GC116 I Felt A Lump Below Urinary Incontinence In Females; Genital Prolapse
Urinary incontinence in females is the involuntary loss of urine, and genital prolapse is the descent of pelvic organs (such as the uterus, bladder, or rectum) through the vaginal canal due to weakened pelvic floor support.
This lecture (GC 116, Dr. Paulin MA, HKU O&G) covers two intimately linked conditions in women: pelvic organ prolapse (POP) and female urinary incontinence (UI). Both share the same root cause — a weakened or damaged pelvic floor. The lecture systematically builds from anatomy → pathophysiology → risk factors → clinical presentation → examination → investigation → management for both conditions.
Why it matters for exams: This is a classic O&G + Urology crossover topic. Past papers regularly test: (a) identifying the type of incontinence from a clinical vignette, (b) the three levels of pelvic support, (c) first-line investigation for UI, (d) conservative vs surgical management, and (e) the concept of occult stress incontinence masked by prolapse.
Learning Objectives (from the lecture) [1]
- Structure and function of female pelvic floor
- Factors that adversely affect pelvic floor function
- Genital prolapse
- Urinary incontinence
- Summary – the link between prolapse and stress UI
1. Structure and Function of the Female Pelvic Floor
"Pelvic floor" may be used broadly to include all the structures supporting the pelvic cavity rather than the levator ani group of muscles alone. [1]
High Yield – Definition of Pelvic Floor
The pelvic floor is NOT just the levator ani. It includes: peritoneum, pelvic viscera, endopelvic fascia, levator ani muscles, perineal membrane, superficial genital muscles — all connected to the bony pelvis. (Wei 2004) [1]
Why this matters: Students often equate "pelvic floor" with "levator ani." The examiners specifically want you to demonstrate a broader understanding. Prolapse arises from failure of ANY of these layers, not just muscle.
| Function | Explanation |
|---|---|
| Support | Holds pelvic organs (uterus, bladder, rectum) in place against gravity and intra-abdominal pressure |
| Sphincteric | Maintains urinary and faecal continence |
| Sexual | Contributes to vaginal tone and orgasm |
"In all forms of pelvic organ prolapse, the primary problem is in the pelvic floor — NOT in the organ that has been displaced." [1]
This is conceptually crucial. A cystocele is not a "bladder disease"; it is a pelvic floor disease. Treatment targets the floor support, not the bladder itself.
Vaginal support is a combination of:
- Constriction — the tonic contraction of levator ani closing the urogenital hiatus
- Suspension — ligaments and fascia suspending the vagina from the pelvic sidewalls
- Structural geometry — the horizontal orientation of the levator ani creates a "flap-valve" effect under pressure
Reading the five-panel pressure diagram (slide 8): The drawings are a mechanical analogy, not five different diseases. An unsupported opening can gape and elongate downward under pressure; narrowing the hiatus (constriction), tethering its walls (suspension) and laying the vagina against a supportive surface (geometry) each redirect the same downward force away from the opening. Normal support uses all three, which is why failure cannot be reduced to a single "weak organ".
| Compartment | Structures | Prolapse type |
|---|---|---|
| Anterior | Bladder, urethra | Cystocele, urethrocele |
| Central / Apical | Uterus/cervix (or vault post-hysterectomy) | Uterine prolapse, vault prolapse |
| Posterior | Rectum | Rectocele |
This is the most commonly tested anatomy point from this lecture.
High Yield – Three Levels of Vaginal Support (DeLancey)
| Level | Structure | Function | Effect of Damage |
|---|---|---|---|
| Level I: Suspension | Cardinal and uterosacral ligaments → attach cervix/uterus to pelvic sidewalls; paracolpium supports upper vagina | Suspends uterus and upper vagina | Uterine prolapse or vaginal vault prolapse |
| Level II: Attachment | Paracolpium attaches mid-vagina to pelvic sidewall → forms pubocervical fascia (anterior) and rectovaginal fascia (posterior) | Supports bladder anteriorly and rectum posteriorly | Cystocele, urethrocele, rectocele |
| Level III: Fusion | Distal vagina fuses directly to: urethra (anterior), perineal body (posterior), levator ani (lateral) — no intervening paracolpium | Fixes distal vagina to adjacent structures | Rectocele, urethrocele, perineal deficiency |
How to remember: Think "top → middle → bottom" of the vagina. Level I is at the top (cervix), Level III is at the bottom (introitus).
