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S2D: The Symptom to Diagnosis Podcast - Episode 33: Incontinence
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S2D: The Symptom to Diagnosis Podcast - Episode 33: Incontinence
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[upbeat intro music] [upbeat intro music] [upbeat intro music] [Dr. Cifu] I'm Adam Cifu. [Dr. Stern] And I'm Scott Stern. [Dr. Cifu] And we're here with another episode of S2D, the Symptom to Diagnosis podcast. This podcast teaches evidence-based strategies for diagnosing common medical symptoms.
We begin each episode with a case unknown to one of us. We then discuss five high yield features that help to accurately diagnose the cause of the symptom at hand. We then return to our case before finishing up with a discussion of fingerprints, common misconceptions, pet peeves, and other random pearls of knowledge. The cases that we discuss are drawn from our clinical experiences, but, because protecting patient privacy is part of our oath, we never discuss actual patients.
What are we talking about today, Scott? [Dr. Stern] Well, today we're talking about urinary incontinence, but we're not doing it alone today, are we, Adam? [Dr. Cifu] No, we are not. I'm not sure how we got to episode 33, and have featured two other guests before being joined by Dr. Diane Altkorn. Hello, Diane. [Dr. Altkorn] Hi, Adam. Hi, Scott.
It's great to be here. [Dr. Stern] It's great to have you, Diane. [Dr. Cifu] So by way of introduction, Diane was a professor of medicine at the University of Chicago. She's a founding author and now editor with Scott and I, of the Symptom to Diagnosis textbook. She spent her career working on curriculum development and teaching at every level along the medical education continuum.
That's what we call it now, right? [Dr. Altkorn] I think so. [Dr. Cifu] Her areas of interest include evidence-based medicine, obviously, feedback in medical education, and teaching clinical reasoning. I could obviously go on and on. She was recently referred to as, I love this quote, "God's gift to medicine, Her Highness, Dr. Diane Altkorn" by Marie Dreyer, one of our chief residents.
Diane's not only a treasured colleague of ours, but also a mentor and a friend. So welcome, and thank you for joining us today. [Dr. Altkorn] I'm only sorry that my mother isn't here to hear that introduction. [Dr. Cifu chuckles] If you can teach her how to listen to podcasts, she can listen to it. [Dr. Stern chuckles] So, Your Highness, I think Dr. Cifu has a case to present to us today.
Is that correct? [Dr. Cifu] I do. I do. And it's a very short case. It's from a long time ago that I'm going to abstract a little bit and it's mostly to shed great light and thanks to one of my co-interns. So, I was an intern in a cancer hospital, taking care of all people with malignancies, and I was taking care of an elderly woman who was in the hospital.
I had the day off, and my co-intern went to see the patient in the morning. He had cared for this woman in the past, and what he was struck by when he went to greet her and examine her in the morning, was that the bed really smelled like urine. And he said, "I know this person, that is absolutely not like her," asked her if she'd been having trouble holding her urine, and she said yes. That's all I'm going to give you, guys.
[Dr. Stern] Oh, my goodness. [Dr. Cifu] So what would you think? What would you ask? [Dr. Stern] Oh, okay. So, let's start from the top. First of all, how old is this lady? [Dr. Cifu] She's 68. [Dr. Stern] So 68 is relatively young by my current standards that continues to evolve, but not old enough that I would expect her to be incontinent just because she's hospitalized.
She's a hospitalized patient, I take it? [Dr. Cifu] Yes, she is. [Dr. Stern] And would you mind telling us what she's hospitalized for? [Dr. Cifu] She's hospitalized for round 435 of chemotherapy for her metastatic cancer. [Dr. Stern] Ah, okay. So we have a patient with metastatic cancer who is incontinent, and do we have a time course on when this started?
[Dr. Cifu] So, she says it's very new. She was hospitalized last about three months before, it was not an issue, that's when my co-intern had taken care of her. And she said she's really just noticed this over probably the last week. [Dr. Stern] Okay. So I guess what I'd want to know next, is when does this happen? Does this happen just when she's coughing and sneezing and it seems to be stress-related?
Does she have a sense that she has to go suddenly and doesn't have the time to get to the bathroom? Or is this just happening and she's not aware of it? [Dr. Cifu] She's not aware of it. [Dr. Stern] She's not aware of it, so she's just leaking - urine the whole time? - [Dr. Cifu] Right. She says sort of a pain, just started. [Dr. Stern] And does she have any other neurological symptoms?
