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Philippine Obstetrical and

Gynecological Society (POGS), Foundation, Inc.



November 2010

Task Force on Clinical Practice Guidelines

on Urogynecology


Philippine Obstetrical and Gynecological Society (Foundation), Inc. (POGS), 2010




Editor in Chief, Clinical Practice Guidelines, 2010
The Clinical Practice Guidelines on Urogynecology is the First Edition of this
Publication, 2010. The Philippine Obstetrical and Gynecological Society,
(Foundation), Inc. (POGS), through the Committee on Clinical Practice Guidelines
initiated and led to completion the publication of this manual in plenary consultation
with the Residency Accredited Training Hospitals Chairs and Training Officers, The
Regional Board of Directors, The Board of Trustees, The Task Force on
Urogynecology and the Committee on Continuing Medical Education (CME).
This publication represents the collective effort of the POGS in updating the
clinical practice of Obstetrics and Gynecology, specifically on Urogynecology, and
making it responsive to the most current and acceptable standard in this procedure.
A greater part of the inputs incorporated in this edition are the contributions
originating from the day-to-day academic interactions from the faculty of the different
Residency-Accredited Hospitals in Obstetrics and Gynecology in the country.
This Clinical Practice Guideline on Urogynecology is envisioned to become
the handy companion of the Obstetrician-Gynecologist in his/her day-to-day rendition
of quality care and decision making in managing the Gynecologic patient. This is also
envisioned to provide the academic institutions in the country and in Southeast Asia
updated information on Urogynecology as being practiced in the Philippines.
Profound gratitude is extended to all the members of the POGS, the Chairs
and Training Officers of the Residency-Training Accredited Institutions, the Regional
Directors, The Task Force Reviewers/Contributors, The CME Committee members,
and the 2010 POGS Board of Trustees.



Regta L. Pichay, MD
Sylvia delas Alas Carnero, MD
Vice President
Ditas Cristina D. Decena, MD
Jericho Thaddeus P. Luna, MD
Gil S. Gonzales, MD
Public Relations Officer

Efren J. Domingo, MD, PhD
Virgilio B. Castro, MD
Blanca C. de Guia, MD
Raul M. Quillamor, MD
Rey H. delos Reyes, MD
Ma. Cynthia Fernandez-Tan, MD


Efren J. Domingo, MD, PhD
Editor in Chief
Ann Marie C. Trinidad, MD
Ma. Victoria V. Torres, MD
Lisa T. Prodigalidad-Jabson, MD
Christine D. Dizon, MD
Rommel Z. Duenas, MD
Ana Victoria V. Dy Echo, MD
Ms. Emiliana C. Enriquez
Ms. Jhasmin G. De Guzman
Lisa T. Prodigalidad-Jabson, MD
Almira J. Amin-Ong, MD
Lennette L. Chan, MD
Jennifer B. Jose, MD
Maria Teresa C. Luna, MD
Manuel S. Ocampo, MD
Judith M. Sison, MD
Rainerio S. Abad, MD
Ruth Jinky Aposaga, MD
Ricardo Braganza, MD
Grace D. Caras, MD
Cherrie Climaco, MD
Macrina A. De Guzman, MD
Rodante P. Galiza, MD
May N. Hipolito, MD
Margarette Lavalle, MD
Ma. Cecilia Maclang, MD
Jocelyn Z. Mariano, MD
Suzette Miclat, MD
Belen Pantangco-Rajagukguk, MD
Sarah Pingol, MD
Rico E. Reyes, MD
Pura Rodriguez-Caisip, MD
Esmarliza Tacud-Luzon, MD
Jean Anne B. Toral, MD
Faith Villaruiz, MD

Ma. Flores Adiong, MD

Prudence V. Aquino, MD
Sybil Lizanne R. Bravo, MD
Abigail Elsie D. Castro, MD
Antonio Cortez, MD
Grace D. delos Angeles, MD
Gil S. Gonzales, MD
Rosemarie R. Hudencial, MD
Lourdes Ledesma, MD
Marilou Mangubat, MD
Rudie Frederick B. Mendiola, MD
Cristia S. Padolina, MD
Gladys Pelicano, MD
Kenet Prado, MD
Ricalynn Rivera, MD
Alice Salvador, MD
Patricia L. Tan, MD
Florentina A. Villanueva, MD
Marilou Viray, MD
Amaryllis Digna A. Yazon, MD

Regional Directors
Betha Fe M. Castillo, MD (Region 1)
Concepcion P. Argonza, MD (Region 3)
Diosdado V. Mariano, MD (Region 4A NCR)
Evelyn R. Lacson, MD (Region 6)
Fe G. Merin, MD (Region 8)
Jana Joy R. Tusalem, MD (Region 10)

Imelda O. Andres, MD
Nurlinda Arumpac, MD
Maria Nelvez Candilario, MD
Ma. Theresa Cedullo, MD Ma.
Lara David-Bustamante, MD
Lorina Q. Esteban, MD
Maribel Hidalgo-Co, MD
Humildada Asumpta Igana, MD
Jericho Thaddeus P. Luna, MD
Corazon B. Mata, MD
Marites Mendoza, MD
Mary Christine F. Palma, MD
Regta L. Pichay, MD
Ma. Carmen H. Quevedo, MD
Bella G. Rodriguez, MD
Jean Marie Salvador, MD
Ma. Theresa B. Tenorio, MD
Julieta Villanueva, MD
Regina P. Vitriolo, MD

Noel C. de Leon, MD (Region 2)

Ernesto S. Naval, MD (Region 4)
Cecilia Valdes-Neptuno, MD (Region 5)
Belinda N. Paares, MD (Region 7)
Cynthia A. Dionio, MD (Region 9)
Amelia A. Vega, MD (Region 11)



This is the Clinical Practice Guidelines (CPG) on Urogynecology, First Edition,

November 2010.
This is the publication of the Philippine Obstetrical and Gynecological Society,
(Foundation), Inc. (POGS).
This is the ownership of the POGS, its officers, and its entire membership.
The obstetrician gynecologist, the general practitioner, the patient, the student, the
allied medical practitioner, or for that matter, any capacity of the person or
individual who may read, quote, cite, refer to, or acknowledge, any, or part, or the
entirety of any topic, subject matter, diagnostic condition or idea/s willfully
release and waive all the liabilities and responsibilities of the POGS, its officers
and general membership, as well as the Committee on the Clinical Practice
Guidelines and its Editorial Staff in any or all clinical or other disputes,
disagreements, conference audits/controversies, case discussions/critiquing.
The reader is encouraged to deal with each clinical case as a distinct and unique
clinical condition, which will never fit into an exact location if reference is made
into any or all part/s of this CPG.
The intention and objective of this CPG is to serve as a guide, to clarify, to make
clear the distinction. It is not the intention or objective of this CPG to serve as the
exact and precise answer, solution and treatment for clinical conditions and
situations. It is always encouraged to refer to the individual clinical case as the
one and only answer to the case in question, not this CPG.
It is hoped that with the CPG at hand, the clinician will find a handy guide that
leads to the a clue, to a valuable pathway that leads to the discovery of clinical
tests leading to clinical treatments and eventually recovery.
In behalf of the POGS, its Board of Trustees, the Committee on The Clinical
Practice Guidelines, 2010, this CPG is meant to make each one of us a perfect
image of Christ, the Healer.


Introduction 1
Dr. Lisa T. Prodigalidad-Jabson
Definition of Terms (Standardization of Terminology)
Dr. Almira J. Amin-Ong
Evaluation of Pelvic Floor Dysfunction and POP-Q Scoring System ..
Dr. Judith M. Sison
Conservative Management of Stress Urinary Incontinence
Dr. Almira J. Amin-Ong
Surgical Management of Stress Urinary Incontinence .
Dr. Lisa T. Prodigalidad-Jabson
Conservative Management of Pelvic Organ Prolapse
Dr. Maria Teresa C. Luna
Surgical Management of Pelvic Organ Prolapse
Dr. Manuel S. Ocampo, Jr and Dr. Lisa T. Prodigalidad-Jabson
Fecal Incontinence and Obstetric Anal Sphincter Injuries (OASIS) ..
Dr. Lennette L. Chan
Urinary Retention ...
Dr. Jennifer B. Jose
Appendix: Level of Evidence and Grade of Recommendations .


Lisa T. Prodigalidad-Jabson, MD
Urogynecology and Reconstructive Pelvic Surgery has long been a recognized
specialty in the field of Obstetrics and Gynecology. However, here in the Philippines,
Urogynecology is still at its infancy stage and only recently has there been a growing
interest in this field of pelvic reconstruction. Pelvic floor disorders such as pelvic
organ prolapse (POP), fecal incontinence (FI), and urinary incontinence (UI) are, at
present, aspects of womens health that are frequently neglected or ignored.
POP is among the most common indications for benign gynecologic surgery.
A review by the National Center for Health Statistics in the United States lists genital
prolapse as one of the 3 most common reasons for hysterectomy in women. In the
University of the Philippines - Philippine General Hospital alone, over 100 cases of
vaginal hysterectomies are performed each year for prolapse. In a recent review by
the Womens Health Initiative, POP was found to be a very common condition in
women during menopause and was consistently related to parity.2 This becomes of
particular importance in a society such as ours where family planning, although
strongly advocated, is not widely practiced.
Likewise, female UI is a common problem that is often unrecognised, neglected,
or ignored. It is a condition believed to be as natural as pregnancy, childbirth,
menopause, and aging. The prevalence of UI is reported to range from 2% to 57% and
afflicts both the young and old. The wide range may reflect the difficulty in
estimating the incidence of UI, as most women experiencing such symptoms often do
not seek medical advice. In a 2001 study by the Asia-Pacific Continence Advisory
Board, the prevalence of overactive bladder as a cause of incontinence in Asians was
noted to be 51.4%. More specifically, Diokno states a 13% prevalence rate of UI
among Filipinos.3 This is in contrast to the incidence of 31% reported by RamosoJalbuena in 1994.4
With recent emphasis on womens health and quality of life, caring for women
with various pelvic floor disorders would become an increasingly important aspect of
womens health care. And, for a rapidly growing and aging population, the demand
for such care will inevitably escalate.


Milsom I, Altman D, Lapitan MC, Nelson R, Sillen U, and Thom D. Epidemiology of urinary
(UI) and fecal incontinence (FI) and pelvic organ prolapse (POP). In Abrams P, Cardozo L,
Khoury S, and Wein A (Eds). Incontinence: WHOICUD International Consultation on
Incontinence, 4th edition, 2009.
Hendrix SL, Clark A, Nygaard I, Aragaki A, Barnabei V, McTiernan A. Pelvic organ prolapse
in the womens health initiative: gravity and gravidity. Am J Obstet Gynecol
Lapitan MC and Chye PLH on behalf of the Asia-Pacific Continence Advisory Board. The
epidemiology of overactive bladder among females in Asia: A questionnaire survey. Int
Urogyn J 2001;12(4):226-31.
Ramoso-Jalbuena J. Climacteric filipino women: a preliminary survey in the Philippines.
Maturitas 2004;19(3):183-190.

Almira J. Amin-Ong, MD
Lower urinary tract symptoms are classified into three major categories
namely, storage, voiding and postmicturition symptoms. The following terms are
culled from the latest International Continence Society (ICS) Standardization of
Terminology for lower urinary tract symptoms published in 2009. The terminologies
serve to eliminate confusion and facilitate communication amongst clinicians.





1. Urgency the complaint of a sudden compelling desire to pass urine which is
difficult to defer
2. Increased daytime frequency the complaint of the patient who considers that
she voids too often by day; equivalent to pollakisuria used in many countries
3. Nocturia the complaint that the individual has to wake up at night one or
more times to void
4. Stress urinary incontinence (SUI) the complaint of involuntary leakage on
effort or exertion, or on sneezing or coughing
5. Urge UI the complaint of involuntary leakage accompanied by or
immediately preceded by urgency
6. Mixed UI the complaint of involuntary leakage associated with urgency and
also with exertion, effort, sneezing or coughing
7. Nocturnal enuresis complaint of loss of urine occurring during sleep
8. Continuous urinary leakage the complaint of continuous leakage
9. Normal bladder sensation the individual is aware of bladder filling and
increasing sensation up to a strong desire to void
10. Increased bladder sensation the individual feels an early and persistent
desire to void
11. Reduced bladder sensation the individual is aware of bladder filling but does
not feel a definite desire to void
12. Absent bladder sensation the individual reports no sensation of bladder
filling or desire to void
13. Non-specific bladder sensation the individual reports no specific bladder
sensation but may perceive bladder filling as abdominal fullness, vegetative
symptoms, or spasticity
1. Slow stream perception of the individual of reduced urine flow, usually
compared to previous performance or in comparison with others
2. Splitting or spraying self-explanatory
3. Intermittent stream (intermittency) urine flow described as a stop and start
flow, on one or more occasions, during micturition
4. Hesitancy difficulty in initiating micturition resulting in a delay in the onset

of voiding after the individual is ready to pass urine

5. Straining describes the muscular effort used to either initiate, maintain or
improve the urinary stream
6. Terminal dribble term used when an individual describes a prolonged final
part of micturition, when the flow has slowed to a trickle/dribble
1. Feeling of incomplete emptying self-explanatory term for a feeling
experienced by the individual after passing urine
2. Postmicturition dribble involuntary loss of urine immediately after the
patient has passed urine, or after rising from the toilet
1. Bladder pain pain felt suprapubically or retropubically, and usually
increases with bladder filling, it may persist after voiding
2. Urethral pain felt in the urethra and the individual indicates the urethra as
the site
3. Vaginal pain felt internally, above the introitus
4. Perineal pain felt between the posterior fourchette and the anus
5. Pelvic pain less well defined than the bladder, urethral or perineal pain and
is less clearly related to the micturition cycle or to bowel function and is not
localized to any single pelvic organ
1. Painful bladder syndrome complaint of suprapubic pain related to bladder
filling accompanied by other symptoms such as increased daytime or
nighttime frequency, in the absence of a proven urinary infection or other
obvious pathology
2. Urethral pain syndrome occurrence of recurrent episodic urethral pain
usually on voiding, with daytime frequency and nocturia, in the absence of a
proven infection or other obvious pathology
3. Vulval pain syndrome / Vaginal pain syndrome / Perineal pain syndrome
occurrence of persistent or recurrent episodic vulval, vaginal or perineal pain
which is either related to the micturition cycle or associated with symptoms
suggestive of urinary tract or sexual dysfunction, with no proven infection or
obvious pathology
4. Pelvic pain syndrome occurrence of persistent or recurrent episodic pelvic
pain associated with symptoms suggestive of lower urinary tract, sexual,
bowel or gynecological dysfunction, with no proven infection or obvious
1. Daytime frequency number of voids during waking hour inclusive of the last
void before sleep and the first void upon waking in the morning
2. Nocturia number of voids recorded during a nights sleep, each void is

preceded and followed by sleep

3. Polyuria urine production of more than 2.8 liters in 24 hours in adults
4. Nocturnal polyuria is present when an increased proportion of the 24-hour
output occurs at night (> 20% in young adults to > 33% over 65 years)
5. Maximum voided volume largest recorded volume of urine voided in a single
micturition as determined in the bladder diary or frequency/volume chart
6. SUI observation of involuntary leakage from the urethra, synchronous with
exertion/effort, or sneezing or coughing
7. Overactive bladder characterized by the storage symptoms of urgency with
or without urgency incontinence, usually with frequency and nocturia
8. Mixed UI complaint of involuntary leakage associated with urgency and also
with effort, exertion, sneezing and coughing
9. Extraurethral incontinence observation of urine leakage through channels
other than the urethra
10. Uncategorized incontinence observation of involuntary leakage that cannot
be classified into one of the above categories on the basis of signs and
11. Intravesical pressure pressure within the bladder
12. Abdominal pressure pressure surrounding the bladder which is estimated
from rectal, vaginal, or less commonly, from extraperitoneal pressure or bowel
13. Detrusor pressure the component of vesical pressure that is created by
forces in the bladder wall, both active and passive. It is estimated by
subtracting the abdominal pressure from the intravesical pressure.
14. Filling cystometry method by which the pressure/volume relationship of the
bladder is measured during bladder filling
15. Bladder diary records the times of micturitions and voided volumes,
incontinence episodes, pad usage and other information such as fluid intake,
the degree of urgency and the degree of incontinence
16. Detrusor overactivity a urodynamic investigation characterized by
involuntary detrusor contractions during the filling phase which may be
spontaneous or provoked
17. Terminal detrusor overactivity defined as a single, involuntary detrusor
contraction, occurring at cystometric capacity, which cannot be suppressed
and results in incontinence usually resulting in bladder emptying
18. Detrusor overactivity incontinence incontinence due to an involuntary
detrusor contraction
19. Neurogenic detrusor overactivity involuntary detrusor contractions
occurring in patients with relevant neurological condition
20. Idiopathic detrusor overactivity no defined cause for the involuntary
detrusor contractions
21. Bladder compliance describes the relationship between change in bladder
volume and change in detrusor pressure
22. Cystometric capacity the bladder volume at the end of the filling
cystometrogram when permission to void is given. It is the volume voided
together with any residual urine.
23. Maximum cystometric capacity the volume at which a patient with normal
sensations feels she can no longer delay micturition (has a strong desire to
24. Urodynamic stress incontinence noted during filling cystometry and is

defined as the involuntary leakage of urine during increased intraabdominal

pressure, in the absence of a detrusor contraction. It replaces the term
genuine stress incontinence.
25. Abdominal leak point pressure the intravesical pressure at which urine
leakage occurs due to increased abdominal pressure in the absence of a
detrusor contraction.
26. Detrusor leak point pressure the lowest detrusor pressure at which urine
leakage occurs in the absence of either a detrusor contraction or increased
abdominal pressure
27. Detrusor underactivity a contraction of reduced strength and/or duration,
resulting in a prolonged bladder emptying and/or failure to achieve complete
bladder emptying within a normal time span.
28. Acontractile detrusor one that cannot be demonstrated to contract during
urodynamic studies.
29. Bladder outlet obstruction a generic term for obstruction during voiding and
is characterized by increased detrusor pressure and reduced urine flow rate
30. Dysfunctional voiding characterized by intermittent and/or fluctuating flow
rate due to involuntary intermittent contractions of the peri-urethral striated
muscle during voiding in neurologically normal individuals.
31. Detrusor sphincter dysynergia a detrusor contraction concurrent with an
involuntary contraction of the urethral and/or peri-urethral striated muscle.
32. Non-relaxing urethral sphincter obstruction occurs in individuals with a
neurological lesion and is characterized as non-relaxing, obstructing urethra
resulting in reduced urine flow.
33. Pelvic organ prolapse (POP) defined as the descent of one or more of the
anterior vaginal wall, the posterior vaginal wall, and the apex of the vagina
(cervix/uterus) or vault (cuff) after hysterectomy.
34. Anterior vaginal wall prolapse defined as the descent of the anterior vagina
so that the urethrovesical junction (a point 3 cm proximal to the external
urethral meatus) or any anterior point proximal to this is less than 3 cm above
the plane of the hymen
35. Posterior vaginal wall prolapse defined as any descent of the posterior
vaginal wall so that a midline point on the posterior vaginal wall 3 cm above
the level of the hymen or any posterior point proximal to this is less than 3 cm
above the plane of the hymen
36. Prolapse of the apical segment of the vagina defined as any descent of the
vaginal cuff scar (after hysterectomy) or cervix below a point which is 2 cm
less than the total vaginal length above the plane of the hymen
37. Rectal prolapse defined as the circumferential full thickness rectal
protrusion beyond the anal margin
38. Anal incontinence defined as any involuntary loss of fecal material and/or
flatus and maybe divided into:
a. Fecal incontinence (FI) any involuntary loss of fecal material
b. Flatus incontinence any involuntary loss of gas (flatus)
39. Acute retention of urine defined as a painful, palpable or percussable
bladder, when the patient is unable to pass any urine.
40. Chronic retention of urine defined as a non-painful bladder, which remains
palpable or percussable after the patient has passed urine. Such patients may
be incontinent.

