Emory Reynolds Program
URINARY INCONTINENCE
CASE 2
Mr. B is an 82-year-old man who is seen in clinic because of incontinence. His diagnoses and
medications are as follows:
Diagnoses
Dementia, Alzheimer’s type
Gastroesophageal reflux
Glaucoma
Medications
Donepezil
Ranitidine
Beta blocker eye drops
He lives with his daughter and is ambulatory, but dependent in all basic activities of daily living
because of dementia. He seems very frustrated by his incontinence, and his daughter is having a
very difficult time managing the problem. She reports that his condition seems to be worsening,
and he now is voiding about every 1½ hours during the day and 4 – 5 times between the hours of
9:00 p.m. and 7:00 a.m. while he is in bed. His daughter also expresses concerne over the cost of
the 4-5 adult diapers he is using per day. He has a history of a transurethral resection of the
prostate (TURP) at age 75, and according to his primary care physician his symptoms of
frequency and nocturia did not respond to a recent trial of tamsulosin.
Despite frequent attempts by his daughter to help him toilet with prompting, he remains
incontinent on most voids.
Questions to Consider
1. What additional treatment might be appropriate and helpful for Mr. B?
Mr. B has typical symptoms of overactive bladder (OAB). OAB symptoms are the most
common symptoms associated with incontinence in frail, older people. They are usually
caused by a hyperactive bladder muscle. In older men, OAB symptoms can also be
associated with obstruction from an enlarged prostate, which can be either benign or
cancerous.
The treatment of OAB is primarily behavioral interventions and drug therapy. For
patients with dementia, prompted voiding or some form of scheduled toileting is the most
appropriate behavioral intervention. “Bladder training,” pelvic muscle exercise, and
biofeedback are all effective for OAB, but are not appropriate for people with advanced
dementia because these treatments require learning, memory, practice, and incorporation
into everyday life.
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April, 2004
Drug therapy for OAB is primarily with bladder relaxant medications. The two most
commonly used bladder relaxants are tolterodine (Detrol) and oxybutynin (Ditropan).
Both are available in once-per-day forms.
2. What diagnostic assessment would be appropriate for Mr. B before further
treatment?
Because Mr. B’s incontinence seems to have worsened recently, so it would be
appropriate to do a urinalysis to make sure he has not developed an infection. A
urinalysis will also exclude glucosuria, a sign of diabetes (although it would be unusual
for an 82 year old to suddenly develop diabetes).
Mr. B should also have a post-void residual determination because men are at risk for
urinary retention from an enlarged prostate or urethral blockage from a stricture than can
develop after prostate surgery. Evaluation for prostate cancer is probably not indicated
since, unless he had urinary retention, the prostate cancer would not be specifically
treated.
3. What side effects should you be most concerned about when treating Mr. B with a
bladder relaxant drug?
Bladder relaxant drugs all have anticholinergic side effects. The most common include:
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Dry mouth
Constipation
Gastroesophageal reflux
Blurry vision
Urinary retention
Confusion
Mr. B has several conditions that put him at risk for side effects, including:
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Dementia, already on drug treatment with donepezil (which has the opposite
effects of the anticholinergic bladder relaxants).
Gastroesophageal reflux, on drug treatment.
Glaucoma, on drug treatment.
Therefore, if Mr. B is treated with a bladder relaxant he would have to be monitored
carefully for:
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Altered mental status or worsening confusion
Increased symptoms of heartburn
Blurry vision (it would be most appropriate to get approval from his eye
doctor to start the bladder relaxant)
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April, 2004
Subsequent Course
With the help of an in-home care assistant and his two granddaughters, Mr. B was continued on a
prompted toileting schedule every two hours from 7:00 a.m. to 10:00 p.m., and was given a 2month trial of long-acting tolterodine. Over the next six weeks, his daytime frequency and
incontinence improved markedly, going from 3-5 episodes per day to one or less. In addition, his
voiding at night decreased to once or twice, which greatly improved his overall sleep and mood.
His adult diaper use was also reduced to one per 24-hour period.
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April, 2004