Review Note

A 40-year-old G3P3 comes to your office for a routine annual GYN examination. She tells you that she gets up several times during the night to void. On further questioning, she admits to you that during the day she sometimes gets the urge to void, but sometimes cannot quite make it to the bathroom. She attributes this to getting older and is not extremely concerned, although she often wears a pad when she goes out in case she loses some urine. This patient is very healthy otherwise and does not take any medication on a regular basis. She still has regular, monthly menstrual periods. She has had three normal spontaneous vaginal deliveries of infants weighing between 7 and 8 Ib. An office dipstick of her urine does not indicate any blood, bacteria, WBCs, or protein. Her urine culture is negative. Based on her office presentation and history, which of the following is the most likely diagnosis?

• Urinary stress incontinence Urinary tract infection
  Overflow incontinence
  Bladder dyssynergia
  Vesicovaginal fistula
  

Bladder dyssynergia
The presentation of the patient in question most consistent with bladder dyssynergia (urge incontinence). Urge incontinence is the involuntary loss of urine associated with a strong desire to void. Most urge incontinence is caused by detrusor or bladder dyssynergia in which there is an involuntary contraction of the bladder during distension with urine. The management of urge incontinence includes bladder training, elimination of excess caffeine and fluid intake, biofeedback, or medical therapy. If conservative measures fail, treatment with anticholinergic drugs (oxybutynin chloride), Bsympathomimetic agonists (metaproterenol sulfate), Valium, antidepressants (imipramine hydrochloride), and dopamine agonists (Parlodel) have been successful. These pharmacologic agents will relax the detrusor muscle. In postmenopausal women who are not on estrogen replacement therapy, estrogen therapy may improve urinary control. Kegel exercises may strengthen the pelvic musculature and improve bladder control in women with stress urinary incontinence.

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