A 29-year-old woman comes to the clinic for evaluation of leakage of urine. For the past week, the patient has had to urinate every hour and has had leakage of urine while trying to run to the bathroom. She has had no hematuria, dysuria, or flank pain. The patient has no chronic medical conditions and has had no surgeries. She has had 2 vaginal deliveries without complications. The patient drinks multiple cups of coffee and diet soda daily. Temperature is 99 F (37.2 C), blood pressure is 122/76 mm Hg, and pulse is 84/min. BMI is 29 kg/m². On speculum examination, the bladder has no descent, but the patient leaks urine with Valsalva maneuver. Urine dipstick shows: Pregnancy test is negative. Which of the following is the best next step in management of this patient?

Question

A 29-year-old woman comes to the clinic for evaluation of leakage of urine.  For the past week, the patient has had to urinate every hour and has had leakage of urine while trying to run to the bathroom.  She has had no hematuria, dysuria, or flank pain.  The patient has no chronic medical conditions and has had no surgeries.  She has had 2 vaginal deliveries without complications.  The patient drinks multiple cups of coffee and diet soda daily.  Temperature is 99 F (37.2 C), blood pressure is 122/76 mm Hg, and pulse is 84/min.  BMI is 29 kg/m².  On speculum examination, the bladder has no descent, but the patient leaks urine with Valsalva maneuver.  Urine dipstick shows:  Pregnancy test is negative.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d9ea_23d1_bc81_5fed22c885e9_MD0003_00 This patient with leakage of urine also has new-onset urinary frequency and urgency, with urinalysis findings suggestive of a urinary tract infection (UTI). UTIs are common in women due to the short length of the female urethra and its proximity to the vagina and rectum. Although UTI typically causes dysuria, it may also present with more subtle symptoms, including urgency (eg, running to the bathroom), frequency (eg, urinating every hour), and urinary incontinence (eg, leakage of urine) due to bladder spasm. Patients with classic UTI symptoms are treated empirically with no additional evaluation. Those (such as this patient) with more subtle symptoms can undergo urine dipstick or urinalysis testing. Patients with UTIs often have positive leukocyte esterase (indicating white blood cells in the bladder due to cystitis). The presence of nitrites is more variable and depends on inoculation time, pathogen type, and urine pH changes. The most common pathogen, Escherichia coli, typically causes positive nitrites; however, less common pathogens (eg, Staphylococcus saprophyticus) and some home remedies (eg, cranberry juice) can cause a negative nitrite result. Patients with urinary symptoms (eg, urgency, frequency, leakage) and a positive leukocyte esterase are diagnosed with UTI, and first-line treatment is with oral antibiotic therapy (eg, nitrofurantoin, trimethoprim-sulfamethoxazole). (Choices A and C) Continence pessaries and midurethral slings treat stress urinary incontinence, which causes leakage of urine with Valsalva maneuver due to urethral hypermobility (associated with bladder descent) or intrinsic sphincteric deficiency. This patient's acute onset of symptoms and lack of bladder descent make this diagnosis less likely; her leakage with Valsalva maneuver is due to bladder irritation exacerbated by increased intraabdominal pressure. (Choice B) Patients with diabetes mellitus can have urinary symptoms, including urinary frequency (due to hyperglycemia-induced diuresis) and urinary retention (due to neuropathy). This patient's urine dipstick is negative for glucose, making this diagnosis unlikely. (Choice E) Urodynamic testing is typically reserved for patients who have mixed urinary incontinence, complicated urinary incontinence (ie, no response to treatment), or are considering surgical intervention. Educational objective: Urinary tract infections typically cause dysuria, urinary urgency, and frequency but may also present with more subtle symptoms, including acute-onset urinary incontinence due to bladder irritation and spasm. Positive leukocyte esterase on urine dipstick or urinalysis supports the diagnosis. References: Diagnosis and treatment of acute uncomplicated cystitis. (http://www.ncbi.nlm.nih.gov/pubmed/22010614) Urinary incontinence in women: a review. (http://www.ncbi.nlm.nih.gov/pubmed/29067433)

A 29-Year-Old Woman Comes to the Clinic for Evaluation of Leakage