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Difficulty: HardPelvic Floor Disorders and Urogynecology

Match each patient's clinical and urodynamic presentation with the most accurate underlying pathophysiologic diagnosis.

  • A 65-year-old woman with continuous dribbling and a postvoid residual of 500 mL; cystometry shows absent pressure rise during attempted voiding.Detrusor underactivity
  • A 45-year-old woman with leakage during coughing; urethral pressure profilometry shows maximal urethral closure pressure of 15 cm H2O and a Q-tip test angle of 15 degrees.Intrinsic sphincter deficiency
  • A 55-year-old woman with frequent, large-volume leakage preceded by a sudden urge; urodynamics demonstrate uninhibited pressure spikes during bladder filling.Detrusor overactivity
  • A 42-year-old woman with continuous, painless leakage two weeks after an abdominal hysterectomy; dye instilled into the bladder appears in the vaginal vault.Vesicovaginal fistula

Answer

The presentations match exactly to their distinct underlying mechanisms: the patient with absent voiding contractions matches Detrusor underactivity; the patient with low urethral closure pressure and low Q-tip angle matches Intrinsic sphincter deficiency; the patient with uninhibited filling contractions matches Detrusor overactivity; and the patient with a positive dye test after surgery matches Vesicovaginal fistula.
Each clinical presentation aligns precisely with a specific pathophysiologic mechanism. Detrusor underactivity causes an acontractile bladder resulting in overflow incontinence. Intrinsic sphincter deficiency presents with stress leakage due to an open, weak urethra without hypermobility. Detrusor overactivity features spontaneous bladder contractions leading to urgency incontinence. A vesicovaginal fistula presents as continuous bypass leakage following pelvic surgery.

Step-by-Step Solution

1
Analyze the clinical presentation and urodynamic findings for each patient.
Identified the primary symptom pattern (e.g., stress leakage, urgency, continuous leakage, overflow) and objective data (postvoid residual, cystometry findings).
Clinical symptoms provide the presumptive diagnosis, while urodynamics confirm the exact pathophysiologic mechanism.
2
Evaluate the patient with continuous dribbling, high postvoid residual volume, and absent detrusor contraction.
Matched to Detrusor underactivity.
An acontractile bladder fails to empty properly, causing urine retention and subsequent overflow incontinence.
3
Evaluate the patient with stress leakage, a Q-tip angle < 30 degrees, and low urethral closure pressure.
Matched to Intrinsic sphincter deficiency.
Lack of urethral hypermobility combined with a weak sphincter indicates intrinsic sphincter deficiency rather than typical urethral hypermobility.
4
Evaluate the patient with urgency and uninhibited filling pressure spikes.
Matched to Detrusor overactivity.
Spontaneous detrusor contractions during the filling phase are the classic urodynamic hallmark of urgency incontinence.
5
Evaluate the patient with continuous post-surgical leakage and a positive dye test.
Matched to Vesicovaginal fistula.
The passage of instilled dye from the bladder into the vagina confirms an anatomical communication.

Key Concept

Pathophysiology and Urodynamic Evaluation of Urinary Incontinence
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Topics

Pelvic Floor Disorders and Urogynecology

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