Physical Examination and Office-based Assessment of Women with Urinary Incontinence and Pelvic Organ Prolapse

NPN Received: June 4, 2007 Accepted: June 14, 2007

Address correspondence to: Dr. Hann-Chorng Kuo, Department of Urology, Buddhist Tzu Chi General Hospital, 707, Section 3, Chung Yang Road, Hualien, Taiwan E-mail: hck@tzuchi.com.tw

Physical Examination and Office-based Assessment of Women with

Urinary Incontinence and Pelvic Organ Prolapse

Ming-Ping Wu, M.D.

_{, Hann-Chorng Kuo, M.D.}

Division of Urogynecology and Pelvic Floor Reconstruction, Department of Obstetrics and Gynecology1_{, Chi Mei Foundation Hospital, Tainan, Taiwan;}

Department of Obstetrics and Gynecology2_{, College of Medicine, Taipei Medical University, Taipei, Taiwan; Department of Urology}3_{, Buddhist Tzu Chi}

General Hospital and Tzu Chi University, Hualien, Taiwan

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NPO Evaluate urinary continence

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Evaluate voiding dysfunction

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Evaluate symptoms of POP

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Evaluate bowel function

nìÉëíáçåë=~Äçìí=~=é~íáÉåíDë=ÄçïÉä=ÑìåÅíáçåI=ëìÅÜ=~ë=ÑêÉèìÉåÅóI ÅçåëáëíÉåÅóI=~åÇ=Åçåëíáé~íáçå=ëÜçìäÇ=ÄÉ=áåÅäìÇÉÇK

Table 2. Standardized Terminology for Lower Urinary Tract (LUT) Storage Symptoms Approved by the ICS in 2002 [7]

Increased daytime frequency the complaint that he/she voids too often by day. This term is equivalent to pollakisuria used in many countries Nocturia the complaint that the individual must wake one or more times at night to void

Urgency the complaint of a sudden compelling desire to pass urine, which is difficult to defer Urinary incontinence the complaint of any involuntary leakage of urine

Stress urinary incontinence the complaint of involuntary leakage on effort or exertion, or on sneezing or coughing Urge urinary incontinence the complaint of involuntary leakage accompanied by or immediately preceded by urgency

Mixed urinary incontinence the complaint of involuntary leakage associated with urgency and also with exertion, effort, sneezing or coughing

Enuresis any involuntary loss of urine. If it is used to denote incontinence during sleep, it should always be qualified with the adjective "nocturnal"

Nocturnal enuresis the complaint of loss of urine occurring during sleep

Other types of urinary incontinence may be situational, for example, incontinence during sexual intercourse or giggling

Table 3. Standardized Terminology for Lower Urinary Tract (LUT) Voiding Symptoms Approved by the ICS 2002 [7]

Slow stream the perception of reduced urine flow, usually compared to previous performance or in comparison to others Intermittency the individual describes urine flow, which stops and starts, on one or more occasions, during micturition

Hesitancy an individual describes difficulty in initiating micturition resulting in a delay in the onset of voiding after the individual is ready to pass urine Straining to void the muscular effort used to either initiate, maintain or improve the urinary stream

Terminal dribble an individual describes a prolonged final part of micturition, when the flow has slowed to a trickle/dribble

Table 1. Bladder-Urethra Unit Physiologic and Pathologic conditions

Normal Abnormal

Bladder Urethra Bladder Urethra

Storage Relaxed Contracted Overactive Incompetent under stress or inappropriate relaxation Voiding Contracted Relaxed Underactive Functional or anatomic obstruction

