Continence

Welcome to the Continence module.

This module will provide you with two interactive case studies in which you will diagnose, treat and develop a management plan for patients experiencing incontinence.

Once you have completed the Pre-Module Test below you will be able to commence the Continence Case Study.

(If you are returning to the module you can skip the Pre-Test by clicking on the Continue button to go straight to the case).

Objectives

Pre-Module Test

Resources

Module 1

Mr Robert Scott is a 78 year old man. His wife Veronica has made an appointment for him to see you, as she is concerned about his toileting habits.

Review Mr Scott’s history through the links below before moving on to his assessments.

History of Presenting Complaint
Medical History
Medication History
Social History

Mrs Scott has noticed that over the last month or so, her husband has been going to the bathroom about four or five times during their one hour choir practice. At the last practice he lost control of his bladder while waiting to use the toilet. He was so embarrassed that he won’t go back to church or to singing in the choir, which is something that he usually loves to do.

Over the last 6 months, Mrs Scott has also noticed that Mr Scott has been changing his underwear at least three times a day. He always rinses it out before putting it in the laundry basket. She is feeling increasingly concerned about what has been happening, but doesn’t want to embarrass him by mentioning it.

Veronica has made this appointment for him to see you and she told him it is for an annual check up.

Mr Scott has been a type 2 diabetic for many years, but no longer checks his own blood sugar levels. This makes it difficult to know the status of his glycemic control.

Mr Scott is currently taking metformin 500mg tds and glipizide 5mg bd and the diuretic hydrochlorothiazide 25mg daily.

Mr Scott is a 78 year old retired carpenter. He has been married to his second wife Veronica, 75, for 20 years. Together, they have 6 children (3 each from previous marriages), 17 grandchildren and 3 great grandchildren. Two years ago they moved to St Ives Centro Retirement Village in Jolimont. This allowed them to stay within their familiar neighbourhood, whilst also enjoying all the benefits of retirement living lifestyle, such as sporting and social facilities.

Both of their previous partners passed away from cancer and as such, they are avid fundraisers for the Cancer Council WA, regular participants in cancer support groups and volunteers at the Hollywood Hospital.

Mr Scott enjoy bowls, tennis, golf and swimming. He and his wife are also movie-goers and their great passion is singing. in addition to the local church choir, they also sing regularly in concerts at the village.

Family History
Mr Scott has a family history of type 2 diabetes mellitus, hypertension and stroke.

Patient Interview

Physical Assessment

Transient causes of incontinence are factors outside of the lower urinary tract, that can either cause or worsen incontinence. Because transient causes often respond to conservative treatment, identifying and reversing them should be the first step in any attempt to improve continence status.

Based on the information obtained during your discussion with Mr Scott and through physical examination, what would you identify as possible transient causes of incontinence?

Click on the factors you feel are relevant to obtain feedback. There are a number of possibilities. Can you identify all of them?

Could be a contributor as this drug is a diuretic, although the risk is low

Could be a contributoor as oedema can cause nocturia, even though Mr Scott’s oedema is mild

Not a contributor as Mr Scott has not reported constipation

Not a contributor as Mr Scott’s MSU was negative

Unlikely contributor as even though Mr Scott reports depressive symptoms, his affect is reactive

Could be a contributor as Mr Scott drinks fluids that are diuretics and bladder irritants

Could be a contributor as polyuria can occur in diabetics and with use of diuretic drugs

Could be a contributor, but as Mr Scott has not been measuring his BGL’s, diabetic control is difficult to assess

Request further laboratory tests to help determine the cause of incontinence, by clicking on the tabs below. Review results before proceeding.

On request, Mr Scott voided 100ml of clear yellow urine, which proved to be negative on dipstick testing. No evidence of UTI present. His post void residual (PVR) was measured using ultrasound and was recorded as 600mL (normal range PVR < 50ml).

Mr Scott may be interested in his cholestrerol level as part of a general health assessment and in relation to his diabetes, but it is not mandatory in the investigation of incontinence. His total fasting cholesterol is slightly high, 5.8mmol/L (normal range < 5.5mmol/L).

You discuss the pros and cons of the PSA test with Mr Scott and he feels that he would like to go ahead and have one. His result of 5µg/L is within the normal range (<6.1 µg/L for men aged 70-79).

Na 136 mmol/L (normal range 134-146 mmol/L)

K 4.1 mmol/L (normal range 3.4-5.0 mmol/L)

Urea 4.2 mmol/L (normal range 3.0-8.0 mmol/L)

Cr 84 µmol/L (normal range for adult males 60-120 µmol/L)

Creatinine levels may become elevated in men as a result of an enlarged prostate that blocks urine flow or from kidney disease.

