Pelvic organ prolapse (POP) and urinary incontinence are common problems experienced by women of all ages. With the publication of Seizing the opportunity to improve patient care: Pelvic floor services in 2021 and beyond (Pelvic Floor Society, 2021) comes recognition of how common pelvic floor disorders are but how little investment has been put into these services. Such publications highlight the need for services to be provided which encourage women to come forward to be assessed and treated. This article, the first in a two-part series, discusses the signs and symptoms of POP and urinary incontinence. It details important issues to consider and remember when assessing a patient with either of these conditions in primary care. The second article will explore treatment options which should be started in primary care before considering onward referral.

Photograph: wavebreakmedia/Shutterstock 

PELVIC ORGAN PROLAPSE 


Pelvic organ prolapse (POP) has been defined by Haylen et al (2016) as ‘the descent 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 scar after hysterectomy)’. The most common type of prolapse is found in the anterior vaginal wall (cystocele), then the posterior vaginal wall (rectocele), and finally the uterus or vault (Richardson and Hagen, 2009; Figure 1). Prolapse can occur in isolation but may also co-exist in any combination – many women experience all types of prolapse at once. 


Figure 1. Types of pelvic floor prolapse.  

Risk factors 


The development of POP is associated with several risk factors (Table 1), most of which the majority of women experience at some point in their lives, making POP such a common problem (Royal College of Obstetricians and Gynaecologists [RCOG], 2013). It is important that the assessor understands these potential risk factors, as if they notice behaviours and patterns which may increase the risk, they are able to highlight them to the patient during assessment and advise accordingly of ways to try and reduce any risk. 

 Parous women often develop symptoms of POP. Studies suggest that pelvic floor disorders (including POP) are associated with childbirth (Blomquist et al, 2018), because these conditions are often strongly associated with parity. They are more common after vaginal birth than a caesarean section. Observational studies cited by Memon and Landa (2013) have identified that certain methods of delivery appear to be more traumatic to the pelvic floor, particularly forceps delivery, prolonged second stage of labour, and tears to the sphincter. Nulliparous women can, however, also experience symptoms of vaginal prolapse. Someone with symptoms of chronic constipation, for example, may present with symptoms of vaginal prolapse because of the chronic straining and pushing to empty their bowels (Miedel, 2009). 

 
Table 1. Risk factors for developing POP (Vergldt, 2015). 

Symptoms 
 

Women with POP often present with several different symptoms. Table 2 details some of the most common symptoms experienced. In the author’s clinical experience, most women ‘put up with’ symptoms of a vaginal prolapse for many years – often only presenting to seek treatment and help when things are significantly affecting their quality of life, or when their symptoms start to affect other areas of their life, such as sex life, or they start to develop problems with recurrent infections or urinary urgency and frequency. Sometimes, however, women have an incidental finding of a prolapse when they attend to have their smear or another investigation. Women can be afraid that the ‘lump’ they feel in their vagina is a tumour or something worse, which makes seeking help even more important to allay their fears. 
 
Table 2. Signs and symptoms of prolapse (adapted from Rantel, 2019).  

URINARY INCONTINENCE 


Reported prevalence of urinary incontinence varies, but studies suggest a figure of around 25-45% (Buckley and Lapitan, 2010). Urinary incontinence is thought to affect up to 70% of women at some point in their life (Milsom and Gyhagen, 2019).  

There are different types of urinary incontinence (Table 3), which often present with similar symptoms. For example, the symptoms of an overactive bladder (OAB) are similar to those of a urinary tract infection (UTI). This highlights the need for thorough, accurate assessment to ensure that the correct treatment pathway is started. Women presenting with urinary incontinence should have a dipstick urinalysis to check for infection, as if this is the underlying problem treating the infection could cure the incontinence (Rantell, 2019).