[Dr. Cifu] Not that she's a aware of. [Dr. Stern] Okay. Well, it's kind of a scary story. I'll talk first and then I'll ask Dr. Altkorn to pitch in, but incontinence is very common. This doesn't sound like your run of the mills stress incontinence, nor does it sound like urge incontinence where she just can't get to the bathroom. It sounds more overflow incontinence, which can either be due to bladder hypoactivity or what they like to call detrusor underactivity, which can be due to neurological phenomenon, and I guess in a woman with metastatic cancer, my leading concern would be that she is actually having my leading concern would be that she is actually having urinary retention and overflowing secondary to the urinary retention due to a spinal cord lesion.
[Dr. Cifu] Okay, okay. [Dr. Stern] So it's pretty worrisome actually. [Dr. Cifu] Diane, what would you add? What would you do maybe with her? Examining her or would you just say, this lady needs an LS spine MRI? [Dr. Altkorn] Well, that's definitely the must not miss diagnosis, but there's a few other things to consider in an acute onset of incontinence like this, especially in a hospitalized patient.
You'd also want to think about UTI, even though she doesn't have any other UTI symptoms. [Dr. Cifu] Sure. [Dr. Altkorn] You would also think about how much IV fluid she's been getting. [Dr. Cifu] Good point. Yeah. [Dr. Altkorn] And maybe she's just getting so much fluid with this chemotherapy, it's kind of overwhelming her bladder's ability to handle it, plus- [Dr. Cifu] And she's obviously feeling lousy, she's in the hospital, and maybe she's just like, "I can't keep getting up going to the bathroom-" [Dr. Altkorn] Or she may be tied down by IVs, and really sort of immobilized.
And then if she has metastatic cancer to the bone, she could have hypercalcemia that's causing increased urinary flow. [Dr. Cifu] That's why we have Diane here to broaden our differentials. [Dr. Stern] Indeed. That's very good. Didn't you write the calcium chapter? The hypercalcemia chapter? [Dr. Cifu] I wrote the hypercalcemia chapter.
[Dr. Stern] Oh, sorry. [Dr. Cifu] Thank you very much. [Dr. Stern chuckles] [Dr. Cifu] One of my favorites. [Dr. Altkorn] So those are the other things I'd think about, and I would certainly examine her and do a very detailed neurologic exam in particular, and definitely would get a urinalysis to get started. [Dr. Cifu] Great. Sounds good.
[Dr. Stern] And I would add to that, given the fact she doesn't feel it though, we're still very concerned, like it's a peculiar story for standard incontinence. Right? So you'd probably want to do a bladder scan to see if she's not emptying properly. And if she is indeed having urinary retention, then she definitely needs to have a spinal MRI. Don't you think?
[Dr. Altkorn] Absolutely. [Dr. Cifu] Good. Well, let's stop there, okay? [Dr. Stern] Okay. Now, Adam, do you have five points to help us diagnose incontinence? [Dr. Cifu] I do as the expert of the day. So my first point and my fifth point are pretty pathetic, but I thought they were important to throw out there. Okay? So number one, urinary incontinence, it's kind of obvious, the involuntary leakage of urine.
It is really, really common. Depending on what you're reading, it's estimated that nearly 50% of adult women experience some urinary incontinence, and of that 50%, somewhere between 40 and 75%, don't tell their doctor about it. Okay? So, hopefully we'll talk about it later, that this is one of those things that, you know, often as a physician, you won't hear about it unless you work to turn it up.
And if you have any doubt about that, just like, watch some commercial TV and see all the ads for incontinence supplies, which lets you know that it's a really common problem that people are trying to take care of. There are also some cool studies that it's got a huge effect on quality of life. The things that are always thrown out there are, caregiver burden for people who've got a lot of incontinence, sexual dysfunction, isolation, people who are less apt to go out and do things, and actually real sort of health morbidity.
[Dr. Stern] Do you have any sense in your reading, like how often this occurs to men? I mean, definitely, it seems to be a problem that's really prevalent in women. [Dr. Cifu] Yeah. So it's overwhelmingly a problem of women, except in men who've had iatrogenic trauma, of women, except in men who've had iatrogenic trauma, or some other sort of injuries that cause it. [Dr. Stern] So we should be particularly worried if it happens to men because it's not standard in men at all?
