Review Question - QID 107224

This patient is suffering from stress urinary incontinence. Noninvasive treatment options for stress incontinence include Kegel exercises to strengthen the pelvic floor.

Stress incontinence (loss of urine with an increase in abdominal pressure, such as with coughing, laughing, and exercise) is caused by laxity of the pelvic floor muscles. This laxity allows for the proximal urethra to drop below the pelvic floor with increases in abdominal pressure. The change in angle between the urethra and bladder results in bladder pressure exceeding urethral pressure at times of strain and an ensuing involuntary loss of urine. Stress incontinence is associated with cystocele and decreased levels of estrogen, as seen in post-menopausal women. Beyond Kegel exercises, additional noninvasive treatment options for stress urinary incontinence include: bladder training/biofeedback, topical vaginal estrogen cream for postmenopausal patients, pessaries, vaginal cones, alpha-adrenergic agonists, duloxetine (SNRI), incontinence pads, weight loss, smoking cessation, fluid restriction, and avoidance of caffeinated beverages and alcohol (behavioral modification).

Hersh et al. discuss the management of urinary incontinence in women. The approach to management should consist of progression from least invasive to more invasive treatment options, with surgery reserved for cases that have not responded to less invasive treatment options. Pelvic floor strengthening exercises are the first-line treatment for stress incontinence. Other noninvasive options include vaginal inserts, urethral plugs, or electrical and magnetic stimulation devices. Currently, no medications are approved by the USDA for treatment of stress incontinence.

Luber reviews the prevalence of and risk factors for stress urinary incontinence. Stress urinary incontinence affects 4-35% of women. This high variability in the estimated prevalence of the disease is due to the lack of a standardized definition of the condition. With aging and obesity increasing and having causal relationships with stress urinary incontinence, the prevalence of stress urinary incontinence is expected to increase in the future.

Illustration A shows how the change in the angle between the bladder and urethra that occurs with pelvic floor laxity at times of strain can lead to leakage or urine.

Incorrect Answers:
Answer 2: Anticholinergic agents such as imipramine have been shown to have minimal effect on the smooth muscle of the urethra; anticholinergics may be more effective for urge incontinence.
Answer 3: Bethanechol is a cholinergic agonist that may be helpful in the treatment of outflow incontinence, not stress incontinence.
Answer 4: Urethropexy is appropriate surgical treatment for stress incontinence; however, less invasive options should be tried first.
Answer 5: Tension-free vaginal tape is a procedure that involves placement of mesh under the urethra - it is an invasive surgical procedure that should be pursued after failure of conservative management.