Pelvic organ prolapse and urinary incontinence

• Pelvic organ prolapse (POP) and urinary incontinence are common, treatable pelvic floor problems. They often coexist, but they are not inevitable with ageing and they are not the same condition.
• POP is a descent of the bladder, uterus, vaginal vault or rectum into or out of the vagina; it is graded with the POP-Q system. Incontinence is involuntary urine loss and is divided by mechanism into stress, urgency (overactive bladder), mixed, overflow and functional types.
• In women, stress incontinence and POP are usually mechanical: the hammock of pelvic floor support has failed, or the urethra and bladder neck are no longer well supported. Urgency incontinence is a bladder problem: involuntary detrusor contractions during filling.
• Initial assessment classifies the type from the history, bladder diary, examination and post-void residual. Urodynamics is reserved for selected women, such as those with unclear type, urge-predominant mixed incontinence, voiding symptoms, prolapse or previous continence surgery.
• First treatment is conservative: pelvic floor muscle training, bladder training, lifestyle advice, pessaries, and drugs for overactive bladder. Surgery is offered when symptoms persist and the woman chooses it.
• New, sudden incontinence in an older woman should trigger a search for reversible causes first, using the DIAPPERS checklist (delirium, infection, atrophy, pharmacological, psychological, endocrine or excessive output, restricted mobility, stool impaction).

By the end of this page you should be able to:

1. Define pelvic organ prolapse and its types, and grade prolapse with the POP-Q system. ^[1]
2. Separate the five types of urinary incontinence by mechanism, history and examination.
3. Take a focused history, keep a bladder diary, and perform first-line investigations including dipstick urine, post-void residual and urodynamics when indicated.
4. Apply stepwise management for POP and for stress, urgency, overflow and functional incontinence, including NICE NG123 surgical options.
5. Explain the interaction between POP and stress incontinence, including concurrent surgery.
6. Recognise red flags, mesh-related problems, and the needs of older women, pregnant women and women who may wish to bear children.

POP is usually described by compartment and organ. Anterior vaginal wall prolapse (cystocele, urethrocele, cystourethrocele) allows the bladder and urethra to drop. Apical prolapse is descent of the uterus or vaginal vault. Posterior vaginal wall prolapse (enterocele, rectocele) allows the rectum or small bowel to bulge. Several compartments are often involved together; complete procidentia involves failure of anterior, apical and posterior support.^[2]

The five patterns are set out in Table 1. The clinical decision that most often changes management is whether leakage is triggered by raised abdominal pressure (stress), by an irresistible urge (urgency), or by a bladder that never empties (overflow).

New, sudden incontinence is rarely a new bladder problem. The classic checklist for reversible causes is DIAPPERS, originally from Resnick and Yalla and now used in urology and geriatrics teaching.^[3]

Ask about and treat these before labelling a woman with a chronic type. This is especially important after hospital admission, when incontinence that was not present at home is usually multifactorial.

Pelvic floor problems are common in women, but rates depend on whether complaints or examination findings are used. About 8% of women (8.3% in one Swedish population survey) report symptomatic prolapse.^[2] Women in the United States have a 13% lifetime risk of undergoing surgery for prolapse or stress incontinence, with the peak incidence of POP symptoms at age 70 to 79 years, and the number of women with POP is expected to rise by about 50% by 2050 as populations age.^[6] About 300,000 women in the United States undergo surgery for POP each year.^[5]

Urinary incontinence occurs at all ages. Stress incontinence dominates in younger and middle-aged women, especially after vaginal delivery. Urgency incontinence and overactive bladder become more common with age: the EPIC telephone survey found an overall OAB prevalence of 11.8% (10.8% in men, 12.8% in women).^[4] Overflow incontinence is more common with prostatic obstruction and neurological disease. Functional incontinence tracks frailty, cognitive impairment and environment more than bladder physiology.

Neither condition should be dismissed as inevitable ageing. Most women improve, and many are cured, when the mechanism is correctly identified.

POP and stress incontinence share risk factors because both reflect support of the pelvic organs.

