Q-tip Test

[Jenine Killebrew]

Anypart of the vulva can be symptomatic with irritation, itching, stinging, burning, or pain. There may be tenderness from a known cause such as atrophy, lichen planus or other dermatosis, infection with Candida albicans, neoplasm, post-herpetic neuralgia, chronic contact with an irritant, or other myriad sources. There may also be discomfort from an unknown cause, i.e. there may be no identifiable lesion, nothing to see at all on inspection.

In order to help your patient, you must locate her symptoms precisely, with close attention to whether the tender areas are associated with physical findings or not. You must map systematically to identify each symptom in its exact location and to discern patterns that will help with diagnosis. It is important to remember that women may be unaware of tender foci. That is, their sensations may appear to be more generalized to them, until you ask, in the setting of the exam room, about specific foci. Discussion is not enough. Pain and symptom mapping through targeted touch is essential for diagnosis and can be quickly performed once it is part of your systematic approach.

It is possible to have tenderness to touch with the Q-tip from 1-10 in a patient with no spontaneous pain. It is possible to have zero tenderness to touch with the Q-tip but spontaneous pain from 1-10. Both spontaneous pain and tenderness may occur together.

Documentation of pain mapping sites and quantification of the pain from 0-10 will give you an idea of the location and the severity of the pain (scores over five are considered moderate to severe pain) and will allow you to compare pain scores from visit to visit to evaluate progress.

The vulvar vestibule, derived from endoderm, is subject to all the epithelial diseases of mucosa, as well as to allergy, inflammation from sexual activity, mechanical irritation, or elimination. Nevertheless, it is an area unfamiliar to clinicians, who fail to give it adequate attention in their quest to place the speculum for Pap smear. It is unknown to women as well.

The definition of vulvar vestibulitis syndrome, now called provoked or spontaneous (unprovoked) vulvodynia, has changed over the years as clinicians and researchers have tried to understand it. (Annotation K: Vulvar pain and provoked and unprovoked vulvodynia).

Pain on touch or pressure in the vestibule with no identifiable cause, including normal pH and microscopy and serial negative yeast cultures, allows the diagnosis of provoked localized vulvodynia (vulvar vestibulitis, vestibulodynia).While the Q-tip test has become synonymous with this diagnosis, positive findings have a variety of other interpretations.

ReferencesFriedrich EG Jr. Vulvar vestibulitis syndrome. J Reprod Med. 1987; 32:110-114.Key Points to Annotation I: Pain and symptom mapping and the Q-tip test History alone is inadequate for documenting exact location of symptoms; women often cannot define location, and there may also be areas of tenderness that women are unaware of. Start with request for patient to point with one finger to the area. Explain quantification of symptoms from 0-10 by comparing touch on symptom free area (thigh = 0) with touch in affected area. Map the symptoms using the 0-10 touch process, moving in sequence from labiocrural folds to the vestibule. Perform Q-tip test of the vestibule, also using 0-10 touch score. Review the multiple interpretations of positive testing.CloseA Pathway to Diagnosis and Treatment. Clear steps to clinical proficiency beyond yeast, bacterial vaginosis, and STIs.

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UDS may be considered the most reliable test for achieving an objective preoperative evaluation of patients with SUI5, given that it allows to measure the leak point pressure (LPP), which in turn provides insight on the underlying mechanism4,6. However, even if theoretically the urodynamic study (UDS) optimizes the selection of cases and the choice of surgical procedures, to date there is no consensus on whether performing UDS results in better surgical outcomes7,8. Therefore, interest has been raised about the value of other tests to guide the diagnosis of ISD and/or to predict its surgical outcome.

The Q-tip test offers a simple, office-based approach for identifying urethral hypermobility. It is performed by introducing a cotton swab through the urethral meatus to the bladder neck, and measuring its displacement with a goniometer during Valsalva maneuver. Although is invasive and that several European guidelines (e.g. EAU, NICE/UK, French) either do not offer comment or recommend its use it is still considered in American guidelines such as the latest Surgical Treatment of Female Stress Urinary Incontinence (SUI): AUA/SUFU Guideline9 and we can see on recently published evidence that it is still part of the repertoire of available diagnostic and follow-up tests for stress urinary incontinence for certain study groups10,11. Q-tip ability in predicting UDS findings is still unclear for the above our aim is to assess the level of correlation and agreement between ALPP and the degree of urethral mobility measured by the Q-tip test in females with SUI.

