Med Clin N Am

92 (2008) 1273–1293

Urinary Incontinence and Pelvic Organ

Prolapse: Diagnosis and Treatment
for the Primary Care Physician
Husam Abed, MD, Rebecca G. Rogers, MD*
Division of Urogynecology, Department of Obstetrics and Gynecology,
University of New Mexico Health Sciences Center, 4th Floor, Ambulatory Care Center,
2211 Lomas Blvd. NE, Albuquerque NM 87106, USA

Pelvic floor disorders

One in nine women undergoes surgery for urinary incontinence or pelvic or-
gan prolapse or both in her lifetime, with increasing incidence with increasing
age [1]. The estimated demand for consultations for pelvic floor disorders is
anticipated to increase by 30% by the year 2030 [2]. Although not life threat-
ening, urinary incontinence and pelvic organ prolapse are life altering and
carry significant quality-of-life changes. Despite being among the top ten rea-
sons for expenditure of health care dollars, pelvic floor disorders are not typ-
ically addressed by primary care physicians. Barriers to diagnosis and
treatment include a misunderstanding of the conditions and a commonly
held belief that effective treatments are surgical or that an extensive evaluation
is required before initiating treatment [3–5]. In this article, we outline a simpli-
fied approach to diagnosis and treatment of women with urinary incontinence
or pelvic organ prolapse that can be used by primary care physicians to iden-
tify patients with these conditions and initiate treatment for basic problems.

Urinary incontinence
Definitions and classification
Urinary incontinence is a hidden epidemic that consumes approximately
$19.5 billion in health care expenditures annually [6]. Defined as the invol-
untary leakage of urine, incontinence is more common among women than
men. Fewer than 50% of women affected by incontinence seek treatment.

* Corresponding author.
E-mail address: rrogers@salud.unm.edu (R.G. Rogers).

0025-7125/08/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.mcna.2008.04.004 medical.theclinics.com
1274 ABED & ROGERS

Many patients feel that urinary incontinence is a normal part of aging and
are embarrassed to discuss this problem with their health care provider.
Most cases of incontinence in women are either stress urinary incontinence
(SUI)dthe loss of urine associated with coughing, sneezing, exercise, or ex-
ertiondor urge urinary incontinence (UUI)dloss of urine preceded by or
accompanied by urgency. Many women have mixed incontinence, which
is a combination of stress and urge incontinence. Not all women with blad-
der problems are incontinent; overactive bladder is urinary urgency usually
with frequency and nocturia, with or without incontinence, and may se-
verely affect many women.

Epidemiology
Approximately 38% of women have some type of urinary incontinence
[7]. Although not all incontinence is bothersome, an estimated 20% of
women aged 45 to 59 years women report daily or severe incontinence
and one third report weekly incontinence [7]. A recent study found that
the 2-year incidence for development of urinary incontinence was 13.7%, al-
though during the same time frame there was also a 13.9% remission rate
[8]. The same study revealed that the peak incidence of frequent SUI and
UUI (leak at least once weekly) differs. The peak incidence of SUI is be-
tween the ages of 46 and 50, whereas the peak incidence of UUI is older,
between the ages of 51 and 55. Reported risk factors for urinary inconti-
nence include age, race, hormonal status, obesity, and history of pregnancy
and childbirth. The prevalence of urinary incontinence increases from 15%
for the age group 18 to 24 years to 46% for the age group 60 to 64 years [9].
Higher prevalence rates of incontinence are reported for whites and His-
panics compared with African Americans and Asian women [10]. The prev-
alence of urinary incontinence also increases with increasing body mass
index, increased parity, and smoking [10]. Other risk factors not consistently
reported include constipation and family history.

Pathophysiology and anatomy

The lower urinary tract is composed of the bladder, bladder neck, and
urethra. It is innervated by the sympathetic and parasympathetic nervous
systems and is responsible for urinary storage and evacuation. During the
storage phase, the detrusor muscle is relaxed through stimulation of b-ad-
renergic receptors and inhibition of muscarinic M3-cholinergic receptors,
which allows the bladder to fill without significant increase in intravesical
pressure. At the same time, the bladder neck and urethral sphincter are con-
tracted because of stimulation of a-adrenergic receptors, which creates
a pressure gradient that prevents urine from leaking through the urethra.
As the bladder fills to capacity (350–600 mL of fluid), bladder stretch recep-
tors are stimulated. Signals are transferred at S2-4 nerve root levels and sent
to the spinal cord and brain, which creates awareness of the need to void.
 URINARY INCONTINENCE AND PELVIC ORGAN PROLAPSE 1275

During evacuation, signals from the pons micturition center to the sacral
portion of the spinal cord results in parasympathetic stimulation, which
causes the detrusor muscle to contract. At the same time, the internal ure-
thral sphincter is signaled to relax and urination ensues.

