Assessment
This section is broken into the different types of pelvic floor dysfunction you may come across.
Urinary Incontinence
What is normal?
-
The bladder can hold 300-400mL during the day and up to 800mL overnight [1].
-
There should be no leaking, no straining to urinate, no pain on urination.
-
When passing urine, it should be easy to start and should be an unbroken flow with no dribbling afterwards.
Types of urinary incontinence
-
Stress urinary incontinence - is the accidental leaking of urine when you exercise, cough, sneeze or laugh. It can be a small amount such as a drop, or a large loss of urine.
-
Urge urinary incontinence - is the involuntary loss of urine associated with urgency, a strong and sudden need to urinate. Patients may experience flooding.
-
Functional incontinence - 'disability associated' or iatrogenic incontinence. This occurs when there is no pelvic floor dysfunction; however due to other physical or cognitive conditions they are unable to reach the toilet.
-
Overflow incontinence - there is a loss of the urge to urinate or an inability to urinate. As such, the bladder becomes overly full and there is an involuntary loss of urine. Examples of conditions where this may occur include: any kind of neurological disruption, cauda equina injury, pudendal nerve palsy.
-
Transient incontinence - caused by an underlying condition. When the condition is resolved or treated, the patient is continent e.g. delirium.
-
Reflex incontinence - a neurological cause, the signal to void is not being received centrally OR not transmitting peripherally due to a spinal cord injury, central or peripheral lesion, or neurological decline.
-
Nocturnal enuresis - more commonly known as bedwetting (some medications can cause this).
Nocturia = waking up multiple times in a night with the urge to urinate.
Overflow, Transient and Reflex Incontinence
Overflow
Your patient may describe:
-
Dribbling post-void
-
Poor flow
-
High frequency of voids
-
Constant leakage of small amounts
-
Frequent infections
Common in postnatal population, male or spinal cord injury patients.
Most common causes:
-
Enlarged prostate
-
Tumours
-
Neurological conditions
-
Obstructions
Transient
Your patient may describe:
-
Frequent infections
-
Psychological changes
-
Neurological or cognitive decline
-
Severe illness
-
Significant changes to medications
Reflex
Neurological cause - the signal to void is not being received centrally or not transmitting peripherally due to spinal cord injury, multiple sclerosis, neurological and/or cognitive decline.
Reverts to a simple reflex arc where [1]:
-
No sensation of the need to pass urine reaches the brain, and no recognised nerve impulses are transmitted centrally or peripherally.
-
The stretch impulse triggers the reflex arc in spinal cord, which causes the detrusor (bladder) muscle to contract, and the urethral sphincter relaxes, allowing urination.
Stress Urinary Incontinence
What a patient may describe to you:
-
I leak when I laugh or sneeze or cough or lift or change position
-
A little bit just leaks out when I don't want it to
What you could ask:
-
How much leaks out - e.g. drop, teaspoon, saturated underwear, drips down leg
-
Is it every single time you cough/sneeze/etc?
-
Can you feel it come out or does it happen without you knowing?
Urge Urinary Incontinence
What a patient may describe to you:
-
I need to rush to the toilet as soon as I feel the urge
-
I suddenly have to go when I put the key in the front door
-
I sometimes can't make it to the toilet in time
-
I always go just in case
-
I have to get up lots of times in the night
What you could ask:
-
How many times do you get up at night/need to go during the day?
-
How long can you put off going to the toilet when you get the urge?
-
If you start urinating before making it to the toilet, do you have any control to stop it?
-
How much urine do you pass when you go to the toilet? 1/2 cup, a few drops, 2-3 cups?
Functional Incontinence
What a patient may describe to you:
-
I can't make it to the toilet in time
-
My back pain/osteoarthritis/mobility/etc means I am too slow to get to the toilet
-
Similar to patients who cannot reach the phone in time
-
This may be a very important mobility goal for someone you are treating
What you could ask:
-
Are they able to:
-
Transfer and/or ambulate to the toilet?
-
Be able to dress and undress self independently?
-
Able to identify the urge to go to the toilet?
-
Able to identify appropriate toilet facilities?
-
Able to process the steps needed to get to the toilet (cognitive function)?
