Gynaecology: Pelvic floor ovary and vulva

• Pelvic floor: Pelvic Organ Prolapse | Treating Prolapse | Urinary Incontinence — Assessment | Stress Incontinence | Overactive Bladder and Urge Incontinence | Other Bladder Problems
• Ovaries and acute gynaecology: Benign Ovarian Cysts | Assessing an Adnexal Mass | Ovarian Torsion | Cyst Rupture and Haemorrhage | Acute Pelvic Pain — Approach
• Vulva and vagina: Bartholin's Cyst and Abscess | Lichen Sclerosus | Other Vulval Skin Conditions | Vulvodynia and Painful Sex | Vulval Intraepithelial Neoplasia | Female Genital Mutilation | Common Gynaecological Operations
• Revision: Drug Reference Table | Spot the Diagnosis | Exam-style Scenarios | Key Points | Guidelines and Further Reading

🩺 Pelvic floor, ovarian and vulval problems — prolapse and urinary incontinence affect many women after childbirth and the menopause, yet are often hidden through embarrassment; simple pelvic floor exercises help most. Ovarian cysts are common and usually benign, but ovarian torsion is a surgical emergency, and any pelvic mass in an older woman needs assessment for cancer. Vulval itching in an older woman is often lichen sclerosus, which needs treatment and follow-up.
Your four questions for every patient: Could she be pregnant (pelvic pain)? Is this an emergency (torsion, bleeding, sepsis)? Is there a risk of cancer (pelvic mass, CA125, vulval lesion)? How much is this affecting her life — and what does she want to do about it?

Pelvic Organ Prolapse

• What it is: One or more pelvic organs bulge down into or out of the vagina because of weak support (pelvic floor muscles and ligaments).
• Types:
  • Anterior wall — cystocele (bladder); urethrocele.
  • Posterior wall — rectocele (rectum); enterocele (small bowel, upper posterior wall).
  • Apical — uterine prolapse; vault prolapse (after hysterectomy).
  • Procidentia — the whole womb outside the vagina.
• Risk factors:
  • Vaginal childbirth (especially large babies, forceps, long second stage).
  • Age and menopause (low oestrogen).
  • Obesity; chronic cough; constipation and straining; heavy lifting.
  • Previous hysterectomy; connective tissue disorders (Ehlers–Danlos).
• Symptoms:
  • A feeling of a lump or something "coming down"; dragging; worse at the end of the day or after standing.
  • Bladder — frequency, urgency, incomplete emptying, slow stream, needing to push the bulge back to void, recurrent UTIs.
  • Bowel — incomplete emptying, needing to press on the perineum or vagina to open the bowels (rectocele).
  • Sexual problems; ulceration and bleeding (procidentia).
• Examination — Sims' speculum in the left lateral position; ask her to bear down; grade the prolapse (e.g. POP-Q stages 0–4). Check for incontinence (cough test), and examine the abdomen for a mass (rare — a pelvic mass can push organs down).

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Treating Prolapse

• No symptoms — no treatment needed; advise on risk factors.
• Conservative (NICE NG123):
  • Lifestyle — weight loss, treat constipation and cough, avoid heavy lifting.
  • Supervised pelvic floor muscle training for at least 16 weeks — helps mild to moderate prolapse.
  • Vaginal oestrogen — if vaginal atrophy, especially with a pessary.
• Vaginal pessaries:
  • Ring (most common), shelf, Gellhorn, cube.
  • Good for women who don't want or are unfit for surgery, or are planning more children.
  • Changed or cleaned every 6–12 months (or self-managed).
  • Complications — discharge, bleeding, ulceration, rarely fistula or impaction (neglected pessary).
• Surgery:
  • Anterior or posterior repair (colporrhaphy).
  • Vaginal hysterectomy with repair (uterine prolapse); uterus-sparing procedures (sacrohysteropexy).
  • Vault prolapse — sacrocolpopexy, sacrospinous fixation.
  • Colpocleisis — closing the vagina (for frail women who are not sexually active).
  • Mesh — transvaginal mesh for prolapse is no longer used in the NHS (high-vigilance restrictions since 2018 because of serious complications — pain, erosion). Mesh is still used in some abdominal procedures with strict governance.

