Campbell Incontinencia Urinaria

16 Urinary Incontinence and Pelvic
Prolapse: Pathophysiology,
Evaluation, and Medical
Management
ELIZABETH ROURKE AND W. STUART REYNOLDS
CONTRIBUTORS OF CAMPBELL-WALSH-WEIN,
12TH EDITION
Toby C. Chai, Lori A. Birder, Elizabeth T. Brown, Alan J. Wein,
Roger R. Dmochowski, Alvaro Lucioni, Kathleen C. Kobashi,
Riyad T. Al-Mousa, Hashim, Benjamin M. Brucker, Victor W.
Nitti, Gary E. Lemack, Maude Carmel, Casey Cg Kowalik, Alan J.
Wein, Roger R. Dmochowski, W. Stuart Reynolds, Joshua A.
Cohn, Christopher R. Chapple, Nadir I. Osman, Stephen D.
Marshall, Jeffrey P. Weiss, Karl-Erik Andersson, Diane K. Newman,
Kathryn L. Burgio, John P.F.A. Heesakkers, and Bertil Blok
OVERVIEW AND PATHOPHYSIOLOGY OF URINARY

INCONTINENCE AND PELVIC ORGAN PROLAPSE
Urinary Incontinence (UI)
Overview of Neurophysiology. UI is the symptomatic complaint
of the involuntary loss of urine and can develop because of ana-
tomic and functional abnormalities of the lower urinary tract
(LUT). The LUT is composed of the bladder and urethra, sup-
ported by a complex system of neural innervation and musculo-
fascial support in the lower pelvis. It functions with the integration
of many components, including the central nervous system (CNS),
the peripheral nervous system, bladder smooth muscle, bladder
stroma, suburothelial and intradetrusor interstitial cells, bladder
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392 CHAPTER 16 Urinary Incontinence and Pelvic Prolapse
urothelium, urethral smooth muscle, pelvic floor striated muscles,

and the external urethral sphincter (EUS).
Pelvic parasympathetic nerves arise at the sacral level of the
spinal cord, stimulate the bladder, and relax the urethra. Lumbar
sympathetic nerves inhibit the bladder body and stimulate the
bladder base and urethra. Pudendal nerves stimulate the EUS.
These nerves contain afferent (sensory) as well as efferent axons.
Urethral and Sphincter Pathophysiology and Anatomy. The ure-
thra is part of the bladder outlet, along with the pelvic floor muscu-
lature. The urethra has components of smooth muscle and striated
muscle (rhabdosphincter or EUS). The periurethral striated muscle
is part of the pelvic floor muscle complex. The EUS is composed of
two parts. The periurethral striated muscle of the pelvic floor con-
tains fast-twitch and slow-twitch fibers. The striated muscle of the
distal sphincter mechanism contains predominantly slow-twitch
fibers and provides .50% of the static resistance. In addition to
striated muscle, the EUS appears to contain smooth muscle, which
receives noradrenergic innervation. Investigators have shown that
stimulation of the hypogastric nerve elicits myogenic potentials in
the EUS.
In the male, the membranous urethra extends from the pros-
tatic apex through the pelvic floor musculature (including the
EUS) until it becomes the bulbous and penile urethra at the base
of the penis. The male EUS covers the ventral surface of the pros-
tate in a crescent shape proximal to the verumontanum, then as-
sumes a horseshoe shape distal to the verumontanum, and is
crescent shaped at the bulbar urethra.
In women, the urethra extends throughout the distal third of
the anterior vaginal wall from the bladder neck to the meatus. The
bulk of the muscle responsible for sphincteric control in women is
circular striated muscle located in the proximal urethra and/or
mid-urethra. A network of vascular subepithelial tissue/estrogen
sensitive submucosa in women contributes to a urethral seal
effect and promotes continence. The female EUS covers the ven-
tral surface of the urethra in a horseshoe configuration.
Urinary continence is maintained during elevations in intraab-
dominal pressure by means of passive transmission of abdominal
pressure to the proximal urethra along with a guarding reflex in-
volving an active contraction of striated muscle of the EUS. The
most common causes of intrinsic sphincteric deficiency (ISD)
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CHAPTER 16 Urinary Incontinence and Pelvic Prolapse 393
are iatrogenic, although, less commonly, neurologic disease can

