We’re back with a USMLE® Step 2 CK Question of the Day! Today’s case involves a 31-year-old woman with urinary incontinence. Which of the following interventions is used in treating this patient’s condition?
A 31-year-old woman has come to an outpatient clinic for urinary incontinence over the past week. Since the symptoms began, she reports urinating on herself before having time to reach the bathroom. Past medical history is notable for an episode of transient acute vision loss in her left eye and an episode of left-arm weakness that self-resolved after two weeks. She works as a news reporter and drinks 3-4 cups of coffee per day to stay awake. The patient’s temperature is 37.6°C (99.7°F), blood pressure is 115/79 mmHg, pulse is 67/min, and respirations are 16/min. Which of the following interventions is used in treating this patient’s condition?
A. Prescription of an alpha-receptor antagonist
B. Prescription of an acetylcholine-receptor antagonist
C. Placement of a vaginal pessary
D. Initiation of intermittent bladder catheterization
E. Referral for surgical repair of a urogenital tract fistulaScroll down for the correct answer!
The correct answer to today’s USMLE® Step 2 CK Question is…
B. Prescription of an acetylcholine-receptor antagonist
Before we get to the Main Explanation, let’s see why the answer wasn’t A, C, D, or E. Skip to the bottom if you want to see the correct answer right away!
Incorrect answer explanations
Today’s incorrect answers are…
A. Prescription of an alpha-receptor antagonist
Incorrect: Alpha-antagonists, such as prazosin or tamsulosin, are used in the treatment of overflow incontinence. The condition can be caused by an underactive detrusor muscle and results in urinary retention. Multiple sclerosis (MS), which may present with transient visual deficits, episodes of urinary incontinence, and focal weakness/numbness, is a cause of overflow incontinence. However, patients with this condition typically present with urinary dribbling that occurs as the bladder starts overflowing.
C. Placement of a vaginal pessary
Incorrect: Pessaries are used in the treatment of stress incontinence. The condition presents with loss of urine when intra-abdominal pressure is increased. This patient has none of these symptoms. In contrast, this patient’s history of having sudden urges to urinate and not being able to reach the bathroom in time is more consistent with the presentation of urge incontinence. Pessaries are not effective in treating urge incontinence.
D. Initiation of intermittent bladder catheterization
Incorrect: Intermittent self-catheterization can be used in patients with overflow incontinence to prevent urinary stasis and infection. However, this patient’s symptoms of sudden urges to void and involuntary loss of urine are most consistent with those of urge incontinence. Patients with urge incontinence are not at increased risk for urinary stasis, and self-catheterization is unnecessary.
E. Referral for surgical repair of a urogenital tract fistula
Incorrect: A vesicovaginal fistula is an abnormal passageway between the bladder and vagina. As a result, urine from the bladder can pass through the fistula. Surgery is used to treat this condition. Risk factors for developing a vesicovaginal fistula include pelvic radiation and pelvic surgery. The patient in this vignette has none of the aforementioned risk factors, and a vesicovaginal fistula would not explain her previous neurologic symptoms.
Main Explanation
This patient has urge incontinence, which presents as a sudden urge to urinate, resulting in involuntary expulsion of urine. Many cases are idiopathic. However, some medical conditions may cause urge incontinence. They can be divided into neurologic conditions (e.g., neuropathy, multiple sclerosis) and non-neurologic conditions (e.g., urinary tract infections, bladder stones). The patient in this vignette has a history of transient vision loss and extremity weakness, which suggests that a multiple sclerosis flare-up is the most likely cause of her recent incontinence.
Urge incontinence can be diagnosed based on the history & physical exam. Additional testing, such as urinalysis or bladder ultrasound, can be ordered to identify the underlying cause of the patient’s presentation. Urodynamic studies are not required to make the diagnosis, but if ordered, will show detrusor hyperactivity.
First-line treatment consists of lifestyle modifications, including caffeine restriction, Kegel exercises, and bladder training (e.g., developing a timetable that specifies when to urinate). In terms of medications, anticholinergic agents, such as oxybutynin and tolterodine, are most commonly used to treat urge incontinence. In cases where non-invasive management has failed, surgical intervention such as sacral nerve stimulation or botulinum toxin injection into the bladder wall can be used to reduce detrusor activity.
Major Takeaway
Patients with urge incontinence present with sudden urges to urinate that result in involuntary expulsion of urine. Most cases are idiopathic, but some cases are secondary to other medical conditions (e.g., multiple sclerosis, UTI). Treatment includes addressing any underlying causes, lifestyle modifications, and anticholinergic medications. In refractory cases, surgery may be indicated.
References
Callahan, T.L., Caughey, A.B. (2013) Blueprints Obstetrics & Gynecology. Lippincott Williams & Wilkins. ISBN: 978-1451117028.
Lin, S.D., Butler, J.E., Boswell-Ruys, C.L., Hoang, P., Jarvis, T., Gandevia, S.C., McCaughey, E.J. (2019) The frequency of bowel and bladder problems in multiple sclerosis and its relation to fatigue: A single centre experience. PLoS One. 14(9), e0222731. Doi: 10.1371/journal.pone.0222731.
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