Fig. 4.1
e-PAQ-PF
The questionnaires are largely designed as outcome measures and are most useful in a research setting. The benefit to the practitioner not in a research environment is that a great deal of information about patient symptoms and the impact of those symptoms can be obtained in a short period of time.
4.1.1 Urinary Symptoms
Urinary symptoms range from frequency, urgency and nocturia, to dysuria and incontinence [5]. Urge incontinence, as its name implies, is typically preceded by an urge to void, and can involve a trigger such as opening home door, 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.
Many women with urinary incontinence have components of both stress and urge loss, otherwise called mixed incontinence. Few key questions may help in assessing the incontinence type (Table 4.1).
None of the time | Rarely | Once in awhile | Often | Most of the time | All of the time | |
|---|---|---|---|---|---|---|
Do you leak urine (even small drops), wet yourself, or wet your pads or undergarments… | ||||||
1. When you cough or sneeze? | □ | □ | □ | □ | □ | □ |
2. When you bend down or lift something up? | □ | □ | □ | □ | □ | □ |
3. When you walk quickly, jog or exercise? | □ | □ | □ | □ | □ | □ |
4. While you are undressing in order to use the toilet? | □ | □ | □ | □ | □ | □ |
5. Do you get such a strong and uncomfortable need to urinate that you leak urine (even small drops) or wet yourself before reaching the toilet? | □ | □ | □ | □ | □ | □ |
6. Do you have to rush to the bathroom because you get a sudden, strong need to urinate? | □ | □ | □ | □ | □ | □ |
4.2 Implementation of Urinary Symptoms by Voiding Diary and Pad Test
Voiding diary is an inexpensive way to obtain information about a woman’s daily bladder function. It is completed by the patient over a 24 h period and includes oral fluid intake, episodes of incontinence, associated activities and voids. Voiding volumes and times are recorded. The diary alone reveals that symptoms are attributable to excessive fluid intake, resulting in polyuria, or frequency due to OAB syndrome, and nocturia assignable to a nocturnal polyuria [7]. The severity of a patient’s incontinence can be roughly assessed by the type and quantity of protection used (e.g. maxi pads or panty liners).
Pad test is a more objective method to determine the amount of urine loss [8]. The test may be short term or long term. Short-term test has the advantage of convenience and assured compliance. Long-term tests may be more representative of daily incontinence.
Short-term test generally involve the subject drinking a known volume of liquid or undergoing retrograde filling of the bladder. A preweighed sanitary pad is applied. The individual is instructed to perform specific activities such as coughing, running in place, bending and lifting, and handwashing. The testing interval can range from 15 min to 2 h. At the end of the test period, the pad is removed and weighed.
Long-term test is conducted under normal living conditions for 24–48 h. Each pad is preweighed and then weighed again after use by the patient at home, or alternatively, the pad is placed in an airtight plastic bag and weighed later by the clinicians.
According to ICS, the normal upper limits are 1 g for short-term test and 8 g for 24 h test.
The range for ‘mild incontinence’ is between 1.3 and 20 g, ‘moderate incontinence’ ranges from 21 to 74 g, and ‘severe incontinence’ is defined as 75 g or more in 24 h.
4.2.1 Pelvic Prolapse Symptoms
Minimal pelvic organ prolapse is usually asymptomatic. However, vaginal or uterine descent at or through the introitus can become symptomatic.
Symptoms of pelvic organ prolapse may include a sensation of vaginal fullness or pressure, sacral back pain with standing, vaginal spotting from ulceration of the protruding cervix or vagina, coital difficulty, lower abdominal discomfort and voiding and defecatory difficulties. Typically, the patient feels a bulge in the lower vagina or the cervix protruding through the vaginal introitus. Symptoms of voiding dysfunction, such as straining, hesitancy, intermittent flow, incomplete emptying, postvoid dribbling, are often associated to vaginal pressure or bulging.
4.2.2 Bowel Symptoms
Several faecal incontinence surveys attempt to quantify and qualify the severity of faecal incontinence. Two examples are the Fecal Incontinence Quality of Life Scale produced by Rockwood et al. and the Fecal Incontinence Questionnaire by Reilly et al. [9, 10]. Conversely, constipation surveys based on Rome III criteria seems less reliable [11].
However, patients who present for evaluation of bowel symptoms, particularly faecal incontinence, usually have had to overcome extreme embarrassment over their condition prior to their office visit. Care should be given to the manner in which the topic is approached in order to promote an open and comfortable discussion.
Questions about bowel function should include frequency of evacuations, faeces consistency, and presence of constipation. Faecal incontinence may include gas, liquid or solid stool.
Vaginal delivery is widely accepted as the most common predisposing factor to faecal incontinence in an otherwise young and healthy woman [7]. Vaginal delivery may result in internal or external anal sphincter disruption, or may cause more subtle damage to the pudendal nerve through overstretching and/or prolonged compression and ischaemia. An obstetric history should be taken carefully: prolonged second stage of labour, forceps delivery, significant tears and episiotomy, among other causes, are associated with increased risk for anal sphincter disruption and pudendal nerve injury.
Faecal urgency also must be differentiated from faecal incontinence because urgency may be related to medical problems other than anal sphincter disruption.
If constipation is the chief complaint, “splinting”, i.e. the use of a finger pressing in the vagina or on the perineum during faecal evacuation, can be a sign of posterior prolapse or rectocele.
4.2.3 Sexual Symptoms
Sexual dysfunction includes disorders of sexual desire, arousal, orgasm and pain.
Like faecal incontinence, many patients are reluctant to proffer their sexual complaints, even when a sexual issue might be the very reason why the patient is seeking help. Thus, the responsibility of gathering a sexual history lies with the clinician, more than self-completion questionnaires. A good general strategy might be a step-by-step approach: first, by explaining the rationale for inquiring about sexual topics, while sympathizing with the patient reluctance to discuss intimate topics; then gradually introducing the topic of sexual issues, and finally addressing questions about the overall level of sexual interest and satisfaction and the presence of discomfort, pain or incontinence during sexual activity. Pain is the most common disorder in the post-partum as a consequence of perineal trauma. Although many women experience sexual problems in the post-partum period, the subject is still underexplored. Embarrassment and preoccupation with the newborn are some of the reasons why many women do not seek help.
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