Case Studies in Urinary Tract/Bladder Dysfunction

Case Studies in Case Studies in Urinary Urinary

Tract/Bladder Tract/Bladder DysfunctionDysfunction

Case Study #1Case Study #1


► How would you evaluate this patient? How would you evaluate this patient?

► What is the likely diagnosis?What is the likely diagnosis?

► What is a reasonable treatment plan?What is a reasonable treatment plan?

► What are reasonable expectations for pharmacological therapy?What are reasonable expectations for pharmacological therapy?

A 51-year old otherwise healthy woman presents to her primary A 51-year old otherwise healthy woman presents to her primary care physician with complaints of feeling the urge to void after care physician with complaints of feeling the urge to void after dropping her child off at school every day. She manages not to dropping her child off at school every day. She manages not to void before entering the house, but sprints to the bathroom to void before entering the house, but sprints to the bathroom to avoid urinary incontinence. avoid urinary incontinence.

She is going on her “dream vacation” to Tuscany in two weeks She is going on her “dream vacation” to Tuscany in two weeks and wants HELP!”and wants HELP!”



► How should this patient be evaluated? How should this patient be evaluated?

► What treatment options should be offered?What treatment options should be offered?

A 39-year old woman is healthy and takes no medications. She reports wetting her underwear small amounts after vigorous workouts at the gym.

She denies nocturia, and has 8 micturitions per 24-hour period.



A 64-year-old woman reports at 2 or more episodes of significant A 64-year-old woman reports at 2 or more episodes of significant urgency per day, and a constant desire to void that interrupts her urgency per day, and a constant desire to void that interrupts her activities. She has nocturia x2, and reports one or two episodes of activities. She has nocturia x2, and reports one or two episodes of wetting her clothes when unable to find a toilet at the mall and the wetting her clothes when unable to find a toilet at the mall and the airport. These symptoms that have been increasing in the last year. airport. These symptoms that have been increasing in the last year. In addition, she reports urinary loss with coughing (she has had In addition, she reports urinary loss with coughing (she has had increased coughing–new allergies?) or lifting.increased coughing–new allergies?) or lifting.

She restricts her fluid intake, has stopped alcohol beverages and She restricts her fluid intake, has stopped alcohol beverages and caffeine and voids before taking car trips.caffeine and voids before taking car trips.

ACE inhibitor (new) and HCTZ for hypertension. ACE inhibitor (new) and HCTZ for hypertension. Fluoxetene for depression.Fluoxetene for depression.Oral estrogen since menopause.Oral estrogen since menopause.

She was treated previously with a “bladder drug” that resulted in She was treated previously with a “bladder drug” that resulted in minimal dry mouth, but bothersome constipation and somnolence.minimal dry mouth, but bothersome constipation and somnolence.

Case Study #3 Case Study #3 (cont)(cont)

► What should the components be of her initial evaluation? What should the components be of her initial evaluation?

► What is the provisional diagnosis? What is the provisional diagnosis?

► Should this patient’s initial treatment plan consist of behavioral Should this patient’s initial treatment plan consist of behavioral therapy alone, and if so, what should this be?therapy alone, and if so, what should this be?

► Or, should initial approach to treatment consist of Or, should initial approach to treatment consist of pharmacologic therapy? pharmacologic therapy?

► Is it likely that this antihypertensive agent, antidepressant or Is it likely that this antihypertensive agent, antidepressant or estrogen has anything to do with the patient’s urinary estrogen has anything to do with the patient’s urinary complaints? complaints?

► Should this patient be referred to a urologist, and if so, why?Should this patient be referred to a urologist, and if so, why?


► How long should patient be treated?How long should patient be treated?

The patient was started on a behavioral therapy program The patient was started on a behavioral therapy program and anticholinergic medication. Her ACE inhibitor was and anticholinergic medication. Her ACE inhibitor was discontinued.discontinued.

She returned to the office, and reports 8-10 micturitions She returned to the office, and reports 8-10 micturitions per day, is able to enjoy her coffee in the morning, and per day, is able to enjoy her coffee in the morning, and decreased focus on voiding defense strategies.decreased focus on voiding defense strategies.



A 71-year old male with symptoms of mild cognitive impairment A 71-year old male with symptoms of mild cognitive impairment (MMS exam) reports leaking variable amounts of urine on his (MMS exam) reports leaking variable amounts of urine on his underwear 4-5 times a day. He also reports nocturia, requiring 3 underwear 4-5 times a day. He also reports nocturia, requiring 3 trips to the bathroom each night to void. trips to the bathroom each night to void.

