1. Case Studies in Urinary Tract/Bladder Dysfunction

2. Case Study #1

3. 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 care physician with complaints of feeling the urge to void after dropping her child off at school every day. She manages not to void before entering the house, but sprints to the bathroom to avoid urinary incontinence. She is going on her dream vacation to Tuscany in two weeks and wants HELP!

4. Case Study #2

5. 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.

6. Case Study #3

7. 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 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 airport. These symptoms that have been increasing in the last year. In addition, she reports urinary loss with coughing (she has had increased coughing–new allergies?) or lifting. She restricts her fluid intake, has stopped alcohol beverages and caffeine and voids before taking car trips. ACE inhibitor (new) and HCTZ for hypertension. Fluoxetene for depression. Oral estrogen since menopause. She was treated previously with a bladder drug that resulted in minimal dry mouth, but bothersome constipation and somnolence.

8. Case Study #3 (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 patients initial treatment plan consist of behavioral therapy alone, and if so, what should this be? Should this patients initial treatment plan consist of behavioral therapy alone, and if so, what should this be? Or, should initial approach to treatment consist of pharmacologic therapy? Or, should initial approach to treatment consist of pharmacologic therapy? Is it likely that this antihypertensive agent, antidepressant or estrogen has anything to do with the patients urinary complaints? Is it likely that this antihypertensive agent, antidepressant or estrogen has anything to do with the patients urinary 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?

9. Case Study #3 (cont) How long should patient be treated? How long should patient be treated? The patient was started on a behavioral therapy program and anticholinergic medication. Her ACE inhibitor was discontinued. She returned to the office, and reports 8-10 micturitions per day, is able to enjoy her coffee in the morning, and decreased focus on voiding defense strategies.

10. Case Study #4

11. A 71-year old male with symptoms of mild cognitive impairment (MMS exam) reports leaking variable amounts of urine on his underwear 4-5 times a day. He also reports nocturia, requiring 3 trips to the bathroom each night to void. His prostate exam shows minimal diffuse enlargement, but no nodules. His urinalysis is normal. The patient is started on an anticholinergic agent for OAB. The patient returns in follow up two weeks later and reports that the number of accidents has decreased but the severity of urinary loss remains the same. He is accompanied by his wife who reports that her husband has increased confusion, and sometimes forgets that he has eaten a meal. He has had recent problems with ambulation.

12. Case Study #4 (cont) 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 management? Start anti-cholinergic agent for OAB management?

13. Case Study #5

14. 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 occurring with urgency and loss on the way to bathroom. The symptoms also occur when coughing, laughing, or sneezing, although they are less bothersome during these episodes. She has had recurrent urinary tract infections. On physical exam, the patient has urethral hypermobility, vaginal atrophy, Grade II cystocele, and a well-supported uterus. The U/A is negative.

15. Case Study #6

16. 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 and mild decrease in urinary stream. The patient has been placed on an alpha-blocker and noted symptomatic improvement in his urinary stream, but still voids 10 to 12 times per day and 2 times per night. The choices for therapy would include one or more of the following: Increase dose alpha-blocker Increase dose alpha-blocker Add androgen reductase inhibitor Refer patient for surgical therapy of prostate Refer patient for surgical therapy of prostate Re-evaluate with urinalysis and urine cytology Re-evaluate with urinalysis and urine cytology Add anticholinergic agent to alpha blocker. Add anticholinergic agent to alpha blocker.

17. Case Study #7

18. An 82 year-old male patient with Parkinsons and mild dementia, who is post laser-TUR for urinary retention, now presents with frequency, urgency, urgency incontinence, and nocturia x 3-4. Urinary incontinence episodes occur during the day and night related to mobility issues related to toileting. He is noted to have good urinary flow and post surgical bladder emptying shows minimal urinary residual. Patient is on multiple medications, including fluoxetine, digoxin, and resperidone. The patient was previously treated with oxybutynin and developed increased confusion.

19. Case Study #7 (cont) 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?

20. Case Study #8

21. A 62-year-old G4P2 white female had a two-year history of urge incontinence with ten episodes of urge incontinence per day and insensible urine loss for the last three months. She denied any complaints of stress incontinence and has a history of dyspareunia and urge incontinence during coitus. Her past medical and surgical history were remarkable for 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 unremarkable. Review of the patients voiding diary showed that she was drinking three cups of caffeinated coffee each morning and takes 2400 ml of liquids per day with a urine output of 2200 ml per day. Shes urinating an average of every one-hour during the day with volumes of two to three ounces.

22. Her spontaneous uroflow revealed that the patient voided normally with a maximum flow rate of 35ml as she voided 200ml over ten seconds with a 40ml residual. Urinalysis revealed a specific gravity of 1.020 and a pH of 5. Microscopic urinalysis was negative. X3 with an average volume of three ounces. Case Study #8 (cont)

23. The patient underwent cystourethroscopy to evaluate her bladder tenderness, nocturia, urgency, and frequency. She had cystourethroscopy with a fill and refill study to a maximum cystometric capacity, in the supine position, of 275ml. As the bladder filled it was obvious that the patient was developing a detrusor contraction with a trabeculated appearance to the bladder that was not noted on initial examination at lower volumes. The patient underwent cystourethroscopy to evaluate her bladder tenderness, nocturia, urgency, and frequency. She had cystourethroscopy with a fill and refill study to a maximum cystometric capacity, in the supine position, of 275ml. As the bladder filled it was obvious that the patient was developing a detrusor contraction with a trabeculated appearance to the bladder that was not noted on initial examination at lower volumes. While there was no leakage at this volume, the patients bladder neck was noted to be intermittently funneled, when the patient complained of severe bladder spasms and suprapubic discomfort. On further questioning it was clear that the patient had these symptoms at least once or twice a day at home. While there was no leakage at this volume, the patients bladder neck was noted to be intermittently funneled, when the patient complained of severe bladder spasms and suprapubic discomfort. On further questioning it was clear that the patient had these symptoms at least once or twice a day at home. Case Study #8 (cont)

