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LEARNING OBJECTIVES

After completing this case study, the reader should be able to:

  • Differentiate among overactive bladder syndrome, stress urinary incontinence, overflow urinary incontinence, and functional urinary incontinence.

  • Recommend appropriate nondrug therapy for managing overactive bladder syndrome.

  • Determine when anticholinergic drugs should be recommended for managing overactive bladder syndrome.

  • Compare and contrast muscarinic receptor selectivity, lipophilicity, and pharmacokinetic properties of commonly used antimuscarinic agents for managing overactive bladder syndrome and discuss the clinical implications of these properties.

  • Explain how concomitant medications may exacerbate overactive bladder syndrome.

  • Recommend medication options for patients who poorly tolerate initial anticholinergic therapy for overactive bladder syndrome.

PATIENT PRESENTATION

Chief Complaint

“I can’t seem to control my urine. I feel like I have to urinate all the time. However, when I do go to the bathroom, I often pass only a small amount of urine. Sometimes I wet myself. I was started on a medication for my leaking a few weeks ago, but it doesn’t seem to be working. I also can’t seem to remember anything. It is a wonder that I remembered to come to the clinic today.”

HPI

Susan Jones is a 65-year-old woman with urinary urgency, frequency, and incontinence. She reports soiling her underwear at least two to three times during the day and night and has resorted to wearing panty liners or changing her underwear several times a day. The patient has curtailed much of her volunteer work and social activities because of this problem. Urinary leakage is not worsened by laughing, coughing, sneezing, carrying heavy objects, or walking up and down stairs. She does not report wetting herself without warning. She has been taking Detrol LA 2 mg PO daily for the past month with no improvement in her voiding symptoms, and she complains of new-onset confusion and difficulty remembering routine tasks.

PMH

HTN for many years, treated with medications for 10 years. Dyslipidemia for 5 years, controlled with a low-cholesterol diet, weight control, regular exercise, and medication. Menopausal; stopped ovulating at age 52; no longer has hot flashes. Has difficulty falling asleep and often has sleepless nights. She has no history of spinal or pelvic surgery.

FH

Noncontributory

SH

Nonsmoker; social drinker; married

Meds

Hydrochlorothiazide 25 mg PO once daily with supper

Irbesartan 150 mg PO daily

Pravastatin 40 mg PO at bedtime

Detrol LA 2 mg PO daily

Sominex (diphenhydramine) 15 mg PO at bedtime as needed, usually about five times a week

Amitriptyline 50 mg ...

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