6. Observation / Physical Examination
These notes are for use together with the Colley Model.
A physical examination is carried out by a competent professional, with the informed consent of the patient (in line with local policy and national guidelines). The assessing clinician will be either a registered clinician or a qualified Assistant Practitioner or Nursing Associate (Foundation degree) as a minimum qualification. In addition they will have received specific competency based training in bladder and bowel (continence) assessment and will be able to demonstrate they have kept their knowledge and skills up to date. In advance of the assessment, a chaperone must be offered to the patient (male or female).
Included in a physical examination will be:
Visual assessment of the abdomen and genitalia may reveal previous surgery scars, hernia (rupture), a significantly enlarged bladder or pelvic mass, prolapsed rectal mucosa, haemorrhoids, skin conditions for example, psoriasis or lichen sclerosus, skin excoriation and damage and any discharge. In the female patient, organ prolapse, and in the male patient, hydrocele, epispadias or hypospadias (a congenital abnormality in which the urethra opens on the upper or underside of the penis). Record any abnormalities present. Women with urinary incontinence who have a symptomatic prolapse should be referred to a specialist (NICE, 2019).
Safeguarding vulnerable adults: Please note that signs of neglect or abuse might also be found during physical examination and the healthcare professional must know what action they must take if this is suspected or reported to them.
The abdomen will be palpated for any obvious enlarged bladder, pelvic mass, loaded colon and any other abnormalities.
Measuring any urine which remains in the bladder after voiding is an invaluable aid to diagnosis. If the assessor has this option available (i.e., access to a portable bladder scan device and has been trained to undertake this procedure), it can be done here otherwise this test can be considered again under number 12. However, if there is an obvious enlarged bladder, the patient must be referred for further advice and a bladder scan.
Assess the condition of the skin, any excoriation, sores, obvious abnormalities, infection, inflammation or discharge. Note any tightness of the foreskin in male patients. Note previous circumcision (male) and suspected female genital mutilation (FGM). If FGM is found discuss with patient and seek safeguarding advice. Observe for vaginal atrophy, obvious infection, inflammation or sclerotic changes and for any leakage from the urethra on coughing. Observe the urethra for urethral caruncle in postmenopausal women (a soft, red fleshy protrusion of urethral lining from the urethral opening). Does not usually require treatment but document this and inform a senior clinician of any findings.
Observe for leakage of urine which appears to be draining from the vagina. Report and refer for further assessment.
RECTAL EXAMINATION (if clinically indicated)
Assess for the presence of faeces in the rectum and to determine the stool consistency using the
Bristol Stool Form Scale (download here) and amount.
A digital rectal examination (DRE) can be undertaken by a registered nurse who can demonstrate professional competence to the level determined by the Nursing and Midwifery Council (NMC) in its Code of professional conduct.
Other examination if deemed necessary, including vaginal examination, pelvic floor muscle assessment, specialised rectal examination and neurological examination, would require referral to a Specialist Clinician (registered clinician with post registration specialist training).
References and further reading:
General Medical Council (2013) Intimate examinations and chaperones, London: GMC. Download it here.
Lewis SJ, Heaton KW (1997) Stool form scale as a useful guide to intestinal transit time. Scandinavian Journal of Gastroenterology 32: 920–4
National Institute for Care and Health Excellence (2019) Urinary incontinence and pelvic organ prolapse in women: management. NICE guideline [NG123]. View it here.
Nursing and Midwifery Council (2020) The Code: Professional standards of practice and behaviour for nurses and midwives, London: NMC. View it here
Royal College of Nursing (2020) Genital Examination in Women: A resource for skills development and assessment Download it here.
Royal College of Nursing (2019) Bowel Care: Management of Lower Bowel Dysfunction, including Digital Rectal Examination and Digital Removal of Faeces. Download it here.