Importance of Urologic Assessment for Pelvic Organ Prolapse With Occult Incontinence

A Case Study

William E. Somerall, Jr., MD, MAEd; Lisa S. Pair, DNP, RN, WHNP-BC

Disclosures

Urol Nurs. 2020;40(5):245-247, 257. 

In This Article

Clinical Considerations

The first step in evaluation is the physical examination that should include an abdominal, pelvic, and neurologic assessment (Knarr et al., 2014). The health care provider should assess the abdomen for the presence of gross masses, surgical scars from previous operations, tenderness, and herniation. Pelvic examination begins with neurological assessment of the sacral nerve roots, focusing on perineal sensation and reflexes (anal wink via the bulbocavernosus reflex). To assess vulvar integrity and estrogen effects, the external genitalia are evaluated for color, presence or absence of labial fusion, presence or absence of a urethral caruncle, and masses, particularly in the Bartholin's and Skene's glands. Further assessment includes evaluation for obvious prolapse with Valsalva, evidence of previous birth trauma, urethral diverticula, and urethral prolapse. If pelvic examination identifies prolapse, the prolapse should be quantified using the International Continence Society Pelvic Organ Prolapse Quantification Scale (ISC POP-Q) for optimal grading consistency (Abrams et al., 2018; Bump et al., 1996). For optimal prolapse evaluation, it may be necessary for the patient to stand if her symptoms do not correlate with supine prolapse assessment (Bureau & Carlson, 2017; Iglesia, & Smithling, 2017). The bimanual examination should assess the size of the uterus, if present, and for tenderness or presence of adnexal masses. Immediately following the bimanual examination is a perfect time to assess pelvic floor muscle strength by digital examination (Elser, 2019). A speculum examination helps assess for vaginal atrophy and possible epithelial or mucosal ulceration from the prolapse, generally located in the region of the fourchette (Abrams et al., 2018, Bureau & Carlson, 2017; Elser, 2019).

Laboratory assessment includes a clean-catch mid-stream urine as the patient prepares for the examination (Knarr et al., 2014). This will ensure the patient has emptied her bladder to the best of her ability prior to her physical examination, and at the same time, a point-of-care test is performed for possible urinary tract infection. Urethral mobility is assessed either using the Q-Tip test or by observing the mobility of the urethra with Valsalva (Robinson et al., 2012). An angle change of greater than 30 degrees indicates hypermobility of the urethra, suggesting lack of urethral support (Knarr et al., 2014). The provocative stress test is performed first with no reduction of POP followed by reduction of the POP. Many patients will report no SUI with POP. However, when the prolapse is reduced, occult SUI is identified (Bureau & Carlson, 2017).

A post-void residual (PVR) is recommended either by ultrasound or catheterization to assess for possible bladder outlet obstruction from the POP, as well as for possible neurologic disorders (Knarr et al., 2014). A normal PVR should be less than 100 mL. A PVR of greater than 200 mL is cause for concern. For accuracy, assess the PVR within 20 minutes of voiding (Knarr et al., 2014).

If the patient has a negative empty bladder provocative (cough) stress test, a second provocative stress test with a bladder fill stress test (simple cystometrics) is recommended (Abrams et al., 2018; Knarr et al., 2014). This is performed easily in most office settings. If using catheterization to assess PVR, the bladder is filled with 300 mL of sterile water by gravity through a 60 mL catheter tip syringe attached to the previously placed catheter. The provocative stress test is performed again without and with reduction of the POP. In addition, during the filling phase of 300 mL volume, the provider can assess for detrusor overactivity. This is identified through backflow of the water into the syringe from the bladder. Evidence of detrusor overactivity indicates the need for complete urodynamic evaluation for assessment of possible complicated urinary disorders (Abrams et al., 2018).

