Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with symptoms of urinary urgency, frequency (>8 voids/day), and nocturia. Reports episodes of urgency incontinence. Denies dysuria, hematuria, or pelvic pain. No history of recent UTI or pelvic surgery. Symptoms are persistent and impact quality of life.
Clinical Examination Findings
Abdominal exam: Soft, non-tender, no palpable bladder distension. Pelvic exam: Normal external genitalia, no evidence of atrophic vaginitis, cystocele, or rectocele. Pelvic floor muscle strength: [Grade 0-5]. Cough stress test: Negative. Neurological exam: Normal lower extremity reflexes and sensation.
Treatment Protocol
Initiate behavioral therapy: fluid management, timed voiding, and bladder retraining. Pelvic floor physical therapy referral. Pharmacotherapy: Initiate [Antimuscarinic/Beta-3 agonist] at [Dosage]. Follow-up in 4-6 weeks to assess efficacy and side effects (dry mouth, constipation).