A 66-year-old woman, who resides in a nursing home following a stroke, is hospitalized because of loose stools and confusion. On the second hospital day, the patient has two episodes of urinary incontinence. Neither the nursing-home staff nor family members report previous problems with incontinence. Medical history is significant for a cerebrovascular accident with severe aphasia and left hemiparesis, hypertension, and type 2 diabetes mellitus. Current medications are aspirin, dipyridamole, lisinopril, and glipizide.
On physical examination, temperature is 36.8 °C (98.2 °F), blood pressure is 164/96 mm Hg, pulse rate is 92/min, and respiration rate is 18/min. Arterial oxygen saturation is 98% on ambient air. Results of cardiopulmonary, abdominal, and rectal examinations are normal. On neurologic examination, the patient is not oriented to place or date and she keeps trying to climb out of bed. There is expressive aphasia and moderate weakness of the left arm and leg.
| Laboratory studies: | |
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Complete blood count
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Normal
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Calcium
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8.6 mg/dL (2.15 mmol/L)
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Creatinine
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1.2 mg/dL (106.1 µmol/L)
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Glucose
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100 mg/dL (5.55 mmol/L)
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Electrolytes
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Normal
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Urinalysis
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2+ glucose, moderate protein, 10-20 leukocytes and 3-5 erythrocytes/hpf
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Results of urine and blood cultures are pending. An electrocardiogram and chest radiograph are normal.
Which of the following is the best management for this patient’s incontinence?
Answer and Critique (Correct Answer: A)
Educational Objective:Manage reversible causes of urinary incontinence.
Key Point
- Empiric antibiotic treatment pending the results of a urine culture may be warranted in elderly patients with new-onset urinary incontinence and pyuria.
This patient with new-onset urinary incontinence should first be evaluated for transient, reversible causes, for which the mnemonic DIAPERS may be useful: Drugs, Infection, Atrophic vaginitis, Psychological (depression, delirium, dementia), Endocrine (hyperglycemia, hypercalcemia), Restricted mobility, and Stool impaction. Urinary tract infection is a very common cause of transient incontinence in the elderly, particularly if other contributing factors such as cognitive impairment or impaired mobility are present. The presence of significant pyuria in this setting generally justifies administration of empiric antibiotic therapy pending urine culture results. Therefore, beginning ciprofloxacin is appropriate for this patient.
Although some medications may induce transient incontinence, causative agents are most often diuretics or drugs that affect autonomic nervous system or bladder function. Oral hypoglycemic agents do not typically cause incontinence, and discontinuing these agents in a patient with diabetes mellitus could precipitate hyperglycemia and increased incontinence.
Indwelling catheterization is a treatment of last resort for patients who have chronic incontinence that is unresponsive to other therapy and in whom intermittent catheterization is not feasible.
This patient’s confusion is more consistent with delirium in an elderly patient as a generalized response to an acute illness rather than a focal neurologic event. CT scan of the head is typically not helpful in such patients and is unlikely to provide an explanation for this patient’s incontinence.
The question and answer are from MKSAP 15.
