A 34-year-old woman, gravida 3 para 3, comes to the office 2 weeks after a spontaneous vaginal delivery for evaluation of urinary leakage. Since delivery, the patient has had leaking of urine in small amounts 5-6 times daily. She sometimes does not feel the urge to urinate despite a good appetite and frequent hydration. The patient has no dysuria or hematuria. She has no chronic medical conditions and has had no surgeries. Temperature is 98.8 F (37.1 C), blood pressure is 124/78 mm Hg, and pulse is 86/min. The uterus is firm, nontender, and extends 2 fingerbreadths above the pubic symphysis. There is urethral leakage of urine with Valsalva maneuver, but no urine in the vaginal vault. A postvoid residual is normal. The perineum is intact and there is scant lochia. Which of the following is the best next step in management of this patient?

Question

A 34-year-old woman, gravida 3 para 3, comes to the office 2 weeks after a spontaneous vaginal delivery for evaluation of urinary leakage.  Since delivery, the patient has had leaking of urine in small amounts 5-6 times daily.  She sometimes does not feel the urge to urinate despite a good appetite and frequent hydration.  The patient has no dysuria or hematuria.  She has no chronic medical conditions and has had no surgeries.  Temperature is 98.8 F (37.1 C), blood pressure is 124/78 mm Hg, and pulse is 86/min.  The uterus is firm, nontender, and extends 2 fingerbreadths above the pubic symphysis.  There is urethral leakage of urine with Valsalva maneuver, but no urine in the vaginal vault.  A postvoid residual is normal.  The perineum is intact and there is scant lochia.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_da8f_3d98_bc81_2177b916b6ca_MD0003_00 11ec25c8_da8f_3d99_bc81_e32837a7c352_MD0003_00 This postpartum patient with new-onset leakage of urine with Valsalva maneuver has stress urinary incontinence (SUI) due to pelvic floor laxity. SUI is common following labor and delivery due to 2 main mechanisms: Weakening of the pelvic floor muscles (eg, levator ani muscle complex), which normally support the bladder and urethra, due to increased intraabdominal pressure with fetal descent and pushing. Pelvic floor weakness causes urethral hypermobility and the inability of the urethra to fully compress closed during periods of increased intraabdominal pressure, resulting in leakage of urine with Valsalva maneuver. Stretch injury to the pudendal nerve, which helps maintain continence because it innervates voluntary contraction of the external urethral sphincter. The pudendal nerve is also a main sensory nerve of the pelvis, and damage to it can result in a decreased voiding sensation, as seen in this patient. Although postpartum SUI increases the risk of chronic SUI, most cases are self-limited because the pelvic floor muscles and pudendal nerve heal after delivery; therefore, patients <6 weeks postpartum are managed with observation and reassurance and encouraged to perform Kegel exercises to strengthen pelvic floor muscles. Patients who later have chronic SUI can be treated with a continence pessary or midurethral sling procedure to compress the urethra to the anterior vaginal wall, thereby decreasing urethral hypermobility (Choices B and C). continence pessary (Choice A) Bladder dye testing can help diagnose vesicovaginal fistula, a potential complication of vaginal delivery (eg, prolonged labor, operative vaginal delivery). Patients typically have persistent urinary dribbling from the vagina and urine in the vaginal vault due to a direct conduit between the bladder and vagina. vesicovaginal fistula (Choice D) Mirabegron, a beta-3 adrenergic agonist, stimulates selective beta receptors in the detrusor muscle to cause smooth muscle relaxation; it is used to treat urgency incontinence (ie, overactive bladder due to detrusor hyperactivity), which is not seen in this patient. Educational objective: Stress urinary incontinence is common after vaginal delivery due to pelvic floor muscle weakness (resulting in urethral hypermobility) and stretch injury to the pudendal nerve. Patients in the immediate postpartum period (ie, <6 weeks after delivery) are managed with observation and reassurance because the condition is typically self-limited. References: Postpartum stress urinary incontinence: lessons from animal models. (http://www.ncbi.nlm.nih.gov/pubmed/21113428) Postpartum urinary incontinence: asking the right questions. (http://www.ncbi.nlm.nih.gov/pubmed/26663855)

A 34-Year-Old Woman, Gravida 3 Para 3, Comes to the Office