Evaluation of pelvic floor disorders: History, physical examination, and diagnostic testing

Urinary incontinence and lower urinary tract symptoms

Early in a patient interview, one should elicit a description of the patient’s main complaint, including duration and frequency, with specific questions to differentiate amongst the known genitourinary and nongenitourinary etiologies and specific types of urinary incontinence (see Chapter 8 ). The initial goal should be to diligently seek out and treat all reversible causes of urinary incontinence and voiding difficulty ( Box 9.1 ). The mnemonic DIAPPERS has long been used to remember this list (Delirium, Infections, Atrophic vaginitis, Psychological causes, Pharmacological, Endocrine, Restricted mobility, Stool impaction). A clear understanding of the severity of the problem or disability and its effect on quality of life should be sought. Assessment of physical 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 9.2 lists questions that are helpful in evaluating urinary incontinence in women. The first question is designed to elicit the symptom of stress urinary incontinence (i.e., urine loss with events that increase intraabdominal pressure). The symptom of stress urinary incontinence is usually (but not always) associated with the diagnosis of urodynamic stress incontinence. Questions 2 through 9 help elicit the symptoms associated with overactive bladder and urgency urinary incontinence. The symptom of urgency incontinence is present if the patient answers question 3 affirmatively. Frequency (questions 4 and 5), bedwetting (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 to 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.

Stress urinary incontinence and voiding difficulties can also coexist with anterior and apical vaginal prolapse. However, overt symptoms of stress urinary incontinence may not be present in women with advanced degrees of prolapse, owing to mechanical obstruction of the urethra that prevents urinary leakage. Instead, these women may require manual replacement of the prolapse, also known as splinting, to accomplish voiding. The prolapse increases the 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. In addition to difficulty voiding, other urinary symptoms such as urgency, frequency, and urgency incontinence can be 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.

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 disc disease, may cause or contribute to 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 urinary incontinence, increased bladder capacity, and POP. A history of hysterectomy, vaginal repair with or without mesh, 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 9.1 . 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.

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 bedwetting 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. Electronic bladder diaries have become widely available in recent years. These application-based diaries are easy to use and correlate well with paper diary results across age, gender, and education level. Urinary diaries are also a useful and accepted research method to measure the severity of incontinence and as an outcome measure after interventions. This is reviewed in Chapter 41 .

After the history, patients can often be categorized as having probable urodynamic stress incontinence and/or probable detrusor overactivity (with or without coexistent stress incontinence, i.e., mixed urinary incontinence). Women who have the symptom of stress urinary incontinence as their only complaint have a 64% to 90% chance of having urodynamic stress incontinence confirmed on diagnostic urodynamic testing. Of these patients, 10% to 30% are found to have detrusor overactivity (alone or coexistent with urodynamic stress incontinence). Other rare conditions that can cause the symptom of stress incontinence are urethral diverticulum, genitourinary fistula, ectopic ureter, and urethral instability. Inquiry directed at differentiating amongst these conditions should be considered when an atypical history is provided by the patient or when initial therapy is not effective.

Sensory urgency, urgency incontinence, diurnal and nocturnal frequency, and bedwetting all are associated with overactive bladder. The more of these abnormal urinary symptoms the patient has, the greater the chance that she has detrusor overactivity. observed that 81% of patients with three or more of these symptoms had detrusor overactivity on cystometry.

For either diagnosis, appropriate behavioral or medical therapy can be given, and a substantial percentage of patients are expected to respond. Even patients with mixed disorders (coexistent stress and urgency urinary incontinence) respond to various forms of conservative therapy in about 60% of cases. Alternatively, the initial therapy selected for mixed incontinence should be directed toward the first occurring and most bothersome symptom, as this relates most closely to the urodynamic diagnosis. Complex causes of incontinence should be triaged for urodynamic testing or for consultation (see Box 9.3 ).