This test measure long term control of diabetes by measuring the average level of glucose over the previous two months. Mr Scott’s HbA1C is 7.2% (normal range <6%).

This suggests Mr Scott's diabetes is under acceptable control, but could be improved.

Normal <6.0%

Good control 6.0-7.0%

Acceptable control 7.1-8.0%

Poor control >8.1%

Mr Scott scores 7/15 on the GDS indicating that he is likely to be depressed (a score above 5 suggests depression). Click here to see his completed GDS.

Based on the patient history and physical examination, answer the following questions:

You arrange for Mr Scott to attend for a follow up visit in two weeks, to discuss results of his investigations and review his progress. In the meantime, you refer him to see the Continence Advisor.

Click on the button below to see Mr Scott's report from the Continence Advisor.

What other advice would make up your initial management strategy for Mr Scott's continence problems?

Click on each of those you feel is relevant to obtain feedback.

Reduce caffeine, alcohol and diet coke intake
Stop hydrochlorothiazide
Prescribe oxybutynin 5mg at bedtime
Prescribe sleeping tablets
Resume regular use of blood glucose meter

You explain the diuretic and irritating effects on the bladder of caffeine, alcohol and aspartame and advise Mr Scott to slowly reduce his intake of tea, coffee, coke and alcohol by replacing them with water or other non-caffeinated drinks and aspartame free drinks.

It may be necessary to re-assess the need for hydrochlorothiazide with close monitoring of blood pressure. You decide that at this point in time it may be best not to change too much at once. Monitor and consider reduced dose or discontinuation if necessary.

Oxybutynin is an anticholinergic agent used to relieve urinary and bladder difficulties, including frequency of urination and nocturia. This may be indicated for Mr Scott because of his complaint of lack of sleep due to nocturia. However, he has an enlarged prostate and symptoms of overflow incontinence, so oxybutynin may cause further retention and therefore be contraindicated.

This is not recommended. They will do nothing to alleviate his incontinence, leading to bed wetting and likely further feelings of embarrassment, frustration and distress. They may also increase risk of falls if he wakes in the night and tries to get to the toilet in a hurry.

This would be highly advisable in order to get an idea of how Mr Scott’s diabetes is being managed and any effect this might be having on continence and general health. You ask him to bring his record of capillary glucose readings, including pre meal and two hour post meal readings, to his next appointment.

What further referrals are required to diagnose and manage Mr Scott’s condition?

Click on each to see the specialist assessment

Referral to Urologist
Referral to Psychologist

Mr Scott is referred to a urologist for investigation of his enlarged prostate. He had a normal PSA score, but this does not conclusively rule out the possibility of prostate cancer, as false negatives are common. The urologist does a biopsy of his prostate, guided by transrectal ultrasound. The results demonstrated Benign Prostatic Hyperplasia, and no evidence of maligancy.

Mr Scott scored 7/15 on the GDS and this warrants further evaluation. The psychologist spends time talking with Mr Scott in order to establish the underlying cause/s of his depressive symptoms. They correlate very strongly with his feelings of inadequacy and hopelessness relating to incontinence. Withdrawl from social activities and lack of confidence associated with bladder issues. Mr Scott does not want to take medication. Both you and the psychologist are confident that with improvement of his incontinence, his depression may well improve and concur with Mr Scott’s decision to decline anti-depressant therapy.

When Mr Scott returns to see you 2 weeks after his previous visit you review the NCA’s report and concur that Mr Scott has overflow incontinence, primarily caused by urethral constriction due to benign prostatic hyperplasia.

The NCA report states that after one week of implementing the recommended voiding and behavioural strategies, Mr Scott’s nocturia had improved slightly but his voiding diary indicated that he was still experiencing urgency and frequency with occasional urinary incontinence. His PVR was 300 mL, a significant improvement.

Mr Scott reports that he is now only drinking one cup of coffee each day, has stopped drinking coke and alcohol and has increased his water intake. He feels that his bladder problems are still affecting his quality of life and although he feels more confident that he can avoid embarrassing situations by using the continence pads, he still avoids social outings where possible.

His pre meal finger prick glucose readings have ranged between 6.0 and 7.2. His 2 hour post meal readings have ranged between 8.6 and 10.6.

What treatment options will you consider for Mr Scott?

