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Learning objectives
After reading this feature you should be able to:
- Describe the different types of urinary incontinence including characteristic signs, risk factors and causes
- Offer patients support and advice to improve their quality of life
- Explain what pelvic floor exercises and bladder training involve
- Understand the medicines used to manage incontinence
Urinary incontinence (UI) is common in women, with data suggesting a prevalence of between 34-40%, while in men it is believed to be around half as prevalent at around 17%.
Not only can incontinence have an emotional and psychological impact, it can cause physical complications (such as skin damage and infections), sexual problems (such as reduced intimacy) and have consequences for the person’s social life and employment. However, in most cases, incontinence can be treated or significantly improved.
Key facts
- Urinary incontinence (often referred to as bladder weakness) is a common condition among both men and women
- Many people suffer in silence because they are embarrassed about their symptoms
- Pharmacy teams can help improve patient care with products, support, signposting and referral
Classification
There are several different types of urinary incontinence, although the most likely to be encountered in community pharmacy are:
- Stress incontinence – involuntary leakage of urine caused by increased intra-abdominal pressure upon physical exertion, coughing, sneezing, or even laughing
- Urge incontinence – involuntary leakage of urine accompanied or preceded by a sudden and compelling desire to pass urine.
Other types to be aware of include:
- Mixed urinary incontinence – involves both urge and stress incontinence
- Overflow incontinence – characterised by frequent dribbling because the bladder does not empty completely.
Functional incontinence is where there is a physical or mental impairment. This could be due to a medical condition, such as severe arthritis, which makes it challenging to remove clothes quickly enough. There are, of course, a host of other conditions that can make it more difficult to reach a toilet in time.
Urinary incontinence can also be classified as continuous, a condition that normally arises due to bladder problems from birth. However, the main risk factor for urinary incontinence is older age due to physiological changes because of natural ageing.
Patient assessment
Pharmacists should take a detailed medical history to identify the type of incontinence and rule out any serious or underlying conditions. Ask about the duration, frequency and severity of symptoms, as well as any impact on someone’s emotional wellbeing and daily functioning.
This involves asking about any other symptoms experienced including voiding and urinary effects, pain, recurrent UTIs, or other signs such as blood in the urine. To rule out any underlying causes it is important to ask about other medical conditions a person may have, any relevant surgical procedures they have undergone, and medications they are taking.
An abdominal and pelvic examination should normally be conducted as well (see below). However, due to its intimate nature, this is not appropriate in community pharmacy.
Assessing pelvic floor muscle contractions
The strength of pelvic floor muscle contractions can be assessed digitally – this is an intimate examination performed by an appropriately trained medical professional. A gloved and lubricated finger is inserted into the vagina to assess the pelvic floor muscles. However, this is clearly and obviously inappropriate in a pharmacy setting, so this detail is provided to help inform conversations you may have with patients.
A grading scale, such as the Oxford grading system, can be used to quantify the strength of the contraction:
- 0 = no contraction. No discernible muscle contraction
- 1 = flicker. A flicker or pulsation is felt under the examiner's finger
- 2 = weak. An increase in tension is detected, without any discernible lift
- 3 = moderate. There is lifting of the muscle belly and elevation of the posterior vaginal wall
- 4 = good. Increased tension and a good contraction elevate the posterior vaginal wall against resistance (pressure by the examining finger applied to the posterior vaginal wall)
- 5 = strong. Strong resistance is applied to the elevation of the posterior vaginal wall. The examiner's finger is squeezed and drawn into the vagina.
Finally, urinalysis should be carried out in all patients to test for blood, glucose, protein, leucocytes and nitrites, and appropriate action taken if necessary. Importantly, anyone with features suggestive of bladder or renal cancer should be referred urgently to their GP (see box below).
NICE suspected cancer guideline
The NICE suspected cancer guideline advises that GPs should refer people using a suspected cancer pathway referral for bladder cancer (for an appointment within 2 weeks) if the woman is:
- Aged 45 years and over with:
- Unexplained visible haematuria without urinary tract infection (UTI)
- Visible haematuria that is persistent or recurrent after successful treatment of UTI
- Aged 60 years and over with unexplained non-visible haematuria and dysuria or a raised white cell count on a blood test
Referral
Pharmacists should be aware of clinical features that necessitate GP referral. These include (but are not limited to):
- Persistent bladder or urethral pain
- Voiding difficulty
- History of chronic urinary retention
- Bladder that is palpable on abdominal or bimanual examination after voiding
- Associated faecal incontinence
- Suspected neurological disease
- History of previous incontinence surgery, pelvic cancer surgery, or radiation therapy
- Recurrent UTI
[Source: NICE CKS]
Stress incontinence
Anything that causes weakening of the pelvic floor muscles can give rise to stress incontinence. Childbirth, for example, may lead to anatomical or neuromuscular injury. A higher number of vaginal births, combined with the use of forceps and heavier birthweight babies, are all risk factors.
There also seems to be an association between the menopause and UI in that some women first develop it during this time in their lives. While vaginal oestrogen improves continence, oral HRT does not provide the same benefit.
Other risk factors include obesity; smoking (due to greater coughing); high impact activities such as long-distance running; hysterectomy; genetic factors that predispose to weakened pelvic tissue; and medicines – alpha blockers relax the bladder outlet and weaken the urethral sphincter.
