Female Pelvic Floor

Support Anatomy — DeLancey's 3 Levels

Level	Suspends	Structures	Loss produces
I	Uterus + upper vagina	Uterosacral–cardinal complex (the parametrium) → sacrum and lateral pelvic side wall	Apical prolapse (uterine / vault)
II	Middle third of vagina	Paravaginal attachments to the ATFP and the superior fascia of levator ani	Cystocele (anterior wall)
III	Lower third of vagina	Perineal membrane, levator ani, perineal body	Anterior → urethral hypermobility; posterior → distal rectocele / perineal descent

• ATFP runs pubic bone → ischial spine; separation from it = paravaginal defect
• Urogenital hiatus held closed by tonic levator tone — fascia carries almost no load until the muscle fails, then ligaments take everything and fail over time
• Levator avulsion in 23% of symptomatic women → higher stage, three-compartment POP
• Visible levator defects on MRI in 20% of primiparas, none in nulliparas
• Levator innervation S3–S5; pudendal supplies urethral/anal sphincters
• Ehlers-Danlos and Marfan → increased POP risk (altered collagen I:III)

Integral theory — the 3 supports of the proximal/midurethra

1. Pubourethral ligaments
2. Suburethral vaginal hammock
3. Pubococcygeus muscle

• ISD is the primary cause of female SUI; hypermobility is secondary — all women with SUI have some ISD, not all have hypermobility
• Hypermobility is a symptom of damaged support, not a cause of SUI
• In continent women MUCP occurs at the midurethra

Pelvic Organ Prolapse — Basics

Compartment	Organ	POP-Q points
Anterior	Bladder (cystocele), urethra	Aa, Ba
Apical	Uterus, cervix, vault, bowel (enterocele)	C, D
Posterior	Rectum (rectocele), small bowel	Ap, Bp

• Frequency: anterior > posterior > apex (least common) — but apex is under-diagnosed, not rare
• Enterocele = true hernia of intestine into the vaginal wall
• Procidentia → bilateral ureteric obstruction — relieved by reducing the prolapse
• Apical descent (C ≥ −3) present in 42% / 85% / 100% of stage 2 / 3 / 4 anterior POP → suspect it before every cystocele repair
• Prevalence 3–6% by symptoms, up to 50% anatomically; lifetime risk of POP surgery 12.6%
• Asymptomatic stage 1–2 is normal — symptoms rarely appear until the prolapse reaches the hymen
• Natural history slow: at 16 months 19% progress · 78% no change · 3% regress
  • Progression risk higher if age >60, Ba ≥4 cm, or genital hiatus ≥5 cm

Risk factors

• Well-established (3): age · obesity · parity — parity carries the strongest association with the development of POP
  • Adjusted RR 8.4 after 2 deliveries, 10.85 after 4
  • Each extra delivery up to 5 births adds 10–20%
  • Forceps OR 5.4 vs vaginal delivery OR 2.9 for POP surgery
  • Cesarean section appears protective against prolapse
• Less established (10): smoking · chronic constipation · menopause · hysterectomy/pelvic surgery · heavier vaginally delivered fetus · genetic · race · heavy lifting · intense physical activity · chronic pulmonary disease
  • Hysterectomy done for POP strongly predicts repeat pelvic floor surgery
  • Hispanic women have the highest prevalence, Black women the lowest; more common in Caucasian and Hispanic than African-American women

POP-Q

Point	Definition	Range
Aa	Anterior wall 3 cm proximal to meatus (≈ bladder neck)	−3 to +3
Ba	Most distal point of anterior wall prolapse	−3 to +tvl
Ap	Posterior wall 3 cm proximal to meatus	−3 to +3
Bp	Most distal point of posterior wall prolapse	−3 to +tvl
C	Cervix (or vaginal cuff)	−10 to +10 or more
D	Posterior fornix (only if cervix present)	−10 to +10 or more — not recorded after hysterectomy
gh	Mid-meatus → posterior midline hymen	—
pb	Posterior gh margin → middle of anus	—
tvl	Total vaginal length, fully reduced	—

• Hymen = the reference point (more precisely identified than the introitus); negative = above, positive = below
• All points measured while straining
• C vs D distinguishes cervical elongation from true uterine prolapse
• Ba and Bp can reach +5 or +6 in extreme prolapse — the +tvl ceiling is not a small number

Stage	Leading edge	Formal criterion
0	No prolapse	Aa, Ap, Ba, Bp all at −3, and C or D ≤ −(tvl − 2)
1	>1 cm above the hymen	Stage 0 criteria not met and leading edge < −1 cm
2	Within 1 cm either side of the hymen	Leading edge ≥ −1 cm but ≤ +1 cm
3	>1 cm below the hymen, not totally everted	Leading edge > +1 cm but < +(tvl − 2)
4	Complete eversion	Leading edge ≥ +(tvl − 2)

• Do NOT measure immediately after removing a vaginal pessary — it underestimates the true degree of prolapse

POP — Evaluation

• Vaginal bulge is the ONLY symptom strongly associated with prolapse at or below the hymen — everything else correlates weakly with site and severity
• Examine in lithotomy AND standing; if symptoms and stage disagree, re-examine standing or later in the day
• Signs of estrogen deficiency (3): urethral caruncle · urethral prolapse · labial adhesions
• Anal sphincter tone = S2–4
• No routine imaging — but dynamic MRI adds real information pre-operatively when the pelvic examination is difficult or inconclusive
• Evaluate defecatory dysfunction before operating

POP and incontinence

• >40% of women with SUI have a significant cystocele
• POP surgery improves storage symptoms: frequency 36.6 → 14.6%, urgency 36.8 → 12.9%, UUI 21.2 → 6.1% (de novo 5–6%)
• Anti-incontinence surgery without correcting POP can worsen POP
• Advanced untreated POP → retention (urethral compression) and rarely renal failure (ureteric compression)

Occult SUI — the pre-op question

• SUI appearing only after prolapse reduction, previously masked by high-stage anterior POP
• Detection 4.4% unreduced → 22% with pessary reduction; 29.2% of symptom-free women with POP leak on at least one of five stress tests
• Do a POP reduction test in every continent woman before POP surgery (EAU Strong)
• If significant POP, run UDS with AND without a pessary
• Additional evaluation indicated if POP-Q ≥3 and SUI not demonstrated on reduction
• A vaginal pack works as well as a pessary for reducing the prolapse during the study
• Run a filling study (CMG) for detrusor overactivity and measure VLPP during the reduced study — not just a stress test
• If manual reduction during UDS produces no leak, a pessary adds nothing — do not repeat it
• Remove any urethral catheter and reassess — an indwelling catheter can itself mask SUI

POP — Management

Click the algorithm to open it full size.

Conservative

• Options: observation · pessary · PFMT
• PFMT improves POP symptoms and/or POP stage by one stage in stage I–III
• Do NOT give pre-operative PFMT if a pessary or surgery is already indicated — 10 RCTs show no benefit; OPTIMAL found peri-operative PFMT did not improve outcome

Three surgical families

Type	Principle	Best for
Restorative	Repair discrete defects with native tissue	Reasonable tissue, discrete defects
Compensatory	Reinforce with a graft	Weak tissue, failed prior repair
Obliterative	Close the vagina	Comorbid, elderly, not sexually active

• The first operation is the best chance — recurrence rises with each attempt
• Vaginal: fewer complications, shorter stay ⟷ abdominal: more durable
• Success = symptom resolution, not anatomy; patients perceive catheters, constipation and urgency as complications — counsel explicitly

ALWAYS SUPPORT THE APEX. Isolated anterior, enterocele or rectocele repair without apical resuspension increases recurrence.

