Clinical approach to urinary incontinence: a comparison between internists and geriatricians.

To compare the initial approach and pattern of practice between internists and geriatricians in treating urinary incontinence. A retrospective chart review of 300 consecutive charts of elderly patients over the age of 65, seen by either internists (IM) or Geriatricians (GERI) for urinary incontinence at the Cleveland Clinic Florida was performed. The clinical approaches to the management of urinary incontinence were compared between IM and GERI groups by using a Student's t test. The mean age for these patients was 77 y for the IM group and 79 y for the GERI group. Majority of patients suffered from two chronic illnesses. We found that geriatricians performed more initial work up such as urodynamic testing before referring, while internists obtained more referrals to gynecologist with special interest in urologic disorders (currently called urogynecologist) without initial workup. IM and GERI groups equally prescribed medications for incontinence. However, the GERI group recommended Kegel exercises more frequently. This study showed that geriatricians manage urinary incontinence more extensively by performing more initial work up including urodynamics and providing initial behavioral therapy (Kegel exercise and toilet schedule) before referring to specialists. Perhaps geriatricians feel more comfortable treating urinary incontinence as shown by their lower frequency of referrals and are therefore more comfortable than internists at addressing this medical issue. On the contrary, the internist did the initial evaluation but preferred to get a referral perhaps due to less familiarity with urinary incontinence.

Leg edema: clinical clues to the differential diagnosis.

Leg edema is a common problem in older patients, with a wide range of possible causes. The diagnosis can be narrowed by categorizing the edema according to its duration (acute or chronic), distribution (unilateral or bilateral), and accompanying symptoms (such as dyspnea, pain, thickening of skin, and pigmentation). The differential diagnosis includes systemic illnesses such as heart failure, liver disease, malnutrition, and thyroid disorder; local conditions such as pelvic tumors, infection,, trauma, and venous thrombosis; and various medications known to increase the risk of edema of the lower extremities. Appropriate therapy is based on the presentation of edema and its identified cause.