Urogynaecology and pelvic reconstructive surgery
Introduction
Urogynaecology tests the classification of urinary incontinence and prolapse, conservative versus surgical treatment, and the complications specific to mesh and fistula surgery.
Urinary incontinence
- Stress incontinence: leakage on effort or sneeze from urethral hypermobility or intrinsic sphincter deficiency. Diagnosis is clinical; urodynamics is reserved for mixed symptoms, previous surgery, neurological disease or before repeat surgery.
- Overactive bladder and urgency incontinence: urgency, frequency, nocturia with or without leakage. Start with bladder training, fluid and caffeine advice and pelvic floor training, then antimuscarinics or mirabegron, then intradetrusor botulinum toxin, sacral neuromodulation or augmentation cystoplasty.
- Exclude overflow, functional incontinence and fistulas before operating.
Surgery for stress incontinence
- Mid-urethral sling (retropubic TVT or transobturator TOT) is the standard, with colposuspension as the alternative.
- Complications: voiding dysfunction and retention, de novo urgency, tape erosion, bladder or urethral perforation - cystoscopy is mandatory while passing the trocars.
Prolapse
- POP-Q points in every compartment: Aa/Ba anterior, Ap/Bp posterior, C cervix or vault, D posterior fornix, plus gh, pb and tvl.
- Conservative: pelvic floor muscle training, ring or cube pessary - with vaginal oestrogen in atrophy and scheduled review for erosion.
- Surgery: anterior and posterior colporrhaphy, vaginal hysterectomy with McCall or sacrospinous fixation, sacrocolpopexy for vault prolapse. Mesh kits are restricted after safety warnings; native tissue repair is first choice in most women.
Worked example
A 58-year-old para 2 leaks on coughing and running. Examination shows a cystocele reaching 1 cm below the hymen and a positive cough test. Urodynamics are not required for pure stress symptoms; she is offered supervised pelvic floor training for three months, and if still symptomatic a mid-urethral sling with counselling about voiding dysfunction and tape erosion, and consent for concomitant anterior repair.
Traps
- Operating for stress incontinence without excluding detrusor overactivity when symptoms are mixed.
- Fitting a pessary without treating atrophy or arranging follow-up.
- Omitting cystoscopy after trocar passage.
- Attributing all postoperative leakage to failure rather than de novo urgency.