Office Evaluation of Pelvic Floor Disorders
Ralph Raymond Chesson Jr.
Nia Thompson Jenkins
Introduction
Currently, there is no generalized consensus statement or guidelines addressing the evaluation of patients presenting with pelvic floor complaints, including but not limited to, urinary and fecal incontinence, pelvic organ prolapse, fistulas, and vulvovaginal pathology. Various medical specialties ranging from female pelvic medicine and reconstructive surgeons, gynecologists, urologists, colorectal surgeons, and general practitioners may approach patient evaluation differently. Over the years, improvements have been made in the standardization of terminology prompting uniformity in the evaluation and diagnosis amongst practitioners. As it pertains to incontinence in the female, there are published studies; however, none examine the relationship between recommendations and therapeutic outcomes. Given the varying range of invasive and noninvasive therapeutic options for pelvic floor disorders, it is crucial that a practitioner can reliably establish the correct diagnosis. This chapter discusses the utilization of a detailed history, physical exam components, laboratory studies, and in office studies for the evaluation of patients with pelvic floor disorders.
BACKGROUND
The Agency for Health Care Policy and Research (AHCPR), American College of Obstetricians and Gynecologists (ACOG), International Continence Society (ICS), and American Urologic Association (AUA)/Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU), and Female Pelvic Medicine & Reconstructive Surgery (FPMRS) have all published documents outlining guidelines for the evaluation of the incontinent female or pelvic floor disorders. In 1992 (modified in 1996), the AHCPR first published their guidelines detailing the suggested workup of urinary incontinence.1 Their consensus was that a basic evaluation included a thorough history with voiding diary, physical examination, postvoid residual (PVR), and urinalysis. These guidelines were drafted by a panel of experts and targeted for use by primary care practitioners. The inclusion of a PVR was the major change in their recommendations.
In 1996, the Pelvic Organ Prolapse Quantification System (POP-Q) was introduced by the American Urogynecologic Society as a standardized tool used to assess and stage pelvic organ prolapse in females.2 This also was adopted by the International Urogynecological Association (IUGA), ICS, and eventually the National Institutes of Health. Numerous systems were previously used to stage prolapse; however, the POP-Q was the only system that used objective values to quantify prolapse.3
Since then, ACOG has published both practice bulletins and committee options targeted for use by the gynecologic provider. In 2017, a reaffirmed committee opinion on the evaluation of complicated stress urinary incontinence in women before surgical treatment recommended a history, urinalysis, physical examination with assessment for pelvic organ prolapse, cough stress test, assessment of urethral mobility, and measurement a PVR prior to placement of a retropubic midurethral sling for treatment of stress urinary incontinence.4 To provide better guidance, ACOG also published a practice bulletin on urinary incontinence in 2018 recommending a history, physical exam, symptom severity assessment, goals for treatment, screening for urinary tract infection (UTI), PVR, and cough stress test as key components in the office evaluation.5 Additionally, the document suggested the use of validated questionnaires could be helpful to aid in thorough and accurate assessment of symptoms. There are six different questionnaires that a provider may choose to use to guide their treatment of a patient: Urogenital Distress Inventory, Incontinence Impact Questionnaire, Questionnaire for Urinary Incontinence Diagnosis, Incontinence Quality of Life Questionnaire, Incontinence Severity Index, and International Consultation on Incontinence Questionnaire. Encompassing the spectrum of pelvic floor disorders, a practice bulletin on the evaluation and treatment of fecal incontinence was released in 2019.6 Clinical practice guidelines for the treatment of
pelvic organ prolapse also issued in 2019.7 Unlike previously published recommendations, these documents were tailored to the scope of gynecologists and offered more guidance for the initial office evaluation and in the preoperative setting.
pelvic organ prolapse also issued in 2019.7 Unlike previously published recommendations, these documents were tailored to the scope of gynecologists and offered more guidance for the initial office evaluation and in the preoperative setting.
The sixth international consultation on incontinence published their detailed guidelines in 2017.8 Subsections focused on evidence-based findings as it related to physiology, treatment of urinary incontinence in both men and women, treatment of prolapse and fecal incontinence, and painful bladder syndrome. Unfortunately, the published findings reviewed the available treatment options and does not cover any specific recommendations for evaluation except for painful bladder syndrome. Although the public guidelines offer exceptional insight into the available clinical evidence, it is limited in its use for evaluation pelvic floor disorders.
