A 58-year-old woman presents to the GP with concerns regarding difficulties with urination. She reports leakage of urine when she coughs, sneezes, or lifts heavy objects. Due to this, she has had to avoid going out and reduce outdoor activities. She previously had two normal vaginal deliveries.

On physical examination, a well-supported uterus and vaginal atrophy are noted. A urinalysis is unremarkable.

What is the most appropriate initial step in her management?

Options:
explanation: Oxybutynin is a medication used to treat **urge incontinence**, or 'overactive bladder'. It works by relaxing the muscles of the bladder and preventing involuntary contractions. If the patient's symptoms persist despite bladder training and frequency being a significant issue, encourage her to continue with bladder training and consider adding oxybutynin as a first-line treatment option.
name: Oxybutynin
label: d
answer: no
explanation: Duloxetine is a selective serotonin and norepinephrine reuptake inhibitor (SSNRI) that is also used to treat **stress incontinence**. It works by inhibiting the reuptake of serotonin and norepinephrine in the brain, which can improve muscle tone in the pelvic floor and reduce leakage. However, pelvic floor exercises are generally the first line of treatment for stress incontinence, and duloxetine is typically reserved for patients who have not responded to pelvic floor muscle training. Therefore, duloxetine is considered a second-line treatment option for the patient, but only if she prefers medication to surgery or is not a suitable candidate for surgery.
name: Duloxetine
label: c
answer: no
explanation: Oestrogen therapy is used to treat symptoms of vaginal atrophy, which is thinning and inflammation of the vaginal lining that can occur due to a lack of oestrogen. It is often used to treat symptoms such as dryness, itching, and painful intercourse that can occur after menopause. While it may benefit the patient's vaginal atrophy, it is not explicitly targeted at her urinary incontinence and is not the most appropriate initial step in her management.
name: Intravaginal oestrogen therapy
label: e
answer: no
explanation: Pelvic floor exercises, also known as 'Kegel exercises', involve contracting and relaxing the pelvic floor muscles to improve muscle strength and tone. They are an effective treatment for **stress incontinence**, characterised by urine leakage during activities that increase intra-abdominal pressure, such as coughing, sneezing, or lifting heavy objects. Refer the patient to an appropriate specialist for supervised pelvic floor muscle training (PFMT) for a minimum of 3 months. The patient should perform **a minimum of 8 pelvic floor muscle contractions at least three times daily**.
name: Pelvic floor exercises
label: a
answer: yes
explanation: Bladder training (at least six weeks) involves retraining the bladder to hold more urine for extended periods and emptying it at scheduled intervals. It is often used to treat urinary incontinence caused by **urge incontinence**, characterised by a strong, sudden urge to urinate and frequent urination. However, in this case, the patient's symptoms are consistent with stress incontinence rather than urge incontinence (or 'overactive bladder'), and bladder training is not the most appropriate initial step in her management.
name: Bladder training
label: b
answer: no

Correct answer: a