Use of a Sims speculum or the posterior blade of a Graves speculum can allow the examiner to inspect the anterior and posterior compartments separately, and the apex can be examined digitally or by retracting the anterior and posterior compartments simultaneously. Rectovaginal examination can also be useful in evaluation of the posterior compartment, including differentiating between rectocele and enterocele [27].

The Pelvic Organ Prolapse Quantification (POPQ ) System is widely used in the research setting as it allows for standardization of physical findings by defining the locations of points on the anterior, posterior, and apical vagina as well as genital hiatus and perineal body (see Fig. 13.2) [28]. While the entire POPQ does not necessarily need to be performed in the clinical setting, identification and recording of key attributes including the leading edge of the anterior, apical, and posterior compartments is important and clinically relevant [27]. Stages of prolapse are 0-IV based on the leading edge, e.g. most severe portion, of the prolapse with 0 being no prolapse (apex is within 2 cm of total vaginal length) and stage IV being total eversion within 2 cm of the total vaginal length [28].

Pelvic organ prolapse presents along a spectrum from asymptomatic women with minimal anatomic findings to severely bothered patients with total vaginal vault prolapse or uterine procidentia. Generally speaking, asymptomatic patients do not require treatment, and surgery should not be performed unless the patient’s symptoms warrant the potential risks of intervention [27]. Whereas in the past, some thought that early surgical treatment of prolapse may prevent progression, observation of a cohort treated for stress urinary incontinence showed that only 2 % of asymptomatic women with stage II prolapse had any anatomic worsening of their disease and none underwent surgical treatment in the 5- to 7-year follow-up period [29].

For women who are symptomatic, non-surgical management options include pessaries and pelvic floor muscle training. These options can be very appealing for women who have less bothersome symptoms or significant surgical risk, but they should be considered and offered to all women. Adjunct therapies to optimize other aspects of disease should also be considered including lifestyle changes, like weight loss, as well as treatment of chronic constipation and defecatory dysfunction [27].

The pessary is a very useful device for the non-surgical treatment of prolapse, and most women can be successfully fit. Of Medicare beneficiaries with a prolapse diagnosis, 11–13 % were treated with a pessary [30]. While there are many different designs and sizes, the two main categories are support and space-filling, and the ring with support and Gellhorn pessaries are probably the most useful in each of these respective categories (see Fig. 13.3) [27, 31]. The ring with support is often the first choice because of its ease of use and ability for many patients to remove, clean, and manage it themselves. For women who cannot retain the ring with support, a Gellhorn is often an effective option, but it tends to require provider visits for removal and cleaning [31]. Women who are sexually active and use a pessary should be able to remove and reinsert the pessary themselves since most, if not all, pessaries are not compatible with vaginal intercourse [31]. Vaginal epithelial health is an important consideration with pessary use, and vaginal estrogen therapy should be considered if needed, although many women may not require it. Periodic inspection of the vagina for abrasions and ulcerations is essential, and compliance with follow-up is key to identifying problems before they result in severe complications [27, 31]. While there are no data-driven guidelines on follow-up intervals, typically every 3–6 months for a patient unable to remove her own pessary is reasonable, and that can be extended as long as 1 year for a woman who is able to remove and clean the pessary frequently herself [31, 32]. Usually minor abrasions or ulcerations can be resolved by leaving the pessary out and applying vaginal estrogen cream for several weeks. More significant complications, such as fistula formation, typically only result from extended neglect [31]. Vaginal discharge and unmasking of occult stress urinary incontinence can also be bothersome side effects of pessary use [31, 33].

Pelvic Floor Muscle Training (PFMT ) can be effective in reducing symptoms for women with mild to moderate (usually stage I to II) prolapse [31]. This treatment usually involves working on isolation of pelvic floor muscles and doing exercises which strengthen and improve muscle bulk. Studies have shown both symptomatic and anatomic improvements with PFMT for patients with stages I, II, and III prolapse [31, 34]. Success of these treatments is likely dependent, however, on having motivated patients who are willing to comply with the exercise program.

