Preoperative Preparation and Diagnostics
A thorough examination must be performed before planning surgical intervention. During the physical examination, the doctor determines the degree of pelvic organ descent, assesses the mobility of the bladder neck using the cough test or straining, and inspects the vaginal mucosa and perineal skin. In severe forms of incontinence, hyperemia and areas of maceration may be present.
The patient is prescribed a micturition diary for 3–5 days, recording the volume of urine voided, frequency of bathroom visits, episodes of urine loss, number of pads used, and physical activity.
The instrumental stage includes:
- Pelvic and renal ultrasound: to assess the urethrovesical segment, the condition of the urethra, residual urine volume, and to rule out organic pathologies (stones, diverticula, tumors).
- Urodynamic study (UDS): a hardware-based method mandatory for recurrences, ineffective therapy, or a discrepancy between symptoms and test results. UDS helps accurately determine the predominant type of incontinence and avoid unjustified surgeries.
Surgical Correction of Stress Incontinence
If urine loss occurs during exertion (coughing, laughing, physical activity), the use of sling (mesh) operations is recognized as most effective.
The essence of the intervention is placing a special supportive sling around the bladder neck. Priority is given to minimally invasive techniques with free-floating synthetic prostheses (sling types: TVT, TVT-O, TVT SECUR).
The most common procedure is TVT-O (Transobturator vaginal tape). During the procedure, a polypropylene sling is passed retrogradely from an incision in the anterior vaginal wall in the mid-urethral zone through the obturator foramen to the inner thigh.
As an alternative minimally invasive method, periurethral injections are used. Special bulking agents (collagen, teflon, autologous fat) are injected into the tissues to help the urethra close more tightly when intra-abdominal pressure increases.
Features of Surgery for Combined Prolapse
Treatment tactics are significantly complicated if urinary incontinence is accompanied by marked descent or prolapse of the internal genital organs.
Critically important rule: performing only anterior colporrhaphy for combined cystocele and stress incontinence is completely ineffective as a standalone method. This surgery must obligatorily be supplemented with one of the anti-stress sling procedures.
The choice of the specific surgical scope for prolapse is based on three factors:
- The woman's age.
- The presence and nature of concomitant diseases of the uterus and appendages.
- The qualifications and technical capabilities of the surgeon.
The main options for surgical correction of prolapse include:
- Vaginal hysterectomy.
- Vaginal extraperitoneal colpopexy using synthetic prostheses.
- Sacrocolpopexy.
Each of these interventions in the presence of a stress urinary loss component must be accompanied by sling placement.
Differential Diagnosis and Alternatives
Surgical treatment is not always indicated. For mild degrees of stress incontinence or strict contraindications to surgery, conservative approaches are used: pelvic floor muscle training (including vaginal cones and weights), hormone replacement therapy during the climacteric period, wearing pessaries or removable urethral obturators, and prescribing $\alpha$-sympathomimetics.
It is extremely important to differentiate stress incontinence from overactive bladder (OAB), which involves detrusor instability. OAB is characterized by frequent (more than 8 times a day) and imperative (sudden, urgent) urges, nighttime awakenings, and the inability to reach the bathroom in time. Surgery is not used for OAB — pharmacotherapy with anticholinergic drugs (oxybutynin, tolterodine) forms the basis of treatment.
Briefly: answers to topical questions
What types of surgical operations exist for the treatment of pelvic organ prolapse?
A wide range of surgical interventions is used for the surgical treatment of pelvic organ prolapse.
- Anterior colporrhaphy — repair of the anterior vaginal wall fascia.
- Colpoperineorrhaphy — restoration of the musculo-fascial structure of the perineum with isolation of the m. levator ani.
- Manchester operation — amputation of the elongated cervix with shortening of the cardinal ligaments.
- Vaginal hysterectomy — removal of the uterus via the vaginal approach.
- Culdoplasty — fixation of the vaginal vault (McCall, Halban, Moschcowitz procedures).
- Sacrocolpopexy — fixation of the vaginal vault or cervix to the sacrum.
- Sacrospinous fixation — fixation of the vaginal vault to the sacrospinous ligament.
- Colpocleisis — obliteration of the vagina (Le Fort-Neugebauer, Labhardt procedures).
Which drug groups are used for the medical treatment of overactive bladder (OAB)?
Anticholinergic drugs are used for the medical treatment of overactive bladder.
- Oxybutynin — drug of choice (trade name Driptan).
- Tolterodine — drug of choice (trade name Detrusitol).
For the differential diagnosis of incontinence, remember: Stress is movement, OAB is time. In stress incontinence, the problem arises from physical exertion (coughing, laughing), while in overactive bladder, it arises from a sudden and sharp urge when the patient does not have time to reach the bathroom.
Class and exam questions
Can cystocele with stress urinary incontinence be cured by anterior colporrhaphy alone?
No, as a standalone type of surgery for such combined pathology, it is ineffective. It must strictly be combined with a sling (mesh) operation.
In what cases is multichannel urodynamic testing mandatory before surgery?
A comprehensive urodynamic study is necessary for incontinence recurrences, lack of response to therapy, and a mismatch between clinical symptoms and baseline test results.
What is the essence of the TVT-O procedure?
This is a minimally invasive sling procedure in which a synthetic polypropylene mesh is passed retrogradely through the obturator foramen to reliably support the urethra.
Do sling procedures help with overactive bladder?
No, surgical intervention is not indicated for detrusor instability and imperative urges. In this case, conservative pharmacotherapy with anticholinergic drugs is used.
What else to study on this topic
- Methodology for performing the cough test and assessing bladder neck mobility
- Interpretation of the micturition diary: norms and deviations
- Risk factors for prolapse development: from obstetric trauma to splanchnoptosis
- Conservative methods: pessaries, vaginal cones, and pelvic floor exercises
- Pharmacotherapy of OAB: mechanism of action of anticholinergic drugs
Master the entire topic in the "Obstetrics and Gynecology" course
This is a summary. The course covers everything tested in classes and exams.
- Complete study guide on "Surgical Treatment of Pelvic Organ Prolapse" and 973 more pages of the subject
- Assignments and quizzes after every topic — just like in a colloquium
- AI tutor answers questions on the topic anytime
- 21 video lessons on the subject
Other topics in the "Gynecology" section
Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.