Using Behavioral Approaches to Bladder Care and Making

Using Behavioral Approaches to Bladder Care and Making Anticholinergics Work More Effectively

Release Date: 12/23/2011

Expiration Date: 12/23/2012

FACULTY:

Frankie Bates RN, NCA

FACULTY AND ACCREDITOR DISCLOSURE STATEMENTS:

Ms. Bates has no actual or potential conflict of interest in relation to this program.

ACCREDITATION STATEMENT:

Pharmacy PharmCon Inc is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. Program No.: 0798-0000-11-098-H01-P Credits: 2 contact hour, 0.2 CEU

Nursing

Pharmaceutical Education Consultants, Inc. has been approved as a provider

of continuing education for nurses by the Maryland Nurses Association which is

accredited as an approver of continuing education in nursing by the American

Nurses Credentialing Center’s Commission on Accreditation.

Program No.: N-718

Credits: 2 contact hour, 0.2 CEU

TARGET AUDIENCE:

This accredited program is targeted nurses and pharmacists practicing in hospital and community pharmacies. Estimated time to complete this monograph and posttest is 120 minutes.

DISCLAIMER:

PharmCon, Inc does not view the existence of relationships as an implication of bias or that the value of the material is decreased. The content of the activity was planned to be balanced and objective. Occasionally, authors may express opinions that represent their own viewpoint. Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient or pharmacy management. Conclusions drawn by participants should be derived from objective analysis of scientific data presented from this monograph and other unrelated sources.

Program Overview:

To provide nurses and pharmacists with an understanding the use of behavioral control to regulate bladder and methods in making anticholinergics more effective..

OBJECTIVES:

After completing this program, participants will be able to:

Understand the prevalence of urinary incontinence (UI)

Define urinary incontinence (UI)

Describe the symptoms of OAB

Understand the taboo nature of the topic of UI and importance of Physician education to enhance care

Determine methods of treatment for UI in patients with overactive bladder (OAB) symptoms including conservative, behavioral and pharmaceutical management

Understand relevance of combination therapy for OAB symptoms

Bates – Behavioral Approaches to Bladder Care Page 1

PREVELENCE OF URINARY INCONTINENCE AND OVERACTIVE BLADDER:

Around the world, approximately 260 million individuals suffer with urinary incontinence (UI). The

International Continence Society (ICS) has defined urinary incontinence as a condition in which

involuntary urine loss, which is objectively demonstrable, is a social or hygienic problem. A recent

study found the prevalence of urinary incontinence, difficult bladder emptying, and irritative bladder

symptoms as 18.9, 22.1 and 11.8 per cent respectively in men, and 37.7, 10.8 and 17.4 per cent

respectively in women. 1, 2, 3

Worldwide it is estimated that 19% of women under the age of forty-five experience UI, whereas 29% of

women over the age of eighty also complain of UI.The rate level off from age 50 yrs to 70 yrs, after

which prevalence increases again.4

Prevalence in women of any type of UI is higher in non-Hispanic whites (41%) than in non-Hispanic

blacks (20%) or Mexican Americans (36%).5

With the exception of prevalence of urinary incontinence, most estimates of the incidence and prevalence

of urinary incontinence in adults are based on relatively few studies. Because these studies used varying

definitions of incontinence, and different methods of population sampling, the proceeding statistics

should be considered to be fairly crude estimates.6

A survey conducted by The Canadian Continence Foundation demonstrated 16% of men and 33 % of

women over the age of 40 have symptoms of urinary incontinence but only 26% have discussed it with

their family doctors A number of factors have been cited to explain the high prevalence rate of UI and

low consultation rate. These include the embarrassment women feel when talking to a physician about a

very private topic as well as the belief that UI is a normal part of ageing or a natural consequence of

childbirth.

Unfortunately, most will suffer in silence due to the taboo nature of this topic. Thus, UI continues to be

under-reported, under-diagnosed, and under-treated. Increasing global awareness around this common

disorder will help UI-sufferers know that they do no suffer alone, and they have treatment options.


TYPES OF URINARY INCONTINENCE

There are five main types of urinary incontinence (UI): stress UI; urge UI or overactive bladder (OAB);

mixed UI; overflow; and functional incontinence.

