Other Bladder/Vaginal Symptoms

Sensory Symptoms
Voiding Symptoms
Other Urinary Incontinence
Pelvic Organ Prolapse
Vaginal Pain

Sensory Symptoms:

Increased, reduced or absent bladder sensation with filling.
Extended periods of time without an urge to void.
Leaking without a desire to void.
Insensible loss.
Intense, sudden urge to void with insufficient time to reach the toilet.
Bladder pain.

Contributing Factors:

Neurological disease.
Peripheral nerve dysfunction.
Chronic pain.
Side effects of medications (including natural remedies).
Prior bladder injury or trauma.
Repeatedly holding on with large bladder volumes.

Assessment and Management:

In the absence of pathology, refer to Continence and Women’s Health Physiotherapist or Continence Nurse.
Physiotherapy assessment may include a detailed history, bladder diary and screening of post void residual.
Physiotherapy management includes education about maintaining normal void volumes, healthy bladder/bowel habits, pain management and education about sensitising factors, normalising pelvic floor muscle function.

Red Flags:

Further investigation or referral to specialist is indicated when incontinence is associated with, or accompanied by:

Persistent or recurring urinary tract infections.
Dysuria, persisting bladder or urethral pain.
Haematuria, glycosuria or persistent proteinuria.
Inability to empty bladder or straining to empty.
Post void residual volume >200ml.
Nocturnal enuresis.
Rectal bleeding or unexplained vaginal bleeding.
Recent sudden alteration of bowel habits with no obvious explanation.
Persistent vulvo-vaginal itching area or undiagnosed vulval or rectal dermatological conditions.
Pelvic organ prolapse (POP) past introitus causing difficulty emptying bladder.
Pelvic masses, unexplained weight loss or unremitting night pain.
Suspected neurological disease e.g. MS, Parkinson’s disease, stroke, dementia or spinal cord symptoms, such as muscle weakness/wasting, altered reflexes, altered sensation (generally and saddle region), inability to empty bladder, loss of sensation when voiding.

Voiding symptoms:

Hesitancy, slow or intermittent stream.
Straining to void.
Sense of incomplete emptying or needing to immediately re-void.

Contributing Factors:

Reduced fluid intake.
Inadequate voiding volumes.
Pelvic organ prolapse or obstructed outlet.
Pelvic floor muscle dysynergia.
Suboptimal voiding mechanics.

Assessment and Management:

In the absence of pathology, refer to Continence and Women’s Health Physiotherapist or Continence Nurse.
Physiotherapy assessment may include: a detailed history, uroflowmetry where available, screening for post void residual, bladder diary, pelvic floor muscle assessment.

Physiotherapy management includes instruction in voiding techniques, healthy bladder and bowel habits, management of pelvic floor muscle dysfunction.

Continence nurse may teach clean intermittent self-catheterisation where required.

Red Flags:

Further investigation or referral to specialist is indicated when incontinence is associated with, or accompanied by:

Persistent or recurring urinary tract infections.
Dysuria, persisting bladder or urethral pain.
Haematuria, glycosuria or persistent proteinuria.
Inability to empty bladder or straining to empty.
Post void residual volume >200ml.
Nocturnal enuresis.
Rectal bleeding or unexplained vaginal bleeding.
Recent sudden alteration of bowel habits with no obvious explanation,
Persistent vulvo-vaginal itching area or undiagnosed vulval or rectal dermatological conditions.
Pelvic organ prolapse (POP) past introitus causing difficulty emptying bladder.
Pelvic masses, unexplained weight loss or unremitting night pain.
Suspected neurological disease e.g. MS, Parkinson’s disease, stroke, dementia or spinal cord symptoms, such as muscle weakness/wasting, altered reflexes, altered sensation (generally and saddle region), inability to empty bladder, loss of sensation when voiding.

Other Urinary Incontinence Symptoms:

Continuous urinary incontinence.
Insensible urinary incontinence.
Coital incontinence.
Post-micturition dribble.

Contributing Factors:

Constipation.
Sphincter insufficiency.
Poor voiding dynamics.
Poor bladder habits.
Pelvic floor muscle weakness.

Assessment and Management:

In the absence of pathology, refer to Continence and Women’s Health Physiotherapist or Continence Nurse.
Physiotherapy assessment may include a detailed history, vaginal examination and pelvic floor muscle assessment.
Physiotherapy management includes education about contributing lifestyle factors, optimising bladder and bowel function including voiding and defecation dynamics. Pelvic floor muscle rehabilitation may be included in the management.

