Urogynecology and Pelvic Floor Medicine
Domain 7 - Urogynecology and Pelvic Floor Medicine
This domain tests the classification of urinary incontinence, POP-Q staging, and stepwise conservative versus surgical management. Questions frequently hinge on reading a POP-Q chart or choosing the correct first-line therapy.
Core rules
- Incontinence types: stress (leak on effort, no urge), urge (detrusor overactivity), mixed. Exclude infection, haematuria and fistula before treating.
- Stress incontinence first-line: supervised pelvic floor muscle training for 8–12 weeks; then mid-urethral sling (TVT/TOT) or colposuspension. Urodynamics before surgery in complex, recurrent or mixed cases.
- Overactive bladder: bladder training, fluid and caffeine reduction, then antimuscarinics or mirabegron; check post-void residual.
- POP-Q: six points (Aa, Ba, C, D, Bp, Ap) plus genital hiatus, perineal body and total vaginal length. Stage 0 no prolapse; stage 1 leading edge >−1 cm; stage 2 −1 to +1 cm; stage 3 >+1 cm but not complete eversion; stage 4 complete eversion.
- Pessary is appropriate for women who wish to avoid surgery or are unfit; anterior colporrhaphy for central cystocele; sacrospinous fixation or sacrocolpopexy for apical prolapse.
- Mesh complications: erosion, pain, dyspareunia - report and manage in a specialist centre.
Worked example
A POP-Q examination records Aa −2, Ba +0.5, C −3, D −4, Bp −2, Ap −2, gh 4, pb 3, tvl 9. The leading edge is Ba at +0.5 cm, which lies between −1 and +1, so this is stage 2 anterior compartment prolapse; the apex is well supported. Management begins with a pessary or pelvic floor training rather than immediate surgery.
Traps
Staging by symptoms instead of measurements; operating before conservative therapy; treating urgency without excluding urinary tract infection; ignoring apical descent when repairing a cystocele.