(detrusor instability, irritable bladder)

Cause:Decreased CNS inhibition, eg, dementia, Parkinson's, CVA; or parasympathomimetic drugs such as bethanechol (Urecholine); or irritation from cytitis, prostatitis, BPH, bladder tumor

Pathophys:Detrusor instability w or w/o impaired contractility

Lab:Cystometrics show spastic contractions

Rx:Antibiotics for any infection only if recent change in incontinence pattern or other evidence of symptomatic UTI (Ann IM 1995;122:749)

Anticholinergics (parasympathetic inhibition), but all bad for cognitive function in older pts:

• Antimuscarinics (all cause dry mouth sx)
• Imipramine 25-50 mg po hs
• Oxybutynin (Ditropan) 2.5-5 mg po tid; long-acting (XL) (Med Let 2001;43:28) and transdermal (Oxytrol) (Med Let 2003;45:38) forms not as effective; $22/mo generic, $90/mo trade
• Muscarinic receptor antagonists (much less dry mouth)
• Darifenacin (Enablex) 7.5-15 mg po qd; less anticholinergic actiivity in elderly than others (Jags 2011;59:501); $100/mo
• Flavoxate (Urispas)
• Solifenacin (VESIcare) 5 mg po qd; very long half-life, could use qod; no better than cheaper ones; $100/mo
• Tropsium chloride (Sanctura) (Med Let 2004;46:63) 20 mg po bid; poor gi absorption and less blood/brain barrier penetration so less confusion; $90/mo
• Tolterodine (Detrol) (Med Let 1998;40:101) 1-2 mg po bid; long-acting forms not as effective (Med Let 2001;43:28); $100/mo

Biofeedback (Ann IM 1985;103:507) or behavioral training (w urge, stop, do Kegel anal sphincter contraction w abd muscle relaxation until urge contraction passes, then bid) (Jama 2002;288:2293); better than medications (Jama 2004;191:986, 996; Jags 2000;48:370) vs no clear benefit (Cochrane Library meta-analysis—ACP J Club 1999;130:67)

Estrogens vaginally no help by DBCT (Jama 2005;293:935)