Diagnosis
The first step to diagnosing urinary incontinence is screening patients for
symptoms. Like other embarrassing conditions, women may be reluctant to
broach the subject with their primary care provider. Screening question-
naires have been developed that screen for incontinence and simplify the di-
agnosis of type of incontinence. Use of a questionnaire in clinical practice
can allow for easy diagnosis and intervention in many women. The 3
Incontinence Questions questionnaire consists of three questions and has
a sensitivity of 0.75 (95% CI, 0.68–0.81) and a specificity of 0.77 (95% CI
0.69–0.84) in distinguishing urge from stress incontinence [11]. The Ques-
tionnaire for Urinary Incontinence Diagnosis consists of six questions
with similar specificities and sensitivities (Appendix 1) [12]. Women who
are unresponsive to first-line treatment after screening may benefit from
a more in-depth history and physical examination, including pelvic examina-
tion, voiding diary, and simple office testing.
The history should include evaluation of medical comorbidities, including
diabetes, neurologic disorders, and cognitive impairment, and a complete sur-
gical history, including prior incontinence or prolapse procedures. A review of
current medications is important because they can cause incontinence through
several different mechanisms (Table 1) [13]. During pelvic examination, objec-
tive evidence of urine leakage with Valsalva maneuver and cough supports the
diagnosis of SUI. Patients also should be evaluated for significant pelvic organ
prolapse by observing the vaginal introitus during straining. During the pelvic
bimanual examination, patients can be asked to contract their pelvic muscu-
lature or perform a ‘‘Kegel’’ exercise. Incorporating evaluation and coaching
of pelvic floor exercises during the pelvic examination is a simple way to ensure
that patients are performing exercises correctly. Some women are unable to
correctly contract their pelvic floor muscles and might benefit from referral
to a physical therapist [14]. Voiding diaries are diagnostic and therapeutic
and may point to interventions, including reducing or increasing fluid intake
and timing of voids. Voiding dairies record volumes and types of fluids con-
sumed, frequency and amount of voids, and episodes of incontinence and trig-
gers for incontinence. Normal voided volumes range from 200 to 250 mL per
void, with normal voiding frequency ranging from 8 to 12 voids daily with 1
void per night [15]. A sample voiding diary can be downloaded online at
http://www.augs.org/Portals/0/Voiding_Diary.pdf.
Urinary tract infections can mimic either SUI or UUI; screening for
infection in incontinent women with urine dip or urinalysis is important.
Although bladder cancers are relatively rare in women, the urine dip or
 1276
Table 1
Examples of various effects of medications on lower urinary tract function
Lower urinary tract effect Mechanism Category Examples
Urethral relaxation Decreased urethral pressure a-adrenergic blockers Doxazosin, prazosin, tamsulosin, terazosin
Neuroleptics Haloperidol, chlorpromazine,
prochlorperazine
Benzodiazepines Alprazolam, clonazepam, diazepam
Increased intravesical Detrusor stimulation Parasympathomimetics Bethanechol, cisapride

ABED & ROGERS

pressure Increased urine production Diuretics Furosemide, hydrochlorothiazide
Urinary retention Anticholinergics Atropine, hyoscyamine, oxybutynin,
tolterodine
Anti-parkinsonians Carbidopa, levodopa
a-agonists Guanfacine, phenylephrine, clonidine
b-adrenergic blockers Atenolol, labetalol, propranolol
Calcium channel blockers Amlodipine, nifedipine
Disopyramide
Indirect effect Cough Angiotensive-converting enzyme Captopril, enalapril, ramipril, lisinopril
inhibitors
Sedation, delerium, immobility Sedatives Trazadone, lorazepam, quetiapine
Alcohol
 URINARY INCONTINENCE AND PELVIC ORGAN PROLAPSE 1277

urinalysis also can screen for hematuria. If hematuria is present, further

evaluation should be undertaken.
Postvoid residual testing for bladder emptying should be performed in
women with history of pelvic surgery, diabetes, or other neurologic disor-
ders. The test can be performed either by catheterization or ultrasound. Al-
though exact agreement on what is considered an elevated postvoid residual
varies, residuals of more than 150 mL on two separate occasions warrant
further investigation by a subspecialist. More invasive testing, such as uro-
dynamics, is performed by many subspecialists before surgical intervention.
Performing these tests is not indicated in most patients interested in starting
nonsurgical treatment.