For women who desire more than non-surgical management for their prolapse symptoms, there are many surgical treatment options available. These options include both obliterative and reconstructive procedures.

Obliterative procedures, such as the Le Fort colpocleisis with levator plication and high perineorrhaphy, have many advantages for women who do not desire preservation of the ability for vaginal intercourse. These procedures tend to be shorter and less morbid than reconstructive repairs and are highly effective [27, 35–39]. Success rates range from 91 to 100 %, which is outstanding for efficacy of prolapse repair [38]. Patient-centered outcomes are excellent with 90–95 % of patients experiencing improved quality of life, satisfaction with outcome, and willingness to recommend the procedure to others [35, 36, 38]. Post-surgical regret, although very uncommon (approximately 5–10 %), is not zero risk [27, 35, 40].Urinary tract infection is the most common postoperative complication, and women who underwent simultaneous colpocleisis and midurethral sling do not have increased complications in the immediate postoperative period [37].

Reconstructive repairs can be performed vaginally or abdominally, and can be performed with native tissue or using augmentation with mesh, fascia, or biologic grafts. Minimally invasive options include the vaginal, laparoscopic, and robotic approaches. Currently, no clinical trials have definitively shown which methods of prolapse repair are the most effective.

Vaginal native tissue or “traditional” repairs can be performed in all three compartments: apical, anterior, and posterior. The two most common methods used for apical support are the high uterosacral ligament suspension and sacrospinous ligament fixation (see Figs. 13.4 and 13.5) [41–44]. These methods were compared head-to-head in the Pelvic Floor Disorders Network’s Operations and Pelvic Muscle Training in the Management of Apical Support Loss (OPTIMAL) trial and were shown to have similar outcomes for anatomic and functional success as well as adverse events [44]. The types of adverse events did differ, however, with ureteral obstruction being more likely with uterosacral suspension and buttock pain being more likely in the sacrospinous suspension groups. Usually ureteral obstructions can be identified on intraoperative cystoscopy and can be resolved without any lasting repercussions. The buttock pain from sacrospinous suspension generally resolves without intervention in most patients by 6 weeks postoperatively, however a small subset (<5 %) may require interventions including physical therapy or trigger point injections for the pain [44, 45]. With the strict definition of success used for the OPTIMAL trial, approximately 60 % of patients were considered to have successful outcomes, 5 % of patients required repeat surgical treatment.

Suspension of the apex is critical to the success of prolapse repairs. In addition to appropriate apical suspension, other defects should also be addressed including enterocele, cystocele, and rectocele. Enterocele can be repaired with cephalad purse-stringing of the enterocele sac, with or without excision of the sac, and reapproximating the anterior and posterior apical vaginal connective tissue [27]. Anterior colporrhaphy is the preferred native tissue repair for the anterior compartment defects, but paravaginal repairs can also be considered when appropriate for surgeons with sufficient expertise [27]. Posteriorly, traditional colporrhaphy is recommended with perineorrhaphy as needed. Care must be taken not to overcorrect or narrow the vagina, which could cause pain or worsened sexual function [27].

Vaginal repairs augmented with mesh have been a recent topic of controversy. In light of apparent failure rates with native tissue repairs, there was keen interest in the possibility of improved results with mesh augmentation. Popularity of mesh augmentation grew more quickly than the data supporting its use, and concerns about safety and efficacy were raised [46, 47]. Many of the original vaginal mesh products have been discontinued, and those that remain are being rigorously investigated to assess their clinical outcomes.

From the existing data, it appears that mesh augmentation may improve outcomes in the anterior compartment, but further study is needed [46–48]. There are not currently data to support the use of vaginal mesh for apical and posterior support [46, 47, 49, 50].

