Introduction

If the body was divided into specialties by physiological rather than anatomical boundaries, there would be no need for an explanation of urogynaecology. As it is, this specialty represents an interface between gynaecologist and urologist. Physiological events or disease affecting gynaecological organs invariably affect the urinary tract, as they will also sometimes affect the adjacent alimentary system.

It is increasingly recognized that colorectal surgeons have an important role in the management of pelvic floor disorders. The studies of Snooks et al (1984a,b) and Sultan et al (1993) show the traumatic effects of vaginal delivery on the pelvic floor and anal sphincters. Wall and de Lancey (1991) succinctly summarized the need for a holistic approach involving gynaecologists, urologists and colorectal surgeons in the management of pelvic floor disorders.

Following the introduction of subspecialization by the American College of Obstetricians and Gynecologists, the Royal College of Obstetricians and Gynaecologists considered and then recommended subspecialization in 1982. Four subspecialties were created, among them urogynaecology. This comprised the following disorders: congenital anomalies, incontinence, voiding difficulties, urinary fistulae, bladder neuropathy, genital prolapse, urgency and frequency, and urinary tract infection. By common consent, all ‘supravesical’ conditions and neoplasia arising anywhere in the urinary tract belong to the realm of urology.

To these might now be added disordered bowel motility, descending perineum and rectal prolapse, anal sphincter injuries, rectovaginal fistula, perineal hernia, and faecal and flatal incontinence.

Terminology

As in any developing branch of medicine and science, old terms and definitions have become inadequate. To provide a common language for both clinician and researcher, the International Continence Society’s (1973) Standardization Committee drew up standards of terminology of lower urinary tract function.

Nine reports have now been published, as follows.

The term ‘stress incontinence’ was coined by Sir Eardley Holland in 1928 and meant the loss of urine during physical effort. It came to be used not only as a symptom and sign, but also as a diagnostic term. As the pathophysiology of urinary incontinence became more clearly understood, it was apparent that the term ‘stress incontinence’ was ambiguous as it could be applied to a symptom, a sign and a diagnosis; indeed, the symptoms and sign of stress incontinence can be found in most types of incontinence.

Nowadays, the term ‘stress incontinence’ is retained for the symptom of involuntary loss of urine on physical exertion and the sign of urine loss from the urethra immediately on increase in abdominal pressure. The term ‘genuine stress incontinence’ was proposed by the International Continence Society in 1976 (Bates et al 1976) to mean the condition of involuntary loss of urine when ‘the intravesical pressure exceeds the maximum urethral pressure in the absence of a detrusor contraction’. This condition has a number of synonyms: urethral sphincter incompetence, stress urinary incontinence and anatomical stress incontinence. The authors prefer the term ‘urethral sphincter incompetence’ because this accurately describes the pathophysiology of this condition.

In a similar way, the term ‘dyssynergic detrusor dysfunction’ was introduced by Hodgkinson et al in 1963 and other synonyms followed: urge incontinence, uninhibited bladder, bladder instability/unstable bladder and, more recently, overactive bladder. In 1979, the International Continence Society defined an unstable bladder as one ‘shown objectively to contract, spontaneously or on provocation during the filling phase, while the patient is attempting to inhibit micturition. Unstable contractions may be asymptomatic and do not necessarily imply a neurological disorder.’ The contractions are phasic. Another term, ‘low compliance’, is used to mean a gradual increase in detrusor pressure without a subsequent decrease during bladder filling. The term ‘neurogenic detruser overactivity’ is used for phasic uninhibited contractions when there is objective evidence of a relevant neurological disorder. Terms to be avoided include ‘hypertonic’, ‘spastic’ and ‘automatic’.

Classification