Evaluation & Treatment of Urinary Incontinence Andy M. Norman, M.D. Assistant Clinical Professor,...

Evaluation & Treatment of Evaluation & Treatment of Urinary IncontinenceUrinary Incontinence

Andy M. Norman, M.D.Andy M. Norman, M.D.

Assistant Clinical Professor, Assistant Clinical Professor, Ob-GynOb-Gyn

Vanderbilt University Medical Vanderbilt University Medical CenterCenter

GoalsGoals

• Discuss Urinary Incontinence (UI)Discuss Urinary Incontinence (UI)

• Discuss Incidental Causes of UIDiscuss Incidental Causes of UI– DIAPERS MnemonicDIAPERS Mnemonic

• Discuss Preliminary DiagnosticsDiscuss Preliminary Diagnostics

• Discuss Treatment of Urgency UIDiscuss Treatment of Urgency UI

• Discuss Treatment of Stress UIDiscuss Treatment of Stress UI

• Discuss Overflow IncontinenceDiscuss Overflow Incontinence

• Review Some Cases of UI with Review Some Cases of UI with Emphasis on Medical ManagementEmphasis on Medical Management

AcknowledgementAcknowledgement

• Cases designed by:Cases designed by:

Dr. Patricia Goode, IM/Geriatrics, UABDr. Patricia Goode, IM/Geriatrics, UAB

• Special thanks to:Special thanks to:

Kathryn Burgio, PhD, UABKathryn Burgio, PhD, UAB– Author of “Staying Dry,” a self help book Author of “Staying Dry,” a self help book

for patients incontinence.for patients incontinence.

DisclaimerDisclaimerI am a Urogynaecologist. All of I am a Urogynaecologist. All of

my incontinence patients are my incontinence patients are female. This discussion is, female. This discussion is, therefore, mostly centered therefore, mostly centered around problems of females. around problems of females. Some of the observations and Some of the observations and treatments are also applicable to treatments are also applicable to male patients. male patients.

Prevalence of Urinary IncontinencePrevalence of Urinary Incontinence

• Age 15 to 64 1.5 - 5% men10-30% women

• Noninstitutionalized 15-35%>60 years old Twice as high in

women

• Homebound elderly 50%

• Nursing home residents 50% (two thirds if catheterized population included)

In 1995, more than $16.3 In 1995, more than $16.3 billion was spent on urinary billion was spent on urinary

incontinence care.incontinence care.More is spent on incontinence More is spent on incontinence

care than other chronic care than other chronic diseases such as breast diseases such as breast

cancer and osteoporosis.cancer and osteoporosis.

ICS DEFINITION OF ICS DEFINITION OF URINARY INCONTINENCEURINARY INCONTINENCE

Complaint of any Complaint of any involuntary leakage of urineinvoluntary leakage of urine

International Continence Society.Abrams P, et al. Neurourol Urodyn. 2002;21(2):167-178.

Urinary IncontinenceUrinary Incontinence

• Transient Causes of IncontinenceTransient Causes of Incontinence

• Urge IncontinenceUrge Incontinence

• Stress Urinary IncontinenceStress Urinary Incontinence

• Mixed Incontinence Mixed Incontinence – Both Urgency & Stress InducedBoth Urgency & Stress Induced

• Overflow IncontinenceOverflow Incontinence

URINARY URINARY INCONTINENCE INCONTINENCE


• 3884 community-dwelling older adult 3884 community-dwelling older adult volunteers for a health promotion studyvolunteers for a health promotion study

• Ages 65 – 79Ages 65 – 79

• 1104 (28.4%) had self-reported incontinence1104 (28.4%) had self-reported incontinence

Burgio, et al: JAGS 42: 208, 1994Burgio, et al: JAGS 42: 208, 1994

• 3884 community-dwelling older adult 3884 community-dwelling older adult volunteers for a health promotion studyvolunteers for a health promotion study

• Ages 65 – 79Ages 65 – 79

• 1104 (28.4%) had self-reported incontinence1104 (28.4%) had self-reported incontinence

Burgio, et al: JAGS 42: 208, 1994Burgio, et al: JAGS 42: 208, 1994

Treatment Seeking (1)Treatment Seeking (1)



Treatment Seeking (2)

Burgio et al: JAGS 42: 208, 1994

Volume

31

4757

0

20

40

60

80

100

Drop or Two ChangeUndergarments

Wet OuterClothing

% r

ep

ort

ing

to M

.D.

