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Overactive bladder with genitourinary syndrome of menopause — MSRA MCQ

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HardLUTSOveractive bladder with genitourinary syndrome of menopauseMSRA

A 64-year-old woman presents with 8 months of urinary urgency, daytime frequency and urge urinary incontinence. A 3-day bladder diary records 12 small-volume voids daily, each preceded by urgency; nocturnal urine volume is 21% of her 24-hour output. Urine culture is negative and post-void residual volume is 40 mL. She has completed a supervised 6-week bladder-training programme and reduced caffeine intake without sufficient benefit. She also reports vaginal dryness, superficial dyspareunia and intermittent dysuria despite negative urine cultures. Examination shows pale, thin vaginal epithelium with loss of rugae; there is no prolapse. She has no personal history of breast cancer or unexplained vaginal bleeding. She has untreated narrow-angle glaucoma. Her blood pressure is 184/112 mmHg on repeat measurement, and urgent hypertension assessment has been arranged. What is the most appropriate initial pharmacological management for her urinary symptoms?

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Correct answer: D — Begin local vaginal oestrogen

This woman has overactive bladder (OAB): urgency precedes urge urinary incontinence, voids are small, and the diary does not show nocturnal polyuria. Infection and clinically significant incomplete emptying have also been excluded. Crucially, she has genitourinary symptoms and signs associated with menopause, including vaginal dryness, superficial dyspareunia and atrophic vaginal epithelium. NICE recommends offering vaginal oestrogen to women with OAB symptoms and menopausal genitourinary symptoms or signs. A beta-3-adrenoceptor agonist is not the best next step here. Mirabegron is contraindicated in severe uncontrolled hypertension, defined as blood pressure of at least 180/110 mmHg; her measured pressure exceeds this threshold. An oral antimuscarinic is plausible for OAB after bladder training, but is inappropriate with untreated narrow-angle glaucoma and would not directly treat her coexisting genitourinary syndrome of menopause. Systemic HRT should not be prescribed solely to treat urinary incontinence. Desmopressin is for troublesome nocturia in selected patients; she does not have nocturnal polyuria and has severe hypertension.

Reference: Urinary incontinence and pelvic organ prolapse in women: management (NG123), recommendation 1.4.37 (2019; current page checked 16 August 2026) — https://www.nice.org.uk/guidance/ng123/chapter/recommendations Mirabegron Astellas 50 mg prolonged-release tablets: Summary of Product Characteristics, sections 4.3 and 4.4 (2026; checked 16 August 2026) — https://www.medicines.org.uk/emc/product/7540/smpc Urinary incontinence and pelvic organ prolapse in women: management (NG123), recommendations 1.4.34 and 1.4.36 (2019; current page checked 16 August 2026) — https://www.nice.org.uk/guidance/ng123/chapter/recommendations