So urinary incontinence, if you use the strict definition, is the involuntary loss of urine. And so that’s basically leakage of urine. We divide it because, into different types of incontinence, because the way we can manage urinary incontinence depends on the type of incontinence. So, some people might have to rush to the loo, and we call that urge incontinence, so they don’t make it in time, they have urgency. We talk about stress incontinence, which is leakage with coughing, sneezing and exertion. But many people have mixed, a bit of both, which makes managing that quite challenging. Some people just leak without awareness, so we call that involuntary incontinence, or insensible incontinence. And then urinary incontinence is tied into other types of bladder symptoms, so people will often hear about over-active bladder, or if you have an over-active bladder, over-active bladder syndrome, and that might be the kind of need to run to the loo, go really regularly, getting up at night, feeling like you have to rush, and that may or may not be associated with incontinence.

So prevention of pelvic floor problems is probably the big, the big kind of new phase of our speciality, in trying to work out how we prevent, because they are very common. We know that nearly half of women will develop some form of prolapse, incontinence, or pelvic floor problem. And nearly one in ten women will have surgery. So it’s clearly an epidemic or an endemic, and as we have an aging population becoming more common so trying to prevent it is, is, is really key. A lot of those things are simple: healthy living, maintaining an ideal body mass index, avoiding things that we know to trigger bladder, so things like caffeine for example, and certain environmental or dietary things can make the bladder worse. Maintaining pelvic floor, strengthen pelvic floor tone, so we all don’t bat an eyelid going to the gym to workout and make sure that we can run a marathon or, or undertake exercise classes, but we often neglect the pelvic floor. And when we talk about pelvic floor, we can kind of think of it as a group of muscles that act as a hammock for the bladder, the bowel and the vagina and just like any other muscle group whether it’s your cardiovascular fitness, or your abs, you can work out those pelvic floor muscles to try and prevent the development of prolapse and incontinence.

And then there are the kind of two big risk factors for pelvic floor problems; one is childbirth, and obviously that’s difficult because that’s something that a significant proportion of the population go through, and for most women undertaking a vaginal delivery, or a normal birth if you want to call it that, remains the safest option. But we do know that having a vaginal delivery significantly increases your risk of pelvic floor problems. But of course the alternative, a caesarean section, definitely doesn’t prevent you from getting a prolapse incontinence, and has its own set of risks. So often discussions about prevention veer into to how we manage childbirth and labour, but there’s a lot of other competing factors beyond the pelvic floor. And then sadly genetics, or bad luck. We know that you know that there’s a familial inheritance prolapse and incontinence which you can’t do anything about. And the other thing I didn’t mention as a cause is ageing, and of course we haven’t got anything, any treatments or solutions to the bad luck of ageing, which contributes to bladder symptoms and prolapse.

Urogynaecology is a sub-speciality of gynaecology which is a kind of women’s health medical speciality, and it focusses really on the pelvic floor or pelvic floor disorders, and the ‘uro’ bit is the bladder, and because a lot of these patients have bladder problems. That might be things like incontinence, overactive bladder, infections, but we’ve also cover things as I mentioned like vaginal prolapse, vaginal symptoms, birth trauma, and both the vaginal symptoms and bladder symptoms often involve bowel symptoms as well, things like anal incontinence, and obviously being female the reproductive tract, sexual dysfunction, sexual disorders. So urogynaecology encompasses managing all of those sorts of symptom and body systems that kind of surround anatomically the female genital tract.

One of the things that I really enjoy about being a pelvic floor specialist is I look at women through, look after women through all stages of the lifecycle. So that can be very young women having urinary tract infections, bladder pain, or period related problems, through to women in their reproductive years having pelvic floor problems during pregnancy or as a result of pregnancy and delivery. through to being older, post-menopausal, hormone related changes around the change of menopause, and then elderly population.

So it might be that you’ve had prolapse or incontinence surgery that’s involved mesh, or you think you’ve involved it, it’s involved mesh. Now for the vast majority of patients that have had mesh augmented, so prolapse or incontinence surgery that involves mesh, the vast majority are well. The vast majority don’t have problems, and the vast majority get improvement. But sadly because it was used so commonly and still is often used, there are a significant proportion of women that have had really life altering or devastating problems from the use of mesh.