URINARY INCONTINENCEURINARY INCONTINENCE

• Personal problem (not medical)Personal problem (not medical)• EmbarrassedEmbarrassed• Normal after childbearingNormal after childbearing• Normal aging changeNormal aging change• Fear of nursing home placementFear of nursing home placement• Afraid treatment requires Afraid treatment requires

surgerysurgery

Failure to Report UI to Health Care ProviderFailure to Report UI to Health Care Provider

INCONTINENCEINCONTINENCE

YOU GOTTA ASK!!YOU GOTTA ASK!!

Diagnosis of UIDiagnosis of UI

• HistoryHistory

• Physical ExamPhysical Exam1.1. Pelvic Organ Prolapse AssessmentPelvic Organ Prolapse Assessment

2.2. In & Out Cath for Residual Urine VolumeIn & Out Cath for Residual Urine Volume

3.3. U/A U/A +/-+/- Urine C & S Urine C & S

4.4. Qtip Test for Bladder Neck HypermobilityQtip Test for Bladder Neck Hypermobility

BLADDER DIARYBLADDER DIARY• Fluid intakeFluid intake

– Time, type, amountTime, type, amount

• Urine outputUrine output– Time, amountTime, amount

• Urine leakageUrine leakage– Time, amountTime, amount– Precipitating events (cough, sneeze, exercise, Precipitating events (cough, sneeze, exercise,

etc.)etc.)– Associated symptoms (urgency, pain, etc.)Associated symptoms (urgency, pain, etc.)

• Pad usagePad usage– Number, typeNumber, type

Transient Causes of UITransient Causes of UI

• DDrugs & rugs & DDietiet• IInfectionnfection• AAtrophic Urethritistrophic Urethritis• PPsychological - Depression, Deliriumsychological - Depression, Delirium• EEndocrine - Diabetes, Hypercalcemiandocrine - Diabetes, Hypercalcemia• RRestricted Mobilityestricted Mobility• SStool Impactiontool Impaction

Transient Causes of UITransient Causes of UI• DRUGS DRUGS

– ACE Inhibitors -- coughACE Inhibitors -- cough– Alpha Blockers – relax internal sphincterAlpha Blockers – relax internal sphincter– Anticholinergics/Antimuscularinics – decrease Anticholinergics/Antimuscularinics – decrease

effective bladder emptyingeffective bladder emptying– Diuretics -- timingDiuretics -- timing– Neuroleptics – pseudoparkinsonismNeuroleptics – pseudoparkinsonism– Sedatives – especially in the dementedSedatives – especially in the demented

• DIETDIET– Caffeine – provokes detrusor instabilityCaffeine – provokes detrusor instability– Artificial Sweeteners-bladder irritantsArtificial Sweeteners-bladder irritants

Urgency IncontinenceUrgency Incontinence(Overactive Bladder)(Overactive Bladder)

Therapeutic OptionsTherapeutic Options

Behavioral Treatment: Behavioral Treatment: Multi-component ProgramsMulti-component Programs

• Pelvic floor muscle trainingPelvic floor muscle training

• Home practice and exerciseHome practice and exercise

• Self-MonitoringSelf-Monitoring

• Voiding schedules—timed and Voiding schedules—timed and prompted voidingprompted voiding

• ““Urge” strategies—FREEZE & Urge” strategies—FREEZE & SQUEEZESQUEEZE

BiofeedbackBiofeedback

• Teaching methodTeaching method

• Facilitates learned control of Facilitates learned control of physiological responsesphysiological responses

• Patients learn by feedback of Patients learn by feedback of their attempts to control bladder their attempts to control bladder and sphincter responses.and sphincter responses.

