What information should be gathered in the patient history in the assessment of bladder dysfunction?

Updated: Jan 04, 2019
  • Author: Gregory T Carter, MD, MS; Chief Editor: Elizabeth A Moberg-Wolff, MD  more...
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In general, patients present with retention, urinary incontinence, or a mixed picture of incomplete emptying and incontinence. During the interview, try to establish the etiology of the patient’s symptoms before initiating pharmacologic treatment. [12]

Review the medical history, paying particular attention to any endocrine or neurologic conditions. In most patients, a clear neurologic event (eg, traumatic brain injury [TBI], cerebrovascular accident [CVA], spinal cord injury [SCI], or onset of multiple sclerosis [MS]) precedes the urologic symptoms. In others, there is a history of previous pelvic surgery or trauma. If a neurologic event has led to symptoms, establish premorbid voiding function and symptoms.

Consider medications known to be capable of affecting bladder control and function, such as sedatives, muscle relaxants, opiates, calcium channel blockers, and antihistamines. Consider the patient’s fluid intake and level of hydration. Finally, administer a functional assessment and determine the individual’s ability to perform self-care tasks, such as hygiene, bathing, and dressing.

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