Chapter 7: The first office visit

Like any other visit to the doctor’s office, your encounter with a medical professional should include an interview or history taking and physical examination. During the interview the doctor will try to gather all the relevant information. During the physical examination the doctor will check you with special emphasis on pelvic examination (the urethra, vagina, uterus and rectum).

Getting your medical history

Getting down your medical history is the most important part in making the diagnosis. The doctor will ask you about your bladder control problem. What problem do you have? For how long has it been going on? Was there any previous evaluation or treatment? What previous surgical procedures have you undergone including surgery to treat incontinence and bladder control problems, hysterectomy, instrumental delivery, cesarean section, and other vaginal and abdominal surgery.

Many specialists consider the pelvic floor to be one unit with multiple functions, bladder control being just one of them. They will therefore ask you about your bowel function (constipation, diarrhea, bowel incontinence) and your sexuality (sexual dysfunction and pain during sexual intercourse).

They will finally inquire as to the effect your symptoms have on your quality of life and how bothered you are by your bladder control problems. This will help the doctor to establish an evaluation plan tailored especially for you.

You will also be asked about your general health and any other medical conditions you may have, the medication you take and whether you have any allergy to medications.

On the next page you will find an example of the questionnaire and a voiding diary I use with my patients. It has been my experience that patients who fill out the questionnaire and the voiding diary before arriving at the office can define the problems they have better. Women are less stressed when asked about their symptoms and complaints, and therefore can better participate in making decisions regarding their future evaluation and treatment plans.

The questionnaire

A. Bladder control problems and pelvic floor prolapse:
Do you leak urine when coughing, sneezing, or laughing (stress incontinence)?
Do you suddenly feel a strong need to urinate (urge)?
When you feel the urge, does it happen that you cannot make it to the bathroom and leak on yourself on the way there (urge incontinence)?
How often (or how many times) do you urinate during the daytime (Frequency)?
How often or how many times do you urinate after going to bed (Nighttime frequency or nocturia)?
Do you leak when you are lying flat on your back (Supine incontinence)?

Urinary incontinence severity:

As some women with incontinence or urge use pads for protection it is important to know if you use a pad to protect yourself?  How many pads do you use in a regular day?

How often do you leak on yourself in a typical day?

Obstructive voiding symptoms:

Do you find it hard to initiate urination?
Do you have to strain to urinate?
Is your stream interrupted?
How good is your force of stream? Fluid intake:
How many glasses of fluid do you drink in a day?
Do you drink a lot of caffeinated beverages (coffee, tea, soda)?

Pelvic floor prolapse:

Do you feel a lump or a bulging between your legs?

B. Obstetrics and gynecologic history:

How many times have you been pregnant?

How many times have you delivered a baby?

Did you have prior pelvic or obstetric surgery (Cesarean Section)?

Did you have any surgery to correct incontinence or a falling bladder?

When was your last period?

Are you on hormonal replacement therapy?

C. Urologic history:

Have you ever had blood in your urine? (if the answer is positive you should consult a urologist without delay).

Did you ever have kidney stones?

Have you ever had urinary tract or bladder infection?

D. Quality of life

To what degree are you bothered by your urinary incontinence or bladder control problem?

 

Voiding diary

You may also be asked to complete a voiding diary. This is a diary in which you record the amount of fluid you take how many times you urinate and how much and how many “accidents” or incontinence episodes you had. The voiding diary is completed during 24-hour period.

This is a sample of a “voiding diary.”

