The Pelvic Floor Service
(Name of Trust )NHS Foundation Trust
Patient Name: Surname______First Name______NHS No.: ______
Date of Birth: ______
Please use this form together with the NHS e-R[1]eferral letter, which will contain practice details, patient demographics, relevant medical history and medications.
1.The Pelvic Floor Dysfunction Service is provided predominantly for women with pelvic organ prolapse and urinary incontinence such as stress incontinence, urgency or urge incontinence. If the patient also has any of the following, please indicate as below. Referral should be made to Urogynaecology (UG) or Urology (U) as indicated.
Symptoms of voiding difficulty or urinary retention (U)
Continuous urinary leakage (U)
Bladder pain (U)
Recurrent UTIs (U)
Prolapse with lower urinary tract symptoms (UG)
Neurological signs with lower urinary tract symptoms (U)
Failed conservative management (3/12 supervised pelvic floor muscle training via Continence Advisors or Women’s Health Physiotherapists and/or 6 weeks bladder training) (UG/U)
Previous continence surgery (UG/U)
Palbable pelvic mass (UG) /fistula (U) / palbable bladder (U)
Persistent reduced voided volume on bladder diary (UG/U)
Other problems related to prolapse or incontinence: ______
Patients with haematuria should be referred to Urology Fast Track Haematuria Clinic.
2.If the patient only has stress urinary incontinence, urgency or urge incontinence:
2.1. Is the urinalysis normal? YesNo
2.2 Has a pelvic mass been excluded by abdominal and bimanual examination? YesNo
2.3 Has any atrophic vaginitis been treated with 2/12 of topic oestrogen? YesNo
2.4 Has urinary diary been completed and fluid intake issue been considered? YesNo
2.5 Has the women been referred to the Continence Advisory Service or YesNo
Women’s Health Physiotherapy for 3 months of conservative management?
2.6 If frequency, urgency and urge incontinence, after bladder training, has anticholinergic (up to 2) YesNo
orMirabegron(when anticholinergic contraindicated) been tried? [See OAB Algorithm]
2.7Has weight management been discussed/offered if BMI above 35
- contributing factor to pelvic floor problems and risk for surgery and anaesthesia. YesNo
If you have answered NO to ANY of the above, please consider if secondary care referral is appropriate at this time. Link to Referral Forms to Continence Advisory Services/Women’s Health Phyiotherapy can be found on NHS e-Referral.
a.Referral proforma for Continence Advisory Services
b.Referral proforma for Women’s Health Physiothrapy
3.Please indicate any other relevant history: ______
4. Current medication:______
[1] Reviewed January 2016