Common risk factors for POP include vaginal parity (number and type of vaginal deliveries), obesity, increasing age, pelvic injury including surgery, and chronic raised intra-abdominal pressure from constipation, heavy lifting or chronic respiratory disease. Less common risk factors are sacral nerve and connective tissue disorders.^[2] Obstetric risk factors include prolonged second stage of labour, operative vaginal delivery and delivery of a large-for-gestational-age infant.^[2]

For incontinence:

• Stress incontinence: vaginal delivery, pelvic surgery, obesity, chronic cough, and (in men after prostate surgery or radiotherapy) sphincter injury.
• Urgency incontinence: idiopathic detrusor overactivity, infection, bladder outlet obstruction, constipation, neurological disease (stroke, dementia, multiple sclerosis, Parkinson disease, spinal cord injury), caffeine, high fluid intake and alcohol. Many cases in older women are mixed.
• Overflow incontinence: benign prostatic hyperplasia or stricture (men), detrusor underactivity, neurological disease, postoperative retention, diabetes.
• Functional incontinence: frailty, cognitive impairment, pain, inaccessible toilets, clothing and bed height.

Risk factors are not simply causes; they identify who to ask and point to reversible contributors such as weight, constipation, fluid intake and smoking that can be addressed before surgery.

Everything in this topic follows from two failures: failure of support (POP and stress incontinence) and failure of control (urgency and overflow incontinence).

Support failure. The pelvic floor is a muscular diaphragm with connective tissue attachments that suspend the bladder, uterus and rectum. Childbirth, ageing, raised intra-abdominal pressure and inherited collagen quality gradually stretch or tear this support. When the anterior wall no longer supports the bladder neck, coughing raises bladder pressure faster than the sphincter can close, and urine leaks: this is stress incontinence. When support is lost more generally, organs descend into a cystocele, rectocele, enterocele, uterine prolapse or vault prolapse. POP and stress incontinence therefore share a mechanism and frequently coexist; anterior or apical prolapse can mask stress incontinence by kinking the urethra.

Control failure. The bladder must store urine at low pressure and empty by coordinated detrusor contraction with sphincter relaxation. In urgency incontinence the detrusor contracts involuntarily during filling, producing a sudden urge, frequency and nocturia. In overflow incontinence the bladder never empties, either because of obstruction (prostate, stricture) or because the detrusor is weak (neuropathy, postoperative). Pressure then rises silently and the bladder leaks when overfull; in men this is retention with overflow. Functional incontinence is different: the bladder works, but the person cannot reach a toilet in time.

Hormonal tissue changes matter. Low oestrogen after the menopause thins vaginal and urethral epithelium and reduces elasticity, worsening both urgency symptoms and prolapse discomfort.

Ask the woman to describe the leak in her own words, then match it to a type.

• Does leakage happen with cough, movement or impact, or with a sudden urge that cannot be deferred?
• When does it occur: daytime only, or also at night?
• How much is lost: drops, a splash, or a full bladder?
• Frequency, duration, triggers and coping behaviour.
• Stream quality (hesitancy, poor flow, splitting, dribbling) and sensation of incomplete emptying.
• Pain, fever or haematuria suggest infection or other disease, not simple incontinence.
• Bowel habit, constipation and prolapse symptoms in women; prostate symptoms in men.
• Mobility, cognition, home environment and drugs.
• Obstetric and surgical history, pelvic cancer, radiotherapy and neurological symptoms.
• Impact on daily life, sleep and mood.

A bladder diary of at least 3 days, covering both working and leisure days, records drinks, voids and leaks, gives daytime and night-time frequency, typical volumes, urgency and the relation of leaks to activities; it is more reliable than recall.^[1] A useful single question is "Do you leak when you cough, or when you get the urge?", because it separates the two common types.

Examine the abdomen (scars, masses, palpable or distended bladder), the perineum and pelvis, and the neurological system.

In women:

• Inspect the vulva and vagina; assess pelvic floor muscle contraction.
• Cough stress test for urine leakage.
• Assess prolapse in anterior, central and posterior compartments, preferably with the woman straining or standing.
• Assess vaginal epithelium (thinning, dryness, inflammation, shortening) and pelvic floor muscle activity.^[1]
• Re-examine if findings do not match symptoms when surgery is considered.

