A: Urinary incontinence symptoms
B: Irritative bladder symptoms
C: Sensory symptoms
D: Voiding symptoms
E: Prolapse symptoms
F: Lower urinary tract pain / other pain
Symptom: Any morbid phenomenon or departure from the normal in structure, function or sensation, experienced by the patient and indicative of disease (1). Symptoms are either volunteered by or elicited from, the individual or may be described by the individual’s caregiver (2, 3, 5).
1A: Urinary Incontinence Symptoms:
- Urinary incontinence: Involuntary loss of urine.
- Urinary incontinence (symptom): Complaint of involuntary loss of urine (3, 5).
- Stress (urinary) incontinence: Complaint of involuntary loss of urine during coughing, sneezing or physical exertion such as sports activities etc. (3, 5)
- Urge (urinary) incontinence: Complaint of involuntary loss of urine associated with urgency (3, 5).
- Postural (urinary) incontinence: Complaint of involuntary loss of urine associated with change of body position, e.g. rising from a seated or lying position. FN1.
- Nocturnal enuresis: Complaint of urinary loss which occurs during sleep (3, 5).
- Mixed (urinary) incontinence: Complaint of involuntary loss of urine associated with urgency and also with exertion, effort, sneezing or coughing (3).
- Continuous (urinary) incontinence: Complaint of continuous involuntary loss of urine (5).
- Unconscious (unaware, insensible urinary) incontinence: Complaint of involuntary loss of urine unaccompanied by either urgency or stress incontinence provocative factors. The only awareness of the incontinence episode is the feeling of wetness (5).
- Coital incontinence: Complaint of involuntary loss of urine with sexual intercourse.
- Post void (micturition) dribble: Complaint of dribbling loss of urine after voiding (5).
1B: Irritative Bladder Symptoms:
Irritative (adjective): To stimulate an organ (i.e the bladder) to an active response (6).
- Diurnal (daytime urinary) frequency: Complaint of passage of urine more than seven times during the day (wakeful hours) (7).
- Nocturia: Complaint of interruption of sleep more than once each night because of the need to micturate (7). FN2
- Urgency: Complaint of a compelling desire to void which is difficult to defer (3). FN3
- Overactive bladder (OAB, Urge) syndrome: The combination of symptoms of urgency, frequency and nocturia with (OAB wet) or without (OAB dry) urge incontinence, in the absence of urinary tract infection or other obvious pathology. FN
1C: Sensory Symptoms:
Sensory symptoms: A departure from normal sensation or function, experienced by the patient during bladder filling (1, 3). Normally the individual is aware of increasing sensation with bladder filling up to a strong desire to void (3).
- Increased bladder sensation: Complaint of an early and persistent desire to void during bladder filling (3).
- Reduced bladder sensation: Complaint of the absence of a definite desire to void despite awareness of bladder filling (3).
- Absent bladder sensation: Complaint of both the absence of the sensation of bladder filling and a definite desire to void (3).
1D: Voiding Symptoms:
Voiding symptoms: A departure from normal sensation or function, experienced by the patient during the act of micturition (1).
- Hesitancy: Complaint of difficulty resulting in delay in initiating micurition (3).
- Poor stream: Complaint of a urinary stream perceived as inferior (slower or more interrupted) to that previously experienced or in comparison to others.
- Straining to void: Complaint of the need to make an intensive effort to either initiate, maintain or improve the urinary stream. The Crede manoeuvre is when this effort is the application of suprapubic pressure (3).
- Sense of incomplete (bladder) emptying: Complaint that the bladder does not feel empty after voiding.
- Need to immediately re-void: Complaint that a further void is necessary soon after passing urine.
1E: Prolapse symptoms
Prolapse: (From the Latin prolapsus, a slipping forth) refers to the falling out of place of a part or whole of a viscus, here generally the vagina or uterus (8).
Prolapse symptoms: A departure from normal sensation, structure or function, experienced by the individual in reference to the position of her pelvic organs. Symptoms are generally worse at the times when gravity might make the prolapse worse (e.g. after long periods of standing or exercise).
- Vaginal lump: Complaint of a “bulge” or “something” coming down towards or through the vaginal introitus.
- Suprapubic dragging or heaviness sensation: Complaint of increased heaviness or dragging in the pelvis.
- Need to manually assist voiding and/or defecation: Complaint of the need to digitally replace the prolapse or to otherwise manually apply pressure to assist voiding or defecation.
- Sacral backache: Complaint of sacral backache (generally related to increased tension in the uterosacral ligaments).
