Monday, April 9, 2012

Clinical Evaluations of female pelvic organs (part 1)


Clinical Evaluations 

Introduction
History taking
Lower Urinary Tract Symptoms
       ­A-Storage symptoms
       B- Voiding symptoms
       C- Post micturition symptoms
Symptoms associated with pelvic organ prolapse
Physical Examination                                 
     1- General examination
     2- Abdominal examination
     3- Gynecological (Pelvic) examination
           A- Perineal/genital inspection
           B- Vaginal examination
                 a- Anatomical abnormalities
                 b- Assessment of pelvic floor muscle function
           C- Rectal examination
      4- Office tests
      5- Neurological examination























Introduction
          Early description of disease relied much on the ability of the clinician to accurately record the history and clinical examination, confirmatory investigations were rudimentary, most information being provided by histological specimens either removed during the operation or at a postmortem examination. Complex and sophisticated investigations have gradually evolved, but we still rely on the history and examination to provide the framework for diagnosis, although these have also undergone changes (Stanton, 1984).

History taking
          Most history taking uses patient’s own words and is written in prose (usually neither as lengthy nor as literate as in the past). More use is made now of the structured questionnaire-designed for the condition being studied. General history should include questions relevant to neurological and congenital abnormalities as well as information on previous UTI and relevant surgery. Information must be obtained on medication with known or possible effects on the LUT. General history should also include assessment of sexual and bowel function and obstetric history. Urinary history must consist of symptoms related to both storage and evacuation functions of the LUT (Walters and Karram, 1999).

Early in the interview, one should elicit a description of patient’s main complaint, including duration and frequency. A clear understanding of severity of the problem or disability and its effects on quality of life should be sought. A bowel history should be noted because chronic severe constipation has been associated with voiding difficulties, urgency, SUI and increased bladder capacity (Wein et al, 1991).

          Multivariate analysis established age as a risk factor for UI, with a 30% greater prevalence for each 5years increase in age (Weber and Walters, 1999). Stress urinary incontinence is common in younger and middle-aged women, whereas mixed urinary incontinence predominates in older women (Cardozo, 2004).  

Lower Urinary Tract Symptoms (LUTS)
          Lower urinary tract symptoms are divided into three groups: storage, voiding and post micturition symptoms (Abrams et al, 2002).

A-Storage symptoms are experienced during the storage phase of the bladder and include daytime frequency and nocturia. Nocturia is the complaint that the individual has to wake at night one or more times to void. Urgency is the complaint of a sudden compelling desire to pass urine, which is difficult to defer. Urinary incontinence is the complaint of any involuntary leakage of urine. Mixed UI is the complaint of involuntary leakage associated with urgency and also with exertion, effort, sneezing or coughing. Continuous UI is the complaint of continuous leakage (Abrams et al, 2002). Voiding more than seven times a day is defined as frequency (Stanton et al, 1976).  

          Stress urinary incontinence is often seen in multiparous women. However, women who have never borne children can also exhibit this condition (Wein, 2000). Overactive bladder is a medical condition referring to symptoms of frequency and urgency with or without urge incontinence, when appearing in absence of local pathologic or metabolic factors that would account for these symptoms. Incontinence is not a necessary condition for the diagnosis because half of people with overactive bladder do not have incontinence (Abrams and Wein, 2000).
Detrusor instability is now known to be an urodynamic observation of uncertain clinical significance. Symptoms reported by patients are not equivalent to an urodynamic diagnosis but the problem seems to be more in the urodynamics than in the symptoms. Evidence shows that sensory urge incontinence and motor urge incontinence are probably gradations of the same condition. The relationship between SUI and an overactive bladder is complex (McGuire, 2000).

B- Voiding symptoms are experienced during the voiding phase. Slow stream is reported by the individual as her perception of reduced urine flow, usually compared to previous performance or in comparison to others. Intermittent stream (Intermittency) is the term used when the individual describes urine flow, which stops and starts, on one or more occasions, during micturition. Hesitancy is the term used when 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 describes the muscular effort used to initiate, maintain or improve the urinary stream. Terminal dribble is the term used when an individual describes a prolonged final part of micturition, when the flow has showed to trickle/dribble (Abrams et al, 2002).

Women are aware of hesitancy, difficulty in voiding, poor stream, having to stand to void and incomplete emptying (Stanton et al, 1983 I). Patients may feel urgency and then rush to relieve themselves, only to find that they have difficulty voiding. This difficulty may occur because the detrusor contraction that gave the patient urgency has subsided and the patient now has difficulty initiating another contraction to void adequately (Farrar et al, 1975). Voiding difficulty may result from advanced prolapse (Karram et al, 1999).      
C- Post micturition symptoms are experienced immediately after micturition. Feeling of incomplete emptying is a self-explanatory term for a feeling experienced by the individual after passing urine. Post micturition dribble is the term used when an individual describes the involuntary loss of urine immediately after she has finished passing urine, usually after rising from the toilet (Abrams et al, 2002).

Symptoms associated with pelvic organ prolapse
The feeling of a lump "something coming down", low backache, heaviness, dragging sensation, or the need to digitally replace the prolapse in order to defecate or urinate, are amongst the symptoms women may describe who have a prolapse (Abrams et al, 2002)

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