Case Study

“I can’t seem to control my urine. I feel like I have to urinate all the time. However, when I do go to the bathroom, I often pass only a small amount of urine. Sometimes I wet myself. I was started on a medication for my leaking a few weeks ago, but it doesn’t seem to be working. I also can’t seem to remember anything. It is a wonder that I remembered to come to the clinic today.”

HPI

Susan Jones is a 65-year-old woman with urinary urgency, frequency, and incontinence. She reports soiling her underwear at least two to three times during the day and night and has resorted to wearing panty liners or changing her underwear several times a day. The patient has curtailed much of her volunteer work and social activities because of this problem. Urinary leakage is not worsened by laughing, coughing, sneezing, carrying heavy objects, or walking up and down stairs. She does not report wetting herself without warning. She has been taking Detrol LA 2 mg PO daily for the past month with no improvement in her voiding symptoms, and she complains of new-onset confusion and difficulty remembering routine tasks.

PMH

HTN for many years, treated with medications for 10 years. Dyslipidemia for 5 years, controlled with a low-cholesterol diet, weight control, regular exercise, and medication. Menopausal; stopped ovulating at age 52; no longer has hot flashes. Has difficulty falling asleep and often has sleepless nights. She has no history of spinal or pelvic surgery.

FH

Noncontributory

SH

Nonsmoker; social drinker; married

Meds

Hydrochlorothiazide 25 mg PO once daily with supper

Irbesartan 150 mg PO daily

Pravastatin 40 mg PO at bedtime

Detrol LA 2 mg PO daily

Sominex (diphenhydramine) 15 mg PO at bedtime as needed, usually about five times a week

Amitriptyline 50 mg PO at bedtime as needed

All

NKDA

ROS

Complains of urinary incontinence that has not responded to Detrol LA. Feels confused and has difficulty remembering routine tasks. Patient states that her ability to remember what she has to do became impaired in the past 3 weeks after Detrol was started.

Physical Examination

Gen

WDWN woman

VS

BP 135/84 mm Hg, P 90 bpm, RR 16, T 37°C; Wt 65 kg, Ht 5′2″

Skin

No rashes, wounds, or open sores

HEENT

PERRLA; EOMI; no AV nicking or hemorrhages

Neck/Lymph Nodes

No palpable thyroid masses; no lymphadenopathy

Pulm

Clear to A&P

Breasts

Normal; no lumps

CV

Regular S1, S2; (+) S4; (–) S3, murmurs, or rubs

Abd

Soft, NTND, (+) bowel sounds

Genit/Rect

Genital examination shows atrophic vaginitis consistent with menopausal status. Perineal sensation and anal sphincter tone are normal.

Pelvic examination shows no uterine prolapse and a mild degree of cystocele. Cervix is normal. No pelvic, adnexal, or uterine masses found.

External hemorrhoids; heme (–) stool.

Ext

Normal; equal motor strength in both arms and legs

Neuro

Although alert, the patient is not oriented to correct month, day, or year. CNs II–XII grossly intact; DTRs 3/5 bilaterally; negative Babinski. When asked to recall a series of five objects after 5 minutes, the patient had difficulty and could only recall one object.

Labs

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Na 140 mEq/L

Hgb 12 g/dL

K 4.2 mEq/L

Hct 37%

Cl 105 mEq/L

Plt 400 × 103/mm3

CO2 28 mEq/L

WBC 5.0 × 103/mm3

BUN 17 mg/dL

SCr 1.2 mg/dL

Glu 100 mg/dL

UA

No bacteria; no WBC

Other

Using an ultrasonic bladder scan, a residual urine volume was measured after the patient voided. No residual urine was found. The bladder was then filled with 300 mL saline. The patient felt the first desire to void at 100 mL. The catheter was removed. The patient was asked to cough in different positions. No stress urinary incontinence was demonstrated. The patient voided the entire volume of saline that was instilled.

Assessment

Overactive bladder with symptoms of urinary urgency, frequency, and incontinence, which has not responded to Detrol LA 2 mg PO daily for 1 month. Patient is also having new-onset confusion and forgetfulness, which are probably related to Detrol LA and to the total anticholinergic burden. Will evaluate carefully and consider alternative medication options.

QUESTIONS

2.a. Assess the severity of incontinence based on the subjective and objective information available.

2.c. Differentiate urge incontinence from stress incontinence, overflow incontinence, and functional incontinence.

2.f. What are the possible consequences of persistent CNS adverse effects of anticholinergic agents in this patient?

3.c. What pharmacotherapeutic alternatives are available for treating overactive bladder? Compare and contrast antimuscarinic agents for treatment of overactive bladder syndrome.

4- Provide patient educational material to assist with adherence and /or  nor –pharmacologic management of overactive bladder.