A 39-year-old woman comes to the office due to intermittent episodes of involuntary loss of urine. Her symptoms started several months ago with drops of urine leaking while exercising or lifting her children. Coughing and laughing now cause her to pass large amounts of urine. The patient is embarrassed to go out with friends and has started wearing an adult diaper. Her children, ages 4 and 6, were delivered vaginally, and both pregnancies were complicated by gestational diabetes mellitus and fetal macrosomia. Temperature is 36.8 C (98.4 F), blood pressure is 120/82 mm Hg, and pulse is 80/min. BMI is 24 kg/m². Urinalysis is negative for nitrites and leukocyte esterase. Which of the following is most likely to improve this patient's urinary symptoms?

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11ec25c8_da9c_ab2c_bc81_f59e612291c9_MD0003_00 This patient's loss of urine with increased intraabdominal pressure (eg, lifting, coughing, laughing) is due to stress urinary incontinence (SUI). The bladder and urethra are normally maintained in the appropriate anatomic position by the pelvic floor (levator ani) muscles. Patients develop SUI from pelvic floor muscle weakness due to chronic pressure or injury to these muscles; this often occurs in multiparous women with multiple vaginal deliveries (particularly those complicated by fetal macrosomia). Chronic pelvic floor weakness can create urethral hypermobility, in which the urethra moves improperly and is unable to fully compress against the anterior vaginal wall during times of increased intraabdominal pressure (eg, Valsalva maneuver). Therefore, first-line treatment of SUI is pelvic floor muscle (Kegel) exercises, which strengthen and stabilize the pelvic musculature. The strengthened pelvic musculature provides a base for urethral compression and suppresses bladder contractions, improving incontinence. A continence pessary may be used in conjunction with Kegel exercises, and a midurethral sling procedure may be performed for those who desire surgical management or do not respond to conservative therapy. (Choices A and D) Antimuscarinics and timed voiding treat urgency incontinence (ie, overactive bladder), in which bladder spasms cause a sudden urge to void that is followed by an immediate loss of urine. Antimuscarinics (eg, oxybutynin) inhibit the bladder smooth muscle, thereby preventing bladder spasms and promoting bladder relaxation. Timed voiding involves scheduling bathroom breaks based on planned time intervals rather than sense of urgency, with subsequent increases in time between voids to increase bladder capacity. (Choice B) Cholinergic therapy (eg, bethanechol) stimulates muscarinic receptors, which increase bladder contractility and help treat overflow incontinence due to urinary retention (eg, neurogenic bladder). Overflow incontinence typically causes constant dribbling of urine; not leaking with intraabdominal pressure increase (eg, lifting, coughing), as in this patient. (Choice E) Vaginal estrogen can be used to treat the genitourinary syndrome of menopause, which may cause urinary incontinence due to vulvovaginal atrophy from decreased estrogen. This diagnosis is unlikely because the median age of menopause is 51. Educational objective: Stress urinary incontinence is loss of urine with increased abdominal pressure (eg, lifting, coughing, laughing). First-line treatment is with pelvic floor muscle (Kegel) exercises. References: Effect of home-based Kegel exercises on quality of life in women with stress and mixed urinary incontinence. (http://www.ncbi.nlm.nih.gov/pubmed/25264854) Short-term effect of adding pelvic floor muscle training to bladder training for female urinary incontinence: a randomized controlled trial. (http://www.ncbi.nlm.nih.gov/pubmed/25266357) Urinary incontinence in women. (http://www.ncbi.nlm.nih.gov/pubmed/28681849)

A 39-Year-Old Woman Comes to the Office Due to Intermittent