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Emory Reynolds Program
URINARY INCONTINENCE
CASE 1
Mrs. A is an 88-year-old woman who has resided in a nursing home for the past year. Her health
and functional status have been stable during that time. She is independent in eating, ambulatory
with a walker, and needs assistance with other basic activities of daily living (ADLs), including
dressing, grooming, toileting, and bathing.
Her diagnosis and medications are as follows:
Diagnoses
Dementia, probable Alzheimer’s
Congestive heart failure
Degenerative arthritis
Medications
Donepezil
Lisinopril
Acetominophen
Over about 2 – 3 days Mrs. A becomes increasingly confused, agitated and exhibits paranoia.
Her doctor is called, and prescribes risperidone (Risperidal) and lorazepam (Ativan). The next
day, she is still agitated, but also intermittently drowsy. As a result, she suffers a fall that causes
bruising of her ribs and right hip. She is then placed on oxycodone (Oxycontin) for pain. Over
the next two days she remains confused, spending most of the time in bed. She also becomes
incontinent of urine on every void – whereas previously she had been responding to prompted
toileting with only an infrequent episode of incontinence. Three days after her fall she develops a
fever of 101oF and is sent to the emergency room. In the emergency room, Mrs. A is found to
have a large fecal impaction on rectal exam. A post-void residual bladder volume yields 500 ml
of cloudy urine. Her urinalysis shows a large amount of bacteria and white cells. She is admitted
to the hospital for further evaluation and treatment.
Questions to Consider
1. What could have caused Mrs. A’s initial symptoms of increased confusion, agitation,
and paranoia?
Answer:
In a stable nursing home patient with dementia, these are usually symptoms of delirium,
which can be caused by almost any acute medical problem.
The most common problems that cause delirium in elderly nursing home patients are
infections (urinary tract and respiratory are most common), and worsening of underlying
medical conditions (such as worsening of congestive heart failure, possibly as the result of a
myocardial infarction). The addition of a new medication can also cause delirium.
Other causes of this patient’s symptoms include a small “lacunar” stroke without obvious
neurological signs, worsening of dementia, and depression.
2. What is the most appropriate response to these symptoms?
Any elderly patient who develops an acute worsening of mental status should have a
diagnostic assessment including a careful check of vital signs, a history to elicit new
symptoms, a brief physical exam, and consideration of basic laboratory tests including:
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Complete blood count
Chemistry panel (electrolytes, glucose, BUN)
Pulse oximetry
Finger stick glucose
Depending on history and physical exam:
- Chest X-ray
- Urinalysis and culture
- EKG
3. What side effects could the medications prescribed for Mrs. A’s agitation and pain
have?
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Risperidone can cause some parkinsonian–like effects and contribute to gait
problems.
Lorazepam can cause drowsiness and confusion, and predispose to falls
Oxycodone can cause drowsiness, confusion, constipation, and urinary retention
4. What factors could be contributing to Mrs. A’s urinary incontinence (UI)?
Remember the potentially reversible causes of UI:
D – Delirium *
R – Restricted mobility *, Retention *
I – Infection *, Impaction *, Inflammation (atrophic vaginitis)
P – Pharmaceuticals *, Polyuria
* factors probably contributing to Mrs. A’s UI
She had an infection (urinary), causing delirium. Drug side effects contributed to her
delirium, fall, restricted mobility, and may have caused worsening constipation and fecal
impaction, and urinary retention.
5. What is the most appropriate way to manage this patient’s urinary retention and
incontinence?
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Generally, the bladder should be decompressed with an indwelling catheter for at
least 5-10 days
o Insure appropriate catheter care (secure the catheter, gravity drainage and/or
an anti-reflux valve)
Initially, the patient needs to be monitored for a post-retention diuresis, and fluids
replaced accordingly
After the infection is treated and the bladder has been decompressed, the patient
should undergo a “voiding trial” or “bladder retraining” protocol.
o Remove the catheter (no clamping routine is necessary)
o Monitor intake and output
o If the patient begins to void, perform at least one post-void residual (PVR)
determination to insure residual is less than 400ml
 Continue monitoring PVR until it is less than 200ml (bladder recovery
may take several days up to several weeks)
o If there is no void in an 8-hour shift, then catheterize and record volume. If
multiple (3 or 4) consecutive PVRs are >400 ml, then consider another period
of decompression by indwelling catheterization followed by another voiding
trial
Subsequent Course
After a 5-day hospitalization Mrs. A was sent back to the nursing home on an oral antibiotic and
a stool softener, in addition to her previous medications. Three days later she was back to her
baseline status and continent of urine with a post-void residual of 50 ml.