Urinary Incontinence: Partnering with Patients for Success

Patient profiles should be reviewed for drugs that may cause or exacerbate incontinence.

The squirming demeanor, the darting eyes, the awkward shuffle…as women age, they begin to understand “the look.” It’s the look that women get when something—or nothing obvious—causes the urge to void or an accidental urine leakage. Around 25% of young women, 44% to 57% of middle-aged or postmenopausal women, and 75% of older women in nursing homes experience urinary incontinence (UI).^1-4 Dissecting “the look” reveals UI’s physical, psychological, and social repercussions. The squirming indicates the bothersome wetness and anxiety. The darting eyes indicate an acute need for the nearest restroom and fear that someone knows, and the shuffle is an attempt to prevent further incontinence.

The International Continence Society defines several types of UI (Table 1^1,5). UI is associated with depression^,6,7 impaired sexual functioning,^8,9 an increased risk of falls and fracture in the elderly,^10-12 skin ulceration,^1,13 and urinary tract infections.¹⁴ In the frail elderly, UI often prompts admission to nursing homes and increases medical expenditures.^13,15

Risk factors for UI include race (with Caucasians at highest risk), increasing age, family history of incontinence, neurologic conditions (eg, Parkinson’s, stroke, multiple sclerosis), impaired mobility, cognitive impairment, obesity, diabetes mellitus, constipation/fecal impaction, urinary tract infection, multiple vaginal births (especially >4 vaginal births), prior pelvic surgery or radiation, pelvic organ prolapse, and menopause.¹⁶

What Women Want

Women want interventions that lead to continence (complete voluntary bladder control), allowing them the freedom to resume their normal activities. Continence is possible, but accurate diagnosis depends on the following¹:

• Obtaining a thorough medical history
• Having the patient use a frequency volume chart/bladder diary and interpreting it correctly
• Conducting a cough stress test
• Excluding pathologic causes such as infection or prolapse

Nonpharmacologic Treatments

Patients who have mild to moderate UI may find that behavioral changes reduce incontinence. Pelvic floor strengthening exercises (eg, Kegel exercises) are effective for treatment of both urge and stress incontinence. It may take weeks to months for exercises to be effective, and they must be done correctly and regularly.^1,5,17 Scheduled toileting during waking hours, especially for patients who have mobility issues, can help. Scheduled toileting includes prompting by caregivers, voiding at appointed times, or habit retraining so that accidents are preempted.^1,18,19 In addition, weight loss has been shown to reduce symptoms of UI.⁵

Constipation sometimes exacerbates UI, so treating it can reduce pressure. Note that antimuscarinic and anticholinergic drugs can cause or contribute to constipation.^5,20 Some clinicians recommend caffeine elimination, but there is little evidence indicating it helps. Expert panels seem to believe that decreasing caffeine intake decreases fluid intake, and it’s the lessened fluid load rather than the lowered caffeine intake that helps with urgency symptoms.^21-23 Many effective absorbent products are available to manage discomfort.

Medication can also cause UI; therefore, pharmacists should review patients’ profiles for drugs that may cause or exacerbate incontinence. Discontinuing medications that could cause cough, constipation, diuresis, or urinary retention is an often overlooked conservative approach (Table 2^24-26).

Drug Therapy

Several medications can be employed to treat UI (Online Table 3^1,8). Anti-cholinergic medications are the treatment of choice for many urinary tract symptoms; these agents block postganglionic muscarinic receptors on the detrusor muscle. Many patients discontinue drug therapy due to anticholinergic side effects (eg, dry eyes, dry mouth, blurred vision, increased heart rate, cognitive impairment). Approximately half of patients report significant improvement, but some authors maintain that achieving complete continence using drugs alone is unlikely.²⁷ Few head-to-head studies have been conducted, so choosing a drug may require trial and error.

Table 3: Medications Used for Urinary Incontinence

Drug or Drug Class

Indication

Notes

Estrogens (topical)

Stress UI

• Systemic estrogen (oral or transdermal) is associated with increased UI or stress UI and is not recommended

Mixed action anticholinergics:

flavoxate, oxybutynin

Urinary tract symptoms and urgency UI

• Oxybutynin is available as a topical gel and an OTC patch
• Dry mouth and constipation are frequent side effects; nausea, somnolence, dizziness, fatigue, and diarrhea are also concerns

Muscarinic-receptor blockers:

darifenacin, fesoterodine, solifenacin, tolterodine, trospium

OAB and urgency UI

• Drugs demonstrate similar effectiveness
• Discontinuation due to adverse effects is common
• Compliance rates are traditionally low

Serotonin-noradrenaline uptake inhibitors: duloxetine, imipramine

Stress UI (off-label indication)

• Response is inconsistent, and many women may discontinue the drug due to side effects

Toxins: botulinum toxin

OAB and urgency UI

• Maintenance treatments are required due to waning effects after treatment is discontinued

Vasopressors:

midodrine

Stress UI

• Off-label use
• It is a strong hypertensive

OAB = overactive bladder; UI = urinary incontinence. Adapted from references 1 and 8.

Although the extended-release or long-acting formulations have been associated with a lower adverse event burden, the immediate-release doses are often preferred for simple nocturia or for patients who wish to medicate only when necessary (eg, before attending church or social events).²⁸ Flexible dosing is a patient-centered overactive bladder treatment strategy. It involves having patients adjust the drug dose—independently or after calling the prescriber—in increments at preplanned intervals, until patients (1) achieve complete continence, (2) experience side effects they cannot tolerate, or (3) reach the agent’s maximum dose.^29-32

Finally, other treatment options include percutaneous nerve stimulation, synthetic midurethral slings, pessaries, and neuromodulation.^1,5

Virginia Bartok is a retired pharmacist who lives in eastern Connecticut. Her primary practice was indigent care.

References

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