- Deep dyspareunia: Complaint of discomfort on deep penetration (due possibly to impingement, particularly on a prolapsing uterine cervix, with intercourse).
1F: Lower Urinary Tract Pain / Other Pain
- Bladder pain: Complaint of pain felt suprapubically or retropubically, and usually increasing with bladder filling. It may persist after voiding (3).
- Bladder pain syndrome: Complaint of suprapubic pain related to bladder filling, accompanied by other symptoms such as increased diurnal and nocturnal frequency, in the absence of proven urinary tract infection or other obvious pathology (3). FN4
- Other possible areas of pain: Complaints of pain may be referable to the urethra, vulva, vagina and/or perineum.
- Pelvic pain: The complaint of pain in the pelvis. It is less well-defined than the above types of pain. A cyclical basis will raise the possibility of a gynecological cause.
- 1G: Other Symptoms / Other History (2)
The general history should include questions relevant to:
- Neurological and congenital abnormalities:
- Urinary tract infections (UTIs): Including the number of medically documented urinary tract infections over the previous 12 months. FN5
- Relevant surgery: Including and especially prior hysterectomy, prolapse and/or continence surgery.
- Medications: Including those with known or possible effects on the lower urinary tract.
- Obstetric history:
- Assessment of menstrual function:
- Assessment of bowel function:
- Assessment of sexual function:
1H: Quality-of-Life (Q-o-L) Symptom Questionnaires
- Definition: Questionnaires developed to quantify the effect of chronic lower urinary tract symptoms on patients’ lives. Aspects might include the family relationships, social life, work situation, sexual function and general well-being.
- Application: These questionnaires might measure the impact of different interventions on psychosocial function.
G: Other symptoms / other history
H: Quality-of-life (Q-o-L) symptom questionnaires
A: Abdominal signs
B: Urinary incontinence signs
C: Signs of pelvic organ prolapse
D: Other physical examinations / signs
E: Frequency volume chart / Bladder diary
Sign: Any abnormality indicative of disease, discoverable on examination of the female patient; an objective indication of disease, in contrast to a symptom which is a subjective indication of disease (1).
2A: Abdominal Signs:
Amongst numerous possible abdominal signs are:
- Bladder fullness/retention: The bladder may be felt by abdominal palpation or suprapubic percussion.
- Other abdominal masses:
- Scars: Indicating previous relevant surgery.
2B: Urinary Incontinence Signs: All examinations for urinary incontinence are best performed with the individual’s bladder comfortably full.
- Urinary incontinence: Observation of involuntary loss of urine on examination: this may be urethral or extraurethral (3).
- Stress (urinary) incontinence (clinical stress leakage): Observation of involuntary loss of urine from the urethra synchronous with coughing, sneezing or physical exertion (3, 5).
- Urge (urinary) incontinence: Observation of involuntary urinary loss from the urethra synchronous with a compelling desire to void that can’t be deferred (5).
- Extra-urethral incontinence: Observation of urine leakage through channels other than the urethra.
- Occult (hidden or masked) stress incontinence: Stress incontinence is only observed after the reduction of co-existent prolapse (which otherwise hinders or prevents urine loss). FN6.
2C: Signs of Pelvic Organ Prolapse:
All examinations for pelvic organ prolapse should be performed with the patient’s bladder empty. An increasing bladder volume has been shown to restrict the degree of descent of the prolapse (9). Local practice will generally govern the choice of the patient’s position during examination: left lateral (Sims), supine or standing. The degree of prolapse may be worse later in the day (after a long time in the erect position) than it is earlier in the day.
- Pelvic organ prolapse (definition): The descent (towards or through the vaginal introitus) of one or more of the anterior vaginal wall, posterior vaginal wall, the uterus (cervix) or the apex of the vagina (vaginal vault or cuff) after hysterectomy.
- Pelvic organ prolapse (staging [3,8,10]):
- Stage 0: No prolapse is demonstrated.
- Stage 1: Most distal portion of the prolapse is more than 1cm above the level of the hymen.
- Stage II: Most distal portion of the prolapse is 1 cm or less proximal to or distal to the plane of the hymen.
- Stage III: The most distal portion of the prolapse is more than 1cm below the plane of the hymen.
- Stage IV: Essentially complete eversion of the total length of the lower genital tract is demonstrated. FN7
- Uterine/ cervical prolapse: Observation of descent of the uterus or uterine cervix.