Treatment
Treatment options for urinary incontinence vary depending on whether
the diagnosis of stress or urge incontinence is made, although the two disor-
ders do share several behavioral and physical therapy interventions. Strate-
gies to prevent development of urinary incontinence are not well defined.
Cesarean delivery on demand is advocated by some as a protective interven-
tion for development of urinary incontinence. The Term Breech Trial, which
randomized women to vaginal versus cesarean delivery for breech presenta-
tion infants, is the single randomized trial that followed women postpartum
for pelvic floor changes. Although a protective effect of cesarean delivery in
preventing urinary incontinence was found at 3 months after delivery (RR
0.62; 95% CI, 0.41–0.93) the effect was lost at 2 years (RR 0.81; 95% CI,
0.63–1.06). Until further data are available, the decision to perform cesarean
section to prevent pelvic floor problems remains an individual decision be-
tween a patient and her provider [16].

Stress urinary incontinence

Behavioral and physical and pharmaceutical therapy
Management of fluid intake may play some role in controlling stress uri-
nary incontinence. It is one of the main coping strategies for up to 38% of
women with bothersome urinary incontinence [17]. One study found that re-
ducing fluid intake resulted in a significant reduction in incontinence epi-
sodes [18]. Weight reduction also may play a role in the management of
SUI, especially in obese women. In one small study, women who experi-
enced weight loss reported a marked improvement in SUI symptoms [19].
Decreased smoking also may be helpful in the treatment of SUI. A retro-
spective case control study compared women who never smoked to women
who currently smoke and showed that the relative risk of urge or stress in-
continence increased by a factor of 2.2 for women who previously smoked
and by 2.5 for women who currently smoke, compared with never smokers.
Risk increased with number of cigarettes smoked and years of smoking [20].
1278 ABED & ROGERS

Pelvic floor exercises are a mainstay of therapy for SUI. Many women
can be trained on performing these exercises while performing manual vag-
inal examination (http://kidney.niddk.nih.gov/kudiseases/pubs/exercise_ez/
#how). A recommended regimen includes three sets of 8 to 12 slow-velocity,
maximum intensity pelvic floor muscle contractions sustained for 6 to 8 sec-
onds. The exercises should be performed three to four times a week and con-
tinued for at least 15 to 20 weeks [21]. It might take as long as 5 months
before clinical improvement is noticed [22]. Learning to perform a properly
timed pelvic floor muscle contraction during cough or any activity that
causes a SUI episode results in decreased incontinence episodes [23].
Currently, there is no US Food and Drug Administration–approved
pharmacologic therapy for SUI; however, duloxetine, a selective serotonin
and norepinephrine reuptake inhibitor antidepressant, has been shown to
have some efficacy in the treatment of stress incontinence [24].

Devices
Many women use absorptive products, including panty liners or perineal
pads, for treatment of mild urinary incontinence. Many women prefer these
pads as opposed to incontinence pads for their discreetness, although men-
strual pads are not as effective in absorbing fluids and managing odor [25].
For women with severe incontinence, diapers are more helpful [26].
Pessaries are silicon devices that can be inserted into the vagina to pro-
vide support to the pelvic organs and treat stress incontinence by increasing
urethral resistance (Fig. 1). Many women have observed that their stress in-
continence improves when a tampon is in place, and tampons are thought to
work by a similar mechanism as pessaries by providing urethral support.
Pessaries and tampons have been shown to be helpful in controlling SUI
during exercise in a randomized trial when compared with no device [27].
Approximately half of women who attempt to use a pessary to treat their
stress incontinence continue to use the pessary at 2 years [28].
Some of the reasons for pessary discontinuation include irritation of the
vaginal mucosa, with associated discharge, odor, ulcerations, and bleeding.
Other devices used for the management of SUI with varying success include
the contraceptive diaphragm, intravaginal sponge, urethral plugs, and exter-
nal urethral occlusive devices [29–32]. Despite the lack of strong evidence
supporting the role of mechanical devices in the management of urinary in-
continence, it is feasible to use such devices because of their low cost, ease of
use, and rare side effects [33].

Surgery
Patients who fail pelvic floor exercises and devices should be referred to
a specialist for evaluation for surgery. Surgery, which remains a major ther-
apeutic option for treatment of SUI, can be in the form of minimally inva-
sive midurethral slings, urethral bulking agents, or retropubic operations.
 URINARY INCONTINENCE AND PELVIC ORGAN PROLAPSE 1279

Fig. 1. Commonly used pessaries. Upper row (pessaries for incontinence): (A) Incontinence
ring. (B) Incontinence ring with support. (C) Incontinence dish. (D) Incontinence dish with
support. Lower row (pessaries for prolapse): (E) Ring. (F) Ring with support. (G) Gellhorn.
(Courtesy of R. Rogers, MD, Albuquerque, NM.)