Stress incontinence occurs as a result of weakening of the pelvic floor muscle and endopelvic fascia. This

occurs over time with age, childbirth, pregnancy, constipation, chronic cough, excess weight and anything

that may cause stress to the pelvic floor muscle. External rotational descent of the bladder occurs with

weakening of the pelvic floor, which changes the closing pressure of the urethrovesicle junction. This

allows urine to leak when there is excess pressure over the abdomen and bladder. This type of urinary

leakage typically occurs during activities such as coughing, sneezing, laughing, lifting, or at the gym

during impact sports and exercise.

Overactive bladder (OAB) is often referred to as urge incontinence. It is a common and often chronic

medical disorder. OAB is a symptom complex that includes urinary urgency with or without urge

incontinence, urinary frequency (voiding 8 or more times in a 24 hour period) and nocturia (awakening

two or more times a night to void ) 7,,8, 9

Mixed incontinence is a combination of stress incontinence and overactive bladder symptoms. Patients

will complain of urgency, frequency and leaking on the way to the bathroom as well as leaking during

stress maneuvers such as coughing, laughing and lifting.

Overflow incontinence occurs when the bladder is unable to empty, and once the bladder capacity is

exceeded the urine will leak, rather like an overflow in a sink. The patient will typically complain of

continuous dripping of urine and never have a feeling of emptying his bladder. This occurs more

commonly in men from obstructive outlet disease (benign prostatic hyperplasia) but can also occur in

both sexes from neurological diseases such as multiple sclerosis, Parkinson’s disease, and spinal cord

injuries.

Functional incontinence occurs solely because of a functional disability the patient may have. If the time

to reach the bathroom is delayed due to a physical disability then the patient often suffers from

incontinence before reaching the bathroom. Having the bathroom more accessible to the patient, (by

bringing a commode chair to the living area) or making simple changes (such as a grab bar or heightened

toilet seat) will often make the difference between continence and incontinence.


This monograph will focus on OAB.

OVERACTIVE BLADDER

The International Continence Society classifies overactive bladder as a syndrome for which no precise

cause has been identified, with local abnormalities ruled out by diagnostic evaluation. It affects quality of

life and can have a devastating impact on the daily lives of many women and men globally. Individuals

will complain of having a strong overwhelming urge to void and insufficient time to reach the bathroom.

OAB can be further classified as “wet” (urinary incontinence is present) or “dry” (urgency and frequency

is present without urinary leakage). These symptoms are often present during the daytime and can also

cause nocturia (having to get up at night to void two times or more).3

A search of the literature (Medline, Plumbed, Cochrane review), falls short when dealing with

incontinence in men, and even more so when searching for conservative treatments. Most studies revolve

around male incontinence associated with BPH or post radical prostatectomy. Hans et al. found that OAB

was primarily undiagnosed in almost 50 % of all patients treated for lower urinary tract symptoms

(LUTS). The focus seems to be primarily on OAB in females. However, OAB symptoms are evident in

males as well, and more research needs to be conducted in this area so that we have a better understanding

of the prevalence in both sexes.

The estimates of prevalence of OAB range from 7 % to 27 % in men and 9% to 43% in women; with

some studies reporting higher prevalence in women and others finding similar rates in men and women. 10,

11, 12

BARRIERS TO CARE

Globally we see a need to educate family physicians and encourage them to initiate discussion. In a

survey of primary care physicians, the majority inquired about UI in 25% or fewer of their patients. 13

Family doctors often have limited knowledge about the different types of urinary incontinence as well as

its assessment and treatment.14

An important component of the ongoing activities provided by The

Canadian Continence Foundation (TCCF) is educating healthcare providers. This can be seen in a survey

conducted by the foundation in 2000 that looked at training that Canadian family physicians obtained

during their undergraduate program. Of the 210 physicians that were surveyed, only 77 responded,

(already showing disinterest in the topic)


Ninety-four percent stated that less than 25% of their practice involved UI. Only 16% asked their patients

about UI. Twenty-nine percent felt that they had received adequate training about pelvic floor dysfunction

and 38% felt they received adequate training about UI.