If the patient has adequate emptying, no further urologic testing related to voiding is needed. However, if the patient has a PVR of greater than 200 mL, uroflowmetry or pressure flow studies should be considered to assess for emptying issues (Abrams et al., 2018). Placement of a pessary after simple cystometrics will provide support to the pelvic prolapse and may assist with emptying. If the patient voids well with the pessary in place, it can be reasonably determined that the voiding dysfunction is related to the prolapse (Bureau & Carlson, 2017). In addition, placing the pessary may relieve that patient's symptoms of pressure and discomfort from the prolapse and is a conservative option for managing patients with prolapse (Elser, 2017).

Physical Examination Reviewed

On physical examination, the patient was 66 inches tall and weighed 138 pounds (body mass index = 22.3). The abdomen was soft, flat, and without masses, tenderness, scarring, or evidence of hernias. The external genitalia was thin, pale, and without erythema or ulcerations. The anal wink and bulbocavernosus reflexes were present. The vaginal mucosa was atrophic and without lesions, erythema, or ulcerations. Pelvic floor muscle strength was assessed by digital examination and graded as 3 using the Oxford scale (Elser, 2017). The patient had a third-degree cystocele based on the POP-Q examination that revealed Gh 4, Pb 3, Aa +2, Ba +2, Ap -2 Bp -2, C -9, D NA, TVL 9. There was no evidence of vaginal cuff prolapse. Bimanual examination revealed no masses or tenderness. Rectovaginal examination revealed normal anal tone; no rectocele was identified.

Before checking for PVR, an empty bladder stress test was performed. With no reduction of the cystocele, the patient was asked to Valsalva and cough. No leakage was noted. Following reduction of the cystocele using ring forceps, leakage was observed with cough and Valsalva. Her measured PVR was 210 mL. Simple cystometry was not indicated because the empty bladder stress test was positive for SUI.

The patient was prescribed vaginal estrogen cream for atrophic vaginitis. Six weeks later, the patient underwent urodynamic studies to evaluate her leak point pressures and voiding function.

At her follow-up appointment at 2 weeks, the urodynamic evaluation results were reviewed. With post-reduction Valsalva, leaking occurred at pressures of approximately 90 cm H2O, confirming the patient had SUI. Testing revealed no detrusor dysfunction. Her pressure flow study also revealed obstructed and incomplete voiding. The patient's bladder capacity was 400 mL; she voided 200 of the 400 mL, with a maximum flow of 7 mL/sec. A vaginal pessary was placed to see if emptying improved. For diagnostic purposes, a #3 ring-with-support pessary was placed without difficulty. The patient voided 200 mL with max flow of 14 mL/sec.

Diagnosis and Management Plan

The patient was diagnosed with a Stage 3 cystocele, incomplete voiding secondary to cystocele, vaginal atrophy, and SUI. Treatment options, including conservative management with a pessary versus surgery, were discussed with the patient. A patient decision aid was used to assist the patient to weigh the risks and benefits of treatment options, taking into account her personal values and preferences using a shared decision-making model (Healthwise, 2019). The patient opted for short-term use of the #3 ring-with-support pessary as a trial. The advanced practice nurse educated the patient on the use and care of the ring-with-support incontinence vaginal pessary. The continued use of estradiol vaginal cream for vaginal atrophy was reinforced. It is important to note the role of ongoing education, encouragement, and support to optimize patient satisfaction, reduce anxiety, and improve sustained benefits of non-surgical treatment. In this case, the importance of estrogen use for optimal urovaginal health was addressed along with other concerns the patient had during the pessary trial.

The patient returned to clinic 6 weeks later. She voiced that while the pessary had eased her vaginal pressure and discomfort, she experienced incontinence while playing tennis when wearing the pessary. She expressed a desire for surgical intervention.

The patient was scheduled for an anterior colporrhaphy with transvaginal tape placement. Post-operatively, she had resolution of her prolapse and demonstrated no incontinence at her 6-week and 3-month follow up. She planned to continue her estradiol vaginal cream to provide optimal vaginal tissue health and to prevent possible erosion from the tape mesh.

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