Female Urology and Pelvic Floor

Female patients present with incontinence, recurrent UTIs, pelvic organ prolapse, and pelvic pain. Chapters 5 (OAB/SUI), 6 (UTI/rUTI), and 27 (IC/BPS) cover much of the medical management; this chapter adds the female-specific anatomy, exam, and procedures.

15.1 The focused female pelvic exam

• Examine with a comfortably full bladder if you intend to assess for stress leakage.

• Look for: vaginal atrophy (pale, thin, dry mucosa with loss of rugae), urethral caruncle or diverticulum (a tender anterior vaginal wall mass that expresses purulent fluid or urine), prolapse (use a split speculum to assess each compartment separately), and pelvic floor muscle tone and tenderness.

• Cough stress test: have the patient cough with a full bladder — instantaneous leakage confirms stress incontinence. Leakage that is delayed or prolonged suggests a cough-induced detrusor contraction.

• Assess pelvic floor strength digitally and note whether the patient can isolate a contraction — many cannot, and instead bear down (which is exactly wrong).

15.2 Pelvic organ prolapse (POP)

Descent of the pelvic organs through a weakened vaginal support system. The cardinal symptom is a sensation of bulge or pressure — “something falling out” — that worsens through the day and with standing. Prolapse can also cause voiding dysfunction (a large cystocele can kink the urethra and cause retention), defecatory dysfunction, and sexual dysfunction.

• Staging: POP-Q, referenced to the hymen. Stage 0 = no prolapse; Stage 2 = at the hymen; Stage 4 = complete eversion. Symptoms correlate best with prolapse at or beyond the hymen.

• Conservative: a vaginal pessary is highly effective, low-risk, and appropriate for essentially any patient who wants to avoid surgery — it is fitted in the office and is a common APP-managed service (requires periodic removal, cleaning, and mucosal checks; use vaginal estrogen alongside it to prevent erosion). Pelvic floor physical therapy helps mild prolapse and associated symptoms.

• Surgical: reconstructive repair (anterior/posterior colporrhaphy; apical suspension — robotic sacrocolpopexy is the gold standard for apical prolapse, or a vaginal sacrospinous ligament fixation), or an obliterative procedure (colpocleisis) for elderly patients not desiring vaginal intercourse.

15.3 Vaginal estrogen — the highest-yield tool in female urology

• For peri- and postmenopausal women, local vaginal estrogen treats the genitourinary syndrome of menopause (GSM): vaginal dryness, dyspareunia, urinary urgency, frequency, dysuria, and recurrent UTIs.

• It works by restoring vaginal pH, repopulating protective lactobacilli, and thickening the urethral and vaginal epithelium.

• Safety: minimal systemic absorption; it does NOT require a progestogen, and the FDA has removed the boxed warning from low-dose vaginal estrogen. It is appropriate for long-term use in most women. Coordinate individually for women with a hormone-sensitive cancer history (many can still use it — discuss with their oncologist).

• Forms: cream (Estrace), tablets/inserts (Vagifem, Imvexxy), and the ring (Estring). Typical use is a loading period then 2–3×/week. Full benefit takes 4–12 weeks — tell the patient, or she will quit at week three.

• Alternatives: vaginal DHEA (prasterone) and oral ospemifene.

15.4 Recurrent UTI in women

• Follow our practice Beyond-Antibiotics protocol (Chapter 6): Hiprex, vaginal estrogen (Estrace), reduced sugar, and daily CIC bladder irrigation with ~300 cc sterile/distilled water — not supplements — with antibiotics reserved for the rare true, symptomatic infection.

• Confirm each true infection with culture; bacteriuria and cloudy/odorous urine without symptoms are not treated.

• Straightforward rUTI without red flags does not mandate cystoscopy/imaging; investigate (cystoscopy, upper-tract imaging) for hematuria, obstruction, stones, symptoms with repeatedly negative cultures, or new-onset recurrent infection over age 50.

• Do not miss a urethral diverticulum: the classic triad is dysuria, dyspareunia, and post-void dribbling, with a tender anterior vaginal wall mass. MRI is the best imaging. It is a fixable cause of “refractory recurrent UTI.”

15.5 Stress urinary incontinence — our practice treatment options

SUI is leakage with cough/laugh/exertion (Chapter 5). Beyond pelvic floor therapy and pessary support, Associated Medical Professionals of New York offers:

• Bulkamid (urethral bulking): an in-office, cystoscopically delivered polyacrylamide hydrogel injected into the urethral wall to restore coaptation. Minimally invasive, repeatable, no mesh, quick recovery — an excellent option for women who want to avoid a sling, who have intrinsic sphincter deficiency, or who are poor surgical candidates.

• Midurethral sling: the most durable surgical correction for stress incontinence.

• Magnetic pelvic floor therapy (“Magic Chair”): non-invasive electromagnetic stimulation to strengthen the pelvic floor, done clothed in the office.

• For post-prostatectomy male SUI: male sling, the ProACT adjustable balloon system, or an artificial urinary sphincter.

15.6 Female pelvic pain and voiding dysfunction

• Interstitial cystitis / bladder pain syndrome (IC/BPS): chronic bladder pain/pressure with urgency/frequency and NO infection — a key mimic of recurrent UTI (repeatedly negative cultures point here). Covered in depth in Chapter 27.

• Pelvic floor dysfunction (non-relaxing pelvic floor): hypertonic muscles can drive urgency, hesitancy, incomplete emptying, dyspareunia, and pain. Pelvic floor physical therapy — with a therapist skilled in internal work — is the cornerstone. Do NOT prescribe Kegels for a hypertonic pelvic floor; you will make it worse.

• Lichen sclerosus: a chronic inflammatory skin condition of the vulva causing itching, white atrophic “cigarette-paper” skin, and architectural loss. Treat with high-potency topical steroids; it carries a small risk of squamous cell carcinoma and needs monitoring.

• Fowler's syndrome: urinary retention in a young woman from a non-relaxing urethral sphincter; associated with polycystic ovaries. Sacral neuromodulation is the treatment of choice — an important InterStim indication (Chapter 25).