Urogynecology is the area of gynecology focused on lower urinary tract and pelvic floor dysfunction. Common diagnoses seen in urogynecology include urodynamic stress incontinence, detrusor overactivity, voiding difficulties, and uterine/vaginal prolapse. Urodynamic testing is often used to confirm diagnoses and assess severity through tests like cystometry, uroflowmetry, and pelvic floor imaging.

24. Figure 1: Prolapse staging – 0,1,2,3,4 (uterine – by the position of the leading edge of the cervix) N.B. vaginal eversion in stages 3 & 4 Symphysis Position: Section 2D (ii/iii) BH / JL 2007 0 1cm 1cm Hymen Bladder (Empty) Rectum 4 3 2 1

25. Figure 11: Pelvic Organ Prolapse Stage 2 Anterior Vaginal Wall Prolapse Position: Section 2D (v) OR Section 4E (i) Stage 4 Enterocele / Vaginal Vault Prolapse Position: Section 2D (iv) OR Section 4E (i) Stage 3 Uterine Prolapse Position: Section 2D (iii) OR Section 4E (i)

28. Figure 2: Bladder Diary This simple chart allows you to record the fluid you drink and the urine you pass over 3 days (not necessarily consecutive) in the week prior to your clinic appointment. This can provide valuable information. • Please fill in approximately when and how much fluid you drink, and the type of liquid. • Please fill in the time and the amount (in mls, or ounces) of urine passed, and mark with a star if you have leaked or mark with a “P” if you have needed to change your pad. (Please find below an example of how to complete this form.) Summary Frequency = 9 Nocturia = 1 Urine pr oduction / 24 hour = 1250 ml Maximum voided volume = 300 ml Average void = 125 ml Position: Section 2F (i/ii) DATE/TIME DD.MM.YY LIQUID INTAKE (mls) VOLUME OF URINE (mls. or ounces) LEAKS PAD CHANGE 21.02.06 0215 150 0715 250 0800 Mug coffee 250ml 0820 60 P 0930 Cup Orange juice 1000 100 1200 2 mugs coffee 1400 300 1430 20 1530 Cup of Tea 200ml P 1600 100 1800 Cup of Tea 200ml 1900 100 2000 Glass Beer 200ml 20 2030 Glass wine 50ml 2200 P 2300 150

37. Figure 5: Schematic diagram of filling cystometry Flow rate mls/sec P abd cmH 2 O P det cmH 2 O P ves cmH 2 O Fill volume mls 30 40 20 10 20 40 60 80 20 40 60 80 20 40 60 80 100 200 300 400 FD ND SD U filling cystometry voiding cystometry CC 48 year old female with urinary frequency. No phasic activity during filling. Voided with normal flowrate at normal detrusor pressure. Normal study. FD = First Desire to Void, ND = Normal desire to void, SD = Strong desire to void, U = Urgency, CC = Cystometric Capacity (permission to void given). Position: Section 3C (v – vii), Section 3D (iii/iv) BH / JL 2007

39. Figure 9: Schematic diagram of detrusor overactivity Flow rate mls/sec P abd cmH 2 O P det cmH 2 O P ves cmH 2 O Fill volume ml 30 40 20 10 20 40 60 80 20 40 60 80 20 40 60 80 100 200 300 400 FD ND SD U filling cystometry voiding cystometry L L 52 year old female with urgency and frequency. Phasic activity during filling. Leakage associated urgency and detrusor contractions. L = leakage, MCC = Maximum Cystometric Capacity. U MCC Position: Section 3D (v:b) & Section 4B (i) BH / JL 2007

41. Figure 4: Liverpool Nomogram for maximum urine flow rate in women Reference: 20 Position: Section 3A (ix) Equation: Ln (Maximum flow rate) = 0.511 + 0.505 x Ln (voided volume) Root mean square error = 0.340

42. Reference: 23 Figure 10: Voiding difficulty Vaginal Probe (Ultrasound) Pubis Example of voiding difficulty Voided volume = 250ml Qmax = 15mls/sec < 10 th centile on Liverpool Nomogram and / or Post void residual (TV USS) = 78ml PVR = (H x D) x 5.9 – 15 = X ml PVR = (4.5 x 3.5) x 5.9 – 15 = 78ml Reference: 20 Position: Section 4D (i) Height (H=4.5) Depth (D=3.5) X