A 52-year-old woman comes to the office for an annual examination. The patient reports increased urinary frequency and involuntary leakage of urine for the past several years. The leakage occurs when she stands up, sneezes, or coughs. The patient manages the leakage by wearing a pad, but for the past 6 months she has needed to use 2 or 3 pads daily. She reports no dysuria or hematuria. The patient has type 2 diabetes mellitus that she manages with diet and oral medication. She has had 3 uncomplicated pregnancies, each resulting in spontaneous vaginal deliveries. The patient has smoked a quarter of a pack of cigarettes daily for the last 30 years and drinks alcohol socially, but she does not use illicit drugs. She drinks 2 cups of coffee each morning and a glass of caffeinated diet soda with dinner. Blood pressure is 130/84 mm Hg and pulse is 76/min. BMI is 29 kg/m². A pelvic examination shows a small anteverted, nontender uterus and no adnexal masses. The vagina is pale and without rugae. During examination, leakage of urine occurs with coughing while lying down and standing. Results of urinalysis are normal. Which of the following additional tests is required prior to recommending treatment for this patient's condition?

Question

Quizplus · Accepted Answer

Explanation: 11ec2b69_c1c7_3121_8f63_13fb083db6b2_MD0005_00 Urinary incontinence, involuntary leakage of urine, causes significant functional and psychological stress; affects quality of life; and can lead to depression, anxiety, social isolation, and sexual dysfunction. Risk factors for urinary incontinence include increased age, history of multiple vaginal deliveries, obesity, vaginal atrophy, tobacco use, and caffeine intake. The initial evaluation of patients with urinary incontinence involves a thorough history, physical examination, and urinalysis. Reversible underlying causes of urinary incontinence (eg, excessive fluid intake, stool impaction, medications, delirium) are identified. Urinary leakage frequency, pattern, volume, and aggravating and relieving factors are reviewed. Physical examination assesses for vulvovaginal atrophy, pelvic masses, pelvic organ prolapse, and urethral hypermobility. A bladder stress test (leakage of urine with cough/Valsalva) is performed for evaluation of stress urinary incontinence, as with this patient. Urinalysis evaluates for underlying pathology, including infection or malignancy. For the majority of patients (including this patient, who has stress incontinence), the initial evaluation is sufficient to classify the type of uncomplicated urinary incontinence (eg, stress, urgency, overflow) and no further evaluation is indicated. Further evaluation is indicated only if the history, physical examination, or urinalysis suggest complicated incontinence (eg, mixed) or underlying pathology. (Choice A) Cystoscopy is indicated in patients with persistent hematuria (eg, malignancy) or bladder pain (eg, tumors, interstitial cystitis); it is not part of the routine urinary incontinence evaluation. (Choices B and D) Overflow incontinence is typically a complication of poorly controlled diabetes mellitus (eg, diabetic neuropathy) and presents with constant urinary dribbling from incomplete bladder emptying. Patients with features of overflow incontinence (eg, peripheral or perineal neuropathy) are evaluated with a post-void residual volume (>200 mL is diagnostic of overflow incontinence). Additional evaluation with a hemoglobin A1c can be performed to either diagnose diabetes mellitus or assess blood glucose control. This patient has no features of overflow incontinence; therefore, neither a post-void residual volume nor hemoglobin A1c is indicated. (Choice E) Urodynamic testing evaluates urethral and bladder function and pressure and is indicated in the evaluation of mixed or complicated urinary incontinence. Educational objective: Uncomplicated urinary incontinence can be diagnosed and classified via history, physical examination, and urinalysis. Further evaluation is indicated only if there is concern for additional underlying pathology. References: Diagnosis of urinary incontinence. (http://www.ncbi.nlm.nih.gov/pubmed/23668444) Clinical management of urinary incontinence in women. (http://www.ncbi.nlm.nih.gov/pubmed/23668526)

A 52-Year-Old Woman Comes to the Office for an Annual