Prof. Giacomo Novara — Urology, University of Padua
Urogynecology — Benign disorders of the female pelvic floor
Urinary incontinence is defined as any involuntary leakage of urine through the urethra. Three main types are distinguished, each with distinct pathophysiology and management:
Urine leakage during physical exertion, coughing, sneezing, or any increase in intra-abdominal pressure. Not preceded by urgency. This is the form addressed on this page.
Leakage preceded by an irrepressible urge to void. It is the clinical expression of detrusor overactivity. Treatment: antimuscarinics, beta-3 agonists, botulinum toxin.
Coexistence of both forms. The most challenging to treat: no single drug or procedure addresses both components simultaneously.
Estimates vary widely across studies depending on the clinical setting. Many women do not seek treatment, erroneously assuming incontinence is a normal consequence of ageing. It is not. The prevalence of prolapse is declining in high-income regions, in parallel with falling birth rates.
Urinary continence in women depends on the striated urethral sphincter and on the urethral support mechanisms. Damage to one or both elements results in incontinence.
Direct damage to the striated urethral sphincter or its innervation, caused by: pelvic surgery (hysterectomy, rectal resection), radiotherapy, trauma. Continence is compromised because the closure mechanism is damaged irrespective of urethral position.
Weakening of the pelvic floor musculature that supports the posterior urethral wall. During increases in intra-abdominal pressure, the posterior wall separates from the anterior wall, opening the urethral lumen. The sphincter may be intact, but support is lacking.
Many patients have both mechanisms simultaneously. The unifying concept: neither the bladder nor the urethra is diseased — it is the pelvic floor that no longer adequately supports the structures.
Prolapse arises for the same reason as incontinence: failure of the musculo-ligamentous pelvic floor support mechanisms. The prolapsing organs are anatomically healthy. Prolapse is frequently multicompartmental.
Descent of the bladder bulging into the anterior vaginal wall. Synonyms: anterior vaginal wall prolapse, anterior colpocele, cystocele.
If the uterus is present: uterine descent (uterine prolapse). If the uterus is absent (post-hysterectomy): vaginal vault prolapse (vault prolapse, colprocele).
Descent of the anterior rectal wall bulging into the posterior vaginal wall. Managed by proctologists, not urologists.
The most widely used system in clinical practice for its speed (30 seconds). The reference plane is the vaginal introitus (hymenal plane).
No prolapse — normal organ position.
Halfway between normal position and the hymenal plane.
Prolapse reaches the hymenal plane.
Beyond the hymenal plane but not at maximum descent.
Maximum possible descent — complete prolapse.
Number of pregnancies and deliveries (mode, neonatal weight, lacerations), menstrual and menopausal history, chronic constipation, chronic cough, obesity, prior pelvic surgery and radiotherapy.
The IPSS is validated in women as well. The ICIQ-SF quantifies frequency, severity, and quality-of-life impact of incontinence, and identifies the circumstance of leakage (stress vs urgency vs both).
The sensation of a "ball in the vagina" or of protrusion is the cardinal symptom of prolapse. It worsens throughout the day and with physical activity, and improves in the morning and at rest.
Bladder filled to 300 mL, patient standing: the patient is asked to bear down and perform jumping jacks. Observed urine leakage documents stress incontinence. The Q-tip test (cotton swab in the urethra) measures urethral hypermobility: displacement >30° during Valsalva indicates impaired muscular support.
Assessment of each compartment (anterior, apical, posterior) using the Baden-Walker system. Rectal examination to evaluate sphincter tone and rectocele.
Not mandatory but recommended prior to any surgical procedure. Documents urodynamic stress incontinence and the presence of concomitant detrusor overactivity. Particularly useful in prolapse patients because the prolapse may act as a urethral "plug," masking occult incontinence: the study is repeated with the prolapse reduced by a pessary.
Not mandated by guidelines as obligatory, but routinely performed: renal and bladder morphology, post-void residual volume.
Less fluid intake means less leakage. Target: diuresis ~1,500 mL/day.
