Bladder problems may have a variety of causes but can still be relatively straightforward to manage with the right products, advice and ongoing support.

 

 

Urinary incontinence affects between three and six million people of all ages in the UK, causing distress, embarrassment and inconvenience. For some it can even go so far as to threaten their self-esteem and be so debilitating that they withdraw from the world as a result.

However, with customers encouraged to ‘ask their pharmacist’, this gives pharmacy teams a great opportunity to help break down the taboos surrounding this sensitive issue and recommend appropriate treatments and care. With that in mind, let us look at some scenarios that pharmacists might encounter:

A middle-aged man experiencing lower urinary tract symptoms who is concerned about prostate cancer and who may benefit from tamsulosin

The risk factors for prostate cancer include age (it mainly affects men over the age of 50 years) and a family history of the disease. If the man has a father or brother who has had prostate cancer, he is 2.5 times more likely to develop it. Prostate cancer is also commoner in black men.

In the UK one in four black men will get prostate cancer in their lifetime compared to one in eight in the general population. “By 2030 prostate cancer is going to be the commonest cancer overall and a lot of men are rightly concerned about it,” says Ali Rooke, senior specialist nurse at Prostate Cancer UK. The availability of OTC therapy for benign prostatic hyperplasia (BPH) gives pharmacists an opportunity to get more involved with prostate health, reaching men at higher risk of prostate cancer.

However, urinary symptoms could be due to bladder problems or a prostate issue, which is why it is also important to encourage men affected to see their GP. “Men with a prostate problem may experience weak flow, need to urinate more frequently and more urgently, or they may have difficulty starting to urinate, experience dribbling, or have blood in their urine,” says Rooke.

“Most men with early stage prostate cancer do not have any symptoms – and in many cases bothersome symptoms are more likely to be due to an enlarged prostate. Tamsulosin can relax the smooth muscle around the neck of the bladder and the prostate gland.”

Prostate Cancer UK has developed an e-learning module providing pharmacists with the information required to successfully identify symptoms of possible prostate disease, including prostate cancer, in a pharmacy setting. The module is available at the Prostate Cancer UK website, or pharmacists can call Prostate Cancer UK’s specialist nurse line on 0800 0748383 for information and support.

 

 

A post-menopausal woman who is purchasing feminine hygiene products to manage an overactive bladder

Overactive bladder (OAB) is defined as urgency symptoms that occur with or without incontinence, usually with frequency and nocturia. Symptoms are often the result of overactivity of the detrusor muscle. OAB can be further defined as ‘OAB-wet’, associated with urge incontinence, and ‘OAB-dry’, where no incontinence occurs.

Incontinence is reported by around a third of patients with OAB and occurs more commonly in women than in men. Most cases of urinary incontinence will require investigation by a GP to determine the cause and nature of the symptoms and to implement an appropriate management plan. Many patients may feel that some degree of incontinence is inevitable as they age and may be too embarrassed to ask for help or talk about their symptoms, so pharmacists should be alert to repeat purchases of incontinence or sanitary products.

“Pharmacy staff could invite the patient into the consultation room to talk about symptoms and how they are affecting their daily life,” says Michael Stewart, an information pharmacist at Numark. “They can reassure the patient that there is a lot of support available to help manage symptoms and that they do not have to rely solely on sanitary products or staying within easy reach of facilities.”

“Where pharmacists suspect that the symptoms being reported are indicative of OAB, the patient should be encouraged to visit their GP for assessment. Pharmacy staff can advise on completing a bladder diary in advance of any visit to the GP, noting the frequency and timing of urination, the number of incontinence episodes and nocturia, as well as the urgency.”

All patients diagnosed with OAB will be advised to make certain lifestyle adjustments. Pharmacy teams are in an excellent position to reinforce and encourage these modified behaviours:

• Bladder training (gradually increasing the time between voids until continence is regained)
• Caffeine reduction
• Modifying fluid intake
• Weight management
• Limiting alcohol intake
• Stopping smoking.

Many community pharmacies already offer services in these areas.

 

A new mum struggling with SUI

Stress urinary incontinence (SUI) is characterised by urine leaking in dribbles or spurts when (for example) coughing, sneezing, laughing or lifting. This is usually due to weakness of the bladder or pelvic floor muscles, especially after childbirth or during the menopause.

“Pharmacists can reassure women that it is not unusual to have stress incontinence after the birth of a baby – or even while they are pregnant – due to the weight of the baby and the effect of relaxing hormones on the muscles,” says Rosemary Dodds, senior policy advisor at NCT. “This is why it is very important to do pelvic floor exercises, even if you do not think they are helping. If women are not sure they know what to do, they can ask their midwives.”

