Pharmacy Practice: Incontinence

Risk Factors for Urinary Incontinence

• Pregnancy

• Having had children

• menopause

• obesity

• UTI

• constipation

• Surgery like: prostatectomy and hysterectomy

• reduced mobility

• Neuro or MS conditions

• Health conditions (Diabetes, stroke etc)

• SOME meds

Types of Incontinence

Includes stress incontinence, urge incontinence, overflow incontinence, overactive bladder, nocturia, functional incontinence, and mixed incontinence.

Stress Incontinence

Defined as involuntary loss of urine with increases in intra-abdominal pressure.

Urge Incontinence

Incontinence that occurs due to an uncontrollable urge to urinate.

Sensory + detrusor muscle instability

More urine volume than stress

Overflow Incontinence

Incontinence that occurs due to incomplete emptying of the bladder.

May be due to neurological problems, or obstructions.

Nocturia

Waking up to go to the toilet more than once per night.

Nocturnal Enuresis

Involuntary loss of urine occurring during sleep.

Functional Incontinence

Urinary leakage associated with the inability to toilet because of impairment of cognitive and or physical functioning.

Mixed Incontinence

Incontinence that occurs as a combination of other types of incontinence. Usually urge + stress

Barriers to Seeking Help

Embarrassment, social stigma, and the perception that incontinence is inevitable and untreatable.

Pharmacological Treatment for Urgency

Includes

• anticholinergics (reduces detrusor muscle over-contracility in URGE)

• mirabegron (URGE)

• Vaginal estrogen (URGE AND STRESS)

• Selective Alpha Blockers (OVERFLOW due to enlarged prostate)

Good Bladder Habits

• Include proper hydration

• Avoiding 'just in case' toileting

• Strengthening pelvic floor muscles.

Skin Care for Incontinence

Requires using pH neutral cleansers, keeping the skin dry, and appropriate use of barrier creams.

Continence Aids

Include pads, commodes, catheters, and leg bags to manage incontinence.

Causes of Faecal Incontinence

• Constipation

• Neurological Damage

• Loss of sphincter control

• Laxative Abuse

Other Comorbidities

• Incontinence often exists with physical, mental, functional and social problems

• Mobility and impaired cognition act synergistically

• Diagnosis that increase likelihood of incontinence include: dementia, stroke, Parkinson’s (neurological issues)

Incontinence is NOT

• normal with ageing

• limited to old people (pregnancy and childbirth are common causes)

Anatomy of Urination

The detrusor muscle that forms the walls of the bladder contracts to expel urine, while the sphincter muscles relax to allow urine to flow out of the bladder.

(Parasympathetic M3 receptors on detrusor agonism triggers urination)

Pelvic Floor

The most important part are deep muscle layers known as the levator ani.

3 sections include: pubococcygeus, puborectalis, and iliococcygeus.

Their functions

• controlling urine flow

• supporting bladder during times of intraabdominal pressure

• Relax to allow urination prn

Reversible Causes of Incontinence

• delirium

• Infections

• Atrophic vaginitis (thinning/drying of vagina during menopause)

• Physiological conditions like depression

• Pharmaceutical agents

• Endocrine conditions

• Restricted mobility

• Stool impaction

• Obesity

Drugs that can cause incontinence

• Anticholinergics (i.e oxybutynin): Cause retention of urine due to reduced bladder contractions, cognitive impairment and constipation

• Cholinesterase Inhibitors (donepezil): Cause urge incontinence by increasing bladder contractions

• CCBP (verapamil, diltiazem): Cause retention of urine by reducing bladder contractions and causing constipation

• ACE inhibitors (ramipril): Cause stress incontinence by inducing cough

• Diuretics (frusemide, HCTZ): Cause urge incontinence and retention of urine by increasing urine volume

• Antipsychotics (risperidone): Cause retention of urine and functional incontinence by reducing bladder contraction and causing confusion

• Benzodiazepine (diazepam): Cause functional incontinence by sedation

• TC Antidepressents (amitriptyline): Cause retention of urine and functional incontinence by reducing bladder contractions and causing sedation

• SSRIs: Cause urge and functional incontinence by increasing bladder contractions and causing sedation

• Opioids: Cause retention of urine and functional incontinence by reducing bladder contractions and causing confusion

• Selective Alpha Blockers (prazosin): cause stress incontinence in women by relaxing bladder outlet

Factors that Exacerbate Incontinence

• Diet (low fibre, low fluid, caffeine)

• Lifestyle (obesity, smoking, alcohol)

• Physical Environment(lack of accessibility, bathroom availability)

All modifable