Tapping into research for urinary incontinence

With urinary incontinence such a widespread and chronic problem, the search is on for new treatments that are effective, well-tolerated and minimally invasive.

Learning objectives

After reading this feature you should be able to:

• Describe different types of urinary incontinence including characteristic signs/symptoms, risk factors and causes
• Explain the main management strategies used to treat the different types of urinary incontinence
• Provide self-care information to urinary incontinence sufferers, including advice and support on key interventions such as pelvic floor exercises and bladder training. 

Key facts

• The two most common types of urinary incontinence are stress and urge incontinence 
• Around 9 million people in the UK are thought to be currently experiencing some form of stress incontinence
• Pharmacy teams can provide discreet advice and support to customers suffering with bladder weakness.

One particularly exciting area of current research lies in regenerative medicine and the use of stem cell therapies to treat stress urinary incontinence.¹ This approach involves the implantation of muscle stem cells into the sphincter area with the aim of restoring function.

The hope is that implanted stem cells would act to increase maximal urethral closure pressure (MUCP) and enable resistance to higher intraabdominal strain without leaking. Muscle progenitor cells have been evaluated in this area in preclinical and clinical trials with some promising early results, although key issues remain to be overcome including survival/metabolism of injected cells and tracking of long-term viability and functionality.¹

Another approach under active investigation is regenerative pharmacology, which uses small molecule chemokines to stimulate the body to self-heal in situ.¹

Heavy toll

Urinary incontinence can exert a heavy toll on sufferers, leading to negative emotions such as embarrassment, loss of self-esteem and depression. Affected individuals may also curtail everyday activities, socialising and sports due to concerns about leaking, thereby perpetuating feelings of isolation and further worsening the mental health impact.

As with most chronic medical conditions, the Covid-19 pandemic has created extra challenges for individuals with urinary incontinence due to difficulties accessing GP routine appointments and other supportive services. The closure of many public toilets (including those in cafes and shops) also served to heighten stress and anxiety among sufferers when away from their home.

There are several different types of urinary incontinence, with stress incontinence and urge incontinence the two types most likely to be encountered in the pharmacy setting. The overriding risk factor for all types of urinary incontinence is older age, with bladder weakness arising from physiological changes that occur with natural ageing.

Stress incontinence

The Bladder and Bowel Community (B&BC), the UK’s leading support group for urinary incontinence, estimates that 9 million people in the UK are currently experiencing some form of stress incontinence.² This is where small amounts of urine leak out during everyday physical activities that increase pressure on the bladder, such as coughing, sneezing, laughing, heavy lifting or exercise.

Stress incontinence results from damage or weakness to muscles in the pelvic floor or the urethral sphincter, which renders the urethra unable to stay closed as pressure inside the bladder rises.

Key culprits that can cause damage to these muscles include childbirth (especially as a result of vaginal or instrumented deliveries) and surgery (notably a hysterectomy or prostate gland removal).

Hormonal changes associated with pregnancy and the menopause can also result in progressive weakening of the pelvic floor muscles, while certain neurological conditions (e.g. Parkinson’s disease and multiple sclerosis) and connective tissue disorders can contribute to muscle dysfunction.

Obesity increases pressure in the abdomen, which puts extra strain on the pelvic floor muscles and can make stress incontinence worse, while certain drugs may increase the risk of, or exacerbate symptoms of stress incontinence. Angiotensin converting enzyme (ACE) inhibitors can trigger coughing that increases pressure on the bladder, while alpha adrenergic agonists act to relax the bladder outlet and urethra.

Pelvic floor exercises have traditionally been seen as the mainstay of treatment for stress incontinence but research has shown that they can actually benefit all incontinence sufferers. For stress incontinence that fails to respond to lifestyle intervention or pelvic floor muscle training, surgery to tighten or support the bladder outlet is usually recommended as the next step.

The only pharmacological option for patients unwilling or unsuitable to undergo surgery is duloxetine, which helps boost muscle tone in the urethra. Pharmacists can help patients deal with potential side-effects, which include nausea, dry mouth, fatigue and constipation.

Urge incontinence

Urge incontinence is typified by a strong urge to urinate (urgency), which is followed by an uncontrollable tightening of the bladder and subsequent leakage or complete bladder emptying. The majority of cases of urge incontinence stem directly from an overactive bladder but other possible causes include a urinary tract infection, bladder stones or an underlying neurological disorder.

Side-effects of certain medications can also promote detrusor muscle overactivity or indirectly contribute to symptoms of urge incontinence. Key culprits are cholinesterase inhibitors, any drug which causes constipation (e.g. opioid analgesics), medicines with anticholinergic effects and diuretics.

Bladder training is the best approach for urge incontinence, while second-line pharmacological options include antimuscarinics (most commonly oxybutynin, tolterodine and darifenacin) or the beta-3 adrenergic agonist mirabegron.

Antimuscarinics help quell the effects of overactive bladder and dampen down the frequent urge to urinate. They are most commonly prescribed as oral tablets but patch formulations of oxybutynin are also available. People with urge incontinence are typically started at low doses of antimuscarinics, with dose titration to effective levels over a period of several weeks. Potential side-effects include dry mouth, constipation, fatigue and blurred vision. In rare instances antimuscarinics can cause a build-up of pressure in the eye, potentially resulting in angle closure glaucoma.