“Women who do have stress incontinence should ask their GP to refer them to a specialist physiotherapist, as it is important to do the exercises correctly so that they can strengthen their muscles.” If SUI isn’t treated it can have long-term consequences for the woman and the NHS, says Rosemary Dodds.

“Encourage women to insist on a referral from their GP. Women with SUI are more likely to be depressed and that has other consequences for them, their family and the wider health service. This is not a condition that should be ignored.” More information on pelvic floor exercises can be found here.

An older man who is embarrassed to go out due to post-micturition dribble (PMD)

PMD or ‘after-dribble’ is when men experience an involuntary loss of urine immediately after they have finished passing urine, usually after leaving the toilet. Few men admit to having this problem but a great many suffer from it and men of all ages can be affected. PMD is due to a weakness of the muscles of the pelvic floor which surround the urethra.

The pelvic floor muscles can be weakened by operations for an enlarged prostate; continual straining to empty the bowels especially when constipated; a constant cough; being overweight; neurological damage; or persistent heavy lifting. According to the Bladder & Bowel Foundation (B&BF), other signs of urinary dysfunction are not normally present, although some men have symptoms such as urgency, frequency, hesitancy and straining.

Older men may develop PMD following a prostatectomy and may have associated urinary symptoms. The B&BF recommends two ways of dealing with this problem. One is to perform pelvic floor exercises; the other is to push the last few drops of urine from the urethra with the fingers before the final shake. Men can find out how to perform pelvic floor muscle exercises here.

 

A young woman experiencing repeated UTIs

Over-the-counter products may offer some relief from the pain and discomfort of a urinary tract infection (UTI) but they will not cure it, so customers may need to be referred to their GP for antibiotics. If the customer is on medication you could offer a MUR, as some medications have side-effects which may cause incontinence (e.g. ACE inhibitors, diuretics, some antidepressants, hormone replacement therapy and some sedatives).

This is because – in some patients – these treatments can disrupt the normal process of storing and passing urine, or increase the amount of urine produced. If patients are only taking these medications for a short time, then the incontinence should end once they stop, but if they are being treated for long-term conditions then, again, it is worth advising them to talk to their GP to see if alternative medicines are available that may not have incontinence as a side-effect.

It is also important to look out for customers of any age who appear to be suffering from repeated or recurring UTIs that are not being resolved by treatment with antibiotics. They should be encouraged to go back to their GP to discuss other options or to ask for a referral to a specialist for further investigation.

Parents concerned that their 10-year-old child is bedwetting

Bedwetting (nocturnal enuresis) that occurs less than twice a week is a common condition, with research suggesting that 21 per cent of children aged four-and-a-half years and 8 per cent of nine-and-a-half year-olds wet the bed occasionally. There is a hereditary link and boys are affected more than girls.

More frequent bedwetting is known to affect 8 per cent at four-and-a-half years, but only 1.5 per cent will still have the problem when they are aged nine-and-a-half years (Butler and Heron 2008), so it is understandable if parents are concerned about a child of 10 years of age. “One of the first things a pharmacist can do in this situation is to reassure the parents that bedwetting is very common and is treatable, and that there are many reasons why children wet the bed at night,” says Sharron Gibson, helpline and information adviser at ERIC, the children’s continence charity.

“For example, the child might not be drinking enough during the daytime meaning their bladder hasn’t learned to stretch to hold a lot of urine and therefore can’t hold the urine produced overnight. Or the child might be constipated and their full bowel could be pressing against their bladder, preventing it from stretching and filling properly, or the wetting might be the result of an overactive or twitchy bladder.”

“It could also be that the child simply doesn’t wake to the signal that their bladder is full. If this is the case, the family might like to try a bedwetting alarm. The reason might be that the child doesn’t produce enough vasopressin, which limits how much urine the kidneys produce overnight. Pharmacists should emphasise that it is important for the child to be seen by a GP to determine what the cause of the bedwetting is and be prescribed the right treatment.”

One medicine that can top up vasopressin levels is desmopressin. In the meantime, a helpful resource is ERIC’s Guide to Night Time Wetting), which advises parents on what they can do to help their child get dry. The guide also includes information about continence clinics.

Pharmacists can help parents deal with the symptoms of bedwetting in the meantime by showing them products to protect their child’s bed such as mattress protectors and waterproof duvet and pillow covers. Parents can also call or email the ERIC helpline (0845 370 8008/helpline@eric.org.uk) if they want confidential one-to-one information for managing their child’s bedwetting.

Appropriate support

No matter how discreet or tactful you are, some customers will always be embarrassed by incontinence and bladder problems. Supporting them with appropriate and sensitive advice could make all the difference when it comes to helping them deal with the condition, rather than suffering in silence.