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Dawn Colomb-Lippa, PA-C; Amy Mercantini Klingler, MS, PA-C

Dawn Colomb-Lippa is Professor of Physician Assistant Studies at Quinnipiac University, Hamden, Connecticut. Amy Klingler practices in primary care at the Salmon River Clinic, Stanley, Idaho. The authors are department editors for the Quick Recertification Series and members of the JAAPA editorial board.

URINARY INCONTINENCE

GENERAL FEATURES

• Risk factors for women include childbearing, obesity, other urinary symptoms (urinary urgency, frequency), and functional and cognitive impairment (inability to appropriately access a bathroom).

• Risk factors for men include functional and cognitive impairment, neurologic disorders, and prostatectomy.

• Neurogenic bladder is especially common in patients with multiple sclerosis, diabetes, spinal cord injury, etc, and manifests with incontinence and a large postvoid residual urine volume.

• Overflow incontinence is dribbling or continuous leakage associated with urinary retention and bladder distention.

• Urge incontinence is involuntary loss of urine associated with a sudden, involuntary bladder contraction causing the abrupt need to void.

— Overactive bladder: a set of symptoms: urgency with or without urge incontinence; usually with frequency and nocturia

• Stress incontinence is involuntary leakage of urine with activity such as physical exercise, coughing, or sneezing.

• Mixed incontinence is a combination of the characteristics of both urge and stress incontinence.

• Functional incontinence is involuntary loss of urine due to a physical or mental impairment preventing the recognition of the need to urinate.

CLINICAL ASSESSMENT

• Review risk factors and obtain a detailed history to determine the type of incontinence.

DIAGNOSIS

• The physical examination should include functional assessment (gait evaluation, cognition); estrogen status; vaginal examination to assess for cystocele, rectocele, enterocele; assessment of pelvic floor strength; rectal tone to rule out neurologic deficit or constipation, both of which can contribute to incontinence, and bulbocavernosus reflex. A postvoid residual urine volume should be done to rule out incomplete voiding secondary to neurogenic bladder, outflow obstruction, etc.

• Laboratory tests should include urinalysis and culture, urine cytology (if tumor is a concern), BUN, and creatinine. Ultrasound or CT can rule out a mass sitting on the bladder.

TREATMENT

• Treatment is directed at the type and cause of incontinence:

— Urge incontinence: bladder relaxants (anticholinergics), biofeedback, pelvic floor exercises (Kegel exercises), timed voiding

— For purposes of the recertification exam, consider the use of estrogen in postmenopausal females. Bear in mind, however, that estrogens have very recently been shown to be of no benefit and may be counterproductive. (JAMA. 2005;293:935-948. JAMA. 2005;293:998-1001; Obstet Gynecol. 2005;106:940-945; Obstet Gynecol. 2008;111:667-677.)

— Stress incontinence: pelvic floor exercises, biofeedback, pessary devices, alpha-adrenergic agonists, timed voiding

— Overflow incontinence: the removal of obstructing lesions, bladder catheterization

— Functional incontinence: behavioral training, timed voiding, incontinence undergarments.

SARCOIDOSIS

GENERAL FEATURES

• Sarcoidosis is a chronic systemic granulomatous disease characterized histologically by the presence of nonspecific, noncaseating granulomas.

• The etiology is unknown.

• Patients at risk include all groups, but the disease is especially common in American blacks and women.

CLINICAL ASSESSMENT

• The history may uncover

— Fever, malaise, weight loss, fatigue, night sweats

— Respiratory complaints: shortness of breath, nonproductive cough

— Other systemic complaints: vision changes (corneal involvement), chest pain (lung involvement), arthralgias, facial paralysis, neurologic complaints (CNS involvement), GI complaints.

• The disease may be asymptomatic, diagnosed serendipitously by routine radiographs.

• Physical findings may include

— Palpable, tender lymph nodes (common)

— Lung crackles (uncommon, from associated pulmonary fibrosis)

— Extrapulmonary sites: skin, eyes, reticuloendothelial system, musculoskeletal system, exocrine glands, heart, kidneys, and CNS (most common)

— Skin lesions: erythema nodosum (erythematous nodules), lupus pernio (violaceous indurated nodules), infiltration of previous scars and tattoos

— Tender, swollen joints; muscles tender to palpation

— Hepatosplenomegaly

— Löfgren’s syndrome: fever, erythema nodosum, arthralgias, bilateral hilar lymphadenopathy.

DIAGNOSIS

• Clinical and radiographic manifestations should be compatible (enlarged intrathoracic lymph nodes, interstitial infiltrates, diffuse nodular infiltrates, lung fibrosis).

• Angiotensin-converting enzyme levels may be elevated.

• Abnormalities in creatinine, BUN, liver enzymes, creatine kinase-MB, and calcium are common.

• Chest film may show hilar adenopathy, pleural effusion, parenchymal disease.

• Arrhythmias are common (ventricular tachycardia, heart block).

• Definitive diagnosis is via lung biopsy.

TREATMENT

• Treatment may prolong the course and should be provided only when symptomatic disease—for example, dyspnea, worsening pulmonary fibrosis, CNS disease, eye disease—is limiting the patient. Do not treat the asymptomatic patient.

• Treatment consists of corticosteroids for 8 to 12 weeks (prednisone, 40 mg, then tapered).

• If disease is refractory to corticosteroids, methotrexate may be beneficial.

• NSAIDs may help musculoskeletal symptoms.

• Most patients will have spontaneous remission within 2 years. They can be followed with periodic assessments, chest radiographs, and pulmonary function tests. JAAPA

This Quick Recertification Series is not meant to replace in-depth studying for the recertification exam and should be used only as an adjunct. Furthermore, the information contained here may not be sufficient to provide diagnosis and treatment in the clinical setting.