Nerves that work poorly can lead to three different kinds of bladder control problems.

Overactive bladder. Damaged nerves may send signals to the bladder at the wrong time, causing its muscles to squeeze without warning. The symptoms of overactive bladder include

• urinary frequency—defined as urination eight or more times a day or two or more times at night
• urinary urgency—the sudden, strong need to urinate immediately
• urge incontinence—leakage of urine that follows a sudden, strong urge to urinate

Poor control of sphincter muscles. Sphincter muscles surround the urethra and keep it closed to hold urine in the bladder. If the nerves to the sphincter muscles are damaged, the muscles may become loose and allow leakage or stay tight when you are trying to release urine.

Urine retention. For some people, nerve damage means their bladder muscles do not get the message that it is time to release urine or are too weak to completely empty the bladder. If the bladder becomes too full, urine may back up and the increasing pressure may damage the kidneys. Or urine that stays too long may lead to an infection in the kidneys or bladder. Urine retention may also lead to overflow incontinence.

Many events or conditions can damage nerves and nerve pathways. Some of the most common causes are

• vaginal childbirth
• infections of the brain or spinal cord
• diabetes
• stroke
• accidents that injure the brain or spinal cord
• multiple sclerosis
• heavy metal poisoning

In addition, some children are born with nerve problems that can keep the bladder from releasing urine, leading to urinary infections or kidney damage.

Any evaluation for a health problem begins with a medical history and a general physical examination. Your doctor can use this information to narrow down the possible causes for your bladder problem.

If nerve damage is suspected, the doctor may need to test both the bladder itself and the nervous system, including the brain. Three different kinds of tests might be used:

Urodynamics. These tests involve measuring pressure in the bladder while it is being filled to see how much it can hold and then checking to see whether the bladder empties completely and efficiently.

Imaging. The doctor may use different types of equipment—x-rays, magnetic resonance imaging (MRI), and computerized tomography (CT) scans-to take pictures of the urinary tract and nervous system, including the brain.

EEG and EMG. An electroencephalograph (EEG) is a test in which wires with pads are placed on the forehead to sense any dysfunction in the brain. The doctor may also use an electromyograph (EMG), which uses wires with pads placed on the lower abdomen to test the nerves and muscles of the bladder.

Treatment depends on the cause and severity of your OAB. Treatments may include:

• Changing your peeing habits. Your healthcare provider may advise certain methods, such as delayed voiding or timed urination.

• Making dietary changes. Stay away from certain foods and drinks that are known to irritate the bladder. These include caffeine, alcohol, spicy foods, citrus foods, and chocolate.

• Exercising your pelvic muscles. This can help strengthen pelvic muscles used when you pee. These exercises are called Kegels. They include contracting as if you were stopping your urine stream. And tightening your rectum as if trying not to pass gas. Your provider can help you learn how to do Kegels.

• Biofeedback. This can help you learn to control the movement of your bladder muscles. Sensors are placed on your belly. They turn signals given off by your muscles into lines on a computer screen.

• Medicine. This may be given to relax the bladder muscle. Medicine can also help ease bladder contractions. This reduces the urge to urinate. You may need to take medicine for months or years.

• Neuromodulation. This may be done if medicine and behavioral changes don’t work. Electrical pulses are sent to the nerves that affect the pelvic area (sacral nerves). These pulses help relieve OAB and urge incontinence.

• Botulinum toxin shots. These can be injected into the muscle of the bladder to relax the muscles.

• Surgery. When less invasive treatments don't work, surgery to make the bladder larger may be done in severe cases.

With treatment, OAB can be managed. You may need to continue muscle-strengthening exercises and make changes in your daily routine. This may include going to the bathroom more often than you think you need to or developing a timed schedule. Your healthcare provider can tell you more.

Medicines for bladder control generally work by blocking signals that may cause muscle spasms in the bladder. A group of drugs called antispasmodics are usually the first drugs your doctor will consider for treating bladder control problems. Another group of medicines, called tricyclic antidepressants, may be considered, although these drugs are primarily intended to treat depression. Tricyclic antidepressants can calm nerve signals and decrease spasms in the bladder muscles.

Antispasmodics

Extended-release forms of oxybutynin and tolterodine are now available.

Oxybutynin also comes in a patch that may decrease the side effects.

Side effects. Antispasmodics can cause your eyes to become sensitive to light. These medicines also keep you from sweating and can cause dry mouth. If you take any of these medicines, you may need to take a few steps to deal with side effects.

• Wear sunglasses if your eyes become more sensitive to light.
• Take care not to become overheated.
• Chew gum or suck on sugarless hard candy to avoid dry mouth.

Tricyclic Antidepressants

Side effects. Tricyclic antidepressants can cause your vision to blur when you read, dry mouth, constipation, and light-headedness when you stand after sitting.

Antidiuretic

Desmopressin is a man-made form of a natural hormone that your body makes. The hormone, called antidiuretic hormone (ADH) or vasopressin, directs the kidneys to make less urine. The urine is therefore more concentrated. Desmopressin is not usually prescribed for adult women with overactive bladder or stress incontinence. It is more often used to treat bedwetting in children. It is also used to treat a condition called diabetes insipidus.

Side effects. Desmopressin rarely causes side effects, but you should call your doctor if you have headaches, stomach cramps, nausea, reddening of the skin, a stuffy or runny nose, or pain in the genital area.

Interstitial Cystitis Medicine

Pentosan is approved to treat the symptoms of bladder pain, urinary frequency, and urinary urgency that characterize interstitial cystitis, also known as painful bladder syndrome. Doctors do not know exactly how it works, but one theory is that it may repair defects that might have developed in the lining of the bladder.

