Urinary incontinence and prolapse

Gynaecology

Family practice or urogynaecology clinic

The first question

Is the leak with urgency, with effort, or both, and is there something coming down?

01
Type the leak
Stress (cough, laugh, lift), urgency (a sudden need she cannot defer), or mixed; overflow and continuous leakage are different problems with different causes.
02
Find the reversible
Infection, glycosuria, constipation, caffeine and fluid volume, diuretics and sedatives, mobility and access to the toilet, atrophy after the menopause.
03
Look for prolapse
A bulge, dragging or a lump she can feel; examine straining and standing; grade what descends and from which compartment.
04
Conservative first
Bladder training and pelvic floor muscle training for at least three months, weight loss, vaginal estrogen after the menopause, a pessary for prolapse.
05
Then the specialist
Urodynamics only when the type is unclear or surgery is planned; anticholinergics or mirabegron for urgency; sling or colposuspension for stress; pessary or repair for prolapse.

Where it is

Each opens the structure on the 3D pelvis.

When she leaks: coughing, laughing, lifting; a sudden urge; on the way to the toilet; continuously; only at night
Frequency, nocturia, volume and pads; the effect on her life and what she has stopped doing
Fluid, caffeine and alcohol intake; a bladder diary for three days
Dysuria, haematuria, recurrent infections
Bowels: constipation, straining, faecal incontinence
A bulge or dragging sensation, worse at the end of the day or with lifting
Obstetric history: number of births, forceps, big babies, tears; previous pelvic surgery
Menopausal status and vaginal dryness; medications (diuretics, sedatives, alpha blockers); mobility, cognition and the route to the toilet

BMI and mobility
Abdomen for a palpable bladder or mass
Vulva and vagina for atrophy, excoriation from leakage
Cough test with a full bladder for stress leakage
Speculum and half-speculum examination straining and standing: anterior, apical and posterior compartment descent, and its grade relative to the hymen
Pelvic floor muscle strength on digital examination
Neurological screen of the sacral segments when the story is unusual

Urinalysis and culture
A three-day bladder diary
Post-void residual by scan when retention or overflow is possible
Glucose or HbA1c
Urodynamics only when the diagnosis is uncertain, conservative treatment has failed, or surgery is planned
Renal tract ultrasound or cystoscopy for haematuria or recurrent infection

Diagnosis	Favours	Against	Urgency
Stress urinary incontinence	Leak with cough, laugh, lifting; a positive cough test; births and forceps	Leak preceded by urgency, nocturia	routine
Urgency incontinence (overactive bladder)	A sudden urge she cannot defer, frequency, nocturia, key-in-the-door leakage	Leak only with effort	routine
Mixed incontinence	Both patterns; ask which bothers her more	A single pattern	routine
Overflow or retention	Dribbling, incomplete emptying, a palpable bladder, a large post-void residual; anticholinergics, prolapse kinking the urethra, neurological disease	Normal residual	urgent
Pelvic organ prolapse	A bulge or dragging, worse late in the day; descent on straining; needing to reduce it to void or defecate	No descent on straining while standing	routine
Urinary tract infection or another reversible cause	Dysuria, positive dipstick, a new diuretic, glycosuria, constipation	A long stable history with clean urine	routine
Fistula	Continuous leakage after pelvic surgery, radiotherapy or obstructed labour	Intermittent leakage with a trigger	urgent

Pitfalls this pathway refuses

Treating urgency with an anticholinergic before the diary, the urine, the sugar and the drug chart have been checked
Examining only lying down, when the prolapse is only there standing
Offering surgery for stress incontinence before three months of supervised pelvic floor training
Missing retention behind a large prolapse
Not asking about faecal incontinence, which is under-reported and treatable