NPS News 66: Managing urinary incontinence NPS News 66: Managing urinary incontinence

• Think about medicines and mobility
• Physical and behavioural therapies are first line
• Anticholinergics for urge incontinence
• Online list: Medicines that may cause incontinence (PDF available here)
• Online: Case study 61 – Achieving bladder control
• Reviewers

Urinary incontinence is common, but under-reported. This issue of NPS News discusses how health professionals can identify and manage incontinence in primary care, and examines the evidence for physical, behavioural and anticholinergic therapies.

Discussing urinary incontinence

A survey conducted in Australian GP waiting rooms found that only 30% of participants with urinary incontinence had spoken to a health professional about it.[1] People may be reluctant to talk about incontinence because they believe that it is a normal part of ageing.[2] Embarrassment, lack of awareness of treatment options, fear of surgery or the doctor’s gender may be important factors for some.[3,4]

Sensitive questioning, using everyday language, can encourage disclosure at routine cervical smear consultations.[5] Providing information about management options, including physiotherapy and anticholinergic therapy, may help those concerned about surgery.[3,4]

Screen those women who are at greatest risk of becoming incontinent. Flags include recent childbirth, being overweight, chronic conditions, and increasing age.[6,7] Constipation was significantly associated with urinary incontinence in a large survey of older (> 70 years) Australian women.[8]

Symptomatic diagnosis determines management

Thorough assessment is important because treatment options vary depending on the type of incontinence; for example anticholinergics can exacerbate incontinence associated with retention of urine. Clinical history-taking correctly identifies most women with stress incontinence in primary care.[9]

Asking when incontinence occurs — for example on exertion, coughing or sneezing, or when there is a strong urge on the way to the bathroom — will help to identify women with stress or urge incontinence.[10] Mixed incontinence describes a combination of these symptoms. Urgency, with or without incontinence, is called overactive bladder and is commonly associated with detrusor overactivity. Ask about hesitancy, straining and weak urinary flow if symptoms are not associated with stress or urge incontinence.[10]

Examination should exclude neurological conditions, cognitive impairment, enlarged bladder, pelvic mass, prolapse, constipation, urinary tract infection and urinary glucose.[5,6,11]

A bladder diary can help in the initial assessment of overactive bladder, and in monitoring the effects of treatment. A 3-day diary covering variations in routine (e.g. work days and weekend) may be more acceptable to people than a 7-day diary.[11,12] The RACGP clinical practice guideline — Managing Incontinence in General Practice — contains a simple bladder diary in appendix 1.

Think about medicines and mobility

Ask about medicine use, or request a formal medicines review, to help to identify incontinence that is caused or worsened by medicines. For more information on medicines that may cause or make incontinence see the list of medicines that may cause incontinence (below).(Also available as a PDF- Medicines that may cause incontinence.)

Environmental factors, reduced mobility, impaired dexterity and cognitive impairment can prevent people from getting to or using the toilet. Removing clutter and providing non-slip floor surfaces and adequate lighting may help — occupational therapists can provide further advice.[5,13] Height adjustment or grab rails can make the toilet easier to use.[13] Clearly identify the toilet for those with cognitive impairment and consider velcro fastenings or trousers with elastic waistbands if clothing or dexterity is an issue.[5,14]

A case study covering the causes and management of urinary incontinence is now available.

Lifestyle measures may benefit some

Recommend weight loss for overweight and obese women with incontinence. Weight reduction of 8kg during an intensive 6-month weight loss program reduced weekly incontinence episodes by nearly half (from 24±18 to 13±15 episodes [mean ± standard deviation]).[15]

Reducing caffeine may help those with overactive bladder.[5,11] Urinary urgency and frequency, but not leakage, was reduced in men and women who limited their caffeine intake to a maximum of 100 mg/day (about 2 cups of weak instant coffee).[16]

There is no conclusive evidence that modifying fluid intake significantly reduces urinary incontinence episodes.[17–19]

Physical and behavioural therapies are first line

Physical and behavioural therapies promote self-management and have less risk of side effects than medicines. On referral from a GP, people with complex care needs may be eligible for Medicare rebates for services provided through the Enhanced Primary Care program.