Traditional retropubic procedures, such as the Burch procedure, have

a lower success rate than traditional fascial sling procedures, both of which
require a postoperative catheter, abdominal incisions, and hospital stay [34].
Minimally invasive midurethral slings currently are preferred by most pa-
tients and surgeons and offer an outpatient procedure for the treatment of
stress incontinence. The slings with proven success are made of polypropyl-
ene mesh and travel either from the abdomen through the retropubic space
under the urethra (eg, tension-free vaginal tape) or through the obturator
foramen and under the urethra (eg, trans-obturator tape). Success rates of
81% subjective and objective cure have been reported with a mean fol-
low-up of 7.6 years [35].

Urge urinary incontinence

Prevention and treatment
The mainstay of therapies for UUI, in contrast to SUI, is pharmaceutical
and behavioral. Surgery does not help UUI, and there are no reports of im-
provement in UUI symptoms with the use of pessaries. As with SUI, there
are also no proven preventive interventions.

Behavioral and physical therapy

Behavioral interventions for urge urinary incontinence include changing
bladder function by altering voiding habits and urge suppression strategies
1280 ABED & ROGERS

and fluid management. Behavioral therapy plays an important role in the

management of UUI. It has been shown that biofeedback-assisted behav-
ioral training was more effective than oxybutynin in the treatment of
UUI, rendering this as an effective, safe, and acceptable conservative treat-
ment with high level of patient satisfaction [36]. Another form of behavioral
therapy, timed voids, has been shown to be effective in reducing urinary fre-
quency and increasing voided volume. ‘‘Bladder drills’’ or ‘‘timed voids’’
place women on a voiding schedule in which they are prompted by a timer
or clock to void rather than responding to the urge to void. Women gradually
lengthen the time period between voids [37]. The efficacy of timed voids is
proven, with episodes of incontinence reduced by as much as 57% [38].
Limiting fluid intake in general or at certain times of the day decreases
voiding frequency, urgency, and incontinence episodes [18]. Physiologic ev-
idence suggests that caffeine precipitates symptoms of UUI [39], but clinical
evidence of the effectiveness of caffeine reduction is unclear [40,41].
The role of pelvic floor exercises (Kegel exercises) in the management of
UUI is less clear than SUI, yet it has proven better than no treatment, placebo
drug, or inactive control [42]. Referral to a physical therapist is warranted if
patients are unable to contract their pelvic floor muscles during the pelvic ex-
amination or for more help with behavioral training. Some physical therapists
may use vaginal electrical stimulation to treat overactive bladder symptoms,
although no data support the efficacy of this treatment modality [43].

Pharmacologic therapy
Anticholinergic medication is the mainstay of treatment for UUI despite
lower efficacy than behavioral therapy for treatment of symptoms [36].
These drugs block the postganglionic muscarinic receptors on the detrusor
muscle, thus affecting the contractility of the bladder muscle. A recent Co-
chrane review found that patients taking anticholinergics were more likely
to report cure or improvement than patients taking placebo (56% versus
41%, respectively), with a relative risk for cure or improvement of 1.39
(95% CI 1.28–1.51). This resulted in patients reporting approximately
four fewer leakage episodes and five fewer voids per week when compared
with placebo medications [44]. The most common side effects of anticholin-
ergic therapy include dry mouth, constipation, and blurred vision. Oxybuty-
nin chloride and immediate-release tolterodine are the most widely used
agents for treatment of UUI. Both have significant anticholinergic side af-
fects and require repeated dosing during the day. Anticholinergic side effects
are decreased but still present in their extended release forms [45,46].
Recently, three new anticholinergics have become available in the United
States. Trospium chloride has decreased lipophilicity with no penetration to
the blood-brain barrier and has a theoretic lack of effect on the cognitive
function, which is important in treating elderly patients. Because of its re-
ceptor selectivity, trospium chloride theoretically may have decreased rates
 URINARY INCONTINENCE AND PELVIC ORGAN PROLAPSE 1281

of severe dry mouth, although when studied, the overall incidence of dry
mouth and short-term adverse events were similar to those of immediate-re-
lease oxybutynin [47]. Solifenacin has increased specificity for muscarinic re-
ceptors in the urinary bladder compared with salivary glands, resulting in
decreased rates of dry mouth [48]. Darifenacin has more M3 specificity
(bladder) than M1 (central nervous system) with decreased central nervous
system side effects and decreased dry mouth [48]. Overall, these anticholin-
ergic drugs are effective in treating symptoms of UUI. There may be some
advantage to the newer agents in reducing side effects, but it must be
weighed against the additional expense of these agents. All anticholinergics
have a significant discontinuation rate with long-term use.
Other reported treatment options for UUI include acupuncture [49], sa-
cral nerve stimulation [50], and various intravesical therapies, including oxy-
butynin, atropine, trospium, capsaicin, resiniferatoxin, and botulinum A
toxin. None of these is considered first-line therapy.

