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Chapter 10: Urogynaecology and Pelvic Floor Problems — Summary

Author: Ranee Thakar

Applied Anatomy

The pelvic floor is anchored by the levator ani muscle (comprising the puborectalis, pubococcygeus, and iliococcygeus), which maintains constant contraction to support pelvic organs. Three levels of fascial support exist:
  • Level 1 (apical): Uterosacral ligaments suspend the uterus/vaginal vault to the sacrum
  • Level 2 (mid-vaginal): Pubocervical and rectovaginal fascia attach laterally to the pelvic side wall
  • Level 3 (perineal): Posterior vaginal fascia fuses to the perineal body

Urinary Symptoms & Continence Mechanisms

The micturition cycle involves detrusor relaxation during filling (parasympathetic control) and coordinated sphincter relaxation before voiding. The urethral sphincter system includes internal (smooth muscle) and external (striated muscle) components, innervated by sympathetic and pudendal (somatic) nerves respectively.
Key symptom categories:
  • Storage: frequency, nocturia, urgency, urge incontinence, stress incontinence, nocturnal enuresis
  • Voiding: slow stream, hesitancy, intermittent stream, terminal dribble
Stress incontinence results from urethral hypermobility (most common) or intrinsic sphincter deficiency. Prevalence: 29–75%. Risk factors include vaginal delivery, forceps, obesity, postmenopause, and chronic cough.
Overactive bladder (OAB) syndrome: urgency ± frequency/nocturia ± incontinence, in the absence of infection. Prevalence ~20%.

Clinical Assessment

  • Detailed history (symptom type, severity, bother, red flags such as haematuria)
  • Physical examination (abdominal + pelvic, Sim's speculum, pelvic floor strength, stress test)
  • Basic investigations: urinalysis, 3-day bladder diary
  • Further investigations: post-void residual, pad test, ultrasound, urodynamic studies (multichannel cystometry — reserved for complex/failed conservative cases), cystourethroscopy

Treatment for Incontinence

Conservative (first-line for all):
  • Fluid/caffeine modification, weight loss
  • Pelvic floor muscle training (PFMT): 3×/day for ≥3 months — women with stress UI are 6× more likely to report cure vs. controls (74% vs. 11%)
  • Bladder retraining: gradually extending voiding intervals to 2.5 hours; used for OAB/mixed incontinence
Medical:
  • Anticholinergics (oxybutynin, tolterodine, solifenacin, fesoterodine, trospium) — first-line pharmacotherapy for OAB; side effects include dry mouth, constipation, blurred vision; caution with dementia/cognitive impairment
  • Mirabegron (beta-3 agonist) — enhances detrusor relaxation; can combine with anticholinergics
  • Topical vaginal oestrogen — postmenopausal women with urgency
  • Duloxetine — occasionally used for stress incontinence (SNRI; increases sphincter tone)
Surgical (when conservative management fails):
  • Stress incontinence: midurethral tapes (TVT/TOT — 80–85% cure), pubovaginal fascial sling, retropubic colposuspension (80–85% cure), urethral bulking agents (60–80%, less durable)
  • OAB: Botulinum toxin A (50–80% reduction in symptoms; 8–15% voiding difficulty risk), sacral neuromodulation
  • Mesh/tape use is currently restricted in the UK

Pelvic Organ Prolapse

Types: Cystocele (anterior), urethrocele, rectocele (posterior), enterocele, uterine prolapse, vaginal vault prolapse (post-hysterectomy)
Staging (POP-Q system): Stages 0–IV based on descent relative to the hymen
Symptoms: vaginal bulge/heaviness, voiding or bowel difficulty, sexual dysfunction, lower back pain
Management:
  • Conservative: PFMT (≥4 months for mild/moderate prolapse), vaginal pessaries (ring, shelf, Gellhorn — replaced every 6 months)
  • Surgical: anterior/posterior repair, sacrospinous fixation, sacrocolpopexy (abdominal — most durable for vault prolapse), colpocleisis (obliterative). Vaginal mesh for prolapse is currently banned in the UK.

Anal Incontinence

Involuntary passage of flatus or faeces. The internal anal sphincter (smooth muscle) maintains 70% of resting pressure; damage causes passive leakage. The external anal sphincter (striated muscle) provides voluntary squeeze; damage causes urge-related faecal incontinence.
Affects ~10% of adults. Obstetric sphincter injury (~3.5% of vaginal deliveries) is the most common cause in young women.
Assessment: Anal manometry, endoanal ultrasound, validated questionnaires (Vaizey, Wexner)
Management:
  • Conservative: dietary modification, loperamide/codeine, PFMT, biofeedback, electrical stimulation
  • Surgical: sphincter repair, sacral nerve modulation, bulking agent injection
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