1. Urinary Incontinence Case Donald R. Noll DO FACOI Edited by Edward Warren, MD, Chair Geriatrics Carolinas Campus, March 2012

2. Case 1 - History CC: Urinary Incontinence HPI: A 70 year old man presents to the office with near constant loss of urine of small amounts of urine, onset about five days ago, getting modestly worse. He is brought in by his wife. He is wheelchair bound from a previous stroke which has left him with left sided hemiplegia, (especially weak in the left lower leg) and expressive aphasia. Coughing makes it worse, a trial of oxybutynin did not help. PMH: BPH, COPD, DJD, Stroke, HTN. PSH: None. Social: still smokes Medications: Aspirin daily, Inhaled Beta-agonists and steroids for COPD, celecoxib 200mg daily, enalapril5 mg bid. No Known Drug Allergies ROS: Limited due to his expressive aphasia, no apparent trouble breathing, no chest pain, he does indicate vague abdominal discomfort, left leg is weaker than the left arm.

3. Case 1 - Exam Exam: BP 170/90, P 100, R 22 General - appears to be in some distress Skin - warm and moist, no rash HENT - unremarkable Lungs - Clear to auscultation, diminished breath sounds Heart - rate is regular, heart sounds are distant, a grade III/VI ejection murmur noted Abdomen - diffusely tender but soft, with normal bowel sounds. There is a large supra-pubic midline mass, the top palpated just below the umbilicus. Extremities - some pitting edema in the lower extremities, minor bruising Neurologic - weakness in the left lower extremity, greater than the left upper extremity, expressive aphasia – speech not comprehendible.

4. Question 1 Based on the case history and physical, what type of urinary incontinence does the patient most likely have? • Urge • Stress • Overflow • Functional • Mixed

5. Question 2 In this case, what would be the best immediate treatment? • Prescribe a stronger, more specific anti-spasmodic medication. • Prescribe pelvic floor strengthening exercises • Straight cath. the patient and document the post-void residual volume • Counsel the wife how to “toilet” the patient on a schedule • Try all of the above

6. Question 3 If you were going to just manage this with medications, what medication would be best to use for this patient’s urinary incontinence? • Darifenacin • Tolterodine • Bethanechol • Tamsulosin • Imipramine

7. Question 4 In this case, could the Oxybutynin be making his condition worse? • Yes • No • Not enough information

8. Question 5 If medication failed, what would be a likely and effective long term treatment / solution to this patients problem? • Physical Therapy • Surgical opening of the bladder outlet obstruction • Counseling • Avoid caffeine and alcohol completely • Biofeedback

9. Question 6 Multi-parous and obese women are at risk for which type of urinary incontinence? • Urge • Stress • Overflow • Functional • Mixed

10. Question 7 Although not used widely now, Vaginal Pessaries can be used to manage what type of urinary incontinence? • Urge • Stress • Overflow • Functional • Mixed

11. Question 8 In general, can acute confusion cause urinary incontinence? • Yes • No

12. Question 9 Which causes the bladder to hold urine and be continent? • Sympathetic Response • Parasympathetic Response • Cholinergic Response • Anti-cholinergic Response • None of the above

13. Question 10 Approximately, what percentage of community dwelling elders experience some degree and type of urinary incontinence? • 1% • 5% • 33% • 50% • 80%

14. Question 11 A man who lived in Aberyswth, Who worked with things one grinds grist with, Took the miller’s daughter And did what he shouldn’t aughter, By connecting the organs they _______ ____!

15. Answers • C The painful, lower midline mass is the bladder. It is distended from outlet obstruction. This is overflow incontinence. • C The bladder needs to be emptied. this test is diagnostic and therapeutic. Never take off more than 500 ml at a time. Clamp the Foley, wait 15 minutes and take more. Suddenly decompressed bladders can bleed badly. • CBethanechol will cause the detrusor to contract with more vigor. • A The oxybutynin is relaxing the bladder and causing it to be unable to empty. • B The prostate may need removal with a TURP. If a long term Foley is indicated, then he will need a suprapubiccystostomy. • B Stress incontinence due to weakness in the pelvic floor. • B The pessary in the vagina, holds up the bladder and supports it. • A Of course • A The sympathetics cause the bladder to relax and tightens the trigone and sphincter. • C One third of community dwelling elders • pissed with