- Vaginal vault (cuff) prolapse:. Observation of descent of the vaginal vault (cuff scar after hysterectomy). If there is the observation of bowel peristalsis underneath the vaginal vault prolapse, an enterocoele can be diagnosed. FN8
- Anterior vaginal wall prolapse: Observation of descent of the anterior vagina. Most commonly this would be due to bladder prolapse (cystocele). Higher stage anterior vaginal wall prolapse will generally involve uterine or vaginal vault (if the uterus is absent) descent. Occasionally, there might be anterior enterocoele formation after prior surgery. FN8
- Posterior vaginal wall prolapse: Observation of descent of the posterior vaginal wall. Most commonly, this would be due to rectal protrusion into the vagina (rectocele). Higher stage posterior vaginal wall prolapse after prior hysterectomy will generally involve some vaginal vault descent and possible enterocoele formation. FN8
2D: Other Physical Examinations / Signs:
These examinations are generally best performed with the patient’s bladder empty.
- Bimanual pelvic examination: Observations for any unusual pelvic mass or tenderness. The most common mass is an enlarged (generally fibroid) uterus with adnexal pathology less frequently diagnosed.
- Urethral inspection/ palpation:
- Urethral caruncle: Prolapse of the urethral (more commonly posterior) mucosa. This is often reflective of the presence of co-existent pelvic organ prolapse.
- Urethral diverticulum: The presence of a sac opening from the urethra might be suspected by the presence of a lump along the vaginal aspect of the urethra. Tenderness or the observation of urethral discharge on palpation will increase the index of suspicion.
- Urethral tenderness: Tenderness on urethral palpation might be an index of urethral inflammation or infection.
- Pelvic floor muscle function (3): 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 symptom (e.g Oxford 1-5). Pelvic muscle contractions may be assessed by visual inspection, by palpation, electromyography, perineometry or ultrasound. Factors to be assessed include strength, duration, displacement and repeatability. It is desirable to document findings for each side of the pelvic floor separately to allow for any unilateral defects.
- Rectal examination: Observations can include:
- Anal sphincter tone/ weakness/ defects:
- Confirm rectocele:
- Eliminate fecal impaction:
- Other pathology: Rectal or anal lesion.
- Pad testing: Quantification of the amount of urine lost over the duration of testing, by measuring the increase in the weight of the perineal pads used. This may give a guide to the severity of incontinence. Different regimens from a short test to 24 hours have been used with provocation varying between everyday activities to set provocative programs.
2E: Frequency Volume Chart / Bladder Diary
- (i) Frequency volume chart (FVC): The recording of the time of each micturition and the volume voided for at least 24 hours.
- Information obtained will confirm:
- Diurnal Frequency: Number of voids by day (wakeful hours).
- Nocturnal Frequency: Number of times sleep is interrupted by the need to micturate.
- 24-hour urine production: Summation of all volumes voided in 24 hours.
- Maximum voided volume: Highest voided volume recorded.
- Average voided volume: Summation of volumes voided divided by the number of voids.
- Functional bladder capacity: Median maximum voided volume in everyday activities.
- Polyuria: Excessive excretion of urine resulting in profuse and frequent micturition (3). It has been defined as over 2.8 litres of urine per 24 hours (12).
- Nocturnal urine volume: Cumulative urine volume from voids after going to bed with the intention of sleeping to include the first void of the morning.
- Nocturnal polyuria: Excess proportion of urine production occurs at night (or when the patient is sleeping). More than 20% (young adults) to 33% (over 65 years) has been suggested as excessive (3).
- Bladder diary: Adds to the FVC above, the fluid intake, pad usage, incontinence episodes and the degree of incontinence. Episodes of urgency might also be recorded.
Additional information obtained from the bladder diaries involve:
The severity of incontinence in terms of leakage episodes and pad usage.
Figure 1 (below): provides an example of a bladder diary.
FIGURE 1: Bladder diary This simple chart allows you to record the fluid you drink and the urine you pass over 3 days (not necessarily consecutive) in the week prior to your clinic appointment. This can provide valuable information.
- Please fill in approximately when and how much fluid you drink, and the type of liquid.
- Please fill in the time and the amount (in mL) of urine passed, and mark with a star if you have leaked or mark with a “PC” if you have needed to change your pad.
(Please find below an example of how to complete this form.)
Frequency = 9; Nocturia = 1; Urine production/24hr = 1250 mL; maximum voided volume = 300 mL; average voided volume = 125 mL.
Frequency = 9; Nocturia = 1; Urine production/24hr = 1250 mL; maximum voided volume = 300 mL; average voided volume = 125 mL.
