Having tests and examinations for urogynaecological conditions

This section covers:

  • The different tests and examinations for urogynaecological symptoms
  • Pelvic examinations
  • Tests about urine flow and control (urodynamics)
  • Tests for urine infections
  • Scans and investigative procedures

In this section we use the terms:
Pelvic organ prolapse (prolapse) is a condition in which pelvic organs, like the bladder and uterus (sometimes called the womb), move down or slip out of place and may bulge into the vagina.

Urinary incontinence is the unintentional loss of wee/urine. There are other bladder symptoms that do not involve incontinence, such as needing to urinate a lot, getting up at night a lot for a wee, or difficulties emptying the bladder.

UTIs (Urinary Tract Infections) are when bacteria infect the system that stores urine (such as the bladder). There are other types of conditions that can involve bladder irritation and pain, such as interstitial cystitis (also called bladder pain syndrome).

The different tests and examinations for urogynaecological symptoms

There are different types of tests and examinations for urogynaecological symptoms. These include pelvic examination, tests such as urodynamics or urinalysis (e.g. a dipstick urine test), and procedures such as ultrasound and surgical investigations like cystoscopy (where a camera is used to look inside the bladder). Many people we talked to had several different types of tests and examinations.

Kerry describes the process of attending the first appointment with her GP and finding out what her symptoms meant.

Some tests and examinations can be done by a GP or nurse at a GP clinic; others by a specialist, such as a urogynaecology doctor or nurse, or a pelvic floor physiotherapist. Some types of tests need particular equipment or facilities, or for a healthcare professional to have specialist training.

Examinations and tests for urogynaecological symptoms can lead to a diagnosis and give information, such as the severity or ‘grade’ of prolapse. The results of tests and examinations may be known and shared with the patient right away, or it may take a while to find out this information. Some people we talked to had not yet had any examinations or tests for urogynaecological symptoms. Others had several different types of tests.

Having tests and examinations to rule out other conditions or causes could be difficult, especially if the tests were unpleasant, invasive, or take a long time to be arranged and get results back. Penny described going through lots of “prodding and poking and testing… to try and find out what’s gone wrong”. The gynaecologist Vicky saw about bladder pain and urinary symptoms seemed to have “his own agenda that other things needed to be ruled out first”.

Dr. Sharon Dixon, a GP, describes the thought processes a GP might go through when they see a patient with bladder, urinary or pelvic symptoms, and why it’s important to rule out other causes.

Because healthcare professionals often do lots of medical tests and examinations on patients as part of their job, it can feel very normal and ordinary to them. For patients though, it can feel overwhelming, embarrassing and confusing. Alice wished she had been given more information in advance about the tests she had at hospital, as they were different to what she had expected.

Phoebe felt that her specialists sometimes spoke about her like a “slab of meat”, and lost sight of explaining things that were unfamiliar to her.

Pelvic examinations

Pelvic (or internal) examinations are a physical check of the reproductive organs. The patient is usually lying down, or they may stand or turn on their side as part of the examination. A tool called a speculum may be used to open up the vagina walls to help see inside the vagina. As well as looking, the healthcare professional may touch the vulval area (the outer part of the female sex organs) and vagina as part of the examination.

Sharon requested to be examined standing up, in addition to lying down, to get more information about her prolapses.

People can ask to have a chaperone in the room with them for a pelvic examination. Vickie appreciated the “camaraderie” of the chaperone when she had an internal examination at her GP surgery around 8 weeks after giving birth. The patient can ask the healthcare professional performing the pelvic examination to stop at any time.

Dr. Sharon Dixon, a GP, recognises that internal examinations can be difficult for some patients and how she might support someone who has concerns.

For most people we talked to, a few minutes of discomfort or embarrassment during a pelvic exam were seen as worthwhile in order to be properly checked over. Cynthia appreciated that her GP “had a quick look” and was “very straightforward” in confirming she had a prolapse. Sue Y saw it as “just one of those things you have to do” and that “it doesn’t really bother me”. Sue X says that, since having children, she feels “less precious” about pelvic examinations.

Jan encourages uptake of pelvic examinations to get answers.

A few people talked about insensitive or inappropriate comments during the examinations, which made them feel vulnerable. A physiotherapist asked Catherine if she needed a poo during a pelvic examination, which left her “really paranoid” about losing control of her bowels. Chloe said it was very important for healthcare professionals to help patients feel “comfortable and relaxed” before and during a pelvic examination.

Sometimes there were additional reasons why someone might find a pelvic exam particularly distressing, including past experiences of traumatic medical events or sexual abuse.

Jessy hasn’t seen a doctor about her urinary incontinence, as she expects she would need an internal examination. She had distressing previous experiences of internal examinations and having a coil fitted.

