Diagnosis and Management of Complex Pelvic Floor Disorders in Women

Past medical history should include common medical comorbidities such as diabetes, hypertension and cardiovascular disease. Obstetric history is important due to the increased risk for pelvic floor disorders in women with multiple pregnancies and vaginal deliveries [2]. Prior hysterectomy, colon resection, or other pelvic surgeries may also contribute to symptoms. Smokers have a greater risk of genitourinary malignancy and high caffeine consumption is implicated in urgency-frequency syndromes. Exercise, sleep, and work may also be affected.

Pelvic examination should evaluate for vaginal atrophy or other vaginal mucosal abnormalities such as tears, ulcerations, lichen sclerosis, or erythema. To evaluate for prolapse, using one-half of a Graves or Pederson speculum, examine the 3 compartments of the vagina: anterior, posterior and apical. To view the anterior wall, the speculum is placed posteriorly to retract the posterior wall downward. Next it is rotated anteriorly to retract the anterior wall up and examine the posterior compartment. The uterus or the apex is evaluated with 2 halves of the speculum, one pushing anteriorly and the other posteriorly. At each point in the evaluation, the patient is told to strain or valsalva. The pelvic organ prolapse quantification system (POP-Q) is a systematic description of site-specific measurements of a woman’s pelvic support [7]. Using this classification system, a standardized and reproducible method of documenting the severity of the prolapse is done based on 6 points of the vaginal wall in relation to the hymen (2 on the anterior wall, 2 in the superior vagina, and 2 on the posterior vaginal wall). A corresponding prolapse stage can then be assigned to the patient based on POP-Q measurements. If unable to reproduce the patient’s symptoms, or exam findings do not correlate with the history, a standing exam can be helpful. Close evaluation of the urethra is also important. In severe prolapse the urethra may become kinked and mask a potential underlying problem (occult SUI). Patients should be asked to valsalva or cough with prolapse reduction and a full bladder to evaluate for this. Lastly, the pelvic floor muscles should be palpated to assess for pain or pelvic floor atrophy, hypertonicity, tenderness, or spasms.

If the patient complains of urgency, frequency, and/or dysuria, urine cultures should be performed to exclude infection even if the urinalysis is negative. Antibiotics should be given based on culture results. A postvoid ultrasound or catheterization is used to evaluate for incomplete bladder emptying. Patients with microscopic or gross hematuria should undergo further testing with radiologic and cystoscopic evaluation as indicated, especially with a history of smoking. Women should be questioned regarding their menstrual history and if postmenopausal, about any vaginal bleeding. A pelvic ultrasound should be considered if the patient has a history of endometriosis, gynecological cancers, uterine fibroids, or ovarian cysts or if considering uterine preserving surgery or colpocleisis. Urodynamics are often indicated in complex patients with prolapse and lower urinary tract complaints or prior pelvic surgery.

Diagnosis

The patient was diagnosed with mixed urinary incontinence and a grade 2 cystocele. Treatment options were discussed and she was most interested in conservative management options.