Courtney Lee1 and Sandip Vasavada1
(1)
Center for Female Urology and Reconstructive Pelvic Surgery, Glickman Urological and Kidney Institute, Cleveland Clinic, Q-10-1 Urology, 9500 Euclid Avenue, Cleveland, OH 44195, USA
Sandip Vasavada
Email: Vasavas@ccf.org
Abstract
The initial evaluation of a patient with suspect urinary incontinence or pelvic organ prolapse should be quite detailed as there are many aspects to these disorders that tie in to other disease processes throughout the body. A complete and thorough history and physical exam will help the clinician optimize the correct approach to the patient, be it observation or more interventional approaches to management. Initial assessment of urinary incontinence and pelvic organ prolapse should evaluate a patient’s signs and symptoms in order to develop a differential diagnosis, determine need for additional testing, and decide possible treatment options. A thorough history and physical exam is necessary for initial evaluation and subsequent testing should be based on clinical suspicion and treatment goals. Further tests should be considered if surgical intervention is planned, conservative therapies are not effective, or there is suspicion for pelvic pathology such as stone, cancer, or fistula. In addition, further testing is valuable if there is a prior history of pelvic surgery or radiation, recurrent UTI, neurologic disease, voiding dysfunction, significant prolapse, pain, or hematuria.
The initial evaluation of a patient with suspect urinary incontinence or pelvic organ prolapse should be quite detailed as there are many aspects to these disorders that tie in to other disease processes throughout the body. A complete and thorough history and physical exam will help the clinician optimize the correct approach to the patient, be it observation or more interventional approaches to management.
Initial assessment of urinary incontinence and pelvic organ prolapse should evaluate a patient’s signs and symptoms in order to develop a differential diagnosis, determine need for additional testing, and decide possible treatment options. A thorough history and physical exam is necessary for initial evaluation and subsequent testing should be based on clinical suspicion and treatment goals.
Further tests should be considered if surgical intervention is planned, conservative therapies are not effective, or there is suspicion for pelvic pathology such as stone, cancer, or fistula. In addition, further testing is valuable if there is a prior history of pelvic surgery or radiation, recurrent UTI, neurologic disease, voiding dysfunction, significant prolapse, pain, or hematuria [1].
Important in the assessment of both urinary incontinence and pelvic organ prolapse is an assessment of the impact of the pelvic floor disorder on the patient. Several questionnaires have been developed to assess the severity of the disease, the degree of bother from the disease, and the effect of the disease on quality of life.
History
Urinary symptoms should be evaluated in all patients with urinary incontinence and pelvic organ prolapse. Storage symptoms are symptoms that occur with bladder filling. They include urinary urgency, daytime and nighttime frequency, nocturnal enuresis, and urinary incontinence.
A patient with urinary incontinence should be questioned about the duration of her symptoms and whether the leakage appears to be per urethra or per vagina. The severity of incontinence can be estimated by asking the patient about the frequency of incontinent episodes and pad usage. A micturition diary, which will be described below, is useful to determine the severity of incontinence.
The physician should attempt to determine the precipitating factors of incontinence in order to characterize the incontinence. Stress urinary incontinence (SUI) is an involuntary loss of urine during physical activity; urgency incontinence is leakage of urine associated with urinary urgency; mixed incontinence is a combination of both stress and urgency incontinence. When a patient complains of mixed incontinence, the physician should ask which type of incontinence occurred first and which is more bothersome to the patient.
During questioning regarding urinary incontinence, patients may complain of continuous incontinence or insensate incontinence when the patient is unaware of urinary leakage. Patients may also complain of postural urinary incontinence, which occurs when the patient loses urine when changing positions. The exact mechanism of postural incontinence is unknown and will require further evaluation [2]. Bladder sensation during filling should also be assessed. Bladder sensation can be increased, reduced, or absent.
Both urinary incontinence and pelvic organ prolapse can be associated with urinary obstruction. Therefore, voiding symptoms, such as hesitancy, slow stream, straining to urinate, position-dependent micturition, and inability to pass urine, should be assessed. Patients with prolapse may also complain of a need to reduce the prolapse in order to void.
Other urinary symptoms such as dysuria, gross hematuria, and a history of urinary tract infections are important to ascertain during a history for pelvic floor dysfunction. These symptoms signify a need for additional tests to rule out pelvic pathology.
