A 49-year-old woman, gravida 5 para 5, comes to the office due to involuntary, intermittent loss of urine over the past 5 months. The patient is an avid jogger and now must wear absorbent pads while jogging. She has no dysuria, urgency, or hematuria and usually awakens once a night to void. Three years ago, the patient was diagnosed with type 2 diabetes mellitus, which is treated with metformin. She does not use tobacco, alcohol, or illicit drugs. Vital signs are normal. BMI is 31 kg/m². Pelvic examination shows normal external genitalia, a well-rugated vagina, and an anterior vaginal bulge. The patient loses a small amount of urine when asked to cough. Postvoid residual urine volume is 40 mL. Clean-catch urinalysis results are as follows: Serum hemoglobin A1c is 7.7%. Which of the following is the most likely cause of this patient's symptoms?

Question

Quizplus · Accepted Answer

11ec25c8_d9e5_de08_bc81_6556de5b1ee8_MD0003_00 This patient has stress urinary incontinence, a common cause of incontinence in women. The bladder and urethra are normally maintained in the appropriate anatomic position by the pelvic floor (levator ani) muscles. However, with chronic pressure or injury to the pelvic floor muscles-commonly due to childbirth (ie, multiparity), obesity, or chronic high-impact exercise such as jogging (as in this patient)-women can develop pelvic floor muscle weakness. Substantial weakness of the pelvic floor muscles can result in urethral hypermobility, in which the urethra abnormally moves with increased intraabdominal pressure (eg, jogging, coughing) and is unable to fully close. In addition, inadequate bladder support can develop (ie, prolapse), as evidenced by the anterior vaginal bulge (cystocele) in this patient. Due to both the urethra's inability to fully close and increased bladder pressure, patients have intermittent leakage of urine when intraabdominal pressure is increased (ie, Valsalva). cystocele Urinalysis and postvoid residual volume are normal (<150 mL in women, <50 mL in men). First-line treatment includes pelvic floor muscle exercises (eg, Kegel exercises) and lifestyle modifications (eg, weight loss). Unresponsive cases may require use of a pessary or midurethral sling surgery. (Choices A and C) Bladder outlet obstruction or a neurogenic bladder (due to diabetic neuropathy) can cause overflow incontinence due to bladder overdistension from incomplete bladder emptying. In contrast to this patient, those with overflow incontinence have continuous dribbling of urine and markedly elevated postvoid residual volume. (Choice B) Detrusor overactivity causes inappropriate bladder spasms associated with urgency incontinence; patients have a sudden need to urinate followed by immediate, involuntary loss of urine. (Choice D) Postmenopausal women may have vulvovaginal atrophy and associated urinary symptoms (eg, frequency, urgency) due to estrogen deficiency. This patient has a well-rugated vagina, suggesting normal estrogen levels. (Choice F) Vesicovaginal fistula, an abnormal communication between the bladder and vagina, is a complication following prolonged labor, pelvic surgery, or pelvic radiation therapy. These patients have constant (rather than intermittent) leakage of urine because the bladder continuously drains through the vagina. Educational objective: Stress urinary incontinence occurs due to weakened pelvic floor muscles that cause urethral hypermobility and reduced bladder support. Patients typically have intermittent loss of urine from increased intraabdominal pressure (eg, jogging). References: Urinary incontinence in women: a review. (http://www.ncbi.nlm.nih.gov/pubmed/29067433) Female voiding dysfunction and urinary incontinence. (http://www.ncbi.nlm.nih.gov/pubmed/29406060) Practice bulletin no. 185: pelvic organ prolapse. (http://www.ncbi.nlm.nih.gov/pubmed/29064965)

A 49-Year-Old Woman, Gravida 5 Para 5, Comes to the Office