Step 2 CK · Obstetrics & Gynecology

Pelvic Organ Prolapse & Urinary Incontinence

Name: Pelvic Organ Prolapse & Urinary Incontinence
Creator: Veli Bakalov, MD

Name the leak, find the reversible cause, and match the fix to the mechanism

Obstetrics & Gynecology·Gynecology·5 min read·9 high-yield points·Reviewed by Veli Bakalov, MD @HemeOncBuddy

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Every new incontinence workup begins with urinalysis, a medication review, a bladder diary, a cough stress test, and a post-void residual (under 50 mL normal; above about 150–200 mL suggests overflow).
Stress incontinence is instant small-volume leakage with cough or strain from urethral hypermobility or sphincter deficiency; treat with pelvic floor training and weight loss, then a midurethral sling.
No drug is FDA-approved for stress incontinence; antimuscarinics treat urgency only.
Overactive bladder is treated in steps: bladder training and fluid/caffeine changes, then an antimuscarinic or β3-agonist, then onabotulinumtoxinA or sacral/tibial neuromodulation.
Avoid antimuscarinics, especially oxybutynin, in older adults; mirabegron or vibegron is preferred, and mirabegron can raise blood pressure.
Overflow incontinence means dribbling with a high residual from diabetic neuropathy, drugs, or obstruction; treat the cause and use clean intermittent self-catheterization.
Continuous painless vaginal leakage 1–3 weeks after hysterectomy is a vesicovaginal fistula until proven otherwise; methylene blue in the bladder stains a vaginal tampon blue.
Prolapse causes bulge, pressure, and splinting to void or defecate; POP-Q stage II lies within 1 cm of the hymen and stage IV is complete eversion.
Observe asymptomatic prolapse; offer a pessary or surgery (sacrocolpopexy, native-tissue repair) for symptoms, and colpocleisis for frail women forgoing intercourse.

Overview and initial evaluation

Why the type matters. Incontinence and prolapse both reflect failing pelvic support and rise with vaginal childbirth, aging, obesity, and menopause. Stress, urge, overflow, functional, and fistula-related leakage have different causes and often opposite treatments, so classify before treating.

Reversible causes first. A urinalysis screens for UTI, hematuria, and glycosuria. Review medications: diuretics cause urgency, anticholinergics and opioids cause retention with overflow, α-blockers relax the bladder neck and worsen stress leakage in women, and ACE-inhibitor cough provokes stress leaks. DIAPPERS lists transient causes: Delirium, Infection, Atrophic vaginitis, Pharmaceuticals, Psychological illness, Excess urine output (hyperglycemia, hypercalcemia, heart failure), Restricted mobility, Stool impaction.

Urinalysis and medication reviewExclude infection, hematuria, glycosuria, offending drugs
Three-day bladder diaryIntake, voids (more than 8 per day = frequency), nocturia, leaks
Cough stress testLeakage at the instant of a cough with a full bladder = stress incontinence
Post-void residualUnder 50 mL normal; above about 150–200 mL suggests retention with overflow

Urodynamics are not needed before treating uncomplicated stress incontinence; reserve them for mixed or unclear symptoms, neurologic disease, a high residual, prior surgery, or failed therapy.

Types of urinary incontinence

Type	Mechanism	Clues	First step
Stress	Urethral hypermobility or sphincter deficiency	Small spurts with cough or lifting; normal PVR	Pelvic floor training
Urge	Detrusor overactivity	Urgency, frequency, nocturia, larger leaks	Bladder training
Overflow	Underactive detrusor or obstruction	Dribbling, high PVR	Treat cause; self-catheterize
Functional	Normal tract; cannot reach toilet	Dementia, immobility	Scheduled toileting
Fistula	Bladder–vagina tract	Continuous painless leakage	Dye (tampon) test

Stress urinary incontinence

Mechanism. Loss of pelvic floor support makes the urethra hypermobile, or intrinsic sphincter deficiency lowers closure pressure; small amounts leak the instant abdominal pressure spikes with coughing, sneezing, laughing, lifting, or exercise. Leakage beginning seconds after a cough instead suggests cough-triggered detrusor overactivity.

Treatment ladder. Start with supervised pelvic floor muscle (Kegel) training for at least 3 months, weight loss, and treatment of chronic cough and constipation. An incontinence pessary or vaginal insert suits women avoiding surgery. The synthetic midurethral sling (retropubic or transobturator) is the most-used, best-studied operation; Burch colposuspension, an autologous fascial sling, and urethral bulking are alternatives. Sling risks include retention, mesh exposure, and bladder perforation.

