Sort the incontinence first
- History and a bladder diary do most of the sorting. Examine for prolapse, atrophy and a cough leak; dipstick the urine; measure a post-void residual if voiding is abnormal.
- Urodynamics are not needed before conservative treatment and are reserved for surgery planning when the diagnosis is uncertain.
- Continence products and a frank conversation are treatment too.
| Type | Story | First treatment |
|---|---|---|
| Stress | Leaks with cough, sneeze, laugh, lifting, running; small volumes; after childbirth, with age | Supervised pelvic floor muscle training for at least 3 months; weight loss; treat cough and constipation |
| Urgency (overactive bladder) | Sudden need, cannot reach the toilet, frequency, nocturia; may leak large volumes | Bladder training for at least 6 weeks, caffeine and fluid advice; then an antimuscarinic or mirabegron; vaginal oestrogen after the menopause |
| Mixed | Both stories | Treat the dominant symptom first |
| Overflow | Dribbling, incomplete emptying, high residual volume | Look for obstruction (prolapse, post-operative), neurological disease, medicines; catheterise and refer |
Pelvic organ prolapse
- The vaginal walls and the uterus descend when the levator ani and the connective tissue supports fail: parity, vaginal birth, age, oestrogen loss, chronic straining, obesity.
- Compartments: anterior (bladder, 'cystocele'), apical (uterus or vault), posterior (rectum, 'rectocele'). Describe by compartment and stage (POP-Q) rather than by organ.
- Symptoms: a bulge or dragging, worse by evening and with standing; voiding or defaecatory difficulty; it is not usually painful. Treat the symptom, not the finding: a prolapse seen on examination that does not bother her needs no treatment.
- Conservative care first: pelvic floor training for mild prolapse, vaginal oestrogen for atrophy, weight and constipation, and a pessary (ring or Gellhorn) fitted and reviewed, which many women use for years.
- Surgery when conservative care fails and she wants it: native-tissue repairs, sacrospinous or uterosacral suspension, sacrocolpopexy; transvaginal mesh for prolapse is restricted or withdrawn in most jurisdictions after harm.
When surgery is the answer
- Stress incontinence after failed pelvic floor training: midurethral sling (retropubic or transobturator), colposuspension, or a urethral bulking agent, each with its own trade-offs; the mesh sling conversation names the complications (exposure, pain, voiding difficulty) and the alternatives.
- Refractory overactive bladder: intravesical botulinum toxin (teach self-catheterisation risk), percutaneous tibial nerve stimulation, sacral neuromodulation.
- Refer sooner for haematuria, recurrent infection, pain, a neurological story, a palpable mass, or prolapse beyond the introitus with obstructed voiding or ulceration.
Check
A 48-year-old, two vaginal births, leaks when she runs and laughs; never urgency. Examination normal apart from a cough leak. First step?
On the modelPelvic floorBladderVagina