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. Andersons 2nd annual
Both patients and physicians tend to disregard incontinence, Ms.
Smith said. "Ive 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
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 patients 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."