Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Reason for Visit:
Initial evaluation for overactive bladder (OAB) symptoms
Follow-up for diagnosed OAB (monitoring response to treatment,
management of symptoms or side effects)
Evaluation of urinary frequency, urgency, or incontinence
Chief Complaint:
Urinary urgency (sudden, strong need to urinate)
Frequency (urinating more often than usual, often during the day
and night)
Nocturia (waking up at night to urinate)
Urinary incontinence (unintended loss of urine) – may or may not be present
History of Present Illness:
Onset, duration, and severity of symptoms.
Frequency and volume of urination (voiding diary may be helpful).
Presence of urgency incontinence (leakage with sudden urge to urinate)
or stress incontinence (leakage with coughing, laughing, or activity).
Any risk factors for OAB (e.g., neurological conditions, diabetes,
pregnancy,
postpartum, medications, history of pelvic surgery).
Past Medical History:
Underlying medical conditions that may contribute to OAB symptoms
(e.g.,
urinary tract infections [UTIs], bladder stones, prostate enlargement in
men).
Previous surgeries (relevant surgeries on the pelvis or urinary tract).
Medications (some medications can worsen OAB symptoms).
Family History:
Not typically relevant for OAB.
Social History:
Impact of OAB symptoms on daily life (work, social activities,
sleep).
Fluid intake habits (excessive caffeine or alcohol intake can
worsen symptoms).
Physical Examination:
General examination: Assess vital signs for signs of infection.
Abdominal examination: Palpate for bladder distention.
Pelvic examination (females): Evaluate for pelvic organ prolapse
(if suspected).
Diagnostic Tests (if indicated):
Urinalysis and urine culture: Rule out UTI as a cause of symptoms.
Urodynamic testing (may not be necessary in all cases):
Evaluates
bladder function and storage capacity.
Post-void residual (PVR) measurement: Measures the amount of urine
remaining in the bladder after urination.
Assessment:
Overactive bladder (OAB): Based on clinical presentation
(symptoms and frequency-volume diary) and may be supported by additional
testing (urinalysis, urodynamics if performed).
Type of OAB: May be categorized as urgency-dominant,
mixed (urgency and frequency), or non-urgency (frequency without urgency).
Severity of symptoms: Consider the frequency and bothersomeness of
symptoms and impact on daily life.
Potential underlying causes: Identify any medical conditions or
risk factors that may be contributing to OAB.
Differential Diagnoses:
Consider other conditions that may mimic OAB symptoms:
Urinary tract infection (UTI)
Interstitial cystitis (painful bladder syndrome)
Diabetes
Pelvic organ prolapse (females)
Plan:
Treatment plan: Depends on the type and severity of OAB,
patient preference, and presence of any underlying causes. Treatment
options may include:
Lifestyle modifications: Fluid management, bladder training
(techniques to increase time between urinations), pelvic floor muscle
exercises (Kegels).
Medications: Anticholinergics (first-line therapy), beta-3
agonists, mirabegron (Myrbetriq).
Neuromodulation: Sacral nerve stimulation (SNS) for
refractory cases.
Surgery: Bladder augmentation or other surgical procedures
may be considered in severe cases or if there are specific underlying
anatomical abnormalities.
Management of underlying causes: If identified, addressing
contributing factors like UTIs or diabetes can improve OAB symptoms.
Patient education: Educate the patient about OAB, causes, treatment
options, and self-management strategies.