directly affect sphincter function.
Types of Urinary Incontinence. Stress urinary incontinence (SUI)
is the complaint of involuntary loss of urine with physical exer-
tion (i.e., walking, straining, exercise, sneezing, coughing) or
other activities that cause a rise in intraabdominal pressure.
SUI in women is unlikely to be caused solely by anatomic laxity of
the anterior vaginal wall and may be also due to poor intrinsic
(physiologic) sphincteric function.
Urgency urinary incontinence (UUI) is the complaint of in-
voluntary urine loss associated with urgency. It can, occasion-
ally, be noted on physical exam as the observation of involuntary
leakage from the urethra synchronous with the sensation of a sud-
den, compelling desire to void that is difficult to defer. This may be
accompanied by detrusor overactivity incontinence, a urodynamic
diagnosis, although this does not have to be present to establish a
diagnosis of UUI. Any neurologic process interrupting the normal
suprapontine inhibition of the pontine micturition center may
result in neurogenic detrusor overactivity (NDO) and cause UUI.
Mixed urinary incontinence (MUI) is the complaint of invol-
untary urine loss associated with urgency as well as activities
causing a rise in intraabdominal pressure. Postural UI is the
complaint of involuntary urine loss associated with a change in
position (typically from sitting or lying down to standing). Noc-
turnal enuresis is the complaint of involuntary urine loss occur-
ring during sleep and should be distinguished from urgency in-
continence. Continuous UI is the complaint of continuous urine
loss, day and night, typically seen with fistula of the lower urinary
tract involving the vagina (i.e., vesicovaginal and ureterovaginal
fistulae). Insensible UI is the complaint of urine loss when the
patient is unaware of how or precisely when the urine loss oc-
curred. Coital incontinence is the complaint of involuntary loss
of urine with sexual intercourse. It may occur with initial penetra-
tion, intromission, and/or during orgasm. Poor emptying from
detrusor underactivity or detrusor areflexia (causing overflow in-
continence) can also cause UI (Table 16.1).
Pelvic Organ Prolapse (POP)

Types of Prolapse. POP refers to the downward displacement
of the pelvic organs, which results in protrusion of the uterus

Table 16.1 Standard International Urogynecological Association/

International Continence Society Terminology of
Urinary Incontinence Symptoms
TERMINOLOGY DESCRIPTION
Urinary incontinence Complaint of any involuntary leakage of

urine
Stress urinary inconti- Complaint of involuntary leakage on effort or
nence exertion or on sneezing or coughing
Urgency Complaint of a sudden compelling desire to
pass urine, which is difficult to defer
Urgency urinary inconti- Complaint of involuntary leakage
nence accompanied by or immediately preceded
by urgency
Postural incontinence Complaint of voluntary loss of urine
associated with change of body position,
for example, rising from a seated or lying
position
Nocturnal enuresis Complaint of involuntary loss of urine that
occurs during sleep
Mixed incontinence Complaint of involuntary leakage associated
with urgency and with exertion, effort,
sneezing, or coughing
Continuous urinary Complaint of continuous leakage
incontinence
Insensible incontinence Complaint of urinary incontinence when the
woman has been unaware of how it
occurred
Coital incontinence Complaint of involuntary loss of urine with
coitus
From Abrams P, Cardozo L, Fall M, et al. The standardisation of terminology of lower urinary tract
function: Report from the Standardisation Sub-Committee of the International Continence
Society. Neurourol Urodyn 2002;21:167-178. (reprinted in Urology 2003;61:37-49); Haylen BT, de
Ridder D, Freeman RM, et al. An International Urogynecological Association (IUGA)/International
Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction.
Neurourol Urodyn 2010;29:4-20.
and/or the different vaginal compartments and their surrounding

organs, such as the bladder, the rectum, or the bowel. It results
from the loss of support of one or more compartments of the vagina
(Fig. 16.1). The levator ani muscles, and their interaction with en-
dopelvic fascia, are an important component of the pelvic organ
support.

