A 54-Year-Old Woman, Gravida 3 Para 3, Comes to the Office

question 215

Multiple Choice

A 54-year-old woman, gravida 3 para 3, comes to the office due to difficulty voiding for the past few weeks.  When the patient voids, she has difficulty initiating the urine stream and emptying completely, but has no dysuria or hematuria.  The patient has 2 episodes of nocturia every night, but no involuntary leakage of urine.  She also has pelvic pressure that is worse with standing.  Ten months ago, the patient underwent a total abdominal hysterectomy with bilateral salpingo-oophorectomy for epithelial ovarian cancer and has completed a course of chemotherapy.  Vital signs are normal.  BMI is 36 kg/m².  The abdomen is without masses or ascites.  Pelvic examination shows a protruding soft, nontender mass at the level of the hymen that descends past the introitus with the Valsalva maneuver, which does not cause leakage of urine.  The uterus and ovaries are surgically absent.  Sensation and deep tendon reflexes are intact.  Urinalysis is normal.  Which of the following is the most likely cause of this patient's symptoms?

• A)Intrinsic sphincter deficiency
• B)Ovarian cancer metastasis
• C)Pelvic organ prolapse
• D)Urethral diverticulum
• E)Urgency incontinence
• F)Urinary tract infection
• G)Vesicovaginal fistula

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Definitions:

Restraints Against Trade

Actions or regulations that restrict, limit, or impede the free flow of trade and competition in the market.

Different Levels

Different levels refer to varying degrees or stages in a hierarchy, system, or classification.

Vertical

Relating to a structure or position that is straight up and down, in alignment with the direction of gravity.

Horizontal Restraint

involves agreements among competitors operating at the same level of the market or supply chain to limit competition or manipulate market conditions.