NPP • ^ëâ=~Äçìí=ìëÉ=çÑ=ä~ñ~íáîÉë=çê=~åíáJÇá~êêÜÉ~ä=ãÉÇáÅ~íáçåëI=ëáåÅÉ=íÜÉëÉ ã~ó=åçí=ÄÉ=áåÅäìÇÉÇ=çå=ÜÉê=äáëí=çÑ=ãÉÇáÅ~íáçåëK • ^äëç=áåèìáêÉ=~Äçìí=?ëéäáåíáåÖ?JíÜÉ=ìëÉ=çÑ=~=ÑáåÖÉê=éêÉëëáåÖ=áå=íÜÉ=î~J Öáå~=çê=çå=íÜÉ=éÉêáåÉìã=ÇìêáåÖ=ÑÉÅ~ä=Éî~Åì~íáçåJ~ë=íÜáë=Å~å=ÄÉ=~ ëáÖå=çÑ=éçëíÉêáçê=éêçä~éëÉ=çê=êÉÅíçÅÉäÉK • ^ëâ=ëéÉÅáÑáÅ~ääó=~Äçìí=~å~ä=áåÅçåíáåÉåÅÉ=áåîçäîáåÖ=äáèìáÇI=Ö~ëI=çê ëçäáÇ=ëíççäK jb^profkd=qeb=cobnrbk`vI=pbsbofqv=^ka=fjm^`q=lc irqp ^ÑíÉê=Éî~äì~íáåÖ=íÜÉ=ëìÄàÉÅíáîÉ=ëóãéíçãë=çÄí~áåÉÇ=Ñêçã=íÜÉ=é~J íáÉåíëD=ÜáëíçêóI=íÜÉ=åÉñí=ëíÉé=áë=ÇçÅìãÉåíáåÖ=çÄàÉÅíáîÉ=áåÑçêã~íáçå=EëáÖåëFI ~ë=äáëíÉÇ=áå=q~ÄäÉ=Q=xTzK • rêáå~êó=áåÅçåíáåÉåÅÉ=E~=ëáÖåF=áë=ÇÉÑáåÉÇ=~ë=ìêáåÉ=äÉ~â~ÖÉ=ÉîáÇÉåí ÇìêáåÖ=Éñ~ãáå~íáçåW=íÜáë=ã~ó=ÄÉ=ìêÉíÜê~ä=çê=Éñíê~ìêÉíÜê~ä=xTzK • píêÉëë=ìêáå~êó=áåÅçåíáåÉåÅÉ=áë=íÜÉ=çÄëÉêî~íáçå=çÑ=áåîçäìåí~êó=äÉ~âJ ~ÖÉ=Ñêçã=íÜÉ=ìêÉíÜê~=ëóåÅÜêçåçìë=ïáíÜ=ÉñÉêíáçåLÉÑÑçêíI=çê=ëåÉÉòáåÖ çê=ÅçìÖÜáåÖI=éêÉëìã~Ääó=ÇìÉ=íç=ê~áëÉÇ=~ÄÇçãáå~ä=éêÉëëìêÉ=xOzK

