Instructor: Sharee A,Wiggins, NP, PostMS(N), ARNP, BC-GNP, BC-ANP
Module Revised by: Sharee A. Wiggins, NP; Tomas Griebling, MD; Anne Walling, MB ChB
Reviewed by: Anne Walling, MB, ChB
Specific Learning Objectives:
A. Introduction:
Before reviewing the learning objectives and content, please take the Pre-Test.
Please review the Objectives, Content material, and Cases before our class session. We will apply the tasks in the Skills Objectives to these cases, and you should think about them ahead of time.
B. Attitudes - Medical students should recognize:
C. Knowledge - Medical Students should be able to:
D. Skills - Medical students should be able to:
E. Readings:
Required Readings:
DeMaagd, G. (2007). Urinary incontinence: Treatment update with a focus on pharmacological management. U. S. Pharmacist; 32(6):34-44. Available online at: http://www.uspharmacist.com/index.asp?show=article&page=8_2047.htm
Weiss, B. D. (2005). Selecting medications for the treatment of urinary incontinence. American Family Physician; 71(2). Available online at:http://www.aafp.org/afp/20050115/315.html
Recommended Resources & References:
Cefalu, C. A. (2007). Urinary Incontinence, 306-323. In Ham, R. J., Sloane, P. D., Warsaw, G. A., Bernard, M. A., & Flaherty, E. Primary Care Geriatrics: A Case Based Approach (5th Ed.). Moby: St. Louis.
DeMaagd, G., & Geibing, J. D. (2006). An overview of overactive bladder and its pharmacological management with a focus on anticholinergic drugs. P&T; 31(8); 462-474. Available online at: http://www.ptcommunity.com/ptjournal/fulltext/31/8/PTJ3108462.pdf
[Note: the student is directed to the excellent discussion of anticholinergic and antimuscarinic pharmacology in this Pharmacy and Therapeutics article.]Mayo Clinic. (2007, March 23). Urinary incontinence surgery: When other treatments aren’t enough. Available online at:http://www.mayoclinic.com/health/urinary-incontinence-surgery/WO00126
Morrison, A., & Levy, R. (2006). Fraction of nursing home admissions attributable to urinary incontinence. International Society for Pharmacoeconomics and Outcomes Research (ISPOR); Value in Health; 9(4); 272-274. Available online at: http://www.blackwell-synergy.com/doi/abs/10.1111/j.1524-4733.2006.00109.x?journalCode=vhe
Zagaria, M. E. (2006). Persistent urinary incontinence in older women: Treatment can improve quality of life. U. S. Pharmacist; 31(9):20-34. Available online at: http://www.uspharmacist.com/index.asp?show=article&page=8_1846.htm
American Medical Directors Association. (2005). Urinary Incontinence: Clinical Practice Guideline. Columbia, MD: AMDA..
Urinary incontinence (UI) is defined as the involuntary, unintended leakage of urine. It is a major geriatric syndrome and awkward topic for many older adults to discuss. Many patients suffer in silence from social, emotional, or medical consequences of incontinence. These can include anxiety, sleep disturbance, low self esteem, shame, guilt, social isolation, depression, pressure ulcers, infections, and falls.
Acute (transient) UI: characterized by abrupt onset and association with a precipitating cause. Treatment is directed at removing the cause and preventing recurrence. The mnemonics DIAPPERS and DRIP have been suggested to help remember the causes of acute incontinence (and potentially reversible).
Delirium (drugs, acute illness)
Infection/Inflammation/Immobility
Atrophic Vaginitis
Pharmacologic
Psychological
Endocrine (Diabetes, Calcium)
Restricted Mobility/Retention
Stool ImpactionDelirium (drugs, acute illness)
Retention (hypocontractility or outflow obstruction)
Impacted stool/Inflammation/Infection
Polyuria (drugs, high output states)A less common cause of acute or semi-acute incontinence is normal pressure hydrocephalus (NPH). An over-simplified description of the condition is the presence of ventricular enlargement with increased cerebrospinal fluid resulting in the triad of cognitive impairment, gait disorder, and incontinence (“wet, wobbly, and wacky”), occurring after the fifth decade of life. An index of suspicion for possible NPH should be maintained since symptoms may be reversible or improved by prompt diagnosis and intervention.
