A 60-year-old woman comes to the clinic due to the persistent feeling of "always having to go to the bathroom." For the past 3 years, the patient has had urinary urgency followed by involuntary loss of urine 2 or 3 times per day. She has dysuria and nocturia and sometimes awakens to find her undergarments wet but she does not lose urine with coughing or sneezing. Menopause occurred at age 52 when a total laparoscopic hysterectomy with bilateral salpingo-oophorectomy was performed for endometrial adenocarcinoma. Medical history is significant for recurrent urinary tract infections during the past year. The patient is not sexually active and takes no medications. On physical examination, the vulvar skin shows reduced elasticity with labia minora retraction. The vaginal epithelium is smooth, dry, and has areas of patchy erythema. On Valsalva maneuver, there is no loss of urine. Urinalysis and postvoid residual urine testing are normal. Which of the following is the most likely cause of this patient's urinary symptoms?

Question

A 60-year-old woman comes to the clinic due to the persistent feeling of "always having to go to the bathroom."  For the past 3 years, the patient has had urinary urgency followed by involuntary loss of urine 2 or 3 times per day.  She has dysuria and nocturia and sometimes awakens to find her undergarments wet but she does not lose urine with coughing or sneezing.  Menopause occurred at age 52 when a total laparoscopic hysterectomy with bilateral salpingo-oophorectomy was performed for endometrial adenocarcinoma.  Medical history is significant for recurrent urinary tract infections during the past year.  The patient is not sexually active and takes no medications.  On physical examination, the vulvar skin shows reduced elasticity with labia minora retraction.  The vaginal epithelium is smooth, dry, and has areas of patchy erythema.  On Valsalva maneuver, there is no loss of urine.  Urinalysis and postvoid residual urine testing are normal.  Which of the following is the most likely cause of this patient's urinary symptoms?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d9f0_b38a_bc81_5538391ef7b4_MD0003_00 This patient's urinary symptoms and vulvovaginal atrophy are due to the genitourinary syndrome of menopause (or atrophic vaginitis). Both age-related ovarian follicle depletion (ie, menopause) and surgical removal of the ovaries (eg, bilateral salpingo-oophorectomy) result in an estrogen deficiency that affects the urogenital tissue and causes the associated urinary symptoms of atrophic vaginitis: Decreased collagen, elasticity, and blood flow in the bladder trigone and urethra (which are estrogen-sensitive tissues) result in urogenital atrophy, which can induce urgency incontinence (urgency followed by immediate loss of urine), often causing wet undergarments and nocturia (as seen in this patient). Decreased glycogen content results in loss of vaginal lactobacilli and an elevated vaginal pH, which increase the risk of recurrent urinary tract infections. At the vulva, decreased glycogen content results in a thin, easily denuded vulvovaginal epithelium that causes dysuria when in contact with urine. Additional clinical features of atrophic vaginitis include reduced vulvar elasticity; labial retraction; and a smooth, nonrugated vaginal epithelium with areas of patchy erythema. First-line treatment is with nonhormonal moisturizers and lubricants. Vaginal estrogen is indicated in patients with no symptom relief or in those with severe symptoms. (Choice A) Chronic bladder pain syndrome (ie, interstitial cystitis) is an idiopathic bladder pain syndrome associated with urinary frequency and urgency. Patients have bladder pain that worsens with filling and is relieved with emptying. There is typically no associated urinary incontinence, making this diagnosis unlikely. (Choice C) Patients with overflow incontinence have a persistently full, distended bladder that causes continuous loss of urine (dribbling) due to incomplete bladder emptying (ie, high postvoid residual volume). This patient's postvoid residual is normal. (Choice D) Urethral hypermobility is a cause of stress urinary incontinence, which presents with intermittent urine loss with increased intraabdominal pressure (eg, cough, sneeze). This patient has no loss of urine with Valsalva maneuver, making this diagnosis unlikely. (Choice E) Vesicovaginal fistula leads to continuous urine leakage through an abnormal connection from the bladder to the vagina, typically presenting within months after pelvic surgery (eg, hysterectomy). This patient does not have continuous leakage of urine. Vesicovaginal fistula Educational objective: Genitourinary syndrome of menopause causes an estrogen deficiency that results in urogenital atrophy and can present with multiple urinary symptoms (eg, dysuria, urgency incontinence, recurrent urinary tract infections). Treatment is with nonhormonal moisturizers; vaginal estrogen is prescribed for nonimproving or severe symptoms. References: The role of local estrogen therapy in the management of pelvic floor disorders. (http://www.ncbi.nlm.nih.gov/pubmed/26830033) Treatment of the genitourinary syndrome of menopause. (http://www.ncbi.nlm.nih.gov/pubmed/26366797) Genitourinary syndrome of menopause. (http://www.ncbi.nlm.nih.gov/pubmed/29787390)

A 60-Year-Old Woman Comes to the Clinic Due to the Persistent