Monday, April 9, 2012

Clinical Evaluations of female pelvic organs (part 2)




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


Physical Examination
1- General examination
The physical examination should focus on detecting anatomic and neurologic abnormalities that contribute to urinary dysfunction. The attitude and demeanor of the patient and any obvious personality or mental disorders should be noted. The height and weight of the patient are recorded (Mark and Edward, 1999).    

2- Abdominal examination
          The abdomen and flanks should be examined for masses, hernias, scars and a distended bladder. The bladder may be felt by abdominal palpation or by suprapubic percussion. (Abrams et al, 2002).

3- Gynecological (Pelvic) examination
            After a general examination is completed, the remaining examination is divided into gynecological and neurological parts (Abrams et al, 2002).

A- Perineal/genital inspection
Inspection allows description of skin, for example the presence of atrophy or excoriation, any abnormal anatomical features and the observation of incontinence. Urinary incontinence (as a sign) is defined as urine leakage seen during examination: this may be urethral or extra urethral. Stress urinary incontinence is the observation of involuntary leakage from the urethra, synchronous with exertion/effort or coughing. Extra urethral incontinence is defined as the observation of urine leakage through channels other than the urethra (Abrams et al, 2002).

  
The anus is inspected, looking for soil of stool on skin, evidence of skin irritation, gaping of the muscles and any scarring. The patient is asked to squeeze and simulate holding in a bowel movement to look for uniform circular contraction of muscle. Next, asking the patient to strain may show exaggerated perineal descent or prolapse or prolapse of hemorrhoids or even rectum (Tracy, 1999).

Clinicians should be encouraged to describe the pelvic floor defects clearly and specifically and to avoid the use of general grades or classes of poorly defined entities (Wall, 1996). Prolapse in each segment is evaluated and measured relative to the plan of the hymen (not introitus), which is a fixed anatomic landmark that can be identified consistently and precisely (Bump et al, 1996).
 
B- Vaginal examination
Vaginal examination allows description of observed and palpable anatomical abnormalities and the assessment of pelvic floor muscle function (Bump et al, 1996).



a- Anatomical abnormalities
Pelvic organ prolapse is defined as the descent of one or more of anterior vaginal wall, posterior vaginal wall and apex of the vagina (cervix/uterus) or vault (cuff) after hysterectomy. Anterior vaginal wall prolapse is defined as descent of the anterior vagina so that the urethrovesical junction (a point 3cm proximal to external urinary meatus) or any anterior point proximal to this is less than 3cm above the plane of the hymen. Prolapse of the apical segment of the vagina is defined as any descent of the vaginal cuff scar (after hysterectomy) or cervix, below a point which is 2cm less than the total vaginal length above the plane of the hymen. Posterior vaginal wall prolapse is defined as any descent of posterior vaginal wall so that a midline point on posterior vaginal wall 3cm above the level of hymen or any posterior point proximal to this is less than 3cm above the plane of the hymen (Abrams et al, 2002).

A vaginal examination should be performed with the bladder both empty (to check the pelvic organs) and full (to check for incontinence and prolapse). With the bladder comfortably full in the lithotomy position, the patient is asked to cough or strain in an attempt to produce the incontinence. The physician should observe the patient for a while with a speculum in place and ask her to cough. Anterior vaginal wall prolapse occurs commonly and may be coexisting with disorders of micturition. The examination is first performed with the patient supine. If physical findings do not correspond to symptoms or if the maximum extent of the prolapse cannot be confirmed, the woman is reexamined in the standing position. A retractor or Sims’ speculum can be used to depress the posterior vagina to aid in visualizing the anterior vagina. After the resting examination, the patient is instructed to strain down forcefully or to cough vigorously. During this maneuver, the order of descent of the pelvic organs is noted, as is the relationship of the pelvic organs at the peak of straining. Anterior vaginal wall descent usually represents bladder descent with or without concomitant urethral hypermobility (Romanzi et al, 1995).

