The role of duloxetine in treating stress incontinence ‌ page 10
Straight talking on erectile dysfunction ‌ page 12
Issue 20 Winter 2009/10
continence care
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Contents
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Medical insight Intermittent catheterisation by Ann Winder
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Practical care Are you eligible for benefits? by Frank J Pitfield
Treatment 10 The role of duloxetine in treating stress incontinence by Rob Sherwin and Mark Slack Coloplast 11 Coping on your travels Break away for the weekend! Straight talking 12 Erectile dysfunction by Petros Tsafrakidis, Emmanuel Johnson, Richard Pearcy and Raj Persad 14 Resources Forum 15 Q&A
Comment
Looking back, and ahead 2010 – another year older, another year wiser. We have seen many changes during the past year, some of which have been good and some not so good. I am the sort of person that always likes to have their cup half full, not half empty; therefore, it was nice to read about some funding for research into very practical issues – the management of constipation by abdominal massage – led by Dr Doreen McClurg. The literature has often mentioned how some patients with constipation are helped by this technique, especially those with multiple sclerosis or requiring palliative care. I hope we are I am hoping that I can persuade Dr McClurg to helping in some write an article about her way to improve findings for this journal in the future. your knowledge Another interesting and quality of life piece of work by Jackie Rees and Fania Pagnamenta, nurse consultants from Newcastle with specialties of continence care and tissue viability, also caught my eye. They have devised skin care guidelines for incontinence dermatitis. This tool will prove very useful for staff to help relieve this very uncomfortable problem, which is experienced by many patients. Last November I attended a lecture by a very eminent professor who gave some practical advice for those who have to pass urine frequently at night, especially those in the older population. He recommended not to take extra diuretics, which can be dangerous in the more elderly, but to put elastic stockings on before going to bed. This will help considerably to improve the situation.
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Dementia and incontinence
Cover picture PLAINPICTURE/FANCY
CHARTER CONTINENCE CARE ISSUE 20
Another tip that I have found works well for those who have dementia and find it difficult to pass urine in the appropriate place – or miss the toilet altogether (especially men when standing) – is to colour the toilet seat and use a coloured toilet pedestal mat. I would recommend applying a wide piece of coloured tape around the pedestal because the mat can cause accidents, such as tripping over. Continued overleaf 3
When a person has dementia, they lose their spacial awareness. Toilets, which are often white, are positioned on a plain floor against a pale surface. This results in the person not being able to identify the distances between the surfaces. The result is great difficulty when trying to identify where to pass urine. Some people will wander off and pass urine in a cupboard or bin, or miss altogether. Toilet seats can be changed, but in a person’s home a bright piece of Fablon attached to the seat will help. This is still available from most DIY shops and can be very useful in helping the sufferer gain more independence.
Your suggestions Many authors have contributed to Charter continence care over the past year and I thank them once again for all their articles. I hope we are helping in some way to improve your knowledge and quality of life, but I would welcome any suggestions for future issues which are of interest to readers. Maybe we need to revisit some of the original articles with updates or additional ideas for improving management and coping. I would encourage readers to send their experiences to me and we can share them with others throughout this year’s publications. I would like to thank you all for the kind letters I have received over the years from readers. The letters demonstrate how you all cope with real problems and how you have overcome some of them.
A sensitive issue In this issue we have several excellent articles. I hope you find Frank Pitfield’s article on continence and benefits useful, especially in the current economic climate. The article by Rob Sherwin regarding the use of duloxetine for stress incontinence clearly shows there is some medication which can enhance the exercises for pelvic floor weakness before considering surgery. Petros Tsafrakidis and colleagues have touched on a topic that is still not raised by many men – erectile dysfunction. This sensitive article, I hope, will offer support to many readers who may not have discussed this issue with any professional, or even their close partners, before. Ann Winder, Editor The Editor Charter continence care Hayward Medical Communications 8–10 Dryden Street London WC2E 9NA Tel: 020 7240 4493 email: edit@hayward.co.uk 4
continence care Publication of Charter continence care is made possible through the support of Coloplast Limited. Editor Ann Winder RN Senior Continence Specialist, Park Drive Health Centre, Baldock Editorial Board Liz Bonner RN DNCert BSc(Hons) BA(Hons) HV MSc Nurse Consultant (Bladder/Bowel Dysfunction), Bedfordshire Continence Service, Dunstable Mary Brown RGN BA(Hons) PGCE Continence Nursing Team Manager, NHS Lothian Michael Cogswell Paraplegic, Pluckley, Kent Rachel Busuttil Leaver BSc(Hons) RN PGCE Lecturer Practitioner in Urological Nursing, London South Bank University and University College London Hospitals Sunil Mathur BA(Hons) MBBS MRCS Specialist Registrar, Musgrove Park Hospital, Taunton Mark Slack MB ChB MMed MRCOG FCOG(SA) Consultant Urogynaecologist, Addenbrooke’s Hospital, Cambridge Paul Smith Executive Director, Spinal Injuries Association
Editorial Director Elaine Bennett. Chief Sub Joel Barrick. Senior Sub Editor Anne-Claire Bouzanne. Sub Editor Christian Bell. Editorial Assistant Danielle Colyer. Art Editor Richard Seymour. Art Director Andrina de Paiva. Publisher Keena McKillen. The data, opinions and statements appearing in the articles herein are those of the contributor(s) concerned; they are not necessarily endorsed by the sponsor, publisher, Editor or Editorial Board. Accordingly, the sponsor, publisher, Editor and Editorial Board and their respective employees, officers and agents accept no liability for the consequences of any such inaccurate or misleading data, opinion or statement. Published by Hayward Medical Communications, a division of Hayward Group Ltd, The Pines, Fordham Road, Newmarket CB8 7LG. Tel: 01638 723560. Fax: 01638 723561. email: admin@hayward.co.uk Design & Editorial Office Hayward Medical Communications, 8–10 Dryden Street, London WC2E 9NA. Tel: 020 7240 4493. Fax: 020 7240 4479. email: edit@hayward.co.uk Copyright © 2010 Hayward Group Ltd. All rights reserved. ISSN 1745-9982. Printed by Turners.