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Urinary Incontinence — Assessment

• Assessment (NICE NG123):
  • History — type, triggers, fluid intake (especially caffeine and alcohol), drugs (diuretics), bowel function, effect on life.
  • Bladder diary for at least 3 days (frequency, volumes, leaks, drinks).
  • Urine dipstick — infection, blood, glucose; culture if symptoms of infection.
  • Post-void residual (bladder scan) — if voiding symptoms or suspected retention.
  • Examination — abdominal (bladder), vaginal (prolapse, atrophy, pelvic floor strength), neurological if indicated.
  • Urodynamics — before surgery for stress incontinence if the type is unclear, or after failed treatment.
• Red flags (refer) — visible haematuria, recurrent UTIs with haematuria in older women, pelvic mass, suspected fistula, palpable bladder after voiding, neurological symptoms (cauda equina — urgent), previous pelvic cancer surgery or radiotherapy.

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Stress Incontinence

• Risk factors — pregnancy and vaginal birth, menopause, obesity, chronic cough, constipation, prolapse, previous pelvic surgery.
• Treatment:
  • Lifestyle — weight loss (BMI over 30), reduce caffeine, avoid too much or too little fluid, stop smoking.
  • Supervised pelvic floor muscle training for at least 3 months — at least 8 contractions three times a day (first line; helps most). Biofeedback or electrical stimulation if she can't contract the muscles.
  • Vaginal oestrogen for atrophy (doesn't treat stress incontinence on its own).
  • Duloxetine — second line if surgery isn't wanted or suitable (nausea common).
  • Vaginal devices (continence pessaries) for exercise.
  • Surgery (if conservative measures fail):
    • Colposuspension (open or laparoscopic).
    • Autologous rectus fascial sling.
    • Urethral bulking agents — less invasive, less durable.
    • Mid-urethral mesh tapes (TVT, TOT) — under strict restrictions since 2018 in the UK (pain and erosion concerns); used only with full informed consent in specialist centres.

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Overactive Bladder and Urge Incontinence

• Overactive bladder — urgency, with or without urge incontinence, usually with frequency and nocturia, without infection or other disease.
• Causes and triggers — idiopathic (most); caffeine, alcohol, fizzy drinks; UTI (exclude); bladder stones or cancer (haematuria); neurological disease (MS, Parkinson's, stroke, spinal injury); drugs (diuretics); atrophy; constipation.
• Treatment (step up):
  • Lifestyle — reduce caffeine and fizzy drinks; fluid intake about 1.5–2 L a day; weight loss; treat constipation.
  • Bladder training for at least 6 weeks — gradually increasing the time between voids.
  • Vaginal oestrogen if postmenopausal with atrophy.
  • Antimuscarinic drugs — e.g. solifenacin, tolterodine, fesoterodine, trospium:
    • Side effects — dry mouth, constipation, blurred vision, urinary retention, confusion.
    • Anticholinergic burden — linked to falls and cognitive decline and dementia in older people. Avoid oxybutynin (immediate release) in frail older women; consider the total burden.
    • Contraindicated in angle-closure glaucoma, myasthenia, urinary retention.
  • Mirabegron (beta-3 agonist) — if antimuscarinics are contraindicated, not tolerated, or not effective; or preferred in older people. Check BP (avoid in severe uncontrolled hypertension). Vibegron is another option.
  • Review drug treatment at 4 weeks.
  • Specialist — urodynamics; botulinum toxin A injections into the bladder (may need self-catheterisation); percutaneous tibial nerve stimulation; sacral nerve stimulation; augmentation cystoplasty (rarely).
• Nocturia — also consider heart failure, diabetes, sleep apnoea, evening fluids, and nocturnal polyuria (desmopressin with sodium monitoring in some).

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Other Bladder Problems

• Voiding dysfunction and retention in women — after childbirth or surgery, epidural, drugs (anticholinergics, opioids), prolapse, neurological disease, constipation, pelvic mass. Catheterise if residual over 500 mL; intermittent self-catheterisation for chronic retention.
• Bladder pain syndrome (interstitial cystitis) — pain related to bladder filling, frequency, urgency, normal cultures; cystoscopy; bladder instillations, amitriptyline, pentosan polysulfate (eye toxicity — screening), specialist care.
• Recurrent UTIs — see the Tubular, Inherited and Stones chapter.
• Fistulas — vesicovaginal (continuous leaking) after hysterectomy, radiotherapy, cancer, obstructed labour; surgical repair.
• Urethral diverticulum — dribbling after voiding, painful sex, a tender anterior vaginal lump.
• Containment products and continence services for those who can't be cured.