Table 3. Types of urinary incontinence. 
In the author’s clinical experience, most women will ‘put up’ with urinary incontinence as they see it as a normal sign of ageing. This often means that when a woman presents in primary care for assessment, her symptoms are considerable and affect her quality of life significantly. Education is needed to prompt ladies to seek help while their symptoms are milder to enable conservative treatments to be tried, thus avoiding referral to secondary care for surgical management. Healthcare professionals should use every opportunity to ask a woman about whether she has any problems with her bladder or bowels, so that simple, conservative advice, such as advice on fluids, pelvic floor exercises and prolapse prevention, can be given straight away, which will hopefully improve symptoms before they get too bothersome. 

Urinary incontinence remains a taboo subject (Bedoya-Ronga and Currie, 2014). However, an increase in discussion of this topic on social media in the past few years has been noticed by the author and companies have started to advertise their products. Yet, in the author’s opinion, rarely are women directed to sites or signposted to healthcare professionals who could help to improve their symptoms. Healthcare professionals, particularly in primary care, are ideally placed to direct women to support groups, physiotherapists and to give simple information which may help improve symptoms, and, in turn, reduce the need for onward referral. 

 

TYPE OF ASSESSMENT – VIRTUAL OR IN PERSON? 


Since the Covid-19 pandemic, new ways of providing health care have been explored, as face-to-face consultations have had to be cancelled when staff were relocated to other areas, or vulnerable, shielding patients were unable to leave their homes to attend appointments. Many have used virtual/telephone consultations to maintain their clinical workloads. This has enabled patients to continue to be seen and assessed, although seeing people in this way has meant that physical assessment, a vital part of a pelvic floor and continence assessment, has not been possible (Laws, 2020).  

It is important to remember when considering this type of assessment as an option, that video or telephone consultations may not be appropriate for every patient or consultation (Car et al, 2020). Some patients may not be able to operate a device (or have the support of someone who can), and those with certain learning disabilities, such as English not being their first language, may also be disadvantaged. It is vital, therefore, if virtual/telephone clinics are maintained after the Covid pandemic, that patients are asked about their preferred method of assessment and that if virtual assessments are undertaken, regular audits are performed to help ensure that they are safe and do not widen health inequalities. 

In the author’s clinical opinion, virtual consultations are an excellent way to follow up patients once the initial assessment and treatment plan have been developed and will continue to play a role in the way we provide care moving forward. They enable patients not to take a day off work, or attend hospital, but as said, it is important to remember that they are not suitable for everyone. 

ASSESSMENT OF PELVIC ORGAN PROLAPSE AND URINARY INCONTINENCE 


It is essential that a thorough assessment is undertaken when examining a woman presenting with POP or urinary symptoms. There are no set/standardised assessment forms to do this, and often nurses/allied healthcare professionals/doctors will have their own formula for making sure nothing is missed. The Colley Model outlines some basic investigations to undertake (Colley, 2020). The section below details some of the areas to consider when performing the assessment. 
 

Nursing skills 


The skill of the person assessing the patient is vital, as getting as much accurate information as possible during the consultation helps the correct diagnosis and treatment plan to be made. Often this is the first time that the woman has discussed such intimate and personal symptoms with anyone, let alone a total stranger. Thus, the assessor’s body language should be open and inviting, and the language used during the assessment should be easily understood, avoiding use of medical jargon. For example, ‘do you have any nocturia?’ could be asked in another way, such as, ‘how many times do you get up to go to the toilet at night? Does your bladder wake you or are you already awake?’. Open-ended questions should be used to allow the patient to give detailed answers and provide useful information (Haylen et al, 2010). The way questions are asked may need to be tailored to suit an individual, depending upon their language, age and ethnicity.  

Non-verbal body language is as important as verbal communication and should always be considered during an assessment. The stance of the practitioner should be open and inviting. They should gain eye contact and make the patient feel at ease. This is especially important as nurses have been wearing masks during the Covid-19 pandemic. Fedele (2021) suggests that eye contact and head movement have become important tools in conveying reassurance and comfort to patients while wearing masks and visors. 

