Basic Evaluation of the Patient with Pelvic Floor Dysfunction (General Review)

Abstract

Pelvic floor dysfunction encompasses multiple symptom complexes that can occur alone or in combination. The underlying etiology should be thoroughly elucidated by careful patient history, evaluation of symptoms, and physical examination. Unnecessary tests and procedures should be avoided in the straightforward patient. In complex patients, however, appropriate additional testing is recommended.

Commentary by Eric S. Rovner, Medical University of South Carolina, Department of Urology, Charleston, SC, USA

Commentary

• Eric S. Rovner 

This is an excellent chapter describing the initial evaluation of the patient with pelvic floor dysfunction. These authors provide a comprehensive description and rationale for the salient components of a good history, physical examination, and other preliminary lines of inquiry (e.g., questionnaires and diaries) which provide a basis for the initial diagnosis and interventional planning in most patients presenting with pelvic floor dysfunction. The importance of these components, especially taking a good history and doing a complete physical examination, when done well, cannot be overemphasized. It is easy to overlook the value and expertise required to do these most basic components of the patient intake process well. These skills were initially acquired as medical students and then developed as interns and residents in training and then continuously refined as active practitioners. To this end, the astute clinician practices, retains, and exploits these proficiencies on a daily basis and does not permit the “templating” and “box checking” of the modern electronic medical record to supplant this acquired expertise.

Patients with pelvic floor dysfunction represent a broad array of connected pathologies. As the authors point out, symptoms in one system or compartment (i.e., urinary) should lead to an exploration and solicitation of other potentially related symptoms and signs (defecatory, sexual, etc.). Although, as clinicians, we are acutely aware of the intimate relationship between the various domains of the pelvic floor, the patient may not realize that these disorders are very often connected and may not offer their full array of complaints unless directly queried. Such patients are often quite relieved when they are counseled that their seemingly disparate symptoms are related and can be addressed simultaneously in a well-constructed therapeutic plan.

The bladder has been historically and famously termed an “unreliable witness” for many reasons including the limitations of patient recall of symptoms, as well as a lack of exact correlation of individual symptoms to a definitive diagnosis [47]. This characterization has been historically utilized as justification to pursue invasive diagnostic testing such as urodynamics in many patients. However, the wise clinician can elicit relevant symptoms, signs, and physical examination findings, parse through these data, and often arrive at a provisional and even definitive diagnosis prior to pursuing additional testing in the majority of patients with pelvic floor dysfunction, thus avoiding the cost and inconvenience of such investigations. In fact, recent publications have questioned the widespread utility of urodynamics in particular even when contemplating surgery [48].

In an era of buzzwords including cost containment, and quality of care, a thorough “H and P” can preclude the need for invasive and expensive tests such urodynamics or imaging in many, if not most, uncomplicated cases. Recently published guidelines certainly support such an approach [49,50,51]. Though the pace of advanced technological innovation in the diagnosis of pelvic floor disorders and indeed in all of medicine is accelerating, and the momentum is sometimes difficult to resist, such investigations are only variably and infrequently indicated when a proper, well-done, and complete initial evaluation is performed. This is not to suggest that such testing is unnecessary, but rather it should be selectively utilized, always balancing the incremental information gleaned from these investigations with the cost, invasiveness, and discomfort resulting from their utilization. It is appropriately emphasized by these authors that additional invasive testing should be reserved for those patients who remain complex diagnostic dilemmas following a thorough initial evaluation and/or obtained in those patients in whom irreversible, invasive, and expensive interventions are being pursued (e.g., surgery) and further or definitive diagnostic clarity is necessary.