1. Pelvic floor training repetitive selective voluntary contraction and relaxation
of specific pelvic floor muscles
2. Biofeedback technique by which information about a normally unconscious
physiological process is presented to the patient and/or therapist as a visual,
auditory or tactile signal
3. Behavioral modification the analysis and alteration of the relationship
between the patients symptoms and her environment for the treatment of
maladaptive voiding patterns
4. Electrical stimulation the application of electrical current to stimulate the
pelvic viscera or their nerve supply
5. Catheterization technique for bladder emptying employing a catheter to
drain the bladder or a urinary reservoir
6. Intermittent (in/out) catheterization defined as drainage or aspiration of the
bladder or urinary reservoir with subsequent removal of the catheter
a. Intermittent self-catheterization performed by the patient herself
b. Intermittent catheterization performed by an attendant (e.g., doctor,
nurse, or relative)
c. Clean intermittent catheterization use of a clean technique. This
implies ordinary washing techniques and use of disposable or cleansed
reusable catheters
d. Aseptic intermittent catheterization use of a sterile technique. This
implies genital disinfection and use of sterile catheters and
7. Indwelling catheterization an indwelling catheter remains in the bladder,
urinary reservoir or urinary conduit for a period of time longer than one


Bump RC, Mattiasson A, Bo K, Brubaker LP, DeLancey JOL, Klarskov P, Shull BL, Amith
ARB. The standardization of terminology of female pelvic organ prolapse and pelvic floor
dysfunction. Am J Obstet Gynecol 1996;175:10-1.
Abrams P, Cardozo L, Khoury S, Wein A. Incontinence. 4th International Consultation on
Incontinence. 4th ed. 2009.


Judith M. Sison, MD, MPH
1. Patients with urinary incontinence (UI) should undergo a basic evaluation
that includes a history1, physical examination2,3, measurement of postvoid residual volume (PVR), urinalysis, and 3-day bladder chart.
Standard chemical tests for renal function are recommended in patients
with UI and a high probability of renal damage. (Level II-3, Grade A)
Summary of Evidence
Post-void residual volume
A PVR < 50 ml is considered adequate bladder emptying and > 200 ml is
considered inadequate.4,5
Routine urinalysis with or without urine culture and sensitivity test
To assess for any lower urinary tract infection (UTI), a clean midstream or
catheterized urine sample should be obtained for dipstick urinalysis which
provides necessary information as a multi-property strip should be used.6 It
can also screen any urothelial lesion and stone disease.7
Three-day bladder diary (frequency/volume chart)
Urinary diaries are highly reproducible and correlated well with urodynamic
diagnosis.8 Consistent results have been shown between the first 3-day period
and the last 4-day period, suggesting that a 3-day chart may be adequate to
document symptoms, thus, improving compliance.9, 10
Standard blood chemistries for renal function
The routine use of a battery of common chemical tests in patients with UI
appears to be a prudent rule of good practice in the following conditions:
a. chronic retention with UI (overflow UI)
b. neurogenic lower urinary tract dysfunction
c. when surgery is contemplated
d. when there is a clinical suspicion
2. Cough stress test strongly suggests a diagnosis of stress urinary
incontinence (SUI). Borderline or negative test results should be repeated
to maximize its diagnostic accuracy. (Level II-2, Grade B)
Summary of Evidence
Loss of small amounts of urine in spurts, simultaneous with coughing
and in the absence of urge, strongly suggests a diagnosis of SUI.11 Prolonged
loss of urine, leaking 5-10 seconds after coughing, or no urine loss with
provocation indicates that other causes of incontinence, especially detrusor
overactivity, may be present. The inability to demonstrate the sign of SUI

during simple bladder filling and cough stress test correlates highly with the
absence of urodynamic stress incontinence.11,12
3. Q-tip or cotton swab test is not useful in differentiating SUI from
abnormalities of voiding and detrusor functions. (Level II-3, Grade B)
Summary of Evidence
Q-tip or cotton swab test refers to placement of a cotton swab in the
urethra at the level of the bladder neck and measurement of the axis change (>
30o) to demonstrate urethral mobility. Investigators found that a sizable
minority of women with urodynamic diagnosis of SUI did not have a positive
Q-tip test and that many women with positive Q-tip test did not have SUI on
urodynamic testing. It is now used primarily to assess the results of antiincontinence surgery or to determine whether the degree of urethral
hypermobility may influence treatment outcomes.13,14
Other tests, e.g. perineal ultrasonography and magnetic resonance
imaging (MRI), can be used for assessment of bladder neck mobility, but these
are not commonly used in clinical practice.
Modifications of the Bonneys test require support of the urethrovesical junction during coughing in women who leak during a stress test.
These modifications are not reliable in selecting a surgical procedure or in
predicting cure.15
4. The standard 1-hour pad test quantifies the volume of urine lost by
weighing a perineal pad before and after some type of leakage
provocation. A pad weight gain of > 1 g is considered positive for a 1-hour
test, and > 4 g for a 24-hour test.16,17 (Level II, Grade B)
Summary of Evidence
The Committee on Investigations from the 2nd International
Consultation on Incontinence concluded that the 1-hour pad test would yield
increased accuracy if done with a fixed bladder volume.18,19 It was able to
discriminate most of the time between continent and incontinent women.
5. Dye test: The identification of the site of a fistula is best carried out by
instillation of methylene blue into the bladder. (Level III, Grade C)
Summary of Evidence
If leakage of clear fluid continues after dye instillation, a ureteric
fistula is most likely and this is most easily confirmed by a 2-dye test, using
Phenazopyridine or indigo carmine (or any drug that colors the urine like
Nitrofurantoin, in the local setting) to stain the renal urine, and methylene blue
to stain the bladder contents.20,21
6. Assessment of pelvic floor muscle strength has practical application in
determining whether the patient has nil, weak or good muscles to

effectively carry out passive contraction therapy, an exercise program, or

any need for further evaluation. (Level III, Grade C)
Summary of Evidence
The continence mechanisms imply that integrity of the levator ani and
the external urethral sphincter is necessary to maintain continence. It is
therefore important to test the contractility of these muscles.
A pelvic muscle contraction may be assessed by visual inspection,
palpation, electromyography or perineometry. When considering
methods/devices used to measure pelvic muscle strength, cost and availability
are important considerations.21
This can be qualitatively defined by the tone at rest and the strength of
a voluntary contraction as strong, weak, or absent by a validated grading
system, e.g. Oxford scale 1-5. Factors to be assessed include strength,
duration, displacement, and repeatability.22 The modified Oxford scale has
been shown to correlate well with surface electromyography and manometry
of pelvic floor muscles.23
7. Urine cytology is recommended in patients with persistent microscopic
hematuria in the absence of UTI to exclude bladder neoplasm. (Level III,
Grade C)
Summary of Evidence
Urine cytology should be requested in patients with microscopic
hematuria (RBC 2-5/hpf), ! 50 year-old with persistent hematuria or those
with acute onset of irritative voiding symptoms in the absence of UTI to
exclude bladder neoplasm.24 It is not recommended in the routine evaluation
of patients with incontinence.25
8. Cystometric testing is not required in the routine or basic evaluation of
UI.26 Whenever objective clinical findings do not correlate with or
reproduce the patients symptoms, simple cystometry is appropriate for
detecting abnormalities of detrusor compliance and contractibility.27
(Level II, Grade B)
Summary of Evidence
Office cystometry: Retrograde bladder filling provides an assessment
of bladder sensation and an estimate of bladder capacity. The definition of
normal bladder capacity lacks consensus, with values that range from 300-750
ml. In addition, large bladder capacities are not always pathologic.
Researchers showed that 33% of women with bladder capacities > 800 ml.
were urodynamically normal, and only 13% had true bladder atony.28
9. Minimum urodynamic investigation includes uroflowmetry, pressureflow study of voiding together with one or more of the following, as
indicated for the individual patient: abdominal leak point pressure
measurement, urethral pressure measurement. (Level II, Grade B)

Indications for urodynamics29:

a. Prior to invasive or irreversible treatment or retreatment of all types of
b. Complex incontinence cases whenever there is doubt about the
underlying pathophysiology
c. Neurogenic bladders as an initial assessment or as part of a long-term
surveillance. If possible, videourodynamic testing should be employed.
Summary of Evidence
There was not enough evidence to show whether women with UI who
underwent urodynamics were less likely to be incontinent after treatment than
women who did not undergo urodynamic testing.30, 31
10. Urethral pressure profilometry (UPP) and leak point pressure
measurements have not proved useful in the evaluation of UI. (Level III,
Grade C)
Summary of Evidence
Researchers found that UPP is not standardized, reproducible, or able
to contribute to the differential diagnosis in women with SUI symptoms.
Therefore it does not meet the criteria for a useful diagnostic test.32 Leak point
pressure measures the amount of increase in intraabdominal pressure that
causes stress incontinence, although its usefulness also has not been proved.33
11. Cystoscopy should not be performed routinely in patients with
incontinence to exclude neoplasm. (Level II-2, Grade B)
Summary of Evidence
Indications for cystoscopy in patients with UI include those who have:
sterile hematuria or pyuria; irritative voiding symptoms, e.g. frequency,
urgency, urge incontinence in the absence of any reversible causes; bladder
pain; recurrent cystitis; suburethral mass; and when urodynamic testing fails to
duplicate symptoms of UI.34 Bladder lesions are found in < 2% of patients
with incontinence35; therefore, cystoscopy should not be performed routinely
in patients with incontinence to exclude neoplasm36.
12. Imaging: Ultrasound is not recommended in the primary evaluation of
patients with UI and/or POP. It is likewise an optional test in the
evaluation of patients with complex or recurrent UI and or POP.37, 29
MRI of the pelvic floor is rapidly gaining field in the evaluation of
enteroceles and in the morphological analysis of pelvic floor muscles
although the evidence of its clinical benefit is still unclear.29,38 (Level III,
Grade C)

Summary of Evidence
Transabdominal, perineal or translabial, transrectal, and transvaginal
ultrasound is currently used due to its noninvasive nature, ready availability,
and absence of distortion. Although ultrasound is rapidly evolving and much
progress has been made, it remains optional as evidence of its clinical benefit
is still weak.29
MRI provides anatomical detail to the pelvic floor in a single noninvasive study that does not expose the patient to ionizing radiation. Gousse,
et. al. reported a sensitivity of 83%, specificity of 100%, positive predictive
value of 100%, when comparing dynamic MRI to intraoperative findings.
These numbers were similar compared to physical examination alone.39
1. The only symptom specific to prolapse is the awareness of vaginal bulge
or protrusion. For all other pelvic symptoms, resolution with prolapse
treatment can not be assumed.40 (Level II-3, Grade A)
Summary of Evidence
Almost half of parous women can be identified as having prolapse by
physical examination criteria, most are not clinically affected; the finding is
not well correlated with specific pelvic symptoms.41
2. The amount or severity of prolapse in each vaginal segment may be
measured and recorded using the pelvic organ prolapse quantification
system (POP-Q). (Level III, Grade C)
Summary of Evidence
The POP-Q system was introduced for use in clinical practice and
research. Some have argued that the 9-points of the POP-Q system maybe
more detailed than necessary for clinical practice, and it is better suited for
clinical research purposes. It often is useful to include a measurement of the
extent of protrusion relative to the hymen to better assess change overtime.42
2. Cystoscopy or cystourethroscopy should be performed intraoperatively to
assess for bladder or ureteral damage after all prolapse or incontinence
procedures during which the bladder or ureters may be at risk of
injury.43 (Level II-2, Grade B)
Summary of Evidence
A recent systematic review of urinary tract injuries during
cystourethroscopy reported the overall ureteral injury rate was 8.8/1,000

procedures (95% CI 2.3-12.6).43 The overall bladder injury rate after

urogynecologic surgical procedures was 16.3 (95% CI 4.3-26.6).44
The POP-Q is the current gold standard for measuring prolapse stage in
patients. It offers an objective evaluation that can be communicated between
physicians and used to compare pre- and post-surgical intervention examinations. It
was developed and adopted by the International Continence Society (ICS) and
endorsed by leading international organizations dealing with pelvic floor dysfunction.
Stages are based on the maximal extent of prolapse relative to the hymen, in one
or more compartments. The hymen is assigned the value of zero; points proximal to
the hymen are negative (inside the body) while points distal to the hymen are positive
(outside of the body). There are 6 vaginal sites as represented in the POP-Q grid, and
3 additional measurements which always have a positive value namely: a) genital
hiatus (Gh) b) perineal body (Pb), and c) total vaginal length (TVL). All
measurements, except for TVL, are made while patient is doing Valsalva maneuver.
All measurements are made to the nearest 0.5 cm. Both the patients position
(lithotomy, birthing chair, or standing) during the examination, and the state of her
bladder and rectum (full or empty) should be noted.
Quantification Definitions and Ranges:

Anterior vaginal wall 3 cm proximal to hymen
Leading-most point of anterior vaginal wall prolapse
Most distal edge of cervix or vaginal cuff (if absent cervix)
Most distal portion of posterior fornix
Post vaginal wall 3 cm proximal to hymen
Leading-most point of post vaginal wall prolapse
Perpendicular distance from mid-urethral meatus to posterior hymen
Perpendicular distance from mid-anal opening to posterior hymen
Post vaginal fornix or vaginal cuff (if absent cervix) to the hymen

-3 to +3
-3 to + TVL
- /+ TVL
- /+ TVL
-3 to +3
-3 to + TVL
No limit
No limit
No limit

The stages of POP are:

Stage 0 No descent of any compartment
Stage 1 Descent of the most prolapsed compartment between perfect support and
-1 cm
Stage 2 Descent of the most prolapsed compartment between -1 cm and +1 cm
Stage 3 Descent of the most prolapsed compartment between +1 cm and TVL -2
Stage 4 Descent of the most prolapsed compartment from TVL -2 cm to complete

Reproduced from: Bump RC, et al. The standardization of terminology of female pelvic organ prolapse
and pelvic floor dysfunction. Am J Obstet Gynecol 1996; 175: 10-7. 42


1. A simple assessment of possible anorectal dysfunction by history and
physical examination should be performed whenever lower urinary tract
function is evaluated. (Level III, Grade C)
Summary of Evidence
Jackson, et. al. evaluated 247 women with either UI or POP. Thirty
one percent (31%) of women with UI and 7% with POP had concurrent anal
2. The cheapness and speed of investigation makes endosonography the
ideal screening procedure to assess anal sphincter. Manometry may offer
little extra information where ultrasound is available. Preoperative
assessment in patients with possible atrophy is the main indication for
MRI.21 (Level III, Grade C)

Summary of Evidence
Anorectal manometry is an optional test that may be used in difficultto-evaluate cases of fecal or anal incontinence. It should be considered if
therapy based on simpler assessments fails to yield the desired improvement.46
MRI is superior to ultrasound in diagnosis of perianal sepsis and in
quantifying external anal sphincter muscle degeneration.47

