A 41-year-old woman comes to the office for evaluation of urinary incontinence. The patient has had intermittent leaking of urine for the past 2 years and now feels like she never empties her bladder completely. She voids every 1-2 hours and still finds her undergarments wet with urine. The patient has no dysuria, constipation, or pelvic pain. Her menses are every 26 days and last 6 days, with heavy bleeding and passage of clots on the first 2 days. She had 3 term vaginal deliveries in her 30s and has had a new sexual partner for the last 6 months. The patient drinks 2 cups of coffee daily and takes a thiazide diuretic for well-controlled chronic hypertension. She does not use tobacco, alcohol, or illicit drugs. Physical examination reveals an enlarged, anteverted, and anteflexed uterus with multiple irregular protrusions. The remainder of the pelvic examination is normal. Which of the following is the most likely cause of this patient's symptoms?

Question

A 41-year-old woman comes to the office for evaluation of urinary incontinence.  The patient has had intermittent leaking of urine for the past 2 years and now feels like she never empties her bladder completely.  She voids every 1-2 hours and still finds her undergarments wet with urine.  The patient has no dysuria, constipation, or pelvic pain.  Her menses are every 26 days and last 6 days, with heavy bleeding and passage of clots on the first 2 days.  She had 3 term vaginal deliveries in her 30s and has had a new sexual partner for the last 6 months.  The patient drinks 2 cups of coffee daily and takes a thiazide diuretic for well-controlled chronic hypertension.  She does not use tobacco, alcohol, or illicit drugs.  Physical examination reveals an enlarged, anteverted, and anteflexed uterus with multiple irregular protrusions.  The remainder of the pelvic examination is normal.  Which of the following is the most likely cause of this patient's symptoms?

Quizplus · Accepted Answer

11ec25c8_d9eb_8363_bc81_21111b2266a0_MD0003_00 This patient with involuntary urine dribbling (eg, undergarments constantly wet) and incomplete bladder emptying despite increased urinary frequency (eg, every 1-2 hours) has overflow incontinence. Overflow incontinence occurs when urine accumulates in the bladder, distends the bladder, and raises the intravesicular pressure higher than the urethral closing pressure, leading to urine leakage. Overflow incontinence Common causes of overflow incontinence are detrusor underactivity (often secondary to peripheral neuropathy [eg, diabetes mellitus]) and bladder outlet obstruction. In this patient with a history of heavy menstrual bleeding and an enlarged uterus with multiple irregular protrusions, the most likely cause of overflow incontinence is bladder outlet obstruction due to uterine fibroids (leiomyomata uteri). leiomyomata uteri Large fibroids can have a direct mass effect on adjacent pelvic organs and alter the position of the uterus. Because the bladder is anterior to the uterus, an anterior uterine fibroid or fibroids causing uterine anteversion and anteflexion (as in this patient) can compress the bladder neck and/or urethra, increasing the urethral closing pressure and leading to urinary retention and overflow incontinence. Diagnosis is with pelvic ultrasound, and definitive treatment of bladder outlet obstruction in these patients is with fibroid reduction (eg, GnRH agonist, surgery). uterine anteversion and anteflexion (Choice A) Bacterial overgrowth in the bladder can lead to cystitis, which can present with urinary frequency, incontinence, and retention (bladder outlet obstruction due to urethral inflammation/edema). However, these symptoms are typically acute rather than chronic, and dysuria is usually present. (Choices C and E) Decreased urethral sphincter tone (ie, intrinsic sphincter deficiency) and insufficient urethral support (ie, urethral hypermobility) are causes of stress urinary incontinence (SUI), the involuntary leakage of urine with increased intraabdominal pressure (eg, coughing, Valsalva). Unlike overflow incontinence, SUI is not associated with constant urine dribbling or incomplete bladder emptying. stress urinary incontinence (Choice D) Increased detrusor muscle contractility is characteristic of urgency incontinence (or overactive bladder syndrome). Urgency incontinence can cause urinary frequency and a feeling of incomplete bladder emptying, but patients classically have a sudden, overwhelming urge to void followed by the immediate, involuntary loss of urine. urgency incontinence Educational objective: Bladder outlet obstruction in women can result from large fibroids compressing the bladder neck and/or urethra. Patients can develop urinary retention and overflow incontinence (eg, persistent urine dribbling, incomplete bladder emptying). References: Female acute urinary retention caused by anterior deflection of the cervix which was augmented by an uterine myoma. (http://www.ncbi.nlm.nih.gov/pubmed/18936006) Acute urinary retention caused by a large impacted leiomyoma. (http://www.ncbi.nlm.nih.gov/pubmed/19333612) Urinary retention and uterine leiomyomas: a case series and systematic review of the literature. (http://www.ncbi.nlm.nih.gov/pubmed/25752469)

A 41-Year-Old Woman Comes to the Office for Evaluation of Urinary