Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 78-year-old woman living in a nursing home is evaluated for incontinence. Over the past year, she has had progressive decline in her cognitive status and now spends most of the day in bed. She requires coaxing to join the other residents in their communal meals and requires assistance for eating and bathing. When accompanied by an aide or family member, she is able to walk slowly to the bathroom without leakage and to urinate. Medical history is significant for dementia and depression treated with citalopram.

She is a frail, elderly woman in no acute distress. On physical examination, temperature is normal, blood pressure is 132/88 mm Hg, and pulse rate is 68/min. BMI is 23. Her score on the Mini-Mental State Examination is 14/30. Her gait is slow and she requires assistance. Abdominal examination is without suprapubic fullness. Rectal examination reveals normal sphincter tone. Results of urinalysis are normal.

Which of the following is the most appropriate management of this patient?

A: Cystoscopy
B: Indwelling Foley catheter
C: Pelvic floor muscle training
D: Prompted voiding
E: Tolterodine

MKSAP Answer and Critique

The correct answer is D: Prompted voiding.

This patient would be best managed by establishing a prompted voiding protocol. Urinary incontinence affects more than 50% of nursing home patients and is associated with significant morbidity and cost. Most of these patients have limited mobility or significant cognitive impairment, leading to a high prevalence of functional incontinence, defined as simply not getting to the toilet quickly enough. In a systematic review of 14 randomized controlled studies involving 1,161 nursing home patients, the use of prompted voiding (periodically asking the patient about incontinence, reminding the patient to go to the toilet, and providing praise for maintaining continence and using the toilet) was associated with modest short-term improvement in urinary incontinence.

History, focused examination, and urinalysis are often adequate to classify urinary incontinence. Postvoid residual urine volume determination is most useful if overflow incontinence due to outlet obstruction or a flaccid neurogenic bladder is suspected. Detailed urologic evaluations, such as cystoscopy and urodynamic testing, are unnecessary in uncomplicated urinary incontinence.

An indwelling Foley catheter is not advised as a first-line measure to manage urinary incontinence owing to an increased risk of urinary tract infection, resultant antibiotic treatment, and the development of antibiotic complications and resistance.

Pelvic floor muscle training is effective for stress incontinence, which may be coexistent in this patient, but successful implementation requires a cooperative and cognitively intact patient who can understand and participate in the exercise program.

Tolterodine, a selective anticholinergic antimuscarinic medication, is primarily indicated for urge incontinence and is of no benefit in functional incontinence. In addition, adverse side effects, such as dry mouth and worsening cognitive function, render its use in this patient ill advised.

Key Point

• Prompted voiding is an effective management strategy for patients with functional urinary incontinence.

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