Week 7 response 2

Table 1:

 

Testing or Managem

ent Define and Describe

Candidates Eligible For This Include

Special Considerations

Urinalysis and Urine Culture

Basic diagnostic tests to rule out urinary tract infection (UTI) as a cause of urinary symptoms.

All patients presenting with urinary symptoms (e.g., dysuria, frequency, urgency, incontinence).

Not diagnostic for incontinence but helps exclude infection.

Urodynam ics

Series of tests to assess bladder function, pressure, and flow. Helps identify type of incontinence.

Considered if diagnosis is unclear, symptoms are severe, or before surgical intervention.

May not be necessary in straightforward cases of stress incontinence. Costly and invasive.

Pelvic Floor Muscle Therapy (PFMT)

Strengthening exercises (Kegels) to improve pelvic floor muscle tone and control. Often includes biofeedback.

First-line for most women with stress or mixed incontinence, especially in mild to moderate cases.

Requires consistency and proper technique. Referral to physical therapy recommended.

Percutane ous Tibial Nerve Stimulatio n (PTNS)

Minimally invasive neuromodulation technique using electrical impulses to stimulate bladder control.

Women with overactive bladder (OAB) or urge incontinence not responsive to behavioral therapy or medications.

Not first-line for stress incontinence. Weekly sessions for 12 weeks are required initially.

Pessary Therapy

Vaginal device inserted to support the bladder and pelvic organs, reducing stress incontinence and prolapse.

Women with pelvic organ prolapse and stress incontinence who want to avoid or delay surgery.

Needs regular cleaning and monitoring. May cause vaginal irritation or discharge.

Surgical Managem ent

Includes midurethral sling, colposuspension, or prolapse repair to support urethra and bladder.

Candidates who fail conservative therapy and have significant impact on quality of life.

Invasive. Requires preoperative evaluation and carries risks such as mesh complications.

Type of Incontine Definition and Example How to Assess

Treatment/

 

 

 

Soap Note

Demographic Data: 
 Hillary, 63 year old female, G7P7

Subjective

Chief Complaint (CC): 
 “I leak urine when I laugh, cough, or sneeze. Lately, I also feel something bulging at the opening of my vagina.”

History of Present Illness (HPI):
 Hillary is a 63 year old female, G7P7, presenting with involuntary urine leakage during physical activities such as coughing, sneezing, and laughing. Symptoms began intermittently after the birth of her last three children but have worsened over time. She currently wears a sanitary pad daily due to fear of odor and visible wetness. She also reports a new sensation of “something at the entrance” of her vagina, which she began noticing within the past month. Denies dysuria, urgency, hematuria, or nocturnal enuresis. Denies constipation or pelvic pain. No prior pelvic surgery or history of urinary tract infections.

Stress Incontinen ce

Involuntary urine leakage with increased intra-abdominal pressure (e.g., coughing, sneezing). Common in women with pelvic floor weakness.

Ask about leakage during activity. Perform cough test and pelvic exam.

PFMT, pessary, weight loss, surgical sling.

Urge Incontinen ce

Sudden urge to void followed by involuntary leakage. Common in overactive bladder.

Bladder diary, assess for urgency, frequency, nocturia. Rule out UTI.

Bladder training, anticholinergic or β3 agonist meds, PTNS, Botox injections.

Nocturnal Incontinen ce (Nocturia or Enuresis)

Involuntary voiding at night. May be due to detrusor overactivity, sleep disorders, or high nighttime urine production.

Ask about nighttime frequency, volume, fluid intake. Check for CHF or diabetes.

Fluid restriction, manage comorbidities, OAB meds, nighttime voiding schedule.

Transient Incontinen ce

Temporary incontinence due to reversible causes (e.g., UTI, medications, mobility).

Full history, medication review, physical exam, urinalysis.

Treat underlying cause (e.g., discontinue meds, treat infection).

 

 

Relevant Questions Asked:

• Do you feel a strong urge to urinate and then leak before reaching the bathroom? → No. • Do you urinate frequently at night (nocturia)? → 1–2 times, but no leakage at night. • Any pain or burning during urination? → No. • Do you experience constipation or chronic coughing? → Occasional constipation. • Impact on quality of life or social activities? → Avoids social events due to fear of leaking or

odor.

Past Medical History:

• Hypertension, well controlled on amlodipine. • No prior surgeries or pelvic procedures. • Seven spontaneous vaginal deliveries; last childbirth at age 36. • No known neurologic conditions.

Surgical History:

• None.

Medications:

• Amlodipine 5 mg PO daily • Occasional calcium carbonate for indigestion

Allergies:

• NKDA

Immunizations:

• Up to date, including shingles and pneumococcal vaccines.