CHARTER CONTINENCE CARE ISSUE 20
Medical insight
Intermittent catheterisation Intermittent self-catheterisation is a common procedure. Ann Winder highlights some of the issues that patients and healthcare professionals should be aware of Urinary catheterisation is a common procedure, carried out by healthcare professionals in both hospital and community settings. A catheter is inserted into the bladder to either drain urine or instil solutions, as part of a treatment programme or to manage bladder problems such as incontinence or retention of urine. The two methods used are indwelling catheterisation (the catheter [‘Foley catheter’] is retained in the bladder by a small balloon) and intermittent catheterisation ([IC] an in/out procedure carried out by the patient or a carer, using a ‘Nelaton catheter’). The Nelaton catheter has no balloon and does not stay in the bladder. However, variations of both methods exist. Indwelling catheters often give patients a reasonable quality of life but can also present serious health risks, such as urinary tract infection leading to the presence of bacteria in the blood, urethral scarring and narrowing or perforation, catheter encrustation, bladder stones and cancerous changes.1 Professionals should, therefore, be reluctant to pursue this course of action, unless necessary.
The gold standard IC, especially intermittent self-catheterisation (ISC) or clean IC (CIC), is considered the ‘gold standard’ management for artificial drainage of the bladder. ISC allows maximum freedom in regard to when and where bladder emptying can be performed, presents the least risk of infection and requires a minimum amount of equipment.2 A plethora of articles has been published on IC, but to many it can still remain a, relatively, new concept. It has been explained as safe and simple and few professionals realise the complex skills required to safely teach ISC or know how to plan the number of times that ISC is required in a day by each individual; it is not safe enough to just think of a number and hope that this suits a person’s lifestyle. Adjustments may be required for a sudden high fluid intake, for example, for urine infections or as a result of a night out with the boys! Bladder patterns and lifestyles can change; jobs and mobility can alter how/when an individual performs their routine. For many patients, guidance, annual reviews and long-term management are still lacking.
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IC can be performed at all ages, but culture and religious beliefs must be considered. Teaching IC requires a competent interviewer, as many issues around sexuality and abuse may have not been spoken about by the patient previously, and may be brought to the fore during the teaching. Mobility and dexterity problems can often be overcome with the experience of the instructor and with the plethora of devices now available. In newborn children with a congenital lower urinary tract problem, the recognised safe practice is for the child to have their bladder drained intermittently, first by clinical staff who will then instruct the parents in this technique. ISC has been most successful in improving quality of life as well as other health issues in patients with neurological diseases, especially multiple sclerosis (MS). With support and carer assistance, ISC can also be achieved in patients with a learning disability. When teaching these patients, ISC technique is broken down into small tasks that can be attached to rewards. This does, however, need the commitment of staff and carers and can take about four months, depending on the patient. Indwelling catheterisation and ISC are not mutually exclusive; patients can combine the
An example of a modern intermittent catheter
Ann Winder RN Senior Continence Specialist, Park Drive Health Centre, Baldock
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Case history: Why patients need to understand catheterisation Thirty-five-year-old Mark* was discharged from hospital, having undergone spinal surgery for a work-related injury. Mark had a urethral catheter in situ following his surgery. He had no idea why he was catheterised and assumed that it was part of the surgical procedure. The catheter was removed the day before discharge and, although he found emptying his bladder (voiding) uncomfortable, he could pass urine in small amounts. A discharge letter was given to his wife to pass to the GP, but this only mentioned Mark’s medication and the surgery he had undergone. Mark had tried to ask many questions before his discharge but was put off by the busy medical staff. Nobody had enquired about his home environment, or whether he would require any additional equipment or help.
indwelling catheter, the continence adviser felt that it would be safer to catheterise Mark and review him five days later. This would also allow the bowels to respond to the constipation management programme. After Christmas, following the removal of the indwelling catheter and the instruction of ISC, a plan of catheterising times was established. The local practice is to give the patient two weeks of antibiotic cover. This was especially important for Mark as he had had an indwelling catheter in place and had recently had surgery.
Comment: maintaining a fluid chart is vital; there should be no incontinence. Each patient will have their own voiding pattern. It is important that the instructor understands fluid intake and how this can affect the Comment: this highlights the lack of communication patient’s output, both day and night. between the hospital and the community staff. Mark recovered far quicker than expected. He did not have any Mark was discharged home on the Friday before Christmas. urine infections and his bowels returned to his daily pattern. Unfortunately, he then had to contact the GP as he felt Although Mark continues to have some neurological problems uncomfortable when trying to pass urine and was experiencing of sensory damage and foot drop, these too are improving. He back pain. He could not get in or out of his sofa or chairs at also reports that he can now get an erection (at a previous home and had to lie upstairs in bed. The GP was a trainee and meeting he and his wife had been extremely concerned as he had not dealt with this problem previously. The continence had not managed an erection since his surgery). specialist visited and performed a bladder ultrasound. It was Comment: it is very difficult for patients to discuss found that Mark had retained urine (506 ml), having previously sexuality and this can often place a lot of stress on passed 50 ml normally. When he was being assessed, Mark relationships. The ISC instructor should raise this issue explained that he had not had his bowels open for at least five with the appropriate patients and at an appropriate time. days, although his normal pattern was daily. Mark and his wife were put through unnecessary stress. Comment: constipation can cause a problem with voiding Overdilation (retention of urine) or infections could have and, therefore, it could have caused Mark’s symptoms; damaged Mark’s bladder. Communication is vital before however, before assuming constipation, the individual’s discharge from hospital. Professionals who care for patients in routine bowel patterns needs to be checked. the community must be informed; not only GPs but also The constipation was treated with Movicol®, and linseed was district nurses and, in Mark’s case, an occupational therapist introduced into the patient’s diet. Abdominal massage was and a physiotherapist. Quick discharge can result in a quicker demonstrated, and was to be continued by Mark or his wife. return to hospital ■ It was the night before the festive season and, therefore, *Name has been changed to protect the patient’s confidentiality with a long discussion explaining the reasons and issues of an benefits of each to fit their individual needs.3 ISC may, for example, not be acceptable or appropriate while travelling, when toilet facilities may make this particularly difficult; an indwelling catheter may, therefore, be more suitable. Patients with MS may use ISC when in remission and indwelling catheterisation in periods of relapse.
