CPD 43: URINARY INCONTINENCE Biography - Ronan Sheridan graduated from the Robert Gordon University, Aberdeen in 2009 with a Masters in Pharmacy with Distinction. Ronan worked as a pre-registration and clinical pharmacist at the Chelsea and Westminster Hospital NHS Foundation Trust, London for three years. He currently works as Supervising Pharmacist at Market Point Pharmacy, Mullingar, Co Westmeath. Ronan was recently awarded the 2012 Helix Health Young Pharmacist of the Year and is a Peer Support Pharmacist at Irish Institute of Pharmacy
Module 1 June 2012
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Chronic Pain – assessment and management in primary care
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60 Second Summary
Urinary Sheehan et al reported in 1996 that the estimated cost of incontinence is the unintentional pain for 95 patients to the Irish Health Services when added Pain is one of the commonest reasons for patients to seek passing of to the amount of Social Welfare payments received and urine. Urinary 1 medical attention. A recent survey has shown that as many incontinence ispatient not the lost earnings of each amounted to 1.9 million timescare a day, though this varies from person to According to a survey carried in the as 8.3out visits per late year to primary physicians in Ireland a condition itself 6 pounds at the time of referral. The recent data from PRIME person. A person whose daily fl uid intake is 90’s, urinary incontinence is amongst the top but is a symptom 2 were embarrass due to symptoms of pain. large ascale survey high orAtakes diuretic, willcarried naturally pass moreshowfrom three health problems which Irish more cost per chronic pain patient survey thatone theormean out in 15 European countries andAIsrael in 2006, underlying conditions. urine. person’s daily screening activity will also influence people. In 2013, it was estimated that over 28% estimated Effective at €5,665 per year across all grades of pain, treatment depends howthat frequently they pass some ofiswhich of the Irish population are affected by urinary reported 46,394 respondents the prevalence ofurine, chronic on a thoroughto assessment and or 2.86% of Irish which was extrapolated €5.34 billion include relationships, work, sleep and emotional incontinence at some stage in their lifetime. compliance with treatment plan. pain of moderate to severewell-being. intensity in adult Europeans was 7 GDP per year. This demonstrates an urgent need for cost 3 19%. Urinary incontinence is the unintentional Urinary incontinence affects about twice as many women to as manage men, and chronic becomespain moreeffectively. common THE NORMAL VOIDING PROCESS effective strategies passing of urine and is an extremely common
with age. The condition can seriously influence complaint in every part of the recent world. Itsurvey is More data from another study, carried out the physical, psychological and social wellbeing Urine is produced in the kidneys and stored in estimated that between three and six million of the affected individuals in 2,019 people with and 1,472 primary chronic pain7,8. thepain bladder. It travels to the outside via aUnderstanding tube people are affected by the condition in the UKchronic 2 called the urethra. Surrounding the urethra is care is physicians across 15 European countries, have alone . Urinary incontinence not a condition Acute incontinence can be used by certain Chronic painmedicinesis defineddiuretics, as pain antihypertensive that outlasts normal ringaffects of muscles called urinary sphincter. drugs, healing itself but is a symptom from one or more demonstrated that chronic apain 12-54% of the adult sleeping tablets, sedatives, and muscle relaxant. Nerve signals from the sphincter regulate time (usually three to six months), and is most frequently underlying conditions. Effective treatment 2 in Ireland is up to 13%. The It can also be caused by alcohol, certain movement of muscles, thus preventing urine depends on a thorough Europeans, assessment and and its prevalence associated with musculoskeletal disorders such and as low foods and drinks, urinary tract infections out of of Chronic the body.Pain) During urination, the PRIME and Cost study, compliance with treatment plan.