What does the NICE incontinence guidance mean for you? ... page 5
The use of drugs for overactive bladder in the elderly ... page 12
Issue 23 Autumn 2010
continence care
How incontinence can affect a woman’s sex life
EXPLICIT CONTENT
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Contents
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Practical care What NICE means for you by Marlene Powell
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Straight talking How urinary incontinence affects a woman’s sex life by Anne-Marie Roos, Ranee Thakar and Abdul H Sultan
Coloplast 11 Peristeen has given me confidence and peace of mind by Melita Denaro Treatment 12 Drugs for an overactive bladder by Adrian Wagg and Laura Camburn
14 Resources Forum 15 Q&A
Comment
It will be all change in primary care services I hope that, by now, you are all over the summer’s ‘election fever’, but although the new coalition government promised there would be no side-effects on the NHS from trying to address the country’s overspend, they told a few fibs!
NHS changes The NHS White Paper proposes the biggest shake-up to the health service in its history. It is proposed that primary care trusts and strategic health authorities will be abolished, every trust will be required to become a foundation trust and other services will be provided by social enterprises and other organisations. The GPs themselves will be responsible for much of the NHS spending budget. However, while I am not going to depress you further with all the statistics of how many front-line staff are not being replaced, management structural changes and budget cuts will definitely affect care. I The GPs hope, nonetheless, to be themselves will a little optimistic and try be responsible for to look forward to a brighter future. much of the NHS All the front-line professionals in the NHS spending budget remain caring and strive to do all they can to help those in their care. At present, there is a drive to recruit more students and it is hoped that 25,000 will enter training in 2011. This could well be dependent upon whether the budget cuts will affect places available. The increase will help towards care in the future. It is 100 years since the death of Florence Nightingale. Maybe we should all take heart from her tireless work as a campaigner for healthcare and reform. I wonder what she would say today!
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This issue’s contents As I hurtle back to reality, in this issue of Charter continence care, I have really enjoyed the variety of Cover picture B2M PRODUCTIONS/GETTY IMAGES
CHARTER CONTINENCE CARE ISSUE 23
Continued overleaf 3
articles. I hope you enjoy this issue of Charter, and find it beneficial and gain as much from reading it as I always do from editing it. Please do remember to feel free to send in any comments or letters we could publish about your experiences or solutions you have developed to help you cope with continence problems. It would also be interesting to know if you think that there is a subject that we can revisit or commission someone to write on. Professor Adrian Wagg, who has now unfortunately left our shores and is resident in Alberta, Canada, has written an article for this issue that I know will be of benefit to a lot of readers. In it, he explains the problems of an overactive bladder. To maintain the variety, How urinary incontinence affects a woman’s sex life by Anne-Marie Roos, Ranee Thakar and Abdul Sultan, will, I hope, offer some relief to the many women who often feel they are the only one with a problem and therefore find it extremely difficult to raise this delicate concern – either with healthcare professionals or with friends. Marlene Powell has provided a very clear and helpful article around the National Institute for Health and Clinical Excellence (that is, NICE) guidelines for bowel care with sensible and useful advice. I would like to thank all the authors for the contributions, especially at this time of tension and uncertainty in the NHS. Ann Winder, Editor
The Editor Charter continence care Hayward Medical Communications 8–10 Dryden Street London WC2E 9NA
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 Lead Nurse Continence, Tynemouth Road Health Centre, Tottenham, London 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, Department of Urology, Bristol Royal Infirmary Mark Slack MB ChB MMed MRCOG FCOG(SA) Consultant Urogynaecologist, Addenbrooke’s Hospital, Cambridge Paul Smith Executive Director, Spinal Injuries Association
email: edit@hayward.co.uk Editorial Director Elaine Bennett. Sales Director Ian Arkless. Managing Editor Robin Jones. Chief Sub Joel Barrick. Senior Sub Editor Anne-Claire Bouzanne. Editorial Assistant Jessica Atkey. Art Editor Richard Seymour. Publications Co-ordinator Hayley Mayes. 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.
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CHARTER CONTINENCE CARE ISSUE 23
Practical care
What NICE means for you In 2007, NICE issued guidance on the management of faecal incontinence. Marlene Powell explains a little about NICE and talks you through the guidelines
What is NICE? Most of you will have heard of NICE and perhaps wondered what sort of organisation it is. Sadly, too often, NICE is publicised in the media when patients suffering life-limiting illnesses are refused treatments that may extend their lives. At times like these it is difficult to understand how that decision has been made. So NICE can be seen as the ‘Big Bad Ogre’ and not a very ‘caring’ organisation. NICE was set up as a special health authority for England and Wales on 1 April 1999. As part of the NHS, it is responsible for producing guidance (advice) for the NHS about preventing, diagnosing and treating different medical conditions. It searches the best available evidence, ranging from randomised, controlled trials and case control studies through to expert opinions. Then a formal consensus is published as a guideline. Guidelines aim to relate to 80% of cases 80% of the time, so there will be individual cases that fall outside the recommendations. Experiences of clinicians and views of patients and carers are also considered, as the guidelines should be able to help the patient understand as much as possible about their problems. It should empower them to ask the right questions about possible treatments.
