Kate H. Moore1
Department Obstetrics & Gynaecology, St George Hospital, Kogarah, New South Wales, Australia
When examining a patient with urinary incontinence or prolapse, more care may be needed to be taken to avoid embarrassment than with the usual gynecology patient.
When examining a patient with urinary incontinence or prolapse, more care may need to be taken to avoid embarrassment than with the usual gynecology patient.
For example, a patient with menorrhagia is often fed up with her symptoms and just seeks your help to get rid of a practical problem that has little social stigma. On the other hand, a patient with incontinence often feels that she is “dirty” and “cannot control herself.” A patient with prolapse is often horrified about the lump appearing at her vaginal opening and may have ceased intercourse because of embarrassment.
Therefore, always make sure that the patient’s abdomen and genitalia are covered with a sheet, and only expose that part which you are about to examine. Establish a sympathetic rapport before you begin the examination.
Examine the Abdomen
Before starting the examination, a urine specimen should be taken for culture, and if foul smelling, it should undergo a rapid dipstick test to screen for infection. The patient’s height and weight should be measured, so that BMI can be determined and obesity discussed if present.
Many patients attending the gynecologist for a first visit lie on the couch with their knees drawn up, assuming that only the vagina and pelvis will be examined. This is not appropriate in urogynecology: the abdomen must be examined first, so ask the patient to drop her knees down so that a relaxed abdominal exam can be performed. Check that you know the nature of all her abdominal scars; she may have forgotten some during the history!
Any mass that raises intra-abdominal pressure may cause incontinence.
· In our unit, we see one to two patients per annum presenting with incontinence or urgency/frequency who in fact have an ovarian cyst (benign or malignant), or an enlarged uterus that has previously been undetected.
· Also, patients may present with frequency and urgency but in fact have subacute retention, so it is important to percuss the abdomen to exclude an enlarged bladder. Shifting dullness needs to be elicited if ascites is suspected, which may accompany an ovarian cancer that provokes stress incontinence.
Check the renal angles for tenderness, for example, calculi.
Inspect the Vulva
First, look for evidence of postmenopausal atrophy. Initially, this appears as thin, shiny, glistening red epithelium that appears fragile, rather than the healthy pink “skin”-like appearance of the premenopausal women. Later changes include patchy whitish areas of cornification with some “cracks” or fissure-like lesions often between the labia majora and minora. In end stage, the labia minora may be fused at the midline. Urethral caruncle, a red rosebud appearance at the urethral meatus, also indicates estrogen deprivation (see Fig. 2.1).
Classic atrophic vagina with urethral caruncle
Do not be lulled into a sense of security because the patient is on systemic HRT. A percentage of these patients do not achieve adequate blood levels in the vagina and vulva and may still get atrophic changes, which also affect the urethra.
Next, look at the introitus at rest; a cystocele or rectocele may be evident even without cough. Inspect the perineum for signs of post-obstetric perineal deficiency.
Elicit a “Stress Leak”
Part the labia, and ask the patient to cough. In order to save embarrassment, explain to the woman that you will place a piece of tissue/paper towel at the urethra, so that if she leaks, nothing will spill onto the linen. Patients are often terrified that they will leak urine in front of the doctor, yet this is exactly what we are trying to get them to do. You should have a tissue ready in any case, because a strong projectile spurt of urine may reach your clothing and embarrass the women even further (she will know if the spurt has been large enough to do this!).
Typically, a stress leak involves a short spurt of urine that occurs during the height of the cough effort. An urge leak typically occurs an instant after the cough, but a large prolonged urine leak is seen due to the detrusor contraction.
In practice, patients with urge incontinence will not get up onto your examining couch with a full bladder; they will always request to visit the toilet first.
Assess hypermobility of the anterior vaginal wall. When the patient coughs, there may not be a proper cystocele “bulge,” but the whole anterior wall may move down with the cough.
Pass a Bivalve Speculum
Always check that the cervix is healthy, and take a Pap smear if due. As you withdraw the speculum, check for normal vaginal epithelium as in any gynecological exam.
Pass a Sims Speculum
Traditional advice is to ask the patient to assume the left lateral position for a Sims speculum exam. In fact, if they are obese, this may not be necessary; the bottom of the Sims may not hit the couch if the buttocks are sufficiently plump. If equipment is in short supply, the two leaves of a bivalve speculum can be unscrewed, and the anterior leaf used as a Sims speculum.
Cystocele (prolapse of the bladder into the vagina) and rectocele (prolapse of the rectum into the vagina) are traditionally graded (during Valsalva or cough) as the following:
· Mild: The prolapse descends more than halfway down the vagina but not to the introitus.
· Moderate: The prolapse descends to the level of the introitus.
· Severe: The prolapse descends well beyond the introitus and is outside of the vagina.
Uterine descent follows the same classification, but if the majority of the organ is outside the vagina, the term procidentia is used. See Fig. 2.2.
In highly parous women, the uterus may be well supported, but the cervix may be very bulky and protuberant (worth noting when considering surgical options).
· Enterocele (prolapse of the small bowel into the vagina) is not a common major finding unless the patient has had a hysterectomy, when it is called a “vault enterocele” (the top of the post-hysterectomy vagina is called the vault). This prolapse is also graded mild/moderate/severe as above.
This “mild/moderate/severe” terminology has been used for many decades and is called the Baden Walker system of classification.
POPQ Scoring System of Prolapse
Prior to the 1990s, the Baden Walker system of classification, as described above, was used, but it was realized that there is considerable subjectivity in defining “mild,” “moderate,” and “severe” under this system. Therefore, urogynecologists devised a new system of measuring the degree of prolapse of the anterior and posterior walls of the vagina in centimeters, called pelvic organ prolapse quantification or POPQ (see Fig. 2.3a).
