Urinary incontinence

Pelvic organ prolapse is descent of the anterior or posterior vaginal wall, the uterus, or the vaginal cuff into or beyond the vaginal introitus from loss of pelvic floor support. It is a clinical diagnosis made on Valsalva examination; treatment is a vaginal pessary for most patients and compartment-specific reconstructive or obliterative surgery for those who fail or decline conservative care.

Overactive bladder is a clinical diagnosis of urinary urgency, usually with frequency and nocturia, with or without urge incontinence, in the absence of urinary tract infection or another identifiable cause, reflecting involuntary detrusor contraction during bladder filling. First-line treatment is behavioral therapy (bladder training with timed voiding, fluid and bladder-irritant modification), second-line is an antimuscarinic or a beta-3 agonist, and refractory cases proceed to intradetrusor onabotulinumtoxinA or sacral neuromodulation after confirming a normal postvoid residual.

Neurogenic bladder is dysfunction of bladder storage or emptying caused by disease or injury of the central or peripheral nervous system, producing either a spastic, high-pressure bladder with urgency incontinence or an atonic, high-volume bladder with retention and overflow incontinence depending on lesion location. Diagnosis rests on the neurologic history and exam with urodynamic testing, and management is centered on a regular, low-pressure emptying regimen, most often clean intermittent catheterization, to protect renal function and prevent infection.

Genitourinary syndrome of menopause is the chronic, progressive constellation of vulvovaginal and lower urinary tract symptoms caused by estrogen deficiency, presenting with vaginal dryness, dyspareunia, and recurrent urinary symptoms in menopausal women. It is a clinical diagnosis treated first with nonhormonal moisturizers and lubricants, then low-dose vaginal estrogen, with ospemifene or vaginal prasterone reserved as second-line options.

Vesicovaginal fistula is an abnormal epithelialized tract between the bladder and vagina that produces continuous, painless leakage of urine from the vagina, most often after pelvic surgery (especially hysterectomy) in resource-rich settings or prolonged obstructed labor in resource-limited settings. Small fistulas found early may heal with prolonged bladder (Foley) catheter drainage; established fistulas require surgical closure, timed to let inflammation resolve.

Obesity is a chronic disease of excess adiposity, defined by a body mass index of 30 or greater, that raises risk for type 2 diabetes, cardiovascular disease, sleep apnea, liver disease, and several cancers. Management is staged: lifestyle intervention for all patients, pharmacotherapy after 3 to 6 months of unmet lifestyle goals, and bariatric surgery for a body mass index of 40 or greater or 35 or greater with a comorbidity.

Constipation is infrequent, difficult, or incomplete defecation that is secondary to an identifiable cause, most often a medication, or functional once secondary causes are excluded. Diagnosis rests on alarm-feature screening and Rome IV criteria for the functional subtype, and treatment proceeds stepwise from fiber and osmotic laxatives through secretagogues, prokinetics, biofeedback, or peripheral opioid antagonists.