Urinary incontinence question from free 150

[britesky89]

Hi guys, I'm confused about a question from the free 150. It would be great if someone could clear up my confusion. Thanks in advance!


An 82-year-old woman with a 20-year history of urinary incontinence has had a mild exacerbation of her symptoms over the past 3 months. Urine loss generally occurs when she is carrying out daily activities such as shopping or driving and is not affected by coughing or sneezing. She underwent appendectomy at the age of 24 years. She has one daughter. She takes no medications. Pelvic examination shows an atrophic cervix without a palpable uterus or an adnexal mass. Laboratory studies show:

Hemoglobin 13 g/dL
Serum Na+ 140 mEq/L
Cl − 105 mEq/L
K+ 4.5 mEq/L
HCO3 − 25 mEq/L
Urea nitrogen 15 mg/dL
Glucose 120 mg/dL
Creatinine 1.1 mg/dL
Urine Epithelial cells 5–10
Glucose negative
WBC 0–1/hpf
Bacteria occasional

Which of the following is the most likely cause of this patient's urinary incontinence?
(A) Detrusor instability (CORRECT)
(B) Hyperglycemia
(C) Neurogenic bladder (wrong)
(D) Obstructive uropathy
(E) Urinary tract infection

So this scenario is supposed to be "urge incontinence" but I don't understand why? I remember answering a uworld question with a similar scenario where the woman had incontinence while standing, getting out of her car, but that was overflow incontinence. The concept was that when the bladder was over filled and increased pressure would cause urinary leakage.

I just don't see what clue gives the answer as urge incontinence.

Would somebody be so kind as to explain how this scenario points to urge incontinence?

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[Zephor0]

Age, Urge is older women, stress is middle aged. Also because the 4 are completely wrong.

 

[pd1112]

stress would be less likely with only 1 child

 

[Hamsterlope]

I've seen a handful of forums say this is detrusor instability and a couple say it is neurogenic bladder. But I'm just not convinced it's detrusor instability. For this to be urge incontinence, the patient needs to have an URGE before her incontinence episodes. It's literally the hallmark of an overactive bladder and the patient does not report it.

Now she's had this problem for 20 years. And 24 years ago she had an appendectomy, so neurogenic bladder doesn't quite fit with the timeline, but it's really the only thing that fits. Maybe she has sub-par detrusor muscle tone and she retains urine. She really doesn't have unique risk factors for either urge of overflow incontinence (diabetes, obesity, constipation, prior catheter irritation, caffeine consumption) other than one prior pregnancy and maybe an appendectomy. But there is no urge.

Someone please tell me what I must be missing because I just don't see how we can say there is detrusor instability without the patient having an urge before incontinence episodes.

 

[bullethead]

Post-menopausal woman have decreased estrogen=> which leads to vaginal and bladder dryness => which leads to irritation => which leads to urge incontinence and stress incontinence. Since the question ruled out stress incontinence the answer is Urge by default. Also they gave you a clue by saying that the pt had an "atrophic cervix".

 

[JamaicanHerb]

So post-menopausal women have decreased estrogen, the pelvic floor muscles, urethral musculature and detrusor muscle become unstable in response to a lack of estrogen and no longer maintain their muscular integrity leading to incontinence. First thing you do in someone old is to rule out UTI which is a common cause of urinary incontinence (ruled-out), diabetes (no history and high end of normal random glucose), so best answer is detrusor instability.

Post-menopausal woman have decreased estrogen=> which leads to vaginal and bladder dryness => which leads to irritation => which leads to urge incontinence and stress incontinence. Since the question ruled out stress incontinence the answer is Urge by default. Also they gave you a clue by saying that the pt had an "atrophic cervix".

You got the decreased estrogen part right, but the rest is wrong. It doesn't lead to stress incontinence. Urge incontinence is an overactive bladder, which the vignette doesn't give you any clues about that.

Vaginal/cervical dryness was the clue for hypoestrogen bladder insufficiency. This isn't even an overflow incontinence. A retention incontinence in a sense.

 

[EmergDoc2B]

what would be her cause of neurogenic bladder? She has no evidence of brain, spinal cord, or nerve damage.

 

[Rosey893]

Hi guys, I'm confused about a question from the free 150. It would be great if someone could clear up my confusion. Thanks in advance!


An 82-year-old woman with a 20-year history of urinary incontinence has had a mild exacerbation of her symptoms over the past 3 months. Urine loss generally occurs when she is carrying out daily activities such as shopping or driving and is not affected by coughing or sneezing. She underwent appendectomy at the age of 24 years. She has one daughter. She takes no medications. Pelvic examination shows an atrophic cervix without a palpable uterus or an adnexal mass. Laboratory studies show:

Hemoglobin 13 g/dL
Serum Na+ 140 mEq/L
Cl − 105 mEq/L
K+ 4.5 mEq/L
HCO3 − 25 mEq/L
Urea nitrogen 15 mg/dL
Glucose 120 mg/dL
Creatinine 1.1 mg/dL
Urine Epithelial cells 5–10
Glucose negative
WBC 0–1/hpf
Bacteria occasional

Which of the following is the most likely cause of this patient's urinary incontinence?
(A) Detrusor instability (CORRECT)
(B) Hyperglycemia
(C) Neurogenic bladder (wrong)
(D) Obstructive uropathy
(E) Urinary tract infection

So this scenario is supposed to be "urge incontinence" but I don't understand why? I remember answering a uworld question with a similar scenario where the woman had incontinence while standing, getting out of her car, but that was overflow incontinence. The concept was that when the bladder was over filled and increased pressure would cause urinary leakage.

I just don't see what clue gives the answer as urge incontinence.

Would somebody be so kind as to explain how this scenario points to urge incontinence?

Having a urine infection can be a common problem when you are older. Urinary incontinence and infections is typically the result of weak pelvic floor muscles. I recently read in an article that physiotherapy can help to treat such urinary infections and related problems. Just read it- http://www.physionow.ca/blog/general-category/urinary-tract-infections/ . Hope it helps for someone.

 

[Code Blah]

Detrusor instability. It's the only one that makes sense and symptoms fit. It's not stress b/c its not associated with cough, bearing down, etc. Neurogenic bladder is associated with some sort of neuro insult; example, diabetes, MS, stroke, spinal cord injury, something that screws up the control of bladder and she can't squeeze the urine out, and she would be dribbling urine constantly from a full bladder that she can't empty. She has NONE of these. As for detrusor instability, it usually occurs randomly, and that fits the story (she is shopping, walking, driving; no connection between these). If the problem said she has an urge before she went incontinent, this question would be WAY TOO easy. They specifically left that part out so that you have to think about her symptoms and choose the most likely one, which is detrusor instability/urge incontinence.