A competent approach to incontinence
Bladder leakage affects one in three women over the age of 35 and one in four men over 40 in the UK and continues to remain a taboo topic, writes Victoria Goldman…
Many men and women are still too embarrassed to seek help about their symptoms.
Research by Ontex Healthcare in January 2019 revealed that while four in 10 women say they would seek advice about bladder leakage from the internet, 18 per cent are too embarrassed to approach their GP.
“In our modern society, it’s surprising that attitudes towards bladder leakage still aren’t really evolving and women don’t even feel they can talk to each other about it,” says Karen Irwin, manager and specialist nurse for Bladder & Bowel UK (www.bbuk.org.uk).
“I can’t stress enough that there really isn’t anything to be embarrassed about and just how important it is for women, and men, to seek advice and solutions if it’s holding them back and impacting their lives.”
‘Bladder weakness’ is the term most often used to describe urinary leakage. But pelvic health physiotherapist Myra Robson, creator of the Squeezy App, encourages people to avoid using this phrase. “It is very rarely a true description of what is going on, and often women believe that they can’t do anything about a ‘weak bladder’,” she says.
“We also like to use the phrase ‘common not normal’ as it is never normal to be incontinent.”
Getting a diagnosis
Bladder leakage is often associated with getting older, but it can affect people of all ages. Stress incontinence in women is often related to pelvic floor muscle function.
This may be triggered by pregnancy, childbirth, ageing, the menopause and/or obesity. Urge incontinence may be due to overactivity of muscles that control the bladder, which may be triggered by certain drinks, foods and medicines.
Some women experience a combination of the two types – called ‘mixed incontinence.’ Other types of incontinence in men and women can be related to neurological conditions, surgery (such as hysterectomy), urinary tract infections, prostate cancer and constipation.
Dr Nisa Aslam, GP in Tower Hamlets, London, says the symptoms of urinary incontinence often depend on the cause.
“Women tend to experience ‘involuntary leakage of urine’ when the bladder is under pressure (e.g. coughing, sneezing) – called stress incontinence,” she says.
“In urge incontinence, which affects both men and women, the main symptom is urine leaking following a sudden, intense urge to pass urine. Men often present to their doctor with problems in passing urine (difficulty in initiating flow of urine and fully emptying the bladder).
“They may have bladder problems due to age-related enlargement of the prostate gland (benign prostate hyperplasia), which can also cause a frequent need to pass urine or poor stream of urine.”
Dr Aslam recommends that pharmacy customers with any form of incontinence should be encouraged to speak to their GP.
“There is always hope,” she says, “whether it is symptom relief or providing a cure. A GP can prescribe tablets to alleviate symptoms of irritable bladder or bladder obstruction.
“If this doesn’t help, they can refer patients to a special physiotherapist for bladder training and pelvic muscle strengthening or to a urologist/gynaecologist. Bladder training specialists can provide a tailored bladder-training regime and offer devices to assist in restoring pelvic muscle strength. There are also surgical options available if the above methods don’t help.”
Any lifestyle factors that could be causing or aggravating incontinence need to be addressed.
“We know that being overweight, smoking and constipation can play havoc with your bladder and bowels so dealing with these can make all the difference,” says Myra Robson.
“Pregnancy and childbirth are a key cause of stress urinary incontinence and this is around 80 per cent curable with pelvic floor exercises and physiotherapy.”
Men aged 45 to 75 years with symptoms of benign prostatic hyperplasia may be able to take tamsulosin hydrochloride 400mcg capsules. Tamsulosin works by relaxing the muscles around the bladder and prostate gland so that it’s easier to pass urine, but it can cause side effects and may affect driving safety.
“Pharmacists should warn customers that tamsulosin can cause a drop in blood pressure, causing dizziness or even a faint,” says Dr Aslam. “If this occurs, patients should see a GP urgently, on the same day. Other side effects include sexual dysfunction, skin rashes, vomiting, headache and bowel problems.”
There are many ways in which community pharmacies can expand on the incontinence advice they offer. Contacting (and working with) the local continence team would help to establish current local treatments and policies.
“Some continence services allow people to self refer,” says Paula Pitcher, specialist bladder and bowel nurse at Bladder Health UK (https://bladderhealthuk.org). “They may be able to provide training on products to staff in the pharmacy or provide literature. They could also run a campaign in the pharmacy during ‘World Continence Week’, which is usually in June.”
Myra Robson suggests that pharmacies have a large poster in the bladder leakage pad section with a ‘common not normal’ message and the offer to speak to someone about their symptoms.
“A simple form could also be handed out in the bag of medications, with links to websites such as PelvicRoar (www.pelvicroar.org), Pelvic, Obstetric and Gynaecological Physiotherapy (https://pogp.csp.org.uk) and NHS Choices,” she says.
Daily pelvic floor exercises have solid evidence behind them as a preventative strategy as well as treatment.
“These have around 80 per cent cure rate for stress incontinence in women,” says Myra Robson.
“They are also proven to reduce the urge in people with overactive bladder, as well as reduce a mild prolapse, reduce post-prostatectomy incontinence in men and improve erectile dysfunction. Customers can get a referral from the GP to see a pelvic health physiotherapist, or self-refer if possible, or see a physio privately.
“There is a directory of pelvic health physios at www.squeezyapp.com and customers can also download the Squeezy app.”
Various pelvic floor toners available to buy over the counter, including vaginal cones and weights, biofeedback aids and digital neuromuscular stimulation devices.