The types of problems that mesh may cause commonly include pain, it might cause chronic infection, it might cause discharge, the mesh may move or migrate away from where it was placed into surrounding structures like the bladder or the bowel. So, either because of worry about problems or having an overt problem like pain or mesh moving, extruding into another organ you may have a conversation with your GP, gynaecologist or a specialist mesh removal surgery, surgeon, about removing mesh. The decision to remove mesh sometimes is very simple or easy. So if for example mesh is sat in your bladder or your bowels, and is causing them really significant problems that might be quite an easy decision for you to make with your clinician. But often it’s more complicated. So you might not have any symptoms from the mesh being in the wrong place. There might be a worry that your pain is related to other aspects of your health and wellbeing, or it might be that where the mesh is placed there is a worry about mesh removal causing significant other complications. NICE, the National Institute for Health and Care Excellence, does have a decision aid for women thinking about removal of mesh that was used for either prolapse or incontinence. So I would encourage people thinking about mesh removal first of all to use the NICE decision aids and to have a chat with their clinician. I think it’s really important that if patients feel that they’re not getting the answer they want, or they’re not getting their concerns taken seriously that they ask to be referred to a specialist, and if their concerns aren’t being taken seriously by their specialist, they ask to be referred to a mesh centre. So NHS England has commissioned a number of centres in the UK, across the UK, to be available for women who have had a mesh augmented prolapse surgery to discuss the pros and cons of removal. Mostly that would be for patients that are having problems, but for some people it’ll be because of a concern or worry about problems. Hopefully that environment and those clinicians will help form a relationship with you to discuss the problems or concerns you’re having, to discuss the options. They’ll often involve other specialists like pain specialists, physiotherapists, bowel specialists and bladder specialists to come to an agreement as to what your options may be. If they’re talking about removal, there’ll be a number of important discussions that they have with you. The first would be what the potential risks are: is there a risk of damaging things? Is there a risk of needing a stoma or a bag? Is there a risk of injuring your bladder and needing a catheter? And for a lot of the mesh that’s been put in, those were quite significant or real risks. One of the biggest difficulties we have is talking about pain and mesh. So if mesh appears to be in the right location but someone has pain, there’ll be a number of non-surgical options. If you’re talking about mesh removal it’s very difficult, we still don’t really know how likely you are to get benefit, whether that benefit is going to be permanent, and whether it’s actually the mesh that’s causing the pain or the mesh surgery. There’s a huge number of patients that will get pain with mesh, but that pain maybe many different causes, and so really you want to work with your specialist or work out whether we really think that mesh removal is likely to give you benefit. And when you’re having that conversation, they’ll discuss removing a bit of the mesh, all of the mesh, doing another procedure at the same time. So for example if you’ve had an incontinence mesh device like a sling or TVT, there’s a significant proportion that, there’s a significant likelihood that your incontinence will come back so they may discuss doing another incontinence procedure at the same time. And I think really the focus, I think the main message that I want to say to patients considering mesh removal surgery is that this is a really individualised decision. It’s about you and what’s affecting you, and coming together with your clinicians, your family and potentially support groups, there’s lots of online support groups for patients with mesh problems, but coming up with an individualised plan because what you may have read about or heard from someone else may not apply for you or to you.

Bladder symptoms, prolapse, vaginal or bowel symptoms are obviously an intimate part of the body and when we’re talking about in, intimate parts of your health that then translates through to sex. Sex is of course a highly individualised process, so there’ll be patients that I see that aren’t sexually active, and have no interest in being sexually active, and it’s a very quick discussion and we move on. But of course for a lot of people sex is a really important part of day-to-day living, their interpersonal relationships, their self-identity, body image, and a lot of their pelvic floor disorders are tied into their sexual function. It’s a complicated area because having a satisfying sex life looks very different for different people. So one of my jobs is to explore with you what your sex life ideally would be like for you, and what it’s like at the moment.

They [urogynaecologists] may ask some quite difficult questions and if you don’t feel comfortable that’s fine, but the purpose of those quite intimate and personal questions is to try and identify where in the sort of sexual cycle your problems are lying, so that they can help signpost you and target your treatment towards a suitable professional or support service and to try and improve your wellbeing.

So through treating bladder symptoms, prolapse and bowel symptoms you may have some chats about sex, and sex life. So it might be that for example sexual intercourse is flaring up cystitis, or causing pain to worsen, so it might be that you come to an agreement with your clinician that that’s something that you pause for a while until you get on top of your symptoms. Sex maybe uncomfortable with your prolapse. Sex isn’t generally a risk factor or damaging to prolapse, incontinence or bladder and of course having satisfying sexual, your sex life is important for your wellbeing, so it’s very rare that we would say don’t have sex. Sex is generally safe with these problems. A lot of people ask about pessaries and sex and actually there’s some great research that shows that for most women with who have had a ring pessary that actually sex lives have improved with the pessary than they are without. So it’s absolutely fine to have sex with a ring pessary in situ, and some other forms of pessaries, but there will be certain types of pessaries where you can’t have intercourse because of the way they sit in the vagina. And so your clinician should discuss with you whether you’re sexually active and whether that pessary is suitable for you. There’ll be a group of patients that self-manage their pessaries, take them in and out and it maybe that you take your pessary in and out for intercourse because that feels right for you and your partner.

