Clinical Evaluation of Incontinence and Prolapse
Lioudmila Lipetskaia
Cara Grimes
Shefali Sharma
Introduction
This chapter aims to provide a systematic and practical approach to the evaluation of pelvic organ prolapse (POP) and urinary incontinence (UI). There is significant overlap in these conditions with at least 34% women older than 40 years reporting one pelvic floor disorder and as many as 7% suffering from both POP and UI.1 In the majority of cases, a diagnosis can be established through a carefully collected history and detailed physical examination; rarely invasive testing is required to confirm a diagnosis or guide management. In addition, assessing patient’s goals prior to conducting an examination can save time and improve care. First-line treatments can be offered and started without establishing a definitive diagnosis.2,3 In practice, the more complex the patient’s history and the longer the list of bothersome symptoms, the higher likelihood that additional testing beyond a routine clinical evaluation will be needed.
A comprehensive approach to the evaluation of prolapse and UI is presented here in the following order: chief complaint, history of present illness, treatment goal assessment, detailed physical examination, and ancillary evaluation tools. Due to the significant overlap between prolapse and incontinence, the clinical evaluation is conducted as a single workflow rather than separate evaluation pathways for both conditions. This workflow should be tailored to the chief complaint and some steps described in the following text can be omitted if a diagnosis is established with the information already gathered.
CHIEF COMPLAINT
Urinary Incontinence
Patients with UI typically present with the very specific complaint of involuntary urinary loss. Occasionally, complaints of clear vaginal discharge or wetness are also reported.
Prolapse
Prolapse complaints tend to be more nuanced. The most specific chief complaint is feeling (or seeing) a bulge protruding past the vaginal opening. This complaint is associated with a confirmed diagnosis of prolapse 85% of the time.4 Additional prolapse related complaints include a feeling of pressure in the pelvis, difficulty evacuating bladder or bowels, sensation of something falling out of the vagina, personal sexual complaints of “my vagina feels loose during sex,” or partner-related complaints “my partner feels that he is hitting something during penetration.” Those less specific complaints are not as predictive of prolapse and should be scrutinized more during careful history collection.
HISTORY OF PRESENT ILLNESS
Urinary Incontinence
In the assessment of UI, we find the following approach most practical: First, obtain a detailed description of the leakage episodes. Second, gather pertinent information on comorbidities, functional status, social situations, and environmental factors which can affect the management options and decisions.
Obtain a detailed description of leakage episodes
Eliciting a vignette of the patient’s leakage episodes helps to clarify the timing, quality, frequency, quantity, and other factors of the incontinence. For example, leakage associated with exertion such as coughing, laughing, and sneezing (in the absence of urgency, frequency, or other pelvic symptoms) is highly predictive of stress UI (SUI); a diagnosis can easily be made with history and a physical examination alone.
It is more difficult to describe the gestalt of patients with urgency incontinence. The majority of patients describe a significant amount of urgency (“I’ve got to
go and cannot make it on time to bathroom”) prior to the leakage episode. A common misconception is that leaks due to urgency incontinence need to be preceded by urgency or some other irritative voiding complaints. In fact, it is possible for patients to have “leakage out of the blue while sitting on the couch and reading a book” without feeling any preceding urge; the absence of sensory urgency prior to leakage does not rule out urgency incontinence.
go and cannot make it on time to bathroom”) prior to the leakage episode. A common misconception is that leaks due to urgency incontinence need to be preceded by urgency or some other irritative voiding complaints. In fact, it is possible for patients to have “leakage out of the blue while sitting on the couch and reading a book” without feeling any preceding urge; the absence of sensory urgency prior to leakage does not rule out urgency incontinence.