His prostate exam shows minimal diffuse enlargement, but no His prostate exam shows minimal diffuse enlargement, but no nodules. His urinalysis is normal. nodules. His urinalysis is normal.

The patient is started on an anticholinergic agent for OAB. The patient is started on an anticholinergic agent for OAB.

The patient returns in follow up two weeks later and reports that The patient returns in follow up two weeks later and reports that the number of accidents has decreased but the severity of urinary the number of accidents has decreased but the severity of urinary loss remains the same. loss remains the same.

He is accompanied by his wife who reports that her husband has He is accompanied by his wife who reports that her husband has increased confusion, and sometimes forgets that he has eaten a increased confusion, and sometimes forgets that he has eaten a meal. He has had recent problems with ambulation.meal. He has had recent problems with ambulation.


► What is the strategy at this point? What is the strategy at this point?

► Refer patient for evaluation of dementia?Refer patient for evaluation of dementia?

► Refer patient for urodynamic study?Refer patient for urodynamic study?

► Start anti-cholinergic agent for OAB Start anti-cholinergic agent for OAB management? management?



► What is the likely provisional diagnosis? What is the likely provisional diagnosis?

► Is behavioral therapy a consideration in this patient? Is behavioral therapy a consideration in this patient?

► Devices? Devices?

► Medications? Medications?

► Surgery?Surgery?

A 60-year-old woman complains of daily urinary incontinence x 5 A 60-year-old woman complains of daily urinary incontinence x 5 occurring with urgency and loss on the way to bathroom. The occurring with urgency and loss on the way to bathroom. The symptoms also occur when coughing, laughing, or sneezing, although symptoms also occur when coughing, laughing, or sneezing, although they are less bothersome during these episodes. She has had recurrent they are less bothersome during these episodes. She has had recurrent urinary tract infections. urinary tract infections.

On physical exam, the patient has urethral hypermobility, vaginal On physical exam, the patient has urethral hypermobility, vaginal atrophy, Grade II cystocele, and a well-supported uterus. The U/A is atrophy, Grade II cystocele, and a well-supported uterus. The U/A is negative. negative.



► How does the clinician navigate these options?How does the clinician navigate these options?

A 62 year-old male patient presents with frequency and urgency A 62 year-old male patient presents with frequency and urgency and mild decrease in urinary stream. The patient has been and mild decrease in urinary stream. The patient has been placed on an alpha-blocker and noted symptomatic placed on an alpha-blocker and noted symptomatic improvement in his urinary stream, but still voids 10 to 12 times improvement in his urinary stream, but still voids 10 to 12 times per day and 2 times per night. per day and 2 times per night.

The choices for therapy would include one or more of the The choices for therapy would include one or more of the following:following:

• • Increase dose alpha-blockerIncrease dose alpha-blocker•• Add androgen reductase inhibitorAdd androgen reductase inhibitor• • Refer patient for surgical therapy of prostateRefer patient for surgical therapy of prostate• • Re-evaluate with urinalysis and urine cytologyRe-evaluate with urinalysis and urine cytology• • Add anticholinergic agent to alpha blocker.Add anticholinergic agent to alpha blocker.



An 82 year-old male patient with Parkinson’s and mild An 82 year-old male patient with Parkinson’s and mild dementia, who is post laser-TUR for urinary retention, now dementia, who is post laser-TUR for urinary retention, now presents with frequency, urgency, urgency incontinence, presents with frequency, urgency, urgency incontinence, and nocturia x 3-4. and nocturia x 3-4.

Urinary incontinence episodes occur during the day and Urinary incontinence episodes occur during the day and night related to mobility issues related to toileting. He is night related to mobility issues related to toileting. He is noted to have good urinary flow and post surgical bladder noted to have good urinary flow and post surgical bladder emptying shows minimal urinary residual. Patient is on emptying shows minimal urinary residual. Patient is on multiple medications, including fluoxetine, digoxin, and multiple medications, including fluoxetine, digoxin, and resperidone. resperidone.

The patient was previously treated with oxybutynin and The patient was previously treated with oxybutynin and developed increased confusion.developed increased confusion.


► What is the most likely diagnosis? What is the most likely diagnosis?

► Is further evaluation warranted?Is further evaluation warranted?

► What factors go into the equation for drug selection? What factors go into the equation for drug selection?

► CNS issues? CNS issues?

► Liver metabolism? Liver metabolism?

► Onset of action?Onset of action?