Defecatory symptoms should be evaluated. A patient should be asked whether vaginal or perineal splinting is required to evacuate her bowels. Constipation is relatively common in the community. A meta-analysis showed the prevalence of chronic idiopathic constipation in North America is about 14 % [3]. It is more common in the elderly and in women and can be exacerbated by anticholinergics used to treat OAB symptoms. A history of fecal incontinence should also be elicited.
Patients with prolapse can present with a variety of symptoms. The most common and specific symptom of prolapse is the sensation or visualization of a vaginal bulge [4–9]. Several studies have shown that visualization or sensation of a vaginal bulge correlates with the degree of pelvic organ prolapse [5–7, 9]. Women with pelvic organ prolapse are more likely to complain of pain and pressure in the lower abdomen, pelvis, and genital region [10]. While low back pain is common in the community, this has been evaluated and thought to not likely be caused by pelvic organ prolapse [11].
Sexual symptoms should be assessed as part of the routing pelvic floor evaluation. Issues including dyspareunia, disorders of vaginal lubrication, and coital incontinence should be further evaluated. As such, coital incontinence can occur during penetration or orgasm yet the pathology of incontinence during sexual activity is likely multifactoral. SUI is common in patients with leakage during penetration and urgency incontinence tends to be more common in patients with incontinence describing leakage during orgasm [12].
One of the most effective adjuncts to the clinical office visit is the use of a fluid or voiding diary. This diary allows the clinician to assess the timing and amount of fluid intake as well as consumption of caffeinated and other bladder stimulant type beverages. Furthermore, the log can be used as an objective measure of a patient’s level of frequency and urgency and allows the physician to estimate one’s functional capacity. From the voiding diary the physician can calculate daytime and nighttime frequency, number of incontinence episodes, number of urgency episodes, pad usage, total urine volume, maximum voided volume, and nighttime urine volume. It is a good quantitative measure of patients’ urinary frequency and incontinence episodes and can be used to track treatment. Perhaps it is most useful for patients who present with nocturnal symptoms as it allows the physician to determine if the patient has nocturnal polyuria—a medical cause of nocturia.
In addition, a good gynecologic history is necessary in pelvic floor disorders and will include obstetric and menstrual history including menopausal status. The medication list should be evaluated for hormone replacements, diuretics, and medications that can affect the urinary tract. Prior medical history should be evaluated for history of trauma, congenital abnormalities, pelvic radiation, neurological diseases, and prior history of treatment for incontinence and pelvic organ prolapse. A history of diabetes mellitus or diabetes insipidus may account for an increase in urine volume leading to urinary incontinence. Diabetes mellitus may also cause an acontractile bladder and overflow incontinence. Prior surgical history should include prior hysterectomy, pelvic surgery, and past surgical treatment for incontinence or prolapse.
Questionnaires
Diagnostic questionnaires are administered as a tool to determine if a patient has a disease. Furthermore, it can provide a baseline measurement or assessment of symptoms prior to a planned intervention. Currently, two validated questionnaires designed for the diagnosis of OAB are used commonly: the overactive bladder awareness tool (OAB-V8) and the overactive bladder symptom score (OAB-SS). OAB-V8 is an 8-item patient administered questionnaire to identify men and women with bothersome OAB symptoms that may benefit from treatment [13]. This questionnaire is designed ideally for a primary care setting. The OAB-SS is a 7-item patient administered symptom score for men and women [14]. It has 4 items related to urgency and urge incontinence, and two questions related to nighttime and daytime frequency, and one general question regarding “bladder control.” The OAB-SS does not address bother or quality of life issues but is designed to grade the severity of urgency using an urgency subscale.
The questionnaire for urinary incontinence diagnosis (QUID) is a 6-item questionnaire to diagnose and differentiate between SUI, UUI, and MUI in women [15]. It has a stress and urge subscale. Patients with a stress subscale greater than or equal to 4 are more likely to have a diagnosis of stress incontinence, and those with an urge subscale greater or equal to 4 are more likely to have a diagnosis of urgency incontinence. Those with both evidence of stress and urge have mixed incontinence.