Chronic (established) UI can be classified according to symptoms; these 4 types are: 1) urge, 2) stress, 3) overflow, and 4) mixed. Another form of UI, functional incontinence, is not symptom based.
Urge Incontinence: characterized by leakage of urine (usually large volumes) due to inability to delay voiding after perceiving the sensation of bladder fullness.It is the most common type of UI in the elderly and occurs as uninhibited bladder contractions with a sudden urge to void. Patients perceive the "urge" to urinate, but cannot maintain bladder continence long enough to reach a toilet in time. Urgency, frequency, and nocturia are typical symptoms. The mechanism is detrusor overactivity. Other names for the condition include overactive bladder (OAB – however, not all OAB results in incontinence), detrusor hyperreflexia, and irritable bladder (older term). Many cases are idiopathic. Other causes include:
- Local irritation: inflammation, hyperosmolar states, drugs, caffeine, alcohol, spicy foods, citrus, infection, stones, tumors, diverticuli, obstruction (prostate enlargement)
- CNS: dementia, Parkinson's, CVA, cord injury or disease
- DHIC: Detrusor Hyperreflexia with Impaired Contractility; more common in, but not limited to, institutionalized patients
Stress Incontinence: nearly immediate involuntary leakage of urine (small volumes) when intra-abdominal pressure increases during activities such as coughing, laughing, sneezing or sudden movement.It is more common in women and the third most common type of UI. The mechanism is mainly a sphincter problem caused by pelvic floor muscle relaxation (both parity and age-related changes) or sphincter/bladder outlet incompetence (prior instrumentation, prostate surgery).
Overflow Incontinence: frequent or continuous leakage of urine due to mechanical forces on a full or over-distended bladder or from other effects of urinary retention on bladder and sphincter function. The bladder does not contract properly. As a result it stretches to hold a large capacity of urine, small amounts of which leak frequently or continuously once the bladder is filled. Causes include:
- Obstruction – prostate hypertrophy, urethral stricture, cystocele, pelvic mass
- Hypocontractility – associated with both muscular and neurologic etiologies. Examples include: diabetic neuropathy, spinal cord injuries, multiple sclerosis, medications, sphincter dyssynergy.
Mixed Incontinence: more than one type of UI in same patient. Usually mixed incontinence refers to the presence of both stress and urge types. The postmenopausal woman is an example. This is the second most common type of UI.
However, an example of a different type of mixed UI is the patient with arthritis who receives a diuretic for heart failure and becomes incontinent in the hospital. He has functional incontinence due to severe mobility impairments, and urge incontinence from the diuretic.
Functional Incontinence: is due to extrinsic causes in patients who may have normal bladder function. The bladder itself functions properly, but the patient is unable to recognize the urge to void or is physically unable to get to the toilet in time. Causes include orthopedic limitations/immobility, cognitive or psychological problems (dementia, depression, delirium and anger or hostility), and environmental barriers.
Estimates vary by population studied and definitions used. Even in younger adults, UI is surprisingly common (up to 30% women and 5% men younger than 65 years of age) but fewer than half of sufferers ever seek medical attention. Estimates by elderly population include:
- community dwelling and hospitalized elderly – 40%
- long term care facilities – 60%.
A large number of caregivers cite UI as a factor in the decision to institutionalize an older adult. Data published in 2006 identified the attributable fraction of nursing home admissions due to UI was 6% for women and 10% for men. Further, the annualized cost of nursing home admissions due to UI is estimated at about $6 billion. (Morrison & Levy)
Normal micturition (urination) depends on several factors working synchronously. Many pathological processes and age-related changes can result in UI. Control of urination primarily depends on the detrusor and sphincter muscles plus associated structures. Mechanisms of various forms of incontinence are noted in the preceding definitions of each type. Innervation is briefly addressed below.