The AUA/SUFU also have guidelines for the evaluation for overactive bladder (OAB) and female stress urinary incontinence (Table 10.1). In 2014, their recommendations for the evaluation of OAB included a detailed medical history, history of bladder symptoms, assessment of fluid intake, medications, degree of bother, Mini-Mental Status Exam, and urinalysis. It notes that urine culture, and PVR, and other validated questionnaires are reasonable to use for unclear diagnoses.9 In 2017, their recommendations for initial evaluation prior to treatment for female stress incontinence included history, assessment of bother, physical examination including a pelvic examination, demonstration of stress urinary incontinence with a comfortably full bladder, PVR urine, and urinalysis.10
TABLE 10.1 Current Recommendations by Society/Organization | |||||||||
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OFFICE EVALUATION
A data collection tool as modified from a form that originated from Emory University is a good example of a useful tool for patients presenting with pelvic floor dysfunction (Fig. 10.1). Given the variation among consensus statements, the following four-page tool encompasses a detailed depiction of what is reasonable to collect during the basic office evaluation. This form can assist in the evaluation of a large array of problems with a comprehensive review of systems affecting pelvic floor complaints. It also acts as a guide for a comprehensive physical exam, including the use of the POP-Q. The tool is a useful guide to ensure the collection of important data and is helpful for the experienced FPMRS as well as the teaching of learners at all levels in the evaluation of pelvic floor dysfunctions.
History of Present Illness and Patient History
Often, patients presenting for initial workup may have more than one pelvic floor complaint. Close proximity of the bowel, bladder, and reproductive organs often leads to a constellation of symptoms that can make a diagnosis or diagnoses challenging. It is crucial for the provider to
obtain a detailed history and solicit answers to the appropriate questions for efficient and accurate diagnosis.
obtain a detailed history and solicit answers to the appropriate questions for efficient and accurate diagnosis.
 FIGURE 10.1 Urogynecology data base for data collection in the clinic. (continued) |
 FIGURE 10.1 (Contiued) |
 FIGURE 10.1 (Contiued) |
 FIGURE 10.1 (Contiued) |
Upon initial presentation, the history of present illness as well as previous treatments should first be established. Given that patients may have multiple complaints, it is pertinent to define the most bothersome symptom. This symptom could be broken up into categories such as nonspecific incontinence, stress incontinence, urge incontinence, frequency, urgency, nocturia, nocturnal enuresis, dysuria, bladder pain, lack of bladder sensation, voiding difficulty, hesitancy, straining to void, poor flow, intermittent stream, incomplete emptying, prolapse, bulge, or any other unnamed symptom. It is also helpful to establish the degree of bother. After the identification of the most bothersome symptom, it is important to systematically address complaints within the categories of incontinence, voiding dysfunction, bowel function, history, and medications.
Urinary frequency: Increased daytime frequency is the complaint by the patient who considers that he or she voids too often by day (ICS 2016).
Specifically, the patient should be questioned about how many times a day they void, and if frequently, it is best to break it down into how many times per hour(s). Although voiding patterns may vary, a healthy adult should void approximately six times per day.11,12 Next, the patient should be questioned about how many times they void at night. Nocturia is the complaint that the individual has to wake at night one or more times to void (ICS 2016). This question should be posed as a statement in which the patient is awakened from sleep, voids, and immediately returns to sleep. It should not include voids where the patient is awake at night or does not return to sleep. Awakening three or more times at night is usually indicative of moderate or severe bother for most patients.13 Occasionally, a voiding diary is necessary to evaluate this component of the history. Most of the voiding diaries are too complex and want too much information. Measuring urine output in a measuring hat in the toilet is more accurate in understanding volume output than trying to figure out dietary intake which is not a precise measurement. We need to know how often and how much they void and possible how many wet pads they have. They need to be given a measuring hat to measure their voids. Three days would be ideal, but in 24 to 48 hours, you will know their intake by measuring their output. Overactive bladder patients will have frequent small voids.
Urinary incontinence: Urinary incontinence is the complaint of any involuntary leakage of urine (ICS 2016).
In order to establish the appropriate etiology of a patient’s incontinence, ideally, a series of questions should be asked in the following order. It is often useful to first ask a patient to describe a typical leaking episode. This should be followed by how many incontinent episodes the patient has per day, per week, or per month if they are less frequent. Stress urinary incontinence is the complaint of involuntary leakage on effort or exertion, on sneezing, or coughing (ICS 2016). Specifically, the patient should be asked about the presence of stress incontinence and, if present, whether it occurs sometimes, often, always. The same series of questions should be asked regarding urgency incontinence. Urge urinary incontinence is the complaint of involuntary leakage accompanied by or immediately preceded by urgency (ICS 2016). Many patients will have a combination of both symptoms; therefore, it is also important to ask whether the incontinence is provoked by coughing, laughing, sneezing, lifting, standing up walking, keys in the door, running water, or intercourse. Mixed urinary incontinence is the complaint of involuntary leakage associated with urgency and also with exertion, effort, sneezing, or coughing (ICS 2016). Further delineation of when the patient leaks is helpful for determining whether the patient has stress or urge incontinence or rather a mixture of the two. Keys in the door and running water would be suggestive of urgency incontinence and not stress incontinence. It is critical to discuss the typical amount of leakage that occurs with episodes of incontinence. Small volumes would be indicative of stress incontinence, whereas large volumes are more concerning for urgency incontinence. Whether or not the patient wears incontinence pads for protection or requires clothing or underwear is also important to ask. A patient who must change their clothing is likely to have larger volume incontinent episodes. Evaluating whether there is limitation in normal activities or change their lifestyle secondary to the incontinence can assess the degree of bother. Lastly, it is very important to discuss nocturnal enuresis and whether this was an issue as a child. If so, details of age and treatment should be reviewed. Again, a bladder diary may help when there are questions regarding this area.