Conclusion IC is the recognised ‘gold standard’ method of managing patients who have problems emptying their bladder, and it may improve their quality of life.4 Staff who teach ISC must fully understand a patient’s individual bladder problems and accept responsibility for ensuring the overall safety of that patient’s bladder, while the patient should check that they have written instructions and contact details from their professionals. Patients need at least an annual review as their needs and, therefore, their management may change over time ■
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References 1. Lowthian P. The Dangers of long-term catheter drainage. Br J Nurs 1998; 7: 366–372. 2. Lapides J, Diokno AC, Silber SJ, Lowe BS. Clean intermittent self-catheterization in the treatment of urinary tract disease. J Urol 1972; 107: 458–461. 3. Pomfret I. Selecting the appropriate method of catheterisation. Journal of Community Nursing 2001; 15: 39–42. 4. Pomfret I, Winder A. The management of intermittent catheterization: assessing patient benefit. British Journal Neuroloscience Nursing 2007; 13: 266–271.
Key points ● Healthcare professionals who train patients in intermittent catheterisation should acquire the appropriate knowledge and skill to do so. ● When patients are catheterised in hospital, good communication with the patient and those who care for them in the community is essential.
CHARTER CONTINENCE CARE ISSUE 20
Practical care
Are you eligible for benefits? Patients with incontinence may be eligible to receive benefits. Frank J Pitfield explains which options are available and where patients can get help to claim these benefits First, the bad news: having a continence problem is not in itself a qualifying criterion for receiving benefits; however, depending on how incontinence affects you – for example, your ability to care for yourself or to work – there are certain benefits that you may be entitled to. The most prominent of these are the Disability Living Allowance (DLA) and Attendance Allowance (AA).
Disability Living Allowance and Attendance Allowance Most people with continence problems can manage independently. For many people, however, continence problems are a byproduct of other disabilities. In addition, there are those who have another disability that prevents them from being able to deal with continence issues. Many people who have problems with continence may, therefore, be able to claim DLA or, if they are over 65 years of age, AA. DLA has two components to it – mobility and care. You have to be under the age of 65 when you make the claim, although you can continue to get it beyond 65 (if you are still entitled).
go out. To receive the lower rate, you will need to show why you need someone with you, what they do and how it relates to your condition. You should also say what could happen if they are not there. If you have examples of incidents that have occurred when you have been out on your own, you should put these on the application form, and also say how having someone with you would have prevented them. Currently, the lower rate of the mobility component is £18.65 per week.
Frank J Pitfield Former Disability Benefits Outreach Manager, Milton Keynes
DLA care component and AA AA and the care component of the DLA are based on the help or supervision you need from another person. The person deciding your claim, known as the ‘decision-maker’, will look at your needs during the day and then your needs after you have gone to bed at night; in other words, ‘day needs’ and ‘night needs’.
Those who are entitled to the higher rate of the mobility component also qualify for a Blue Badge, which they should claim from their local council
DLA mobility component
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MIKHAIL TCHKHEIDZE/SHUTTERSTOCK
The mobility component of the DLA has two rates – higher and lower. Continence problems are unlikely to lead to the higher rate as this is for people with a physical disability that leaves them unable, or virtually unable, to walk, people who are both blind and deaf, people without both lower limbs, or people with a severe mental impairment who also have severe behavioural problems. Those who are entitled to the higher rate of the mobility component also qualify for a Blue Badge, which they should claim from their local council. As long as their benefit award has at least a year to run, they also have the option, under the Motability Scheme, of leasing a car, a motorised wheelchair or a scooter for the duration of their award. Alternatively, they can ‘take the money’, which is currently £49.10 per week. The lower rate of the mobility component is for people who can walk but, because of either a mental or physical disability, need someone for guidance and supervision most times that they
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Welfare rights organisations, both locally and nationally, can help with claim pack completion
There are two ways you can satisfy the day needs: attention and supervision. Attention is the help you get, or need, from another person, for example, to change your clothes or clean up. Supervision is about someone needing to be there to prevent you putting yourself or others in danger. With continence issues, needs are more likely to fall into the attention category. The needs have to be frequent, throughout the day. Because of this, the form asks a lot of personal questions about the help you need and why you need it. Remember, it is about the help you need, whether or not you actually receive that help already. At night, there are, as before, two ways to satisfy the qualifying criteria: attention and supervision. Again, with continence problems, it is more likely to be attention. The attention needed has to be prolonged, which is for about 20 minutes or more, or repeated, which is more than once a night. Help with changing the bedding and rinsing out bedclothes (if it has to be done immediately, rather than be left until morning) can count, as can needing to be soothed back to sleep. You will be asked, however, what practical steps can be taken to avoid incontinence. If the decision-maker accepts that you have enough day and night needs, you will be entitled to the higher rate of either the AA or the DLA care component, which is currently £70.35 per week for either benefit. If you have enough day needs for them to be considered ‘frequent throughout the day’ or as requiring ‘continual supervision’ but not enough night needs, you will be entitled to £47.10 a week, which is the middle rate of the DLA care component or the lower rate of the AA. The same applies if you have enough night needs, but not enough day needs. The DLA care component (but not the AA) has a third rate, the ‘lowest rate’, which is £18.65 per week. There are two ways you can qualify for this. One is if you would be unable to prepare a cooked main meal for yourself; the
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other is if you need help from another person for what is termed ‘a significant portion of the day’. While it would be difficult for someone with continence problems to demonstrate that they were physically or mentally incapable of preparing a main meal for one, it may be possible to show the need for help for ‘a significant portion of the day’. This is considered to be at least one hour a day, not necessarily all at once. Do not forget, however, that this is not enough if you are over 65 years of age and claiming AA, because your needs have to be ‘frequent throughout the day’ to get the lower rate, which is the equivalent of the middle rate of the DLA.