Detrusor ContractionDetrusor Contraction

10 mmHg10 mmHg

U

Urge WaveUrge Wave

When the Urge StrikesWhen the Urge Strikes“Freeze & Squeeze”“Freeze & Squeeze”

• Stop and stay stillStop and stay still

• Squeeze pelvic floor musclesSqueeze pelvic floor muscles

• Relax rest of bodyRelax rest of body

• Concentrate on suppressing Concentrate on suppressing urgeurge

• Wait until the urge subsidesWait until the urge subsides

• Walk to bathroom at normal Walk to bathroom at normal pacepace

When to VoidWhen to Void

WorstWorstTimeTime

WorstWorstTimeTime

BestBestTimeTime

CalmCalmPeriodPeriod

RCT Comparing RCT Comparing Behavior and Drug TherapyBehavior and Drug Therapy

• 197 older, community-197 older, community-dwelling women with Urge dwelling women with Urge IncontinenceIncontinence

• Randomized to:Randomized to:– Behavioral training Behavioral training (biofeedback)(biofeedback)

– Drug therapy (oxybutynin)Drug therapy (oxybutynin)– Placebo controlPlacebo control

Burgio et alBurgio et al, JAMA, , JAMA, 19981998

Biofeedback-Assisted Biofeedback-Assisted Behavioral TreatmentBehavioral Treatment

• Visit #1:Visit #1: Anorectal BF to teach PFM Anorectal BF to teach PFM control. Home exercise instructions.control. Home exercise instructions.

• Visit #2:Visit #2: “Urge strategies” and “stress “Urge strategies” and “stress strategies”strategies”

• Visit #3:Visit #3: If not If not >>50% improved, 50% improved, bladder/sphincter biofeedbackbladder/sphincter biofeedback

• Visit #4:Visit #4: Individual adjustments and Individual adjustments and reinforcementreinforcement

Reduction of IncontinenceReduction of Incontinencein the Randomized Clinical in the Randomized Clinical

TrialTrial

81%

39%

68%

0

20

40

60

80

100

Behavioral Drug Control

% R

edu

ctio

n

Patient Satisfaction with Patient Satisfaction with Treatment Treatment

for Urge Urinary Incontinencefor Urge Urinary Incontinence

78%

22%

0%

49%

40%

11%

28%34%

38%

0%10%20%30%40%50%60%70%80%90%

Completelysatisfied

Somewhatsatisfied

Not satisfied

BehaviorDrugPlacebo

Behavioral Training Behavioral Training

• Tested the same behavioral Tested the same behavioral program with all components program with all components minusminus biofeedbackbiofeedback

vs.vs.• Verbal feedback based on Vaginal Verbal feedback based on Vaginal

PalpationPalpationvs.vs.

• Same program, but Booklet form Same program, but Booklet form (Minimal Treatment Control).(Minimal Treatment Control).

Is Biofeedback a necessary component?

Is Biofeedback a necessary component?

Burgio, Goode, et.al., Burgio, Goode, et.al., JAMAJAMA, 2002, 2002Burgio, Goode, et.al., Burgio, Goode, et.al., JAMAJAMA, 2002, 2002

Reduction of IncontinenceReduction of Incontinencein a Randomized Clinical Trialin a Randomized Clinical Trial

74% 64%69%

0

20

40

60

80

100

Biofeedback ManualTraining

Booklet

% R

edu

ctio

n

Burgio, Goode, et.al., JAMA, 2002Burgio, Goode, et.al., JAMA, 2002

Stress urinary incontinence is the Stress urinary incontinence is the most common type of most common type of incontinence in womenincontinence in women

Burgio, Matthews and Engel, Burgio, Matthews and Engel, 19911991

Stress incontinence = Urethral incompetence

Bladder Neck HypermobilityIntrinsic Sphincter DeficiencyPelvic Organ Prolapse

Treatments for SUI

• Pelvic Floor Physical Therapy

• Topical Estrogen Therapy

• Urethral Plugs

• Incontinence Pessaries

• Surgical Therapy

Women’s lifetime risk of surgery for SUI or POP is 11%

Olsen, Smith and Bergstrom, 1997

The Sling is the Thing!

