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Case 924: Urinary Incontinence in a 67-year-old woman
Authors and Affiliations
Dr. Simon Harley
Royal Adelaide Hospital
A/Prof Nick Brook
Department of Urology, Royal Adelaide Hospital
Case Overview
Urinary incontinence is a problematic condition affecting a large proportion of patients seen in General
Practice. It can have a significant impact on one's quality of life but can be reasonably well treated in
most cases. The case covers the important causes, investigations and the treatment options to be
considered.
Learning Objectives
To
be able to identify risk factors for urinary incontinence
To
be able to take a detailed history and determine the type of urinary incontinence
To
be able to recommend appropriate life-style modifications to aid in treatment
To
understand the appropriate timing and type of investigations that can be used to aid in diagnosis
To
be able to recommend appropriate treatment
Question 1 : FT
Question Information:
Mrs. Vesica is a 67 year old Italian woman who has come to your general practice clinic complaining of
urinary leakage. She lives at home with her husband and apart from diet controlled diabetes mellitis II
and a BMI of 31 she is of reasonable health. She is P4G3 (all uncomplicated vaginal deliveries) and
went through menopause at the age of 51. She suffers from hot flushes which aren†™t too debilitating
and she has preferred to use alternate therapies to combat these without much success. She has had
an appendicectomy and cholecystectomy. She has a 35 pack-year history but consumes minimal
alcohol. Her sister has recently undergone a surgical procedure to help with her urinary incontinence
and Mrs. Vesica wants to have this done as she†™s becoming more and more worried about leaving
her home and being able to find a near-by toilet.
Question:
List the risk factors Mrs. Vesica has for urinary incontinence.
Choice 1: null Score : 0
Choice Feedback:
1.
Age
2.
Female
3.
Post-menopausal (hormone deficient)
4.
Parity
5.
Smoking
6.
Obesity
Question 2 : FT
Question Information:
Before you can recommend some intervention for Mrs. Vesica†™s incontinence, you will need to
identify the type of incontinence she has.
Question:
Provide at least 6 questions you would ask her (do not use medical jargon) to help you make your
diagnosis.
Choice 1: null Score : 0
Choice Feedback:
1.
How long has this been a problem?
2.
When are you incontinent?
3.
How many times a night do you need to go to the toilet?
4.
Do you get unrelenting urges to urinate? Is this associated with incontinence?
5.
How long can you put up with the urge before needing to empty your bladder or become incontinent?
6.
Do you ever leak urine when you†™re laughing, coughing, exercising or having sex? If so, how much?
7.
Do you have a cough?
8.
How much fluid do you drink per day. Do you consume much fluid/caffeine before going to bed?
9.
Do you get the sensation that you don†™t fully empty your bladder when you go to the toilet?
10.
Is your stream weak? Does it stop and start?
11.
Do you need to help yourself urinate by pressing just above your pelvis?
12.
Do you have any pain when you get the urge to urinate or when you urinate?
13.
Does it burn or sting when you urinate?
14.
Do you have problems emptying your bowel?
15.
Have you noticed and lumps or bulge within your vagina?
16.
Are you continuously wet?
17.
Is this problem causing you lots of distress?
Question 3 : FT
Question Information:
Mrs. Vesica tells you that she has been having a horrible time with this issue for over 2 years now.
Initially she would only leak small amounts every other day when she laughed or coughed but now she
is finding that hanging clothes on the line, bending over and carrying heavy dishes results in leaking.
She†™s had to stop playing cards with her friends as she is aware of a constant urine smell. She has
also noticed that she†™s getting the urge to urinate much more throughout the day; having to go to
the toilet 10-12 time per day and at least 3-4 time during the night. She has tried to reduce the amount
of fluid prior to bed but this has not helped. She does not get pain, she†™s just uncomfortable. She
has no obstructive symptoms and she describes no bowel issues.