Abdominal sacrocolpopexy , which can be performed open, laparoscopically, or robotically, is a procedure in which a graft is used to pull the vagina up to the sacrum, and it has been considered the most durable prolapse repair option (see Fig. 13.6). Longer-term studies have shown, however, that even with sacrocolpopexy, success rates decrease over time [51]. At 5 years, nearly a third of women in the eCARE trial met treatment failure criteria, but only 5 % had undergone a repeat procedure. Additionally, mesh exposure rate was about 10 % and exposures continued to occur throughout the extended study period. Minimally invasive abdominal sacrocolpopexy can be performed laparoscopically or robotically and has similar prolapse outcomes as an open abdominal procedure [52, 53]. Minimally invasive procedures have longer operating times but less blood loss and shorter hospital stays than open procedures [52, 54]. When comparing laparoscopic and robotic modalities, laparoscopy has been shown to offer decreased cost, shorter operative time, and less pain at 1 week postoperatively [55]. One study also showed less blood loss, lower rate of bladder injury, and decreased reoperation rate with laparoscopic as compared to robotic sacrocolpopexy [56].

Older patients undergoing urogynecologic surgery have been shown in some studies to have similar outcomes as younger women [57, 58]. Much like with midurethral slings, however, some studies did find higher rates of complications for older patients [59]. Even so, the overall rates of complications are low, and chronological age should not be the only factor in surgical decision making.

Urinary incontinence (UI ) is a common pelvic floor disorder which affects 49.2 % of adult women, and increases to above 60 % prevalence in women over age 70 [60]. Prevalence of incontinence starts off gradually in young adults, reaches a peak in mid-life, and climbs steadily in the older population [61, 62]. While the overall prevalence increases with age, the distribution of incontinence types changes from more stress incontinence in younger women to more urgency and mixed incontinence in older women [60]. Older women also tend to have more severe incontinence than younger women [60, 63]. Urinary incontinence is not considered a normal part of aging and has a huge impact on patients’ lives [64]. UI has been associated with functional decline, fall risk, nursing home placement, depressive symptoms, and frailty [64, 65].

Even when incontinence is significantly bothersome, many women do not seek care [64, 66]. Patients are often reticent to mention these issues to providers, who must initiate the conversation.

The burden of disease for urinary incontinence is significant—economically and emotionally. UI severity has been associated with major depression, medical comorbidity, and decreased quality of life, particularly in those with nighttime and coital symptoms or comorbid fecal incontinence [66–70]. The financial cost of UI is estimated at more than $16 billion in 1995 dollars, $7.6 billion of which was for women over age 65 [71]. In spite of a 15 % decrease in the cost per capita, Medicare costs for female beneficiaries nearly doubled from 1992 to 1998, due to an increase in the number of patients requiring treatment [72].

The terminology for urinary incontinence was standardized by the International Continence Society [73–78].

Other pertinent types of incontinence include [77]:

Age-related changes are important contributors to urinary incontinence in older patients, but they can be difficult to delineate from comorbidities and confounding factors, like parity [79]. There are, however, many age-related changes in the anatomy and physiology of the lower urinary tract (LUT) [65, 79, 80]. Detrusor contractility weakens, urethral closure pressure decreases, urethral blood flow and vascular density decrease [65, 79, 80]. Older patients also tend to have more detrusor overactivity (DO), higher post-void residual (PVR) volume, lower volume voids, and decreased flow rate [79]. These changes accompany the previously discussed increases in urgency UI, frequency, and nocturia [79]. Additionally, medical comorbidities, neurologic/psychiatric status, functional and environmental issues, and medications impact UI and make it a multifactorial geriatric syndrome [65, 79]. This complexity is clinically relevant as addressing those components may improve symptoms without any other interventions [79, 81].

Other risk factors for UI include female gender, white race, and elevated body mass index (BMI) [60, 82, 83]. Hysterectomy, smoking, thyroid disease, depression, decreased physical activity, arthritis, diabetes, and childbirth have also been linked [60, 82, 83]. Both vaginal and cesarean delivery have been associated with an increased risk of UI, but the impact of parity is stronger in younger women and appears to dissipate by age 65 [84, 85]. Neurological status, chronic cough, menopause, collagen integrity, and medication use are also important factors [82]. Persistence of UI has been associated with increased age, white race, higher parity, elevated BMI, decreased physical activity, type 2 diabetes, stroke, and hysterectomy, yet the greatest increased odds of UI were associated with older age, white race, and obesity [86].

