Pharmacology and Non-Surgical Management
What you must know
Know drug classes and their key adverse effects: antimuscarinics (dry mouth, constipation, cognitive impairment, urinary retention), beta-3 agonists (hypertension, headache), local vaginal estrogen (minimal systemic absorption; endometrial safety generally reassuring), and antibiotics (allergy, C. difficile, resistance). Understand pessary types and fitting (ring, Gellhorn, cube; support vs space-filling), maintenance, and complications (erosion, discharge, fistula).
Non-surgical management: pelvic floor muscle training (with biofeedback), bladder training, timed voiding, fluid and caffeine modification, weight loss, constipation management, and behavioral strategies. Know that conservative therapy is first line for stress and urgency incontinence and for prolapse.
Understand medication reconciliation and interactions: anticholinergics in older adults (Beers criteria), beta-3 agonists with uncontrolled hypertension, and estrogen contraindications (breast cancer history - coordinate with oncology).
Traps
Choosing surgery before conservative therapy in uncomplicated cases. Prescribing antimuscarinics to a patient with cognitive impairment or retention. Assuming local estrogen is contraindicated in all breast cancer survivors - coordinate rather than automatically refuse. Forgetting pessary follow-up.
Rule of thumb
"Start conservative, start low, and check the medication list for anticholinergic burden."
Worked example: An older patient on multiple anticholinergic medications develops confusion after starting oxybutynin. The right move is to reduce anticholinergic burden - consider a beta-3 agonist or non-drug therapy.