How is a NICE guideline developed? There is an initial consultation process with key stakeholders – people who have an interest in the subject. Stakeholders are those with an interest in the development of the guideline,
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foot rest Step one. Knees higher than hips
foot rest Step three. Bulge out your abdomen. Straighten your spine
Reproduced by the kind permission of Ray Addison, Nurse Consultant in Bladder and Bowel Dysfunction. Wendy Ness, Colorectal Nurse Specialist.
The first part of this article aims to give you a brief introduction to the National Institute for Health and Clinical Excellence (NICE). As a community continence adviser, I was invited to take part in the planning of NICE Clinical Guideline 49: The management of faecal incontinence in adults (CG49). The second part of the article gives recommendations suggested for diagnosis, assessment and management of the symptoms. foot rest Step two. Lean forwards and put elbows on your knees
foot rest
Correct position
Figure 1. Preferred position for opening your bowels
such as clinicians, patient and carer groups, and also manufacturers and sponsors. Independent experts are invited to form a guideline development group (GDG). Research in the field under consideration is examined and key priorities for implementation of good practice will be recommended in the published guideline. The views of patients and carers are taken into consideration throughout the process. Therefore, you and your healthcare professional (clinician) can understand what is wrong and what management options might be suitable. In this case, the guidelines identify that in many cases there are some very basic strategies that can improve quality of life and often cure the problem completely.
Marlene Powell BSc PG ResDip RGN
Retired Continence Adviser, Bath
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Practical care Faecal incontinence Why was a guideline needed?
NICE had many reasons to address the ‘hidden’ topic of faecal incontinence (FI). Bowel continence problems have been overshadowed by the more prevalent urinary incontinence, which itself has only recently gained widespread attention. FI affects over half a million adults in the UK. Inability to control bowel movements can lead to an unplanned leakage of faeces from the back passage. Symptoms can include urgency and frequency, and even uncontrollable wind. Many people also think it is quite ‘normal’ to have an occasional stain or leak. FI is a symptom, not a disease and, therefore, should be investigated. Many sufferers will not visit their GP as they think that nothing can be done to help. For all these reasons and more, the decision of NICE to address this topic is very welcome.
Creating the guideline
Until recently, there had been a lack of a single professional healthcare group to lead on the problem of FI. A GDG was put together from expert healthcare professionals including consultants, GPs, nurses and physiotherapists. Also included were representatives of patients and carers, and non-clinical staff. Recommendations were finalised after public consultation. Throughout the process of producing this guideline, the greatest challenge has been the almost complete lack of high-quality evidence for most assessment and treatment methods.
How can this guideline help patients?
The patient information booklet on CG49 is available online or as a printed copy (visit http://guidance. nice.org.uk/CG49/PublicInfo/pdf/English). It is written for sufferers of FI, families and carers or anyone with an interest in the condition. The NICE website can be accessed for the recommendations in full. Staff working in the NHS are expected to follow this guidance.
Finding out what is wrong There are certain groups of people who are more at risk of FI than others (see Box 1) and staff should be aware of the need to check for symptoms of FI.
Baseline assessment
Continence nurses and physiotherapists have traditionally managed patients in primary care, but some patients may be referred to colorectal surgeons, gastroenterologists, neurologists and care of the elderly specialists. For examples of questions patients may be asked, see Box 2. Patients will be asked to keep a record of their bowel symptoms for a few days. The Bristol Stool Form Scale is a visual aid towards accurate recording that indicates the different ‘types’ of stool that you may pass. As food and drink can affect bowel movements, patients may also be asked to complete a food diary, again for a few days. Frequently what seems to be a ‘healthy’
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Box 1. Groups at risk of developing faecal incontinence • Frail older people • People with loose stools or diarrhoea for any cause • Women who have recently given birth • People with injury to, or disease of, the nervous system or spinal cord, such as spina bifida, stroke, multiple sclerosis or spinal cord injury • People with severe cognitive impairment; for example, learning disabilities and memory problems • People with urinary incontinence • People with pelvic organ prolapse, such as rectal prolapse and/or vaginal prolapse • People who have had surgery to their large bowel (the colon) or anal surgery; for example, for haemorrhoids • People who have undergone pelvic radiotherapy • People with perianal soreness, itching or pain
Box 2. Examples of questions patients may be asked • When/how often do you usually empty your bowel? • Has your bowel habit changed recently? • Have you had any bleeding? • Do you need help using or getting to the toilet? • What medicines are you taking, including those bought from a chemist? • How much fluid do you drink each day? • What types of food do you eat? • Do you experience soreness or itching around your anus? • How do your symptoms affect your daily life?
diet can often contribute to bowel symptoms. The clinician will also need to take a relevant medical history and a general examination. An anorectal examination is usually required (as long as permission is given) and a cognitive (memory) assessment may also be helpful.
Managing faecal incontinence Conditions that can cause FI should be treated
Some conditions that can cause FI are potentially reversible (see Box 3) and these should be treated before a clinician offers any treatment for the incontinence itself. The NICE guideline then recommends a step-wise approach to the management of patients’ symptoms, covering all aspects of bowel habit, diet, toilet access, medication and coping strategies.
Bowel habit
A ‘normal’ stool should be soft and formed and comfortable to pass, with no straining or pain. Even if you think that constipation is your main problem, FI can be a symptom and there are several strategies that will help you to manage your symptoms.