24. Standing subtracted cystometry revealed escalating phasic involuntary bladder contractions ranging from 25 to 75 cm H20. The detrusor leak point pressure was 75cm H20. Standing subtracted cystometry revealed escalating phasic involuntary bladder contractions ranging from 25 to 75 cm H20. The detrusor leak point pressure was 75cm H20. Endocoscopy revealed mild erythema along the length of the urethra with 50 percent of the trigone being covered by squamous metaplasia and some inflammatory fronds at the bladder neck. Both orifices appeared to be widely dilated and normal efflux of urine was noted during urethroscopy Endocoscopy revealed mild erythema along the length of the urethra with 50 percent of the trigone being covered by squamous metaplasia and some inflammatory fronds at the bladder neck. Both orifices appeared to be widely dilated and normal efflux of urine was noted during urethroscopy Following this testing a detailed consultation was conducted with the patient and her husband discussing her high-pressure detrusor instability and options for treatment. Following this testing a detailed consultation was conducted with the patient and her husband discussing her high-pressure detrusor instability and options for treatment. Case Study #8 (cont)

25. She elected to initiate treatment with Bladder Drill or timed voiding. She was started on a every hour voiding schedule and taught to contract her levator ani muscles to try to suppress her involuntary detrusor contractions. She elected to initiate treatment with Bladder Drill or timed voiding. She was started on a every hour voiding schedule and taught to contract her levator ani muscles to try to suppress her involuntary detrusor contractions. However, after 3 weeks, she was unable to comply with this voiding schedule and we discussed pharmacotherapy. However, after 3 weeks, she was unable to comply with this voiding schedule and we discussed pharmacotherapy. She felt 90% improved on tropsium chloride. She had mild dry mouth, but no other side-effects. She felt 90% improved on tropsium chloride. She had mild dry mouth, but no other side-effects. Case Study #8 (cont)

26. Case Study #9

27. 72-year-old G7P5 white female who over the last 15 years has noted increasing urinary frequency, urgency and urge incontinence with nocturia X4. The patient complains of four episodes of urge incontinence per week and also has complaints of stress incontinence over the last year of two episodes per week. She denies any insensible loss but has had occasional post-void dribbling during the last six months. She denies any anal sphincter incontinence. She has not had any problems with recurrent urinary tract infections. She does not take any estrogen replacement therapy. She was told to take estrogen replacement therapy but did not because of her concerns about the possible risk of breast cancer. Case Study #9

28. The patients past medical history is remarkable for elevated cholesterol and triglyceride treated currently by atorvastatin. The patient has had two TIAs in the last two years and is known to have a 20 % stenosis in her right carotid artery. Review of her voiding diary revealed that she had a functional bladder capacity of 225ml and that she voids during the day on average every two hours and voids at night an average of 225ml. Case Study #9 (cont)

29. The patient was able to contract her levator ani muscles voluntarily. There was no tenderness of the levators. Spontaneous uroflowmetry showed an obstructive pattern with a maximum flow rate of 14 ml/s as the patient voided 175ml over 25 seconds with a residual of 25 ml. The patient was able to contract her levator ani muscles voluntarily. There was no tenderness of the levators. Spontaneous uroflowmetry showed an obstructive pattern with a maximum flow rate of 14 ml/s as the patient voided 175ml over 25 seconds with a residual of 25 ml. Urinalysis and urine culture were negative. Urinalysis and urine culture were negative. Case Study #9 (cont)

30. After consultation with the patient and her daughter, the patient was started on vaginal estrogen cream, one gram nightly for six weeks prior to urodynamic evaluation. After consultation with the patient and her daughter, the patient was started on vaginal estrogen cream, one gram nightly for six weeks prior to urodynamic evaluation. At the time of the patients urodynamic evaluation she noted some decrease in her urgency and urinary frequency but still had urge and stress incontinence complaints. Urethral closure pressure profiles showed the patient to have a functional urethral length of 2.8 cm and a closure pressure of 36cm H20. Leak point pressure testing showed a standing leak point pressure of 134 cm H20 with leakage at maximum cystometric capacity. At the time of the patients urodynamic evaluation she noted some decrease in her urgency and urinary frequency but still had urge and stress incontinence complaints. Urethral closure pressure profiles showed the patient to have a functional urethral length of 2.8 cm and a closure pressure of 36cm H20. Leak point pressure testing showed a standing leak point pressure of 134 cm H20 with leakage at maximum cystometric capacity. Case Study #9 (cont)

31. Both sitting and standing urethrocystometry revealed involuntary, uninhibited detrusor contractions resulting in leakage with a detrusor pressure of 18 cm H20. The patient reached a maximum cystometric capacity of 320 ml. The patient voided by urethral relaxation with a 22 cm H20 detrusor contraction with intermittent Valsalva. Both sitting and standing urethrocystometry revealed involuntary, uninhibited detrusor contractions resulting in leakage with a detrusor pressure of 18 cm H20. The patient reached a maximum cystometric capacity of 320 ml. The patient voided by urethral relaxation with a 22 cm H20 detrusor contraction with intermittent Valsalva. Case Study #9 (cont)

32. Consultation was held with the patient and her daughter to discuss options for treatment of her mixed incontinence. Consultation was held with the patient and her daughter to discuss options for treatment of her mixed incontinence. We discussed treatment with behavioral therapy, antimuscarinics, and pelvic floor electrical stimulation. We discussed treatment with behavioral therapy, antimuscarinics, and pelvic floor electrical stimulation. Case Study #9 (cont)