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treatment of urinary incontinence. Lancet 2000;355:2153-8.
Ouslander JG, et al. Incontinence in the nursing home. Ann Intern Med 1995;122:438-49.
Blaivas JG, et al. The bulbocavernosus reflex in urology: a prospective study of 299 patients.
J Urol 1981;126:197-9.
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chronic management. Clinical Practice Guideline, No.2, 1996 Update. AHCPR Publication
No. 96-0682. Rockville (MD): AHCPR; 1996.
Goode PS, et al. Measurement of postvoid residual urine with portable transabdominal bladder
ultrasound scanner and urethral catheterization. Int Urogynecol J Pelvic Floor Dysfunct
Semeniuk H, et al. Evaluation of the leukocyte esterase and nitrite urine dipstick screening
tests for detection of bacteriuria in women with suspected uncomplicated urinary tract
infections. J Clin Microbiol 1999; 37(9):3051-2.
European Urinalysis Guidelines. Summary. Scand J Clin Lab Invest 2000;60:1-96.
Wyman JF, et al. The urinary diary in evaluation of incontinent women: a test-retest analysis.
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Nygaard I, et al. Reproducibility of a 7-day voiding diary in women with stress urinary
incontinence. Int Urogynecol J Pelvic Floor Dysfunct 2000;11:15-7.
Addla S, et al. Assessment of reliability of 1-day, 3-day, and 7-day frequency volume charts.
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cystometry for the diagnosis of urinary incontinence. Am J Obstet Gynecol 1994;171:1472-7;
discussion 1477-9.
Swift SE, Ostergard DR. Evaluation of current urodynamic testing methods in the diagnosis of
genuine stress incontinence. Obstet Gynecol 1995;86:85-91.
Karram MM, Bhatia NN. The Q-tip test: Standardization of the technique and its
interpretation in women with urinary incontinence. Obstet Gynecol 1988;71(61):807-11.
Walters MD, et al. Q-tip test: a study of continent and incontinent women. Obstet Gynecol
Bergman A. Invalidity of Marshall-Marchetti and Bonney stress tests. In: Ostergard D, Bent
A, eds. Urogynecology and urodynamics: Theory and practice (2e) Baltimore, MD: Williams
and Wilkins, 1991:179-84.
Kromann-Andersen B, et al. Pad-weighing tests; A literature survey on test accuracy and
reproducibility. Neurourol Urodyn 1989;8(3):237-42.
Jorgensen L, Lose G, et al. Diagnosis of mild stress incontinence in females: 24-hour pad
weighing test vs. the 1-hour test. Neurourol Urodyn 1987;6:165-6.
Kinn AC, Larsson B. Pad test with fixed bladder volume in urodynamic stress incontinence.
Acta Obstet Gynecol Scand 1987;66(4): 369-371.
Artibani W, et al. Imaging and other investigations. In: Abrams P, Cardozo L, Khoury S,
Wein A (eds) Incontinence. Plymouth: Health Publication, 2002:425-77.
Raghavaiah N. Double-dye test to diagnose various types of vaginal fistulas. J Urol 1974;
112: 811-2.
4th International Consultation on Incontinence, Paris July 5-8, 2008. Incontinence edited by
Abrams, Cardozo, et al. Health Publication Ltd. 4th edition 2009
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23. Haslam J. Evaluation of pelvic floor muscle assessment: digital, manometric, and surface
electromyography in females. M Phil Thesis. University of Manchester, 1999.
24. Cohen RA, et al. Clinical Practice. Microscopic hematuria. N Eng J Med 2003;348:2330-8.
25. Chahal, et al. Is it necessary to perform urine cytology in screening patients with hematuria?
Eur Urol 2001;39:283-6.
26. ACOG 2007 Compendium Vol.11 Practice Bulletins pp1115-27.
27. Wall LL, et al. Simple bladder filling with a cough stress test compared with subtracted
cystometry for the diagnosis of urinary incontinence. Am J Obstet Gynecol 1994;171:1472-7;
discussion 1477-9.
28. Weir J, et al. Large-capacity bladder. A urodynamic survey. Urology 1974;4:544-8.
29. Cardoso A, et. al. (ed). Incontinence. 4th International Consultation on Incontinence Paris July
5-8, 2008. Health Publication Ltd. 4th edition, 2009.
30. Ramsay IN, et al. A randomized controlled trial of urodynamic investigations prior to
conservative treatment of urinary incontinence in the female. Int Urogynecol J 1995;6:277
31. Khullar V, Cardozo L, et al. 30th Annual meeting of ICS, Finland 2000.
32. Weber AM. Is urethral pressure profilometry a useful diagnostic test for stress urinary
incontinence? Obstet Gynecol Surv 2001;56:720-35.
33. Weber AM. Leak point pressure measurement and stress urinary incontinence. Curr Womens
Health Rep 2001;1:45-52.
34. Association of Professors of Gynecology and Obstetrics. Clinical management of urinary
incontinence. Crofton (MD) APGO; 2004.
35. Awad SA, et al. Final diagnosis and therapeutic implications of mixed symptoms of urinary
incontinence in women. Urology 1992;39:352-7.
36. Agency for Health Care Policy and Research. Urinary incontinence in adults: acute and
chronic management. Clinical Practice Guideline, No.2, 1996 Update.AHCPR Publication
No. 96-0682. Rockville (MD): AHCPR; 1996.
37. Beer-Gabel M, et al. Dynamic transperineal ultrasound in the diagnosis of pelvic floor
disorders: pilot study. Dis Colon Rectum 2002;45:239-45.
38. Pannu HK, et al. Dynamic MR imaging of pelvic organ prolapse: spectrum of abnormalities.
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39. Gousse AE, et al. Dynamic half fourier acquisition single shot turbo spin-echo magnetic
resonance imaging for evaluating the female pelvis. J Urol 2000;164:1606-13.
40. ACOG Compendium of Selected Publications 2009. Clinical Management Guidelines for
Obstetrician-Gynecologists #85, September 2007: 417-29.
41. Samuelsson EC, et al. Signs of genital prolapse in a Swedish population of women 20-59
years of age and possible related factors. Am J Obstet Gynecol 1999;180:299-305.
42. Bump RC, et al. The standardization of terminology of female pelvic organ prolapse and
pelvic floor dysfunction. Am J Obstet Gynecol 1996;175:10-7.
43. Gustilo-Ashby AM, et al. The incidence of ureteral obstruction and the value of intraoperative
cystoscopy during vaginal surgery for POP. Am J Obstet Gynecol 2006;194:1478-85.
44. Gilmour DT, et al. Rates of urinary tract injury from gynecologic surgery and the role of
intraoperative cystoscopy. Obstet Gynecol 2006;107:1366-72.
45. Jackson S, Walters M, et al. Fecal incontinence in women with urinary incontinence and
pelvic organ prolapse. Obstet Gynecol 1997;89:423-7.
46. De Leeuw JW, et al. Relationship of anal endosonography and manometry to anorectal
complaints. Dis Colon Rectum 2002;45:1004-10.
47. Rociu E, et al. Fecal Incontinence: endoanal ultrasound vs endoanal MR imaging. Radiology
1999; 212(2):453-8.
48. Cardozo L, Staskin D (Eds). Textbook of Female Urology and Urogynecology 2006; 2nd
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49. Chappe C, et. al. Multidisciplinary Management of Female Pelvic Floor Disorders 2006.


Almira J. Amin-Ong, MD.
Urinary incontinence (UI) affects women not only in the reproductive age but
more commonly in the postmenopause. It is often a neglected condition even if the
prevalence rate is quite high ranging from 17-55% in older and 12-42% in younger
women. Majority do not seek consult but opt to make provisions in their daily routine
to hide or live with the disorder thus affecting the overall quality of life.
The International Continence Society (ICS) describes three major categories
of incontinence stress, urge and mixed. Differentiating among the three types would
help the primary care physician gear management towards that which will be
beneficial to the patient. There are several management schemes available for UI.
Conservative management alone entails numerous forms of intervention, which are
usually low cost and with low adverse effects. With the current crisis putting a strain
on the health care of most economies, conservative management is offered as an
option especially on the following circumstances: those awaiting or delaying surgery,
those in whom existing medical condition precludes any form of surgical intervention,
and those whose symptoms are not severe enough for surgical intervention.
There are very few randomized controlled trials (RCTs) on the field of
lifestyle intervention to control, prevent or improve UI. None of those available
specifically addresses the impact of age or any other variables on outcome.
1. Women with a body mass index (BMI) of 30 or more should be
encouraged weight reduction as this significantly reduces prevalence of
UI. (Level II-1, Grade A)
Summary of Evidence
Obesity is an independent risk factor for UI even after controlling for
age and parity. In women with BMI of 30 or higher, the odds of severe urinary
incontinence were 3.1 times that of women with BMI between 22 and 241.
Another study found a 2.39 fold risk of UI compared with normal weight
women.2 A 2005 RCT involving 48 participants showed that women who
were put on a liquid diet showed a 60% reduction of weekly incontinent
episodes and a weight loss of 15 kgs.3 Another RCT by the same author
involving 338 women (the Programme to Reduce Incontinence by Diet and
Surgery [PRIDE]) who underwent a 6-month intensive weight loss program
showed a weekly incontinence episode reduction of 70% as compared to 22%
in the control group.4
2. Heavy lifting may predispose to development of UI. (Level III, Grade B)

Summary of Evidence
There are no RCTs comparing heavy lifting with sedentary activities.
The association between heavy lifting and UI should be investigated further,
whether heavy exertion is a risk factor for incontinence or whether changing
exertions can improve existing incontinence. Present studies are conflicting
with one study of 27,936 women in 2003 reporting no difference in UI
between women engaged in high impact activities more than 2 hours per week
with those who engaged in less than 1 hour of activity per week.5 Nygard, et.
al., in a study of 3,364 women reported that UI with physical activity was
more common among highly active than less active women (15.9% versus
11.8%; p=0.01).6
3. Smoking increases the risk of more severe UI. (Level III, Grade B)
Summary of Evidence
There are currently no RCTs regarding the effect of smoking cessation
on resolution or promotion of the onset of UI. Current data are conflicting
with one in vitro study stating that nicotine produces phasic contraction of the
bladder musculature inducing the urge type of incontinence.7 A large study
involving 27,936 women found that smoking increases the odds of severe UI
(Odds Ratio [OR] 1.4, 95% CI 1.2-1.6). However, smokers were found to
have stronger urethral sphincters.5
4. Decreasing caffeine intake improves continence. (Level II-1, Grade B)
Summary of Evidence
Bryant, et. al. found that decreasing caffeine intake to 96.5 mg had
statistically significant reduction in urgency episodes (61% versus 12%) and
number of incontinence episodes (55% versus 26%) but this was not
statistically significant.8 In the Norwegian EPICONT Study, they found that
tea drinkers had higher odds of UI (OR 1.2, 95% CI 1.4-55) for up to 2 cups
per day and an OR of 1.3 (95% CI 1.5-19.0) for 3 or more cups compared to
4. Alcoholic beverages do not increase the incidence of UI. (Level II-2, Grade
Summary of Evidence
Large epidemiologic trials using multivariate analyses assessed the
effect of alcohol consumption and UI but found no association between the
two even after adjusting for age and fluid intake.9
5. Limiting fluid intake to prevent UI should only be reserved to those with
abnormally high intake. (Level III, Grade C)

Summary of Evidence
It is always the assumption that leakages can very well be controlled
by limiting the fluid intake. However, a state of negative fluid balance or poor
fluid intake may lead to urinary tract infections (UTIs), constipation or
dehydration conditions that can readily be prevented by maintaining the
average daily fluid intake. An RCT that used a small crossover design found
that when fluid intake is decreased, women with stress urinary incontinence
(SUI) and women with detrusor overactivity had decreased incontinence
6. Chronic straining may be a risk factor for development of UI. (Level III,
Grade C)
Summary of Evidence
There are no studies regarding the effect of resolving constipation or
regulating bowel function on incontinence. One study reported that women
who strain during defecation are more likely to report SUI (OR 1.9, 95% CI
1.3-2.6) and urgency (OR 1.7, 95% CI 1.2-2.4).11 Further research is needed
to evaluate the role of constipation or chronic straining in the pathogenesis of
7. Postural changes such as crossing the legs and bending forward might be
useful in reducing leakages during coughing or provocation. (Level III,
Grade C)
Summary of Evidence
There was a mean fluid loss of only 1.3 g (95% CI 0.5-2.1, p<0.001)
when legs are crossed to prevent leakages compared to the following postural
changes: 4.7 g when legs are crossed and body bent forward (95% CI 1.4-7.7,
p<0.01); 10.2 g (95% CI 6.5-13.0) when bending forward alone; and 12.3 g
(95% CI 8.5-16.1) when standing.12 Further studies on the effectiveness of
postural changes as treatment for UI still needed.
Many other lifestyle interventions are anecdotal hence there is currently no
evidence to support any of these, specifically, wearing of nonrestrictive clothing,
reducing emotional stress, wearing cotton undergarments, use of a bedside commode,
decreasing lower extremity edema, treating chronic cough and increasing sexual
Pelvic floor muscle training (PFMT) or Kegels exercise should be offered
as first line treatment for stress or mixed type of incontinence. (Level I,
Grade A)

Summary of Evidence
Studies regarding PFMT are conflicting because of variations in the
technique used. However, the most recent Cochrane systematic review (2003)
which included studies of women with urge, stress or mixed type of
incontinence found that PFMT was more effective compared to placebo
intervention (drug, sham electrical stimulation, sham exercise).13 Compared
with vaginal cones, there was a significant reduction in urinary leakage with
PFMT alone. There is also no benefit of combining PFMT with biofeedback.
PFMT supervised and continued for 3 months is a safe and effective treatment
for stress and mixed types of incontinence.
Electrical stimulation for patients with stress or mixed type of
incontinence does not offer any benefit in reducing the frequency of
incontinent episodes. (Level I, Grade B)
Summary of Evidence
Electrical stimulation involves delivery of brief electrical impulses via
needle or surface electrodes to the sacral nerves to inhibit detrusor overactivity
and to improve pelvic floor musculature. A randomized trial of 68 women
with urge type of incontinence did not reveal significant improvement at all.
For women with stress type of incontinence, a small trial of 26 women showed
no changes in urinary leakages per week based on an incontinence impact
questionnaire. Combined with PFMT, a recent trial of 200 women showed no
significant reduction in the frequency of incontinent episodes.9
The benefit of magnetic stimulation for treatment of UI has not been
established. (Level II-3, Grade D)
Summary of Evidence
Extracorporeal magnetic stimulation is delivered to the pelvic floor
muscles and the sacral nerve roots by sitting on a magnetic chair. The patients
perineum is centered on the middle of the seat from where the pelvic floor
muscles are placed directly on the primary axis of the pulsating magnetic field
without any vaginal or anal probes. Usually, the treatment is given for 16
sessions for 6 weeks. There are still no trials regarding primary and secondary
prevention of UI. Regarding treatment, magnetic stimulation might be better
for both stress and urge type of incontinence.14,15 Further investigation is

Vaginal cones offer subjective cure but do not lead to significant
improvement on the number of leakage episodes, pad test or pelvic floor
muscle strength. (Level II-1, Grade B)
Summary of Evidence
Vaginal cones are a set of weighted cylinders that are held in place by
contraction of the pelvic floor muscles. Therapy usually starts with the lightest
cone then graduated to the heavier ones. It is not readily available in our
country. Majority of the trials enrolled women with stress incontinence who
had subjective cure from UI.16 Compared with the control group who had
other forms of intervention, there were no differences in objective outcomes
leakage episodes, pad test or pelvic floor muscle strength.16,17
Bladder training combined with pelvic floor muscle training is more
effective than either alone. It should be offered as first line treatment for
urge or mixed type of incontinence. (Level I, Grade A)
Summary of Evidence
Bladder training is a technique to increase the time interval between
voids using progressive voiding schedules. It is usually advised on patients
who have intact cognitive and physical functions and can take months to
achieve a cure. There are not too many trials to support bladder training. There
were two small trials with 78 patients which showed few subjective cures in
patients who had bladder training alone versus those who did not receive any
at all (OR for failure, 0.07; 95% CI 0.03-0.19). However, when one combines
it with PFMT, it is more effective than a combination of bladder training with
drug therapy. There is good evidence though that bladder training is effective
for urge or mixed type of incontinence, with fewer adverse effects and lower
relapse rates compared to drug treatment with antimuscarinics.13
Anticholinergics are effective in the treatment of urge incontinence. (Level
1, Grade A)
Summary of Evidence
Anticholinergics are drugs prescribed to inhibit involuntary detrusor
contractions that could lead to urine leakages. A Cochrane systematic review
found that anticholinergics were better than placebo in subjective cure rate and
improvement rates (RR 1.41; 95% CI 1.29-1.54) and in improvement in
leakages episodes in 24 hours (WMD, -0.56; 95% CI -0.73 to -0.39).18 When

compared with other drugs used to treat urge incontinence, anticholinergics

still offer both subjective cure and improvement in leakage episodes.






Danforth KN, Townsend MK, Lifford K, Curhan GC, Resnick NM, Grodstein F. Risk factors
for urinary incontinence among middle-aged women. Am J Obstet Gynecol 2006;194(2):33945.
Melville JL, Katon W, Delaney K, Newton K. Urinary incontinence in US women: a
population-based study. Arch Intern Med 2005;165(5):537-42.
Subak LL, Whitcomb E, Shen HUI, Saxton J, Vittinghoff E, Brwon JS. Weight loss: a novel
and effective treatment for urinary incontinence. J Urol 2005;174(1):190-5.
Subak LL, Wing R, Smith West D, et al, A behavioral weight loss program significantly
reduces urinary incontinence episodes in overweight and obese women [Oral presentation].
American Uroynecologic Society Annual Meeting 2007.
Hannestad YS, Rortveit G, Daltveit AK, Hunskaar S. Are smoking and other lifestyle factors
associated with female urinary incontinence? The Norwegian EPINCONT Study. BJOG
Nygaard I, Girts T, Fultz NH, Kinchen K, Pohl G, Sternfeld B. Is urinary incontinence a
barrier to exercise in women? Obstet Gynecol 2005;106(2);307-14.
Hisayama T, Shinkai M, Takayanagi I, Toyoda T. Mechanism of action of nicotine in isolated
urinary bladder of guinea-pig. Br J Pharmacol 1988;95(2):465-72.
Bryant CM, Dowell CJ, Fairbrother G. Caffeine reduction education to improve urinary
symptoms. Br J Nurs 2002;11(8):560-5.
Abrams P, Cardozo L, Kouri S, Wein A: Incontinence. Adult Conservative Management of
Urinary Incontinence. 4th International Consultation in Continence July 2009.
Swithinbank L, Hashim H, Abrams P. The effect of fluid intake on urinary symptoms in
women. J Urol 2005l;174(1):187-9.
Moller L, Lose G, Jorgensen T: Risk factors for lower urinary tract symptoms in women 40 to
60 years of age. Obstet Gynecol 2000;96(3):446-51.
Norton PA, Baker JE: Postural changes can reduce leakage in women with stress urinary
incontinence. Obstet Gynecol 1994;85(5):770-4.
Hay-Smith EJ, Bo K, Berghmans LC, et al. Pelvic floor muscle training for urinary
incontinence in women. Cochrane Database Syst Rev 2003, Issue 1.
But I, Faganelj M, Sostaric S: Functional magnetic stimulation for mixed urinary
incontinence. J Urol 2005;173(5):1644-46.
Morris AR, OSullivan R, Dunkley P, Moore KH. Extracorporeal magnetic stimulation is of
limited clinical benefit to women with idiopathic detrusor overactivity: A randomized sham
controlled trial. Eur Urol 2007;52:876-83.
Herbison P, Plevnik S, Mantle J. Weighted vaginal cones for urinary incontinence. Cochrane
Database Syst Rev 2003, Issue 1.
Williams KS, Assassa RP, Gilleis CL, Abrams KR, Turner DA, Shaw C, et al. A randomized
controlled trial of the effectiveness of pelvic floor therapies for urodynamic stress and mixed
incontinence. BJU Int 2006;98(5):1043-50.
Hay-Smith J, Herbison P, Ellis G, Moore K. Anticholinergic drugs versus placebo for
overactive bladder syndrome in adults. Cochrane Database Syst Rev 2003, Issue 1.
Holroyd-Leduc JM, Straus S. Management of urinary incontinence in women: scientific
review. JAMA 2004;291(8):986-95.