[Dr. Cifu] Right. Are you making a pitch - for men's health there? - [Dr. Stern] No, I wouldn't think of doing such a thing. I was just merely trying to elaborate on that. - Wise guy. - [Dr. Cifu chuckles] [Dr. Altkorn] And by iatrogenic trauma, do you mean prostate surgery? [Dr. Cifu chuckles] Yes. Among other things, but prostate surgery, I think, leads the list.
[Dr. Stern] All right. Do you have a second point? [Dr. Cifu] Yeah. So my second point is going to be a little prolonged, and you guys may need to clarify things for me here, but probably any, you know, learner at any stage who's ever gotten like a, kind of of, you know, whiteboard talk on incontinence, somebody starts out by drawing a two by two table, and the two by two table is, your columns are either overactive or underactive, and your rows are detrusor, which I'm just going to call bladder because it drives me crazy, the whole why do we have to call it detrusor? And sphincter.
And anything in that two by two table, so an overactive or an underactive bladder, or an overactive or underactive sphincter can cause incontinence. Okay? And so, I'm going to fill in that two by two table here. So first, let's do the bladder. So bladder overactivity is urge incontinence. Right? And so, what urge incontinence generally feels like, is people say, "Oh, my God. I got to go to the bathroom," and they're just not able to get there before they lose a little bit of urine.
Bladder underactivity, we've already talked about a little bit, that's where the bladder is kind of atonic, it's just this like, bag of urine, and therefore, will sometimes just overflow, generally, without people even, you know, having any warning, urine just flows out. On the sphincter row, there's sphincter overactivity, and that's really BPH, I think is when we see that the most. So that's men with large prostates, where their prostate gets so large, they have trouble emptying their bladder, they therefore overflow a little bit, they've got a little bit of an urge from a stressed bladder, and will lose urine.
And then the last one, which is the most common, I think, Scott, you already mentioned, is an underactive sphincter, and that is stress incontinence, and that's classically, you know, you cough, you laugh, you step down hard off a curb, and you lose a little bit of urine. [Dr. Stern] And that one's the one that's typically associated with- More common as women get older, and also if they've had multiple children, particularly with vaginal births. Correct?
[Dr. Altkorn] Women of a variety of ages who have had vaginal deliveries or hysterectomies, or even early postmenopausal, and so have loss of pelvic muscle tone from lack of estrogen are at risk for stress incontinence. And it's not just a sphincter issue, it's also sort of the way that the pelvic musculature is supporting the urethra, and if the angle of the urethra and the bladder changes, that can lead to stress incontinence.
[Dr. Cifu] Great. Thank you. That's really good. I'm going to move on to my third point, and my third point is that for these four types of incontinence you should really wait before you reach for meds. I think not only when you watch commercial TV do you see tons of ads for incontinence supplies, but you also see tons of ads for the medications for incontinence. Right?
Always marketed by their trade names, so this is Detrol or Flomax, things like that. Okay? But it's important that most of these types of incontinence can be treated without medications, or at least to some extent, without medications. So urge incontinence, we often talk about removing bladder irritants from the diet, we tell people to do scheduled voiding because if you keep your bladder relatively empty, you're less likely to have spasm.
BPH, hard to treat non-medically but again, you can at least BPH, hard to treat non-medically but again, you can at least have people stay away from things which are going to worsen BPH symptoms, like decongestants. Stress incontinence, we talked a little bit already about pelvic floor exercises. Overflow incontinence, really, the treatment for overflow incontinence is scheduled self-catheterization, since there's not really a medication that can help that.
[Dr. Stern] That's great. So I don't really have anything to add to that. Do you? [Dr. Altkorn] Also, fluid intake can be modified sometimes. Adam mentioned bladder irritants, so that includes things like caffeine, alcohol, soda, so avoiding those, paying attention to what times of day you are drinking your fluids, also can be important. And a bladder diary can be very helpful, the bladder and voiding diary to help people sort of quantify how much fluid they're drinking when, and how much they're voiding when, and that can be helpful in doing some lifestyle modification.
[Dr. Cifu] Great. Yeah, I got to say with BPH. Right? I mean, one of the first symptoms people will tell you, is that, "Ah, you know, I've got nocturia." They don't say that. [chuckles] They say, "I'm waking up three times during the night." And often the thing that fixes that is, "Look, don't drink anything for the last two hours before you go to sleep." Right? And that often gets people having a good night sleep for two, three, four years, right?