Mixed incontinence
In patients with mixed incontinence, an initial trial of medical or behav-
ioral therapy or both directed at the urge component may be beneficial. Al-
ternatively, the initial therapy may be selected based on the patient’s
predominant symptom (SUI or UUI). An algorithm that outlines a sug-
gested management plans for urinary incontinence is included (Fig. 2).

Pelvic organ prolapse

Definition and classification
Pelvic organ prolapse is the herniation of the pelvic organs toward or
through the vaginal opening. It is often associated with feelings of pressure
and bowel and bladder complaints. Typically prolapse is described by one of
the three vaginal sites involved, including the anterior wall (bladder or
cystocele), posterior wall (rectum or rectocele), and apex (enterocele)
(Figs. 3–5). Although various classification schemes have been proposed,
the standard for measurement of pelvic organ prolapse is the Pelvic Organ
Prolapse Quantification (POPQ) scale, which describes the prolapse of the
three vaginal compartments in relationship to the vaginal hymen. Overall
prolapse is staged according to the most dependent position of the leading
edge of prolapse [51]. Recently, a validated and simplified version of the
POPQ has been proposed, which consists of four measurements and clas-
sifies prolapse into four stages in relationship to the hymen (Table 2) [52].

Epidemiology
Pelvic organ prolapse is common. The International Continence Society
defines pelvic organ prolapse as any stage of prolapse greater than zero. If
1282 ABED & ROGERS

Patient complains of Urinary Incontinence

Incontinence with:
1. General assessment 1. Pain
2. Urinary symptoms questionnaire (3IQ or QUID) 2. Persistent hematuria
3. Assess quality of life or desire for treatment 3. Recurrent infection
4. Physical exam: 4. Pelvic irradiation
a. Assess prolapse (stage) 5. Radical Pelvic
b. Assess pelvic muscle contraction surgery
5. Check PVR (if patient complains of hesitancy/incomplete 6. Fistula
voiding, weak stream, history of pelvic surgery, large
prolapse, or neurologic disease)
6. UA/culture If exam abnormal:
1. PVR (>150 mL)
2. POP ≥ stage II +
UUI
Urge incontinence Mixed Stress Incontinence 3. Pelvic mass
(QUID Urge score Incontinence (QUID Stress score ≥ 4. Abnormal neurologic
≥ 4) 6) examination

1. Pelvic floor exercise 1. Pelvic floor exercise

2. Timed voiding (Bladder drills) 2. Consider pessary fitting if patient
Can use voiding diary as is interested
feedback 3. Refer for Physical Therapy for
3. Anticholinergics: biofeedback/pelvic floor
a. Oxybutinin 2.5-5mg q4h rehabilitation if the patient is
b. Tolterodine 2mg BID unable to do pelvic floor exercise
c. Oxybutinin (extended release) or no improvement on her own
5-15mg/day
d. Tolterodine (long acting) LA 2-
4mg/day

No improvement in 6-8 weeks

Specialized Treatment/Referral

Common side effects of anticholinergics: Contraindications to the use of Anticholinergics

1. Dry Mouth 1. Closed angle glaucoma
2. Constipation 2. Urinary retention (PVR > 150mL)
Rare SE: Blurred Vision 3. Gastric Retention

Fig. 2. Algorithm for treatment of stress urinary and urge urinary incontinence. (Adapted from
Kammerer-Doak DN, Abed H. Practice algorithm: urinary incontinence. The Female Patient.
March 2007. p. 48–9; with permission.)

this definition is used, 27% to 98% of women have pelvic organ prolapse
[53–58]. Not all prolapse is symptomatic, however. Prolapse above or to the
hymen typically is not symptomatic and does not require treatment if not both-
ersome to patients [59]. The number of women who have prolapse beyond the
hymen is much less, affecting only 3% to 6% of women who present for gyne-
cologic care [58,60]. Approximately 200,000 surgeries a year are performed
for pelvic prolapse, costing more than $1 billion dollars annually [61,62].
Little is known about the natural history of prolapse. A prospective co-
hort study of 249 women found that the maximum descent of prolapse
waxes and wanes. Although the 3-year incidence of prolapse in this cohort
was approximately 40%, prolapse increased by at least 2 cm in 11% and re-
gressed by the same amount in 3% of women, confirming that prolapse is
dynamic disease process and that not all prolapse progresses with time [63].
 URINARY INCONTINENCE AND PELVIC ORGAN PROLAPSE 1283

Fig. 3. Stage 2 anterior compartment prolapse (cystocele). (Courtesy of R. Rogers, MD,

Albuquerque, NM.)

