Urogynaecology: bladder leakage, prolapse and pelvic floor problems in women

Urogynaecology occupies the space between gynaecology, urology and colorectal surgery. It addresses how the bladder, vagina, uterus and bowel are supported by the pelvic floor and how they function, and so covers urinary leakage, bladder urgency, pelvic organ prolapse, recurrent bladder problems, and in some services bowel and sexual function related to pelvic floor damage.

A urogynaecologist is usually a consultant obstetrician and gynaecologist who has undertaken additional subspecialty training in pelvic floor and bladder disorders, though in some units urologists and colorectal surgeons with an interest in pelvic floor also contribute. Care is multidisciplinary. Women's health physiotherapists lead pelvic floor muscle training, specialist continence nurses assess bladder function and manage catheters and devices, and physiologists perform bladder and bowel tests. NICE guideline NG123 includes recommendations on the organisation of specialist services and on collecting data on surgery and surgical complications.

Because pelvic floor problems are common after childbirth and with ageing, and often not discussed, many women wait before seeking help. The reassurance from clinicians is that effective non-surgical treatments exist for most.

• Stress urinary incontinence, where urine leaks when the bladder is under pressure, for example on coughing, laughing or exercise, usually due to weakened pelvic floor muscles and urethral support.

• Urge incontinence and overactive bladder, with sudden strong urges to pass urine, frequency and nocturia, caused by overactivity of the bladder muscle.

• Mixed incontinence, a combination of stress and urge symptoms, which is common.

• Pelvic organ prolapse, where the womb, bladder or bowel bulge into the vagina. The NHS describes symptoms of heaviness or a dragging feeling, a lump or bulge, urinary or bowel difficulty and discomfort during sex, and says it is common in women over 50.

• Voiding difficulty and incomplete bladder emptying, bladder pain syndrome and recurrent urinary tract infections.

• Complications of previous continence or prolapse surgery, including mesh-related problems, and fistulas or injuries after childbirth.

• Pelvic floor problems after childbirth, with or without bowel symptoms, and urinary symptoms around menopause.

The first assessment is a conversation and examination. A clinician asks about the type, amount and triggers of leakage, fluid intake, bowel habit, childbirth history, medicines and the effect on daily life, and may ask you to keep a bladder diary of drinks and toilet visits. The NHS says a GP will ask about symptoms and examine you if prolapse is suspected, including with a speculum, can offer a chaperone and a female doctor, and may grade a prolapse from 1 to 4.

Further tests are guided by symptoms. A urine test excludes infection, and a simple scan measures how well the bladder empties. Urodynamic studies measure bladder pressure and flow while the bladder is filled and emptied, and are generally reserved for complex cases or before surgery. Cystoscopy looks inside the bladder with a thin camera when blood in the urine, pain or recurrent infections raise other concerns. Ultrasound of the pelvis and pelvic floor muscle assessment may also be used.

Treatment generally starts with conservative measures. The NHS lists lifestyle changes such as losing weight and cutting down on caffeine and alcohol, pelvic floor exercises, bladder training, and continence products such as pads, followed by medicines if symptoms persist. Supervised pelvic floor muscle training with a physiotherapist is commonly the best first step for stress incontinence and mild prolapse. For prolapse, the NHS says treatment can include vaginal oestrogen, vaginal support pessaries, physiotherapy and surgery to lift and support the pelvic organs if prolapse is severe, and the decision depends on which organs are affected, age, health and plans for future pregnancies.

For overactive bladder, bladder training and anticholinergic or other bladder medicines are used, and where these fail, options include botulinum toxin injection into the bladder and sacral nerve stimulation. For stress incontinence that persists, procedures include urethral bulking injections and surgical slings or colposuspension. On vaginal mesh, the NHS says surgery for prolapse using vaginal mesh is no longer done on the NHS unless there is no alternative, and that anyone with previous mesh and problems should speak to their GP or surgeon, reflecting the restrictions that followed the independent review of mesh procedures described in NICE guidance.

Surgery has risks including infection, bladder or bowel injury, new urinary symptoms, pain and recurrence, and should be discussed in the context of your priorities and whether you have completed your family.

In the NHS, a GP or women's health physiotherapist usually begins treatment. The NHS says you can see a GP for any type of incontinence and may be referred to a specialist for more tests, and a GP may refer to hospital if there are bladder problems with prolapse. Some areas have community continence services that accept self-referral. Hospital urogynaecology clinics see people whose symptoms persist, who need complex investigation, who are considering surgery or who have previous surgical complications.

Privately, you can usually see a urogynaecologist directly, with urodynamics and imaging in the same unit. Ask about the surgeon's experience with the specific procedure, whether outcomes are submitted to national audit, which materials or devices would be used and why, what alternatives exist and what the quoted price covers, including aftercare and complications.

• What type of incontinence or prolapse do I have, and how severe is it?

• What non-surgical options have I tried properly, and are there any others?

• If surgery is suggested, what is the aim, what does it involve, what are the risks and what is the chance it will not work?

• Will future pregnancy, weight change or menopause affect the result?

• What is the plan if the treatment does not help?

• Seek urgent help for being unable to pass urine at all, new severe pelvic pain, fever with urinary symptoms, blood in the urine, or a prolapse that becomes extremely painful, discoloured or cannot be replaced.