Making the application Both the DLA and AA forms are long (especially the DLA one), difficult and depressing. To complete them properly, you have to get yourself into a negative frame of mind, thinking of all the things you have difficulty with and the situations in which you need help from another person, whether you actually get that help already or not. Just remember, that the person dealing with the form will almost certainly never meet you, unless by complete coincidence, and is likely to have read similar details on numerous claim forms before. The claim is also likely to be processed in a different part of the country. You may find that you cannot complete the form yourself. You could find it too long and difficult, too harrowing and intrusive, or you may have visual or language difficulties. You do not need to worry – if you do not have a friend or relative who can help, a lot of assistance is available. Many welfare rights organisations, both locally and nationally, can help with claim pack completion, and the Department for Work and Pensions (DWP) has its own service. The DWP can go over the form with you on the telephone, and either complete it for you
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RYAN MCVAY/GETTY IMAGES
Practical care
Further information • To claim or find out more about Disability Living Allowance or and then send it to you to sign or, if you prefer, advise you while you complete it. If the form cannot be completed over the telephone, they may be able to arrange a home visit and provide a translator if required. If you are over 60, they will also check what other benefits you might be entitled to.
The decision Once you have sent in your claim form, you may have to wait a while for a decision. DLA claims can take six to eight weeks to be processed; AA claims about half that time. The DWP may contact your GP or another relevant healthcare professional, so make sure that they are aware of your condition and how it affects you, because their report, if they have to provide one, will carry considerable weight in the decision-making process. Alternatively, you may get a call directly from the DWP. There is no need to panic: they are not trying to catch you out, but they may be looking for clarification. You need to be consistent with what you put on the form, so it is a good idea to keep a copy. Remember also that the normal expectation is for people to be able to cope independently with continence problems, using appropriate aids when necessary; so, they will need to know what it is about your situation that requires the help of another person. If you are not happy with the decision when you get it, you can ask for your claim to be looked at again. It then has to be reconsidered by a different decision-maker, but it may be helpful if you can provide some additional evidence in support of your claim. If you are still not happy when you get the reconsideration decision, you can appeal. You will possibly be asked to attend a tribunal hearing. It is in your interest to attend this as it gives you a much better chance of success, but you should also contact a local welfare rights organisation to get representation. These organisations know the law and the format of appeals, and can take a lot of the stress away from you.
Other information The DLA and AA are not means tested. It does not matter how much you have in savings, if you are working or what other benefits you are receiving; if you are entitled, you can get a DLA or AA in addition. In fact, these allowances can enhance your entitlement to means tested benefits like
Key points ● People with continence problems may be entitled to a number of benefits; in particular, a Disability Living Allowance or an Attendance Allowance. ● Having a continence problem is not a reason in itself for receiving benefits. ● A lot of assistance from welfare rights organisations is available to patients claiming benefits. The Department for Work and Pensions can even go over the form on the telephone.
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Attendance Allowance, ring the Disability Benefits Helpline on 08457 123 456 or visit www.direct.gov.uk/en/Dl1/ Directories/DG_10011169 • To claim or find out more about Employment and Support Allowance, ring your local Jobcentre Plus office. To find your local Jobcentre Plus office, visit www.jobcentreplus.gov.uk/JCP/ Aboutus/Ouroffices/Search/LocalOfficeSearch.aspx?type=1 &name=Local%20Office • To claim or find out more about Tax Credits, ring the Tax Credits Helpline on 0845 300 3900 or visit www.hmrc.gov.uk/taxcredits/ Income Support, Pension Credit, income-related Employment and Support Allowance (ESA) or Job Seekers Allowance, Housing Benefit and Council Tax Benefit. This means that, if you are awarded a DLA or AA and you are not getting a means tested benefit, it may be worth making a claim, even if you have been disallowed in the past.
Employment and Support Allowance If your condition prevents you from being able to work, you should claim ESA. This replaced Incapacity Benefit (IB) in October 2008, although people who were already on IB stayed on that benefit. You will normally need to provide doctor’s certificates and may have to undergo a medical assessment called the ‘Work Capability Assessment’ during the first 13 weeks of your claim. A decision-maker will then decide whether you will be placed in the ‘Work Related Activity Group’, where the aim is to prepare you for suitable work, possibly different from what you have done before, or in the ‘Support Group’, where it is recognised that your capability for work is severely restricted. The rates of benefit depend on which group you are in and whether you are over or under the age of 25. The amount you receive will be reduced if you have a gross pension income of more than £85 per week. If you have not paid enough National Insurance contributions to qualify for contribution-based ESA, you may be entitled to income-related ESA. This is worked out in a similar way to Income Support for people who do not qualify for IB, and depends on individual circumstances.