In men: digital rectal examination of the prostate and neurological examination. In an older patient check memory, gait and dexterity; a simple toileting barrier explains more functional incontinence than any bladder test.

Most leaking is one of the five types. The task is to recognise conditions that mimic them and red flags that require referral.

For POP, the main clinical alternatives are an ovarian or fibroid mass, pelvic abscess, vaginal cyst or tumour and urethral diverticulum. Careful speculum examination while the woman strains usually separates these. Do not dismiss a vaginal mass as "just prolapse" without inspection.

Assessment should classify the type, catch reversible causes and identify women needing specialist testing. For many women this can be done in primary care.

• History and bladder diary as above.
• Urine dipstick in every woman, for blood, glucose, protein, leucocytes and nitrites. If infection is suspected, send a midstream urine sample for culture and treat on the basis of the result. Do not give antibiotics to an asymptomatic positive dipstick.^[1]
• Examination of abdomen, pelvis and nervous system.
• Post-void residual measured by bladder scan (preferred to catheterisation for comfort and safety) in women with symptoms of voiding dysfunction, recurrent UTI, or a history suggesting overflow. A low residual reassures; a raised residual points to obstruction or underactivity and changes management toward catheterisation.^[1]
• Symptom and quality-of-life questionnaire when therapy is being evaluated.^[1]
• Pad tests, Q-tip, Bonney, Marshall and Fluid-Bridge tests are not used in routine assessment, and MRI, CT and X-ray are not used other than to measure residual urine. Cystoscopy is not used in the initial assessment of uncomplicated incontinence.^[1]

Multichannel filling and voiding cystometry (urodynamics) is not performed before primary surgery for stress or stress-predominant mixed incontinence diagnosed clinically and demonstrated on examination. It is added when the type is unclear, when there is urge-predominant mixed incontinence, when voiding dysfunction is suspected, when there is anterior or apical prolapse, or after previous continence surgery.^[1] A normal clinical diagnosis is usually enough for straightforward stress incontinence; urodynamics changes planning where a mistake would matter.

For prolapse, NICE recommends assessment with the POP-Q (Pelvic Organ Prolapse Quantification) system, recording anterior, central and posterior compartment support. Imaging is not routinely used if prolapse is found on examination. If symptoms are not explained by the examination, repeat the examination with the woman standing or squatting, or at a different time.^[1]

POP-Q is preferred over the older Baden-Walker system because it is reproducible and based on defined anatomical landmarks.^[2] A validated pelvic floor symptom questionnaire can aid assessment, and urine dipstick and basic assessment should still exclude a mass or other pathology.^[1]

• Measure and discuss the impact and set realistic goals. Cure is not always possible, but improvement always is.
• Offer lifestyle advice: caffeine reduction for overactive bladder, modify very high or very low fluid intake, weight loss where body mass index is above 30, treatment of constipation, stopping smoking and reducing heavy lifting.^[1]
• Absorbent containment products, urinals and toileting aids are not used to treat incontinence; they are offered only as a coping strategy while definitive treatment is awaited, as an adjunct, or for long-term management after treatment options have been explored. Review women using them at least yearly, checking skin integrity and suitability.^[1]
• Complementary therapies are not recommended.^[1]

Pelvic floor muscle training (PFMT) is first-line: a supervised trial of at least 3 months. Programmes comprise at least 8 contractions performed 3 times a day. Continue if beneficial. Biofeedback and electrical stimulation are not routine; they are reserved for women who cannot voluntarily contract the pelvic floor, to aid motivation.^[1]

When non-surgical treatment fails and the woman wishes surgery, the NICE options for stress incontinence are:

• Colposuspension (open or laparoscopic).
• Autologous rectus fascial sling.
• Retropubic mid-urethral mesh sling (type 1 macroporous polypropylene; suitability, mesh risk and local practice need discussion).