Anterior — cystocele

• Central defect → anterior colporrhaphy · lateral defect → paravaginal repair — usually combined; isolated central defects are rare
• Midline incision to 1.5 cm from the meatus — but stop 3 cm from the meatus if a sling is planned (sling needs its own midurethral incision)
• Plicate 2-0 delayed absorbable, tension-free, stay shallow to avoid the bladder → cystoscopy with dye
• Complications: de novo DO 5–7% (but pre-existing DO resolves in up to 63%), retention, bleeding >350 mL, bladder/ureteric injury, VVF, dyspareunia
• Bleeding usually = wrong plane — dissect on the white shiny surface of the pubocervical fascia
• No dye efflux → remove the plication sutures

Apical — vaginal route

Procedure	Key technical point	Results	Signature complication
Uterosacral suspension (USLS)	3 permanent sutures per USL, proximal and medial to the ischial spine; cystoscopy before cutting sutures	Success 85% (48–96%); reoperation 5.8%; by compartment ant 81.2% / apical 98.3% / post 87.4%	Ureteric kinking or injury 1–11%
Sacrospinous fixation (SSLF)	Suture 1.5–3.0 cm medial to the ischial spine — too close risks Alcock's canal, too medial risks failure and sacral nerves	Cure 84.6%; apical recurrence 5.3%; anterior recurrence 18.3%	Ipsilateral buttock pain 15%, resolves 2–3 months
Iliococcygeus suspension	Fixation 1 cm distal to the ischial spine; bilateral	Cure 53–96%	Buttock pain

• SSLF deflects the vagina posteriorly (and right if unilateral) → anterior compartment recurrence
• OPTIMAL trial: USLS vs SSLF — no difference, 2-year success 64.5%
• Absorbable suture is non-inferior to permanent for apical recurrence
• Concomitant anterior repair improves success only in higher-stage POP (Ba > +1) undergoing SSLF

Apical — abdominal (sacrocolpopexy)

• The most durable repair — best for failed vaginal repair, isolated uterine prolapse/enterocele, young, active, sexually active women. Maximises functional vaginal length
• Type I macroporous monofilament polypropylene to the anterior longitudinal ligament
• Promontory lies medial to the right ureter, immediately caudad to the aortic bifurcation
• Avoid middle sacral vessels, presacral venous plexus, and the left common iliac vein (often more medial than the artery)
• 2–3 non-absorbable sutures to the ligament; 6–8 sutures to each vaginal wall, full-thickness without entering the lumen
• Tension: advance the obturator fully cephalad, then release to a neutral "sagging" position — excess tension → pain and de novo SUI. Leave two fingerbreadths between graft and rectum
• Halban culdoplasty (linear) preferred over Moschcowitz (purse-string) — the purse-string can angulate and obstruct the ureter
• Supracervical hysterectomy preferred if a hysterectomy is done concurrently; otherwise meticulous two-layer cuff closure
• Results: >90% success; extended CARE at 7 years — anatomic failure 27%, symptomatic 29%, composite 48% (half of failures asymptomatic and never retreated)
• Counsel: up to 20% need a secondary vaginal repair for distal defects
• Complications: transfusion 4.4% · cystotomy 3.1% · enterotomy 1.6% · ureteric injury 1.0% · UTI 10.9% · mesh exposure 3.4–5.4% (9.9% in extended CARE), presenting at ≈14 months with bleeding and discharge
• Learning curve ~30–40 cases laparoscopic, ~50 robotic

Posterior — rectocele

• Symptoms split three ways: herniation · defecatory dysfunction · sexual dysfunction — defecatory dysfunction does NOT include fecal incontinence
• Treat anismus (failure of puborectalis to relax) with biofeedback and pelvic floor PT first; motility disorders with diet/medication
• Counsel: repair reliably fixes the bulge and the need to splint; constipation may persist
• Transvaginal beats transanal: symptom resolution 93% vs 73%, recurrence 7% vs 66%
• Native tissue only — no routine graft in the posterior compartment
• Confirm the introitus admits 2–3 fingerbreadths; plicate rectovaginal fascia 0/2-0 delayed absorbable, tie proximal first
• Do NOT plicate the levator ani in a sexually active woman → 50% dyspareunia. Levator plication is largely abandoned
• Level 1–2 evidence favors midline plication without levatorplasty OVER site-specific repair

Obliterative — colpocleisis

• Total (post-hysterectomy): denude to 2–3 cm from the meatus, close completely
• Partial / Le Fort (uterus in situ): excise 3 cm from meatus to 3 cm from cervix, leaving lateral drainage channels
• Absolute requirement: no desire for vaginal intercourse
• Uterus in situ → pre-op Pap, pelvic US ± endometrial biopsy; risk of pyometra if channels obstruct
• Finish with a high perineorrhaphy

Mesh — where it stands

Indication	Status
Transvaginal mesh for POP	FDA ordered stop-sale in 2019 — off the market (class III since 2016)
Midurethral sling for female SUI	Not affected — safety and effectiveness well established
Single-incision mini-slings	Efficacy/safety not adequately demonstrated at panel review
Transabdominal mesh for POP (sacrocolpopexy)	Not affected — less recurrent POP, fewer mesh complications than vaginal placement
Male SUI slings	Not affected

• Perforation = mesh in the lower urinary tract · exposure/extrusion = mesh through skin or vagina
• POP mesh complications ≈ 10%; counsel exposure 1–19% · buttock/groin/pelvic pain 0–18% · de novo dyspareunia 2–28% · reoperation 1–22%
• Nerve injury: retropubic arms → ilioinguinal (L1) / genitofemoral; obturator arms → obturator (L2–L4), pudendal, posterior femorocutaneous (S2–S3)
• Imaging by question: VCUG obstruction · CT abscess · MRI osteitis/osteomyelitis · translabial US mesh location and size
• The price of removal — recurrent anterior POP ≈20%, incontinence after sling removal 30–50% (up to 74%, one-third need another SUI procedure). The more mesh removed, the greater the risk
• Pain improves in 60–90% after excising the offending portion
• In infection, remove the ENTIRE mesh — residual infected mesh → chronic infection, sinus tracts, abscess, fistula
• Mesh does not increase cancer or autoimmune disease risk

Female SUI — Definitions

• SUI: leakage on raised abdominal pressure — cough, sneeze, exertion, position change
• UUI: leakage with urgency · MUI: both
• ISD: ALPP <60 cm H₂O or MUCP <20 cm H₂O, often with minimal mobility
  • ALPP >90 = no or very little ISD
• Prevalence of female SUI up to 49%

Three theories of SUI pathophysiology

Theory	Core claim
Pressure transmission	The urethra descends out of its protected intra-abdominal position, so raised abdominal pressure is transmitted directly onto the urethra instead of being shared with it. The proximal urethra becomes functionally contiguous with the bladder, and the more distal sphincteric mechanism cannot compensate
Hammock hypothesis	The urethra is not truly intra-abdominal. Firm posterior and lateral support lets rising pressure compress the urethra closed, working together with the active midurethral sphincter. Loss of that backboard permits SUI
Integral theory	UI and SUI arise from laxity of the vaginal wall and its supports, notably the pubourethral ligaments. Stretch receptors at the bladder neck, triggered when urine is deposited into the proximal urethra under raised pressure, also drive urgency incontinence

• The hammock hypothesis is the one that unifies the older theories — it explains hypermobility anatomically rather than treating it as the cause

Less common ICS terms — know these

Term	Meaning
Continuous UI	Continuous involuntary loss → think fistula or ectopic ureter
Insensible UI	Aware of the leak, unaware of how or when it happened
Postural UI	On change of position (sitting/supine → standing)
Coital UI	During or after intercourse
Disability-associated UI	Cannot reach the toilet in time — physical or mental impairment
Nocturnal enuresis	Involuntary voiding during the main sleep period
Stress incontinence on prolapse reduction	Occult / latent SUI

Differential of SUI — 7 to exclude

1. Overflow incontinence
2. Detrusor overactivity incontinence
3. Low bladder compliance
4. Stress-induced detrusor overactivity
5. Urethral diverticulum → post-void dribble
6. Urinary fistula → continuous
7. Ectopic ureter → continuous

Drugs that worsen incontinence

Class	Effect
Sympatholytics (tamsulosin, doxazosin, alfuzosin, silodosin)	Decrease outlet resistance → worsen SUI
Cholinesterase inhibitors (donepezil, galantamine, rivastigmine)	Increase bladder contractility → precipitate UUI
Diuretics	Increased urine production → frequency/UI
Calcium channel blockers	Impaired emptying, retention, constipation
Anticholinergics	Retention, especially with BOO
SGLT2 inhibitors	Glycosuria, polyuria, increased UTI
SSRIs	Increased cholinergic transmission → UI
Lithium	Polyuria via diabetes insipidus
Opioids / psychotropics	Retention, confusion, immobility

Female SUI — Evaluation

Click the algorithm to open it full size.

