What medication should be given to a patient with stress urinary incontinence (SUI) experiencing incontinence when coughing?

Management of Stress Urinary Incontinence with Coughing

For patients with stress urinary incontinence who experience leakage when coughing, pelvic floor muscle training (PFMT) is the first-line treatment, not medication. 1

Understanding Stress Urinary Incontinence (SUI)

Stress urinary incontinence is characterized by involuntary urine loss during activities that increase abdominal pressure, such as coughing, sneezing, or physical exertion. This occurs due to urethral sphincter failure associated with intra-abdominal pressure, resulting in the inability to retain urine 1.

Treatment Algorithm

First-Line Treatment:

1. Pelvic Floor Muscle Training (PFMT)
   • The American College of Physicians strongly recommends PFMT as first-line treatment for stress UI based on high-quality evidence 1
   • PFMT involves voluntary contraction of pelvic floor muscles (Kegel exercises)
   • Significantly improves continence rates and quality of life in women with stress UI
   • Has few adverse effects compared to pharmacological options

For Overweight/Obese Patients:

• Weight loss and exercise are strongly recommended (moderate-quality evidence) 1
• Reduces intra-abdominal pressure that contributes to leakage during coughing

Pharmacological Treatment:

• Systemic pharmacologic therapy is NOT recommended for stress UI (strong recommendation, low-quality evidence) 1
• Medications commonly used for urgency UI have not been shown to be effective for stress UI
• While duloxetine (a serotonin-norepinephrine reuptake inhibitor) has been studied for SUI 2, 3, it is not approved for this indication in many countries and is not recommended as first-line treatment

If Conservative Measures Fail:

• Consider surgical options (not covered in this response but mentioned in guidelines) 1
• Surgical approaches may be considered when non-surgical management fails to provide adequate symptom relief

Efficacy of Treatments

• PFMT has demonstrated high success rates (81-90% cured/dry rates) for stress UI 1
• Vaginal estrogen formulations may improve continence in some cases, but transdermal estrogen patches can worsen UI 1
• Duloxetine has shown some efficacy in reducing incontinence episodes but has significant side effects, with nausea being the most common 2, 4

Important Considerations

• Proper technique for PFMT is crucial for effectiveness
• Patient education about avoiding triggers (like coughing without pelvic floor muscle contraction)
• Addressing modifiable risk factors such as obesity, smoking (which can cause chronic cough), and constipation
• Evaluating for and treating any urinary tract infections that may exacerbate symptoms

Common Pitfalls to Avoid

1. Inappropriate medication use: Prescribing anticholinergics (effective for urgency UI) for stress UI, where they have not shown efficacy
2. Delaying non-pharmacological interventions: PFMT should be initiated promptly rather than waiting for medication trials
3. Inadequate PFMT instruction: Patients need proper instruction on correct technique for effective results
4. Overlooking comorbidities: Chronic cough from conditions like asthma, COPD, or ACE inhibitor use should be addressed as they can worsen SUI

By following this evidence-based approach prioritizing PFMT as first-line treatment, most patients with stress urinary incontinence triggered by coughing can achieve significant improvement in their symptoms and quality of life.