FEATURE: Managing incontinence in pharmacy

Ade Williams discusses how community pharmacy teams can offer well-evidenced and effective interventions to help sufferers of bladder weakness…

There are few conditions that bring the degree of isolation, embarrassment and self-consciousness that bowel and urinary incontinence does. In the UK, about 14 million adults experience bladder control problems and 6.5 million have bowel control difficulties.

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Additionally, there are just under a million children in the UK experiencing continence conditions at any one time. Over £200 million is spent on personal incontinence products; this is in addition to over three times the same amount spent by the NHS.

With a rapidly ageing population and unaddressed contributing factors, the significant financial burden, but importantly, the impact on the quality of life and dignity is devastating. We also know that cultural and communication difficulties can create barriers making treatment access and symptom alleviation more difficult.

Considering the demography that this has a greater impact on – patients with a learning disability, non-English speakers and disabled patient – it becomes apparent this is a form of health inequality. However, pharmacy teams are best placed to tackle this head-on.

Incontinence is the inability to control your bladder or bowel, so you accidentally lose urine from the bladder (urinary incontinence) or faces from the bowel (bowel incontinence).

Causes of urinary incontinence include:

• weak pelvic fl oor muscles
• changes or damage in the nerves controlling the bladder or pelvic floor
• overactive bladder
• enlarged prostate (for men). Some medicines can disrupt the normal process of storing and passing urine or increase the amount of urine you produce. These include:
• angiotensin-converting enzyme (ACE) inhibitors
• diuretics
• some antidepressants
• hormone replacement therapy (HRT)
• sedatives

Patients should discuss with their doctor the best options to resolve incontinence caused by these medicines. Pharmacy teams have a significant clinical role in identifying and supporting patients, and prescribers with their knowledge and expertise.

The various causes of bowel incontinence may include:

• weak bowel muscles
• changes or damage in the nerves controlling the bowel
• severe or long-lasting diarrhoea and constipation
• inflammatory bowel disease such as Crohn’s disease

Community pharmacy teams are usually the first stop for most patients with bladder or bowel problem. Many will be seeking incontinence products. It is crucial to be able to facilitate such conversations in the consultation room, ensuring it is handled discreetly and sensitively. Embarrassment must be managed by enhancing and protecting dignity throughout the conversation.

Holistic approach

A holistic conversation is a must, and it is vital to assess presenting symptoms, identify the cause if possible, and discuss what possible remedial exercises can help tackle the problem.

Onward referral to a GP will usually be necessary to ensure a thorough physical examination and, or any further investigative tests necessary. Patients may be hesitant to progress with this, so it is essential that the pharmacy team can offer support and encouragement.

Some of the main risk factors for urinary incontinence include:

• family history – there may be a genetic link to urinary incontinence, so you may be more at risk if other people in your family have the problem
• increasing age – urinary incontinence becomes more common in middle age and is very common in people who are 80 or older
• having lower urinary tract symptoms (LUTS) – a range of symptoms that affect the bladder and urethra

The urgent and frequent need to pass urine can be caused by a problem with the detrusor muscles in the walls of your bladder.

Sometimes the detrusor muscles contract too often, creating an urgent need to go to the toilet. This is known as having an overactive bladder.

What are the possible causes of overactive bladder?

• drinking too much alcohol or caffeine
• not drinking enough fluids – this can cause strong, concentrated urine to collect in your bladder, which can irritate the bladder and cause symptoms of over activity
• constipation
• conditions affecting the lower urinary tract (urethra and bladder) – such as urinary tract infections (UTIs) ortumours in the bladder
• neurological conditions
• certain medicines

Treatment options

Managing a weak bladder or bowel is an individual thing, and sometimes more than one treatment is needed. Treatments include:

• exercises to help you strengthen the muscles surrounding the bladder (pelvic floor exercises) or bowel
• bladder or bowel training
• medications
• surgery may be an option if other treatments haven’t worked. How can incontinence products help patients? The right incontinence products will also help your patients manage the problem and carry on with everyday life.

Products include:

• washable products such as reusable pads, which often come as part of a pair of pants
• disposable pads which are held in place by close-fitting pants
• disposable pants, or all-in-one pads with a plastic backing and adhesive patches to seal the sides
• bed or chair protectors in the form of disposable or washable pads
• for men, there is a range of products that fit over the penis and collect urine into a bag strapped to the leg.

Most product manufacturers offer free training materials and educational resources for pharmacy teams and patients that support patient choice.

To qualify for free incontinence products provided by the NHS, you’ll need to meet criteria set out by your local NHS.

Contact your local NHS continence service or clinic for a location in your area and check if you need to be referred by your doctor.

Patients may also be eligible for Attendance Allowance or Personal Independence Payment if they need help with tasks such as using a toilet, changing their continence pads, or need reminding to go to the toilet.

Incontinence in children

Childhood incontinence is largely invisible yet, arguably, even more devasting. Over the last two years, the Bedminster pharmacy team has collaborated with ERIC to increase pharmacy’s role in childhood incontinence. This Children’s Bowel & Bladder Charity is dedicated to improving the lives of all children and teenagers in the UK facing continence challenges.

In the UK, an estimated or one in 12, 5-19-year-olds suffer from bowel and bladder conditions. These include bedwetting, daytime wetting, constipation and soiling.

The stress that comes with dealing with a child’s wetting or soiling problem can be considerable for families too. Disrupted sleep, constant washing of clothing or bedding and a reluctance to leave the house can place a heavy burden on family life.

According to NICE, most bowel and bladder problems are avoidable and treatable, yet it is estimated that only 11 per cent of those affected ask for help. Of the 15,000 hospital admissions for paediatric cases of chronic constipation and UTIs in England each year, 80 per cent of these could be avoided if the problems were spotted early and dealt with appropriately.

Prevention and education are key areas to enable children and older adults to be more effectively supported and treated. Incontinence can become a long term condition if not identified and well-managed early.

Community pharmacies are well placed to offer well-evidenced and effective interventions, including lifestyle advice and pelvic floor muscle training.

Empowering individuals to take control of their symptoms and employ self-care strategies can prevent these symptoms from deteriorating to the point that the consequences are farther reaching and costly, often for health services as well as the individual.

The esteemed duo – Professor Nikki Cotterill, leading academic in improving incontinence care, and Professor Margaret Watson, leading pharmacy practice and health services researcher with a particular focus on optimising community pharmacy to improve patient outcomes, are now looking to investigate how community pharmacy teams can better address the challenges posed by incontinence in an evidence backed scalable manner.

This is exciting for community pharmacy, and I am privileged to be working with and learning from them.

Moving beyond just supplying and recommending incontinence products but harnessing our clinical skills to improve patient outcomes in a cost-effective evidence backed manner will be vital.

Pharmacy teams are already a lifeline for so many patients and families; I am convinced that with the Healthy Living Pharmacy ethos embedded and a well-funded service model, community pharmacy teams will be able to do more to protect and enhance dignity, quality of life and wellbeing of the sufferers of bladder weakness.

Ade Williams is superintendent pharmacist at Bedminster Pharmacy in Bristol.

This feature also appears in the print edition of Pharmacy Business/Oct 2020.