Genital prolapse with and without urinary incontinence.

Procidentia, vaginal vault prolapse and severe cystocele may be associated with potential urinary incontinence, which becomes overt only after surgical repair of the genital prolapse. The normal support of the pelvic organs is provided by the pelvic diaphragm (levator ani and coccygeus muscles). The levator plate is a firm, muscular plate between the coccyx and anus formed by fusion of the levator ani muscles on each side. Recent investigators have indicated that the main mechanism for weakening the pelvic muscles occurs as a result of childbearing, when stretch injury of the pudendal nerve causes denervation of the muscles. This injury is aggravated with the changes of aging and has effects on anogenital prolapse and stress incontinence. There may be iatrogenic causes of both prolapse and stress incontinence when an operation produces a change in the direction of tissue forces or removes a prior barrier to incontinence. The evaluation of patients must include the actual and potential aspects of genital prolapse and incontinence. Testing for stress incontinence must be performed before and after reduction of the genital prolapse. Surgical repair should be planned carefully to correct all the significant and potential defects in the urogenital tract. Ideally a normal vaginal axis with adequate length will be restored, and urinary function will not be compromised.