A 49-year-old woman, gravida 1 para 1, comes to the office due to leakage of urine. The patient first noticed intermittent loss of urine a few years ago. The leakage has progressively worsened and now she is constantly leaking a small amount of urine. The patient soaks through a thin incontinence pad 2 or 3 times a day. She has no dysuria, hematuria, or urge to void.
The patient has type 1 diabetes mellitus managed with an insulin pump. Her last hemoglobin A1c was 10.4%. At age 30 she had an operative vaginal delivery complicated by a large perineal laceration. She does not use tobacco, alcohol, or illicit drugs.
Vital signs are normal. Pelvic examination reveals leakage of urine that increases with Valsalva. Postvoid residual volume is increased. There is decreased sensation to light touch and pinprick involving the perineum and both feet.
Laboratory results are as follows:
Which of the following is the best next step in management of this patient?

Question

A 49-year-old woman, gravida 1 para 1, comes to the office due to leakage of urine.  The patient first noticed intermittent loss of urine a few years ago.  The leakage has progressively worsened and now she is constantly leaking a small amount of urine.  The patient soaks through a thin incontinence pad 2 or 3 times a day.  She has no dysuria, hematuria, or urge to void.
The patient has type 1 diabetes mellitus managed with an insulin pump.  Her last hemoglobin A1c was 10.4%.  At age 30 she had an operative vaginal delivery complicated by a large perineal laceration.  She does not use tobacco, alcohol, or illicit drugs.
Vital signs are normal.  Pelvic examination reveals leakage of urine that increases with Valsalva.  Postvoid residual volume is increased.  There is decreased sensation to light touch and pinprick involving the perineum and both feet.
Laboratory results are as follows:
 Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_97e9_9dc6_853d_bb22cb24b520_MD0002_00 Patients with overflow incontinence often have poor urine stream, dribbling, sensation of incomplete emptying, and nocturia. This is due to continuous leakage of urine from persistent urinary retention caused by either: Outflow obstruction - incomplete bladder emptying due to compression of the urethra, often by uterine fibroids or severe pelvic organ prolapsePoor detrusor function - decreased bladder contractility due to advancing age, medications (eg, anticholinergics), spinal pathology (eg, spinal stenosis), and neuropathy (eg, diabetes mellitus) Outflow obstruction - incomplete bladder emptying due to compression of the urethra, often by uterine fibroids or severe pelvic organ prolapse Outflow obstruction - incomplete bladder emptying due to compression of the urethra, often by uterine fibroids or severe pelvic organ prolapse Poor detrusor function - decreased bladder contractility due to advancing age, medications (eg, anticholinergics), spinal pathology (eg, spinal stenosis), and neuropathy (eg, diabetes mellitus) Poor detrusor function - decreased bladder contractility due to advancing age, medications (eg, anticholinergics), spinal pathology (eg, spinal stenosis), and neuropathy (eg, diabetes mellitus) Patients with poorly controlled diabetes develop neuropathies (eg, decreased pinprick sensation), causing loss of the sensation of bladder fullness and incomplete voiding that in turn leads to urinary retention. Chronic urinary retention increases the risk for urinary tract infection and renal damage; therefore, patients require intermittent self-catheterization. Additional treatment includes cholinergic agonists (eg, bethanechol) and correction of underlying causes (eg, optimization of hemoglobin A1c, correction of prolapse). (Choices B and C) Patients with stress urinary incontinence have increased leakage of urine with Valsalva; however, they do not have an associated elevated post residual volume. Stress urinary incontinence is treated with lifestyle modifications (eg, weight loss, smoking cessation), pelvic floor muscle exercises (eg, Kegel exercises), and midurethral slings. Strengthening the pelvic floor prevents urethral hypermobility and decreases leakage with Valsalva (eg, sneezing, coughing). Midurethral slings are reserved for patients who fail lifestyle modifications and pelvic floor therapy. (Choice D) Suprapubic catheters can be used in cases of severe urinary retention; however, indwelling catheters increase the risk of urinary tract infection and antibiotic resistance. (Choice E) Tolterodine is an antimuscarinic that inhibits bladder contractions and is used to treat urgency incontinence. Patients with urgency incontinence have a sudden need to urinate (eg, overactive bladder) followed by immediate involuntary loss of urine. Educational objective: Overflow incontinence presents with continuous leakage of urine secondary to urinary retention caused by underactive detrusor function (eg, diabetes mellitus) or outflow obstruction (eg, pelvic organ prolapse). Treatment focuses on correcting reversible causes, cholinergic agonists, and intermittent self-catheterization. __________ References: An overview of urinary incontinence. (http://www.ncbi.nlm.nih.gov/pubmed/27734727) New treatments for incontinence. (http://www.ncbi.nlm.nih.gov/pubmed/26088072)

A 49-Year-Old Woman, Gravida 1 Para 1, Comes to the Office