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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
Use this guideline to:
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
Laboratory studies show fasting plasma glucose level of 89 mg/dL
(5.0 mmol/L) with hemoglobin A1c of 6.5%. Urinalysis is
Which of the following is the most appropriate
A. Pelvic floor muscle training
B. Prompted voiding
C. Pubovaginal sling
A. Pelvic floor muscle training
Pelvic floor muscle training is first-line treatment for stress
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
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:
This question is derived from MKSAP® 16, the Medical Knowledge
October 2014 Issue of IMpact
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