Vickie, Pauline, and Sharon, amongst others, had experienced times when healthcare professionals seemed reluctant to do a pelvic exam. Vicky felt that her consultant made assumptions: “I felt [that he thought] he was doing me a favour by saying he wouldn’t examine me, wouldn’t put me through an examination, whereas I actually wouldn’t have had any issue with being examined… [if] it might have helped diagnose my issues”. When women had directly asked for a pelvic examination but had not been given one, or instead, like Sharon, only a “cursory external exam” it felt the healthcare professional was not taking their health concerns seriously.

Vickie asked her GP to examine her at the 6-8 week postnatal check. Her GP seemed reluctant and she initially felt “a little bit guilty” about this, but then felt “cross” that she had needed to insist.

Several years ago, Pauline went to her GP with suspected prolapse symptoms. She felt her GP was not interested in examining her, which she thought was to do with NHS funding cuts.

A few people said they would rather have a female doctor or nurse do the pelvic exam. Jessy explained that she would “just feel really uncomfortable” with a male doctor. Jenny tended to see a female GP, but wondered if this meant they then get “fed up” of doing intimate examinations. Others, like Mary X, said they didn’t mind about the gender of the healthcare professional. Chloe felt that “expertise, experience, knowledge” was more reassuring than “lived experience or gender”.

Tests about urine flow and control (urodynamics)

Urodynamics are tests usually done at hospital which measure urine flow, control, and retention. These tests were sometimes used to rule out other problems, for example Leah had urodynamics to check that “there’s nothing structurally wrong with you that could be meaning that you’d get increased UTIs”.

For a few days before having urodynamics, ‘bladder diaries’ were often completed, which involved measuring and recording fluid input (how much they drink) and output (how much they wee out) at home, as well as the types of liquids someone drinks.

Minnie had to measure her urine input and output in order to complete paperwork for incontinence pads. She found the process challenging, and it left her feeling “very, very tired and very, very down”.

There are various urodynamic tests and techniques, and these can vary from place to place and over time. Some tests look at the amount and speed of urine released. Others look for urinary leaking with particular activities, like jumping or coughing. Devices like probes and catheters may also be used as part of these tests, as for Katy, Emma, Elizabeth, and Mary Y. Megan and Elizabeth had ultrasound as part of urodynamics to check for urine retention.

Vicky describes what happened when she went for urodynamics.

Looking back, some people had found the urodynamic tests unpleasant and embarrassing. Emma described the process as “just quite bizarre”, particularly because it was in the corner of a ward rather than a consulting room. Mary Y found it “mortifying” and Vicky said it was “quite undignified”.

Gwen had a “dreadful” experience of urodynamic testing.

Megan felt “vulnerable” when she had urodynamics, but praised the healthcare professionals who were “very supportive” and put her “at ease”.

Having information in advance about the tests and potential side-effects was important. Vicky had received a helpful booklet which highlighted that she should drink plenty of water afterwards and that there was a risk of UTI. But Alice felt that she hadn’t been told enough.

Alice attended hospital for a flow test. This was not a good experience, as she hadn’t been given any instructions beforehand, was separated from her parents, and the process was different to what she had expected.

Tests for urine infections

Tests which look at and analyse the contents of urine are used to diagnose urinary tract infections (UTIs). One of the most common urine analysis tests is a ‘dipstick test’, in which a paper strip changes colour if certain substances are present when dipped into a sample of urine. Other types involve sending a urine sample off to a laboratory to grow a culture to identify a particular bacteria causing the infection. Lab-based tests can give more information, for example, about the best antibiotics for a specific type of infection, but it does mean waiting for results. Gwen had also bought UTI test kits, which are sold online and in some shops, to use at home.

There were some practical issues raised about urine samples. Anita pointed out that it is not always very easy to produce a urine sample on demand, for example at a GP appointment, especially when you don’t have a full bladder. Clare found that getting access to drop off a urine sample at a GP clinic was difficult during the pandemic. Rebecca had a urine sample go missing because of a miscommunication when it was sent off to a lab.

Jasmine’s GPs managed her UTIs as one-offs and didn’t seem to be interested in the recurrence or underlying causes. She had just moved to the UK, and worried she might be seen as a “hypochondriac”.

Urinary infection tests were an important topic for everyone diagnosed with recurrent, embedded or chronic UTI. Holly, Phyllis, Leah, Melanie, and others, described frustration and concern about the common use of midstream urine (MSU) samples and dipstick tests. They had been told that these test results were negative (indicating no infection) when they had ongoing symptoms, and felt the tests had been wrong. Leah described “a ‘computer says no’” situation: test results come back negative and, in her experience, most doctors won’t then prescribe antibiotic treatment.

Jane has read research about urinary infection tests. She would like healthcare professionals to treat symptoms and to place less value on current tests.

Those people now diagnosed with embedded or chronic UTI felt that healthcare professionals had tried to ‘explain away’ their ongoing symptoms when they had a negative urine test result. Mehar’s GP suggested “therapy instead of doing further tests” and she started to think “maybe it is in my head”. Jane started doubting herself too: “I must be better because the dipstick said I was better”.