(Prevalence, Impactleaking dehydration. back pain and arthritis. However, it can also be associated muscles of the wall of the bladder contract on the other hand, determined the prevalence of chronic In most cases or forcing urine4 out of the bladder and into with the other disorders Urinary incontinence affects about twice as suchofasincontinence, depressionconservative or metabolic pain to be asmore high as 35.5% in Ireland. invasive management is tried initially. urethra. WhileThe the PRIME bladderstudy contracts, thedisorders or minimally many women as men and becomes neurologic conditions such as multiple This may include fluid management, bladder relaxes and allows urine to pass out common with age. The condition can seriously was designed to investigateurethra the prevalence of this chronic pain sclerosis. training, pelvic floor exercises and/or medication. through theand body. influence the physical, psychological and social in Ireland; compare the psychological physical health wellbeing of the affected individuals7,8. Antimuscarinics are the drug of choice for profiles of those with and without pain; and explore Urinarychronic incontinence can occur as a result patients withcan persistent urinary incontinence, Pain (acute or chronic) be categorised as nociceptive 4 despite lifestyle interventions. They act by of a number of abnormalities of the function The condition can be short term, but disability. it pain-related Responses to survey questions were or neuropathic. Nociceptive pain is caused an active blocking muscarinic receptors in theby bladder wall. of the lower urinary tract or as a result of can develop into a chronic condition if obtained from 1,204 people. illness, injury and/or inflammatory process associated with other illnesses, which tend to cause leakage left untreated. It can also have a huge Desmopressin- Is indicated for the management in different situations. There are a number of or potential psychological impact due to the social stigma actual tissue damage i.e. Nociceptive pain of primary nocturnal enuresis Despite the magnitude of the problem, chronic painincontinenceis different types of urinary associated with it. Urinary incontinence results from activity in neural secondary to actual Duloxetine - is usedpathways for the treatment of stress should never be dismissed, it could be a bothasunder-recognised and undertreated in primary care.2,5 incontinence. or potential tissue damage. Nociceptive pain is mediated • Stress urinary incontinence is involuntary symptom for a more serious underlying health Indeed, up to 38% of patients reported being inadequately urine leakage on effort or exertion or by on pain receptors The most common and most popular surgery for problem. Neurological causes should always be located in skin, musculoskeletal system, 2 managed in primary care for their pain symptoms. stress8 incontinence is the sling procedure. sneezing or coughing.In Causes includeeliminated as a possible cause of symptoms. bone, and joints. Neuropathic pain, on the other hand, pregnancy, childbirth, menopause, post addition, people with chronic pain reported waiting up to Pharmacists can offer educational support to results from direct injury to a peripheral or central sensory hysterectomy, age and obesity. FREQUENCY OF URINATION patients by questioning and monitoring the
2.2 years between seeking help and diagnosis, and 1.9 effectiveness and of thetransduction various nerve; the affected nerves dotolerability not produce at 2 yearsurine before their pain was•adequately managed. Urge urinary incontinence is involuntary The average person passes every three pharmacotherapies. 8 nociceptors. Pain characteristics and associated conditions urine leakage accompanied or immediately to four hours, equating to approximately 6 for both types of pain are shown in Table 1. use by Healthcare Professionals in the Republic of Ireland only Learning, Evaluation,For Accredited, Readers, Network | www.learninpharmacy.ie © Copyright 2012 Pfizer Healthcare Ireland Date of Preparation: Module 1 June 2012 EPBU/2012/XXX
CPD 43: URINARY INCONTINENCE
RISK FACTORS FOR DEVELOPING URINARY INCONTINENCE
Module 1 June 2012
sionals in Ireland
anagement in primary care
preceded by urgency. Causes includeenlarged prostate, cystitis and neurological problems. ehan et al reported in 1996 that the estimated cost of
Gender causes When treating Urinary Incontinence, you must be aware of specific genderrelated causes that can be an indicator of an alternative issue. Many women find that it can be unpleasant side-effect of childbirth either due to weakened or damaged pelvic floor muscles or nerve damage during childbirth. Similarly, the reduced production of Oestrogen Hormone can also prompt issues with Urinary Incontinence for women currently experiencing or having recently experienced menopause. Possible causes of Urinary Incontinence in men include prostate cancer or having undergone a prostatectomy to remove their prostate gland but factors that affect both genders can include neurological issues and obesity as well as too much caffeine or bladder stones.