Lisa T. ProdigalidadJabson, MD
Stress urinary incontinence (SUI), or urodynamic stress incontinence (USI), is
believed to result from either poor anatomic support associated with bladder neck and
urethral motion (referred to as urethral hypermobility) or a combination of defects of
the urethral sphincteric mechanism that may also result in decreased urethral
resistance (referred to as intrinsic sphincter deficiency).
There have been over a hundred procedures described for the surgical
correction of SUI. With a better understanding of the etiology of SUI, many surgical
procedures have been developed, and/or abandoned, to improve success rate and to
minimize morbidity.
Selecting the type of surgical procedure would depend on the individual
patients characteristics (assessment of bladder neck mobility and urethral sphincter
function), urodynamic evaluation, and the inherent risks/complications attendant to
the type of procedure. Other factors to consider include pelvic organ prolapse (POP),
previous failed abdominal surgery, previous radiation therapy or radical pelvic
Anterior colporrhaphy should NOT be used in the management of SUI.
(Level II-2, Grade A)
Summary of Evidence
Ten randomized trials compare anterior colporrhaphy with pelvic floor
muscle training (PFMT), colposuspension, needle suspension, MarshallMarchetti-Krantz (MMK) or tension-free vaginal tape (TVT). In these studies,
967 women were included with 346 undergoing anterior colporrhaphy.
Reported cure rates range from 31% to 88%, with anterior colporrhaphy
consistently showing statistically and clinically poorer outcomes.
In the few trials that report follow-up beyond 12 months, subjective
outcomes fell from 80% at 1 year to 60% at 5-7 years in one study, and
combined subjective and objective cure rates fell from 80% at 3 months to
63% at 1 year and 37% at 5 years in another study.
One randomized trial compared anterior colporrhaphy with the TVT in
50 women with at least a stage II anterior wall prolapse and occult SUI.
Meschia, et. al. found both subjective (96% vs 64%) and objective (92% vs
56%) cure rates to be significantly higher following TVT.1
The Cochrane review of anterior vaginal repair reported that there was
evidence to indicate that anterior vaginal repair was less effective than open
retropubic suspension in the treatment of primary urodynamic stress
incontinence. Likewise, the recent National Institute of Health and Clinical
Excellence (NICE) guidance recommends that anterior colporrhaphy should
not be used for the treatment of SUI.


1. Open retropubic colposuspension can be recommended as an effective
treatment for primary SUI, which has longevity. (Level I, Grade A)
Summary of Evidence
Randomized trials comparing the open colposuspension with anterior
colporrhaphy, the MMK procedure, needle suspension procedures, abdominal
paravaginal repair, traditional sling procedures, the TVT, the transobturator
tape, and laparoscopic colposuspension include 4161 women with 1900
randomized to colposuspension. Analysis shows objective cure rates ranging
from 59% to 100% (median 80%) and subjective cure rates from 71% to 100%
(median 88%). The results from these studies show that the open
colposuspension has objective and subjective outcomes comparable to both
traditional sling procedures and to newer minimally-invasive mid-urethral
sling procedures. However, the colposuspension had better outcomes
compared to the anterior colporrhaphy, the MMK, bladder neck needle
suspension, and paravaginal repair.
2. Although open colposuspension has to some extent been replaced by less
invasive mid-urethral slings, it should still be considered for those women
in whom an open abdominal procedure is required concurrently with
surgery for SUI. (Level I, Grade A)
Summary of Evidence
Abdominal retropubic urethropexy or colposuspension procedures,
particularly the Burch colposuspension, have become the gold standard for
treatment of primary or recurrent SUI. Main indications include primary and
secondary urethral sphincter incompetence, with or without a
cystourethrocele, but with adequate vaginal mobility and capacity. The
paravaginal tissues on either side of the bladder neck and bladder base are
sutured and attached to the ipsilateral iliopectineal ligament. The
colposuspension is most successful in patients with pure SUI with
hypermobility of the urethrovesical junction. The colposuspension had better
outcomes compared to the anterior colporrhaphy, the MMK, bladder neck
needle suspension, and paravaginal repair.
3. The MMK procedure is not recommended for the treatment of SUI.
(Level I, Grade A)
Summary of Evidence
Randomized trials comparing the open colposuspension with anterior
colporrhaphy, the MMK procedure, needle suspension procedures, abdominal
paravaginal repair, traditional sling procedures, the TVT, the transobturator
tape, and laparoscopic colposuspension include 4161 women with 1900
randomized to colposuspension. The studies showed that colposuspension had

better outcomes compared to the anterior colporrhaphy, the MMK, bladder

neck needle suspension, and paravaginal repair.
4. Bladder neck needle suspension procedures are not recommended for the
treatment of SUI. (Level I-II Grade A)
Summary of Evidence
Randomized trials comparing the open colposuspension with anterior
colporrhaphy, the MMK procedure, needle suspension procedures, abdominal
paravaginal repair, traditional sling procedures, the TVT, the transobturator
tape, and laparoscopic colposuspension include 4161 women with 1900
randomized to colposuspension. The studies showed that colposuspension had
better outcomes compared to the anterior colporrhaphy, the MMK, bladder
neck needle suspension, and paravaginal repair.
5. Paravaginal defect repair is not recommended for the treatment of SUI
alone. (Level II-1, Grade A)
Summary of Evidence
Randomized trials comparing the open colposuspension with anterior
colporrhaphy, the MMK procedure, needle suspension procedures, abdominal
paravaginal repair, traditional sling procedures, the TVT, the transobturator
tape, and laparoscopic colposuspension include 4161 women with 1900
randomized to colposuspension. The studies showed that colposuspension had
better outcomes compared to the anterior colporrhaphy, the MMK, bladder
neck needle suspension, and paravaginal repair.
1. Laparoscopic colposuspension is not recommended for the routine
surgical treatment of SUI in women. (Level I-II, Grade A)
Summary of Evidence
The laparoscopic approach has been compared to the standard open
Burch colposuspension and the more recent mid-urethral slings, in particular
the TVT. Since 1997, there have been 10 randomized controlled trials (RCTs)
comparing laparoscopic colposuspension with the open colposuspension and 8
with the mid-urethral slings. Although studies included in the Cochrane
review had various lengths of follow-up (majority had follow-up of 6-18
months), subjective cure rates ranged from 58% to 96% in the open technique
and 62% to 100% in the laparoscopic approach, with a nonsignificant 5%
lower relative subjective cure rate for laparoscopic colposuspension (RR 0.95,
95% CI 0.90-1.00).
The objective cure rate, as determined by cough stress testing or pad
test within 18 months, was statistically lower following the laparoscopic
technique (RR 0.91, 95% CI 0.86-0.96). Following urodynamic testing,

however, the open colposuspension had significantly higher success rates (RR
0.91, 95% CI 0.85- 0.99).
Studies comparing laparoscopic colposuspension with minimally
invasive mid-urethral slings (TVT) show no statistically significant difference
in subjective cure rates within 18 months (RR 0.91, 95% CI 0.80 to 1.02). The
overall objective cure rate, however, was higher for mid-urethral slings.
A systematic review on laparoscopic colposuspension and TVT
showed evidence to favor the mid-urethral sling as the minimal-access
technique of choice for USI.
2. Laparoscopic colposuspension may be considered for the treatment of
SUI in women who also require concurrent laparoscopic surgery for
other reasons. (Level I-II, Grade B)
3. Laparoscopic colposuspension should only be carried out by surgeons
with specific training, expertise, and appropriate workload in
laparoscopic surgery and with expertise in the assessment and
management of UI in women. (Level I, Grade A)
1. Autologous fascial sling is recommended as an effective long-lasting
treatment for SUI. (Level I, Grade A)
Summary of Evidence
Trials on suburethral slings have compared this procedure with open
abdominal retropubic suspension (MMK and Burch colposuspension), needle
suspension, and even the TVT. Studies comparing different sling materials are
also numerous. In comparison with open colposuspension, the objective cure
rate from sling operations was not significantly different within the first year
(Relative Risk [RR] 0.19; 95% CI 0.02-1.53) or on longer follow-up (RR 0.49;
95% CI 0.17-1.42). In the largest RCT study done by Albo, et. al. comparing
colposuspension and fascial sling, the combined subjective and objective
outcome in terms of any incontinence (38% vs 47%, p=0.01) and SUI (49% vs
66%, p=<0.001) was significantly better from the sling procedure.10 Although
adverse events and voiding difficulty were also more common in the sling
group, 47% vs 63% and 14% vs 2% respectively.
Studies comparing autologous rectus fascial sling with TVT involve a
total of 284 patients from 3 RCTs.11,13,14 Cure rates at 12 months range from
83% to 88% after TVT and 81% to 93% after fascial sling.
2. Autologous fascial sling may be more effective than biological and
synthetic slings. (Level II)
Summary of Evidence
Pubovaginal sling procedures have traditionally been recommended for
SUI caused by intrinsic sphincter deficiency (ISD). Sling materials vary and

may be synthetic or biological. The autologous sling may be harvested from

either the rectus fascia (as initially described by Aldridge in 1942) or fascia
lata. Recently, sling procedures have been done using allograft material
(cadaveric fascia or dura mater), xenograft (porcine dermis and small
intestinal mucosa or bovine fascia) or synthetic material (such as merselene or
prolene). The sling is placed at the level of the bladder neck and proximal
urethra (in contrast to the minimally invasive mid-urethral slings) thru a
combined vaginal and abdominal route. Complications include vaginal erosion
(0-16%), urethral erosion (0-15%), de novo detrussor instability (3.7-66%),
and voiding difficulties (10.8%).5
Studies comparing autologous rectus fascial sling with TVT involve a
total of 284 patients from 3 RCTs.11,13,14 Cure rates at 12 months range from
83% to 88% after TVT and 81% to 93% after fascial sling.
3. Further high quality research is required to clarify the place of
traditional sling procedures in relation to other procedures and to
establish the optimum sling materials.
1. Retropubic mid-urethral slings (TVT) are recommended as an effective
treatment for SUI. (Level I-II, Grade B)
Summary of Evidence
Mid-urethral slings are performed via the retropubic approach (e.g.
TVT, IVS, and SPARC) or via the transobturator approach (e.g. transobturator
tape [TOT] and tension-free vaginal tape-obturator [TVT-O]). The TVT is a
modification of the traditional sling procedure that was introduced by
Ulmsten, et. al. in 1996.15 The procedure, initially described to be performed
in an ambulatory setting, has been compared to more traditional surgical
procedures (such as burch colposuspension and traditional sling procedure)
and is seemingly the new standard to which other mid-urethral slings are
2. TVT is equally effective as colposuspension and traditional sling
procedures. (Level I-II)
Summary of Evidence
Several randomized trials and cohort studies show that there is no
significant difference in the cure rates for the TVT procedure compared to the
Burch colposuspension and the fascial sling. Available literature suggests that
the TVT has short- and medium-term efficacy (cure rate of 63% to 97%)
similar to the open Burch colposuspension but is associated with shorter
operating time and hospital stay, less postoperative voiding dysfunction, and
quicker recovery. The TVT however appears to have significantly more
bladder perforations (6% versus 1%, RR 4.24, 95% CI 1.71-10.52) compared
to the open retropubic colposuspension. The TVT is also equally effective as

the traditional fascial sling procedures. Significantly higher objective and

subjective cure rates are seen however in the TVT compared to laparoscopic
3. Transobturator mid-urethral slings (TOT or TVT-O) may be used for the
treatment of SUI. (Level I-II Grade B)
Summary of Evidence
The TOT is another modification of the pubovaginal sling procedure
and of the TVT. This relatively new technique was introduced in 2001 by
Delorme.16 A helical needle/trocar is used to pass a synthetic suburethral sling
thru the superomedial aspect of the obturator foramen and behind the
ischiopubic ramus (Monarc/ObTape; outside-in technique) via an incision at
the labio-crural fold. This procedure presumably reduces the risk of bladder
and vascular/visceral injuries attributed to the TVT.
In 2003, De Leval described another modification to the TOT - the
inside-out technique to the transobturator approach, the TVT-O.16 Since the
technique involved passage of the needle away from the urinary tract, risk of
urinary tract injury should significantly decrease.
Unlike the TVT, limited data exists comparing the efficacy of the TOT
to other standard surgical procedures. Although long-term studies are also not
available, reported cure rates of the transobturator approach in various case
series range from 59% to 97%. A meta-analysis by Latthe, et. al. comparing
the transobturator (TOT or TVT-O) and retropubic (TVT) approaches showed
no significant difference in subjective or objective cure rates and in
complication rates for a follow-up period of 2 to 12 months.18
1. If urethral bulking agents are to be used, women should be made aware
that repeat injections are likely to be required to achieve efficacy, that
efficacy diminishes with time, and is inferior to conventional surgical
techniques. (Level I-II, Grade B)
Summary of Evidence
Urethral bulking agents, injected transurethrally or periurethrally, have
long been used for the treatment of SUI. Various substances have been used
for this purpose (including bovine collagen, porcine dermal implant, carboncoated beads, autologous fat, etc) but no ideal bulking agent has yet been
identified. Likewise, there are no defined standards for optimal location for
injection, volume of agent used, injection technique or route, and number of
re-injections required.
Based on limited data and evidence, benefit from urethral bulking
agents appears to be short-term. The Cochrane review includes 12 RCTs with
periurethral injection therapy being compared to open surgery, bladder neck
suspension, pubovaginal sling procedure, or Burch colposuspension.
Numerous studies also compare different bulking agents or the injection

techniques (periurethral or transurethral). However, the group felt that the

studies were small and of moderate quality such that meta-analysis was not
appropriate. Currently, greater subjective improvement was observed after
conventional surgery. Studies comparing bulking agents with non-surgical
therapy or minimal access surgery are lacking.
2. Women should be made aware of alternative minimally invasive




Meschia M, Pifarotti P, Spennacchio M, Buonaguidi A, Gattei U, and Somigliana E. A

randomized comparison of tension-free vaginal tape and endopelvic fascia plication in women
with genital prolapse and occult stress urinary incontinence. Am J Obstet Gynecol
Glazener CMA and Cooper K. Anterior vaginal repair for urinary incontinence in women.
Cochrane Database Syst Rev 2001, Issue 1.
Burch J. Urethrovaginal fixation to Coopers ligament for stress incontinence, cystocele, and
prolapse. Am J Obstet Gynecol 1961;81:281-290.
Lapitan MC, Cody DJ, and Grant AM. Open retropubic colposuspension for urinary
incontinence in women. Cochrane Database Syst Rev 2005, Issue 3. !
Bidmead J, Toozs-Hobson P, Cardozo L, Robinson D, Bailey J. Randomised comparison of
Burch colposuspension versus anterior colporrhaphy for patients with stress urinary
incontinence (letter). BJOG 2001;108:128-129"!
Colombo M, Vitobello D, Proietti F and Milani R. Randomised comparison of Burch
colposuspension versus anterior colporrhaphy in women with stress urinary incontinence and
anterior vaginal wall prolapse. BJOG 2000; 107: 544-551.
Dean NM, Ellis G, Wilson PD, and Herbison GP. Laparoscopic colposuspension for urinary
incontinence in women. Cochrane Database Syst Rev 2006, Issue 3.
Su TH, Wang KG, Hsu CY, Wei HJ, Hong BK. Prospective comparison of laparoscopic and
traditional colposuspensions in the treatment of genuine stress incontinence. Acta Obstet
Gynecol Scand 1997;76:576-582.
Dean NM, Herbison P, Ellis G, Wilson D. Laparoscopic colposuspension and tension-free
vaginal tape: a systematic review. BJOG 2006;113:1345-1353.
Albo ME, et al and Urinary Incontinence Treatment Network. Burch colposuspension versus
fascial sling to reduce urinary stress incontinence. NEJM 2007;356:2143-2155.
Bai SW, Jeon JD, Chung KA, Kim JY, Kim S, Park KH. The effectiveness of modified 6
corner suspension in patients with paravaginal defect and stress urinary incontinence. Int
Urogyne J 2002;13:303-307.
Bezerra CA, Bruschini H, Cody DJ. Traditional suburethral sling operations for urinary
incontinence in women. Cochrane Database Syst Rev 2005, Issue 3.
Lucas M, Emery S, Alan W, Kathy W. Failure of porcine xenograft sling in a randomized
control trial of three sling materials in surgery for stress incontinence. Joint meeting of
International Continence Society & International Urogynecological Association. Paris,
France, 2004.
Wadie BS, Edwan A, Nabeeh AM. Autologous fascial sling vs polypropylene tape at shortterm follow up: a prospective randomized study. J Urol 2005;174: 990-993.
Ulmsten U, Henriksson L, Johnson P, Varhos G. An ambulatory surgical procedure under
local anesthesia for the treatment of female urinary incontinence. Int Urogynecol J Pelvic
Floor Dysfunc 1996;7: 81-86.
Delorme E. Transobturator urethral suspension: mini-invasive procedure in the treatment of
stress urinary incontinence in women. Prog Urol 2001;11:1306-13.
De Leval J. Novel surgical technique for the treatment of female stress urinary incontinence:
transobturator vaginal tape inside-out. Eur Urol 2003;44:724-730.