Innervation of Urinary Bladder
Detrusor muscle: multilayered contractile bladder muscle can allow filling until distension triggers voiding urge. Cortical activity as well as spinal and pelvic (cholinergic) nerves control voiding. When the bladder has filled with 200-400mls of urine, urge to void is perceived. During micurition (voiding), it is the parasympathetic nervous system which causes a release of acetylcholine, which in turn, results in detrusor contractions. Detrusor contraction may be inhibited by damage or interference with this system directly or by medications blocking cholinergic, prostaglandin or calcium channel activity.
Sphincter muscles: internal and external sphincter functions depend on integrity of muscle, innervation, and anatomic relationship (angle of the bladder to the urethra). Appropriate angulation and integrity of structures prevent urine loss when intra-abdominal pressure increases. Regarding innervation: alpha-adrenergic activity causes sphincter contraction (retention of urine) whereas beta-adrenergic activity causes sphincter relaxation (leakage) of urine (and obviously blocking agents cause the reverse!)
Contributions of aging to UI: urinary incontinence is one of the geriatric syndromes and is not inevitable or accepted as a normal age-related change. However, several changes that accompany aging do contribute to a predisposition toward the development of UI. The table below summarizes many of these changes and potential outcomes.
Age Related Changes which may Contribute to Urinary Incontinence
Atrophic vaginitis & urethritis
Decreased urethral mucosal seal, irritation, UTI
Urge; Stress
Benign prostate hyperplasia
Outlet obstruction; frequency, urgency nocturia, detrusor overactivity
Urge; Overflow
Reduced ability to delay voiding
Frequency, urgency, nocturia
New/worsened: Urge, Stress, Mixed
Decreased detrusor contractility
Decreased flow rate; increased postvoid residual; hesitancy
Overflow; DHIC
Decreased bladder capacity
Frequency, urgency, nocturia
New/worsened: Urge, Stress, Mixed
Detrusor overactivity (about 20% of continent persons)
Frequency, urgency, nocturia
Urge; Mixed; DHIC
Increased postvoid residual (< 50 mL)
Frequency, nocturia
New/worsened: Urge, Stress, Mixed
Increased urine output later in the day
Nocturia
Nocturnal
* DHIC = detrusor hyperactivity with impaired contractility
Geriatrics Review Syllabus, 6th ed., p. 186
Most cases of UI can be adequately evaluated without cystoscopy, imaging or urodynamic studies. Careful history and exam remain the clinician’s best tools to assess the characteristics and causes of the patient’s incontinence and to rule out potentially reversible conditions.
Potentially reversible conditions include medication effects, delirium, atrophic vaginitis, polyuria of diabetes, fecal impaction, urinary tract infection, and mobility problems.
- History -- Recall that history is 70-90% of diagnosis.
- HPI of UI: onset, duration, frequency, timing, volumes, triggers (if any), awareness of need to void, environmental factors, caffeine and alcohol consumption (irritants that can cause urgency and frequency), ability to toilet (function), associated signs/symptoms
- hematuria
- irritative symptoms – urgency, frequency, dysuria
- obstructive symptoms -- hesitancy, intermittency, incomplete voiding, weak urinary stream, dribbling, straining
- voiding diary can be very helpful
- Recurrent urinary tract infections, pelvic prolapse, pelvic surgery, parity, vaginal delivery problems, pelvic radiation, constipation, CNS condition
- Treatments already tried and outcome
- Current Medications – many drugs are commonly related to UI
- Alpha-agonists
- Anticholinergics
- Antipsychotics
- Beta-agonists
- BZDs (benzodiazepines) – especially long-acting
- CCBs (calcium channel blockers)
- Diuretics
- Opioids
- Parkinsonism medications
- Tricyclic antidepressants
- not appropriate in older adults due to anticholinergic properties
- Physical Exam – consider major conditions/comorbidities such as CHF CNS conditions (CVA, PD), Dementia
- General Impression
- Psychological - affect, cognition
- Abdomen – masses, bladder distention, surgical scars
- Rectal – tone, impaction, masses, prostatic enlargement
- Genitourinary - skin condition, pelvic exam: atrophic vaginitis, candidiasis, masses, cystourethrocele
- Neurologic - sphincter tone, perianal sensation, bulbocavernousus reflex, lumbar cremasteric reflex L1 & L2, abdominal reflexes
- Extremity - gait, neuropathy, edema
- Functional Status – ADL abilities
- Testing (as indicated by history)
- Urine studies (dipstick, gram stain, culture) in overflow, urge incontinence
- Blood chemistries (glucose, electrolytes, BUN, creatinine)
- Post void residual if overflow suspected
- Observe void, stress test with full bladder, post void residual (PVR) > 200 should prompt urologic evaluation
- Consider cystometrogram, voiding cystourethrogram, urethral pressure profile, sphincter EMG, and other urodynamic studies in selected cases if surgery considered
Over 80% of patients may experience complete resolution or improvement by appropriate treatment targeted to the cause(s) or aggravating factors. This is particularly true for medications as culprits and functional problem.
