A 49-Year-Old Woman, Gravida 1 Para 1, Comes to the Office

question 321

Multiple Choice

A 49-year-old woman, gravida 1 para 1, comes to the office due to leakage of urine.  The patient first noticed intermittent loss of urine a few years ago.  The leakage has progressively worsened and now she is constantly leaking a small amount of urine.  The patient soaks through a thin incontinence pad 2 or 3 times a day.  She has no dysuria, hematuria, or urge to void.
The patient has type 1 diabetes mellitus managed with an insulin pump.  Her last hemoglobin A1c was 10.4%.  At age 30 she had an operative vaginal delivery complicated by a large perineal laceration.  She does not use tobacco, alcohol, or illicit drugs.
Vital signs are normal.  Pelvic examination reveals leakage of urine that increases with Valsalva.  Postvoid residual volume is increased.  There is decreased sensation to light touch and pinprick involving the perineum and both feet.
Laboratory results are as follows:
Which of the following is the best next step in management of this patient?

• A)Intermittent self-catheterization
• B)Pelvic floor muscle exercises
• C)Placement of midurethral sling
• D)Placement of suprapubic catheter
• E)Tolterodine therapy

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Definitions:

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