18. Latthe PM, Foon R, Toozs-Hobson P. Transobturator and retropubic tape procedures in stress
urinary incontinence: a systematic review and meta-analysis of effectiveness and
complications. BJOG 2007;114: 522-31.
19. Ogah J, Cody JD, Rogerson L. Minimally invasive synthetic suburethral sling operations for
stress urinary incontinence in women. Cochrane Database Syst Rev 2009, Issue 4.
20. Keegan PE, Atiemo K, Cody JD, McClinton S, Pickard R. Periurethral injection therapy for
stress urinary incontinence in women. Cochrane Database Syst Rev 2007, Issue 3.
21. NICE Guidance on Urinary Incontinence. National Collaborating Center for Womens and
Childrens Health, 2006, National Institute for Health and Clinical Excellence, 2006b.
22. Smith ARB, Dmochowski R, Hilton P, Rovner E, Nilsson CG, Reid FM, Chang D. Surgery
for urinary incontinence in women. In: Abrams P, Cardozo L, Khoury S, and Wein A (Eds)
Incontinence: WHO ICUD International Consultation on Incontinence, 4th edition, 2009.


Maria Teresa C. Luna, MD
A vaginal pessary is a removable device placed into the vagina. It is designed to
support different sites of pelvic organ prolapse (POP). Available pessaries are
either made of silicone or latex rubber.
1. Pessaries can be fitted in most women with prolapse, regardless of
prolapse stage or site of predominant prolapse. (Level III, Grade A)
Summary of Evidence
Vaginal pessaries are the standard nonsurgical treatment for POP. A
vaginal pessary can be properly fitted in 78% of patients with approximately
50% of those properly fitted continuing to use a pessary a year later.1-3
Pessaries are most often used when the patient has a strong preference for
nonsurgical management of POP or when the patients health status confers a
significant risk for surgical morbidity and mortality. 4
2. Clinicians should discuss the option of pessary use with all women who
have prolapse that warrants treatment based on symptoms. In particular,
pessary use should be considered before surgical intervention in women
with symptomatic prolapse. (Level III, Grade B)
Summary of Evidence
Patient factors that determine the type of pessary to be used are sexual
activity, site of POP and stage of POP. If the patient is fitted with the correct
pessary size, she is not aware of its presence when she wears it, she can void
readily, freely and completely and the pessary stays in place (while seated on a
toilet bowl and during ambulation). If the patient is fitted with the correct
pessary type, no site of defect protrudes when the pessary is in place.
Vaginal atrophy should be treated before and concomitant with pessary
Serious complications such as erosions to adjacent organs are rare with
proper use and usually result only after a long time of neglect.
Pessary complications are rare occurrences in medically compliant
patients. The most common side effects of vaginal pessaries are vaginal
discharge and odor. Other complications include vaginal bleeding,
pelvic/vulvar/vaginal discomfort/pain, pessary expulsion, urinary incontinence
(UI), and rectal pain, depending on the type of pessary. Rarely, vaginal
pessaries can cause major urinary, rectal and genital complications including
fistula, fetal impaction, hydronephrosis and urosepsis.5
The vaginal pessary is removed nightly, washed with soap and water
and replaced the next morning. After initial pessary placement, the patient is
advised to come back for check-up after 1 week, during which time, the

vagina is inspected for erosions, abrasions, ulcerations, granulation tissue

formation and infection. Scheduling of subsequent visits is individualized.6
Vaginal estrogen is generally recommended to patients who, at the
time of their initial fitting or at subsequent follow up, are noted to have
vaginal atrophy or areas of ulceration or abrasions from pessary use. 7
3. Currently there is no evidence from randomized controlled trials (RCT)
upon which to base treatment of women with POP through the use of
mechanical devices/pessaries.8 There is no consensus on the use of
different types of device, the indications, nor the pattern of replacement
and follow-up care. (Level III, Grade B)
Despite of the lack of high quality scientific evidence supporting pelvic
floor muscle exercise for prevention and treatment of POP, it poses no
risk and cost to the patient. It is offered to all patients who are
asymptomatic or mildly symptomatic and are interested in preventing the
progression of the condition and who decline other treatments. There is
some encouragement from a feasibility study that pelvic floor muscle
training (PFMT), delivered by a physiotherapist to symptomatic women
in an outpatient setting, may reduce severity of prolapse.10 (Level II-3,
Grade B)
Summary of Evidence
The muscles of the pelvic floor help support the abdominal and pelvic
contents from below, help control bowel and bladder function and play a role
in sexual response.
Pelvic floor muscle exercise helps in reducing the progression of POP.
The pelvic floor muscle exercise, also known as the Kegel exercise,
has been thought to offer a number of benefits to the patient. Firstly, the
patient learns to consciously contract before and during increases in
abdominal pressure. Secondly, the pelvic floor muscle exercise builds
permanent muscle volume and structure support.9
Patients with POP should be counseled on the importance of various
lifestyle modifications that may prevent or improve their symptoms of
prolapse. (Level III, Grade C)
Summary of Evidence
Maintaining an ideal body weight limits the pressure that the
abdominal content places on the pelvic floor. Any activity that engages the
pelvic floor such as walking or gardening can help strengthen the muscles.
Patients should be instructed to contract their pelvic floor muscles when lifting

or straining. Patient education should also include bowel movement retraining.

This will teach a passing motion without straining the pelvic floor muscles.
Advising women on correct posture will in aid in preventing strain on the
pelvic floor muscles.11

Wu V, Farrel SA, Baskett TF, Flowerdew G. A simplified protocol for pessary management.
Obstet Gynecol 1997;90:990-994.
2. Sulak PJ, Kuehl TJ, Shull BL. Vaginal pessaries and their use in pelvic relaxation. J Reprod
Med 1993;38:919-923.
3. Clemons JL, et al. Patient satisfaction and changes in prolapse and urinary symptoms in
women who were fitted successfully with a pessary for pelvic organ prolapse. Am J Obstet
Gynecol 2004; 190(4): 10251029.
4. Rodriguez E, Trowbridge MD and Fenner DE. Conservative management of pelvic organ
prolapse. Clin Obstet Gynecol 2005;48(3):668-681.
5. Jelovsek JE, Maher C, Barber MD. Pelvic organ prolapse. Lancet 2007;369:1027-1038.
6. Farrell SA. Practice advice for ring pessary fitting and management. J SOGC 1997;19:625.
7. Poma PA. Management of incarcerated vaginal pessaries. J Am Geriatr Soc 1981;29:325-327.
8. Hagen S, Stark D, et al. Conservative management of pelvic organ prolapse in women.
Cochrane Database Syst Rev 2006, Issue 4.
9. Bo K. Pelvic floor muscle training is effective in treatment of stress urinary incontinence, but
how does it work? Int Urogynecol J 2004;15:76.
10. Hagen S, Stark D, Maher C, et al. Conservative management of pelvic organ prolapse in
women. Cochrane Database Syst Rev 2:CD003882, 2004.
11. Rodriguez E, Trowbridge MD, Fenner DE. Conservative management of pelvic organ
prolapse. Clin Obstet Gynecol 2005;48(3):668-681.


Manuel S. Ocampo Jr., MD and Lisa T. Prodigalidad-Jabson, MD
Previous to the latter half of the twentieth century, the concept of prolapse
surgery was based on fascial weakness and defects and so procedures were done to
attenuate or strengthen ligaments or fascia supporting the pelvic organs. The work of
anatomists in the 1970s resulted in discovering breaks in the continuity of support
within the endopelvic fascia. This thinking redirected how pelvic reconstructive
surgery is currently performed. This fulfilled the first goal of pelvic organ prolapse
(POP) repair that is to restore normal anatomy.1 In 2005, The Surgery for Pelvic
Organ Prolapse Committee of the World Health Organization (WHO)s 3rd
International Consultation on Incontinence (ICI) made a comprehensive review of
POP surgery studies and published its recommendations based on the strength of
evidence using the Oxford System.2 Among the Level I conclusions are :
o Overall outcomes indicate that abdominal and vaginal surgeries are
o Abdominal surgery has higher short term morbidity.2
o The recommendation for the use of autologous and non-autologous materials
in pelvic floor reconstruction is guarded until more randomized controlled
trials (RCTs) are presented and sources of these meshes have confirmed their
efficacy and safety.3





1. Options for repair include the traditional vaginal anterior colporrhaphy,

retropubic paravaginal defect repair, vaginal paravaginal defect repair.
(Level III, Grade A)
Summary of Evidence
Traditional vaginal anterior colporrhaphy has cystocele recurrence
rates up to 20% when done alone. Large studies on retropubic paravaginal
repair have cystocele recurrence rates from 3-5%.4 There are no published
studies comparing the traditional vaginal and retropubic approaches. Vaginal
paravaginal defect repairs have a 7% recurrence rate.4
2. Transvaginal permanent mesh placement may reduce the incidence of
recurrent cystocele but this has unacceptably a high rate of postoperative
complications. These would include erosion, infection, sepsis, and
dyspareunia. (Level I, Grade B)
Summary of Evidence
Introduction of mesh or graft inlays together with the anterior repair
may decrease the incidence of recurrent cystocele.5 Three RCTs comparing
anterior colporrhaphy alone and with a polyprolene mesh were reviewed,
examining populations from 76- 202 women and examined after 12 months.

Anterior colporrhaphy alone had recurrent cystocele rates from 34.4-45%.

When a mesh was added, the lower recurrence rates were from 6.7-19%.
However, vaginal erosion rates for the mesh groups were 5.6-17.3%.6-8
Laparoscopic repair studies are few. A laparoscopic paravaginal defect repair
study of 212 consecutive women showed a recurrence rate of 24%. Addition
of a graft with anterior colporrhaphy decreased recurrence to 16%.9
3. Options for symptomatic diverticulae are diverticulectomy, partial
ablation, and marsupialisation. (Level III, Grade B)
Summary of Evidence
It is estimated that up to 8% of adult women are diagnosed with a
urethral diverticulum. Only women with symptomatic diverticulae should be
operated on. There is a paucity of published reports on urethral diverticulae
surgery. There have been no studies comparing the different techniques and so
the choice of procedure is driven by the patients presentation and the unique
anatomy as well as the surgeons choice. Options for symptomatic
diverticulae are diverticulectomy, partial ablation, and marsupialisation.1
Because there are few RCTs comparing procedures and most are
uncontrolled retrospective studies, there is no gold standard to speak of. Because
of this, the choice of surgery would depend on the specific fascial defects.
Additionally the patient's age, co-morbidities, activity level, desire for future
fertility, history of prior prolapse surgery in other compartments, patient
preference, as well as the skill and comfort level of the surgeon with the particular
surgery are to be considered.10 Options for uterine preservation are the
Manchester procedure, sacrospinous hysteropexy, and the abdominal/laparoscopic
hysteropexy. The most common procedures for post-hysterectomy vaginal vault
prolapse include sacrospinous ligament fixation, McCall culdoplasty, uterosacral
ligament suspension, iliococcygeus fascia suspension, and colpocleisis. The route
of hysterectomy will depend on multiple factors to be considered. Options include
vaginal, abdominal, and laparoscopic hysterectomy. Laparoscopic hysterectomy
approaches are divided into laparoscopic assisted vaginal hysterectomy with or
without uterine artery release and total laparoscopic vaginal hysterectomy that
includes vault closure laparoscopically.
The Manchester procedure can be recommended for a patient who is
desirous of maintaining her uterus. It has a high middle compartment
success rate. The addition of uterosacral ligament plication increases the
success rate. (Level II-3, Grade B)

Summary of Evidence
This procedure is indicated for a patient with an elongated cervix, an
anterior vaginal wall prolapse, with a desire of maintaining her uterus. A
retrospective study of 187 consecutive patients with a majority having a stage
3 uterine prolapse underwent a Manchester procedure. Early post-operative
complications were urinary retention (22.05%) and cervical stenosis (11.27%).
Follow-up after 3 years revealed almost 4% had undergone surgery for
prolapse recurrence and urinary incontinence.11 A comparison of a Modified
Manchester procedure with the addition of a uterosacral ligament plication
versus a vaginal hysterectomy with a high uterosacral ligament plication
showed similar anterior and posterior compartments prolapse recurrences
(50%). After a one-year follow-up, the Modified Manchester had no recurrent
middle compartment prolapse compared to 4% for the vaginal hysterectomy
with a high uterosacral plication group.12
The American College of Obstetrics and Gynecology (ACOG) released Bulletin
85, recommendations are:15
1. Alternative operations for uterine preservation in women with prolapse
include uterosacral or sacrospinous ligament fixation by the vaginal
approach or sacral hysteropexy by the abdominal approach. (Level II-3,
Grade B)
Summary of Evidence
These procedures use suture or mesh to attach the cervix/uterus to the
sacrospinous ligament or the sacrum. Few studies are available for
sacrospinous and abdominal hysteropexy. One observational study for
sacrospinous fixation involved 133 women where 84% of women were highly
satisfied. No serious complications were noted. The uterine prolapse
recurrence rate that needed reoperation was 2.3%. Cystocele recurrence was
35%.13 A review by Ridgeway, et. al. concluded that favorable postoperative
outcomes range from 62-100% and additional data show improved quality of
life and sexual function. Anatomic outcomes appear to be comparable to
vaginal hysterectomy with sacrospinous ligament vault suspension.14 The
open or laparoscopic sacrohysteropexy has similar results when compared
with sacrospinous fixation, with cure rates ranging from 91-100%. Several
studies favoring sacrohysteropexy also showed improvements in quality of life
and sexual function.14
2. Hysteropexy should not be performed by using the ventral abdominal
wall for support because of the high risk for recurrent prolapse,
particularly enterocele. (Level II, Grade B)

3. Round ligament suspension is not effective in treating uterine or vaginal

prolapse. (Level II, Grade B)
1. Because of equal or significantly better outcomes on all parameters,
vaginal hysterectomy should be performed in preference to abdominal
hysterectomy where possible. (Level I, Grade B)
Summary of Evidence
Hysterectomy is an option for middle compartment prolapse. The route
of hysterectomy depends on multiple factors, which include the stage of
uterine prolapse, the gynecologists training and comfort with the route of
hysterectomy, the patients condition, and the patients preference. A vaginal
or laparoscopic route is favorable if the uterus is less than 12 weeks size and
accessible vaginally, size reduction is possible during surgery, the pathology is
limited to the uterus, the extra-uterine pathology is mild, the cul de sac is
accessible, and there is an absence of severe endometrioses and severe
adhesions. Otherwise an abdominal hysterectomy is the safer choice. Figure 1
is a pathway for choosing the route of hysterectomy for benign disease.1
2. Where vaginal hysterectomy is not possible, laparoscopic hysterectomy
may avoid the need for abdominal hysterectomy. (Level I, Grade B)
Summary of Evidence
In an analysis of multiple RCTs comparing vaginal, abdominal, and
laparoscopic hysterectomies, it was found that recovery was fastest in vaginal
and laparoscopic than in abdominal routes, there were more urinary tract
complications in laparoscopic than abdominal hysterectomy, there was no
advantage of laparoscopic hysterectomy over vaginal hysterectomy, and that
the differences between laparoscopic assisted vaginal hysterectomy over total
laparoscopic hysterectomy were a shorter operation time, fewer febrile
episodes, and unspecified infections.16,17
3. The surgical approach to hysterectomy should be decided by the woman
in discussion with her surgeon in light of the relative benefits and
hazards. (Level I, Grade B)



The ACOG released Bulletin 85, recommendations are:

1. Cadaveric fascia should not be used as graft material for abdominal
sacral colpopexy because of a substantially higher risk of recurrent
prolapse than with synthetic mesh. (Level I, Grade A)





















Figure 1. Determining the route of hysterectomy


2. For stress-continent women planning abdominal sacral colpopexy,

regardless of the results of preoperative stress testing, the addition of the
Burch procedure substantially reduces the likelihood of postoperative
stress incontinence without increasing urgency symptoms or obstructed
voiding. (Level I, Grade A)
3. Compared with vaginal sacrospinous ligament fixation, abdominal sacral
colpopexy has less apical failure and less postoperative dyspareunia and
stress incontinence, but is also associated with more complications. (Level
II, Grade B)
Summary of Evidence
The 3rd ICI reported that sacrospinous-based vaginal procedures have a
higher anterior and apical anatomical recurrence rate than sacrocolpopexybased abdominal repairs.2 Sacrospinous ligament fixation has post-operative
risks for temporary buttock pain in 6% of patients, cystocoele in 8%,
dyspareunia in 2.7%, and de novo stress urinary incontinence in 2.6%.18 In a
recent study by Benedito de Castro, the sacrospinous fixation cure rate was
93.1%. Preoperative and postoperative evaluation of the anterior vaginal
compartment was respectively: stage 1 (5.2%; 48.3%). De novo cystocele
occurred in 87.9% of cases.19 Abdominal sacrocolpopexy without paravaginal
defect repair showed a 26.9% recurrence of cystocele.20 Laparoscopic
sacrocolpopexy results from >1000 patients in 11 series were reviewed by
Ganatra, et. al. and found a 6.2% prolapse reoperation rate and a 2.7% mesh
erosion rate. They concluded that laparoscopic sacrocolpopexy is comparable
to abdominal sacrocolpopexy.21
McCalls culdoplasty, high uterosacral ligament suspension, iliococcygeus
fascia suspension may be performed with success rates above 80%. (Level
II-III, Grade B)
Summary of Evidence
The goal of endopelvic fascia repair (or modified McCall culdoplasty)
is to suspend the vaginal vault to the endopelvic fascia. A study by Chene, et.
al. used a modified McCall procedure where 185 patients underwent vaginal
hysterectomy. The 2-year follow-up showed the absence of apical prolapse in
89.2% and a 10% incidence of stage 1 vaginal vault prolapse that did not
require re-operation. About eighty one percent (81.2%) of patients had
satisfactory sexual function.22 A history of macrosomic infant delivery,
indicating pelvic floor damage, was linked to failure of the modified McCall
culdoplasty and resulted in 44.4% post operative apical prolapse.23