Pelvic organ prolapse

Patients with POP may present with symptoms directly related to the prolapse, such as vaginal bulge, pressure, and discomfort, and with a plethora of associated symptoms relating to voiding, defecation, and sexual dysfunction. 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, feeling or seeing a protruding mass or, more rarely, pain. In a study by , the feeling of “a bulge or that something is falling outside the vagina” had a positive predictive value of 81% for POP; 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 presence of vaginal bulge symptoms is a highly specific (but not sensitive) symptom for predicting the presence of prolapse beyond the hymen on a straining examination (specificity 99%–100%). A variety of questions should be asked to understand the POP impact on bladder, bowel, and sexual function (see associated sections), especially as urinary splinting and digital assistance with defecation are also common in women with advanced prolapse.

Elucidating the symptom severity is the most important component of POP evaluation. This should include how the symptoms have changed over time, whether or not the symptoms impact physical activities, and the overall effect on the patient’s quality of life. This information will ultimately direct the provider to the most appropriate treatment options available to the patient.

Fecal incontinence and defecatory dysfunction

Obtaining a thorough bowel history is an important component of the pelvic floor disorder evaluation. The basic inquiry should include the frequency of bowel movements, typical consistency, presence of incontinence, and any difficulty with defecation.

When patients report anal incontinence, the provider first determines whether it is incontinence of flatus, liquid stool, solid stool, mucus, or a combination. Further characterization of the incontinence should include frequency/timing of occurrence, provoking factors, pad/diaper use, stool consistency, medication history, and severity. The provider should elucidate whether the soiling is associated with urgency or is passive. A detailed inquiry of the patient’s medical, surgical, obstetric, medication, and dietary histories is performed.

Similarly, if the patient reports defecatory dysfunction, a history should be obtained to determine the specific bothersome symptoms and their frequency. This may include anorectal pain with defecation, a sensation of incomplete emptying, straining to defecate, the need for manual assistance with defecation such as perineal or vaginal splinting, digital evacuation of stools, or other maneuvers to aid in defecation. A medical history may reveal conditions associated with chronic constipation, whereas inquiry of medication use may identify agents known to cause (such as opioids) or treat (stool softeners, laxatives) constipation.

POP, 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. These patients often have outlet-type constipation secondary to the trapping of stool within the rectal hernia, necessitating the need for splinting to reduce the prolapse and aid in defecation. Interestingly, splinting is the only symptom specifically associated with posterior compartment POP ( ). Although defecatory dysfunction remains an area that is least understood in patients with POP, clinical and radiographic studies have shown that the severity of prolapse is not strongly correlated with increased symptomatology. Further review of this topic can be found in Chapter 27, Chapter 28 .

Sexual dysfunction

Questions regarding sexual dysfunction must be included in the evaluation of patients with pelvic floor disorders. Patients may report symptoms of dyspareunia, decreased libido and orgasm, and increased embarrassment with altered anatomy that affects body image. Urinary or fecal incontinence may also have a significant negative impact on sexual activity. Some studies, but not all, have reported that POP adversely affects sexual functioning, with subsequent improvement in sexual function after repair of prolapse. Evaluating sexual dysfunction may be especially difficult in this patient population, as factors other than pelvic floor disorders, such as menopausal symptoms, partner limitations, and functional deficits, may contribute. See Chapter 10 for further discussion of female sexual dysfunction.

Adjuncts for obtaining pelvic floor disorder history

Symptoms of pelvic floor disorders 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. New tools have been reported recently, including the Comprehensive Assessment of Self-Reported Urinary Symptoms ( ). These outcome measures can be useful in clinical practice and in research; they are reviewed in detail in Chapter 41 .

Gynecologic examination

The physical examination for pelvic floor disorders 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. One should note any vulvar abnormalities, including skin irritation secondary to pad use and/or incontinence. Incontinence-associated dermatitis can be present in up to 46% of older patients with urinary incontinence ( ). If no displacement of the labia owing to prolapse 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 vaginal 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 epithelium should be examined for atrophy and thinning because this may affect management. Healthy, estrogenized tissue, without significant evidence of POP, will be well perfused and have rugation and physiologic moisture. Atrophic vaginal tissue consistent with hypoestrogenemia appears pale, thin, and 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 the Valsalva maneuver or to cough vigorously. During this maneuver, one should note the presence and severity of stress urinary incontinence, while also observing the order of descent of the pelvic organs, as this corresponds to the relationship of the pelvic organs at the peak of increased intraabdominal 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 classification (further discussed in Chapter 8 ). 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. It can be easily learned and taught by means of a brief video tutorial. Prolapse in each vaginal 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 to (beyond) the hymen should be described as +3 cm. Studies have demonstrated excellent inter- and intraexaminer reliability when using the POPQ system to quantify prolapse. The POPQ system does not take into account lateral defects and perineal body prolapse, but these can be added in descriptive terms. POPQ measurements can also help predict or aid in the diagnosis of voiding dysfunction ( ) and levator hiatus ballooning ( ). Despite its limitations, the POPQ system is currently the classification system used in most academic centers, research studies, and National Institutes of Health trials.

