Clinical
Evaluations
Introduction
History taking
Lower Urinary Tract Symptoms
A-Storage symptoms
B- Voiding symptoms
C- Post micturition symptoms
Symptoms associated with pelvic
organ prolapse
Physical Examination
1- General examination
2- Abdominal examination
3- Gynecological (Pelvic) examination
A- Perineal/genital inspection
B- Vaginal
examination
a- Anatomical abnormalities
b- Assessment of pelvic
floor muscle function
C- Rectal examination
4-
Office tests
5- Neurological examination
Introduction
Early
description of disease relied much on the ability of the clinician to
accurately record the history and clinical examination, confirmatory
investigations were rudimentary, most information being provided by
histological specimens either removed during the operation or at a postmortem
examination. Complex and sophisticated investigations have gradually evolved,
but we still rely on the history and examination to provide the framework for
diagnosis, although these have also undergone changes (Stanton
History taking
Most
history taking uses patient’s own words and is written in prose (usually
neither as lengthy nor as literate as in the past). More use is made now of the
structured questionnaire-designed for the condition being studied. General
history should include questions relevant to neurological and congenital abnormalities
as well as information on previous UTI and relevant surgery. Information must
be obtained on medication with known or possible effects on the LUT. General
history should also include assessment of sexual and bowel function and
obstetric history. Urinary history must consist of symptoms related to both
storage and evacuation functions of the LUT (Walters and Karram, 1999).
Early in the interview,
one should elicit a description of patient’s main complaint, including duration
and frequency. A clear understanding of severity of the problem or disability
and its effects on quality of life should be sought. A bowel history should be
noted because chronic severe constipation has been associated with voiding
difficulties, urgency, SUI and increased bladder capacity (Wein et al,
1991).
Multivariate analysis established age as a risk factor for UI,
with a 30% greater prevalence for each 5years increase in age (Weber and
Walters, 1999). Stress urinary incontinence is common in younger
and middle-aged women, whereas mixed urinary incontinence predominates in older
women (Cardozo, 2004).
Lower
Urinary Tract Symptoms (LUTS)
Lower urinary tract symptoms are divided into three groups: storage,
voiding and post micturition symptoms (Abrams et al, 2002).
A-Storage symptoms are experienced during the storage phase of the
bladder and include daytime frequency and nocturia. Nocturia is the complaint
that the individual has to wake at night one or more times to void. Urgency is
the complaint of a sudden compelling desire to pass urine, which is difficult
to defer. Urinary incontinence is the complaint of any involuntary leakage of
urine. Mixed UI is the complaint of involuntary leakage associated with urgency
and also with exertion, effort, sneezing or coughing. Continuous UI is the
complaint of continuous leakage (Abrams et al, 2002). Voiding more than seven
times a day is defined as frequency (Stanton et al, 1976).
Stress
urinary incontinence is often seen in multiparous women. However, women who
have never borne children can also exhibit this condition (Wein,
2000). Overactive bladder is a medical condition referring to symptoms
of frequency and urgency with or without urge incontinence, when appearing in
absence of local pathologic or metabolic factors that would account for these
symptoms. Incontinence is not a necessary condition for the diagnosis because
half of people with overactive bladder do not have incontinence (Abrams
and Wein, 2000).
Detrusor instability is
now known to be an urodynamic observation of uncertain clinical significance. Symptoms
reported by patients are not equivalent to an urodynamic diagnosis but the
problem seems to be more in the urodynamics than in the symptoms. Evidence
shows that sensory urge incontinence and motor urge incontinence are probably
gradations of the same condition. The relationship between SUI and an
overactive bladder is complex (McGuire, 2000).
B-
Voiding symptoms are experienced
during the voiding phase. Slow stream is reported by the individual as her perception
of reduced urine flow, usually compared to previous performance or in
comparison to others. Intermittent stream (Intermittency) is the term used when
the individual describes urine flow, which stops and starts, on one or more
occasions, during micturition. Hesitancy is the term used when an individual
describes difficulty in initiating micturition resulting in a delay in the
onset of voiding after the individual is ready to pass urine. Straining to void
describes the muscular effort used to initiate, maintain or improve the urinary
stream. Terminal dribble is the term used when an individual describes a
prolonged final part of micturition, when the flow has showed to
trickle/dribble (Abrams et al, 2002).
Women are aware of
hesitancy, difficulty in voiding, poor stream, having to stand to void and
incomplete emptying (Stanton et al, 1983 I). Patients may
feel urgency and then rush to relieve themselves, only to find that they have
difficulty voiding. This difficulty may occur because the detrusor contraction
that gave the patient urgency has subsided and the patient now has difficulty
initiating another contraction to void adequately (Farrar et al,
1975). Voiding difficulty may result from advanced prolapse (Karram
et al, 1999).
C-
Post micturition symptoms are experienced
immediately after micturition. Feeling of incomplete emptying is a
self-explanatory term for a feeling experienced by the individual after passing
urine. Post micturition dribble is the term used when an individual describes
the involuntary loss of urine immediately after she has finished passing urine,
usually after rising from the toilet (Abrams et al, 2002).
Symptoms
associated with pelvic organ prolapse
The feeling of a lump
"something coming down", low backache, heaviness, dragging sensation,
or the need to digitally replace the prolapse in order to defecate or urinate,
are amongst the symptoms women may describe who have a prolapse (Abrams
et al, 2002).
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