Click on each of the treatment option/s that you might consider to obtain feedback.

Finasteride is an Alpha-reductase inhibitor, which inhibits the production of dihydrotestosterone (DHT) from testosterone (a hormone involved in prostate enlargement). The medication may stop the prostate from growing further or, in some cases, cause it to shrink. Benefits can include reduction of urinary retention and avoiding the need for surgery. However it is only subsidised for use third line treatment (surgery and other drug therapies need to have failed or be contraindicated). It would not be recommended at this stage for Mr Scott.

Correct. This would be the best treatment option for Mr Scott at this stage. Alpha blockers such as prazosin relax the smooth muscle of the prostate and bladder neck, which allows urine to flow more easily. Alpha-adrenergic antagonists provide immediate benefits and are usually recommended as a first-line treatment for men with mild to moderate symptoms.

This could be considered, but most primary care providers would seek to manage Mr Scott’s diabetes within their own multidisciplinary team.

TURP involves removing the prostate in small pieces. Removing part of the prostate gland stops it from pressing on the urethra. TUPR is an invasive procedure and can have adverse side effects. It would not be recommended as a first line treatment in Mr Scott’s case.

Cystoscopy is an investigation which enables the doctor to look inside the bladder and the urethra. This procedure can help identify stones, bleeding, tumours and structural abnormalities. It is an invasive procedure and is probably not indicated at this time in Mr Scott’s case. It would be considered if he fails to improve with conservative management.

The lipophilic extract of the Saw Palmetto (serenoa repens) berries is the most widely used herbal preventive and therapeutic agent for benign prostatic hyperplasia (BPH). In clinical studies, saw palmetto extract has been shown to reduce subjective micturition symptoms, improve urinary outflow and reduce volume of residual urine with few adverse effects. While popular in the USA, Canada and Europe, recent studies have questioned its efficacy. While it may do Mr Scott no harm to try it, it may not be the most ideal treatment option to alleviate his symptoms.

Bent S et al. (2006) Saw palmetto for benign prostatic hypertrophy New England Journal of Medicine. 2006;354:557-566
URL: content.nejm.org

You decide that conservative management may be the best way to approach Mr Scott’s overflow continence problem and you recommend that he commence prazosin 05mg daily and advise that he make an appointment to see you in one month.

Mr Scott will continue regular appointments with the nurse continence advisor, who will monitor his PVR. The aim is to reduce Mr Scott’s PVR to <200ml consistently and to reduce his experience of nocturia.

If Mr Scott’s PVR cannot be reduced to <200ml, he will be referred to a urologist for further investigation, most likely a cystoscopy in order to evaluate the need for surgery should he have co-existent pathologies (eg. urethral stricture, bladder neck contracture).

Mr Scott returns to see you one month later, accompanied by his wife. He is feeling more rested and is happier and more confident than he has felt in a long time. He occasionally has to get up once in the night to go to the toilet, but is not experiencing frequent nocturia. He says that if only his wife didn’t get up so many times each night, he’d be sleeping like a baby! He is no longer feeling depressed.

The NCA has reported consistently low PVR of less than <200ml. He is still practising double voiding and hasn’t had any major instances of incontinence since beginning medication. He does report occasional dribbling, but is not so concerned about this as he still uses the pads recommended by the NCA, just in case. His increase in confidence and self esteem mean that he has resumed his regular social activities, including singing and playing golf.

As a long term management plan you recommend that Mr Scott continue to take prazosin 0.5mg bd – before food.

You are concerned about why Mrs Scott is getting up so frequently in the night, so you ask her to come back and see you so you can investigate this further.

Module 2

Mrs Veronica Scott is a 75 year old woman. Her husband has reported that she gets up many times throughout the night to use the toilet. You feel that this requires further investigation.

Review Mrs Scott’s history through the links below before moving on to her assessments.

History of Presenting Complaint
Medical History
Medication History
Social History

Mrs Scott recently raised concerns regarding her husband’s toileting habits, sparked mostly by her concern that he had withdrawn from regular social activities that he had previously enjoyed. She felt he was depressed. Mr Scott’s overflow incontinence is being successfully managed with prazosin and his symptoms of both incontinence and depression have significantly improved.

You now suspect that Mrs Scott may also be experiencing nocturia and probable incontinence. It is possible that she was so concerned for her husband that she downplayed her own problems.

Mrs Scott has osteoarthritis affecting her hips, knees, ankles, wrists and shoulders. She mobilises slowly and frequently relies on Mr Scott to help her getting up from sitting.

