oe ecg) bina may hist at some type of ° Pelvic muscle strength

geanourinary ¢ > Digitally evaluate the contractility of the pelvic

* Initial examination may be done with the patieat in rauscies.
the stirrups (rather than supine) to assess for prolapse « Insert index and middle fingers inside vagina and
and leakage. especially with vatsalva. ask the patient to squeeze or do a Kegel squeeze
© If paticnt docs not Icak have patient stand or squat. then (both 1s and 3 s squeezes).
repeat stress tes. ¢ Often patients mistakenly perform valsaiva, use
* Shicld yourcif to prevent soiling with urine during abdominal and gluteal muscles instead of the pub-
tmoluntary Ieakage with valsalva. ococcygeus muscles.
* Look for penincal scans from previous episiotomy or ~ Strong muscles: A patient with very strong contrac-
laceration repairs. tion of these muscles will not benefit from physical
¢ Speculum examination should be performed in the therapy but may benefit from strengthening exercises.
usual fashion and you may want to do a pap snear if o Weak muscles: Referral to a physical therapist
she 1s not a referred patient. should be made if pelvic Noor muscles are weak.
* Bimanual cxamination should assess uterine size (if 2 No strength: This suggests severe atrophy of the
present). pelvic masses, and subjectively assess vagi- pelvic floor muscles and/or neuropathy. This
nal length, expecially in patients with previous surgery. patient may benefit from biofeedback or electrical
¢ Vaginal support should be evaluated for the presence stimulation.
of anterww prolape (cystocele), posterior prolapse ° Many clinicians evaluate urethral hypermobility, in
(rectacele). or apical prolapse (entcrocele. uterine or patients with symptoms of stress incontincace via the
vault prolapse). Note that it may be difficult to differ- Q-tip test. Q-til
entizte between cystocele and urethrocele because -—° Initially introduced by Crystle. Pp
they usually cocxist. Use POP-Q (standard) or Baden- o By standard, >30 degrees movement of the Q-tip is
Walker classification to assess degree of prolapse (see considered hypermobile urethra (HMU), but there is
Chap. 5, Evaluation of Pelvic Organ Prolapse [POP]). no clear cutoff between normal and abnormal as there
© Patients with POP may have distortion, compression, . is overlap between asymptomatic, parous women and
or kinking of urethra which occludes it and may mask women with SUI.
UL. This is referred to as occult incontinence (aka © Procedure: (1) cleanse with antibacterial solution or
potential, latent, or masked incontinence). Therefore, iodine, (2) place 2% lidocaine gel-impregnated cotton
those with advanced prolapse (i.c.. grade 3 or 4) swab in bladder. Decrease in resistance means you are
should have it reduced (via pessary, Sims speculum, past bladder neck. Location of Q-tip is very important
ring forceps, of large swabs with care not to occlude as bladder placement or midurethral placement
the urethra sw as to simulate the effect of surgery) and changes values. therefore, (3) after insertion into the
then ashed to cough or valsalva with the bladder full bladder, Q-tip should be withdrawn slowly until resist-
to sce if SUL is now present. ance is felt. This is the bladder neck or UVJ! The Q-tp
*¢ Remember two things about occult incontinence test- portion should be just beyond the UVJ.
ing: (1) do not occlude the urethra as this will create © Disadvantage is that (1) it can be uncomfortable for
_ false negative results. and (2) be careful not to push patients, (2) it is misunderstood: urethral hypermo-
down on the levator ani as this will paralyze the levator bility does not automatically mean SUI.
muscles, fead to relaxation of the bladder outlet, and © The degree of movement of the swab, from the hori-
therefore false-positive occult incontinence. zon, between rest and valsalva are measured using
© Currently, some experts perform a prophylactic sling protractor or orthopedic goniometer.
along with surgery for prolapse to avoid de novo SUI in © There is nothing magical about the number “30.” By
a patient who has occult incontinence. However, the data changing the criteria to >40 degrees, one reduces the
for this are lacking. The pelvic floor disorders network false-positive rate while only slightly reducing the
(PFDN) and other studies will shed light on this matter. true-positive rate. By increasing the criteria angle to
* Anorectal examination 80 degrees, one reduces false-positive to zero but
Digitally evaluate the tone and integrity of the exter- sacrifices truc-positive rate (20%).
nal anal sphincter. Flatal or fecal incontinence © This test is positive in women with advanced POP
occurs in 20% of patients with UI. (stage 3 or 4) and usually positive in stage 2.
: Fecal impaction—UI improves after resolution of ¢ However, this test is not significantly affected by
fecal impaction in elderly institutionalized patients. bladder volume.
> Caod time te perform 8 fecal occult blood test and * There is good intraobserver (~85%) and interob-
dicenes compliance with colon cancer screening. server correlation (~90%) for this test.