History of Urinary Incontinence

Early in the interview, one should elicit a description of the patient’s main complaint, including duration and frequency. A clear understanding of the severity of the problem or disability and its effect on quality of life should be sought. Assessment of mobility and living environment is especially important in certain patients. Questions should be asked about access to toilets or toilet substitutes and about social factors, such as living arrangements, social contacts, and caregiver involvement.

Box 6-1 lists questions that are helpful in evaluating incontinence in women. The first question is designed to elicit the symptom of stress incontinence (i.e., urine loss with events that increase intra-abdominal pressure). The symptom of stress incontinence is usually (but not always) associated with the diagnosis of urodynamic stress incontinence. Questions 2 through 8 help elicit the symptoms associated with detrusor overactivity. The symptom of urge incontinence is present if the patient answers question 3 affirmatively. Frequency (questions 4 and 5), bed-wetting (question 6), leaking with intercourse (question 8), and a sense of urgency (questions 2 and 7) are all associated with detrusor overactivity. Questions 9 and 10 help define the severity of the problem. Questions 11 through 13 screen for urinary tract infection and neoplasia, and questions 14 through 16 are designed to elicit symptoms of voiding dysfunction.

After the urologic history, thorough medical, surgical, gynecologic, neurologic, and obstetric histories should be obtained. Certain medical and neurologic conditions, such as diabetes, stroke, and lumbar disk disease, may cause urinary incontinence. Furthermore, strong coughing associated with chronic pulmonary disease can markedly worsen symptoms of stress incontinence. A bowel history should be noted because chronic severe constipation has been associated with voiding difficulties, urgency, stress incontinence, and increased bladder capacity. A history of hysterectomy, vaginal repair, pelvic cancer and/or radiotherapy, or surgery for incontinence should alert the physician to the possibility of prior surgical trauma to the lower urinary tract.

A complete list of the patient’s medications (including nonprescription medications) should be sought to determine whether individual drugs might influence the function of the bladder or urethra, leading to urinary incontinence or voiding difficulties. A list of drugs that commonly affect lower urinary tract function is shown in Table 6-1. In these cases, altering drug dosage or changing to a drug with similar therapeutic effectiveness, but with fewer lower urinary tract side effects, will often improve or cure the offending urinary tract symptom.

Table 6-1 Medications That Can Affect Lower Urinary Tract Function

Urinary Diary

Patient histories regarding frequency and severity of urinary symptoms are often inaccurate and misleading. Urinary diaries are more reliable and require the patient to record volume and frequency of fluid intake and of voiding, usually for a 1- to 7-day period. A 3-day diary seems to be as accurate as a 7-day diary to document symptoms, and compliance is improved. Episodes of urinary incontinence and associated events or symptoms, such as coughing, urgency, and pad use, are noted. The number of times voided each night and any episodes of bed-wetting are recorded the next morning. The maximum voided volume also provides a relatively accurate estimate of bladder capacity. The physician should review the frequency/volume charts with the patient and corroborate or modify the initial diagnostic impression. If excessive frequency and volume of fluid intake are noted, restriction of excessive oral fluid intake (combined with scheduled voiding) may improve symptoms of stress and urge incontinence by keeping the bladder volume below the threshold at which urinary leaking results.

Urinary diaries are a useful and accepted research method to measure the severity of incontinence and as an outcome measure after interventions. This is reviewed in detail in Chapter 39.

History of Pelvic Organ Prolapse

Patients with pelvic organ prolapse may present with symptoms directly related to the prolapse, such as vaginal bulge, pressure, and discomfort, as well as a plethora of associated symptoms relating to voiding, defecatory, and sexual dysfunctions. The severity of the prolapse is not necessarily associated with increased visceral symptomatology.

Vaginal prolapse in any compartment—anterior, apical, or posterior—can manifest as vaginal fullness, pain, and/or protruding mass. In a recent study by Tan et al. (2005), the feeling of “a bulge or that something is falling outside the vagina” had a positive predictive value of 81% for pelvic organ prolapse, and the lack of this symptom had a negative predictive value of 76% for predicting prolapse at or past the hymen. Not surprisingly, increased degree of prolapse, especially beyond the hymen, is associated with increased pelvic discomfort and visualization of a protrusion. The association of POPQ measures on examination with three commonly related symptoms—urinary splinting, digital assistance with defecation, and vaginal bulge—is shown in Figure 6-1.

Figure 6-1 Prevalence of prolapse symptoms per POPQ group. The percentage of patients who report urinary splinting, digital assistance, and vaginal bulge for each relevant POPQ measurements.

(Modified from Tan JS, Lukacz ES, Menefee SA, et al. Predictive value of prolapse symptoms: a large database study. Int Urogynecol J 2005;16:203.)

