A 45 year old woman repos that she has been having increased involuntary loss of urine, which is especially pronounced when she is feeling nervous or while sitting at her desk. Jogging does not worsen the incontinence. She has not had these symptoms in the past and is otherwise healthy. She is not taking any medications and has never been pregnant. On physical examination, she is afebrile, with stable vital signs. Her abdomen is benign, and vaginal examination reveals no prolapse. Sensation in all extremities is intact, with good motor strength. Her gait is normal, and reflexes are intact. Her work-up reveals a negative urinalysis, and blood cultures and urine cultures are all negative. Serum glucose level and glycosylated hemoglobin level is normal. Which of the following tests would be the most appropriate next step in diagnosis?
The patient most likely has detrusor instability or dyssynergia. She does not seem to have a neurologic, infectious, or systemic (e. g. , diabetes) disorder. Since she can tolerate jogging without a problem, she probably does not have stress-induced incontinence (SUI). Thus, the diagnosis will probably be made by cystometry to assess her urodynamics. This test is also used to evaluate bladder capacity and tone. An IVP would be used in a patient with renal failure. It would help delineate the cause of reduced urinary output. Essentially, a dye is injected, and films are taken to track the uptake in the kidneys. This would not help in the evaluation of incontinence. Stress testing reveals leakage of urine coincident with increased intra-abdominal pressure, which is diagnostic of stress urinary incontinence. The Q-tip test is an indirect measure of the urethral axis (angle of inclination). A Q-tip is inseed into the urethra with the patient in the lithotomy position. If the Q-tip moves more than 30 degrees from the horizontal, there is abnormal urethral mobility. This would be helpful in the evaluation of stress urinary incontinence, since it would help indicate a distoion between the urethra and the bladder. Ref: Hoffman B.L., Schorge J.O., Schaffer J.I., Halvorson L.M., Bradshaw K.D., Cunningham F.G., Calver L.E. (2012). Chapter 23. Urinary Incontinence. In B.L. Hoffman, J.O. Schorge, J.I. Schaffer, L.M. Halvorson, K.D. Bradshaw, F.G. Cunningham, L.E. Calver (Eds), Williams Gynecology, 2e.
Intravenous pyelogram (IVP)
Stress testing
Q-tip test
Cystometry