Red Flags:

Further investigation or referral to specialist is indicated when incontinence is associated with, or accompanied by:

Persistent or recurring urinary tract infections.
Dysuria, persisting bladder or urethral pain.
Haematuria, glycosuria or persistent proteinuria.
Inability to empty bladder or straining to empty.
Post void residual volume >200ml.
Nocturnal enuresis.
Rectal bleeding or unexplained vaginal bleeding.
Recent sudden alteration of bowel habits with no obvious explanation.
Persistent vulvo-vaginal itching area or undiagnosed vulval or rectal dermatological conditions.
Pelvic organ prolapse (POP) past introitus causing difficulty emptying bladder.
Pelvic masses, unexplained weight loss or unremitting night pain.
Suspected neurological disease e.g. MS, Parkinson’s disease, stroke, dementia or spinal cord symptoms, such as muscle weakness/wasting, altered reflexes, altered sensation (generally and saddle region), inability to empty bladder, loss of sensation when voiding.
Suspected urogenital fistulae.

Sypmtoms of Pelvic Organ Prolapse (POP):

POP is the herniation of pelvic organs through the urogenital diaphragm into the vagina or beyond.
Feeling of a bulge or heaviness in the genital area.
Urinary and/or faecal incontinence.
Difficulties passing urine or stool.
Pelvic pain and sexual dysfunction.

Contributing factors:

Repetitive coughing or sneezing.
Obesity/Increased BMI.
Defaecation dysfunction.
Hormonal status.
Excessive loading with lifting or exercise.

Assessment and management:

In the absence of pathology, refer to a Continence and Women’s Health Physiotherapist.
Physiotherapy assessment will include a detailed history, vaginal examination and pelvic floor muscle assessment.
Physiotherapy management of contributing lifestyle factors, optimisation of bowel function (reducing constipation), and pelvic floor muscle rehabilitation. A vaginal pessary may be recommended to assist return to more active lifestyle.

Red Flags:

Further investigation or referral to specialist is indicated when incontinence is associated with, or accompanied by:

Persistent or recurring urinary tract infections.
Dysuria, persisting bladder or urethral pain.
Haematuria, glycosuria or persistent proteinuria.
Inability to empty bladder or straining to empty.
Post void residual volume >200ml.
Nocturnal enuresis.
Rectal bleeding or unexplained vaginal bleeding.
Recent sudden alteration of bowel habits with no obvious explanation.
Persistent vulvo-vaginal itching area or undiagnosed vulval or rectal dermatological conditions.
POP past introitus causing difficulty emptying bladder.
Pelvic masses, unexplained weight loss or unremitting night pain.
Suspected neurological disease e.g. MS, Parkinson’s disease, stroke, dementia or spinal cord symptoms, such as muscle weakness/wasting, altered reflexes, altered sensation (generally and saddle region), inability to empty bladder, loss of sensation when voiding.

Symptoms of Vaginal Pain (including Vulvodynia):

Pain on vaginal examination or PAP smear (women of any age).
Pain inserting or removing tampons.
Superficial or deep pain of the vulva or vagina with sexual intercourse.
Primary vaginal pain (no previous sexual experience that was pain free) or secondary vaginal pain (prior experience of pain-free intercourse).
Vulval or vaginal pain provoked by specific activities, clothing, soaps or other topical applications (vaginal pain can also be non-provoked).

Contributing Factors:

Increased pelvic floor muscle tension.
Prior obstetric injury or perineal repair/scar tissue.
Peripheral tissue sensitivity.
Dermal conditions: Candidiasis, Atrophic Vaginosis, Bacterial Vaginosis, Fungal infections, Lichen’s Sclerosis, or other.
Centrally driven pain: Chronic pain, specific pain event, increased stress levels, emotional/psychological event or trauma.

Assessment and Management:

In the absence of pathology, refer to a Continence and Women’s Health Physiotherapist.
Physiotherapy assessment is likely to include: a detailed history; vulval/vaginal examination; pelvic floor muscle assessment; abdominal and pelvic muscle assessment.
Physiotherapy management may include: education about persistent pain; pain management strategies; stress management; paced exercise; pelvic floor muscle rehabilitation; education about sexual function; devices such as dilators to assist graduated exposure to intercourse/having a vaginal examination.
If vaginal pain is longstanding, management often requires a multidisciplinary approach.

Red Flags:

Further investigation or referral to specialist is indicated when incontinence is associated with, or accompanied by:

Persistent or recurring urinary tract infections.
Dysuria, persisting bladder or urethral pain.
Haematuria, glycosuria or persistent proteinuria.
Inability to empty bladder or straining to empty.
Post void residual volume >200ml.
Nocturnal enuresis.
Rectal bleeding or unexplained vaginal bleeding.
Recent sudden alteration of bowel habits with no obvious explanation.
Persistent vulvo-vaginal itching area or undiagnosed vulval or rectal dermatological conditions.
Pelvic organ prolapse (POP) past introitus causing difficulty emptying bladder.
Pelvic masses, unexplained weight loss or unremitting night pain.
Suspected neurological disease e.g. MS, Parkinson’s disease, stroke, dementia or spinal cord symptoms, such as muscle weakness/wasting, altered reflexes, altered sensation (generally and saddle region), inability to empty bladder, loss of sensation when voiding.