n for 95 patients the Irish Health Services when added • Mixedtourinary incontinence is involuntary urine leakage associated with both urgency he amount of Social Welfare payments received and • Age is a significant risk factor for both male 2 and effort, sneezing to or 1.9 coughing and female with increasing risk up to 46% in lost earnings of exertion, each patient amounted million. women and 34% in men aged over 80 years 6 nds at the referral. The data is from PRIME • time Totalof incontinence is recent where urine ( Kuh D, et al 1999). continually andchronic is usually aspatient a vey show that the meanleaking cost per pain of the sphincter muscle no longer • The prevalence of urinary incontinence is stimated at result €5,665 per year across all grades of pain, functioning. Causes include a fistula, a higher in adults who have suffered nocturnal ch was extrapolated toinjury €5.34 or 2.86% of Irish spinal cord orbillion an injury to the kidneys enuresis or daytime wetting for children. birth. P per year.7 during This demonstrates an urgent need for cost • Although urinary incontinence problems ctive strategies to manage chronic pain effectively.
• Overflow incontinence - this type of urinary incontinence is more common in men with prostate gland problems, a damaged derstanding chronic pain bladder or a blocked urethra. The enlarged gland obstructs the bladder; onic pain isprostate defined as pain that outlasts normal the healing person often only manages to urinate in e (usually three totrickles six months), and frequently small and has toisgomost frequently. They ociated withmay musculoskeletal disorders suchreally as low feel that his bladder is never completely emptied, evenalso afterbe trying hard. k pain and arthritis. However, it can associated Causes include constipation, urinary stones, h other disorders such as depression or metabolic an enlarged prostate and cancer of the orders or neurologic bladder. conditions such as multiple
• Functional incontinence is an inability to make it to the bathroom in time. It is often n (acute or chronic) can be categorised as nociceptive as a result of a physical barrier or immobility europathic.that Nociceptive caused bytone an active causes a pain delayisbut lack of in the sphincter causes loss of urine suddenly. with ss, injury and/or inflammatory process associated Functional incontinence is more prevalent ual or potential tissue damage i.e. Nociceptive pain among elderly people, and is common in ults from activity in neural pathways secondary to actual nursing homes.
otential tissue damage. Nociceptive pain is mediated Acute incontinence can be used by certain pain receptors located in skin, musculoskeletal system, medicines- diuretics, antihypertensive drugs, 8 e, and joints. Neuropathic pain, onand the muscle other hand, sleeping tablets, sedatives, It can be caused by alcohol, ults from relaxant. direct injury to also a peripheral or central sensory certain foods urinarytransduction tract infections ve; the affected nervesand do drinks, not produce at and dehydration. iceptors.8 Pain characteristics and associated conditions both types of pain are shown in Table 1.
often follow prostate surgery, there are no studies clearly identifying risk factors for the development of urinary continence problems in men.