Besides the lack of knowledge, the other barrier that seems to prevent family physicians from promoting

continence care in their practice is a lack of time for adequate assessment in order to make an accurate

differential diagnosis. As Millard and Moore noted “What is required is a short focused history to

distinguish stress leak from urge leak or obstructive symptoms: this combined with a simple examination

to exclude obstructive prolapse or prostatomegaly, a urine culture and a post void ultrasound of residual

volume, can establish a working diagnosis in most instances.” 15

As 70% of incontinent patients do not report the problem to their physician but more than 75% report the

condition when asked by their physician, the emphasis seems to focus on the fact that family physicians

and other healthcare providers need to initiate discussion.13, 16

Palmer developed a conceptual model for continence promotion and prevention. In her model, primary

prevention strategies include public education regarding prevention of urinary tract infections,

constipation, straining and normal genitourinary function; environmental modifications such as adequate

toilet facilities in public buildings; and caregiver education that stresses the importance of maintaining

independence and the expectation of continence. Secondary prevention strategies include treatment with

behavioral strategies and drugs. Tertiary prevention includes knowledgeable use of equipment and

supplies or surgical therapies. 17

TREATMENT OPTIONS

Treatment options for OAB range from the conservative (behavioral management) to medications. In all

cases, the least invasive should be the first choice for the patient. In addition to reviewing

pharmacological treatment options, this article also covers conservative treatments, including pelvic floor

rehabilitation, behavioral interventions and life style changes, biofeedback and stimulation therapy,

Transcutaneous Electric Nerve Stimulation (TENS) or Percutaneous Tibial Nerve Stimulation (PTNS),

and a combination of these therapies adjunctive to medical management with anticholinergics.

Evidence has shown that antimuscarinic agents (often referred to as anticholinergics) have been effective

in reducing the symptoms of OAB but they are not without their side effects. As anticholinergics work by

relaxing the smooth muscle of the detrusor, they also affect the relaxation of the smooth muscle of the

bowel and salivary glands causing constipation and dry mouth. Side effects can also include dry, irritable

eyes, or affected cognitive function, particularly in the elderly. There are many other choices that work


alone and in combination therapy to benefit individuals with OAB symptoms. These can range from

simple lifestyle changes to behavior modification. These therapies can often be more beneficial to the

patient than stand alone medical treatment and are more effective when used in combination.

Oxybutynin, Oxybutynin Transdermal system (Oxytrol), Tolterodine, Darifenacin Solifenacin and

Trospium are all medications indicated in the treatment of overactive bladder in adults who complain of

urinary urgency, frequency and urge incontinence.

Oxybutynin (Ditropan) is classified as an anticholinergic / antispasmodic drug and was the first of its kind

to arrive on the market. It comes in the form of a tablet, syrup, or an extended release (long acting) tablet.

The usual dose is 5 mgs two or three times a day in the immediate release form or 5 mgs once a day in the

extended release form. Unfortunately, the immediate release form can cause multiple side effects and the

patient often will discontinue treatment. These include dry mouth, blurred vision, dry eyes, stomach pain,

constipation, gas, heartburn, dizziness, headache, facial flushing, confusion, sleepiness and swelling of

the lower extremities. The patient is usually started on a lower dose of the immediate release so they can

gradually build up to a full dose and experience fewer side effects. The patient is always encouraged to

continue on the medication as the side effects will often dissipate with prolonged use as long as the

symptoms are not severe. These side effects are seen much less frequently with the extended release form.

Tolterodine (Detrol) is described as an anticholinergic / antispasmodic drug and comes as a tablet, as well

as an extended release (long acting) capsule. The recommended starting dose for Tolterodine is 2 mgs two

times a day unless otherwise indicated and comes in 1 mg and 2 mg dosages. The extended release form

(Detrol LA) comes in 2 mg and 4 mg capsules. The most common side effect is dry mouth; others include

dry, irritable eyes and blurred vision, constipation, dyspepsia, fatigue, headache, dizziness, and sometimes

difficulty in urination.

Darifenacin (Enablex) is described as a muscurinic M3 selective receptor antagonist and is indicated in

the treatment of overactive bladder. It comes in the form of an extended release tablet in 7.5 mg and 15

mg doses. Side effects include dry mouth, constipation and, less commonly, dyspepsia, headache, dry

eyes, abdominal pain, nausea, diarrhea and respiratory tract infections.

