Urogynecology and Pelvic Reconstructive Surgery
Urogynecology tests pelvic organ prolapse, urinary incontinence, fistulas, and reconstructive surgery. The OEOG emphasizes clinical diagnosis, conservative first-line treatment, and recognizing occult incontinence before prolapse repair.
Core rules
- POP-Q staging: stage 0 is no prolapse; stage I is the leading edge more than -1 cm; stage II is -1 to +1 cm; stage III is more than +1 but less than +4 cm; stage IV is complete eversion or +4 cm.
- Stress urinary incontinence is leakage with coughing, sneezing, or effort. First-line treatment is supervised pelvic floor muscle training for at least 3 months; midurethral sling is an option for suitable women who fail conservative care.
- Overactive bladder causes urgency and frequency; start with bladder training, fluid management, and pelvic floor training, then antimuscarinic or beta-3 agonist therapy.
- Occult stress incontinence is unmasked by reducing the prolapse and repeating the cough stress test; counsel the patient before prolapse surgery.
- Vesicovaginal fistula causes continuous leakage after pelvic surgery; diagnose with a dye test and repair after inflammation has settled.
Worked example
A 58-year-old has a vaginal bulge and leakage with coughing. Examination shows stage III anterior prolapse. Reasoning: reduce the prolapse with a pessary or swab and repeat the cough test. If leakage appears only after reduction, she has occult stress incontinence. Plan prolapse repair with a concomitant anti-incontinence procedure and counsel her preoperatively.
Traps
- Prescribing anticholinergics for stress urinary incontinence.
- Not checking postvoid residual before treating overactive bladder.
- Missing a vesicovaginal fistula after hysterectomy because continuous leakage is attributed to incontinence.