A 53-year-old woman with five adult children complains of losing urine shortly after coughing or jumping. She occasionally loses urine while lying in bed if she happens to cough vigorously. She is unable to stop the urine once it has begun to flow.
Which of the following is the most likely diagnosis?
- GSI
- a vesicovaginal fistula
- a urethrovaginal fistula
- an atonic bladder
- detrusor dyssynergia
Answer(s): E
Explanation:
Two clues to the diagnosis of detrusor dyssynergia are loss of urine in the recumbent position and inability to stop the urine loss once the stream has begun. Generally, large volumes of urine are lost because of the inability to stop the flow of urine. With GSI, urine is lost only in the upright position when intra-abdominal and intravesical pressure exceeds urethral closing pressure, such as with coughing. Women with SI are able to stop the flow of urine voluntarily and, therefore, the volume of urine lost is small. With GSI, urine loss with coughing is immediate. Women with a vesicovaginal or urethrovaginal fistula will complain of a watery vaginal discharge. Women with an atonic bladder typically void small amounts and complain that the bladder still feels full (which it is). This is a disorder seen in women with neurologic dysfunction of the bladder, such as multiple sclerosis and diabetic neuropathy.