Until you really need to intervene with something else. [Dr. Stern] The other strategy I've used with patients sometimes is to have them elevate their legs for a couple hours before they go to bed, because a lot of folks keep edema in their legs, and part of the nocturia is they're reabsorbing that fluid and then urinating during the night. And if they can get their legs up after dinner, then they can get rid of some of that urine before they go to bed.
[Dr. Cifu] Right. Well, we're actually, I think, already sort of throwing in some clinical pearls. The other thing I would add to that is diuresis, right? Because it may be counterintuitive, but there are some people that diuresis early in the day, will get that extra fluid off them. So they're not mobilizing at night, and then they're not up all night going to the bathroom. [Dr. Stern] Right, a little counterintuitive, right?
"Here, take this diuretic for your incontinence." [Dr. Cifu] Right. We may be going into polyuria rather than incontinence, but certainly it all comes together. [Dr. Stern] All right. What's your fourth point? [Dr. Cifu] So my fourth key point is a pneumonic, which I throw out there just cause I know that Scott hates pneumonics. [Dr. Stern] I hate pneumonics, but go ahead. [Dr. Cifu] But this is a pretty good one.
And this, I think of, as being acute incontinence. So people who develop incontinence acutely, where maybe you're not even going to get into that two by two table yet. And you're ready? The pneumonic is DIAPERS, okay? Which is kind of awful. But so, D is delirium, okay? People who are confused, maybe a toxic metabolic-encephalopathy, and are just so confused that they're not able to control their urine.
Infection, Diane, you mentioned, so someone who's sort of doing fine, but then gets a bad urinary tract infection, and their urgency is so great that they lose some urine. Atrophic vaginitis, a big one. You know, again, common in older women, and often instead of getting to all of the, "Ah, I got to think about stress incontinence," sometimes it's just treating the atrophic vaginitis that helps.
Pharmaceuticals. Boy, you know, you can come up with an enormous list of pharmaceuticals, and you could almost put those in the two by two table of, you know, what sorts of drugs worsen what kinds of the chronic incontinence? Right? What's going to lead to more bladder spasm? What's going to lead to more stress incontinence? E is endocrine, which is diabetes insipidus, diabetes mellitus. R, restrictive mobility.
Scott, you sort of mentioned this when we were talking about our patient that like, "I'd like to go to the bathroom, but I can't get out of bed." And then lastly, interestingly, is stool impaction. So people with really bad stool impaction will have incontinence both from just pressure on the bladder because of the stool, and because of the common innervation of the bladder and the rectum.
[Dr. Stern] As pneumonics go, that's pretty good. [Dr. Cifu] That's a pretty good one. Right? [Dr. Stern] I mean DIAPERS, right? I mean, I like the- As much as you can like saying diapers- [Dr. Cifu] Yeah. [Dr. Stern] I don't think I'd revealed that to a patient. [Dr. Cifu] No, I don't think so. [Dr. Stern] Here, let me think about you. Diapers. Hm. [Dr. Cifu chuckles] Right. The only two pneumonics that I actually remember and use are DIAPERS and MUDPILES.
Everything else, I've either forgotten, or more commonly, I've remembered the word, but I've forgotten what the hell each letter corresponds to. [Dr. Stern] Wait, you like POUNDING for migraine? [Dr. Cifu] Oh, I do like POUNDING for migraine. [Dr. Stern] See, we've been together a long time. [Dr. Cifu] Okay, thank you. [Dr. Stern] I can remember remember his pneumonics better than he can remember his pneumonics. [chuckles] All right. Do you have a fifth point?
[Dr. Cifu] Yes. Before you pull out the MOCA, let's do the fifth point. Okay. You ready? This is the most pathetic fifth point. How do you spell incontinence? I-N-C-O-N-T-I-N-E-N-C-E. I-N-C-O-N-T-I-N-E-N-C-E. And I say that; one, because every time I write incontinence, I just thank God that Epic has a spell check, because I always spell it wrong, and B, because Dr. Altkorn's here, who's been correcting my spelling for 25 years and everything that we've done working together.