The constant muscle tone of the pubococcygeal portion is responsible for holding the pelvic floor closed by coapting the urogenital hiatus. The muscle also forms a relatively horizontal shelf on which the pelvic organs are supported. [1]
Why horizontal matters: When standing, intra-abdominal pressure pushes organs down. The levator ani creates a horizontal "shelf" so that pressure pushes organs against the shelf (like pressing a lid onto a box), rather than pushing them through the hiatus. When the levator weakens and the shelf tilts, the hiatus opens and organs prolapse.
- As long as the pelvic floor is intact, anatomically and neurologically, the viscera are maintained in their normal position.
- When there is an anatomic and/or neurologic defect in the pelvic floor structure, one or more of the viscera can be displaced.
- The location of the support defect(s) will determine which of the structures will prolapse. [1]
2. Structures Involved in Continence [1]
- Smooth muscles of the bladder neck and urethra
- Urethral connective tissue
- Urethral submucosal vascular plexus — contributes to mucosal coaptation (like a washer sealing a pipe)
- Urethral mucosa — oestrogen-dependent; atrophies after menopause
- Connective tissue supports (endopelvic fascia)
- Muscular supports (levator ani muscles)
- Striated urogenital sphincter
Poor support of the proximal segment of the urethra and bladder neck is the most common cause of stress incontinence. [1]
| Mechanism | Pathophysiology |
|---|---|
| Bladder neck hypermobility | Loss of pelvic floor support → bladder neck descends outside the zone of intra-abdominal pressure → during cough/strain, abdominal pressure no longer transmitted equally to urethra → urine leaks. This is the most common mechanism. |
| Intrinsic sphincter deficiency (ISD) | The urethral sphincter itself is weak despite normal anatomical support → seen after radiation, repeated surgery, neurological damage |
Why does normal anatomy maintain continence? During coughing, intra-abdominal pressure rises. If the bladder neck and proximal urethra are inside the abdominal pressure zone, the pressure increase is transmitted to both bladder AND urethra equally, so the urethra stays closed. When the bladder neck drops below this zone (hypermobility), pressure only increases on the bladder but not the urethra, causing leakage.
Reading slides 21–22: In the first schematic, the proximal urethra lies above the pelvic-floor reference plane, so the green arrows show pressure reaching both bladder and proximal urethra. In the second, the bladder neck/proximal urethra has descended below that plane; the bladder still receives the pressure rise but urethral pressure transmission is lost, and the white downward arrow marks leakage. This is a teaching model of support failure, not a literal pressure boundary that can be located on routine examination.
"Symptoms of stress, urge, and abnormal emptying mainly derive, for different reasons, from laxity in the vagina or its supporting ligaments, a result of altered connective tissue." (Petros 2007) [1]
The Integral Theory unifies prolapse and incontinence under one framework: restoration of form (structure) leads to restoration of function.
What the bridge and force diagrams are showing: The vagina is drawn as a flexible bridge deck, the ligaments as suspension cables and pelvic muscles as opposing tension systems. The more detailed diagram labels the pubourethral and uterosacral anchoring points and shows anterior, posterior and downward muscle vectors; if those forces become unbalanced, the urethra can funnel instead of being supported. Treat this as the lecture's conceptual biomechanical model—useful for linking structure and function, but not a stand-alone diagnostic test or proof that every urgency symptom is caused by a vaginal ligament defect.
Pathophysiology of idiopathic detrusor overactivity remains a mystery. [1]
The slide lists urethral outflow obstruction, childhood toilet-training/enuresis history, possible primary urethral pathology and altered detrusor-cell contractility. Several are explicitly speculative lecture-era hypotheses; do not present poor toilet training as an established causal diagnosis. OAB/urgency also has neurological, urothelial, myogenic, medication and age-related contributors, while many cases remain idiopathic.
Key Point
There are no specific examination signs of detrusor overactivity. Overactive bladder is the clinical syndrome of urgency, usually with frequency/nocturia, with or without urgency incontinence; detrusor overactivity is the urodynamic observation of involuntary contractions during filling. They overlap but are not interchangeable. [1]
3. Factors That Adversely Affect Pelvic Floor Function
The most common factor is vaginal delivery. Over 90% of patients with prolapse are parous (OR 4.7), and particularly instrumental delivery with a macrosomic baby and a long second stage of labour. [1]
The percentage and odds ratio are historical cohort estimates from the slide, not universal probabilities. The durable teaching point is the dose-related obstetric injury pattern, especially operative vaginal birth, prolonged second stage and larger infant size.
