Download Pelvic floor service referra form

The Pelvic Floor Service
(Name of Trust ) NHS Foundation Trust
Patient Name: Surname_____________First Name___________
Date of Birth: _______________________
NHS No.: ___________________
Please use this form together with the NHS e-R1eferral 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?
Yes
No
2.2 Has a pelvic mass been excluded by abdominal and bimanual examination?
Yes
No
2.3 Has any atrophic vaginitis been treated with 2/12 of topic oestrogen?
Yes
No
2.4 Has urinary diary been completed and fluid intake issue been considered?
Yes
No
2.5 Has the women been referred to the Continence Advisory Service or
Women’s Health Physiotherapy for 3 months of conservative management?
Yes
No
2.6 If frequency, urgency and urge incontinence, after bladder training, has anticholinergic (up to 2)
or Mirabegron(when anticholinergic contraindicated) been tried? [See OAB Algorithm]
Yes
No
1
Reviewed January 2016
2.7Has weight management been discussed/offered if BMI above 35
- contributing factor to pelvic floor problems and risk for surgery and anaesthesia.
Yes
No
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.
b.
Referral proforma for Continence Advisory Services
Referral proforma for Women’s Health Physiothrapy
3. Please indicate any other relevant history:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
4. Current medication:
____________________________________________________________________________________
____________________________________________________________________________________
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