A 51-year-old woman presents with worsening symptoms of urinary frequency, urgency and urgency incontinence over the past several years. She denies a history of urinary tract infection or haematuria, but on direct questioning reveals that she is also incontinent of urine on physical exertion. She is overweight, a smoker and has hypertension. She has three children, two born by normal vaginal delivery and one by a forceps delivery. Urinalysis is normal, and she has no significant residual volume on post-void bladder scanning.
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1 What important signs should be elicited on physical examination?
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Correct answer:
A brief neurological examination to exclude a neurological cause for her symptoms should be followed by a chaperoned vaginal examination. Important components of the examination include inspection for vaginal atrophy which may respond to vaginal oestrogen replacement, evaluation of pelvic floor strength, and the presence of demonstrable stress urinary incontinence. Measure her height and weight to calculate her body mass index: weight (kg)/height2 (m2).
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2 How would you treat this patient in the first instance?
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Correct answer:
Initial management should consist of advice to stop smoking and to lose weight, both of which may improve her symptoms. Advice about reducing her intake of caffeine and fizzy drinks should be followed by asking the patient to complete a frequency–volume chart. Behavioural therapies such as bladder training and supervised pelvic floor muscle training should then be suggested.
She returns after 3 months, without any benefit from these conservative therapies. She is mostly bothered by urgency and urgency incontinence.
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3 What would you do next?
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Correct answer:
Her most bothersome symptoms should be treated first. In this case, her overactive bladder syndrome (OAB) symptoms are predominant and so a trial of pharmacological therapy with anticholinergics should be commenced. If this fails to improve her symptoms or she has adverse effects from the treatment, then she should be prescribed a beta-3 agonist instead. If pharmacological therapy fails the patient should undergo urodynamic investigation prior to consideration of more invasive treatment options.
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4 What are the second-line options for patients with OAB symptoms that are refractory to medical therapy?
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Correct answer:
Intravesical botulinum toxin A or sacral neuromodulation.
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5 What surgical options exist for patients who fail treatment with all other options?
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Correct answer:
Augmentation cystoplasty, or urinary diversion as a last resort.