Mechanism: Vaginal birth damages:
- Pelvic floor muscles (direct stretch/tear of levator ani)
- Ligaments and fascia (overstretching of cardinal/uterosacral ligaments)
- Pudendal nerve (traction neuropathy during descent of fetal head) → denervation of pelvic floor muscles
| Factor | Why |
|---|---|
| Menopause (lack of oestrogen) | Oestrogen maintains collagen, vascularity, and mucosal thickness in pelvic tissues. Its loss leads to atrophy. [1][3] |
| Increasing age | Progressive denervation and collagen degeneration |
| Obesity | Chronically raised intra-abdominal pressure |
| Chronic cough/constipation | Repeated straining increases downward force on pelvic floor |
| Occupational stress | Heavy lifting |
| Congenital weakness of connective tissue | e.g., Marfan's syndrome, Ehlers-Danlos |
| Prior hysterectomy | Disrupts Level I support → risk of vault prolapse |
| Population associations | The slide's older "Whites more prone than Blacks" statement is an observational population-level association, not a useful biological rule for an individual. Obstetric exposure, age, BMI, access to care, ascertainment and social factors can confound such comparisons. |
4. Genital Prolapse
About 50% of parous women have prolapse, which is symptomatic in 20%. [1]
Vaginal vault prolapse in up to 2% of women who had hysterectomy for benign diseases, but up to 12% when performed for prolapse. [1]
These are lecture-era estimates and depend heavily on whether prolapse is defined by examination, symptoms or surgery. The clinically important distinction is that anatomical descent is common, but treatment is driven by bothersome symptoms, complications and patient preference—not the examination stage alone. [9]
| Compartment | Type of Prolapse |
|---|---|
| Anterior | Cystourethrocele |
| Middle | Uterine prolapse or vault prolapse |
| Posterior | Rectocele |
Reading the three-row clinical/MRI panel (slide 32): Each row pairs an external bulge with a sagittal dynamic MR image and a coloured anatomical overlay.
- Top: the bladder/anterior vaginal wall descends—an anterior compartment prolapse (cystocele).
- Middle: the uterus/cervix and vaginal apex descend through the hiatus—apical/uterine prolapse.
- Bottom: the rectum pushes the posterior vaginal wall forward—posterior compartment prolapse (rectocele).
The image is a localisation exercise. Dynamic MRI can demonstrate compartment movement, but it is not routine when prolapse is already evident on physical examination. [9]
Described by the position of the cervix relative to the introital opening during maximal straining:
| Grade | Definition |
|---|---|
| First degree | Cervix descends into the vagina below the ischial spine but NOT as far as the introitus |
| Second degree | Cervix descends to the introital opening or just beyond |
| Third degree | Cervix AND uterine body both beyond the introitus |
The POP-Q is a standardized, quantitative grading system referenced to the hymen (Bump 1996).
Key landmarks:
| Point | Location | Range |
|---|---|---|
| Aa | 3 cm proximal to external urethral meatus (anterior wall) | -3 to +3 |
| Ba | Most distal position of upper anterior vaginal wall | -3 (no prolapse) to +tvl |
| C | Most distal edge of cervix or vaginal cuff | — |
| D | Posterior fornix (only in women with cervix) | — |
| Ap | 3 cm proximal to hymen (posterior wall) | -3 to +3 |
| Bp | Most distal position of upper posterior vaginal wall | -3 (no prolapse) to +tvl |
| gh | Genital hiatus (urethral meatus to posterior hymen) | — |
| pb | Perineal body (posterior hymen to mid-anal opening) | — |
| tvl | Total vaginal length | — |
POP-Q Ordinal Stages:
| Stage | Definition |
|---|---|
| 0 | No prolapse |
| I | Most distal part > 1 cm above the hymen |
| II | Most distal part ≤ 1 cm proximal or distal to the hymen |
| III | Most distal part > 1 cm below hymen but no further than tvl − 2 cm |
| IV | Complete eversion; at least tvl − 2 cm |
How to read the POP-Q diagram: The hymen is the zero reference: negative values are proximal/inside and positive values are distal/outside. Aa/Ap are fixed points 3 cm inside the anterior/posterior wall; Ba/Bp are the most distal points of the remaining wall; C is the cervix or cuff, and D is the posterior fornix only when a cervix is present. gh, pb and tvl describe hiatus, perineal body and total vaginal length. Stage is assigned from the single most distal leading edge, not by averaging points.
