KEY POINTS
- A voiding diary, stress test, and postvoid residual volume measurement often can provide as much useful information as complex urodynamic investigations.
- In addition to performing the standard gynecologic exam, clinicians should assess patients for evidence of pelvic organ prolapse.
- A lower urinary tract infection can cause urgency, frequency, and nocturia, which can mimic urge incontinence or interstitial cystitis.
- Documentation of the postvoid residual volume is a prerequisite for any incontinence or anterior/apical prolapse procedure, because the clinician will need the information to interpret any postoperative voiding difficulty.
The meticulous evaluation and diagnosis of pelvic floor disorders, critical precursors of treatment, are feasible for any gynecologist—without specialized equipment. A specific history, voiding diary, focused physical exam, and simple office tests provide sufficient data to diagnose most complaints in a single office visit, allowing clinicians to initiate a management plan immediately.
This approach frequently can be carried out without additional studies. In other cases, the evaluation steers the practitioner to the appropriate investigations.
Increasing need for skill in assessing pelvic floor disorders
Although the underlying etiology of pelvic floor disorders is the subject of debate, the increasing demand for management of these problems is not.1 Urinary incontinence is thought to affect 10% to 25% of women 15 to 64 years old, becoming more common with age, although prevalence rates vary considerably according to the definition and survey method used and the population studied.2 A woman’s lifetime risk of undergoing a surgical procedure for prolapse or urinary incontinence is 11.1% by the age of 80.3
As the proportion of postmenopausal women increases over the next 30 years, these conditions will become even more prevalent.1 Thus, the ability to respond appropriately will be a key determinant of a gynecologic practice’s success. Clearly, the need for proper evaluation and diagnosis has never been greater.
How to assess the patient’s history
One way to facilitate a pelvic floor history is to give the patient a detailed questionnaire that can be completed prior to her initial office visit. First, elicit the patient’s main complaint, including its impact on her lifestyle. Other essential components of the pelvic floor history are a description of symptoms and quantification of their duration, frequency, and severity, as well as any previous treatment the patient has undergone.
Evaluate urinary continence. Urinary symptoms range from frequency, nocturia, and urgency to dysuria and hematuria. If the patient does not volunteer a history of urinary incontinence, she should be asked about it. Have her describe any incontinent episodes she has experienced, particularly the frequency and amount of urine lost.
- Urge incontinence, as its name implies, is typically preceded by an urge to void, and can involve a trigger such as running water or cold temperature.
- Stress incontinence generally occurs with sudden movements or increases in intra-abdominal pressure, such as those brought about by coughing, laughing, sneezing, or running.
Estimate urine loss. The severity of a patient’s incontinence can be crudely assessed by the type and quantity of protection used (e.g., maxi pads or panty liners). Evaluate the level of activity needed to provoke an incontinent episode. Incontinence with positional change between lying, sitting, and standing is more severe than occasional incontinence with vigorous exercise. Keep in mind that many women with urinary incontinence have components of both stress and urge loss, otherwise called mixed incontinence.
Look for voiding dysfunction, prolapse. Elicit any symptoms of voiding dysfunction, such as straining, hesitancy, intermittent flow, incomplete emptying, postvoid dribbling, and retention. Symptoms of pelvic-organ prolapse include vaginal pressure or bulging and associated discomfort.
Evaluate bowel function. Include questions about the patient’s bowel function, such as frequency, consistency, and constipation.
- Ask about her use of laxatives or antidiarrheal medications, since these may not be included in her list of medications.
- Also inquire about “splinting”—the use of a finger pressing in the vagina or on the perineum during fecal evacuation—as this can be a sign of posterior prolapse or rectocele.
- Ask specifically about the presence of any anal incontinence, which may involve liquid, gas, or solid stool.
Don’t overlook sexual ramifications. Finally, address the patient’s sexual function, particularly symptoms of discomfort, pain, or incontinence with sexual activity.
Voiding diary
This is an inexpensive way to obtain information about a woman’s daily bladder function. It is completed by the patient over a 24-hour period and includes oral fluid intake, episodes of incontinence, associated activities, and voids (FIGURE 1). Voiding volumes and times are recorded.4 The amount of fluid intake listed on voiding diaries often is surprising and can provide clues to treatment.
The International Continence Society (ICS) defines adult polyuria as more than 2,800 mL (approximately 94 oz) of urine output in 24 hours.4 The voiding diary depicted in FIGURE 1 came from a patient who complained of urinary frequency, nocturia, and rare stress incontinence. It shows that her 24-hour fluid intake was 3,360 mL (112 oz), and her urinary output was 3,720 mL (124 oz). The diary alone reveals that her symptoms are attributable to excessive fluid intake, resulting in polyuria, frequency, and nocturia. This patient experienced symptomatic relief with fluid and methylxanthine reduction.