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Benign Ovarian Cysts

• Symptoms — often none (found on scans); pelvic pain or pressure, bloating, urinary frequency, dyspareunia; acute pain with torsion, rupture or bleeding.
• Management of simple cysts in premenopausal women (RCOG):
  • Under 5 cm — usually functional; no follow-up needed.
  • 5–7 cm — repeat ultrasound yearly (refer to gynaecology).
  • Over 7 cm — further imaging (MRI) or surgery (laparoscopic cystectomy — keeps the ovary).
• Postmenopausal women — any cyst needs CA125 and ultrasound; small simple cysts (under 5 cm) with normal CA125 can be monitored.

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Assessing an Adnexal Mass

• Premenopausal women:
  • Pregnancy test (ectopic).
  • Transvaginal ultrasound.
  • CA125 is not needed for simple cysts on ultrasound (raised in endometriosis, fibroids, PID, pregnancy, menstruation).
  • Tumour markers (LDH, AFP, hCG) in women under 40 with a complex mass — germ cell tumours.
• Postmenopausal women and any suspicion of cancer:
  • CA125 and transvaginal ultrasound.
  • Risk of Malignancy Index (RMI) = ultrasound score (U) × menopausal status (M) × CA125:
    • U — 0, 1 or 3 based on features: multilocular, solid areas, bilateral, ascites, metastases.
    • M — 1 (premenopausal) or 3 (postmenopausal).
    • RMI 200 or more (or 250 in some protocols) — refer to the gynaecological oncology MDT.
  • Newer tools — IOTA simple rules, ADNEX model, O-RADS.
  • Worrying ultrasound features — solid areas, thick septations, papillary projections, increased blood flow, ascites, bilateral masses.
• Ovarian cancer symptoms in primary care (NICE NG12) — persistent bloating, early satiety, pelvic or abdominal pain, urinary urgency or frequency, especially in women over 50: check CA125 (35 IU/mL or more → ultrasound). Ascites or a pelvic mass (not obviously fibroids) → suspected cancer pathway.
• See the Breast and Gynaecological Cancers chapter.

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Ovarian Torsion

• What it is: The ovary (often with the tube) twists on its blood supply, causing ischaemia. A surgical emergency — delay risks losing the ovary.
• Risk factors — an enlarged ovary: cysts (especially dermoid), tumours, ovarian stimulation (IVF, OHSS), pregnancy. Can happen in children and teenagers with normal ovaries.
• Features:
  • Sudden, severe, one-sided lower abdominal pain, often colicky or intermittent (twisting and untwisting).
  • Nausea and vomiting (common).
  • Sometimes after exercise or a sudden movement.
  • Tender adnexal mass; low-grade fever.
• Diagnosis — mainly clinical.
  • Pregnancy test (exclude ectopic).
  • Ultrasound — enlarged, oedematous ovary, free fluid, "whirlpool sign" (twisted pedicle). Normal Doppler flow does not exclude torsion.
• Management — urgent laparoscopy to untwist (detort) the ovary — even a dark, ischaemic-looking ovary often recovers, so conserve it (especially in young women); cystectomy if a cyst is present; oophorectomy only if necrotic. Analgesia and fluids before surgery.

⚠️ Safety Pearl: A normal Doppler doesn't rule out ovarian torsion. If the story fits — sudden one-sided pain, vomiting, and an ovarian cyst — arrange urgent laparoscopy.

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Cyst Rupture and Haemorrhage

• Ruptured or haemorrhagic cyst (usually a corpus luteum cyst in the second half of the cycle):
  • Sudden one-sided pain, often after sex or exercise; may be peritonism.
  • Free fluid on ultrasound.
  • Most settle with analgesia and observation.
  • Significant haemoperitoneum (falling Hb, shock — especially on anticoagulants) — laparoscopy.
• Dermoid rupture — chemical peritonitis; surgery.
• Endometrioma rupture — peritonitis-like pain.