In obese patients, weight reduction decreases pelvic floor loading and can improve continence.
Kegel exercises with a pelvic floor physiotherapist. Often not curative alone, but useful to defer surgery — particularly in younger women.
Smoking cessation (chronic cough), treatment of constipation, correction of obesity.
The therapeutic revolution was the tension-free vaginal tape (TVT): a synthetic tape that does not obstruct the urethra but merely suspends it. The mechanism of action relies on fibrotic tissue ingrowth into the mesh pores, forming new pubourethral ligaments.
The tape is placed transvaginally, with needles passing through the obturator foramen (TOT) or stopping at the obturator membrane (mini-sling). No critical structures are at risk. Procedure duration: 15–20 minutes. Excellent long-term efficacy for urethral hypermobility. Risk of voiding dysfunction ~15%, clean intermittent catheterisation ~4%, de novo urgency ~15%. Erosion risk <1% (minimal mesh volume).
The original tape technique, with needles passed blindly through the retropubic space. Abandoned due to the risk of vascular and visceral injury during needle passage.
Indicated only in patients with severe intrinsic sphincter deficiency refractory to sling procedures (e.g. after radical pelvic surgery). High risk of long-term device failure.
In patients with urethral hypermobility, transobturator slings perform very well. The role of the artificial urinary sphincter is limited to cases with pure sphincteric deficiency not addressable by sling.
The standard repair is transvaginal anterior colporrhaphy: incision of the vaginal wall, plication and suture of the pubocervical fascia flaps, closure of the vaginal wall. A minimally invasive, rapid procedure with no synthetic material.
Adding a polypropylene mesh reduces prolapse recurrence risk (13% vs 20%), however:
Conclusion: anterior colporrhaphy without mesh remains the standard for isolated cystocele, because the transvaginal mesh erosion risk is unacceptably high. The same conclusion applies to cadaveric fascia lata: it does not improve outcomes over native tissue.
Hysterectomy for prolapse used to be the standard of care. Today this is wrong: the uterus prolapses because supporting mechanisms fail, not because it is diseased. There is no rationale for removing a healthy organ. Hysteropexy is now preferred — suspending the uterus without removing it.
A Y-shaped mesh is fixed proximally to the sacral promontory and distally to the uterine body (anterior and posterior walls). The mesh is placed abdominally, not transvaginally → near-zero erosion risk (the abdominal cavity is sterile; uterine tissue is thick and robust). Compared to hysterectomy: faster, less blood loss, fewer complications, earlier discharge, equivalent recurrence rate. Risk of occult uterine malignancy when the uterus is left in situ: 0.22%.
If the uterus is pathological (fibroids, cervical dysplasia, BRCA family history, tamoxifen therapy) but the cervix is healthy: the uterine body and fundus are removed while the cervix is retained. The mesh is fixed to the residual cervix (thick tissue → erosion 0.3%) rather than to the vaginal wall (thin tissue → erosion 4%). Erosion risk is reduced tenfold compared to total colposacropexy.
When both the uterus and cervix have already been removed and mesh must necessarily be anchored to the vaginal wall, cadaveric fascia lata (biological tissue) is used instead of polypropylene to minimise infection and erosion risk.
When a patient presents with both prolapse and stress urinary incontinence, what is our approach?
Prolapse repair only. No concomitant anti-incontinence procedure.
The prolapse acts as a urethral plug and prevents leakage. Urodynamics with the prolapse reduced (pessary) reveals incontinence. Our strategy: repair the prolapse alone and reassess postoperatively. Only patients who become truly incontinent after surgery will then receive a sling (approximately 40%).
Same rationale: repair the prolapse alone. If the woman remains incontinent postoperatively, a sling is then added. Why not intervene simultaneously? Because if we place a sling in all patients, we are performing 100 procedures to benefit the 40 who will actually need it — exposing the remaining 60 to unnecessary procedural risk.
In women with prolapse and occult incontinence, treating prolapse alone vs prolapse + sling: