The patient is a 59-year-old woman with a history of pelvic pain who presents for initial evaluation. In 1987, she had a difficult delivery which resulted in “damage in the rectal and bladder areas” with uterine prolapse. She had a hysterectomy in 1991. She experienced voiding symptoms and difficulty with bowel evacuation from 2003 to 2006. She had seen multiple providers over the years for ongoing “voiding issues.” In 2007, she had a TVT, vaginal enterocele repair, sacrospinous ligament vault suspension, posterior colporrhaphy with perineorrhaphy, and dermal allograft in the posterior compartment. Later in 2010, she underwent a laparoscopic sacrocolpopexy for vault prolapse and a traction enterocele. Finally, in 2014, she had transanal rectocele repair performed with synthetic material. She presented to our clinic in 2015 due to primarily urinary frequency. She was “worried that [her] bladder is at the wrong angle.” The most recent rectocele surgery had aggravated her symptoms. She described LUTS (frequency every 2 h while awake, nocturia × 2–3, weak stream, incomplete emptying, post-void dribbling, intermittency, and posturing/straining to void). She also endorsed urge incontinence and used 1–2 pads per day. She continued to have pelvic pain. The patient underwent a comprehensive evaluation including examination for mesh complications, intervention for high-tone pelvic floor dysfunction, and urodynamic testing .

Vitals within normal limits. BMI 26. Alert and oriented to person, place, and time. Normal mood and affect. No acute distress. Heart regular rate and rhythm no murmurs, rubs, or gallops. Chest clear bilaterally. Abdomen soft, non-distended, non-tender, and no masses. Well-healed surgical scars. No costovertebral angle tenderness. No spinal scars. Pelvic: + vaginal atrophy. Baden-Walker Grade 1 cystocele (POPQ Aa and Ba-2). Some palpable kinking at the level of the TVT. No appreciable stress incontinence or urethral hypermobility. + High-tone pelvic floor (levator: puborectalis and iliococcygeus) muscles with tender trigger points. No mesh erosion. Nonlocalizing neurological exam, normal anal wink and sphincter tone .

Urinalysis—negative for blood, nitrates, leukocyte esterase, and protein. Post-void residual volume 100 cm³ directly post-void.

See Figs. 8.3 and 8.4.

For this complex patient, we performed a trial of pessary prior to sling takedown in order to reassure her that the sling rather than the prolapse was causing the obstruction. She was sent for pelvic floor rehabilitation and treated the urgency with anticholinergics as part of her program given the multiple surgeries and the likelihood of acquired voiding dysfunction related to her pain and obstruction. Additional treatment options would have included intermittent catheterization but given the normal bladder contraction on urodynamics this was down-counseled. Recurrent stress incontinence and worsening of the urge incontinence were advised as risks of urethrolysis .

The patient is a 67-year-old woman who was seen in consultation for pelvic organ prolapse. She was initially referred by her primary physician to a gynecologist who confirmed her diagnosis of cystocele. She stated that she had had trouble with her “bladder dropping.” She denied symptoms, but it did bother her to know that the “bulge” was there. She denied LUTS. She did, on further questioning, describe unawares incontinence of two light pads per 24 h, and the odor bothered her.

Vitals within normal limits. BMI 27. Alert and oriented to person, place, and time. Normal mood and affect. No acute distress. Heart regular rate and rhythm no murmurs, rubs, or gallops. Chest clear bilaterally. Abdomen soft, non-distended, non-tender, with no masses. Well-healed lower midline abdominal surgical scars. No costovertebral angle tenderness. No spinal scars. Pelvic: + vaginal atrophy. Baden-Walker Grade 3 cystocele and Grade 1–2 uterine prolapse (POPQ Aa + 3, Ba +5, C-3) on supine as well as standing exam. Levator muscles soft, strength three fifths. There was no leakage with cough/Valsalva. Urethral mobility 30°. Normal resistance on catheterization with a post-void residual of 325 mL. Nonlocalizing neurological exam, normal anal wink and sphincter tone .

Urinalysis—negative for blood, nitrates, leukocyte esterase, and protein.

Renal ultrasound without hydronephrosis.

Post-void residual urine assessment via catheterization was 325 mL.

See Figs. 8.5 and 8.6.

The patient was managed initially with a pessary, and we demonstrated improved emptying. She also appreciated dry liners with resolution of the unawares incontinence. There was no new stress incontinence with pessary reduction. She was presented with the option of surgical repair and underwent sacrospinous ligament apical vaginal vault suspension and cystocele repair with plication and cadaveric dermal graft to the arcus tendineus fascia pelvis and sacrospinous ligaments. At follow-up she did very well, with resolution of the bulge as well as the urinary leakage, normal voiding patterns, and the absence of de novo stress urinary incontinence .

The patient is a 42-year-old woman who was seen in consultation for urinary retention, referred by her nephrologist with a creatinine of 3.1 and hydronephrosis on ultrasound. She reported gradual onset of incontinence followed by frank retention, leading to a hospital stay in the United Kingdom in which she was diagnosed with “Fowler’s syndrome .” She was started on clean intermittent catheterization prior to travel to the United States one month prior to evaluation. She described unawares incontinence, and when the bladder was full she had back pain.