Overcoming shame to treat incontinence

By Jillene Magill-Lewis, R.Ph.

One of the biggest problems with urinary incontinence (UI) is that no one seems to want to talk about it. Many patients have the misconception that incontinence is a normal part of aging. Others aren’t aware that the condition can be easily and successfully treated. Still others are too embarrassed to ask for help. Practitioners seem reluctant to bring up the subject as well.

Because of this reluctance, it is difficult to ascertain just how many Americans have some form of UI. In 1996, the Agency for Healthcare Research & Quality (AHRQ) (then the Agency for Health Care Policy & Research) estimated 13 million people suffered from UI. Current estimates range from 15 million to 25 million sufferers, depending on the source.

The vast majority of UI patients are female, and about one-half of all patients are elderly, estimates AHRQ. According to the National Association for Continence (NAFC), less than 10% of these individuals are receiving treatment for their condition. "There’s incredible embarrassment about it," said Leslie Shimp, Pharm.D., M.S., an associate professor of pharmacy at the University of Michigan College of Pharmacy.

"A lot of patients are happy with self-management," noted Shimp. Many patients suffer with UI for years before mentioning it to their physicians. Compounding the problem, practitioners often neglect to include questions about incontinence during routine exams.

Identifying those with UI is not as difficult in long-term care facilities. However, this patient population presents a slew of other problems. "I think the elderly, particularly in nursing homes, have a lot of functional barriers to continence," said Thomas Lackner, Pharm.D., CGP, FASCP. Patients who are in pain may be unwilling to walk to the bathroom. Some of those who need assistance may be reluctant to bother the staff. Others may have psychiatric conditions that prevent them from getting to the toilet in time, if at all.

Another problem lies with practitioners. "In many cases, patients don’t carry a diagnosis of incontinence, even though some of them may be severely incontinent," said Lackner, who is a consultant pharmacist and professor of geriatrics at the University of Minnesota College of Pharmacy and the Institute for the Study of Geriatric Pharmacotherapy. He’s not sure why treatment of UI is sometimes deliberately neglected. One possibility is that a diagnosis of UI would then require treatment, which physicians may not want to bother with.

"Clearly, it’s not a condition that’s on the high-priority list of a lot of caregivers," Lackner said. Cardiovascular conditions, malignancies, nerve disorders, and the like may beat out UI for practitioners’ attention. However, failure to treat UI can result in complications that are every bit as costly. Treating the condition can produce considerable cost and care benefits. Lackner suggests that consultant pharmacists help the health-care team by working to foster better diagnosis and documentation of UI.

That’s just the first hurdle, though. Sometimes, Lackner explained, even if UI has been diagnosed, the actual type is not determined.

Types of urinary incontinence

"For pharmacists to be able to identify patients who have incontinence, first they need to know the different types of incontinence," said Mary W. L. Lee, Pharm.D., BCPS, FCCP, dean and professor at the Chicago College of Pharmacy.

In 1996, AHRQ published a clinical practice guideline for UI, which defined and described the various types. One of the most common types is urge incontinence. Characterized by urgency and frequency of urination, urge incontinence is often caused by involuntary contractions of the bladder wall, or detrusor. The term overactive bladder is now frequently used by advertisers to refer to this type of UI.

Stress incontinence is the loss or leakage of urine during activities that increase intra-abdominal pressure. Bending over, lifting objects, coughing, laughing, and sneezing can all lead to urine loss in this disorder. Stress incontinence can be caused by damage to the pelvic floor muscles that assist in closing the urethra or by a malfunctioning or hypermobile urethra.

Patients with this variation of UI are usually female and have often gone through childbirth, surgery, or a trauma that resulted in injury to the pelvic floor or urethra. Stress incontinence may also be caused by a congenital problem. What’s unique about this type is that a large number of patients are not elderly. Many of them are younger women in their twenties, thirties, or forties. In fact, while doing research for a book, Shimp discovered that 47% of regular exercisers experience stress incontinence. Of varsity university athletes, 28% experienced urine loss while participating in their sports.

Some patients have symptoms of both urge and stress incontinence, and these individuals are said to have mixed incontinence. AHRQ found that these patients tend to be older women and very often are bothered by one symptom and not the other.

Overflow incontinence occurs when the bladder wall is unable to contract enough to expel the urine or when there is a blockage affecting the urethra (e.g., benign prostatic hyperplasia). Occasionally, both of these may occur simultaneously. The end result is that the bladder fills to capacity with urine and eventually overflows. Diagnosis can be tricky because symptoms may be similar to those of urge or stress incontinence.

Patients with functional incontinence have some condition that prevents them from voiding in the toilet. As Lackner mentioned, functional barriers to continence may include physical inability to ambulate or cognitive impairment. In nursing homes, patients may have functional limitations as well as another type of incontinence, so it is critical to assess for other types before making a diagnosis.

Other variations of incontinence include unconscious incontinence (occurring in patients with decreased or no urinary nerve function), UI caused by surgery or radiation therapy, and transient incontinence. This last type may be triggered by infection, certain endocrine disorders (such as diabetes), drugs, and so on.

Treatment for UI

While pharmacists most often think of drug therapy for UI, there are several nondrug treatments that can be very effective. Scheduled toileting and prompted voiding can help patients develop habits that prevent wetting accidents. Pelvic muscle exercises or Kegel exercises build strength and make patients aware of the muscles that close the urethra. For women, vaginal weights may be used for this purpose also.