TVT – Transvaginal Tape

• Relatively new procedure

• Large cohort analysis shows cure rate 80%, improvement 94%

Kuuva, 2000

• Numerous surgical techniques to treat stress incontinence

• Important to know both objective and subjective cure rates as well as side effects of surgical procedures

• Thoughtful evaluation of patients with individualization of therapy is advisable

CONCLUSIONS regards Surgical Care of SUI

Overflow Incontinence

• Common Causes1. Obstuctive Uropathy such as BPH in men

and Pelvic Organ Prolapse in women.

2. Neurogenic Bladder

• Treatments1. Relief of the Obstruction

2. Clean Intermittent Self Catheterization

3. Indwelling Catheters

4. Diversion Procedures

SUMMARY

• Incontinence is very common, so question ALL patients

• Reversible causes of UI– D – I – A – P – E – R – S

• Behavioral Therapy– Effective– No side effects

Transient Causes of UI

• Drugs & Diet• Infection• Atrophic Urethritis• Psychological - Depression, Delirium• Endocrine - Diabetes, Hypercalcemia• Restricted Mobility• Stool Impaction

Try with Some Case StudiesTry with Some Case Studies

PATIENT CASE 1 PATIENT CASE 1 PATIENT CASE 1 PATIENT CASE 1

• 48 year old woman48 year old woman– Complains that she just can’t get to Complains that she just can’t get to

the bathroom fast enough for the the bathroom fast enough for the past 3 monthspast 3 months

– 1-2 urge accidents per day (no 1-2 urge accidents per day (no stress)stress)

– Nocturia x 2, often with an accidentNocturia x 2, often with an accident– Wears a pad all the timeWears a pad all the time– Wants a bladder tackWants a bladder tack

• 48 year old woman48 year old woman– Complains that she just can’t get to Complains that she just can’t get to

the bathroom fast enough for the the bathroom fast enough for the past 3 monthspast 3 months

– 1-2 urge accidents per day (no 1-2 urge accidents per day (no stress)stress)

– Nocturia x 2, often with an accidentNocturia x 2, often with an accident– Wears a pad all the timeWears a pad all the time– Wants a bladder tackWants a bladder tack

History


• Last menstrual period 6 Last menstrual period 6 months agomonths ago– Having hot flashesHaving hot flashes– Afraid to take hormone Afraid to take hormone

replacement therapyreplacement therapy

• Trying to lose weight; drinks Trying to lose weight; drinks 6-8 diet Cokes per day6-8 diet Cokes per day

• Last menstrual period 6 Last menstrual period 6 months agomonths ago– Having hot flashesHaving hot flashes– Afraid to take hormone Afraid to take hormone

replacement therapyreplacement therapy

• Trying to lose weight; drinks Trying to lose weight; drinks 6-8 diet Cokes per day6-8 diet Cokes per day

History

PATIENT CASE 1 PATIENT CASE 1 PATIENT CASE 1 PATIENT CASE 1 • EXAMEXAM

– Vaginal mucosa mildly atrophicVaginal mucosa mildly atrophic– Otherwise exam normalOtherwise exam normal

• URINALYSISURINALYSIS– NormalNormal

• PVRPVR– 40 cc40 cc

• EXAMEXAM– Vaginal mucosa mildly atrophicVaginal mucosa mildly atrophic– Otherwise exam normalOtherwise exam normal

• URINALYSISURINALYSIS– NormalNormal

• PVRPVR– 40 cc40 cc

PATIENT CASE 1PATIENT CASE 1

• DDrugs & Dietrugs & Diet1.1. CaffieneCaffiene2.2. Taper off caffeine ½ per weekTaper off caffeine ½ per week3.3. Begin ExercisingBegin Exercising

