For Student

History
Mrs. L, a 75-year-old widow, came to your office after being discharged from the hospital,
where she underwent surgery for a fracture of her right shoulder. Mrs. L has been under your
care for several years and has been treated for hypertension, osteoarthritis of both knees, and
obesity. She had a stroke 4 years ago but the deficit resolved. She has no history of diabetes or
glaucoma. Her hypertension had been well controlled with daily hydrochlorothiazide 25 mg and
atenonol 50 mg. Because she does not tolerate nonsteroidal antiinflammatory agents, she takes
acetaminophen for her knee pain but still has pain when she walks and sometimes uses a cane.
Other medications include enteric-coated aspirin and a multivitamin.
Mrs. L explains that, on the night of the fracture, she woke up to urinate around midnight, and
then fell and broke her shoulder. She related her fall to drinking wine that night with a friend,
which had made her a little drowsier than usual when she got up at midnight. She drinks alcohol
only occasionally, and has not had trouble before. The conversation reminded Mrs. L that she
experienced frequent nocturnal urination during the hospitalization and on several occasions was
unable to get to the toilet on time and became incontinent. When questioned, she admits that she
has had urinary frequency for several years but managed it by avoiding beverages before sleep or
before leaving her house. She also avoids going out for long periods during the day, and,
whenever she returns from her brief excursions, she develops urinary urgency “as soon as the
key goes into the lock.” She has occasionally experienced leakage when sneezing, standing, or
coughing, but this most commonly occurs when she is trying to hold her urine during one of her
“urgent” episodes. Still, she did not view her urinary pattern as a big problem until her recent
hospitalization. Mrs. L last visited her gynecologist 1 year ago. She has no cystocele, rectocele,
or uterine prolapse. She denies dysuria, fever, or constipation.

Tasks:
1, What factors contributed to this patient’s urinary incontinence?
2. How should her problem be approached?
3. What nonpharmacologic approaches could be of benefit to this patient?
 Student’s name
For examiner

