Female Urology and Voiding Dysfunction
Core concepts
Understand stress, urge, and mixed incontinence; overactive bladder; pelvic organ prolapse; and urethral syndromes. Evaluation includes history, bladder diary, pelvic exam, urinalysis, and urodynamics when diagnosis is unclear or surgery is planned for complex cases. Treatment ladder: behavioral/pelvic floor therapy, then pharmacotherapy (antimuscarinics, beta-3 agonists), then procedural options (onabotulinumtoxinA, sacral neuromodulation, sling for stress). Know prolapse staging (POP-Q) and that asymptomatic prolapse may be observed.
Traps
Do not operate on urge incontinence with a sling. Urodynamic stress incontinence plus detrusor overactivity is mixed - treat the predominant symptom first. Recurrent UTI with prolapse may relate to incomplete emptying. Post-void residual matters before starting anticholinergics in a patient with retention risk.
Worked example
A woman with leakage on coughing, no urgency, positive cough stress test: stress incontinence. First-line is pelvic floor muscle training; a midurethral sling is offered after conservative failure. If she also has strong urgency and frequency, evaluate and treat OAB components before surgery.
Exam strategy
Identify the predominant symptom and match the least invasive effective option.