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 laugh-ing. 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 laparo-scopic sterilization. There is no other relevant medical history and she takes no medica-tions. 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.
Questions
• What is the diagnosis?
• How would you advise and manage this woman?
Medicine
This woman is suffering from stress incontinence. Stress incontinence can be diagnosed from the history – involuntary loss of urine when the intraabdominal 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 pres-sure 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 The two main surgical techniques used currently are:
• transvaginal or transobturator vaginal tape
• colposuspension.
Both are effective but the former technique is minimally invasive and recovery is there-fore more rapid. Alternative techniques such as periurethral bulking injections can be used in refractory cases or where the woman is unsuitable for surgery.
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.
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