Answer
B: Pelvic floor muscle training
Critique
Pelvic floor muscle training (PFMT) is most appropriate for this patient. The involuntary loss of urine with sneezing, coughing, laughing, or physical exertion is consistent with stress incontinence. Stress incontinence is thought to be related to anatomic changes in which the support structures of the urethra are weakened (through age, pregnancy and childbirth, or repetitive pelvic floor stress), decreasing the ability of the urethra to maintain adequate pressure to prevent incontinence. Treatment for stress incontinence begins with conservative measures. In this patient, the first-line therapeutic option is bladder training using PFMT in conjunction with weight loss counseling. These measures decrease bladder pressure and increase the pressure generated by the urethra and surrounding tissues.
Weight loss in overweight and obese women generally improves urinary control. An 8% decrease in BMI has been shown to reduce incontinence by 50%. PFMT in women involves learning repetitive exercises (Kegel exercises) to strengthen the voluntary urethral sphincter and levator ani muscles. Outcomes are improved when PFMT is combined with biofeedback and when skilled physical therapists direct the training. Adherence remains an issue, as PFMT must be done repetitively and consistently for best results.
Oxybutynin is one of several available anticholinergic agents approved for treating overactive bladder. It is not indicated for treatment of uncomplicated stress incontinence, nor is pharmacotherapy a first-line therapy for this disorder.
Measurement of postvoid residual urine volume is not necessary in this patient whose presentation is consistent with stress incontinence. Clinical evaluation and history, including the patient's report of frequency, severity, precipitants, and impact on quality of life, are adequate for discriminating among types of incontinence and for making nonsurgical treatment decisions. Voiding diaries are useful in defining symptoms.
Prompted voiding and scheduled toileting may help older patients with functional urinary incontinence. Providing assistance and scheduled toileting are effective for patients who have impaired mobility or cognition, neither of which is present in this patient.
Urodynamic studies are not indicated in women with uncomplicated stress urinary incontinence. Compared with diagnosing the patient based on symptom report, evidence-based reviews indicate that urodynamic studies do not better predict response to treatment.
Key Point
Pelvic floor muscle training, along with other conservative measures such as weight loss, is first-line therapy for women with stress urinary incontinence.
Bibliography
Qaseem A, Dallas P, Forciea MA, et al; Clinical Guidelines Committee of the American College of Physicians. Nonsurgical management of urinary incontinence in women: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2014 Sep;161(6):429-40. [PMID: 25222388]