(a) Six sites (Aa, Ba, Ap, Bp, C, and D) used to quantitate POP. (b) Rectocele at the introitus with POPQ measuring device, perineum = 2.8 cm. (c) POPQ definitions. (d) Complete eversion vagina POPQ (A, C, and D are reprinted, with permission from Bump et al. ; Copyright 1996, Elsevier)
First, the reference point of the introitus (the hymenal remnant) is taken as 0 cm. Then using the normal vagina, a reference point of 3 cm inside the introitus is called “−3 cm,” for both the anterior and posterior walls. When asking the patient to strain or cough, the distance that the cystocele or rectocele descends is measured.
When a normal woman coughs, the vaginal walls do not move, so the −3 point remains 3 cm inside the introitus. In a woman with cystocele, say, for example, that with cough, the anterior wall (at the −3 point) protrudes out to 2 cm beyond the introitus. This is measured and recorded as +2 cm (meaning that the anterior wall at the reference point moves down by 5 cm with strain).
Next, the total vaginal length is measured, at the posterior fornix (as shown in Fig. 2.3b) at point D. Then the width of the perineal body is measured as shown in Fig. 2.2b, from the fourchette to the mid-anal opening. The length of the genital hiatus, from the lower margin of the urethra to the inner aspect of the fourchette, is also measured.
These dimensions are recorded in the grid shown in Fig. 2.3c.
Although the POPQ system may seem a little cumbersome to begin with, it is easy to pick up after a few practice attempts. Over the next decade, most gynecologists and all urogynecologists will inevitably take it up, because it is objective and allows for scientific research as to the outcome of prolapse surgery that has never been possible before (as shown in Chap. 9). The normal values, with an example of complete vault eversion, are shown in Fig. 2.3d.
Perform a Bimanual Examination
Again, examine for pelvic masses that may press on the bladder to cause frequency, urgency, or incontinence. If a patient with incontinence comes to surgery, any other gynecological disorders such as menorrhagia with a large fibroid uterus, ovarian cysts, etc., should be corrected at the same time; hence, the term “urogynecology,” that is, “one-stop shopping,” should be provided!
At the time of bimanual exam, if patient has had colposuspension, put the fingers into the retropubic space to feel for the typical “dimples” of the vagina adherent to the back of the pubic bone. If they are “rock solid” behind the bone, the operation is probably still anatomically intact. If not, the sutures may have come loose.
Also, palpate the urethra to feel for a cystic swelling, suggesting a urethral diverticulum.
Assess the Pelvic Floor Muscle Contraction Strength: Oxford Score
Several studies have shown that when asked to contract their pelvic floor muscles during examination, about 50–60 % of women will mistakenly contract their gluteal muscles (lifting their buttocks off the couch slightly) or contract their abdominal muscles (which increases the intra-abdominal pressure, the opposite of what is needed).
It is important to place one finger partly in the vagina and exert very gentle downward traction on the pelvic floor muscles about 2 cm inside the introitus, then explain that this is the muscle we want to contract. We find it helpful to ask the patient to pretend that she is in a public place (church or movie theater) and feels wind building up in the rectum and to tighten the muscles around the rectum to stop the wind escaping. Most patients have a rough idea of what you are talking about and give a small contraction. You then encourage them by explaining that this is the correct muscle, with gentle digital traction on the muscle, and explain that now you are going to ask them to contract the muscle as hard as possible and count the number of seconds that they can hold on. The strength of the contraction and the duration are recorded as the modified Oxford score (Table 2.1).
Pelvic floor assessment grading
0 = Nil
1 = muscle on stretch—flicker
2 = weak squeeze with 2-s hold
3 = fair squeeze and 5-s hold with lift
4 = good squeeze and 7-s hold and lift, repeats ×5
5 = strong squeeze and 10-s hold with lift, repeats ×10
Once you have assessed the strength and duration of the pelvic floor contraction, you can start the patient on a pelvic floor muscle training program (see Chap. 6).
Do All Urogynecology Patients Need a Rectal Examination?
Patients with a fairly simple history of stress and/or urge incontinence do not really require a rectal examination, which is uncomfortable and embarrassing. If you suspect neurological disease (which can affect anal function), or the patient has anal incontinence, a rectal exam to assess the tone and quality of the external anal sphincter is often useful. Fecal impaction is often palpable as hard lumps of feces impinging on the posterior wall of the vagina during the assessment of the pelvic floor muscles vaginally.
Screening Neurological Examination
If a patient has a history of trauma to the lumbosacral region or neurological symptoms that have not been investigated, a basic neurological exam is important. The lumbosacral region is of most interest.
The power of the lower limbs, the deep tendon reflexes at the heels, and the sensation of the perineal skin (S4), the skin over the inner lower thigh (S3), or the mid-inner thigh (S2) should be checked. Inspect and palpate the lumbosacral spine (sacral dimple may suggest spinal dysraphism; sacral lipoma may be seen). Lightly stroking the skin just beside the anus should provoke a slight contraction of the anus. After explanation, lightly tapping the clitoris should also cause the anus to contract (the bulbocavernosus reflex). After clothing is replaced, observe the patient’s gait. If these simple tests are abnormal, a full exam by a neurologist is worthwhile. For a good overview, see Rushton .
Bump RC, Mattiasson A, Bo K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol. 1996;175:10–1.PubMedCrossRef
Rushton D. Neurological disorders. In: Cardozo L, editor. Urogynaecology. New York: Churchill Livingston; 1997. p. 481–502.