Physical Examination
When examining a patient with urinary incontinence or prolapse, more care may be needed to be taken to avoid embarrassment than with the usual gynecology patient.
For example, a patient with menorrhagia is often fed up with her symptoms and just seeks your help to get rid of a practical problem that has little social stigma. On the other hand, a patient with incontinence often feels that she is “dirty” and “can’t control herself.” A patient with prolapse is often horrified about the lump appearing at her vaginal opening, and may have ceased inter- course because of embarrassment.
Therefore, always make sure that the patient’s abdomen and genitalia are covered with a sheet, and only expose that part which you are about to examine. Establish a sympathetic rapport before you begin the examination.
EXAMINE THE ABDOMEN
Many patients attending the gynecologist for a first visit lie on the couch with their knees drawn up, assuming that only the vagina and pelvis will be examined. This is not appropriate in urogynecology: the abdomen must be examined first, so ask the patient to drop her knees down so that a relaxed abdominal exam can be performed.
Any mass that raises intra-abdominal pressure may cause incontinence.
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In our Unit, we see one to two patients per annum presenting with incontinence or urgency/frequency who in fact have an ovarian cyst (benign or malignant), or an enlarged uterus, that has previously been undetected.
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Also, patients may present with frequency and urgency but
in fact have sub-acute retention, so it is important to percuss
the abdomen to exclude an enlarged bladder. Shifting dullness
needs to be elicited if ascites is suspected, which may accom- pany an ovarian cancer that provokes stress incontinence.
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Check the renal angles for tenderness, e.g. calculi.
INSPECT THE VULVA
First look for evidence of post-menopausal atrophy. Initially this appears as thin shiny glistening red epithelium, that appears fragile, rather than the healthy pink “skin” like appearance of the pre-menopausal women. Later changes include patchy whitish areas of cornification with some “cracks” or fissurelike lesions often between the labia majora and minora. In end stage, the labia minora may be fused at the midline. Urethral caruncle, a red rosebud appearance at the urethral meatus, also indicates estrogen deprivation (see Figure 2.1).
Do not be lulled into a sense of security because the patient is on systemic HRT. A percentage of these patients do not achieve
F
IGURE2.1. Classic atrophic vagina with urethral caruncle.
adequate blood levels in the vagina and vulva and may still get atrophic changes, which also affect the urethra.
Next, look at the introitus at rest, a cystocele or rectocele may be evident even without cough. Inspect the perineum for signs of post-obstetric perineal deficiency.
ELICIT A “STRESS LEAK”
Part the labia and ask the patient to cough. In order to save embarrassment, explain to the woman that you will place a piece of tissue/paper towel at the urethra, so that if she leaks, nothing will spill onto the linen. Patients are often terrified that they will leak urine in front of the doctor, yet this is exactly what we are trying to get them to do. You should have a tissue ready in any case, because a strong projectile spurt of urine may reach your clothing and embarrass the women even further (she will know if the spurt has been large enough to do this!).
Typically, a stress leak involves a short spurt of urine that occurs during the height of the cough effort. An urge leak typi- cally occurs an instant after the cough, but a large prolonged urine leak is seen due to the detrusor contraction.
In practice, patients with urge incontinence will not get up onto your examining couch with a full bladder; they will always request to visit the toilet first.
Assess hypermobility of the anterior vaginal wall. When the patient coughs, there may not be a proper cystocele “bulge”, but the whole anterior wall may move down with the cough.
SPECULUM EXAMINATION
Pass a Bi-valve Speculum
Always check that the cervix is healthy and take a Pap smear if due. As you withdraw the speculum check for normal vaginal epithelium as in any gynecological exam.
Pass a Sims Speculum
Traditional advice is to ask the patient to assume the left lateral position for a Sims speculum exam. In fact, if they are obese this may not be necessary; the bottom of the Sims may not hit the couch if the buttocks are sufficiently plump. If equipment is in short supply, the two leaves of a bivalve speculum can be unscrewed, and the anterior leaf used as a Sims speculum.
Cystocele (prolapse of the bladder into the vagina) and rec-
tocele (prolapse of the rectum into the vagina) are traditionally
graded (during Valsalva or cough) as the following.
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Mild: The prolapse descends more than halfway down the vagina but not to the introitus.
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Moderate: The prolapse descends to the level of the introitus.
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Severe: The prolapse descends well beyond the introitus and is outside of the vagina.
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Recently, the type of anterior prolapse has been divided into
—Distension cystocele, resulting from overstretching in labor, or atrophic post-menopausal changes. The rugae have disappeared.
—Displacement cystocele arises from tears in the lateral liga- ments of the vagina. The vaginal rugae are usually still evident. If the lateral borders of the vagina are lifted with an open sponge forcep, the whole prolapse is easily replaced. This is more common in nullipara or women of low parity.
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Uterine descent follows the same classification, but if the majority of the organ is outside the vagina, the term proci- dentia is used.
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In highly parous women, the uterus may be well supported but the cervix may be very bulky and protuberant (worth noting when considering surgical options).
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