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Review Question - QID 210019

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QID 210019 (Type "210019" in App Search)
A 67-year-old man presents to his primary care physician for urinary incontinence. He has been waking up every morning with his underwear soaked in urine. He notices that at work if he does not take regular bathroom breaks his underwear will have some urine in it. He urinates 5 to 11 times per day but he claims it is a small volume. His current medications include lisinopril, metformin, insulin, aspirin, atorvastatin, sodium docusate, and loratadine. His temperature is 98.3°F (36.8°C), blood pressure is 167/108 mmHg, pulse is 90/min, respirations are 13/min, and oxygen saturation is 98% on room air. Physical exam is notable for decreased pinprick sensation in the lower extremities and a systolic murmur along the right upper sternal border. Which of the following is the best treatment for this patient?

Bethanechol and intermittent straight catheterization

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Bethanechol during the day and oxybutynin at night

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No recommendations needed

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Oxybutynin and scheduled bathroom breaks

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Reduce fluid intake and discontinue diuretics

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Select Answer to see Preferred Response

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This patient is presenting with symptoms of a neurogenic bladder which is treated with bethanechol and intermittent straight catheterization.

A neurogenic bladder typically presents secondary to poorly controlled diabetes. Patients will typically present with incomplete voiding, a distended bladder (with high post-void residual volumes), and constant urinary dribbling. The treatment of choice is to drain the bladder frequently (intermittent self-catheterization) and to increase cholinergic tone to the bladder to aid in its contraction (bethanechol).

Incorrect Answer:
Answer 2: Bethanechol during the day and oxybutynin at night is inappropriate as oxybutynin will worsen this patient's symptoms.

Answer 3: No recommendations needed fails to treat this patient's neurogenic bladder.

Answer 4: Oxybutynin and scheduled bathroom breaks would be appropriate for a spastic bladder but would worsen this patient's symptoms of a neurogenic bladder.

Answer 5: Reduce fluid intake and discontinue diuretics is inappropriate as it may dehydrate this elderly patient and his angiotensin-converting enzyme (ACE) inhibitor is necessary for nephroprotection.

Bullet Summary:
Bethanechol and intermittent straight catheterization is the treatment for a neurogenic bladder.

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