Level I
• Suspends the uterus and upper vagina to the
sacrum and lateral pelvic sidewall
• Composed of the parametrium and the
paracolpium
• Loss of level I contributes to the prolapse of the
uterus or vaginal apex
Level II
• Paravaginal attachments of the middle third of
Pelvic organ the vagina laterally to the superior fascia of the
prolapse levator ani muscle and the arcus tendineus
fascia pelvis
• Anterior vaginal wall prolapse
Level III
• Distal vagina
• Loss of level III support anteriorly results in
urethral hypermobility
• Loss of posterior level III support results in a
distal rectocele or perineal descent
FIG. 16.1 Levels of support.
Anterior compartment prolapse corresponds to the descent of

the anterior vaginal wall. Most commonly, this represents the de-
scent of the bladder (cystocele), but it can also represent an anterior
enterocele, especially after prior reconstructive surgery. Apical pro-
lapse corresponds to the descent of the uterus (uterine or cervical
prolapse) or, in a posthysterectomy patient, the vaginal cuff. It can
include the small intestine (enterocele). Posterior compartment
prolapse is a weakness of the posterior vaginal wall and can involve
the rectum (rectocele) but can also include the small bowel or colon
even in the presence of an intact uterus. Procidentia refers to total
vaginal eversion with complete uterine or vaginal cuff prolapse. POP
occurs most frequently in the anterior compartment, followed by
the posterior compartment, and least commonly in the apex.
Risk Factors. Vaginal childbirth, advancing age, and obesity are
the most established risk factors for POP. The risk of POP in-
creases with every additional vaginal childbirth, and forceps deliv-
ery further increases the risk of developing POP. Cesarean section
seems to be protective against prolapse, but the degree of protection
is unclear. The incidence and the prevalence of POP increase with
advancing age with women 60–69 and 70–79 years of age having a
higher risk of prolapse than women ages 50–59 years. Hysterectomy
is associated with an increased risk of developing POP. Addition-
ally, POP is more common in white and Hispanic women than
African American women.

EVALUATION OF URINARY INCONTINENCE

AND PELVIC ORGAN PROLAPSE
The purpose of evaluation of patients with UI includes documen-
tation and characterization of the UI, including consideration
of the differential diagnosis, prognostication, and facilitation of
treatment selection. Additionally, proper evaluation helps assess
symptom bother and establish a patient’s expectations of potential
outcomes. It is helpful to determine the impact that the leakage
has on the patient’s daily life and activities and can be done
so with patient reported outcome measures and quality of life
questionnaires. The American Urological Association (AUA)
guidelines emphasize the importance of establishing patient
expectation of treatment and an understanding of the balance
between the benefits and risks/burden of available treatment options.
(https://www.auanet.org/guidelines/guidelines/stress-urinary-
incontinence-(sui)-guideline)
Regarding POP specifically, important questions focus on
whether the patient is aware of any prolapse and what, if any,
symptomatology and bother the prolapse may be causing. Patients
with POP should also be assessed for presence of SUI given the
high cooccurrence of these conditions.
Past medical and surgical histories are vital to the assessment
of incontinence and should include the following: neurologic con-
ditions (Parkinson disease, multiple sclerosis, stroke, spinal cord
injury), medical diagnoses (diabetes, dementia), history of radia-
tion, pelvic trauma, gynecologic and obstetric history, and previ-
ous pelvic surgery. Medications, especially those that can affect the
LUT, should be reviewed (Table 16.2 and Fig. 16.2).
The general appearance of a patient, including age, gait, stature,
and fragility, can provide important information regarding perfor-
mance status, neurologic status, and other factors that may direct
proper treatment planning. Similarly, an abdominal examination
evaluating incisions, hernias, organomegaly, bladder distension,
and body habitus is important, particularly if abdominal surgery is
considered. A comprehensive female pelvic exam should comment
on the external genitalia, estrogen status, lesions, and labial size/
adhesions.
The most common methodology to document SUI on examina-
tion is the supine cough stress test, although this can also be per-
formed in the standing position if SUI is not demonstrated in the
Table 16.2 Pharmacologic Agents That Can Affect the Lower

