Pelvic floor dysfunction is associated with multiple symptoms including bladder, bowel and sexual complaints. In addition, women may present with neurological symptoms, psychological issues and relationship dysfunction. It is therefore imperative that the history and examination are performed in a comprehensive fashion.
Urogynaecological symptoms are never life-threatening but they can have a profound impact on the women’s quality of life. Clinical assessment therefore aims to determine the extent of the impairment on quality of life and thereby institute the most appropriate route of investigation and management.
Clinicians use the traditional approach of history and examination. Symptoms as elicited by the traditional interview by the doctor have been shown to be fraught with subjective influences. A number of questionnaires are now available which are able to elicit symptoms in a standardised form and quantify them. This is particularly useful in a research setting but these instruments are now increasingly being used in day-to-day practice. Similarly, the examination of the urogynaeological patient has become more scientific with the advent of more detailed and scientific prolapse scoring systems.
This is defined as the number of voids during waking hours. Normal frequency is considered to be between four and seven voids a day.
This is the number of times a woman has to awake from sleep to pass urine. This varies with the age of the woman, with an increase reported in woman above the age of 70 years where normal would be considered to be twice at night, three times for women over 80 and four times for women over 90 years of age.
Symptoms of Urinary Incontinence are notoriously difficult to evaluate. The International Continence Society defines this as the “involuntary loss of urine which is a social or hygienic problem and objectively demonstrable”.
This is the involuntary loss of urine with a rise in intra-abdominal pressure. Factors that commonly elicit stress incontinence include running, laughing, coughing, sneezing and standing up from a seated position.
This is the compelling desire to void which is difficult to defer. It must be differentiated from urinary urge which is a normal desire to void which can be comfortably deferred by the woman.
Here, the women describes the symptoms of urgency and she is unable to get to the toilet in time and develops incontinence as a result.
Determining the severity of Incontinence
It is important to make a clinical attempt to determine the severity of the incontinence symptoms. The woman could be asked to quantify the symptoms on a scale of 0 to I0. When this is done using a chart it is called a visual analogue scale (VAS). Many women present with mixed symptoms of both stress and urge incontinence and by asking them to quantify each symptom using the visual analogue score, we are able to determine which is more severe.
The patient should also be asked about the use of continence aids such as pads and how often she changes her underwear. The number of incontinence episodes per day can also be indicative of the severity of the condition.
Symptoms of voiding dysfunction
These symptoms are not as common in women as in men but if present, should prompt the appropriate investigation of urinary residual and flow rate.
These symptoms include:
• Straining to void
• Incomplete Emptying
• Post- Micturition dribbling
• Poor Stream
• Double Voiding
Women with bladder pain should be questioned in detail regarding the nature and occurrence of the symptoms. Pain that is relieved with passing urine may be associated with Interstitial Cystitis/ Painful Bladder Syndrome. Women with pain as a significant symptom should be evaluated with cystoscopy and biopsy since pain may also be associated with tumours and stones.
Urethral Pain This may be associated with infections or urethritis.
Women with urinary symptoms should always be questioned regarding the presence or absence of blood in the urine and investigated appropriately.
Women with prolapse have a broad range of symptoms. Studies have shown that the symptoms increase significantly with stage 2 prolapse or greater. Most women will complain of a bulge or a lump, whilst others will describe either discomfort or a burning sensation. Still others will describe associated voiding or defaecatory difficulty, needing to reduce the prolapse to void or completely evacuate their bowels.
Evaluation and questioning regarding bowel symptoms is an essential part of the evaluation of the pelvic floor.
This is the involuntary passage of flatus.
This is defined as the involuntary passage of liquid or solid stool. This should be quantified by asking the women about the frequency, severity, use of continence aids and impact on quality of life.
Faecal urgency and urge incontinence
This is an important symptom which is often underreported and seldom elicited by the clinician.
Women should be asked about any difficulty in completing defaecation including digitation, splinting or manual evacuation.
A record should be made of frequency of stools and any symptom of constipation.
A detailed history of sexual function is vital to a thorough assessment of pelvic floor disorders. Women should be asked if they are sexually active. Any problems should be noted including dyspareunia, vaginal slackness, vaginal tightness, anorgasmia, coital faecal or urinary incontinence during intercourse.