• IInfectionnfection• AAtrophic Urethritistrophic Urethritis

1.1. YesYes2.2. Consider HRTConsider HRT3.3. Vaginal estrogen cream – ½ gram 3 Vaginal estrogen cream – ½ gram 3

times/week to vaginal entrancetimes/week to vaginal entrance


•PPsychological - nosychological - no•EEndocrine - nondocrine - no•RRestricted Mobility – noestricted Mobility – no•SStool Impaction – notool Impaction – no


• Taper off CaffeineTaper off Caffeine• Vaginal EstrogenVaginal Estrogen

• Drugs?Drugs?– Hold off for nowHold off for now

• Behavioral TrainingBehavioral Training

• Taper off CaffeineTaper off Caffeine• Vaginal EstrogenVaginal Estrogen

• Drugs?Drugs?– Hold off for nowHold off for now


TREATMENT


• Teach Kegel exercises during her Teach Kegel exercises during her examexam

• Home ExercisesHome Exercises– 10 paired contractions and 10 paired contractions and

relaxationsrelaxations– 3 seconds each – build up to 10 3 seconds each – build up to 10

secondsseconds– TID (standing, sitting, lying)TID (standing, sitting, lying)

• Urge StrategyUrge Strategy– Freeze/Squeeze to suppress urgencyFreeze/Squeeze to suppress urgency

• RTC 1 monthRTC 1 month

• Teach Kegel exercises during her Teach Kegel exercises during her examexam

• Home ExercisesHome Exercises– 10 paired contractions and 10 paired contractions and

relaxationsrelaxations– 3 seconds each – build up to 10 3 seconds each – build up to 10

secondsseconds– TID (standing, sitting, lying)TID (standing, sitting, lying)

• Urge StrategyUrge Strategy– Freeze/Squeeze to suppress urgencyFreeze/Squeeze to suppress urgency


Behavioral Treatment


• Doing much betterDoing much better• Down to 1-2 accidents per Down to 1-2 accidents per

weekweek• Nocturia resolvedNocturia resolved• Continue Behavioral TherapyContinue Behavioral Therapy

– Will continue to improve for 6 Will continue to improve for 6 monthsmonths

• RTC 3 monthsRTC 3 months

• Doing much betterDoing much better• Down to 1-2 accidents per Down to 1-2 accidents per

weekweek• Nocturia resolvedNocturia resolved• Continue Behavioral TherapyContinue Behavioral Therapy

– Will continue to improve for 6 Will continue to improve for 6 monthsmonths


Return Visit


• 26 year old woman, P 100126 year old woman, P 1001• Leaks when she sneezes or Leaks when she sneezes or

coughscoughs• Has to wear a pad all the timeHas to wear a pad all the time• Planning to have 2 more childrenPlanning to have 2 more children• Smokes 1 PPDSmokes 1 PPD• Has diabetes – last Hgb A1C = Has diabetes – last Hgb A1C =

8.08.0

• 26 year old woman, P 100126 year old woman, P 1001• Leaks when she sneezes or Leaks when she sneezes or

coughscoughs• Has to wear a pad all the timeHas to wear a pad all the time• Planning to have 2 more childrenPlanning to have 2 more children• Smokes 1 PPDSmokes 1 PPD• Has diabetes – last Hgb A1C = Has diabetes – last Hgb A1C =

8.08.0

History


• Small cystoceleSmall cystocele• Q tip test – 60Q tip test – 60o o rotation with coughrotation with cough• No leakage with coughNo leakage with cough• Otherwise normalOtherwise normal

• Normal UrinalysisNormal Urinalysis• PVR = 25PVR = 25

• Small cystoceleSmall cystocele• Q tip test – 60Q tip test – 60o o rotation with coughrotation with cough• No leakage with coughNo leakage with cough• Otherwise normalOtherwise normal

