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Analyzing Annals: Clinical Guideline: Urinary Incontinence

Analyzing Annals: Clinical Guideline: Urinary Incontinence

Review the recent Annals article Nonsurgical Management of Urinary Incontinence in Women: A Clinical Practice Guideline From the American College of Physicians

This guideline on the nonsurgical management of urinary incontinence (UI) recommends pelvic floor muscle training in women with stress UI, bladder training in women with urgency UI, and both in women with mixed UI. It also recommends against systemic pharmacologic therapy for stress UI but recommends pharmacologic treatment in women with urgency UI if bladder training was unsuccessful.

Use this guideline to:

  • Consider the following multiple-choice question. The answer is provided below.
    • A 69-year-old woman is evaluated for involuntary leakage of urine with coughing, sneezing, laughing, or when lifting heavy boxes at work. She has no dysuria, frequency, or urgency and she has no mobility problems. She is gravida 4, para 4, and underwent a total abdominal hysterectomy 20 years ago for uterine fibroids. She has type 2 diabetes mellitus. Medications are metformin and lisinopril. She has no known drug allergies.

      On physical examination, vital signs are normal. BMI is 31. There is bulging of the anterior vaginal wall when the patient is asked to cough, accompanied by leakage of urine. Bimanual examination is unremarkable. The remainder of her examination is normal.

      Laboratory studies show fasting plasma glucose level of 89 mg/dL (5.0 mmol/L) with hemoglobin A1c of 6.5%. Urinalysis is normal.

      Which of the following is the most appropriate treatment?

      A. Pelvic floor muscle training
      B. Prompted voiding
      C. Pubovaginal sling
      D. Tolterodine

  • What are the different types of urinary incontinence? Use ACP Smart Medicine - Urinary Incontinence in Women to review how each presents and how they are diagnosed.
  • Consider the pharmacologic treatment of incontinence. What does pelvic floor muscle training involves? Ask a gynecologist or urologist a few questions: How do you teach these exercises to patients? What benefits may be expected?
  • Should patients be screened for urinary incontinence?

Correct Answer
A. Pelvic floor muscle training

Key Point
Pelvic floor muscle training is first-line treatment for stress urinary incontinence.

Educational Objective
Treat stress urinary incontinence.

This patient has stress urinary incontinence and should receive pelvic floor muscle training (PFMT). Stress urinary incontinence, defined as loss of urine with physical activity, cough, or sneeze, is caused by sphincter incompetence. Findings on physical examination include weakened anterior or posterior vaginal wall support (cystocele or rectocele, respectively). PFMT is considered first-line therapy for urinary stress incontinence. In PFMT, women learn repetitive exercises (Kegel exercises) to strengthen the voluntary urethral sphincter and levator ani muscles. For PFMT to be effective, it is important that the patient learn to correctly contract her muscles without straining, which increases abdominal pressure. Each contraction is held for approximately 10 seconds, followed by an equal relaxation period. The number of repetitions should be increased weekly until the patient is performing 8 to 12 repetitions three times daily, every day or at least 3 to 4 days per week. In a systematic review of nonsurgical therapy, PFMT improved stress urinary incontinence episodes. Outcomes were even better when PFMT was combined with biofeedback and when skilled therapists directed the treatment.

Prompted voiding is indicated in and is effective in patients with significant mobility or cognitive impairments that may hinder the patient's ability to reach the toilet in time, neither of which this patient has.

Sling procedures are effective for moderate to severe stress incontinence, but surgery is usually reserved for patients who do not benefit from more conservative approaches, including behavioral or appropriate pharmacologic therapy.

Tolterodine, a selective antimuscarinic anticholinergic medication, is most effective for patients with urge, rather than stress, incontinence. This patient does not experience the classic sense of urinary urgency with her incontinence episodes, and, therefore, tolterodine would not be an appropriate first choice.

Bibliography
Shamliyna TA, Kane RL, Wyman J, Wilt TJ. Systematic review: randomized, controlled trials of nonsurgical treatments for urinary incontinence in women. Ann Intern Med. 2008;148(6):459-473. PMID: 18268288

This question is derived from MKSAP® 16, the Medical Knowledge Self-Assessment Program.


Back to October 2014 Issue of IMpact

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