Immediately before the physical examination,
The lumbosacral nerve roots should be assessed by checking deep tendon reflexes, lower extremity strength, sharp/dull sensation and the bulbocavernosus and clitoral sacral reflexe. Abnormal findings such as deep tendon hyperreflexia or absence of the bulbocavernosus reflex should alert the physician to possible underlying neurologic lesions contributing to urinary incontinence.
The pelvic examination should include an evaluation for inflammation, infection and atrophy. Such conditions can increase afferent sensation and thereby cause urinary urgency, frequency, dysuria and overactive bladder. Because the urethra and trigone are estrogen-dependent tissues, estrogen deficiency can contribute to urinary incontinence and urinary dysfunction. The most common signs of inadequate estrogen levels are thinning and paleness of the vaginal epithelium, loss of rugae, disappearance of the labia minora and presence of a urethral caruncle.
A urethral diverticula is usually identified as a distal bulge under the urethra. Gentle massage of the area will frequently produce a purulent discharge from the urethral meatus.
Stress incontinence may be objectively demonstrated before initiating treatment. Testing for stress incontinence is performed by asking the patient to cough vigorously while the examiner watches for leakage of urine. Women who demonstrate urine leakage in the supine position with the bladder relatively empty (i.e., soon after determining post-void residual volume) are at increased risk of having a severe form of stress incontinence known as intrinsic sphincter deficiency, possibly making treatment by conservative measures difficult.
While performing the bimanual examination, levator ani muscle function can be evaluated by asking the patient to tighten her "vaginal muscles" and hold the contraction as long as possible. It is normal for a woman to be able to hold such a contraction for five to 10 seconds. Very weak or absent voluntary levator ani muscle contractions are an indication that biofeedback training sessions with a pelvic floor physical therapist may be necessary. The bimanual examination should also include a rectal examination to check anal sphincter tone and, for fecal impaction, the presence of occult blood or rectal lesions.
Finally, vaginal discharge can mimic urinary incontinence, especially in obese patients. In differentiating between vaginal discharge versus urinary incontinence, a phenazopyridine (Pyridium) test may be performed. A single oral dose of phenazopyridine will turn a patientís urine bright orange. She can then be asked to wear a pad and perform provocative maneuvers that would normally result in "urine loss." True urine loss will stain the pad orange, while a vaginal discharge should not.
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