Transobturator mesh is limited to specific circumstances, and single-incision short mesh slings are restricted to clinical trials. Intramural bulking agents are a third-line option when surgery is unsuitable or unwanted, with the caveat that effects may wear off. NICE lists procedures not to offer: anterior colporrhaphy, needle suspension, paravaginal defect repair, porcine dermis sling and Marshall-Marchetti-Krantz. Artificial urinary sphincter is not offered unless previous surgery has failed.^[1]

Bladder training is first-line: a minimum of 6 weeks, teaching the patient to postpone the first urge, lengthen the interval between voids, and use distraction and pelvic floor contraction to suppress urgency. In women, add pelvic floor training. If benefit is partial, combine an overactive bladder medicine with bladder training when frequency is troublesome.^[1]

If training fails, pharmacological options are:

• Anticholinergic (antimuscarinic) drugs, blocking M3 receptors in the detrusor and increasing functional capacity. NICE advises offering an anticholinergic using the one with the lowest acquisition cost, taking account of coexisting conditions, other anticholinergic load and cognitive risk, and avoiding oxybutynin immediate release in older women at higher risk of sudden physical or mental decline. Do not offer flavoxate, propantheline or imipramine. Review at 4 weeks, then every 12 months (6 months if over 75).^[1]
• The EAU guideline summarises comparative evidence: all anticholinergics beat placebo on urgency and incontinence, with small differences between drugs; adverse events include dry mouth, constipation and cognitive effects. Extended-release formulations have lower adverse-event rates than immediate-release ones.^[4]
• Beta-3 agonists (mirabegron, and in some countries vibegron) relax the detrusor during filling. The EAU guideline notes mirabegron at 25, 50 and 100 mg improves urgency and incontinence compared with placebo, with similar adverse-event rates and hypertension in about 7.3%. Beta-3 agonists are as effective as antimuscarinics with lower dry-mouth rates. NICE recommends mirabegron as an option when antimuscarinics are unsuitable, ineffective or not tolerated (see NICE technology appraisal TA290).^[1][4]
• Vaginal oestrogen for women with overactive bladder symptoms and genitourinary symptoms and signs associated with the menopause. Systemic hormone replacement does not treat incontinence.^[1]
• Desmopressin may be considered for troublesome nocturia, with caution, and avoided in women over 65 with cardiovascular disease or hypertension.^[1]
• Transdermal oxybutynin when oral therapy is not tolerated.^[1]
• Botulinum toxin A, 100 units injected into the bladder wall, is offered after multidisciplinary review for women whose detrusor overactivity on urodynamics has not responded to non-surgical management and drugs. She must be willing to perform clean intermittent catheterisation if retention occurs. Response is reviewed within 12 weeks; later doses may be increased to 200 units if needed.^[1]
• More invasive options (sacral nerve stimulation, augmentation cystoplasty, urinary diversion) are reserved for specialist centres.

Anticholinergic burden is the central caution in older women. Cumulative anticholinergic load from medicines for sleep, depression, allergy, Parkinson disease and pain adds to urological anticholinergics and produces confusion, constipation, dry mouth, imbalance and falls. Weigh total anticholinergic load and cognition before prescribing, and choose the lowest-cost effective option first.^[1][4]

Treat the cause. Remove obstruction where possible; review renal function and comorbidity. Offer intermittent urethral catheterisation to women with urinary retention who can self-catheterise or who have a carer, and to men with persistent retention or an underactive detrusor when obstruction is not correctable. Clean intermittent catheterisation is the safest route because it relieves high pressure without the infection risk of an indwelling catheter. Indwelling catheters (urethral or suprapubic) are reserved for women who cannot self-catheterise; women should be told that they may not be continent with an indwelling catheter, and suprapubic catheters have lower rates of symptomatic infection and urethral complications than urethral ones.^[1]

Drugs do not help a bladder that works. Treatment is of the person and the environment: timed toileting, reachable toilets, adjusted bed height, good lighting, familiar clothing, continence pads as a coping measure rather than a treatment, and treating pain, infection, constipation and the drug list. In care homes, a simple toileting schedule often helps because many residents are continent between scheduled visits.