Institutional review board of clinical studies and ethics committee approval was obtained (Protocol no. CCEI-2158-2013) at Fundacin Santa Fe de Bogot. The study was developed following good clinical practices and the declaration of Helsinki in compliance with ethical institutional and international standards.

Females with complaints if SUI, aged 18 years and older who attended our Incontinence Care Center between September 2014 and September 2016 were eligible. Patients had to qualify and consent for assessment UDS.

Exclusion criteria were: to suffer from any neurological condition affecting the function of the urinary tract, history of urethral stricture, acute urethral inflammatory disease, active urinary tract infection, urodynamic evidence of detrusor overactivity, history of Onabotulinum Toxin A bladder neck injection in the last 6 months, and suffering from any active mental or psychiatric conditions that may hinder adequate completion of the medical consultation, UDS or questionnaires. A small group of patients presented symptoms corresponding to over active bladder but they are the resulting patients who have stress UI with some urge component.

Stress test is performed in the absence of detrusor overactivity, at approximately half the maximum bladder capacity. Also, above 100 mL of instilled volume, patients are asked to cough every 100 mL and if leakage occurs, it is recorded. First sensation and urinary urgency are also recorded. The ALPP was recorded as the lowest value of intentionally increased intravesical pressure that provokes urinary leakage in the absence of a detrusor contraction, following the ICS1.

Based on these prior results we aimed to find a correlation between ALPP and Q-tip test results that would aid in predicting ISD, but, although we found that 58.8% of woman with diverse SUI severity had a positive Q-tip test, correlation and concordance between these two variables was poor, even after selecting for severity using high ICIQ-UI scores by creating a composite variable.

Similar to our study, Kreder et al.28 implied in a retrospective study evaluating women subjected to sling cystourethropexy and periurethral collagen injection based on whether ISD was present or not. Among ISD patients, 20 (40%) had urethral hypermobility, 7 (35%) of which had a prior history of incontinence surgery. Regarding this issue, the differentiation between the two conditions is recognized as a historical fact but of limited clinical value as it is widely recognized that a certain degree of ISD may be associated with urethral hypermobility leading to an overlap between these two conditions28,32.

Strengths of this study include its longitudinal prospective design which reduces recall bias in evaluating UI symptoms and a standardized technique for UDS. Limitations may be provided by the fact that physical examination and the Q-tip were performed by different examiners which may give rise to interobserver differences, however standardization of the technique and compliance to good urodynamic practice guidelines were employed to mitigate this risk.

Our results show that neither the degree of urethral mobility, nor the composite variables correlate or agree with urethral function tests in UDS, specifically LPP; suggesting ALPP cannot be predicted using the Q-tip test or the ICIQ-SF for classifying patients with ISD-SUI.

Negative results provided by our study should thus be viewed in regard to the bulk of evidence pointing to ISD being a complex entity. ISD diagnosis requires an amount of clinical suspicion, thorough history and physical evaluation, and cumbersome testing, in most cases incorporating invasive urodynamic and videourodynamic evaluation; all of this directed to prevent recurrence, treatment failure and retreatment, which ultimately affects the patient and her quality of life.

D.R.: Protocol development, project administration, data collection and management, data analysis, manuscript writing and editing. L.Z.: Data analysis, manuscript writing and editing, paper submission. A.B.: Project administration, data analysis, and manuscript editing. C.D.: Protocol development, data collection and manuscript editing. C.G.T.: Manuscript writing and editing. J.I.C.: Manuscript writing and editing M.R.: Data analysis, biostatistics and epidemiological supervision. J.A.: Manuscript editing. M.P.: Protocol and project development, manuscript writing and editing, overall supervision of the project. We, as authors, have no commercial or financial incentive associated with the writing and publishing of this manuscript. As such, this work is the product of self-invested effort undertaken without charge, accomplished through task-directed teamwork. Moreover, our research group is structured by several urology specialists (J.I.,C. C.G.T., J.A. and M.P.) that oversee and mentor the work of Research Fellows & Residents (C.D., A.B., L.Z., and D.R.). As none of the aforementioned has formal training in biostatistics, Rondn M. guides and supports us with his statistical and epidemiological knowledge. First authorship is granted on the basis of the amount of work handled and continuity. Senior authorship is granted on the basis of expertise on the topic and therefore provides overall consistence approval.

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