• Normal UrinalysisNormal Urinalysis• PVR = 25PVR = 25

ExamExam

TestsTests


• Surgery & MedicationSurgery & Medication– Still 2 more pregnancies Still 2 more pregnancies

plannedplanned

• PessaryPessary– She is not enthusedShe is not enthused


• Surgery & MedicationSurgery & Medication– Still 2 more pregnancies Still 2 more pregnancies

plannedplanned

• PessaryPessary– She is not enthusedShe is not enthused


Treatment Treatment OptionsOptions


• Teach Kegel exercises during her examTeach Kegel exercises during her exam• Get/Read “7 Steps to Normal Bladder Get/Read “7 Steps to Normal Bladder

Control”Control”• Home ExercisesHome Exercises

– 10 paired contractions and relaxations10 paired contractions and relaxations– 3 seconds each – build up to 10 seconds3 seconds each – build up to 10 seconds– TID in 3 positions (standing, sitting, TID in 3 positions (standing, sitting,

lying)lying)• Stress StrategyStress Strategy

– Squeeze before you sneeze or coughSqueeze before you sneeze or cough• RTC 1-3 monthsRTC 1-3 months

• Teach Kegel exercises during her examTeach Kegel exercises during her exam• Get/Read “7 Steps to Normal Bladder Get/Read “7 Steps to Normal Bladder

Control”Control”• Home ExercisesHome Exercises

– 10 paired contractions and relaxations10 paired contractions and relaxations– 3 seconds each – build up to 10 seconds3 seconds each – build up to 10 seconds– TID in 3 positions (standing, sitting, TID in 3 positions (standing, sitting,

lying)lying)• Stress StrategyStress Strategy

– Squeeze before you sneeze or coughSqueeze before you sneeze or cough• RTC 1-3 monthsRTC 1-3 months

Behavioral Behavioral TreatmentTreatment


• Diabetes – suboptimal controlDiabetes – suboptimal control• Tobacco useTobacco use

• Quit SmokingQuit Smoking• Diabetes EducationDiabetes Education

• Diabetes – suboptimal controlDiabetes – suboptimal control• Tobacco useTobacco use

• Quit SmokingQuit Smoking• Diabetes EducationDiabetes Education

Other Other DiagnosesDiagnoses

Other TreatmentsOther TreatmentsOther TreatmentsOther Treatments


• She is much improved, She is much improved, both in volume and both in volume and frequency of accidentsfrequency of accidents

• Only wearing a minipad Only wearing a minipad when she goes outwhen she goes out

• Completely satisfied with Completely satisfied with her treatmenther treatment

• She is much improved, She is much improved, both in volume and both in volume and frequency of accidentsfrequency of accidents

• Only wearing a minipad Only wearing a minipad when she goes outwhen she goes out

• Completely satisfied with Completely satisfied with her treatmenther treatment

Return VisitReturn Visit


• 65 year old woman65 year old woman• Can’t reach the bathroom in Can’t reach the bathroom in

timetime• 5-6 accidents / day5-6 accidents / day• Urinary frequency and urgency Urinary frequency and urgency

interfering with her golf gameinterfering with her golf game• Wants something done Wants something done

yesterday!yesterday!

• 65 year old woman65 year old woman• Can’t reach the bathroom in Can’t reach the bathroom in

timetime• 5-6 accidents / day5-6 accidents / day• Urinary frequency and urgency Urinary frequency and urgency

interfering with her golf gameinterfering with her golf game• Wants something done Wants something done

yesterday!yesterday!

HistoryHistory


• MedsMeds– HCTZ 50 mg/dayHCTZ 50 mg/day– AspirinAspirin

• NKDANKDA• S/P TAHS/P TAH

• MedsMeds– HCTZ 50 mg/dayHCTZ 50 mg/day– AspirinAspirin

• NKDANKDA• S/P TAHS/P TAH

HistoryHistory


• Atrophic mucosaAtrophic mucosa• Small CystoceleSmall Cystocele• No leakage with coughNo leakage with cough

• Urinalysis - normalUrinalysis - normal• PVR = 30 ccPVR = 30 cc

• Atrophic mucosaAtrophic mucosa• Small CystoceleSmall Cystocele• No leakage with coughNo leakage with cough