No drug is FDA-approved for stress incontinence; antimuscarinics treat urgency, not a weak outlet.

Overactive bladder and urge incontinence

Presentation. Urgency with frequency and nocturia, with or without larger-volume leaks on the way to the toilet (triggers: running water, a key in the door), from involuntary detrusor contractions. Most cases are idiopathic; neurogenic causes include stroke, multiple sclerosis, Parkinson disease, and spinal cord lesions above the sacral cord.

First line. Bladder training (timed voiding with lengthening intervals, urge suppression by contracting the pelvic floor and waiting), moderating total and evening fluids, cutting caffeine and alcohol, weight loss, and relieving constipation.

Second line. Antimuscarinics (oxybutynin, tolterodine, fesoterodine, solifenacin, darifenacin, trospium) block detrusor M3 receptors and cause dry mouth, constipation, blurred vision, and confusion. Avoid them in older adults, oxybutynin above all (Beers list; linked to cognitive decline), and in urinary retention or uncontrolled narrow-angle glaucoma. Trospium, a quaternary amine, barely enters the CNS. The β3-agonists mirabegron and vibegron relax the detrusor without anticholinergic effects and are preferred in the elderly; mirabegron can raise blood pressure. The two classes can be combined.

Third line. Cystoscopic intradetrusor onabotulinumtoxinA (lasts about 6–9 months; risks UTI and retention, so the patient must accept intermittent self-catheterization), sacral neuromodulation via an implanted S3 lead, or weekly percutaneous tibial nerve stimulation. Augmentation cystoplasty or diversion is rare.

Mixed, overflow, functional, and fistula

Mixed. Stress plus urge leakage, common in older women. Use measures that help both (pelvic floor and bladder training, weight loss), then target the most bothersome component; urgency may persist after a sling.

Overflow. Continuous dribbling with incomplete emptying and a high residual, from detrusor underactivity (diabetic autonomic neuropathy, spinal cord or cauda equina injury, anticholinergics, opioids) or obstruction (severe prolapse, overcorrected sling, fecal impaction; BPH in men). Treat the cause and use clean intermittent self-catheterization rather than an indwelling catheter; bladder relaxants worsen it.

Functional. A normal lower urinary tract, but dementia, arthritis, stroke, or environmental barriers delay toileting. Manage with prompted or scheduled toileting, a bedside commode, mobility aids, and easy-release clothing.

Vesicovaginal fistula. Continuous, painless vaginal leakage day and night, often with normal voiding. Hysterectomy is the leading cause in high-resource countries (onset typically 1–3 weeks postoperatively); prolonged obstructed labor with pressure necrosis leads worldwide; radiation fistulas appear months to years later. Methylene blue instilled into the bladder stains a vaginal tampon blue. Adding oral phenazopyridine (double-dye test) identifies a ureterovaginal fistula as an orange but not blue tampon. Cystoscopy and CT urography define the tract. Small early fistulas may close with weeks of catheter drainage; most need surgical repair.

Pelvic organ prolapse

Anatomy and risk. Anterior wall descent is a cystocele (bladder), posterior wall a rectocele (rectum), and apical descent uterine or post-hysterectomy vault prolapse; an enterocele is small bowel in the rectovaginal space. Vaginal delivery and parity are the strongest risk factors, then age, obesity, chronic cough or constipation, heavy lifting, and connective tissue disease.

Symptoms. A seen or felt vaginal bulge is the most specific symptom; pressure worsens by day's end and eases lying down. Patients may splint the bulge to void or defecate and empty incompletely. Advanced prolapse can ulcerate, cause hydronephrosis, or kink the urethra and mask stress incontinence (occult SUI) that emerges after repair.

POP-Q staging (hymen = 0)

Stage	Most distal point
I	More than 1 cm above the hymen
II	Within 1 cm above or below the hymen
III	More than 1 cm beyond the hymen, short of eversion
IV	Complete eversion (procidentia)

Management. Observe asymptomatic prolapse of any stage. For symptoms, offer a pessary (ring with support; Gellhorn for advanced; clean periodically, vaginal estrogen limits erosions), pelvic floor training for mild disease, or surgery. Sacrocolpopexy suspends the apex with mesh to the sacral promontory and is the most durable apical repair; native-tissue vaginal repairs include colporrhaphy and uterosacral or sacrospinous suspension. Colpocleisis closes the vagina and suits frail women forgoing intercourse.

Exclude cervical and endometrial disease before LeFort colpocleisis, since the uterus becomes inaccessible. Transvaginal mesh for prolapse was withdrawn from the US market in 2019.