Bladder diaries and other recording of micturition events _ä~ÇÇÉê=Çá~êáÉë=~êÉ=~å=áåÉñéÉåëáîÉ=ï~ó=íç=çÄí~áå=áåÑçêã~íáçå=~Äçìí ~=ïçã~åDë=Ç~áäó=Ää~ÇÇÉê=ÑìåÅíáçåK=qÜÉ=é~íáÉåí=ÅçãéäÉíÉë=áí=çîÉê=~=OQJ Üçìê=éÉêáçÇI=êÉÅçêÇáåÖ=çê~ä=ÑäìáÇ=áåí~âÉI=ÉéáëçÇÉë=çÑ=áåÅçåíáåÉåÅÉ=~åÇ ~ëëçÅá~íÉÇ=~ÅíáîáíáÉëI=~åÇ=îçáÇáåÖ=îçäìãÉë=~åÇ=íáãÉë=xUzK=qÜÉ=~ãçìåí çÑ=ÑäìáÇ=áåí~âÉ=äáëíÉÇ=çå=îçáÇáåÖ=Çá~êáÉë=áë=çÑíÉå=ëìêéêáëáåÖ=~åÇ=Å~å=éêçJ îáÇÉ=ÅäìÉë=íç=íêÉ~íãÉåíK • jáÅíìêáíáçå=íáãÉ=ÅÜ~êíW=íÜáë=êÉÅçêÇë=çåäó=íÜÉ=íáãÉ=çÑ=ãáÅíìêáíáçåI=Ç~ó ~åÇ=åáÖÜíI=Ñçê=~í=äÉ~ëí=OQ=ÜçìêëK • cêÉèìÉåÅó=îçäìãÉ=ÅÜ~êí=Ecs`FW=íÜáë=êÉÅçêÇë=íÜÉ=îçäìãÉë=îçáÇÉÇ=~ë ïÉää=~ë=íÜÉ=íáãÉ=çÑ=É~ÅÜ=ãáÅíìêáíáçåI=Ç~ó=~åÇ=åáÖÜíI=Ñçê=~í=äÉ~ëí=OQ ÜçìêëK • _ä~ÇÇÉê=Çá~êóW=íÜáë=êÉÅçêÇë=íÜÉ=íáãÉë=çÑ=ãáÅíìêáíáçå=~åÇ=îçáÇÉÇ îçäìãÉëI=áåÅçåíáåÉåÅÉ=ÉéáëçÇÉëI=é~Ç=ìë~ÖÉ=~åÇ=çíÜÉê=áåÑçêã~íáçå ëìÅÜ=~ë=ÑäìáÇ=áåí~âÉI=ÇÉÖêÉÉ=çÑ=ìêÖÉåÅó=~åÇ=ÇÉÖêÉÉ=çÑ=áåÅçåíáåÉåÅÉ xTzK qÜÉ=f`p=ÇÉÑáåÉë=~Çìäí=éçäóìêá~=~ë=ãçêÉ=íÜ~å=OIUMM=ãi=çÑ=ìêáåÉ çìíéìí=áå=OQ=Üçìêë=xUzK=kçí=ìåÅçããçåäóI=é~íáÉåíë=ÉñéÉêáÉåÅáåÖ=éçäóJ ìêá~=ã~ó=Åçãéä~áå=çÑ=ìêáå~êó=ÑêÉèìÉåÅóI=åçÅíìêá~I=~åÇ=çÅÅ~ëáçå~ä=ëíêÉëë áåÅçåíáåÉåÅÉK=qÜÉ=Ää~ÇÇÉê=Çá~êó=ëÜçïë=OQJÜçìê=ÑäìáÇ=áåí~âÉ=~ë=ÜáÖÜ=~ë PIRMM=ãiI=ïáíÜ=~=ëáãáä~ê=~ãçìåí=çÑ=ìêáå~êó=çìíéìíK=qÜÉ=Ää~ÇÇÉê=Çá~êó ~äçåÉ=êÉîÉ~äë=ïÜÉå=íÜÉ=ëóãéíçãë=ëìÅÜ=~ë=éçäóìêá~I=ÑêÉèìÉåÅó=~åÇ åçÅíìêá~=~êÉ=~ííêáÄìí~ÄäÉ=íç=ÉñÅÉëëáîÉ=ÑäìáÇ=áåí~âÉK=qÜÉ=ëóãéíçãë=Å~å íÜÉå=ÄÉ=êÉäáÉîÉÇ=ëáãéäó=Äó=ÑäìáÇ=êÉëíêáÅíáçå=~åÇ=íÉ~=~åÇLçê=ÅçÑÑÉÉ êÉÇìÅíáçåK

