Prescribing for bladder and bowel

1. Prescribing for bladder and bowel Gillian Nottidge, Maria Moor Continence Nurse Specialists BDCT

2. Aims of this session • Overview of incontinence • Medical management

3. Cute Not so cute

4. Facts and statistics • WHO report that bladder control problems affect more than 200m people worldwide and that it is “a largely preventable and treatable condition” • The NHS estimates that between 3 and 6 million people in the UK have some degree of urinary incontinence. • In the UK, 24% of older people are affected by urinary incontinence. • In institutional care, 30-60% are affected by urinary incontinence • A study in 2002 found that 32% of women in the UK, 34% in Germany, 32% in France and 15% in Spain had symptoms of urinary incontinence in the previous 30 days.

5. Definition of Urinary Incontinence The complaint of any involuntary leakage of urine Abrams 2002

6. The psycho – social impact of incontinence • Work • Exercise • Travelling • Socialising / relationships • Anxiety • Depression

7. The physical impact of incontinence • Increased risk of falls • Skin problems • Pressure ulcers • Urinary tract infections • Delayed discharge

8. Environmental cost

9. Types of Incontinence • Urge incontinence (Overactive bladder) • Stress incontinence • Overflow incontinence • Constipation • Faecal incontinence

10. What is bladder overactivity? • It is the strong and sudden need to pass urine due to bladder spasms which may result in incontinence

11. Why Does it Happen? • The bladder is a muscle that can hold around 500mls of urine. Around 200-300mls may get a sensation to urinate • Normal bladder: passing urine is under voluntary control • Overactive bladder: becomes increasingly involuntary • The bladder starts to contract driving a sudden and strong urge to pass urine, often with little warning

12. Symptoms • An urgent need to urinate • The need to urinate often, 8 or more times a day • Waking up to urinate 2 or more times a night • The need to urinate even if you have just gone to the toilet • Taking many trips to the toilet only to urinate just a little bit each time • Leaking urine when you have the urge to urinate

13. Risk factors for overactive bladder • Nervous system conditions can increase susceptibility • Diabetic Neuropathy • Multiple sclerosis • Stroke • Spinal cord Injury • Dementia • Parkinsons • Idiopathic Overactive bladder • No cause can be found • Obesity

14. Reduce caffeine intake Minimise alcohol intake Drink adequate amounts of healthy fluids Pelvic floor exercises Bladder retraining Avoid constipation Anticholinergic medication Management of OAB

15. Non-medical prescribing • Examine the holistic needs of the patient. Is a prescription really necessary? • Consider the appropriate strategy • Consider the choice of product • Negotiate a contract and achieve concordance with the patient • Review the patient on a regular basis • Ensure record keeping is both accurate and up-to-date • Reflect on your prescribing

16. Physical and Psychological effects • Increased risk of falls • Depression and anxiety • Social isolation • interpersonal relationships • Decrease in sexual function

17. Diagnosing Overactive Bladder • Thorough assessment to include:- • Past medical history • Bladder diary for 3 days • Urine test • Post void residual ultrasound scan • Pelvic examination

18. Behavioural Therapy • Supervised pelvic floor muscle training • Bladder training for 6 weeks (Nice 2006) • In combination with fluid and lifestyle advise • Understanding the causes and risk factors

19. Oxybutynin Tolterodine Fesoterodine Solifenacin Trospium Trospium XL Darifenacin Anticholinergic Medication

20. How do they work? • block the neurotransmitter, acetylcholine in the central and the peripheral nervous system. • operate on the muscarinic acetylcholine receptors. • Muscarinic receptors in smooth muscle, especially gastro-intestinal system, eyes, brain • M3 receptors more specifically in bladder

22. Therapeutic effects • Reduces frequency • Reduces urgency • Reduces nocturia • Reduces urge incontinence .

23. Side effects • Dry mouth • Dry eyes/altered eye accommodation • GI disturbances/increased gastric secretions • Constipation • Cognitive impairment • Increased residual/urinary retention

24. Contra-indications • Pregnancy and lactation (no available data) • Narrow-angle glaucoma • Allergy • Severe renal/hepatic impairment • Urinary retention/high residuals • Myasthenia gravis

25. Interactions • Ketoconozole increases action of anticholinergic • Anticholinergics can reduce absorption of Levadopa

26. Oxybutynin Oxybutynin patches Tolterodine Fesoterodine Advantages Disadvantages Effective, cheap Side effects Licensed in <18s Better tolerated Skin irritation than oral Oxybutynin Effective cardiac side effects More effective New drug so no Both doses same price long term data Pros and cons of each drug

27. Trospium Trospium XL Darifenacin Solifenacin Advantages Disadvantages Does not cross bd dose Blood/brain barrier 1 hour before food Does not cross 1 hour before food Blood/brain barrier (label23) Tolerated in elderly Recommended in obesity Does not cross availability blood/brain barrier Tolerated in elderly Selects M3 receptors Effective GI disturbances Minimal CNS s/e 10mg dose expensive Pros and cons of each drug