A 62-year-old G4P2 white female had a two-year history of urge A 62-year-old G4P2 white female had a two-year history of urge incontinence with ten episodes of urge incontinence per day incontinence with ten episodes of urge incontinence per day and insensible urine loss for the last three months. She denied and insensible urine loss for the last three months. She denied any complaints of stress incontinence and has a history of any complaints of stress incontinence and has a history of dyspareunia and urge incontinence during coitus. dyspareunia and urge incontinence during coitus.

Her past medical and surgical history were remarkable for Her past medical and surgical history were remarkable for hypothyroidism on synthroid 0.15 mg each day. The patient is hypothyroidism on synthroid 0.15 mg each day. The patient is S/P TAH-BSO at age 47 for fibroids. Her review of systems was S/P TAH-BSO at age 47 for fibroids. Her review of systems was unremarkable.unremarkable.

Review of the patient’s voiding diary showed that she was Review of the patient’s voiding diary showed that she was drinking three cups of caffeinated coffee each morning and drinking three cups of caffeinated coffee each morning and takes 2400 ml of liquids per day with a urine output of 2200 ml takes 2400 ml of liquids per day with a urine output of 2200 ml per day. She’s urinating an average of every one-hour during per day. She’s urinating an average of every one-hour during the day with volumes of two to three ounces. the day with volumes of two to three ounces.

Her spontaneous uroflow revealed that the patient voided Her spontaneous uroflow revealed that the patient voided normally with a maximum flow rate of 35ml as she voided normally with a maximum flow rate of 35ml as she voided 200ml over ten seconds with a 40ml residual. 200ml over ten seconds with a 40ml residual.

Urinalysis revealed a specific gravity of 1.020 and a pH of Urinalysis revealed a specific gravity of 1.020 and a pH of 5. Microscopic urinalysis was negative. X3 with an 5. Microscopic urinalysis was negative. X3 with an average volume of three ounces.average volume of three ounces.


► The patient underwent cystourethroscopy to evaluate her The patient underwent cystourethroscopy to evaluate her bladder tenderness, nocturia, urgency, and frequency. bladder tenderness, nocturia, urgency, and frequency. She had cystourethroscopy with a fill and refill study to a She had cystourethroscopy with a fill and refill study to a maximum cystometric capacity, in the supine position, of maximum cystometric capacity, in the supine position, of 275ml. As the bladder filled it was obvious that the 275ml. As the bladder filled it was obvious that the patient was developing a detrusor contraction with a patient was developing a detrusor contraction with a trabeculated appearance to the bladder that was not trabeculated appearance to the bladder that was not noted on initial examination at lower volumes. noted on initial examination at lower volumes.

► While there was no leakage at this volume, the patient’s While there was no leakage at this volume, the patient’s bladder neck was noted to be intermittently funneled, bladder neck was noted to be intermittently funneled, when the patient complained of severe bladder spasms when the patient complained of severe bladder spasms and suprapubic discomfort. On further questioning it and suprapubic discomfort. On further questioning it was clear that the patient had these symptoms at least was clear that the patient had these symptoms at least once or twice a day at home. once or twice a day at home.


► Standing subtracted cystometry revealed escalating Standing subtracted cystometry revealed escalating phasic involuntary bladder contractions ranging from 25 phasic involuntary bladder contractions ranging from 25 to 75 cm H20. The detrusor leak point pressure was 75cm to 75 cm H20. The detrusor leak point pressure was 75cm H20. H20.

► Endocoscopy revealed mild erythema along the length of Endocoscopy revealed mild erythema along the length of the urethra with 50 percent of the trigone being covered the urethra with 50 percent of the trigone being covered by squamous metaplasia and some inflammatory fronds by squamous metaplasia and some inflammatory fronds at the bladder neck. Both orifices appeared to be widely at the bladder neck. Both orifices appeared to be widely dilated and normal efflux of urine was noted during dilated and normal efflux of urine was noted during urethroscopyurethroscopy

► Following this testing a detailed consultation was Following this testing a detailed consultation was conducted with the patient and her husband discussing conducted with the patient and her husband discussing her high-pressure detrusor instability and options for her high-pressure detrusor instability and options for treatment.treatment.


► She elected to initiate treatment with “Bladder Drill” She elected to initiate treatment with “Bladder Drill” or timed voiding. She was started on a every hour or timed voiding. She was started on a every hour voiding schedule and taught to contract her levator voiding schedule and taught to contract her levator ani muscles to try to suppress her involuntary ani muscles to try to suppress her involuntary detrusor contractions.detrusor contractions.

► However, after 3 weeks, she was unable to comply However, after 3 weeks, she was unable to comply with this voiding schedule and we discussed with this voiding schedule and we discussed pharmacotherapy.pharmacotherapy.