Family History:

• Mother: Hypertension, osteoporosis • Father: Type 2 diabetes • No family history of pelvic organ prolapse or incontinence

Social History:

• Retired schoolteacher. • Widowed, lives independently. • Sexually inactive for several years. • Nonsmoker, no alcohol or drug use. • Walks 2-3 times weekly for exercise.

 

 

• Denies occupational exposures.

Review of Systems (ROS):

• General: Denies weight loss or fever. • HEENT: Denies headaches or visual changes. • Respiratory: No chronic cough. • Cardiovascular: Denies palpitations. • GI: Occasional constipation. • GU: Stress-related urinary leakage; no dysuria or hematuria. • Neuro: No headaches or dizziness. Alert and oriented. • Skin: Intact perineal skin; no rashes. • Psych: Denies depression or anxiety.

Objective

Vital Signs:

BP: 122/78 mmHg

HR: 72 bpm

RR: 16/min

Temp: 98.6F

Height: 5’3”

Weight: 162 lbs

BMI: 28.7 (Overweight)

Physical Examination:

• General: Alert, oriented, in no acute distress. • Abdomen: Soft, non-tender, no masses. • Pelvic Exam: o External genitalia: Normal o At rest: Small bulge at the 12 o’clock position, approx. 1 cm protruding from vaginal

introitus o With Valsalva: Bulge becomes more prominent o Bimanual exam: Uterus and adnexa non-tender; normal size o No vaginal discharge, lesions, or bleeding o No signs of infection or trauma

 

 

• Neurologic: Reflexes intact, no signs of neuropathy

In Office/POCT Ordered:

• UA/Urine culture: To rule out UTI – pending • Bladder diary initiated: To evaluate voiding patterns • PVR (post-void residual) via bladder scan: To rule out incomplete emptying • Pelvic floor assessment: Referral to pelvic PT • Referral for transperineal or pelvic floor ultrasound (if indicated)

Assessment

Primary Diagnosis:

• Stress Urinary Incontinence (ICD-10: N39.3) o Classic presentation with leakage during increased intra-abdominal pressure o Common in multiparous women o Bulge consistent with mild anterior vaginal wall prolapse (cystocele)

Differential Diagnoses:

1. Pelvic Organ Prolapse (ICD-10: N81.10) a. Mild prolapse with anterior wall involvement (likely bladder) 2. Mixed Urinary Incontinence (ICD-10: N39.46) – Unlikely, no urge component 3. Overactive Bladder (ICD-10: N32.81) – No urgency or frequency

Incontinence Type:

• Stress Incontinence

Plan

Diagnostics:

• Urinalysis with culture – Rule out infection • Bladder diary – Track symptoms and fluid intake • Post-void residual – Assess for urinary retention • Pelvic organ prolapse quantification (POP-Q) scoring – If symptoms worsen • Consider urodynamic testing if symptoms persist or if surgery is later considered

Treatment:

• Pessary Fitting – Non-surgical support for prolapse and incontinence o Type: Ring pessary with support o Consider for patients with mild anterior prolapse who decline surgery • Pelvic Floor Muscle Therapy (PFMT)

 

 

o Referral to pelvic physical therapy o Kegel exercises, biofeedback • Lifestyle Modifications: o Weight loss, reduce caffeine/alcohol, manage constipation • Pharmacologic: o No medications indicated at this time due to pure stress incontinence • Supplements: o Calcium and vitamin D if needed based on diet and bone health • Patient declined surgery at this time

Patient Education:

• Discussed etiology of stress incontinence and pelvic organ prolapse • Explained how a pessary works and possible side effects (e.g., vaginal irritation) • Educated on proper Kegel technique and importance of consistency • Discussed hygiene, signs of infection, and pessary maintenance • Provided printed materials and online resources (e.g., ACOG patient guide)

Follow Up:

• Reassess in 6 weeks to evaluate response to pessary and PFMT • Annual pelvic exam or earlier if symptoms worsen • Consider referral to urogynecology if pessary fails or if prolapse worsens

References

Abrams, P., et al. (2017). ICS Fact Sheets on Female Urinary Incontinence. International Continence Society.

American College of Obstetricians and Gynecologists (ACOG). (2019). Urinary Incontinence in Women: Practice Bulletin No. 155. https://www.acog.org

Handa, V. L., & Cundiff, G. W. (2020). Pelvic Organ Prolapse. UpToDate.

Haylen, B. T., et al. (2010). An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Neurourology and Urodynamics, 29(1), 4–20. https://doi.org/10.1002/nau.20798