Mirabegron may be prescribed as an alternative to antimuscarinics and works by promoting bladder muscle relaxation, allowing the bladder to fill up and effectively store urine. Possible adverse events include an increased risk of urinary tract infections, palpitations, arrhythmias, dizziness, headache, rash and itchy skin. Blood pressure monitoring is advised before starting mirabegron and regularly during treatment, particularly in those patients with pre-existing hypertension.

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 commonly 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 describes the condition where the bladder is unable to store any urine at all, requiring constant urination to avoid leakage. Some people also suffer from mixed incontinence and display combined symptoms of both urge and stress incontinence.

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 in order to optimise outcomes.

Pharmacy teams should be on hand to provide advice on the following important self-care tools for dealing with urinary incontinence:

• Bladder training

This is the first-line intervention for urge incontinence and focuses on techniques to help sufferers gradually extend the length of time between feeling the need to urinate and actually visiting the toilet. Most bladder training courses last six weeks. This method sounds simple but bladder retraining takes time and determination and will not work overnight, says the B&BC.

“To have a chance of successful bladder retraining a person must try and ignore the feeling that they need to go to the toilet for as long as possible. If someone can learn to ignore the feeling that they need to go straight away, their bladder will begin to relax and become less irritable. It is possible for a person to be in control of their bladder and not the other way round.”²

To help track bladder habits and patterns, customers should be advised to keep a bladder diary. This should document the number of toilet visits per day, length of time between bladder emptyings and volume of fluid consumed. This can then be used as a basis for developing realistic goals to aim for during bladder training, as well as charting progress throughout the programme.

For any customers who are wary of accidents while undertaking a bladder training programme, light protection in the form of pads or protective underwear can provide reassurance against leaks.

• Pelvic floor exercises

Training to strengthen the pelvic floor muscles is usually initiated by a specialist based on assessment of baseline muscle function. As a minimum, a programme of eight muscle contractions at least three times a day for three months is typically recommended. Pharmacists should be prepared for potential customer scepticism about the effectiveness of pelvic floor muscle training. 

“Many people have heard of pelvic floor exercises but perhaps don’t believe in them,” says Gail Ford-Rowley, nurse adviser for Hartmann. “However, they are a clinically proven noninvasive treatment that can improve continence for both men and women. The key is making sure they are done correctly and regularly… Patients need to stick with them as it may take some time before the benefit of the exercises is seen.”³

Information on specific pelvic floor muscle exercises recommended for urinary incontinence sufferers is available from nhs.uk, while pdf guides and instructional videos can be downloaded from the B&BC website.

For customers unable to contract their pelvic floor muscles voluntarily, electrical stimulation delivered via a small probe inserted into the vagina or anus is a potential alternative approach. Biofeedback, which monitors the effectiveness of pelvic floor muscle contractions (via an inserted probe or electrodes attached to the skin), can also prove beneficial in some cases.

Another option for strengthening the pelvic floor is the use of vaginal cones. These are small weights inserted into the vagina, which are then held in place by the pelvic floor muscles.

• Fluid intake

Somewhat counterintuitively, customers 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. Customers should also be encouraged to reduce their intake of caffeine as its diuretic effects act to increase urine production.

• Pads and protective underwear

A wide range of very effective, specially designed absorbent products such as pads, pants and protective underwear can now be purchased OTC from pharmacy (or obtained on prescription if customers are concerned about the cost). In the current Covid-19 era, self-referral to the local bladder and bowel or continence service may still be possible in some cases.

Other key self-care tips for urinary incontinence sufferers include weight loss to relieve pressure on the pelvic floor muscles and avoidance of high-impact sports or strenuous exertion (in particular heavy lifting), which can exacerbate symptoms.

Going to the toilet ‘just in case’ is not recommended as this can encourage the bladder to become more ‘irritable’ or sensitive.

Discretion and sensitivity

Above all, community pharmacy teams should be aware of the importance of exercising discretion and sensitivity when dealing with customers with urinary incontinence.

The consultation room should be offered to individuals who seem embarrassed or uncomfortable and may prefer to discuss the problem in a more private setting. It is also important to ensure the store is ‘incontinence friendly’ with in-store displays encouraging customers to ask for more information.

Urinary incontinence products should be positioned in accessible locations (i.e. not on high shelves or behind the counter where customers will be forced to ask for assistance) in less busy areas of the store where people will feel more comfortable taking time to browse the available selection.

Sufferers should also be encouraged to apply for a ‘Just Can’t Wait’ toilet card, supplied by B&BC. This universally recognised toilet access card is available in both a digital and paper version, and helps quickly and discreetly communicate the need to use a WC when away from home.

References

1. Schmid F, et al. Treatment of stress urinary incontinence with muscle stem cells and stem cell components: chances, challenges and future prospects. Int J Mol Sci. 2021; 22(8):3981
2. Bladder & Bowel Community. Available at: Bladder & Bowel Community 
3. Ford-Rowley. Incontinence Myths. Published 23 February 2021. Available at: Incontinence Myths – Bladder & Bowel Community.