Helping Patients Manage Urinary Incontinence

It is estimated that nearly 4 million Australians are affected by urinary incontinence to some degree, with an increase in prevalence seen in people aged over 651. However, despite its relative prevalence, a survey conducted in Australian GP waiting rooms revealed only 30% of participants with urinary incontinence had spoken to a healthcare professional about it2. Pharmacists in the community are well placed to discuss bladder concerns and encourage referrals for patients to seek effective treatments.

Clinical Features
Urinary incontinence is defined by the International Continence Society as being the complaint of any involuntary leakage of urine3. Normal continence requires coordination between the bladder, urethra, pelvic muscles and nerve supply to the bladder. The detrusor muscle (smooth muscle enclosing the body of the bladder) is innervated by parasympathetic nerves and the bladder neck is innervated by sympathetic nerves4. Additionally, continence also requires adequate manual dexterity, mobility and the cognitive ability to recognize and react appropriately to the bladder filling4.

Overactive bladder Syndrome (OBS) and detrusor muscle overactivity can be classified into different types of urinary incontinence, according to the presentation of symptoms;

• Stress incontinence4,5: Involuntary leakage caused by increases in intra-abdominal pressure overcoming sphincter closure mechanisms. This is a common cause of urinary incontinence, particularly in older women. Obesity, chronic cough and chronic straining during bowel motions are risk factors in the development of stress incontinence.
• Urge incontinence4,5: Involuntary leakage arising from uninhibited bladder contractions (detrusor muscle overactivity/impaired detrusor muscle). In men, this can occur secondary to bladder outlet obstruction in Benign Prostatic Hyperplasia (BPH)
• Mixed incontinence4: Involuntary leakage associated with both urgency and increased exertion, effort, sneezing or coughing.
• Overflow incontinence4,5: Involuntary leakage due to an overfill of the bladder, can result from significantly impaired bladder emptying. Associated symptoms include weak urinary system, dribbling, hesitancy, frequency and nocturia. Commonly associated with diabetes mellitus and in men, often caused by sever bladder outlet obstruction due to BPH
• Functional incontinence4,5: Incontinence which occurs in otherwise continent individuals who have mobility or cognitive issues which prevent timely use of the toilet. Can be associated with medicines which affect cognition or mental alertness.

Contributing Factors
One of the initial keys in management strategies is to identify any contributing factors to incontinence. Obesity is associated with an elevated risk of urge and stress incontinence, making weight loss a component of management strategies for many patients6. Constipation may also contribute to incontinence by straining pelvic floor muscles, with treatment of constipation often improving incontinence symptoms7.

Another factor which can be addressed is the modifying of fluid intake, as both excessive and inadequate fluid intakes can have impacts on urinary incontinence. An insufficient fluid intake may result in concentrated urine which can irritate the bladder (worsening incontinence), whilst for excessive fluid intake, a decrease of around 25% may improve symptoms of stress and urge incontinence8. Other strategies relating to fluid intake may involve the reducing of caffeine consumption, which can affect urge incontinence8.

An important consideration for pharmacists when reviewing potential contributing factors to urinary incontinence is commonly prescribed medications which may either cause or worsen incontinence (see table 1).

Table 1. Medications which may worsen or cause incontinence, adapted from NPS5,9,10.

Management Strategies

The aim of management strategies for urinary incontinence is to reduce symptoms and improve quality of life.

Non Pharmacological Management
There are a number of physical and behavioural therapy strategies which can be employed to help manage urinary incontinence. Pelvic floor training involves the strengthening of the pelvic floor muscles, and is a first line treatment for stress or mixed incontinence in both men and women11. Bladder training is first line treatment for men and women with urge incontinence, as it is non-invasive and can be implemented easily with minimal cost. The aim of bladder training is to re-establish voluntary bladder control and also increase bladder capacity – techniques may include a regimen of pelvic floor exercises, scheduled voiding with incremental durations between voids and urge suppression techniques11.

For individuals with functional incontinence related to mobility, assessment from a physiotherapist or occupational therapist may be of benefit and simple measures such as improving toilet access by removing clutter, non-slip flooring, hand rails and raising toilet seat height5.

There are also a number of absorbent pads and products available in the pharmacy which may be used as an adjunct to other treatments, to avoid discomfort and embarrassment.

Pharmacological Management
Whilst conservative non-pharmacological treatments are typically first line, for patients with incontinence not responding to these measures pharmacological treatments may be trialled.

Anticholinergic Medications
Anticholinergic (or antimuscarinic) medications are the mainstay of treatment in urge incontinence, used in combination with bladder training techniques (unless unsuccessful/impossible). The most commonly prescribed anticholinergic agent for urge incontinence in Australia is oxybutynin – a non-selective anticholinergic agent which is available in both immediate release tablets and transdermal patch formulations12. Newer, more uroselective (selective for M3 muscarinic receptors) agents solifenacin and darafenacin are also available (though not covered through the PBS) and have a lower rate of side effects such as dry mouth and constipation compared to non-selective agents13.

Anticholinergic agents are effective in reducing the number of episodes of incontinence per day (by about 1.5 episodes per day on average) and the number of voiding episodes in a day (by 2.2 on average)14.

Treatment with anticholinergic agents should be undertaken with caution, particularly in the elderly as they are more susceptible to anticholinergic side effects such as blurred vision, dry mouth, constipation and confusion13.