Question:
You examine the patient. Discuss what findings you will look for using the headings †˜ general
observation†™, †˜ abdominal exam†™, †˜ pelvic exam,†™â€ ˜ rectal exam†™and †˜ other
bedside investigations†™
Choice 1: null Score : 0
Choice Feedback:
1.
General Observation
a.
Weight
2.
Abdominal Examination
a.
Pain/tenderness
b.
Masses
c.
Palpable bladder
3.
Pelvic Examination
a.
Pain/Tenderness
b.
Vaginal atrophy
c.
Cervical lesion/ Paps Smear
d.
Bimanual examination (adnexal masses)
e.
Prolapse
f.
Sims speculum with valsalva manoeuvre
4.
Rectal Examination
a.
Perineal sensation
b.
Rectal muscle tone
c.
Faecal impaction
5.
Other
a.
Urinalysis
Question 4 : SC
Question Information:
There are no palpable masses. Speculum examination reveals a small posterior vaginal prolapse and
you perform a smear test as she is due for one. During the valsalva manoeuvre she leaks a small
amount of urine. Urinalysis in unremarkable.
Question:
From history and examination, this suggests a diagnosis of..
Choice 1: Pure Stress Urinary Incontinence Score : -1
Choice Feedback:
Incorrect. She describes symptoms that suggest an element or Urge Urinary Incontinence as well.
Choice 2: Pure Urge Urinary Incontinence Score : -1
Choice Feedback:
Incorrect. She describes symptoms that suggest an element of Stress Urinary Incontinence as well.
Choice 3: Mixed Urinary Incontinence Score : 1
Choice Feedback:
Correct.
Choice 4: Overflow Urinary Incontinence Score : -1
Choice Feedback:
Incorrect. This describes that process of a full bladder leaking as it's unable to contract and expel the
urine when its full. This is typically seen in patients with a neurological disease.
Choice 5: Urinary Tract Infection Score : 0
Choice Feedback:
Partially Correct. Although the Urinalysis is negative, there is a false negative rate of around 10-15%.
Her urine should be sent for MC+S to rule out an underlying pathogen that may be contributing to some
aspect of her symptoms.
Choice 6: Painful Bladder Sydrome Score : -1
Choice Feedback:
Incorrect. As the name suggests, this is typically associated with lower abdominal pain upon micturition.
It is also known as interstitial cystitis.
Question 5 : SC
Question Information:
Now that a diagnosis has been reached, the patient will require some advice.
Question:
What would you suggest next?
Choice 1: Refer to specialist Score : 1
Choice Feedback:
Partially correct. Specialist referral is not usually required on first presentation of urinary incontinence
unless concerning features of more sinister pathology such as being constantly wet (fistula) or
haematuria and weight loss (malignancy) are present. In this case however, Mrs. Vesica†™s
symptoms are possible bad enough to warrant immediate referral.
Choice 2: Recommend she has the prolapse repaired Score : -1
Choice Feedback:
Incorrect. Repair of her posterior vaginal prolapse is not required. This is not likely to be the cause of
her urinary symptoms but does give a sign of the local tissue structure and integrity. She doesn†™t
give a history of this being symptomatic so it is best to leave this alone
Choice 3: Recommend life style changes such as smoking cessation, dieting, bladder training and pelvic floor
exercises Score : 3
Choice Feedback:
Correct. As you have identified, Mrs. Vesica has a mixed incontinence picture. From the stress
incontinence point of view she may benefit from targeting those modifiable risk factors such as her
weight and smoking (which both weakens connective tissue and produces cough). Assessment of
caffeine intake is important as caffeine is a diuretic and is irritative to the bladder, and benefit is often
seen with caffeine restriction. She is most likely hormonal deficient and could benefit from a local
oestrogen cream vaginally.