The amount of urine leakage

m~Ç=íÉëíë=Å~å=ÄÉ=ìëÉÇ=íç=èì~åíáÑó=íÜÉ=~ãçìåí=çÑ=ìêáåÉ=äçëí=ÇìêáåÖ áåÅçåíáåÉåÅÉ=ÉéáëçÇÉëK=jÉíÜçÇë=ê~åÖÉ=Ñêçã=~=ëÜçêí=éêçîçÅ~íáîÉ=íÉëí íç=~=OQJÜçìê=é~Ç=íÉëí=xTzK=m~Ç=íÉëíë=~êÉ=ïáÇÉäó=ìëÉÇ=áå=é~íáÉåíJçêáÉåíÉÇ êÉëÉ~êÅÜI=~ë=~å=çÄàÉÅíáîÉ=ï~ó=çÑ=~ëëÉëëáåÖ=íêÉ~íãÉåí=ÉÑÑÉÅíáîÉåÉëëK qÜÉó=~êÉ=éÉêÑçêãÉÇ=çå=ïçãÉå=ïáíÜ=~=Ñìää=Ää~ÇÇÉêI=èì~åíáÑóáåÖ=íÜÉ=îçäJ ìãÉ=çÑ=ìêáåÉ=äçëí=Äó=ïÉáÖÜáåÖ=~=éÉêáåÉ~ä=é~Ç=ÄÉÑçêÉ=~åÇ=~ÑíÉê=ëéÉÅáJ ÑáÉÇ=~ÅíáîáíáÉë=xVzK=jçÇáÑáÉÇ=OMJãáåìíÉ=é~Ç=íÉëíáåÖ=Ü~ë=~äëç=ÄÉÉå=éêçJ éçëÉÇ=ïáíÜ=íÜÉ=áåÑìëáçå=çÑ=ORM=ãi=çÑ=ï~íÉê=áåíç=íÜÉ=Ää~ÇÇÉêK=få=èì~åíáJ í~íáîÉ=ëíìÇáÉëI=íÜÉ=íïç=é~Ç=íÉëíë=ëÜçïÉÇ=Ñ~áê=~ÖêÉÉãÉåíI=~åÇ=íÜÉ=é~Ç ïÉáÖÜí=êÉëìäíë=Ñçê=íÜÉ=NJÜçìê=íÉëí=êÉîÉ~äÉÇ=ëáÖåáÑáÅ~åíäó=ä~êÖÉê=~ãçìåíë íÜ~å=íÜÉ=OMJãáåìíÉ=é~Ç=íÉëíK=qÜÉ=OMJãáåìíÉ=é~Ç=íÉëí=ÇÉãçåëíê~íÉÇ ÖêÉ~íÉê=ëÉåëáíáîáíó=áå=ïçãÉå=ïáíÜ=ëíêÉëë=ìêáå~êó=áåÅçåíáåÉåÅÉ=xNMzK mevpf`^i=bujfk^qflkp Abdominal examination qÜÉ=Ää~ÇÇÉê=ã~ó=ÄÉ=ÑÉäí=Äó=~ÄÇçãáå~ä=é~äé~íáçå=çê=Äó=ëìéê~éìJ ÄáÅ=éÉêÅìëëáçåK=mêÉëëìêÉ=ëìéê~éìÄáÅ~ääó=çê=ÇìêáåÖ=Äáã~åì~ä=î~Öáå~ä Éñ~ãáå~íáçå=ã~ó=~äëç=áåÇìÅÉ=íÜÉ=ÇÉëáêÉ=íç=é~ëë=ìêáåÉ=xTzK Perineal/vaginal inspection mÉêáåÉ~ä=~åÇ=î~Öáå~ä=áåëéÉÅíáçå=~ääçï=Ñçê=ÇÉëÅêáéíáçå=çÑ=íÜÉ=ëâáåI ÉKÖK=~íêçéÜó=çê=ÉñÅçêá~íáçåI=~Äåçêã~ä=~å~íçãáÅ~ä=ÑÉ~íìêÉë=~åÇ=çÄëÉêJ

Table 5. Recent Revisions to ICS 2002 Terminology Recommendations [5,8]

Previous term New term

Genuine stress incontinence Urodynamic stress incontinence Incontinence related to urethral instability* Urethral relaxation incontinence Incontinence related to involuntary detrusor contraction* Detrusor overactivity incontinence Detrusor instability Idiopathic detrusor overactivity Detrusor hyper-reflexia Neurogenic detrusor overactivity Early sensation of bladder filling during filling cystometry* Increased bladder sensation Diminished sensation of bladder filling during filling cystometry* Reduced bladder sensation No sensation of bladder filling during filling cystometry* Absent bladder sensation

*No prior defined term

Table 4. Standardized Terminology for Signs Suggestive of Lower Urinary Tract Dysfunction (LUTD) as Approved by the ICS in 2002 [7] Urinary incontinence urine leakage seen during examination: this may be urethral or extraurethral

Stress urinary incontinence the observation of involuntary leakage from the urethra, synchronous with exertion/effort, or sneezing or coughing. It is pre sumed to be due to raised abdominal pressure

Extra-urethral incontinence observation of urine leakage through channels other than the urethra

