A 48-year-old woman comes to the office with a 6-month history of involuntary passage of a few drops of urine when sneezing or coughing. She has recently been leaking even more urine with minimal activity, which has been embarrassing and has caused her to limit her social activities. The patient has no weakness, numbness, or fecal incontinence. She has a history of hypertension and type 2 diabetes mellitus. She does not use tobacco, alcohol, or illicit drugs. She is married and has 4 children. Her supine blood pressure is 126/82 mm Hg and her upright blood pressure is 120/80 mm Hg. External genitalia examination shows leakage of a small amount of urine from the urethra when the patient is asked to cough. Neurological examination is within normal limits. Which of the following is the most likely cause of her condition?

Question

A 48-year-old woman comes to the office with a 6-month history of involuntary passage of a few drops of urine when sneezing or coughing.  She has recently been leaking even more urine with minimal activity, which has been embarrassing and has caused her to limit her social activities.  The patient has no weakness, numbness, or fecal incontinence.  She has a history of hypertension and type 2 diabetes mellitus.  She does not use tobacco, alcohol, or illicit drugs.  She is married and has 4 children.  Her supine blood pressure is 126/82 mm Hg and her upright blood pressure is 120/80 mm Hg.  External genitalia examination shows leakage of a small amount of urine from the urethra when the patient is asked to cough.  Neurological examination is within normal limits.  Which of the following is the most likely cause of her condition?

Quizplus · Accepted Answer

11ec160b_35de_ae7d_9249_efeb232fd380_MD0001_00 This patient's presentation is consistent with stress incontinence, which is due to urethral sphincter dysfunction. The internal urethral sphincter is mainly smooth muscle controlled by the autonomic nervous system (sympathetic - contraction, parasympathetic - relaxation). The external urethral sphincter (EUS) is mostly pelvic floor skeletal muscle under voluntary control. Bladder emptying is mainly due to detrusor muscle contraction, while continence is maintained by the urethral sphincters. During bladder filling, sympathetic activation closes the internal sphincter and inhibits detrusor contraction. Parasympathetic stimulation causes detrusor muscle contraction and internal sphincter relaxation but the urine is held in check by the EUS. Incompetence of the urethral sphincter (mainly EUS) is a major factor causing incontinence. Stress incontinence is the most common form of incontinence and typically presents after age 45. Patients have brief involuntary urine loss through the dysfunctional or weak urethral sphincter during activities (eg, coughing, sneezing, or vigorous effort) that increase abdominal pressure. It is almost twice as common in women because EUS trauma or pudendal nerve (innervates EUS) injury is common during vaginal child birth. Postmenopausal women have estrogen deficiency, which can cause laxity and weakness of pelvic floor support. Other risk factors for incontinence in women include obesity, co-morbidities (eg, diabetes, stroke), and genitourinary surgery (eg, hysterectomy). (Choices A, C, and E) Overflow incontinence is due to impaired detrusor contractility (eg, diabetic autonomic neuropathy) or bladder outlet obstruction (eg, tumor obstructing urethra) causing incomplete bladder evacuation. Patients usually develop involuntary and continuous urinary leakage when the pressure inside the full bladder exceeds that of the sphincters. This patient's symptoms with activity and sneezing make these less likely. (Choices B and D) Urge incontinence is due to detrusor overactivity that causes a sudden and/or frequent urge to urinate and empty the bladder. Triggers can include running water, hand washing, or exposure to cold weather. Loss of inhibitory central nervous system input to the bladder, due to frontal lobe and internal capsule infarcts, commonly cause detrusor hyperreflexia and urge incontinence. This patient's absence of a sudden urge to urinate makes these less likely. Educational objective: Stress incontinence is due to loss of pelvic floor support and incompetence of the urethral sphincter. Increased abdominal pressure (eg, coughing, sneezing, or vigorous effort) greater than the urethral sphincter pressure can cause brief involuntary urine loss, which is virtually diagnostic of stress incontinence. __________ References: Stress Urinary Incontinence in Women: Diagnosis and Medical Management. (http://www.ncbi.nlm.nih.gov/pubmed/16614684)

A 48-Year-Old Woman Comes to the Office with a 6-Month