This picture can be frequently complicated by complaints of incomplete bladder emptying. A common chief complaint may be “It seems that I cannot empty my bladder and I leak all the time.” This statement can falsely lead a physician toward the diagnosis of overflow incontinence, when in reality, their symptoms may be secondary to sensory urgency. Further questioning typically will uncover a scenario such as “I just finished urinating 15 minutes ago. Right after I left the bathroom, I suddenly felt the need to urinate again. When I’m on my way to the bathroom, I leak. I don’t think I empty my bladder!”
Another important aspect in the description of urgency incontinence episodes is an assessment of triggers that provoke either urgency or leakage. Some of the most common triggers are hearing the sound of running water, doing dishes, inserting house keys into the lock, or pulling into the driveway at home. Identifying the triggers not only aids in diagnosis but also helps with the management of the condition.
The other types of incontinence (overflow incontinence and anatomic disruption of urinary tract) are encountered less frequently but should be considered. A complaint of continuous urinary leakage is highly suggestive of a fistula or abnormal ureteral implantation. If a patient states “I just leak all the time and feel like I am constantly wet,” attention should be dedicated to the onset of the symptoms. Fistulas are very rarely spontaneous and in the vast majority of cases have an identifiable preceding event: typically surgery or radiation to the pelvic area in developed countries or complicated childbirth in underdeveloped countries. Abnormal ureteral implantation in the vagina is present at birth and is typically diagnosed in a patient’s youth.
Overflow incontinence can frequently mimic stress incontinence as the majority of the most noticeable leaks will be similarly associated with external bladder compression (e.g., cough or sneeze). The key distinguishing characteristic is that patients typically report many more episodes of insensible urine loss and often suffer from conditions which make retention a more likely diagnosis. These conditions include advanced age, diabetes, and various neurologic conditions. The easiest way to distinguish overflow incontinence from SUI is to routinely incorporate a postvoid residual (PVR) check into clinical exams, as those with overflow typically present with elevated PVRs. PVRs more than 100 to 150 mL are concerning and should trigger further investigation.
The presence of nocturnal enuresis (leakage during nighttime while asleep) defines a specifically challenging subset of patients with urgency incontinence. The presence of sleep apnea is frequently associated with nocturia and subsequent nighttime leakage. An inquiry should be made into potential snoring or partner-observed short-term breathing cessation at night to see if sleep apnea testing is indicated.
The history of a patient’s prior treatments and interventions for incontinence should be gathered at this stage and their efficacy noted. Prior surgical interventions for incontinence can prompt a subsequent, more complex evaluation with the possible need for invasive studies. Prior nonsurgical treatments should be assessed for quality: For example, pelvic floor therapy with a trained professional can yield very different results for incontinence control as compared to self-guided Kegel exercises.
The type of history gathering described earlier uses a “story-telling approach” wherein the majority of symptoms are provided by the patient. The specific details are elicited by the clinician with open-ended questions such as “What makes your symptoms worse?” or “Tell me more about your leakage episodes?” This approach allows for collection of a clinical vignette which serves as a “working theory” or theoretical framework for establishing the final diagnosis. Many physicians prefer to ask a standardized set of questions, in combination with the use of validated questionnaires. Table 9.1 lists some frequently used questions.
Assess incontinence comorbidities, functional status, social situations, and environmental factors
Comorbidities and modifiable factors can affect incontinence and choice of treatment. It is important to assess for medical conditions such as constipation, diabetes, hypertension, recurrent urinary tract infections (UTIs), and overall functional status.
Defecatory dysfunction can significantly worsen urgency incontinence. Persistent presence of hard stool in the rectum due to constipation or obstructed defecation can increase pressure exerted by the rectum onto the bladder, thereby decreasing functional bladder capacity. Poorly controlled diabetes worsens incontinence especially if it is accompanied by polyuria. Diabetes not only is predictive of less optimal treatment outcomes but also raises the probability of overflow incontinence given its association with neuropathy and retention. Diuretic treatments can worsen UI by leading to shifts in urine production throughout the day. UTIs can worsen or cause urinary leakage, especially in elderly
patients whose initial presentation may be worsening incontinence rather than dysuria.
patients whose initial presentation may be worsening incontinence rather than dysuria.
