Good Counsel on Continence
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If a patient is experiencing severe overactive bladder symptoms, JoAnn will prescribe an antimuscarinic agent such as tolterodine tartrate (Detrol™, Pharmacia & Upjohn, Peapack, NJ). “The patient may not have to be on it forever,” JoAnn says. “Once the bladder is retrained, he/she may be able to wean off the medication. Unfortunately, some clinicians simply hand the patient a prescription pill and do not discuss urge inhibition or a fluid management program. Or healthcare providers will prescribe oxybutin, unmindful of the fact that this is a difficult medication for the older patient to tolerate; it is short-acting, causing peaks and dips in medication blood levels which alters its efficacy, and it produces side effects such as dry mouth or eyes, constipation, and central nervous system consequences. Polypharmacy is problematic for the elderly — adding an anticholinergic with a strong side effect profile can put patients in jeopardy regarding fecal impaction, urinary retention, and confusion.
JoAnn is also a fan of another underutilized treatment for stress incontinence — the pessary. “It’s a wonderful option at any age,” she says. “Traditionally it was used only for cystocele and uterine prolapse and never considered for stress incontinence. Some women’s surgical risks may far outweigh the benefits of the procedure; a pessary may be an excellent alternative. For women in childbearing years who want to exercise and play with their children without leaking, it provides an easy option. If a patient is overweight and has difficulty with insertion, the clinician can place the pessary, have the patient wear it for the prescribed period of time (JoAnn’s patients average about 2 months), and come back to the clinic for cleaning and replacement. Because it takes trial-and-error time to fit, urologists and OB-GYNs often may not use the pessary. This provides a good opportunity for WOCNs to become involved — you don’ have to be an advanced practice nurse to do the things I do.”
Men also seek help from JoAnn’s continence clinic. “It takes guts to come to a women’s health center,” she says. “But sometimes men are too embarrassed to tell their male healthcare provider about their urgency or frequency problems or may have spoken to someone else but received little assistance. Sometimes they are afraid they have prostate cancer and just need someone who will listen to their fears and symptoms. If their concerns are valid, I will tell them they need to talk to a urologist, but often I’m the one they come to first.”