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Practical care Box 3. Conditions that can cause faecal incontinence • Faecal loading (associated with chronic constipation) • Diarrhoea, including inflammatory bowel disease, irritable bowel syndrome and diarrhoea caused by infection • Signs of cancer of the bowel, rectum or anus • Prolapse of the rectum • Third-degree haemorrhoids (severe piles that extend from the anus) • Recent injury to the anal sphincter • A ‘slipped disc’ in the back
Box 4. Specialist management • Pelvic floor muscle training • Bowel retraining • Specialist dietary assessment and management • Biofeedback • Electrical stimulation • Rectal irrigation Try to have a regular bowel habit. The best time to have your bowels open is in the morning and also after exercise and meals later in the day. There is a preferred position – using a foot rest when sitting on the toilet to raise your knees higher than hips, then placing your elbows on your knees (see Figure 1) – for the easiest way to pass stool. Also, your clinician should teach you how to empty your bowels without straining.
Diet and fluid intake
You should be given advice on a diet that will promote ideal stool consistency and a predictable bowel emptying. A food and fluid diary will be helpful. Try to identify one food at a time that may alter stool consistency. If hard stools are a problem, a fluid intake of 1.5 litres is generally recommended. Referral to, and support from, a specialist dietitian is helpful for many people.
Toilet access
Difficulty with toilet access can make the difference between bowel urgency and FI. You should have access to private, comfortable toilet facilities, especially in a work environment. If mobility is a problem, an occupational therapist may assess your home and mobility to see what extra help you may need. It may be that you have difficulty reaching or transferring to the toilet. Clothing should be easily removable and you should also be able to sit safely and in comfort for long enough to achieve complete bowel emptying. Any equipment to improve access should be provided and, if you are in a hospital or care home, toilets should be easy to find. If you need to travel, you can obtain a RADAR key, enabling access to disabled toilets in the
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National Key Scheme (this is available online at www.radar-shop.org.uk/Detail.aspx?id=0).
Medication
There are drugs that might be contributing to FI and your doctor may consider alternatives. An anti-diarrhoeal may be prescribed. The drug of first choice is loperamide, which can be used in doses of 0.5–16 mg per day. It should be introduced at a very low dose and increased slowly until the desired stool consistency is achieved.
Coping strategies
FI can be depressing, demoralising and detrimental to social activities. It can be socially stigmatising and have an emotional impact on individuals and their carers. Anxiety, depression and poor self-image could lead to restrictions on work, social life and relationships. Counselling or psychological therapy may be suggested and information about support groups should be available. Sufferers should be given advice on disposable continence products and also on any skincare problems.
Specialist management
The step-wise approach to management is continued when patients are referred to a continence nurse or a women’s health physiotherapist (see Box 4). Most community continence services currently have specially trained clinicians who are able to offer these treatments without further referral.
If you are considering surgery
CG49 recommends that referral pathways are in place between primary and secondary care. There should be easy access to colorectal, gastroenterological or other specialist care. Surgery may be appropriate for patients who have not responded to conservative management. The patient information booklet for CG49 gives you information on surgery that might be offered. It also suggests questions to ask concerning surgical treatment.
Review and long-term management
Some symptomatic patients do not wish to continue with active treatment, but follow-up should be offered in the long term. As FI may not always be cured, the emphasis is on symptom control using the management strategies described, and a review every six months ■ Further information For further information on continence and other issues, visit www.stmarkshospital.org.uk/index.php?page=patient-information-leaflets
Key points ● NICE has published a guideline on faecal incontinence (FI) that is useful for both healthcare professionals and patients. ● The NICE guidance directs that people with suspected FI should be assessed and potential causes should be treated.
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Straight talking
B2M PRODUCTIONS/GETTY IMAGES
Treatment for urinary incontinence can have a positive effect on sexual function
How urinary incontinence affects a woman’s sex life Incontinence can have distressing effects on your sexuality. Anne-Marie Roos, Ranee Thakar and Abdul H Sultan provide a frank and open discussion of the topic Anne-Marie Roos MD MSc Clinical Research Fellow Ranee Thakar MD MRCOG Consultant Obstetrician and Urogynaecologist Abdul H Sultan MD FRCOG Consultant Obstetrician and Urogynaecologist, Department of Obstetrics and Gynaecology, Mayday University Hospital, Croydon
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Sexual problems are very common in women. A UK national survey showed that 54% of sexually active women suffered from at least one sexual problem lasting at least one month in the preceding year, but fewer than one in five look for help for their sexual concerns. Barriers to seeking help could be embarrassment and feeling that the doctor will not be able to provide help. Barriers such as age and gender of the doctor, the perceived attitude of the doctor towards an older person seeking help for a sexual problem, seeing sexual problems as part of ‘normal aging', and the perception that sexual problems are not a ‘severe’ health problem have been mentioned by older women. Sexual problems may, therefore, not
be brought to the doctor’s attention unless an active effort is made to uncover the problem. However, a survey of UK and US urogynaecologists, who predominantly treat women with urinary problems, showed only 50% and 77% respectively regularly screen for sexual dysfunction. The most important reason for not informing about sexual problems was the lack of time. Other important barriers were uncertainty about therapeutic options and not knowing what or how to ask, indicating a global lack of training with respect to sexual dysfunction. Both the barriers demonstrated by the patient and those of the doctor can be the cause of unnecessary suffering for women with sexual problems.
