GP may suggest at least 3 days [10], NIDDK suggests 2 to 3 days before seeing your health care professional [11], and the EAU says keeping it for a few days gives your doctor helpful information to figure out what is causing your symptoms and find the best treatment [12].

What You Can Do Yourself

Conservative treatments, which do not involve medicines or surgery, are tried first [9], and self-management is usually the first step [5]. Pelvic floor exercises and bladder training are among these first steps [9][5]. In the US, a 2018 review of research in adult women by the Agency for Healthcare Research and Quality (AHRQ), which AHRQ has since archived as no longer current, also supports behavioral therapy for both stress and urgency incontinence [13].

Pelvic Floor Exercises

Your pelvic floor muscles surround the bladder and urethra and control the flow of urine as you pee [9]. Research has shown that pelvic floor muscle training can benefit everyone with urinary incontinence [9]. If a specialist sets you an exercise programme, it should include a minimum of 8 muscle contractions at least 3 times a day and last for at least 3 months [9].

To find the right muscles, try imagining stopping yourself peeing and passing wind [14]. Be patient: you may have to do pelvic floor exercises for a few months before you see any benefits [14]. You should not do them while you are urinating, and men can benefit from them too [15].

Sometimes strengthening is needed, and other times relaxation exercises are better, especially for men with tense muscles, and a physiotherapist who specialises in urology can teach the best exercises for your situation [5]. For women, the RCOG says pelvic floor exercises strengthen the muscles around the bladder, bowel and uterus, and can help to prevent and improve common symptoms of pelvic floor dysfunction [8].

Bladder Training and Controlling Urges

Bladder training involves learning techniques to increase the length of time between feeling the need to urinate and passing urine, and a course will usually last for at least 6 weeks [9]. It can mean urinating on a schedule to reduce leaking, and your health care professional may use your bladder diary to suggest a regular schedule [15]. Your doctor can also use the diary to help you follow a schedule that trains your bladder to hold urine longer and reduce urgent trips [5].

When an urge comes on, some people distract themselves, while others find long, relaxing breaths or holding still can help [15]. Quick, strong squeezes of the pelvic floor muscles can help suppress urgency when it occurs, which may help you get to the toilet before you leak [15].

Bladder training follows a planned schedule, which is different from often holding urine in because it is not a convenient time to go [15][16]. NIDDK advises going to the bathroom when you need to go, because regularly holding urine in can wear out your bladder muscles [16].

Drinks, Food, Weight and Other Habits

• Keep drinking enough. The NHS advises drinking 6 to 8 glasses of fluid a day (but no more) unless your doctor advises you otherwise, and warns that limiting your fluid intake makes incontinence worse, because it reduces your bladder's capacity [14]. NIDDK suggests drinking enough liquids so you need to urinate every few hours, with urine that is pale yellow, and says that if you have kidney failure or heart failure, you should not drink too much water [16].
• Evening drinks. For night-time trips, the NHS says to try drinking less in the hours before you go to bed, while still drinking enough fluids during the day [1]. NIDDK says you may want to stop drinking liquids a few hours before bedtime, but only if your health care professional suggests it [15].
• Caffeine and alcohol. Try cutting down on alcohol and on drinks containing caffeine, such as tea, coffee and cola [1]; limiting caffeine may help reduce leaks [15]. The EAU says caffeine, alcohol and soft drinks do not cause incontinence but can irritate your bladder and make you need to pee more often or urgently [5].
• Food. Spicy and acidic foods, such as curries and citrus fruits, can irritate the bladder and make leaks and other incontinence symptoms worse [14]. Cutting possible triggers for a while, then adding them back one by one, can show which ones affect you [5]. NIDDK notes that no direct scientific evidence links nutrition to making urinary incontinence better or worse, but that many people find spicy foods and high-acid foods, such as citrus and tomatoes, may contribute to bladder irritation and inflammation, which can sometimes lead to urinary incontinence [16].
• Weight. Losing weight can improve or even stop symptoms for many people [5] and can help you have fewer leaks [15].
• Constipation. Straining to poo weakens your pelvic floor muscles and makes urinary incontinence worse [14], and full bowels press on the bladder [5].
• Smoking. Smoking raises the risk of incontinence because coughing strains the pelvic floor [14], and quitting at any age is good for your bladder health and overall health [15].

If Self-Care Is Not Enough

Your treatment will depend on the type of urinary incontinence you have and the severity of your symptoms [9]. After conservative treatments, medicine or surgery may be considered [9]. If lifestyle changes do not improve your urinary incontinence, speak with your health care professional about other options [15].

Living With Bladder Symptoms

OAB can mean planning bathroom breaks, avoiding new places, giving up social events or sports and leaving meetings, and getting up at night can make you tired, affect your mood and disturb your partner [17]. Untreated bladder problems can lead people to avoid activities they once enjoyed, which can lead to depression or social anxiety, and some people avoid intimacy because they worry about leaking during sex [4]. Incontinence might also make you feel stressed, sad or less confident [5]. The sooner you get help, the sooner urinary incontinence may improve [4].

Conclusion

Bladder leaks and urgency can feel hard to bring up, but health care professionals often talk with people about bladder control problems and can help. Starting a bladder diary before your first appointment gives you something concrete to bring and helps your health care professional see patterns.

Medical Disclaimer

This article is for general information and does not replace advice from a qualified health professional. If you think you need urgent medical care, get emergency help straight away.