Urinary Tract
PHARMACOLOGIC POTENTIAL EFFECTS ON
EFFECTS COMMON AGENTS URINARY TRACT
Sympathomimetics Ephedrine, Can increase outlet

methylphenidate, resistance and exacerbate
cocaine, obstructive symptoms/
amohetamine overactive bladder
symptoms
Can decrease detrusor
contractility and
precipitate retention
Sympatholytics Terazosin, doxazosin, Can decrease outlet
tamsulosin, alfuzo- resistance and exacerbate
sin, silodosin stress incontinence
Anticholinergics Oxybutynin, fesoteri- Can contribute to urinary
dine, solifenacin, retention, particularly in
trospium, darifena- patients with outlet
cin obstruction
Diuretics Furosemide, Do not affect bladder
thiazides, directly, but because of
spironolactone, increased urine
triamterene, production, can aggravate
bumetanide incontinence problems
recumbent position (Table 16.3). For males, a digital rectal exam

should be performed evaluating for an enlarged prostate gland.
Urethral position and mobility should be assessed at rest and
during straining and coughing. Mobility may be estimated by direct
visualization or, less commonly, using a small, lubricated Q-tip in
the urethra. Hypermobility is defined as a Q-tip deflection angle of
.30 degrees from horizontal or resting position.
Assessment of POP should include evaluation of each compart-
ment (anterior, posterior, and apical) and the perineal body should
be assessed for laxity. A complete systematic examination is per-
formed using two posterior blades of a split Grave’s speculum at rest
and with straining. Several classification systems are used to quan-
tify POP, with the Baden-Walker classification and the Pelvic Or-
gan Prolapse-Quantification system (POP-Q) being the most
common (Table 16.4 and Fig. 16.3).
Additional evaluation tools include urinalysis, micturition diaries,
urine flow rate, post-void residual (PVR) volume, and measurement
Basics of incontinence
evaluation
1. Subjective characterization of incontinence

• With physical activity? With a sense of urgency?
Without sensory awareness?
• Does one component cause more bother or occur
more frequently than the other?
2. Quantify leakage
• Number of pads used per day
• Frequency of clothing changes
• Objective measures such as pad weight testing
3. Define voiding pattern

• Frequency of urination during the day and night
• Are obstructive symptoms present?
• Hesitancy, incomplete emptying, trickle, intermittency
and/or straining
4. Duration of symptoms and any inciting events

• Following pregnancy or vaginal delivery
• After strain, fall or trauma
• Any prostate or urethral surgery
• History of LUT instrumentation
• Associated neurologic symptoms
FIG. 16.2 History of present illness highlights for incontinence evaluation. LUT,
Lower urinary tract.
of prostate specific antigen (PSA) in men. More advanced investiga-

tions may be performed to further elucidate the etiology of symptoms.
These include computed tomography (CT)/magnetic resonance im-
aging (MRI)/ultrasound, cystoscopy (to evaluate for urethral stricture,
outlet obstruction, or cause of hematuria), and urodynamics. Urody-
namics may help to identify factors contributing to LUT dysfunction,
predict consequences of LUT dysfunction on the upper tracts, predict
consequences of interventions, and elucidate reasons for treatment
failures. Urodynamics (UDS) may be performed before and after
undergoing surgical intervention.
MEDICAL MANAGEMENT OF URINARY

INCONTINENCE AND PELVIC ORGAN PROLAPSE
The approach to the treatment of incontinence is contingent on a
clear understanding of the etiology and pathophysiology behind
the patient’s symptoms. The clinician must first determine whether
the cause of the symptoms is a bladder or an outlet problem or a

Table 16.3 Components of a Focused Pelvic Examinationa

Genitourinary Female
Pelvic examination (with or without specimen collection for smears
and cultures), including:
• External genitalia (e.g., general appearance, hair distribution, lesions)
and vagina (e.g., general appearance, estrogen effect, discharge,
lesions, pelvic support, cystocele, rectocele)
• Urethra (e.g., masses, tenderness, scarring). Examination of bladder
(e.g., fullness, masses, tenderness)
• Cervix (e.g., general appearance, lesions, discharge)
• Uterus (e.g., size, contour, position, mobility, tenderness,
consistency, descent or support)
• Adnexa/parametria (e.g., masses, tenderness, organomegaly, nodularity)
• Anus and perineum
a
At the time of this writing, all bullet points are required to be considered a complete female
genitourinary examination. However, other organ systems/body areas not limited to the
genitourinary system may be included in a report to accomplish the requirements of various
levels of examination.
From CMS 97 guidelines for focused female pelvic examination. Documentation Guidelines for
Evaluation and Management (E/M) Services, jointly approved by the American Medical
Association and HCFA with revisions November, 1997.
Table 16.4 Baden-Walker Classification and the Pelvic Organ