The most specific symptom is when the woman can see or feel a bulge of tissue that protrudes to or past the vaginal opening. (ACOG 2007) [1]
| Symptom | Compartment | Explanation |
|---|---|---|
| Feeling/seeing a lump | Any | The most specific symptom |
| Urinary symptoms (difficulty voiding, incomplete emptying) | Anterior | Bladder base descent kinks the urethra |
| Bowel symptoms (e.g., splinting — need to push back prolapse to defaecate) | Posterior | Rectocele traps stool in the pouch |
| Pelvic pressure/heaviness | Any | Non-specific — CANNOT assume prolapse treatment will relieve it [1] |
| Back pain | Any | Non-specific [1] |
| May be asymptomatic | Any | Prolapse on examination does not always cause symptoms |
High Yield – Occult Stress Incontinence
Prolapse may MASK incontinence which can present once prolapse has been corrected. [1] This is called occult (latent) stress incontinence. The prolapse kinks the urethra and compresses it, preventing leakage. After surgical repair of the prolapse, the urethra is no longer kinked, and stress incontinence becomes apparent. Always test for occult stress incontinence by reducing the prolapse (e.g., with a pessary or fingers) and performing a cough test. If surgery is indicated, surgery for both conditions may be needed. [1]
Renal damage may occur in the presence of severe genital prolapse as a result of ureteric obstruction. [1]
The highlighted paper on slide 37 followed 259 postmenopausal women with repeated POP-Q examinations over 4 years. It showed that measured descent can both progress and regress. Over 3 years, maximal descent increased by at least 2 cm in 11.0% and decreased by at least 2 cm in 2.7%; higher BMI and grand multiparity were associated with progression. This older observational cohort is useful mainly for one counselling point: mild prolapse is not inevitably and continuously progressive.
General:
- Obesity (BMI) — risk factor and affects surgical planning
- Respiratory system — chronic cough?
Abdominal:
- Abdominal/pelvic mass — fibroid or ovarian cyst can worsen prolapse or cause diagnostic confusion
Pelvic examination:
- Lithotomy position — initial assessment
- Sims (left lateral) position — using Sims speculum to retract anterior and posterior vaginal walls sequentially to assess each compartment individually
Reading the examination photographs (slides 41 and 43): The instrument tray includes Sims specula of different sizes and cervical sampling spatulas. In the model photograph, a single-bladed speculum retracts one vaginal wall while the opposite wall is observed during strain. Reposition the blade to isolate the anterior and posterior compartments; a single undifferentiated view of the bulge can miss a mixed defect. If symptoms are not reproduced, repeat the examination standing or squatting or at another time. [9]
Pelvic examination checklist: [1]
- Assess degree of descent in each compartment during straining
- Assess condition of vaginal wall (oestrogenization) — pale, thin = atrophic
- Take cervical smear if indicated
- Uterine assessment (bimanual — size, mobility, tenderness)
- Look for adnexal mass
4.8 Management of Genital Prolapse
The slide frames a ring pessary mainly as an option for women who decline surgery, are unfit for it or are awaiting it. Current guidance is broader: offer no treatment, supervised pelvic-floor muscle training, a pessary or surgery according to symptoms and preference. Consider supervised PFMT for at least 16 weeks as a first option for symptomatic POP-Q stage 1–2, and consider a pessary at any symptomatic stage, alone or with PFMT. [9]
Mechanism: The ring sits in the vagina and provides a mechanical support platform for the prolapsed organs.
Evidence for pelvic floor muscle training (PFMT) in prolapse: The POPPY trial (Hagen et al., Lancet 2014; multicentre RCT, n = 447) demonstrated that individualised one-to-one pelvic floor muscle training reduced prolapse symptoms modestly (POP-SS adjusted difference 1.52; 95% CI 0.46–2.59; p = 0.005) compared with a lifestyle-advice leaflet alone. The paper image supports symptom improvement, not a promise of anatomical cure. [1]
Sizing: Choose a pessary that gives support to the prolapsed organ but does not cause discomfort to the patient. [1]
Complications: [1]
- Pressure ulcer
- Bleeding
- Infection with discharge
Also counsel about expulsion, difficulty removing it and effects on intercourse. More than one fitting may be needed, and the pessary should be removed/changed at least once every 6 months to avoid serious neglected-pessary complications; women unable to self-manage need scheduled clinic follow-up. Consider vaginal oestrogen when menopause-associated genitourinary symptoms/signs coexist. [9]
Historical evidence slide: The old Cochrane slide found only one small RCT and reported successful use in about 60% of completers. Do not treat that as a current universal success rate: pessary fitting, continuation and outcome definitions vary, and current recommendations explicitly require fitting, counselling and ongoing care. [9]