McCalls culdoplasty, high uterosacral ligament suspension, iliococcygeus
fascia suspension may be performed with success rates above 80%. (Level
II-III, Grade B)
Summary of Evidence
This aims to suspend the prolapsed vaginal vault bilaterally to the
uterosacral ligaments. This is similar to the McCalls culdoplasty. The vault
suspension sutures suspend the vagina deep into the pelvis, up to the level of
the ischial spines. High uterosacral ligament suspension carries a risk of
ureteral injury or kinking. Intra-operative cystoscopy is an option. Silva, et. al.
presented a high uterosacral vault suspension over an average of 5 years
follow-up of 110 patients. They only had a 2.8% recurrence of an apical
prolapsed.24 A meta-analysis of uterosacral ligament suspension by Marquiles,
et. al. showed that uterosacral suspension was most favorable for the apical
compartment with a pooled rate of 98.3%, followed by the posterior
compartment (87.4%), and the anterior compartment (81.2%).25
McCalls culdoplasty, high uterosacral ligament suspension, iliococcygeus
fascia suspension may be performed with success rates above 80%. (Level
II-III, Grade B)
Summary of Evidence
The purpose of iliococcygeus fascia suspension is to suspend the
vaginal vault to the fascia of the iliococcygeus muscle in patients with weak
uterosacral ligaments. There are few recent studies on this procedure. A study
comparing McCalls culdoplasty alone and with iliococcygeus fascia
suspension showed that 8.3% had postoperative vaginal defects in the
combined group and 33.3% were observed in the group undergoing McCall
culdeplasty alone.26
For women who are at high-risk for complications with reconstructive
procedures and who no longer desire vaginal intercourse, colpocleisis can
be offered. (Level III, Grade B)
Summary of Evidence
Total colpocleisis procedures are performed for patients with posthysterectomy vaginal vault prolapse. Colpocleisis carries a risk for
postoperative de novo stress urinary incontinence (SUI). Published data were
reviewed by Fitzgerald, et. al. and their conclusions were: 1) Colpocleisis for

POP is successful in almost 100% of patients in recent studies. 2) The data is

incomplete with regards reoperation rates for stress incontinence. 3)
Concomitant elective hysterectomy does not improve outcomes. 4) Pelvic
symptoms were not usually assessed by the studies.27 Colpocleisis is an
option for women who have a high risk for complications with reconstructive
procedures and are not desirous of intercourse.27






1. For posterior vaginal wall prolapse, the vaginal approach was associated
with a lower rate of recurrent rectocele and/or enterocele than the
transanal approach.15 (Level II-1, Grade B).
2. Posterior colporrhapy has a greater success rate compared to site-specific
rectocele repair with or without a graft. (Level I, Grade A)
Summary of Evidence
In a study by Paraiso, et. al., 3 different rectocele repair techniques
were compared where 106 women with stage II or greater posterior vaginal
wall prolapse were randomly assigned to either posterior colporrhaphy, sitespecific rectocele repair, or site-specific rectocele repair augmented with a
porcine small intestinal submucosa graft. Results after one year follow-up
showed that those who received graft augmentation had a significantly greater
anatomic failure rate (46%) than those who received site-specific repair alone
(22%) or posterior colporrhaphy (14%). Overall postoperative sexual function
had significantly improved in all groups postoperatively. Posterior
colporrhaphy and site-specific rectocele repair had similar anatomic and
functional outcomes. Addition of a porcine-derived graft did not improve
anatomic results.28 The same groups were followed one year postoperatively
and assessed for bowel symptoms and were found to have less straining and
less of a feeling of incomplete emptying.29

Kovac SR, Zimmerman C. Advances in reconstructive surgery. Lippincott Williams &

Wilkins 2007;187-88.
Atiemo H, Griebling T, Daneshgari F. Advances in geriatric female pelvic surgery. BJU Int
2006;98(Suppl 1):92-93.
Cardozo L. Editorial comment: The use of synthetic mesh in female pelvic reconstructive
surgery. BJU Int 2006;98(Suppl 1):77.
Stanton S, Zimmern P. Female pelvic reconstructive surgery. Springer-Verlag London Ltd
Maher C, Baessler K, Glazener CM, Adams EJ, Hagen S. Surgical management of pelvic
organ prolapse in women. Cochrane Database Syst Rev 2007 Jul;18(3):CD004014.
Carey M, Higgs P, Goh J, Lim J, Leong A, Krausse H, Cornish A. Vaginal repair with mesh
versus colporrhaphy for prolapsed: a randomized controlled trial. BJOG 2009; 116(10):13806.





Nguyen JN, Burchette RJ. Outcome after anterior vaginal prolapse repair: a randomized
controlled trial. Obstet Gynecol 2008 Apr;111(4):891-8.
Hiltunen R, Nieminen K, Takala T, Heiskanen E, Merikari M, Niemi K, Heinonen PK. Lowweight polypropylene mesh for anterior vaginal wall prolapse: a randomized controlled trial.
Obstet Gynecol 2007;110(2 Pt 2):455-62.
Behnia-Willison F, Seman El, Cook JR, OShea Rt, Keirse MJ. Laparoscopic paravaginal
repair of anterior compartment prolapse. Minim Invasive Gynecol 2007;14(4):475-80.
Park AJ, Paraiso MF. Surgical management after uterine prolapsed. Minerva Ginecol 2008
Ayhan A, Esin S,Guven S, Salman C, Ozyunco O. The Manchester operation for uterine
prolapsed. Int J Gynaecol Obstet 2006 Mar;92(3):228-33.
De Boer TA, Milani AL, Kluivers KB, Withagen MI, Vierhout ME. The effectiveness of
surgical correction of uterine prolapse: cervical amputation with uterosacral ligament plication
(modified Manchester) versus vaginal hysterectomy with high uterosacral ligament plication.
Int Urogynecol J Pelvic Floor Dysfunct 2009 Nov;20(11):1313-9.
Dietz V, de Jong J, Huisman M, Schraffordt Koops S, Heintz P, van der Vaart H. The
effectiveness of the sacrospinous hysteropexy for the primary treatment of uterovaginal
prolapse. Int Urogynecol J Pelvic Floor Dysfunct. 2007 Nov;18(11):1271-6.
Ridgeway B, Frick AC, Walter MD. Hysteropexy: A review. Minerva Ginecol 2008
ACOG Practice Bulletin No. 85. Pelvic organ prolapse. American College of Obstetricians
and Gynecologists (ACOG). Washington (DC)
Nieboer TE, Johnson N, Lethaby A, Tavender E, Curr E, Garry R, van Voorst S, Mol BW,
Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane
Database Syst Rev 2009 Jul 8;(3):CD003677.
Johnson N, Barlow D, Lethaby A, Tavender E, Curr L, Garry R. Methods of hysterectomy:
systematic review and meta-analysis of randomised controlled trials. BMJ 2005 Jun
Lovatsis D, Drutz HP. Safety and efficacy of sacrospinous vault suspension. Int Urogynecol J
Pelvic Floor Dysfunct 2002;13(5):308-13.
Benedito de Castro E, Palma P, Riccetto C, Herrmann V, Bigozzi MA, Olivares JM. Impact of
sacrospinous vaginal vault suspension on the anterior compartment. Actas Urol Esp 2010
Shippey SH, Quiroz LH, Sanses TV, Knoepp LR, Cundiff GW, Handa VL. Anatomic
outcomes of abdominal sacrocolpopexy with or without paravaginal repair. Int Urogynecol J
Pelvic Floor Dysfunct 2010 Mar;21(3):279-83.
Ganatra AM, Rozet F, Sanchez-Salas R, Barret E, Galiano M, Cathelineau X, Vallancien G.
The current status of laparoscopic sacrocolpopexy: a review. Eur Urol 2009 May;55(5):1089103.
Chene G, Tardieu AS, Savary D, Krief M, Boda C, Anton-Bousquet MC, Mansoor A.
Anatomical and functional results of McCall culdoplasty in the prevention of enteroceles and
vaginal vault prolapse after vaginal hysterectomy. Int Urogynecol J Pelvic Floor Dysfunct
2008 Jul;19(7):1007-11.
Cam C, Karateke A, Asoglu MR, Selcuk S, Namazov A, Aran T, Celik C, Tug N. Possible
cause of failure after McCall culdoplasty. Arch Gynecol Obstet 2010 Mar 16.
Silva WA, Pauls RN, Segal JL, Rooney CM, Kleeman SD, Karram MM. Uterosacral ligament
vault suspension: five-year outcomes. Obstet Gynecol 2006 Aug;108(2):255-63
Margulies RU, Rogers MA, Morgan DM. Outcomes of transvaginal uterosacral ligament
suspension: systematic review and metaanalysis. Am J Obstet Gynecol. 2010 Feb;202(2):12434.
Koyama M, Yoshida S, Koyama S, Ogita K, Kimura T, Shimoya K, Murata Y, Nagata I.
Surgical reinforcement of support for the vagina in pelvic organ prolapse: concurrent
iliococcygeus fascia colpopexy (Inmon technique). Int Urogynecol J Pelvic Floor Dysfunct.
2005 May-Jun;16(3):197-202.
FitzGerald MP, Richter HE, Siddique S, Thompson P, Zyczynski H. Colpocleisis: a review.
Int Urogynecol J Pelvic Floor Dysfunct. 2006 May;17(3):261-71.
Paraiso MF, Barber MD, Muir TW, Walters MD. Rectocele repair: a randomized trial of three
surgical techniques including graft augmentation. Am J Obstet Gynecol 2006

29. Gustilo-Ashby AM, Paraiso MF, Jelovsek JE, Walters MD, Barber MD. Bowel symptoms 1
year after surgery for prolapse: further analysis of a randomized trial of rectocele repair. Am J
Obstet Gynecol 2007 Jul;197(1):76.e1-5.


Lennette L. Chan, MD
1. Non-operative therapy is the initial management to improve the
symptoms of fecal incontinence (FI). Patient education is important.
(Level III, Grade C)
2. Attempt should be done to establish a bowel routine. (Level III, Grade C)
Summary of Evidence
Expert opinion supports the use of general health education, patient
teaching about bowel function and advice on lifestyle modification.2-4
3. Treat reversible causes of diarrhea. Antidiarrheal agents, such as
adsorbents or opium derivatives, may reduce FI. (Level II, Grade C)
Summary of Evidence
Diarrhea or loose stools is consistently found to be a risk factor for FI.
Potentially preventable causes of diarrhea include drugs, dietary supplements,
and some foods. There is some evidence that loperamide may decreased stool
frequency, improve stool consistency, and reduce side effects in patients with
4. A trial of soluble dietary fiber is recommended for the management of FI
associated with loose stool. (Level I, Grade B)
Summary of Evidence
Dietary fiber supplementation appears to be a safe and tolerable
intervention for fecal incontinence. In Bliss study, subjects were communityliving adults with incontinence of loose or liquid stools given supplementation
with one of two soluble dietary fibers compared to placebo resulted in reduced
rate of FI in patients with loose stool.8
On the other hand, there are reports that dietary fiber may exacerbate
FI in some patients. Some patients with FI benefit from moderating their
intake of foods containing largely insoluble fiber.9 Another study reported that
treating constipation in elderly immobile people with a supplement of
insoluble fiber and bran, resulted in FI in half of them.10,11 Fiber supplements
appear to benefit diarrhea-associated but not constipation associated FI.
5. Enemas, laxatives, and suppositories may help to promote more complete
bowel emptying in appropriate patients and minimize further post
defecation leakage and treat constipation associated FI. (Level II, Grade

Summary of Evidence
For constipation-associated FI, daily or more frequent oral laxative
regimens may be effective.12
6. Pelvic floor muscle exercises are recommended in patients who have not
responded to simple dietary modification or medication. (Level III, Grade
7. The use of biofeedback as a treatment for FI is recommended after other
behavioral and medical management have been tried if inadequate
symptom relief is obtained. (Level III, Grade C)
Summary of Evidence
National Institute of Health and Clinical Excellence (NICE) clinical
guidelines consensus statement regarding and the use of biofeedback for FI.
Given the numerous positive outcomes from uncontrolled trials,
limitations in the current randomized controlled trials (RCTs) and low
morbidity associated with its application the use of pelvic floor muscle
exercises and biofeedback, as treatment for fecal incontinence, is
recommended as possibly effective and currently unproven and can be used
after other behavioral and medical management has been tried.
8. Patients who failed conservative therapy or not be candidates for
conservative therapy due to severe anatomic, physiologic or neurologic
dysfunction are referred for surgical management.
1. Endoanal ultrasonography has the largest diagnostic value to detect
morphological integrity of the anal sphincter complex in patients with FI.
(Level III, Grade C).
2. Ancillary tests: Anal manometry, electromyography (EMG) and
defecography may be helpful in guiding management. (Level III, Grade C)
Summary of Evidence
Endoanal ultrasound is helpful in defining the extent of anal sphincter
injury. Preoperative physiologic testing may be helpful in the overall
management of patients with FI. However, the value of anal manometry and
pelvic floor electrophysiological assessment as prognostic indicators for
outcome following sphincteroplasty is controversial. There are no established
parameters that reliably predict outcome following sphincteroplasty.17,18

3. In case of failed conservative management, the surgical approach to the

patient depends on the presence and magnitude of an anatomic sphincter
defect. If no sphincter defect is present, the patient should undergo initial

percutaneous nerve evaluation (PNE), which, if successful, should lead to

sacral nerve stimulation (SNS). It has the unique advantage of allowing a
therapeutic trial prior to permanent stimulator implantation. (Level III
Grade B)
Summary of Evidence
SNS was primarily used it in patients with neurologic origin of fecal
incontinence without sphincteric defects.19 A report by Rosen, et. al.
highlights the effect of SNS in a cohort of patients, 75% of whom suffered
from FI of neurologic origin.20 Frequency of incontinence episodes/week was
reduced from 6 to 2 at 15 months follow-up. The technique is safe, minimally
invasive, and has the unique advantage of allowing a therapeutic trial prior to
permanent stimulator implantation.21-23
4. If sphincter loss is < 180 degrees, sphincteroplasty is recommended. Due
to increasing evidence that sphincteroplasty deteriorates with time, SNS
for sphincter defect may be used for most patients with clinically
significant incontinence with sphincter defect. (Level III, Grade B)
Summary of Evidence
Most patients improve after overlapping sphincteroplasty, but
outcomes deteriorate over time. A number of studies have looked at long term
outcomes after repair of a 3rd or 4th degree tears and all have shown an
increasing prevalence of continence disorders with age.24-28,30,31 In the largest
study reported to date, Bravo Gutierrez, et. al. found that only 6% of patients
retained full continence 10 years following anal sphincteroplasty.32 Long-term
atrophy of the sphincters may be relevant.30
There is now an increasing body of evidence indicates that SNS may
also be a treatment option for patients with sphincter defects, unrepaired or
after attempted anatomic reconstruction. The presence of an internal anal
sphincter defect on endoanal sonography is reportedly unrelated to the success
of permanent SNS.33 Three of five patients with ultrasound evidence of
sphincter disruption measuring 25-33% of the circumference benefited from
chronic SNS.34 In 20 patients with unrepaired obstetric trauma, SNS resulted
in significant improvement of incontinent episodes with a minimum follow-up
of 4 years.35 In patients with an unrepaired external or internal anal sphincter
or both, the frequency of incontinent episodes per week decreased from 1.3 to
0.3 and the Cleveland Clinical Score (CCS) improved (from 15 to 3.5) with a
follow-up of 12-97 months.36 SNS in 6 of 8 patients presenting with fecal
incontinence related to obstetric full thickness anal sphincter lesions ranging
from > 30-150 degree resulted at a median follow-up of 26.5 months in
improved frequency of incontinent episodes per week from 5.5 to 1.5 clinical
function37, improved ability to postpone bowel emptying and improved
American Society of Colon and Rectal Surgeons (ASCRS) quality of life
scores. Melenhorst, et. al. showed that the primary use of SNS in patients with
a sphincter gap 17-33% of the circumference appeared to result in an outcome
similar to its use after failed sphincter repair.38