Other clinical observations and tests to help delineate prolapse include examination techniques differentiating between various types of defects (e.g., central versus paravaginal defects of the anterior vaginal wall), description and measurement of posterior prolapse, measurement of perineal descent, and measurement of the transverse diameter of the genital hiatus or of the protruding prolapse.

Regarding urinary incontinence, physical findings associated with urodynamic stress incontinence are anterior vaginal relaxation and observed transurethral urine loss with coughing or Valsalva maneuver (i.e., positive bladder stress test). Anterior vaginal wall descent usually represents bladder descent with or without concomitant urethral hypermobility. However, in about 1% of women with anterior vaginal prolapse, an anterior enterocele can mimic a cystocele on physical examination. Cotton swab testing to measure urethral axis mobility (Q-tip test) as part of the incontinence evaluation is of questionable utility. The angle of urethral inclination does not differ between continent and incontinent women with pelvic relaxation. showed that essentially all women with stage II to IV prolapse by POPQ had Q-tip angle greater than 30 degrees. Furthermore, adding serial measurement of urethral inclination with a Q-tip to the history and pelvic examination does not appreciably change the sensitivity or specificity for diagnosing urodynamic stress incontinence. However, because most women with primary urodynamic stress incontinence have urethral hypermobility, a nonmobile urethra should cause one to question that diagnosis, perhaps indicating the need to perform urodynamic testing. Several other tests are available for estimating the amount of urethral mobility in women, including the measurement of Aa in the POPQ system, visualization, palpation, and ultrasonography. Determination of urethral mobility in urinary incontinence also may add value in determining which surgical therapy is most appropriate. For example, patients without hypermobility may not benefit from a retropubic suspension or midurethral sling and may be better candidates for urethral bulking.

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 of 117 women with prolapse, the sensitivity of clinical examination to detect paravaginal defects was good (92%), yet the specificity was poor (52%). 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. Thus, the clinical value of determining the location of midline, apical, and lateral paravaginal defects remains unknown, but may be valuable for surgical planning when identified.

For posterior vaginal prolapse, clinical examination does not always accurately differentiate between rectoceles and enteroceles. Some investigators have advocated performing imaging studies to further delineate the exact nature of the posterior wall prolapse. Traditionally, most clinicians believe they are able to detect the presence or absence of these defects without anatomically localizing them. However, little is known regarding the accuracy or utility of clinical examinations in evaluating the anatomic locations of prolapsed small or large bowel or of specific defects in the rectovaginal space. 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, what remains unclear is the clinical consequence of not detecting these defects preoperatively.

Rectal examination

Rectal and rectovaginal examinations are recommended to evaluate both bowel continence and defecatory issues, as well as to fully characterize posterior vaginal wall prolapse and perineal body descent. Inspection of the perianal region is performed with the buttocks separated. The resting anal tone should be noted, as well as any fecal soiling, scarring, hemorrhoids, anal fissures, and asymmetry or gaping of the anal opening, which can be associated with neurologic disorders. Women with disruption of the external anal sphincter may have gross abnormalities of the perineal body, with a “dove tail” sign in the area of the disrupted sphincter.