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Straight talking When does a problem become dysfunction? The female sexual response is highly variable. Normal variations can occur, both between different women and in different stages of a woman’s life. Women’s motivations for having sex are usually related to attraction, pleasure, affection, love, emotional closeness and reproduction, but sexual desire and sexual urges experienced ahead of sexual activity are rare. In fact, many women, especially those in established relationships, are frequently unaware of spontaneous sexual thoughts. More commonly, sexual desire is triggered rather than spontaneous. The appropriate sexual stimulation, which could be kissing, caressing, or reading an erotic novel, can make you feel aroused. Arousal is a state of mental excitement together with physical responses, including lubrication. If arousal is accompanied by positive emotions and thoughts, you will feel the desire to engage in sexual activity. Sexual activity will lead to increasing arousal and in some cases orgasm, although orgasm may not be necessary for sexual satisfaction. This series of actions is called the sexual response cycle. A woman’s sexual response differs from a man’s – men more often have sexual fantasies and thoughts and feel the urge to have sex. With aging, the difference in sexual response between women and men becomes less obvious. Female sexual dysfunction can occur in six major categories: reduced or absent sexual desire/interest; reduced or absent arousal; persistent sexual arousal; orgasmic disorders; dyspareunia (pain associated with sexual intercourse); and vaginismus (involuntary spasms of the muscles of the vagina interfering with penetration). A problem in any of these categories can be labelled as dysfunction only when it causes you personal distress – sexual issues must only be treated when they become a dysfunction. Your problems should be approached keeping in mind normal variability between individuals and the natural sexual response of women.
Urinary incontinence Urinary disorders can have a negative effect on all parts of your sexual response cycle. This includes effects on sexual desire, arousal, lubrication and orgasm. It can also be a cause of pain during sexual activity. Dyspareunia (often caused by constant wetness and soreness), wetness at night, embarrassment and depression, leakage during intercourse, fear of smelling of urine, the need for separate beds, and marital problems, have been shown to be reasons for the negative effect of urinary disorders on sexual function. A negative effect on one aspect of your sexual response cycle can have a knock-on negative effect on all other aspects of your cycle. Different types of urinary incontinence (UI) can have different effects on sexual function. If you have stress UI (see Box 1), you may have reduced sexual
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desire, because sexual fantasies are frequently associated with the fear of having a UI episode during intimacy, which results in sexual anxiety. If you have urge UI, you may be uninterested in sex because of a strong increase in the desire to urinate during intercourse, with subsequent frequent leakage of urine during such attempts. Moreover, urge UI has been associated with pain and anxiety related to intercourse, and fear of reaching an orgasm due to the risk of having a UI episode at this time. Although not all women with urge UI report incontinence during intercourse, the majority are embarrassed by their incontinence and overactive bladder (OAB) symptoms resulting in loss of body-image. If you have OAB without urge incontinence, you may still also experience pain with intercourse, and may have to interrupt intercourse to pass urine. Coping behaviours to lessen the impact of urinary problems on sexual health have been described and include avoidance of sexual activity, ‘grin and bear it’, massage and other ways to connect intimately: showering before intercourse, having sex in the shower/hot tub, padding the bed with sheets and even eating chocolate!
Coital incontinence
Coital incontinence (UI during sexual activity) occurs in 11–36% of sexually active women with UI. It can occur at any point during sexual activity, but the mechanism seems to be divided into ‘mechanical’ (introduction of the penis, deep penetration, pressure on the abdomen) and ‘non-mechanical’ factors (clitoral stimulation, arousal and orgasm). The problem can be present with any type of UI, but incontinence occurring on penetration is more likely if you have stress UI, while incontinence during orgasm is more likely if you have OAB. Mechanical factors can alter the anatomical position of your bladder and when combined with abdominal pressure this can induce stress UI. Incontinence during orgasm, arousal and clitoral stimulation seems to be caused by simultaneous contractions of the bladder and relaxation of the urethra (the tube through which urine passes from the bladder). While coital incontinence does not interfere with sexual enjoyment in all women, it can have an impact on their quality of life for some.
Underlying psychological problems
Apart from causing sexual problems, UI may be the presenting symptom of an underlying psychological problem with sexuality. Psychological disturbance and sexual dysfunction have been associated with urinary problems, in particular with OAB symptoms. Patients with OAB symptoms are more likely to be victims of physical and/or sexual abuse when compared with women with stress UI and women without urinary problems. Previous sexual abuse in childhood can also cause urinary difficulties. UI is more common in victims of childhood sexual abuse compared with women without such a history.
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Straight talking The effect of other factors Menopause
UI occurs more often in older and post-menopausal women. With increasing age and the decrease in female hormones after menopause, women with or without UI can suffer with sexual problems. Changes related to the menopause are: diminished sexual responsiveness, dyspareunia, decreased sexual activity, and a decline in sexual desire. Furthermore, your partner might be experiencing sexual problems as well.
Box 1. The different types of urinary incontinence (UI) • Stress UI is the complaint of involuntary leakage of urine on effort or exertion, or on sneezing or coughing • Urge UI is the sudden, urgent desire to urinate, with associated leakage of urine (before you reach the toilet) • Overactive bladder is the complaint of urinary urgency, with or without urge incontinence, which is often accompanied by increased frequency of passing urine and the need to pass urine during the night
Pelvic organ prolapse
The presence of prolapse (a ‘lump’ in the vagina) in women with UI has an added negative effect on sexual function. Women with prolapse have lower measures of sexual function compared with those without. Women with prolapse express less satisfaction with their sexual relationship, suffer more dyspareunia and are more likely to avoid sexual activity due to embarrassment and fear of incontinence.
