Urogynecology History

Urinary incontinence and pelvic organ prolapse are problems that cause social embarrassment and inconvenience. It is, therefore, critical to fully understand the patient's chief complaint and its effect on quality of life. Detailed questions should be asked regarding the degree to which the problem has impacted social functioning and living situations.

Specific questions will often help clarify the type of incontinence distressing the patient. Women with stress urinary incontinence (SUI), or urine loss associated with exertion, report urine loss with coughing, sneezing, or laughing. Urine loss during physical activity that increases intraabdominal pressure, such as running and sit-ups, also occurs frequently. Women with urge urinary incontinence (UUI), or urine loss associated with uninhibited detrusor muscle contractions,will typically also complain of urinary urgency, nocturia, and symptoms of frequency. These patients often report an urgency to void that occurs with little warning and cannot be repressed, with leakage often occurring on the way to the toilet. They should be asked how many daytime and nocturnal voids they average. More than eight voids per day and two voids per night is considered abnormal. Episodes of enuresis should be specifically elicited. Urge incontinence will often have triggers such as running water, handwashing, sexual intercourse, or emotional stress. Inquiry into these contributory factors will frequently be helpful in making a diagnosis. Women with mixed incontinence (MI) will have a combination of stress and urge symptoms. Elucidating which type of symptoms predominates will be helpful in later making therapeutic recommendations. A bladder diary, kept over 3 days, reporting voids, urgency events, incontinence events, and fluid intake can be very useful in clarifying often unclear and complex symptoms (Figure 3-1.1).

The degree of urine loss should also be quantified. The frequency of accidents should be noted. Pad use will often indicate symptom severity. The patient should be asked if pads are used and, if so, how many per day.

Voiding dysfunction is common in this population of patients. Questions about difficulty initiating the void, interrupted or slow voiding, needing to strain with voiding, a feeling of incomplete emptying, frequent urinary tract infections, postvoid dribbling, and double voids will aid in diagnosis and dictate need for a voiding study during urodynamics.

Patients with significant prolapse will typically complain of pelvic pressure or low back pain that worsens with prolonged standing. If the prolapse is exteriorized, they will often note a vaginal mass or bulge. Patients with prolapse involving the posterior vaginal wall often describe the need to digitally splint their vagina or manually extract stool in order to evacuate the rectum.

Sexual dysfunction frequently occurs in conjunction with incontinence and prolapse, and it should not be ignored. Although some symptoms may be primarily hormonal in nature (i.e., decreased libido, vaginal dryness) and others primarily neurologic (i.e., decreased vaginal sensation, secondary anorgasmic), there is frequently a combination of etiologic factors. In addition, parameters defining normal sexual function have not yet been determined because of varying individual characteristics, as well as cultural factors.

Symptoms related to fecal incontinence and defecatory dysfunction are discussed later in this chapter.

After the symptoms are well characterized, a complete medical history should be obtained. Focused questions to

Time

Urinations in toilet

Urge

Leakage accidents

Fluid intake 1 = teacup

Urge

Stress

Other

2 = glass/can 3 = water bottle

12 midnight - 2 a.m.

□ □ □ □

□ □

□1 da OS

2-4 a.m.

□ □ □ □

□ □

□1 Da Û9

4-6 a.m.

□ □ □ □

□ □

□ 1 Da Q 3

6-7 a.m.

□ □ □ □

□ □

□1 Da B3

7-8 a.m.

□ □ □ □

□ □

□1 Da p3

8 - 9 a.m.

□ □ □ □

□ □

□ 1 Da p3

9-10 a.m.

□ □ □ □

□ □

□ 1 P-2 O 3

10 -11 a.m.

□ □ □ □

□ □

□1 Da Ds

11 a.m. - 12 noon

□ □ □ □

□ □

□1 G.a D3

12 noon - l p.m.

□ □ □ □

□ □

□ 1 O2 Q3

i - 2 p.m.

□ □ □ □

□ □

□1 Û2 Da

2-3 p.m.

□ □ □ □

□ □

□1 CU n3

3-4 p.m.

□ □ □ □

□ □

□ 1 D 2 Ds

4-5 p.m.

□ □ □ □

□ □

□ i C 2 D3

5 - 6 p.m.

□ □ □ □

□1 Da D3

6-7 p.m.

□ □ □ □

□ □

□1 Da D3

7-8 p.m.

□ □ □ □

□ □

□1 Da D3

8-9 p.m.

□ □ □ □

□ □

□ 1 Da n3

9-10 p.m.

□ □ □ □

□ □

□1 m D 3

10 -11 p.m.

□ □ □ □

□ □

□1 Da n3

11 p.m. - 12 midnight

□ □ □ □

□ □

□ 1 Da n3

Figure3-1.1. Bladder diary.

uncover contributing factors should be asked. Past urologic and gynecologic procedures such as incontinence surgery, urethral dilatations, radical hysterectomy, or radiation treatment might help explain the etiology of the patient's symptoms. A careful obstetric history including modes of delivery, fetal weights, use of forceps, large tears, or other indications of significant urogenital trauma are important. Neurologic conditions such as multiple sclerosis, Parkinson's disease, stroke, or previous back trauma also often contribute to incontinence and prolapse symptoms. Pulmonary pathology associated with a chronic cough is a risk factor for SUI and prolapse and will also challenge a repair. Moreover, the risk of all forms of urinary incontinence is increased by up to three times with a history of smoking.1 Therefore, a smoking history is also important to obtain.

Other conditions associated with repetitive significant increases in intraabdominal pressure, such as chronic con stipation and heavy lifting, are also important to inquire about because they can be associated with voiding dysfunction, pelvic neuropathy, and pelvic organ prolapse.

The patient's medications should be thoroughly reviewed to identify drugs that may be contributing to symptoms and to prevent untoward interactions. In particular, usage of medications with a-adrenergic activity (agonists such as phenylephrine enhance urethral sphinc-teric function; blockers such as prazosin relax the urethral sphincter) and cholinergic effects (procholinergic effects, from bethanechol, increase detrusor form; anticholinergic effects, from oxybutynin and tolterodine, relax the detru-sor muscle) should be recorded. The patient's menopausal and estrogenation status should be addressed, because of the marked effect female hormones may have on urogenital function (Chapter 11-1). Likewise, the patient's diet and dietary supplements should be examined to identify bladder irritants that may worsen possible symptoms.

Herbal Remedies For Acid Reflux

Herbal Remedies For Acid Reflux

Gastroesophageal reflux disease is the medical term for what we know as acid reflux. Acid reflux occurs when the stomach releases its liquid back into the esophagus, causing inflammation and damage to the esophageal lining. The regurgitated acid most often consists of a few compoundsbr acid, bile, and pepsin.

Get My Free Ebook


Post a comment