So if you’ve noticed that you’ve got a pelvic floor problem and you’ve maybe tried some things at home, and had a little read and you feel like you need some help and support, the healthcare facilities that are available to patients in the UK are generally structured in the same way. So often the first port of call will be your primary care clinician, your GP. And they’ll often refer you to community support services. So they may give you some advice themselves, they may look at and exclude easily treatable things like infection. They may offer you a pessary, review your bladder diary, but often if that’s not easily fixing the pelvic floor problems you have, they’ll have access to physiotherapists in the community, or bladder and bowel services, which are very commonly found in most parts of the UK. It might be because of the way the funding works that you access those services within a hospital, or a regional care centre, or a community hub. We talked earlier about the importance of non-surgical and non-medical management and so I think it’s very rare or uncommon that you’ll see a uro-gynaecologist if you’re having your first presentation of the pelvic floor problems without negotiating through those services first. And I say negotiation because, for the vast majority of patients, those are the right types of services for them to see, and for the vast majority of patients they’ll get improvement and stop there. Sadly, for a small group of patients they’ll have physio, they’ll see community bladder and bowel services, they’ll see their GP and their problems are still affecting their quality of life. In that situation we’d encourage you to go back to your GP and say, “Look I’ve tried all these things that you’ve recommended, I’ve accessed all my resources, I’ve had a chat, and it’s still affecting me, it’s still impacting my quality of life.” Then the next person you’ll see will really depend on where you are in the country. So probably for the vast majority of patients you’ll see a general hospital specialist, and that might be a urologist, a urologist if it’s bladder mainly, it might be a gynaecologist if it’s prolapse with bladder symptoms associated with prolapse, and it might be a bowel specialist. They’ll often see you and offer the first line treatments, and if they don’t feel that your problems are easily managed within their area of expertise, they may refer you to what’s known as a tertiary centre. So all parts of the UK have big centres where they have more specialised clinicians that have access to complicated tools, tests and surgical medical treatments, that may not be available everywhere. And that’s a small proportion of patients that need that.

Surgery is a really complicated discussion, and that’s for a number of reasons. First of all, surgery can have complications, and if you have a complication clearly that can affect your quality of life. And then there are a huge range of surgical options for women with vaginal prolapse. We can go through the vagina, we can go through the tummy. It can involve a hysterectomy, it can involve them keeping their womb. It can use stitches, it can use mesh.

So the surgical options that you’ll be offered will really depend on the type of prolapse you have, what your expectations are, what your surgeon is able to offer you comfortable offer, offer you think is best. And we’ve got some great tools and decision aids that can help guide you into in terms of the type of surgery. The last thing I’ll mention is surgery for bowel problems. So that’s a difficult area, we’ll often involve our colorectal colleagues with that. There are treatments for bowel prolapse what’s called rectal prolapse that are done by colorectal surgeons, but we may also offer you vaginal surgery for vaginal bowel prolapse as well. So those would be the sorts of things that we’d often discuss with patients.

So one of the things that people often talk about if they’ve exhausted conservative management, they’ve tried therapies and their thinking about surgery, is the impact that surgery will have on life. And that’s particularly difficult if you’ve got a caring role for either children or a partner or a relative, it can have impact on work. For most forms of prolapse surgery there is a relatively substantial recovery. And that’s because we’re generally restoring quite a sensitive part of the body, and trying to restore an anatomical deformity, it involves an element of surgery. So for most people recovering from, from surgery you’ll often be in hospital for a day or two, you’ll often be reasonably sore for a couple of weeks and for most forms of prolapse incontinence surgery for about six weeks you’ll be advised not to drive, not to have intercourse, to avoid heavy lifting, and that can be very difficult if that’s part of your day to day or work. And for some people perhaps because they’re older, more frail, they have other medical complexities, having surgery for prolapse incontinence can take months to get better and recover from. So it’s important you think and you ask your clinician how long can you expect to be recovering so that you can help plan your life.

Generally when people talk about POP or pelvic organ prolapse we’re talking about vaginal prolapse. So, this is where the vaginal canal, which is part of the lower female genital tract, inverts on itself, or drops down, and that’s normally related to weaknesses in the supporting structures around it, which has lots of causes. And there are typically three structures or elements of pelvic organ prolapse or, and vaginal prolapse. So on the front of the vagina we’re talking about the bladder and that’s why a lot of these patients have bladder symptoms. On the back of the vagina it sits next to the lower part of the bowel, so we call that rectal prolapse, or rectocele or back wall vaginal prolapse. And that often will be related to bowel symptoms. And then really importantly the top of the vagina normally sits the womb, or the uterus, and the cervix, and a lot of women have hysterectomies so they can have what’s called a vault, and the top of the vagina can also drop down too. Generally we’re talking about three different areas of the vagina that are dropping down into the vaginal canal, and at its worst, forms coming towards the outside of the entrance to the vagina.

