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
Physical Examination
1- General examination
The physical examination
should focus on detecting anatomic and neurologic abnormalities that contribute
to urinary dysfunction. The attitude and demeanor of the patient and any
obvious personality or mental disorders should be noted. The height and weight
of the patient are recorded (Mark and Edward, 1999).
2- Abdominal examination
The
abdomen and flanks should be examined for masses, hernias, scars and a
distended bladder. The bladder may be felt by abdominal palpation or by
suprapubic percussion. (Abrams et al, 2002).
3- Gynecological (Pelvic) examination
After a general examination is completed, the remaining examination is
divided into gynecological and neurological parts (Abrams et al, 2002).
A- Perineal/genital inspection
Inspection allows
description of skin, for example the presence of atrophy or excoriation, any
abnormal anatomical features and the observation of incontinence. Urinary
incontinence (as a sign) is defined as urine leakage seen during examination:
this may be urethral or extra urethral. Stress urinary incontinence is the
observation of involuntary leakage from the urethra, synchronous with
exertion/effort or coughing. Extra urethral incontinence is defined as the
observation of urine leakage through channels other than the urethra (Abrams
et al, 2002).
The anus is inspected,
looking for soil of stool on skin, evidence of skin irritation, gaping of the
muscles and any scarring. The patient is asked to squeeze and simulate holding
in a bowel movement to look for uniform circular contraction of muscle. Next,
asking the patient to strain may show exaggerated perineal descent or prolapse
or prolapse of hemorrhoids or even rectum (Tracy
Clinicians should be
encouraged to describe the pelvic floor defects clearly and specifically and to
avoid the use of general grades or classes of poorly defined entities (Wall,
1996). Prolapse in each segment is evaluated and measured relative to the
plan of the hymen (not introitus), which is a fixed anatomic landmark that can
be identified consistently and precisely (Bump et al, 1996).
B- Vaginal examination
Vaginal examination
allows description of observed and palpable anatomical abnormalities and the
assessment of pelvic floor muscle function (Bump et al, 1996).
a- Anatomical abnormalities
Pelvic organ prolapse is
defined as the descent of one or more of anterior vaginal wall, posterior
vaginal wall and apex of the vagina (cervix/uterus) or vault (cuff) after
hysterectomy. Anterior vaginal wall prolapse is defined as descent of the
anterior vagina so that the urethrovesical junction (a point 3cm proximal to
external urinary meatus) or any anterior point proximal to this is less than
3cm above the plane of the hymen. Prolapse of the apical segment of the vagina
is defined as any descent of the vaginal cuff scar (after hysterectomy) or
cervix, below a point which is 2cm less than the total vaginal length above the
plane of the hymen. Posterior vaginal wall prolapse is defined as any descent
of posterior vaginal wall so that a midline point on posterior vaginal wall 3cm
above the level of hymen or any posterior point proximal to this is less than
3cm above the plane of the hymen (Abrams et al, 2002).
A vaginal examination
should be performed with the bladder both empty (to check the pelvic organs) and
full (to check for incontinence and prolapse). With the bladder comfortably
full in the lithotomy position, the patient is asked to cough or strain in an
attempt to produce the incontinence. The physician should observe the patient
for a while with a speculum in place and ask her to cough. Anterior vaginal
wall prolapse occurs commonly and may be coexisting with disorders of
micturition. The examination is first performed with the patient supine. If
physical findings do not correspond to symptoms or if the maximum extent of the
prolapse cannot be confirmed, the woman is reexamined in the standing position.
A retractor or Sims’ speculum can be used to depress the posterior vagina to
aid in visualizing the anterior vagina. After the resting examination, the
patient is instructed to strain down forcefully 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 straining. Anterior vaginal
wall descent usually represents bladder descent with or without concomitant
urethral hypermobility (Romanzi et al, 1995).
