Urinary Urgency and Frequency in a 53-Year-Old Woman

Home , Dysuria, Overactive bladder, Urinary urgency

CMAJ Practice CME

Decisions Urinary urgency and frequency in a 53-year-old woman

Mohammad Hajiha MD, Dean Elterman MD MSc

A healthy 53-year-old woman visits her family der includes abdominal (bladder overdistention) Competing interests: Dean doctor regarding a one-year history of urinary and pelvic examination in women, as well as a Elterman has received speaker fees from Astellas, frequency. She describes sometimes having a basic neurologic examination. The pelvic exam Allergan and Pfizer. No strong urge to void, with resulting urge incon- includes assessment for vaginal prolapse and vag- competing interests declared tinence not associated with physical activity, inal estrogen status, and a cough stress test for by Mohammad Hajiha. and requires one to two pads per day. stress urinary incontinence (grade C recommenda- This article has been peer tion).2 (The grades of recommendations are reviewed. What diagnoses should be considered? defined in Appendix 1, available at www.cmaj.ca/ The clinical scenario is Several diagnoses can be considered for this patient, lookup/suppl/doi:10.1503/cmaj.150255/-/DC1). fictional. including urinary tract infection, stress or urge Correspondence to: incontinence and overactive bladder. Lower urinary What tests should be ordered Dean Elterman, tract symptoms can include a combination of stor- for this patient? [email protected] age and voiding symptoms. Storage symptoms When overactive bladder is suspected, guidelines CMAJ 2016. DOI:10.1503 include frequency, urgency, nocturia, and stress recommend limited investigations to rule out other /cmaj.150255 and urge incontinence. Voiding symptoms include causes of symptoms.4 These include urinalysis for poor stream, hesitancy and incomplete voiding.1 urinary tract infection and hematuria. Urinalysis A urinary tract infection is usually associated should be done to rule out urinary tract infection with dysuria, urgency and frequency in urination. and hematuria. Urine culture may be considered if Stress urinary incontinence is defined as involun- the urinalysis result is positive for one of the fol- tary leakage of urine on effort, exertion, sneezing lowing: leukocytes, erythrocytes and nitrites. or coughing. Urge urinary incontinence is leak- Guidelines recommend a postvoid residual age immediately associated with a sudden desire urine test if the history indicates incomplete to void.2 emptying.4 The test can be done in the office by Overactive bladder is defined as urgency, with means of an ultrasound or bladder scanner, or by or without urge incontinence, usually associated catheterization to measure residual volume if with frequency and nocturia.2 Overactive bladder noninvasive means are unavailable. affects 14% of Canadians, with equal prevalence among males and females.2 Of patients with the What treatments should this patient condition, two-thirds experience no incontinence be offered? and are generally dry.3 Urgency is a defining If investigations do not indicate another cause for symptom of overactive bladder and is described the patient’s symptoms, guidelines recommend as a sudden desire to void that is often difficult to lifestyle modifications as first-line treatment of defer, which causes fear of leakage and inconti- overactive bladder: total daily fluid intake of nence. Frequency is defined as needing to urinate about 2 L/d, and reduced intake of caffeinated eight or more times a day. Nocturia is the need to drinks because they can promote urinary ur- urinate two or more times a night.1 gency.4 Pelvic floor muscle training by an expert Given the patient’s symptoms, including uri- physiotherapist is also recommended by guide- nary frequency, urgency and urge incontinence, lines, especially if the patient is interested in non- and the lack of clinical signs for urinary tract pharmacologic therapy.5 Lifestyle modifications infection, such as dysuria, overactive bladder is can be combined with second-line pharmacologic the most likely diagnosis. treatment, depending on symptom severity and patient preference. Guidelines recommend that What should be included in the physical pharmacologic treatment be prescribed if optimal examination of this patient? improvement with conservative management has According to the Canadian Urological Association, not been reached within 8–12 weeks after the start focused physical examination for overactive blad- of treatment.5

