Below are summaries of some of the tests used in the evaluation of urinary and fecal incontinence, problems with bladder emptying, and pelvic prolapse.

Pelvic Examination

The pelvic examination allows evaluation for vaginal prolapse, the estrogen status of your vaginal tissue, evidence of urinary leakage, and the strength of your pelvic floor and anal sphincter muscles. This test will be performed painlessly and only in the presence of the members of our medical team.

Vaginal prolapse is identified by performing a speculum exam using an instrument also used to perform pap smears (which may also be done at this visit). We will also evaluate the strength of the ligaments and muscles that support your bladder, urethra, rectum, uterus, and vaginal walls.

The strength of these muscles will be graded, and this grading will help determine the need for 'pelvic floor rehabilitation. When these muscles are strong, they help maintain the position of the pelvic organs. They also are involved in maintaining urinary and fecal continence.

The term vaginal prolapse is often used to describe a number of medical diagnoses such as cystocele, rectocele, and enterocele, but often you will simply be told that you have a dropped bladder.

However, the exact type of prolapse that you have is most important in determining the treatment necessary. There is no single operation that fixes all problems. If the prolapse is symptomatic, non surgical management with a pessary may be an option. However, commonly surgery is recommended.

After menopause, estrogen may not be produced by the ovaries. If this hormone is not replaced by either oral or vaginal therapy, the vaginal tissue may become thin and dry. This is called an atrophic vagina, and it can aggravate urinary incontinence, recurrent urinary tract infections, and vaginal prolapse as well as cause discomfort during intercourse. Estrogen therapy may be necessary, and the regimen recommended will depend on many factors, including whether the uterus is present.

Kegel exercises are extremely important in preventing the worsening of urinary incontinence and pelvic prolapse, and they are important in treatment as well. We will inform you of the correct way to perform these exercises, and prescribe physical aids (e.g. vaginal cones).

Pelvic floor exercises are a part of the behavioral therapy management of incontinence and prolapse. It may be necessary for you to receive a biofeedback session to help you with your pelvic floor therapy. Such a session will be scheduled with the physical therapy department as a separate appointment.

Should we identify vaginal wall prolapse, we will objectively assess the degree of prolapse by taking measurements.

Urinary leakage can often be visualized when a patient is asked to cough during the pelvic examination. Whether it is seen to occur will depend on bladder fullness and the strength of the cough.

If leakage does occur, it is often evidence of a weak urethra. Also important will be the degree of loss of support of the urethra and bladder at the time of the observed leakage -- this may play into the selection of treatments.

In most cases, when leakage does occur, a more detailed look at the function of the bladder and urethra is necessary, and a test called video urodynamics is performed. Incontinence treatment may be behavioral, minimally invasive, or surgical depending on the severity of the urinary leakage and on the patient's needs and expectations.

The anal sphincter is the important muscle to maintain fecal continence. Child-bearing can disrupt the muscle’s circular structure, as can anal fissure surgery and hemorrhoidectomy.

A rectal examination will often help determine whether the muscle is intact. Besides an anatomic disruption, the muscle can also be weak from nerve damage that occurred with child bearing. If the symptoms warrant treatment, further investigation may include an anal sphincter EMG or ultrasound. Constipation symptoms very commonly accompany problems of the pelvic floor and urinary incontinence and may need further evaluation with a defecography or MRI.

These problems can often be addressed medically.

Urine Examination

Urine examination will be performed and will include the examination of the urine under the microscope and culture of the urine for infection

The best way to obtain the urine specimen is by the insertion of a catheter into the bladder. If the results suggest an infection, antibiotic therapy is given. Sometimes the results suggest that a cystoscopy is necessary to further evaluate the inside of the bladder and urethra.

Cystoscopy

Cystoscopy is an office procedure that involves the insertion of a small lighted telescope through the urethra to visualize the inside of the urethra and bladder. Prior to cystoscopic examination, xylocaine gel is placed in the urethra to numb it.

This test will look for causes for your symptoms and is particularly valuable in patients complaining of incontinence, those with blood in the urine, some patients with urinary infections, and those women with painful bladders. The test is viewed on a TV monitor, and you may share what your doctor sees, if you wish.

Video Urodynamics

Video urodynamics is a test used to evaluate any problems with storage (continence) of urine or the voiding (elimination) of urine from the bladder. The test is performed in the clinic and is painless, so no sedating medication is necessary.

Without urodynamics, the diagnosis of bladder problems is often guesswork.

Urodynamics involves several tests that evaluate various aspects of your bladder’s function. The first test performed is uroflowmetry, which measures the amount and speed of urine you void from your bladder. You will urinate into a funnel attached to a computer that will record your urine flow over time. The amount of urine left in your bladder after you void (residual urine) may also be measured immediately after this test.

The next test performed is the cystometrogram. This test will require the insertion of a small catheter into the bladder and the placement of a similar small tube into the rectum. The bladder will be filled with an x-ray solution, and the bladder pressures will be recorded as you report the sensations that you experience.

We will attempt to mimic the problems that you complain of in your everyday life, helping us diagnose and treat your problem more accurately. You will be asked to stand and to cough and to bear down during this test to study your ability to hold your urine during stress, and this will help us determine the best treatment for your incontinence.

After this part of the test you will be asked to urinate the fluid that you have been filled with. The pressure that your bladder achieves and the flow established will be recorded. This pressure-flow test helps us identify problems of urination.

Periodically throughout the urodynamic evaluation, an X-ray picture will be taken of the bladder and the urethra, giving us an image of how the bladder looks and functions. In a few circumstances, EMG tests will also be performed. These are usually only necessary when a neurologic cause is present or is suspected as a cause for the bladder problem.

Ultrasound Tests

Ultrasound tests may be performed to look for problems in the kidneys and are also used to 'map' the muscles around the anus in patients who complain of anal incontinence.

This test may also be used to check how well your bladder is emptying, and is used to look at the structure of the kidneys in selected cases.

Defecography

Defecography is a radiographic test that evaluates your ability to evacuate stool from the rectum. This test is performed in some patients who have pelvic organ prolapse (especially rectocele and enterocele), and particularly those with constipation problems.

You will be asked to drink a solution one hour before the procedure, and at the time of the test, contrast material will also be placed in your rectum, to help identify any motility problems involving your rectum.

You will be asked to perform several maneuvers such as coughing, straining, and squeezing your rectum, and then to evacuate your rectum. This test is only performed in difficult cases, so don't worry!

Magnetic Imaging Resonance (MRI)

MRI is a test that images all of the organs in your pelvis.

This test is also performed in complex cases of pelvic organ prolapse. If you are severely claustrophobic or have a pacemaker, you may not be a candidate for this test.