NICE recommends discussing management options (no treatment, non-surgical, surgical) with women, taking account of preferences, site of prolapse, lifestyle, comorbidities including cognitive or physical impairment, age, desire for future childbearing, previous surgery and risks and benefits.^[1]

Conservative options:

• Lifestyle: weight loss if BMI above 30, minimising heavy lifting, preventing or treating constipation.^[1]
• Vaginal oestrogen for women with POP and genitourinary symptoms and signs associated with the menopause; an oestrogen-releasing ring is considered when cognitive or physical impairment makes vaginal preparations difficult.^[1]
• Supervised pelvic floor muscle training for at least 16 weeks as a first option for women with symptomatic POP-Q stage 1 or 2, continuing afterwards if beneficial.^[1]
• Vaginal pessary for symptomatic POP, alone or with supervised pelvic floor muscle training. Before starting: consider vaginal oestrogen; explain that more than one fitting may be needed; discuss effects on sexual intercourse; describe complications (discharge, bleeding, difficulty removing, expulsion); explain that the pessary should be removed at least once every 6 months to prevent serious complications. Women at risk of complications (physical or cognitive impairment) are reviewed in a pessary clinic every 6 months. Pessaries can also reduce prolapse-associated stress incontinence in some women. In up to 9% of cases pessaries cause local devascularisation or erosion, in which case they are removed for 2 to 4 weeks while the woman has local oestrogen therapy.^[1][5]

Surgery is offered to women whose symptoms have not improved with, or who have declined, non-surgical treatment.^[1] Shared decision making is supported by NICE patient decision aids; discussion must cover benefits and risks of each procedure, changes in urinary, bowel and sexual function, risk of recurrence, long-term uncertainty (especially mesh), type of anaesthesia, hospital stay, incisions and recovery, plus the woman's social and psychological factors.^[1]

• Do not offer surgery to prevent incontinence in women having prolapse surgery who do not have incontinence, and explain the risk of developing new postoperative incontinence after anterior or apical prolapse repair.^[1]
• Uterine prolapse: for women with no preference about preserving the uterus, offer vaginal hysterectomy with or without vaginal sacrospinous fixation, vaginal sacrospinous hysteropexy with sutures, or Manchester repair; mesh (sacro-hysteropexy, abdominal or laparoscopic) is included as an option following the NICE mesh guidance. For women wishing to preserve the uterus: sacrospinous hysteropexy with sutures, or Manchester repair unless she may wish to have children in future. Women who may wish to have children in future need regional MDT review.^[1]
• Vault prolapse: vaginal sacrospinous fixation with sutures, or sacrocolpopexy (abdominal or laparoscopic) with mesh.^[1]
• Anterior prolapse: anterior repair without mesh.^[1]
• Posterior prolapse: posterior vaginal repair without mesh.^[1]
• Colpocleisis is considered for women with vault or uterine prolapse who do not intend to have penetrative vaginal sex and who have a physical condition that may increase operative or postoperative risk.^[1]
• Concurrent surgery for stress incontinence and prolapse (anterior and/or apical prolapse with stress incontinence) may be considered. Evidence beyond one year is uncertain, and stress incontinence may persist despite surgery; the risk of combined versus sequential surgery needs discussion.^[1]
• Vaginal mesh repair of anterior or posterior vaginal wall prolapse (NICE IPG599) should only be used in the context of research, following the 2019 withdrawal of the earlier NG123 recommendations. Abdominal (sacrocolpopexy) mesh is still offered with national registry recording. NICE recommends referring women with suspected mesh-related complications to a urogynaecologist, urologist or colorectal surgeon and a regional centre.^[1]
• Follow-up is offered 6 months after prolapse surgery including vaginal examination, with mesh-exposure check if mesh was used. Women should have access to further referral for recurrent symptoms or suspected complications.^[1]

The same two failures can be addressed at one operation. NICE allows consideration of concurrent surgery in women with anterior and/or apical prolapse and stress incontinence, but explains uncertainty beyond one year and the possibility that stress incontinence persists. The decision rests on the woman's priorities (symptom relief now versus avoiding combined risk) and on specialist judgement.^[1]