Urinary incontinence and pelvic organ prolapse do not cause significant morbidity or mortality in a majority of patients suffering from these conditions. The main effect of incontinence and prolapse is on a patient’s quality of life. Therefore, it is important to evaluate the effects of UI and pelvic organ prolapse on a patient’s quality of life at initial presentation and throughout a patient’s treatment course.
Many of quality of life questionnaires have validated short forms with fewer questions to make them easier to use in a clinical setting. The short forms may also be beneficial in a research situation where patients are given numerous questionnaires. While there are a multitude of questionnaires available for use, several more common ones are highlighted below.
The Bristol Female Lower Urinary Tract Symptoms Questionnaire (BFLUTS) measures the severity and bother of urinary incontinence and lower urinary tract symptoms in women [16]. It also evaluates the effects of lower urinary tract symptoms on quality of life. It consists of 33 questions with 4 domains. The domains are incontinence severity, associated lower urinary tract symptoms, quality of life, and sexual function. The BFLUTS-SF is a scored form of the BFLUTS with 19 items and 5 domains. BFLUTS-IS measures urinary incontinence symptoms, BFLUTS-VS measures voiding symptoms, BFLUTS-FS measures urinary storage symptoms, and the BFLUTS-sex and BFLUTS-QoL measure sexual symptoms and quality of life symptoms related to lower urinary tract symptoms [17].
The urinary distress inventory (UDI) and incontinence impact questionnaire (IIQ) are paired measures that evaluate the bother and psychosocial impact of urinary incontinence in women. The UDI evaluates bother from urinary incontinence. It has 19 questions with 3 subscales: irritative symptoms, obstructive/discomfort, and stress symptoms [18–20]. The IIQ measures the psychosocial impact of urinary incontinence. It has 30 items with 4 subscales: physical activity, travel, social relationships, and emotional health [18–20]. The UDI-6 and IIQ-7 are short forms of the UDI and IIQ [21, 22].
The Kings Health questionnaire is a 21-item questionnaire that evaluates the impact of urinary incontinence on a woman’s quality of life. It has 8 domains which evaluates perception of severity of incontinence and the effect of urinary incontinence on general health, role, physical interactions, social interactions, personal relationships, emotions, and sleep [23].
The overactive bladder symptoms and health-related quality of life questionnaire (OAB-Q) is an OAB-specific measure that evaluates bother and impact of OAB in men and women [24, 25]. This survey, which is validated for use in continent and incontinent patients, has 33 questions with 2 parts. The first part evaluates symptom bother. The second part has 4 domains that evaluate the impact of OAB in areas of coping, concern, sleep, and social interaction. The OAB-Q SF is a 19 question short form of the OAB-Q with questions related to symptom bother and health-related quality of life [26].
The short form of the International Consultation on Incontinence Modular Questionnaire (ICIQ-SF) is a 4-question measure that evaluates symptom severity and bother from lower urinary tract symptoms in men and women [27]. The York Incontinence Perception Scale (YIPS) is an 8-item questionnaire that evaluates the psychosocial effects of incontinence in women [28].
Single question global measures can be used as a quick tool to evaluate a patient’s experience with urinary symptoms. A patient is asked to sum all the effects of a symptom to answer one question. These measures don’t allow a physician to determine specifics about a patient’s bother or quality of life, but gives a general impression how a symptom affects the patient. The Patient Perception of Bladder Condition (PPBC) is a single-item global index to evaluate the impression of urinary problems in men and women with OAB. It is validated for use in both continent and incontinent patients with OAB [25, 29]. The Patient Global Impression of Severity is a single question global index validated to evaluate the severity of SUI [30].
Two commonly used questionnaires for the evaluation of health-related quality of life in patients with pelvic organ prolapse is the Pelvic Floor Distress Inventory (PFDI) and the Pelvic Floor Impact Questionnaire (PFIQ) [31]. The PFDI is a 61-item measure with 3 domains. The first domain is the UDI. It contains the aforementioned UDI and 9 questions related to lower urinary tract symptoms in women with pelvic organ prolapse. Similar to the UDI, it has 3 sections: obstructive, irritative/discomfort, and stress. The second domain, the POPDI, has questions related to pelvic organ prolapse. It is divided into 3 sections: general, anterior, and posterior. The CRADI (Colorectal and Anal Distress Inventory) is the last section. This portion helps evaluate lower bowel function and is divided into 4 sections: obstructive, incontinence, pain/irritation, and rectal prolapse.