-
Faecal Incontinence
Faecal incontinence affects 1 in 200 Australian adults and can be caused by many conditions:
-
Colorectal disease
-
Diarrhoea
-
Faecal impaction
-
Neurological causes
-
Immobility
-
Fluid intake
-
Prostate Ca surgery
-
Pharmacological causes
Particularly if you are working on the wards or in an aged care environment, general knowledge of medications that can disrupt bowel function is useful as these patient populations tend to have polypharmacy:
-
Antihypertensives
-
Antidepressants - SSRI's
-
Diuretics
-
Analgesics - particularly codeine-containing
-
Iron supplements
-
Antiobiotics
-
Cytotoxics [1]
What is normal?
Normal can look different depending on your patient. Some people may use their bowels 2-3 times per day, others may go once every two days. Generally, 'normal' for an individual means having a routine, and deviating from that routine would be abnormal. For example, if your patient usually uses their bowels every morning, but they have not gone for three days, they have deviated from their usual habit.
This chart is useful for patients to describe what their bowel movements are like. Normal is 3-4, constipation looks like 1-2 and diarrhoea or accidents tend to look like 5-7.
The bowel is most active 30 minutes after eating due to the gastro-colic reflex, and after physical activity. This could help someone identify if they do have a pattern.
What a patient may describe to you:
-
I sometimes have to take medications to help me empty my bowels/keep me regular
-
I have diarrhoea often
-
There is no pattern to my bowel movements
-
I have to push out a bowel motion
-
I have pain or bleeding with bowel actions
-
I have a lazy bowel
-
I am always constipated
What you could ask:
-
Do you suffer from wind?
-
Do you have any regular pattern to your bowel movements?
-
Can you feel the urge to go, and do you go when you have that urge or ignore it?
-
Do you have to strain/push/bear down?
-
Do you have accidents?
[16]
Prolapse
The pelvic floor muscles act as a sling to support the bladder, bowel and reproductive organs. When the pelvic floor structures are weakened, torn or neurologically disrupted, the pelvic organs can sit lower and bulge into the vagina or - when more severe - externally.
There are different types of pelvic organ prolapse [13]:
-
Cystocele/anterior wall prolapse - prolapse of the bladder which falls posteriorly into the anterior vaginal wall
-
Enterocele/intestinal prolapse - the small intestine bulges into the vagina
-
Rectocele/posterior wall prolapse - the rectum bulges into the posterior wall of the vagina
-
Uterine prolapse - the uterus falls into the vagina
-
Vaginal vault prolapse - the superior portion of the vagina moves inferiorly
-
Urethrocele - the urethra presses into the vaginal space
[17]
What is normal?
Normal is having no feeling of bulging, heaviness or dragging into the vaginal area. The pelvic floor muscles are strong and active to keep the pelvic organs in place.
What a patient may describe to you:
-
I feel heaviness, pressure, bulging or dragging in my vagina
-
I need to push the wall of my vagina back in to urinate/use my bowels
-
I can see or feel something coming out of my vagina or rectum
-
I have urinary incontinence and/or constipation
What you could ask:
-
How long have you had this problem?
-
Is the pain/pressure/bulging sensation relieved when lying down and/or better in the mornings?
-
Do you have difficulty emptying your bowels?
-
Have you had children or a history of repeated heavy lifting?
Increased Pelvic Floor Tone and Dyspareunia
Overactive pelvic floor is where there is an inability for the pelvic floor muscles to completely relax. This is also known as increased tone of the pelvic floor. Patients with this find it very difficult to relax and let go. It is common in people who:
-
Have a history of holding on to their bladder and/or bowels
-
Have a high level of stress or anxiety
-
Have chronic pain and conditions such as endometriosis or IBS
-
Have had a traumatic birth of their child - long or risky labour, tears.
-
Are a high level athlete
-
Past sexual abuse/trauma
Dyspareunia is pain felt in the vaginal region associated with sexual activity. Pain may be felt during initial or deep penetration. Many different things can contribute to dyspareunia, however the most common are:
-
Mental health concerns or past trauma
-
Postpartum return to sexual activity
-
Vaginismus
-
Vaginal atrophy
Overactivity of the pelvic floor muscles are intrinsically linked to dyspareunia.
What a patient may describe to you:
-
I feel tense often
-
I have trouble starting urine flow
-
I need to go use my bladder frequently
-
I hold on to my bladder or bowels
-
I can't place a tampon in my vagina
-
It is extremely painful to have any penetrative sexual intercourse
-
I have erectile dysfunction
-
I have pain in my vagina/lower abdomen
What you could ask:
-
Does this happen to you every time you ...
-
How long have you had this problem? Can you identify a trigger/initial cause?
-
Can you feel your muscles when you do a pelvic floor contraction?