B: Post void residual (PVR)
C: Cystometry – General
D: Filling cystometry
E: Urethral function during filling cystometry
F: Voiding cystometry (pressure / flow studies)
G: Urethral function during voiding cystometry
H: Ultrasound imaging with urodynamics
I: Radiological imaging with urodynamics
A: Urodynamic stress incontinence (USI)
B: Detrusor overactivity (DO)
C: Sensory urgency (SU)
D: Voiding difficulty (VD)
E: Pelvic organ prolapse (POP)
F: Recurrent urinary tract infections (UTIs)
A: Urodynamic Stress Incontinence (USI)
- Definition: As noted in section 3D:(vii), this urodynamic diagnosis is the involuntary leakage of urine during filling cystometry, associated with increased abdominal pressure, in the absence of a detrusor contraction. The sign of stress incontinence might been noted with the physical examination. Cystometry then completes the assessment of detrusor function.
- Prevalence: This is the most common urogynecological diagnosis, occurring in up to 72% patients presenting for the first time (28).
B: Detrusor Overactivity (DO)
- Definition: As noted in section [3D:(v:b)], this urodynamic diagnosis is made in women with lower urinary tract symptoms (more commonly OAB-type symptoms – section [1B:(iv)] when involuntary detrusor contractions occur during filling cystometry. These contractions, which may be spontaneous or provoked, are unable to be suppressed by the patient.
- Prevalence: The prevalence of DO ranges between 13% (28) and 40% (29) of patients attending for urodynamics. There may be a disparity between the severity of the woman’s symptoms and the amplitude of the contractions.
C: Sensory Urgency (SU)
- Definition: Sensory urgency, a urodynamic diagnosis, generally occurs in a women with some of all of the symptoms of urgency, frequency and nocturia with or without urge incontinence and a voiding diary showing average voided volumes under 150mls. It can be defined as an increased perceived bladder sensation during filling [1C: (i)], a low first desire to void [3D:(iii:a)] (generally under 100mls) and a low maximum cystometric bladder [3D:(iv:b)] capacity (under 400mls in a predominantly Caucasian population) in the absence of recorded urinary tract infection (UTI) or detrusor overactivity[3D:(v:b)] (30, 31). FN11
- Prevalence: The prevalence of sensory urgency in urogynecology patients is 10 – 13% (32, 31).
D: Voiding Difficulty (VD)
- Definition: Voiding difficulty, a urodynamic diagnosis, is defined as abnormally slow and/or incomplete micturition (33). The only validated definition of voiding difficulty is: (i) urine flow rate under the 10th centile of the Liverpool nomogram (15, 28) and/or a PVR (measured by transvaginal ultrasound) 30mls or under (17). Alternate criteria of a maximum urine flow rate less than 15ml/sec and/or PVR greater than 50ml with a minimum total bladder volume of 150ml before voiding, have been proposed but not validated (34). Pressure / flow studies are indicated to evaluate the cause of any voiding difficulty. Assessment of voiding difficulty from pressure / flow charts has been the subject of ongoing research (25).
- Prevalence: Depending on the definition, voiding difficulty has a prevalence of 14% (34) to 39% (28), the latter figure making it either the third or fourth most common urodynamic diagnosis (after USI, prolapse and possibly detrusor overactivity). FN12
- Alternative presentations:
- Acute retention of urine(3): This is defined as a painful, palpable or percussable bladder when the patient is unable to pass any urine.
- Chronic retention of urine: This defined as a non-painful bladder, where there is a chronic PVR of over 200mls (19).
E: Pelvic Organ Prolapse (POP)
- Definition: This diagnosis [2C:(i)] by clinical examination, involves the identification of descent (towards or through the vaginal introitus) of one or more of the anterior vaginal wall, posterior vaginal wall, the uterus (cervix) or the apex of the vagina (vaginal vault or cuff) after hysterectomy.
- Prevalence: Around 61% (28) of women presenting for initial urogynecological assessment will have some degree of prolapse, not always symptomatic. FN13
F: Recurrent Urinary Tract Infections (UTIs)
- Definition: The number of medically documented urinary tract infections (UTI) over the last 12 months is included as a “working diagnosis”, by history, awaiting further research.
- Prevalence: Using this definition, 2 or more and 3 or more UTI’s can occur with a prevalence of 21% and 13% respectively (36). This then becomes a significant, generally intercurrent, diagnosis likely to require treatment additional to that planned for other diagnoses found. FN14.
Figure 1 shows prolapse staging – 0, I, II, III, IV. (uterine – by the position of the leading edge of the cervix).