PRE DIAGNOSIS CONSIDERATIONS Prior to any treatment it is essential that the urine is assessed to rule out any underlying infections or conditions. Reagent strip (‘dipstick’) urinalysis may detect infection, proteinuria, haematuria and glycosuria: • Nitrite and leucocyte esterase may indicate a UTI. • Protein may indicate infection and/or renal disease. • Blood may indicate malignancy (or infection). • Glucose may indicate diabetes mellitus. DIAGNOSIS OF INCONTINENCE To diagnose the condition, an assessment of the symptoms and medical history must first be carried out, along with the pattern of
voiding and/or urine leakage to determine the type of incontinence. As well this, patients are advised to maintain a sleep diary. If referred to a urologist/urogynecologist, patients can expect to undergo some of the following • Physical examination • Urinalysis • Postvoid Residual measurement (PRM) • Urodynamic testing • Cystogram • Cystoscopy • Pelvic ultrasound In clinical practice, ‘urodynamics’ is generally used as a collective term for all tests of bladder and urethral function2. CONSERVATIVE MANAGEMENT A number of medical conditions can predispose a patient to urinary incontinence. Such conditions include diseases of the cardiac, reparatory and renal system, as well as diabetes and neurological conditions. These conditions can cause polyuria, nocturia, increased abdominal pressure or CNS disturbances which lead to incontinence. Correction or treatment of the underlying condition can help reduce the severity of symptoms. In most cases of incontinence, conservative or minimally invasive management is tried initially. This may include fluid management, bladder training, pelvic floor exercises and/or medication. PELVIC FLOOR MUSCLE TRAINING: Strengthening or Kegel exercises can fortify the pelvic floor and sphincter muscles and improve urinary control. These exercises include repeated contractions of isolated muscles several times a day. Sometimes techniques including biofeedback, electrical stimulation of the pelvic muscles, and weighted vaginal cones can be helpful in teaching the patient how to isolate these muscles. Recommendation for lifestyle advice • Obese patients experiencing UI should be offered weight reduction programmes to help relieve symptoms. • Reducing caffeine intake helps reduce urgency and frequency, thus improving symptoms but not incontinence. • Smoking cessation advice should be offered as part of a healthy lifestyle, though no evidence suggests smoking cessation improves UI. • Patients with abnormally high fluid intake should be advised to modify their daily fluid intake. • There is a consistent association between a
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CPD 43: URINARY INCONTINENCE
history of constipation and the development of UI, therefore always treat constipation and prevent reoccurrence. • Counsel female athletes experiencing urinary incontinence with intense physical activity that it will not predispose to urinary incontinence in later life7,8.
Desmopressin Desmopressin- Is indicated for the management of primary nocturnal enuresis. It is chemically similar to the antidiuretic hormone (ADH) which is found naturally in the body. It increases urine concentration and decreases urine production.
previous incontinence, are 30% more likely to experience worsening of symptoms. Vaginal cones
1 assist Vaginal cones may be usedModule by women to JuneVaginal 2012 cones with pelvic floor muscle training. are small weights that are inserted into the Duloxetine vagina. The weight is held in place by using the • Identify and resolve environmental factors pelvic floor muscles. When the patient feels ( e.g. distance of toilet, medication, distance learning Educational content in Ireland with one weight, they progress to Duloxetineis usedfor for healthcare the treatmentprofessionals of stress comfortable equipment’s obstructing mobility of patient incontinence. It works by increasing intracellular the next vaginal cone, which weighs more. etc.) associated with urinary incontinence serotonin and noradrenaline within the nerves before classifying specific type of urinary increasing the strength of the pelvic floor Some women find vaginal cones uncomfortable incontinence. muscles. This increase in muscle tone helps or unpleasant to use, but they may help with control the flow of urine and prevent any stress or mixed urinary incontinence. PHARMACOLOGICAL INTERVENTION involuntary loss. Onabotulinumtoxin type A (Botox) Antimuscarinics Alpha-Reductase Inhibitors Injections of Botox into the bladder muscle may Antimuscarinics are the drug of choice for The alpha-reductase inhibitors finasteride benefit people who have an overactive bladder. patients with persistent urinary incontinence, and dutasteride are also used to treat Botox blocks the actions of acetylcholine and despite lifestyle interventions. They