A fresh perspective on incontinence
At least three million people in the UK experience urinary incontinence, while up to a third of women have problems with their pelvic floor muscles. Pharmacies are well placed to raise awareness of incontinence and the importance of pelvic floor health, as well as recommending incontinence aids.
“We have a unique and invested relationship that goes beyond episodic ill health,” says Ade Williams, pharmacist at Bedminster pharmacy, Bristol. “These unique bonds offer the opportunity to support our patients with incontinence and bladder weakness. We are also ideally placed to help tackle health inequalities, earlier diagnosis of other urogenital conditions and even support young families experiencing incontinence and bladder weakness.”
Stephanie Hickford, brand manager for TENA, says Covid-19 has prompted changes in the incontinence market. “During the pandemic, many consumers cut down on shopping journeys, making fewer visits out of the home, meaning online sales increased as customers turned to delivery,” she says. “Community and group pharmacies need to be aware of this switch and be ready to compete with online or delivery services.”
According to Numark services development pharmacist Mathew Peters, having holistic conversations with customers is a must. “It is vital to assess presenting symptoms, identify the cause if possible, and discuss what exercises can help tackle the problem, as well as being able to offer temporary solutions,” he says. “Onward referral to a GP will usually be necessary to ensure a physical examination and further tests if necessary.”
A growing market
The bladder weakness category is worth £21.9 million in pharmacy (IRI: 52 weeks ending 12 June 2021), says TENA. Men’s products as well as pads and pants for women are showing the strongest growth.
Ontex marketing manager Alex Shaw says the ageing population is a key source of growth, with the number of over-65s in the UK set to double by 2030. Sales of incontinence products through UK pharmacy are expected to rise by 19.3 per cent by 2024. “Traditionally, most of our market is through hospitals and home delivery,” says Ms Shaw. “However, the non-tender [pharmacy and retail] market is the big growth area and we are focusing on independent pharmacies with our iD brand for the next few years.”
The company has nurses available to train pharmacy staff in its products. “Our research with consumers found that the majority are looking for a healthcare brand and they prefer to buy this from a pharmacy,” says Ms Shaw.
According to Cathy Crossthwaite, Numark OTC business development executive, incontinence products account for 3 per cent of total pharmacy space. “In terms of merchandising, bladder weakness is commonly included as part of the fixture alongside the feminine hygiene category, but bladder weakness is now the dominant category among these products,” she says. “There is still a strong focus on female products, but more products are being introduced for men as the condition becomes more talked about and understood.”
TENA’s Stephanie Hickford says there is no such thing as a typical incontinence customer. “It can affect men and women of all ages and each customer’s needs are different,” she says. “The strength of pharmacy is that staff can have individual conversations and use their expertise to offer the right products for each customer as well as advice on how to access the right support.” TENA provides training and advice on how to talk to different customers on its website (tenapharmacy.com).
Vinay Patel, Alphega pharmacy services and contract pharmacist, says more men are coming into pharmacies for advice about products. “The pharmacies that are most successful in catering for their needs have removed barriers such as poor category signage, knowledge and positioning, and have normalised the condition.”
Mr Patel believes it’s important to remember that caregivers are often those making the purchase. “Where possible, try to encourage them to bring in the patient,” he advises. “You can also consider arranging a phone call with the patient.”
To keep up with online competition, he recommends keeping up to date with the latest stock availability and new product development. “If you have a website – with or without e-commerce facilities – it’s important to keep your incontinence range up to date with the latest images and information,” he says.
Ms Crossthwaite adds: “New buyers, or those who have altered symptoms or are looking to try an alternative product will benefit from guidance from a healthcare professional. Guidance that can be found online may not answer the customer’s questions. This puts pharmacy in a great position.”
Causes and symptoms
There are many different types of incontinence. “Some are age-related – post-menopausal or due to benign prostate enlargement – or it can start because of a UTI,” explains Karen Powell, clinical nurse manager at Bladder Health UK. Bladder weakness can also occur as a side effect of certain types of medication, including ACE inhibitors, diuretics, HRT and sedatives.
Stress incontinence affects 90 per cent of people with incontinence. Symptoms present as leaking urine when the bladder is put under sudden pressure, such as when coughing, jumping or sneezing.
It is vital to assess presenting symptoms, identify the cause if possible, and discuss what exercises can help tackle the problem
The problem occurs when weakness in the muscles around the bladder prevents the urethra from closing properly. It is more common after a difficult birth, and in men after prostate or bladder surgery.
Pelvic floor exercises can strengthen the muscles to help manage the condition, while bladder weakness pads and liners will help people feel confident to carry on with their lives in the meantime.
Urge incontinence happens when the bladder is overactive or unstable. It affects as many as one in six adults, says Bladder Health UK. The urge to urinate comes on suddenly and can’t be controlled. This is sometimes part of a group of symptoms called Overactive Bladder Syndrome (OAB), which often has no apparent cause.
