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. The patient returns to the office 10 weeks later for follow-up. She reports no response to the initial therapy. Repeat urinalysis is normal. Which of the following is the best next step in management of this patient?

Question

Quizplus · Accepted Answer

Explanation: 11ec2b69_c14a_1223_8f63_cf14be7dfb5c_MD0005_00 Patients who have no improvement in their urgency incontinence symptoms despite lifestyle modifications (eg, bladder training) may benefit from the addition of an antimuscarinic medication such as tolterodine, solifenacin, or oxybutynin. Antimuscarinic medications improve bladder capacity and inhibit detrusor muscle contraction during bladder filling by blocking acetylcholine release in the bladder. The anticholinergic properties of these medications frequently result in side effects (eg, dry mouth, constipation, drowsiness, blurry vision) that may limit their usefulness. To minimize these side effects, antimuscarinics are initiated at the lowest dose and titrated up as tolerated. Patients with persistent incontinence symptoms despite the use of antimuscarinic medication can be considered for botulinum toxin injections or percutaneous tibial nerve stimulation. (Choice A) Urinary tract infections are a reversible cause of urinary incontinence, and a urine culture is indicated in patients with a urinalysis suggestive of infection. Urine cytology evaluates for bladder cancer and is indicated for patients with hematuria on urinalysis. This patient had 2 normal urinalyses; therefore, neither a urine culture nor a cytologic evaluation is indicated. (Choice B) Terazosin, an alpha-1 antagonist, is indicated in the treatment of benign prostatic hypertrophy, which can present with urgency incontinence or, in men, with poor bladder emptying. (Choice D) A urethral sling procedure is indicated for patients with stress urinary incontinence who have failed conservative management (eg, weight loss, dietary modification, pessary). Urethral sling procedures do not alter detrusor overactivity and are not indicated in the management of urgency incontinence. (Choice E) Intermittent self-catheterization is indicated in the management of patients with overflow incontinence. These patients have an increased post-void residual volume (>150 mL) and constant urinary dribbling that occurs due to bladder over-distension from incomplete emptying (not seen in this patient). Educational objective: Patients with urgency incontinence who fail bladder training with timed voids are treated with antimuscarinic medications such as oxybutynin and tolterodine. Patients with persistent symptoms can be considered for botulinum toxin injections or percutaneous tibial nerve stimulation. References: Modifiers of response to treatment with Fesoterodine for urgency-predominant urinary incontinence in a randomized controlled trial. (http://www.ncbi.nlm.nih.gov/pubmed/28118174)

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