• Urinalysis - normalUrinalysis - normal• PVR = 30 ccPVR = 30 cc

ExamExam

TestingTesting


• Dx – Urge UI, Atrophic VaginitisDx – Urge UI, Atrophic Vaginitis• D/C HCTZ, start beta blocker or D/C HCTZ, start beta blocker or

ACE inhibitor for BP controlACE inhibitor for BP control• Estrogen Cream ½ gram 3x / wk Estrogen Cream ½ gram 3x / wk

(apply into introitus with finger (apply into introitus with finger amount like kidney bean size)amount like kidney bean size)

• Ditropan XL 5 mg dailyDitropan XL 5 mg daily• RTC 1 monthRTC 1 month

• Dx – Urge UI, Atrophic VaginitisDx – Urge UI, Atrophic Vaginitis• D/C HCTZ, start beta blocker or D/C HCTZ, start beta blocker or

ACE inhibitor for BP controlACE inhibitor for BP control• Estrogen Cream ½ gram 3x / wk Estrogen Cream ½ gram 3x / wk

(apply into introitus with finger (apply into introitus with finger amount like kidney bean size)amount like kidney bean size)

• Ditropan XL 5 mg dailyDitropan XL 5 mg daily• RTC 1 monthRTC 1 month

TreatmentTreatment


• Doing betterDoing better• Only 1-2 accidents per day versus Only 1-2 accidents per day versus

5-6, but often large volume, still 5-6, but often large volume, still afraid to play golf.afraid to play golf.

• Taking Ditropan XL 5 mg, but Taking Ditropan XL 5 mg, but mouth is quite drymouth is quite dry

• Teach pelvic muscle exercises and Teach pelvic muscle exercises and urge strategiesurge strategies


• Doing betterDoing better• Only 1-2 accidents per day versus Only 1-2 accidents per day versus

5-6, but often large volume, still 5-6, but often large volume, still afraid to play golf.afraid to play golf.

• Taking Ditropan XL 5 mg, but Taking Ditropan XL 5 mg, but mouth is quite drymouth is quite dry

• Teach pelvic muscle exercises and Teach pelvic muscle exercises and urge strategiesurge strategies


Visit 2Visit 2


• Doing much betterDoing much better• Able to play golfAble to play golf• 1 accident in last 2 weeks1 accident in last 2 weeks• Continue Behavioral Continue Behavioral

Therapy, Meds, Estrogen Therapy, Meds, Estrogen creamcream


• Doing much betterDoing much better• Able to play golfAble to play golf• 1 accident in last 2 weeks1 accident in last 2 weeks• Continue Behavioral Continue Behavioral

Therapy, Meds, Estrogen Therapy, Meds, Estrogen creamcream


Visit 3Visit 3


• Continues to do wellContinues to do well• Golf game improvingGolf game improving• Rare accident in last 2 Rare accident in last 2

monthsmonths• D/C Ditropan XL?D/C Ditropan XL?

• Continues to do wellContinues to do well• Golf game improvingGolf game improving• Rare accident in last 2 Rare accident in last 2

monthsmonths• D/C Ditropan XL?D/C Ditropan XL?

Visit 3Visit 3


• 80 year old woman, 80 year old woman, referred by her golf referred by her golf partnerpartner

• Can’t reach the bathroom Can’t reach the bathroom in timein time

• 5-6 urge accidents / day5-6 urge accidents / day• Gave up golfGave up golf

• 80 year old woman, 80 year old woman, referred by her golf referred by her golf partnerpartner

• Can’t reach the bathroom Can’t reach the bathroom in timein time

• 5-6 urge accidents / day5-6 urge accidents / day• Gave up golfGave up golf

HistoryHistory


• ExamExam– Mildly atrophic vaginal Mildly atrophic vaginal

mucosamucosa

• UrinalysisUrinalysis– NormalNormal

• PVR = 80PVR = 80

• ExamExam– Mildly atrophic vaginal Mildly atrophic vaginal

mucosamucosa

• UrinalysisUrinalysis– NormalNormal

• PVR = 80PVR = 80


• Declines Estrogen Vaginal creamDeclines Estrogen Vaginal cream

• You prescribe Detrol LA 4 mg dailyYou prescribe Detrol LA 4 mg daily

• She calls and tells you her She calls and tells you her frequency and urgency are worsefrequency and urgency are worse

• What is going on?What is going on?