The urinary incontinent women are examined for functional urethral anatomy as it related to the Valsalva and Kegel maneuvers. The anterior urethral crease, the middle urethral bulge and the posterior urethral fold are identified in each patient. These three landmarks represent the portion of the urethra supported in part by the pubourethral ligaments. Kegel or pubococcygeal retractions can be performed to note any compensatory capacity to the supportive structures (Cruikshank and Kovac, 1997).

Enterocele and rectocele can be demonstrated by using the speculum to retract the anterior vaginal wall. Asking the patient to cough and simultaneously examining the rectum and vagina can make differentiation (Stanton, 1984).

b- Assessment of pelvic floor muscle function
Pelvic floor muscle function can be qualitatively defined by the tone at rest and the strength of a voluntary or reflex contraction as strong, weak or absent or by a validated grading system (e.g. Oxford 1-5). A pelvic muscle contraction may be assessed by visual inspection, palpation, electromyography or perineometry. Factors to be assessed include strength, duration, displacement and repeatability (Abrams et al, 2002).

          With two examining fingers in the vagina, levator muscles are located at the 5- and 7-o’clock positions just superior to the hymeneal ring. Patient is instructed to contract these muscles. A correctly performed pelvic floor contraction is demonstrated by cephalad retraction of the perineum and anus, posterior rotation of the clitoris and anterior displacement of the examining fingers (Bump et al, 1991).

C- Rectal examination
          Rectal examination further evaluates for pelvic pathology and fecal impaction, the later of which may be associated with voiding difficulties and incontinence in elderly women (Mark and Edward, 1999). In virgins who have intact hymen, pelvic organs can be examined by the rectal-abdominal technique (Hochstein and Rubin, 1964).

4- Office tests
These tests attempt to differentiate between GSI and uninhibited bladder. First of these is the Q tip test which is useful to determine the amount of vesical neck descent on straining. Rotational angle measured by Q-tip test with a full bladder, showed (48 degrees, range 31-60) in women with genital prolapse of different grades. Measurement of urethral mobility by the Q-tip test is significantly affected by genital prolapse (Pollak et al, 2003).

Bonney test utilizes two fingers to elevate the BN toward the umbilicus, tacking care not to compress the urethra. Urethroscopically, however, urethral compression almost always occurs, thereby, negating the predictive value of the Bonney test. The Marchetti test, using local anesthesia and Alli’s clamps and the Read test, using rubber-shod clamps, also compress the urethra. So these tests are limited value (Pelosi et al, 1975).

A frequency/volume bladder chart is an invaluable aid in the evaluation of patients with urinary incontinence, but use of this tool is often neglected (Wyman et al, 1998).

Pad test provides a semi objective measurement of urine loss over a given period of time. A number of pad tests have been described (Hahn and Fall, 1991).

Stress test: physician examines the patient with a full bladder in standing position. While the physician closely observes urethral meatus, the patient coughs. If short spurts of urine escape simultaneously with each cough, this suggests GSI. A delayed leakage or loss of large volumes of urine suggests the diagnosis of uninhibited bladder contractions. Continence status can be confirmed by stress test and one day pad test for women with negative stress test and complained SUI (Miller et al, 2001).

5- Neurological examination
          A simplified neurological examination should be performed to screen all patients. The back is examined for lesions such as spina bifida (overt or occult) and prolapsed intervertebral disk or spondylosis. Sacral segments 2 through 4, which contain the important neurons controlling micturition, are particularly important. To test motor function, the patient extends and flexes the hip, knee and ankle and inverts and everts the foot. The strength and tone of the bulbocavernosus muscle and external anal sphincter are estimated digitally. Sensory function along the sacral dermatomes is tested by using light touch and pinprick on the perineum and around the thigh and foot. In the anal reflex, stroking the skin adjacent to the anus causes reflex contraction of the external anal sphincter muscle. The bulbocavernosus reflex involves contraction of bulbocavernosus and ischiocavernosus muscles in response to taping or squeezing of the clitoris (Walters, 1999).

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