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Acute Pelvic Pain — Approach

• Always start with a pregnancy test.
• Gynaecological causes:
  • Ectopic pregnancy; miscarriage.
  • Ovarian torsion; cyst rupture or haemorrhage.
  • Pelvic inflammatory disease and tubo-ovarian abscess (see the Sexual Health chapter).
  • Endometriosis; fibroid degeneration; mittelschmerz (mid-cycle, mild, self-limiting).
  • OHSS after IVF.
• Non-gynaecological causes:
  • Appendicitis.
  • UTI, pyelonephritis, kidney stones.
  • Diverticulitis (older women), IBD, IBS, constipation, bowel obstruction.
  • Hernias.
• Tests — pregnancy test, urine dipstick, FBC, CRP, STI swabs (NAAT), group and save; transvaginal ultrasound; CT if non-gynae cause suspected.
• Diagnostic laparoscopy if the cause is unclear and pain or peritonism continues.

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Bartholin's Cyst and Abscess

• Bartholin's glands — two pea-sized glands at the back of the vaginal opening (at 4 and 8 o'clock) that make lubricating mucus.
• Bartholin's cyst — the duct blocks: a painless swelling on one side of the vulva. Small cysts need no treatment (warm baths).
• Bartholin's abscess — infected cyst: a very painful, hot, red swelling; difficulty walking and sitting.
  • Organisms — skin and gut bacteria; sometimes gonorrhoea or chlamydia (test).
  • Treatment — analgesia; antibiotics if cellulitis (e.g. co-amoxiclav); drainage — Word catheter insertion (left for 4 weeks), or marsupialisation (stitching the cyst open) to reduce recurrence.
• Over 40 — a new Bartholin's swelling or a solid mass should be biopsied (rare Bartholin's gland cancer).

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Lichen Sclerosus

• What it is: A chronic inflammatory skin condition, usually of the vulva and around the anus; probably autoimmune. Most common in postmenopausal women (also prepubertal girls and men — foreskin).
• Features:
  • Intense itching (often worse at night), soreness, painful sex, splitting.
  • White, shiny, thin ("cigarette paper") patches; can affect the vulva and perianal skin in a figure-of-eight.
  • Purpura, fissures; scarring — loss of the labia minora, fusion over the clitoris, narrowing of the vaginal opening.
  • Doesn't affect the vagina itself.
• Diagnosis — clinical; biopsy if atypical, not responding, or suspicion of cancer.
• Treatment:
  • Potent topical steroid — clobetasol propionate 0.05% ointment: once daily for 4 weeks, alternate days for 4 weeks, twice weekly for 4 weeks, then as needed for maintenance (e.g. 1–2 times a week).
  • Emollients and soap substitutes; avoid irritants.
  • Surgery for severe scarring (narrowed introitus).
• Cancer risk — about 2–5% lifetime risk of vulval squamous cell carcinoma; good control with steroids reduces this. Long-term follow-up; teach self-examination; biopsy any persistent ulcer, lump or thickened area.
• Associated with other autoimmune diseases (thyroid, vitiligo).

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Other Vulval Skin Conditions

• Vulval itch — causes:
  • Candida (thrush) — the commonest; recurrent in diabetes, antibiotics, pregnancy.
  • Irritant or allergic contact dermatitis — soaps, bubble baths, wipes, pads, topical creams, urine.
  • Lichen sclerosus; lichen simplex chronicus (thickened skin from scratching).
  • Lichen planus — erosive, can affect the vagina and mouth (vulvovaginal–gingival syndrome); scarring.
  • Psoriasis (shiny red, no scale in skin folds); eczema.
  • Atrophy after the menopause.
  • Infections — trichomonas, scabies, pubic lice.
  • VIN and vulval cancer (persistent itch with a lesion).
• General advice — avoid soaps and irritants; use emollients as soap substitutes; cotton underwear; avoid tight clothing.
• Vulval lumps — Bartholin's cyst, sebaceous cysts, genital warts, molluscum, hidradenitis suppurativa (recurrent painful nodules and sinuses in groins), varicosities, skin tags; vulval cancer (ulcer or lump in an older woman — refer).
• Vulval ulcers — herpes simplex, syphilis, Behçet's disease, Crohn's, aphthous, erosive lichen planus, cancer.

