A 63-year-old woman, gravida 3 para 3, comes to the office for urinary incontinence. The patient has been experiencing involuntary leakage of urine that occurs after a strong sensation "that I really have to go." After the sensation occurs, "I can never get to the bathroom in time." The patient reports that her symptoms started over 2 years ago. The leakage was initially occasional but now occurs 2 or 3 times a day and soaks an entire pad. The patient's symptoms occur randomly and she now avoids leaving the house. She has hypertension controlled on an ACE inhibitor. She has had no surgery. The patient's deliveries were all vaginal; her Pap tests have been normal. She drinks 8 ounces of water 3 or 4 times a day but limits water intake in the evening; on weekends she drinks a cup of caffeinated coffee with breakfast. The patient does not use tobacco, alcohol, or illicit drugs. Blood pressure is 130/80 mm Hg and pulse is 72/min. BMI is 23 kg/m². Speculum examination shows a pale vagina without rugae. Bimanual examination reveals a small, mobile uterus and no adnexal masses. No leakage of urine occurs when the patient coughs with a full bladder. After voiding, the patient is catheterized and 30 mL of urine are drained from the bladder. Urinalysis is within normal limits.
Which of the following is the best next step in management of this patient?

Question

Quizplus · Accepted Answer

Explanation: This patient presents with urgency incontinence - involuntary urine leakage - that occurs after a strong urge to urinate. Due to the rapidity of the subsequent leakage, patients are unable to get to the bathroom in time. Other presenting symptoms include increased urinary frequency, nocturia, and small-volume voids. Diuretic use often exacerbates symptoms. Urgency incontinence is caused by bladder detrusor muscle overactivity, leading to an involuntary intense contraction that causes leakage. Although the detrusor overactivity is typically idiopathic, it can be caused by neurologic disease (eg, multiple sclerosis) or bladder abnormalities. Risk factors for urgency incontinence include increasing age, stroke, depression, diabetes mellitus, obesity, caffeine intake, and tobacco abuse. Management of urgency incontinence typically begins with timed voids and bladder training. With bladder training, the patient determines a baseline voiding interval and gradually increases the time between voids, eventually voiding every 3-4 hours. Other initial measures include weight loss, smoking cessation, and avoidance of caffeine and alcohol. (Choices A and C) A pessary and duloxetine, a serotonin-norepinephrine reuptake inhibitor, are indicated for the treatment of stress incontinence, which presents with leakage precipitated by increased intraabdominal pressure (eg, cough, Valsalva). Patients with stress urinary incontinence typically have a positive bladder stress test (ie, leakage of urine with cough on examination). (Choice B) Vulvovaginal atrophy can cause urinary incontinence; vaginal estrogen cream is indicated in incontinence treatment if vaginal atrophy is a contributing factor. Oral hormone replacement therapy is not indicated in the treatment of incontinence. (Choice E) Women with incontinence who drink >1.9 L (64 oz) of fluid daily should decrease their fluid intake. Fluid restriction to amounts less than this can cause dehydration. Educational objective: Urgency incontinence, the involuntary loss of urine that is associated with a sudden intense urge to urinate, is caused by detrusor muscle overactivity. Initial management includes bladder training with timed voids, weight loss, smoking cessation, and avoidance of caffeine and alcohol. References: Medical management of urinary incontinence in women. (http://www.ncbi.nlm.nih.gov/pubmed/28198687)

A 63-Year-Old Woman, Gravida 3 Para 3, Comes to the Office