5. For patients who remain incontinent following sphincteroplasty, repeat

endoanal ultrasound should be done to reassess the status of the repair. If
there is a persistent sphincter defect, repeat anal sphincter repair could
be considered. (Level II, Grade C)
Summary of Evidence
Initial success of sphincteroplasty is related to whether the anal
sphincter defect is corrected.39 Early failure is usually associated with a
persisting defect, identifiable using endoanal ultrasound.40 This may be
amenable to a further attempt at repair.39,42
6. For patients with sphincter defects of greater than 180 degrees or major
perineal tissue loss, individualized treatment is indicated. Initial pelvic
floor reconstruction can be performed. (Level III, Grade C)
Summary of Evidence
Deen, et. al.43 in an RCT comparing three procedures in 36 women with
neuropathic FI, found that complete continence was achieved in 42% of
patients after postanal repair, 33% after anterior levatorplasty, and 67% after
total pelvic floor repair while van Tets, et. al.44 conducted an RCT comparing
postanal repair and total pelvic floor repair in 20 women with neurogenic FI.
Complete continence to solid or liquid stool was achieved in 27% of patients
after postanal repair and in 22% after total pelvic floor repair. Studies with a
median follow-up of more than 5 years revealed that continence after pelvic
floor reconstruction deteriorated with time. Possible explanations for
deterioration of continence following initial improvement included
unrecognized denervation and/or muscular injury of the sphincter and pelvic
floor musculature and the presence of occult anal sphincter disruption. These
reports of increasingly poor outcomes have diminished the popularity of this
procedure significantly.
7. For patients with persistent incontinence after pelvic reconstruction,
alternative management includes stimulated muscle transposition,
artificial anal sphincter implantation, or SNS. (Level II, Grade B)
Summary of Evidence
Stimulated muscle transposition involves the transposition of the
gracilis muscle to reconstruct the anal sphincter, which was then electrically
stimulated transforming type II into type I muscle fibers. Stimulated muscle
transposition has been shown to have reasonable success but is associated with
significant morbidity such as disturbed evacuation, infection, pain, pulse
generator displacement, and anorectal perforation.47 It remains a useful
technique in selected patients with significant perineal tissue loss and in those
who have failed other treatments.45-47
8. For patients who remain incontinent despite an anatomically satisfactory
sphincteroplasty, SNS is recommended. (Level III, Grade B)

Summary of Evidence
A cohort study reports on the effect of permanent SNS in 53 patients
presenting with either an intact external anal sphincter (N=32 [37.5% after
sphincter repair]) or an external anal sphincter lesion (N=21 [81% after prior
sphincter repair]) of < 90 (N=11) or 90-120 (N=10).48 Improvement of
symptoms and quality of life was achieved in all groups. Outcome after 12
months was statistically not significantly different between those patients with
an intact sphincter complex and those without. Chan and Tjandra reviewed 53
consecutive patients who underwent SNS for FI.49 There was no significant
difference in outcomes between those with and without an external sphincter
defect. SNS is an effective therapy for most patients with clinically significant
incontinence who fail conservative management.50
9. Patients with sphincter defect who have failed SNS, sphincteroplasty can
be considered. Other alternatives include stimulated muscle transposition
and implantation of an artificial anal sphincter (AAS). (Level II, Grade B)
Summary of Evidence
The device (Acticon Neosphincter, American Medical Systems,
Minnesota, USA) is a totally implantable system consisting of 3 parts: an
inflatable occlusive cuff that is implanted around the native sphincter, a
pressure-regulating balloon that is implanted in the prevesical space, and a
control pump that is implanted in the labia majora. AAS has been shown to
have reasonable success. Most of the patients (78-100%) with a functioning
device were continent to solid stool, 56-95% were continent to solid and liquid
stool, and 22-67% were completely continent. The success rate in patients
with a functioning device was 44-100%, and the intention-to-treat success rate
was 41-83%. Overall complication rate varied between 11-87% but no
mortality rate was reported. Surgical site infections (9-58%) and erosion of the
adjacent skin (6-32%) were common. Up to 46% of patients underwent
revisional surgery, and the proportion of patients with a functioning device
after follow-up of between 6 and 34 months ranged between 24-100%. Sixty
seven percent patients have their devices explanted. The AAS is a useful
technique in carefully selected patients, particularly those who have failed
other treatments.
10. Patients with passive FI to liquid or solid stool who had failed
conventional therapy, the use of injectable biomaterials report reasonable
short and midterm term success rate. (Level III, Grade C)
Summary of Evidence
Shafik in 1993 began treating patients with FI (7 of whom had internal
sphincterotomy and 4 idiopathic incontinence) using injectable biomaterials of
polytetrafluoroethylene paste into the anal submucosa.57 Sixty four percent
reported complete cure and 36% had partial improvement. There is only one
report of long-term results for injectable agents. Maeda, et. al. reported the 5year outcome of 6 patients injected with Bioplastique.58 One patient had

undergone a colostomy. However, four of the remaining five patients reported

subjective improvement in their incontinence and quality of life scores. Most
series of injectable biomaterials report reasonable success rates though with
short-term efficacy.
11. Patients who fail surgical therapy for FI, or who do not wish to undergo
extensive pelvic reconstruction, should consider placement of an end
sigmoid colostomy. (Level III, Grade C)
Summary of Evidence
A permanent colostomy is usually performed as a last resort for severe
FI when all other interventions have failed. It restores dignity and allows
patients to regain social function. An age- and gender-adjusted regression
analysis of the FI Quality of Life score revealed significantly higher scores in
the coping, embarrassment, and lifestyle scales in the colostomy group
compared to the FI group.61 It also could be the most cost-effective in the short
to medium term, compared to more complicated surgical procedures such as
artificial anal sphincter and dynamic graciloplasty. Colostomy should not be
regarded as a treatment failure but rather a reasonable treatment option for
patients whose lives are restricted by FI that is not amenable to other
1. Treat reversible causes of diarrhea. (Level II, Grade C)
Summary of Evidence
Diarrhea or loose stools is consistently found to be a risk factor for FI.
Potentially preventable causes of diarrhea include drugs, dietary supplements,
and some foods such as lactose, fructose and sorbitol and natural foods such as
prunes. Drugs known to cause diarrhea as a side effect include antibiotics,
especially the erythromycin analogs; orlistat, the serotonin reuptake inhibitor
class of antidepressants; digoxin; and laxatives. Chronic laxative dependence
or abuse may cause frequent diarrhea. There is some evidence that loperamide
may decreased stool frequency, improved stool consistency, and reduced side
effects in patients with fecal incontinence.5-7 Fiber supplements appear to
benefit diarrhea-associated but not constipation associated FI.
2. There is no convincing evidence of role for preventive cesarean section for
FI. (Level III, Grade A)
Summary of Evidence
Cesarean delivery before the onset of the second stage of labor was
found to be protective64, however, in a systematic review, Nelson, et. al.65
found that pregnancy rather than delivery was a more important indicator of
post partum continence.

3. Avoid midline episiotomy. (Level I, Grade A)

4. Restrictive rather than liberal episiotomy protocols. (Level II, Grade A)
Summary of Evidence
Midline episiotomy is associated with higher incidence of anal
sphincter injury.66 The angle of mediolateral episiotomy may also influence
perineal outcome. In a prospective casecontrol study there was a 50%
relative reduction in risk of sustaining third-degree tear observed for every 6
degrees away from the perineal midline that an episiotomy was cut.67 A policy
of restrictive use of episiotomy may reduce the incidence of anal sphincter
5. All women having a vaginal delivery with evidence of genital tract trauma
should be examined systematically to assess the severity of damage prior
to suturing. (Level I, Grade C)
Summary of Evidence
With increased awareness and training there appears to be an increase
in the detection of obstetric anal sphincter injuries. One observational study
showed that increased vigilance about anal sphincter injury can double the
detection rate.69 In another study where endoanal ultrasound was used
immediately following delivery, the detection rate of anal sphincter injury was
not significantly increased compared to clinical examination alone.70
6. Primary overlapping sphincter repair performed by a fully trained
surgeon in obstetric anal sphincter injuries (OASIS) repair is indicated.
(Level I, Grade B)
Summary of Evidence
Primary repair of an obstetrical tear is usually performed by the
obstetrician immediately after delivery most commonly in the delivery room
under local or epidural anesthetic. Results of the four RCTs71-74 and one metaanalysis75 that have investigated different techniques of immediate primary
repair of the external anal sphincter following obstetric injury points to a trend
towards better outcome with an overlap repair. Inexperienced attempts at anal
sphincter repair may contribute to maternal morbidity, especially subsequent
FI. Training may be improved by the implementation of surgical skills
workshops with the use of models and audiovisual material. A report on the
effect of hands-on training workshops on repair of third- and fourth-degree
perineal tears showed that there is increased awareness of perineal anatomy
and recognition of anal sphincter injury following attendance at hands-on
training workshops.76,77
7. Discourage the use of internal anal sphincter division for treatment of
anal fissure and hemorrhoids. (Level II-3, Grade A)

Summary of Evidence
A persistent defect in the internal anal sphincter was found to be an
important determinant of FI.78 Patients with chronic anal fissure or
hemorrhoids may be offered internal anal sphincterotomy (slit in the internal
anal sphincter for 50-60% of its length to reduce anal canal pressures). In a
large series of 585 patients with a chronic anal fissure treated in this fashion at
the Mayo Clinic, 11% developed FI.79

Norton C, Whitehead WE, Bliss DZ, Metsola P, Tries J. Conservative and pharmacological
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4. Whitehead WE, Wald A, Norton N. Treatment options for fecal incontinence: consensus
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8. Bliss DZ, Jung H, Savik K, Lowry AC, LeMoine M, Jensen L, et al. Supplementation with
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12. Ryan D, Wilson A, Muir TS, Judge TG. The reduction of faecal incontinence by the use of
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13. Byrne CM, Solomon MJ, Rex J, Young JM, Heggie D, Merlino C.Telephone vs. face-to-face
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14. Boselli AS, Pinna F, Cecchini S, Costi R, Marchesi F, Violi V, Sarli L, Roncoroni L.
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15. Williams AB, Bartram CI, Halligan S, Spencer JA, Nicholls RJ, Kmiot WA. Anal sphincter
damage after vaginal delivery using three-dimensional endosonography. Obstet Gynecol
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16. Mortele KJ, Fairhurst J. Dynamic MR defecography of the posterior compartment: Indications,
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20. Rosen HR, Urbarz C, Holzer B, Novi G, Schiessel R. Sacral nerve stimulation as a treatment
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27. Malouf AJ, Norton CS, Engel AF, Nicholls RJ, Kamm MA. Long- term results of overlapping
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29. Mous M, Muller SA, de Leeuw JW. Long-term effects of anal sphincter rupture during vaginal
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30. Dudding TC, Vaizey CJ, Kamm MA. Obstetric anal sphincter injury: incidence, risk factors,
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31. Madoff RD. Surgical treatment options for fecal incontinence. Gastroenterology 2004;126(1
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32. Bravo Gutierrez A, Madoff RD, Lowry AC, Parker SC, Buie WD, Baxter NN. Long-term
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33. Dudding TC, Pares D, Vaizey CJ, Kamm MA. Predictive factors for successful sacral nerve
stimulation in the treatment of faecal incontinence: a 10-year cohort analysis. Colorectal Dis
34. Conaghan P, Farouk R. Sacral nerve stimulation can be successful in patients with ultrasound
evidence of external anal sphincter disruption. Dis Colon Rectum 2005;48(8):1610-4.
35. Maslekar SK, Gardiner A, Duthie GS. Sacral nerve stimulation as primary treatment for faecal
incontinence secondary to obstetric anal sphincter damage: medium and long-term results
[abstract]. Dis Colon Rectum 2006;49(5):730. Abstract 38
36. Ratto C. Sacral nerve stimulation in fecal incontinence due to anal sphincter lesions. Paper
presented at: European Society of Coloproctology 2nd Annual Scientific Meeting; September
27, 2007; Malta
37. Jarrett ME, Dudding TC, Nicholls RJ, Vaizey CJ, Cohen CR, Kamm MA. Sacral nerve
stimulation for fecal incontinence related to obstetric anal sphincter damage. Dis Colon
Rectum 2008;51(5):531-7.
38. Melenhorst J, Koch SM, Uludag O, van Gemert WG, Baeten CG. Is a morphologically intact
anal sphincter necessary for success with sacral nerve modulation in patients with faecal
incontinence? Colorectal Dis 2008;10(3):257-62.
39. Pinedo G, Vaizey CJ, Nicholls RJ, Roach R, Halligan S, Kamm MA. Results of repeat anal
sphincter repair. Br J Surg 1999;86(1):66-9.
40. Nielsen MB, Dammegaard L, Pedersen JF. Endosonographic assessment of the anal sphincter
after surgical reconstruction. Dis Colon Rectum 1994;37(5):434-8.
41. Giordano P, Renzi A, Efron J, Gervaz P, Weiss EG, Nogueras JJ, Wexner SD. Previous
sphincter repair does not affect the outcome of repeat repair. Dis Colon Rectum
2002;45(5):635- 40.
42. Vaizey CJ, Norton C, Thornton MJ, Nicholls RJ, Kamm MA. Long-term results of repeat
anterior anal sphincter repair. Dis Colon Rectum 2004;47(6):858-63.
43. Deen KI, Oya M, Ortiz J, Keighley MR. Randomized trial comparing three forms of pelvic
floor repair for neuropathic faecal incontinence. Br J Surg 1993;80(6):794-8.
44. van Tets WF, Kuijpers JH. Pelvic floor procedures produce no consistent changes in anatomy
or physiology. Dis Colon Rectum 1998;41(3):365-9.
45. Rongen MJ, Uludag O, El Naggar K, Geerdes BP, Konsten J, Baeten CG. Long-term followup of dynamic graciloplasty for fecal incontinence. Dis Colon Rectum 2003;46(6):716- 21.
46. Tillin T, Gannon K, Feldman RA, Williams NS. Third-party prospective evaluation of patient
outcomes after dynamic graciloplasty. Br J Surg 2006;93(11):1402-10.

47. Thornton MJ, Kennedy ML, Lubowski DZ, King DW. Long- term follow-up of dynamic
graciloplasty for faecal incontinence. Colorectal Dis 2004;6(6):470-6.
48. Matzel KE, Stadelmaier U, Hohenfellner M, Hohenberger W. Chronic sacral spinal nerve
stimulation for fecal incontinence: long term results with foramen and cuff electrodes. Dis
Colon Rectum 2001 Jan;44(1):59-66.
49. Tjandra JJ, Chan MK, Yeh CH, Murray-Green C. Sacral nerve stimulation is more effective
than optimal medical therapy for severe fecal incontinence: a randomized, controlled study.
Dis Colon Rectum 2008;51(5):494-502.
50. Chan MK, Tjandra JJ. Sacral nerve stimulation for fecal incontinence: external anal sphincter
defect vs. intact anal sphincter. Dis Colon Rectum 2008;51(7):1015-24; discussion 1024-5.
51. OBrien PE, Dixon JB, Skinner S, Laurie C, Khera A, Fonda D. A prospective, randomized,
controlled clinical trial of placement of the artificial bowel sphincter (Acticon Neosphincter)
for the control of fecal incontinence. Dis Colon Rectum 2004;47(11):1852-60.
52. Ortiz H, Armendariz P, DeMiguel M, Solana A, Alos R, Roig JV. Prospective study of
artificial anal sphincter and dynamic graciloplasty for severe anal incontinence. Int J
Colorectal Dis 2003;18(4):349-54.
53. Wong WD, Congliosi SM, Spencer MP, Corman ML, Tan P, Opelka FG, et al. The safety and
efficacy of the artificial bowel sphincter for fecal incontinence: results from a multicenter
cohort study. Dis Colon Rectum 2002;45(9):1139-53.
54. Mundy L, Merlin TL, Maddern GJ, Hiller JE. Systematic review of safety and effectiveness of
an artificial bowel sphincter for faecal incontinence. Br J Surg 2004;91(6):665- 72.
55. Belyaev O, Muller C, Uhl W. Neosphincter surgery for fecal incontinence: a critical and
unbiased review of the relevant literature. Surg Today 2006;36(4):295-303.
56. Altomare DF, Binda GA, Dodi G, La Torre F, Romano G, Rinaldi M, Melega E. Disappointing
long-term results of the artificial anal sphincter for faecal incontinence. Br J Surg
57. Shafik A. Polytetrafluoroethylene injection for the treatment of partial fecal incontinence. Int
Surg 1993;78(2):159-61.
58. Maeda Y, Vaizey CJ, Kamm MA. Long-term results of perianal silicone injection for faecal
incontinence. Colorectal Dis 2007;9(4):357-61.
59. Shafik A. Perianal injection of autologous fat for treatment of sphincteric incontinence. Dis
Colon Rectum 1995;38(6):583-7.
60. Vaizey CJ, Kamm MA. Injectable bulking agents for treating faecal incontinence. Br J Surg
61. Colquhoun P, Kaiser R, Jr., Efron J, Weiss EG, Nogueras JJ, Vernava AM, 3rd, Wexner SD. Is
the quality of life better in patients with colostomy than patients with fecal incontience? World
J Surg 2006;30(10):1925-8.
62. Norton C, Burch J, Kamm MA. Patientsviews of a colostomy for fecal incontinence. Dis
Colon Rectum 2005;48(5):1062- 9.
63. Catena F, Wilkinson K, Phillips RK. Untreatable faecal incontinence: colostomy or colostomy
and proctectomy? Colorectal Dis 2002;4(1):48-50.
64. Fynes M, Donnelly VS, OConnell PR, OHerlihy C. Caesarean delivery and anal sphincter
injury. Obstet Gynecol 1998;92(4 Pt 1):496-500.
65. Nelson RL, Westercamp M, Furner SE. A systematic review of the efficacy of caesarean
section in the preservation of anal continence. Dis Colon Rectum 2006;49(10):1587-95.
66. Fenner DE, Genberg B, Brahma P, Marek L, DeLancey JO. Fecal and urinary incontinence
after vaginal delivery with anal sphincter disruption in an obstetrics unit in the United States.
Am J Obstet Gynecol 2003 Dec;189(6):1543-9.
67. Eogan M, Daly L, OConnell PR, OHerlihy C. Does the angle of episiotomy affect the
incidence of anal sphincter injury? BJOG 2006;113(2):190-4.
68. Clemons JL, Towers GD, McClure GB, OBoyle AL. Decreased anal sphincter lacerations
associated with restrictive episiotomy use. Am J Obstet Gynecol 2005;192(5):1620-5.
69. Groom KM, Paterson-Brown S. Can we improve on the diagnosis of third degree tears? Eur J
Obstet Gynecol Reprod Biol 2002;101:1921.
70. Andrews V, Sultan AH, Thakar R, Jones PW. Occult anal sphincter injuries: myth or reality?
BJOG 2006;113:195200.
71. Fitzpatrick M, Behan M, OConnell PR, OHerlihy C. A randomized clinical trial comparing
primary overlap with approximation repair of third-degree obstetric tears. Am J Obstet
Gynecol 2000;183(5):1220-4.
72. Fernando RJ, Sultan AH, Kettle C, Radley S, Jones P, OBrien PM. Repair techniques for

obstetric anal sphincter injuries: a randomized controlled trial. Obstet Gynecol

73. Williams A, Adams EJ, Tincello DG, Alfirevic Z, Walkinshaw SA, Richmond DH. How to
repair an anal sphincter injury after vaginal delivery: results of a randomised controlled trial.
BJOG 2006;113(2):201-7.
74. Garcia V, Rogers RG, Kim SS, Hall RJ, Kammerer-Doak DN. Primary repair of obstetric anal
sphincter laceration: a randomized trial of two surgical techniques. Am J Obstet Gynecol
75. Fernando R, Sultan AH, Kettle C, Thakar R, Radley S. Methods of repair for obstetric anal
sphincter injury. Cochrane Database Syst Rev 2006;3:CD002866
76. Fernando RJ, Sultan AH, Radley S, Jones PW, Johanson RB. Management of obstetric anal
sphincter injury- A systematic review and national practice survey. BMC Health Serv Res
77. Thakar R, Sultan AH, Fernando R, Monga A, Stanton S. Can workshops on obstetric anal
sphincter rupture change practice? Int Urogynecol J 2001;12:S5.
78. Mahony R, Behan M, Daly L, Kirwan C, OHerlihy C, OConnell PR. Internal anal sphincter
defect influences continence outcome following obstetric anal sphincter injury. Am J Obstet
Gynecol 2007;196(3):217 e1-5.
79. Nyam DC, Pemberton JH. Long-term results of lateral internal sphincterotomy for chronic
anal fissure with particular reference to incidence of fecal incontinence. Dis Colon Rectum
1999 Oct;42(10):1306-10.

