Urogynecology and Pelvic Floor Medicine
Core concepts
Urogynecology questions test the assessment of urinary incontinence, pelvic organ prolapse, and faecal incontinence. Know the types of urinary incontinence (stress, urgency, mixed, overflow), the role of urodynamics, and the conservative and surgical management options. Pelvic organ prolapse is assessed with the POP-Q system; understand the compartments (anterior, posterior, apical) and the role of pessaries versus surgery.
Understand the anatomy of the pelvic floor, the risk factors for prolapse (parity, vaginal delivery, ageing, connective tissue disorders, chronic raised intra-abdominal pressure), and the principles of repair. Know the complications of mesh and the regulatory and ethical issues surrounding its use. Faecal incontinence requires an understanding of sphincter injury, endoanal ultrasound, and the role of sacral neuromodulation.
Traps
- Treating urgency incontinence with surgery before conservative measures.
- Missing that a large prolapse can mask stress incontinence.
- Forgetting that urodynamics are not mandatory before all incontinence surgery.
- Overlooking obstetric anal sphincter injury as a cause of faecal incontinence.
Worked rule of thumb
For urinary incontinence, classify first: stress (leak with cough), urgency (leak with urgency), mixed, or overflow (retention). Conservative measures - pelvic floor muscle training, bladder training, weight loss - come first for stress and urgency. Surgery is reserved for stress incontinence after failed conservative management, and the choice of procedure depends on the patient's anatomy, comorbidities, and preferences. The common error is operating without a clear diagnosis.
Exam technique
State the type of incontinence, the confirming investigation, and the conservative-first plan. Examiners reward an understanding of when not to operate.