Faecal incontinence
There is little research into the effects of faecal incontinence on female sexual function. One study explored emotional issues associated with faecal incontinence. In this group of women shame and/or embarrassment as well as fear of incontinence were common problems. Faecal incontinence was also reported as causing stress, depression, isolation, secrecy and poor body image. Sexual aversion and avoidance were mentioned, as were concerns regarding starting a new relationship. Although a lack of arousal or desire was reported, it was not perceived as a problem unless faecal incontinence occurred during sexual contact. Other studies suggest that there is no difference in sexual function between women with and without faecal incontinence. However, when women complained of incontinence of solid stools and/or of symptoms of depression related to faecal incontinence, sexual functioning was worse.
The effects of treatment Non-surgical management
Non-surgical treatment for stress UI consists of pelvic floor muscle exercises (PFME) and a positive effect on sexual function has been demonstrated in studies. After two months of treatment, improvement was shown for
Key points ● Sexual dysfunction is common in women suffering from urinary incontinence. ● Urinary disorders can have an adverse affect on sexual desire, arousal, lubrication and orgasm, and can be a cause for pain during sexual activity.
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sexual desire problems, dyspareunia and incontinence during intercourse. After 12 months of treatment, there was a reduction in the number of episodes of urinary leakage and a significant improvement in desire, arousal, lubrication, orgasm, satisfaction and pain. Behavioural intervention, also known as bladder retraining, is the first-line treatment for OAB and urge UI symptoms. You should be offered anticholinergic drug therapy (drugs that block nerve impulses) if you have OAB or if mixed UI and bladder retraining is ineffective. Studies have demonstrated a positive effect of anticholinergic drug use on sexual function. Improvement can be seen in desire/interest in sex, arousal, lubrication, orgasm and satisfaction as well as in the relationship with the partner. Sexual experience can improve due to a reduction in physical problems, such as coital incontinence, and reduced anxiety.
Surgical treatment
The tension-free-vaginal tape (TVT) procedure is the treatment of choice if you have stress UI. TVT improves sexual function mainly due to the improvement in incontinence during coitus and a reduction in the anxiety and avoidance of sex due to urinary problems. Worsening of sexual function after surgery, however, can be caused by dyspareunia, loss of interest in sex, increase in incontinence after surgery, as well as partner discomfort due to dryness and vaginal narrowing.
What can you do? If you find that you are experiencing distressing sexual problems, find help! Express your concerns to a person in whose presence you are comfortable – a GP, urologist, nurse, or (uro)gynaecologist. It is also the responsibility of the healthcare professional to make an active effort to uncover any sexual problems you may have. All female patients suffering from UI should be asked if they are sexually active and if there are any problems or pain associated with intercourse. If you have a sexual complaint, the level of bother by the complaint should be assessed. A sexual, medical and psychosocial history as well as a physical examination should be performed to identify any medically treatable cause. If no medically treatable cause is found, the physician may refer you to a psychosexual counsellor ■
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Peristeen has given me confidence and peace of mind Melita Denaro, an artist, writes here about her experience with the Peristeen anal irrigation system and how using it has affected her quality of life I am a full-time artist working in my studio near my home in London and also in a field near my studio home on the north-west coast of my native Ireland. I was diagnosed with multiple sclerosis (MS) in 1996, which initally manifested with bladder problems. Only in the last three years did I experience problems with my bowel. I was told by one consultant that I would eventually need a stoma, but I was not to worry as you can get floral bags! Thank goodness I was referred to the excellent Dr Emmanuel at University College Hospital London and the most impressive, direct and absolutely brilliant bowel Clinical Nurse Specialist Julie Storrie. They found no other reasons for the bowel not working except the MS and some of the medicines I was taking. Two or three years later, still struggling, I got a call from Julie Storrie telling me about the Peristeen system – the rest is a much happier story. Using Peristeen has given me peace of mind and confidence. So brilliant: no more laxatives, no more enemas, no more sitting on the toilet for hours smoking cigarettes to help me open up the bowels. No more bowel blockers for worrying days or long journeys. No more keeping a mobile under my pillow in case I have an accident and needed to call a friend or assistant. I can honestly say that my bowel problems were the most distressing and lonely aspect of MS, as I cannot get on and off the lavatory without a lot of help or a hoist. I love this Peristeen system. Nothing but warm water washing out the bowel and cleaning up everything. No
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Here is an example of Melita’s artwork. You can view more at www.jmlondon.com or contact her c/o John Martin Gallery, 38 Albermale Street, London W1S 4JG
more having to make a great joke about how awful bowel problems are to ease the humiliation of asking for the help of friends and assistants. Please try Peristeen and see. It’s brilliant for travel. I travel every month to Ireland for work and now I can cope, and even look forward to a journey I used to dread. Thank you Peristeen and all your staff at Charter Healthcare home delivery for being friendly, helpful and professional on the phone, especially when I was nervous at the beginning. They were so informative, I could not have asked for more. The system always arrives within two days of my order, so that I never feel afraid I’ll be left without supplies. Yippee for this system! ■
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Treatment
Drugs for an overactive bladder Overactive bladder is very common in older people and can have a significant impact on their lives. Adrian Wagg and Laura Camburn explore the available treatments Adrian Wagg MB FRCP FHEA Professor of Healthy Ageing, Division of Geriatric Medicine, University of Alberta, Canada Laura Camburn MBBS Senior House Officer, Department of Geriatric Medicine, University College Hospital, London
Overactive bladder (OAB) is characterised by a very strong urge – called urgency – to pass urine (with some people unable to make it to the toilet before they leak urine), often accompanied by a need to pass urine frequently. OAB affects up to 13% of us in Europe and Canada1 and becomes more common as you get older. OAB has a significant impact on your life. Higher rates of depression and unemployment, reduced work productivity and decreased and less enjoyable sexual activity are all seen in OAB sufferers.2 Appropriate management can help reduce the impact of OAB on quality of life, but cannot cure the problem as the underlying cause is often unknown. First-line treatment for OAB consists of lifestyle advice, fluid management and bladder retraining;3 should these fail or, if you want earlier treatment, drugs to inhibit nerve impulses (anticholinergics) are used.
