A 59-year-old woman comes to the office due to a 3-month history of continuous urinary dribbling. She says, "I never feel like my bladder is fully empty, and urine just constantly leaks out all day." She has a 20-year history of type 2 diabetes mellitus that is poorly controlled, with a recent hemoglobin A1c of 9.2%. Her current medications include metformin, glipizide, and insulin glargine. On pelvic examination, the vaginal mucosa is pink and well-rugated, and there is no evidence of pelvic organ prolapse. Neurologic examination shows decreased sensation to monofilament testing over the plantar surface of both feet. Which of the following is the most appropriate next step in the evaluation of this patient's urinary symptoms?
- Measurement of postvoid residual volumeAnswer
- BUrodynamic testing
- CPrescription of daily oral oxybutynin
- DCystourethroscopy
- EInstruction on pelvic floor muscle exercises
Answer
Measurement of postvoid residual volume
This patient's continuous urinary dribbling, sensation of incomplete emptying, and long-standing poorly controlled diabetes with peripheral neuropathy strongly suggest overflow incontinence due to a neurogenic bladder (detrusor underactivity). The initial and most appropriate step in evaluating suspected overflow incontinence is measuring the postvoid residual (PVR) volume, typically using a non-invasive bladder ultrasound. A high PVR (usually >150-200 mL) confirms urinary retention.
Step-by-Step Solution
Key Concept
Diagnosis of overflow incontinence