Solifenacin (Vesicare) is often referred to as a urinary antispasmodic and comes in the form of a 5 mg or

10 mg tablet to be taken once a day. Side effects include dry mouth, constipation, stomach pain, nausea

and vomiting, dyspepsia, dry eyes and blurred vision. Less common complaints are extreme tiredness and

edema in the lower limbs.


Trospium (Trosec) is classified as an antispasmodic drug and comes in the form of a coated 20 mg tablet

to be used once daily for overactive bladder symptoms. Side effects include dry mouth, dry eyes,

constipation, abdominal pain, dyspepsia, headache and flatulence.

Anticholinergic therapy is often prescribed following insufficient results with behavior modification

alone; however, rates of discontinuation are consistently high. Like other chronic conditions, reducing

OAB symptoms typically requires long term persistence and adherence to therapy.18, 10

Combined therapies described below have demonstrated high patient satisfaction and will greatly benefit

the patient with OAB symptoms. . A study conducted by Wymen, et. al. assessed contributors to

treatment satisfaction with a focused, self-administered behavioral intervention combined with

Tolterodine Extended Release (ER). These patients had reported dissatisfaction with stand-alone

antimuscarinic treatment. Treatment satisfaction and OAB symptoms were improved in many patients

using a focused educational pamphlet with verbal reinforcement, strategies for improving bladder control,

behavioral interventions, and bladder diaries.19, 20

CONSERVATIVE TREATMENTS

To be Used as Adjunctive Therapy (Medical Management) for

Urinary Incontinence

Pelvic Floor Exercises (PFE) were first introduced by Dr. Arnold Kegel in the 1950’s, but unfortunately

these exercises remain much underutilized. 17

The pelvic floor is a complex combination of nerve, fascia, and striated muscle. Whereas pelvic floor

muscle is similar to skeletal muscle by being under voluntary control, it differs by being in a constant

state of semi-contraction. It is also difficult to locate because it is an internal muscle.

The original regimen proposed by Dr. Kegel included three steps:

External Observation

Rectal / Vaginal Exam

Insertion of Perineometer


The contraction was then measured with a Perineometer in place

6 second hold

6 second rest

20-50 mm Hg registration on biofeedback

100 repetitions

3 sets

8 weeks before you see improvement

As muscles get stronger,60-80 mm Hg

These exercise routines vary considerably from center to center. More research is necessary to bring about

agreement among the experts on the work/rest ratio, number of sets, and repetitions required to

standardize this approach. This can be seen (below) in radically different routines cited at numerous

centers.

Used with permission of Dr. J. Skelly, McMaster University Hamilton ON 2009.

Pelvic Floor Exercises. How often ?How often?

Reps? Sets?

36 to 360 4 sets - 3 days per week

80-100 N/A

8-12 3-4

8 to 12 3 sets

5 to 25 times At least 5 times a day

10 to 20 times repeat q1 during the day

24 N/A

15- 45 every 3 weeks

20-40 twice a day

12 per day 3 sets

N/A alternate sets of quick and slow Kegels

100 3

10 each day 5 - 10 sessions

N/A for 15 minutes 4 times a day

NA 1-3 times for 7- 10 minutes

twice per day 5 days per week

10 3 times a day (morning,afternoon, night)

5 to 25 times at least 5 times a day


Maintaining an adequate pelvic floor exercise program is crucial to seeing a benefit. The literature varies

substantially in exercise routines and, unfortunately, the evidence is poor in confirming the number of

PFE’s recommended or required to build up muscle bulk. Generally anything from 45 to 100 exercises

can be cited as a home program, varying profoundly from center to center. Typically working up to a 10

second hold and resting 10 seconds is a good maintenance contraction. Our center recommends three sets

of ten exercises two to three times daily. This will aid in isolation of the pelvic floor musculature,

improve endurance and strength, as well as isolate the slow and fast twitch muscle fibers.