Bladder sensation
Because it relates to bladder sensation and neurourology, it is important to determine if the patient is aware of their bladder fullness and aware of wetness if they have issues with incontinence. Absence of these findings would be concerning for a neurologic etiology that should prompt a different evaluation. Neurologic signs such as abnormalities of the nervous system detected by physical examinations may reflect an underlying neurologic disease such as multiple sclerosis, strokes, or injury. Examples of abnormal signs may include altered sensation, muscle tone, or reflexes. If present, the patient should be referred for a full neurologic examination (Joint terminology 2020). The presence of dysuria should also be discussed. If a patient endorses this symptom, one should discern whether this is in the
absence or presence of an infection. It is also pertinent to ask about bladder pain. If the patient endorses pain, the most important factor is to determine whether this pain is relieved by voiding. Pain, in the absence of infection, with frequent voiding would suggest an etiology such as painful bladder syndrome. Painful bladder syndrome is the complaint of suprapubic pain related to bladder filling, accompanied by other symptoms such as increased daytime and nighttime frequency, in the absence of proven urinary infection or other obvious pathology. The ICS believes this to be a preferable term to “interstitial cystitis.” Interstitial cystitis (IC) is a specific diagnosis and requires confirmation by typical cystoscopic and histologic features. In the investigation of bladder pain, it may be necessary to exclude conditions such as carcinoma in situ and endometriosis (ICS 2016).
absence or presence of an infection. It is also pertinent to ask about bladder pain. If the patient endorses pain, the most important factor is to determine whether this pain is relieved by voiding. Pain, in the absence of infection, with frequent voiding would suggest an etiology such as painful bladder syndrome. Painful bladder syndrome is the complaint of suprapubic pain related to bladder filling, accompanied by other symptoms such as increased daytime and nighttime frequency, in the absence of proven urinary infection or other obvious pathology. The ICS believes this to be a preferable term to “interstitial cystitis.” Interstitial cystitis (IC) is a specific diagnosis and requires confirmation by typical cystoscopic and histologic features. In the investigation of bladder pain, it may be necessary to exclude conditions such as carcinoma in situ and endometriosis (ICS 2016).
Voiding dysfunction
Voiding patterns and habits are critical to the appropriate diagnosis. The patient should be asked about hesitancy, straining to void, poor flow, intermittent stream, the ability to interrupt their stream, incomplete emptying, postmicturition dribble, and acute urinary retention. Each one of these categories should be explained in detail to the patient for an appropriate response.
Infections and stones/hematuria
A history of previous UTIs and how many have occurred within the last calendar year should be discussed. It is also important to ask about pyelonephritis isolated from pregnancy, previous intravenous pyelogram (IVP), and history of kidney stones or urinary bladder stones. If the patient endorses any of these, the details and findings should be discussed. Briefly, the patient should be asked whether or not they are actively passing blood in their urine or have seen blood in their urine before. For completeness, it is helpful to ask if a provider has been concerned about blood in their urine.
Bowel function
Shared neurovasculature and proximity of the bowel and bladder can lead to an overlap in pelvic floor disorders. The patient should be questioned about how many times per day they have a bowel movement. If bowel movements are not daily, it should be broken down by week and/or month if less frequently than once per week. The use of laxatives, suppositories, enemas, manual pressure, fiber, and disimpaction should also be discussed. Brief descriptions of the type of stool are sometimes helpful, and the use of the Bristol scale is covered in Chapter 56. Patient should also be asked about incontinence of gas, liquid stool, or solid stool.
Personal history
Gynecologic history, sexual functioning, obstetric history, family history, and medical history should be discussed in detail with the patient. First, it should be established whether the patient is menopausal or not. If not, menarche, last menstrual cycle, cycle length, flow, and contraceptive use should be discussed. If the patient is experiencing bladder symptoms, it is important to know whether or not the symptoms are related to the menstrual cycle. Timing and results of the last Pap smear and previous history of an abnormal Pap smear should be discussed.
Sexual functioning
Sexual activity and the frequency should be reviewed. If the patient is not sexually active, intention of future sexual activity is important to discuss especially when considering surgical options for the treatment of prolapse. Evaluation should include questions about dyspareunia and the categorization of this pain as superficial, deep, both, and occasional or always. Lastly, coital incontinence should be discussed; if present, note whether it is with penetration, orgasm, or both.
