A 53-year-old white woman reports that during the past year she has had three episodes of urinary incontinence during rapid-eye-movement (REM) sleep. She reports that she wakes up and can recall dreams (she does not have night terrors). A neurologic exam, MRI, and electroencephalogram (EEG) were normal. A urologist found normal urodynamics. She has no other diseases. Five years ago, she had a mastectomy for breast cancer, but she did not have radiation or chemotherapy. What workup would you recommend for this patient?
—Carl Adler, DO, Forest Hills, N.Y.

I would not assume that the episodes are occurring in REM sleep without some type of physiologic recording. Inquire about the circumstances of the episodes, including any unusual sensations prior to retiring, alcohol use, medications, time of night, fluid intake, etc. For the sake of completeness, I would do an MRI of the brain with and without gadolinium enhancement. I assume the EEG was done during the awake state only. I recommend admitting her for up to about 72 hours of video EEG monitoring with nocturnal polysomnogram on one of the nights, preferably the second or third.
—Jay E. Selman, MD (117-3)

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