Question of the Week # 401

401)  A 78 year old woman presents for annual health-maintenance examination. Her medical problems include Hypertension, Diabetes, Coronary artery disease and Chronic obstructive pulmonary disease. During review of systems, she reports that she has been experiencing involuntary loss of urine upon coughing almost daily for few months. She has been too embarrassed to disclose it and so, has not mentioned it during previous visits. However, the problem has been limiting her social activities and she really would like to “do something about it”. She denies any nocturia, frequency, hesitancy or urgency symptoms. Her medications include albuterol, ipratropium, glyburide, clopidogrel and losartan. She had a myocardial infarction followed by coronary stent placement six months ago. On examination, vitals are stable. Pelvic examination reveals changes consistent with vaginal atrophy and presence of moderate cystocele.   She has marked urinary leakage when she was asked to cough in lithotomy position. She has tried pelvic floor exercises and scheduled-voiding for past several weeks and has cut down on her coffee consumption however, these measures have not helped her much.  Complete blood count, Plasma glucose, Serum electrolytes and Urinalysis are within normal limits. Which of the following is the most appropriate recommendation for this patient?

A) Check Post-Void Residual volume

B) Vaginal Estrogen

C) Pessary

D) Mid-Urethral Sling placement

E) Oxybutynin

16 Responses

  1. b

  2. B?

    • Why would you do “D” first? – what is the correct answer to this?

    • For the above question on SUI ( Stress Urinary incontinence), the correct answer is C – Pessary. This patient has SUI from the history and also has a concomitant cystocele ( Level 2 Prolapse). Her symptoms are from SUI rather than prolapse and she may benefit from SUI procedure alone such as mid-urerthral sling. Though mid-urethral sling is a minimally invasive procedure , the complications are higher in patients with multiple co-morbidities. The patient in the question has multiple issues along with a coronary stent placement recently and is also on plavix. Withholding plavix prior to surgery increases her peri-operative risk of having another MI . Such measures can be done if the benefits of surgery outweighs the risk. But in her case , risks outweigh benefits . It is also possible that she might need cystocele repair in future if it worsens and causes obstructive urinary symptoms. So, choosing a pessary is non-invasive, relatively safe, inexpensive and will address bother her SUI as well as Cystocele and is a better choice in her case ( given her age, severe co morbidities and recent coronary disease). Always, when you evaluate geriatric patients for surgery, look in the question if they can be medically cleared. If the risk of surgery outweighs benefits, they should not be cleared and conservative option should be offered.
      Vaginal estrogen may offer some mild benefit in SUI and systemic estrogens actually worsen the SUI as per studies. If the patient has symptoms of vaginal atrophy ( bleeding, dyspareunia, vaginal dryness); this can be used but it doe snot benefit her SUI much.

  3. B. vaginal estrogen


    “C” is the answer

  5. c? she has 78 y/o with a lot of comorbid condition dont think that estrogen can work here.

  6. D

  7. C) Pessary- She has both vaginal atrophy and pelvic floor relaxation (cystocele) contributing to her Stress incontinence -first try all possible non-surgical treatments. Kegel exercises did not help so Vaginal estrogen would be the NEXT best step but the most appropriate treatment at this time would be to recommend a Pessary. If this failed then go for Urethropexy.
    Pessary because she has marked urinary leakage with cystocele which would probably not resolve only with vaginal estrogen.

  8. This woman has stress incontinence and kegel’s have not worked. So I would now try vaginal estrogen?

  9. C

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