[Dr. Stern] That's right. We refer to you as the grammar lady as we write each edition of our book, don't we? [Dr. Altkorn] Yes, you do refer to me as grammar lady. [Dr. Stern chuckles] Okay. All right. So, we go back to our case? [Dr. Cifu] Yes, let's. So you guys sort of hit everything. Urinalysis was done, which was clean.
The physical exam was notable mostly for some really perineal loss of sensation. mostly for some really perineal loss of sensation. This woman actually had an MRI that day, showed mets to her lumbar spine with cord compression, was actually started on steroids, and scheduled for surgery for decompression of her cervical spine. This all happened on my day off, and I get in the next day, and my co-intern is telling me all the incredible things he did on my patient.
And I was A, super impressed with him, B, kind of felt terrible that I had missed it when I admitted the person. [Dr. Stern] Well, it's a great case, I mean, I've missed a case like that in the past too. And we tend to forget that urinary symptoms can be an incredibly important clue. So I think it's a great learning point. All right. So let's go on now, and we're going to move into the section of fingerprints, common misconceptions, pet peeves, and other random pearls of knowledge.
Diane, we're going to put you on the spot first. You want to start us off with some fingerprints? [Dr. Altkorn] So there isn't really a fingerprint for diagnosing chronic urinary incontinence, but there's a questionnaire that's been developed called the 3IQ, and asking these questions has been found to be helpful. So the first question, well, actually the very first question is, "Do you have any leakage of urine?" If you answer no to that, you're done.
But we're going to assume you've answered yes to that. [Dr. Stern] That goes under the, "Thank you, Captain Obvious," statement. [chuckles] [Dr. Altkorn] Indeed, but I'm just reporting the full questionnaire here. [Dr. Stern] Okay. Sorry, sorry. [Dr. Altkorn] So then the second question is, "During the last three months, did you leak urine?" And you can choose as many of these answers as apply.
"When you were performing some physical activity such as coughing, sneezing, lifting, or exercise; wen you had the urge or the feeling that you needed to empty your bladder but you could not get to the toilet fast enough, or without physical activity and without a sense of urgency." So you can check as many of those as applies. Then the last question is, you only get to choose one answer, "During the last three months, did you leak urine most often with physical activity, or with the feeling of urgency, or without physical activity and without urgency, or about equally with physical activity and a feeling of urgency?" So if you answer most often with physical activity, this suggests either stress incontinence by itself, or at least stress predominant urinary incontinence.
If you answer most often with urgency, that suggests urge incontinence, or at least urge predominant. And if you answer without physical activity or a sense of urgency, then that suggests another cause such as overflow, and the positive likelihood ratio for diagnosing urge incontinence with this questionnaire is 3.29, which is not an outstanding positive likelihood ratio, but for historical questions, it's really not bad.
And then the positive likelihood ratio for stress incontinence is a little bit lower at 2.13. So these questions aren't a slam dunk, but they are still, I think, useful. [Dr. Cifu] Right. So not near our 10 cut-off for a real fingerprint, but it's kind of nice because it reminds you of, look, these are the three main diagnoses, right? Stress incontinence, urge incontinence, or overflow, these are the questions you should ask to get the history.
And so probably remembering this just reminds you to get into it. Right? [Dr. Altkorn] I think that's a good summary. [Dr. Cifu] So 3IQ, is that three incontinence questions? [Dr. Altkorn] Exactly. Very clever pneumonic they came up with, isn't it? [Dr. Cifu chuckles] Not as good as COURAGE or OPTIMA, or something like that, but well, we'll give it to them. Scott, do you have one?
[Dr. Stern] I do, and it's actually quite relevant for the case that we just had. So the presence of urinary retention with two out of the three following is highly predictive of cauda equina, essentially our patient, although there's- I didn't see a specific LR likelihood ratio associated with it. So the three factors that any two would be very suggestive of, would be bilateral sciatica, a subjective sense of retention which we had, or a rectal incontinence.
And so, interesting case. [Dr. Cifu] Yeah. So it sounds like if that would be the sort of the thing, you see a patient, they've got sciatica, feel like they're retaining urine, have a little bit of stool incontinence, your suspicion would just be super high and at that point you'd say, "I'm going to do a bladder scan." You see that they're overloaded, you've basically made your diagnosis of cauda equina syndrome, if that makes sense.