Urge incontinence is thought to be caused by abnormal communication between the brain and the bladder, which makes the bladder muscle contract spontaneously or too often. It can be triggered by a UTI, a prostate problem, Parkinson’s, multiple sclerosis or diabetes. Lifestyle changes and pelvic floor exercises can help.
Mixed incontinence causes symptoms of both stress incontinence and urge incontinence.
Overflow incontinence is when the bladder can’t empty completely, so that it swells. Sufferers pass small amounts of urine frequently. It’s often caused by a blockage to the bladder.
Total incontinence is severe and continuous incontinence. Possible causes include spinal injury, a bladder fistula or a congenital bladder problem.
Case study: Bedminster Pharmacy, Bristol
Bedminster Pharmacy has created a specialist incontinence care service model and has many new and repeat patients who come in for advice and purchases.
“There is no typical patient; people come in for themselves, loved ones, clients or neighbours,” says pharmacist Ade Williams. “It’s important to remember that irrespective of who is seeking help for whom, the priority is for us to offer this in a dignified, professional manner.
“We have prioritised creating a male-friendly service. We have also linked incontinence health with acute kidney injuries, frequent UTIs, and enlarged prostate, so our message is always holistic, not condition or product centred.”
On dealing sensitively with the subject, he advises: “Many people find these sorts of conversations easier in the third person. Try to find ways to break any tension. One key lesson is to initiate all conversations by offering use of the consultation room.”
How does he make sure the category stands out? “Make sure your category speaks of your ambition to offer inclusive, holistic, dignified professional care. Invest in training your team. Create an affordable offering, but position yourself beyond just a retailer/supplier avenue.”
Pelvic floor education
Pelvic floor exercises strengthen the muscles around the bladder, bottom, vagina and penis. They are an important way of helping to reduce and control urine leakage.
“Pelvic floor dysfunction in both sexes can result in urinary leakage, difficulty emptying the bowel effectively, or faecal leakage. In women, it can also cause pelvic organ prolapse,” says Katie Mann, clinical specialist physiotherapist and spokesperson for Pelvic Obstetric Gynaecological Physiotherapy (POGP).
The main thing to emphasise, says Ms Mann, is that pelvic floor exercises are simple. It is possible to feel where the pelvic floor muscles are located by trying to stop the flow of urine when going to the toilet.
“The exercise should consist of a ‘squeeze and lift’ movement,” she says. “There is no need to move the muscles in stages – we used to advise people to go up in stages like an elevator, but now we think more like an escalator – upwards and forwards all in one go. You can’t contract the back part of the muscle separately from the front – it all works as one unit.”
Ms Mann advises aiming for a 10 second ‘hold’. NICE guidelines are for 10 contractions lasting for 10 seconds each. She recommends doing these four times a day. “You also need to recommend doing quick pelvic floor contractions, without the hold, and then relaxing the muscles at the end of the exercises,” she says. “A pelvic floor that does not relax can give as many problems as one that is too loose.”
The main mistake people make is to bear down instead of pulling up. “This can make the problem worse. Another mistake is to hold your breath,” says Ms Mann.
In addition, people often mistakenly contract the gluteal muscles instead of the pelvic floor. “Frequently, you hear someone being told to tighten their bottom. But what is your bottom? So, the language needs to be specific – tighten your back passage as if holding in wind, squeeze at the front as if trying to stop a wee.”
It’s also important to remind customers that it takes time to get results. “We know it takes three to four months to achieve your potential, so there is no quick fix,” says Ms Mann.
She adds that after customers have achieved the level of recovery they are looking for, they should keep doing the exercises at a maintenance regime: “Twice a day is usually enough.”
If necessary, pharmacists can refer customers to see a specialist physiotherapist, who will devise a programme of tailor made exercises. For details, visit the directory of specialist physios.
Pharmacy staff are in a great position to have a supportive discussion in educating men
For customers unable to contract their pelvic floor muscles, electrical stimulation devices may be suitable. These work by inserting a small probe into the vagina or anus (men) so that an electric current runs through the probe to strengthen the muscles.
Alternatively, vaginal cones may help. These are small weights that are inserted into the vagina and held in place using the pelvic floor muscles.
Matthew Peters, Numark services development pharmacist, says: “There appears to be growing availability of pelvic floor devices, although due to higher cost, it is perhaps an area not currently explored by community pharmacy.”
A new app called CONfidence has been jointly launched by the Bladder & Bowel Confidence Health Integration Team (BABCON), the Florence Nightingale Foundation, UWE Bristol, and associated partners. Developed by Expert Self Care, including a team of national clinical experts, and patient and public partners, it aims to address inequalities in care for patients with pelvic floor disorders by providing advice and support.
