Guidelines for Nurse Practitioners in Gynecologic Settings 2016
Care Plan – Pelvic Floor Dysfunction
R32 – Unspecified urinary incontinence
N81.9: Female genital prolapse, unspecified
R15.9: Full incontinence of feces
K59.02: Outlet dysfunction constipation
R10.2: Pelvic and perineal pain
N30.30: Trigonitis without hematuria
I. DEFINITION
Pelvic floor dysfunction is common among women, affecting approximately 25% of all women. Pelvic floor dysfunction disorders include urinary incontinence, pelvic organ prolapse, anal incontinence, sensory disorders of the lower urinary tract, defecation dysfunction, and chronic pelvic pain. a careful history, physical exam, and laboratory testing are crucial for diagnosis and treatment. although not life threatening, pelvic floor dysfunction can impair the physical, psychological, and quality of life of the affected individual.
II. HISTORY
a. medical history
1. chronic diseases
2. current medications
B. surgical history
c. gynecological history
1. gravida, para, living, terminations
2. methods of delivery: vaginal or cesarean section
3. traumatic births
4. menstrual history: last menstrual period (lmP), menarche, interval, duration, flow; recent changes in pattern
D. sexual history
1. orientation, number of partners, last coitus
2. libido, dyspareunia, postcoital bleeding
e. social history
1. smoking history: age of first cigarette use, number of cigarettes/ packs per day, medications used for smoking cessation
2. alcohol use: age of first drink, current use; number of drinks/day, type of alcohol
3. recreational drug use: past/current use, types of drugs used
4. intimate partner violence screening: past/current
F. History of current problem
1. onset of symptoms: acute onset or subtle
2. Duration of symptoms
3. medications/activities undertaken to relieve symptoms
4. medications/activities that aggravate symptoms
5. other health care providers/specialists visited and interventions prescribed
6. urinary symptoms
a. Frequency, hesitancy, urgency, dysuria
b. urine loss with coughing, sneezing, laughing, or exercising
c. urine leakage with urgency
d. slow urine stream, postvoiding dribble, incomplete bladder emptying (urinary retention)
e. urinary urgency at night (nocturia), bed-wetting (nocturnal enuresis), leakage with orgasm
f. use of urinary leakage products: number pads/day, frequency of changing underwear
7. Bowel symptoms
a. Bloating, constipation, leaking of stool
b. Difficulty evacuating stool, incomplete evacuation
c. straining with bowel movements, digital removal of stool
d. sense of anal blockage with defecation
e. splinting of posterior vagina
8. Pelvic prolapse
a. Feeling/sensation of vaginal bulge/protrusion
b. inability to insert/wear tampon
c. Feelings of sitting on a weight or bulge rubbing in the underwear
d. Pelvic or low back pain with radiation to thighs/groin
III. PHYSICAL EXAMINATION
a. vital signs, height, weight, body mass index (Bmi)
B. general physical exam
1. assess mental status
2. skin
3. Head, eyes, ears, nose, throat (Heent)
4. thyroid/lymph nodes
5. Heart/lungs
6. Breasts: review breast self-examination (Bse)
7. extremities: assess sensory function with light touch, pinprick, and cold sensation. assess lumbosacral cord function by flexion/ extension/inversion/eversion of knee, ankle, foot, and hip. Perform deep-tendon reflex assessment for upper/lower motor lesions.
c. gynecologic exam
1. external genitalia: inspect for rashes or lesions
2. Bartholin’s and skene’s glands
3. urethra: discharge, tenderness or masses
4. vagina: palpate vaginal wall at 5:00 and 7:00 for levator ani muscles. ask patient to cough or perform valsava maneuver for stress incontinence. using a half speculum, place anteriorly or posteriorly to assess for vaginal wall prolapse.
5. cervix
6. adnexa
7. rectum: assess rectal muscles by eliciting anal wink (stroke perianal skin)
IV. LABORATORY/RADIOLOGY TESTING
a. Pap smear as indicated by Pap guidelines
B. sexually transmitted infection (sti) testing
c. vaginal cultures if indicated
D. urine symptoms
1. three-day bladder diary, including symptoms, frequency (time), urine leakage, amount of voids, incontinence episodes, number of pads worn/change of underwear
2. urodynamic testing to evaluate the bladder’s function
e. Bowel symptoms
1. stool for guaiac, stool for ova and parasite, stool culture
2. endoscopy/colonoscopy
3. anorectal manometry to measure anal pressure and strength of sphincter muscles
4. mri defecography—will provide information about muscles and supporting structure of anus, rectum, and pelvis
F. Pelvic organ prolapse
1. cystoscopy
2. intravenous pyelogram (ivP)
3. Pelvic ct
V. DIAGNOSIS
a. urinary conditions
1. overactive bladder: sudden involuntary contraction of bladder muscles that results in urine urgency; symptoms: incontinence, frequent urination, nocturia
2. stress incontinence: unintentional loss of urine, usually during physical activity; symptoms: loss/leaking of urine when coughing, sneezing, standing up, heavy lifting, exercising, engaging in sexual activity
B. Bowel conditions: physical exam and testing
c. Pelvic organ prolapse conditions: physical exam
VI. TREATMENT
a. urinary conditions
1. Pelvic floor exercises: Kegel 10 times daily, vaginal cones to strengthen muscles
2. Bladder training, including voiding schedules
3. Biofeedback and electrical stimulation
4. management of fluid intake: greater than 2,100 ml can increase bladder filling and urgency; discontinue fluid intake 2 hours before bedtime.
5. nutritional interventions: caffeine reduction, elimination of bladder irritants, including sugar substitutes, citrus fruits, and tomato products; reduce carbonated beverages
6. review of medications: diuretics
7. medications
a. treat urinary tract infections (utis) with appropriate antibiotics
b. anticholinergic medication to relax bladder muscles includes Ditropan, Detrol, enables, vesicare
c. urispas use to calm muscle spasms
d. tricyclic antidepressants can help to “paralyze” smooth muscles of the bladder.
8. surgical interventions
B. Bowel conditions
1. nutritional interventions: normal fluid intake, increase high-fiber foods, fiber supplements
2. maintenance of normal bowel habits
3. enemas to stimulate, regulate normal bowel habits
4. evaluation of medication that may cause constipation or loose stools
c. Pelvic organ prolapse conditions
1. Pelvic floor exercises, including Kegel exercises
2. Biofeedback and pelvic floor physical therapy
3. Bladder training, including schedules to void every 2 hours
4. High-fiber diet, including 20 g fiber daily to reduce constipation
5. Weight reduction and avoidance of exercises that stress pelvic muscles
6. estrogen or hormone therapy to prevent vaginal dryness and support pelvic muscles
7. Pessaries to support the prolapse
8. surgical interventions: refer to urogynecologist