The PFIQ evaluates health-related quality of life and the affect prolapse symptoms have on a patient’s daily activities relationships and emotion. It is based off of the IIQ and like the PFDI is separated into 3 scales with 31 questions each: the IIQ, the colorectal impact questionnaire (CRAIQ), and the pelvic organ prolapse impact questionnaire (POPIQ). Each scale assesses 4 areas of quality of life: travel, social, emotions, and physical activity. Though intended to be administered in entirety, each domain in the PFDI and PFIQ is scored separately. The PFDI-12 and PFIQ-7 are short forms of the PFDI and PFIQ [32].
Quality of life and bother from defecatory symptoms can be evaluated by the CRAIQ and CRADI, which are domains of the PFDI and PFIQ that address lower GI symptoms. The Fecal Incontinence Quality of Life Scale is a 29-item measure that evaluates the affect of fecal incontinence on men and women. It has 4 domains: lifestyle, coping/behavior, depression/self-perception, and embarrassment [33].
The Female Sexual Function Index (FSFI), the BFLUTS-sex, and the PISQ are three measures used to evaluate sexual function in women. The FSFI is a 19-item questionnaire with 6 domains: desire, arousal, lubrication, orgasm, satisfaction, and pain [34]. Though it can be administered to all women regardless of their sexual activity, the questionnaire is more appropriate for sexually active women.
The BFLUTS-sex is part of the BFLUTS that assesses sexual function in patients with lower urinary tract symptoms. The PISQ is a 31-item questionnaire designed to evaluate sexual function in sexually active heterosexual women with urinary incontinence or pelvic organ prolapse [35]. It has 3 domains: behavioral/emotive, physical, and partner related. The PISQ-12 is the short form of PIDQ [36].
Patient-reported outcomes are important to evaluate when performing outcomes research for pelvic organ prolapse. Two outcome measures for the medical treatment of OAB are the Benefit, Satisfaction, and Willingness questionnaire (BSW) and the Overactive Bladder Treatment Satisfaction Questionnaire (OAB-S).
The BSW is a 3 question investigator administered tool for men and women with OAB [23]. The first question measures the patient’ perception of benefit from treatment, the second question measures the patient’s satisfaction with treatment, and the final question measures the patient’s willingness to continue treatment.
The OAB-S was developed to evaluate patient satisfaction with OAB treatment and is validated as a patient administered survey that evaluates patient satisfaction with pharmaceutical treatment for OAB [37]. There are 2 questionnaires: a 21-item pretreatment instrument and a 41 question post-treatment instrument. The pretreatment instrument has 3 domains: OAB control, impact on daily living with OAB, and interruption of day-to-day life due to OAB. The posttreatment instrument contains the aforementioned domains and 6 additional domains that evaluate medication tolerability, fulfillment of treatment expectations, overall satisfaction with treatment, willingness to continue medication, and improvement in quality of life with treatment.
The Patient Global Impression of Improvement (PGI-I) is a patient-administered single question global index validated for use in women following treatment for pelvic organ prolapse or SUI [30, 38]. The question rates the response to treatment.
From the voiding diary the physician can calculate daytime and nighttime frequency, number of incontinence episodes, number of urgency episodes, pad usage, total urine volume, maximum voided volume, and nighttime urine volume. It is a good quantitative measure of patients’ urinary frequency and incontinence episodes and can be used to track treatment. A fluid diary allows the physician to evaluate a patient’s fluid and caffeine intake. It also allows for measurement of polyuria and nocturnal polyuria, which are medical problems that can exacerbate lower urinary tract symptoms.
Physical Examination
A general exam should be performed that includes a patient’s height, weight, and BMI. Several studies have shown that obesity is a risk factor for urinary incontinence and pelvic organ prolapse [39–43].
A patient’s cognition and mental status are important to ascertain, as a direct correlation may exist in which urinary incontinence can be due to poor mental status and inability to prevent urination when it is socially appropriate. It is also important to know a patient’s cognition when developing a treatment plan. Similarly a patient’s functional status, mobility, and hand function are factors that can affect both urinary incontinence and treatment decisions. A patient with functional incontinence that cannot physically get to the bathroom in situations of potential incontinence may not receive adequate benefit from therapies due to these mobility issues.