► She felt 90% improved on tropsium chloride. She She felt 90% improved on tropsium chloride. She had mild dry mouth, but no other side-effects.had mild dry mouth, but no other side-effects.



72-year-old G7P5 white female who over the last 15 years has 72-year-old G7P5 white female who over the last 15 years has noted increasing urinary frequency, urgency and urge noted increasing urinary frequency, urgency and urge incontinence with nocturia X4. The patient complains of four incontinence with nocturia X4. The patient complains of four episodes of urge incontinence per week and also has episodes of urge incontinence per week and also has complaints of stress incontinence over the last year of two complaints of stress incontinence over the last year of two episodes per week. She denies any insensible loss but has had episodes per week. She denies any insensible loss but has had occasional post-void dribbling during the last six months. She occasional post-void dribbling during the last six months. She denies any anal sphincter incontinence.denies any anal sphincter incontinence. She has not had any problems with recurrent urinary tract She has not had any problems with recurrent urinary tract infections. She does not take any estrogen replacement infections. She does not take any estrogen replacement therapy. She was told to take estrogen replacement therapy but therapy. She was told to take estrogen replacement therapy but did not because of her concerns about the possible risk of did not because of her concerns about the possible risk of breast cancer. breast cancer.


The patient’s past medical history is remarkable for elevated The patient’s past medical history is remarkable for elevated cholesterol and triglyceride treated currently by atorvastatin. cholesterol and triglyceride treated currently by atorvastatin. The patient has had two TIA’s in the last two years and is The patient has had two TIA’s in the last two years and is known to have a 20 % stenosis in her right carotid artery. known to have a 20 % stenosis in her right carotid artery. Review of her voiding diary revealed that she had a functional Review of her voiding diary revealed that she had a functional bladder capacity of 225ml and that she voids during the day on bladder capacity of 225ml and that she voids during the day on average every two hours and voids at night an average of average every two hours and voids at night an average of 225ml. 225ml.


► The patient was able to contract her levator ani The patient was able to contract her levator ani muscles voluntarily. There was no tenderness of the muscles voluntarily. There was no tenderness of the levators. Spontaneous uroflowmetry showed an levators. Spontaneous uroflowmetry showed an obstructive pattern with a maximum flow rate of 14 obstructive pattern with a maximum flow rate of 14 ml/s as the patient voided 175ml over 25 seconds ml/s as the patient voided 175ml over 25 seconds with a residual of 25 ml. with a residual of 25 ml.

► Urinalysis and urine culture were negative.Urinalysis and urine culture were negative.


► After consultation with the patient and her daughter, After consultation with the patient and her daughter, the patient was started on vaginal estrogen cream, the patient was started on vaginal estrogen cream, one gram nightly for six weeks prior to urodynamic one gram nightly for six weeks prior to urodynamic evaluation. evaluation.

► At the time of the patient’s urodynamic evaluation At the time of the patient’s urodynamic evaluation she noted some decrease in her urgency and urinary she noted some decrease in her urgency and urinary frequency but still had urge and stress incontinence frequency but still had urge and stress incontinence complaints. Urethral closure pressure profiles complaints. Urethral closure pressure profiles showed the patient to have a functional urethral showed the patient to have a functional urethral length of 2.8 cm and a closure pressure of 36cm length of 2.8 cm and a closure pressure of 36cm H20. Leak point pressure testing showed a standing H20. Leak point pressure testing showed a standing leak point pressure of 134 cm H20 with leakage at leak point pressure of 134 cm H20 with leakage at maximum cystometric capacity. maximum cystometric capacity.


► Both sitting and standing urethrocystometry revealed Both sitting and standing urethrocystometry revealed involuntary, uninhibited detrusor contractions resulting involuntary, uninhibited detrusor contractions resulting in leakage with a detrusor pressure of 18 cm H20. The in leakage with a detrusor pressure of 18 cm H20. The patient reached a maximum cystometric capacity of 320 patient reached a maximum cystometric capacity of 320 ml. The patient voided by urethral relaxation with a 22 cm ml. The patient voided by urethral relaxation with a 22 cm H20 detrusor contraction with intermittent Valsalva. H20 detrusor contraction with intermittent Valsalva.


► Consultation was held with the patient and her Consultation was held with the patient and her daughter to discuss options for treatment of her daughter to discuss options for treatment of her mixed incontinence. mixed incontinence.

► We discussed treatment with behavioral therapy, We discussed treatment with behavioral therapy, antimuscarinics, and pelvic floor electrical antimuscarinics, and pelvic floor electrical stimulation. stimulation.


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Case Studies in Urinary Tract/Bladder Dysfunction