Working Tax Credit It could be that you can only take a low-paid job because of your condition. In this case, you may be entitled to Working Tax Credit. This is far too complicated to fully explain here, but the amount you may be entitled to depends on a number of factors, the most important of which is your level of income. Other factors include how many dependent children you have (although you could qualify without having any), how many hours you work (it must be over 16), whether you or a dependant has a disability and whether you pay for childcare. Working Tax Credits are administered by Her Majesty’s Revenue and Customs, formerly the Inland Revenue, whereas DLAs, AAs and ESAs are administered by the DWP ■
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Treatment
The role of duloxetine in treating stress incontinence Duloxetine presents an alternative to surgery in the treatment of stress urinary incontinence. Rob Sherwin and Mark Slack explain the benefits of this treatment Rob Sherwin MA PhD MRCOG Subspeciality Trainee in Urogynaecology Mark Slack MB ChB MMed MRCOG FCOG(SA)
Consultant Urogynaecologist and Lead Clinician, Addenbrooke’s Hospital, Cambridge
Stress urinary incontinence (SUI) is defined as ‘the involuntary leakage of urine on effort or exertion, or on sneezing or coughing’.1 The treatment options available in primary care include lifestyle advice, fluid management and smoking cessation, along with physiotherapy. Barrier methods (pads) are the most commonly used treatment. Until recently, surgery was the only option if physiotherapy and lifestyle modifications failed. In the UK, this situation has now changed with the introduction of duloxetine, a drug known as a serotonin and noradrenaline reuptake inhibitor (SNRI). Duloxetine works in SUI1 by allowing increased stimulation of the pudendal nerve during the storage of urine in the bladder.2 This results in an increase in contraction of the sphincter (valve) that controls urine outflow from the bladder. This increased contraction reduces the urinary leakage experienced by patients with SUI and so results in improved control of urine storage and bladder emptying.2
How effective is duloxetine? Various placebo controlled studies suggest that duloxetine has the potential to help women with SUI. In these studies, where the patients and their doctors were not told which treatment they were receiving, the effectiveness of duloxetine in treating SUI was compared with placebo (pills containing no active compounds for treating incontinence). One of these studies showed that half of the women who took 40 mg duloxetine twice a day experienced a greater
than 64% reduction in frequency of incontinence compared with those taking the placebo. That meant that women who had previously leaked daily would leak only once or twice per week, and this reduction was shown to have a significant effect on their quality of life. There is also evidence that a combination of pelvic floor exercises and duloxetine will result in the best outcome for patients.
Duloxetine treatment All recorded studies have shown that duloxetine is well tolerated, the most common side-effect being mild-to-moderate nausea. Others include dry mouth, constipation, fatigue, insomnia, dizziness, sweating, vomiting and drowsiness. To manage these side-effects, duloxetine can be started at a dose of 20 mg twice a day, increasing weekly by 20 mg to a maximum of 40 mg twice daily. Patients experience maximum benefit by three weeks, so the initial trial of duloxetine need not be longer than this. There is no consensus on how long a patient should take the drug. Pelvic floor exercises are usually undertaken for 12 weeks, so it seems sensible to take the drug for a similar duration. Although some patients suffer from SUI in isolation, many more also experience symptoms of overactive bladder syndrome (OAB), which include urinary frequency, urgency and urinary incontinence associated with urgency. Duloxetine can be used in conjunction with anticholinergic medication to treat patients who have both SUI and OAB.
Key points
Conclusions
● Treatment options for stress urinary incontinence include lifestyle advice, specialist physiotherapy, use of pads to contain urine loss, and, if these are unsuccessful, medical treatment with duloxetine and surgical procedures.
Duloxetine, through its ability, predominantly, to block noradrenaline and serotonin reuptake and increase pudendal nerve signalling, is a major breakthrough in SUI management ■
● Studies have shown that duloxetine is effective and well tolerated, and can be used as an alternative to surgery.
References 1. Voelker R. International group seeks to dispel incontinence "taboo". Jama 1998; 280: 951–953. 2. Yentreve Summary of Product Characteristics. Basingstoke: Eli Lilly and Company Limited, 2004.
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CHARTER CONTINENCE CARE ISSUE 20
Coping on your travels Dealing with incontinence can be a challenge when on holiday, so it pays to be prepared. In this article, we present our advice on how to plan for a trip away Pack your sun hat, lotion, beach towel and your continence products! It’s time to start planning your summer holiday. For people suffering with incontinence, going away on holiday can be a daunting thought. However, to help you get the most out of your holiday, we’ve put together a few tips to help you feel prepared and, of course, cope with your incontinence when away from home. The key to feeling confident about your holiday is good planning. Here are our top tips to help you have that perfect holiday: 1. Carry our complimentary wipes and antibacterial hand cleansing gel with you to keep yourself clean and comfortable. This reduces the chance of picking up an infection. 2.Pack your continence products in your hand luggage and suitcase, so if your luggage gets lost or delayed, you’ll have a supply of product with you. 3.Contact your airline prior to travelling to confirm the products you pack in your hand luggage are allowed. Some products contain water; for example, SpeediCath Compact.