Causes and risk factors

The most established risk factors for pelvic organ prolapse include vag-
inal childbirth, advancing age, and obesity [64]. The risk of developing pel-
vic organ prolapse from vaginal childbirth has been studied in several
epidemiologic studies. The Oxford Family Planning study found that

Fig. 4. Stage 2 posterior compartment prolapse (rectocele). (Courtesy of R. Rogers, MD, Albu-
querque, NM.)
1284 ABED & ROGERS

Fig. 5. Stage 4 anterior, apical, and posterior (not shown) prolapse (uterine prolapse or vault
prolapse). (Courtesy of R. Rogers, MD, Albuquerque, NM.)

a vaginal parity of two conferred a relative risk of 8.4 of developing pro-

lapse. The Women’s Health Initiative had similar findings, with every addi-
tional delivery up to five deliveries conferring an increased risk of prolapse
by 10% to 20%. Not all prolapse changes are attributable to vaginal birth.
Some anatomic changes are observed during pregnancy; up to 46% of nul-
liparous women have been shown to have some prolapse in the late third
trimester. Other studies have demonstrated that bladder and urethral mobil-
ity increase in pregnancy, with the greatest changes seen in the third trimes-
ter [55,65–67].
Older women are at increased risk for pelvic organ prolapse. Among 1000
women who presented for an annual gynecologic examination, every

Table 2
Stages of prolapse
Stage Description
Stage 1 Prolapse in which the given point remains at least 1 cm above the hymenal
remnants
Stage 2 Prolapse in which the given point descends to an area extending from 1 cm
above to 1 cm below the hymenal remnants
Stage 3 Prolapse in which the given point descends more than 1 cm past the hymenal
remnants but does not represent complete vaginal vault eversion or
complete procidentia uteri. It implies that at least some portion of the
vaginal mucosa is not everted
Stage 4 Complete vaginal vault eversion or complete procidentia uteri. It implies that
the vagina and/or uterus is maximally prolapsed with essentially the entire
extent of the vaginal mucosa everted
 URINARY INCONTINENCE AND PELVIC ORGAN PROLAPSE 1285

additional 10 years of age conferred an increase risk of prolapse of 40% [58].

Obesity has been shown in several epidemiologic studies to be associated
with an increased risk of prolapse, with overweight and obese women
(body mass index of O 25) having a 50% higher chance of developing pro-
lapse [58]. Another survey of more than 2000 women identified vaginal par-
ity, health status, and history of constipation as independent risk factors for
symptomatic prolapse, but it did not find age or increased body mass index
to be associated with increased risk [68]. Other risk factors have variable
support in the literature, including white or Hispanic race, hysterectomy, oc-
cupations that involve heavy lifting, and various obstetric factors, including
operative delivery, infant weight, and length of pushing in the second stage
of labor [64].

Pathophysiology and anatomy

Support of the pelvic organs, including the rectum, bladder, and small
bowel, depends on the apical, lateral, and distal attachments of the vaginal
canal and the strength and integrity of the levator ani, or pelvic floor. The
vagina is supported by a system of endopelvic fascia and supportive liga-
ments attached to the bony pelvis. Vaginal support can be divided into three
levels. Level one support is the attachment of the vaginal apex to the utero-
sacral ligament complex, which in turn is attached to the sacrum. Level two
support includes the lateral attachments of the anterior and posterior vagi-
nal walls to the arcus tendineous fascious pelvis, or pelvic white line. Level
two support also encompasses the inherent support of the vaginal tube by
the vaginal muscularis, sometimes inappropriately termed vaginal fascia.
Level three support is composed of the attachment of the anterior vaginal
wall to the symphysis pubis and the posterior wall to the perineal body
(Fig. 6) [69]. When all three levels are intact, there is continuous support
from the perineum to the sacrum. Disruption may occur at any level of sup-
port or at multiple levels, resulting in pelvic organ prolapse. Integrity of the
levator ani is essential to this support system by providing a platform on
which the pelvic organs rest. Women with symptomatic prolapse commonly
have multiple sites of defects and damage to the levator ani. Although de-
scriptions of pelvic organ prolapse are reported in respect to which compart-
ment is affected, the vagina is a continuous organ, and separation of the
vagina into anterior, posterior, and apical compartments is somewhat arbi-
trary. Recent studies have underlined the importance of thinking of the va-
gina as continuous organ; approximately half of anterior prolapse can be
attributed to apical descent [70].