TABLE 9.1 Frequently Used Questions during Urinary Incontinence History Taking | ||||||||||||||||||
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Assessment of patients’ functional status is of great importance. Specifically, inquiring about their level of mobility, use of assisting walking devices, and dexterity helps in identifying functional incontinence. Access to bathrooms can be hindered for patients whose mobility status precludes them from moving quickly. Patients with altered dexterity might leak because they are unable to open bathroom doors easily or have trouble removing their undergarments. Functional status and ability to perform activities of daily living can be assessed formally or informally. Informal assessments include collecting data via simple conversation with questions such as “Did you have any trouble getting to our office? Do you like cooking? What did you cook for dinner last night?” Simple observations on how the patient moves in the room, gets up from the chair, climbs on the exam table, and/or moves into lithotomy position are revealing of patient functional status. Formal assessment can be performed by administering the Functional Status Questionnaire,5 which takes about 15 minutes to complete and can be used for initial evaluation as well as monitoring of the patient’s progress.
Cognitive impairment plays a major role in prognosis and management options. In some situations, cognitive impairment will be evident through basic patient interactions. Using a Mini-Mental State Examination is a quick and more formal way to assess mental status. Interviewing patients’ caregivers and family members is a useful way to assess the level of mental decline, and it also provides insight into the level of social support your patient has.
Fluid intake measured as the amount and type of fluid consumed is important when considering the effectiveness of behavioral modifications for incontinence control. So-called “bladder irritants” such as alcohol, soda, artificial sweetener, carbonated, and caffeinated beverages can be modifiable factors in UI treatment. Fluid overconsumption (increases in fluid intake more than 80 to 90 oz/d) can significantly worsen urgency incontinence.
With a careful and detailed history collection, a differential diagnosis for UI can be established even prior to physical examination. The first aim should be to assess so called “transient (or modifiable) causes of UI” frequently described by mnemonic “DIAPPERS” described in Table 9.2.8 When incontinence is established as a chronic nontransient condition, the physical examination will further assess the pelvic floor to guide the treatment plan.
Prolapse
We recommend gathering a history for prolapse in a similar fashion: Start with disease-specific symptoms and assess for comorbidities and social and environmental components. The key challenge in this aspect of history taking is not only to assess for all symptoms pertinent to prolapse but to also evaluate the symptoms in respect to their “cause-and-effect” relationship with prolapse. In contrast to the evaluation of incontinence, pelvic examination almost always provides the most definitive diagnosis of prolapse. It is important to realize that not all patient-reported symptoms will be related to prolapse, reiterating the importance of a thorough physical exam. The ultimate goal of history taking should be to assess whether the patient’s most bothersome symptoms will be alleviated by prolapse treatment.
TABLE 9.2 DIAPPERS: Transient/Modifiable Causes of Urinary Incontinence | ||||||||||||||||||
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Obtain detailed description of the bulge
As stated earlier, feeling the sensation of a bulge and seeing a bulge protruding past the vaginal opening are the most predictive symptoms of prolapse. The more detailed description of a bulge that a patient is able to provide increases the likelihood that the diagnosis of prolapse will be confirmed. Specific references to bulge size (egg size, walnut size), complaints that the bulge worsens with prolonged standing, and descriptions of a bulge rubbing against clothing indicate that prolapse is likely to be discovered during examination.
Vague complaints include the sensation of pelvic pressure and pain and difficulty with voiding and defecation.9,10 Pelvic pressure can result from pelvic floor muscle spasm which may or may not be related to prolapse. In cases where pelvic pressure and pain are the primary bothersome symptoms, it is worth assessing for alleviating factors. Pelvic pressure and pain worsening with standing and at the end of the day are more likely to be associated with prolapse. When pressure is not time (or position) dependent, and if the pressure is quickly relieved by heat and nonsteroidal anti-inflammatory drugs (NSAIDs), the relationship becomes less obvious. Distinguishing muscle spasm as a primary compensatory response to worsening of prolapse versus muscle spasm caused by other conditions such as a prior episiotomy, high-impact exercise, surgery, endometriosis, or vulvodynia can be nebulous. Taking a thorough history is typically not enough in these more complicated situations, and these patients often require trials of different therapeutic approaches to establish the definitive relationship.
