Pharmacists' Role in Managing Male Urinary Incontinence
Pharmacists' Role in Managing Male Urinary Incontinence
The specific management of UI depends on the patient's predominant symptoms. For overflow incontinence, if the patient's symptoms are mild, watchful waiting and lifestyle modifications are appropriate. Patients may need to void on a regular schedule (e.g., every 2 hours) to minimize bladder volume and distention. For moderate-to-severe symptoms, patients should receive interventions that promote acetylcholine transmission to the bladder (e.g., discontinue anticholinergic medications prior to a trial of bethanecol) and/or decrease bladder outlet obstruction (caused by prostate enlargement, urolithiasis, inflammation, or infection).
Medications for benign prostatic hyperplasia (BPH) include alpha1-adrenergic antagonists (e.g., alfuzosin, doxazosin, silodosin, tamsulosin, terazosin), 5-alpha-reductase inhibitors (e.g., dutasteride, finasteride), and phosphodiesterase 5 (PDE5) inhibitors (e.g., tadalafil). Alpha1-adrenergic antagonists provide the most immediate relief for bladder outlet obstruction caused by BPH, but they increase the risk of orthostatic hypotension; 5-alpha-reductase inhibitors predominantly reduce prostate size and, subsequently, prostate-specific antigen levels. Alpha1-adrenergic antagonists and 5-alpha-reductase inhibitors can be combined for the treatment of moderate-to-severe symptoms. PDE5 inhibitors can also be used safely with 5-alpha-reductase inhibitors, but they should not be routinely combined with alpha1 receptor antagonists, owing to the potential for additive hypotensive side effects.
Antimuscarinic therapy may be prescribed in patients with moderate-to-severe bladder-storage symptoms (although cautiously, as it may eventually worsen bladder outlet obstruction). Surgical treatment (e.g., bipolar or monopolar transurethral resection of the prostate, prostatectomy, intraprostatic onabotulinumtoxinA) may be warranted for symptoms that are not resolved by pharmacologic therapy.
For stress incontinence, which may be a result of prostate surgery, patients should receive information on pelvic-floor exercises, as well as on minimizing triggers (climbing stairs, coughing, exercising, jumping, laughing, lifting, pulling, sneezing). Patients should also be offered medications that increase contraction and sphincter muscle tone (e.g., pseudoephedrine, duloxetine, imipramine). If these pharmacologic interventions do not provide any benefit, some surgical options are available (collagen injection, artificial urinary sphincter).
Therapies for urge incontinence, or overactive bladder, are widely practiced. Behavioral therapy (e.g., bladder training, bladder control strategies, pelvic-floor muscle training, fluid management) is a first-line treatment. Although losing weight, reducing caffeine ingestion, and limiting fluid intake may not result in complete symptom relief, these nonpharmacologic interventions can be as effective as medications for significantly reducing incontinence, improving urinary frequency and nocturia, and enhancing quality of life in some patients. Second-line treatment includes the use of antimuscarinic medications (darifenacin, fesoterodine, mirabegron, oxybutynin, solifenacin, tolterodine, trospium). These agents have similar efficacy but differing pharmacokinetics (and therefore slightly different adverse-effect profiles), as highlighted in Table 3. Tricyclic antidepressants (desipramine, doxepin, imipramine, nortriptyline) are additional options, but they are not specific for muscarinic receptors in the bladder.
The benefits of antimuscarinic medications should be reviewed within 1 month of initiation. Of note, more than 50% of patients may discontinue antimuscarinic medications within the first 3 months because of lack of benefit, adverse effects, or cost of therapy. Extended-release, topical, and transdermal formulations generally confer lower rates of xerostomia. Patients who experience inadequate symptom control and/or unacceptable adverse effects should have their antimuscarinic dose modified or receive a different antimuscarinic. The mild side effects of occasional constipation or xerostomia can initially be controlled with bowel or fluid management, respectively. Antimuscarinic medications should not be prescribed for patients with narrow-angle glaucoma, impaired gastric emptying, or a history of urinary retention. Caution should always be exercised when prescribing antimuscarinic medications for patients who are already taking anticholinergics or who may be more susceptible to adverse effects (e.g., frail and older adults).
Patients who are refractory to first- and second-line therapies require referral to a specialist. Third-line treatments include neuromodulation (e.g., sacral nerve stimulation, percutaneous tibial nerve stimulation) and intradetrusor onabotulinumtoxinA. Indwelling catheters are not recommended because of the adverse risk/benefit balance, unless it is a last-resort option in selected patients. Rare cases may require augmentation cystoplasty or urinary diversion. Follow-up appointments are imperative for assessing adherence, safety, efficacy, and alternative treatment options.
For iatrogenic functional incontinence, the suspected medications and/or their respective doses should be modified. Otherwise, patients should have scheduled or prompted toileting and removal of physical barriers. If functional incontinence is not remedied, patients may soil themselves continuously, leading to hygienic and dermatologic complications (e.g., skin breakdown, ulceration, infections).