Time

Drinks

urination

Special events

7 A.M.– 9 A.M. (example)

Coffee, 1 cup

250 milliliters

One leakage, felt an urge before arriving at the bathroom

7 A.M. – 9 A.M.

 

 

9 A.M.- 11 A.M.

11 A.M – 1 P.M

 

 

 

1 P.M.- 3 P.M.

 

 

 

3 P.M. – 5 P.M.

 

 

 

5 P.M. – 7 P.M.

 

 

 

7 P.M.- 9 P.M.

 

 

 

9 P.M. – 11 P.M.

 

 

 

11 P.M.- 1 A.M.

 

 

 

1 A.M. – 3 A.M.

 

 

 

3 A.M. – 5 A.M.

 

 

 

5 A.M. – 7 A.M.

 

 

 

 The voiding diary should be filled in for at least for 24 hours. Fill in the amount of fluids you take, the volume in milliliters, cubic centimeters or ounces, and special events such as leakage, pad changes etc.

Once presented to the doctor it can provide a lot of information. Some women drink a lot. They were told it is good for their diet, for their daily bowel movements, etc. By looking at your voiding diary one could figure out how much you drink. As a patient of mine once put it: the equation is really simple: the more you drink the more you pee. Some of the complaints presented by many women can be related merely to their excessive drinking. The voiding diary can also provide information as to your frequency during the day and during the night and on the number of episodes in which you leak urine—one of the variables that have a bearing on how severe your incontinence is.

Physical Examination

On your first visit the doctor will perform a complete physical examination including pelvic examination.

This is very similar to the routine yearly check up examination you have at your gynecologist. You will be lying on your back with your legs apart and your vagina will be evaluated with a speculum. The doctor will evaluate your vagina when you are relaxed and will ask you to strain or bear down to evaluate the degree of prolapse or dropping of the various pelvic organs, namely the uterus, the bladder and the rectum. He will also look for any urinary leakage especially when you are straining.

Additional tests

The physician may order additional tests. These include the following:

Urinalysis:  

Urinalysis is an analysis of the chemical and cellular (yes, there may be cells in your urine) makeup of your urine. It is an integral part of your evaluation and is used mainly to rule out other conditions such as urinary tract infection and bladder tumor.

Pad test:  

You will be asked to wear pads for 20-minute, 1-hour, or 24-hour periods. During this time you will be  asked to perform a series of exercises representing normal activities during a day. Weighing the absorbent pads after the test can provide information as to how much urine you lose.

Post voiding residual urine (PVR): This is the amount of urine left in your bladder after you have voided. A high PVR can be related to poor bladder emptying resulting from a weak bladder muscle or from an obstruction to the urinary flow. High PVR is also related to increased risk of urinary tract infection and overflow incontinence. It can be measured in a non-invasive method by ultrasound or during urodynamic evaluation which is another new term and is explained right now.

Urodynamics:

This is a test that will help to determine what kind of incontinence you have and how severe it is. It allows the physician to examine how the bladder functions during the storage phase when you bladder is continuously filled and when it empties.

The test is carried out by first inserting a small catheter into your bladder. The bladder is then filled with fluid and its behavior is monitored with special pressure sensors placed in your bladder and in the rectum. These pressure measurement probes are small, the size of a tip of a pen, and cause minimal inconvenience. The rate of filling, and the pressures that develop in your bladder are all viewed on a monitor at the same time. During the test you are asked to report when you first feel the fluid in your bladder, when you first feel that you have to urinate, when you have a strong desire to void and when you feel you can no longer delay voiding.

This test may sound terrible: After all it is not everyday that you have catheters attached to you or that you are asked to void in the presence of others. However, in almost all cases the test is not painful, short (about 10 minutes), and inconvenient at the most.  The benefits of the test as a diagnostic tool surpass its side effects.

Cytoscopy:

The word cystoscopy (pronounced sistoscopi) stems from the Greek word kustis or bladder and scope from the Greek work skopein which means to see. The cystoscope is a tubular instrument that allows the physician to observe your bladder, bladder neck and the urethra. The test is always indicated when evidence of blood is present in your urine analysis or if you have seen blood in your urine. Some doctors prescribe the test also for patients with urinary incontinence who do not have blood in their urine. The test is simple and although uncomfortable, it is not painful. Newer types of cystoscopes are of small caliber and are flexible, making the test even more tolerable.