Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint:
Urinary incontinence (involuntary loss of urine)
Frequency (urinating frequently)
Difficulty voiding (straining to urinate)
Urinary retention (inability to completely empty the bladder)
Recurrent urinary tract infections (UTIs)
History of Present Illness:
Onset, duration, and severity of urinary symptoms.
Type of incontinence (stress, urge, overflow).
Frequency and volume of urination (including nocturia – urination at night).
Difficulty initiating or completing urination.
History of UTIs and antibiotic use.
Risk factors for neurogenic bladder (e.g., spinal cord injury, multiple sclerosis, spina bifida).
Past Medical History:
Underlying neurological conditions (e.g., spinal cord injury, stroke, multiple sclerosis).
Previous surgeries (pelvic or urologic procedures).
History of bladder dysfunction or incontinence.
Social History:
Impact of urinary symptoms on daily life and quality of life.
Use of absorbent products (diapers, pads).
Catheterization practices (if applicable).
Family History:
No familial association with neurogenic bladder.
Physical Exam:
Abdominal examination: Assess for bladder distention.
Genitourinary examination: Evaluate for pelvic muscle tone and signs of urinary retention.
Laboratory Tests:
Urinalysis: Rule out UTI and assess for microscopic hematuria (blood in the urine).
Urine culture: If UTI is suspected.
Urodynamic Studies:
Urodynamic testing is essential for diagnosis and management of neurogenic bladder. It assesses bladder function, storage capacity, and voiding dynamics. Specific tests may include:
Uroflowmetry: Measures urine flow rate and voiding pattern.
Cystometry: Evaluates bladder pressure and capacity during filling and voiding.
Electromyography (EMG): Assesses electrical activity of the bladder
and sphincter muscles.
Imaging Studies:
Abdominal/pelvic X-ray or ultrasound: May be used to assess for bladder stones or residual urine volume after voiding.
Cystoscopy (optional): Visualizes the inside of the bladder and urethra to rule out structural abnormalities.
Assessment:
Neurogenic bladder: Confirmed by urodynamic studies and supportive history and physical examination findings.
Type of neurogenic bladder: Classified as detrusor sphincter dyssynergia (DSD), atonic bladder, or reflex bladder based on urodynamic findings.
Severity of bladder dysfunction: Impacts treatment approach.
Risk factors for complications: Urinary tract infections, urinary retention, bladder stones.
Differential Diagnoses:
Consider other causes of urinary incontinence, especially early in the presentation:
Stress incontinence (common in women)
Urge incontinence (overactive bladder)
Functional incontinence (cognitive impairment, limited mobility)
Plan:
The treatment plan will depend on the type and severity of neurogenic bladder, and the patient’s overall health and preferences. Possible elements include:
Bladder retraining: Behavioral techniques to improve bladder control.
Intermittent catheterization: Self-catheterization to empty the bladder regularly and prevent retention.
Medications: Anticholinergics to relax the bladder muscle (for urge incontinence), alpha-blockers to relax the bladder outlet (for voiding difficulties).
Neuromodulation: Electrical stimulation of sacral nerves to improve bladder function.
Surgery (rare): Augmentation cystoplasty (enlarging the bladder) or urinary diversion procedures may be considered in severe cases.
Catheter management: Education and support for patients using catheters to prevent complications.
Pelvic floor muscle exercises (Kegels): May be helpful for some patients with stress incontinence.
Prognosis:
The prognosis depends on the underlying neurological condition and the severity of bladder dysfunction. Early diagnosis and treatment can improve symptoms and prevent complications.