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Overactive bladder in primary care

Katherine Wilkinson
RGN DN MA
DN/HV Prescribing ENB 900 ENB 978
Independent and Supplementary Nurse Prescribing
Nurse Consultant Continence Care Airedale PCT
West Yorkshire

Many epidemiological studies reporting the prevalence of urinary incontinence have been published. Due to the different populations, sample sizes and research methodologies used, there is a wide variation in the results.(1) It is estimated that over 50 million people in the developing world are affected by urinary incontinence,(2) with 2.5-4 million people with incontinence in the UK.(3) Underreporting of incontinence is a problem in all ages. Lack of understanding and embarrassment are major factors stopping individuals seeking professional help.(4)

Overactive bladder
Overactive bladder is described by the International Continence Society as a chronic and disabling condition characterised by urinary frequency, with or without urge incontinence, usually in combination with urinary frequency and nocturia.(5) It is recognised as a clinical condition that occurs in the absence of any identifiable local pathology.(6) Recent studies in America reported a prevalence of 16.6% in adult men and women,(7) increasing with age, although it is believed that the prevalence is underreported.(8)
The symptoms of overactive bladder occur as a result of uncontrolled bladder contractions during the filling phase due to detrusor hyperreflexia or instability, which are mediated by stimulation of cholinergic muscarinic receptors.(9)
The underlying causes of overactive bladder are numerous. In neurological diseases such as multiple sclerosis, stroke and Parkinson's disease, the inhibitory impulses from the brain to the detrusor muscle may be interrupted, allowing activation of the sacral arc reflex, which results in an unwanted detrusor contraction, causing urinary urgency with or without urge incontinence.
A common cause of urinary urgency and frequency, particularly in older people, is urinary tract infection. Other sensory causes include bladder stones, bladder tumour, an enlarged prostate and faecal impaction.

Quality of life issues
Overactive bladder can have a huge impact on quality of life. Patients with overactive bladder are known to have a significantly poorer quality of life than an age- matched population.(10) Many people with overactive bladder restrict social activities, avoid travelling, plan daily activities around toilet stops, and as a result can become depressed and low in self-esteem. Johannesson et al reported that overactive bladder was found to have a greater impact on quality of life than type 2 diabetes mellitus.(11)

The importance of assessment
Good Practice in Continence Services sets out a model of good practice for integrated continence services.(12) It emphasises the importance of identifying all people with incontinence in primary care, and offering them an assessment by a suitably trained health professional. Nurses working in primary care have many opportunities to identify individuals with incontinence, for example at well-woman clinics. Most areas have continence nurse specialists who will take referrals to assess patients at a clinic or at home.
The aim of the continence assessment is to identify the type of incontinence, initiate appropriate treatment and make secondary referral where indicated. A thorough continence assessment is time-consuming, generally taking around 45 minutes. In patients presenting with new urinary symptoms it is essential to exclude any underlying physical causes before assuming a provisional diagnosis of overactive bladder.
Patients with overactive bladder are often very anxious about their condition and have low self-esteem as a result of the impact on their quality of life. They may need time to talk about their feelings; therefore listening skills and the ability to empathise are important.
A medical and obstetric history should be taken and the medication reviewed. It is important to be aware that many drugs can cause bladder symptoms such as urgency, frequency, voiding difficulty, retention and nocturia.
The bladder record diary has been described as the single most useful tool in assessing urinary incontinence.(13) The patient records the fluid intake and type, urinary output and any incontinent episodes for a period of 3-5 days, providing an objective record of their voiding pattern that can be used as a baseline upon which the effectiveness of treatment can be measured.
Urinalysis dip testing should be carried out for leucocytes, nitrite, blood, protein, pH, specific gravity, ketones and glucose. This may detect conditions such as urinary tract infection or diabetes; both can cause urinary frequency and urgency. Haematuria may be indicative of pathology such as bladder tumour, stones or renal disease, and therefore such patients must always be referred for urological investigations.
A bladder scan should be performed to exclude a postmicturition residual volume. In men a rectal examination may be carried out to assess the size and consistency of the prostate gland. A prostate-specific antigen (PSA) blood test may be done as part of the diagnostic tests for prostate cancer.
In female patients, after gaining informed consent a vaginal examination may be performed to assess the strength of the pelvic floor muscles and observe for prolapse, atrophic changes and excoriation.
 