The 4 mandatory investigations

1. History (including bother) and physical exam
2. Objective demonstration of SUI
3. Urinalysis
4. PVR

• Bother is paramount to the decision to operate in the index patient
• History alone does NOT diagnose SUI
• Inspection of pads soaked with urine is sufficient objective confirmation of leakage — the demonstration does not have to happen in front of you

Physical exam — 6 elements

1. Stress test, supine and/or standing, comfortably full bladder
2. Focused abdominal exam
3. Urethral mobility
4. Pelvic prolapse
5. Vaginal atrophy / estrogenization
6. Focused neurologic exam

• Negative supine → repeat standing
• Q-tip test does not diagnose SUI — SUI exists without hypermobility and vice versa; it only quantifies mobility. Hypermobility = >30° from horizontal
• Pad test confirms incontinence but not the type
  • Short test >1.4 g = incontinence; 24-hour test >1.3 g = positive (some accept up to 8 g in 24 h as normal); 24-h severity 4.4–20 g mild · 21–74 g moderate · >75 g severe
• Assess frailty in patients ≥65 — distinct from comorbidity, predicts poor post-op outcomes
• Only 18–50% of women with pelvic floor disorders seek care — ask directly
• Voiding diary: 3 days is optimal, but a single day is acceptable
• Validated questionnaires: the ICIQ family — ICIQ-UI, ICIQ-SF, ICIQ-FLUTS, ICIQ-MLUTS

Cystoscopy — 3 indications

• Not in the index patient

1. Suspected bladder pathology (e.g. microhematuria)
2. Structural lower tract abnormality
3. Undergoing MUS or PVS — confirm integrity, exclude foreign body

• Also: prior anti-incontinence or POP surgery if perforation is suspected — suspect it with new LUTS, hematuria or recurrent UTI

Urodynamics

• May be OMITTED in the index patient when SUI is clearly demonstrated
• VALUE (NEJM 2012): 630 women with uncomplicated SUI — office evaluation alone was NOT INFERIOR to evaluation plus UDS
• 9 non-index triggers: neurogenic LUTD · unconfirmed SUI · subjective/objective mismatch · elevated PVR · significant voiding dysfunction · significant urgency/UUI/OAB · abnormal urinalysis — unexplained hematuria or pyuria · prior POP surgery · prior anti-incontinence surgery
• Significant POP → UDS with and without a pessary
• DO present → consider something other than a sling alone; small capacity and low compliance also worsen sling outcomes
• UDS answers two questions: (1) is this a storage problem only, or is there an emptying problem too? (2) is the incontinence a detrusor problem or an outlet problem?
• For higher-risk interventions — that is, surgery — multichannel UDS remains the most accurate test available, and is most useful after previous surgical intervention

Female SUI — Conservative & Medical

• Non-surgical options (4): urethral plugs · vaginal inserts · continence pessary — chiefly for prolapse-related SUI · PFMT ± biofeedback
• Observe if minimal bother, or not a candidate for other therapy
• No stem cell therapy outside trials
• Surgery only after conservative management has failed

Intravaginal continence devices — pessaries, tampons, contraceptive diaphragms; satisfaction >50%. But EAU does NOT recommend offering mechanical devices routinely (Strong) — the trade-offs below are why.

Advantages	Disadvantages
Work across a broad spectrum of stress or mixed UI	Insertion and removal for cleaning can be difficult
Fitted in clinic without invasive testing	Vaginal discharge, odor, irritation
Worn only for predictable activities that provoke leakage	Dislodgement
Mild side-effect profile	Cannot address ISD, and cannot transmit pressure properly to a fibrotic urethra
Also manage bothersome prolapse symptoms

• Urinary diversion is a last resort — refractory cases with severe sphincter damage only
• Bladder neck closure with simultaneous lower-tract reconstruction can succeed when the outlet is destroyed; a functional urethral closure with a pubovaginal sling leaves a pop-off valve at high pressures and preserves transurethral access

Intervention	Position
Supervised intensive PFMT ≥3 months	First line for all SUI and MUI (Strong) — including elderly and pre/postnatal
Weight loss	Encourage in all overweight/obese (Strong)
Vaginal estrogen	Offer in postmenopausal women with vulvovaginal atrophy (Strong)
Electrical stimulation	Consider, or as an adjunct for teaching a contraction (Weak)
Electroacupuncture	Offer (Strong)
Electromagnetic stimulation	Do NOT offer outside research (Strong)
Vaginal laser	Do NOT offer outside research (Strong)
Duloxetine	Offer to selected patients unresponsive to conservative therapy who want to avoid surgery (Weak); titrate on and off (Strong)

• PFMT evidence: 8× more likely to report cure; as effective as surgery for about half of women
  • Biofeedback adds nothing when dose and attention are matched; group training is non-inferior and cost-effective
  • Less effective when MUI/UUI patients are included; more effective if intensive and supervised
• Head-to-head vs MUS at 12 months: improvement 90.8% surgery vs 64.4% physiotherapy — but 49% of the physiotherapy arm crossed over to surgery
• Duloxetine mechanism: blocks presynaptic 5-HT and noradrenaline reuptake → enhanced pudendal motor neuron drive → increased sphincter resting tone; cure ≈10%
• Do NOT offer antimuscarinics when the problem is primarily SUI — they treat the wrong mechanism
• α-agonists raise urethral muscle tone, but the evidence that they beat placebo is weak
• TCAs (imipramine) are the other oral option alongside the SNRI duloxetine
• Oral estrogen ± progestogen makes incontinence WORSE — it increases the incidence of SUI and UUI in women continent at baseline and worsens UI in those already incontinent. This is the opposite of vaginal estrogen, which treats vulvovaginal atrophy and is offered (Strong)

Female SUI — Surgery

The 4 options

1. Periurethral bulking agent
2. Midurethral sling (MUS)
3. Autologous pubovaginal sling (PVS)
4. Burch colposuspension

All four carry an individual Strong "offer" — they are deliberately not ranked. Choose by shared decision-making.

• Anterior colporrhaphy alone must NOT be used to treat SUI (Grade A) — combine it with a sling. Needle suspensions are abandoned

Bulking agents

• Bulkamid (polyacrylamide hydrogel), FDA approved 2020; little long-term data
• Indications (2): wants to avoid more invasive surgery / longer recovery · insufficient improvement after a previous anti-incontinence procedure
• Counsel on the expected need for repeat injections
• Ideal candidate: isolated ISD, ALPP <100 cm H₂O, minimal hypermobility (≤15° descensus)
• Inject at the PROXIMAL urethra — too near the bladder neck → extravasation and poor coaptation; too distal into the sphincter → failure, pain, irritative symptoms
  • Transurethral: 3 and 9 o'clock · periurethral: 4 and 8 o'clock
• Efficacy up to 75% improvement short-term, substantially less at 1 year — improvement ≠ dryness
• AEs: pain at implantation 13% · retention 6% · UTI 4% · hematuria 2%
• Do NOT use autologous fat or hyaluronic acid (Strong) — higher AE risk. Collagen is no longer available
• Agents used historically: collagen · PTFE · dextranomer/hyaluronic acid · Durasphere (graphite-coated beads) · Coaptite (calcium hydroxyapatite) · polydimethylsiloxane elastomer (Macroplastique) — all share a short duration of effect, which is why repeat injection is the expectation

Midurethral sling

• Three types: retropubic (TVT-R) · transobturator (TVT-O) · single-incision
• Mechanism (2): restricts posterior urethral wall movement · narrows the lumen as the posterior wall moves inward
• Material: macroporous monofilament polypropylene, pore size >75 μm — allows ingrowth, decreases encapsulation and infection
• Patients without urethral hypermobility respond poorly — a fixed urethra means ISD
• Exclude POP and a urethral diverticulum before offering an MUS — both change the operation

NEVER place a synthetic MUS concomitantly with: urethral diverticulectomy · urethrovaginal fistula repair · urethral mesh excision. Use autologous fascia.

