Clinical: Case Study: Urinary Incontinence

Original materials created in August 1998 by Tamara G. Bavendam, M.D.

History
Ms. EQ is a 56 y/o Caucasian female with a six month history of acute onset urge-related urinary incontinence. She denied dysuria, hematuria, sense of fecal urgency or fecal incontinence. Previous urinalysis revealed no evidence of bladder infection.She has no ongoing medical illnesses and does not take medication on a regular basis. She denies any global or localizing neurological symptoms.

She had three C-sections and a hysterectomy remotely for localized uterine cancer. She has not been on hormone replacement therapy and is not currently sexually active.

She is employed in sales and her job involves extensive driving. She drinks coffee and caffeinated sodas to stay alert. She rarely drinks more than sips of water. She has never used tobacco products.

Exam
Her urinalysis is negative for blood and evidence of infection. Ultrasound estimation of post-void residual urine was negligible.

Abdominal examination reveals a moderately obese abdomen with active bowel sounds and no palpable masses. Vaginal exam revealed atrophic external genitalia and vaginal tissues. She had good anatomic support of her bladder and urethra and no evidence of enterocele, vault prolapse, or rectocele. She was able to perform a weak and unsustained voluntary contraction of pelvic floor muscles. Her bulbocavernosus reflex was intact. Anal tone was normal.

Her screening neurological examination (perineal sensation, anal tone, lower extremity sensation and reflexes) was unremarkable.

Discussion
Acute onset of urge-related incontinence can be secondary to a bladder infection which are often, but not always associated with symptoms of frequency and dysuria. As the urinalysis shows no evidence of infection, her history of acute onset of urge incontinence should raise suspicion for neurogenic etiology. In the absence of any history or physical findings supporting a neurological event, there is no need to immediately pursue an extensive neurological assessment. The absence of blood in the urine and the fact that she is a nonsmoker makes it unlikely that there is an underlying bladder malignancy causing the symptoms. She has no post-void residual making a bladder emptying dysfunction unlikely.

Once the “serious” potential causes are eliminated, attention can be turned to other potential causes and contributing factors. Her behavior of drinking significant amounts of caffeinated coffee and colas can be an underlying source of these symptoms, especially when combined with atrophic urogenital tissues. It is also important to know what her “safe” bladder capacity is - volumes voided when she gets to the toilet in time.

Plan 1
She was asked to keep a “Bladder Diary” - recording the time and volume of urinations; increase her water intake; and decrease her intake of coffee and soda and return in one week to go over her diary.

ONE WEEK FOLLOW-UP
Her daytime bladder volumes are 200-500cc and nighttime volumes - 200-300cc. She had noticed less urgency with increased water intake.

Plan 2
Begin topical estrogen and low dose anticholinergic each morning and follow-up in six weeks.

Siw Week Follow Up
Her frequency and urge incontinence almost resolved. She had dramatically decreased her coffee and soda while increasing her water. No problems with topical estrogen. She had not filled her prescription for the anticholinergics. Her symptoms were completely managed with topical estrogen replacement and behavioral changes in her fluid intake. It is important to note that decaffeinated coffee and sodas can also be “irritating” to the bladder - the acidity is an independent factor to the caffeine.

List of Potential Bladder Irritants
(acidic and high potassium foods) ACIDIC FOODS AND BEVERAGES

Avoid or use in moderation At least half of fluid intake every day should be noncarbonated water.
 * All alcoholic beverages
 * Apples and apple juice
 * Coffee - even decaffeinated
 * Cantaloupe
 * Carbonated beverages
 * Chocolate
 * Citrus fruits and juices
 * Cranberries and juice
 * Grapes
 * Lemon
 * Onions
 * Peaches
 * Pineapple
 * Plums
 * Spicy/hot foods
 * Strawberries
 * Tea - even decaffeinated
 * Tomatoes and tomato based products
 * Vinegar

When bladder symptoms are caused by dietary factors, avoiding the above food products combined with maintaining a good water intake should bring improvement in symptoms within 7-10 days. The proof is returning to previous habits and experiencing return of the symptoms. Once symptoms are better, foods can be added back one at a time to identify what products are most likely to cause symptoms. IT IS CRUCIAL TO MAINTAIN A GOOD WATER INTAKE!!!