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Clean intermittent catheterization
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Levator ani strengthening
Mirabegron use
Oxybutynin use
Topical estrogen application
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This patient who presents with small volume incontinence only during the day when she laughs or sneezes most likely has stress incontinence. The first-line treatment for stress urinary incontinence is Kegel exercises that function by strengthening the levator ani complex. Stress incontinence is a form of urinary incontinence that presents primarily during episodes of increased intra-abdominal pressure such as coughing, sneezing, laughing, and physical exertion. Importantly, since the abdomen is relaxed during sleep, these patients will not have any nocturnal incontinence. This form of incontinence may be secondary to a number of factors such as weakened pelvic floor muscles due to multiple vaginal deliveries, poor intrinsic sphincter function, or increased urethral mobility. Diagnosis can be aided by a bladder stress test. In all cases of stress incontinence, the first-line treatment is strengthening the pelvic floor muscles via Kegel exercises. Other treatments can include topical estrogen for post-menopausal women, placement of a pessary, and creation of a mid-urethral sling. Jochum et al. studied the effectiveness of using a biofeedback Kegel trainer in patients with stress urinary incontinence. They found that the use of these devices improves the quality of life in most patients. They recommend consideration of Kegel trainer usage. Incorrect Answers: Answer 1: Clean intermittent catheterization is the first-line treatment for overflow incontinence. This disease would present with urine loss without warning or triggers due to decreased function of the detrusor muscle resulting in the accumulation of large urine volumes in the bladder. Answers 3 & 4: Mirabegron is a beta-3-adrenergic agonist and oxybutynin is an anticholinergic medication that are both widely used in the treatment of urge incontinence. This disease would present with frequent urinary leakage after experiencing an urge that would also occur at night. It is caused by detrusor muscle over-stimulation such that patients cannot make it to the bathroom in time. Answer 5: Topical estrogen application can also be helpful in the treatment of stress incontinence in post-menopausal women since atrophy of the genitourinary system can occur in the absence of estrogen production; however, it would not be indicated in this 35-year-old woman. Bullet Summary: Kegel exercises improve symptoms of stress incontinence by strengthening the muscles of the levator ani complex.
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