see attachment
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.
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.