• Also avoid mesh where healing is poor: prior radiation · significant scarring · poor tissue quality · long-term steroids · impaired collagen from systemic autoimmune disease (Sjögren's, SLE) · immunosuppression
• Tension: place LOOSE at the midurethra — a loose sling with a mobile urethra compresses on Valsalva but is non-obstructive at rest
  • Single-incision slings are the exception — tension them TIGHTER, and restriction of mobility afterwards predicts a better result
• Cystoscopy is mandatory (Strong); perforation → withdraw and repass more laterally, catheter 5–7 days
• Retropubic anatomy: obturator vessels are the closest major vessels; dorsal nerves of the clitoris run on the inferior surface of the ischiopubic rami, ~1.4 cm from the midline; keep the needle on the bone
• Transobturator anatomy: avoids the true pelvis. Traverses: obturator internus → obturator membrane → obturator externus → adductor magnus, adductor brevis, gracilis. Must NOT traverse: adductor longus or levator ani
  • Nerves running close to the pass: obturator nerve, dorsal nerve of the clitoris, pudendal nerve
  • Avoid the adductor longus tendon — contact causes substantial pain
  • Stay medial and close to bone — obturator nerve and vessels lie cephalolateral in the canal
  • Skin entry at the notch where the adductor longus tendon meets the inferior pubic ramus, at the level of the clitoris
  • Urethral injury on dissection → repair 4-0 over a 16F catheter and POSTPONE the sling 6–12 weeks

Outcomes

• Retropubic and transobturator look similar short-term, but retropubic is SUPERIOR long-term (Strong) — ESTER OR 0.74, SUCRA 89.1% vs 64.1%
• Single-incision slings lose efficacy with longer follow-up — short-term equivalent, long-term uncertain
• ISD: success is lower with a fixed urethra and low LPP; retropubic > transobturator in ISD. Low LPP alone is not a contraindication
• Pre-operative urethral mobility predicts success
• Not compromised by concomitant vaginal surgery, age, or obesity
  • Elderly: cure comparable, but more persistent SUI and more de novo urgency; do not exclude on age alone
  • Obese: higher bladder trocar injury in NON-obese patients
• Recurrent SUI: salvage efficacy ≈ primary; higher bladder perforation risk after prior retropubic suspension

Autologous pubovaginal sling

• Gold standard for ALL forms of SUI
• Indications: ISD (retropubic suspension is contraindicated in ISD) · urethral hypermobility · deficiency of the midurethral complex · MUI · concomitant cystocele · urethral diverticulum · neuropathic bladder — e.g. myelodysplasia, to treat the SUI that emerges once CIC begins · after trauma · after failed retropubic suspension or failed MUS · after mesh erosion · urethral reconstruction
• Graft: 2 cm × 8 cm rectus fascia (most common) or fascia lata (classically 20 × 2 cm, now often 8 cm)
  • Keep the transverse fascial incision ≥2 cm from the symphysis for tension-free closure
• Positioned at the bladder neck / proximal urethra, via an inverted-U vaginal incision, through a combined abdominal and transvaginal approach — both ends end up in the retropubic space
• Tension: tie above the rectus fascia leaving a TWO-FINGERBREADTH gap. Close the vagina, remove the speculum, and finish any POP repair before final tensioning
• Advantages: minimal inflammation · negligible urethral erosion risk
• Disadvantages: longer operation and stay · post-op pain · suprapubic seroma · incisional hernia (~1%)
• Synthetic PVS is no longer used — inflammation, infection, perforation, exposure

Graft	Source	Note
Autologous	The patient's own tissue	Best for PVS — negligible risk of urethral erosion
Allograft	Another human
Xenograft	Animal
Synthetic	Manufactured	No longer used in PVS

• Autologous or allograft sling perforating the urethra: incise or excise the intraluminal portion only and close the urethra simply. Additional coverage such as a Martius flap is rarely needed — unlike a synthetic sling, which almost always needs it

	PVS	MUS
Position	Bladder neck	Midurethra
Material	Autologous	Synthetic
Donor morbidity	Yes	None
Corrects	ISD and hypermobility	Hypermobility only
With diverticular repair	Can be used	Cannot be used
Voiding dysfunction	Higher	Lower

• SISTEr (NEJM 2007): PVS vs Burch — cure 47% vs 38%, but significantly more voiding dysfunction and cystitis; all 20 BOO procedures were in the PVS group
  • 5 years: continence 31% vs 24%, satisfaction 83% vs 73%; serious AEs similar (9–13% vs 10%)
• 33% have persistent urge incontinence and up to 9% develop de novo UUI

Burch colposuspension

• Indications (2): wants to avoid mesh AND avoid fascial harvest · undergoing a simultaneous abdominal procedure
  • Also when vaginal access is limited (contractures, stenosis)
• Requires urethral mobility

Contraindications (4)

1. Prior failed incontinence surgery with a high likelihood of ISD
2. SUI due solely to ISD — a fixed, non-functional proximal urethra
3. Pan-pelvic floor weakness — needs a combined pelvic floor repair instead, especially with a central cystocele, rectocele or introital deficiency
4. Inadequate vaginal length or mobility — after previous vaginal surgery or radiotherapy

• Elevates the anterior vaginal wall and paravesical tissue toward Cooper's (iliopectineal) ligament with 2–4 sutures of the pelvic sidewall — the urethral wall is deliberately NOT included. Sutures pass medial-to-lateral, tie distal first with knots anterior to the ligament, aiming for two fingerbreadths between bladder neck and pubic bone
• A V-shaped suspension increases obstructive problems — and the repair remains suture-dependent long term
• Be ready for sudden copious bleeding at Cooper's ligament
• Success 85–90% at 1 year, 70% at 5 years; laparoscopic = open
• Failure predictors: BMI >25 · anticholinergic use · age >60 · prior SUI procedure

Two complications specific to colposuspension

1. Enterocele — 5%. Commoner after Burch because it aggravates posterior wall weakness. Prophylactic obliteration of the cul-de-sac reduces the risk
2. Post-colposuspension syndrome — pain in one or both groins at the suspension site

The other retropubic operations

Operation	Fixed to	Technique	Position
MMK	Periosteum of the symphysis pubis	3 sutures at the bladder neck — involves the urethral and vaginal wall, unlike Burch	No longer recommended. Osteitis pubis 1–3%; suture-dependent; less durable than Burch
Paravaginal repair	ATFP	3–8 sutures through the lateral vaginal sulcus and overlying fascia. Bladder and urethra are not mobilized off their vaginal attachments	Not recommended for SUI alone (Grade A); less effective than other colposuspensions. Horizontal suspension → obstruction is less common
VOS (vagino-obturator shelf)	Internal obturator fascia ± the iliopectineal line as a modification	Anchors the vagina laterally	Horizontal suspension → obstruction is less common
Needle suspensions	—	—	Abandoned — suture pull-through

• There is a laparoscopic version of all of them
• Retropubic beats the vaginal route (anterior colporrhaphy) for long-term results, and is the better choice with a concomitant cystocele — where it should be combined with a sling

AUS in women

• Second-line. Continence 79.6%, but explantation 13% · revision 15% · vaginal erosion 9% · mechanical failure 13%
• Transvaginal implantation is not favored (infection, cuff erosion)
• Counsel: high risk of complications, mechanical failure or explantation even in expert centers (Strong)

