Urogynaecology & Pelvic Floor Problems — Summary

Applied Anatomy

• The levator ani (puborectalis, pubococcygeus, iliococcygeus) is the key pelvic floor muscle, maintaining constant contraction to support pelvic organs
• Three levels of fascial/ligamentous support:
  • Level 1 (apical): uterosacral ligaments suspend uterus/vaginal vault
  • Level 2 (mid-vagina): pubocervical and rectovaginal fascia attach to pelvic sidewall
  • Level 3 (distal): perineal body supports lower posterior vaginal wall

Urinary Symptoms & Incontinence

• Micturition cycle: detrusor relaxes during filling; voiding requires coordinated relaxation of pelvic floor + sphincter and detrusor contraction
• Stress incontinence: leakage with coughing/exertion; caused by urethral sphincter weakness (usually hypermobility); prevalence 29–75%
• Overactive bladder (OAB): urgency ± frequency, nocturia, urge incontinence; prevalence ~20%
• Risk factors for stress incontinence: multiparity, forceps delivery, obesity, postmenopause, connective tissue disease, chronic cough, alpha-blockers
• Risk factors for OAB: obesity, alcohol, smoking, neurological disease, previous hysterectomy

Clinical Assessment

• Detailed history: symptom type, severity, pad use, fluid intake, drug history
• Alert for red flags: haematuria, rectal bleeding, significant pain
• Investigations:
  • Midstream urine (all patients)
  • 3-day bladder diary
  • Post-void residual (if voiding dysfunction suspected)
  • Pad test, pelvic ultrasound (if indicated)
  • Urodynamics: reserved for failed conservative treatment, complex histories, or prior surgery
  • Cystourethroscopy: for haematuria, failed treatment, or suspected fistula/tumour

Treatment — Urinary Incontinence

• Fluid and caffeine modification; weight loss if BMI >30
• Pelvic floor muscle training (PFMT): 3×/day for ≥3 months; 6× more likely to achieve cure vs. no treatment
• Bladder retraining: gradually extend voiding intervals to 2.5 hours (for OAB/mixed)

• Antimuscarinics (oxybutynin, tolterodine, solifenacin, fesoterodine, trospium) — block muscarinic receptors; similar efficacy; side effects: dry mouth, constipation, blurred vision; avoid oxybutynin IR in elderly
• Mirabegron (beta-3 agonist) — enhances detrusor relaxation; alternative or add-on to antimuscarinics
• Topical vaginal oestrogen — for postmenopausal urgency/bladder symptoms
• Duloxetine — occasionally used for stress incontinence; 50% improvement in ~half of patients but poor tolerability (nausea)

• Midurethral tape (TVT/TOT): 80–85% cure rate, durable long-term; currently restricted in UK pending review
• Pubovaginal fascial sling: autologous tissue, abdomino-vaginal approach
• Retropubic colposuspension: 80–85% cure rate; risk of posterior prolapse (5–10%)
• Urethral bulking agents (Bulkamid, Macroplastique, Durasphere): 60–80% cure, suitable for frail patients; may require repeat treatments

• Botulinum toxin A (intradetrusor injection): 50–80% reduction in urgency/leakage; voiding difficulty in 8–15%
• Sacral neuromodulation: effective second-line option

Pelvic Organ Prolapse

• Symptoms: vaginal bulge/heaviness, dragging discomfort, voiding/bowel difficulty, sexual dysfunction
• Staging (POP-Q): Stage 0–IV based on descent relative to hymen
• Types: cystocele (anterior), rectocele/enterocele (posterior), uterine prolapse, vaginal vault prolapse
• Risk factors: same as stress incontinence (childbirth, pudendal nerve damage, pelvic floor avulsion)

• Conservative: PFMT (≥4 months for mild/moderate prolapse); vaginal pessaries (ring, shelf, Gellhorn); replaced every 6 months
• Surgery: anterior/posterior repair, sacrospinous fixation, sacrocolpopexy (abdominal — best for vault prolapse); hysterectomy not always required
• Vaginal mesh for prolapse is currently not available in the UK following safety review

Anal Incontinence

• Involuntary passage of flatus or faeces; affects ~10% of adults
• Internal sphincter (smooth muscle): 70% of resting pressure; damage → passive leakage/flatus incontinence
• External sphincter (striated muscle): voluntary squeeze; damage → urge faecal incontinence
• Common causes: obstetric sphincter injury (~3.5% of vaginal deliveries), neurological disease, IBD, overflow, cognitive impairment
• Assessment: digital rectal exam, anal manometry, endoanal ultrasound
• Treatment:
  • Conservative: dietary modification, loperamide, PFMT, biofeedback, electrical stimulation
  • Surgical: sphincter repair, sacral nerve modulation, bulking agent injection