Station 79
Racheal Thompson
Age: 45 year old female
Full Case
Patient’s Data
Patient’s Name: Racheal Thompson
Age: 45-year-old female
Past Medical History:
- None recorded
- Normal cervical smear 2 months ago ; next screening is scheduled as per routine interval.
Drug and Allergy History:
- Not currently on any medication
- No know drug allergy
Recent consultation
- No recent consultations recorded
Patient booked routine video appointment to discuss some concerns.
Patient's Story (Role player’s brief)
Patient’s Story
Opening Statement: “Hi doctor, I’ve been having some trouble with leaking urine, and it’s been going on for years now, but it’s gotten worse recently and it’s really starting to affect my life.”
You are Racheal, a 45-year-old woman attending a video consultation to discuss urinary incontinence that started after the birth of your only child, seven (7) years ago. The delivery was via forceps. Initially, you experienced occasional urine leakage with coughing or sneezing, which you managed without seeking medical advice.
Over the last four months, however, the symptoms have become more bothersome. The leakage has become more frequent, and you now wear urinary pads all the time.
More recently (last 2-3 months), you’ve developed a frequent and urgent need to pass urine, and sometimes you don’t make it to the toilet in time. However, these are less frequent than the leakage that occurs with physical movement like coughing or sneezing.
If asked which type of leakage occurs most often, say: “It’s usually when I cough or sneeze”
You’ve started sitting closer to the toilet at work out of fear of having an accident. You now actively avoid sex with your partner because you’re worried you might experience urine leakage during intercourse. This has affected your confidence and your relationship, even though your partner is supportive.
You have no dragging sensation down below.
Social History: You live with your husband. You do not smoke or drink alcohol, and you avoid caffeine. You’ve been restricting your water intake in an attempt to control your symptoms, but this seems to have made things worse.
Your periods are regular (last menstrual period 2 weeks ago), and you’re not on any contraception, as your husband had a vasectomy. Your bowels are normal.
You have not seen a doctor about this before, but you now feel overwhelmed and frustrated. It’s starting to affect your quality of life, and you’ve reached the point where you want help.
Say no to any other symptoms asked.
Ideas: You wonder if you may have a prolapse from your delivery and think this might be causing your symptoms.
Concerns: You’re worried that you may have to wear urinary pads for the rest of your life.
Expectations: You hope the doctor can help explain what’s going on and offer treatment or support so you can regain control of your life.
Say NO to any other questions asked outside of the details already provided in the scenario. Accept anything offered to you by the doctor.
Marking Scheme
Data Gathering and Diagnosis
- Ask when the patient first began experiencing urinary incontinence.
- Ask if the incontinence occurs when she coughs, sneezes, laughs, or does any strenuous activity (to assess for stress incontinence).
- Ask if she often experiences a sudden, strong urge to urinate and sometimes leaks before reaching the toilet (to assess for urge incontinence).
- Ask which of the two types (stress or urge incontinence) is more troublesome for her. Example phrasing: “Racheal, to better understand how we can help you, could you tell me which type affects you more: the leakage with coughing or movement (stress incontinence), or the sudden urgency with occasional accidents (urge incontinence)?”
- Ask about other urinary symptoms: including nocturia, dysuria, haematuria
- Ask about associated lower abdominal or bladder pain.
- Ask if she has noticed a sensation of heaviness, dragging, or pressure in the vaginal area (to assess for prolapse).
- Ask if she has recurrent urinary tract infections.
- Ask about bowel habits, particularly constipation, as chronic constipation can contribute to incontinence.
- Ask about her menstrual cycle and whether she uses any contraception.
- Signpost before asking personal questions: Ask about vaginal discharge, ask if she is sexually active and whether she experiences pain during intercourse (dyspareunia), which may suggest vaginal dryness
- Ask about her gynaecological history, including number and type of deliveries (especially vaginal or forceps-assisted).
- Ask about her fluid intake and whether she has been restricting fluids due to incontinence.
- Ask about caffeine consumption.
- Ask about possible diabetes symptoms such as increased thirst, frequent urination, or weight changes.
- Ask how the incontinence has impacted her life: has it disrupted her sleep (if nocturia)? has it affected her confidence, intimacy, or self-esteem?
- Ask about her smoking history (as smoking can contribute to chronic cough and worsen incontinence or prolapse).
- Ask what coping strategies she has used so far (e.g. wearing pads).
- Give a diagnosis of mixed urinary incontinence.
Example of explanation to patient
Thanks for sharing all of that with me, Racheal. I can really see how much this has been affecting you, both physically and emotionally.