Treatment of overactive bladder
To make a definitive diagnosis of overactive bladder, urodynamic studies must be done. However, it is generally considered to be good practice to make a working diagnosis on the medical history alone, treating the patient empirically for a 2-3 month period.(14) Bladder retraining, pelvic floor exercises and pharmacotherapy is the mainstay of treatment of overactive bladder. Botulinum toxin A injections into the detrusor muscle have been reported to be a promising new treatment.(15) Other treatments include electrical stimulation,(16) hypnotherapy and acupuncture.(17) In severe cases, as a last resort, surgery in the form of clam ileocystoplasty may be an option. However, this procedure can have unacceptable complications, which include voiding difficulty, mucus production, stone formation, infection, and fluid and electrolyte disturbance.(18)

Bladder retraining
The aim of bladder retraining is to restore the voiding pattern to one that is acceptable to the patient. Individuals with severe urgency and frequency can find bladder retraining to be very difficult and often need motivation and support.(19)
Having established the baseline of the patient's voiding pattern through the use of a bladder diary, an individualised programme of bladder retraining can be devised. For example, the patient may be asked to try to hold on for 15 minutes after feeling the urge to void. When this is achievable, the holding-on period is extended to 30 minutes, and so on until the interval between voiding is between two and four hours.
Contracting the pelvic floor muscles may help to reduce the feeling of urgency and enable the patient to defer the urge to void.

Pharmacotherapy
For patients with severe urgency and frequency, or for those who have failed to respond to a six-week period of bladder retraining, drug therapy may be indicated.
Effective pharmacotherapy is available in the form of anticholinergic drugs (see Table 1). Antimuscarinic drugs suppress the muscle activity of the bladder by acting at the neuromuscular junction of the detrusor muscle, working on the muscarinic receptors (M2 and M3) in the bladder. They act by blocking the transmission of acetylcholine and preventing the transmission of parasympathetic nerve impulses.

[[NIP25_table1_76]]

Muscarinic receptors are distributed throughout the body, for example in the salivary glands, brain, spinal cord, heart, liver, gall bladder, pancreas, stomach and colon, as well as the bladder. Therefore with this type of drug, patients can experience side-effects such as dry mouth and constipation. There are currently several available anticholinergic drugs; some are more bladder receptor selective and available in extended- release form, therefore less likely to cause side-effects.
Oxybutynin is the least expensive and one of the most commonly prescribed drugs for overactive bladder in the UK. The main drawback in trials of high-dose oxybutynin has been the incidence of side-effects, with up to 80% suffering significant adverse reactions.(8) The modified-release preparation of oxybutynin retains the efficacy of the standard release form but with up to 40% fewer reported side-effects.(8) Transdermal patches of oxybutynin are now available and offer a new alternative to oral anticholinergic medication.
Tolterodine is a newer, nonselective anticholinergic drug and is reported to have some functional selectivity for the bladder muscarinic receptors. The drug is as efficacious as oxybutynin and has the advantage of greater tolerability.(8) In its extended-release form its overall efficacy and tolerability have contributed to increased compliance.(20)
When selecting antimuscarinic medication, local prescribing guidelines should be consulted. Medication for overactive bladder can be found in section 7.4.2 of the British National Formulary 49.(21)

