SOAP Note
Subjective
Demographic Data
Age/Gender: 63-year-old, Female
Chief Complaint: I have been urinating on myself whenever I cough, sneeze, or laugh heartily.
HPI: 63-year-old female G7P7 presents today with reports that she sometimes urinates uncontrollably when she coughs, sneezes, laughs, or any activities that raise intra-abdominal pressure. Since the birth of her last three children, this has been an infrequent problem, but it has been more common and uncomfortable. She states that the leaking is severe enough to interfere with her social life, self-esteem, and everyday activities. She also reports feeling a bulge and a heaviness feeling at the entrance of her vaginal area. Denies pain. She admits to worrying about a possible odor and wearing a sanitary napkin.
Questions to Ask
How long have you been having the urination leakage?
Do you engage in any activities that help or worsen your symptoms?
Have you had any further symptoms, such as burning, pain, or a change in the color of your urine?
Do you notice any visible blood in your urine?
Have you ever had any incidents of nighttime incontinence or urgent need to urinate?
Is this affecting your marriage and sexual relationship?
Are you taking any medications for this problem?
Family History
Does anyone in your family have a history of pelvic organ prolapse or urine incontinence?
Anyone in your family with a history of bladder cancer?
Does your family have any other diseases or hereditary conditions?
Mother and Father alive?
Social History:
What kind of work/occupation do you do?
What is your education background?
Do you drink alcohol or smoke?
Do you exercise daily?
Is your husband your only sexual partner?
Have you ever had an STI?
Medical History:
Have you ever had a urinary tract infection (UTIs) before?
Have you undergone any surgeries, particularly those involving the abdomen or pelvis?
Have you ever been hospitalized?
Do you suffer from any long-term illnesses like diabetes or neurological disorders?
Current Medications: None
Objective
Physical Examination:
Vital signs: Temp 98.6, HR 78, RR 16, B/P 130/80, Pain 0/10.
Constitutional: Alert, well developed, well-nourished, no acute distress.
Respiratory: Lung sounds clear to auscultation, unlabored and symmetric.
Cardiovascular: Regular rhythm, S1 S2 heard, no murmurs. No peripheral edema noted.
GI: Bowel sounds present X4, no diarrhea or constipation. No hepatosplenomegaly.
GU: Incontinence, frequency, and urgency. Denies vaginal bleeding. No vaginal lesions or rashes.
Psych: A&O X3. Mood and affect appropriate. Admits to periods of anxiety.
Examining the abdomen: No masses or organomegaly, round, soft and non-tender.
Pelvic Exam:
External genitalia normal. No masses, lesions, excoriation, or tenderness.
The mucosa of the vagina seems normal, with no abnormalities, lesions, or discharge.
No vulva redness or swelling.
Organ prolapse observed at the vaginal entrance, about 1 cm projecting at the 12 o’clock position.
Cervix no lesions or discharge.
Uterus enlarged.
The strength of the pelvic floor muscles appears weak/poor.
Tests to Order
Urine culture and urinalysis, this test helps to exclude out urinary tract infections, which can make incontinence worse.
Urodynamics, this test is used to evaluate the level of incontinence and bladder function.
Pelvic Ultrasound/Ultrasonography, to view the organs in the pelvis and evaluate any anomalies in structure.
Assessment/ Working Diagnosis:
Stress Urinary Incontinence: Most likely because of the recorded pelvic organ prolapse and the history of a large number of vaginal births. Activities that raise intra-abdominal pressure aggravate symptoms. Exercises targeting the muscles of the pelvic floor, lifestyle changes, and surgical procedures are available as treatments if non-invasive approaches fail (Mamou, 2024). Early intervention can stop symptoms from getting worse and greatly enhance quality of life.
Differential Diagnoses:
Pelvic Organ Prolapse: May be a contributing factor to incontinence and the feeling of “something at the entrance”. A pelvic organ prolapse may also cause pain and difficulties passing stool.
Urge Incontinence: If nocturia or urgency signs are present, this should be checked out. To confirm the diagnosis, other diagnostic procedures including urodynamic investigations can be required.
Mixed Incontinence: Perhaps mixed incontinence if she also feels a sense of urgency. Treatment for this problem may involve a combination of strategies aimed at addressing symptoms of urge incontinence and stress.
Plan
Management and Treatment
Pelvic Floor Muscle Therapy- This therapy is instrumental in strengthening the pelvic muscles, seek the services of a physical therapist who specializes in pelvic floor rehabilitation or pelvic floor muscle therapy (Schreuder et al., 2022). By performing these exercises regularly, incontinence severity can be decreased, and muscular tone can be improved.
Pessary therapy -This therapy assists the pelvic organs and maybe lessen incontinence and prolapse symptoms (Trowbridge & Hoover, 2022). However, routine follow-ups are required to guarantee a good fit and to keep an eye out for any indications of discomfort or infection.
Lifestyle Modifications
If overweight, suggest losing weight to lower intra-abdominal pressure.
Both alcohol use and smoking should be discouraged since they might irritate the bladder.
Medications
If non-pharmacological treatments for stress incontinence are ineffective, take into consideration Duloxetine (SNRI). Talk about possible adverse effects such nausea, mouth dryness, and sleeplessness.
Topical estrogen: If atrophy is evident, to restore the health of the urethral and vaginal mucosa.
Patient Education
Educated the patient about the value of pelvic floor exercises and demonstrated the proper way to do them.
Provided information on how to maintain a pessary, how to use it properly, maintenance, and any potential risks or complications.
Talked about scheduled voiding and strategies for bladder training.
Follow-up Plan
Follow-up in six weeks to evaluate the impact of pelvic floor treatment and pessary usage.
Adhere to the medication and monitor for any negative effects.
If symptoms do not improve or seem to be getting worse come in and consider doing more urodynamic tests.
By following this plan, Hillarys quality of life can be significantly improved with a focus on non-surgical management options tailored to her specific needs and preferences. Continued monitoring and adjustment of the treatment plan will ensure optimal outcomes and address any emerging issues promptly.
