Urogynaecology Assessment
On this page
Direct answer
Urogynaecological assessment rests on a disciplined triad: a symptom history organised into storage, voiding and prolapse complaints; a three-day frequency-volume (bladder) diary that turns vague urgency into numbers; and a focused examination with the cough stress test, post-void residual scan and POP-Q staging of any prolapse. Urinalysis and residual urine precede any overactive bladder diagnosis, and urodynamics are reserved for complex cases — prior continence surgery, mixed symptoms, or diagnostic doubt. Most referrals leave the first consultation with a diary, a stress test result and a conservative plan — precisely what the exam expects to hear.
What you must remember
- Symptom taxonomy: storage symptoms (frequency, nocturia, urgency, incontinence), voiding symptoms (hesitancy, straining, incomplete emptying), and prolapse symptoms (bulge, dragging ache worse by evening, relieved lying down) — the ICS vocabulary that structures the answer.
- Bladder diary numbers: three days of times, volumes and intake; normal functional capacity is roughly 250–400 mL with daytime voiding up to about 7–8 times and one nocturnal void; habitual volumes under 150 mL suggest sensory urgency, and excessive caffeine is a modifiable driver.
- Cough stress test: performed with a comfortably full bladder, standing, a single firm cough — visible urine loss confirms urodynamic stress incontinence provisionally; absent leak in a symptomatic woman hides occult stress incontinence behind prolapse, unmasked only after reduction (a pessary or swab during the test).
- Post-void residual: ultrasound-measured; under 50 mL is normal, above 200 mL abnormal, and the range between needs context — large residuals push toward voiding dysfunction workup.
- POP-Q system: nine points (Aa, Ba, C, Ap, Bp, D, gh, pb, tvl) measured against the hymen in centimetres — negative above, positive below — yielding stages 0–IV; stage II spans the hymen ±1 cm, the staging every viva asks.
- Urinalysis before labels: infection, glycosuria and haematuria are ruled out before diagnosing overactive bladder; recurrent infection changes the pathway entirely.
- Urodynamics indications: before redo continence surgery, when mixed symptoms or significant prolapse complicate the picture, neuropathy, or failed conservative therapy where the diagnosis is uncertain — not routine in straightforward stress incontinence.
- Conservative management starts now: pelvic floor training for at least three months, bladder training, weight loss, pessaries for prolapse — assessment and first treatment belong to the same visit.
The first consultation, step by step
A 61-year-old describes a bulge she can feel at the introitus by evening, voiding twice at night, and leaking when she laughs. The history files her as prolapse with possible mixed incontinence; the diary she brings back shows eleven daytime voids with volumes of 90–140 mL and four incontinence episodes. Examination with a Sim's speculum shows a stage III anterior wall (Ba +4), cervix at the introitus (C 0); the cough test with the prolapse unreduced leaks nothing — then, reduced by a fitted ring, she leaks unmistakably: occult stress incontinence a prolapse repair alone would not fix. Urinalysis is clear and residual urine is 30 mL. The consultation ends with a ring pessary, pelvic floor referral, and a surgical conversation that includes sling assessment if the leak persists after repair. Every element — diary numbers, reduced stress test, POP-Q stage — changed the plan, which is the entire point of the assessment.
How the exam frames it
The exam loves the diary as discriminator: give the numbers and watch whether the candidate separates a polyuric intake problem from a small-volume frequency pattern, because treatment diverges from that page. The POP-Q question is a fixture — reproduce the hymen reference, name C as the cervix or vault, and grade a stem by its Ba and C values. The cough stress test appears with its trap: no leak behind a stage III prolapse does not exclude stress incontinence — reduction testing rescues the answer. The urodynamics question runs as a gatekeeping test — does every incontinent woman need urodynamics? — with the expected answer naming uncomplicated stress incontinence a clinical diagnosis and reserving urodynamics for complex, mixed or recurrent cases. The assessment ends in conservative management; skipping pelvic floor training and jumping to tapes loses the guideline marks that open every model answer.
Frequently asked questions
What does a normal bladder diary show?
Roughly 250–400 mL voided volumes, up to seven or eight daytime voids and one nocturnal void, with three days recorded — habitual small volumes suggest sensory urgency.
How is the cough stress test performed?
With a comfortably full bladder, the standing woman coughs firmly once; visible urine loss supports stress incontinence, ideally repeated with any prolapse reduced.
What is POP-Q staging based on?
Nine anatomical points measured in centimetres relative to the hymen — negative above, positive below — producing stages 0 through IV.
When are residual volumes abnormal?
Above about 200 mL is clearly abnormal; under 50 mL is normal, and the range between is interpreted against symptoms and voiding history.
When is urodynamics indicated?
Before redo continence surgery, in mixed or uncertain diagnoses, with significant prolapse or neurological disease — not routinely in uncomplicated stress incontinence.