<prompt> Please answer with one of the option in the bracket. Write reasoning in between . Write answer in between .Q:A 68-year-old woman comes to the physician for the evaluation of loss of urine for the last year. The patient states that she loses control over her bladder when walking or standing up. She reports frequent, small-volume urine losses with no urge to urinate prior to the leakage. She tried to strengthen her pelvic muscles with supervised Kegel exercises and using a continence pessary but her symptoms did not improve. The patient is sexually active with her husband. She has type 2 diabetes mellitus controlled with metformin. She does not smoke or drink alcohol. Vital signs are within normal limits. Her hemoglobin A1c is 6.3 and fingerstick blood glucose concentration is 110 mgdL. Which of the following is the most appropriate next step in the management of this patient?? A: Topical vaginal estrogen, B: Urethropexy, C: Tighter glycemic control, D: Biofeedback, E: Urethral sling,  <response>: This is a patient with urinary incontinence that has not responded to conservative management with pelvic floor exercises and pessary. Based on the description of small volume leakage without urge, this is most consistent with stress urinary incontinence. The patients diabetes is well controlled based on the A1c, so tighter glycemic control is unlikely to help. Biofeedback could be considered but is less likely to help compared to surgery given failed conservative management. Urethropexy surgically elevates and fixes the urethra and bladder neck to prevent leakage with physical stress. A urethral sling also provides structural support to prevent stress incontinence. Of these two surgical options, a urethral sling is less invasive and is typically the first-line surgical approach. Vaginal estrogen is not indicated as this patient is already sexually active.E: Urethral sling 