Underactive Bladder Causes, Treatments and Counseling Tips for Compounding Pharmacists
Kelly visited the bathroom four times in 15 minutes before finally feeling as if she had emptied her bladder. She figured her struggle with debilitating anxiety made her muscles too tense to let urine flow. This struggle lasted for months before her doctor finally ran tests and diagnosed underactive bladder. Matt faced the same issues. His urinary hesitancy meant that every trip to the bathroom took such a long time that his friends began to notice and cracked jokes at his expense. The causes of underactive bladder are complex and marked by diverse underlying conditions. Compounding pharmacists can improve their patients’ quality of life by offering desperately needed information.
Complex Underlying Causes of Underactive Bladder
Underactive bladder is going through an identity crisis. Historically, detrusor underactivity (DU) and underactive bladder (UAB) were synonymous, but as this under-researched condition garners more attention, experts realize they may represent distinct entities. While DU causes underactive bladder, not everyone with an underactive bladder has DU. In fact, a retrospective chart review of patients with voiding dysfunction found that urodynamic studies confirmed DU in only 23 percent.1 The estimated prevalence of underactive bladder—23 percent—is actually higher than that of its better-known opposite, overactive bladder.2
An evidence-based definition of UAB was still lacking as of March 2016, which limits its recognition and diagnosis in clinical practice. Expert consensus defines it as a syndrome with the following symptoms:
- Prolonged urination time with or without incomplete bladder emptying
- Urinary hesitancy
- Slow stream of urine
- Straining to urinate
- Sensation of incomplete bladder emptying
The evolving perspective of UAB acknowledges multiple pathophysiologies arising from central nervous system control, motor control, and peripheral response in the bladder. As a result, underactive bladder causes are hard to target. Even though diverse health conditions are associated with UAB, the three at the top of the list represent the highest risk factors:3
- Bladder outlet obstruction
- Acute cerebrovascular accidents
- Multiple sclerosis
- Parkinson’s disease
- Bladder outlet obstruction
- Injury to the peripheral nervous system
- Infectious neurologic diseases such as AIDS
When any type of neurological disorder affects the bladder, the condition is called neurogenic bladder. The distinction is important because a neurogenic bladder can cause overactive and underactive bladder.
Conservative and Pharmaceutical Treatment Options
It wasn’t long ago—just 2013—when underactive bladder was called a new frontier for the academic community and pharmaceutical industry, which reflects the lack of definition and treatment options. Any underlying disease must first be diagnosed, as that directs therapy, then detailed neurologic and urodynamic examinations are needed to assess UAB. Still the process isn’t straightforward. For example, diabetic cystopathy may have few symptoms and often occurs with concomitant diseases such as stress urinary incontinence and urinary tract infection.
Pharmaceutical Interventions: Unlike the effective treatments available for overactive bladder, health professionals have few choices for underactive bladder. Drug therapy for neurogenic bladder relies on a different regimen that includes antispasmodic drugs, antidepressants such as amitriptyline and sometimes estrogen. But pharmaceutical treatment for UAB is limited to:
- Muscarinic receptor agonists: bethanechol and carbachol
- Acetylcholinesterase: distigmine
- Alpha-adrenoceptor antagonists: indoramin and doxazosin
Since none of the medications are bladder-specific and side-effects often outweigh benefits, the industry desperately needs more research. Misoprostol and cholinesterase inhibitors show promise but carry safety concerns. A variety of approaches, from novel muscarinic receptor manipulation to prokinetics used in gastroenterology and smooth muscle ionotropics used in cardiology, have also peaked researcher’s interest, notes a 2013 report in Reviews in Urology.4
Conventional Treatments: The vast majority of patients, especially those diagnosed with detrusor dysfunction, learn to rely on conventional methods to improve underactive bladder.
- Intermittent self-catheterization: In some cases, a short-term indwelling catheter or suprapubic catheter may be used, but most self-catheterize several times daily.
- InFlow Device: Once inserted into the urethra, this device contains a pump that enables normal bladder emptying when activated by remote control. However, it’s only approved for women and must be replaced every 29 days.
- Reflex double voiding: Patients can be taught how to stimulate zones that trigger urination.
- Sacral neuromodulation: Shows promise and is successful for some patients.
How to Reach Out to Patients with Underactive Bladder
People tend not to talk about bladder problems in general and UAB is especially likely to leave patients in the dark due to its complex presentation. Pharmacists are always discrete, but remember that this group of patients often suffers from embarrassment and anxiety. Except for those purchasing catheters or incontinence products, this is a hard group to proactively target. Stay on the alert for these opportunities:
Recurrent urinary tract infections: When you see the same patient filling prescriptions for UTIs, don’t hesitate to talk about UAB. It may have been overlooked as a potential cause, yet UAB is increasingly implicated as a cause of UTI.
Medications that exacerbate symptoms: Neuroleptics, calcium channel blockers and alpha-receptor agonists may worsen symptoms in individuals with or at risk for UAB. Ask about bladder problems during medication reviews.
Prior pelvic and back surgery: Forty percent of post-pelvic surgery patients and nearly 20 percent of patients who have had back surgery develop UAB. Yet 33 percent of them also take medications known to promote urinary retention. While patients should be warned about UAB, this is a good time to reach out to physicians to establish a collaborative effort.
Compounded options for elderly: As people age, they’re at a higher risk of UAB and other chronic diseases. Improve adherence for patients taking multiple meds by combining them into a single dose or another form that’s best for the patient.
Pads and diapers: The bladder may retain so much urine that patients leak, so some adults purchasing incontinence products may have UAB and not know it. Take a moment to talk with them or offer a brochure about UAB.
Underactive Bladder Increasingly in the Spotlight
As the urology community continues to research underactive bladder, the number of treatments—and their subsequent market—will continue to grow. Then there’s the aging population and the ever-growing number of people with chronic disease linked to UAB to consider. Compounding pharmacists can grow their business and improve their patients’ health by getting involved now and including underactive bladder as part of their communication with patients.
Pharmaceutica North America is dedicated to ongoing pharmaceutical research efforts, so we’ll help you stay on top of new products that help treat underactive bladder. Contact us today to talk about how our line of high-quality bulk APIs, pre-weighed active and custom compounding kits and OTC supplements can fill your pharmaceutical needs.
- “Underactive Bladder: Clinical Features, Urodynamic Parameters and Treatment,” September 2015, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4582091/ ↩
- Epidemiology and Demographics of the Underactive Bladder: A Cross-Sectional Survey,” September 2014, http://www.ncbi.nlm.nih.gov/pubmed/25238889 ↩
- “Underactive Bladder: Definition, Diagnosis and Treatment,” December 2015, http://urologytimes.modernmedicine.com/urology-times/news/underactive-bladder-definition-diagnosis-and-treatment ↩
- “The Other Bladder Syndrome: Underactive Bladder,” 2013, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3651538/ ↩