Side effects. Pentosan's side effects are limited primarily to minor gastrointestinal discomfort. A small minority of patients experience some hair loss, but hair grows back when they stop taking the drug. Researchers have found no negative interactions between pentosan and other medications.

Your doctor will order regular blood tests to monitor your liver function while you take pentosan.

Because pentosan has not been tested in pregnant women, the manufacturer recommends that it not be used during pregnancy, except in the most severe cases.

The job of the sphincter muscles is to hold urine in the bladder by squeezing the urethra shut. If the urethral sphincter fails to stay closed, urine may leak out of the bladder. When nerve signals are coordinated properly, the sphincter muscles relax to allow urine to pass through the urethra as the bladder contracts to push out urine. If the signals are not coordinated, the bladder and the sphincter may contract at the same time, so urine cannot pass easily.

Drug therapy for an uncoordinated bladder and urethra. Scientists have not yet found a drug that works selectively on the urethral sphincter muscles, but drugs used to reduce muscle spasms or tremors are sometimes used to help the sphincter relax. Baclofen (Lioresal) is prescribed for muscle spasms or cramping in patients with multiple sclerosis and spinal injuries. Diazepam (Valium) can be taken as a muscle relaxant or to reduce anxiety. Drugs called alpha-adrenergic blockers can also be used to relax the sphincter. Examples of these drugs are alfuzosin (UroXatral), tamsulosin (Flomax), terazosin (Hytrin), and doxazosin (Cardura). The main side effects are low blood pressure, dizziness, fainting, and nasal congestion. All of these drugs have been used to relax the urethral sphincter in people whose sphincter does not relax well on its own.

Botox injection. Botulinum toxin type A (Botox) is best known as a cosmetic treatment for facial wrinkles. Doctors have also found that botulinum toxin is useful in blocking spasms like eye ticks or relaxing muscles in patients with multiple sclerosis. Urologists have found that injecting botulinum toxin into the tissue surrounding the sphincter can help it to relax. Although the FDA has approved botulinum toxin only for facial cosmetic purposes, researchers are studying the safety and effectiveness of botulinum toxin injection into the sphincter for possible FDA approval in the future.

Urine retention may occur either because the bladder wall muscles cannot contract or because the sphincter muscles cannot relax.

Catheter. A catheter is a thin tube that can be inserted through the urethra into the bladder to allow urine to flow into a collection bag. If you are able to place the catheter yourself, you can learn to carry out the procedure at regular intervals, a practice called clean intermittent catheterization. Some patients cannot place their own catheters because nerve damage affects their hand coordination as well as their voiding function. These patients need to have a caregiver place the catheter for them at regular intervals. If regular catheter placement is not feasible, the patients may need to have an indwelling catheter that can be changed less often. Indwelling catheters have several risks, including infection, bladder stones, and bladder tumors. However, if the bladder cannot be emptied any other way, then the catheter is the only way to stop the buildup of urine in the bladder that can damage the kidneys.

Urethral stent. Stents are small tube-like devices inserted into the urethra and allowed to expand, like a spring, widening the opening for urine to flow out. Stents can help prevent urine backup when the bladder wall and sphincter contract at the same time because of improper nerve signals. However, stents can cause problems if they move or lead to infection.

Surgery. Men may consider a surgery that removes the external sphincter-a sphincterotomy-or a piece of it-a sphincter resection-to prevent urinary retention. The surgeon will pass a thin instrument through the urethra to deliver electrical or laser energy that burns away sphincter tissue. Possible complications include bleeding that requires a transfusion and, rarely, problems with erections. This procedure causes loss of urine control and requires the patient to collect urine by wearing an external catheter that fits over the penis like a condom. No external collection device is available for women.

Urinary diversion. If other treatments fail and urine regularly backs up and damages the kidneys, the doctor may recommend a urinary diversion, a procedure that may require an outside collection bag attached to a stoma, a surgically created opening where urine passes out of the body. Another form of urinary diversion replaces the bladder with a continent urinary reservoir, an internal pouch made from sections of the bowel or other tissue. This method allows the person to store urine inside the body until a catheter is used to empty it through a stoma.

Kegel exercises strengthen the muscles that hold up the bladder and keep it closed.

The first step in doing Kegel exercises is to find the right muscles. Imagine you are trying to stop yourself from passing gas. Squeeze the muscles you would use. If you sense a "pulling" feeling, those are the right muscles for pelvic exercises.

Try not to squeeze other muscles at the same time. Be careful not to tighten your stomach, legs, or buttocks. Squeezing the wrong muscles can put more pressure on your bladder control muscles. Just squeeze the pelvic muscles. Don't hold your breath.

At first, find a quiet spot to practice-your bathroom or bedroom-so you can concentrate. Pull in the pelvic muscles and hold for a count of 3. Then relax for a count of 3. Repeat, but don't overdo it. Work up to 3 sets of 10 repeats. Start doing your pelvic muscle exercises lying down. This position is the easiest because the muscles do not need to work against gravity. When your muscles get stronger, do your exercises sitting or standing. Working against gravity is like adding more weight.

Be patient. Don't give up. It takes just 5 minutes a day. You may not feel your bladder control improve for 3 to 6 weeks. Still, most people do notice an improvement after a few weeks.

Some people with nerve damage cannot tell whether they are doing Kegel exercises correctly. If you are not sure, ask your doctor or nurse to examine you while you try to do them. If you are not squeezing the right muscles, you can still learn proper Kegel exercises by doing special training with biofeedback, electrical stimulation, or both.