Once the patient is able to isolate the pelvic floor muscle and has good strength and endurance (or holding

power), then he/she can be taught to use this muscle for urge suppression. The emphasis is on appropriate

use (AU) of the pelvic floor during stress maneuvers that cause leaking or during strong sudden urges to

void. The patient is taught to contract the pelvic floor prior to activities that cause them to leak (moving

from a sitting to standing position, bending over, coughing, sneezing or any activity that causes increase

in abdominal pressure (SUI). These are often referred to as the “Knack” in Europe.22

The patient can also be taught to perform “fast twitch muscle exercises” to prevent OAB symptoms.

These are the muscle fibers that are used for urge suppression. By “flicking” the pelvic floor muscle in a

quick routine of 10 exercises in 10 seconds, a perineo-detrusor inhibitory reflex is triggered. Simply put, a

signal is sent to the overactive detrusor muscle to settle down during strong inappropriate urges to void.

Over-exercising is not encouraged as it can cause fatigue of the pelvic floor musculature to the point of

exhaustion. This can actually increase UI especially in the evening hours as the patient tires.

Evidence shows that PFE’s and behavioral interventions combined with medical management such as

anticholinergic therapy produce better results than stand- alone therapy.23, 24

However, approximately 30%

of patients are unable to correctly locate and isolate their pelvic floor muscles after receiving simple

verbal or written instruction. 25

In patients’ that have impaired sensation or difficulty isolating the PF

muscles, biofeedback and electrical stimulation can be beneficial.26

Biofeedback is pain-free, drug-free, minimally invasive, and is an effective way of treating urinary

incontinence. Generally speaking, biofeedback is a technique by which the client receives visual,

auditory, or sensory information in relation to a particular body function. With pelvic floor biofeedback,

we are feeding back information about the specific location of the pelvic floor muscle in real time.


Six to twelve weekly sessions are typically recommended with the emphasis being on the home program

intervention between treatments. Depending on patient compliance, the treatment time varies

considerably from patient to patient. Expert opinion continues to be divided on the use of pelvic floor

electrical stimulation.

Patients are cued to contract the pelvic floor muscles during treatment, hold the contraction, and then rest

until they are given the next cue. Patients often use accessory muscles, such as the abdominals (most

often in the case of women,) or gluteals (most often in the case of men,) to try to accentuate the

contraction of the pelvic floor muscles. The pelvic floor muscle training consists of a total of 15 minutes

of stimulation therapy followed by biofeedback. During stimulation therapy, rectal or vaginal probes

equipped with metal bands are used to stimulate the pudendal nerves for 15 minutes to afford a reflex

contraction of the pelvic floor. The application of electric current to the pelvic floor muscle produces a

reflex contraction without any effort on the part of the patient. During the biofeedback portion of the

training, the patient must actively contract the pelvic floor muscles around the probe. The patient can be

taught how to isolate both their slow twitch and fast twitch muscle fibres and receive a graphic

representation of their contractions on a screen.

Wymen, Burgio and Newman demonstrate that practical aspects of lifestyle modifications and behavioral

interventions in the treatment of overactive bladder and urgency incontinence may improve function and

symptoms and perhaps even prevent future bladder problems.27

Behavioral interventions for overactive

bladder include life style interventions, bladder retraining and behavioral interventions such as timed

voiding. These produce better results when combined with drug therapy than either approach alone.24

Even patients that were previously dissatisfied with antimuscarinic therapy have been seen to experience

improved treatment outcomes by adding a self-administered behavioral intervention to their drug

regimen.28

With percutaneous tibial nerve stimulation (PTNS), neuromodulation occurs through projections from

post tibial nerve to sacral nerve plexus at the S2 – S4 junction. This treatment can be performed via a fine

needle inserted percutaneously near the ankle. Alternatively transcutaneous electric nerve stimulation

(TENS) can be used via surface electrodes. Treatments last 30 minutes and typically range from eight to

twelve weekly sessions.


Assessment of the patient with UI includes a detailed history with attention paid to medications both

prescribed and over the counter.29

Drugs that may be contributing to UI should be stopped whenever

possible, especially if urinary incontinence is present. If it is not possible to discontinue therapy, reducing

the dose or modifying the dosage schedule should help improve management of UI.30

Lifestyle changes such as increasing fluid intake, lowering caffeine intake, and avoidance of carbonated

beverages and alcohol have been beneficial to irritative voiding symptoms.31, 32

The amount, type, and

spacing of fluids will affect the ability of the bladder to handle containment of fluids (i.e. refraining from

“bolus drinking”). Water is encouraged and a total intake of at least 2 liters is recommended.