Pharmacologic treatment for overactive blad- therapies) should be referred to a urologist for der can be divided into two groups: antimusca- evaluation and additional treatment. Additional rinic (anticholinergic) and non-antimuscarinic treatment could include intravesical injection of medications. Choice of treatment depends on botulinum toxin A, sacral neuromodulation or physician experience, patient preference and in- percutaneous tibial nerve stimulation (grades surance coverage. Possible adverse effects should A–C recommendations).2 be considered and discussed with the patient Patients who initially present with symptoms when deciding on treatment.2 Recommended an- suggestive of complicated overactive bladder timuscarinic medications include oxybutinin (oral (history of substantial pelvic pain, hematuria and or transdermal), tolterodine, solifenacin, darifena- recurrent urinary tract infection) should be con- cin, trospium chloride and fesoterodine.4 Possible sidered for referral to a urologist. Guidelines rec- adverse effects of antimuscarinic drugs are dry ommend cystoscopic evaluation for this patient mouth, constipation, somnolence, blurred vision, population.5 pruritus, tachycardia, impaired cognition and headache and hypertension. Antimuscarinic Case resolution drugs are contraindicated in patients with urinary The patient had normal findings on physical retention and narrow-angle glaucoma. examination and urinalysis. Overactive bladder Non-antimuscarinic medications include mi- was diagnosed, and a trial of conservative man- rabegron, tricyclic antidepressants and desmo- agement was started. However, her symptoms pressin. A systematic review supports the use of persisted after six weeks. An antimuscarinic med-

mirabegron, a novel β3 agonist specifically indi- ication (solifenacin 5 mg/d) was prescribed. The cated for overactive bladder, because it causes patient reported substantial reduction of her uri- relaxation of the detrusor muscle during bladder nary symptoms 4 weeks later and no adverse filling.6 The starting dose is 25 mg once daily, effects. Her condition will be monitored at regular and the dose can be increased to 50 mg/d depend- follow-up appointments at 3, 6 and 12 months. ing on effectiveness. Common adverse effects include headache and mild hypertension. These References effects are no more likely than with antimusca- 1. Abrams P, Cardozo L, Fall M, et al. The standardisation of ter- minology of lower urinary tract function: report from the Stan- rinic drugs; however, mirabegron should not be dardisation Sub-committee of the International Continence prescribed to patients with severe uncontrolled Society. Am J Obstet Gynecol 2002;187:116-26. hypertension.6 2. Bettez M, Tu LM, Carlson K, et al. 2012 update: guidelines for adult urinary incontinence collaborative consensus document for Pharmacologic treatment is usually recom- the Canadian Urological Association. CUAJ 2012;6:354-63. mended to be continued for as long as it is found 3. Corcos J, Schick E. Prevalence of overactive bladder and incontinence in Canada. Can J Urol 2004;11:2278-84. to be effective and tolerated by the patient. A 4. Abrams P, Andersson KE, Birder L, et al.; Fourth International systematic review showed that average com Consultation on Incontinence Recommendations of the Interna- tional Scientific Committee. Evaluation and treatment of urinary pliance for anticholinergic agents is 20%–30% incontinence, pelvic organ prolapse, and fecal incontinence. by 12 months.6 Consideration to stop medication Neurourol Urodyn 2010;29:213-40. 5. Gormley EA, Lightner DJ, Burgio KL, et al. Diagnosis and can be based on assessment of adverse effects, treatment of overactive bladder (non-neurogenic) in adults: treatment effectiveness and patient preference. If AUA/SUFU guideline. J Urol 2012;188(Suppl 6):2455-63. 6. Jayarajan J, Radomski SB. Pharmacotherapy of overactive symptoms recur after pharmacologic treatment is bladder in adults: a review of efficacy, tolerability, and quality stopped, restarting treatment should be consid- of life. Res Rep Urol 2013;6:1-16. ered if it was previously effective. Affiliation: Division of Urology, University Health Network, When should this patient be referred University of Toronto, Toronto, Ont. to a urologist? Contributors: Both authors contributed equally to preparing Patients whose condition is refractory to treat- the article, including the literature review and the drafting and revising of the manuscript. Both authors approved the ment (no response to 8–12 wk of initial manage- final version to be published and agreed to act as guarantors ment with up to two different pharmacologic of the work.

60 CMAJ, January 5, 2016, 188(1)