Urinary Incontinence an Often Unrecognized Cancer Complication

HOUSTON--Urinary incontinence is a common complication of cancer and cancer therapies that can impose long-term effects on quality of life; yet, this condition remains underemphasized in this patient population, Dorothy Smith, RN, OCN, director of Clinic Relations, Des Chutes Medical, Bend, Oregon, said at M.D. Anderson’s 2nd annual nursing conference.

Both patients and physicians tend to disregard incontinence, Ms. Smith said. "I’ve seen patients, men and women, who have been wet for 10 or 11 years. Although they are frustrated, they are coping with their condition rather than discussing it because they are embarrassed."

Caregivers may not understand the physiological effects certain cancers and cancer therapies can have on continence; rather, they may consider it a natural progression of age, she said. As such, urinary incontinence may not be considered an important quality-of-life concern and is typically underassessed and undertreated.

"We commonly associate incontinence with prostate cancer," Ms. Smith said. "But it can also occur as a complication of tumors of the bladder, cervix, lung, spine, vagina, urethra, and rectum, as well as all forms of cancer therapy."

The peripheral nerves that help control bladder function can be cut during surgery for cancer or damaged during radiation therapy, she said, and chemotherapy can also lead to peripheral nerve neuropathy.

Sedatives, antidepressants, and some anticancer agents have been shown to attack the mechanisms that control continence with severe results. As an example, Ms. Smith reported that "many women who have undergone tamoxifen (Nolvadex) treatment are now complaining of vaginal dryness, a sure sign of urethral dryness, which puts them at risk for developing incontinence."

Radiation can cause fibrosis, stric-turing, and other types of tissue scarring that compromise the blood supply and cause urinary incontinence. Advances in radiation therapy techniques and equipment have enabled doctors to adjust the field of radiation to spare normal tissue and reduce the risk of complications such as incontinence, but in some instances, normal tissue damage is unavoidable.

Ms. Smith commented that "three-dimensional (3D) radiation therapy enables doctors to conform the radiation to the prostate and totally spare the rectum. But physicians cannot spare the urethra."

Radiation exposure will cause the urethra to become dry and thin and lose tissue layers, she said. These changes may worsen and may eventually result in incontinence.

She noted that although physicians have always known that chemotherapy can cause cystitis and neurotoxicity, only recently have they begun to look at the effects of chemotherapy on the bladder.

When cancer therapies are combined, the risk of incontinence is magnified, she said. And the risk is further increased in older patients. Factors associated with aging that increase the risk of incontinence include decreased muscle tone in the bladder; a decrease in cardiac output, which means patients have more urinary output at night when they lie down and when there is less demand on the heart; and decreased inflammatory response.

Successful management of urinary incontinence should involve a combination of educational, preventive, and medical approaches, Ms. Smith said. She recommends that the care team assembled to assess and treat a patient’s incontinence should include physicians, nurses, and dietitians.

"Urinary incontinence presents an opportunity for multitask collaboration because some recommendations will be for medical intervention and some will be for preventive education and behavioral modification," she said.

A Careful History

Both patients and the medical staff need to be educated about the risk of incontinence presented by certain cancers. Ms. Smith said, "I have seen patients who have experienced incontinence for 10 or 11 years, yet neither the patient nor the physician has associated the incontinence with cancer or a cancer treatment. But when a careful history is done, there are no other risk factors that would explain the incontinence."

Treatment for incontinence is individual and involves consideration of many factors. Surgery is typically performed for stress incontinence, and medications are prescribed for patients with urge incontinence (see box).

Behavioral modification has been shown to be particularly successful in helping some patients control incontinence. Ms. Smith recommends pelvic muscle exercises, biofeedback, urge suppression techniques, prompted voiding, dietary and fluid management, and double voiding.

She added that everyone should be encouraged to practice pelvic muscle exercises regularly as a preventive measure. "People need to know that developing the pelvic muscle provides urinary support. Every woman needs to learn this before her first child is born, and every man needs to learn it before he reaches the age for increased risk of prostate cancer."