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Stress urinary incontinence — MSRA MCQ

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HardLUTSStress urinary incontinenceMSRA

A 58-year-old woman is reviewed for urinary incontinence. She previously had mixed urinary incontinence, but urgency and frequency resolved after a 6-week supervised bladder-training programme. She now leaks urine several times daily with coughing, running and lifting, without preceding urgency. A 3-day bladder diary and cough stress test support stress-predominant symptoms. Urine dipstick is negative, post-void residual volume is 30 mL, and there is no prolapse or voiding difficulty. She completed 4 months of supervised pelvic floor muscle training with confirmed correct technique and good adherence, without worthwhile improvement. She does not currently wish to consider surgery and requests an oral medicine. She has no liver disease and her eGFR is 68 mL/min/1.73 m². Her blood pressure is 178/108 mmHg today and was 176/106 mmHg at a repeat review 1 week ago despite antihypertensive treatment. What is the most appropriate management plan for her urinary symptoms now?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: C — Defer duloxetine while her hypertension remains uncontrolled, provide containment support and revisit treatment options after blood pressure control

Explanation lettering: D = shown as A · E = shown as D · A = shown as E

Her current problem is stress urinary incontinence: urgency has resolved, and leakage is consistently provoked by exertion without urgency. She has also had an adequate supervised pelvic floor muscle training trial. Duloxetine can be considered as second-line therapy when a woman prefers pharmacological management to surgery, but it must not be initiated in uncontrolled hypertension because of the risk of hypertensive crisis. Therefore, treatment of the uncontrolled blood pressure takes priority and duloxetine should be deferred. ([nice.org.uk](https://www.nice.org.uk/guidance/ng123/chapter/Recommendations?utm_source=openai)) A is initially attractive because the dose escalation is consistent with the SmPC, and she prefers medication, but uncontrolled hypertension is a contraindication to initiation. B and E treat overactive bladder/urgency symptoms, which are no longer the clinically predominant problem; mirabegron would also be inappropriate while blood pressure is uncontrolled. D may help genitourinary symptoms associated with menopause and overactive bladder where these are present, but she has neither genitourinary menopausal symptoms nor ongoing urgency-predominant symptoms. Containment products are appropriate as a coping strategy while the contraindication is addressed and subsequent options are revisited. ([nice.org.uk](https://www.nice.org.uk/guidance/ng123/chapter/Recommendations?utm_source=openai))

Reference: NICE NG123: Urinary incontinence and pelvic organ prolapse in women: management — Recommendations (Last reviewed 26 March 2025) — https://www.nice.org.uk/guidance/ng123/chapter/Recommendations Yentreve 20 mg hard gastro-resistant capsules — Summary of Product Characteristics (2024) — https://www.medicines.org.uk/emc/product/5561/smpc