In the initial evaluation of UI, patient history is essential to differentiate the type of incontinence (SUI, UUI, MUI, overflow), and urinalysis is also recommended to rule out hematuria, pyuria, bacteriuria, and glycosuria [64]. Physical examination is useful for evaluation of anatomy, atrophy, pelvic floor tone, strength, and coordination. Post-void residual (PVR ), simple cystometrics, and complex urodynamics can also be useful but are usually not needed in the initial evaluation of most patients [87].

When urgency symptoms are refractory to first line therapy, behavioral therapy, lifestyle interventions, pharmacotherapy, and combinations thereof, other, more invasive options may be considered. These therapies include the neuromuscular toxin, Botulinum, and neuromodulation of sacral and tibial nerves.

Percutaneous tibial nerve stimulation (PTNS ) involves using a small needle inserted near the ankle to stimulate the posterior tibial nerve [102]. These 30-min stimulation treatments are performed weekly for 12 weeks and additional treatments can be repeated as needed [102]. This technique has been shown to improve OAB symptoms up to 24 months [102].

Sacral neuromodulation (SNM ) involves a staged procedure where a lead is placed into the S3 foramen. Test stimulation is typically performed for 2 weeks, and if the patient has at least a 50 % improvement in symptoms, a permanent neurostimulator is implanted and connected to the lead [103, 104]. The neurostimulator provides continuous stimulation of sacral nerves to modulate neural signals to and from the bladder, anal sphincter, and pelvic floor (see Fig. 13.7) [105]. SNM is FDA approved for the treatment of OAB, urgency UI, non-obstructive urinary retention, and fecal incontinence (see section to follow), and appears to be as safe and effective in older patients as younger ones [64, 103, 104, 106].

Botulinum toxin is an FDA-approved treatment for refractory OAB, which has been shown to improve symptoms and quality of life [107–109]. Botulinum toxin works at the presynaptic cholinergic junction by inhibiting the release of acetylcholine and thus causing temporary detrusor muscle paralysis [110]. It is administered cystoscopically by injecting the toxin into multiple points in the detrusor or suburothelially (see Fig. 13.8) [109, 111]. Potential adverse events include urinary retention and urinary tract infection. Patients that receive this therapy must be willing to self-catheterize if needed [108]. Botulinum toxin has been shown to be effective in the older population [112]. The Refractory Overactive Bladder: Sacral NEuromodulation vs. BoTulinum Toxin Assessment (ROSETTA) trial, a comparative effectiveness trial between Botulinum toxin and SNM for patients with refractory OAB, is currently in follow-up [113].

Evaluation for SUI can be straightforward with a good history and physical examination. Leak with Valsalva maneuver on exam or simple cystometrics using a bladder fill and cough stress test can be sufficient, and complex urodynamic testing is not needed for women with uncomplicated, demonstrable SUI [116].

Conservative management options for SUI include behavioral therapy and urethral or vaginal inserts [117]. Some women have symptom improvement with continence pessaries, continence tampons, or urethral inserts, but the cure rates are lower than with behavioral therapy [117, 118]. Pelvic floor muscle training and bladder training have been shown to improve objective and subjective cure rates for SUI and are a good initial option for treatment [117]. If a woman does not improve with conservative therapy, she can consider more invasive options.

SUI can be managed surgically with procedures such as polypropylene midurethral sling placement (Fig. 13.9), pubovaginal sling, Burch colposuspension, and periurethral bulking. Studies have shown trends with an increase in the number of total incontinence procedures performed per year in the USA as well as a shift from inpatient to outpatient procedures with the advent of the synthetic midurethral sling [119, 120]. These increases are notable in women over age 52 [121]. Women over age 75, however, do not appear to be getting the same treatment as rates of polypropylene midurethral sling in this population have increased much more slowly than in younger women [122]. This disparity may stem from concerns regarding surgical complications in older patients with more comorbidities or questions regarding successful outcomes. In spite of comprising a significant proportion of the population suffering from UI, older women have been historically under-represented in clinical trials for SUI surgery [123]. More recently, however, many different studies have tried to evaluate the surgical treatment of SUI in older women [115, 124–148].

