A 61-year-old postmenopausal woman comes to the office due to leakage of urine. The patient reports increased urinary frequency and voids 1 or 2 times per hour. She often awakens at night with an immediate need to void and occasionally does not make it to the bathroom in time.
The patient has mild intermittent asthma controlled with an albuterol inhaler. Her other medications include low-dose aspirin and a multivitamin. She had 2 cesarean deliveries, the last of which was complicated by a venous thromboembolism after delivery.
Vital signs are normal. BMI is 27 kg/m². Pelvic examination reveals a thin, atrophic vagina. Cough stress test is negative and postvoid residual volume is 65 mL. Urinalysis and urine culture are normal.
Which of the following is the best next step in management of this patient?

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Quizplus · Accepted Answer

11ec193a_97ea_6117_853d_257c73b6da83_MD0002_00 Urgency incontinence presents with the frequent, sudden need to urinate followed by immediate loss of urine. Patients typically have urinary frequency, urgency, and nocturia secondary to increased detrusor contractility during bladder filling (ie, overactive bladder). Risk factors include older age, neurologic injury, and chronic bacteriuria. Lifestyle modifications are encouraged and include weight loss, avoiding bladder irritants (eg, alcohol, caffeine), and smoking cessation. Bladder training involves a voiding diary and timed voiding, followed by a slow increase in intervals between voids to minimize leaking. Behavioral therapy with pelvic floor (Kegel) exercises and relaxation techniques help overcome urgency symptoms between voids. These techniques retrain the bladder by minimizing involuntary detrusor contractions and allowing a slow increase in bladder capacity. Antimuscarinics (eg, oxybutynin, tolterodine) or beta-3 agonists (eg, mirabegron) are used if urgency symptoms persist despite conservative therapy. (Choices B and C) Stress urinary incontinence presents with leakage of urine with Valsalva maneuver (eg, coughing, sneezing) and a positive cough stress test. Lifestyle modifications, pelvic floor exercises, and pessary placement are first-line treatments. Midurethral sling placement is performed for patients who have incomplete relief from first-line therapies. (Choice D) A transdermal (systemic) estrogen patch provides vasomotor symptom relief (eg, hot flashes, night sweats) in postmenopausal women but can worsen urinary incontinence. The patient's prior thromboembolism contraindicates systemic estrogen use. This patient's vaginal atrophy can be treated with vaginal estrogen, which has limited systemic absorption. (Choice E) Urodynamic testing is helpful with complicated stress or mixed incontinence, overflow incontinence, and in preoperative evaluation. Educational objective: Lifestyle modifications and behavioral therapy (eg, pelvic muscle exercises, bladder training) are first-line treatments for urgency incontinence. Keeping a voiding diary, scheduling bladder emptying, and slowly increasing the time between voids can be an effective therapy for urgency incontinence. If first-line treatments fail, pharmacologic therapy (eg, antimuscarinics, beta-3 agonists) is initiated. __________ References: Urinary incontinence in women. (http://www.ncbi.nlm.nih.gov/pubmed/28681849)

A 61-Year-Old Postmenopausal Woman Comes to the Office Due to Leakage