Pelvic floor exercises are recommended initially for stress or mixed incontinence, and may be part of the treatment plan for urge incontinence.[5,6,11] Women with stress incontinence appear to benefit the most.[20]

Compared with standard antenatal and postpartum care, intensive pelvic floor exercises can help to reduce the risk of becoming incontinent or of existing incontinence becoming worse.[21] In previously continent women, 25% of those receiving standard care reported incontinence 3 to 6 months after giving birth, compared with 17.5% of women who started pelvic floor exercises during pregnancy.[21]

Continued support from continence exercise specialists may be needed to maintain benefits.[22]

Bladder training should be considered first for women with urge, or mixed, incontinence and for mentally able residents in aged care facilities with urge incontinence.[5,6,11,23] Bladder training encourages patients to gradually increase the interval between voiding episodes. Controlled trials suggest that it improves symptoms of urge or mixed incontinence, but better quality studies are needed to confirm this.[24]

Unblinded studies suggest that prompted voiding (carers asking regularly about the need to go to the toilet) may reduce urinary incontinence by 1 episode per day in aged care residents with or without cognitive impairment.[25] It is not known if the effect persists once prompting stops.

Anticholinergics for urge incontinence

Anticholinergics, combined with continued bladder training, are an option when urge incontinence does not respond to physical or behavioural therapies. About 7 people with overactive bladder need to be treated for up to 12 weeks with an anticholinergic instead of placebo for 1 additional person to report improvement or cure.[26]

Start with a 4–6 week trial of an anticholinergic.[10,27] For those who respond, reassess the balance of benefits and harms at 6 months to determine whether to continue treatment.[10]

Inform patients about the potential adverse effects of anticholinergics, including dry mouth and constipation, and how to manage them.[10] Dry mouth was reported by 31% of people taking an anticholinergic and 9.8% of those taking placebo in clinical trials.[26]

Are there differences between anticholinergics or formulations?

Head-to-head comparisons suggest that anticholinergic agents have similar efficacy; however immediate-release oxybutynin is more likely to cause dry mouth than immediate-release tolterodine (available on private prescription).[28,29]

Differences in efficacy between extended- and immediate-release formulations are small, although extended-release formulations are less likely to cause dry mouth.[28,29] In people with up to 5 incontinence episodes per day before treatment, extended-release anticholinergics reduced incontinence by 1.8 episodes per day compared with 1.5 episodes per day for immediate-release formulations and 1 episode per day for placebo.[28]

The newer anticholinergics, darifenacin and solifenacin, are selective for the receptor that causes bladder contraction. Dry mouth may be less likely with darifenacin and solifenacin compared with immediate-release oxybutynin.[28] There is no evidence to suggest that they are more effective at reducing incontinence episodes than other anticholinergics.[28]

Exercise caution in older people and postmenopausal women

Avoid anticholinergic agents in people with dementia because of the risk of cognitive decline and delirium.[14] More information about prescribing drugs used in dementia can be found in NPS News 59: Drugs used in dementia in the elderly.

Use anticholinergic agents with caution in frail and older people: if prompted voiding or bladder training fail start at the lowest possible dose — switch to an alternative drug if cognitive adverse effects occur.

Oral hormone replacement therapy can worsen symptoms of urinary incontinence in postmenopausal women.[30] However, intravaginal oestrogen significantly improved self-reported symptoms of incontinence in these women compared with placebo.[30]

What’s what: Anticholinergics
darifenacin: Enablex
oxybutynin: Ditropan, Oxybutynin (Sandoz), Oxybutynin (Winthrop), Oxytrol Transdermal System
propantheline: Pro-Banthine
solifenacin: Vesicare
olterodine: Detrusitol

Expert reviewers

Associate Professor Christopher Benness, Head of Urogynaecology Unit, Royal Prince Alfred Hospital, Sydney

Assoc Prof Pauline Chiarelli, Program Convener, Bachelor of Physiotherapy, School of Health Sciences, University of Newcastle, Callaghan

Susan Hunt, Senior Nurse Advisor, Ageing and Aged Care Division, Commonwealth Department of Health and Ageing

Communications review group

Dr James Best, General Practitioner, Sydney

A/Prof Nick Buckley, Consultant Clinical Pharmacologist and Toxicologist, University of New South Wales

Jan Donovan, Consumer Representative

Dr John Dowden, Editor, Australian Prescriber

Dr Graham Emblen, General Practitioner, Toowoomba

Deborah Norton, QUM Pharmacist, West Vic DGP

Susan Parker, Pharmacist, Sydney

Dr Jane Robertson, Senior Lecturer, Discipline of Clinical Pharmacology University of Newcastle

Simone Rossi, Managing Editor, Australian Medicines Handbook

Dr Guan Yeo, Clinical Education Consultant and General Practitioner, Berowra

Any correspondence regarding content should be directed to NPS. Declarations of conflicts of interest have been sought from all reviewers. The opinions expressed do not necessarily represent those of the reviewers.