Voiding and defecatory dysfunction are other challenging presentations of prolapse.11,12 Occasionally, the relationship to prolapse is obvious, such as in the case of feeling incomplete bladder emptying relieved by splinting. When patients report that their vaginal bulge needs to be reduced manually and replaced inside their body to help them urinate, it is likely that their voiding
dysfunction is related to prolapse. Patients who report an ability to urinate freely in the morning followed by a complete blockage of their urinary stream in the evening when their prolapse worsens can help establish this “cause-and-effect relationship.” Some voiding dysfunction symptoms, such as increased urgency and frequency, are less predictive of prolapse: Urinary frequency can be triggered by chronic displacement of the bladder out of its normal anatomic position or can be a sign of overactive bladder. Frequently, performing a trial of pessary placement can provide insight: Reduction of a patient’s prolapse with a pessary that leads to subsequent improvement of frequency can help establish prolapse as a cause of irritative voiding symptoms.
dysfunction is related to prolapse. Patients who report an ability to urinate freely in the morning followed by a complete blockage of their urinary stream in the evening when their prolapse worsens can help establish this “cause-and-effect relationship.” Some voiding dysfunction symptoms, such as increased urgency and frequency, are less predictive of prolapse: Urinary frequency can be triggered by chronic displacement of the bladder out of its normal anatomic position or can be a sign of overactive bladder. Frequently, performing a trial of pessary placement can provide insight: Reduction of a patient’s prolapse with a pessary that leads to subsequent improvement of frequency can help establish prolapse as a cause of irritative voiding symptoms.
TABLE 9.3 Differential Diagnosis of Prolapse-Associated Symptoms | |||||||||||||||||||||||||||||||||||||||||||||||||||
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Splinting with defecation is even less predictive of prolapse as a diagnosis. A thorough assessment of stool consistency using a tool such as the Bristol stool scale is needed if obstructive defecation symptoms such as splinting, straining, or manual evacuation is noted by the patient. When other symptoms consistent with constipation are present (e.g., lumpy and rare stools, straining with defecation), it is less likely that prolapse alone is responsible for splinting (Table 9.3). One helpful question that assists in determining whether splinting is due to prolapse or constipation is “Do you feel that your stool is stuck and gets out only when you press on the bulge?” Typically, a definitive relationship between defecatory dysfunction and a vaginal bulge can only be established after prolapse correction, a point that is important to explain when counseling your patients.
Assess prolapse comorbidities, functional status, social situations, and environmental factors
Gathering information on comorbidities and social and environmental factors should be based on potential therapeutic options. Surgical interventions for prolapse
are typically more extensive compared to procedures to treat incontinence especially if apical correction of prolapse is required. Hence, comorbidities such as cardiac and pulmonary diseases and determination of physical status should be used to guide management: For high-risk patients, surgery is a less optimal management choice. Social support and cognitive status play a significant role in guidance of nonsurgical treatments. Patients with cognitive impairment and a lack of social support are at increased risk for inconsistent follow-up; hence, pessary trials and physical therapy might not be feasible.
are typically more extensive compared to procedures to treat incontinence especially if apical correction of prolapse is required. Hence, comorbidities such as cardiac and pulmonary diseases and determination of physical status should be used to guide management: For high-risk patients, surgery is a less optimal management choice. Social support and cognitive status play a significant role in guidance of nonsurgical treatments. Patients with cognitive impairment and a lack of social support are at increased risk for inconsistent follow-up; hence, pessary trials and physical therapy might not be feasible.
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