(Ideally No Longer Than 1-2 Months after Visit #1)

1. Review Completed Bladder Diary
   
   
2. Continue To Review UI History
   
   
3. Perform Physical Exam
   
   
4. PVR
   
   
5. Prescribe Appropriate Treatments - Behavioral, Pharmacologic, Devices, Surgery
   
   
6. Schedule Return Visit in 1-2 Months

I. Review Completed Bladder Diary.

• Voiding 8 times or less during waking hours is normal; more than 8 times is urinary frequency. (ICD9 code for diagnosis of Overactive Bladder = 596.51)
  
  
• Voiding once during the night is a common experience for most older adults, but voiding more than 2-3 times nightly is often bothersome to the patient. Treatments should be directed at the likely causes (See Table 3). (ICD9 code for nocturia = 788.43)
  
  
• Leaking while coughing, sneezing, or lifting is stress incontinence. (ICD9 code for stress incontinence = 788.32 in men and 625.6 in women)
  
  
• Leaking after feeling an urge to urinate but before one can reach the bathroom is urge incontinence. (ICD9 code for urge incontinence = 788.31)

Back to top

II. Continue to Review Patient's UI History.

• Review fluid intake for volume and caffeine, which can contribute to UI.

Back to top

III. Perform Physical Exam.

• Assess patient's mobility.
  
  
• Assess volume status, including checking for pedal edema.
  
  
• Perform rectal exam - note sphincter strength with voluntary contraction, an excellent method of teaching pelvic floor muscle exercises.
  
  
• Perform pelvic exam and note any significant pelvic prolapse (consider gynecology referral if past the introitus).

Back to top

IV. Evaluate or Refer for PVR

(See Table 5)

• Measure PVR in all men and in women with diabetes, neurological disorders, significant pelvic prolapse, and in patients taking anticholinergic medications. After the patient urinates, place a catheter into the bladder through the urethra within 15 minutes of normal voiding and measure the volume of urine that comes out. The PVR can also be measured non-invasively using ultrasound.

Back to top

V. Prescribe Appropriate Treatments.

1. Reinforce Behavioral Therapy

   Behavioral Reinforcement Therapy for Visit #2
   

   • Is the patient doing pelvic floor muscle exercises? Any problems?
   • Has the patient tried strategies to prevent urine loss (e.g., urge suppression or squeezing pelvic floor muscles during a cough or sneeze? Any problems?)
   • Consider increasing voiding frequency for patients voiding less than eight times per 24 hours.
   • Consider bladder training by gradually increasing intervals between voids for patients voiding more than eight times per 24 hours.
   • Suggest bedside commode and/or physical therapy referral for patients with impaired mobility.

2. Volume Management
   • Prescribe diuretic for patients with volume overload.
   • Recommend compression hose during waking hours for patients with lower extremity edema.
   • Recommend lying down with feet elevated at least once during the day for patients with lower extremity edema.
   
   
3. Consider Medications for Urge UI or Overactive Bladder (OAB) (See Table 6).
   • Start with the lowest recommended dose of a medication and increase dosage every few weeks as required to reach maximal efficiency with fewest side effects.
   • Inform patient about side effects such as dry mouth, dry eyes, urinary retention, constipation, and recommend symptomatic treatment when necessary.
   • When increasing dose or switching from a short-acting to a long-acting anticholinergic medication, follow PVR closely to avoid urinary retention.

When to Consider Referral

• History suggestive of sleep apnea (order sleep study or refer to sleep disorders clinic or sleep specialist)
• Hematuria that fails to resolve when UTI treated
• PVR volume of 200cc or more
• Pelvic prolapse past the introitus (or try pessary)
• Patient requests specialist in behavioral therapy or surgical consultation

Back to top

VI. Schedule Return Visit in 1-2 Months to Evaluate Response to Therapy.

NEXT: Visit Three

Back to top