Mrs. Smith is a 67 year old obese woman with urinary incontinence who wakes up four times per night to void. She wonders if she should stop drinking her daily 3 cups of tea. She thinks she drinks about 2.5 litres of water daily. Her urine dip was negative when she arrived at your office. You note that her recent blood work, including renal function and a screening Hgb A1c was also normal.
In terms of her medical history Mrs Smith has high blood pressure, hypothyroidism, suffers from a bit of leg swelling due to chronic venous insufficiency, difficulty sleeping and osteoarthritic pain in her hands and knees. Her medications include nifedipine XL 60 mg qam, levothyroxine 0.112 mg qam, furosemide 20 mg po bid, iboprophen 200 mg bid, lorazepam 1 mg po qhs.
Dr. Shaw, a family doctor, and Dr. Tannenbaum, an expert in geriatric incontinence, discuss how best to handle the above clinical scenario.
In a busy practice, I often query when is the best time to investigate a patient like Mrs. Smiths’ urinary symptoms.
A practical barrier, as I look at this case is how long it would take to get this woman undressed and get her onto the exam table.
I am trying to decide if I could complete the verbal history today and then bring her back for the pelvic-in a week or so.
You raise a pragmatic concern, as the appropriate work-up and development of a treatment plan for patients with incontinence takes at least 20 minutes.
My suggestion would be not to do the exam at this visit, but to give the patient a 3-day bladder diary to fill out for her next visit. See an example of a diary in this guide.
Then schedule a 20-minute follow-up visit in a week or so which would be solely dedicated to her urinary symptoms.
If I focus on the history, what are the most time efficient and evidence-based questions to identify the type of incontinence?
How can I easily measure or judge the impact of these incontinence symptoms on her quality of life?
There is good evidence that the following 3 questions are all that are required:
- To diagnose stress incontinence, “Do you lose urine during sudden physical exertion, lifting, coughing or sneezing?”
- To diagnose urgency incontinence, “Do you experience such a strong and sudden urge to void that you leak before reaching the toilet?”(1)
- "On a scale of 1-to-10, how much does your incontinence bother you?"(2)
It is not clear to me what the best evidence-based physical examination components to assess incontinence are.
I always do a pelvic exam in women, but nothing special in men. Other than an obvious cystocoele or prolapse in my female patients, how could I reliably assess “weak” pelvic floor muscles (PFM)?
In women, I check PFM strength using a digital vaginal exam. I ask patients to squeeze my finger with their vagina, in order to assess whether:
- I can feel a strong contraction and
- the woman has a good technique prior to suggesting a regular PFM exercise routine.
In men, I put my fingers on his perineum and then I ask the patient to try to “lift up” his penis. I see if I can feel a contraction.
Referral to physiotherapy is required if patients are unable to squeeze the PFM sufficiently well on their own, and would benefit from supervision.
In Mrs. Smiths’ case I would also check for pedal edema if the patient complains of night-time symptoms, as fluid redistribution may contribute to nocturia.
When would more additional diagnostic testing be required (including urodynamics)?
Is an office urine dip negative for blood OK? I would not generally send a urine analysis unless there was something on the dip.
If the urine dip comes back positive for blood, nitrites or leukocytes, I order a urine culture to rule out infection. If the culture is negative but there is persistent microscopic hematuria, examination for casts and/or cystoscopy to rule out a renal disorder or a bladder tumour are required.
If the patient complains of incomplete bladder emptying, it is important to check the sacral nerves or order an ultrasound to assess the post-void residual volume.
Urodynamic testing is generally not required except if the patient is contemplating surgery for stress incontinence.
Concomitant fecal incontinence requires a rectal exam to check for impaction or poor sphincter tone.
The sudden onset of symptoms accompanied by other neurological symptoms leads me to do a full neurological exam to rule out a cerebrovascular event.
A functional assessment – looking at mobility and dexterity – can help identify contributors that may be reversible with physiotherapy.
I’m pretty certain that some of Mrs. Smith’s medications could be contributing to her incontinence. Which ones do you think are the most likely culprits?
It is worthwhile reviewing her patients’ medication list as there is good evidence that many medications contribute to urgency incontinence.
There are several medications that could be contributing to urinary symptoms(3)
- nifedipine causes leg swelling,
- ibuprophen could be contributing to fluid retention and swelling,
- furosemide gives her urgency and frequency,
- lorazepam makes her sleepy and it takes her longer to get to the bathroom at night so she leaks.
How easy it is to get the patient to comply with a PFM regimen, for instance, Kegels?
My only frame of reference is with my post-partum patients, which are quite different than elderly patients such as Mrs. Smith. Will elderly patients be motivated to do these exercises?
PFM exercises are always recommended as first line therapy (4;5). These can be prescribed alone or under the supervision of a physiotherapist, and should only take 10-15 minutes per day. See the exercise guide in the self-management brochure as an example(6).
Regarding adherence to PFM exercises, an advantage of testing their PFM strength in clinic is that patients understand that weakness will be a factor. When I tell them the muscles are weak, the patient can sense this (sometimes it is REALLY obvious because they cannot even identify and contract the muscles at all).
I ask if they are motivated to try building strength, either with a home based program or under the supervision of a specialized physiotherapist. I tell them that one of my 98 year old patients was cured of incontinence, just by doing PFM exercises and cutting out her tea. I also tell them that there are no medications that can strengthen muscles, only exercise. Then I see if they want to give it a try.
I’d like to recommend lifestyle changes, but given how challenging they can sometimes be to implement, is there good evidence they make a difference?
Explain that reducing or eliminating caffeinated beverages, a well as reducing total fluid intake, can really make a difference to her incontinence(3).
Weight loss is effective for reducing symptoms of incontinence for patients with both stress and urge symptoms(3).
I often recommend the use of compression stockings to control pedal edema instead of diuretics.
I also routinely prescribe an exercise program for patients with arthritis and mobility problems to increase gait speed to get to the bathroom on time.
This discussion has helped me to develop a focused, evidence-based approach to the efficient assessment and management of incontinence:
- a few basic questions;
- a simple examination technique ("squeezing the finger") and an office urine dip;
- a medication review;
- and some simple lifestyle changes with caffeinated and other fluids and PFM exercises.
Thanks for the handouts!