Lower Urinary Tract Symptoms follow-up

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Returns for a ‍LUTS follow-up

Last visit was ‍ ‍months ago

Progress since last visit: ‍unchangedimprovedworsenedvariable in intensityresolved



Updates on symptoms:

‍urinary frequency

‍urinary urgency

‍nocturia

‍incomplete bladder emptying

‍urinary incontinence

‍urinary retention

‍dysuria

‍hematuria

‍weak urinary stream

‍intermittency

‍straining to void

‍post-void dribbling

‍lower abdominal pain



Medication tried: ‍alpha blockers, ‍5-alpha reductase inhibitors, ‍anticholinergics, ‍mirabegron, ‍effectiveineffective, ‍adverse effect, ‍good adherence

Dietary changes: ‍nonereduced fluid intakereduced caffeinereduced alcoholavoiding fluid intake before sleep, ‍effectiveineffective

Lifestyle modifications: ‍nonepelvic floor exercises, ‍effectiveineffective



Labs:

PSA: ‍ ‍normalincreasing

Creatinine: ‍ ‍normal

Urinalysis: ‍ ‍normal





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Abdomen: ‍soft, ‍non-tender ‍, ‍non-distended, ‍guarding, bowel sounds ‍normal, ‍, ‍CVA tenderness ‍

Anorectal: DRE ‍normal, prostate ‍normal, ‍blood, ‍mass, anus ‍

Pelvic: external genitalia ‍normal, vagina ‍normal, cervix ‍normal, uterus ‍normal, adnexa ‍normal, ‍cervical motion tenderness

Genital: penis ‍normal, testes and epididymis ‍normal, ‍inguinal hernia





ASSESSMENT:

‍Lower urinary tract symptoms ‍likelysuspectedpossible, ‍improving

DDx: benign prostatic hyperplasia, overactive bladder, urinary tract infection, neurogenic bladder, urethral stricture, bladder stones, prostate cancer, diuretic use, medication side effect, constipation, diabetes mellitus, pelvic floor dysfunction, cystocele, pelvic organ prolapse, spinal cord injury, neurologic condition, psychogenic polydipsia, excessive fluid intake, excessive caffeine intake, sleep apnea





PLAN:

Investigations:

- Urinalysis

- Urine culture

- Blood work: ‍CBC, ‍creatinine, ‍CRP

- Pelvic ultrasound

- Cystoscopy

Treatments:

- ‍Overactive bladder medications

- ‍BPH medications

- ‍Antibiotics

- Increase fluid intake

- Avoid caffeine, alcohol, and spicy foods

Further care:

- Referral to urologist

- Follow-up in ‍ ‍weeksmonths

- Return if symptoms worsen or if fever develops