Frequency/volume charts can establish baseline bladder capacity (BC) as well as intake consumption and

types of fluid consumed, and can be an extremely effective assessment tool.33

A bladder diary, in which

the patient records a 48 to 72 hour record of their intake, voiding events, episodes of incontinence and

sensation can provide extremely valuable information in this regard.34

It is a simple way that a health care

provider can establish baseline bladder capacity, fluid intake habits (type and amount of consumption), as

well as urgency episodes and frequency.

Bladder retraining techniques to increase BC and assist with urge suppression are an important part of

treatment for symptoms of urgency, frequency and

UI.35, 36

This helps to reduce voiding frequency by resisting the sensation of the first urge to void and

prolonging the interval gradually between voids using various techniques. PFE’s can be taught for SUI as

well as urge suppression, especially when utilizing the fast twitch muscle fibers of the pelvic floor.

Distraction techniques can also be beneficial especially for “Key in the door syndrome”. Several studies

have demonstrated the efficacy of bladder training. 36, 37

Obesity and smoking have both been linked to bladder irritability and detrusor overactivity. 38

Obesity

plays a role as a contributing factor to urinary incontinence. The muscles and fascia supporting the pelvic

organs are normally under a constant gravitational pull, which exerts intra-abdominal pressure. Obesity

raises this pressure, as excess soft tissue in the abdomen pushes down on the bladder and pelvic floor.

Heavy lifting, coughing and straining during bowel movements can have similar effects. When pressure is

prolonged, the muscles and fascia stretch and become damaged, resulting in a weakening of support to

pelvic organs and structures. 39


Weight loss studies have shown significant improvement in UI following bariatric surgery and with as

little as 5% weight reduction in more traditional weight loss programs.

Constipation must be ruled out as a causative factor to increasing the symptoms of UI. As the rectum and

bladder share the pelvic cavity, constipation can cause compression of the lower bowel and rectum

against the bladder causing diminished bladder capacity and leading to urgency and frequency and

possibly urge incontinence (OAB) symptoms. Educating the patient on healthy lifestyle habits, exercise,

diet and fluid intake will help alleviate constipation. All of these behavioral interventions are safe and

reversible but do require active participation by a motivated patient and the time and expertise of a

knowledgeable clinician.40

Several studies have noted the importance of patient education to help patients realize their symptoms are

not an inevitable part of the aging process. By increasing awareness of treatment options and combination

therapy, as well as close follow up by the patient’s family doctor, the patient will be more amenable to

taking medication and performing behavioral interventions.

With a combination of personal attitudes and practical barriers preventing individuals from seeking help,

the onus is on health care professionals to ask specifically about urinary incontinence at routine check-

ups. As Fantyl and Webb recommended, every woman should be asked about the presence of UI and be

evaluated as necessary.

Referrals to specialists, gynecologists, urogynecologists, urologists, nurse continence advisors is

suggested if further assessment is necessary, or if appropriate treatments are not available in the primary

care setting.

Surveys carried out more than 20 years ago yield similar results regarding UI’s high prevalence, its

systematic underreporting, and its devastating impact in the daily lives of many women.41

Clearly there is

still a long way to go and a lot of work ahead to make sufferers and society aware of urinary incontinence,

the misconceptions, assessment, and management options. By increasing awareness around this (still

taboo) topic and by working globally to increase basic assessment skills and initial management strategies

by family physicians and specialist nurses, the burden of UI can be reduced and successful treatment

maximized.

It is interesting to note that UI continues to be denied by most individuals experiencing symptoms and

that most of society continues to disapprove, thereby preventing adequate development of continence


services. Irvine (1988) noted that most clients suffering from UI are “silent sufferers” raising difficulties

in discussing and therefore treating the condition.

Understanding medical management and behavioral approaches to care will ensure better outcomes for

patients suffering with urinary incontinence.


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Using Behavioral Approaches to Bladder Care and Making