Urogynecology and Pelvic Floor Disorders
Core concepts
Urogynecology addresses pelvic floor disorders. Anatomy: the levator ani, endopelvic fascia, and uterosacral ligaments support the pelvic organs; the pudendal nerve supplies the external urethral sphincter. Pelvic organ prolapse is quantified by POP-Q; stage 0 is no prolapse, stage 1 is more than 1 cm above the hymen, stage 2 is within 1 cm of the hymen, stage 3 is more than 1 cm beyond the hymen, and stage 4 is complete eversion. Stress urinary incontinence is leakage with increased abdominal pressure; urge incontinence is associated with detrusor overactivity. Urodynamics is useful when the diagnosis is unclear or before surgery. Conservative treatment includes pelvic floor muscle training, weight loss, and pessaries. Surgical options include midurethral sling and colporrhaphy.
Traps
Do not assume all incontinence is stress; mixed incontinence is common. Do not operate for prolapse without assessing urinary symptoms. Mesh complications require specialist management. A post-void residual should be checked in women with voiding difficulty.
Worked example
A 55-year-old woman leaks urine when coughing or laughing, has no urgency, and a positive cough stress test. She has stress urinary incontinence. First-line treatment is supervised pelvic floor muscle training for at least 8 weeks; surgery is considered if conservative treatment fails.
Rule of thumb: POP-Q stage 2 is the hinge point-prolapse at the hymen-and symptoms, not stage alone, drive treatment.