either by visiting www.charterhealthcare.co.uk or by calling 0800 132 787. Alternatively, you may choose to order them before you go and have them ready for when you arrive! Please contact Charter Healthcare well in advance of your holiday to find out more about this service ■
Break away for the weekend! Breakaway offers the UK’s only residential weekend activity breaks designed for young people aged 4–18 with bowel and bladder diversions/dysfunctions, and their families. Breakaway offers the opportunity to meet others in similar situations, to talk and share experiences, and to take part in confidence-building action adventure activities. In 2010, Breakaway will run two events: on 28–31 May and 27–30 August – both at YHA National Forest. Activities may include climbing, high ropes, zip wire, canoeing and much more! The Breakaway fund exists to help people attend events who may otherwise be unable to because of financial hardship. For a funding application, please visit www.breakaway-visit.co.uk Coloplast is proud to be a sponsor of the Breakaway charity ■
Being prepared for your holiday can help you enjoy it more
4.To avoid any embarrassing questions at the airport, carry the Coloplast Travel Certificate with you, which explains what you’re carrying and why you’re carrying it. If you’re stopped at the airport, you can simply hand the certificate over to the airport staff and let it do the explaining for you! 5.Empty your bladder immediately before boarding the plane and as soon as the pilot announces you’ll be landing shortly. 6.Request an aisle seat so you can reach the toilet more easily and you don’t need to ask anyone to move.
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7. For extended holidays or in an emergency, you can order your continence products abroad and have them delivered to your hotel. You can do this using our Charter Healthcare delivery service,
CK
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Straight talking
Erectile dysfunction Erectile dysfunction is a condition that affects many men, but is very rarely discussed. Petros Tsafrakidis and his
Dr Petros Tsafrakidis Clinical Fellow Emmanuel Johnson FRCS Clinical Fellow Richard Pearcy FRCS Urological Surgeon Raj Persad ChM FRCS Urological Surgeon, Bristol Royal Infirmary
Broadly speaking, erectile dysfunction (ED), or impotence, is the inability to achieve or maintain an erection that is adequate for sexual intercourse to the mutual satisfaction of both partners. Studies have shown that the incidence and severity of ED vary with age. Overall prevalence rates of about 40% at age 40 and 67% at age 70 have been reported, with no significant differences between races/ethnic groups. Studies of the effects of socioeconomic class or social customs on prevalence are ongoing.1
Pathophysiology Attaining and sustaining an erection is a complex neurovascular event, initiated via involuntary (autonomic) or voluntary (somatic) nervous system pathways and mediated by chemical substances that convey nerve signals (neurotransmitters). Nitric oxide is the most important, acting on the vascular smooth muscles to expand the blood vessels, increase the blood flow to the penis and reduce its outflow, with erection as the end result. Flaccidity occurs after narrowing of the blood vessels, reduced arterial flow and cessation of venous outflow. In most patients (except some young men), ED is multifactorial in origin and arises when problems occur at any of these levels/sites. Its causes are grouped as organic or non-organic. Organic causes include: ● Neurological disorders (such as multiple sclerosis, Parkinson’s disease or spinal injury) ● Endocrine (affecting hormones and glands) abnormalities (such as diabetes mellitus) ● Vascular disorders (such as high blood pressure or heart attack) ● Systemic (affecting the whole body) conditions (such as arthritis, cancer or drugs). Systemic psychiatric disorders (such as anxiety or depression) and psychological problems (such as performance anxiety, religious scruples or aging) are classed as non-organic causes.1,2
Clinical examination History The doctor should take a medical history, bearing in mind the potential for multiple
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colleagues do some straight talking on the subject
Daily exercise, abstinence from smoking and fat-free nutrition have proved to be beneficial in preventing erectile dysfunction
causes. It is also important at the outset to determine what the patient understands by ‘impotence’ and their expectations regarding a satisfactory sexual experience. Points to be explored in the sexual history include the nature of the problem, onset, factors that may have been a cause, duration and severity. The general history should include a medical, surgical and drug history, as well as questions on social habits (alcohol, smoking, recreational drug use). An organic cause is more likely with a history of gradual onset, loss of spontaneous erections, intact libido and ejaculatory functions.
Physical examination The physical examination should look for any signs of systemic conditions or syndromes associated with ED, paying attention to body habitus, secondary sexual characteristics, muscle mass, fat distribution and evidence of peripheral vascular diseases on general inspection. More specifically, this covers the cardiovascular system (blood pressure and peripheral pulses), abdomen (abnormally enlarged internal organs) and nervous system (limb sensation and anal tone). Particular attention should be given to the genitalia (size and shape, foreskin, testicular abnormalities), as well as the response to the bulbocavernous reflex (contraction of the anal sphincter when squeezing the head of the penis). Lastly, the prostate must be assessed.
