Case 18: Urinary incontinence

 

Case 18: Urinary incontinence

CASE 18: URINARY INCONTINENCE

History

A 61-year-old woman complains of involuntary loss of urine. She has noticed it gradually over

the last 10 years and has finally decided to see her general practitioner about it after hearing a

programme on the radio about treatment for incontinence. The leaking is generally of small

amounts and she wears a pad all the time. It tends to occur when she cannot get to the toilet

in time. She never leaks on coughing or sneezing. She suffers urgency, particularly when she

comes home after being out and is about to come into the house. She also has frequency, passing urine every hour during the day and getting up two or three times each night.

Due to the incontinence she tries not to drink much and usually has two cups of tea first thing

in the morning, coffee mid-morning and a further cup of tea mid-afternoon. Other than that

she drinks one glass of squash per day and has one glass of wine at night.

She is a non-smoker. She has had two uncomplicated vaginal deliveries. Her periods stopped

at the age of 54 years. There is no other gynaecological or medical history of note.

Examination

Abdominal examination is normal. On vaginal examination there is minimal uterovaginal

descent and no anterior or posterior vaginal wall prolapse.

INVESTIGATIONS

Midstream urinalysis: protein negative, blood negative, leucocytes negative, nitrites

negative

Urodynamics: the first urge to void was reported at 150 mL bladder filling. Involuntary

detrusor contractions were noted while the patient was attempting to inhibit micturition.

There was no loss of urine with coughing.

Questions

• What is the diagnosis?

• How would you advise and manage this patient?100 Cases in Obstetrics and Gynaecology

44

ANSWER 18

The diagnosis is of urge urinary incontinence and overactive bladder syndrome (OAB),

defined as urgency that occurs with or without urge incontinence (UI) and usually with frequency and nocturia. This was formerly referred to as detrusor instability. In this condition

the bladder contracts involuntarily without the normal trigger to void caused by bladder

filling. This results in involuntary loss of urine that is embarrassing and often impacts enormously on women’s lives, as they are constantly aware of needing to void and where the nearest toilet might be.

Urodynamic investigation with filling and voiding cystometry is helpful (as in this case) in confirming the diagnosis by showing spontaneous detrusor contractions during bladder filling.

It is important to exclude other causes of such symptoms (such as urinary tract infection or a

bladder tumour) with urine microscopy.

Management

• Conservative:

• The woman should be advised that both caffeine and alcohol are bladder

stimulants and are likely to worsen symptoms so should be minimized. She

should take a normal fluid intake per day but avoid drinks after about 7 pm

to limit nocturia.

• Bladder retraining for 6 weeks, involving a ‘drill’ restricting voiding to increasing intervals should be taught.

• Medical treatment:

• If lifestyle advice and bladder retraining fail then anticholinergic medication

such as oxybutynin, tolterodine, fesoterodine or darifenacin should be commenced. The associated side effects to be warned of include dry eyes, dry mouth

and constipation. Mirabegron is a beta-3-adrenoceptor agonist, which may be

used if anticholinergics fail.

• The effects of treatment should be monitored using one of the validated incontinence-specific quality-of-life scales.

KEY POINTS

• Overactive bladder syndrome is associated with urgency, frequency and urge

incontinence.

• Conservative measures are bladder retraining and caffeine avoidance.

• Medical treatment is with anticholinergics.