act by overflow incontinence secondary to BPH. paralyzes the bladder muscle. blocking muscarinic receptors in the bladder Their mechanism of action is through wall. inhibiting the conversion of testosterone to Studies have found that Botox significantly dihydrotestosterone, resulting in reduced improves symptoms of incontinence and Muscarinic receptor antagonists are a treatment androgenic prostate stimulation and leading to causes few side effects. Some studies indicate option in men with moderate to severe lower reduced gland size and improved urine outflow. it may increase urinary tract infections, but the urinary tract symptoms that have predominantly Although usually considered a second-line data aren't conclusive. Benefits can last up to bladder storage symptoms, independent of therapy, they may be used first-line in patients nine months. Botox may be helpful for people bladder outlet obstruction. with contraindications to the alpha-blockers who haven't responded to other medications (hypotension or heart failure) or in combination This class of drugs decrease the ability of the with alpha-blockers in progressive or more Sheehan etALTERNATIVE al reported in 1996 that the estimated cost of MEDICINES Introduction bladder to contract by blocking the muscarinic moderate-to-severe disease, e.g., large glands. receptors on the detrusor muscle, the muscle pain for 95 patients to the Irish Health Services when added Although effective in treating the symptoms of The efficacy of plant extracts vary, although Painofisurine. one of the commonest reasons for patients to seek responsible for the passing to the amount of Social Welfareagent payments received and BPH, their side-effect profile (e.g., decreased no phytotherapeutic has been shown 1 medical attention. A recent survey has shown that as many libido, impotence, dry sex, and gynecomastia) to clinically reduce theamounted size of the to prostate the lost earnings of each patient 1.9 million Drugs within class as 8.3 visits per year to primary care physicians in Ireland and slower onset of action, which may take up gland and trial has proven reduction of PRIME 6 pounds at the time ofno referral. The recent data from to six2 A to large 12 months, limits their use. bladder outlet obstruction or decreased disease were due to symptoms of pain. scale survey carried • Fesoterodine fumarate survey show that the mean cost per chronic pain patient progression. out in 15 European countries and Israel in 2006, screening for postSystemic oestrogen replacement • Oxybutynin HCL is estimated at €5,665 per year across all grades of pain, 46,394 respondents reported that the prevalence ofno chronic menopausal women with previous history Some of the agents used include: which was extrapolated to €5.34 billion or 2.86% of Irish incontinence is Europeans said to double • Propiverine HCL pain of moderate to severeofintensity in adult wasthe incidence GDP per year. This demonstrates an urgent • 7Cucurbita pepo (pumpkin seeds)need for cost of urinary incontinence. While women with 3 • Solifenacin succinate19%. effective strategies to manage chronic pain effectively.
Chronic Pain – assessment and management in primary care
• Tolterodine tartrate More recent survey data from another study, carried out
in 2,019 people with chronic pain and 1,472 primary
This group of medicines are generally well care physicians across 15 European countries, have tolerated with the side effect profile relating to the well-known peripheral anti-muscarinic demonstrated that chronic pain affects 12-54% of adult adverse effects, such as dryness of the Europeans, and its prevalence in Ireland is up to 13%.2 The mouth, tachycardia and constipation. The side PRIME effects of anti-muscarinics often(Prevalence, lead to poorImpact and Cost of Chronic Pain) study, compliance and discontinuation of therapy. on the other hand, determined the prevalence of chronic
pain to be as mainstay high as 35.5% in Ireland. The PRIME study The antimuscarinic Oxybutynin is the was designed of treatment for incontinence. This drugto investigate the prevalence of chronic pain offers maximum dosageinflexibility carry the psychological and physical health Ireland; but compare a greater risk of side effects due to its higher profiles of those plasma peak levels. A systematic review with and and without chronic pain; and explore meta-analysis by Chapple et al. in 2008 (2), pain-related disability.4 Responses to survey questions were which updated previousobtained reviews, showed from 1,204 people. that oxybutynin versus placebo was better for improvement and cure of UI2. 4
Despite the magnitude of the problem, chronic pain is
Antimuscarinics in people with dementia have and undertreated in primary care.2,5 both under-recognised an increased the risk of causing cognitive Indeed, up to 38% of patients reported being inadequately decline and delirium.