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Straight talking Investigations Tests can be divided into general and specialised. It is usual to begin with non-invasive tests. A urinalysis is performed to exclude raised levels of glucose and blood in the urine. Blood tests should include fasting glucose, urea and electrolytes, fasting lipid (mostly in men over 40) profile, prostate-specific antigen and hormone levels. Pharmacological tests are also useful to assess your response to intrapenile (intracavernosal) injections (to attain and maintain an erection) and visual sexual stimulation. Specialised tests to define the origin of the problem include the colour Doppler ultrasound scan, monitoring erections during sleep, penile arteriography (where a dye is injected into arteries believed to be damaged and X-rays are taken), and tests to look for venous leaks.1–4
Treatment Treatment can be offered to patients with ED due to psychological reasons, post-traumatic blood vessel damage and hormone deficiency, but most patients are treated for their symptoms rather than the actual causes.2 The factors that determine the type of treatment are efficacy, safety (patients may have heart or arterial disease), cost, invasiveness (patients may not want to undergo penile prosthesis), efficacy and patient–partner satisfaction. If a cause of ED is detected, treatment can be more specific; for example, testosterone replacement therapy for deficiency in this hormone, a surgical procedure for pelvic or perineal injury, and psychosexual counselling for patients with significant psychological problems. Symptomatic therapy consists of three lines. First-line therapy involves oral medication, offered alone or in combination with sexual therapy counselling.2,4 It includes three potent phosphodiesterase type 5 (PDE5) inhibitors: ● Sildenafil (effective from 30 minutes after administration and for up to 12 hours) ● Tadalafil (effective from 30–60 minutes after administration and for up to 36 hours) ● Vardenafil (effective from 30 minutes after administration and for up to 24 hours).2,4 These drugs cause smooth muscle relaxation, vasodilation and penile erection. They are not, however, efficient without sexual stimulation.2–4 They cannot be combined with each other. In patients on PDE5 inhibitors, nitrates (used to treat heart disease) are contraindicated absolutely, as they cause a significant decrease in blood pressure. Taking these with most blood pressure-lowering drugs is considered to be quite safe, even if the patient is receiving multiple medicines. However, combined with an alpha-blocker, PDE5 inhibitors can cause significant low blood pressure and the only combination not contraindicated is sildenafil with tamsulosin 0.4 mg.2 As well as low blood pressure, PDE5 inhibitors can cause headache, flushing, dizziness, abnormal vision and back pain. Clinical trials have shown that PDE5 inhibitors do not cause an increase in heart attack rates.2 Some clinicians classify vacuum constriction devices (a ring placed at the base of the penis to assist erection) as
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first-line therapy. These are not generally used in the long term or by younger patients. Their commonest side-effects are pain, bruising, numbness or, rarely, skin lesions. They are contraindicated in patients with bleeding disorders or on blood-thinning therapy.2 Second-line therapy involves intracavernous and intraurethral injections of medication. A test dose needs to be administered and the patient must be examined by a specialist nurse or doctor. Risks include bleeding, scarring and priapism (a painful erection lasting over four hours that can cause permanent damage to the intracavernous muscle).1–4 Currently, alprostadil is the only licensed agent.2,4 Intraurethral alprostadil has been shown to be beneficial for patients with ED, especially when combined with a drug taken by mouth. The commonest side-effects of intracavernous and intraurethral injections are local pain and, rarely, bruising.2 Third-line therapy involves implanting a penile prosthesis and is indicated when the first two approaches fail. Penile prosthesis has very high satisfaction rates but requires a prompt selection of patients. The main complications are mechanical failure and infection.
Prevention As already discussed, several factors, including stress or depression, obesity, smoking, sedentary lifestyle, diabetes and high blood pressure, are related to ED. Daily exercise, abstinence from smoking and fat-free nutrition have, therefore, proved to be beneficial in preventing ED.
Conclusion Despite ED’s multifactorial nature and potential psychosocial impact, major progress has been made in pharmacological and surgical treatment. The physician needs to conduct a thorough investigation and support the patient in every aspect, as dealing with ED can be extremely difficult – both mentally and physically. Sound clinical assessment and specialised diagnostic tests guarantee the best means of managing the problem ■ References 1. Reynard J, Brewster S, Biers S. Oxford Handbook of Urology. Oxford: Oxford University Press, 2009: 480–481. 2. European Association of Urology. Guidelines on Male Sexual Dysfunction: Erectile dysfunction and premature ejaculation. www.uroweb.org/fileadmin/tx_eauguidelines/2009/Full/Male_Sexual_Dysf.pdf (last accessed 03/12/09) 3. Walsh PC, Retik AB, Stamey TA, Darracott Vaughan E. Campbell’s Urology: Vol 2. London: WB Saunders, 1992: 1589–1730. 4. Brosman SA. Erectile Dysfunction. http://emedicine.medscape.com/ article/444220-overview (last accessed 03/12/09)
Key points ● Erectile dysfunction has many causes and results from multiple medical conditions in many patients. ● Management consists of treatment of both the underlying cause and symptoms.
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Resources ■ UK Paruresis
Trust
■ Sexual
Dysfunction Association
■ Education
and Resources for Improving Childhood Continence
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The UK Paruresis Trust (UKPT) is a national charity that supports men and women for whom urinating in the presence or vicinity of other people is difficult or impossible. We aim to help sufferers with the problems this causes. Paruresis is the opposite of enuresis; instead of an involuntary loss of control resulting in bladder emptying, it is an involuntary loss of control resulting in retention. The condition severely restricts life choices, specifically social life, work choices and relationships. The condition is rarely admitted to, resulting in sufferers thinking they have something unique and untreatable; shame and embarrassment are common.