NPQ î~íáçå=çÑ=áåÅçåíáåÉåÅÉ=xTzK=píêÉëë=íÉëíë=~êÉ=~=ëáãéäÉ=ãÉíÜçÇ=íç=ÇçÅìJ ãÉåí=íÜÉ=ÉñíÉåí=çÑ=ëíêÉëë=áåÅçåíáåÉåÅÉ=ÄÉÑçêÉ=~åó=~åíáJáåÅçåíáåÉåÅÉ éêçÅÉÇìêÉ=áë=ÅçåëáÇÉêÉÇK • píêÉëë=íÉëíW=~ëâ=íÜÉ=é~íáÉåí=íç=ÅçãÉ=íç=ÜÉê=çÑÑáÅÉ=îáëáí=ïáíÜ=~=Ñìää Ää~ÇÇÉêI=~ë=áÑ=ëÜÉ=Ü~Ç=~å=ìäíê~ëçìåÇ=~ééçáåíãÉåíK=^í=íÜÉ=ëí~êí=çÑ=íÜÉ éÜóëáÅ~ä=Éñ~ãI=éÉêÑçêã=íÜÉ=ëíêÉëë=íÉëí=ïáíÜ=íÜÉ=é~íáÉåí=áå=~=ëí~åÇáåÖ Eçê=ëèì~ííáåÖF=éçëáíáçåK=qÜÉ=Ñìää=Ää~ÇÇÉê=~åÇ=ëí~åÇáåÖ=éçëáíáçå=ãáãáÅ íÜÉ=êÉ~ä=Ç~áäó=äáÑÉ=ÅáêÅìãëí~åÅÉë=çÑ=áåÅçåíáåÉåÅÉ=ÉéáëçÇÉëI=~åÇ=Å~å êÉÇìÅÉ=Ñ~äëÉJåÉÖ~íáîÉ=êÉëìäíëK cáêëíI=Ü~îÉ=íÜÉ=é~íáÉåí=ëí~åÇ=ïáíÜ=çåÉ=Ñççí=çå=íÜÉ=ëíÉé=çÑ=íÜÉ=ÉñJ ~ãáå~íáçå=í~ÄäÉK=qÜÉåI=ëáí=çå=~=ëíççä=~åÇ=ëÉé~ê~íÉ=íÜÉ=ä~Äá~=ïáíÜ=çåÉ Ü~åÇI=ëç=íÜ~í=íÜÉ=ìêÉíÜê~ä=ãÉ~íìë=áë=îáëáÄäÉK=e~îÉ=íÜÉ=é~íáÉåí=ÅçìÖÜ ÑçêÅÉÑìääó=ëÉîÉê~ä=íáãÉë=ïÜáäÉ=óçì=çÄëÉêîÉ=íÜÉ=ãÉ~íìë=Ñçê=äçëë=çÑ=ìêáåÉK ^=ëéìêí=çÑ=ìêáåÉ=ÅçáåÅáÇÉåí=ïáíÜ=íÜÉ=ÅçìÖÜ=áë=~=éçëáíáîÉ=êÉëìäíK=fÑ=íÜÉ é~íáÉåí=Ü~ë=~=ëáÖåáÑáÅ~åí=~ãçìåí=çÑ=éêçä~éëÉI=áKÉK=ëí~ÖÉ=fff=çê=fsI=êÉéÉ~í íÜÉ=ëíêÉëë=íÉëí=ïáíÜ=íÜÉ=éêçä~éëÉ=êÉéä~ÅÉÇ=íç=Éäáãáå~íÉ=íÜÉ=ÉÑÑÉÅí=çÑ=~åó ìêÉíÜê~ä=âáåâáåÖ=~åÇ=íç=ÇÉíÉÅí=çÅÅìäí=ìêáå~êó=áåÅçåíáåÉåÅÉK=qÜÉ=éêçJ ä~éëÉ=Å~å=ÄÉ=êÉÇìÅÉÇ=ìëáåÖ=~=éÉëë~êó=çê=íÜÉ=éçëíÉêáçê=Ää~ÇÉ=çÑ=~ ëéÉÅìäìãK=^ÑíÉê=íÜÉ=ëíêÉëë=íÉëíI=Ü~îÉ=íÜÉ=é~íáÉåí=îçáÇ=áåíç=~=ãÉ~ëìêáåÖ ÇÉîáÅÉ=íç=êÉÅçêÇ=íÜÉ=îçäìãÉK

