Abstract
Case Report
A 52
In her physical exam, vital signs are normal, body mass index is 30, and the exam is otherwise unremarkable. Specifically, the vaginal mucosa appears normal and there is no evidence of a cystocele or uterine prolapse. The bimanual exam is normal. Urinalysis is within normal limits.
What is your next best step?
A. Begin therapy with an anti-muscarinic agent
B. Refer patient for additional imaging and urodynamic testing
C. Recommend weight loss
D. Instruct the patient in pelvic floor exercises
E. C and D
Discussion
This patient is complaining of urinary incontinence (UI), which is very common in middle aged and elderly women, but commonly underdiagnosed. In adults, it is more common in women than men. The prevalence in women is approximately 25% in young women, 44%–57% in women 40–60 years of age, and up to 75% in women over 75. 1 Despite its significant impact on one's quality of life, many patients are reluctant to discuss this problem with their health provider. It is estimated that only 45% of women who reported experiencing urinary incontinence at least weekly were seen by a provider for their symptoms. 2 While the incidence of urinary incontinence increases with age, it should not be considered a normal consequence of aging. Most patients, with proper evaluation and management can see a reduction if not the elimination of their incontinence symptoms. There are several causes of UI and because effective treatment options depend on the specific cause, an accurate diagnosis is vital.
The most common types of persistent incontinence include stress and urge incontinence. 3 Stress incontinence is seen primarily in women, but is also seen in men following prostatectomy for prostate cancer. Urge incontinence can affect both sexes. 4
Stress incontinence involves the involuntary loss of urine with activities that temporarily increase intra-abdominal pressure. This includes activities such as sneezing, laughing, and coughing. Pathophysiology of urinary stress incontinence is multifactorial and related to a combination of factors affecting urethral pressure and support. Risk factors for stress incontinence include aging, white race, and obesity. Multiple vaginal deliveries, the use of forceps or traumatic vaginal deliveries, premature loss of estrogen, caused by either menopause or surgery, also increases the risk 5,6
Urge incontinence usually results from an overactive bladder, a syndrome characterized by urinary urgency and frequency caused by premature bladder contractions. 7 The prevalence of overactive bladder increases with age and typically occurs in both men and women equally. However, overactive bladder associated with urinary incontinence (urge incontinence) is more common in women as a result of changes in bladder innervation and other factors.
Mixed incontinence represents a combination of stress and urge incontinence. Patients with mixed incontinence often present with a confusing history since they describe manifestations of both stress and urinary incontinence. Effective management usually requires treatment of both conditions.
This patient is clearly describing symptoms of pure stress incontinence. The evaluation of patients with stress incontinence is straightforward and appropriate for primary care settings. Rarely is a urology or urogynecology consultation required to make a diagnosis and initiate effective treatment. Recently, the American College of Physicians released clinical practice guidelines for the nonsurgical management of UI in women. 1 The goal of treatment is to improve continence with success defined as a decrease in frequency of UI by at least 50%.
Evaluation
The most important part of the evaluation of a patient with incontinence is the history. In most cases, a thorough history will tell the provider the type of incontinence the patient is experiencing. Most patients with stress incontinence describe losing small amounts of urine in response to physical activities that transiently increase intra-abdominal pressure such as coughing, laughing, or sneezing. Urine loss from stress incontinence is more likely to occur with a full bladder. Patients describe a wide variation in symptom severity. In extreme cases, some patients lose urine when walking or even when assuming a standing position. In others, it may occur only during vigorous physical activities, such as exercising or running. A voiding diary can also be valuable in the assessment of a patient with UI. 8
A limited physical exam should be performed as part of the evaluation. A pelvic examination helps to determine the degree of bladder, uterine or rectal prolapse, intra-abdominal or pelvic masses, and genitourinary atrophy. The patient's ability to contract her pelvic floor muscles should be assessed during the pelvic exam. This will be useful in teaching the patient pelvic floor muscle exercises. Anal sphincter tone should be evaluated as part of the pelvic exam. Although a comprehensive neurologic examination is usually not necessary, it should be determined whether there are any neurologic abnormalities of the central nervous system, spinal cord, or peripheral nerves.
Very few laboratory studies are helpful in the evaluation of a patient with stress incontinence. A urinalysis with either a urine gram stain or culture should be done to rule out a urinary tract infection. Urodynamic studies are generally not needed, although they may be occasionally helpful in the evaluation of a patient with a confusing history commonly seen with mixed incontinence.
Management
There are no Food and Drug Administration–approved drugs for treatment of patients with pure stress UI. The traditional antimuscarinic medications useful for urge incontinence have no role in the management of stress incontinence. 1 One of the most effective treatments for stress incontinence is weight loss. A reduction in weight of 8% resulted in a 47% decrease in stress incontinence episodes in 338 overweight and obese women. 9 Pelvic floor exercises (Kegel exercises) consist of voluntary contractions of the pelvic floor muscles and can be extremely effective. They result in improved tone of the periurethral muscles, which can eventually increase urethral resistance. 10 To perform these exercises, the patient should contract her pelvic floor muscles for 10 seconds. Ten sets of contractions are performed four times a day. Expert opinion varies as to the length of contractions and number of contractions per day. It may take up to 8 weeks for the patient to notice an improvement in symptoms, and they need to be continued indefinitely in order for the beneficial effects to be maintained. Clinical improvement in up to 95% of patients can occur. 11 Since some patients have difficulty performing these exercises correctly, the technique may be taught during a pelvic examination. Some will require biofeedback from physical therapy. 12 If frequent coughing is associated with stress incontinence, attempts to reduce the cough may be useful in preventing urine loss. If the incontinence is associated with exercise, symptoms may be less if the patient empties her bladder just prior to the activity. Finally, surgery may be helpful for some patients, but it should be considered only after other treatment modalities have been tried and failed. Surgical procedures include urethral slings, bladder suspension, or placement of an artificial urethral sphincter. An injection of sphincter bulking agents is occasionally performed to increase the resistance to urine outflow.
Answer: The Correct Answer is E
Our patient is presenting with pure stress urinary incontinence a relatively common diagnosis, especially in women. It can result in a significantly impaired lifestyle. The history is the most important component of the evaluation and will usually establish a correct diagnosis. Additional imaging or urologic testing are not indicated. Pharmacologic therapy for stress incontinence has not shown benefit. The most effective management includes weight loss and pelvic floor exercises.