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LOWER URINARY TRACT SYMPTOMS Referral Form GSTT gynaecology clinic details KCH gynaecology clinic details Gynaecology Out patients McNair Centre, Guy’s Hospital SE1 9RT Gynaecology outpatients, Suite 8, 3rd floor, Golden Jubilee Wing, KCH, Denmark Hill London, SE5 9RS 020 7188 2000 0203 299 3246 (option 1) Fax 020 7188 3674 0203 299 3471 Email n/a n/a Address Contact details: Phone Referral date System Date Referring doctor: Referring Doctor Address: Practice Address Stacked Referral urgency Patient name: DOB: Title Forenames Surname DOB Address: (include postcode) Practice Main Telephone Phone: Other Phone: NHS number: Patient Address List Home Telephone Mobile Telephone NHS Number Hospital Number: 1 2 3 4 5 6 7 8 1 Has a bladder diary been completed for three days? Has a diagnosis been made, based on the woman’s history, of stress, urge, (over active bladder syndrome OAB) or mixed incontinence?1 Has the patient had a vaginal examination to exclude: a any pelvic masses 2 b urogenital prolapse3 c a fistula3 d faecal loading4 e urogenital atrophy5 Has an abdominal or bimanual examination confirmed there is no palpable bladder after voiding? 3 Has urinalysis been performed to exclude? a macroscopic haematuria6 b microscopic haematuria6 c UTI7 d recurrent or persisting UTI3 Have lifestyle measures been discussed? 1 Have appropriate initial conservative treatments been tried? Three months of Pelvic floor exercises, (some patients may benefit from community incontinence nurse supervision), bladder training antimuscarinic drugs such as oxybutynin for 6 weeks1 Does the patient need to be referred because of one of the following: a treatment for their incontinence has failed?3 1 582726463 Review date: December 2013 Yes / No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No 9. b persisting bladder or urethral pain?3 c previous pelvic cancer surgery or pelvic radiation therapy?3 d a suspected neurological cause of the urinary symptom? 8 e associated faecal incontinence? 9 Reason for referring if answering ‘No’ to any of above: Information required for referral Medical history & examination Problem Table Allergies Allergy Table Medications Medication Table GP comments (including any other relevant information) 582726463 Review date: December 2013 Yes No