A general exam usually includes abdomen and genitalia as well as a focused neurologic exam. During the abdominal exam, the patient’s abdomen should be inspected for scars from prior surgeries and hernias. An attempt should be made to palpate the kidney and bladder. During palpation, the abdomen should also be evaluated for a mass or organomegaly which can increase intra-abdominal pressure. The back should be examined for costovertebral angle tenderness which could be a sign of urinary obstruction. If there is a suspicion for neurologic disease, the low back can be visualized for evidence of myelomeningocele, hairy patch, obvious scoliosis, or other spinal disease.
The lower extremities should be evaluated for lower extremity edema that can lead to nocturnal polyuria and increased nighttime lower urinary tract symptoms.
The main focus of the female incontinent or prolapsed patient is the vaginal exam which should be performed in the dorsal lithotomy position initially. If the patient’s symptoms of incontinence or prolapse cannot be replicated in the dorsal lithotomy position, the exam can be repeated while the patient is standing.
The gynecological exam starts with an examination of the external genitalia: the clitoris, urethral meatus, vulva, labia, perineum, and anus. Estrogen status is evaluated. Estrogenized tissue is well perfused with thick epithelium, transverse rugae, and physiologic moisture. Atrophic tissue is pale thin and friable without rugae. During the examination of the external genitalia, evidence of irritation from urine such as excoriation, erythema, or skin breakdown should be noted. Urine within the vaginal vault should also be noted. Any discharge from the vagina or urethra should be observed and a vaginal swab for gonococcus, chlamydia, candida, bacterial vaginosis, or mycoplasma should be performed as clinically indicated. A bimanual exam can be performed to evaluate for other gynecologic pathology.
The urethral meatus is evaluated for evidence of caruncle, urethral prolapse, or uethral mass. The urethra is palpated and the position of any tenderness, mass, or discharge per urethra upon palpation should be noted for further evaluation.
While the patient is in dorsal lithotomy position with an empty bladder and the urethra exposed, the patient should be asked to strain or cough in order to elicit SUI on exam. If the patient has a history of SUI that could not be reproduced by the supine empty bladder stress test, the exam can be repeated with the patient standing.
The bladder can also be retrograde filled to around 200 cc. Resistance to filling or a rise in water level during filling can indicate detrusor overactivity. After filling the patient is asked to Valsalva or cough in supine position. The test can be repeated while the patient is standing if incontinence is not elicited.
Extra-urethral urine is suspicious for vesicovaginal fistula, urethrovaginal fistula, or ectopic urethra. Location of fistula can be evaluated with a thorough vaginal exam, cystoscopy, and vaginoscopy.
If a patient complains of leakage and the source is unknown, a pyridium pad test can be performed to determine if the fluid is urine. If the patient is leaking urine, the pad will stain orange. Similarly the bladder can be retrograde filled with methylene blue or indigo carmine. A blue stained pad indicates a bladder source of fluid. A combination of pyridium and bladder dye is given to distinguish between a ureteric and bladder source of urine. If the pad is stained orange, the patient should be evaluated for a possible ureterovesical fistula.
Urethral hypermobility can be assessed using a q-tip test. With an empty bladder, a q-tip is placed through the urethra to the area of the bladder neck. The angle of the urethra to the vertical axis at rest and with Valsalva or cough is recorded. A straining urethral angle greater than 30° above the horizontal is considered positive for urethral hypermobility. Urethral hypermobility can also be measured by cysourethrography and ultrasound.
In 1995 the International Continence Society proposed the Pelvic Organ Prolapse Quantification system (POP-Q) as the standardized measure of pelvic organ prolapse [44]. The POP-Q exam should be performed on all patients complaining of urinary incontienence and pelvic organ prolapse. When recording the results of the exam, it is important to note the patient’s bladder volume, position of the patient, and whether the exam was performed during the cough or Valsalva.
Using the hymen as a fixed point of reference, the position of points Aa, Ba, C, D, Ap, and Bp are recorded (Table 1.1). The genital hiatus, perineal body, and total vaginal length are also measured and recorded (Table 1.1). Pelvic organ prolapse is then staged from stage 0 (no prolapse) to stage 4 (complete eversion) (Table 1.2).