• Prolapse: discomfort, vaginal ulceration or infection with advanced (stage IV) prolapse, sexual dysfunction, voiding and defaecatory symptoms. Recurrence after surgery is common and should be discussed in advance.^[1]
• Incontinence: skin breakdown, infection, social restriction, falls in older women, and (with overflow) renal impairment.
• Surgery for stress incontinence: follow-up within 6 months, with vaginal examination if a retropubic mesh sling was inserted. Failed primary surgery, or return of symptoms, should be referred to a regional MDT.^[1]
• Mesh: NICE requires discussion of uncertainty about long-term adverse effects. In ACOG's interim update, polypropylene mesh repair of anterior prolapse carried about 11% mesh erosion, with 7% needing surgical correction. Mesh complications can present with pain, vaginal extrusion, dyspareunia, urinary and bowel symptoms, and rarely organ injury. Refer suspected mesh complications to a urogynaecologist, urologist or colorectal surgeon and, where confirmed, to a regional mesh centre.^[1][5]
• Postoperative new incontinence: surgery for anterior or apical prolapse in a continent woman can unmask stress incontinence, so it must be discussed beforehand.^[1]
• Pessary complications: discharge, bleeding, expulsion, difficulty removing; rarely devascularisation. Remove for 2 to 4 weeks and treat with local oestrogen.^[5]

• Most women who receive the correct first-line treatment improve substantially. Cure is not guaranteed, but meaningful improvement is the norm.
• PFMT for stress or mixed incontinence is effective when done properly and continued: NICE advises at least 3 months initially, continuing if beneficial.^[1]
• For POP, PFMT is considered as a first option in symptomatic stage 1-2, with benefit assessed over at least 16 weeks.^[1]
• Botulinum toxin A for overactive bladder requires retreatment; NICE reviews response within 12 weeks and increases later doses to 200 units if 100 units gave inadequate or short-lived relief.^[1]
• Recurrence of POP after surgery is well recognised; satisfaction depends on matched expectations, which is why the NICE decision aids include sexual, bowel and urinary function outcomes.^[1]

There is no routine screening programme. Practical prevention:

• Pelvic floor muscle training during and after pregnancy, and after delivery (including after caesarean section in women with risk factors).
• Weight control, constipation prevention, treating chronic cough, and avoiding repeated heavy lifting.
• At antenatal and postnatal visits, ask about leaking and prolapse symptoms routinely rather than waiting for the woman to volunteer them, because embarrassment means these problems are under-reported.

Low-resource settings are not disadvantaged: history, a 3-day bladder diary, cough test, POP-Q by torchlight and timed toileting require no equipment. Pessaries, oestrogen creams and training programmes are cheap. Surgery still needs a trained surgeon and appropriate follow-up.

Pregnancy and the postpartum. Pregnancy and delivery stretch the pelvic floor. Leakage is common in the third trimester and after delivery. PFMT during and after pregnancy reduces stress incontinence, but a new leak in pregnancy should still be assessed, not dismissed. Surgery is not offered in pregnancy; training and support are. Women who may wish to have children in future need review by a regional MDT before prolapse surgery, and hysterectomy-based repairs should be deferred.^[1]

Older women. Older women usually have mixed incontinence with a functional overlay. Treat the treatable components (constipation, infection, drugs, mobility, environment) before reaching for antimuscarinics. If an anticholinergic is needed, start low, choose an agent that minimises central effects, review cognition, and reassess at 4 weeks, then every 12 months (6 months if over 75). Older women also benefit most from pessaries and from help with toileting schedules.^[1][4]

Men. Although this topic is written for women, stress incontinence in men most often follows prostate surgery or radiotherapy. Drugs for urgency incontinence work in men as well as in women, but antimuscarinics and mirabegron can worsen urinary retention in prostatic obstruction, and benign prostatic hyperplasia itself may need treatment. Non-neurogenic male LUTS guidance applies the same principles of history, diary, flow and residual, but the surgical options differ from the NICE women's guideline.