Jennifer Marie B. Jose, MD
Voiding dysfunction or lower urinary tract dysfunction is a term used to
describe various problems related to the bladders ability to store and empty urine.
Urinary retention is the inability to complete the voiding phase of the micturition
cycle and, often times, represent the end stage of voiding dysfunction.
Physiologically, a problem may be present with either the bladder, the outlet or both.
Voiding dysfunction is manifest clinically in lower urinary tract symptoms (LUTS)
which may be characterized as storage symptoms (frequency, urgency, nocturia and
urge incontinence) or emptying symptoms (decreased force of stream, incomplete
emptying, hesitancy straining to void and urinary retention). Symptoms do not always
correlate with the underlying pathology, and numerous conditions may exist that can
have similar presentations.
Distinguishing neurogenic from non-neurogenic voiding dysfunction is
important. The latter category is often caused by bladder outlet obstruction and this
may be functional, as in the case of dysfunctional voiding and primary bladder neck
obstruction or anatomic as in the case of pelvic floor prolapse or post surgical
The standardization of terminology of lower urinary tract dysfunction,
published by the International Continence Society (ICS), has recently defined LUTS
in relation to voiding difficulty and retention.2
Acute retention of urine is defined as a painful, palpable or percussable
bladder, when the patient is unable to pass any urine.
Chronic retention of urine is defined as a non-painful bladder, which remains
palpable or percussable after the patient has passed urine. Such patients may
be incontinent.
1. Acute retention should be managed with an indwelling catheter and
evaluation and management of possible precipitant and contributory
factors, followed by a voiding trial after about 1 week (perhaps longer for
retention volumes over 1 liter).3 If the voiding trial fails, then further
electromyography [EMG]). If prolonged catheterization is necessary,
suprapubic catheterization should be considered because of its lower risk
of catheter associated infection and urethral trauma.4 (Level I, Grade A)
Summary of Evidence
Short term use of an indwelling catheter is commonly used to manage
acute urinary retention. In most cases, continous drainage by foley catheter is
necessary until bladder function normalizes, usually within 48 to 72 hours.5

2. Intermittent self-catheterization as a nonsterile procedure is now the

principal treatment for chronic urinary retention. It allows women to lead
independent lives with efficient bladder emptying and low rates of
urinary tract infection when performed properly.5 (Level I, Grade A)
Summary of Evidence
Clean intermittent straight catheterization is the procedure performed
in many voiding difficulties. Continuous bladder drainage is best avoided in
cases of urinary retention because of the high complication rate from the
infection, ulcerations, calculi, malignancies and bladder spasms. 6
1. Cholinergic agents - for example, betanechol chloride and distigmine
bromide (an anti-cholinesterase) - and intra vesical prostaglandin E2 and
F2 have been advocated for treatment of urinary retention, however there
is no real evidence of clinical benefits.6 (Level III, Grade C)
Summary of Evidence
Bethenacol has been used as treatment for retention caused by detrusor
contractility, but it has not been used for women with sphincteric overactivity.
Its treatment value is therefore unknown.7
2. Although adrenergic blocking agents (e.g. phenoxybenzamine, prazocin
and indoramine) have proven benefit in women, they are useful in men
with urodynamically proven bladder neck obstruction. Anxiolytic agents
such as diazepam may help with postoperative voiding problems. In
women with combined urge incontinence and retention, anticholinergic
agents such as tolterodine maybe used effectively in conjunction with
clean intermittent straight catheterization (CISC) if required, but the
incidence of this is reassuringly low due to the site of action of
anticholinergics in their current doses.6 (Level III, Grade C)
Summary of Evidence
Adrenergic blocking agents, like prazocin hydrochloride and
phenoxybenzamine, have been used to decrease the contractility of the smooth
muscle component of the urethral sphincter. Diazepam can be used to decrease
urethral resistance.7
4. Voiding difficulties following pelvic and particularly continence surgery
and delivery are important causes of patient morbidity and litigation.
Strict protocols on the management of patients before and after surgery
and delivery need to be defined.6 (Level III, Grade C)

Summary of Evidence
If voiding difficulty is due to urethral stenosis, urethral dilatation using
Hegar dilators or preferably the Otis urethrotome is an appropriate option.
The place of bladder neck incision in patients with outflow obstruction
should never be performed unless diagnosis is confirmed by pressure/ flow
Partial cystectomy has been performed for treating the myogenic
decompensated bladder and excessive residual urine. However, the results are
disappointing. Urinary diversion using appendix or fallopian tube,
colocystoplasty, latissimus dorsi myoplasty and vesical cap operation with
ileal seomuscular patch grafts have all been tried with variable success.9
Bladder training should be guided by patients bladder capacity,
symptoms and fluid intake. A general guide for adults is to do CISC
often enough to maintain catheterized volumes at 500 ml or less (every 4
to 6 hours). (Level III, Grade C)
Summary of Evidence
There are no randomized trials comparing CISC and clamping the foley
catheter intermittently for bladder training. One main advantage of CISC is that
the voiding trials can be done before self-catheterization. In addition, it can be
implemented as a one-time treatment repeatedly over a short period of time,
on an occasional basis, or may be life-long for persons with chronic bladder
emptying disturbances. It is often preferred to indwelling catheters, because it
can result in a better quality of life for the patient has less complications, such
as urinary tract infections (UTI), urethral stricture, compared to indwelling
The evaluation, management and treatment of female patients with
voiding dysfunction and urinary retention is often complex and must take
multiple factors into consideration, including the degree to which the patients
symptoms is bothersome and whether the upper tracts are in jeopardy. A
patient specific diagnostic approach is recommended, depending on
symptoms, degree of bother and whether there is a history of suspicion of
neurologic disease. In certain cases, empirical treatment is appropriate.
However, when a formal diagnosis is indicated, specific therapy can be
directed based on urodynamics and other basic tests.8


1. CISC is the mainstay of therapy for neurogenic voiding dysfunction. The
same is true for retention secondary to impaired contractility. (Level I,
Grade A)
Summary of Evidence
The ideal treatment for detrusor external sphincter dyssynergia
(DESD) is anticholinergics with CISC.1
The management of multiple sclerosis includes anticholinergics with or
without CISC and behavioral therapy.15
Urinary retention for cauda equine syndrome resolves within months,
with one CISC to facilitate emptying.1
2. In some cases, a catheterizable stoma can facilitate independence when
neurologic disease is advanced and urethral catheterization cannot be
performed independently. (Level I, Grade A)
3. Botulinum toxin has been injected transurethrally for the treatment of
detrusor internal sphincter dyssynergia (DISD). (Level I, Grade A)
Summary of Evidence
Botulinum A toxin injections do have therapeutic value in urethral
spasticity, but larger, controlled trials are necessary to establish their role.12
4. Chronic indwelling catheters are generally not recommended for
treatment of chronic retention but may be used as a last resort in select
patients. (Level I, Grade A)
5. In situations in which chronic indwelling catheters desirable and
necessary, appropriate catheter care and frequent changing of the
catheter is recommended.7 (Level I, Grade A)
1. The use of CISC is considered satisfactory management. (Level I, Grade
Summary of Evidence
CISC is the mainstay of therapy. All management strategies are
directed at successful bladder emptying.1
2. Biofeedback and behavioral modification has become the recommended
treatment for women with dysfunctional voiding. (Level I, Grade A)

Summary of Evidence
Behavioral and biofeedback treatments are safe, noninvasive, and
effective interventions that are useful in the management of idiopathic urinary
retention. Behavioral changes enlighten patients about their fluid intake and
voiding behavior. Biofeedback involves surface or internal (vaginal or rectal)
electrodes that transducer muscle potentials into auditory or visual signals.
This helps the patient learn to increase or decrease voluntary muscle activity.17
3. Diazepam was reported to be successful to be used in treatment. (Level II1, Grade B)
Summary of Evidence
Diazepam relaxes the pelvic floor striated musculature during bladder
contraction, or that such relaxation removes an inhibitory stimulus to reflex
bladder activity.1
4. Amitryptyline was reported to be successful. (Level III, Grade A)
5. Endoscopic and transperineal injection of botulinum toxin has been
performed in women with dysfunctional voiding. (Level III, Grade A)
6. Sacral neuromodulation is effective for restoring voiding in patients with
idiopathic retention (Fowlers syndrome).7 (Level III, Grade A)
Summary of Evidence
Dagupta and colleagues provided long term results of sacral nerve
stimulation in women with Fowlers syndrome. The retrospective study
included 26 women who were followed for more than 6 years. Seventy-seven
percent were voiding successfully more than 5 years post operatively: 54%
required revision surgery. The study supported effectiveness of sacral nerve
stimulation (SNS) for at least 5 years after implantation.18
Shaker and Hassouna treated 20 patients, with idiopathic, nonobstructing, chronic urinary retention dependent on CISC who had at least
50% improvement on percutaneous nerve evaluation screening. The patients
were followed for a mean of 15.2 months and had significant improvement in
voiding function, pelvic pain, and sensation of emptiness after voiding. The
study authors emphasize that the lack of change in cystomyography after SNS
implantation indicates that the cause of the problem is not the bladder but the
pelvic floor musculature.19


1. The treatment options for primary bladder neck obstruction (PBNO)
include watchful waiting, pharmacotherapy and surgical intervention.
(Level III, Grade A)
Summary of Evidence
Inflammatory processes, such as bladder neck fibrosis, urethral
stricture, meatal stenosis, urethral caruncle, Skenes cyst or abscess, and
urethral diverticulum are associated with anatomic obstruction. Management
usually involves treatment of the offending infection and surgical excision of
the obstructing lesion.22
2. PBNO can be treated surgically with transurethral incision of the bladder
neck.8 (Level III, Grade A)
Summary of Evidence
The management for primary bladder neck obstruction is medical and
surgical. Surgical options include transurethral incision of the bladder neck and
Y-V-plasty of the bladder neck. Care is taken to avoid injury to the external
sphincter, which can lead to stress incontinence.9
1. Voiding dysfunction caused by pelvic organ prolapse (POP) can be
treated by pessary or surgical repair.9 (Level I, Grade A)
Summary of Evidence
After the diagnosis of the prolapse, a pessary or packing can be used to
reduce the prolapse and confirm the diagnosis. This helps predict the outcome
of prolapse repair. Treatment of symptomatic prolapse is usually surgical. In
case of significant morbidity and age, a pessary alone may be used.10
1. Treatment is dictated by degree of bother of postoperative symptom. An
obstructed patient will opt for conservative management with CISC.7
(Level I, Grade A)
Summary of Evidence
Treatment of postoperative retention begins with catheter
decompression and management of contributory factors, such as constipation.
If these measures fail, then CISC and or surgical repair (urethrolysis, sling

release) are recommended.14

2. The role of urethral dilatation is not known. (Level III, Grade C)
Summary of Evidence
Urethral dilatation leads to post-dilatation bleeding or urine
extravasation into periurethral tissue, causing scarring of the urethral wall and
periurethral fibrosis.14
3. Urethrolysis or sling incision is the most definitive treatment available
whether retropubic, transvaginal or supreameatal approach. (Level I,
Grade A)
Summary of Evidence
Bladder neck surgery, tension free vaginal tape placement (TVT), and
collagen injection are recognized causes of compression and voiding difficulty.
Postoperative factors contributing to retention may include failure of
the sphincter to relax, edema surrounding the vesical neck and urethra, pelvic
floor spasm, and obstruction from bladder neck elevation.
Age, higher preoperative urethral resistance, straining during voiding,
and magnetic resonance imaging (MRI) evidence of greater bladder neck
elevation and urethral compression have been associated with the number of
days of voiding dysfunction after colposuspension.19
4. The cholinergic agent bethenacol is not effective.10 (Level I, Grade A)
Summary of Evidence
Bethenacol has been used as treatment of retention caused by detrusor
acontractility, but it has not been used in women with sphincteric overactivity.
Its treatment value is unknown.14
5. The use of botolinum toxin injection into the urethral sphincter for
retention after anti-incontinence surgery is under investigation.11 (Level
III, Grade C)
Summary of Evidence
Phelan and colleagues were the first to report successful outcomes with
a botulinim A injections in women and in non neurogenic voiding dysfunction.
They studies 21 patients (13 women) with impaired bladder emptying who
were dependent on catheterization. All except one were able to void
spontaneously after the injection of 80-100 units of botulinum toxin.20
Kuo and associates repeated this study in 20 patients with urinary
retention and dysuria due to detrusor hypocontractility and non relaxing
urethral sphincter who who were refractory to conservative therapy. This

study clearly showed that botulinum toxin is effective in decreasing urethral

sphincter resistance and improving voiding dysfunction. Botulinum A toxin
injections do have therapeutic value in urethral spasticity, but larger, controlled
trials are necessary to establish value. 21
1. CISC is the mainstay for patients with significant retention. (Level I,
Grade A)
Summary of Evidence
Impaired neuromuscular transmission at the detrusor and/or myopathic
processes are proposed causes of the decreased contractility. Urodynamics is
essential for diagnosis. CISC is the mainstay of therapy.14
3. Pharmacotherapy with cholinergic agonists such as bethenacol has not
proven to be successful.7 (Level III, Grade C)
Summary of Evidence
Bethenacol chloride is cholinesterase resistant and causes a contraction
of smooth muscle from the bladder, bladder neck and urethra, thus preventing
coordinated and complete bladder emptying. It is no longer considered to be
effective to facilitate voiding.14
There is no standardized definition that qualifies postpartum urinary
A commonly used symptom-based definition is the absence of
spontaneous voiding of urine within 6 hours of delivery. After caesarian section, if
a catheter is used, retention is defined as no spontaneous voiding within 6 hours
after removal of the indwelling catheter. Another commonly used definition is
based on the post-void residual bladder volume as estimated by ultrasound or
catheterization. Although most experts agree that residual volumes of less than 50
ml are normal and more than 200 ml are abnormal, little agreement exist on the
intervening grey zone.
Postpartum urinary retention can be classified into covert and overt forms.
The covert form is asymptomatic and recognized by demonstrating an elevated
post-void residual measurement of more than or equal to 150 ml; with either
ultrasound scanning or catheterization. Clinically overt postpartum urinary
retention refers to the inability to void spontaneously after delivery.
There is no concensus of opinion on the management of postpartum
urinary retention and various treatment regimen have been described. The
treatment includes general measures such as administration of oral analgesia,

helping the woman to mobilize, and ensuring privacy during voiding and having a
warm bath. None of the pharmacologic drugs have been studied systematically in
postpartum women, as most women would be breastfeeding. If conservative
measures fail, it is advisable to insert a urethral catheter and remove it after the
bladder has been emptied. If spontaneous voiding fails to occur within 4 hours or
if the voided volume is less than 150 ml and/or the post void residual urine is more
than 150 ml, a foley catheter should be inserted. A trial without catheter can be
attempted after 24-28 hours. The duration of catheterization is empirical, and no
standard has been agreed to. If trial without catheter fails, the woman can be taught
intermittent self-catheterization every 4-6 hours until she is able to void and then
until the residual is less than 150 ml. If this is not feasible, send her home with an
indwelling catheter for 48 hours and repeat the voiding trial.
Overdistention bladder injury in the postpartum period can be avoided by
strict vigilance in ensuring that voiding occurs regularly. Women with potential
risk factors, e.g. regional anesthesia, instrumental delivery, obstetric anal sphincter
trauma or severe perineal tears should be catheterized during labor and delivery.
There are very few studies on the sequelae of postpartum urinary retention
but published data suggest that this condition returns to normal within a short
period and specific treatment is not necessary.21- 24

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recovering voluntary voiding after acute retention of urine? Eur Urol 1998;33:110.
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Walters M, Karram M. Urogynecology and Reconstructive Pelvic Surgery. (Third edition)
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Smith CP, OLeary M, Erickson J, Somogy GT, Chancellor MB. Botulinum toxin urethral
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Figure 1. Algorithm for the Management of Acute Urinary Retention
















15. Carley ME, Carley JM, Vasdev G, Lesnick TG, Webb MJ, Ramin KD et al. Factors that are
associated with clinically overt postpartum urinary retention after vaginal delivery. Am J
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