Nonpharmacologic Treatment
- Dietary modification
- avoidance of food and beverage irritants (see Urge UI)
- limiting fluids before bedtime (but not overall fluid intake)
- Behavior modification
- Kegel exercises – relaxing and contracting pubococcygeus muscle
- patient must be highly motivated
- first line for stress incontinence; second for urge incontinence
- biofeedback helps identify when contracting correctly
- vaginal weights, same purpose as biofeedback
- Bladder retraining – gradual increase in time between voids
- Scheduled toileting
- Prompted voiding – asking patient if he/she needs to use toilet
- Devices for stress incontinence
- Pessaries – prolapse management
- Urethral plugs (not practical for majority of older women)
- Incontinence products
- Underwear absorbent pads
- Disposable adult briefs (“pull-ups”); adult diapers
- Absorbent cloth or disposable bed pads
- Catheters
- Intermittent Cath Procedure (ICP) – clean technique, not sterile
- re-use of catheter; self-ICP or done by someone else
- patient education handouts for procedure and clean technique management
- strongly preferred in patients with urinary retention problems since indwelling catheters do result in complications over time
- Male external catheter
- aka: condom or “Texas” catheters
- NOT for urinary retention problems; only for those able to empty the bladder
- indwelling transurethral catheter
- urethral trauma risk
- suprapubic catheter
- leg bag during day; large volume bag at night
- transurethral and suprapubic risks include chronic infections, bladder stones, sepsis, hematuria, bladder cancer (long term)
- catheters are used as a last resort. Appropriate situations include:
- urinary retention that cannot be corrected medically or surgically, or with intermittent catheterization …and there is persistent overflow UI, infections or renal dysfunction (AMDA 2005)
- palliative or hospice care as a comfort measure
- patient preference if no response to specific treatment patient whose quality of life is very poor due to UI
- short-term use to allow skin wounds to heal
Invasive Procedures
Being an older adult does not automatically rule out invasive/surgical treatment which may be very helpful in carefully selected patients. Considerations certainly include the older adults overall physical and psychological health, motivation, lifestyle and function.
- Periurethral bulking agents
- stress UI; patients with sphincter control deficits
- collagen injections
- works significantly better in women than in men
- TVT – tension-free vaginal tape (sling) procedure
- stress UI
- different types of sling procedures
- minimally invasive surgery
- Cystoscopy
- Valuable investigative procedure, but not therapeutic alone
- Bladder suspension surgery (MMK, Burch, Raz)
- stress UI with uterine prolapse
- urethral hypermobility
- do not work well for women with intrinsic sphincter deficiency
- Artificial urinary sphincter
- especially for men who have had treatment for prostate hypertrophy or cancer
- a doughnut shaped fluid-filled ring placed around the bladder neck maintaining a tightly closed sphincter
- to void, the ring is deflated by pressing a release valve implanted under the skin
- Surgical correction of obstruction (examples below)
- Prostate resection
- Stricture release: incision, excision and reconstruction, or dilation
- Sacral Nerve Electrical Stimulation (Neuromodulation)
- patients with severe urge UI who do not respond to behavior modification and drug therapy
- minimally invasive surgical technique
- Urinary diversion (moderately invasive)
Pharmacologic Treatment
Medications to treat urinary incontinence are targeted to the underlying pathology. Risks versus benefits should be considered before prescribing any medication; this is particularly true for the elderly, and particularly with several of the medications used to treat UI. A table of medications potentially used in the treatment of urinary incontinence is presented below. First, some specific pharmacologic information will be briefly reviewed.