A look at the evidence In 2003, a systematic review of 32 trials was carried out to determine the effectiveness of anticholinergics for treatment of OAB.3 The authors concluded that, although there was a small but significant improvement in patients’ symptoms when taking anticholinergics, the benefit may not offset the risk of side-effects. A further overview has shown that these drugs are not only effective in controlling symptoms of OAB, but also improve quality of life.4 Anticholinergics are equally effective at treating OAB in older people and those under 65. A dry mouth is the most common sideeffect of anticholinergics, causing some patients to stop treatment. This article will consider another potential risk of these drugs – a worsening ability to think straight (cognitive dysfunction). Anticholinergics work by blocking chemical receptors (muscarinic receptors) in the body. These receptors are found throughout the body, including in the bladder, and it is thought that these receptors play an important role in bladder contraction and, therefore, urination. There are five different types of muscarinic receptor and there are different numbers and types of receptor in different
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organs. Most of the antimuscarinics currently used for OAB are unable to block a particular type of receptor and, therefore, affect all five types to differing extents. All five types of receptor are found in the human brain and there is significant evidence that a receptor called muscarinic acetylcholine receptor (M1) plays a key role in memory and thought processing. Blocking M1 receptors could, therefore, lead to detrimental sideeffects on memory and cognitive function. In 2003, The New England Journal of Medicine published a case of transient memory impairment and hallucinations two weeks after a patient was started on tolterodine for urinary incontinence. When the tolterodine was withheld for several months the patient’s memory improved, but quickly deteriorated again on resuming the medication. When the medication was re-stopped the patient’s memory once again improved, although it was several months before significant improvement was seen.5 In another study, a previously well 65-year-old woman developed new onset of mental confusion eight days after being started on 2 mg of tolterodine twice daily. When the tolterodine dose was reduced to 1 mg twice daily her confusion resolved within 24 hours.6 A study of the effect of another drug, oxybutynin, on brain function in healthy volunteers has shown that it can affect thinking ability.7 This has raised the question of whether or not these drugs are suitable for older people. This is important, as many elderly patients may be on other medications that have antimuscarinic properties, the overall effect of which could result in cognitive side-effects. Even older people who are apparently fit and well may have some impairment of thinking ability when on a number of these drugs in combination.
The cumulative effects One study looked at serum anticholinergic activity (SAA), a measure of the combined effect of similar drugs. They looked at patients aged over 70 and found that those with the highest SAA level were 13 times more likely to achieve low scores on cognitive testing.8
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Treatment Different drugs block the various receptors to differing degrees and not all of them can get into the brain, as they have to cross something called the blood–brain barrier. Even if certain drugs act on the M1 receptors in laboratory tests, in a human they may have no effect on brain function as they do not reach the receptors; this can make it hard to predict side-effects. As a result, a large trial looking at patients’ memory and cognitive function while on anticholinergics compared with a similar group of patients not taking them is needed. Some studies have been done and, so far, there is very little evidence that patients in these trials have decreased cognitive function. In studies of the effects of darifenacin, solifenacin and tolterodine, all newer antimuscarinics, none of them appear to have any adverse effect when compared with oxybutynin. However, all the studies have been of a single dose of a drug tested in small numbers of otherwise well older people, with totally intact cognition, not on lots of other medication. There have been no studies on people who have been taking the drug for a longer time, or have pre-existing memory problems. More studies are needed, but in clinical practice, cognitive impairment is not a common feature of the use of antimuscarinics and the medications appear to be safe. Medications that selectively block the M3 receptor and leave the M1 receptor, those important in short-term memory alone, would potentially have fewer effects on cognition and this has led to the production of more selective drugs. It is unlikely that these drugs will affect thinking ability, but people who are either on lots of other medication, or already have memory problems, may be at greater risk. Your GP will be able to perform a simple memory test, but this may not be sensitive enough to pick up subtle changes. High doses of these drugs have been associated with impaired immediate recall, delayed recall, and information processing, but some of these changes have not been recognised by those taking