urinary incontinence
Doctor Information
Margery Phillips, age 79
PMH
Hypertension
Osteoarthritis
Drug History
Amlodipine 5mg daily
Ketoprofen gel 2.5% prn
Paracetamol 1g qds prn
No known allergies
Last consultation:
Seen by Dr Graham
Medication review, hypertension well controlled on amlodipine and not having any side effects. Recent U+E stable. Continues to use analgesia for OA of knees, doesn't feel anything else needed at this stage.
Plan - review in 12 months.
PMH
Hypertension
Osteoarthritis
Drug History
Amlodipine 5mg daily
Ketoprofen gel 2.5% prn
Paracetamol 1g qds prn
No known allergies
Last consultation:
Seen by Dr Graham
Medication review, hypertension well controlled on amlodipine and not having any side effects. Recent U+E stable. Continues to use analgesia for OA of knees, doesn't feel anything else needed at this stage.
Plan - review in 12 months.
Patient Information
Margery Phillips, age 79
Opening Line: I’m sorry to have to bother you with this doctor but I seem to keep wetting myself.
History: You have been struggling with passing urine for a few years if you are honest. Initially it was just a bit of leaking if you laughed or sneezed, but now things are much worse. You need to go to the toilet every hour or so, but often it is just a trickle of urine. Even at night you are getting up three times at least to pass urine.
If asked only: Your bowel habit is fine and unchanged, and you have no burning pain on urinating or blood in the urine. Your weight is fairly stable although you know you are a little overweight. You had your menopause quite late at 54, and you have had three children, two normal deliveries and one caesarean section. You have no bleeding from your vagina. You eat well and don't have anything to drink after 7pm or you will be up all night in the toilet.
Social history: You live alone in a cottage and are completely independent. You still hold your licence. Your youngest daughter is quite nearby but the other two live in London. You find your symptoms very embarrassing, and have taken to wearing incontinence pads that you bought from tesco. You used to play bridge with three friends once a week and go to coffee morning at your parish, but lately you make excuses to avoid going. Non smoker, no alcohol or caffeine. You are not sexually active.
Past History: High blood pressure and arthritis in your knees
Medication: amlodipine 5mg daily, paracetamol 1g 4 times daily, ketoprofen gel 2.5 % every day
No allergies
Ideas: You cant understand why it is getting worse and would do anything to sort it out
Concerns: Your friends are eventually going to get fed up and stop calling you to come out, then you will be all alone
Expectation: Hopefully there is a tablet that will sort this out
Opening Line: I’m sorry to have to bother you with this doctor but I seem to keep wetting myself.
History: You have been struggling with passing urine for a few years if you are honest. Initially it was just a bit of leaking if you laughed or sneezed, but now things are much worse. You need to go to the toilet every hour or so, but often it is just a trickle of urine. Even at night you are getting up three times at least to pass urine.
If asked only: Your bowel habit is fine and unchanged, and you have no burning pain on urinating or blood in the urine. Your weight is fairly stable although you know you are a little overweight. You had your menopause quite late at 54, and you have had three children, two normal deliveries and one caesarean section. You have no bleeding from your vagina. You eat well and don't have anything to drink after 7pm or you will be up all night in the toilet.
Social history: You live alone in a cottage and are completely independent. You still hold your licence. Your youngest daughter is quite nearby but the other two live in London. You find your symptoms very embarrassing, and have taken to wearing incontinence pads that you bought from tesco. You used to play bridge with three friends once a week and go to coffee morning at your parish, but lately you make excuses to avoid going. Non smoker, no alcohol or caffeine. You are not sexually active.
Past History: High blood pressure and arthritis in your knees
Medication: amlodipine 5mg daily, paracetamol 1g 4 times daily, ketoprofen gel 2.5 % every day
No allergies
Ideas: You cant understand why it is getting worse and would do anything to sort it out
Concerns: Your friends are eventually going to get fed up and stop calling you to come out, then you will be all alone
Expectation: Hopefully there is a tablet that will sort this out
Examination Findings
Pulse 78
Blood pressure 133/77
Abdomen soft and non tender
If pelvic examination performed:
Normal external genitalia, no atrophy
Moderate cystocele with first degree uterine descent. No rectocele, cervix appears healthy.
Uterus normal size, anteverted. No adnexal tenderness.
Blood pressure 133/77
Abdomen soft and non tender
If pelvic examination performed:
Normal external genitalia, no atrophy
Moderate cystocele with first degree uterine descent. No rectocele, cervix appears healthy.
Uterus normal size, anteverted. No adnexal tenderness.
Mark scheme
Data Gathering
|
Positive indicators
Systematic history of symptoms Excludes red flags (e.g. postmenopausal bleeding) Offers chaperone and performs competent examination of patient |
Negative Indicators
Misses important factors in the history or non-systematic approach Failure to examine patient Failure to examine patient or offer chaperone |
Clinical Management Skills
|
Positive indicators
Correctly identifies diagnosis Provides accurate explanation to patient Shares and explains management options If referral offered, considers interim measures e.g pessary |
Negative indicators
Fails to explain diagnosis Makes decisions rather than offering and sharing management options with the patient Fails to offer interim measures if appropriate |
Inter Personal Skills
|
Positive indicators
Sensitive approach, sympathetic Explores idea and concerns Simple explanation of problem in lay terms Non judgemental Good rapport with patient |
Negative indicators
Does not demonstrate sympathy or sensitivity Fails to explore ideas/concerns/expectations Uses jargon during explanation Makes assumptions about the patient Poor rapport |
Management
There are three main types of urinary incontinence:
Stress: involuntary leakage on coughing/sneezing/exertion
Urge: involuntary leakage following a sudden urge to pass urine
Mixed - a bit of both
There is also a condition called overactive bladder (OAB) which is urgency, frequency and nocturia, with or without urge incontinence.
