How to manage a patient with urinary incontinence, alcohol use disorder, and complex medical history including stage 3a chronic kidney disease?

Management of Urinary Incontinence in a Patient with Alcohol Use Disorder and Complex Comorbidities

This patient requires bladder training as first-line therapy for urgency incontinence, with urology referral granted for specialized assessment given his complex medical history, post-stroke status, and refractory symptoms. 1, 2

Immediate Assessment Priorities

Rule Out Reversible Causes

• Obtain urinalysis and urine culture immediately to exclude urinary tract infection, which occurs in 19% of stroke patients and significantly worsens functional outcomes 1
• Review current medications for contributors: metoprolol, gabapentin, and acetaminophen are unlikely culprits, but the combination of multiple antihypertensives may contribute to urgency 2
• Check post-void residual (PVR) to rule out overflow incontinence—if PVR >100 mL, this changes management entirely 2
• The patient's glucose of 118 mg/dL (prediabetes) and absence of dysuria make glycosuria-related polyuria less likely but should be monitored 2

Critical Cognitive Assessment

Screen for cognitive impairment urgently—the patient reports memory difficulties and post-stroke status places him at high risk for vascular dementia, which interferes with medication compliance and self-management strategies 2, 1. His inability to recall hospitalization details is concerning and may explain why incontinence worsens with alcohol intoxication (impaired awareness/mobility).

Classification of Incontinence Type

Based on presentation:

• Urgency incontinence is most likely—episodes occur with intoxication (reduced awareness/mobility), no dysuria, and symptoms began post-stroke 1, 2
• Post-stroke urinary incontinence affects 40-60% of admitted patients, with 25% still incontinent at discharge 1
• Complete bladder emptying with no control suggests urgency rather than overflow 2

First-Line Treatment Algorithm

1. Bladder Training (Highest Priority)

Implement bladder training immediately—this is the strongest evidence-based first-line treatment for urgency incontinence with high-quality evidence 1, 2. This includes:

• Scheduled voiding every 2-3 hours while awake, gradually extending intervals 1
• Urge suppression techniques (distraction, pelvic floor contraction) 1
• Fluid restriction starting 1 hour before bedtime 3

2. Lifestyle Modifications

• Alcohol cessation counseling must be repeated—alcohol directly impairs bladder control and the patient acknowledges symptoms worsen with intoxication 2
• The patient declined cessation, but document repeated counseling and offer resources at every visit 2
• Weight optimization if BMI elevated (not provided in labs but recommended for all incontinent patients) 1, 3

3. Behavioral Strategies for Stroke Patients

Implement timed voiding protocols specific to post-stroke patients—use behavioral strategies including scheduled toileting every 2-4 hours to prevent urgency episodes 1. The patient's cognitive difficulties and alcohol use make adherence challenging, which is why family involvement would be beneficial despite his resistance 1.

Urology Referral Decision

Grant the urology referral—this patient meets multiple criteria for specialty evaluation: 1

• Post-stroke incontinence persisting beyond acute phase
• Complex medical history including CKD stage 3a (eGFR 66)
• Potential need for specialized interventions if first-line therapy fails
• Abnormal coagulation (INR 1.9, aPTT 47) requires investigation—he is on clopidogrel but these values suggest additional coagulopathy that needs evaluation before any invasive procedures 1

Pharmacologic Therapy Considerations

Do NOT initiate antimuscarinic therapy yet—bladder training must be attempted first per guidelines 1, 2. However, if bladder training fails after 4-8 weeks:

Preferred Agents (if needed)

• Tolterodine or solifenacin are preferred over oxybutynin due to lower discontinuation rates from adverse effects 2
• Major concern: antimuscarinic adverse effects in this patient—dry mouth, constipation, cognitive impairment are poorly tolerated in elderly patients, especially those with baseline cognitive issues and post-stroke status 2

Critical Contraindications

• Avoid antimuscarinics if cognitive screening reveals impairment—these medications worsen cognition and may precipitate delirium in vulnerable patients 2
• His elevated aPTT (47 seconds) and INR (1.9) need investigation before considering any medications that might increase bleeding risk 1

Laboratory Abnormalities Requiring Attention

Coagulation Abnormalities

The elevated INR (1.9) and aPTT (47) are concerning—he is on clopidogrel but not warfarin. Possible causes include:

• Hepatitis C with hepatic dysfunction (though bilirubin and alkaline phosphatase are normal)
• Alcohol-related coagulopathy
• This requires hematology evaluation before any invasive urologic procedures 1

Electrolyte Issues

• Potassium 3.4 mmol/L (low) on losartan-HCTZ—may contribute to urinary frequency. Consider potassium supplementation or switching to losartan alone 1
• Sodium bicarbonate 650 mg is appropriate for CKD stage 3a (CO2 20 mmol/L at lower limit) 1

Follow-Up Strategy

4-Week Reassessment

Schedule follow-up in 4 weeks to assess: 2

• Compliance with bladder training
• Frequency-volume chart completion (72-hour diary) 3
• Repeat cognitive screening if not done initially
• Laboratory follow-up: repeat INR/aPTT, potassium, urinalysis

8-Week Decision Point

If bladder training fails after 8 weeks of adherence: 2

• Initiate pharmacologic therapy with tolterodine or solifenacin (if cognitive screening normal)
• Consider posterior tibial nerve stimulation (PTNS) if patient willing to commit to weekly 30-minute office visits for 12 weeks 2

Critical Pitfalls to Avoid

1. Do not prescribe fluoroquinolones empirically—inappropriate in elderly patients with comorbidities and polypharmacy 3
2. Do not start antimuscarinics before attempting bladder training—violates evidence-based treatment hierarchy 1, 2
3. Do not ignore the coagulopathy—must be investigated before urologic procedures 1
4. Do not dismiss alcohol's role—symptoms worsen with intoxication, and continued heavy drinking will undermine all interventions 2
5. Do not overlook constipation risk—gabapentin, antimuscarinics (if prescribed), and alcohol all contribute. Constipation worsens incontinence 1

Addressing Family Involvement

Strongly encourage family engagement despite patient resistance—post-stroke patients with cognitive difficulties and substance use disorder have significantly better outcomes with caregiver support 1. Document his refusal but revisit this at each visit, emphasizing that family involvement improves treatment success rates.

Prognosis and Expectations

• 25% of post-stroke patients remain incontinent at discharge, 15% at one year 1
• Continued alcohol use significantly worsens prognosis—impairs cognition, mobility, and treatment adherence 2
• CKD stage 3a does not contraindicate standard incontinence treatments but requires dose adjustments for renally cleared medications 1