1 How to Perform a Focused Pelvic Examination of a Woman With Pelvic Floor Dysfunction

Nearly 24% of U.S. women are affected by one or more pelvic floor disorders (urinary incontinence, fecal incontinence, pelvic organ prolapse [POP]), and these disorders increase in frequency with age, affecting more than 40% of women aged 60 to 79 years and about 50% of women aged 80 years and older. According to the 2008 U.S. Census Bureau projections, the number of American women older than age 65 will more than double in the next 30 years to more than 44 million by 2040. Furthermore, Luber et al project that the demand for health care services related to pelvic floor disorders will increase at a rate twice that of the growth in this older population group.

Female pelvic floor dysfunction can be broadly categorized into five therapeutic areas:

Women commonly have more than one set of these symptoms, which makes evaluations more complex. History taking should be focused and should provide an understanding of the impact of the presenting symptom(s) on the patient’s quality of life.

All women with any of the aforementioned conditions should undergo a focused examination of the pelvic floor (Videos 1-1 and 1-2 ). The goal of the examination is to attempt to correlate the functional abnormality of which the patient complains with the anatomical abnormalities present on examination. It is also important to view the pelvis as a whole and not to focus on one specific area. For example, if a woman complains of stress incontinence, not only should the anterior vaginal compartment be examined, but also the entire pelvic floor should be checked for functional integrity and associated anatomical abnormalities. A systematic pelvic examination can be facilitated by dividing the pelvic floor into six specific anatomical areas:

Assessment in each area should focus on level of support, sensation, and tone.

The physical examination begins with visual inspection of the vulva, external urethral meatus, perineum, and vaginal tissues. This inspection may identify specific abnormalities such as excoriation, atrophic vaginitis, urethral prolapse or caruncle, obvious prolapse beyond the hymen, or perineal scarring or bulging. A bimanual examination assesses for any pelvic, vaginal, bladder, or urethral masses or tenderness. If the patient still has her uterus, the bimanual examination should document the position and size of the uterus as well as the presence or absence of any palpable adnexal mass.

Assessment of Support and Stress Incontinence

A speculum examination is performed with the posterior blade of a Graves or bivalved speculum (split-speculum technique) in a systematic manner so that the anterior, apical, and posterior compartments of the vagina can be assessed. First the posterior vaginal wall is retracted and assessment is performed for anterior prolapse (cystocele), apical prolapse (prolapse of the cervix or vaginal cuff), and urethral masses (Fig. 1-1). Scarring from previous surgery and the extent of prolapse can be seen during straining (Fig. 1-2). The effect of straining on the external urethral meatus can also be seen. For inspection of the vaginal cuff and apex, two blades can be inserted individually, one anteriorly and one posteriorly, to assess the support of these structures and differentiate apical from anterior defects (Fig. 1-3). In cases in which there appears to be cervical or uterine descent, it is important to differentiate between cervical elongation and true uterine descent (Figs. 1-4 and 1-5).

Figure 1-1 Half of a bivalve speculum is used to displace the posterior vaginal wall to allow inspection of the anterior vaginal wall.

Figure 1-2 Inspection of the vaginal introitus in a patient with anterior vaginal wall prolapse at rest (A) and while straining (B).

Figure 1-3 A, Bivalve speculum is used to inspect the cervix or vaginal cuff. B, Two halves of a bivalve speculum are used to inspect the vaginal apex.

Figure 1-4 Uterine prolapse secondary to an elongated cervix.

Figure 1-5 A, Complete uterine procidentia. Note that palpation of the cervix through the anterior and posterior vaginal wall confirms that this is a case of uterine prolapse, not an elongated cervix. B, Complete uterine procidentia with large vaginal ulcer.

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