A 42-year-old man with a long history of type 1 diabetes mellitus comes to the office due to frequent involuntary loss of urine. For the past several months, he has been having difficulty starting and maintaining a urinary stream. In the last 3 weeks, he has had 2 episodes of nocturnal enuresis and multiple daytime episodes of uncontrolled voiding without any sensation of a full bladder. His other medical problems include chronic kidney disease and gastroparesis. He does not use tobacco or alcohol. Which of the following additional findings would most likely be present in this patient?

Question

A 42-year-old man with a long history of type 1 diabetes mellitus comes to the office due to frequent involuntary loss of urine.  For the past several months, he has been having difficulty starting and maintaining a urinary stream.  In the last 3 weeks, he has had 2 episodes of nocturnal enuresis and multiple daytime episodes of uncontrolled voiding without any sensation of a full bladder.  His other medical problems include chronic kidney disease and gastroparesis.  He does not use tobacco or alcohol.  Which of the following additional findings would most likely be present in this patient?

Quizplus · Accepted Answer

This patient's findings suggest overflow incontinence, which is mainly due to impaired detrusor contractility or bladder outlet obstruction (eg, tumor obstructing the urethra). Patients usually develop involuntary and continuous urinary leakage when the bladder is full and often have incomplete emptying. This patient's overflow incontinence is most likely due to diabetic autonomic neuropathy affecting detrusor muscle innervation, which is common in type 1 diabetics. Patients initially have infrequent urination due to loss of autonomic afferent innervation and inability to sense a full bladder. Involvement of efferent fibers to the bladder subsequently causes incomplete emptying. Patients can develop recurrent urinary tract infections (UTIs) and overflow incontinence with poor urinary stream and dribbling. Pelvic floor relaxation at night combined with a full bladder can lead to nocturnal enuresis. Postvoid residual (PVR) testing with ultrasound or catheterization can confirm inadequate bladder emptying. (Choice A) Enlarged prostate on rectal examination may indicate either benign prostatic hyperplasia or prostate cancer, which causes urge incontinence (bladder irritation from the enlarged prostate) or overflow incontinence (urethral obstruction). However, these conditions are commonly seen in older individuals (age >50-60). (Choice C) Loss of sensation in the perineal area (saddle anesthesia) can indicate cauda equina syndrome, which is commonly due to epidural cord compression from a malignancy. Patients usually develop urinary retention late in the course of the disease, usually associated with fecal incontinence. (Choices D and E) Cognitive impairment (mini-mental status examination score <22) is often seen in normal pressure hydrocephalus, and lower extremity hyperreflexia would suggest spinal cord disease. Both of these conditions can cause loss of central nervous system inhibition of detrusor contraction, leading to urge incontinence. Urge incontinence is characterized by a sudden desire to urinate. However, absence of other symptoms (eg, gait disturbance) in this patient makes these conditions less likely. Educational objective: Diabetic autonomic neuropathy is common in type 1 diabetics and can cause overflow incontinence due to inability to sense a full bladder and incomplete emptying. Postvoid residual (PVR) testing with ultrasound or catheterization can confirm inadequate bladder emptying. __________ References: Diagnosis of urinary incontinence. (http://www.ncbi.nlm.nih.gov/pubmed/23668444)

A 42-Year-Old Man with a Long History of Type 1