Mrs Scott had a hysterectomy at age 47 and has had numerous UTI’s over the last few years.

Mrs Scott is currently taking paracetamol, as needed, for her arthritic pain.

Mrs Scott enjoys swimming, water aerobics, walking, gentle weights and hatha yoga, all of which she says helps her arthritis, but she has been participating in the water sports less frequently over the last few months. She loves to sing.

Mrs Scott has a family history of osteoporosis and bowel cancer.

Patient Interview

Physical Assessment

Based on the information obtained during your discussion with Mrs Scott and through physical examination, what would you identify as possible transient causes of incontinence?

Click on the factors you feel are relevant to obtain feedback. There are four possibilities. Can you guess which ones are most likely?

Constipation and stool impaction
Fluid intake
Arthritis
Depression
UTI
Atrophic changes in perivaginal and periurethral tissues

Mrs Scott has reported no experience of constipation, so this is an unlikely contributory transient factor in this case.

Mrs Scott restricts her fluid intake in the hope of avoiding potentially embarrassing incontinence in public. She drinks three cups of tea each day and very little water. Caffeine has both a diuretic and irritative effect on the bladder. In addition, inadequate fluid intake causes very concentrated urine which can further irritate the bladder. Inadequate fluid intake could therefore be a contributory factor.

Mrs Scott has restricted mobility on account of arthritis and often needs help getting up from a chair. She often doesn’t make it to the toilet on time as she can’t get there quick enough and has fallen several times in the night because of this. Her arthritis is a probable contributory factor in her incontinence.

Mrs Scott reports sleeplessness, but otherwise does not appear overly concerned about the symptoms she is experiencing. She still participates in most of her usual activities and does not appear to be depressed. This is unlikely to be a transient factor in her incontinence.

In elderly women, oestrogen reduction leads to atrophy of the genitourinary tract resulting in poor bladder tone, urinary dysfunction and depletion in normal vaginal flora, all of which increase the risk of UTI. Mrs Scott reports experiencing quite severe symptoms, so UTI is definitely a possible transient factor in this case.

Post-menopausal atrophic changes in genital tissues due to lack of oestrogen can cause the vaginal epithelium to become inflamed, contributing to urinary symptoms such as frequency, urgency, dysuria, incontinence, and/or recurrent infections. Atrophy in periurethral tissues can contribute to pelvic laxity and stress incontinence and changes in vaginal pH and vaginal flora may predispose post-menopausal women to urinary tract infection. This is therefore a possible transient cause of Mrs Scott’s incontinence.

Request further laboratory tests to help determine the cause of incontinence, buy clicking on the tabs below.

Review results before proceeding.

On request, Mrs Scott voided 250ml of dark yellow, cloudy urine, which proved to be positive for nitrites, blood and leukocytes on dipstick testing. Urine culture and sensitivity test showed the presence of psuedonomas. Her PVR was measured by ultrasound and was 70ml (normal range PVR < 50ml).

Na 142 mmol/L (normal range 134-146 mmol/L)

K 4.5 mmol/L (normal range 3.4-5.0 mmol/L)

Urea 6.2 mmol/L (normal range 3.0-8.0 mmol/L)

Cr 68 µmol/L (normal range 50-95 µmol/l for adult females)

Mrs Scott may be interested in her cholesterol level as part of a general health assessment , but it is not mandatory in the investigation of incontinence. Her total fasting cholesterol is normal, 4.3mmol/L.

Is it possible that Mrs Scott is dehydrated due to inadequate fluid intake and could therefore be experiencing orthostatic hypotension, which could be a contributory factor in her falls. Mrs Scott’s blood pressure is 115/85 when lying and 90/75 standing (with mild associated dizziness).

As Mrs Scott is experiencing regular falls and has a family history of osteoporosis, you feel it is relevant to investigate her fracture risk by measuring bone density. Thankfully, Mrs Scott's results were within normal range: results at hip (femoral neck): T = 0; Z = -0.5, and spine T=-0.5 Z=1 (normal range T score >= -1; normal range Z score between -2 and +2).

Even though Mrs Scott seems to be coping well with her symptoms of urinary incontinence, you feel it may still be appropriate to administer the GDS to be sure. She scores 2/15 on the GDS indicating that she is unlikely to be depressed (a score higher than 5 indicates possible depression).

Based on the patient history and physical examination, answer the following questions:

You arrange for Mrs Scott to attend for a follow up visit in two weeks, to discuss results of her referrals and investigations. What will you advise in the meantime?

