Diagnosis and Management of Complex Pelvic Floor Disorders in Women

When evaluating a woman with pelvic organ prolapse and voiding complaints, the clinician should strive to illicit which symptoms bother the patient most. A patient with primarily OAB symptoms and minimal prolapse may be treated with physical therapy or medications addressing the OAB rather than reconstructive surgery. In contrast, the patient with OAB symptoms and bothersome prolapse must be counseled on possible need for additional treatment of voiding complaints following surgical repair. This may include management of persistent OAB symptoms or SUI occurring following prolapse repair. Defecatory problems may be independent of a small rectocele present on exam, especially if long-term constipation is present. Choice of treatment depends on the severity of symptoms, the degree of prolapse, and the patient’s health status and activity level.

Case Study

Initial Presentation

A 68-year-old woman with a 15-month history of urinary urgency, frequency, incontinence and vaginal pressure presents to a urologist.

History and Physical Examination

The patient’s symptoms began shortly after the death of her husband. She initially saw her internist who prescribed antibiotics for a suspected urinary tract infection (UTI) based on office urinalysis. The symptoms did not resolve so another course of antibiotics was tried, again without relief. At her 3rd visit, a urine culture was done which was negative and she was referred to a urologist.

The patient reports 3 UTIs in the last 6 months. Following antibiotic treatment, the burning improves but she still complains of urgency and frequency. She also wears 2 to 3 pads per day for leakage that occurs with coughing and also when she feels an urge but cannot make it to the bathroom. She wakes 1 to 3 times at night to void. She feels that she empties her bladder well but often has to strain to void and sometimes feels a “bulge” in her vagina. All of these symptoms increase after being on her feet all day while she works as a grocery store cashier.

Physical exam demonstrates mild suprapubic tenderness and mild atrophic vaginitis. The anterior vaginal wall protrudes to the hymen with straining and her vaginal apex is supported 5 cm above the hymenal ring. With reduction of the cystocele there was urine leakage with cough. The cervix is surgically absent and her posterior vaginal wall is without bulge on valsalva. Her catheterized post-void residual (PVR) was 105 mL. Urine dipstick analysis was negative for infection or blood.

• What is the initial evaluation of a woman with pelvic organ prolapse and voiding complaints?

The initial evaluation of a woman with pelvic organ prolapse and voiding complaints consists of a detailed history and physical examination. The nature, duration, and severity of symptoms should be assessed. Complaints of vaginal pressure or bulge are important, as well as exacerbating instances (standing, straining, defecation). Local irritation or vaginal spotting is common if prolapse is beyond the hymen. Splinting or reduction of a bulge to void or defecate are important elements of the history. Sexual history should never be overlooked, including both sexual status (active or not) as well as goals for future sexual activity. Voiding symptoms such as dysuria, frequency, urgency, nocturia and incontinence should be discussed. A 3-day voiding diary that captures number of voids per day, voided volumes, and fluid intake can be obtained. If incontinence is present, the clinician should determine what causes the incontinence. Incontinence that is associated with urgency or no warning (urge incontinence) should be treated differently than incontinence associated with activity (SUI). Mixed urinary incontinence is the presence of both stress and urgency incontinence.