Experience-sharing interview: Managing a case o...

Patient presentation

A 52-year-old female raised the issue of frequent visits to the bathroom during the day (10–15 times) and night (5–6 times) during an appointment.
She also experienced leakage when she coughed or sneezed.
Her clinical history included type 2 diabetes, which was well managed by medication, and early menopause starting at age 48.
She was otherwise very healthy.
Her symptoms had been present for 4 years.

1. How did you diagnose the patient and which tests did you conduct?

A physical examination resulted in mostly normal findings, apart from the patient having vaginal atrophy related to her early menopause, and vaginal candidiasis. Urine analyses were within normal ranges, ruling out infection, but a stress test was positive (urine lost with coughing). The patient was also asked to fill out a bladder diary, which confirmed high frequency (10–12 times per day and 4–5 times per night), urgency (2–3 times per day) and leakage following walking, running and coughing. On the basis of these results, the patient was diagnosed with mixed incontinence due to the presence of both urge and stress incontinence.

2. How was the patient treated?

The patient was treated with a combination of tolterodine (4 mg once daily) and behavioural therapy, as behavioural therapy in combination with pharmacotherapy has been shown to be the most effective approach for managing overactive bladder (OAB) (Figure 1).¹

Tolterodine is an antimuscarinic drug that has proven efficacy in addressing the symptoms of urgency in patients with OAB and a favourable safety profile,^2-4 while effective behavioural interventions can include bladder training, exercises to strengthen the pelvic floor and reducing or eliminating diuretics from a patient’s diet (eg, caffeine, alcohol and carbonated drinks).² These treatments could also be administered in conjunction with a local oestrogen cream to treat the patient’s vaginal dryness.

3. What were the patient’s long-term treatment outcomes?

The patient reported that her urgency and frequency symptoms were well controlled within 4 weeks. However, stress incontinence still affected her quality of life (QoL), so midurethral sling surgery was performed. As all incontinence symptoms had resolved 6 months after surgery, tolterodine therapy was discontinued without the patient’s urgency or frequency symptoms relapsing.

4. Why did you initiate therapy with tolterodine?

Tolterodine has proven efficacy and a favourable safety profile compared with other antimuscarinics, such as oxybutynin.^3-5 Furthermore, real-world data suggests that tolterodine is more effective and has a favourable safety profile compared with oxybutynin.⁶

For this patient, tolterodine has also been shown to be effective in reducing both daytime and nocturnal frequency, her two most bothersome symptoms.⁷ In addition, tolterodine is cost-effective and can be taken once daily, which helps improve adherence.^4,8
Tolterodine is generally well tolerated, and patients report a low incidence of treatment-related adverse side effects.⁹ While some patients express concern about adverse events associated with antimuscarinics, such as dry eyes, dry mouth and constipation,³ serious adverse events are rare.⁹ Furthermore, significantly fewer patients treated with tolterodine withdraw from treatment as a result of adverse events compared with oxybutynin.⁶

5. What are the challenges in accurately diagnosing OAB in female patients?

OAB is diagnosed by exclusion, so a physician must first rule out a urinary tract infection.² In addition, other forms of incontinence, such as stress incontinence, are common in women and these may require a different treatment plan.

Therefore, while patients with OAB usually present to a general practitioner, they are often referred to a urologist or gynaecologist for an accurate diagnosis. However, when the appropriate diagnostic tools are utilized, such as a bladder diary and full clinical history, it is relatively easy to diagnose OAB based on the patient’s symptoms alone, and in the absence of urodynamic tests.

6. What are some of the challenges in managing patients with OAB?

While adherence to tolterodine treatment is high, patients often find it harder to adhere to behavioural therapies.¹ Patients generally want a fast resolution of their symptoms so antimuscarinic drugs are usually prescribed immediately, in combination with behavioural therapies which may take longer to become effective.

Patients who have not managed to complete pelvic floor exercises and reduce diuretics in their diet may find that their symptoms return after ceasing tolterodine therapy. Therefore, patient education is paramount for improving adherence.² For example, bladder diaries can be used as an educational tool, demonstrating treatment efficacy to patients over time, in addition to facilitating appropriate symptom assessment.²

7. Do you have any advice or insights you can give to other physicians managing patients with OAB?

An accurate diagnosis of OAB and adherence to treatment are important for addressing the considerable QoL impact that OAB has on patients’ lives. Management with a combination of tolterodine and behavioural interventions, such as pelvic floor exercises, keeping a bladder diary and limiting diuretic intake, is relatively simple.²

Patients should also be advised that all antimuscarinic drugs have potential side effects, and tolterodine is no different.^2,3 While adverse events are generally mild-to-moderate in severity,³ and not considered a burden by patients,^4-9 antimuscarinic treatment should be assessed every 3 months, as per standard clinical practice.

References
1. Mattiasson A, et al. BJU Int 2003;91:54–60.
2. American Urological Association/Society for Urodynamics and Female Pelvic Medicine and Urogenital Reconstruction. Diagnosis and treatment of overactive bladder in adults: AUA/SUFU Guideline. Available at: https://www.auanet.org/common/pdf/education/clinical-guidance/Overactive-Bladder. Accessed 18 April 2017.
3. Detrusitol (tolterodine). Prescribing information. Available at: http://www.mims.com/hongkong/drug/info/detrusitol/?type=brief. Accessed 18 April 2017.
4. Van Kerrebroeck P, et al. Urology 2001;57:414–421.
5. Lee JG, et al. Int J Urol 2002;9:247–252.
6. Sussman D, Alan G. Curr Med Res Opin 2002;18:177–184.
7. Elinoff V, et al. Int J Clin Pract 2006;60:745–751.
8. Siami P, et al. Clin Ther 2002;24:616–628.
9. Zinner NR, et al. J Am Geriatr Soc 2002;50:799–807.

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Experience-sharing interview: Managing a case of urinary incontinence