Nurse prescribing for overactive bladder
Nurses with the appropriate qualifications are now able to prescribe for patients. Extended nurse prescribers can at present prescribe only from a limited formulary for a range of specific conditions. Overactive bladder is not currently a condition that extended nurse prescribers can prescribe for, which is a source of frustration for many continence nurse specialists. This may change when the results are known from a recent consultation on options for the future of independent prescribing by extended formulary nurse prescribers.(21) There are five options, ranging from extended nurse prescribing remaining as it is to extended formulary nurse prescribers being able to prescribe for any medical condition from a full formulary.
Nurses who also hold the supplementary prescribing qualification may prescribe for patients with overactive bladder within a clinical management plan.
Supplementary prescribing is defined as "A voluntary prescribing partnership between an independent prescriber and a supplementary prescriber to implement an agreed patient-specific clinical management plan with the patient's agreement".(22)
Recently it was announced that chiropodists/podiatrists, physiotherapists and radiographers are now able to train to become supplementary prescribers.(23)
Key principles of supplementary prescribing are:

  • Good communication between prescribing partners.
  • The diagnosis must be made by the independent prescriber.   
  • There must be access to shared patient records.
  • The patient is involved in all decision-making.

The clinical management plan
The clinical management plan is a lawful requirement of supplementary prescribing. It is an individualised patient-specific document detailing the illness or condition, which may be treated by the supplementary prescriber and the date for review by the independent prescriber (doctor or dentist), which normally does not exceed one year.

Conclusion
Nurses working in primary care are ideally placed to identify individuals suffering from overactive bladder. Having identified them, they can follow local referral pathways to ensure that patients receive a comprehensive assessment and are offered appropriate treatment in primary care.
Nurse prescribing of medication for patients with overactive bladder enables nurses to provide holistic care for patients. Through partnerships working with medical colleagues and the use of supplementary prescribing to prescribe anticholinergic medication, nurses can streamline care and improve the quality of life for patients with this distressing condition.
Many nurse prescribers working in continence care are hopeful that the outcome of the recent consultation on nurse prescribing will enable them to prescribe independently for patients with overactive bladder in the near future.

References

  1. Abrams P, et al. Incontinence. Volume 1: basics and evaluation. International Continence Society; 2005. p. 266.
  2. Abrams P, et al. Incontinence. Volume 2: management. International Continence Society; 2005. p. 818.
  3. Royal College of Physicians. Report of a working party: Incontinence - causes, management and provision of services. London; RCP: 1995.
  4. White H, et al. Promoting continence. London; Ballière Tindall: 1997. p. 13.
  5. Abrams P, et al. Neurourol Urodyn 2002;21:167-78.
  6. Chapple CR, MacDiarmid SA. Urodynamics made easy. Edinburgh: Churchill Livingstone; 2000.
  7. Milsom I, et al. BJU Int 2001;87:760.
  8. Wagg A. Continence 2004;24(2).
  9. Todorova A, et al. J Clin Pharmacol 2001;41(6):636.
  10. Abrams P, et al. The overactive bladder. Stockholm: Sparre Medical Group; 1998.
  11. Johannesson M, et al. Br J Urol 1997;80:557-62.
  12. Department of Health. Good practice in continence services. London: DH; 2000.
  13. Norton C. Nursing for continence. 2nd rev ed. Bucks: Beaconsfield Publishers; 1996.
  14. Tennant S. Urol Times 2004;1(6).
  15. Lewey J. Prof Nurse 1999;15(3):211-4.
  16. Kelleher C. ACA Continence J 1998;18(3):12.
  17. Venn S, Mundy T. Detrusor instability. In: Clinical Urogynecology. London: Churchill Livingstone; 2000.p. 219-26.
  18. Getcliffe K, Dolman M. Promoting continence. 2nd ed. London: Ballière Tindall; 2003.
  19. Baigrie RJ, et al. Br J Urol 998;62:319-22.
  20. British Medical Association and Royal Pharmaceutical Society of Great Britain. British National Formulary 2005 Mar:49.
  21. Medicines and Healthcare Products Regulatory Agency. Consultation on options for the future of independent prescribing by extended formulary nurse prescribers. Ref MLX 320. London: DH; 2005.
  22. DH. Supplementary prescribing for nurses and pharmacists within the NHS in England. A guide for implementation. London: DH; 2003.
  23. DH. Supplementary prescribing by nurses, pharmacists, chiropodists/ podiatrists, physiotherapists and radiographers within the NHS in England. Gateway reference 4941; 2005.

Resource
International Continence Society
W:www.continet.org