Prolapse-Quantification System (POP-Q) Staging
Criteria
STAGE CRITERIA
0 Aa, Ap, Ba, Bp at –3 cm, and C or D # – (tvl – 2) cm

I Stage 0 criteria not met and leading edge , –1 cm
II Leading edge  –1 cm but # 11 cm
III Leading edge . 11 cm but , 1 (tvl – 2) cm
IV Leading edge  1 (tvl – 2) cm
combination of both. Therapeutic options should be considered

with the goal of providing an individualized, patient-directed treat-
ment plan based on patient’s goals and risk-benefit and cost-benefit
ratios.
Urgency Urinary Incontinence

Nonsurgical intervention for patients with UUI ranges from behav-
ioral and dietary modification to biofeedback or pharmacotherapy.
According to the overactive bladder (OAB) guidelines, behavioral


1963 1972 1980 1996
Severity Vaginal profile Grading system Quantitative POP
(Porges) (Baden) (Beecham) (ICS, AUGS, SGS)
Midplane of
Grade 1
vagina
Straining Stage I
Slight or 1st degree
1st degree Hymenal
Grade 2 ring
Introitus (–) 1 cm
Stage II
(+) 1 cm
Straining Straining
Moderate or
2nd degree
Grade 3
2nd degree
Stage III
Complete
Marked or eversion
3rd degree
Grade 4 3rd degree Stage IV
FIG. 16.3 Visual comparison of systems used to quantify pelvic organ prolapse (POP). AUGS, American Urogynecologic Society; ICS, International
Continence Society; SGS, Society of Gynecologic Surgeons. (From Theofrastous JP, Swift SE. The clinical evaluation of pelvic floor dysfunction.
Obstet Gynecol Clin North Am 1998;25:783-804.)
therapy (e.g., fluid management, dietary modification, and bladder

training) is the first line of therapy (https://www.auanet.org/
guidelines/guidelines/overactive-bladder-(oab)-guideline). Weight
loss reduces SUI and may significantly reduce UUI episodes, as
well. Medications (anticholinergics and/or b-3 adrenergic agonists)
can be added subsequently but are technically considered second-
line therapy. If recommending antimuscarinic medication, pre-
scribers should educate the patient about potential side effects,
including dry mouth, constipation, cognitive effects, and visual
impairment. Extended-release formulations are favored over
short-acting formulations because of lower rates of dry mouth.
Sacral neuromodulation (SNM), posterior tibial nerve stimula-
tion (PTNS), intradetrusor injection of onabotulinumtoxinA, and
augmentation cystoplasty (AC) may be considered in patients with
refractory symptoms or who are not candidates for pharmacother-
apy. For continuity, these surgical interventions for UUI are pre-
sented here, and surgical options for SUI and POP are in Chapter 17.
The posterior tibial nerve contains motor and sensory signals
from the L4-S3 nerve roots. Stimulation of this nerve activates
somatic afferent fibers, which send inhibitory signals to the sacral
and central pontine micturition center allowing for bladder inhibi-
tion and improved storage. It is a relatively noninvasive treatment
modality that consists of 12 (1–3 times weekly) treatments of
30 minutes each. Patients must be able/willing to come to the
clinic to complete weekly induction treatments followed by a
maintenance schedule to prevent symptom relapse after successful
treatment. This often presents as a barrier to compliance with the
treatment. Overall, PTNS may produce a clinical response in ap-
proximately 60% to 80% of patients with medication-refractory
OAB with limited risk of adverse events.
OnabotulinumtoxinA is produced by Clostridium botulinum, an
anaerobic, gram-negative bacterium. It is a potent neurotoxin that
causes inhibition of presynaptic acetylcholine release at the neu-
romuscular junction. This results in a flaccid paralysis. The pro-
cedure can be performed in the office or operating room with either
flexible or rigid cystoscopy. The recommended dose is 100 units for
idiopathic OAB. Injections can result in a 59% decrease in daily
incontinence episodes. The primary risks of onabotulinumtoxinA
injection in clinical trials include symptomatic UTI in ,20% and
the need to initiate intermittent catheterization in up to 12%.