So urinary tract infections are a really complicated part of what we call LUTS, which are lower urinary tract symptoms. So that’s a really nice umbrella term for basically a bladder problem that causes you symptoms of, of bladder dysfunction. And some people will get recurrent or chronic or relapsing urinary tract infection. One of the difficulties is that ties very closely with something called cystitis, which is a very commonly used term but we don’t really know what that means when we’re talking about it. So, cystitis just means inflammation or irritation of the bladder. That might be because someone has a recurrent infection or chronic infection, or a relapsing infection. But there are lots of other causes of cystitis, and cystitis really, if you ask people and look in the medical literature what does cystitis mean it just means an unpleasant sensation within the bladder, often associated with bladder filling, but there are hormonal causes, infective causes, lots of other things can cause that unpleasant sensation of bladder filling that isn’t necessarily an infection.

Bladder pain syndrome is what we call in medicine a diagnosis of exclusion, so that means we’ve ruled out a cancer, a stone, an infection, something that we can easily identify and treat. But some patients will be left with an element of cystitis that is so unpleasant it’s painful, and that might be pain in the bladder on a day-to-day basis, or all the time, or that might be pain in the bladder just when the bladder fills. We don’t really understand why patients get bladder pain syndrome, so it’s a very poorly understood condition. We think some people develop bladder pain syndrome because they’ve got recurrent relapsing or chronic infections that maybe have settled and are not easily detected. It might be that they get it as part of a wider pain syndrome, so we know that patients with bladder pain syndrome share many of the same features with patients that for example have chronic back pain, or chronic pelvic pain or migraines. So sadly some people are just prone to being hypersensitive or feeling pain more easily than, you know, comparatively to someone else.

In terms of treatments, so if I focus on recurrent urinary tract infection, there are a number of options available to patients, so often what we’ll start with is trying to improve bladder function without antibiotics, and I’m sure a lot of people will be familiar with the concept of anti-microbial resistance which is where when a population uses lots of antibiotics, often inappropriately, we start to get super bugs or bacteria that do not respond. And as an individual that’s not generally a huge risk, but as a population basis individuals can pick up infections that are not treatable but can be life threatening. So we try and avoid unnecessary antibiotics. So when I see a patient with recurrent infection what I’m going to try and do is optimise bladder emptying, optimise fluids, maybe alter their hormonal levels if they’re post-menopausal or around the age of menopause. I may think about treating prolapse, often not surgically, but with things like pessaries to improve bladder function to try and find a way of avoiding the infections coming back without necessarily needing antibiotics. It may be that some patients start antibiotics by themselves, what we call self-start antibiotics and that might be because they get common infections, and it’s just easier to get on top of the infection quickly. Or it might be that they have very obvious triggers so common things like intercourse, or penetrative intercourse can cause infections so patients will take a small antibiotic after intercourse to prevent them getting an infection.

One of the difficulties that a lot of people find is that when they’ve had an infection if there’s a delay to treatment it can really get more deep set, it can go up to the kidneys and cause kidney infection, and the symptoms can take quite a long time to respond or resolve. So for some patients, quick access to antibiotics is really important. Often the first person people see is their GP, and your GP will be great at assessing your symptoms, often taking a urine sample, and hopefully if they feel it’s appropriate, giving you antibiotics. There will be a group of patients for whom antibiotics happen multiple times a year despite optimising all of these, and they’ll have a range of options. It might be that we some more invasive investigations, we might put a camera in the bladder to look for anatomical causes of infection, we may take biopsies of the bladder to look for infection. We might study the rest of the renal tract to look for causes of recurrent infection. If we can’t find anything obvious on those investigations we’ll often talk about prolonged courses of antibiotics in these types of patients, and that’s a controversial area. One of the reasons its controversial is there’s a not a lot of high-quality evidence about the role of long-term antibiotic courses and we’ve already talked about the fact that that may provoke resistance. But there’s an increasing body of evidence that shows that bacteria in the bladder, if they’re not treated properly can form little pods that sit in the bladder wall that then can flare up from a range of triggers. And then more and more we’re using non-antibiotic medications that are good at controlling bacterial infections, so two common things people will hear about is D-Mannose, and that’s an over-the-counter preparation that may come as a tablet or a syrup that prevents or helps prevent infection by making the bladder not a very nice place for bacteria to sit. And then there’s a medication called methenamine hippurate or Hiprex, now that’s another non-antibiotic medication that prevents bacteria. And that’s also got really high-quality evidence that shows that it’s as effective as long-term antibiotics. Now so some people will end up taking antibiotics of a small dose daily for many, many years, but there are a number of things we can try and do to avoid patients getting to that stage. But for some people the risk and benefit ratio means that that’s the right thing for them.