Incontinence/Pelvic organ prolapse Flashcards
A 75-year-old woman presents with urinary incontinence. She describes a sudden and very intense need to pass urine which is often followed by incontinence. She has a past medical history of Alzheimer’s disease and closed-angle glaucoma.
What is the preferred treatment?
A. Darifenacin
B. Duloxetine
C. Mirabegron
D. Oxybutynin
E. Tolterodine
C. Mirabegron
Anticholinergics for urge incontinence are associated with confusion in elderly people - mirabegron is a preferable alternative
Mirabegron is correct. Mirabegron (a beta-3 agonist) is the preferred agent in this case due to the side effect profile of anticholinergic agents.
Darifenacin, Oxybutynin, and Tolterodine are incorrect. These agents are all anti-muscarinic agents which can cause confusion and exacerbate closed-angle glaucoma.
Duloxetine is incorrect. This is the agent of choice for stress incontinence.
management of urge incontinence:
-bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding)
-bladder stabilising drugs: antimuscarinics are first-line
NICE recommend oxybutynin (immediate release), tolterodine (immediate release) or darifenacin (once daily preparation)
Immediate release oxybutynin should, however, be avoided in ‘frail older women’
-mirabegron (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patients
management of stress incontinence:
-pelvic floor muscle training
NICE recommend at least 8 contractions performed 3 times per day for a minimum of 3 months
-surgical procedures: e.g. retropubic mid-urethral tape procedures
-duloxetine may be offered to women if they decline surgical procedures
a combined noradrenaline and serotonin reuptake inhibitor
mechanism of action: increased synaptic concentration of noradrenaline and serotonin within the pudendal nerve → increased stimulation of urethral striated muscles within the sphincter → enhanced
management of stress incontinence:
-pelvic floor muscle training
NICE recommend at least 8 contractions performed 3 times per day for a minimum of 3 months
-surgical procedures: e.g. retropubic mid-urethral tape procedures
-duloxetine may be offered to women if they decline surgical procedures
a combined noradrenaline and serotonin reuptake inhibitor
mechanism of action: increased synaptic concentration of noradrenaline and serotonin within the pudendal nerve → increased stimulation of urethral striated muscles within the sphincter → enhanced
A 65-year-old woman presents to the GP with urinary incontinence. Her symptoms occur all day, and she has also noticed that when she does manage to go voluntarily her flow of urine is very poor. On examination, the GP can feel a distended bladder even though the patient has just urinated while waiting for the appointment.
Given this woman’s presentation, what is the most likely diagnosis?
A. Urge incontinence
B. Overactive bladder syndrome
C. Stress incontinence
D. Mixed incontinence
E. Urinary overflow incontinence
E. Urinary overflow incontinence
Bladder still palpable after urination, think retention with urinary overflow
This elderly woman is presenting with symptoms of urinary incontinence. This is confirmed by the palpable bladder after urination. The most common causes of urinary overflow incontinence are prostate problems, however, in this case as she is a woman this is not possible. Other causes can include nerve damage causing a neurogenic bladder such as complication of diabetics, chronic alcoholics or surgery to the pelvic area.
Urge incontinence would be preceded by a sudden need to urinate. This is not noted as the patient has a constant incontinence.
An overactive bladder syndrome is a form of urge incontinence caused by an overactive bladder, it too would be associated with incontinence, polyuria and nocturia.
Stress incontinence would be likely associated with raised intraabdominal pressure, such as a sneeze or a cough. This is not noted in this case.
As no symptoms of urge incontinence or stress incontinence were present, a diagnosis of mixed incontinence is not suggested.
cystocoele management:
- Conservative management (smoking cessation, weight loss & pelvic floor exercises)
- Vaginal (ring) pessary
- Per vaginal Surgery (if cystocoele is small, puts patient at risk of fibroids & adhesions)