The most common causes of stress incontinence are a lax pelvic floor, either from pregnancy, prolapse, chronic cough and obesity (things that cause raised intra-abdominal pressure)
OAB has many causes as well - the most common are UTI, obstruction, neurological conditions e.g. stroke/dementia/multiple sclerosis, diabetes, that can all affect the bladder muscle.
Assessment:
From your history, establish the type of incontinence, any possible causes and the severity. What is the effect on her quality of life (common problems are planning trips around public toilets, attending less social events, wearing daily incontinence pads).
During pelvic examination, ask the women to cough and see if there is any leaking from the external meatus. If available, use a Sims speculum to assess for anterior and posterior wall prolapse, and uterine descent.
It is wise to do a dipstick test to exclude infection
Management for stress incontinence - Suggest some conservative measures, for example weight loss if BMI >30, avoiding excessive fluids. If leaking and incontinence is a major issue, you can suggest the use of absorbent pads whilst awaiting assessment/treatment (you may have a continence team locally that can help with this).
Pelvic floor exercises, for three months is a good starting option. This can either be done through a referral to a physiotherapist, or information leaflets can be printed and given from sources such as patient.co.uk. A minimum of 8 contractions three times a day is required to start with.
Other options:
Management for urge incontinence - lifestyle measures and use of pads are the same as above. Treat any underlying condition, e.g. UTI, Parkinsons disease, Multiple Sclerosis. Consider a bladder diary, to monitor trips to the toilet and fluid intake.
Offer referral for supervised bladder training (lasting for a minimum of at least 6 weeks). This may be available from the local continence nurse, continence physiotherapist, or urology clinic.
If symptoms persist and frequency is a troublesome symptom, encourage the woman to continue bladder training and consider adding in:
If treatment ineffective, refer onward to urology for consideration of: botulinum toxin injections, sacral nerve stimulation, cystoplasty and urinary diversion.
Management of Mixed incontinence - Manage the most predominant type of incontinence as above.
Stress: involuntary leakage on coughing/sneezing/exertion
Urge: involuntary leakage following a sudden urge to pass urine
Mixed - a bit of both
There is also a condition called overactive bladder (OAB) which is urgency, frequency and nocturia, with or without urge incontinence.
The most common causes of stress incontinence are a lax pelvic floor, either from pregnancy, prolapse, chronic cough and obesity (things that cause raised intra-abdominal pressure)
OAB has many causes as well - the most common are UTI, obstruction, neurological conditions e.g. stroke/dementia/multiple sclerosis, diabetes, that can all affect the bladder muscle.
Assessment:
From your history, establish the type of incontinence, any possible causes and the severity. What is the effect on her quality of life (common problems are planning trips around public toilets, attending less social events, wearing daily incontinence pads).
During pelvic examination, ask the women to cough and see if there is any leaking from the external meatus. If available, use a Sims speculum to assess for anterior and posterior wall prolapse, and uterine descent.
It is wise to do a dipstick test to exclude infection
Management for stress incontinence - Suggest some conservative measures, for example weight loss if BMI >30, avoiding excessive fluids. If leaking and incontinence is a major issue, you can suggest the use of absorbent pads whilst awaiting assessment/treatment (you may have a continence team locally that can help with this).
Pelvic floor exercises, for three months is a good starting option. This can either be done through a referral to a physiotherapist, or information leaflets can be printed and given from sources such as patient.co.uk. A minimum of 8 contractions three times a day is required to start with.
Other options:
- Reducing caffeine intake — this may improve symptoms of urgency and frequency but not incontinence.
- Fluid intake — advise the woman to avoid drinking either excessive amounts, or reduced amounts, of fluid each day (reduced fluid intake may worsen or cause constipation). The recommended daily intake is six to eight glasses of water.
- Weight loss if the woman's body mass index is 30 kg/m2 or greater. For more information, see the CKS topic on Obesity.
- Smoking if this is appropriate — advise the woman to stop smoking as this is associated with chronic cough which may contribute to stress urinary incontinence.
- Referring to a urogynaecologist, gynaecologist, or urologist, depending on local service provision for assessment and further surgical management: Treatment options in secondary care include synthetic mid-urethral tape, colposuspension, autologous rectus fascial sling, intramural urethral bulking agents, or an artificial urinary sphincter.
- Offering duloxetine as a second-line treatment, but only if the woman prefers drug to surgical treatment or is not suitable for surgical treatment.
Management for urge incontinence - lifestyle measures and use of pads are the same as above. Treat any underlying condition, e.g. UTI, Parkinsons disease, Multiple Sclerosis. Consider a bladder diary, to monitor trips to the toilet and fluid intake.
Offer referral for supervised bladder training (lasting for a minimum of at least 6 weeks). This may be available from the local continence nurse, continence physiotherapist, or urology clinic.
If symptoms persist and frequency is a troublesome symptom, encourage the woman to continue bladder training and consider adding in:
- An antimuscarinic (anticholinergic) drug. Oxybutynin (immediate release), tolterodine (immediate release), or darifenacin (once daily preparation) can be used first-line.
- Do not offer immediate release oxybutynin to frail older women due to the risk of impairment of daily functioning (for example walking or dressing), chronic confusion, or acute delirium (less common).
- Prescribe the lowest recommended dose and titrate the dose up if required.
- Mirabegron, if an antimuscarinic is contraindicated (depending on local prescribing policy).
- Mirabegron is a 'black triangle' drug and is subject to intensive post-marketing safety surveillance.
If treatment ineffective, refer onward to urology for consideration of: botulinum toxin injections, sacral nerve stimulation, cystoplasty and urinary diversion.
Management of Mixed incontinence - Manage the most predominant type of incontinence as above.