- Stress incontinence:
Stress incontinence is when you leak urine when your bladder is put under sudden extra pressure – for example, when you cough, sneeze, laugh, lift heavy weight, or do exercise. It’s not related to feeling stressed.
Causes of stress incontinence:
- Damage during childbirth – particularly if your baby was born vaginally, rather than by caesarean section.
- Increased pressure on your tummy – for example, pregnancy or obesity.
- Damage to the bladder or nearby area during surgery – such as the hysterectomy, or removal of the prostate gland.
- Neurological conditions, such as Parkinson’s disease or multiple sclerosis.
- Connective tissue disorders such as Ehlers-Danlos syndrome.
- Certain medicines (ACE inhibitors, Antidepressants, HRT, Diuretics, Sedatives.)
- Urge incontinence
Urge incontinence, or urgency incontinence, is when you feel a sudden and very intense need to pass urine and you’re unable to delay going to the toilet. It may be triggered by a sudden change of position, or even by the sound of running water. This type of incontinence often occurs as part of a group of symptoms called overactive bladder syndrome, which is when the bladder muscle is more active than usual.
Causes of urge Incontinence:
- Drinking too much alcohol or caffeine.
- Not drinking enough fluids.
- Constipation.
- Urinary tract infections (UTIs) or tumours in the bladder.
- Neurological conditions.
- Certain medicines (ACE inhibitors, Antidepressants, HRT, Diuretics, Sedatives. )
Who you are:
An FY2 in General practice.Who the patient is:
46-year-old Daphne Winston came to the hospital with some concerns.What you should do:
Talk to the patient, assess, and address his concerns
Presenting complaint (P1) (ODIPARA):
Doctor: Hello I am one of the doctors here. You must be Daphne Winston.
Patient: Yes.
D: Can I get your age, please, before we begin the consultation?
P: I am 46.
D: So, Daphne, I can see that you have been having some concerns?
P: Yes, doctor. I have been having some problems with peeing. It leaks out sometimes and wets my clothes. Which is very embarrassing.
D: Tell me more about it. (Open question)
P: It has been going on for a few months now.
D: How did it start, was it sudden or gradual? (Onset)
P: It was gradual, doctor.
D: When exactly did it start? (Duration)
P: I first noticed it 6 months ago.
D: Has it been getting worse since then? (Progression)
P: Yes, I’d say so.
D: Is there anything that you think makes it better or worse? (Aggravating and elevating factors)
P: No, but it usually happens when I cough or sneeze or maybe lift something heavy.
D: Is there anything else apart from this?
P: No doctor.
D: Any problems with your urine (Burning, frequency,)?
P: No, doctor.
D: Any fever?
P: No, doctor.
D: Any nausea, vomiting?
P: No, doctor.
D: Any changes in urine colour or any blood in the urine?
P: No, doctor.
D: Anything else?
P: No, doctor.
Concern
D: Apart from this, is there anything else that’s concerning you?
P: It’s just this problem, doctor. It gets embarrassing for me when it happens in public.
Past medical conditions (P2)
D: Has this ever happened before?
P: No.
D: Do you have any medical conditions that I should be aware of?
P: No.
D.E.S.A (P3) + Sexual history:
D: How is your diet? Do you take any stimulants like coffee or energy drinks?
P: My diet is good, and I drink a cup of coffee every day.
D: Are you physically active?
P: I try to be physically active, doctor.
D: Do you smoke?
P: No, doctor.
D: What about alcohol?
P: No, doctor.
D: If you don’t mind, I would like to ask you a few questions about your sexual health. Are you sexually active?
P: Yes, doctor.
D: Do you have a stable partner?
P: Yes, doctor.
D: Do you practice safe sex?
P: Yes, doctor.
P4
D: Tell me about your periods?
P: They seem to be fine, doctor, I had them 2 weeks ago.
D: Could you be pregnant by any chance, or have you been pregnant in the past?
P: No, doctor, I don’t think that I am pregnant, but yes I have been pregnant in the past. I have 5 children.
D: Tell me about the deliveries, normal, vaginal deliveries or caesarean sections?
P: All normal, vaginal deliveries, doctor.
D: When was your last delivery?
P: It was 7 years ago.
D: Any instrumentations during any of the deliveries?
P: Yes doctor, In the last 2 deliveries they had to use some instruments.
D: Have you had a Pap smear recently?
P: Yes, last year. It was normal.
D: Are you on any kind of contraception?
P: I am on the pill.
M.A.F.T.O.S.A
D: Are you on any long-term medication? (ACE inhibitors, Antidepressants, HRT,
Diuretics, Sedatives. )
P: No.
D: What about any known allergies to any food or drugs?
P: I don’t have any known allergies.
D: Anyone in your family with similar problems or other medical conditions?
P: No, doctor.
D: How has this been affecting your life, you told me it has been going on for a few months now?
P: It’s just that it gets really embarrassing for me at instances when I am out in public, and this happens.
Expectation
D: Do you have anything specific in mind that you are expecting from us?
P: Maybe some medicine to stop this.
Idea
D: Do you have any idea what might be causing the problem?
P: No doctor, I have no idea.
Examination:
- Observation (Check vitals + BMI)
- Genital and pelvic examination
Provisional diagnosis:
Daphne, you told me that you have been having this problem for the past 6 months. Your urine leaks out unintentionally at instances when you cough or sneeze. Also, you told me you have had 5 normal deliveries in the past. I have done an examination and I suspect you have stress incontinence. It basically means that whenever you cough, sneeze or strain the pressure inside your tummy increases and that causes your bladder to leak. It could be due to multiple reasons but in your case it could be due to multiple pregnancies and instrumentations that can lead to weak pelvic muscles causing this to happen.
Management:
Senior:
Investigations:
- FBC, RFT, LFT, U&E
- Urine dipstick
Non-surgical management:
- Maintain a bladder diary.
- Lifestyle changes including reducing your intake of caffeine, losing weight (if overweight).
- Pelvic floor muscle training (Kegel exercises).
- Bladder training.
Incontinence products that can be used to counter the leakage:
- Absorbent products, such as pants or pads.
- Handheld urinals.
- A catheter.
- Devices that are placed into the vagina or urethra to prevent urine leakage.
Medication:
Stress Incontinence : Duloxetine
Urge Incontinence : Oxybutynin, Tolterodine, Darifenacin
Surgical management:
Stress Incontinence : Colposuspension, sling surgery.
Urge Incontinence: Botulinum toxin A injection, Sacral nerve stimulation.
Specialist: Refer to urologist for further management if initial measures are not helpful.
Safety net
● If symptoms are worsening
● UTI (lethargic/ drowsy/ tired)
● Pyelonephritis (loin pain/ fever & chills/ vomiting)