- Anticholinergics as a class inhibit parasympathetic activity by selectively blocking acetylcholine from binding to its receptors in nerve cells. The parasympathetic nerves control involuntary movements of smooth muscles of the body. Anticholinergics are classified as antimuscarinic agents, ganglionic blockers, and neuromuscular blockers. There are 5 muscarinic receptors (M1-M5) affecting salivary glands, cardiac tissue, ciliary muscle, GI tract, CNS, and the bladder. M2 and M3 are the detrusor muscle muscarinic receptors. The effect of blocking these receptors depends on the specific receptors in each organ system. Antimuscarinics that are selective for M2 and M3 have potentially less anticholinergic side effects since the number of receptors involved is limited.
- Remember SLUD: salivation, lacrimation, urination, and defecation. These are cholinergic effects. Anticholinergic effects then are dry mouth and eyes, urinary and fecal retention. They also can cause confusion, hallucinations, sedation, blurred vision, impaired memory and delirium since the CNS contains all 5 muscarinic receptors.
- Non-selective anticholinergics can be particularly risk in older adults, not only due to age-related pharmacokinetic changes, but also because increased age increases the risk of comorbidities such as cardiac disease and CNS conditions. Careful history, patient selection, and use of the lowest effective dose are all critical. Once antimuscarinic therapy is initiated, ongoing close monitoring of potential side effects needs to occur.
- Because antimuscarinics are a class of anticholinergic drugs, the terms are sometimes used interchangeably.
- Generally, extended release antimuscarinic formulations seem to be better tolerated in older adults than immediate release forms.
- Sympathetic nervous system neurotransmitters are epinephrine and norepinephrine and their alpha or beta receptors.
- Finally, in the VA Cooperative trails, alpha blockers used to treat voiding dysfunction were generally not adequate to treat hypertension.
Table 1 – Medications Used in the Treatment of Urinary Incontinence
URGE UI
darifenacin
(Enablex ®)
Antimuscarinic
7.5 - 15 mg/day
7.5 mg/day if liver impairment
Dry mouth, constipation, dyspepsia
imipramine
(Tofranil ®)
TCA
10 – 75 mg hs
Postural hypotension
Worsened cardiac conduction
Abnormalities Anticholingergic effects similar to tolterodine but more pronounced TCAs usually inappropriate in older adults
oxybutynin extended
release
(Ditropan XL ®)
Antimuscarinic
(non-selective)
5 – 20 mg /day
See tolterodine – but effects may be more prevalent
* Extended release formulation
may reduce SE
oxybutynin immediate release
(Ditropan ®)
Antimuscarinic
(non-selective)
2.5 – 10 mg
bid to qid
Strongest anticholinergic SE
Usually inappropriate for older adults
oxybutynin patch [transdermal]
(Oxytrol ®)
Antimuscarinic
(non-selective)
3.9 mg /day twice weekly
Local skin reactions to patch
solifenacin
(Vesicare ®)
Antimuscarinic
5 – 10 mg /day
5mg liver impaired,
CrCL <30 ml/min
Dry mouth, constipation, blurred vision Caution in patients with prolonged QT on EKG
tolterodine immediate release
(Detrol ®)
Antimuscarinic
1 – 2 mg bid
Dry mouth, constipation, urinary retention, sedation, tachycardia, orthostatic hypotension, confusion, delirium
* May be inappropriate in elderly
tolterodine extended release
(Detrol LA ®)
Antimuscarinic
2 – 4 mg /day
Same SE as above, but less likely with extended release formulation
trospium
(Sanctura ®)
Antimuscarinic
20 mg bid
20 mg daily if > age 75 or CrCl < 30
Dry mouth, constipation
STRESS UI
pseudoephedrine
(Sudafed ®)
Alpha-adrenergic
agonist
15 – 30 mg tid