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Vulvodynia and Painful Sex

• Dyspareunia — painful sex:
  • Superficial (at the entrance) — infection (thrush, herpes), vulvodynia, vaginismus, atrophy, lichen sclerosus, scarring after childbirth (episiotomy), FGM, lack of lubrication.
  • Deep — endometriosis, PID, adhesions, ovarian cysts, fibroids, adenomyosis, pelvic congestion.
• Vulvodynia — chronic vulval pain (burning, stinging) for 3 months or more without a visible cause:
  • Provoked (vestibulodynia — pain on touch, tampons, sex) or unprovoked (constant).
  • Cotton bud test reproduces pain at the vestibule.
  • Treatment — explanation; avoid irritants; topical lidocaine before sex; neuropathic agents (amitriptyline, gabapentin); pelvic floor physiotherapy; psychosexual therapy and CBT.
• Vaginismus — involuntary spasm of the pelvic floor muscles making penetration difficult or impossible; psychosexual therapy, graded dilators, physiotherapy.
• Sexual dysfunction — low desire, arousal or orgasm problems; consider relationship issues, depression, drugs (SSRIs), menopause, past trauma.

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Vulval Intraepithelial Neoplasia

• What it is: Pre-cancerous changes of the vulval skin.
• Types:
  • HSIL (usual-type VIN) — HPV-related; younger women; smokers; often with cervical or anal HPV disease.
  • Differentiated VIN — not HPV-related; older women with lichen sclerosus or lichen planus; higher risk of progression to cancer.
• Features — itch, soreness, raised or thickened patches (white, red or brown); may be found during colposcopy.
• Diagnosis — biopsy.
• Treatment — surgical excision; laser ablation; topical imiquimod (HPV-related); stop smoking; long-term follow-up.
• Vulval cancer — see the Breast and Gynaecological Cancers chapter.

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Female Genital Mutilation

• What it is: Any procedure that intentionally alters or injures the female genitals for non-medical reasons. Illegal in the UK (including taking a girl abroad for it). Usually done to girls before puberty.
• WHO types:
  • Type 1 — removal of the clitoral glans and/or hood.
  • Type 2 — removal of the clitoris and labia minora (± labia majora).
  • Type 3 — infibulation: narrowing the vaginal opening by cutting and sealing the labia.
  • Type 4 — other harmful procedures (pricking, piercing, cauterising).
• Complications:
  • Immediate — pain, bleeding, infection, urinary retention, death.
  • Long term — recurrent UTIs, painful periods (haematocolpos), cysts, painful sex, psychological trauma (PTSD), subfertility.
  • Obstetric — obstructed labour, perineal tears, PPH.
• Legal duties:
  • Mandatory reporting — health professionals in England and Wales must report to the police (call 101) if a girl under 18 tells them she has had FGM, or they see signs of it — within 1 month.
  • Record FGM in the notes (enhanced dataset) for women of any age.
  • Safeguarding referral if any girl (including daughters of a woman with FGM) is at risk.
  • Re-infibulation after birth is illegal.
• Care:
  • Sensitive, non-judgemental; use a professional interpreter (not family).
  • Deinfibulation (opening type 3 FGM) — ideally before pregnancy or in the second trimester, or in labour.
  • Specialist FGM clinics; psychological support.

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Common Gynaecological Operations

• Hysteroscopy — a camera into the womb (outpatient or under anaesthetic): biopsy, polyp or fibroid removal, IUD retrieval. Risks — pain, infection, perforation (rare).
• Laparoscopy — keyhole surgery: diagnosis, ectopic, cysts, endometriosis, sterilisation. Risks — bowel, bladder or vessel injury (about 1 in 1,000), conversion to open surgery, port-site hernia, shoulder tip pain (gas).
• Hysterectomy:
  • Routes — vaginal, laparoscopic, abdominal (open).
  • Total (womb and cervix) or subtotal (cervix kept — still needs cervical screening).
  • With or without removal of tubes (salpingectomy reduces ovarian cancer risk) and ovaries (oophorectomy — causes surgical menopause if premenopausal).
  • Risks — bleeding, infection, VTE, ureteric injury, bladder or bowel injury, vault prolapse later, early menopause.
• Endometrial ablation — destroys the lining (heavy periods; family complete; contraception still needed).
• LLETZ (large loop excision of the transformation zone) — treats cervical pre-cancer (CIN); slight increase in preterm birth risk.
• After gynaecological surgery — watch for ureteric injury (loin pain, fever, leaking urine), bladder injury, bowel injury (pain and sepsis days later), VTE.

