From the Guidelines
The most appropriate initial non-pharmacological management for this patient is to instruct her to start with bladder training, as it is a strongly recommended approach for women with urgency UI, according to the American College of Physicians guideline 1. This approach involves having the patient gradually increase the intervals between voiding over a period of time, in order to improve bladder capacity and reduce symptoms of urgency and frequency. The patient's symptoms of urinary frequency, urgency, and nocturia, in the context of her type 2 diabetes mellitus and hypertension, suggest that she may have an overactive bladder, and bladder training is a well-established non-pharmacological treatment for this condition, as supported by the AUA/SUFU guideline 1. Other options like pelvic floor muscle training (PFMT) may also be beneficial, especially if the patient has mixed UI, as PFMT combined with bladder training has been shown to achieve continence and improve UI in women with mixed UI 1. However, bladder training is a more appropriate initial approach, as it is a simple and non-invasive technique that can be started immediately, and it can help to establish a baseline for further treatment. Additionally, the patient's refusal to take additional medication makes non-pharmacological approaches like bladder training even more appealing, as they can help to improve symptoms without the need for additional medications. It is also important to note that weight loss and exercise can also be beneficial for women with UI, especially if they are obese, as supported by the American College of Physicians guideline 1, but in this case, the patient's symptoms and medical history suggest that bladder training should be the initial approach.
From the Research
Initial Non-Pharmacological Management
The most appropriate initial non-pharmacological management for a 74-year-old woman with urinary frequency, urgency, and nocturia, who has type 2 diabetes mellitus (T2DM) and hypertension (HTN), and refuses to take additional medication, includes:
- Behavioral modification, such as bladder training and pelvic floor muscle exercises (Kegel exercises) 2, 3, 4, 5
- Lifestyle changes, such as modifying fluid intake and voiding habits 4, 6
Rationale
These non-pharmacological approaches are recommended as first-line treatments for urinary incontinence, including urge and mixed incontinence, due to their efficacy and low risk of adverse effects 3, 4, 5. Pelvic floor muscle training, in particular, has been shown to be effective in reducing symptoms of urgency, frequency, and nocturia 5. Additionally, behavioral and lifestyle modifications can be tailored to the individual's needs and preferences, making them a suitable option for someone who refuses to take additional medication.
Considerations
It is essential to note that the management of urinary incontinence should be individualized, taking into account the patient's medical history, cognitive function, and physical abilities 2, 3. A stepped-care approach, advancing from least invasive to more invasive interventions, is recommended to ensure the most effective and appropriate treatment 3. In this case, non-pharmacological management is a suitable initial approach, given the patient's refusal to take additional medication and the presence of comorbidities such as T2DM and HTN.