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Medicines that may cause or make incontinence worse[31–33] (PDF available here)

Medicine	Mechanism	Type of incontinence
alpha-Adrenergic agonists
e.g. ephedrine, phenylephrine, pseudoephedrine	Constrict the bladder outlet, voiding difficulty	Retention of urine[A]
alpha-Adrenergic antagonists
e.g. prazosin, tamsulosin, terazosin	Relax the bladder outlet	Stress
Angiotensin converting enzyme (ACE) inhibitors
e.g. captopril, enalapril, fosinopril, lisinopril, perindopril	Drug-induced cough	Stress
Anticholinergics
e.g. antidepressants, antihistamines, benzhexol, benztropine, disopyramide, oxybutynin[B], tolterodine[B]	Reduce bladder contractions, voiding difficulty, constipation	Retention of urine[A]
beta-Adrenergic agonists
e.g. salbutamol, terbutaline	Relax the bladder outlet	Stress
beta-Adrenergic antagonists
e.g. atenolol, metoprolol, propanolol	Constrict the bladder outlet, voiding difficulty	Retention of urine[A]
Calcium channel blockers
e.g. diltiazem, verapamil	Reduce bladder contractions, voiding difficulty	Retention of urine[A]
Cholinergics
e.g. bethanechol	Increase bladder contractions	Urge
Cholinesterase inhibitors
e.g donepezil, galantamine, rivastigmine	Increase bladder contractions	Urge
Diuretics
e.g. frusemide, hydrochlorothiazide, indapamide	Increase urine volume	Urge
Opioids
e.g. morphine, oxycodone, tramadol	Reduce bladder contractions, confusion, constipation	Retention of urine[A] Functional[C]
Psychotropics
e.g. amisulpride, clozapine, haloperidol, olanzapine, quetiapine, risperidone	Constipation, confusion, sedation, parkinsonism	Retention of urine[A] Functional[C] Stress
e.g. chlorpromazine, pericyazine, trifluoperazine	Anticholinergic effects (see above), confusion, sedation, parkinsonism, impaired mobility	Retention of urine[A] Functional[C]
e.g. benzodiazepines	Sedation, immobility	Functional[C]
e.g. selective serotonin reuptake inhibitors (SSRIs)	Increase bladder contractions, sedation, immobility	Urge Functional[C]
e.g. tricyclic antidepressants (TCAs)	Reduce bladder contractions, sedation, immobility	Retention of urine[A] Functional[C]

A That may result in incontinence.

B Indicated in the treatment of urge incontinence, but can exacerbate incontinence associated with retention of urine.

C Incontinence caused by factors outside the urinary tract (e.g. sedation or confusion).

