Patients can be embarrassed about this common condition, but community pharmacists can play a big part in dispelling their fears, writes Deborah Evans

Key learning points

• There are several types of urinary incontinence, with different causes

• There are many causes of urinary incontinence, ranging from medical conditions, birth defects or the after-effects of childbirth

• Urinary incontinence can be exacerbated by the over-consumption of caffeine or alcohol

Urinary incontinence is the unintentional passing of urine and is a common problem thought to affect around six million people in the UK.

In the UK, one older person in four is affected by urinary incontinence, and an estimated 30-60% of those in institutional care suffer from the condition.

Half of the female population will experience urinary incontinence at some time in their lives with 6% of younger women (15 to 44 years old) experiencing symptoms. One study has shown that 32% of women have experienced symptoms of urinary incontinence in the previous 30 days and yet only one in five affected will seek help.

While urinary incontinence is often considered a female problem, this is only partly true. In younger age groups, more women than men experience this condition because of the effects of childbirth and the menopause. However, the differences are equalised around the age of 70 as a result of men experiencing urinary retention from prostate gland enlargement as they age.

 

Common causes of urinary incontinence

 

Urinary incontinence can occur when the normal process of storing and passing urine is disrupted. This can happen for a number of reasons, with certain factors increasing the likelihood of incontinence developing; advancing age is the biggest risk factor.

Stress incontinence occurs when the pressure inside the bladder as it fills becomes greater than the strength of the urethra to stay closed. Additional pressure to the bladder such laughing or sneezing can then cause urine to leak. Weak or damaged pelvic floor muscles or an inadequate urethral sphincter can result in the urethra opening when it shouldn’t. These problems can be caused by:

• Damage during childbirth, particularly a vaginal delivery.

• Increased pressure on the abdomen, for example during pregnancy or if obese.

• Surgical damage to the bladder or nearby area caused, for example, during a hysterectomy or removal of the prostate gland in men (prostatectomy).

• Birth defects such as a defective bladder or sphincter.

• Neurological conditions that affect the brain and spinal cord, such as Parkinson’s disease, multiple sclerosis, stroke and spinal cord injury.

• Certain connective tissue disorders.

• Menopause, where the reduction in oestrogen results in the bladder becoming lax.

• Some medicines.

Urge incontinence is the urgent and frequent need to pass urine, which can be caused by a problem with the detrusor muscles in the walls of the bladder. These muscles relax to allow the bladder to fill with urine and contract when going to the toilet to let urine out. If these muscles contract too often then this creates an urgent need to go to the toilet – this is known as an overactive bladder. Frequent contraction of the detrusor muscles can be caused by:

• Drinking too much alcohol or caffeine.

• Poor fluid intake, which causes strong, concentrated urine to collect, irritating the bladder.

• Constipation.

• Conditions such as urinary tract infections (UTIs) and bladder tumours.

• Neurological conditions.

• Some medicines.

Overflow incontinence (also called chronic urinary retention) is often caused by  a blockage or obstruction of the bladder. The bladder fills as normal but cannot empty completely because of an obstruction causing pressure to build up behind it, causing leaking around the blockage. An obstruction can be the result of an enlarged prostate gland in men, bladder stones and constipation.

Total incontinence occurs when the bladder cannot store any urine at all. This results in large amounts of urine being passed constantly or passed occasionally with frequent leaking. It can be caused by birth defects, spinal cord injury and bladder fistulas.

 

How can pharmacists help identify people who need help?

 

Urinary incontinence can result in significant suffering, including psychological problems and social isolation, sexual issues, lack of sleep due to nocturia, constipation from limiting fluid intake and falls and fractures in older people who have to rush to the toilet.

It is likely to be under-reported as it is an embarrassing problem to many women and men. One study of adults with symptoms of an overactive bladder found that:

• 54% reported that they were bothered by their symptoms.

• Of this group, 73% of women used a coping mechanism (such as physiotherapy or exercise, absorbent pads or limiting fluid intake).

