Instructions: Listen to the podcast episode available below, and then submit your answers to the multiple choice questions.  You will review the answers and the material covered during your next Continuity Clinic Session.  

Urinary Incontinence

Urinary IncontinenceCREOGs Over Coffee
00:00 / 01:04

1. A 46 yo female reports urinary incontinence that is intermittent throughout the day and night. Her symptoms have been more severe over the last few months. She has leaking when running to the bathroom, after sneezing and when getting out of the car. She wakes up 1-2 times per night with a strong desire to void and leaks along the way. Multichannel cystometrography shows detrusor activity. What is the best next step in management?

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Show Explanation

  • Symptoms and urodynamic findings of detrusor overactivity are consistent with urgency incontinence

  • First line approach to treatment = behavioral modification (modulating amount and timing of fluid intake as well as timed voiding)

  • Consistent timed voiding reduces urgency symptoms as much as anticholinergic medications (without the side effects)

  • Incontinence ring, periurethral bulking injection and pelvic floor PT are used for stress urinary incontinence

  • Sacral neuromodulation can be effective in the treatment of urgency incontinence but more conservative treatments should be trialed first (behavior modification, anticholinergics, intravesical botulinum-A toxin injection or percutaneous tibial nerve stimulation)

2. A 62 yo female with obesity has a diagnosis of mixed urinary incontinence. She does not want to undergo surgery but desires to try behavioral interventions. Along with pelvic floor muscle exercises, the intervention that is most likely to reduce leakage is:

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Show Explanation

  • Behavioral interventions are effective in 55-85% of women with urinary incontinence

  • For stress urinary incontinence, pelvic floor muscle therapy is superior to pessary and there was no benefit to the combination of these therapies in prior studies

  • 50% with pelvic floor PT show improvement

  • Only 1/3 of those with pessary report success

  • A prior RCT of a 6-month behavioral intervention program to target weight loss in overweight/obese women with incontinence found a mean weight loss of 8% and mean drop in incontinence episodes by 48%

  • Caffeine intake and incontinence are weakly associated. There is no significant evidence that caffeine elimination improves incontinence.

  • Weighted vaginal cones may help stress urinary incontinence, but they do not offer additional benefit over pelvic floor PT

3. A 32 yo G1P1 presents with urinary incontinence. She wants to be pregnant next year. She developed urine leakage with exercise and running after her last delivery. This leaking interferes with her quality of life. She has no urgency symptoms. What is the best treatment option?

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Show Explanation

  • Stress urinary incontinence

  • Involuntary loss of urine with effort or physical exertion or with sneezing or coughing that affects a woman’s quality of life

  • 16% of women report symptoms, 29% of these are moderately/extremely bothersome

  • Pessaries can treat stress urinary incontinence by supporting the urethra and increasing urethral resistance; there are a variety of shapes/sizes- incontinence rings and dishes are most common

  • Often serve as temporizing devise for women who have not completed childbearing

  • More than 25% will stop use in the first year after being fitted for pessary

  • Pessary is best for this patient due to her young age and plan for additional pregnancies

  • Urethral bulking agents increase coaptation of the urethra which increases urethral resistance

  • Can be effective as a temporary treatment of stress urinary incontinence, but there is still limited evidence for guiding clinical practice

  • Usually for those who want to avoid surgery or those whose comorbidities preclude surgery

  • Midurethral slings and bladder neck slings are effective for stress urinary incontinence 

  • Limited data to guide treatment in those who want future pregnancies/deliveries so conservative therapies should be offered first in those who desires future childbearing (over surgical options)