Surgery is an option when symptoms have not improved with, or the woman declines, non-surgical treatment. It aims to restore support/function but is not guaranteed curative: recurrence and new urinary, bowel, sexual or pain symptoms are possible. Route and operation are individualised rather than "usually vaginal" by rule. [9]
Key principle: Nature of surgery depends on the nature of the prolapsed organs. [1]
| Prolapse Type | Surgical Options |
|---|---|
| Anterior (cystocele) | Anterior colporrhaphy (anterior repair) |
| Apical (uterine/vault) | Vaginal hysterectomy ± vault suspension, sacrocolpopexy (abdominal), sacrospinous fixation |
| Posterior (rectocele) | Posterior colporrhaphy (posterior repair) |
| Combined | Combined procedures |
Uterus-preserving operations should be discussed alongside hysterectomy-based repair when appropriate. Mesh terminology must be precise: a retropubic mid-urethral mesh sling for SUI and abdominal/laparoscopic mesh sacrocolpopexy are not the same as transvaginal mesh repair of a vaginal wall, and each has distinct risks and jurisdictional restrictions. Shared decision-making should include recurrence, mesh complications and the possibility that complete mesh removal may be impossible. [9]
Stress-incontinence planning: Demonstrate symptomatic or occult leakage with the prolapse reduced and discuss concurrent versus staged treatment. Do not automatically add prophylactic continence surgery to prolapse surgery in a woman without incontinence. For women with anterior/apical prolapse plus SUI, concurrent surgery can be considered, but benefit beyond 1 year is uncertain and complication risks must be compared with sequential surgery. [9]
5. Urinary Incontinence
IUGA/ICS Definition: the complaint of any involuntary leakage of urine. (2010) [1]
The slide reports a 2006 questionnaire study of 540 Hong Kong Chinese women aged 17–77:
- 40.8% self-reported stress urinary incontinence
- 20.4% reported urgency incontinence
- 15.9% reported mixed incontinence
These categories may overlap, and comparison with a separate 1996 survey does not by itself establish a true rise in prevalence because sampling, definitions and ascertainment can differ. Use the panel as historical local context, not a current population estimate.
The lecture distinguishes clinical diagnosis from urodynamic diagnosis:
| Clinical Term | Urodynamic Term | Definition |
|---|---|---|
| Stress urinary incontinence (SUI) | Urodynamic stress incontinence (USI) | Clinical: involuntary loss of urine on effort/exertion/sneezing/coughing. Urodynamic: leakage during filling cystometry with ↑ intra-abdominal pressure, in the absence of a detrusor contraction |
| Overactive bladder (OAB) — Dry vs Wet / Urgency urinary incontinence | Detrusor overactivity (DO) | Clinical: involuntary loss of urine associated with urgency. Urodynamic: involuntary detrusor muscle contractions during filling cystometry |
| Mixed UI | — | Combined SUI + UUI symptoms |
| Overflow incontinence | — | Dribbling without recognizable urge or sensation of fullness (large residual volume) |
Exam Trap – Clinical vs Urodynamic Terminology
"Stress urinary incontinence" is a clinical diagnosis based on symptoms. "Urodynamic stress incontinence" is confirmed only by urodynamic studies. You cannot use the term "USI" without having done urodynamics. Similarly, "detrusor overactivity" is a urodynamic diagnosis, while "overactive bladder" is the clinical term. Examiners may test this distinction directly. [1]
Other causes of urinary incontinence: [1]
The lecture provides a comprehensive table for distinguishing types of UI by history:
| Feature | Stress UI | Urgency UI | Mixed UI | Overflow UI |
|---|---|---|---|---|
| Circumstances | Physical activity, ↑ intra-abdominal pressure | Preceded by sudden strong desire to void | Both urgency and exertion | Without recognizable urge/fullness |
| Specific clues | Coughing, sneezing, exercise, walking uphill | Nocturia, frequency; may NOT involve incontinence (dry OAB) | Identify predominant symptom | Dribbling, incomplete emptying |
| Voiding interval | Normal | ↓ interval | ↓ interval | ↑ interval |
| Nocturia | Absent or mild | Often prominent | Variable | — |
Additional history: [1]
- Irritative voiding symptoms:
- Frequency: the lecture uses > 7 daytime voids as a mnemonic, but frequency is contextual—interpret it with intake, bother and a bladder diary rather than a rigid diagnostic cut-off
- Urgency: sudden and strong desire to void
- Nocturia: waking at night ≥ 1 time to void
- Relation to genital prolapse, bowel and sexual dysfunction
- Severity and effect on quality of life
- Faecal incontinence (shared pelvic floor pathology)
- Fluid intake — caffeine-containing beverages (caffeine is a bladder irritant)
Common Medications and Substances That Can Cause UI [1]
The table is best used as a medication review, not proof that each drug caused the symptom. Look for a plausible timing relationship and reversible mechanisms such as polyuria, cough, sedation, impaired mobility, constipation or retention.