The UKPT helps by providing a website for both sufferers and professionals, a moderated and supportive forum, and running intensive therapeutic residential workshops using the CBT (cognitive behavioural therapy) approach; these methods consistently deliver positive improvements. The UKPT aims to show that the condition can be alleviated to a point where it ceases to have a significant impact. Address: UKPT, PO Box 182, Kendal LA9 9AE. Tel: 01539 735234. email: support@ukpt.org.uk website: www.ukpt.org.uk
The Sexual Dysfunction Association (SDA), (formerly the Impotence Association), is a charitable organisation that helps sufferers of male and female sexual problems as well as their partners. We also raise awareness of the extent to which sexual conditions affect the general population. Originally, the charity focused on helping individuals with erectile dysfunction (impotence) but now it covers all forms of male and female sexual problems. We are committed to helping and supporting people with all forms of sexual dysfunction. We do this by raising awareness and well-being, providing information and education on sexual problems and improving the public’s
understanding of the seriousness and causes of sexual disorders. We can be contacted by post, email or telephone. You can also receive information related to specific enquiries. We have produced a number of fact sheets that are available free. Address: The Sexual Dysfunction Association, Suite 301, Emblem House, London Bridge Hospital, 27 Tooley Street, London SE1 2PR. Helpline: 0207 486 7262. (previously 0870 7743571) which is open Mon, Wed and Fri (10 am – 4 pm). email: info@sda.uk.net website: www.sda.uk.net
In the UK one in 12 children and young people experience continence problems. Whether it is bedwetting, daytime wetting or constipation and soiling, ERIC (Education and Resources for Improving Childhood Continence) – the national charity dedicated to improving the suffering of children with continence issues – offers information and support for children and their families, and professionals. ERIC provides a wide range of information and support resources. The confidential helpline offers a listening ear, guidance and practical solutions for anyone who is affected by childhood continence issues. ERIC’s nationwide training programme provides professionals with the knowledge to support children and their families on all aspects of childhood continence including bedwetting, daytime wetting and
soiling. We also offer bespoke training tailor made to your own needs. Our website has a wide range of resources and information on all aspects of childhood continence, including a series of free leaflets to download. Our online store offers a wide range of continence management products and books to suit all requirements. You can find us on Facebook® and Twitter® too! Address: ERIC, 36 Old School House, Britannia Road, Kingswood, Bristol BS15 8DB. Tel: 0117 960 3060. Fax: 0117 960 0401. Helpline: 0845 370 8008. email: info@eric.org.uk Text: 447 624 811 636 website: www.eric.org.uk
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Forum
In conversation with … If you have a question about managing incontinence, our Editorial Board members are here to help. We want to hear from you, so write to us at the address below Ann Winder RN Senior Continence Specialist, Park Drive Health Centre, Baldock
After trying a wide variety of catheters and having problems with them being painfully ejected (fully inflated) when I move my bowels, I have found one that is suitable and comfortable. Being Ch 16 (5.3 mm), it is rigid enough not to flex and scratch me internally on insertion and the 30 ml balloon is large enough to prevent premature ejection. However, I have had six instances this year of the catheter balloon bursting inside my bladder. This is painful and causes wounding and bleeding that make the replacement catheter more likely to block. I have also had infections from pieces of rolled up latex retained in my bladder, causing kidney problems and needing bladder suction to remove them. Bursting is as likely to occur in the first week after insertion as later, so it is not a case of reducing the length of time between changes. Do you have any maintenance advice to minimise the occurrence of this?
Ms H (via email) I would think that the balloon rejection is caused by weakness of the pelvic floor – the bladder contractions then expel the catheter. However, I do not recommend ever putting in a 30 ml balloon, as this will inevitably lead to other problems within the bladder. I also feel that bladder stones may be the cause of your problems – the catheter rejection, the balloon bursting, the bleeding and the infection. I would have referred you for a cystoscopy (a look into your bladder with a small camera) by a urologist. I strongly advise you to seek some specialist help and would be interested to know the outcome ■
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I am a 67-year-old ‘very busy’ lady. I was born without a ‘back passage’ and had major plastic surgery as a baby up until the age of five and a half. I now understand how ground-breaking that surgery must have been but, sadly, all records are long gone at Pendlebury in Manchester, I am told. Anyhow, I was never brought up to feel ‘disabled’ but, as you can imagine, I have had a lifetime of ‘loo problems’. I have never asked for monetary help or disability allowances, but I am very restricted regarding my shopping and getting from A to B. I cannot carry anything heavy and need quick access to loos. I do drive and was thinking it would be nice to park in the spaces for disabled people, as they are usually near to entrances and so on. Do you think I would qualify and, if so, how should I word my problems? I don’t know all the jargon but I do know my needs are genuine. I have arthritis in my lower spine, osteoporosis and, after two daughters and many operations, I have precious little holding me together
Address your correspondence to: The Editor,
Charter continence care Hayward Medical Communications 8–10 Dryden Street, London WC2E 9NA email: edit@hayward.co.uk The information provided on this page is not intended to be, nor is it to be treated as, a substitute for professional medical advice relative to a specific medical condition or question. Therefore, the Editor, author, publisher, or any of their respective employees, officers and agents, accept no liability for the consequences of any inaccurate or misleading data, opinion or statement. Always seek the advice of your qualified healthcare professional regarding your medical condition.
– if you take my meaning. If I were an aeroplane, I would need a new undercarriage! There are a lot of people worse off than me, but if you could suggest anything I would be grateful.
Mrs K, Lancashire I am sure you can receive help, but I would ask your GP if you could speak to the local community social worker, as they are able to assist much more effectively than me. It is also worth asking your specialist for a covering letter regarding your condition ■ I was involved in developing latex sheaths and baby teats in the 1950s. I am now retired due to many of the manufacturers of latex medical products becoming self-sufficient. Working in 40 countries as a hands-on consultant was very rewarding, although not financially. Ending up as a state pensioner on benefits is a bit depressing, except for the fact that we live in a bungalow on the eastern edge of the Peak District, overlooking Ogston Reservoir/bird sanctuary – an idyllic rural setting. I have been using the EasiCath 5352 for some years now and, occasionally, when travelling, support it with the SpeediCath 28412. However, when I am less active, in the winter months, the volumes of urine being delivered in any three-to-four-hour period increase, so that following an eight-hour sleep, for example, the time taken for a urine delivery is extended to the point that an EasiCath is difficult to remove – presumably due to the polysaccharide coating acting as an adhesive? I choose to live with this rather than disrupt my sleep. I am going to have a go at the pelvic floor exercises.
Mr S (via email) Thank you for your letter, it made very interesting reading and you taught me something – I knew sheaths were made for sexual activity but did not know some were made specifically for urinary drainage. I wish I had known of these when I was working on a spinal injuries unit in the 1970s, when I had to put together the ‘sheath appliance’ from various bits and pieces. I do hope you enjoy the wonderful part of the world you live in, despite the weather sometimes ■
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