[Dr. Altkorn] Because actually, if the patient presents with back pain as a primary complaint, and then urinary retention or incontinence, that actually is a fingerprint for cauda equina- [Dr. Cifu] Right. [Dr. Altkorn] -when you're thinking of it from a back pain - point of view - [Dr. Cifu] Right. Right, which is interesting because, I mean, when I see enormously overloaded bladders, given that I'm a middle-aged male physician, tends to be in older than middle-aged men with urinary retention from BPH, and those people who can have one, two, nearly three liters of urine in their bladder, they often don't really have symptoms, you know, not abdominal pain, not back pain, it's just that their bladder's gotten big slowly for such a long time, that they've ended up, you know, essentially pregnant without really feeling a whole lot different.
[Dr. Stern] I think it helps to distinguish whether the overflow is associated with lack of sensation and just leakage, or whether they're straining to urinate. - [Dr. Cifu] Yes. - [Dr. Stern] You know, in men, obviously, who are obstructed what the history is normally like, I really have to work to urinate, whereas when it's neurological, it's often like in this patient not perceived. And so distinguishing those two, I think is going to be helpful.
[Dr. Altkorn] I agree. [Dr. Stern] Okay. Let's go on to common misconceptions. Diane, back to you. [Dr. Altkorn] So one misconception is that when you've identified someone with urge incontinence, and you want to start a medication, that you need to do a post-void residual before starting that medication. And why would you even think this?
Because the medications for urge incontinence are generally anticholinergic. And so if someone actually had overflow incontinence, you could cause them to have complete urinary retention. Nevertheless, in the average outpatient who does not have active cancer and does not have known neuropathy such from diabetes, overflow incontinence is still much less common than urge incontinence, and so it's considered safe to start a medication, monitor them carefully, and if they develop new or worsening symptoms after the medication is started, just stop the medication and then do a post-void residual.
Also, anytime a patient reports incomplete voiding, has pelvic organ prolapse on exam, or if they're planning to have surgery for stress incontinence, all those patients should get a post-void residual done. [Dr. Cifu] Good. That certainly makes sense. Yeah, I got to say when I'm thinking about urge incontinence, I usually just start the med, and if I've got any questions, I send myself a reminder to call the person in the week and say, "So are you getting any better?" Because almost all people with urge incontinence- You may not fix them, but they'll generally say that they're a little bit better once you start a med.
[Dr. Stern] Would you say the same for urge incontinence in a man? Would you not get a bladder scan in a man who has urge incontinence? [Dr. Altkorn] So it's different in a man because the most common cause is going to be BPH. And so I probably would treat the BPH- - [Dr. Stern] Right. - [Dr. Altkorn] -rather than treating the incontinence symptom itself.
[Dr. Cifu] Though often, right? After treating the BPH, then you end up treating the urge as well, right? Because they have sort of dual causes. [Dr. Stern] Adam, do you have misconceptions for us? [Dr. Cifu] I guess my misconception is, and maybe I've spent the first half of this podcast sort of making this misconception even stronger, is that it's all in the history. Right? So it really is important to get a good history, to think about that two by two table, to think about the pneumonic we talked about before, but the exam really is important as well.
The exam can help clarify stress versus urge versus overflow. I have certainly been confused sometimes in the clinic. And like, although it sounds, you know, maybe a little bit uncomfortable, or embarrassing, whatever, it can really help to say, "Look, I'm going to have you stand up, I'm going to put a gloved hand with a towel underneath you, and say cough." And if that causes incontinence, that's your stress incontinence.
If sometimes a person may cough, nothing happens, and then they say, "Oh, my God! I need to go to the bathroom," because you've sort of induced urge at that time. And I have to say in the last few weeks, I've had a patient who I was preparing to do this, and just getting this patient to stand up, there was leakage, and that told me, boy, this is much more likely to be overflow than anything else. There are also other things which Diane mentioned before, certainly, atrophic vaginitis. Right?
You're going to find on an exam. BPH, although our exams aren't perfect for BPH, certainly, that's going to push that higher up on the differential diagnosis. [Dr. Stern] Okay. I think we're on to pet peeves. Diane, Adam's really good at pet peeves. - What do you got? - [Dr. Stern And Cifu chuckle] [Dr. Altkorn] Well, I wanted to pick something that also started with a P, so I said, skipping the pelvic exam is one of my pet peeves because you need to look for the atrophic vaginitis, and even perhaps more importantly, for pelvic organ prolapse because I think we underestimate how often that can be a cause of incontinence.