The assessor should also be considering the patient’s body language throughout the assessment, as a patient who claims to be fine, may display body language indicating the opposite. Al-Mali (2018) suggests that being aware of the patient’s body language enables the assessor to probe deeper, rather than simply accepting verbal responses at face value. This is especially pertinent when discussing such personal details and is a skill which often develops with experience. 

 

Consent and documentation  


Before any examination, it is essential that the assessing practitioner gains and documents consent. This can be verbal consent. The woman should also be offered a chaperone during any physical examination, which must also be documented. It should also be recorded if a chaperone is declined (Royal College of Nursing [RCN], 2020).   

Accurate and thorough documentation of information obtained or seen during assessment will inform colleagues about what has been discussed and enable appropriate review to be undertaken from the baseline assessment. 

Questionnaires 


Questionnaires can be used during the assessment. They enable the woman to comment on how they view their own symptoms and quality of life (Robinson et al, 2007). Common questionnaires used when assessing bladder symptoms or POP are ICIQ-OAB, I-QOL, ICIQ, P-QOL and King’s Health Questionnaire (Digesu et al, 2005; Okamura et al, 2009). These can provide useful information and are written using language which is easy for the patient to understand. Questionnaires can be given out when someone attends for an assessment or be posted to the patient before the appointment so that the assessor can then run through the questions/answers with the patient. They can also be helpful when reassessing the patient following treatment. 

Medication review 


Any medication the patient is on should be reviewed when assessing a patient with incontinence, as many common medications can affect and exacerbate urinary symptoms (Royal College of Nursing [RCN], 2016; Yates, 2021), particularly with new onset urinary incontinence (Bardsley, 2016). Table 4 details some common drug types which affect continence. If the patient is on any of these, it would be advisable for the GP to review if the assessor is not a nurse prescriber. 

Table 4. Drugs affecting continence (Stewart, 2019). 

Obstetric and gynaecological history 


Herbert (2009) suggests that the number of births, whether there were any tears, whether the deliveries were instrumented, and the type of delivery all have an impact on the pelvic floor. Asking about obstetric history can give the assessor an idea as to why someone may have symptoms of stress incontinence or prolapse, following a forceps delivery for example. 

Past gynaecology surgery may also have an impact on symptoms. Women often report symptoms of POP following a hysterectomy. Vermeulen et al (2021) suggest that women who suffer with POP after vaginal hysterectomy, which was performed for prolapse, occurs more frequently than after hysterectomy for other benign indications. Thus, women who have had surgery already for prolapse are at increased risk of needing further prolapse surgery. 

How bothersome are the symptoms? 


It is always important to discuss the ‘bothersomeness’ of symptoms. In the author’s clinical experience, something which would bother one person significantly, surprisingly does not affect another. A woman may suffer with significant overactive bladder symptoms, but they do not bother her, but a small POP does because it affects how she feels when she has sex. 
 

Bladder diaries 


National Institute for Health and Care Excellence guidance (NICE, 2019) suggests that bladder diaries should be completed for three days as part of a continence assessment. Bladder diaries, if completed correctly, can provide a wealth of information about someone’s bladder function. They show the frequency of going to the toilet and the type and volume of fluid taken in (Nazarko, 2015). Women often do not think about how what and when they drink can affect their symptoms. So, spending time discussing a completed bladder diary can make it easier to explain bad habits which have developed and how they can be overcome. They can also be useful to complete again when reassessing progress made following treatment. 

 RED FLAGS 


When performing an assessment, it is essential that the assessor is aware of the red flags so that appropriate onward referral can be instigated. These include (National Institute for Health and Care Excellence [NICE], 2019):  
  • • Microscopic haematuria in women over 50 years  
  • • Visible haematuria  
  • • Previous pelvic cancers  
  • • Persistent bladder or urethral pain  
  • • Clinically benign pelvic masses  
  • • Voiding difficulties  
  • • Suspected urogenital fistula  
  • • Recurrent UTIs  
  • • Previous continence surgery  
  • • Suspected neurological disease  
  • • Associated faecal incontinence  
  • • Symptomatic vaginal prolapse  
  • • Failure of conservative management  
  • • Complex symptoms.  
Boyd and Stevens (2020) suggest that urgent referral is made to secondary care for microscopic haematuria in women over 50 years, visible haematuria and previous pelvic cancers, and that a speedy referral to secondary care is made for the other red flags. 

