A 68-year-old woman is evaluated for involuntary urine loss that occurs with coughing, sneezing, and laughing and occasionally with physical exertion. She has no dysuria, urinary frequency, hematuria, or nocturia but does report vaginal dryness and dyspareunia. She performs pelvic floor muscle training exercises four times daily.
On physical examination, vital signs are normal. BMI is 22. Pelvic examination reveals vaginal atrophy. Mild leakage of urine occurs during the pelvic examination with bearing down.
Which of the following is the most appropriate management?
A. Oral estradiol
C. Timed voiding
D. Topical vaginal estrogen therapy
MKSAP Answer and Critique
The correct answer is D. Topical vaginal estrogen therapy. This content is available to MKSAP 19 subscribers as Question 32 in the General Internal Medicine 1 section. More information about MKSAP is available online.
The most appropriate management is topical vaginal estrogen therapy (Option D). Urinary incontinence after activities that increase intra-abdominal pressure, such as sneezing, laughing, physical exertion, or bearing down, is consistent with stress incontinence, which primarily affects multiparous, postmenopausal women. This patient has attempted first-line therapy for stress incontinence with pelvic floor muscle training, without success. Vaginal estrogen formulations may increase continence compared with placebo and should be attempted as second-line therapy for postmenopausal women with stress incontinence. Evidence from clinical trials is generally of low quality, and statistical heterogeneity limits confidence in conclusions. However, because this patient is experiencing genitourinary symptoms of menopause (vaginal dryness and dyspareunia), a trial of topical vaginal estrogen is appropriate and reasonable. Weight loss in women with overweight or obesity also improves urinary control in multiple types of incontinence. An 8% decrease in BMI has been shown to reduce incontinence by 50%. This patient, with a BMI of 22, would be unlikely to benefit from weight loss.
Oral estradiol (Option A), transdermal estrogen, or estrogen implants should not be used to manage stress incontinence and may make it worse. Because of the risks associated with systemic hormone replacement therapy (breast cancer, coronary events, stroke, venous thromboembolism), its use should be reserved for vasomotor symptoms of menopause (hot flashes) at the lowest effective dosage for the shortest time required.
Oxybutynin (Option B) is a treatment for urge incontinence when bladder training is only partially successful or has failed. It is not recommended for the treatment of stress incontinence.
Timed voiding (Option C) or bladder training comprises scheduled voiding attempts at intervals shorter than the usual time between incontinence episodes, regardless of the urge to void, with a gradual increase in the time between voids. If an episode of urgency occurs before the designated voiding time, patients are encouraged to use pelvic floor muscle contraction until the urge passes and then proceed with voiding directly afterward. Timed voiding is a behavioral technique used for patients with urge incontinence (urine leakage preceded by a sudden urge to void) and would not be helpful in this patient with stress incontinence.
- For postmenopausal women with stress incontinence, topical vaginal estrogen therapy may increase continence compared with placebo.
- Weight loss in women with overweight or obesity improves urinary control in multiple types of incontinence.