A few people had been told that there was a problem with their urine sample. Holly and Jane were told that their urine had ‘mixed growth’; they later learnt this meant that the lab thought their urine sample had been contaminated (for example, when the sample was collected or by bacteria from the outside of the container). Parminder and Jane had been told that blood in their urine samples must be menstrual blood, even though they knew this was not the case.

Leah has a diagnosis of chronic UTI. She would like the NHS website section on interstitial cystitis to say more about the limits of dipstick urine tests.

Some women who felt that the urine tests available from NHS GPs were not picking up infections had since gone to private clinics. Here, other types of urine tests, like the ‘broth test’, where a urine sample is incubated in a ‘broth’ and tested over time, were available. After being told repeatedly that she didn’t have a UTI based on dipstick tests, it was “really important” for Leah to “hear that validation” when a test at a specialist UTI clinic identified an infection. Laura has urine tests every few weeks at a private clinic, to track any improvements on the long-term antibiotics.

Scans and investigative procedures for urogynaecological symptoms

Other tests and investigations for urogynaecological symptoms include ultrasounds, MRI scans, and cystoscopy (a procedure which use a camera to look inside the bladder). Not all of these tests are routinely offered on the NHS, and some people we talked to had them privately. These tests were often suggested to patients after they had already had some tests and examinations. This was the case for Laura who first had urine analysis and flow tests, and then an ultrasound. She was also offered the option of having an MRI or cystoscopy, but she decided these probably wouldn’t be helpful and would be too costly as a private patient.

As with other tests and examinations, scans and investigative procedures can identify or rule out problems related to urogynaecological symptoms, and sometimes also identified other health issues.

Laura was unexpectedly told at an ultrasound for UTI problems that she might also have cysts on her ovaries and possible endometriosis.

Georgina, Helen, Anna, and others had ultrasound scans of the bladder and/or kidneys. Helen also had an MRI to investigate bladder symptoms. Most people we talked to had found these scans okay, but urine retention is a possible complication after an ultrasound that Alice experienced.

Alice had an ultrasound of her bladder and kidneys. Afterwards, she had some retained urine and was readmitted to hospital, which was frightening as she was shielding at the time.

Helen, Vicky, Amy, Laura, and Mehar also had pelvic ultrasounds. Amy hadn’t been offered any tests until she saw a doctor privately. Vicky had an ultrasound which found uterine fibroids which initially she and her doctors thought might be causing her urinary symptoms, by pressing on her bladder. Amy’s ultrasound showed she had a levator avulsion (a birth injury in which the levator muscles are stretched or torn), which is associated with prolapse. She found it helpful to know about this, and thinks that all women with urogynaecological and pelvic floor problems should be offered these scans to get “a fuller assessment of what’s wrong”.

Cystoscopy is a procedure that inserts a tube with a camera to look inside the bladder and urethra. The images produced can help find the causes behind frequent UTIs, bladder pain, or urinary incontinence. Georgina, Holly, Leah, and others had cystoscopies.

Holly has had several cystoscopies (a procedure to look inside the bladder) for UTIs. She describes two types of cystoscopy, and the outcomes she’s had from these investigations.

For some people, these procedures could be painful or invasive. Leah was in quite a lot of pain afterwards, and several people like Rebecca talked about weighing up the risks of side-effects like new UTIs and flare-ups. Phyllis developed a UTI after one of her cystoscopies. Sue X also underwent bladder imaging, which she didn’t find troublesome at all.

After having a cystoscopy, Helen found the recovery afterwards difficult. She thinks it was helpful to have biopsies taken and cancer ruled out.

Sue X didn’t feel affected emotionally by her bladder imaging. She thinks this may be related to having children, which she found “changes your perception” of invasiveness.

Procedures like cystoscopy can be investigative, but they are also part of the process in some surgical treatment procedures. This was the case for Mehar, who also had Botox injections into her pelvic floor muscles, and Megan and Phyllis, who had bladder instillations.

Some people we talked to also had investigations into their bowels. Elly had had a sigmoidoscopy (an imaging procedure looking inside the colon and rectum). Holly had a gastroscopy and colonoscopy (imaging procedures to look at the upper part of the digestive system and colon) to rule out other causes for UTI problems. Elly and Sophie had both had MRI proctograms, which look at the way the rectum empties and how the pelvic muscles and bladder work when pooing. This procedure helped diagnose Elly’s rectocele (when the rectum protrudes into the uterus), and Sophie’s rectal prolapse (when the rectum protrudes down or through the anal opening). Sophie praised the healthcare professionals she saw, saying that, “as invasive as they [MRI proctograms] are and how undignified, …I was always treated with the utmost care and dignity… it’s not as horrific as it sounds”.