Perineal descent can be assessed by having the patient perform a Valsalva maneuver. During voluntary contraction of the anal sphincter, the perineal body should elevate. Next, a digital rectal examination is performed, noting the resistance to entry of the examining finger. Some 50% to 85% of overall resting anal tone is generated by the internal anal sphincter. Loss of resting tone suggests disruption of the internal anal sphincter and/or an injury to its sympathetic innervation (i.e., pelvic plexus injury). Anoperineal or recovaginal pocketing can be assessed by palpating anteriorly to identify weakness in the rectovaginal septum and/or perineal body. The patient then should be asked to maximally squeeze her anal sphincter. The presence of a strong voluntary anal sphincter contraction indicates intact pudendal innervation and external anal sphincter. The Digital Rectal Examination Scoring System is one scoring system that is available to evaluate sphincter tone ( Table 9.2 ). This system correlates well with resting and squeeze pressures on manometry, and is scored from 0 to 5, with 3 representing normal anal tone. Absence or decrease of both anal sphincter tone and voluntary contraction suggests a possible sacral or peripheral nerve lesion. Preservation of resting tone in the absence of a voluntary contraction suggests a suprasacral lesion. Anal sphincter defects can also be evaluated during anal squeeze, with the examiner noting a weakness or absence of contraction in the anterior or anterolateral regions; however, agreement between digital rectal examination and ultrasonographic findings for sphincter defects is poor, calling into question the specificity of this technique. Lastly, the patient should be instructed to bear down. Digital assessment of bowel contents in the rectovaginal septum during straining examination can help to diagnose an enterocele. At this time, the examiner can also assess for POP.

In patients with pelvic floor dyssynergia, a hypercontracted and tender puborectalis muscle may not relax on command. Patients may also have paradoxical anal sphincter contraction during straining. These patients often complain of difficult or incomplete bowel emptying.

Neurologic examination

Urinary or fecal incontinence may be the presenting symptom(s) of neurologic disease. The screening neurologic examination should evaluate mental status and sensory and motor function of both lower extremities and include a screening lumbosacral neurologic examination. The screening lumbosacral examination includes 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 is performed before any neurophysiologic testing, because any such testing should only be interpreted 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. The Mini-Cog screening tool, which consists of three easily administered components (three-word registration, clock drawing, and three-word recall), and other formal mental status assessments can be helpful, particularly for elderly patients. Disorders associated with mental status aberrations that may result in changes in bowel or bladder function include senile and presenile dementia, brain tumor, stroke, Parkinson disease, and normal pressure hydrocephalus.

Evaluation of the sensory and motor systems may identify an occult neurologic lesion or can help determine the level of a known lesion. Common diseases associated with sensory and motor abnormalities that can produce urologic disturbances include Parkinson disease, multiple sclerosis, cerebrovascular disease, infections, and tumors. Sacral segments 2 through 4, which contain the important neurons controlling micturition, are particularly important. Sensory function is evaluated by testing the lumbosacral dermatomes for the ability to sense light touch, pinprick, and temperature. The sensory dermatomes of interest include the perineum and perianal skin (pudendal nerve, S2–4), mons pubis and upper aspect of labia majora (ilioinguinal nerve, L1–2), front of the knees (L3–4), and sole of the foot (S1). Dermatome maps are useful for characterizing sensory deficits, although it is important to remember that there can be considerable overlap between dermatomes. 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 levator ani muscles and external anal sphincter are estimated digitally. The strength of the pelvic floor musculature is assessed by palpating the levator ani muscle complex bilaterally in the posterior vaginal wall approximately 2 to 4 cm cephalad to the hymen. The patient is then asked to squeeze around the examiner’s fingers. Validated scales include the Brink and Oxford scales ( Table 9.3 ). Weakness in this muscle complex can be a result of neurologic deficits or direct trauma during childbirth. Position sense and vibration should be assessed but need only be evaluated in the distal extremities. The patellar, ankle, and plantar reflex responses are tested.

Visceral sensation of the bladder and rectum can be assessed with cystometry and anal manometry, respectively. Loss of perineal sensation in a patient with bowel or bladder dysfunction, particularly if acute, should always alert the examiner to a potentially serious neurologic problem. Neurophysiologic testing and/or radiologic evaluation would be performed to assess for conus medullaris or cauda equina syndrome.

Two reflexes may help in the examination of sacral reflex activity. 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 the bulbocavernosus and ischiocavernosus muscles in response to tapping or squeezing of the clitoris or stroking the labia majora. Unfortunately, these reflexes can be difficult to evaluate clinically and are not always present, even in neurologically intact women.