And that requires really a different approach than just the usual lifestyle modifications or the usual medications. [Dr. Stern] And can you explain to the people listening how you would do that exam? [Dr. Altkorn] How you would do a pelvic exam? [Dr. Stern] No, I understand how you do a- [Dr. Cifu and Stern chuckle] [Dr. Stern] I meant, were there special maneuvers that you would use during the pelvic exam, to try to elicit the prolapse?
Or you're just looking for frank prolapse that's obvious? [Dr. Altkorn] You're really looking for frank prolapse that's obvious because it's in particular prolapse past the introitus that's the most highly related to incontinence, but doing a speculum exam, you would see a cystocele if it were present. [Dr. Stern] Great. Adam, I know you have a pet peeve. [Dr. Cifu] Diane should get a gold star for pet peeve, pelvic exam for pelvic organ prolapse.
We got to just underline the alliteration star. So my pet peeve is like so obvious, I think we've already beat it to death, but it's skipping the urinalysis. Right? Like, even if you're sure this is stress incontinence, this is urge incontinence, you got to get a urine. Right? Just to make sure that there's not an infection, and you might find other things that you're not expecting. Your know, glycosuria that, oh my God, this person has diabetes or their diabetes is under poor control, maybe a low specific gravity that they're just drinking heaps and heaps of fluid, which you should pull back on, you know, maybe proteinuria, their concentrating ability is not that good.
So, I think there was a time that everybody who came to the doctor, got a urinalysis, and that was totally wrong, but clearly, this is the time that an easy, cheap urinalysis, even just a dip in the clinic, is definitely part of the evaluation. [Dr. Stern] You know, it's funny, I reminded you of a pneumonic, but you just reminded me of a pet peeve that I have.
[Dr. Cifu] Okay, throw it out there. [Dr. Stern] So the pet peeve that I have is this incredible misconception that everybody should drink eight glasses of water a day. If there's something that's common in the community that people believe, it's this crazy notion that everybody should drink eight glasses of water a day. If you are meant to drink eight glasses of water a day, you'd be thirsty enough to drink eight glasses of water a day, drink when you're thirsty.
[Dr. Cifu] I think there is a podcast which is- Sort of, it's the pet peeves of the incorrect thinking Sort of, it's the pet peeves of the incorrect thinking about what we have to do to stay healthy that's just out there in the ether, which, you know, drives you crazy. [Dr. Stern] Oh, that's going to be so much fun. When are we going to do that? [Dr. Cifu] Soon.
[Dr. Stern chuckles] Okay, good. [Dr. Cifu] Okay. Clinical pearls. Diane, you got a clinical pearl for us? [Dr. Altkorn] I think I have two pearls. One is, don't wait for the patient to tell you, as Adam already said, you need to ask about incontinence, often people find it embarrassing and will not tell you. Remember always to talk about lifestyle changes such as changing or reducing fluid intake, frequent toileting, and pelvic floor exercises.
And then one other thing I thought about when we were talking about nocturia earlier in the discussion, is that nocturia can be a symptom of obstructive sleep apnea. People think that the need to go to the bathroom woke them up, but really what woke them up is the fact that they weren't breathing, and then they feel that they have to go to the bathroom. So if someone has unexplained nocturia, don't just always attribute it to a big prostate- [Dr. Cifu] Yeah.
[Dr. Altkorn] -think about sleep apnea. [Dr. Cifu] Yeah. I bet I get into that discussion. So to underline your point about asking about incontinence, boy, it's almost like it should be part of the review of systems, right? Past a certain age. [Dr. Altkorn] I think that geriatricians do consider it part of the review of systems. [Dr. Cifu] As I was saying that, I was like- But it's funny because everybody does have their different review of systems. Right?
So for young women, you know, the menstrual cycle should be part of the review of systems because that's such an important symptom of other diseases, and yes, in older people, this should be. So I know, I know. I know. [chuckles] But I think I do get into a lot of conversations with men when we're talking about their BPH and deciding whether we're going to treat their BPH, and sometimes it's confusing, is it your need to urinate that's waking you up, or is it your poor sleep, or LSA, or whatever that's waking you up?