Stress urinary incontinence and voiding difficulties can occur in association with anterior and apical vaginal prolapse. However, women with advanced degrees of prolapse may not have overt symptoms of stress incontinence because the prolapse may cause a mechanical obstruction of the urethra, thereby preventing urinary leakage. Instead, these women may require vaginal pressure or manual replacement of the prolapse to accomplish voiding. Therefore, they are at risk for incomplete bladder emptying, and recurrent or persistent urinary tract infections, and for the development of de novo stress incontinence after the prolapse is repaired. Patients who require digital assistance to void, in general, have more advanced degrees of prolapse. In addition to difficulty voiding, other urinary symptoms, such as urgency, frequency, and urge incontinence, are found in women with prolapse. However, it is not clear whether the severity of prolapse is directly associated with more irritative voiding symptoms or bladder pain.

Pelvic organ prolapse, especially in the apical and posterior compartments, can be (but is not always) associated with defecatory dysfunction, such as pain with defecation, the need for manual assistance with defecation, and anal incontinence of flatus, liquid, or solid stool. These patients often have outlet-type constipation secondary to the trapping of stool within the rectal hernia, necessitating the need for splinting or applying manual pressure in the vagina, rectum, or perineum to reduce the prolapse aiding in defecation. Although defecatory dysfunction remains an area that is least understood in patients with prolapse, clinical and radiographic studies have shown that the severity of prolapse is not strongly correlated with increased symptomatology.

Although the relationship between sexual function and pelvic organ prolapse is not clearly defined, questions regarding sexual dysfunction must be included in the evaluation of any patients with prolapse. Patients may report symptoms of dyspareunia, decreased libido and orgasm, and increased embarrassment with altered anatomy that affects body image. Some studies have reported that prolapse adversely affected sexual functioning, with subsequent improvement in sexual function after repair of prolapse (Barber et al., 2002; Rogers et al., 2001; Weber et al., 2000). However, Burrows et al. (2004) showed little correlation between the extent of prolapse and sexual dysfunction. Evaluating sexual function may be especially difficult in this patient population because the hindrances to sexual function may include factors other than prolapse, such as partner limitations and functional deficits.

Symptoms of incontinence and prolapse and their impact on the woman can be measured or quantified using a number of easy-to-use and validated questionnaires measuring symptom severity, quality of life, and sexual function. These outcome measures can be useful in clinical practice and in research; they are reviewed in detail in Chapter 39.

Gynecologic Examination

General, gynecologic, and lower neurologic examinations should be performed on every woman with incontinence and/or prolapse; the pelvic examination is of primary importance. A bimanual examination is performed to rule out coexistent gynecologic pathology, which can occur in up to two thirds of patients. The rectal examination further evaluates for pelvic pathology and fecal impaction, the latter of which may be associated with voiding difficulties and incontinence in elderly women. Urinary incontinence has been shown to improve or resolve after the removal of fecal impactions in institutionalized geriatric patients.

The physical examination for incontinence and prolapse should be conducted with the patient in dorsal lithotomy position, as for a routine pelvic examination. If physical findings do not correspond to symptoms, or if the maximum extent of the prolapse cannot be confirmed, the woman can be reexamined in the standing position.

Initially, the external genitalia are inspected, and, if no displacement is apparent, the labia are gently spread to expose the vestibule and hymen. Vaginal discharge can mimic incontinence, so evidence of this problem should be sought and, if present, treated. Palpation of the anterior vaginal wall and urethra may elicit urethral discharge or tenderness that suggests a urethral diverticulum, carcinoma, or inflammatory condition of the urethra. The integrity of the perineal body is evaluated, and the extent of all prolapsed parts are assessed. A retractor, a Sims speculum, or the posterior blade of a bivalve speculum can be used to depress the posterior vagina to aid in visualizing the anterior vagina and vice versa for the posterior vagina. Because most patients with prolapse are postmenopausal, the vaginal mucosa should be examined for atrophy and thinning because it may impact upon management. Healthy, estrogenized tissue, without significant evidence of prolapse, will be well perfused, have rugation, and have physiologic moisture. Atrophic vaginal tissue consistent with hypoestrogenemia appears pale, thin, without rugation, and can be friable; this finding suggests that the urethral mucosa is also atrophic.

After the resting vaginal examination, the patient is instructed to perform Valsalva maneuver or to cough vigorously. During this maneuver, the order of descent of the pelvic organs is noted, as is the relationship of the pelvic organs at the peak of increased intra-abdominal pressure. The presence and severity of anterior vaginal relaxation, including cystocele and proximal urethral detachment and mobility, or anterior vaginal scarring, are estimated. Associated pelvic support abnormalities, such as rectocele, enterocele, and uterovaginal prolapse, are noted. The amount or severity of prolapse in each vaginal segment should be measured, staged, and recorded according to POPQ guidelines noted in Chapter 5. A rectovaginal examination is required to fully evaluate prolapse of the posterior vaginal wall and perineal body. Digital assessment of bowel contents in the rectovaginal septum during straining examination can help to diagnose an enterocele. Other clinical observations and tests that help delineate prolapse include (1) cotton swab testing for the measurement of urethral axis mobility (Q-tip test); (2) measurement of perineal descent; (3) measurement of the transverse diameter of the genital hiatus or of the protruding prolapse; (4) measurement of vaginal volume; (5) description and measurement of posterior prolapse; and (6) examination techniques differentiating between various types of defects (e.g., central versus paravaginal defects of the anterior vaginal wall). Inspection should also be made of the anal sphincter because fecal incontinence is often associated with posterior vaginal support defects. Grossly, women with a torn external sphincter may have scarring or a “dovetail” sign on the perineal body.