managed in primary care for their pain symptoms.2 In
Randomised, placebo-controlled trials with chronic pain reported waiting up to addition, people demonstrated that tolterodine can significantly 2.2 years betweenorseeking help and diagnosis, and 1.9 reduce urgency incontinence and daytime 24-hour frequency compared placebo. years to before their pain was adequately managed.2
use by Healthcare Professionals in the Republic of Ireland only Learning, Evaluation,For Accredited, Readers, Network | www.learninpharmacy.ie © Copyright 2012 Pfizer Healthcare Ireland Date of Preparation: Module 1 June 2012 EPBU/2012/XXX
Understanding chronic pain Chronic pain is defined as pain that outlasts normal healing time (usually three to six months), and is most frequently associated with musculoskeletal disorders such as low back pain and arthritis. However, it can also be associated with other disorders such as depression or metabolic disorders or neurologic conditions such as multiple sclerosis. Pain (acute or chronic) can be categorised as nociceptive or neuropathic. Nociceptive pain is caused by an active illness, injury and/or inflammatory process associated with actual or potential tissue damage i.e. Nociceptive pain results from activity in neural pathways secondary to actual or potential tissue damage. Nociceptive pain is mediated by pain receptors located in skin, musculoskeletal system, bone, and joints.8 Neuropathic pain, on the other hand, results from direct injury to a peripheral or central sensory nerve; the affected nerves do not produce transduction at nociceptors.8 Pain characteristics and associated conditions for both types of pain are shown in Table 1.
CPD 43: URINARY INCONTINENCE • Saw palmetto • Hypoxis rooperi (South African star grass) • Pygeum africanum (bark of the African plum tree) •
Module 1 Secale cereale (rye pollen) June 2012
• Urtica dioica (roots of the stinging nettle).
Currently the committee of European sionals Association in Ireland of Urology are unable to recommend any of the above mentioned agents for the treatment of lower urinary tract symptoms due to the heterogeneity of the agents and the methodological problems with meta-analyses.
anagement in primary care
If a patient is unable to confidently answer these questions, it would be advisable for them to keep a diary of their fluid intake and urinary habits. SURGICAL PROCESURES
Sub urethral Sling Procedures (TVT or TOT): The most common and most popular surgery for stress incontinence is the sling procedure. In this operation a narrow strip of material is used either from: cadaveric tissue, autologous tissue, or soft mesh. It is applied under the urethra to provide a hammock of support and improve urethral closure. The operation is minimally invasive and patients recover very quickly. ehan et For al reported in 1996 that the estimated cost of many years it was thought that biologic materials, the patient’s own fascia or cadaveric n for 95 patients to the Irish Health Services when added fascia, would create better more sustainable he amount of Social Welfare payments received and outcomes.
lost earnings of each patient amounted to 1.9 million 6 ROLE PHARMACIST nds at the timeOF of THE referral. The recent data from PRIME vey showPharmacists that the mean chronic pain patient cancost offerper educational support to by questioning and monitoring the stimatedpatients at €5,665 per year across all grades of pain, effectiveness and tolerability of the various ch was extrapolated to €5.34 billion or 2.86% of Irish pharmacotherapies. Taking time to get to know 7 P per year. demonstrates an urgent need for cost yourThis patients in the ambulatory and clinical settingstoallows the pharmacist opportunity ctive strategies manage chronic painthe effectively.
to provide valuable education, intervention, and recommendations to improve patient care outcomes in the management of this complex derstanding chronic pain disorder.
