Download URINARY INCONTINENCE

Emory Reynolds Program
URINARY INCONTINENCE
CASE 4
Mrs. D is an 88-year-old woman seen in your clinic after the recent death of her husband. She
has the following problems:
Diagnoses
Chronic Obstructive Pulmonary Disease
Allergic Rhinitis
Rheumatoid Arthritis
Status post bilateral knee replacements
Degenerative joint disease of both hips
Hypertension
Insomnia
Medications
Multiple inhalers
Steroid spray
Acetominophen and a COX 2 inhibitor
Lisinopril
Zolpidem prn
She is pleasant and cognitively intact. However, she is severely mobility impaired because of the
DJD in her hips and rheumatoid deformation of her hands. She needs assistance in all basic
activities of daily living, including transfers.
Mrs. D complains that she is frequently incontinent. She does regularly have the urge to void and
uses the toilet 2 – 3 times per day. In between, however, she wears a heavy pad, which is always
wet. She reports that she has had urinary incontinence for the last 10 years that has been getting
worse. It started after she had a “bladder tack” operation. Initially, the incontinence occurred
with coughing and sneezing, but now she cannot tell exactly when she is getting wet. She does
loose urine at night while she is asleep, but it is generally small amounts. She is very frustrated
by the incontinence and wants it treated.
Questions to Consider
1. What is the most likely type of UI in Mrs. D’s case?
Mrs. D’s history is really not that of the most common type of UI in frail older women,
urge UI, which is generally associated with other symptoms of overactive bladder
(frequency, nocturia).
Her history and current symptoms are most compatible with stress UI. Older women who
have a cystocele repair (commonly known as a “bladder tack”) may develop stress UI,
especially if a bladder neck suspension is not done during the surgery. Leaking while
coughing or sneezing, especially in patients with respiratory conditions, is the common
presentation of stress UI. As the urethra and the pelvic muscles weaken, symptoms may
progress to relatively constant leaking induced by most any movement. Generally,
leakage is less at night in the lying position.
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Mrs. D’s history and symptoms are, however, also compatible with overflow UI. Women
who undergo cystocele repair are at risk for urinary retention after the surgery (especially
if a bladder neck suspension is also performed). Overflow incontinence may also result
from the recurrence of severe pelvic prolapse, which can obstruct the bladder outlet and
urethra.
2. What office assessment procedures would be appropriate for Mrs. D’s UI?
At least three assessment procedures are appropriate for Mrs. D:
a)
b)
c)
Physical exam – a brief pelvic examination to inspect the vagina for atrophy and
vaginitis, and to exclude recurrent severe pelvic prolapse
Cough test for stress UI – this is simple to do in a cooperative patient during
toileting, and will objectively demonstrate the presence of stress UI.
Post-void residual determination – this is best done by ultrasound, but if this is
not available, a sterile in and out catheterization within about 15 minutes of a void
will exclude significant urinary retention and overflow UI.
3. What treatments are most appropriate to consider for Mrs. D’s UI?
a)
b)
c)
d)
Assuming she does indeed have stress UI, there are several treatment options:
Regular voiding – if the bladder is kept empty, stress UI will be less severe. In
addition to adequate fluid intake to get a cue to void, Mrs. D should be assisted to
the toilet every 2 – 2 ½ hours during the day and before lying down in bed to go
to sleep.
Cough and sneezing suppression – because Mrs. D has allergic rhinitis and
COPD, frequent coughing and sneezing may cause the stress UI to be more
severe. Use of an anti-allergy medication and a cough suppressant might help her
reduce her stress UI.
Pelvic muscle rehabilitation – cognitively intact patients such as Mrs. D may be
able to learn and practice pelvic muscle (“Kegel”) exercises. Often, biofeedback
is helpful in teaching older women to isolate the correct muscles and get the
“knack” of contracting them. Many physical therapists have training in
biofeedback and Medicare Part B will pay for this treatment. The most common
protocol is to work up to about ten 10-second exercises four times per day. Using
the exercise during situations that cause UI (for example coughing for Mrs. D) is
important for them to be optimally effective.
Medication – stress UI is often treated with a combination of topical estrogen (to
strengthen the tissues) and an alpha agonist (which stimulates the peri-urethral
smooth muscle to tighten. Estrogen alone is not an effective treatment, and most
frail older women need local therapy (i.e., vaginal estrogen cream, estradiol ring).
The only pure alpha-agonist that may be useful for stress UI is pseudoephedrine,
since phenylpropanolamine was removed from the market. However, Mrs. D is
being treated for hypertension and insomnia, both of which could be worsened by
alpha agonists.
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e)
Urologic or gynecologic intervention – a wide variety of surgical procedures can
be effective for stress UI, even in very old women. These procedures range from
periurethral injections of collagen, to simple bladder neck suspension, to a “sling”
surgical procedure. The choice of surgical procedure depends on the patient’s
history, the status of the vaginal and periurethral tissues, whether the primary
problem is hypermobility of the bladder neck and urethra or a weak urethra, and
the experience of the surgeon.
Subsequent Course
Mrs. D was placed on topical estrogen using an estradiol vaginal ring. She was not prescribed
pseudoephedrine because of her hypertension and insomnia. She underwent behavioral therapy
with biofeedback – assisted learning of pelvic muscle exercises and was placed on a scheduled
toileting program during the day. An antihistamine was prescribed for her allergic rhinitis, and a
cough suppressant was prescribed for use as needed.
Over the course of the next six weeks her incontinence severity improved slightly, but she
remained wet most of the day. After a long discussion with her primary care physician and a
consultant urogynecologist, she decided to have a vaginal sling procedure performed. The
surgery was uneventful, and after a one-week period of bladder retraining with a suprapubic
catheter in place, the catheter was removed. She remains dry with no bothersome urinary
symptoms six months after the surgery.
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