Should an elderly woman with chronic constipation, abdominal bloating, excessive flatulence, and fatigue, currently taking 25mg of medication, discontinue her medication or start pelvic floor physical therapy?

Discontinue the Medication Immediately and Start Pelvic Floor Physical Therapy

This elderly woman's symptoms of constipation, bloating, flatulence, and fatigue are likely adverse effects from her 25mg medication (likely an antimuscarinic agent), and she should discontinue it while initiating pelvic floor physical therapy as first-line treatment.

Why Discontinue the Medication

The 25mg dosage strongly suggests an antimuscarinic medication (such as oxybutynin or tolterodine), which are commonly prescribed for urinary incontinence but have significant gastrointestinal side effects:

• Constipation is a well-documented adverse effect of antimuscarinic medications, along with dry mouth, heartburn, and urinary retention 1
• High discontinuation rates due to adverse effects occur with these medications, particularly oxybutynin (NNTH 16) and other antimuscarinics 1
• The American College of Physicians recommends against systemic pharmacologic therapy for stress urinary incontinence (strong recommendation, low-quality evidence) 1
• Constipation is specifically listed as a risk factor for pelvic floor dysfunction, creating a vicious cycle if medication-induced 1

Why Start Pelvic Floor Physical Therapy

The American College of Physicians provides strong recommendations for pelvic floor muscle training (PFMT) as first-line treatment:

• For stress UI: PFMT is recommended as first-line treatment (Grade: strong recommendation, high-quality evidence) 1
• For urgency UI: Bladder training is recommended (Grade: strong recommendation, moderate-quality evidence) 1
• For mixed UI: PFMT combined with bladder training (Grade: strong recommendation, moderate-quality evidence) 1

Evidence Supporting PFMT Effectiveness

• Women with stress UI in PFMT groups were 8 times more likely to report cure compared to no treatment (56% vs 6%; RR 8.38) 2
• Women were 6 times more likely to report cure or improvement (74% vs 11%; RR 6.33) 2
• PFMT reduced leakage episodes by approximately one per day (MD 1.23 lower) 2
• Long-term efficacy is maintained: 85% of elderly women showed improved or stable continence status at 5-year follow-up 3
• Adverse events are rare and minor when they do occur 2

Treatment Algorithm

Immediate Actions:

1. Discontinue the antimuscarinic medication to eliminate constipation and other gastrointestinal adverse effects 1
2. Refer to certified pelvic floor physical therapist for supervised PFMT program 1, 4

PFMT Program Structure:

• 8 sessions on average with a certified physiotherapist teaching repeated voluntary pelvic floor muscle contractions 1, 3
• Home exercise adherence is critical: patients should perform exercises 4-5 times per week 5
• Group-based PFMT is non-inferior and more cost-effective than individual sessions, with 95% attendance rates 5
• Biofeedback therapy improves symptoms in more than 70% of patients with defecatory disorders 1

If PFMT Fails After Adequate Trial:

• For urgency UI only: Consider reintroducing pharmacologic therapy, but choose agents with better tolerability profiles (solifenacin or tolterodine have lower discontinuation rates than oxybutynin) 1
• Base medication choice on tolerability, adverse effect profile, ease of use, and cost 1

Critical Caveats

Common pitfall: Continuing antimuscarinic medications despite gastrointestinal symptoms, which worsens constipation—itself a risk factor for pelvic floor dysfunction 1

Important consideration: The 15-year duration of symptoms suggests chronic pelvic floor dysfunction that requires comprehensive rehabilitation, not just symptom suppression with medications 1, 6

Defecatory disorder assessment: If constipation persists after medication discontinuation, consider anorectal testing and specialized biofeedback for defecatory disorders, which has >70% success rate 1

Weight management: If the patient is obese, weight loss and exercise should be added as they significantly improve symptoms 1, 4