SNM delivers electrical impulses to the S3 sacral nerve root

that is responsible for innervation of the autonomic functions of
the pelvic nerves and striated muscles. A test called a percutaneous
nerve evaluation (PNE) can be performed in the office or an
ambulatory setting and, if successful, can followed by a complete
implant of a permanent lead and implantable generator (IPG).
Alternatively, a permanent lead may be implanted for a longer test
period (stage 1) followed by IPG implant, if successful (stage 2).
SNM can also be utilized in the setting of nonobstructive urinary
retention. SNM had 5-year success rates of 70%–80% and is often
considered a more durable, long-term management option for
OAB with/without incontinence. Drawbacks of SNM include a
revision rate .30% at 5 years from undesirable changes in stimu-
lation, pain, or inadequate efficacy.
In patients who have failed first- to third-line therapies, AC
and/or urinary diversion (UD) (fourth-line OAB therapy) can be
considered (https://www.auanet.org/guidelines/guidelines/overactive-
bladder-(oab)-guideline). Ileum is the preferred bowel segment for
AC and UD, and care must be taken to preserve the terminal ileum
in order to prevent vitamin B12 and salt losses. Patients must also be
able to demonstrate appropriate dexterity and willingness to cathe-
terize the urethra or a concomitant catheterizable channel after AC.
Contraindications to AC include impaired renal function, bowel
disease (Crohn’s, inflammatory bowel, short gut as seen in cloacal
exstrophy, congenital abnormalities), and malignancy.
Female Stress Urinary Incontinence. Patients with SUI may benefit
from conservative measures using pelvic floor muscle training
(PFMT), biofeedback, electrical stimulation, and pharmacother-
apy. Urethral bulking injection therapy can provide an intermedi-
ate option between nonsurgical and surgical therapies, but surgery
remains the mainstay of treatment for SUI.
Continence pessaries are placed transvaginally and are de-
signed to prevent urine loss by stabilizing and supporting the
urethra and bladder neck, increasing urethral length, and provid-
ing gentle compression of the urethra against the pubic bone
during increases in intraabdominal pressure. This structural ar-
rangement can reduce, and often prevent, SUI. Uresta is a bell-
shaped pessary (Fig. 16.4) with a handle at its base for easy inser-
tion and removal. Its narrow tip allows for easy insertion into the
vagina, like a tampon, and it positions itself so that the wide base

FIG. 16.4 Uresta kit.
provides support to the urethra. Impressa is a disposable single-

use tampon-like device that has a core, cover, and applicator.
Impressa is designed to prevent the device from moving within
the vagina and to produce suburethral tension-free support
whenever pressure is transferred from the abdominal cavity to the
pelvic floor
Stress Urinary Incontinence in Males. Treatment must be tailored
to the patient’s needs, goals, and expectations and requires detailed
counseling. Some men may be satisfied with protective garments
and/or urine-collection devices, such as indwelling or condom
catheters, or urethral plugs and external occlusion devices. Injec-
tion therapy has not proven a particularly viable option for the
treatment of male SUI (which occurs most commonly after radical
prostatectomy). The male sling and artificial urinary sphincter are
discussed in Chapter 17.
Pelvic Organ Prolapse. The goal of POP repair is to restore the
normal anatomy and function of the vagina and the lower urinary
and gastrointestinal tracts. Vaginal pessaries have been used for
centuries as a conservative treatment for POP. Pessaries are made
of an inert plastic or silicone material to minimize odors and pre-
vent absorption of vaginal secretions. There are very few contrain-
dications to pessary use, but a pessary should not be placed in
those with an active pelvic or vaginal infection, severe ulcer-
ation, or allergy to silicone or latex, or in patients who are likely
to be noncompliant with maintenance care and follow-up

