A 58yo lady presented with urinary incontinence. She looks anxious for her condition. Urine
culture is sterile. Her urodynamic study is normal. What is the next step?
a. Antibiotics
b. Topical estrogen
c. Systemic estrogen
d. Duloxetine
e. Pelvic floor exercise
answer: E
URGE INCONTINENCE
Definition
• urine loss associated with an abrupt, sudden urge to void
• “overactive bladder”
• diagnosed based on symptoms
Etiology
• idiopathic (90%)
• detrusor muscle overactivity (“detrusor instability”)
Associated Symptoms
• frequency, urgency, nocturia, leakage
Treatment
• behavior modification (reduce caffeine/liquid, smoking cessation, regular voiding schedule)
• Kegel exercises
• medications
anticholinergics: oxybutinin, tolterodine, solifenacin
tricyclic antidepressants: imipramine
STRESS INCONTINENCE
Definition
• involuntary loss of urine with increased intra-abdominal pressure (coughing, laughing, sneezing, walking, running)
Risk Factors for Stress Incontinence in Women
• pelvic prolapse
• pelvic surgery
• vaginal delivery
• hypoestrogenic state (post-menopause)
• age
• smoking
• neurological/pulmonary disease
Treatment
• Kegel exercises
• local vaginal estrogen therapy
• vaginal pessary (intravaginal suspension disc)
• surgical
tension-free vaginal tape (TVT), tension-free obturator tape (TOT), prosthetic/fascial slings or retropubic bladder suspension (Burch or Marshall-Marchetti-Krantz procedures)
Investigation of choice in both: Urodynamic study
Duloxetine and topical estrogen are also used, so is this a case of starting with the non-med option first and then trying these medication options should the kegel exercises not work?
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