28. So which drug? • NICE recommend Oxybutynin IR first line • Remember it is just a guideline • NHS spend is £80 million annually on 2nd line drugs for OAB • NICE make no recommendation re 2nd choice • Counsel re risks and benefits of each drug

29. Oxybutynin IR Oxybutynin MR Oxybutynin patches Trospium bd Trospium XL Solifenacin Tolterodine Darifenacin Fesoterodine £5.89-31.78 £10.29-£14.16 £27.20 £24.27 £23.05 £25.78-£33.52 £25.78-£30.56 £26.13 £25.78 Price per 28 days

30. Reduces symptoms Minimal hospitalisation Effective in neurogenic conditions Not a single treatment May need to self-catheterise Used off license Botox

31. STRESS INCONTINENCE “the complaint of involuntary leakage on effort or exertion, or on sneezing or coughing” (Abrams 2002)

32. Symptoms of Stress Incontinence Small leak of urine on: • Coughing • Sneezing • Exercise • Getting up out of chair • Picking baby up

33. Causes of Stress Incontinence • Childbirth • Obesity • Chronic chest problems • Prostatectomy • Chronic constipation • Weakened pelvic floor

34. Management of Stress Incontinence • Pelvic floor exercises • Squeeze while you sneeze! • Adequate fluids – avoid caffeine and alcohol • Double voiding • Electrical stimulation • Urodynamics • (Duloxetine) • TVT sling procedure

35. Duloxetine – the wonder drug? • is thought to work by increasing the tone of the urethral sphincter by its action on serotonin and noradrenaline in the spinal cord. • prevents re-absorption of serotonin and noradrenaline • used to treat moderate to severe stress incontinence

36. Dizziness and fatigue Postural hypotension or fainting Hypertension Hyponatraemia - drowsiness, confusion, muscle twitching or convulsions. Nausea vomiting and diarrhoea Dry mouth Headache Reduced libido or anorgasmia Sweating Tremor Blurred vision No data for use in pregnancy/lactation Side effects

37. Atrophic vaginitis • Reduced oestrogen post menopause • Vaginal dryness – pain on intercourse • Vulval soreness and itching • Increased risk of incontinence • Increased risk of vaginal and urinary tract infection

39. Atrophic vaginitis • Avoid shower gel, soap, talc • Wash and moisturise the vulva with Aqueous cream/Diprobase • Topical oestrogen – pessaries or cream • Lubricant for intercourse – Sylk

40. Contraindications History or risk of breast cancer Pregnancy or planning pregnancy Current or previous thrombosis Abnormal LFTs Sensitivity to product Side effects Vaginal discharge/bleeding Headache Genital candiasis Breast tenderness or enlargement Nausea Local oestrogen

41. Hesitancy Poor flow Interrupted flow Post micturition dribble Frequency Urgency Nocturia Urge incontinence Urinary tract infections Feeling of incomplete emptying Large residual urine volume Passive incontinence Dribbling/Overflow Incontinence Symptoms

42. Hesitancy Poor flow Interrupted flow Post micturition dribble Frequency Urgency Nocturia Urge incontinence Urinary tract infections Feeling of incomplete emptying Large residual urine volume Passive incontinence Dribbling/Overflow Incontinence Symptoms

43. Outflow Obstruction Enlarged Prostate Urethral Stricture Uterine Prolapse Constipation Obstructive causes of overflow incontinence

44. Multiple Sclerosis Parkinson's Disease Spinal cord injury Spina Bifida Brain Injuries Pelvic Surgery Neurogenic causes of overflow/ dribbling incontinence

45. Management of Overflow • Double voiding • Treat constipation • Treat enlarged prostate or other obstruction • Intermittent Self-catheterisation • Long-term supra-pubic catheter

46. Size matters ! BAUS (2004) guidelines • Size over 30g • MTOPS study says over 25g • PSA greater than 1.4 ng/ml in the absence of CaP Early intervention with 5-ARI • Can reduce need for surgery by about 50% • Has been shown to reduce risk of progression to acute retention by 55%

47. Medical Management • Alpha-blocker Tamsulosin Doxazosin Alfuzosin • 5-alpha-reductase inhibitor Finasteride Dutasteride • Combined therapy (BAUS 2004) Combidart

48. Alpha-blockers • Relax smooth muscle • Relax bladder neck • Improve flow • more complete emptying • Reduction in nocturia = reduction in falls

49. Postural hypotension or dizziness Drowsiness Tiredness Headache Irritability Decrease in semen Retrograde ejaculation Stuffy or runny nose, nausea, Pain in the arms and legs, Weakness Tamsulosin most selective Alpha-blockers – side effects

50. 5-Alpha reductase inhibitors • Androgen blockade • Reduces prostate size • Used in male pattern baldness. (Only in America!)