appointments. Common side effects include vaginal discharge

and odor. Serious complications from pessaries are rare; however,
vesicovaginal fistula, rectovaginal fistula, erosion, and subsequent
impaction have been reported. Combined pessary and PFMT and
PFMT alone can be equally effective in reducing symptoms and
increasing muscle strength and should be considered for treat-
ment. Patients that fail pessary use or who are not candidates
for their use may be considered for surgical management. This is
discussed in Chapter 17.
Suggested Readings
Abrams P, Cardozo L, Fall M, et al. The standardisation of terminology of lower urinary
tract function: report from the Standardisation Sub-Committee of the International
Continence Society. Neurourol Urodyn 2002;21:167-178.
Bump RC, Mattiasson A, Bo K, et al. The standardization of terminology of female
pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol
1996;175:10-17.
Chapple C, Abrams P. Male lower urinary tract symptoms (LUTS): an international
consultation on male LUTS. Montreal, Canada: Société Internationale d’Urologie,
2013.
Gormley EA, Lightner DJ, Burgio KL, et al. Diagnosis and treatment of overactive blad-
der (non-neurogenic) in adults: AUA/SUFU guideline. J Urol 2012;188(6 suppl):
2455-2463.
Haylen BT, de Ridder D, Freeman RM, et al. An International Urogynecological
Association (IUGA)/International Continence Society (ICS) joint report on the
terminology for female pelvic floor dysfunction. Neurourol Urodyn 2010;29:4-20.
Nambiar AK, Bosch R, Cruz F, et al. EAU guidelines on assessment and nonsurgical
management of urinary incontinence. Eur Urol 2018;73:596-609.


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16 Urinary Incontinence and Pelvic

OVERVIEW AND PATHOPHYSIOLOGY OF URINARY

Descargado para Emanuel Figueroa ([email protected]) en Antenor Orrego Private391 University

urothelium, urethral smooth muscle, pelvic floor striated muscles,

Descargado para Emanuel Figueroa ([email protected]) en Antenor Orrego Private University

are iatrogenic, although, less commonly, neurologic disease can

Pelvic Organ Prolapse (POP)

Descargado para Emanuel Figueroa ([email protected]) en Antenor Orrego Private University

Table 16.1 Standard International Urogynecological Association/

Urinary incontinence Complaint of any involuntary leakage of

and/or the different vaginal compartments and their surrounding

Descargado para Emanuel Figueroa ([email protected]) en Antenor Orrego Private University

FIG. 16.1 ​Levels of support.

Anterior compartment prolapse corresponds to the descent of

Descargado para Emanuel Figueroa ([email protected]) en Antenor Orrego Private University

EVALUATION OF URINARY INCONTINENCE

Table 16.2 Pharmacologic Agents That Can Affect the Lower

Sympathomimetics Ephedrine, Can increase outlet

recumbent position (Table 16.3). For males, a digital rectal exam

1. Subjective characterization of incontinence

3. Define voiding pattern

4. Duration of symptoms and any inciting events

of prostate specific antigen (PSA) in men. More advanced investiga-

MEDICAL MANAGEMENT OF URINARY

Descargado para Emanuel Figueroa ([email protected]) en Antenor Orrego Private University

Table 16.3 Components of a Focused Pelvic Examinationa

Table 16.4 Baden-Walker Classification and the Pelvic Organ

0 Aa, Ap, Ba, Bp at –3 cm, and C or D # – (tvl – 2) cm

combination of both. Therapeutic options should be considered

Urgency Urinary Incontinence

Descargado para Emanuel Figueroa ([email protected]) en Antenor Orrego Private University

400 CHAPTER 16 Urinary Incontinence and Pelvic Prolapse

Grade 4 3rd degree Stage IV

therapy (e.g., fluid management, dietary modification, and bladder

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SNM delivers electrical impulses to the S3 sacral nerve root

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FIG. 16.4 ​Uresta kit.

provides support to the urethra. Impressa is a disposable single-

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appointments. Common side effects include vaginal discharge

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Table 16.1 Standard International Urogynecological Association/

FIG. 16.1 Levels of support.

Table 16.2 Pharmacologic Agents That Can Affect the Lower

Table 16.4 Baden-Walker Classification and the Pelvic Organ

FIG. 16.4 Uresta kit.