*Not really used clinically in older adults due to SE risk > potential benefit:
Hypertension, dysrhythmia, anxiety, tremors, agitation
estrogen
(Estrace ®)
Estrogen,
topical
0.5 – 1 gram hs intravaginally
Comment: oral and transdermal estrogen not effective. Vaginal estrogen potentially helpful by potentiating alpha receptors; other benefits include UTI risk reduction and dyspareunia (painful intercourse) relief
Duloxetine
(Yentreve®
SNRI
20 – 40 mg daily
Approved for SUI in Europe, but not in the US for this indication yet. Currently approved use in the US is for major depression, diabetic peripheral neuropathy pain, and generalized anxiety under the name Cymbalta®
OVERFLOW UI
(with BPH)
alfuzosin
(Uroxatral ®)
Alpha-adrenergic
antagonist
10 mg/day for BPH
(avoid with mod-severe liver impairment)
Low SE profile
Weakness, dizziness, URI headache; possible impaired ejaculation
doxazosin
(Cardura ®)
Alpha-adrenergic
antagonist
1 – 8 mg/day
Can increase by 1 mg q 1-2 weeks
Same as prazosin
dutasteride
(Avodart ®)
5-alpha reductase inhibitor
0.5 mg /day for BPH
Impotence, reduced libido, gynecomastia
finasteride
(Proscar ®)
5-alpha reductase inhibitor
5 mg / day
Impotence, reduced libido, mastodynia
prazosin
(Minipress ®)
Alpha-adrenergic
antagonist
1 – 2 mg
bid - qid
Orthostatic hypotension (especially 1st dose); dry mouth, constipation, diarrhea, syncope, tinnitus, tachycardia, rash, dyspepsia, sexual dysfunction
tamsulosin
(Flomax ®)
Alpha-adrenergic
antagonist
0.4 – 0.8 mg/day for BPH
Low SE profile
Weakness, dizziness, insomnia, somnolence, impaired ejaculation
terazosin
(Hytrin ®)
Alpha-adrenergic
antagonist
1 – 10 mg /day
may increase 1 mg q 4 days
Same as prazosin
Note: this table was adapted from the 2005 AMDA Clinical Practice Guideline on Urinary Incontinence.
Little scientific evidence is available to guide preventive efforts for UI, but based on etiologies and exacerbating factors, reasonable measures include:
- preventing chronic constipation
- treatment of vaginal atrophy
- avoidance of obesity (pelvic floor)
- maximize ADL function – treat pain, assistive devices
- encouraging regular toileting
- prudent dosage and timing of diuretics
- avoidance of iatrogenic (mainly medication-related) UI
- early detection and treatment of prostatic enlargement, pelvic floor weakness
- encouraging exercises to strengthen pelvic floor and abdominal muscles
- good evidence suggesting loss of pelvic floor support is associated with voiding dysfunction
- beginning Kegel exercises and other preventive measures early in life
Does She or Doesn't She? If you don’t ask, she won’t tell you
A 65 year-old woman presents for follow-up of her osteoarthritis, clinical breast exam and Pap smear which has been normal the past five years. During your review of systems, you ask her about involuntary loss of urine. She reports that she loses small amounts of urine 4-8 times a day, when she coughs, lifts, bends over or laughs. She reports voiding 4-6 times a day, and rarely at night. During the pelvic examination, she is noted to have a grade 2 cystocele and atrophic vaginal mucosa, without inflammation. She is asked to cough, and a small amount of urine leaks out, without increased bulging of the cystocele. She is sexually active with her husband about once per month.
A post-void residual is measured at 25 mL. Urinalysis is unremarkable.
Questions:
- What is the most likely etiology of her incontinence?
- What kind of testing would you want to do?
- What kind of treatment(s) are you likely to recommend?
- Would you recommend hormone therapy?
- What are some potential benefits of topical estrogen therapy?
Case #2:
When You Gotta Go, You Gotta Go!