the medication. Overall impressions of family or caregivers become crucial in assessing if changes have occurred in the person prescribed these drugs and any suspicions should be reported to a doctor immediately. Some of the decline seen in Alzheimer’s disease (dementia) is thought to be due to degeneration of cholinergic nerves in the brain. Drugs called cholinesterase inhibitors (cognitive enhancers) are used to treat dementia. These drugs reduce the chemical breakdown of acetylcholine at the muscarinic receptors in the brain and increase nerve activity. The National Institute for Health and Clinical Excellence recommends the use of these drugs in patients with moderate cognitive impairment. Urinary incontinence and OAB often occur in people with dementia and there is evidence to show that people on cognitive enhancers develop OAB symptoms more readily – this is not surprising as the cognitive enhancer will also tend to increase the activity of the nerves that control bladder function. Treatment of OAB with antimuscarinics may be fine for OAB symptoms, but may make dementia problems worse as they will block the effects of the dementia drug. US researchers compared thinking and physical abilities of residents of nursing homes taking
CHARTER CONTINENCE CARE ISSUE 23
cholinesterase inhibitors and an antimuscarinic (tolterodine, trospium chloride, oxybutynin or oxybutynin gel) with patients only taking the cholinesterase inhibitors.9 The most physically able residents showed a greater decline over time if on both drugs compared with those only on the dementia drug. Antimuscarinic drugs are underused for OAB in older people. Concerns over side-effects may be contributing to low prescription rates, despite good evidence that they are safe and effective. Currently, only a small proportion of frail older people who are potential candidates for drug therapy for their incontinence are receiving it and this is also the case for relatively fit older people. More research is needed to determine if this low drug use is an active decision based on risk–benefit considerations or a lack of awareness of the potential benefits, or is due to a generalised undertreatment of OAB.
Summary Anticholinergics offer benefit to patients of any age and improve urinary symptoms and quality of life. They have been shown not to cause impairment of thinking ability in the fit elderly, but it has not been proven that they do not cause impairment in the frail elderly or those with pre-existing impairment of thinking ability ■ References 1. Irwin DE, Mislom I, Hunskaar S et al. Population-based survey of urinary incontinence, overactive bladder, and other lower urinary tract symptoms in five countries: results of the EPIC study. Eur Urol 2006; 50: 1306–1314. 2. Coyne K, Sexton C, Irwin D et al. The impact of overactive bladder, incontinence and other lower urinary tract symptoms on quality of life, work productivity, sexuality and emotional well-being in men and women: results from the EPIC study. BJU Int 2008; 101: 1388–1395. 3. Herbison P, Hay-Smith J, Ellis G, Moore K. Effectiveness of anticholinergic drugs compared with placebo in the treatment of over active bladder: systematic review. BMJ 2003; 326: 841–844. 4. Bartoli S, Aguzzi G, Tarricone R. Impact on quality of life of urinary incontinence and overactive bladder: a systematic literature review. Urology 2010; 75: 491–500. 5. Tsao JW, Heilman KM. Transient memory impairment and hallucinations associated with tolterodine use. N Engl J Med 2003; 349: 2274–2275. 6. Salvatore S, Serati M, Cardozo L, Uccella S, Bolis P. Cognitive dysfunction with tolterodine use. Am J Obstet Gynecol 2007; 197: e8. 7. Katz IR, Sands LP, Bilker W et al. Identification of medications that cause cognitive impairment in older people: the case of oxybutynin chloride. J Am Geriatr Soc 1998; 46: 8–13. 8. Mulsant BH, Pollock BG, Kirshner M et al. Serum anticholinergic activity in a community-based sample of older adults: relationship with cognitive performance. Arch Gen Psychiatry 2003; 60: 198–203. 9. Sink KM, Thomas J, Xu H et al. Dual use of anticholinergics and cholinesterase inhibitors: Long term functional and cognitive outcomes. J Am Geriatr Soc 2008; 56: 847–853.
Key points ● Overactive bladder (OAB) can have a significant impact on sufferers’ lives. ● Drugs that inhibit nerve impulses (anticholinergics) can be used to treat OAB effectively. ● A possible side-effect of anticholinergics is a worsening of the ability to think straight (cognitive dysfunction).
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Resources ■ Age UK
Age UK launched in April 2010 as the new force combining previous organisations Age Concern and Help the Aged. The Age UK family includes Age Scotland, Age Cymru and Age Northern Ireland. Age UK is inspired by the belief that it can improve the lives of people in later life. It celebrates aging and believes it presents unprecedented opportunities and challenges at home and abroad. Age UK challenges agist prejudice in society, provides services that address market failures and supports the public and private sectors to design age-friendly products and services. It supports people to remain in their own homes through campaigning and practical services and its Information and Advice service offers millions of people support on a range of issues from claiming benefits to staying fit and healthy.