“Pharmacies could potentially stock basic biofeedback products such as the Neen Educator, as this is a useful tool to aid effective pelvic floor muscle exercises for some patients,” says Gail Stephens, specialist pelvic health physiotherapist at Dynamic Health – MSH Physiotherapy – in Cambridgeshire.
“Good quality vulval health and vaginal health products, such as the Yes range, would also be extremely useful. These products are often recommended as creams and lubricants postnatally and for post-menopausal women and don’t contain any active ingredients that could irritant sensitive tissues.”
For customers buying bladder leakage pads and pants, pharmacists need to stock a range of products. “Products are largely personal,” says Myra Robson.
“But there is a difference depending on the type of incontinence. Stress incontinence usually causes small leaks, so a low-absorbency product or pants with an absorbent lining work well.
“Urge incontinence is usually a larger volume of urine and a higher absorbency is needed. People with dexterity issues will often find pull-ups easier to manage than pads but they are more expensive.”
Prevention tips for customers
1. Drink plenty of fluids
2. Avoid alcohol, coffee, tea and fizzy drinks (especially cola)
3. Exercise the pelvic floor
4. Sit up straight in a ‘very tall’ position
5. Lose weight if applicable
6. Stop smoking
Three pharmacy approaches
Leena Shah, relief pharmacist, Well Pharmacy
By asking customers a range of simple questions such as ‘Is it worse at night’, we can start to piece together the best advice or suitable products. For some, simple lifestyle changes such as reducing caffeine or alcohol intake, losing weight or even just reducing drinks in the evening can make a big difference.
The problem may be worsened by weak or damaged pelvic floor muscles, so exercising these muscles can help. Referral to a GP is often important here – to create a bespoke exercise programme.
We have access to a range of products, such as incontinence pads or pants in various sizes and ranges. These can offer reassurance and maintain dignity and are particularly good for customers with mobility issues.
Lila Thakerar, superintendent pharmacist, Shaftesbury Pharmacy
If customers approach us, we take them aside to a semi-private area or private consultation room.
If incontinence could be a side effect of any medication or their medication for bladder leakage isn’t working, we offer an MUR. If they haven’t had a formal medical diagnosis, we refer them to their GP.
The most popular product brands are TENA and Always for women and TENA for men. We display these in a very prominent position so customers can find them easily.
We find manufacturers are very supportive with dummy packs and leaflets, which helps to decrease embarrassment. If customers have tried pads and still need to talk to someone, or they are distressed, we refer them to relevant organisations, forums and websites, such as Bladder Health UK.
Stuart Gale, owner, Frosts Pharmacy Group and www.oxfordonlinepharmacy.co.uk
We find the best approach is to normalise the condition, making it easier to broach. Train staff so they can start a conversation: Do you find that product works for you? Can I suggest something that may be more effective? Have you tried these?
The more awareness there is among staff, the better able they will be to support customers. Many patients purchase sanitary towels to address their bladder weakness but incontinence-specific products are far more effective.
It sounds obvious but products such as TENA Men should be placed in the men’s section of the pharmacy, not together with women’s products, which are often placed alongside sanitary towels.
Empower the customer where possible. Introduce bold displays with leaflets, so they can inform themselves without having to ask. Never put incontinence products near the counter or in the window, as people will be less likely to browse if they feel they’re being observed.
The expert’s view
Make sure incontinence products are easy to find – don’t hide them away – make sure they’re also visible to pharmacy staff as this will enable them to spot customers who may need assistance
If you spot someone who may be hovering around incontinence products, you should approach them in a calm manner, offering assistance in a discreet way. It is important that once communication has first started, pharmacists speak to customers with empathy, reassuring them that they are not alone with many men and women experiencing bladder weakness
It is also important that pharmacists understand that each person’s incontinence is different and therefore their advice should be tailored to each individual. There is a whole variety of reasons why a customer may experience bladder leakage. For some it may be as a result of recent surgery, whereas others it may be the result of being overweight, pregnant or a heavy smoker. Speak with the customer to understand the level of urine leakage they are experiencing and how often. This will enable you to recommend the best solutions for the individual.
Pharmacy staff should familiarise themselves with the different demographics of people on the shop floor. The footfall could be anyone from a reluctant acceptor to a first-time purchaser so it is important to recognise that a customer may also not be buying for themselves; they could be a caregiving friend or relative.
TENA is committed to supporting pharmacy teams and provides a variety of training materials across all aspects of the category, from education about bladder weakness itself to category management. It also provides a range of marketing tools to support business growth, including point-of-sale materials that tie in with its consumer marketing campaigns for use in store.
There are a number of health conditions that can have an impact on a person’s bladder control. Pharmacists should familiarise themselves with these in order to provide the best care for their customers.
If a customer smokes or is overweight, the pharmacist should look to warn them of the possible effects on their bladder control and encourage them to stop smoking or lose weight. Encouraging people to cut back on caffeine and alcohol and eat a diet that has plenty of fibre can also help to prevent or provide a solution to a weakened bladder.
Pharmacists should also recommend that to counteract a weakened pelvic floor that can be caused by surgery, age and pregnancy, their customers do kegel exercises up to four times a day. Over time this will strengthen their pelvic floor and help with them on their journey to managing or even preventing urinary incontinence.
Lisa Myers, marketing manager, TENA.
Picture: bymuratdeniz (iStock)