There are 4 main parts to the clinical examination:
- Testing for Urinary Incontinence with Coughing (clinical Stress Leakage)
- Examination for Uterine And/or Vaginal Prolapse
- Pelvic Examination
- Vaginal Ultrasound Examination
All of these examinations are well tolerated. They are performed with a maximum amount of care, discretion and consideration.
1. Clinical Stress Leakage
A comfortably full bladder will assist this examination.
2. Examination for Uterine And/or Vaginal Prolapse
This follows the above examination. It requires the bladder to be emptied. The four types of prolapse are:
- Uterine prolapse: Descent of the uterus more than halfway down the vagina. This might be felt as a firm lump near the vaginal opening.
- Cystocele (anterior vaginal wall prolapse): Descent of the bladder down the vagina. This might be felt as a softer lump from the front wall of the vagina.
- Rectocele (posterior vaginal wall prolapse): Descent of the rectum down the vagina. This might be felt as a softer lump on the back wall of the vagina. Often symptoms of difficult or incomplete bowel emptying are associated.
- Enterocoele (vaginal vault prolapse): Descent of the top of the vaginal often to and through the entrance. This is a finding which can follow a variable number of years after hysterectomy.
There are four stages of prolapse (IUGA/ ICS definitions – Haylen et al. 2010). Different grades might apply to each of the above types of prolapse. It is common to have more than one type of prolapse present.
Stage I: Descent at least halfway to the vagina
Stage II: Descent to within 1 cm of the vaginal entrance
Stage III: Descent more than 1 cm outside the vaginal entrance
Stage IV: Type of prolapse totally outside the vagina
Stages of prolapse
3. Pelvic Examination
This is the usual gynaecological examination for any enlargement of the uterus or ovaries. A careful inspection is made of the outside (vulva) as well as the vagina. A cervical smear will be taken if due.
4. Vaginal Ultrasound
This was introduced into Australia in 1989 by the then Dr Haylen as a non-invasive source of excellent clinical information. This includes:
- Bladder neck assessment: Looking for mobility, opening and loss of support in this area. These findings are supportive of a diagnosis of urodynamic stress incontinence.
- Residual urine volume (postvoid residual – PVR) assessment: This determines whether the bladder empties completely (most female bladders do). It avoids the need for a catheter to do the same assessment in most ladies. If a significant PVR is noted after a single void, it can be rechecked after a second attempt to void.
- Uterus: Any enlargement or abnormality of the uterus should be noted. Uterine fibroids (muscle lumps) are probably the most common finding.
- Uterine version (tilt): It will be noted whether the uterus is in its normal position tilted forward over the bladder (anteverted) or whether it is tilted back towards the sacrum (retroverted). Professor Haylen has determined from his studies (see featured publication) that 18% of women will have a retroverted uterus. In women seeing him, the figure is 34% due to a higher propensity for women with a retroverted uterus to experience prolapse or symptoms of voiding dysfunction or dyspareunia.
- Bladder or urethral tumours
- Other pelvic cysts
Residual urine volume (postvoid residual) assessment
Image of postvoid residuals and 65ml by transvaginal ultrasound, reducing to 4ml with a subsequent attempt at voiding.
Examples of anteversion and retroversion. From Llewellyn-Jones D. Fundamentals of Obstetrics & Gynaecology. Vol 2 Gynaecology. 1970. Fig 21/1. P202. Faber & Faber. London. Reproduced by permission of Prof Suzanne Abraham.