Other Bladder/Vaginal Symptoms

Sensory Symptoms:

Increased, reduced or absent bladder sensation with filling.

Extended periods of time without an urge to void.

Leaking without a desire to void.

Insensible loss.

Intense, sudden urge to void with insufficient time to reach the toilet.

Bladder pain.

Contributing Factors:

Neurological disease.

Peripheral nerve dysfunction.

Chronic pain.

Side effects of medications (including natural remedies).

Prior bladder injury or trauma.

Repeatedly holding on with large bladder volumes.

Assessment and Management:

In the absence of pathology, refer to Continence and Women’s Health Physiotherapist or Continence Nurse.

Physiotherapy assessment may include a detailed history, bladder diary and screening of post void residual.

Physiotherapy management includes education about maintaining normal void volumes, healthy bladder/bowel habits, pain management and education about sensitising factors, normalising pelvic floor muscle function.

Red Flags:

Further investigation or referral to specialist is indicated when incontinence is associated with, or accompanied by:

Persistent or recurring urinary tract infections.

Dysuria, persisting bladder or urethral pain.

Haematuria, glycosuria or persistent proteinuria.

Inability to empty bladder or straining to empty.

Post void residual volume >200ml.

Nocturnal enuresis.

Rectal bleeding or unexplained vaginal bleeding.

Recent sudden alteration of bowel habits with no obvious explanation.

Persistent vulvo-vaginal itching area or undiagnosed vulval or rectal dermatological conditions.

Pelvic organ prolapse (POP) past introitus causing difficulty emptying bladder.

Pelvic masses, unexplained weight loss or unremitting night pain.

Suspected neurological disease e.g. MS, Parkinson’s disease, stroke, dementia or spinal cord symptoms, such as muscle weakness/wasting, altered reflexes, altered sensation (generally and saddle region), inability to empty bladder, loss of sensation when voiding.

Voiding symptoms:

Hesitancy, slow or intermittent stream.

Straining to void.

Sense of incomplete emptying or needing to immediately re-void.

Contributing Factors:

Reduced fluid intake.

Inadequate voiding volumes.

Pelvic organ prolapse or obstructed outlet.

Pelvic floor muscle dysynergia.

Suboptimal voiding mechanics.

Assessment and Management:

In the absence of pathology, refer to Continence and Women’s Health Physiotherapist or Continence Nurse.

Physiotherapy assessment may include: a detailed history, uroflowmetry where available, screening for post void residual, bladder diary, pelvic floor muscle assessment.

Physiotherapy management includes instruction in voiding techniques, healthy bladder and bowel habits, management of pelvic floor muscle dysfunction.

Continence nurse may teach clean intermittent self-catheterisation where required.

Red Flags:

Further investigation or referral to specialist is indicated when incontinence is associated with, or accompanied by:

Persistent or recurring urinary tract infections.

Dysuria, persisting bladder or urethral pain.

Haematuria, glycosuria or persistent proteinuria.

Inability to empty bladder or straining to empty.

Post void residual volume >200ml.

Nocturnal enuresis.

Rectal bleeding or unexplained vaginal bleeding.

Recent sudden alteration of bowel habits with no obvious explanation,

Persistent vulvo-vaginal itching area or undiagnosed vulval or rectal dermatological conditions.

Pelvic organ prolapse (POP) past introitus causing difficulty emptying bladder.

Pelvic masses, unexplained weight loss or unremitting night pain.

Suspected neurological disease e.g. MS, Parkinson’s disease, stroke, dementia or spinal cord symptoms, such as muscle weakness/wasting, altered reflexes, altered sensation (generally and saddle region), inability to empty bladder, loss of sensation when voiding.

Other Urinary Incontinence Symptoms:

Continuous urinary incontinence.

Insensible urinary incontinence.

Coital incontinence.

Post-micturition dribble.

Contributing Factors:

Constipation.

Sphincter insufficiency.

Poor voiding dynamics.

Poor bladder habits.

Pelvic floor muscle weakness.

Assessment and Management:

In the absence of pathology, refer to Continence and Women’s Health Physiotherapist or Continence Nurse.

Physiotherapy assessment may include a detailed history, vaginal examination and pelvic floor muscle assessment.

Physiotherapy management includes education about contributing lifestyle factors, optimising bladder and bowel function including voiding and defecation dynamics. Pelvic floor muscle rehabilitation may be included in the management.

Red Flags:

Further investigation or referral to specialist is indicated when incontinence is associated with, or accompanied by:

Persistent or recurring urinary tract infections.