A 44-year-old woman, gravida 2 para 2, comes to the office due to intermittent loss of urine over the last 3 months. Five years ago, she had midurethral sling surgery for stress incontinence that resolved her leakage of urine until recently. Prior to the midurethral sling, the patient's urinary leaking occurred during the day with laughing and jogging. Now, she is leaking unrelated to laughing or exercise and must get up to go to the bathroom throughout the night. The patient has tried Kegel exercises and having a regular bathroom schedule, but she is still leaking urine and often cannot make it to the bathroom in time. Her last menstrual period was 2 weeks ago. Physical examination shows a slight bulge at the anterior vaginal wall. Urinalysis is normal. Postvoid residual volume is 50 mL. Which of the following is the most appropriate therapy for this patient's urinary symptoms?

Question

A 44-year-old woman, gravida 2 para 2, comes to the office due to intermittent loss of urine over the last 3 months.  Five years ago, she had midurethral sling surgery for stress incontinence that resolved her leakage of urine until recently.  Prior to the midurethral sling, the patient's urinary leaking occurred during the day with laughing and jogging.  Now, she is leaking unrelated to laughing or exercise and must get up to go to the bathroom throughout the night.  The patient has tried Kegel exercises and having a regular bathroom schedule, but she is still leaking urine and often cannot make it to the bathroom in time.  Her last menstrual period was 2 weeks ago.  Physical examination shows a slight bulge at the anterior vaginal wall.  Urinalysis is normal.  Postvoid residual volume is 50 mL.  Which of the following is the most appropriate therapy for this patient's urinary symptoms?

Quizplus · Accepted Answer

11ec25c8_d502_56f3_bc81_173852d7967d_MD0003_00 This patient has urgency urinary incontinence, the sudden need to void followed by immediate loss of urine due to detrusor overactivity. Risk factors include age >40 and prior pelvic surgery (eg, midurethral sling). Urgency symptoms occur throughout the day and night and are unrelated to increases in intraabdominal pressure. All patients with urinary incontinence (eg, stress, urgency, mixed) require initial evaluation for urinary retention (eg, postvoid residual) and infection (eg, urinalysis); both tests are normal in this patient. First-line treatment for any type of urinary incontinence includes bladder training and pelvic floor muscle (Kegel) exercises. For urgency incontinence, bladder training involves resisting the urge to void for progressively longer time intervals to increase bladder capacity. Patients whose condition does not respond to first-line treatment, such as this patient, may be prescribed pharmacologic therapy. The detrusor muscle is mediated by the parasympathetic nervous system; therefore, antimuscarinic medications (eg, oxybutynin), which reduce acetylcholine activity, help increase bladder capacity and decrease detrusor contractions, thereby decreasing the sense of urgency. Patients unable to tolerate antimuscarinic therapy due to adverse effects (eg, dry mouth, constipation, blurry vision) may benefit from a beta-adrenergic agonist (eg, mirabegron). (Choice B) Cholinergic agonists (eg, bethanechol) treat urinary retention due to neurogenic bladder by increasing detrusor activity. This patient's postvoid residual is normal (eg, ≤150 mL in women, ≤50 mL in men). (Choices C and D) A continence pessary is used to treat stress urinary incontinence (SUI) and symptomatic pelvic organ prolapse (eg, anterior vaginal wall bulge); it works by stabilizing the pelvic floor in its anatomic position and compressing the urethra against the pubic symphysis. Midurethral sling procedures are performed for SUI due to urethral hypermobility. Although this patient has anterior vaginal wall prolapse and prior SUI managed with a midurethral sling, her current urinary symptoms do not suggest SUI (as they are unrelated to laughing or exercise) and are consistent with new-onset urgency incontinence. pessary (Choice E) Vaginal estrogen therapy is used in patients with genitourinary syndrome of menopause (eg, vaginal dryness, atrophy) due to estrogen deficiency. In postmenopausal patients, localized estrogen can relieve urinary symptoms (eg, stress and/or urge incontinence) related to atrophy. This patient still has menstrual cycles, making genitourinary syndrome of menopause unlikely. Educational objective: First-line treatment for urgency urinary incontinence includes bladder training and pelvic floor muscle (Kegel) exercises. Patients whose condition does not respond to these therapies are treated with antimuscarinic medications (eg, oxybutynin) to decrease detrusor contractions and reduce the sense of urgency. References: Pharmacotherapy of overactive bladder in adults: a review of efficacy, tolerability, and quality of life. (http://www.ncbi.nlm.nih.gov/pubmed/24400248)

A 44-Year-Old Woman, Gravida 2 Para 2, Comes to the Office