SUI Surgery — Complications

MUS — the 10 to quote

Complication	Rate
Bladder trocar injury	2.7–3.8% overall — retropubic 2.7–23.8% vs transobturator 0–1.3%
Voiding dysfunction	7.6%
Vaginal mesh exposure	0.5–8.1% (up to 9%)
Mesh perforation of bladder	0.5–0.6%
Wound healing problems	1%
Bleeding / vascular injury	Higher with retropubic; severe bleeding 2–3%
Groin/thigh pain and numbness	10–15% with transobturator
Sexual dysfunction · infection · bowel perforation · death	Rare

• Trocar injury is generally a benign condition
• Vaginal exposure: manifests weeks to months post-op. Risk factors — diabetes · smoking · older age · previous vaginal surgery. Observation is only for the asymptomatic woman with an exposure <1 cm, with estrogen ± antibiotic cream. Otherwise: vaginal advancement flap or excision via a transvaginal approach
• Urethral perforation → observation is NEVER acceptable. Transurethral excision of the tape with closure of the urethrotomy ± Martius flap; an autologous PVS may be placed at the same sitting. Endoscopic tape transection has a role for a small intraluminal segment
• Mesh perforating the BLADDER → never observe this either. Fill the bladder completely before you look — an underfilled bladder hides the mesh in a fold, and that is the commonest reason it is missed. Send a urine culture and consider upper tract imaging to assess the ureters. First: endoscopic excision. If that fails: a combined transvaginal and retropubic approach
• Pain: most groin pain settles by day 2; discomfort up to 2 weeks. Refractory pain → exclude extrusion, organ injury, adductor longus perforation. Localized pain → limited urethrolysis; widespread pain or infection → complete excision. Removal does not guarantee pain relief
  • Transobturator leg pain is commoner with the inside-out pass and in athletic, muscular builds. Escalation if it does not settle: pain service → sling removal
• Voiding dysfunction after MUS: usually obstruction — sling too tight, too proximal, or associated POP. Rule out POP and do cystoscopy. Approach her as a new patient and manage conservatively first
  • Wait 2–4 weeks before considering sling release
  • In frank retention, intervene sooner — within 4 weeks — because it is unlikely to resolve
  • Within 3 months → the sling can be LOOSENED: reopen the vaginal incision, pass an instrument around the mesh and tug. If it is embedded and will not loosen, simply DIVIDE it — the entire sling does not need to be excised
  • After 3 months → the sling is fixed along its whole course. A midline incision may not release enough — go to formal sling excision and urethrolysis
  • Urethral dilatation is ineffective in obstruction and risks urethral extrusion of the mesh
  • MUS infection → treat conservatively first; remove the sling if that fails
  • Retropubic worse than transobturator: surgery-requiring voiding dysfunction 2.7% vs 0%, retention >6 weeks 3.7% vs 0.7%

PVS obstruction and urethrolysis

• Transient retention is common — most void spontaneously within 10 days
• If she develops UUI or obstruction after a PVS, work her up as a new patient — history, examination, urinalysis, PVR, videourodynamics and cystoscopy
• Conservative package: indwelling catheter or CIC · timed voiding · double voiding · biofeedback · PFMT · α-blockers ± anticholinergics
• Within 6 weeks: loosen the sling in theatre — cystoscope in, gentle caudal traction on the urethra. Not advised with synthetic slings

Complete obstruction — revision may be brought forward

1. Loosen the sling under cystoscopic vision with gentle downward pressure on the urethra — usually ineffective, and contraindicated with a synthetic sling
2. Urethral dilation with downward traction
3. Transurethral resection or incision of the bladder neck — not recommended: it risks the sphincter and the bladder neck, and periurethral fibrosis can leave worse incontinence or a bladder neck contracture

• After 6 weeks, or when conservative measures fail → sling incision, then formal urethrolysis if that fails. Better to wait until 3 months post-operatively before a formal urethrolysis
  • Sling incision: comparable success, shorter, less morbid — but recurrent SUI 34% vs 0–19% after formal urethrolysis
  • Approaches: retropubic · transvaginal · suprameatal; success 65–93%; no parameter predicts success
• The temporal relationship between symptoms and surgery is the key criterion — UDS is essential
• Failure of urethrolysis — 4 causes: persistent/recurrent obstruction · DO · impaired contractility · learned voiding dysfunction
  • Most common reason is insufficient dissection → repeat urethrolysis is justified
• OAB is refractory in 50% after urethrolysis → consider SNM
• Always rule out apical, anterior and posterior prolapse as a cause of obstruction

Recurrent / complicated SUI

• Experienced centers only (Strong)
• Re-evaluate with cystoscopy and multichannel UDS
• Second-line surgery is inferior to first-line use — less effective, more complications (Weak)
• Options: secondary synthetic sling · bulking · Burch · autologous sling · AUS (Weak)
• Do NOT use an adjustable MUS for primary SUI outside research (Strong)

SUI Surgery at the Time of POP Surgery

The single biggest AUA/EAU divergence in this topic.

AUA / Campbell

• Adding a retropubic MUS to fascial plication, Burch, or abdominal sacrocolpopexy may reduce post-operative SUI (Cochrane, 22 RCTs)
• CARE trial: prolapse without pre-op SUI, sacrocolpopexy ± Burch → significantly higher incontinence at every follow-up point without the Burch
• Trade-off: prolapse repair at the time of sling → more outlet obstruction (9.4% vs 5.5%) but fewer repeat SUI or POP procedures at 1 year
• MUS placed for urodynamic or occult SUI at POP repair: risk of intervention for obstruction = risk of intervention for SUI without it (8.5% vs 8.3%)

EAU 2026

• Symptomatic or occult SUI: offer simultaneous surgery ONLY after full discussion of risks vs POP surgery alone (Strong); inform of increased AEs with combined surgery (Strong)
• No symptomatic or occult SUI: inform of de novo SUI risk (Strong); DO NOT offer concomitant anti-incontinence surgery at ABDOMINAL prolapse surgery (Strong)

Both agree (Strong) that occult SUI must be tested for and discussed. The disagreement is only whether to act on it prophylactically at an abdominal repair.

Urogenital Fistula — Principles

Click the algorithm to open it full size.

• Fistula = extra-anatomic communication between two epithelial- or mesothelial-lined cavities or the skin

"Fistula TO MIIND" — 8 factors

	Factor
F	Foreign body
T	Technical surgical problems
O	Obstruction — remove or bypass distal obstruction
M	Malignancy — biopsy the tract in anyone with prior malignancy
I	Ischemia
I	Infection
N	Nutrition
D	Drainage — unobstructed drainage ± stenting

11 principles of repair

1. Adequate exposure
2. Debride devitalized and ischemic tissue
3. Remove foreign bodies / synthetic material
4. Separate the involved cavities
5. Watertight closure
6. Well-vascularized healthy tissue flaps, atraumatic handling
7. Multiple layers
8. Tension-free, NON-OVERLAPPING suture lines
9. Adequate drainage ± stenting
10. Treat and prevent infection
11. Hemostasis

5 factors that prevent VVF at gynecological surgery

1. Immediate detection of bladder injury, using dyes if necessary
2. Watertight closure of the bladder
3. Satisfactory extravesical drain placement
4. Avoid a vaginal incision if possible once a bladder injury has been recognized
5. Prolonged, uninterrupted post-operative bladder drainage

Vesicovaginal Fistula

• 75% of acquired urinary tract fistulae

Causes — "Radical Obstetrical Colleagues' Trauma Causes Incontinence Fistula"

	Cause
R	Radiation — may appear decades later; any post-radiation fistula may be recurrent malignancy
O	Obstetric
C	Cancer
T	Trauma
C	Congenital
I	Infectious / inflammatory
F	Foreign body (vaginal prolapse mesh)
+	Post-surgical — dominant in the industrialized world