Table 1.1
Pelvic organ prolapse quantification system
|
Point |
Location |
Range |
|
Aa |
Midline of the anterior vaginal wall 3 cm proximal to the urethral meatus |
−3 to 3 cm |
|
Ba |
Most distal portion of the upper anterior vaginal wall (from the apex to point Aa) |
−3 cm to total vaginal length |
|
C |
Most distal edge of the cervix or vaginal cuff |
|
|
D |
The posterior fornix in patients with an intact cervix |
|
|
Ap |
Midline of the posterior vaginal wall 3 cm proximal to the hymen |
−3 to 3 cm |
|
Bp |
Most distal portion of the upper posterior vaginal wall (from the apex to point Ap) |
−3 cm to total vaginal length |
|
Genital hiatus (gh) |
Distance from the middle of the urethral meatus to the posterior hymen |
|
|
Perineal body (pb) |
Distance from the posterior aspect of the genital hiatus to the midanal opening |
|
|
Total vaginal length (tvl) |
Greatest depth of vagina when it is reduced to its normal postion |
Table 1.2
Short version of pelvic organ prolapse quantification system
|
Stage |
Definition |
|
0 |
No prolapse |
|
1 |
The most distal portion of prolapse is less than −1 cm |
|
2 |
The most distal portion of prolapse is −1 to 1 cm |
|
3 |
The most distal portion of prolapse is more than 1 cm but less than 2 cm smaller than the total vaginal length |
|
4 |
The most distal portion of prolapse is greater than total vaginal length minus 2 |
Two modifications of the POP-Q have been introduced. A simplified version of the POP-Q was developed by Swift et al. [45]. This version measures points Aa, Ap, C, and D. Stage 0 and 1 are combined as stage 1. Stage 2 is the same as the POP-Q system. Stage 3 is defined as vaginal eversion with some mucosa not everted and stage 4 is complete vaginal eversion.
The Pelvic Organ Prolapse Quantification Index (POP-Q-I) creates a continuous variable for the measurement of pelvic organ prolapse [46]. Two values are calculated for each POP-Q point: the actual distance of the point from its original location and an estimate of the distance of the point to where the point will be in the case of a complete eversion. Value 1 is divided by Value 2 to create the index.
Prolapse is best recorded as anterior, posterior, and apical prolapse. The terms cystocele, rectocele, and enterocele are misleading because it is difficult to determine on exam alone the organ underlying the prolapsed vaginal wall. Though digital evaluation of bowel contents in the rectovaginal septum can help diagnose enterocele, it is difficult to distinguish between rectocele and enterocele on exam alone.
In a patient with pelvic organ prolapse, it is important to test for occult SUI by asking a patient to Valsalva or cough while the prolapse is reduced. In addition, a rectal exam should be performed to evaluate for colorectal pathology such as hemorrhoids or a rectal mass. Fecal impaction, which can lead to lower urinary tract symptoms, can also be assessed.
A neurologic exam should evaluate the patient’s gait, lower extremity sensation and strength, pelvic floor muscle strength, anal sphincter resting tone and contraction, perineal and posterior thigh sensation, and sacral reflexes. The sacral reflexes are the bulbocavernosus and anal reflex. In the bulbocavernosus reflex, the anus contracts after the clitoris is stimulated. In the anal reflex, the anus contracts after light stimulation of the anus with a gloved hand or Q-tip. The bulbocavernosus and anal reflex can often be absent even in neurologically normal women; however, their presence indicates an intact nerves between the conus medularis and the pudendal nerve.
A urinalysis should be performed and used as a guide for further investigation. Patients with hematuria should be evaluated for bladder cancer as a cause of their lower urinary tract symptoms. Glucosuria can indicate diabetes mellitus, and pyuria or bacteruria can indicate bladder inflammation or urinary tract infection.
A post void residual (PVR) may be performed on patient with prolapse, neurologic disease, or a possible diagnosis of urinary retention to measure the amount of residual urine in the bladder immediately following urination. The International Consultation on Incontinence states that normal sensate women with storage-specific symptoms and no risk factors for retention do not require routine PVRs [1]. PVRs can be performed by straight catheterization, a portable ultrasound bladder scanner, or transabdominal ultrasound.
