FEMALE

QUESTION
• 23-year-old Caucasian female is referred for
urinary frequency and suprapubic pain

1. Mention another information that you need to

complete the anamnesis
 Answer
• RPS : 
– Keluhan ini sejak kapan dirasakan
– Apakah keluhan ini dirasakan terus menerus / saat batuk / perubahan posisi saja
– Berapa kali rata-rata BAK sehari? Apakah setiap kali akan berkemih, sulit menahan air kencing dan
apakah sampai ngompol, bila ngompol apakah jumlah urin yang keluar banyak atau sedikit?
– Ada riwayat hematuria, passing stone, benjolan keluar dari kemaluan, frekuensi, urgensi, nokturia,
dysuria, demam dan riwayat infeksi saluran kemih berulang
• Riwayat penyerta : 
– Pola defekasi, teratur / tidak, ada tidaknya konstipasi?
– Riw Kebiasaan (alcohol, caffeine)
– Riw Pemakaian obat-obatan (antikolinergik, antipsikotik, diuretic, ccb, opioid, sedative, hypnotic,
alpha-aderenergik agonis, beta-adremergik blockers)
• Riw. Obstetrik : riw kehamilan? Spontan / operasi? BB bayi lahir? Riw Operasi ginekologis / operasi pelvis
lainnya? Serta radioterapi di daerah pelvis?
• Riw Status Hormonal : kontrasepsi hormonal, menopause, terapi hormonal untuk menopause
• RPD : Hipertensi, DM, Riw Penyakit saraf ( fungsi & kognitif pada pasien usia tua, riw stroke?), Trauma
vertebra/pelvis
• Bladder diary : frekuensi, volume per voiding, urgency, inkotinensia, frekuensi minum, jumlah dan jenis
minuman
 Information
• 23-year-old Caucasian female is referred for urinary frequency
and suprapubic pain. She denies gross hematuria. The bladder
pain has improved with voiding. There is no flank pain. She
endorses urinary urgency and discomfort, which progressively
worsens until she voids.

• She typically wakes 2-3 times per night having to urinate. She
denies urinary incontinence. She has been treated for multiple
urinary tract infections although these have not been culture
proven. Her urinary symptoms worsen with consumption of
orange juice, coffee, strawberries, and pineapples.
• PMH: Fibromyalgia; initable bowel syndrome
• PSH:none
• Allergies:Penicillins (rash); Sulfa (face
swelling); Vicodin (nausea)
• Medications: none
• SH:(+) tob, I-2 cigarettes/day;
• (+) ETOH, drinks I-2 beers/day; drinks 1
coffee/morning
 Question

2. Mention the specific physical examination

laboratory for this case
 Answer
• Vitals : T 36,5 ; BP 110/58 ;P 64; BMI 23
• Generalis: slightly anxious; tearful when describing
symptoms
• Abd: soft, NTND; no scars; no Supra pubic tenderness
• GU: normal external genitalia; normal sensation;no
prolapse; no foreign bodies; well estrogenized and
with normal rugae; examination with mild
tenderness at the bilateral levator ani muscles; rectal
exam with tendemess at levator ani bilaterally
 Answer
Latest

CBC 9,9/28,8/18.070/512.000

PT/aPTT 0.9x/1,2x

SGOT/SGPT 13/8

Ur/Cr 118,3/2,5

Electrolyte 135/4,8/111,2

Albumin 3,7

PCT/CRP 11,53/135,9

Urinalysis yellowish / pH 6,5/SG 1,010/Leu 3-5/Eri 0-

1/Bacteria (-)/Nitrit (-)/LE (-)
Urine Culture negative
 Question

3. What is your assessment and differential

diagnosis?
 answer
23-year-old CF with LUTs and pain improved with urination.
Worsened by acidic foods,The most likely diagnosis is
IC/PBS.

Differential diagnosis :
1. IC/PBS
2. UTI
3. OAB
4. Bladder cancer
5. Endometriosis
 Question

4. What treatment options would you

recommend?
 Answer
Per AUA guidelines:

1. First line therapy should include education about normal bladder

function, teaching about IC/PBS. Encourage self-care, stress management
and coping techniques For this patient recommend dietary modifications:
eliminate coffee and exacerbating foods ; eliminate/decrease alcohol;
smoking cessation

2. Second line therapies include manual physical therapy and multimodal

pain management. Oral therapies include Amitriptyline, Cimetidine,
Hydroxyzine, or Pentosan polysulfate. Intravesical therapies include
DMSO, Heparin, or Lidocaine and may be administered as second-line
intravesical treatments
 Information
The patient is lost to follow up; however, she returns 10 years later.
Her IC/PBS symptoms are well controlled with dietary
modifications. She is no longer taking Pentosan polysulfate or
seeing the pelvic physical therapist.

In the interim, she has had 2 children both via vaginal delivery. The
second required forceps for delivery. She now complains of pelvic
pressure and a sense of incomplete bladder emptying.

She also endorses incomplete bowel evacuation as well. She denies

constipation and urinary incontinence. She does not wear any pads.
 Question

5. What is your next step?

 Answer
1. Physical examination with POP-Q
2. Labs including urine analysis and possible
urine culture
 Question

6. What additional maneuvers are necessary for

this exam?
 Answer
• Need to reduce the anterior prolapse to
determine if any stress incontinence.
• With reduction of the prolapse, the patient
demonstrates leakage of urine with coughing.
 Question

7. What are options for management of stress

urinary incontinence?
 Answer
Per AUA incontinence guidelines:
• Midurethral slings, pubovaginal slings and
retropubic suspensions (open or laparoscopic)
May consider injection of urethral bulking
agents.
• Slings can be synthetic, autologous fascia, or
cadaveric fascia.
THANK YOU AND GOOD LUCK