A 50-year-old woman comes to the office due to involuntary leakage of urine. The leakage started a year ago and currently occurs several times a day when the patient coughs, sneezes, laughs, or stands up. She also sometimes has loss of urine during sexual intercourse. The patient awakens to urinate once each night; she has had no dysuria, hematuria, urinary urgency, or fecal incontinence. She has had 2 vaginal deliveries. Her incontinence makes her self-conscious during social interactions and she has stopped participating in exercise classes. Her general health is otherwise good.
Physical examination is within normal limits, except for a BMI of 32 kg/m². Pelvic examination reveals mild uterine prolapse. A cough with a full bladder elicits an immediate release of a small amount of urine.
Urinalysis is normal. Post-voiding urinary residual volume is 20 mL. The patient is currently collecting information in a voiding diary regarding fluid intake, voiding frequency, and amount of urine.
Which of the following is the best next step in management of this patient?

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Quizplus · Accepted Answer

11ec193a_97d8_3886_853d_eb2edcc93157_MD0002_00 This patient has stress urinary incontinence based on involuntary leakage of urine with coughing, sneezing, or exertion. Patients with stress incontinence are initially managed conservatively with lifestyle changes (eg, restricting fluid intake, weight loss, smoking cessation). Pelvic floor muscle training (eg, Kegel exercise) is recommended to strengthen the pelvic floor musculature; this may help with decreasing the frequency and volume of urine loss. Bladder training with frequent, timed voiding can keep urine volumes low and is helpful when combined with pelvic muscle exercises. (Choice B) Medications usually are not effective for stress incontinence treatment. Duloxetine (a serotonin-norepinephrine reuptake inhibitor) is approved in Europe for treatment of stress incontinence with benefit in some patients. However, it is not approved for treatment of stress incontinence in the United States. (Choice C) An incontinence pessary is inexpensive and safe and can be considered for patients who fail conservative therapy. These devices have a compliance rate of only about 50%, but they are useful in patients who wish to avoid surgery. (Choice D) Surgery for stress incontinence has the highest cure rate and includes mid-urethral sling or Burch retropubic colposuspension. However, surgery is invasive and usually reserved for patients who fail conservative management. (Choice E) Urodynamic testing evaluates urine storage and evacuation, and may help diagnose the incontinence type in patients with mixed symptoms (eg, stress, urgency). However, it is not well standardized and has inconsistent reproducibility in the same patient. Educational objective: Patients with stress urinary incontinence should be evaluated for modifiable risk factors. Initial treatment is with behavioral therapy and pelvic floor muscle exercises. Surgical therapy should be reserved for those who fail noninvasive therapy. __________ References: Diagnosis of urinary incontinence. (http://www.ncbi.nlm.nih.gov/pubmed/23668444) Pelvic floor muscle training: underutilization in the USA. (http://www.ncbi.nlm.nih.gov/pubmed/26757904) Duloxetine versus placebo for the treatment of North American women with stress urinary incontinence. (http://www.ncbi.nlm.nih.gov/pubmed/14501737)

A 50-Year-Old Woman Comes to the Office Due to Involuntary