Pelvic floor exercises have a role and provided these are supervised by a trained physiotherapist or
incontinence nurse, results with maximal benefit can be expected after six weeks of daily therapy. The
interruption of her life by her urge symptoms may be managed by bladder training/drill. This is the
structured application of deliberately delaying bladder emptying once they have the urge. This might
start at just 3 minutes for one week and increase this time by a few minutes each week until the women
gets to a point where she can †˜ hold on†™for a reasonable period of time.
Choice 4: Vaginal Cone Score : 1
Choice Feedback:
Correct. This could be used in association with pelvic floor exercises if you think she would tolerate the
process.
Choice 5: Prescribe Oxybutynin Score : 1
Choice Feedback:
Correct. A trial of Oxybutynin would not be unreasonable. You should counsel her on the expected side
effects of this medication including urinary retention, dry eyes and mouth and blurred vision.
Question 6 : MS
Question Information:
Mrs. Vesico returns 8 weeks later and updates you on her progress. She has tried pelvic floor exercises
but you get the impression she was not overly compliant with these. She has however managed to
lengthen the time she can hold on to her urine to a total of 15 minutes but she is still very distressed
about leaking accidentally. She†™s becoming very frustrated. You refer her to a specialist to have this
managed. The specialist organises some investigations.
Question:
Which would they organise?
Choice 1: CT Abdomen/Pelvis Score : -1
Choice Feedback:
CT abdomen/pelvis and MRI are not necessary for initial investigations but may be used if adnexal
masses are found on US.
Choice 2: US Pelvis Score : 1
Choice Feedback:
Initial investigations would include US and Urodynamic testing. Ultrasound has the ability to look for
structural abnormalities/lesions as well as post-void residuals whilst Urodynamic studies will assess to
what degree her symptoms are stress and urge related.
Choice 3: Cystoscopy Score : 1
Choice Feedback:
This allows further assessment of stress leakage by getting the patient to cough whilst her bladder is
full. It can also exclude other causes of urge incontinence which may be missed on pelvic US, including
small bladder tumours, bladder diverticulae, Hunner†™s ulcers (interstitial cystitis) and urethral
stenosis.
Choice 4: Urodynamic Testing Score : 1
Choice Feedback:
Initial investigations would include US and Urodynamic testing. Ultrasound has the ability to look for
structural abnormalities/lesions as well as post-void residuals whilst urodynamic studies will assess to
what degree her symptoms are stress and urge related.
Choice 5: MRI pelvis Score : -1
Choice Feedback:
CT abdomen/pelvis and MRI are not necessary for initial investigations but may be used if adnexal
masses are found on US.
Question 7 : MS
Question Information:
Ultrasound of the pelvis is generally unremarkable and Urodynamic testing reveals a mixed
incontinence but with a primarily stress component.
Question:
What treatment(s) would the specialist now recommend?
Choice 1: Intradetrusor Botulinum A Toxin injection Score : -1
Choice Feedback:
Intra-detrusor Botulinum A Toxin injections are a new management for Urge Urinary Incontinence. A
number of botox injections into the bladder muscle are made during cystoscopy with the aim to
temporarily paralyse the muscle to some degree. This potentially lasts between 3-12 months with a risk
of prolonged urinary retention being a risk factor. The optimal dose is yet to be worked out and is still a
treatment option in it's infancy.
Choice 2: Oxybutynin patch Score : -1
Choice Feedback:
Oxybutynin patches are used for urge incontinence. Oxybutynin which is an anticholinergic agent acts
on the muscarinic 3 (parasympathetic nervous system) receptors on the bladder and inhibit contraction
of the bladder. This is commonly used as medical management for urge incontinence. Side effects
include dry mouth, dry eyes and urinary retention. These side effects can be intolerable so 2.5mg oral,
daily dose, titrating upwards may be an appropriate starting dose. Patches are better tolerated than the
oral route.
