Tanvir Singh, Sandhya Gupta, and Ajay Rane This chapter deals with the role of different ambulatory practices in the evaluation of pelvic organ prolapse (POP) and urinary incontinence (UI). A good history combined with a proper clinical examination is simple, inexpensive, and a time saving tool, in the diagnosis of pelvic floor disorders. This leaves very few women requiring sophisticated tests for evaluation and management. The aim of eliciting a complete description of the nature of the patient’s symptoms is to put together a working diagnosis and gauge the impact of the symptoms on the patient’s quality of life. While taking a history, it is important to define the most troublesome symptom and the patient’s expectations from the treatment. Urinary Incontinence (UI) is the complaint of any involuntary leakage of urine. It is a storage symptom and should be described by specifying relevant factors such as type, onset, frequency, severity, progression/regression, precipitating factors, social impact, effect on hygiene and quality of life, response or non‐response to treatment, the measures used to contain the leakage (wearing of protection) and whether the individual seeks or desires help because of UI. Urinary leakage may need to be distinguished from other causes of wetness such as sweating or vaginal discharge. Stress Urinary Incontinence (SUI) is the complaint of involuntary leakage on effort or exertion—for example, lifting heavy weights, jumping, or on sneezing or coughing. Urge Urinary Incontinence (UUI) is the complaint of involuntary leakage accompanied by or immediately preceded by urgency. Information on triggering events such as cold, running water and ‘latch key’ incontinence should be noted. Mixed Urinary Incontinence (MUI) is the complaint of involuntary leakage associated with urgency and also with exertion, sneezing, or coughing. Nocturnal Enuresis is the complaint of loss of urine occurring during sleep. History of previous childhood nocturnal enuresis and delayed bladder control in childhood is associated with detrusor overactivity (DO) or overflow incontinence in adulthood. Continuous Urinary Incontinence is the complaint of continuous urinary leakage, usually suggestive of urinary fistula. There is usually an overlap of symptoms with stress, urge, and mixed incontinence. A careful history should be obtained regarding frequency, urgency, dysuria, and nocturia. UI symptoms of recent onset, combined with irritative bladder symptoms, should prompt investigation for an infective cause. To evaluate a patient with incontinence, objective tools to use include the incontinence specific quality‐of‐life scales or validated questionnaires. These allow evaluation of the severity and the relative contribution of UUI and SUI symptoms and the response to their therapies. The following questionnaires have good test–retest reliability: The International Consultation on Incontinence Questionnaire (ICIQ), Bristol Female Lower Urinary Tract Symptoms (BFLUTS), Incontinence Quality Of Life (I‐QOL), Stress and Urge Incontinence Quality of life Questionnaire (SUIQQ), Urinary Incontinence Severity Score (UISS), The Stress related leak, Emptying ability, Anatomy, Protection, Inhibition, Quality of life, Mobility and Mental status (SEAPI‐QMM), and The King’s Health Questionnaire (KHQ). The preferred system to describe and document the POP is the Pelvic Organ Prolapse Quantification (POPQ) system. Over the years, many clinicians have familiarised themselves with the POPQ and use it in their daily practice. The symptomatology of POP, apart from pelvic mass, can be related to bladder or bowel disturbance symptoms. The presenting feature can therefore be a combination of any of the following symptoms, and it is important to elicit the history accordingly. Bowel dysfunction frequently affects urinary function. Constipation is the second most important predisposing factor for UI after vaginal birth. UI may coexist with faecal incontinence, and most women are hesitant to talk about this symptom. One study evaluated 247 women with either UI or POP and found that 31% of women with UI and 7% with POP had concurrent anal incontinences. For these reasons, women should be specifically asked about anal incontinence including the type of loss, such as flatus, liquid stool or solid stool and the frequency. The initial history includes a review of medical problems, current medications, and history of pelvic surgeries. Medical conditions can influence bladder function and symptoms. Some drugs can worsen incontinence (Table 3.1). Neurological conditions such as multiple sclerosis may cause overflow incontinence and urinary retention. Visual impairment and immobility such as severe arthritis makes it difficult for the patient to reach the toilet in time. In addition, obesity, smoking, constipation, and work involving heavy lifting can chronically increase intra‐abdominal pressure, which can worsen urinary symptoms. Obesity in women is associates with a threefold increased risk of UI compared to non‐obese women. Caffeine intake, diabetes, stroke, depression, faecal incontinence, genitourinary syndrome