Results from studies of midurethral slings in older women have been inconsistent, which may be in part due to the heterogenous study populations and varied definitions of success. Some studies show greater risk of voiding dysfunction, outlet obstruction, de novo urinary urgency, urinary tract infection, need for catheterization, need for division of sling, and perioperative medical complications with lower rates of cure and satisfaction after midurethral sling in older patients, whereas others show no differences [115, 124, 125, 128–134, 136–138, 140–143, 145, 146, 148]. Older patients may also be more symptomatic than younger ones, and two studies showed that when differences in preoperative symptom bother were considered, age did not influence quality of life outcomes postoperatively [115, 124]. One prospective, randomized clinical trial comparing immediate midurethral sling versus expectant management for 6 months in older women found a significant improvement in satisfaction, symptoms, and quality of life in the immediate surgery group [147]. Another study showed that urethral hypermobility was an important predictor of midurethral sling treatment success in older women [139]. In summary, the overarching theme of the results is that older women do significantly benefit from midurethral slings and have improved quality of life postoperatively, although their improvements may be less pronounced than in younger women.

The pubovaginal sling (PVS ) using autologous rectus fascia is another option for older patients [144, 149, 150]. Age has not been associated with worsened outcomes for PVS, however, menopausal status has [150]. At 2 years postoperatively, one study showed good short-term outcomes for PVS with 85 % of patients improved and satisfied, and another, smaller study showed 100 % of 19 geriatric women with resolved SUI [149, 151]. Long-term results from SISTEr (Stress Incontinence Surgical Treatment Efficacy Trial) were less promising for PVS with only 27 % continence at 7 years [150].

Treatment with Burch colposuspension was also studied in the SISTEr trial, which found that while patients who underwent the Burch procedure had lower success rates (38 % at 2 years to 13 % at 7 years) than those who underwent PVS they also had fewer urinary tract infections, less difficulty voiding, and less postoperative urgency incontinence [150, 152]. A sub-analysis of the older patients in the trial revealed that older women had similar perioperative outcomes and worse 2-year outcomes than younger women [144].

Periurethral bulking is another option for SUI treatment that is typically used either as a primary treatment in a patient who is a poor surgical candidate or as a secondary procedure after failure of another procedure. Two studies have evaluated bulking agents after failed midurethral sling and found cure rates of 35–60 % with few complications [153, 154]. Even with these modest success rates, one study showed 77 % of patients were satisfied with the treatment and another showed negative pad tests (no leakage on a protective undergarment pad) in more than 70 % of patients [154, 155].

A thorough history and physical examination is essential to establishing the diagnosis of FI and tailoring treatment options. The history should include duration of symptoms, frequency of incontinence, time of day, quality of stool, control of flatus, frequency of bowel movements, constipation or diarrhea, use of pads, and impact on quality of life. Consistency of lost stool may correlate with the severity of incontinence since solid stool is easiest, liquid stool more difficult, and flatus most difficult to control [161]. Thus those patients with loss of solid stool have the most severe incontinence. A thorough obstetrical history should also be obtained including number of vaginal deliveries, weight of babies delivered, use of forceps, and significant tears, repairs, or episiotomies.

The physical examination should start with the inspection of the anal verge area looking for any scars or deformities. The patient should be asked to squeeze to simulate holding in a bowel movement to see if there is uniform contracture of muscles. Making the patient strain, as if having a bowel movement, can show perineal descent, hemorrhoids, vaginal prolapse, or even rectal prolapse [161]. Innervation can be crudely checked by touching the perineal area with a Q-tip and monitoring for an anal wink and also with pinprick sensation.

A digital rectal examination should be performed to check for masses, blood, fistula, or rectocele [162]. During the rectal examination baseline tone represents the internal anal sphincter and the patient should be asked to squeeze for assessment of the external anal sphincter. The accuracy of digital examination is operator dependent but overall, rectal exams have been proven as reliable as anal manometry in assessing anal resting and squeeze tone [163]. The reported positive predictive value of digital examinations to identify low resting and squeeze pressures by experienced clinicians was 67 and 81 %, respectively [164, 165].