Selective Alpha-Blockers & 5-Alpha-reductase Inhibitors
Alpha blockers such as prazosin, tamsulosin and terazosin are often used in men with BPH, to relax the bladder and prostate smooth muscle15. When the size of the prostate exceeds 30-40cm, 5-alpha-reductase inhibitors such as finasteride and dutasteride are used to reduce prostate volume and improve urinary flow rate16.

Botulinum Toxin
Randomised controlled trials show that injection of botulinum toxin type A into the bladder walls is effective in drug refractory and neurogenic OBS, by inhibiting acetylcholine release and dampening detrusor contactility17. This reduces the number of episodes of urge incontinence and can also increase functional bladder capacity17.

Help Your Patients Manage Urinary Incontinence
With urinary incontinence being a common chronic medical condition affecting many of our patients, pharmacist are ideally placed to provide support, assistance and referrals to patients who are experiencing bladder troubles. Some key tips for pharmacists to remember;

• Consider potential contributing factors to urinary incontinence, particularly fluid intake and caffeine consumption as well as common medications which may also cause or exacerbate urinary in continence
• Encourage patients to talk to their general practitioner if they are experiencing episodes of urinary incontinence, also consider other allied health professionals such as physiotherapists and occupational therapists.
• Watch out for side effects with pharmacotherapy options, particularly with the use of anticholinergic agents in the elderly.
• Don’t forget to provide a comfortable and private counselling space when discussing bladder issues and concerns, to help keep your patients at ease and avoid embarrassment.

Assessment Questions

The assessment questions below can be found at the Guild Pharmacy Academy myCPD e-learning platform. Login or register at: www.mycpd.org.au

1. Which of the following best describes the clinical features of ‘stress incontinence’?
   a. Involuntary leakage caused by overfilling of the bladder
   b. Involuntary leakage related to detrusor muscles overactivity or impairment
   c. Involuntary leakage due to increased intra-abdominal pressure
   d. Involuntary leakage due to mobility issues
2. Which of the following medication classes is most likely to aggravate ‘urge incontinence’
   a. Selective alpha-blockers
   b. Ace Inhibitors
   c. Benzodiazepines
   d. Cholinesterase inhibitors
3. Which of the following interventions would be considered the most appropriate initial management strategy for a patient with ‘functional incontinence’?
   a. Anticholinergic therapy
   b. Pelvic floor training exercises
   c. Assessment from a physiotherapist or occupational therapist
   d. Reduction of caffeine intake
4. Which of the following medications would be most appropriate for treatment of urinary incontinence symptoms in an elderly male patient with BPH, whose prostate size exceeds 30cm?
   a. Botulinum toxin
   b. Prazosin
   c. Finasteride
   d. Tamsulosin
5. Which of the following statements regarding treatment with solifenacin is correct?
   a. Solifenacin reduces the number of stress incontinence episodes by 2.2 episodes per day
   b. Solifenacin more selective for M3 muscarinic receptors than oxybutynin, and has a lower rate of dry mouth and constipation
   c. Solifenacin reduces voiding episodes in patients with urge incontinence by 1.5 episodes per day
   d. All of the above

References
1. Australian Institute of Health and Welfare. Australian Incontinence data analysis and development. Canberra. Australian Institute of Health and Welfare 2006
2. National Prescribing Service. Managing urinary incontinence in primary care. NPS News. 2009: 1-5
3. Abrams P, Cardozo L, Fall M et al. The standardisation of terminology of lower urinary tract function. Am J Obstet Gynecol. 2002; 187:116-26
4. Thirugnanasothy S. Managing urinary incontinence in older people. BMJ. 2010; 341:c3835
5. Department of Veterans Affairs (DVA). Veterans Mates: Therapeutic brief 26 – The impact of commonly used medicines on urinary incontinence. Department of Veterans Affairs. 2011
6. Dallosso H, McGrowther C, Matthews R et al. the association of diet and other lifestyle factors with overactive bladder and stress incontinence. BJU Int. 2003; 92:69-77
7. Byles J, Millar C, Sibbritt D et al. Livingwith urinary incontinence; a longitudinal study of older women. Age ageing. 2009 38:333-8
8. Hashim H, Abrams P. How should patients with an overactive bladder manipulate their fluid intake. BJU Int; 2008 62-6
9. NPS – Better choices, Better Health. NPS News 66 (insert) 2009 – medicines that may cause or make urinary incontinence worse.
10. Tsakiris P, Oelke M and Michel M. Drug-induced urinary incontinence. Drugs ageing 2008: 25 (7): 541-49
11. Royal Australian College of General Practitioners. Managing incontinence in general practice; Clinical practice guidelines. Melbourne; RACGP 2002
12. Dmochowski R, Sand P, Zinner N et al. Comparative efficacy and safety of transdermal oxybutynin and oral tolterodine versus placebo in previously treated patients with urge and mixed urinary incontinence. Urology 2003; 62:237-42
13. Hedge S. Muscarinic receptors in the bladder: from basic research to therapeutics. Br J Pharmacology 2006; 147 supp 2: s80-7
14. Hartmann K, Mcpheeters M, Biller D et al. Treatment of overactive bladder in women. Evid Rep Technol 2009: 1-120
15. Wilt T, N’dow J. Benign Prostatic Hyperplasia management. BMJ 2008; 336:206-10
16. Perry S, Shaw C, Assassa P et al. An epidemiological study to establish the prevalence of urinary symptoms and felt need in the community. J Public Health Med 2000; 22:427-34
17. Duthie JB, Vincent M, Herbison G et al. Botulinum toxin injections for adults with overactive bladder syndrome. Cochrane database Syst Rev 2011;CD005493