of menopause, vaginal atrophy, hormone replacement therapy, radiation, pelvic surgeries including hysterectomy are some of the other risk factors. Table 3.1 Effects of common medications on bladder functions. It is important to consider conditions outside the urinary tract that may influence continence. Treating these conditions often restores continence. Functional causes of incontinence as been summarised using the acronym ‘DIAPPERS’ (Resnick): UI in pregnancy is reported by 7–60% of women and in most, will resolve after delivery. Parity, mode of delivery including instrumental deliveries, and birth weight, are some identifiable risk factors in both UI and POP. Vaginal delivery is identified as an independent risk factor for prolapse. This risk increases with forceps delivery, with increasing parity and in women having their first child at a later age. Caesarean delivery however does not appear to be protective. Presence of a pelvic mass, such as fibroids or ovarian cysts, and the menopausal status is also relevant. In several studies, the prevalence of pelvic floor disorders has been shown to increase with menopause. The prevalence of any one pelvic floor disorder with menopause was estimated to be 37%, which included SUI 15%, OAB 13%, POP 6% and anal incontinence 25%. The existence of inherited risk factors for pelvic floor disorders has long been recognised and there is a clear familial aggregation for these conditions. Having an affected first‐degree relative with incontinence or prolapse is associated with an approximately two‐ to threefold increased risk of developing either condition. A study looking at twins, attributed a 35–55% genetic contribution to urge incontinence/overactive bladder but only 1.5% for stress incontinence. A more objective tool to assess the quality of life would be to use the incontinence specific scales or validated patient questionnaires. The Modified Bristol Female Lower Urinary Tract Symptoms Questionnaire can be used to evaluate the severity of UUI and SUI symptoms and the response to their therapies. The Pelvic Floor Distress Inventory (PFDI) and the Pelvic Floor Impact Questionnaire (PFIQ) can assess the urinary, colorectal, and prolapse symptoms in detail. The International Consultation on Incontinence Questionnaire and the Kings Health questionnaire are available for evaluating impact of incontinence on quality of life. The Patient Global Impression of Improvement (PGII) and Patient Global Impression of Severity (PGIS) are also acceptable measures to assess improvement and satisfaction, respectively. Coital incontinence may occur during arousal, on penetration, throughout intercourse, or specifically on orgasm. Urodynamic stress incontinence (USI) is the most common urodynamic finding; however, DO is found more often when leakage is restricted to orgasm. It is therefore helpful to define when urine leakage occurs during these acts. Up to 68% of women report that their sex life is ruined due to urinary symptoms. A general physical examination includes assessment of a women’s body mass index (BMI), identification of mobility restriction or visual impairment, and the odour of urine, smoke, or alcohol. The information gained from these observations needs to be addressed and modified for the success of any treatment.
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Ambulatory Evaluation of Pelvic Organ Prolapse and Urinary Incontinence
History
Presenting Symptoms
Urological History
Pelvic Organ Prolapse (POP)
Bulge Symptoms
Urinary Symptoms
Bowel Symptoms
Pain
Sexual Symptoms
Bowel Habits
General Medical History
Medication
Mechanism
Bladder dysfunction
Cough and cold preparations
Pseudoephedrine, ephedrine, phenylpropanolamine
Increase urethral closure pressure
Urinary retention
Antihypertensive agents
Prazosin, terazosin, methyldopa, reserpine, guanethidine
Alpha adrenergic antagonists decrease urethral pressure
Worsen stress urinary incontinence
Diuretics
Thiazides, loop diuretics, alcohol
Increase urinary output
Worsen urinary frequency/urge incontinence
Anticholinergic agents
Antihistamines, tricyclic antidepressants
Detrusor relaxation
Urinary retention
Antiparkinson agents
Benztropine, trihexyphenidyl
Detrusor relaxation
Urinary retention
Beta‐blockers
Pindolol, disospyramide
Detrusor relaxation
Urinary retention
Antipsychotic agents
Haloperidol, thioridazine
Alpha adrenergic antagonists decrease urethral pressure
Urinary retention
Calcium channel blockers
Verapamil
Detrusor relaxation
Urinary retention
Iron, narcotics, sedatives
Constipation
ACE inhibitors
Enalapril
Indirect cough effects
Obstetric History
Gynaecological History
Family History
Quality of Life
Sexual Dysfunction
Physical Examination
General Examination
Related posts:
Role of Nurse Practitioners in Ambulatory Urogynaecological Care
The Management of Recurrent Urinary Tract Infections
Ambulatory Management of Renal Stone Disease
Plain X‐Ray, Computed Tomography Scanning, and Nuclear Imaging in Urology
An Ambulatory Approach to Benign Prostatic Obstruction
Introduction and Epidemiology of Pelvic Floor Dysfunction
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