Uroflowmetry and Postvoid residual volume (PVR)

rêçÑäçïãÉíêó= áë= åçåáåî~ëáîÉ= ÇÉíÉêãáå~íáçå= çÑ= ìêáåÉ= Ñäçï ÅÜ~ê~ÅíÉêáëíáÅëK=fí=êÉÑäÉÅíë=íÜÉ=Ñáå~ä=êÉëìäí=çÑ=íÜÉ=~Åí=çÑ=îçáÇáåÖK=qÜÉ=mso ~ãçìåí=Éå~ÄäÉë=íÜÉ=ÅäáåáÅá~å=íç=ÇÉíÉêãáåÉ=íÜÉ=Ää~ÇÇÉêDë=~Äáäáíó=íç=ÉãéíóK m~íáÉåíë=ïáíÜ=~Äåçêã~ä=ìêçÑäçïãÉíêó=çê=ãìÅÜ=mso=êÉèìáêÉ=ãçêÉ=ÇÉJ í~áäÉÇ=Éî~äì~íáçå=íç=ÑìêíÜÉê=ÉäìÅáÇ~íÉ=íÜÉ=Å~ìëÉ=çÑ=îçáÇáåÖ=ÇóëÑìåÅíáçåK ^=é~íáÉåí=ïÜç=ìåÇÉêÖçÉë=ìêçÑäçïãÉíêó=ëÜçìäÇ=ÄÉ=ïÉää=ÜóÇê~íÉÇ ïáíÜ=~=êÉ~ëçå~Ääó=Ñìää=Ää~ÇÇÉêK=qÜÉ=é~íáÉåí=ëÜçìäÇ=ÄÉ=ÉåÅçìê~ÖÉÇ=íç îçáÇ=áå=~ë=åçêã~ä=~=Ñ~ëÜáçå=~ë=éçëëáÄäÉK=^ÑíÉê=ãÉ~ëìêáåÖ=ìêáåÉ=ÑäçïI éÜóëáÅá~åë=Å~å=ãÉ~ëìêÉ=êÉëáÇì~ä=ìêáåÉ=ÉáíÜÉê=Äó=ìêáå~êó=Å~íÜÉíÉêáò~J íáçå=çê=ìäíê~ëçìåÇK=tÜÉå=ìëáåÖ=ìäíê~ëçìåÇI=éÉêÑçêã=íê~åë~ÄÇçãáå~ä áã~ÖáåÖ=áå=íÜÉ=íê~åëîÉêëÉ=~åÇ=ãáÇJë~Öáíí~ä=éä~åÉëK=qÜÉ=Ää~ÇÇÉêDë=ÇáJ ~ãÉíÉê= áå= P= éä~åÉë= E~åíÉêáçêJéçëíÉêáçêI= íê~åëîÉêëÉI= ~åÇ= ë~Öáíí~äL äçåÖáíìÇáå~äFI=~ééêçñáã~íÉ=íÜÉ=Ää~ÇÇÉê=îçäìãÉ=xNNzK • cçêãìä~W=sçäìãÉ=EãiF=Z=QLP
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Evaluate pelvic floor tone

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Assess urethral hypermobility

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3 cm

Ba

Aa

D

Ap

C

Bp

gh

pb

D

C

Ba

Aa

gh

Ap

Bp

pb

tvl

anterior

wall

anterior

wall

cervix or

cuff

total vaginal

length

perineal

body

genital

hiatus

posterior

wall

posterior

wall

posterior

fornix

Fig 1. (A) Six sites (points Aa, Ba, C, D, Bp and Ap), genital hiatus (gh), perineal body (pd) and total vaginal length (tvl) used for pelvic organ support quantification. (B) Three-by-three grid for recording quantitative description of pelvic organ support (Reproduced from reference [20] under the permission of Elsivier Com).

NPS ÖÉåáí~ä=Üá~íìë=íç=íÜÉ=ãáÇéçêíáçå=çÑ=íÜÉ=~åìëK

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Staging each compartment

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