• Of these, 69% of women initiated a conversation with a healthcare provider about their symptoms.

Since urinary incontinence is a very common problem, pharmacists and their teams have many opportunities to support and help their customers including:

• In a medicines use review (MUR), new medicines service (NMS) or equivalent consultation where a medicine or medicines are more likely to worsen or cause incontinence.

• When a woman is pregnant or has recently given birth.

• When patients have a known condition that can cause incontinence such as multiple sclerosis, stroke, spinal cord injury, Parkinson’s disease and obesity.

• When men have benign prostatic hyperplasia (BPH).

• When women are experiencing and coming out of the menopause.

• If a person complains they are not sleeping well.

• When a person is purchasing products to protect clothes

• Running a health promotion campaign in pharmacy to raise awareness.

 

Discussing the topic sensitively

 

Even though incontinence has a significant impact on people’s lives, many sufferers write it off as getting older. It can be a difficult topic to raise and yet there is much that can be done to manage the condition.

 

  • Consider moving to the consultation room starting any conversation with “we have a more private area for consultations, would this be preferable?”
  • If an individual raises their incontinence with you, then acknowledge that this is a difficult subject for them but avoid telling them how they should feel
  • Consider asking open questions to allow the patient to tell you more about what is happening to them, how they feel and what they are doing to manage the issue themselves
    • How often do you have an urgent urge to use the toilet?
    • What makes your symptoms worse?
    • What have you done so far to manage the symptoms?
    • How does this affect your everyday activities?
    • How often do you wake at night to use the toilet?
    • What symptoms concern you the most?
    • What impact does this have on everyday activities?
  • Avoid telling the individual what to do, instead ask them what they have considered and ask whether they would like you to advise on the options available to them.

 

Advice to help manage the condition

 

Pharmacists and their teams can help make a difference by:

  • Providing lifestyle support on:
    • Reducing caffeine intake – this may improve symptoms or urgency and frequency but not incontinence
    • Fluid intake – avoid drinking either excessive amounts or reduce amounts each day as this can worsen constipation
    • Weight loss if overweight or obese
    • Smoking if appropriate – chronic cough may contribute to stress incontinence
  • Signposting to self-help resources:
    • NHS Choices
    • The Bladder and Bowel Foundation has a helpline (tel: 01536 533 255) and provides a range of resources.
  • Supporting pelvic floor exercises:
  • Reviewing existing medicines and how these might be impacting on bladder function
  • Advise on the use of absorbent products, hand-held urinals and toileting aids to help cope with urinary leakage whilst awaiting assessment and treatment, or response to ongoing treatment
  • Signpost women with urgency urinary incontinence to advice on bladder training 

  

Refer to a GP when a person:

  • Notices blood in the urine (this can be bright red or sometimes dark brown)
  • Needs to pass urine very often
  • Needs to pass urine very suddenly
  • Has pain when passing urine
  • Has unusual lumps or swellings in the abdomen
  • Has heavy night sweats
  • Has a suspected UTI
  • Associated psychological problems associated with incontinence

Deborah Evans is Managing Director of Pharmacy Complete, a training and consultancy company working with pharmacy and the industry

 

Resources

[1] Irwin, D., Milsom, I. et al. Impact of overactive bladder symptoms on employment, social interactions and emotional wellbeing in six European countries. British Journal of Urology International: 2005; 97, 96-100

2 Hunskaar, S., Lose G, et al. (2003) Prevalence of Stress Urinary Incontinence in Women in Four European Countries, 2002. ICS: UK

3 Tsakiris, P., Oelke, M. and Michel, M.C. (2008) Drug-induced urinary incontinence. Drugs & Aging25(7), 541-549.

4 Irwin, D.E., Milsom, I., Kopp, Z. et al. (2008) Symptom bother and health care-seeking behaviour among individuals with overactive bladder.European Urology53(5), 1029-1037