Diagnosis
Women with pelvic organ prolapse typically present with complaints of
‘‘feeling a bulge’’ or ‘‘something falling out’’ of the vagina. Often patients
1286 ABED & ROGERS

Fig. 6. Level I (suspension) and level II (attachment). In level I, paracolpium suspends vagina
from lateral pelvic walls. Fibers of level I extend vertically and posteriorly toward sacrum. In level
II, vagina is attached to arcus tendineus fasciae of pelvis and superior fascia of levator animuscles.
Vaginal levels of anatomic support. (Adapted from DeLancey JO. Anatomic aspects of vaginal
eversion after hysterectomy. Am J Obstet Gynecol 1992;166(6 Pt 1):1717–24; with permission.)

are concerned that they have a cancerous growth, which prompts them to
seek medical attention. Although prolapse can be present for long periods
of time before women request treatment, protrusion of the prolapse outside
of the vagina often precipitates intervention. Prolapse is associated with
myriad bowel and bladder complaints, including pelvic pressure, obstructed
voiding and/or defecation, need for splinting (placing fingers in the vagina
for support with defecation or urination), urinary or defecatory urgency
and frequency, constipation, and urinary and anal incontinence. These
symptoms are not useful in diagnosing prolapse, and women with pelvic
floor symptoms other than seeing or feeling a bulge should have further in-
vestigation before undergoing treatment for prolapse to resolve the other
symptoms [59].
The gold standard for diagnosis of pelvic organ prolapse is pelvic exam-
ination with measurement of vaginal descent by the POPQ, although com-
pleting the full POPQ is not necessary for screening or before initiation of
conservative therapy. For the basic examination, a patient is examined in
the supine position with the head of the bed at 45 and is asked to perform
Valsalva while the vaginal opening is observed for bulging. To ascertain
which compartments of the vagina are involved, a split speculum is inserted,
and the anterior, posterior, and apical portions of the vagina are observed
sequentially (see Figs. 3–5). Women should be asked to confirm that the de-
gree of prolapse seen on examination is the degree of prolapse that they are
experiencing. If a patient’s history of ‘‘feeling a ball’’ does not concur with
 URINARY INCONTINENCE AND PELVIC ORGAN PROLAPSE 1287

the clinical examination, women should be examined while standing to elicit

maximum descent.
Because prolapse above the hymen does not carry significant risk and
these women are unlikely to have symptoms, the use of screening questions
for detection of significant pelvic organ prolapse may be valid [68]. Exam-
ples of questions used to screen patients include ‘‘Do you usually have
a bulge or something falling out that you can see or feel in your vaginal
area?’’ [71] and ‘‘Do you have a sensation that there is a bulge in your
vagina or that something is falling out from your vagina?’’ [72]. Because
prolapse is often accompanied by urinary or anal incontinence, women
with prolapse also should be asked about these other disorders and vice
versa.

Treatment and prevention

Clinical observation is a viable option for most women with pelvic organ
prolapse. This approach is supported by recent evidence that even advanced
prolapse can regress and that most women with early-stage prolapse are
asymptomatic [73]. Asymptomatic patients with stage 1 or 2 disease (pro-
lapse up to 1 cm distal to the hymenal ring) can be reassured that observa-
tion is warranted in their situation. Asymptomatic patients with stage 3 or 4
prolapse may need evaluation on regular basis to assess the development or
worsening of voiding or defectory symptoms. Obstructed urination or defe-
cation or hydronephrosis from chronic ureteral kinking are all indications
for treatment regardless of degree of prolapse [64].
Nonsurgical treatment strategies for pelvic organ prolapse are limited.
Because the epidemiologic risk factors for prolapse are not clearly defined,
preventive strategies for development of prolapse are likewise not clearly de-
fined. The problem is confounded by the fact that many of the risk factors
for development of prolapse occur far in advance of symptomatic clinical
presentation. This is particularly true for vaginal birth. For example, the
peak age for surgical intervention for prolapse is 55, approximately 20 to
30 years after most women give birth. Cesarean delivery has been proposed
as possible prevention strategy for prolapse. Not all multiparous women de-
velop prolapse, however, and widespread implementation of maternal re-
quest cesarean delivery would expose the 90% of women not at risk to an
unnecessary surgical intervention without sure benefit [59]. Although obesity
has been linked as a risk factor for development of prolapse, weight loss has
not been proven to be a preventive measure. Pelvic floor exercises are other
proposed prevention strategies with limited evidence to support their use
[74].
The cornerstone of nonsurgical treatment for prolapse is the vaginal pes-
sary (see Fig. 1). Pessaries are silicone devices that support the pelvic organs
when inserted into the vagina. Historically, pessaries have been used in el-
derly women who are poor surgical candidates. Given rates of surgical
1288 ABED & ROGERS