• Developing world: prolonged obstructed labor → pressure necrosis. Young primigravida with a narrow pelvis; part of the obstructed labor injury complex
  • Obstetric fistulae are LARGER, more DISTAL, and involve the BLADDER NECK and PROXIMAL URETHRA → difficult to repair
• Industrialized world: >75% follow surgical bladder injury — most commonly HYSTERECTOMY
  • Bladder injury at abdominal hysterectomy 0.5–1.0%; fistula after hysterectomy 0.1–0.2%
  • Of the surgical cases: hysterectomy for benign disease 60–75% · hysterectomy for malignancy ~30% · cesarean section ~6% · obstetric injury ~1% (approximate shares — they do not sum cleanly)
  • Three mechanisms: (1) unrecognized cystotomy near the vaginal cuff → urinoma → drains through the cuff → epithelialized tract; (2) tissue necrosis from cautery; (3) a suture placed through both bladder and vaginal wall at cuff closure, or a hemostatic ligature taken blindly for pelvic bleeding
  • Urogenital fistula is ≈9× more likely after radical hysterectomy for malignancy than simple hysterectomy
• Clear vaginal discharge after hysterectomy is not always urine — also seroma, lymphatic fistula, peritoneal fluid, peritoneovaginal fistula, normal vaginal secretions, tubal fluid, vaginitis

Post-operative risk factors

General	Specific
Diabetes	Malignancy
Ischemia	Neurogenic bladder
Arteriosclerosis	Cesarean section / prior uterine surgery
PID or infection	Pessary use
Prior radiotherapy	Endometriosis
Steroids	Endocervical conization (scarring)

Classification

WHO — simple vs complex

Simple (good prognosis)	Complex (uncertain)
Single, <4 cm	>4 cm, multiple
Vesicovaginal only	Rectovaginal mixed, cervical
Sphincters not involved	Sphincters involved
No circumferential defect	Circumferential defect, scarring
Minimal tissue loss	Extensive tissue loss
Ureters not involved	Intravaginal ureters
First repair attempt	Failed previous repair · radiation

Goh — by distance of the distal edge from the meatus (better predictive value than Waaldijk)

Type	Distal edge from meatus
1	>3.5 cm
2	2.5–3.5 cm
3	1.5–2.5 cm
4	<1.5 cm

• Size A <1.5 cm · B 1.5–3 cm · C >3 cm; fibrosis i / ii / iii. Higher type = worse prognosis

Waaldijk — by the closing mechanism

Type	Definition
I	Not involving the closing mechanism
IIA	Involves it, without (sub)total urethral involvement
IIB	Involves it, with (sub)total urethral involvement
III	Ureteric and other exceptional fistulae

• Closure falls and incontinence rises with type: I → 90.4% closure / 1.4% incontinence · IIB → 76.8% closure / 20.9% incontinence

A "complicated" VVF — 6 features (a separate descriptive list, not the WHO simple/complex split above — note it uses a 3 cm cut-off where WHO uses 4 cm)

• >3 cm in diameter
• Recurrent fistula, or a failed previous repair
• Prior radiotherapy
• Associated with malignancy
• At the trigone, bladder neck or urethra
• Compromised tissue that will heal badly

Diagnosis

• Most common complaint: CONSTANT vaginal drainage. Pain is uncommon
• Timing: either early — when the catheter comes out after the index operation — or at 1–3 weeks. Also recurrent cystitis and perineal skin irritation
• Always do a speculum exam — post-hysterectomy VVF sits on the anterior vaginal wall at the vaginal cuff
• Assess surrounding inflammation — it determines the timing of repair
• Record vaginal depth, coexisting prolapse, atrophy and introital size — each of them changes the surgical approach
• Palpate for pelvic masses that may need dealing with at the same operation, and look for postmenopausal atrophy — she may need pre-operative estrogen
• Look for available flaps — ask about previous perineal, lower abdominal or thigh surgery, which may have used the tissue you were counting on
• Confirm the fluid is urine: creatinine of the pooled fluid ≈ urine creatinine
• Cystoscopy with retrograde bladder filling using a colored fluid confirms the diagnosis (Weak) — and a VVF close to a ureteric orifice may force an abdominal approach with reimplantation, which is a decision to make at cystoscopy, not in theatre
• A cystogram without VOIDING or POST-VOID images is NON-DIAGNOSTIC — and take it in the LATERAL position, so that bladder and vagina do not overlap
• Image the upper tract — up to 12% of post-surgical VVFs have a ureteric injury or ureterovaginal fistula
• Biopsy the defect in anyone with malignancy or radiation history

The dye tests

Single dye (intravesical blue), vaginal packing

Staining	Diagnosis
Introital / distal	Incontinence or urethrovaginal fistula
Proximal	VVF
Dye-free → repeat with IV indigo carmine → proximal staining	Ureterovaginal fistula

Double-dye (tampon): oral phenazopyridine + intravesical blue

Tampon segment	Color	Diagnosis
Top	Yellow-orange	Ureterovaginal
Middle	Green	VVF
Bottom	Blue	Urethrovaginal
No stain anywhere	Clear	Peritoneovaginal fistula

• A negative dye test may just be a dry moment — have her walk for a while and repeat it

Management — 4 options

1. Indwelling catheter

• Trial 2–3 weeks of catheter drainage with an antibiotic and an anticholinergic in newly diagnosed VVF; spontaneous closure ≈13% — essentially only small fistulae under 5 mm
• Start drainage immediately to prevent epithelialization
• Most favorable: <2–3 mm, simple injuries without devascularization or thermal spread
• Still open at 3 weeks → it will not close

2. Fulguration — for small epithelialized tracts <3–5 mm

• Risks failure and ENLARGEMENT if: thin vesicovaginal septum · large VVF · non-oblique tract · significant inflammation

3. Fibrin sealant — adjunctive only

4. Surgery

	Abdominal	Transvaginal
Timing	Eventually within 2–3 weeks, but often delayed 3–6 months	Can be done immediately in the absence of infection or other complication
Exposure	Struggles with a fistula low on the trigone or near the bladder neck	Struggles with a fistula high at the vaginal cuff
Ureters	A fistula near the ureteric orifice may force reimplantation	Reimplantation may be unnecessary even when the tract is near the orifice
Sexual function	No change in vaginal depth	Risk of vaginal shortening, especially with Latzko
Flaps available	Omentum · peritoneum · rectus abdominis	Labial fat pad (Martius) · peritoneum · gluteal skin · gracilis myocutaneous
Relative indications	Large fistula · high in a deep narrow vagina · radiation fistula · failed transvaginal repair · small-capacity bladder needing augmentation · needs ureteric reimplantation · cannot be placed in lithotomy	Uncomplicated, low fistulae
Complications	Higher morbidity · longer stay · more transfusion · more readmission · higher sepsis risk	Vaginal shortening
Cost	High	Low

• Further advantages of the vaginal route: avoids laparotomy · short theatre time · short stay and early return to work · less pain · minimal blood loss · no need to bivalve the bladder · allows a 3- or 4-layer closure · dissection is unaffected by previous abdominal or pelvic surgery · concomitant anti-incontinence or prolapse surgery can be done at the same sitting · local interposition flaps are immediately adjacent · if it fails, the abdominal route is still available

• Further disadvantages: requires high lithotomy · cannot perform concomitant abdominal surgery if any is needed · contraindicated when the fistula is proximal to a ureteric orifice

• Success rates are similar — the surgeon's experience is the most important factor (pooled: transvaginal 90.9% vs transabdominal 84%)

• No difference in ureteric injury risk between routes

• Excising the tract is not always necessary and may compromise the repair

• Transvaginal repair uses a 3–4 layer closure; two techniques — flap-splitting (Raz) and Latzko partial colpocleisis, with no proven superiority

Transvaginal technique	What it does	Key points
Flap-splitting (Raz)	3-layer closure — bladder, perivesical layer, vaginal flap (4 layers with an adjuvant flap)	The tract is NOT excised. Catheter 2–3 weeks then cystogram; vaginal packing 24 h; anticholinergic; no intercourse for 3 months
Latzko high partial colpocleisis	Denudes the vaginal tissue around the tract circumferentially for 1–2 cm, reapproximates the denuded area over the tract, then closes the vaginal wall as a second layer	Less blood loss; no ureteric reimplantation needed. Risks vaginal shortening and — unusually — directly overlapping suture lines, which is the compromise this technique accepts
Webster vaginal cuff excision	Excises the tract, leaving a funnel-shaped defect from bladder to vagina	Closed in 3 or 4 layers

