Urogynecological Risk Assessment in Postmenopausal Women

Table 1. Female pelvis: compartments.
Anterior compartment	Middle compartment	Posterior compartment
Urethra and bladder	Vagina and uterus (vault in hysterectomized women)	Anus and rectum

Table 2. Functional support of female pelvis.
	Level I	Level II	Level III
	Uterus and upper third of vagina (or vault)	Middle third of vagina	Lower third of vagina
Supported by	Cardinal and uterosacral ligaments	Attachments to arcus tendineus fascia pelvis, superior fascia of levator ani muscles, pubocervical fascia rectovaginal fascia	Anteriorly fused with urethra Posteriorly fused with perineal body. Laterally blends with levator ani muscles
Loss of support	Uterine and vault prolapse, enterocele	Cystocele and rectocele	Urethrocele, low rectocele, perineal body defects

Reproduced with permission from [87].

Table 3. Baden-Walker halfway system.
Grade 0	Grade 1	Grade 2	Grade 3	Grade 4
No prolapse	Halfway to hymen	To hymen	Halfway past hymen	Maximum descent

Table 4. Stages of pelvic organ prolapse quantification system measurement.
Stage 0	No prolapse is demonstrated
Stage 1	The most distal portion of the prolapse is more than 1 cm above the level of the hymen
Stage 2	The most distal portion of the prolapse is 1 cm or less proximal or distal to the hymenal plane
Stage 3	The most distal portion of the prolapse protrudes more than 1 cm below the hymen but no farther than 2 cm less than the total vaginal length (for example, not all of the vagina has prolapsed).
Stage 4	Complete vaginal eversion

Table 5. Accuracy of methods for assessing urinary incontinence when compared to multichannel urodynamics (urodynamics used as reference standard).
	Sensitivity	Specificity
Clinical history only	0.92 (SUI) 0.61 (DO)	0.56 (SUI) 0.87 (DO)
Validated scales (UDI question 3)	0.88	0.60
Bladder diary	0.88 (DO)	0.83 (DO)
Ultrasound imaging	0.94 (SUI)	0.83 (SUI)

DO: Detrusor overactivity; SUI: Stress urinary incontinence; UDI: Urogenital distress inventory; UI: Urinary incontinence.
Data taken from [43].

Table 6. Management options for urge incontinence.
Lifestyle interventions	Behavioral therapy	Physical therapy	Drug therapy	Surgery
Caffeine reduction	Bladder training	PFMT TENS	Anticholinergics	Intravesical injection of Botulinum toxin A
Modification of fluid intake		PTNS	β-3 agonist (Mirabegron)	Sacral nerve stimulation
Weight loss in obese			Vaginal estrogen	Augmentation cystoplasty
Moderate physical activity			Desmopressin (for nocturia only)	Urinary diversion
Smoking cessation

PFMT: Pelvic floor muscle training; PTNS: Percutaneous tibial nerve stimulation; TENS: Transcutaneous electrical nerve stimulation.

Table 7. Management options for stress incontinence.
Conservative	Drugs	Surgery
Pelvic floor PFMT)	Duloxetine	Slings: minimally invasive e.g., TVT, TOT, TVT-O, mini-sling, open slings
Vaginal cones		Colposuspension
		Urethral bulking agents
		Artificial urinary sphincter

PFMT: Muscle training; TOT: Transobturator tape; TVT: Tension-free vaginal tape; TVT-O: Tension-free vaginal tape-obturator.

Prolapse

Prolapse is common in postmenopausal women but careful evaluation of its impact on quality of life should be undertaken before considering surgical correction.
Upto 30% women who undergo prolapse surgery will require a second procedure, and lifetime risk of having prolapse surgery by the age of 80 years, in UK is 9.5%.
Recurrent prolapse should only be managed by those with appropriate training and multi-disciplinary support teams.
Vaginal use of mesh for prolapse repairs is not routinely recommended.

Overactive Bladder

Affects almost one out of eight women; incidence increases with age.
Conservative management with modification of fluid intake and bladder training are the key steps.
Anti-cholinergics are mainstay of drug treatment but side effects are common. Extended-release preparations have a better side-effect profile.
Intravesical Botulinum A toxin injections are an effective alternative if anticholinergics are unsuccessful. The effects last from 3–12 months and the injections can be repeated. Upto 10% patients may experience voiding difficulties requiring intermittent self-catheterization.

Stress Incontinence

Prevalence peaks around peri-menopause. Pelvic floor muscle training is the first-line management.
Midurethral slings are currently the most popular and cost-effective intervention. They are usually done as day cases and can be done under local anesthetic and sedation.

Recurrent UTI

Age-related rise in incidence, predisposing factors include: lack of estrogen, urinary incontinence, presence of a cystocele, increased post-void residuals, diabetes and institutionalized elderly women.
Persistent infection should raise suspicion of tumors/calculi or other pathology.
Vaginal estrogens reverse underlying atrophy and can reduce recurrent urinary tract infections. Long-term antibiotic prophylaxis for 6–12 months may also be helpful.