Question of the Week # 406

406)  A 65 year old woman is evaluated in your office for urinary problems. She reports involuntary loss of urine upon coughing almost daily for few months. She presented with similar problems 6 months ago and has been advised pelvic floor exercises and lifestyle modifications . These measures have not improved her symptoms. She denies any nocturia, frequency, hesitancy or urgency symptoms. She has no other medical problems On examination, vitals are stable. Pelvic examination reveals changes consistent with vaginal atrophy. When she is asked to cough in lithotomy position, there is large urinary leakage about 30 seconds after coughing which was difficult for her to stop. Complete blood count, Plasma glucose, Serum electrolytes and Urinalysis are within normal limits. Which of the following is the most appropriate next step?

A) Start Vaginal Estrogen

B) Recommend Vaginal Pessary

C) Obtain Urodynamic Studies

D) Mid-Urethral Sling  placement

E) Trial of Alpha-Adrenergic Agonists

12 Responses

  1. C) Obtain Urodynamic Studies

  2. C-Urodynamic studies

  3. A. vaginal estrogen – stress incontinence (when kegels fail)
    urodynamic studies test urge incontinence

  4. Do Urodynamic studies and then Mid-urethral sling placement.

  5. I’m not sure but the question says ” urine leak occurred after 30sec of coughing & persisted even after stopping the stress ” if it were to be a genuine stress incontinence leak must occur immediately on coughing and must stop immediately after stopping cough; so this case history suggests a pseudo stress incontinence (urge incontinence ) most probably from Atrophic vaginitis so i would try a vaginal estrogen trial if there is no response then i would confirm whether it is genuine stress incontinence or not with urodynamic studies before proceeding for surgery;

  6. a

  7. ~C

    urine leak 30s after stopping stress leads to the urge incontinence. I would go for urodynamic studies first.

  8. Wht is the answer?there is no typical h/o urge incontinence

  9. answer is a…

  10. Vaginal Estrogen

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