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Drug Reference Table

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Spot the Diagnosis

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Exam-style Scenarios

1. A 58-year-old with three vaginal births has a "bulge" in the vagina, worse at the end of the day, and a slow urine stream. Examination shows a grade 2 cystocele.
Answer: Symptomatic anterior wall prolapse.

• Lifestyle (weight, constipation); supervised pelvic floor training for 16 weeks; vaginal oestrogen if atrophy.
• Pessary (ring) if she prefers or exercises fail.
• Surgery (anterior repair) if she wants definitive treatment; check post-void residual.

2. An 80-year-old with mild cognitive impairment has urgency and urge incontinence. Urine dip is negative. Bladder training hasn't helped.
Answer: Overactive bladder in a frail older woman.

• Avoid oxybutynin; consider mirabegron (check BP) rather than antimuscarinics.
• Review fluids and caffeine; vaginal oestrogen if atrophy; check post-void residual.
• Review at 4 weeks.

3. A 22-year-old has sudden severe right iliac fossa pain with vomiting for 3 hours. Pregnancy test negative. Ultrasound: 7 cm right ovarian cyst, Doppler flow present.
Answer: Suspected ovarian torsion (Doppler doesn't exclude it).

• Analgesia, fluids, nil by mouth.
• Urgent laparoscopy — detort and conserve the ovary; cystectomy.

4. A 64-year-old has bloating and early satiety for 3 months. CA125 is 310 IU/mL. Ultrasound: bilateral complex ovarian masses with ascites.
Answer: Suspected ovarian cancer (high RMI).

• Suspected cancer pathway; CT chest, abdomen and pelvis.
• Gynaecological oncology MDT.

5. A 70-year-old has vulval itching for a year. There are white, thin, shiny plaques around the vulva and anus with loss of the labia minora.
Answer: Lichen sclerosus.

• Clobetasol propionate 0.05% ointment (reducing regimen), emollients, soap avoidance.
• Biopsy if atypical or not responding; long-term follow-up; report any lump or ulcer (SCC risk).

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Key Points

• Prolapse: pelvic floor training first; pessaries or surgery; transvaginal mesh is no longer used for prolapse.
• Incontinence: bladder diary for 3 days, urine dip, post-void residual; refer red flags (haematuria, mass, fistula).
• Stress incontinence: pelvic floor training 3 months (8 contractions three times daily); duloxetine or surgery second line.
• Overactive bladder: reduce caffeine, bladder training 6 weeks, then antimuscarinics or mirabegron; avoid oxybutynin in frail older women.
• Simple premenopausal cysts under 5 cm need no follow-up; 5–7 cm yearly scan; over 7 cm MRI or surgery.
• Postmenopausal cyst or suspicion of cancer: CA125 and ultrasound; RMI 200 or more — gynae-oncology.
• Torsion: sudden one-sided pain and vomiting with a cyst — urgent laparoscopy; normal Doppler doesn't exclude it.
• Always do a pregnancy test in acute pelvic pain.
• Bartholin's abscess: drainage (Word catheter or marsupialisation); biopsy new masses over 40.
• Lichen sclerosus: clobetasol ointment; 2–5% lifetime SCC risk — long-term follow-up and biopsy any persistent lesion.
• FGM in a girl under 18 (told or seen): mandatory report to the police; safeguarding for daughters at risk.

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Guidelines and Further Reading

• NICE NG123: Urinary incontinence and pelvic organ prolapse in women — management
• RCOG Green-top Guidelines 62 and 34: Ovarian masses in premenopausal and postmenopausal women
• NICE NG12: Suspected cancer — recognition and referral (ovarian cancer)
• BASHH and British Association of Dermatologists: guideline on vulval lichen sclerosus
• RCOG Green-top Guideline 53: Female genital mutilation and its management; Home Office FGM mandatory reporting guidance
• NHS England: guidance on vaginal mesh (high vigilance restriction)
• BNF — for current doses

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