| Class | Examples | Mechanism of Effect |
|---|---|---|
| Alpha-adrenergic antagonists | Antihypertensives | Decrease sphincter tone → stress incontinence |
| ACE inhibitors | Antihypertensives | Increase coughing → stress incontinence |
| Calcium channel blockers | Antihypertensives | Relax bladder → retention and overflow incontinence |
| Diuretics | Antihypertensives | High urine flow → bladder contractions → urge incontinence |
| Opioids | Pain relievers | Relax bladder, cause faecal impaction/sedation → retention and overflow incontinence |
| Skeletal muscle relaxants | Pain relievers | Inhibit bladder contractions → retention and overflow incontinence |
| Antidepressants / Antipsychotics / Antiparkinsonian agents | Psychotherapeutics | Inhibit bladder contractions → retention and overflow incontinence |
| Sedatives and hypnotics | Psychotherapeutics | Sedation and impaired cognition → functional or overflow incontinence |
| Alcohol | — | Diuretic effect + depressed central inhibition → urge/overflow incontinence |
| Antihistamines / Anticholinergics | — | Inhibit bladder contractions → retention and overflow incontinence |
| Thiazolidinediones | — | Increase fluid retention → nocturnal diuresis and functional incontinence |
- Pads for protection, amount of leaking
Cough test (may need reduction of prolapse to detect occult stress incontinence) [1]
- Assess pelvic floor support (each compartment) and function
- Presence of uterine and adnexal pathology
- Neurological examination to assess S2-4 nerve roots — anal tone, perineal sensation, bulbocavernosus reflex
NB: There are no specific clinical signs in women with detrusor overactivity. [1]
| Investigation | Purpose |
|---|---|
| Urine dipstick | Test blood, glucose, protein, leucocytes and nitrites in every woman presenting with UI; investigate haematuria appropriately |
| Bladder diary | At least 3 days spanning usual working/leisure variation; record time and volume of drinks/voids plus urgency and leakage |
| MSU culture | Send when UTI symptoms or the dipstick pattern warrant it—not routinely for every asymptomatic woman with a negative dipstick |
| Post-void residual | Bladder scan (preferred to catheterisation) if voiding dysfunction or recurrent UTI is suspected |
High Yield – First-Line Investigation for UI
The 2020 local MCQ selected MSU culture rather than urodynamics for a woman with urgency incontinence. The enduring exam principle is exclude reversible urinary pathology and use a bladder diary before invasive testing. Current NICE practice is more specific: dipstick everyone, culture selectively, and use a minimum 3-day bladder diary. [7][9]
Reading the diary form (slide 62): Its three day-columns and hourly rows capture void volume, drink volume, urgency and leakage. Patterns—not a single total—separate high intake/polyuria, small frequent urgency voids, nocturnal polyuria and activity-related leakage, and provide a baseline for response to treatment.
Behavioural therapy: smoking cessation, weight reduction, reduce caffeine intake, fluid intake advice. [1]
"8 glasses of water is a myth!" [1]
This should not become advice to dehydrate. Encourage normal hydration and use the diary to identify excessively high or low intake; modify intake when it plausibly contributes to symptoms. [9]
Why these work:
- Weight reduction → decreases chronic intra-abdominal pressure
- Caffeine reduction → caffeine is a diuretic and bladder irritant
- Smoking cessation → reduces chronic cough (which worsens SUI)
- Fluid advice → excessive fluid = more urine = more leakage; too little = concentrated irritating urine
Urodynamics confirms whether the leakage was related to USI and/or detrusor overactivity. [1]
Components:
- Measurement of pressure–flow relationship between bladder and urethra
- Storage/filling phase AND voiding phase
- Cystometry — evaluates storage function and bladder sensation during filling
Key urodynamic channels: [1]
- Pves — vesical (bladder) pressure, measured via a bladder pressure catheter
- Pabd — abdominal pressure, measured via a vaginal (or rectal) pressure catheter
- Pdet — detrusor pressure, calculated as Pdet = Pves − Pabd (subtracts abdominal pressure artefact to isolate true detrusor activity)
Reading the equipment and traces (slides 65–69): A bladder catheter records Pves and fills the bladder; a vaginal/rectal catheter records Pabd; the system calculates Pdet = Pves − Pabd.
- In the stress-incontinence trace, a cough makes Pves and Pabd spike together, so Pdet stays essentially flat; a simultaneous flow/leak signal demonstrates urodynamic stress incontinence.