Transabdominal technique	What it does
O'Conor suprapubic	Extraperitoneal approach to the bladder, becoming intraperitoneal. The bladder is bivalved down to the fistula and the tract excised; bladder dissected off the vagina for 2–3 cm beyond the fistula; vagina closed, omental interposition, bladder closed in layers. Suprapubic tube + urethral catheter + anticholinergic
Gil-Vernet transvesical	Anterior cystotomy WITHOUT bivalving. The tract is circumscribed and excised transvesically; vaginal edges mobilized, then vagina and bladder closed sequentially. A V-flap of posterior bladder wall closes a large gap
Minimally invasive	Laparoscopic and robotic versions of the above

• Document sexual activity pre-op — Latzko causes vaginal shortening and dyspareunia
• Pre-op topical estrogen in the atrophic postmenopausal patient
• Post-op: continuous drainage is the most important part of the repair — catheter 10 days minimum, usually 2–3 weeks (14–21 days if complex or post-radiation), then VCUG before removal

Tissue interposition — 5 indications

1. Recurrence after a prior repair
2. Previous radiotherapy
3. Ischemic or obstetric fistulae
4. Large fistulae
5. Difficult or tenuous closure from poor tissue quality

Route	Preferred flap
Transvaginal	Martius or peritoneum
Transabdominal	Omentum or peritoneum
Others	Gracilis · labial myocutaneous · seromuscular intestinal · rectus abdominis · gluteal skin

• Martius flap — labial fat pad ± bulbospongiosus. Blood supply (3): superiorly external pudendal · laterally obturator · inferiorly posterior labial (from internal pudendal). The lateral (obturator) and inferior (posterior labial) pedicles are SACRIFICED — the flap swings on the superior external pudendal supply
  • Preferred for LOW/DISTAL fistulae involving trigone, bladder neck, urethra
  • Will not reach a fistula >8–10 cm from the introitus
• Peritoneal flap — preferred for HIGH post-hysterectomy VVF, above the trigone or around the vaginal apex (a Martius flap tunnelled that far may lose its blood supply). It can be harvested through the TRANSVAGINAL approach when the fistula is high — a high fistula does not by itself force you abdominal
• Omental flap — the LEFT gastroepiploic (from the splenic artery) is SACRIFICED; the flap swings on the RIGHT gastroepiploic (from the gastroduodenal, from the common hepatic). Blood supply enters perpendicular to the greater curvature, permitting vertical incisions. Excellent in infection or inflammation. Mainly a transabdominal flap — usable transvaginally only if it was brought down at a previous operation

Outcomes

• Simple VVF repair >90% success (up to 96% primary transvaginal)
• Radiation, obstetric and large fistulae do worse — primary closure in radiation fistulae only 48%
• Time the repair to TISSUE CONDITION, not the calendar — operate once edema, inflammation, necrosis and infection have resolved. There is no evidence that a fixed delay improves outcome; irradiated tissue simply takes longer to become ready
• Post-op cystogram must include voiding or post-void images; 2–3 weeks is adequate timing
• Late complications (3): vaginal shortening · vaginal stenosis · recurrence
• Obstetric fistulae with loss of the bladder neck and proximal urethra → high rates of persistent severe sphincteric incontinence despite successful closure
  • Report fistula CLOSURE and post-op INCONTINENCE separately — anatomic closure does not mean dry
• Failed repeatedly or not repairable → urinary diversion; non-surgical candidates → percutaneous ureteric occlusion and permanent nephrostomy

The Other Urogenital Fistulae

	Ureterovaginal	Vesicouterine	Urethrovaginal
Cause	Injury to the distal third of the ureter, below the iliac vessels; laparoscopic hysterectomy for benign disease is the commonest cause	LOW-SEGMENT cesarean section — much the commonest. Also IUD · placenta percreta · traumatic catheterization · uterine rupture	Iatrogenic — SUI surgery, diverticulectomy, reconstruction. Also obstructed labor · vaginal tumors · radiotherapy · trauma
Presentation	Constant leak 1–4 weeks post-op — but she VOIDS NORMALLY	May NOT leak — the cervix acts as a sphincter; continuous only if the cervix is incompetent (post-partum)	Depends on site: proximal/bladder neck → continuous · distal → splayed stream or asymptomatic
Key test	Upper tract imaging — CT urogram shows obstruction with caliectasis; cystography only to exclude a coexistent VVF	Cystoscopy + CT urography, ± hysterosalpingogram	VCUG most useful; three-swab test often enough
Management	Decompress urgently. Attempt a retrograde JJ stent — if it fails, PCN with antegrade stenting. If stented successfully, remove the stent at 4–6 weeks and re-image; persistent fistula → ureteroneocystostomy, success >90%	Prolonged catheter, or fulguration if small and immature. Induction of amenorrhea (estrogen, estrogen/progesterone or an LHRH analogue) is case-report level only and applies to small (<7 mm) post-cesarean fistulae — not a routine option. Surgery ± hysterectomy, depending on fertility wishes	Vaginal approach preferred. Do NOT excise the tract — incorporate it into the first layer. Martius flap commonly used
Pearl	Most common urinary injury at hysterectomy is a bladder laceration, not the ureter	Among the least common urogynecologic fistulae	Coexisting VVF in up to 20% — evaluate the whole lower tract

• Iatrogenic ureteric injury at major gynecologic surgery ≈0.5–2.5%
• Do NOT routinely place prophylactic ureteric stents in gynecologic surgery (Strong) — an RCT of 3,141 women found no difference to the 1% injury risk
• Suspect ureteric injury after pelvic surgery if there is a fluid leak, pelvicalyceal dilatation, or high-creatinine drainage fluid (Strong)
• Urethrovaginal fistula: 90.1% close at the first vaginal attempt — but SUI develops in 52%; slings then make ~60% dry, 32% improved. If a sling is added, never synthetic
• Hysterectomy does NOT cause urethrovaginal fistula
• Youssef's syndrome — the classic vesicouterine presentation: cyclical hematuria (menouria) · apparent amenorrhea · infertility · and urinary CONTINENCE. She is dry because the cervix is competent, so the urine takes the menstrual route instead

Ureterovaginal fistula — detail

• Risk factors: obesity · prior pelvic surgery · PID · endometriosis · radiotherapy · pelvic malignancy
• Mechanisms: ureteric laceration or transection · blunt avulsion · crush injury · partial or complete suture ligation · ischemia
• A mature, large fistula can leave the upper tract looking completely normal — the give-away is then contrast opacifying the vagina before the post-void image, not obstruction
• Early repair is preferred, though some still advocate a 4–8 week delay
• Consent for a psoas hitch and a Boari flap — you may need length, and confirm the contralateral kidney is functioning before committing to anything

Vesicoenteric fistula — for contrast

• Diverticulitis 65–75% — the commonest cause overall, especially for colovesical fistula; then malignancy 10–15%, then Crohn ~5%
• Urinary symptoms are commoner than bowel symptoms. Pneumaturia 52–77% is the commonest, then fecaluria
• Gouverneur syndrome — the classic presentation: suprapubic pain · urinary frequency · dysuria · tenesmus
• CT with contrast is the modality of choice — 3 suspicious findings: bladder wall thickening next to thickened colon · air in the bladder · colonic diverticula
• Cystography and barium enema are less likely to show it
• Conservative — for a non-malignant cause in a non-septic patient: nil by mouth · TPN · catheter · antibiotics
• Single-stage (excise the fistula, resect the bowel segment, close both organs) — inflammatory cause without gross contamination
• Two-stage (excise, close, plus a proximal diverting colostomy) — gross contamination · unprepared bowel or abscess · severe inflammation · radiation injury · advanced malignancy · intestinal obstruction · significant comorbidity or advanced age

Female Urethral Diverticulum

Click the algorithm to open it full size.