References

1. Byles JE, Chiarelli P, Hacker AH, et al. An evaluation of three community-based projects to improve care for incontinence. Int Urogynecol J Pelvic Floor Dysfunct 2005;16:29–38.
2. Dugan E, Roberts CP, Cohen SJ, et al. Why older community-dwelling adults do not discuss urinary incontinence with their primary care physicians. J Am Geriatr Soc 2001;49:462–5.
3. Norton PA, MacDonald LD, Sedgwick PM, et al. Distress and delay associated with urinary incontinence, frequency, and urgency in women. BMJ 1988;297:1187–9.
4. Miller YD, Brown WJ, Smith N, et al. Managing urinary incontinence across the lifespan. Int J Behav Med 2003;10:143–61.
5. The Royal Australian College of General Practitioners. Managing incontinence in general practice: Clinical practice guidelines. 2002. (accessed 6 August 2009).
6. Scottish Intercollegiate Guidelines Network. Management of urinary incontinence in primary care: A national clinical guideline. 2004. (accessed 6 August 2009).
7. The Royal Australian College of General Practitioners. Guidelines for preventive activities in general practice. 2009. (accessed 6 August 2009).
8. Byles J, Millar CJ, Sibbritt DW, et al. Living with urinary incontinence: a longitudinal study of older women. Age Ageing 2009;38:333–8.
9. Martin JL WK, Abrams KR, Turner DA, Sutton AJ, Chapple C, Assassa RP, Shaw C and Cheater F. Systematic review and evaluation of methods of assessing urinary incontinence. Health Technology Assessment 2006; 10. (accessed 10 August 2009).
10. National Health Service Clinical Knowledge Summaries. Incontinence - urinary, in women. 2009. (accessed 10 August 2009).
11. National Institute for Health and Clinical Excellence. Urinary incontinence: the management of urinary incontinence in women. 2006. (accessed 10 August 2009).
12. Dmochowski RR, Sanders SW, Appell RA, et al. Bladder-health diaries: an assessment of 3-day vs 7-day entries. BJU Int 2005;96:1049–54.
13. Australian Government Department of Health and Ageing. What now? Helping clients live positively with urinary incontinence. 2007. (accessed 11 August 2009).
14. Yap P, Tan D. Urinary incontinence in dementia - a practical approach. Aust Fam Physician 2006;35:237–41.
15. Subak LL, Wing R, West DS, et al. Weight loss to treat urinary incontinence in overweight and obese women. N Engl J Med 2009;360:481–90.
16. Bryant CM, Dowell CJ, Fairbrother G. Caffeine reduction education to improve urinary symptoms. Br J Nurs 2002;11:560–5.
17. Hashim H, Abrams P. How should patients with an overactive bladder manipulate their fluid intake? BJU Int 2008;102:62–6.
18. Swithinbank L, Hashim H, Abrams P. The effect of fluid intake on urinary symptoms in women. J Urol 2005;174:187–9.
19. Dowd TT, Campbell JM, Jones JA. Fluid intake and urinary incontinence in older community-dwelling women. J Community Health Nurs 1996;13:179–86.
20. Hay-Smith EJ, Dumoulin C. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev 2006:CD005654.
21. Hay-Smith J, Morkved S, Fairbrother KA, et al. Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women. Cochrane Database Syst Rev 2008:CD007471.
22. Glazener CM, Herbison GP, MacArthur C, et al. Randomised controlled trial of conservative management of postnatal urinary and faecal incontinence: six year follow up. BMJ 2005;330:337.
23. The Royal Australian College of General Practitioners. Medical care of older persons in residential aged care facilities. 2006. (accessed 28 August 2009).
24. Wallace SA, Roe B, Williams K, et al. Bladder training for urinary incontinence in adults. Cochrane Database Syst Rev 2004:CD001308.
25. Eustice S, Roe B, Paterson J. Prompted voiding for the management of urinary incontinence in adults. Cochrane Database Syst Rev 2000:CD002113.
26. Nabi G, Cody JD, Ellis G, et al. Anticholinergic drugs versus placebo for overactive bladder syndrome in adults. Cochrane Database Syst Rev 2006:CD003781.
27. Australian Medicines Handbook, 2009.
28. Hartmann KE, McPheeters ML, Biller DH, et al. Treatment of Overactive Bladder in Women. Evidence Report/Technology Assessment No. 187. AHRQ Publication No 09-E017 Rockville, MD: Agency for Healthcare Research and Quality, 2009.
29. Hay-Smith J, Herbison P, Ellis G, et al. Which anticholinergic drug for overactive bladder symptoms in adults. Cochrane Database Syst Rev 2005:CD005429.
30. Cody JD, Richardson K, Moehrer B, et al. Oestrogen therapy for urinary incontinence in postmenopausal women. Cochrane Database Syst Rev 2009:CD001405.
31. Pharmaceutical Society of Australia. Australian pharmaceutical formulary and handbook 20th ed: The Pharmaceutical Society of Australia, 2006.
32. The Royal Australian College of General Practitioners. Managing incontinence in general practice: Clinical practice guidelines. 2002. (accessed 6 August 2009).
33. Queensland Health Joint HACC/MASS Continence Project. First steps in the management of urinary incontinence in community-dwelling older people: a clinical practice guideline for primary level clinicians (registered nurses and allied health professionals). 2007. (accessed 18 September 2009).