Answer Happy

Chief Complaint O 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." ΗΡΙ Susan Jones is an 83-year-old woman with urinary urgency, frequency, and incontinence. She reports soiling her underwear at least one 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 downstairs. 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 constipation, 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 Pravastatin 40 mg PO at bedtime Diovan (valsartan) 160 mg PO every morning
Detrol LA 2 mg PO daily Sominex (diphenhydramine) 15 mg PO at bedtime as needed Amitriptyline 50 mg PO at bedtime as needed All NKDA ROS Complains of urinary incontinence that has not responded to Detrol LA and feeling bloated and constipated
Physical Examination Gen WDWN female 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 51, 52; (+) 54; (-)53, murmurs, or rubs Abd Soft, NTND: (+) bowel sounds Genit/Rest Genital examination shows atrophic vaginitis consistent with menopausal status. Perineal sensation and anal sphincter tone are normal.
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 I Neuro Although alert, the patient is not oriented to correct month, day, or year. CNs 11-xil 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.
Favorite Table Download (.pdf) Print Na 145 mg/L Hgb 12 g/dL K 4.2 mg/L Hct 37% CI 105 mg/L Plt 400 x 103/mm3 CO2 28 mg/L WBC 5.0 x 103/mm3 BUN 15 mg/dL SCE 1.0 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 of 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.
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 of 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 constipation, confusion, and forgetfulness, which are probably related to Detrol LA. Will evaluate carefully and consider alternative medication options.
11.a. Create a list of the patient's drug therapy problems. 1.b. What information (signs, symptoms, medical history, laboratory values, and other test results) suggests the presence or severity of urge incontinence? 1.c. Differentiate urge incontinence from stress incontinence, overflow incontinence, and functional incontinence. 1.d. Define overactive bladder syndrome. 1.e. In addition to the medications the patient is currently taking, what other drugs could exacerbate the symptoms of overactive bladder syndrome?
FOLLOW-UP QUESTIONS 1. Explain how constipation could have worsened because of darifenacin. 2. What alternative medication would you recommend for this patient to manage her voiding symptoms with a low potential for causing constipation and CNS adverse effects? 3. Why should medications with anticholinergic effects be used cautiously in elderly patients?