Biofeedback therapy can train some patients to be more aware of urinary tract muscles and function. External electrical stimulation is another alternative.

All of these therapies can resolve UI in some patients and improve it in many others. Some patients may still have bothersome symptoms, however, and several drugs are available for them.

AHRQ included preferred drug selections in the association’s clinical guideline for UI. For stress incontinence, the guideline recommended alpha-adrenergic agonists and estrogen. The alpha-agonists stimulate contraction of the pelvic floor muscles and proximal urethra, preventing urine loss. At the time, the first-line agents were phenylpropanolamine (PPA) and pseudoephedrine. Since then, PPA has been removed from the medication marketplace.

Estrogen helps strengthen the pelvic floor muscles and may enhance alpha-adrenergic response. One advantage is the drug can be administered either orally or vaginally. Some clinicians believe the vaginal form is much more effective than the oral and it has fewer side effects.

AHRQ’s guidelines recommended combination therapy with the two agents if monotherapy is unsuccessful. Estrogen appears to potentiate the effects of alpha-agonists. This increased efficacy may be accompanied by more side effects, which is something to keep in mind when treating the elderly, particularly those with hypertension.

Patients with overflow incontinence must be evaluated for obstructions. Once obstructions are treated or ruled out, drug therapy may begin with alpha antagonists, which open the proximal urethra and allow urine release. Another option is the cholinergic drug bethanechol, which increases detrusor contractions.

The clinical guideline for urge incontinence cites anticholinergics as first-line agents, with oxybutynin (Ditropan XL, ALZA) being the drug of choice. Propantheline is named second, and dicyclomine is given as a third option. Although other anticholinergics have been used to treat UI, AHRQ did not recommend any of them because of the lack of evidence of efficacy in the literature.

Several other drugs have been prescribed for urge incontinence, including calcium-channel blockers, tricyclics, NSAIDs, beta-agonists, and baclofen. AHRQ saw potential uses for some of these agents (for example, tricyclics in depressed patients) and recommended careful, individualized selection.

A bit of controversy

The problem with the clinical guideline is it hasn’t been updated since 1996. "It’s getting just a tad dated," said Shimp. The most obvious defect is that it was published before tolterodine (Detrol, Pharmacia) made it to market.

Tolterodine and oxybutynin are the two major competitors in the urge incontinence market, and the manufacturers of each are vying for first place. Each company has developed an extended-release formulation of its products, and the race is on.

Even the experts don’t agree on this subject. "Clinically, the difference between the two is effectiveness," said Lackner. After a review of clinical study results, he concluded that tolterodine is not much more effective than placebo, although it may be safer than immediate-release oxybutynin. He believes the evidence favors oxybutynin, both extended- and immediate-release, and in fact he has seen this in his own practice.

Lee also reviewed the literature and came to a different conclusion. She feels tolterodine is as effective as oxybutynin, with potentially fewer side effects. Here she’s hit on the second bone of contention between the two drugs: dry mouth. This is the most common side effect with both, and its occurrence is reported to be less with tolterodine.

However, results from a recent study comparing controlled-release oxybutynin with immediate-release tolterodine reported patients on the oxybutynin product experienced less dry mouth. "But how important is that clinically?" asked Lee. In her opinion, dry mouth really isn’t a significant problem with patients. That brings us right back to the efficacy question.

"I would say tolterodine holds the edge right now," said Shimp. Pharmacia has enlisted the help of CVS.com to help keep that edge. CVS.com has added an overactive bladder section to its Web site. The site provides a wealth of information on the subject in an easy-to-understand format.

The benefit for patients is they can privately get answers to many questions. There are also several links to information about Pharmacia and Detrol LA.

Another player on the horizon is an oxybutynin transdermal patch. Watson Pharmaceuticals has submitted a New Drug Application (NDA) for the product.

Putting it all together

Drug therapy for UI can be very complicated, especially in the elderly. Most seniors are taking multiple medications, so interactions and adverse reactions are more prevalent. Other conditions also throw a hitch into treatment. Lackner pointed to Alzheimer’s disease, in which patients lose acetylcholine.

Some of the cholinergic medications used to treat Alzheimer’s can cause UI. Conversely, the anticholinergic drugs used to treat urge incontinence may exacerbate Alzheimer’s. This hasn’t been proven, however, and Lackner intends to study anticholinergic use in patients with mild to moderate dementia. It is his belief that it may be possible to treat UI without significantly affecting the progression of Alzheimer’s.

There’s more: "The same drugs that we use to treat some types [of incontinence] can actually worsen or precipitate other types," Lackner noted. Because of this, consultant pharmacists can be invaluable in selecting the appropriate medications. No one else is better prepared to consider all the options, potential interactions and adverse effects, and coexisting conditions in order to choose the best course of action.

External forces

Sometimes incontinence is caused not by illness or natural loss of bladder control, but by something ingested by the patient. "There are actually a lot of drugs that can cause incontinence," said Mary Lee, Pharm.D., BCPS, FCCP, dean and professor at the Chicago College of Pharmacy. Here’s a list of drugs that can cause or worsen different types of UI:

alcohol
alpha-adrenergic agonists
alpha-adrenergic antagonists
anticholinergics
antihistamines
antipsychotics
beta-adrenergic agonists
beta-blockers
caffeine
calcium-channel blockers
diuretics
methyldopa
narcotics
NSAIDs
sedatives

Based in Washington State, the author writes frequently on health-related subjects.

Jillene Lewis. Overcoming shame to treat incontinence.

Drug Topics

2001;21.