Case 28: Urinary incontinence

 

Case 28: Urinary incontinence

CASE 28: URINARY INCONTINENCE

History

A 49-year-old woman presents with leaking of urine. This started after the birth of her

third child 10 years ago and has gradually worsened. She has not felt comfortable talking

to her general practitioner about it until now. The leakage occurs on coughing and laughing. However she has recently started to play badminton to lose weight and the symptoms

are much worse, but she has discovered though that the symptoms are much better if she

wears a tampon while playing. There is no dysuria, nocturia, frequency or urgency. She is

mildly constipated.

All her children were born by induction of labour post-term. They weighed 3.6 kg, 3.8 kg and

4.1 kg respectively and she needed a forceps delivery for the third child after failure to progress in the third stage. She has a regular menstrual cycle and has had a laparoscopic sterilization. There is no other relevant medical history and she takes no medications. She smokes 15

cigarettes per day and does not drink alcohol.

Examination

Body mass index is 29 kg/m2. There are no significant findings on abdominal or vaginal

examination.

INVESTIGATIONS

Urinalysis: protein negative; blood negative; leucocytes negative; nitrites negative

Urodynamics report: the first urge to void was felt at 300 mL. The maximum bladder

capacity was 450 mL. Involuntary loss of urine was noted with coughing during bladder

filling, in the absence of detrusor activity.

Questions

• What is the diagnosis?

• How would you advise and manage this woman?100 Cases in Obstetrics and Gynaecology

70

ANSWER 28

This woman is suffering from stress incontinence. Stress incontinence can be diagnosed from

the history – involuntary loss of urine when the intra-abdominal pressure increases (such as

with exercise or coughing). Urodynamic stress incontinence (formerly referred to as genuine

stress incontinence) is the involuntary loss of urine when the intravesical pressure exceeds

the maximum urethral pressure in the absence of a detrusor contraction and can only be

diagnosed after urodynamic testing.

Management

Conservative management

• Lifestyle: the woman should be advised to control factors that exacerbate symptoms:

• Reduce weight

• Stop smoking to relieve chronic cough symptoms

• Alter diet and consider laxatives to avoid constipation.

• Pelvic floor exercises: properly taught pelvic floor muscle training is a very effective treatment and can cause improvement in symptoms or cure in up to 85 per cent of women.

Surgical management

Tension-free vaginal tape or transobturator tape

These minimally invasive techniques (known as mid-urethral sling procedures) involve

insertion of a tape to support the urethra and bladder when the intra-abdominal pressure

increases (such as during coughing). The TOT (which uses the obturator route) is associated

with a slightly lower rate of perforation of the bladder or vagina and of voiding difficulty

when compared to the TVT (which uses the retropubic route) but may result in a higher

chance of groin pain or erosion of the tape into the vagina.

Colposuspension

This open or laparoscopic procedure to support the urethra is carried out much less frequently now, as the effectiveness of the mid-urethral slings is comparable with a lower risk of

complications and more rapid postoperative recovery.

Bulking injections

Periurethral injection of bulking agents (such as collagen) may be used in refractory cases or

for women unfit for surgery. These agents augment the urethral wall and increase resistance

to urinary leakage.

Medical management

Duloxetine is a serotonin-norepinephrine reuptake inhibitor (SNRI) which reduces the frequency of episodes of stress incontinence in women declining or otherwise unsuitable for

surgical management.

KEY POINTS

• Stress incontinence is a clinical diagnosis.

• First-line treatment is avoidance of exacerbating factors and pelvic muscle

exercises.

• Urodynamic stress incontinence should be confirmed prior to surgery.