Pad testing can be performed on patients with complaints of incontinence that cannot be exhibited on exam. During the test, women wear pre-weighed incontinence pads for a designated amount of time and the increase in pad weights is measured. A 1-h pad test can be performed in office. The bladder is filled with a fixed volume of fluid and the patient is asked to perform set activities to create urine loss. The 24- and 48-h tests are performed outside the office. The patient wears pre-weighed pads while performing activities of daily living. The pads are collected in a plastic pad and weighed after the test. The 24- and 48-h pad tests are more sensitive than the 1-h pad test, but can be more cumbersome to the patient [47, 48]. If clinically indicated, dynamic testing using uroflow or cystometry can be performed. This will be discussed in detail in the next chapter.
Radiologic Studies
Upper Tract and Collecting System
An ultrasound is a good initial study because it is noninvasive and less expensive than x-ray studies. The kidney can be evaluated for hydronephrosis, masses, and stones. It is not a good study to evaluate the ureters.
An IVU or CT urogram is more expensive than an ultrasound and exposes the patient to radiation and IV contrast dye. Both studies are superior to the ultrasound at showing the anatomy of the collecting system. Hydronephrosis and stones can be clearly evaluated. The anatomy of the ureter, ureteral obstruction, congenital abnormalities such as ectopic ureter and duplicated system, pathology such as ureteral injury and ureterovaginal fistulas can be seen. CT urograms are more commonly performed and have the benefit of showing the anatomy of surrounding organs and tissues. CT is superior to IVU for evaluation of kidney masses.
Lower Urinary Tract and Pelvic Organs Imaging
An ultrasound is useful for the evaluation of pelvic masses, gynecologic pathology, and bladder disease. Pelvic floor muscle structure and function can be evaluated. The degree of pelvic organ prolapse can be determined and the underlying organs can be illustrated. The ultrasound is better than physical exam alone for the detection of an enterocele. Ultrasound has also been used to evaluate urethral diverticuli and visualize slings and vaginal mesh but is clearly operator dependent.
Transabdominal ultrasound is not useful for the evaluation of pelvic organs due to shadowing from the pubic bones. However, the bladder volume can be measured with transabdominal ultrasound by measuring the height, depth, and width of the bladder. The equation is Height × Depth × Width × 0.7.
Other methods for pelvic ultrasound include transvaginal, perineal, and introital. Perineal and introital views are used most often in the evaluation of pelvic organ prolapse and urinary incontinence.
Urethral mobility can be illustrated by an assessment of bladder neck descent and urethral rotation. These are commonly measured using perineal or introital views. Bladder neck descent is estimated by the position of the bladder neck at rest and with Valsalva, and urethral rotation is measured by the axis of the urethra at rest and with Valsalva. Transanal ultrasound can be used for imaging of suspected anal sphincter defects.
A cystogram and a CT cystogram are studies in which contrast dye is injected into the bladder. Images are obtained with a full bladder and after emptying for evaluation of a bladder injury or fistula.
During voiding cystourethrography (VCUG) the bladder is filled with contrast dye and images are obtained during filling and voiding. A VCUG evaluates bladder and urethral fistulas, urethral diverticuli, vesicoureteral reflux, and distal ureteral anomalies such as a ureterocele. Cysto-urethrography can also evaluate ureteral and bladder neck hypermobility similar to methods used during ultrasound. A VUCG is often combined with urodynamic studies of the bladder for a better understanding of lower urinary tract function and pathology.
In positive pressure cystourethrography a catheter with a balloon at the bladder neck and urethral meatus is used to inject dye directly into the urethra, between the balloons in order to visualize a urethral diverticulum.
A pelvic MRI has become the gold standard for the evaluation of urethral diverticuli. It gives good resolution of soft tissue in the pelvis and pelvic floor muscles and can add valuable anatomical information in the evaluation of complex pelvic organ prolapse. Though sometimes used in research for the evaluation of pelvic organ prolapse, it is an expensive test, which should not be used routinely for simple cases of prolapse.
Summary
In summary, the careful and close evaluation of a patient with urinary incontinence and prolapse usually can be done in an office visit with specific questions and a pertinent history and physical examination. The adjunctive use of questionnaires can be useful for a research setting but even in routine practice, this may be helpful to discriminate different types of incontinence, prolapse or urinary or defecatory dysfunction and its correlated impacts on quality of life. Imaging, while useful in select cases, does not need to be performed unless clinical suspicion warrants additional studies.
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