Women with neurological disease. Incontinence may come from detrusor overactivity, impaired sensation, retention with overflow, or a combination. Assessment is as above, but the threshold for urodynamics, intermittent catheterisation and specialist urology referral is lower, because silent retention and renal risk are greater.

Children. Pelvic organ prolapse in children is rare and usually congenital or associated with specific syndromes or connective tissue disease; new paediatric incontinence usually has a neurological or congenital cause and needs specialist assessment rather than routine incontinence treatment.

• Classification does not need technology. The type is diagnosed from the history and a simple examination. A cough test and a 3-day bladder diary can be completed on paper.
• Urine dipstick reading blood, glucose and nitrites is cheap and widely available and remains the minimum investigation. Where culture is unavailable, a stained (Gram) smear, clinical context and response to empirical treatment are used.
• Residual urine can be estimated clinically or with a basic ultrasound. In the absence of any scanner, a post-void catheter with strict asepsis both measures and relieves, but infection risk makes it a last resort.
• Pelvic floor training, bladder training, timed toileting and counselling cost nothing and are the most effective treatments in any setting. A pelvic floor physiotherapist is the most valuable referral; if absent, a trained nurse or midwife is the next best.
• Antimuscarinics and beta-3 agonists may be unavailable or unaffordable. Generic immediate-release oxybutynin and tolterodine are usually cheapest; where no drug is available, extend bladder training and use containment without stigma.

• Stress incontinence is a support problem: leaks on effort, dry at rest; treatment is mechanical (training or surgery). Urgency incontinence is a bladder problem: leaks with urge, often with frequency and nocturia; treatment is behavioural and pharmacological.
• Overflow looks like incontinence but is really retention. Measure the post-void residual before prescribing.
• Prolapse causes a vaginal bulge and pelvic pressure; incontinence causes urine loss. They overlap (stress incontinence is common with anterior prolapse) but need different, and sometimes combined, treatment.
• Interstitial cystitis/bladder pain syndrome causes bladder and pelvic pain with urgency; see the urinary incontinence topic for its stepwise management.

• POP and urinary incontinence are common, treatable and frequently missed because women do not volunteer them; ask directly.
• POP is graded with POP-Q (stages 0 to IV), by examining anterior, central and posterior compartments; routine imaging is not needed if examination confirms prolapse.
• The five incontinence types (stress, urgency, mixed, overflow, functional) have different mechanisms and treatments; classify before treating.
• Stress incontinence: pelvic floor training for at least 3 months first; surgery (colposuspension, autologous fascial sling, retropubic mesh sling) if that fails and she wishes it.
• Urgency incontinence: bladder training for at least 6 weeks; antimuscarinic or beta-3 agonist only if needed; botulinum toxin A 100 units (review within 12 weeks) for detrusor overactivity refractory to non-surgical treatment. ^[1]
• Mixed incontinence: treat the predominant symptom.
• Overflow incontinence is retention; measure the residual and teach intermittent self-catheterisation.
• Functional incontinence is treated by fixing environment, cognition and mobility, not the bladder.
• Reversible causes in new incontinence are remembered as DIAPPERS.
• Urodynamics is not needed before primary surgery for clinically diagnosed stress or stress-predominant mixed incontinence; it is needed for unclear type, urge-predominant mixed, voiding symptoms, prolapse and previous surgery.
• Pessary care: remove at least every 6 months; review women at risk of complications every 6 months.
• POP surgery without mesh for anterior (anterior repair) and posterior (posterior repair) walls; uterine and vault repair with native-tissue or sacro-fixation options; mesh vaginal prolapse repair only in research settings.
• Anticholinergic burden in older women is a safety issue; avoid oxybutynin immediate release in vulnerable older women, review cognition and reassess regularly.
• Nothing on this page replaces a local guideline or a clinician who knows the patient.

• Urinary incontinence and interstitial cystitis
• Uterine leiomyoma
• Cervicitis and pelvic inflammatory disease
• Antepartum haemorrhage
• Hydronephrosis
• Renal stones

This topic covers the book pages B2:381 and B2:382 and the learning objectives above.