Click on each of those you feel is relevant to obtain feedback.

Reduce caffeine intake and increase intake of water to at least six glasses per day
Prescribe oxybutynin 5mg at bedtime
Treat UTI
Prescribe oestrogen cream
Treat and prevent further excoriation of perineum

You explain the diuretic and irritating effects on the bladder of caffeine and the damaging effect that inadequate fluid intake can have on the bladder. You advise Mrs Scott to slowly reduce her intake of tea by gradually replacing it with caffeine free or herbal tea and to increase her intake of water to at least 6 glasses per day. However, you do suggest that she not drink too much after 6pm, in order to help alleviate nocturia.

Oxybutynin is an anticholinergic agent used to relieve urinary and bladder difficulties, including frequency of urination and nocturia. This may be indicated for Mrs Scott because of nocturia and urge incontinence. However, it may be preferable to try non-pharmacologic management first.

Mrs Scott’s MSU was positive for Pseudomonas aeruginosa, which is resistant to many of the antibiotics commonly prescribed for UTI. Fortunately, she is sensitive to ciprofloxacin, which you prescribe. You must ensure her symptoms have resolved and preferably a proof of clear urinalysis.

You prescribe an estrogen cream to address the atrophic changes in perivaginal and periurethral areas and instruct Mrs Scott on how to use this correctly, although the evidence suggests this is less likely to assist with incontinence, it will likely assist with reduction in number of urinary tract infections as well as a reduction in discomfort in the area.

Mrs Scott has been using feminine hygiene products instead of the more appropriate incontinence containment products. As a result of prolonged exposure of urine with the sensitive skin of the perineum, it has become excoriated. You advise Mrs Scott to stop using the feminine hygiene products and to buy specific continence products instead. You suggest that the NCA will be able to help her select the most appropriate product for her needs.

In the meantime, to manage the excoriation, you advise Mrs Scott to wash the area after each episode of incontinence with a soap free gentle cleanser and pat dry. A barrier cream should be applied to protect the skin while it heals.

Multidisciplinary Assessment and Management

Mrs Scott may also benefit from being assessed by a multidisciplinary team.

Click below on the specialists you would refer Mrs Scott to in order to obtain the results of each review

Referral necessary to ensure Mrs Scott’s home environment is conducive to allowing her to mobilise safely and adequately. Also, assess any other fall risk factors that may be present in or around the home and make recommendations regarding necessary modifications.

Click here to see occupational therapy assessment and management plan.

Surgical review not indicated at this time.

Referral requires for arthritis management, pain assessment (determine ability to mobilise safely and adequately) and falls assessment. Also, pelvic floor exercises. Assess and provide treatment plan for managing pain and stiffness due to arthritis.

Click below to see physiotherapy assessment and management plans for:

Urotherapy/Continence Management
Arthritis Management
Falls Assessment

The NCA agreed that it is worthwhile trying non-pharmacological treatments first, to try to alleviate Mrs Scott’s episodes of incontinence. If this proves difficult, a prescription of low dose oxybutynin may be indicated.

Mrs Scott has been restricting her fluids intake to reduce the risk of incontinence. Unfortunately this has had the opposite effect by causing her bladder to become irritated. The NCA thus advised her to increase her fluid consumption, especially water, to 6-8 cups per day. In addition, introduction of caffeine free tea or herbal tea will eliminate the diuretic and bladder irritating effects of caffeine. In avoid to avoid nocturia, I suggest that Mrs Scott does not drink large quantities of fluid after dinner.

Mrs Scott was shown how to correctly apply her oestrogen cream. She does not need to use the applicator as only a small pea sized amount is to be applied around the urethra.

She has been shown how to do the pelvic floor exercises to strengthen her pelvic floor and at present has had no difficulty in learning these techniques. She will have a follow-up appointment with the physiotherapist for further advice on pelvic floor rehabilitation and I will recommend that the physiotherapist check on Mrs Scott’s technique for performing the exercises to ensure that she is performing them correctly.

Use of appropriate containment products was discussed with Mrs Scott and she has taken a few different samples to try. She is aware that she needs to change the pad after each episode of incontinence, to clean and dry the area and apply a barrier cream.

In regards to persistent UTI’s, Mrs Scott is commencing twice daily cranberry 400mg capsules.

In terms of further management of her urge incontinence, Mrs Scott has agreed to try timed voiding.

Mrs Scott scored only 2/15 on the GDS and is showing no significant signs of distress or depression, so referral to a psychologist is not recommended at this time.

