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Urinary and fecal incontinence, pelvic organ prolapse (POP), and female sexual dysfuction are increasingly common conditions and fall in the realm of pelvic floor dysfunction. It is unclear if the true incidence of these conditions is increasing or if they are being detected more physicians, patients and the media to address them.

The intent of this chapter is to give the primary care provider, to women of all ages, a clinical appreciations of the anatomy in the female pelvis that currently explains the mechanisms of pelvic organ suspension and support, as well as urinary and fecal continence. Though this chapter describes the current thinking in the “average normal” patient, the reader must realize that each women is unique in her anatomic makeup. Her pelvic support anatomy is dependent upon the genetic composition of her visceral connective tissues and various muscles—both somatic and visceal—and their adaptations to her aging process and upon the many variables of her lifestyles.

For many women, pregnancy, as well as labor and delivery, represent the key physiological events predisposing to incontinence and pelvic floor dysfunction. Our knowledge of obstetrical pelvic floor injuries, and their connection to incontinence and pelvic floor disorders later on, has vastly increased in recent years. Primary care clinicians addressing urogynecology problems should be aware of the potential effects of pregnancy and childbirth on the pelvic floor.

The female pelvis has many diverse, and sometimes contradictory, functions. Its bony structure and muscles are responsible not only for ambulation but also for support of the internal organs. The urethra and bladder are meant to dependably store urine until it is time to urinate. The rectum stores stool and gas until there is a socially appropriate time for release. The pelvis is also a passageway for childbirth—perhaps the most challenging of all of its functions, especially since we expect a normal return of physiological functioning after a signifi cant degree of neuromuscular and connective tissue trauma.

Primary care clinicians often wonder whether they should be involved in the evaluation and management of urogynecologic issues, such as urinary and fecal incontinence, voiding dysfunction, and pelvic organ prolapse. Referring patients with urogynecologic complaints to specialists such as urogynecologists or urologists is certainly an option for those clinicians who are unfamiliar with the evaluation and management of these problems. As will be covered in this chapter, however, a basic evaluation including a directed history and physical, combined with a few simple tests, is all that is required in most patients in order to arrive at a presumptive diagnosis and initiate a well-structured, conservative treatment plan.

Despite many recent pharmacological and surgical advances in urogynecology, a variety of nonmedical, non-operative strategies still represent the best first-line approach for many patients. The most common goal of behavioral treatments is to improve bladder control through systematic changes in patient behavior and environmental conditions. The primary behavioral treatment for stress incontinence, for instance, is pelvic floor muscle training and exercise. For fecal incontinence, the most effective behavioral treatment, in addition to pelvic floor muscle exercise, may include dietary alterations—such as increased dietary fiber—and bowel habit retraining. A number of behavioral treatments are commonly implemented for overactive bladder, including bladder drill and bladder training, pelvic muscle exercises, urge-suppression techniques, selfmonitoring, and dietary and fluid alterations.

In the last several years, multiple new “bladder medications” have received approval by the Food and Drug Administration. Most of these drugs are designed to treat patients suffering from detrusor overactivity. This chapter will review both old and new pharmacologic treatments for detrusor overactivity and stress urinary incontinence. This chapter will not offer a comprehensive review, but instead will focus on the practical advantages and disadvantages of the most commonly used medications. Before using the drugs mentioned in this chapter, practitioners should familiarize themselves in detail with the relevant clinical pharmacology.

Among women, the majority of urinary incontinence can be categorized into disorders of urethral support mechanisms (stress incontinence) and disorders of detrusor overactivity (urge incontinence). Disorders of obstruction (e.g., overflow incontinence), anatomy (e.g., urethral diverticula), and extra-urethral incontinence (e.g., urogenital fistulae) should always be considered, but are much less common. Similarly, the beneficial effects of conditioning of the female pelvic floor musculature, as discussed in previous chapters, can also be considered in terms of enhancing urethral support and suppressing detrusor overactivity.

Although pessaries have been used successfully for thousands of years, they are often overlooked as a first-line treatment option for women with pelvic organ prolapse. When properly fitted, pessaries can provide immediate relief of prolapse symptoms. These devices, which represent the primary non-surgical management option for pelvic organ prolapse, are appropriate for either temporary or long-term use.

Although nonsurgical treatments outlined in the preceding chapters are invaluable to countless women, it is an unavoidable fact that at least 11% of women ultimately elect to undergo surgery to correct vaginal prolapse or incontinence.1 When behavioral and pharmacological modalities fail to provide adequate symptom relief, surgery is often the only option available to improve a patient’s quality of life.