• Declines Estrogen Vaginal creamDeclines Estrogen Vaginal cream

• You prescribe Detrol LA 4 mg dailyYou prescribe Detrol LA 4 mg daily

• She calls and tells you her She calls and tells you her frequency and urgency are worsefrequency and urgency are worse

• What is going on?What is going on?

TreatmentTreatment


• Urinalysis normalUrinalysis normal• PVR = 200 ccPVR = 200 cc• What do you do?What do you do?• D/C DetrolD/C Detrol• Teach her pelvic muscle Teach her pelvic muscle

exercise and the urge exercise and the urge strategystrategy


• Urinalysis normalUrinalysis normal• PVR = 200 ccPVR = 200 cc• What do you do?What do you do?• D/C DetrolD/C Detrol• Teach her pelvic muscle Teach her pelvic muscle

exercise and the urge exercise and the urge strategystrategy




• Urgency is much betterUrgency is much better• Urge strategy really worksUrge strategy really works• Only 1-2 very small accidents per Only 1-2 very small accidents per

week; also she’s gained control of week; also she’s gained control of her flatusher flatus

• She thinks she will try golf againShe thinks she will try golf again• PVR = 50 ccPVR = 50 cc• Continue Pelvic Muscle Exercises Continue Pelvic Muscle Exercises

and Urge Strategyand Urge Strategy• RTC 3 monthsRTC 3 months

Return VisitReturn VisitReturn VisitReturn Visit


• 90 yo woman brought in by her 90 yo woman brought in by her daughter (also your patient) for daughter (also your patient) for urinary incontinenceurinary incontinence

• Stands up to go to the bathroom and Stands up to go to the bathroom and voids on her clothes and the floor on voids on her clothes and the floor on the waythe way

• About 4 accidents per dayAbout 4 accidents per day• Moderately advanced Alzheimer’s Moderately advanced Alzheimer’s

dementiadementia• Refuses to wear pads (takes them off Refuses to wear pads (takes them off

and hides them)and hides them)• Drinks 2-3 Diet Pepsi’s per dayDrinks 2-3 Diet Pepsi’s per day

HistoryHistory


• Repeats herself frequently during Repeats herself frequently during the examthe exam

• Slow, shuffling gaitSlow, shuffling gait• Mild atrophic vaginal mucosaMild atrophic vaginal mucosa• Soft fecal impactionSoft fecal impaction

• Urinalysis – normalUrinalysis – normal• PVR – 45 ccPVR – 45 cc

ExamExam

TestingTesting


• Functional IncontinenceFunctional Incontinence– Prompted Voiding – Prompted Voiding –

• Before and after each meal, Q am, Before and after each meal, Q am, & Q HS& Q HS

• Q 2 hours even hours while awakeQ 2 hours even hours while awake– Stop CaffeineStop Caffeine– Consider Physical TherapyConsider Physical Therapy– If needed, pull-up diapers and hide If needed, pull-up diapers and hide

regular underwearregular underwear– Manage ConstipationManage Constipation– Consider Geriatric AssessmentConsider Geriatric Assessment

TreatmentTreatment


• Daughter reports she is Daughter reports she is continent.continent.

• Didn’t realize she was Didn’t realize she was constipated, now daily BM constipated, now daily BM with prunes each morning.with prunes each morning.

• Didn’t need the pull-up Didn’t need the pull-up diapers since the prompted diapers since the prompted voiding schedule worked so voiding schedule worked so well.well.


Ouestions?Ouestions?Comments?Comments?

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