Management
All people with stress UI should be advised to keep a bladder diary for at least three days to evaluate the severity and inform its management. The diary should document any variation in usual activity (e.g. changes in work/leisure activities) as well as the timing, type and quantity of fluid intake.
Additionally, a person should record how often they urinate; urine volumes; leakage episodes; and whether there are any activities that cause leakage. Lifestyle advice should also be offered to help improve symptoms.
Lifestyle modification
It is known that the risk of UI is increased by 35% in women who are overweight and nearly double in those who are obese. Pharmacists should provide weight loss advice to women with a BMI over 30; obviously this needs to be done with respect and sensitivity.
Advice on reducing caffeine intake should also be provided as well as modifying fluid intake (this may need to be increased or decreased depending on the individual).
When discussing these changes, it is important to emphasise how they are likely to have a positive effect on UI symptoms. Patients should be advised to persist with these changes because it can often take a few weeks or even months to see any real benefit.
Behavioural approaches
NICE recommends that women with stress or mixed UI try supervised pelvic floor muscle training for at least three months. Training should comprise at least eight contractions performed three times a day. Women should squeeze their pelvic floor muscles quickly, hold for two seconds, relax the muscles, and repeat several times.
NICE also recommends bladder training (through specialist services) for a minimum of six weeks for women with urgency or mixed urinary incontinence. Bladder training requires an individual to follow a fixed voiding schedule, irrespective of whether they feel the urge to urinate. If someone does feel an urge to urinate before the assigned interval, they use urge suppression techniques.
Absorbent containment products such as pads or collecting devices that help achieve social continence can be used until a formal diagnosis is made. NICE says these products should not be used routinely to treat incontinence but can be offered alongside ongoing treatment or for long-term management – but only after treatment options have been explored.
The only pharmacological option for patients unwilling or unsuitable to undergo surgery is duloxetine, which helps improve muscle tone in the urethra. Pharmacists can help patients deal with potential side‑effects, which include nausea, dry mouth, fatigue and constipation.
Urge incontinence
The cause of urge UI is less clear but is linked with overactive bladder (OAB) syndrome, in which overactivity of the detrusor (bladder) muscle leads to involuntary contractions.
OAB can be associated with a range of other conditions, including Parkinson’s disease, spinal cord injury, diabetic neuropathy, multiple sclerosis and stroke. Typically, patients experience urgency, often with an increased frequency of urination and nocturia. Risk factors include:
- Recurrent urinary tract infections
- Caffeinated/alcoholic drinks or high fluid intake
- Smoking (due to the irritant effect of nicotine on the bladder)
- Menopause
- Some medicines – such as cholinesterase inhibitors, drugs which causes constipation, sympathomimetics, antidepressants, oral HRT.
Management
The autonomic nervous system plays an important role in detrusor activity. Contraction of this muscle is controlled by the parasympathetic nervous system and mediated by acetylcholine acting on muscarinic receptors on the bladder.
Initial management involves GP referral for six weeks of bladder training. If symptoms persist, addition of medication may be necessary. An antimuscarinic drug should be offered for four weeks and then reviewed. First-line options include oxybutynin, tolterodine, or darifenacin.
NICE advises against using immediate release oxybutynin in older women as some patients may be at higher risk of a sudden deterioration in their physical or mental health. A further concern is the possible adverse effects of anticholinergics on cognitive function in women using these drugs for overactive bladder. Alternative first-line agents are fesoterodine, propiverine, solifenacin, and trospium.
If an anticholinergic is contraindicated, or if the first line treatment is ineffective or not tolerated, a beta-3 adrenergic receptor agonist should be offered (either mirabegron or vibegron). Treatment should then be reviewed every 12 months, or every six months in women aged over 75 years.
Intravaginal oestrogen therapy in post-menopausal women
Intravaginal oestrogen therapy may improve incontinence and frequency in post-menopausal women who have vaginal atrophy. Use should be reviewed at least annually to reassess the need for continued treatment and monitor for symptoms of endometrial hyperplasia or carcinoma.
Other types of urinary incontinence
In addition to stress and urge incontinence, other types of urinary incontinence include overflow incontinence (also known as chronic urinary retention). This is most seen in men and is often caused by an enlarged prostate gland. The bladder fills normally but is unable to empty completely due to an obstruction, leading to frequent leaking of small amounts of urine.
Total incontinence is when the bladder is unable to store any urine at all, requiring constant urination to avoid leakage. Some people suffer from mixed incontinence and display combined symptoms of both urge and stress incontinence.
Fluid intake
Somewhat counterintuitively, patients with urinary incontinence should be encouraged not to restrict their fluid consumption but instead aim for a recommended intake of 1.5 to 2 litres per day. Cutting down on fluids has no impact on the risk of urinary leakage but does increase the likelihood of bladder infections and constipation which, in turn, can exacerbate bladder weakness.
That said, some drinks such as carbonated beverages, fruit juices and alcohol can irritate the bladder and should be avoided. Patients should also be encouraged to reduce their intake of caffeine as its diuretic effects act to increase urine production.
Pharmacy role
Community pharmacy teams have a key role in helping customers and patients with bladder weakness and urinary incontinence take steps to control their condition and get on with their everyday lives. With self-management interventions such as bladder training and pelvic floor exercises the cornerstone of incontinence care, pharmacy-led advice, education and ongoing support is vital to optimise outcomes.
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