Dr Nikki Cotterill, associate professor in continence care at UWE Bristol and director of the BABCON team, led the app’s development. “A gap exists between people who have incontinence symptoms and access to the help that is out there for them,” she says. “The app bridges that gap. People can discreetly access the right information and help.”
Dr Cotterill believes pharmacy could become more involved in helping customers who come in to buy incontinence aids. “They could be sensitively signposting customers for advice and how to improve their symptoms, as well as recommending the right incontinence products,” she believes.
UWE Bristol has been awarded a National Institute for Health Research grant to look at ways of developing more community pharmacy-based support for incontinence. In conjunction with a number of pharmacies, including Bedminster pharmacy in Bristol, a research study will start this October.
The CONfidence app is free to download for Apple and Android devices from the Mac App Store and Google Play.
While early prostate cancer often has no symptoms, some men do notice a weaker urine flow, increased frequency and difficulty starting to urinate. This could be a sign of prostate cancer or an enlarged prostate, says Lisa O’Sullivan, senior specialist nurse at Prostate Cancer UK.
“Pharmacy staff are in a great position to have a supportive discussion in educating men on the causes of urinary problems,” she says. “Men can be signposted to their GP or the Prostate Cancer UK website.”
Urinary problems in men are most common after prostate surgery as treatment can damage nerves and muscles. “Pharmacy staff can offer support by providing information around incontinence aids and talking about the importance of regular pelvic floor exercises,” says Ms O’Sullivan.
Self-help tips for customers
- Practise daily pelvic floor exercises
- Give up smoking (nicotine irritates the bladder and coughing strains the pelvic floor
- Avoid heavy lifting
- Lose excess weight
- Treat constipation
- Reduce caffeine and alcohol intake
- Drink six to eight glasses of water a day
- Avoid spicy and acidic foods
- Empty the bladder before physical activity
Tips for improving your category
“Clear category signage removes the need for patients to request support with product location. Signage with ‘bladder weakness’ instead of incontinence may provide less of a stigma,” says Mr Patel. “Familiarise yourself with the products you stock so you can better support patients with selection. Have samples available where possible.”
Ms Hickford advises: “Make sure incontinence products are easy to find and visible to pharmacy staff so they can spot customers who might need assistance. If you spot someone hovering around the incontinence products, approach them in a calm manner and help in a discreet way. Speak to customers with empathy. Reassure them they are not alone, and speak to them to understand the level of urine leakage they are experiencing and how often, so you can recommend the best solutions.”
“When merchandising your bladder weakness category, we recommend a discreet area of the pharmacy, perhaps by the consultation room or close
to the counter for easy access to advice,” says Ms Crossthwaite. “When merchandising within feminine hygiene, ensure plenty of space is allocated to bladder weakness as it’s a key sales driver. Ensure there is clear definition between feminine hygiene and bladder weakness by merchandising on different shelves.”
Ms Shaw adds: “We’ve created category management tools for pharmacy staff – shelf edgers, planograms, leaflets, etc – to help shoppers understand what they need.” These are available from Ontex.
- TENA has relaunched Lights by TENA as TENA Lights Liners. Made with soft, breathable materials and free from fragrance or dyes, they come in a range of sizes and absorbencies. The new packaging is made from 100 per cent renewable fibres.
- Ontex Healthcare has extended its iD range with new overnight pants. In September, the brand will also introduce a men’s pant.
Views of the P3pharmacy category panel
“This is an important category in our pharmacy, so much so that we’ve prioritised its location to the most visible and easily accessible area. Lots of customers don’t like to ask for incontinence products, so it’s vital that they can find them easily. It’s becoming an increasingly popular category as people become more accepting that these issues can be better managed. We get many more men coming in now for advice and products, and we are doing so many more deliveries these days, with a whole van load at a time.”
Lila Thakerar, Shaftesbury Pharmacy, Harrow
“With it mainly being older people who purchase these products, many prefer to come to the pharmacy rather than shop online, although our home delivery service has been increasingly popular through the pandemic. Tena does well for us, but we’ve just started stocking Attends, so it will be interesting to see how this does. It’s cheaper than Tena, but people do tend to stick with trusted brands. When you’re stocking a brand, always ask the supplier first which are the best sellers: there is no need to stock the whole range.”
Lindsey Fairbrother, Goodlife Pharmacy, Hatton, Derbyshire
“Incontinence isn’t a very big category in my pharmacy. However, being educated on absorbency and types of products will always come in handy – especially with an ageing population. Customers typically ask about fit, how much of an absorbency rating is needed, and what new products are in stock. Tena is a popular brand, with a large scope of different fits. I’ve noticed there has been more of a push to normalise incontinence as an issue and have products that are closer in look and texture to regular undergarments, which customers like.”
Marisa Maciborka, Well Pharmacy, Tonteg, South Wales
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