At present Mrs Scott is taking paracetamol 1g as needed, but is not experiencing significant relief from arthritic pain. She has no previous history of heart disease, high blood pressure, diabetes, stomach ulcers, asthma, gastrointestinal disorders, kidney disease or liver disease, so it is reasonable to consider celecoxib 100mg bd prn. This may help to reduce pain and inflammation associated with arthritis. However regular paracetamol is the first line therapy recommended.

Mrs Scott may benefit from the introduction of fish oil in her diet as there is some evidence that this effects the inflammatory process and can result improving pain and stiffness. Mrs Scott may also benefit from non-pharmacological methods for managing arthritis. Mrs Scott has a BMI of 28, indicating that her weight exceeds the healthy weight range for her height. Being overweight is likely to be contributing to her worsening arthritic pain. Eating a healthy, balanced diet and maintaining regular physical activity will be crucial in facilitating weight loss. Acupuncture and massage may also be worth exploring as natural pain relief methods.

With a height of 168cm and weight of 76kg, Mrs Scott’s BMI is 28, indicating that she is overweight. Weight reduction is likely to have a significant impact on her experience of arthritic pain. I have asked her to keep a two week food diary and to see me again at the end of this period to discuss any necessary dietary changes.

After examining Mrs Scott’s food diary, it is apparent that there is certainly some room for improvement. At present she is having a cooked breakfast every second day and toasted muesli and/or a croissant every other day. These foods are high in fat and sugar. I have advised Mrs Scott to convert to natural muesli with fresh fruit and yoghurt, rather than the toasted variety. A cooked breakfast once per week is acceptable, but portion size needs to be reduced.

I have advised Mrs Scott to gradually replace sweet biscuits and cakes with fresh fruit, nuts, yoghurt, and other healthy and/or wholegrain snacks. Soups, salads and sandwiches make excellent easy lunches, but she needs to be careful with luncheon meats, dressings, cream and mayonnaise.

Adequate dairy intake is essential for Mrs Scott given her family history of osteoporosis, restricted mobility and experience of recent falls. She should ideally have three serves of dairy each day, including low fat milk, yoghurt and cheeses such as ricotta or cottage. Oily fish with bones will also provide extra calcium.

The Scott’s presently eat too much red meat and very little fish. I have advised them to increase the level of omega 3 fatty acid in their diet by eating at least three fish meals per week for health and to aid in arthritic pain relief. Red meat is fine 1-2 times per week but the portion size should not exceed 100g (palm size). A variety of fresh, raw or slightly cooked vegetables and low GI carbohydrates are also essential.

Mr and Mrs Scott eat out regularly with friends and we have discussed healthy food choices. Portion size is also an issue for Mrs Scott and we have talked about alternatives, such as ordering an entrée size pasta and green salad.

Mrs Scott plans to maintain her regular exercise regime and with improvement in her symptoms of incontinence, will be more comfortable taking up regular swimming and water aerobics again.

You see Mr and Mrs Scott 3 months later for a routine check up.

Mrs Scott’s UTI was successfully treated with antibiotics and she has since been taking daily cranberry tablets, with no recurrence of symptoms. She has also altered her fluid intake and now drinks 8 glasses of water per day and 3 cups of herbal tea. She occasionally has a coffee if out with friends. She practices the Kegel exercises a couple of times per day and the physiotherapist reports that her pelvic floor has strengthened significantly. The oestrogen cream appears to have had a positive effect on the perivaginal and periourethral atrophy and she no longer has excoriated skin around the perineum. As a result of these interventions, Mrs Scott’s bladder problems have responded very well to conservative treatment. She sleeps through the night on most occasions and hasn’t fallen in 7 weeks. The physiotherapy exercises have significantly improved her arthritic pain and she is mobilising easier than before but still requires help occasionally.

Mrs Scott has also managed to lose 4kg in the last 3 months and plans to lose 5 more to reach her goal weight. Both her and Mr Scott have responded well to the dietary changes and are feeling healthier and more energetic as a result. Mrs Scott reports that her arthritic pain has lessened after changing her medication and diet, losing weight and also through the exercises prescribed by the physiotherapist.

Mr Scott’s urological medications are effective in managing his incontinence and his kidney function continues to be within normal range, although you continue to monitor this regularly. His PVR continues to be less than 160mL and he is feeling more comfortable and more confident than he has in quite some time.

Both Mr and Mrs Scott are able to participate in all of the social, artistic and sporting activities that they enjoy.

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