INVESTIGATIONS FOLLOWING VERBAL ASSESSMENT 

 

Vaginal assessment for POP and UI 


The vagina should be assessed for prolapse – both anterior and posterior wall prolapse and uterine prolapse. This can be performed with the patient lying in the supine position. If the symptoms of prolapse, such as bulge in vagina, bulge out of vagina, or the prolapse cannot be seen in the severity of how they are describing it or are not replicated when lying, the patient can be assessed standing or squatting, as this may change the findings. In the author’s clinical experience, women can go away from a consultation feeling like they have not been taken seriously if the clinician has not assessed the prolapse effectively and seen its true severity. Remember, not all prolapses are seen to their full extent when lying in the  supine position.  

A cough test should be performed to assess for urinary incontinence. This is done by asking the patient to cough while lying down and to observe for any incontinence (Rantell, 2017). 

The condition of the skin should also be examined, e.g. are the vaginal tissues atrophic? Is there evidence of dermatitis from incontinence and wearing pads? What is the condition of the skin around the vulva and perineum? Is it red and inflamed? Any signs of lichen sclerosis? 

PRACTICE POINT 


During the vaginal examination, the clinician can ask the woman to squeeze and contract her pelvic floor muscle to see if they are able to feel a contraction. This will give the assessor an idea of the initial strength of the muscle — whether there is a contraction at all, whether they are doing a Valsalva manoeuvre (bearing down), or whether their muscle is very tight (hypertonic) and they are finding it hard to relax. This information would be useful if referring to secondary care or a pelvic health physiotherapist. 

Urinalysis 


A dipstick urinalysis should be performed as a screening test to exclude a UTI. If it is positive to nitrites, blood or leucocytes, it can be sent away for culture and analysis of antibiotic sensitivities (NICE, 2018). Antibiotics can then be prescribed according to local antibiotic prescribing guidance if required. 
 

Post-void residual urine 


If voiding difficulties are suspected, post-void residual urine (PVRU) volume can be undertaken in primary care – either using a bladder scanner if available, or a sterile urethral in and out catheter (Yates, 2018). Women with a large anterior vaginal wall prolapse will often complain about a feeling of not emptying their bladder fully. A PVRU will help to show if this is actually the case or not. It can also be useful to determine treatment options in women presenting with an overactive bladder (Wood and Anger, 2014).  

CONCLUSION  


Thorough assessment of symptoms of POP and urinary incontinence is essential to ensure that the correct diagnosis is made, and appropriate treatment pathways are started, or referral made to secondary care.  

This article has detailed some of the areas which the author feels are important to obtain accurate information to understand the patient’s condition. This will then enable treatment to be started which will hopefully reduce symptoms and improve patient quality of life. The next article in this two-part series will look at treatment options for pelvic floor disorders. 

KEY POINTS 

  • • With the publication of Seizing the opportunity to improve patient care: Pelvic floor services in 2021 and beyond (Pelvic Floor Society, 2021) comes recognition of how common pelvic floor disorders are, but how little investment has been put into these services   

    • The development of pelvic organ prolapse (POP) is associated with several risk factors, most of which the majority of women experience at some point in their lives   

    • Urinary incontinence is thought to affect up to 70% of women at some point in their life (Milsom and Glyhagen, 2019)  

  • • Thorough assessment of symptoms of POP and urinary incontinence is essential to ensure that the correct diagnosis is made, and appropriate treatment pathways started, or referral made to secondary care. 

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This article first appeared in the Journal of General Practice Nursing. To cite this article: Stewart E (2021) Pelvic organ prolapse and female urinary incontinence: assessment. J General Practice Nurs 7(4): 54–9 

 



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