• A urine-filled periurethral cystic structure connected to the urethra by an OSTIUM
• Prevalence 1–6% of adult women (up to 10% in a tertiary LUTS clinic); presents in the 3rd–7th decade
• The vast majority are ACQUIRED — from infection of the periurethral (Skene) glands → abscess → rupture into the urethral lumen → epithelialized cavity
• Up to 20% have prior urethral surgery, dilation or traumatic delivery — including after a synthetic MUS

Anatomy and histology

• Ostium is postero/ventrolateral at the 4 and 8 o'clock positions in the mid- or distal urethra in >90% — matching the periurethral glands
• Two-thirds of resected specimens show inflammation; neoplastic change in 6%

Lesion	Most common malignant histology
Urethral diverticulum	ADENOCARCINOMA
Female urethral carcinoma	Squamous cell
Male urethral carcinoma	Urothelial

Urethra	Proximal / posterior	Distal / anterior
Female	External iliac nodes	Superficial inguinal
Male	Pelvic nodes	Superficial inguinal

Differential — 7 periurethral masses

1. Periurethral bulking agents — also mimic a diverticulum on MRI
2. Vaginal leiomyoma
3. Skene gland abnormalities
4. Gartner duct abnormalities
5. Vaginal wall cysts
6. Urethral mucosal prolapse
7. Urethral caruncle

Caruncle vs prolapse: a caruncle is FOCAL, urethral prolapse is CIRCUMFERENTIAL. Caruncle = inflammatory lesion of the distal urethra in postmenopausal women → topical estrogen / anti-inflammatory cream + sitz baths; excise if large, refractory, or atypical.

Presentation

• Up to 20% are ASYMPTOMATIC
• Three commonest symptoms: storage LUTS · pain · infection
• LUTS + post-micturition dribble + recurrent UTI = the strongest combination
• Recurrent cystitis should raise the suspicion
• Others: dysuria · hematuria · post-void dribbling · retention · incontinence · dyspareunia · vaginal mass · discharge
• Vaginal pruritus is NOT a symptom
• Size does NOT correlate with symptoms — but size DOES correlate with recurrence after repair
• Mean delay to diagnosis 5.2 years across ~nine physicians, despite 52% having a palpable mass
• Milk the urethra distally to express pus or urine. A HARD mass suggests a stone or cancer

Imaging — the sensitivity ladder

Modality	Sensitivity
MRI — the gold standard	97.2%
Double-balloon urethrography	94.7%
Ultrasound	82.0%
VCUG	73.5%
Cystoscopy (seeing the ostium)	42.4%

• VCUG needs AP and lateral views; high false-negative rate — the ostium must be patent and she must be able to void
• Double-balloon is painful, technically demanding and carries UTI risk — reserve for those who cannot have MRI
• Stones are found in the diverticulum 4–10% of the time

Classification

• L/N/S/C3: Location · Number · Size · Configuration · Communication · Continence
• Morphology: simple · SADDLEBAG (partly surrounds the urethra) · CIRCUMFERENTIAL (completely surrounds it)
• Leng & McGuire — the surgically useful one: classified by whether the periurethral fascia is preserved
  • Absent/deficient fascia = PSEUDODIVERTICULUM → needs an interposition flap (Martius) or a graft such as an autologous sling

Management

• Observation: low-dose antibacterial suppression + digital stripping after voiding
  • Counsel the 1–6% risk of cancer. Surveillance interval is unknown
• Intervention for symptoms: dysuria, dyspareunia, refractory post-void dribbling, recurrent UTI, pelvic pain
• 5 options: excision with reconstruction (most common) · marsupialization (Spence-Duckett) · endoscopic unroofing · fulguration · incision and obliteration
• Spence-Duckett marsupialization creates a "hypospadiac" meatus — only for very distal lesions in women who are not sexually active
  • Aggressive proximal extension risks SUI; a pseudoseptum can cause dyspareunia

Diverticulectomy — 8 principles

1. Well-vascularized anterior vaginal wall flap
2. PRESERVE THE PERIURETHRAL FASCIA as a separate layer
3. Identify and excise the neck / ostium
4. Remove the ENTIRE wall or sac
5. Watertight urethral closure
6. Multilayered, NON-OVERLAPPING closure, absorbable suture
7. Close dead space
8. Preserve or create continence

• Inverted-U incision, limbs progressively wider proximally to protect the flap's blood supply
• Inject saline, not a vasoconstrictor — so bleeding vessels declare themselves early
• Incise the periurethral fascia transversely; close the fascial flaps PERPENDICULAR to the urethral suture line — this non-overlap is what prevents a fistula
• Urethra closes over as small as a 12F catheter without long-term stricture risk
• Three-layer closure (four with a Martius flap)
• Add a Martius flap for: recurrence · large defect · deficient flaps · circumferential lesion needing urethral transection · attenuated fascia (pseudodiverticulum) · significant inflammation · a planned future sling

Concomitant SUI

NEVER use synthetic mesh in an anti-incontinence procedure at the time of diverticulectomy — urethral erosion, infection, urethrovaginal fistula, granuloma.

• Bothersome SUI → concomitant NON-SYNTHETIC sling (autologous pubovaginal fascial sling) (Weak)
• Do NOT place a prophylactic sling in a continent patient
• Diverticulectomy alone cures SUI in ~50% — operating on everyone is overtreatment
• Mild, non-bothersome SUI → diverticulectomy alone, then re-evaluate; 60% of de novo SUI resolves with 12 months of conservative measures
• Question and investigate every patient for coexisting voiding dysfunction and incontinence before operating (Strong)
• Videourodynamics separates true SUI from paradoxical incontinence (urine draining out of the diverticulum) and from post-void dribbling / vaginal voiding
• There is no consensus on the timing of the two operations — diverticulectomy and any anti-incontinence procedure
• SUI coexists in up to 60%; more proximal lesions are at greater risk of post-op SUI

Outcomes and complications

• Success (dry) 84–98%, reoperation 2–13%

Complication	Rate
Recurrent diverticulum	10–22% — U-shaped 33%, circumferential 60% at 1 year
Recurrent UTI	0–31%
Urinary incontinence / de novo SUI	1.7–16.1% (de novo SUI 3.8–33%)
Urethrovaginal fistula	0.9–8.3%
Urethral stricture	0–5.2%
De novo retention	0–9% — especially with a concomitant autologous sling

• De novo SUI risk factors: >30 mm · proximal · circumferential · shorter urethral length
• Recurrence causes: incomplete removal · inadequate urethral closure · residual dead space in circumferential lesions
• Post-diverticulectomy urethrovaginal fistula:
  • Distal to the sphincter → split stream / vaginal voiding, may need no repair
  • Mid-urethra to bladder neck → incontinence → repair at 3–6 months, consider a Martius flap
• Counsel that LUTS may persist or appear despite a technically successful operation (Strong)

AUA vs EAU — Quick Reference

Topic	AUA / Campbell	EAU 2026
LPP / UPP to grade severity	ALPP <60 or MUCP <20 defines ISD — the only pre-op route to it	Do NOT use UPP or LPP to grade severity (Strong)
Questionnaires	"Low strength of evidence"; optional	Use a validated condition-specific questionnaire (Strong)
Duloxetine	Absent from the female SUI list	Offer to selected patients (Weak)
Anti-incontinence surgery at abdominal POP repair	CARE: sacrocolpopexy + Burch reduced post-op incontinence	Do NOT offer at abdominal prolapse surgery (Strong)
Imaging the urethral diverticulum	"No single gold standard"; imaging cannot reliably diagnose malignancy	MRI is the gold standard, and useful for tumor
Retropubic vs transobturator MUS	Similar overall with normal urethral function; retropubic better in ISD	Retropubic outcomes are SUPERIOR long-term (Strong)
Bulking agents	Two narrow indications	Offer to any woman requesting a low-risk procedure (Strong)