Dr. Goudelocke outlines stand-up urgency in patients with OAB

Colin Goudelocke, MD

In this article, Colin Goudelocke, MD, discusses the 2024 Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction Winter Meeting abstract NM012: Efficacy of stress incontinence surgery in managing “standup urgency” in overactive bladder patients. Goudelocke is a urologist with Ochsner Health Center in New Orleans, Louisiana.

[This] is a little project about something called stand-up urgency. We think about incontinence/urinary leakage, as either stress incontinence or urgency incontinence. There is stress incontinence: coughing, sneezing, laughing, lifting, anything that increases pressure on the bladder and forces that urine out. And then we have urgency incontinence—I'm rushing to get to the bathroom, I can't make it, sort of under that overactive bladder umbrella. And then we know that women have mixed incontinence. So that's not a surprise. Some women have leakage with coughing, sneezing, laughing, and lifting. And they also have overactive bladder and rush to get to the bathroom. That is certainly not anything new.

But there's a segment—and it's not a lot of people—but I've noticed it over the years. It's not mixed incontinence. It's not stress incontinence. It's not urgency incontinence. It almost seems like a hybrid of the 2, right? So if I have mixed incontinence, I have times when I have stress incontinence and times when I have urgency incontinence. And I have both types of incontinence, but it's still 2 different types of incontinence. But then this other group of women will say things like, "I stand up, and after I stand up, I have this sudden urge to get to the bathroom, and I leak." And so 1 part of me says, well, that's urgency incontinence. You had a sudden urge to go to the bathroom, so you rush to get there. And then another part of me says, you're standing up. That's actually a stress maneuver. Going from a seated to a standing position creates a lot of pressure on the bladder. Or they might tell me, "When I get out of bed," or "when I bend over to pick something up," or "when I get out of the car," or "when I get into the car," or all of these things. It might be coughing. It tends to happen, I think, with these kinds of positional things. And so they're doing all of these things where they're getting into these positions that would normally cause stress incontinence. But then they're reporting symptoms that, to my ear, sound much more like urgency incontinence.

The other issue is that I find when I treat them as urgency incontinence patients, when I put them on an overactive bladder medication, the frequency gets better, some of the urgency gets better. But this urgency that they feel when they stand up doesn't always get better the way I would think that it should. I started thinking, what if we thought about this more like stress incontinence? There are some data that talk about where a little bit of urine into the proximal ureter and a little bit of urine into the bladder neck may act as a signal to the bladder, the idea being that I start urinating, and of course, if I've got urine still coming out, I want to keep urinating. So the reflex would be, as long as there's urine in the urethra, the bladder should still be contracting. People have often talked about stress-induced urgency; "I cough, I put a little bit of urine into the urethra, and so it stimulates urgency." And I think this is probably a form of stress-induced urgency, but patients tend to describe it when they're standing up.

There are plenty of articles written about stress-induced urgency. I, at the time, only found 1 article written in the gynecologic literature about what they called stand-up urgency. They didn't talk about treatments; they just sort of characterized it and talked about urodynamic data and all that kind of stuff. So, we started asking patients about their stand-up urgency. We had them fill out the MESA scale, which talks about both stress incontinence and urgency incontinence. One of the questions on the MESA scale asks, do you have incontinence when you move from a seated to a standing position? That's the stress incontinence question on that scale, but we asked about urgency that's associated with that. And then we started treating them like patients with stress incontinence. Most of them had some stress incontinence, so we started treating them like patients with stress incontinence and found that both the stress incontinence and the urgency incontinence pretty reliably improved, not invariably. We definitely had patients that didn't improve, but overall, it gets much better. And what was really interesting to me, the couple of patients that I saw that really didn't see very much improvement at all, it's because their stress incontinence didn't improve and their urgency incontinence didn't improve as well. Most of our patients, if their stress incontinence got better, their urgency incontinence got better at the same time.

Again, I don't think this is groundbreaking; this is a small series to start off with. I think, at this point in time, we just had 15 patients in this abstract. I've enrolled a few patients since then. We'll get a bigger series, and we'll continue to write about this, as the series gets a little bit bigger. But for me, it's a very interesting way of thinking about a subset of patients that just wasn't getting better and asking myself, is there another way to think about this? If I think about stand-up urgency, or getting out of bed urgency, or getting out of the car urgency, is that a different way of thinking about stress-induced urgency, and predicting patients that may get better with stress incontinence treatments?