BACKGROUND

72-year-old white man presents to the emergency department because of urinary incontinence that started insidiously 2 months ago. He describes an urge component in which he has an abrupt and strong desire to void but often has no sensation of needing to void with urine leaking continuously. He uses a couple of diapers per day and one diaper at night. The patient otherwise has no other significant complaints. He denies fevers, flank pain, gross hematuria, and dysuria. He admits to chronic strain while voiding but without change for more than 15 years. The patient was evaluated for multiple recurrent urinary tract infections that were each treated with oral antibiotics with no subsequent improvement. His medical history is significant only for cardiac surgery years ago. The patient just completed his most recent antibiotic course yesterday. His only medication is aspirin, 81 mg daily.

On physical examination, the patient is thin with a protuberant abdomen. Digital rectal examination reveals a normal-sized, smooth, non-nodular, non-tender, elastic prostate, with no masses or blood in the rectal vault. The rest of the physical examination, including vital signs, is unremarkable. Laboratory tests of significance include a prostate-specific antigen (PSA) level of 0.584 ng/mL and a creatinine level of 0.9 mg/dL.

Duplex ultrasonography and computed tomography (CT) revealed a nonfunctional left kidney with a large infected staghorn calculus. The patient was subsequently scheduled for a laparoscopic left simple nephrectomy. The preoperative CT scan of his abdomen and pelvis are shown in Images 1-2.

What is the cause of the patient’s incontinence?

Laboratory results, including the CBC, are within normal limits. A CT scan of the neck is ordered.

What is the diagnosis?

CASE DIAGNOSIS

What is the diagnosis?
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