- In the detrusor-overactivity trace, Pves and calculated Pdet rise in waves while Pabd remains stable; leakage occurs at the larger involuntary contraction. That is true detrusor activity rather than cough/strain artefact.
When to do urodynamics: Not first-line. Reserved for:
- urge-predominant mixed UI or unclear UI type before SUI surgery
- symptoms of voiding dysfunction
- anterior or apical prolapse before SUI surgery
- previous SUI surgery
- refractory OAB when invasive treatment is being considered
Do not routinely perform multichannel cystometry before primary surgery when stress-predominant UI is clear from history and leakage is demonstrated on examination. [9]
6. Management of Stress Urinary Incontinence [1]
Management is usually based on clinical stress UI; urodynamic confirmation is not required in every uncomplicated case. [9]
| Approach | Details |
|---|---|
| Behavioural therapy | As above (weight, caffeine, smoking, fluid) |
| Supervised pelvic-floor muscle training | First-line for at least 3 months; confirm a voluntary contraction digitally first. A programme should include at least 8 contractions three times daily and continue if beneficial. Routine biofeedback is unnecessary, but may help someone unable to contract effectively. [9] |
| Pharmacotherapy | Duloxetine is not first-line and is not routinely second-line; it may be considered when a woman prefers medication to surgery or is unsuitable for surgery, with adverse-effect and withdrawal counselling. Local licensing/formulary status must be checked. [9] |
Surgery aims to: (a) restore the bladder neck back to the intra-abdominal pressure zone, (b) increase outflow resistance, or (c) attain both. [1]
| Procedure | Mechanism |
|---|---|
| Retropubic mid-urethral mesh sling | Permanent polypropylene implant supporting the mid-urethra; counsel that complete removal may be impossible and discuss uncertain long-term adverse-event frequency |
| Transobturator sling | Not a routine interchangeable first choice in NICE guidance; reserve for specific circumstances in which the retropubic route should be avoided |
| Open/laparoscopic colposuspension | Sutures elevate paravaginal tissue/bladder-neck support |
| Autologous rectus fascial sling | Uses the woman's fascia rather than synthetic mesh |
| Urethral bulking agent | Less invasive, but generally less effective and may require repeat injections; consider when other operations are unsuitable or unacceptable |
| Artificial urinary sphincter | Specialist salvage option; do not offer routinely unless previous surgery has failed |
Choice is preference-sensitive and jurisdiction-dependent. Compare anaesthesia, recovery, success, voiding dysfunction, pain, erosion/exposure and repeat-treatment risk rather than presenting TVT/TOT as automatic next steps. [9]
7. Management of OAB/Urgency UI [1]
- Bladder training for at least 6 weeks is first-line for urgency or mixed UI; use urge-suppression/deferment and gradually lengthen voiding intervals. [10]
- Add caffeine reduction, rational fluid adjustment and weight loss if BMI > 30; pelvic-floor contractions can help urgency suppression but are not a substitute for the bladder-training programme. [9]
| Drug Class | Examples | Mechanism |
|---|---|---|
| Anti-muscarinic agents | Oxybutynin, tolterodine, solifenacin | Block M3 muscarinic receptors on detrusor muscle → reduce involuntary contractions |
| Beta-3 adrenoceptor agonist | Mirabegron, vibegron (availability varies) | Activates β3 receptors → promotes storage-phase detrusor relaxation |
Medication choice is not simply “elderly = mirabegron”: Discuss dry mouth, constipation, blurred vision, retention and total anticholinergic burden; long-term cognitive effects remain uncertain. Avoid immediate-release oxybutynin in older women at risk of sudden physical/mental deterioration. Beta-3 agonists avoid anticholinergic effects but have their own contraindications/monitoring (for example, blood pressure with mirabegron). Review response and adverse effects after about 4 weeks. [9]
- Intradetrusor botulinum toxin A after failure of conservative and drug treatment; counsel about UTI and possible clean intermittent catheterisation. NICE starts at 100 units. [9]
- Sacral neuromodulation after specialist/MDT review, particularly when botulinum toxin fails or catheterisation risk is unacceptable. [9]
- Percutaneous posterior tibial nerve stimulation is a selected alternative in some pathways, not equivalent to surface TENS.