[Dr. Stern] Yeah, I just have to say I'm very tired today because I woke up four times last night, and I thought it was to pee, but maybe it's my sleep apnea. [chuckles] Oh, my goodness. All right. [Dr. Altkorn] Check your CPAP machine settings. [Dr. Stern chuckles] All right. So my next clinical pearl is, you know, although incontinence is very common, and usually benign unlike our case, there are certain alarm features that should definitely tip you off.
You know, one is this overflow incontinence that we've talked about. Other things that would be a clue that it's something particularly worrisome, like your patient, would be a sudden onset severe incontinence that really would be striking, hematuria which might suggest bladder pathology, unexplained pelvic pain which would also suggest bladder pathology, or any neurological symptoms, numbness, etc, bilateral sciatica, which would suggest that you need to work them up neurologically.
[Dr. Cifu] Terrific. My clinical pearl [chuckles] I just wrote down 'handouts' to remind me, I have a bunch of handouts above where I am in the clinic, and two of those handouts are instructions for Kegel maneuvers. Right? Really important, and really actually effective for mild stress incontinence, and then I actually have another printout of bladder irritants for people who've got urge incontinence.
And it's not.. You know, I always tell people, "Look, there are 20 things on here, don't cut these 20 things out of your diet, but just be aware of them, and see if any of these are a problem for you." And I have had some people who are like, "Oh, my God, I realized that caffeinated coffee is the thing that kills me." And that even just switching to decaf makes an enormous difference in those.
Just as an aside, my other handouts, I realized as I looked through them for this, is the Brandt-Daroff maneuver to try to help people with benign positional vertigo, the MOCA, because you always got to bring one of those into the room with you, a Chicago parking placard, a disabled parking handout that I can fill out quickly for the patient, and a thing to help me counsel for smoking cessation.
[Dr. Stern chuckles] You're clearly into the random pearls of knowledge on this one. [Dr. Cifu chuckles] I looked at those and I was like, boy, those six things sort of summarize the job of a general internist. [Dr. Stern] Diane, would you like to get us back on track? Do you have any pearls about incontinence you'd like to share? [Dr. Altkorn] I can get us back on track.
So one thing about the Kegel or the pelvic floor exercises, is that even with a good handout, they're not always done correctly. And you can refer patients to physical therapists who are trained in incontinence treatment and pelvic floor exercise instruction, and they can help women correctly identify the muscles they need to contract. And then of course, as with any exercise, doing it three or four times doesn't result in resolution of the problem.
You have to really stick with it for a number of weeks to see a result. It's also really important to review the patient's medications carefully. A variety of medications can cause incontinence, including anticholinergics, leading to overflow incontinence as we have already discussed. There are other medications that can affect the detrusor muscle, such as benzodiazepines, opioids, antispasmodics, antihistamines, diuretics clearly increase urinary flow.
And then also SSRIs can affect the detrusor muscle and lead to some mild overflow incontinence. [Dr. Stern] That's great. Well, my final clinical pearl is what we always say, which is diagnosis should precede therapy, and clearly, with incontinence where there's different mechanisms, you're going to choose different medications. So it's really worth not having just one standard prescription for incontinence, but figuring out what type it is so that you target your therapy appropriately.
[Dr. Cifu] One thing that we probably should mention just before we finish up, are vesicovaginal fistulas, mostly a complication of childbirth, very common, I think, worldwide. We don't see that a whole lot, and I think when that happens, it's sort of for us, probably within the purview of the obstetrician gynecologist, and so seldom makes it into the office of an internist, but seems like it would be wrong to not say something about it.
[Dr. Altkorn] Absolutely. [Dr. Cifu] So we hope you found this episode of the Symptom to Diagnosis podcast useful and a bit enjoyable. Another huge thanks to Diane for joining us today, we will be giving you an S2D podcast sticker as a thank you. [Dr. Altkorn] I feel like I'm on, wait, wait, don't tell me, I'm going to get your voice on my answering machine. [Dr. Cifu chuckles] As a reminder, our text book, Symptom to Diagnosis An Evidence-Based Guide, takes a much deeper dive into how to think about and reason through the diagnosis of medical presentations.
The book is available in print, on your handheld device, and in a fully searchable mode via the AccessMedicine website available worldwide from McGraw Hill. The music for this, the S2D podcast is courtesy of Dr. Maylyn Martinez. [upbeat outro music] [upbeat outro music] [upbeat outro music]