A recently widowed 76 year-old female who reports new incontinence. She recounts several episodes of losing control of her urine, and indicates she is afraid to go out in public anymore. She recalls 3 episodes when she was away from home where she felt that her bladder was full, but the bladder emptied a large volume before she could find a restroom. She denies burning or obstructive symptoms. There is no history of diabetes or diuretic use. She does have a history of osteoporosis with 3 thoracic vertebral compression fractures.
On review of systems, she reports feeling clumsy and has been stumbling more lately. She has not fallen, but is becoming fearful of falling. Her children do not know about the incontinence, but have expressed concern about her unsteadiness. She is afraid she might have to go to a nursing home.
Current medications are limited to:
- Low dose ECASA (enteric coated aspirin for stroke prophylaxis)
- Risedronate 35 mg/week (for osteoporosis)
- Calcium citrate 500 + Vitamin D bid (for osteoporosis)
Her posture is stooped with overt kyphosis. The GU examination is unremarkable. Her gait is broad-based, with irregular length of stride.
The urinalysis and chemistry profile are negative.
Questions:
- What are the most likely contributions to her incontinence?
- Do you have any concerns other than the UI?
- What type of testing or evaluations are most appropriate?
- Considering the differential diagnosis list, what types of treatment might you consider for her?
- If nursing facility placement occurred, would she be less likely to fall and fracture her hip than at home?
Case #3:
I Didn't Have This Problem Before Surgery
An 84-year-old man has symptoms of urgency, frequent small voids, and nocturia 3 times a night. On three occasions, he has not been able to hold his urine long enough to get to a bathroom. He is now 4 months status post TURP (transurethral resection of the prostate) for benign prostatic hyperplasia (BPH). Obstructive symptoms improved with the surgery.
Past medical history is non-contributory. His only medication is enteric-coated aspirin.
Questions:
- What is(are) the most likely etiologies for this pattern of incontinence given his history?
- Would you like to obtain any laboratory tests? Which ones and why?
- Is a cystoscopy indicated? Urodynamics?
- Is he a candidate for referral to a urologist for an artificial sphincter?
- What drug class(es) might be considered? What are the modes of action, potential benefits and risks of specific drugs within those classes?
Case #4:
This Is So Embarrassing. I Hope You Can Help Me
The patient is an 81-year-old man who had a stroke 2 months ago, and was just discharged from acute rehab 2 weeks ago. Residual deficits from the stroke include a partial left hemiparesis and a disabling apraxia. He is cognitively intact, but unable to dress himself, bathe, or get up from a chair due to the apraxia. He was diagnosed with depression one month ago, and a trial of tricyclic antidepressant was initiated. His wife cares for him at home. She has several pieces of adaptive equipment. Since he is still eligible for skilled services, they also receive the help of a home health aide 3 days/week and physical therapy in the home. He has urinary incontinence that is managed with an external catheter.
He is brought in for his first office visit since discharge from the rehab facility, with considerable difficulty getting him in and out of the car. He and his wife are both concerned about his fecal incontinence. He has been wearing adult diapers, but is beginning to have skin breakdown. He has bowel movements 2-3 times per week, usually after breakfast. The stools are described as formed and hard, but sometimes has fecal “ooze.” At times he is aware of the urge to have a bowel movement, but is unable to retain the stool long enough to be assisted onto the bedside commode.
Medications include:
- HCTZ 25 mg/day for hypertension
- Imipramine 75 mg/day for depression
- ECASA Aspirin 325 mg/day for stroke prophylaxis
The rectal exam is unremarkable. Sphincter tone is normal, and there is no stool in the vault.
Questions:
- What are your concerns about this patient’s incontinence?
- Is fecal impaction possible? How can you rule it out?
- Would changing any of his medications help?
- Would a new medication help? What would you use?
- What non-pharmacologic interventions could be considered?
- Are there any surgeries that may offer some functional benefit and quality of life improvement?
- This patient is still eligible for and receiving “skilled services” benefit from Medicare (skilled professional visits: RN, PT and/or OT and/or ST depending on need). Once he is no longer eligible for this Medicare covered benefit would the family still be able to have the “home health aide” from the home health agency paid for? Or, would they have to private pay for nursing assistant help?
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The University of Kansas Medical Center