From everything you’ve described, it sounds like you’re experiencing what we call mixed urinary incontinence, which means there’s a combination of stress incontinence, where leakage happens when you cough or sneeze, and urge incontinence, where you sometimes can’t get to the toilet in time once you feel the need to go.
You mentioned you’re worried this might be caused by a prolapse due to your forceps delivery. That’s a very reasonable thought. However, from everything you’ve described so far, your symptoms don’t sound typical of a prolapse. Women with prolapse often report a feeling of heaviness, pressure, or a dragging sensation down below (in the vagina). Some even describe it as feeling like something is ‘coming down.’ You’ve not mentioned any of those symptoms, which is reassuring. However, I completely understand your concerns, especially with your history of a forceps delivery, so we’ll still arrange a face-to-face examination to check everything properly and rule it out.
Does that sound okay to you?
In terms of your concerns about having to wear pads for the rest of your life, I want to reassure you that many women see real improvement or even complete resolution of their symptoms with the right support. This includes things like pelvic floor physiotherapy, which we can arrange for you through a specialist team. The pads are a short-term solution to help you stay comfortable and confident while we start proper treatment.
You also mentioned avoiding intimacy because of the fear of leakage. That’s completely understandable. We can also look at additional support, like referral to a relationship/sexual therapist, if you feel that would help rebuild confidence and improve communication with your partner.
And just so you know, the bladder doesn’t like being dehydrated, not drinking enough can make the symptoms worse, so we’ll talk about finding the right fluid balance too.
Racheal, one helpful step is to keep a bladder diary for the next three days. Just note down what you drink, how often and how much you pass urine, any leaks you experience, what you were doing at the time, and whether you used a pad and how wet it was. This will help us understand your symptoms better and guide the right treatment for you. Is this something you are happy to do?
Management
Management
- Offer a face-to-face consultation to allow for pelvic examination, including per vaginal (PV) assessment, urinalysis, and urine culture.
- Advise the patient to keep a bladder diary for at least 3 days. This should include fluid intake, frequency and timing of incontinence episodes and type of leakage (stress or urge)
- As stress incontinence appears to be the predominant issue, offer referral to the pelvic floor physiotherapist or via the local bladder and bowel service for supervised pelvic floor muscle training for 3 months.
- Reassure the patient that long-term pad use is not always the case for most women. With appropriate pelvic floor exercises and the right support, many women experience significant improvement of their symptoms. The pads are just a short-term support, while we work together to manage and reduce the incontinence.
- Emphasise the importance of adequate fluid intake. Explain that reducing fluid can worsen symptoms by causing concentrated urine, which irritates the bladder and increases urgency.
- Acknowledge the emotional and relational impact. Suggest that open communication with her partner may help reduce anxiety and improve intimacy. Consider referral to sexual health/relationship counselling if appropriate.
- If emotional distress or embarrassment is leading to low mood or avoidance behaviour, consider offering or signposting to CBT (Cognitive Behavioural Therapy).
- Recommend that she may also want to discuss her situation with her HR (human resources) department for possible workplace adjustments, such as easy access to toilets, flexible breaks or more private workspace if possible
- Safety net: advise to seek urgent review if she develops new symptoms such as haematuria, pain during urination, fever, or significant worsening of incontinence.
- Arrange a review in 3 months to assess symptom progression and response to pelvic floor training.
Learning point from this station:
Urinary incontinence is defined as any involuntary leakage of urine. It is broadly categorised into three main types:
- Stress urinary incontinence (SUI): Leakage during physical exertion, such as coughing, sneezing, or exercising.
- Urgency urinary incontinence (UUI): Leakage accompanied or immediately preceded by a sudden, strong urge to pass urine. It is often associated with overactive bladder (OAB), which includes symptoms of urgency, frequency, and nocturia.
- Mixed urinary incontinence: A combination of both stress and urgency symptoms.
When a patient has mixed urinary incontinence, it’s important to first identify which type of leakage is more frequent or has the greatest impact on their daily life. Management should then be directed at the dominant type. For example, if stress incontinence is more prominent, pelvic floor muscle training would be the first-line treatment. If urgency symptoms are more troublesome, bladder retraining and anticholinergic medications may be more appropriate. If the patient is unsure, a bladder diary should be advised. This diary should record fluid intake, episodes of urgency, stress leakage, frequency of voiding, and any incontinence episodes over a few days. It can help both the patient and clinician better understand the pattern and severity of symptoms, guiding targeted treatment.