Task 1 (3.5)The patient’s chronic urinary urgency suggests that she suffers from detrusor
instability, but her problem may be multifactorial. She has been taking diuretics, which could be
exacerbating her problem. Although she has found her bladder problems annoying, she coped
with them until she became incontinent in the hospital. Urinary “urge incontinence” is a typical
presentation of detrusor instability. The diagnosis of detrusor instability (also referred to as
“overactive,” “unstable,” “hyperreflexic,” “spastic,” or “uninhibited neurogenic” bladder) is
generally apparent from the history alone. Typically, the affected patient reports frequent
involuntary contractions or severe urgency at a relatively lower bladder volume. Detrusor
instability is the most common cause of urinary incontinence in elderly men and women. It can
be caused by a neurologic condition, such as dementia or stroke, which releases the brainstem
detrusor-reflex from cerebrocortical inhibition. In most cases, however, no specific neurologic
illness is identified, and incontinent elderly patients who develop stroke or other brain lesions
may previously have had detrusor instability. In the setting of detrusor instability, bladder
irritation due to infection, bladder tumor, or stone can worsen existing urgency and frequency. In
Mrs. L’s case, the long history of bladder symptoms, and the absence of fever and dysuria, make
urinary tract infection a less likely cause of acute incontinence. Mrs. L also has occasional stress
incontinence, which can coexist with detrusor instability in women, and which may present in
the perimenopausal years and even earlier. This “true” stress incontinence (in contrast to stress
incontinence in the presence of urinary retention) is characterized by leakage of urine in
association with sudden increased intra-abdominal pressure during coughing, sneezing, laughing,
or, in severe cases, merely standing up. It is due to insufficiency of the internal urethral sphincter
or pelvic floor weakness. The syndrome has been attributed to estrogen deficiency and
childbirth, but variable clinical response to estrogen replacement, and existence of the problem in
nulliparous women, challenge those explanations or suggest that other factors are involved.
Overflow urinary incontinence occurs in the setting of significant urinary retention. Incontinence
may be precipitated by increased intra-abdominal pressure, causing a reflex micturition
contraction and loss of a small amount of urine. Persistent urinary retention is uncommon in
women and, on examination, Mrs. L’s bladder was not palpable. Urinary retention, its causes,
and management are discussed in detail in Case 34. Mrs. L’s “acute” incontinence was partially
functional in nature and was precipitated by circumstances associated with hospitalization.
Functional urinary incontinence (also called “pseudoincontinence”) occurs when the patient is
unable to reach the toilet on time because of physical limitations, environmental barriers, or a
pharmacologic effect, such as sedation. In Mrs. L’s case, ambulatory problems due to arthritis,
now complicated by problems with her right arm and deconditioning during hospitalization,
prevented her from toileting quickly enough and she became incontinent. In addition to her
ambulatory limitations, detrusor instability, diuretics, and alcohol (with its sedating as well as
diuretic properties) were all important factors in her fall.
Task 2 (3.0)Like many patients, Mrs. L’s long-standing urinary frequency did not prompt her to
seek medical attention, and her physicians did not inquire. In general, it is important to inquire
routinely about bladder problems in older adults. Because Mrs. L recently underwent surgery and
probably had an indwelling catheter, urinalysis and culture should now be performed to rule out
a hospital-acquired urinary tract infection as a factor in her “acute” incontinence. However,
asymptomatic bacteriuria often exists in late life (see Case 34) and treatment of the infection
does not reverse the incontinence. In order to address her ongoing bladder problem, the diuretic
could be replaced by an antihypertensive agent that would not exacerbate her bladder problems.
It is best to avoid certain antihypertensive agents, such as alpha-blockers, which can relax the
urethral sphincter and are, in fact, commonly given to promote voiding in benign prostatic
hyperplasia. Calcium channel blockers, though generally well tolerated, have occasionally been
reported to cause urinary retention, probably because detrusor contractions are dependent on
calcium channels. Other medications that can be problematic are sedatives, which can cause
confusion and missed bladder cues. Medications that relax the detrusor muscle, such as
oxybutynin (Ditropan) or tolterodine (Detrol), can sometimes ameliorate detrusor instability but
can cause dry mouth, visual blurring, and other anticholinergic effects. Systemic and topical
estrogen are frequently given for urinary stress incontinence but clinical trials have not
consistently supported their benefit, even in younger women. Mrs. L was given enalapril instead
of hydrochlorothiazide. Her urinalysis was normal, and on follow up 1 week later, and her blood
pressure was still under control. Her urinary frequency seemed diminished, but she still had to
urinate two to three times per night and continued to have frequency during the day. Oxybutynin
was instituted at a very small dose, and she was instructed to take the medication only at specific
times, such as prior to a social activity, a physical therapy session, or at bedtime. This reduced
her urinary frequency somewhat.
Task 3 (3.5)Removal of environmental hazards and a good night light can make it easier to get
to the bathroom safely and on time. A bedside commode can make night-time toileting easier and
can help to prevent functional incontinence. These interventions would be particularly important
in this patient who fractured her arm on the way to the bathroom at night. Pelvic muscle
exercises are helpful for patients with stress incontinence and for some with urge incontinence.
The patient first is taught to identify the pelvic muscles that will be exercised, then to try to stop
the stream in the middle of urination, let it resume, and then stop the stream again. The exercise
consists of 10-second contractions followed by 10-second relaxations, and the exercise is
repeated 15 times approximately three times a day. The ideal patient is cognitively intact,
ambulatory, and able to perform this exercise correctly, so it is not suitable for many frail older
patients. Biofeedback instruments are sometimes used to help the patient learn to identify pelvic
muscles and to master the technique of exercising pelvic muscles selectively while keeping
abdominal muscle relaxed. Bladder training is another approach that could be helpful. This
consists of the patient or caregiver observing and recording the patient’s micturition needs, and
toileting at the longest possible interval (usually 30 minutes to 2 hours) to keep her dry. If
continence is maintained for 48 hours, the interval can be lengthened. This method is repeated
until a reasonable goal is achieved, such as 4 hours of continence. Patients with urge
incontinence are taught to employ “urge strategies,” which are adaptive responses to the
sensation of urgency. These include distraction, relaxation of the entire body, or contracting
pelvic muscles instead of rushing to the toilet. After urgency subsides, the patient proceeds to the
toilet at a normal pace. For patients with dementia, who will be unable to use these strategies or
for others who cannot toilet on their own, a caregiver observes the patient’s voiding patterns and
maintains a regular toileting schedule in accordance with the observed pattern. Adult
incontinence garments and pads are commercially available or can be improvised in the home or
hospital and can be used as a backup for “accidents” to maintain dryness and to give the patient
confidence to participate in social activities.