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Stress urinary incontinence—the involuntary loss of urine through the intact urethra as a result of a sudden increase in intra-abdominal pressure—creates a social problem to the patient. It is the end result of a deficient urinary control system in which the intra-abdominal pressure exceeds the resistance produced by the urethral closure mechanisms. Normal continence in the female results from the delicate balance of several forces, including closing forces of the urethra, a critical functional and anatomical urethral length, the ability of the pelvic floor and the urethra to increase urethral resistance at the time of stress, and the proper anatomical location of the sphincteric unit. We like to organize these factors in what we call the UCLA theory of female continence, in which the U signifies the urethral changes that occur during stress, the C represents the closing function of the urethra, the L is its functional and anatomical length, and A stands for anatomy. These factors are briefly described below.

There are three sections in the chapter on fistulae: vesicovaginal and urethrovaginal fistula, rectovaginal fistula, and repair of perineal fistula.

Bladder outlet obstruction in the female is rare. The patient may complain of symptoms of obstruction such as the need to strain, difficulty in starting the stream, interrupted or prolonged stream, or the sensation of incomplete emptying. The patient’s symptoms may not correlate with the residuals of urine, which can be low or high. Patients with chronic retention can present with minimal symptoms of obstruction but a significant residual of urine.

Clinicians involved in the care of women should possess a clear conceptual understanding of the anatomy and pathophysiology of pelvic support in order to effectively evaluate and treat disorders of pelvic floor relaxation. This chapter provides a basic review of the anatomy and musculofascial support of major pelvic structures and discusses their importance in clinically significant disorders of pelvic prolapse.

Vaginal surgery complications can at times be difficult to manage. Clearly the best management scheme entails steps to prevent complications. These steps require judicious preoperative planning with detailed knowledge of the patient’s case, operative anatomy, surgical indications, and expectations, as well as prudent use of preoperative diagnostic testing. This kind of preparation facilitates better recognition of intraoperative complications and consequent expeditious treatment.

Anterior vaginal wall defects, or cystoceles, are very common. Approximately 50 % of women seeking routine gynecologic or urologic care have some degree of anterior prolapse. Most of these defects are asymptomatic, but as the leading edge of the prolapse extends beyond the hymen, the defect may become symptomatic. The cystocele may present itself as a vaginal bulge, or it may present with urinary symptoms of urgency, frequency, stress or urge incontinence, or even obstructive voiding symptoms. Risk factors for primary or secondary prolapse are age, menopausal status, parity, collagen defects, prior hysterectomy, increased body mass index, smoking, and chronic pulmonary disease.

This chapter discusses a variety of conditions presenting as a vaginal mass unrelated to prolapse. The patient can be asymptomatic or may have bowel or urinary symptoms related to the mass. Masses can be found by the patient herself, but many times they are seen on a routine pelvic examination. The patient can complain of vaginal discomfort, dyspareunia, incontinence of urine, or vaginal bleeding.

A vaginal fistula is defined by extra-anatomic communication between the vaginal and an epithelial lined organ. This communication in the vagina may be straight forward with an abnormal connection to and involve the ureters, bladder, urethra, and rectum. A complex vaginal fistula might involve several different abdominal and pelvic organs which emphasize the importance of a complete workup before attempting to repair. A vaginal fistula negatively affects an individual’s quality of life and prompt repair is suitable in most patients that are properly selected. There are many surgical approaches to repair a fistula, the best repair centers on the first procedure being the most effective. However, there is a lack of high quality comparative studies to guide the surgeon. When selecting the initial surgical approach, the surgeon should consider their expertise and experience after a thorough evaluation to determine the etiology and location of the fistula. In this chapter we will focus on the etiology, diagnosis, evaluation, and surgical repair of vesicovaginal, urethrovaginal, and rectovaginal fistula.

A thorough conversation between the patient and physician should take place before embarking on POP surgery. Specifically, if mesh use is planned to augment a repair, the surgeon should provide full disclosure regarding the potential adverse effects related to mesh. Evaluation of a patient after a mesh complication requires a complete workup. Experienced, trained pelvic surgeons may be able to recognize and treat these conditions with fewer complications. With the patient’s best outcome as the primary goal, all steps should be taken to prevent any complications.