onic pain is defined as pain that outlasts normal healing • Inform women starting systemic oestrogen e (usually three to six months), replacement therapyand thatisitmost may frequently cause ociated withurinary musculoskeletal disorders such as low incontinence, or worsen current symptoms. k pain and arthritis. However, it can also be associated h other disorders as depression or known metabolic • Advisesuch patients to avoid any precipitants that maysuch contribute to their orders or neurologic conditions as multiple symptoms rosis. • Discuss fluid intake and avoidance of
n (acute or chronic) be categorised drinking can excess fluids too lateasinnociceptive the evening. europathic. Nociceptive pain is caused by an active • Offer weight management advice to ss, injury and/or inflammatory overweight patients.process associated with ual or potential tissue damage i.e. Nociceptive pain • Offer smoking cessation advice, as part of ults from activity in neural pathways secondary to actual healthy living advice. otential tissue damage. Nociceptive pain is mediated Pharmacists the care of patients pain receptors locatedinvolved in skin, inmusculoskeletal system, with urinary incontinence should take a 8 e, and joints. Neuropathic on the other thorough medicationpain, history to rule outhand, any such as diuretic usesensory and ults from modifi directable injurycauses, to a peripheral or central excessive alcohol, caffeine, or fluid intake. ve; the affected nerves do not produce transduction at 8 iceptors.Patients Pain characteristics and associated conditions should be reassured of the safety both types of pain are shown in Table 1.
and efficacy of drug therapy for UI, especially anticholinergic. Help patients understand the symptoms of overactive bladder, which include urinary urgency (a strong and sudden desire to urinate), frequent urination day and night, and urge incontinence (accidental loss of urine caused by a sudden and unstoppable urge to urinate) Patients receiving tolterodine or oxybutynin can be counseled to expect the development of dry mouth as the main side effect. The long-acting formulations of these drugs increase patient compliance and decrease the chance for anticholinergic side. Patients also can be referred for bladder training and they should be counseled that exercises help build pelvic muscle strength to reduce. Patients who do not respond to adequate trials of anticholinergic drugs at therapeutic dosages should be referred to a urologist for further evaluation and management. CONSULTATION QUESTIONS -
How often do you urinate during the day
How many times at night do you wake to urinate
How much fluid do you drink each day
Do you feel the urgent need to urinate when you hear water running
Do you ever have trouble getting to the bathroom in time
Do you feel anxious, sad or depressed about your symptoms
WHAT ARE THE TREATMENT OPTIONS FOR CHRONIC INCONTINENCE? Although many people will improve their continence through medications, pelvic-muscle exercises and bladder training, some will never achieve complete continence. For patients within this group a management plan should include -
Improved access to toilets
Managing fluids and diet
Use of disposable absorbent garments
REFERENCES 1. Oelke M et al. EAU Guidelines on the management of male lower urinary tract symptoms, incl. Benign prostatic Obstruction. 2. Chapple CR, Roehrborn CG. A shifted paradigm for the further understanding, evaluation, and treatment of lower urinary tract symptoms in men: focus on the bladder. Eur Urol 2006 Apr;49 (4):651-8. 3. Lucas, M et al. EAU Guidelines on
Assessment and Nonsurgical Management of Urinary Incontinence. Eur Urol (2012) http://dx.doi.org/10.1016/j. eururo.2012.08.047 4. Stohrer M, Blok B, Castro-Diaz D, et al. EAU guidelines on neurogenic lower urinary tract dysfunction. Eur Urol 2009;56: 81–8. 5. Isaacs JT. Importance of the natural history of benign prostatic hyperplasia in the evaluation of pharmacologic intervention. Prostate 1990;3(Suppl):1-7. 6. Brown CT, Yap T, Cromwell DA, et al. Selfmanagement for men with lower urinary tract symptoms – a randomised controlled trial. BMJ 2007 Jan 6;334(7583):25. 7. National Institute of Clinical Excellence. Lower urinary tract symptoms: The management of lower urinary tract symptoms in men, 2010 8. National Institute of Clinical Excellence. Lower urinary tract symptoms: The management of lower urinary tract symptoms in females, 2006. 9. National Institute of Clinical Excellence. Urinary Incontinence: The management of urinary incontinence in women, 2013. 10.A Pharmacist's Guide to Treatment of Urinary IncontinenceDarrell Hulisz, RPh, PharmD, and Joumana Aouad, RPh. Published Online: Friday, March 1, 2002 http://www.pharmacytimes.com/ publications/issue/2002/2002-03/2002-036833#sthash.a3uSejUW.dpuf
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