Age UK funds biomedical research that helps tackle the ill health and poor quality of life that are too common as people age. Working with over 350 partners across the country, Age UK helps influence local decisions and deliver the most appropriate services. Its network of over 500 shops acts as a focal point for the local community, providing information and help with local services. Age UK works across the globe as well as in the UK, with its international partner, HelpAge International, championing older people's rights and needs and as an active member of the Disasters Emergency Committee. Age UK advice line: 0800 169 6565. websites: www.ageuk.org.uk www.ageuk.org.uk/scotland www.ageuk.org.uk/cymru
■ The Stroke
Each year, over 150,000 people in the UK have a stroke. Stroke is the third most common cause of death in the UK, and is the leading cause of severe adult disability. More than 250,000 people live in the UK with disabilities caused by stroke. The Stroke Association is the only UK-wide charity solely concerned with combating stroke in people of all ages. Its main focus is to prevent stroke and to give support to people who have had a stroke, and their families. The Stroke Association also campaigns to raise awareness of strokes and to fund research into stroke prevention, treatment and rehabilitation. It is estimated that about half of all people admitted to hospital after a stroke will have
some problems with bowel or bladder control. About 15% of people who have had a stroke will have ongoing continence problems a year after their stroke. The Stroke Association produces a number of publications, including patient leaflets, information for healthcare professionals and Stroke News (a quarterly magazine). You can ask us for information about any aspect of stroke, from stroke prevention to recovery from stroke, by calling our confidential Stroke Helpline, which is open from Monday to Friday, from 9 am to 5 pm. Helpline: 0303 30 33 100. email: info@stroke.org.uk website: www.stroke.org.uk
Mitrofanoffsupport.co.uk is a website that has been set up for everybody with a bladder defect, or family members, carers or friends who know somebody with this condition. It was launched by a woman with a Mitrofanoff urinary diversion who needed further surgery and tried to research the condition but found very little information. Bladder defects are not a subject that is openly discussed. As a result, there is a lack of public knowledge on what it is like to have a stoma. Mitrofanoffsupport.co.uk started in early 2010 to offer support and reassurance to anyone who may be about to have, or already has, a Mitrofanoff and, of course, your nearest and
dearest. We felt there was not enough support or guidance for adults with Mitrofanoffs. Our primary role is to represent the interests of people with a Mitrofanoff, as we are experts in living with them. Our overriding aim is to raise awareness of what it is like to have a stoma and what it means to live with a Mitrofanoff. By doing this, we hope to address the general lack of public knowledge – present and future. Remember, you are not alone. If you have a question, nothing is too stupid or small to ask. email: kyla@mitrofanoffsupport.co.uk website: www.mitrofanoffsupport.co.uk
Association
■ mitrofanoff
support.co.uk
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CHARTER CONTINENCE CARE ISSUE 23
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
I have a diagnosis of Cauda equina syndrome after suffering a herniated disc in April 2006. I use intermittent catheterisation and the Peristeen system to reduce incontinence. While I experience a degree of success, combined with oral laxatives, I am concerned that when I use the system, I bleed for several hours afterwards. I conclude that when I pump the balloon in order for the water to be retained, I break some small veins in the lower bowel. I have tried to reduce the air but then the irrigation is unsuccessful. My concern is that I leave myself open to infection. I have a family history of bowel cancer and am at a loss as to how to manage the system without blood loss.
me. When travelling, I have found it helpful to include two pairs of pants with fitted, washable pads. Except in the most primitive accommodation, there is always a radiator, or a line where these pants can be dried. It certainly cuts down on the space required for ordinary pads in hand luggage and a shared suitcase. Perhaps readers would find this helpful.
Ms D, London Thank you for your letter. It is nice to hear that you have found benefits from the reusable products; I do think that these products are underused ■ Thank you for the magazines. I have found them very helpful and the last one was very informative about some medical issues. My husband has Parkinson’s disease and at night uses a sheath – the only sort we have found not to wash off, with thanks to our district nurse. My husband has nocturnal polyurea (wees
Ms D (via email) Thank you so much for your letter. I would like to stress you must seek help from your doctor. You should not be experiencing any bleeding from the use of Peristeen. I assume you were fully assessed before you started to use the device, and received guidance as to its appropriate use by a specialist nurse or doctor. There are situations when we do not recommed usage; for example, if you have piles that have arisen after anal surgery. I hope you will contact your doctor to discuss this matter further ■ I read all of the articles in Charter continence care with interest and benefit from those that are relevant to
CHARTER CONTINENCE CARE ISSUE 23
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.
a lot at night) and although we have a two-litre night bag, it can overfill, especially if there is a lot of air and my husband has had a good fluid intake in the day. Now, I puncture the bag through with a sewing needle, at the top side of the bag. (One week, the hole was too near the middle and the bag leaked a bit.) The air escapes well and if the bag is full, it gently leaks into the bowl underneath, without any backflow along the sheath and without waking either of us.
Mrs F (via email) Thank you for your insight into the problems of polyurea. Did you know there are five-litre bags on the market that you can use? This may reduce the leakage. Men do produce some air when passing urine but this should be manageable if the bag is drained before you both settle down to sleep ■ In one of your issues of Charter continence care, an article referred to pseudomonas bacteria, which could be treated topically. My wife has a catheter that has an antibacterial silver alloy coating, changed every four weeks, in the hope that this would counter the discharge, but to no avail. Are you able to suggest what would get rid of the problem?
Mr T, Nottinghamshire According to independent research, these silver-coated catheters actually only prevent bacteria attaching for four days. It is possible that your wife may need longterm antibiotics and the catheter changing more frequently. However, if the problem is not having an effect on your wife, the catheter infections are extremely hard to eradicate. I do find if patients are wearing a disposable pad as well, this can be the route for the ‘bugs’ to get into the bladder, as it is a nice, warm, damp area – it can be ideal for bacterial growth. Unfortunately, I do not know your wife’s medical history and it may be advisable to seek an opinion on this matter from the urologist in your area ■
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