Evaluation of Pelvic Relaxation

Evaluation of pelvic prolapse begins with a thorough history and physical examination.  The following questions need to be answered:

  • Do you have an introital (vaginal) bulge? What activities  promote an increase in the size of the bulge?  Do need to “reduce” the bulge to urinate or defecate?  How much is the introital bulge disturbing you? Have you had any prior treatments for the  bulge?
  • Do you have urinary incontinence, and if so, what type, to what  extent, what means are necessary for protection, and how bothersome is it?  What activities, if any, promote the incontinence?
  • Do you have obstructive voiding symptoms including: hesitancy, decrease in force of the stream, decrease in caliber of the stream, intermittency, the need to strain to void, the feeling that you are not emptying completely, the need to double void?
  • Do you have irritative voiding symptoms including: urgency,  precipitancy, frequency, nocturia? 
  • Do you have urinary tract infections?
  • Do you have vaginal pain? Are you sexually active, and if so, do you have painful intercourse?
  • Do you have a wide and lax vaginal opening that has made sexual  relations less satisfying?
  • Do you have obstructive rectal symptoms including constipation,  incomplete emptying, fecal soiling?
  • Do you have flank and back pain when the prolapse occurs?
  • What medical problems do you have?  Do you have any medical  problems that may contribute to pelvic relaxation such as: obesity, chronic coughing, sneezing or wheezing from bronchitis, allergies or asthma, or chronic straining due to constipation?  What medications  do you take? What allergies do you have to medications? What surgeries have you had, particularly hysterectomy, or prior surgery for pelvic prolapse and incontinence?
  • How many pregnancies have you had?  How many vaginal deliveries?  How large were your babies at birth?  Was labor and delivery prolonged or difficult? Was there significant vaginal tearing requiring repair?  Do you anticipate having more  children? 
  • If menopausal, at what age did you experience menopause?   Are you on replacement female hormone therapy? 
  • Have you ever fractured your pelvic bones or sustained a significant pelvic injury?
  • Is there a tendency for pelvic relaxation and/or incontinence to run in your family, i.e. mother, grandmother, sisters, aunts?

The precise diagnosis of pelvic prolapse is made on the basis of a careful physical exam.  The examination must be performed with the patient straining forcefully enough to demonstrate the prolapse at its largest extent. Each region of potential prolapse must be examined independently, i.e., vaginal roof, vagina apex, vaginal floor. 

A thorough pelvic examination involves visual observation, a single  blade speculum exam, passage of a small female catheter into the bladder, and a bimanual pelvic exam. Initial inspection will determine the presence of urogenital atrophy (loss of tissue integrity of the genital area, including thinning of the vaginal skin, redness, irritation, etc.), commonly seen after menopause. 

 A small caliber catheter is passed after voiding for several purposes: to determine the residual urinary volume, to submit a urine culture in the event that the urinalysis suggests a urinary infection, and to determine the change in urethral angulation that occurs with straining.  Urethral angulation with straining is a sign of loss of support of the urethra, which gives rise to hypermobility and stress urinary incontinence.

 In order to observe the top wall of the vagina for the presence of a urethrocele or cystocele, it is important to retract the bottom wall of the vagina down with a speculum.  To observe the bottom wall of the vagina for the presence of a rectocele and perineal laxity, the top wall of the  vagina must be retracted up with a speculum.  To observe the vaginal apex for uterine prolapse and enterocele, both top and bottom walls must be retracted up and down respectively.  Once the speculum is  placed, the patient is asked to strain vigorously.  This speculum examination will determine what specific structure is prolapsed and grade the degree of prolapse.

 Finally, a bimanual examination is  performed to check for pelvic masses.  This is a combined internal and external exam in which the pelvic organs are felt between an internal examining finger within the vagina and an external examining finger on the lower abdomen.  The limitation of the physical exam in the lying-down position is that this is NOT the position in which prolapse typically manifests itself. The ideal position to examine prolapse is the standing position, but this obviously is a very difficult and awkward position in which to perform an exam.  For this reason a standing x-ray of the contrast filled bladder at rest and with straining is a useful means of determining the degree and type of bladder prolaspe.

Urodynamics are an office procedure helpful in the evaluation of pelvic relaxation. The preparation generally involves only taking an oral antibiotic prior to the procedure. Using sterile technique, a small catheter is placed in the urinary bladder. An additional catheter is placed in the rectum and patch electrodes are placed adjacent to the anal area. The individual catheters will be connected to the computer-assisted urodynamic unit. During the procedure, the pressure in the bladder and the rectum will be monitored as well as the activity of the pelvic floor muscles. When the test begins, fluid at a controlled rate will fill the urinary bladder. You will be asked when you have an initial desire to urinate, when it becomes urgent, and when you feel full. At several times during the procedure you will be asked to strain or cough. Every effort will be made to replicate your symptoms during the course of the study so that the pressures and pelvic floor activity can be measured at that particular time. Once the bladder is filled to capacity, you will be asked to void into the commode at which time the urinary flow rate as well as the pressure within the bladder will be measured. At the end of the urodynamic evaluation, all of the catheters will be removed. The final element of the evaluation is a cystoscopy. During this procedure, the urethra is numbed with anesthetic jelly after which a tiny lighted optical instrument is used to view the urethra, bladder neck, and bladder on a monitor that you will be able to see.

After the urodynamic evaluation has been completed and all the data stored in the computer has been examined, I will review in detail with you (and a family member or significant other, if you so desire) the results of the urodynamic study. This study will provide the necessary quantitative anatomic and functional information to make a precise diagnosis so that management options can be discussed and treatment              plans initiated.

 

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