A trial of desmopressin may be warranted in patients who experience nocturnal diuresis caused by any of the aforementioned UI types.
Current Management
The specific management of UI depends on the patient's predominant symptoms. For overflow incontinence, if the patient's symptoms are mild, watchful waiting and lifestyle modifications are appropriate. Patients may need to void on a regular schedule (e.g., every 2 hours) to minimize bladder volume and distention. For moderate-to-severe symptoms, patients should receive interventions that promote acetylcholine transmission to the bladder (e.g., discontinue anticholinergic medications prior to a trial of bethanecol) and/or decrease bladder outlet obstruction (caused by prostate enlargement, urolithiasis, inflammation, or infection).
Medications for benign prostatic hyperplasia (BPH) include alpha1-adrenergic antagonists (e.g., alfuzosin, doxazosin, silodosin, tamsulosin, terazosin), 5-alpha-reductase inhibitors (e.g., dutasteride, finasteride), and phosphodiesterase 5 (PDE5) inhibitors (e.g., tadalafil). Alpha1-adrenergic antagonists provide the most immediate relief for bladder outlet obstruction caused by BPH, but they increase the risk of orthostatic hypotension; 5-alpha-reductase inhibitors predominantly reduce prostate size and, subsequently, prostate-specific antigen levels. Alpha1-adrenergic antagonists and 5-alpha-reductase inhibitors can be combined for the treatment of moderate-to-severe symptoms. PDE5 inhibitors can also be used safely with 5-alpha-reductase inhibitors, but they should not be routinely combined with alpha1 receptor antagonists, owing to the potential for additive hypotensive side effects.
Antimuscarinic therapy may be prescribed in patients with moderate-to-severe bladder-storage symptoms (although cautiously, as it may eventually worsen bladder outlet obstruction). Surgical treatment (e.g., bipolar or monopolar transurethral resection of the prostate, prostatectomy, intraprostatic onabotulinumtoxinA) may be warranted for symptoms that are not resolved by pharmacologic therapy.
For stress incontinence, which may be a result of prostate surgery, patients should receive information on pelvic-floor exercises, as well as on minimizing triggers (climbing stairs, coughing, exercising, jumping, laughing, lifting, pulling, sneezing). Patients should also be offered medications that increase contraction and sphincter muscle tone (e.g., pseudoephedrine, duloxetine, imipramine). If these pharmacologic interventions do not provide any benefit, some surgical options are available (collagen injection, artificial urinary sphincter).
Therapies for urge incontinence, or overactive bladder, are widely practiced. Behavioral therapy (e.g., bladder training, bladder control strategies, pelvic-floor muscle training, fluid management) is a first-line treatment. Although losing weight, reducing caffeine ingestion, and limiting fluid intake may not result in complete symptom relief, these nonpharmacologic interventions can be as effective as medications for significantly reducing incontinence, improving urinary frequency and nocturia, and enhancing quality of life in some patients. Second-line treatment includes the use of antimuscarinic medications (darifenacin, fesoterodine, mirabegron, oxybutynin, solifenacin, tolterodine, trospium). These agents have similar efficacy but differing pharmacokinetics (and therefore slightly different adverse-effect profiles), as highlighted in Table 3. Tricyclic antidepressants (desipramine, doxepin, imipramine, nortriptyline) are additional options, but they are not specific for muscarinic receptors in the bladder.
The benefits of antimuscarinic medications should be reviewed within 1 month of initiation. Of note, more than 50% of patients may discontinue antimuscarinic medications within the first 3 months because of lack of benefit, adverse effects, or cost of therapy. Extended-release, topical, and transdermal formulations generally confer lower rates of xerostomia. Patients who experience inadequate symptom control and/or unacceptable adverse effects should have their antimuscarinic dose modified or receive a different antimuscarinic. The mild side effects of occasional constipation or xerostomia can initially be controlled with bowel or fluid management, respectively. Antimuscarinic medications should not be prescribed for patients with narrow-angle glaucoma, impaired gastric emptying, or a history of urinary retention. Caution should always be exercised when prescribing antimuscarinic medications for patients who are already taking anticholinergics or who may be more susceptible to adverse effects (e.g., frail and older adults).
Patients who are refractory to first- and second-line therapies require referral to a specialist. Third-line treatments include neuromodulation (e.g., sacral nerve stimulation, percutaneous tibial nerve stimulation) and intradetrusor onabotulinumtoxinA. Indwelling catheters are not recommended because of the adverse risk/benefit balance, unless it is a last-resort option in selected patients. Rare cases may require augmentation cystoplasty or urinary diversion. Follow-up appointments are imperative for assessing adherence, safety, efficacy, and alternative treatment options.
For iatrogenic functional incontinence, the suspected medications and/or their respective doses should be modified. Otherwise, patients should have scheduled or prompted toileting and removal of physical barriers. If functional incontinence is not remedied, patients may soil themselves continuously, leading to hygienic and dermatologic complications (e.g., skin breakdown, ulceration, infections).
A trial of desmopressin may be warranted in patients who experience nocturnal diuresis caused by any of the aforementioned UI types.
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