Choice 3: Tension-free vaginal tape Score : 3
Choice Feedback:
A Tension-free Vaginal Tape (TVT) is a simple procedure during which a small incision is made within
the vagina and two trochars, joined by the prolene tape are passed through and curve anteriorly to exit
the skin above the pubic bone. This supports the bladder neck in a tension free manner. This is a
minimally invasive procedure which a success rate of 90% for pure stress incontinence and around
60% for mixed. It is an inappropriate procedure for pure urge incontinence.
Choice 4: Continue to recommend lifestyle modifications Score : 3
Choice Feedback:
With any further management it†™s essential to stress the importance of lifestyle modification in this
woman. If she remains overweight and smokes she†™s at risk of treatment failure, not to mention the
myriad of other medical conditions in this obese, type II diabetic.
Choice 5: Further Imaging Score : -1
Choice Feedback:
No further imaging is required at this stage. What would you be looking for?
Choice 6: Burch colposuspension Score : -1
Choice Feedback:
Burch colposuspension is a traditional open procedure involving suturing the paravaginal tissues to
Cooper†™s ligament. This is less commonly done due to less invasive procedures such as the TVT
being available.
Synopsis
Urinary incontinence is a very common problem in society with around 35% of women reporting urinary
incontinence at the age of 35. The majority of these cases will be stress incontinence and the remainder
is made up of urge incontinence (due to overactive bladder) and overflow incontinence (due to chronic
bladder outflow obstruction). It is worthwhile remembering that it is not only women who are affected as
overactive bladder and ouflow obstruction affects both men and women.
When seeing a patient, you need to define the problem. What sort of lower urinary tract dysfunction is
this? Do they describe pure stress or urge incontinence, do they have a mixed picture, do they describe
pain; is this overflow incontinence and is there a reversible cause?
There is no single aetiological factor for stress incontinence but there are many predisposing factors
that may contribute. These include;

Obesity

Smoking

Pregnancy (Caesarean Section provides not benefit over vaginal delivery)

Menopause

Prolapse
Medications

such as diuretics and ACE-inhibitors (ACE induced cough), alpha blockers
Gynaecological surgery
Collagen
disorders
Management starts off with lifestyle modifications such as weight loss, smoking cessation and review of
medication. Pelvic floor exercises have proven benefit when done consistently for at least 6 weeks.
Results are best seen if supported by a physiotherapist or continence nurse. Around one-third become
continent, one-third improve and one-third see no change. Incontinence tends to return when exercises
cease.
Vaginal pessary may be used in the case of prolapse to support the surrounding tissues. Application of
topical oestrogen cream within the vagina is generally advised to strengthen surrounding tissue in the
hormonal deficient woman.
Surgery is the most successful means of curing stress incontinence. The Tension-free Vaginal Tape
provides a quick, minimally invasive means of cure with success rates as high as 90% in pure stress
incontinence and a little less in mixed incontinence.
Detrusor overactivity presents a different problem with different, incompletely understood aetiology.
Once again it has multifactorial pathology with the bladder urothelium, neural impulses from the central
and peripheral nervous system and the detrusor muscle all playing a role.
It†™s important to rule out a transient cause for a patient†™s incontinence. This can be remembered
by the acronym DIAPPERS:
Delirium
Infection
Atrophic
vaginitis
Pharmaceutical
Psychological
Excess
urine output
Restricted
Stool
mobility
impaction
It†™s also important to assess how this is affecting the patient†™s quality of life. Small leaks of urine
on the odd occasion may seem trivial to you but it may be interrupting one†™s ability to play sport or
impeding their social interactions, work or sex life. Quality of life (QOL) questionnaires are becoming
increasingly used to assess the impact of incontinence on a person†™s life.
Urodynamic testing is generally reserved for cases in which first line management such as lifestyle
modifications, bladder training, pelvic floor exercises and anticholinergic medications have failed.
Information can be gathered on the strength of urine flow, post-void residual, intra-vesicular pressure,
leak-point pressures and electromyography which may help confirm the diagnosis.
May 2013