failure of approximately 30%, however, pessaries offer a viable, nonsurgical

treatment option for treatment of prolapse. Although there are at least 13
types of commonly used pessaries, most women can be fitted and gain relief
of symptoms with one of two types of pessary: the ring with support or the
Gellhorn. A recent randomized controlled trial determined that patients did
not have a preference for the ring or Gellhorn, and both were effective in the
treatment of prolapse [75]. Approximately 80% of women who desire a trial
of pessary use are successfully fitted. Of those fitted, approximately 50%
continue using the pessary in the intermediate term (1 year) [76–78]. Most
women can learn to care for the pessary themselves after proper instruction,
although a few require ongoing care by the provider. Pessary use may pre-
vent prolapse progression and may prove to be an appropriate prevention
strategy in the future [78].
The mainstay of treatment for symptomatic pelvic organ prolapse is sur-
gery. Although a full description of the different types of prolapse surgery is
beyond the scope of this article, in general, prolapse surgery can be divided
into either obliterative procedures, in which the vagina is amputated, or re-
constructive procedures, which attempt to restore vaginal anatomy. Obliter-
ative procedures are performed vaginally and have high reported success
rates with low morbidity [64]. These procedures are only appropriate in
women who do not desire future vaginal intercourse.
Multiple different reconstructive surgeries have been described for the
treatment of prolapse. Little level 1 evidence exists to guide surgical deci-
sion making, however, and evidence regarding safety and efficacy of new
procedures lags far behind their introduction. Traditional reconstructive
repairs are associated with a one in three lifetime risk of repeat surgery
with a mean interval between the first and second surgery of 12.5 years
[1]. Because of this high failure rate, new procedures have been introduced
using surgical kits and graft materials, which purport to have higher suc-
cess rates despite limited follow-up or comparative data. In general, ab-
dominal procedures with graft materials have higher success rates at the
expense of longer recovery times, higher cost, and longer operating times.
Success of vaginal repairs may be improved with the use of graft materials
at unknown cost of morbidity in sexual function and bowel and bladder
complaints [79].

Summary
Pelvic floor disorders are common and costly in terms of health care dol-
lars and patient quality of life. Effective nonsurgical interventions exist for
urinary incontinence and pelvic organ prolapse, and many women would
benefit from these simple interventions. Primary care providers are ideally
suited to screen for these problems. Because most patients do not have com-
plicated urinary incontinence or pelvic organ prolapse, primary care
 URINARY INCONTINENCE AND PELVIC ORGAN PROLAPSE 1289

physicians can safely initiate first-line treatments, such as instructions on

performing pelvic floor exercises, behavioral modification (fluid and dietary
changes), prescribing anticholinergics, and pessary fitting.

Appendix 1

Simple screening tool for stress urinary and urge urinary incontinence

The Questionnaire for Urinary Incontinence Diagnosis

None of Once in Most of All of
the time: Rarely: a while: Often: the time: the time:
Question score 0 score 1 score 2 score 3 score 4 score 5
Do you leak urine
(even small drops),
wet yourself, or wet
your pads or
undergarments.
1. When you cough
or sneeze?
2. When you bend
down or lift
something up?
3. When you walk
quickly, jog,
or exercise?
4. While you are
undressing to use
the toilet?
5. Do you get such
a strong and
uncomfortable need
to urinate that you
leak urine (even
small drops) or wet
yourself before
reaching the toilet?
6. Do you have to rush
to the bathroom
because you get
a sudden, strong
need to urinate?
Stress urinary incontinence: score items 1, 2, and 3; stress score R 4.
Overactive bladder: score items 4, 5, and 6; urge score of R 6.
Mixed urinary incontinence: combined stress score R 4 and urge score of R 6.
Modified from Bradley CS, Rovner ES, Morgan MA, et al. A new questionnaire for urinary
incontinence diagnosis in women: development and testing. Am J Obstet Gynecol
2005;192(1):66; with permission.
1290 ABED & ROGERS

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