- Augmentation cystoplasty/urinary diversion are rare last-resort operations with major long-term consequences and lifelong follow-up—not the routine “step 3.” [9]
High Yield – Lecture Summary Slide
Lecture message: Weakened support links prolapse and stress UI, childbirth is an important risk factor, and severe prolapse can mask stress leakage. Modern counselling adds that non-surgical treatment can provide worthwhile durable symptom control, and combined surgery is a preference-sensitive option—not an automatic requirement. [1][9]
Role of Primary Care [1]
Patients usually do not volunteer incontinence symptoms due to:
- Embarrassment
- Accept as part of normal ageing and childbirth
- Not aware that treatment is available
- Symptom not troublesome enough
Always take note of the symptom and refer if indicated. [1]
9. Integration with Related Lectures
Genitourinary syndrome of menopause can cause dryness, dyspareunia, urgency, frequency, dysuria and recurrent UTI. Vaginal oestrogen can help menopause-associated genitourinary symptoms and OAB symptoms; it is not a generic treatment for all stress UI or a way to reverse established prolapse. [9]
Aetiological causes of UI include: congenital (duplex ureter below sphincter), infection, iatrogenic (post-prostatectomy), birth injury (VVF, stress incontinence), neoplastic.
- Suprasacral spinal cord lesion: Spinal shock → AROU → later becomes hyperreflexic (urge incontinence / detrusor-sphincter dyssynergia)
- Sacral cord / cauda equina lesion: Hyporeflexic/areflexic bladder → overflow incontinence
Posterior urethral valves (male) → bilateral hydronephrosis → requires urgent investigation. VUR → recurrent UTI → reflux nephropathy.
Active Recall - Lecture Notes
High Yield Summary
- Pelvic floor means the muscle, fascia, ligaments, perineal structures and neural control supporting the pelvis—not levator ani alone.
- DeLancey: Level I suspends the apex; Level II attaches mid-vagina to the sidewall; Level III fuses distal vagina to urethra, perineal body and levator ani.
- Localise prolapse by its leading compartment and record it with POP-Q relative to the hymen. A visible/felt bulge is the most specific symptom.
- Prolapse can mask stress leakage. Reduce it and cough-test, then discuss concurrent versus staged treatment; do not add continence surgery automatically.
- Initial UI work-up is clinical pattern + urine dipstick + at least 3 days of bladder diary; culture and residual-volume testing are selective. Urodynamics is not routine in uncomplicated demonstrated SUI.
- First-line: supervised PFMT for stress/mixed UI; at least 6 weeks of bladder training for urgency/mixed UI; 16-week supervised PFMT and/or pessary for suitable symptomatic prolapse.
- OAB medication choice must consider anticholinergic burden, cognition, constipation, retention and beta-3-agonist contraindications. Botulinum toxin and neuromodulation are specialist refractory options.
- Prolapse and SUI operations require shared decision-making about route, recurrence, mesh, urinary/bowel/sexual outcomes and whether treatment should be combined or staged.
[1] Lecture slides: GC 116. I felt a lump below urinary incontinence in females; genital prolapse.pdf [2] Senior notes: Block C - I felt a lump below_ urinary incontinence in females; genital prolapse.pdf [3] Lecture slides: GC 114. Climacteric symptoms menopause and related illness; amenorrhoea.pdf (p41) [4] Lecture slides: GC 209. Urinary incontinence and overactive bladder.pdf (p22) [5] Senior notes: Ryan Ho Urogenital.pdf (p159-164) [6] Senior notes: Ryan Ho Neurology.pdf (p53, p168) [7] Past papers: 2020 Fourth Summative Assessment MCQ paper.pdf (Q54, Q85) [8] Senior notes: Adrian Lui Pediatrics Notes.pdf (p336) [9] NICE. Urinary incontinence and pelvic organ prolapse in women: management (NG123; last reviewed 2025). https://www.nice.org.uk/guidance/ng123/chapter/Recommendations [10] NICE. Urinary incontinence in women—quality statement 5: bladder training (updated 2021). https://www.nice.org.uk/guidance/qs77/chapter/quality-statement-5-bladder-training [11] ACOG. Pelvic Support Problems (last reviewed October 2025). https://www.acog.org/womens-health/faqs/pelvic-support-problems
GC115 I Am Pregnant Medical Problems Complicating Pregnancy
Pre-existing or newly arising medical conditions—such as hypertension, diabetes, thyroid disorders, cardiac disease, or thromboembolic disease—that complicate pregnancy and require specialized management to optimize maternal and fetal outcomes.
GC117 I Want To Have A Baby Male And Female Infertility
Male and female infertility refers to the inability of a couple to achieve pregnancy after 12 months of regular unprotected intercourse, resulting from disorders of sperm production or function, ovulatory dysfunction, tubal damage, uterine abnormalities, or unexplained factors in either partner.