A 54-year-old postmenopausal woman comes to the office due to involuntary loss of urine. The patient is unable to hold her urine during the day but has no loss of urine while sleeping. She is sexually active but has been avoiding intercourse for the past few months because she sometimes has leakage of urine during intercourse. The patient also loses urine when laughing and coughing. She has no chronic medical conditions and takes no daily medications. Her only surgery was a cesarean delivery at age 30 for a pregnancy complicated by pyelonephritis and preterm labor at 34 weeks gestation. Vital signs are normal, and BMI is 38 kg/m². Pelvic examination shows dribbling of urine when the patient coughs. A postvoid residual is 30 mL. Urinalysis shows no abnormalities. Which of the following is the most appropriate treatment for this patient's incontinence?

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Explanation: 11ec25c8_d9e5_41c6_bc81_2941c2456fc1_MD0003_00 This patient has stress urinary incontinence (SUI), an intermittent leakage of urine associated with increased intrabdominal pressure (eg, intercourse, coughing, laughing). Postmenopausal women are at increased risk for SUI due to: Weakened pelvic floor musculature (ie, levator ani) from chronic intraabdominal and pelvic strain; common etiologies include increasing parity (even in those who deliver by cesarean) and obesity Urogenital mucosa atrophy from decreased estrogen levels The pelvic floor musculature and urogenital mucosa normally work together to support the bladder and urethra; postmenopausal women have decreased function in both, resulting in an unsupported bladder and hypermobile urethra. In women with SUI, this results in the inability of the urethra to fully compress against the anterior vaginal wall during increased intraabdominal pressure and causes subsequent leakage of urine. Conservative management for SUI includes pelvic floor (Kegel) muscle exercises, which strengthen and stabilize the pelvic musculature. Those who do not improve with conservative management or who desire surgical management can undergo a midurethral sling procedure. The midurethral sling prevents urethral hypermobility and allows urethral compression, thereby treating SUI. (Choice A) Alpha blockers (eg, tamsulosin) are used in the treatment of overflow incontinence due to urethral blockage from benign prostatic hyperplasia in men. Alpha blockers increase urinary flow by relaxing the smooth muscle in the bladder neck and prostate. (Choice B) Oxybutynin (an antimuscarinic agent) promotes bladder relaxation in the treatment of urgency incontinence, which is characterized by the sudden urge to void followed by the immediate loss of urine. (Choices C and D) Cholinergic agonists (eg, bethanechol) and intermittent self-catheterization are used to treat overflow incontinence from chronic urinary retention or detrusor underactivity. Patients with overflow incontinence typically have constant urine dribbling (including at night) and an elevated postvoid residual volume. Cholinergic agonists improve overflow incontinence by stimulating muscarinic receptors, thereby increasing bladder contractility and promoting bladder emptying. (Choice F) Postcoital antibiotics may be used in patients with recurrent urinary tract infections (UTIs) (≥2 within 6 months). Postmenopausal women are at increased risk for recurrent UTI due to vulvovaginal atrophy; however, this diagnosis is unlikely in this patient because the urinalysis is normal. Educational objective: Stress urinary incontinence typically presents with leakage of urine with increased intraabdominal pressure (eg, intercourse). It is common in postmenopausal women due to a weakened pelvic floor musculature and urogenital mucosa atrophy. Treatment includes pelvic floor muscle exercises or surgical midurethral sling placement. References: Urinary incontinence in women: a review. (http://www.ncbi.nlm.nih.gov/pubmed/29067433) Mid-urethral sling operations for stress urinary incontinence in women. (http://www.ncbi.nlm.nih.gov/pubmed/28756647)

A 54-Year-Old Postmenopausal Woman Comes to the Office Due to Involuntary