Anterior vaginal wall descent usually represents bladder descent with or without concomitant urethral hypermobility. However, in 1.6% of women with anterior vaginal prolapse, an anterior enterocele can mimic a cystocele on physical examination. Furthermore, lateral paravaginal defects, identified as detachment of the lateral vaginal sulci, may be distinguished from central defects, seen as a midline protrusion with preservation of the lateral sulci, by using a curved forceps placed in the anterolateral vaginal sulci directed toward the ischial spine. Bulging of the anterior vaginal wall in the midline between the forceps blades implies a midline defect; blunting or descent of the vaginal fornices on either side with straining suggest lateral paravaginal defects. However, researchers have shown that the physical examination technique to detect paravaginal defects is not particularly reliable or accurate. In a study by Barber et al. (1999), of 117 women with prolapse, the sensitivity of clinical examination to detect paravaginal defects (92%) was good, yet the specificity (52%) was poor. Despite a high prevalence of paravaginal defects, the positive predictive value was only 61%. Less than two thirds of women believed to have a paravaginal defect on physical examination were confirmed to possess the same at surgery. Another study by Whiteside et al. (2004) demonstrated poor reproducibility of clinical examination to detect anterior vaginal wall defects. Thus, the clinical value of determining the location of midline, apical, and lateral paravaginal defects remains unknown.

In regard to posterior prolapse, clinical examinations do not always accurately differentiate between rectoceles and enteroceles. Some investigators thus have advocated performing imaging studies to further delineate the exact nature of the posterior wall prolapse. Traditionally, most clinicians believe that they are able to detect the presence or absence of these defects without anatomically localizing them. However, little is known regarding the accuracy or use of clinical examinations in evaluating the anatomic locations of prolapsed small or large bowel or of specific defects in the rectovaginal space. Burrows et al. (2003) found that clinical examinations often did not accurately predict the specific location of defects in the rectovaginal septum that were subsequently found intraoperatively. Clinical findings corresponded with intraoperative observations in 59% of patients and differed in 41%; sensitivities and positive predicative values of clinical examinations were less than 40% for all posterior defects. However, the clinical consequence of not detecting preoperative defects remains unclear.

As noted earlier, the POPQ classification should be done on all women with prolapse. This descriptive system contains a series of site-specific measurements of the woman’s pelvic organ support. The measurements can be obtained quickly in both experienced and nonexperienced hands and can be easily learned and taught by means of a brief video tutorial. Prolapse in each segment is evaluated and measured relative to the hymen (not introitus), which is a fixed anatomic landmark that can be identified consistently and precisely. The anatomic position of the six defined points for measurement should be centimeters above or proximal to the hymen (negative number) or centimeters below or distal to the hymen (positive number), with the plane of the hymen being defined as zero. For example, a cervix that protrudes 3 cm distal (beyond) to the hymen should be described as +3 cm. Studies have demonstrated excellent interexaminer and intraexaminer reliability when using the POPQ system to quantify prolapse. The POPQ system does not take into account lateral defects and perineal descent, but these can be added in descriptive terms. Despite its limitations, POPQ system is currently the classification system used in most research studies and NIH trials and is gaining popularity in clinical practice.

Neurologic Examination

Urinary (and fecal) incontinence may be the presenting symptom(s) of neurologic disease. The screening neurologic examination should evaluate mental status, sensory and motor function of both lower extremities, and lumbosacral neurologic function. The screening lumbosacral examination should include assessments of (1) pelvic floor muscle strength, (2) anal sphincter resting tone, (3) voluntary anal contraction, and (4) perineal sensation. This simple screening examination can be performed quickly and easily as part of the gynecologic examination. When abnormalities are noted, or when an individual is suspected of having neurologic dysfunction, a comprehensive neurologic examination, with particular emphasis on the lumbosacral nerve roots, should be performed. This comprehensive evaluation should be performed before any neurophysiologic testing, because any such testing should be interpreted only in the context of the patient’s history and physical examination findings.

Mental status is determined by noting the patient’s level of consciousness, orientation, memory, speech, and comprehension. Disorders associated with mental status aberrations that may result in changes in bowel or bladder function include senile and presenile dementia, brain tumors, stroke, Parkinson’s disease, and normal pressure hydrocephalus.

Related posts:

Epidemiology and Psychosocial Impact of Pelvic Floor Disorders Urethral Injection of Bulking Agents for Intrinsic Sphincter Deficiency Lower Urinary Tract Infection Surgical Treatment of Vaginal Vault Prolapse and Enterocele Urethral Injection of Bulking Agents for Intrinsic Sphincter Deficiency Bladder Drainage and Urinary Protective Methods

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