The urinary incontinent
women are examined for functional urethral anatomy as it related to the
Valsalva and Kegel maneuvers. The anterior urethral crease, the middle urethral
bulge and the posterior urethral fold are identified in each patient. These
three landmarks represent the portion of the urethra supported in part by the
pubourethral ligaments. Kegel or pubococcygeal retractions can be performed to
note any compensatory capacity to the supportive structures (Cruikshank
and Kovac, 1997).
Enterocele and rectocele
can be demonstrated by using the speculum to retract the anterior vaginal wall.
Asking the patient to cough and simultaneously examining the rectum and vagina
can make differentiation (Stanton
b- Assessment of pelvic floor muscle
function
Pelvic floor muscle
function can be qualitatively defined by the tone at rest and
the strength of a voluntary or reflex contraction as strong, weak or absent or
by a validated grading system (e.g. Oxford
With two examining fingers in the
vagina, levator muscles are located at the 5- and 7-o’clock positions just superior
to the hymeneal ring. Patient is instructed to contract these muscles. A
correctly performed pelvic floor contraction is demonstrated by cephalad
retraction of the perineum and anus, posterior rotation of the clitoris and
anterior displacement of the examining fingers (Bump et al, 1991).
C- Rectal examination
Rectal
examination further evaluates for pelvic pathology and fecal impaction, the
later of which may be associated with voiding difficulties and incontinence in
elderly women (Mark and Edward, 1999). In virgins who
have intact hymen, pelvic organs can be examined by the rectal-abdominal
technique (Hochstein and Rubin, 1964).
4- Office tests
These tests attempt to
differentiate between GSI and uninhibited bladder. First of these is the Q tip
test which is useful to determine the amount of vesical neck descent on
straining. Rotational angle measured by Q-tip test
with a full bladder, showed (48 degrees, range 31-60) in women with genital
prolapse of different grades. Measurement of urethral mobility by the Q-tip
test is significantly affected by genital prolapse (Pollak et
al, 2003).
Bonney test utilizes two
fingers to elevate the BN toward the umbilicus, tacking care not to compress
the urethra. Urethroscopically, however, urethral compression almost always
occurs, thereby, negating the predictive value of the Bonney test. The
Marchetti test, using local anesthesia and Alli’s clamps and the Read test,
using rubber-shod clamps, also compress the urethra. So these tests are limited
value (Pelosi et al, 1975).
A frequency/volume
bladder chart is an invaluable aid in the evaluation of patients with urinary
incontinence, but use of this tool is often neglected (Wyman et al, 1998).
Pad test provides a semi
objective measurement of urine loss over a given period of time. A number of
pad tests have been described (Hahn and Fall, 1991).
Stress test: physician
examines the patient with a full bladder in standing position. While the
physician closely observes urethral meatus, the patient coughs. If short spurts
of urine escape simultaneously with each cough, this suggests GSI. A delayed
leakage or loss of large volumes of urine suggests the diagnosis of uninhibited
bladder contractions. Continence status can be confirmed by stress test and one
day pad test for women with negative stress test and complained SUI (Miller
et al, 2001).
5- Neurological
examination
A
simplified neurological examination should be performed to screen all patients.
The back is examined for lesions such as spina bifida (overt or occult) and
prolapsed intervertebral disk or spondylosis. Sacral segments 2 through 4,
which contain the important neurons controlling micturition, are particularly
important. To test motor function, the patient extends and flexes the hip, knee
and ankle and inverts and everts the foot. The strength and tone of the
bulbocavernosus muscle and external anal sphincter are estimated digitally.
Sensory function along the sacral dermatomes is tested by using light touch and
pinprick on the perineum and around the thigh and foot. In the anal reflex,
stroking the skin adjacent to the anus causes reflex contraction of the external
anal sphincter muscle. The bulbocavernosus reflex involves contraction of
bulbocavernosus and ischiocavernosus muscles in response to taping or squeezing
of the clitoris (Walters, 1999).
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