Cystocele and Urethrocele — MCQs
Urinary incontinence in uterovaginal prolapse is mostly due to:
Cause of decubitus ulcer in uterine prolapse is :
A patient 45 years of age, non diabetic, presents with chronic pelvic pain of 1 year duration. She also complains of frequency, urgency and a sense of incomplete evacuation since 1 year without any significant finding on her past ultrasounds, urine examination and urine and high vaginal swab cultures. On pelvic examination there is no significant vaginal discharge. Cystoscopy is normal. Most probable diagnosis is
A patient with second-degree cervical prolapse complains of dribbling of urine when coughing. What is the most likely diagnosis?
Risk factors for stress urinary incontinence are all except
A 55-year-old woman has recurrent urinary retention after a hysterectomy done for a large fibroid. The most likely cause is:
Cystocoele is prolapse of
A 60-year-old woman comes with 3rd degree uterine prolapse. What will be the management?
Match List-I with List-II and select the correct answer using the code given below the Lists:
A 40 year old lady is examined and found to have uterovaginal prolapse. What is the appropriate surgery to prevent recurrence?
Cystocele and Urethrocele Indian Medical PG Practice Questions and MCQs
Question 1: Urinary incontinence in uterovaginal prolapse is mostly due to:
- A. Detrusor instability
- B. Urge incontinence
- C. True incontinence
- D. Stress incontinence (Correct Answer)
Explanation: ***Stress incontinence*** - This is the most common type of urinary incontinence in uterovaginal prolapse, especially with **cystocele**, due to weakened pelvic floor muscles and altered urethrovesical angle. - The prolapsed organs reduce support for the urethra and bladder neck, leading to leakage with increased **intra-abdominal pressure** (e.g., coughing, sneezing, lifting). *Detrusor instability* - This refers to involuntary contractions of the **detrusor muscle**, causing a sudden, strong desire to urinate (urgency), often leading to leakage. - While it can coexist, it is not the primary cause of incontinence directly attributable to the mechanical effects of uterovaginal prolapse. *Urge incontinence* - Characterized by an urgent need to urinate followed by involuntary leakage, often due to **detrusor overactivity**. - Although it can occur in individuals with prolapse, it is a functional bladder issue rather than a direct mechanical consequence of the anatomical descent associated with prolapse. *True incontinence* - This is a broad term that can encompass continuous leakage or total loss of bladder control, often associated with neurological damage, fistula, or severe anatomical defects. - While prolapse can contribute to some forms of incontinence, "true incontinence" does not specifically define the predominant mechanism seen in most cases of uterovaginal prolapse.
Question 2: Cause of decubitus ulcer in uterine prolapse is :
- A. Friction (Correct Answer)
- B. Trauma
- C. Intercourse
- D. Venous congestion
Explanation: ***Friction*** - In uterine prolapse, the **cervix and vaginal walls protrude outside the introitus** and become exposed to the external environment. - The prolapsed tissue undergoes **constant friction against clothing, undergarments, and opposing skin surfaces** during walking, sitting, and daily activities. - This continuous mechanical trauma leads to **mucosal abrasion, drying, keratinization, and eventually ulceration** (decubitus ulcer). - Decubitus ulcers in prolapse are primarily **traumatic/mechanical** in nature, caused by prolonged pressure and friction on the exposed tissue. *Trauma* - While trauma contributes to ulcer formation, it is more accurately described as part of the **friction and pressure mechanism** rather than a separate cause. - Friction is the more specific and primary mechanism, whereas trauma is a broader term that encompasses the injury. *Intercourse* - Sexual intercourse is generally **not implicated** as a cause of decubitus ulcers in uterine prolapse. - It might cause superficial irritation but is not the primary pathophysiological mechanism for ulcer formation. *Venous congestion* - While **venous congestion can occur** in prolapsed tissue, it is **not the primary cause** of decubitus ulcers. - The ulcers are predominantly caused by **mechanical factors** (friction and pressure) rather than vascular compromise. - Venous congestion may contribute to tissue edema but does not explain the characteristic ulceration pattern seen in prolapse.
Question 3: A patient 45 years of age, non diabetic, presents with chronic pelvic pain of 1 year duration. She also complains of frequency, urgency and a sense of incomplete evacuation since 1 year without any significant finding on her past ultrasounds, urine examination and urine and high vaginal swab cultures. On pelvic examination there is no significant vaginal discharge. Cystoscopy is normal. Most probable diagnosis is
- A. Asymptomatic bacteriuria
- B. Cystitis
- C. Urethral syndrome (Correct Answer)
- D. Vulvovaginitis
Explanation: ***Urethral syndrome*** - The patient presents with classic symptoms of **urethral syndrome**, including chronic pelvic pain, frequency, urgency, and incomplete evacuation despite negative urine cultures and normal cystoscopy [1]. - This diagnosis is also supported by the absence of significant findings on ultrasound, urine examination, and vaginal cultures, ruling out common infectious or structural causes [1]. *Asymptomatic bacteriuria* - This condition involves the presence of bacteria in the urine without any associated symptoms and would not explain the patient's **chronic pelvic pain**, frequency, and urgency. - While urine cultures would be positive, the absence of symptoms differentiates it from the patient's presentation. *Cystitis* - **Cystitis**, or bladder inflammation, typically presents with similar symptoms to the patient, but would usually show signs of inflammation or infection in urine analysis (e.g., pyuria) or cystoscopy, which are absent here. - Her negative urine cultures also effectively rule out **bacterial cystitis**. *Vulvovaginitis* - **Vulvovaginitis** is an inflammation of the vulva and vagina, usually presenting with vaginal discharge, itching, or irritation, which is conspicuously absent in this patient [2]. - The patient's symptoms are primarily urinary and pain-related, not genitally localized to the vulva or vagina.
Question 4: A patient with second-degree cervical prolapse complains of dribbling of urine when coughing. What is the most likely diagnosis?
- A. Cystitis
- B. Stress incontinence (Correct Answer)
- C. Overflow incontinence
- D. Functional incontinence
Explanation: ***Stress incontinence*** - **Stress incontinence** is characterized by involuntary urine leakage due to increased intra-abdominal pressure (e.g., coughing, sneezing), which is common in association with **pelvic organ prolapse** like a second-degree cervical prolapse. - The prolapse weakens the **pelvic floor muscles** and supporting structures around the urethra, diminishing its ability to maintain closure during sudden pressure changes. *Cystitis* - **Cystitis** is an inflammation of the bladder, typically presenting with symptoms like painful urination (dysuria), frequent urination, and urgency. - While it can cause bladder irritation, it does not directly lead to urine dribbling with coughing in the absence of other typical infection symptoms. *Overflow incontinence* - **Overflow incontinence** occurs due to an **overfilled bladder** that can't empty completely, leading to constant dribbling or leakage. - This typically results from a **bladder outlet obstruction** or an **underactive detrusor muscle**, not directly from increased abdominal pressure during coughing. *Functional incontinence* - **Functional incontinence** is when a person has control over their bladder but cannot reach the toilet in time due to **physical or cognitive impairments**. - It does not involve a problem with the urinary tract itself but rather with the ability to respond to the urge to urinate.
Question 5: Risk factors for stress urinary incontinence are all except
- A. Obesity
- B. Hypertension (Correct Answer)
- C. Smoking
- D. Pregnancy
Explanation: ***Hypertension*** - While hypertension is a significant health concern, it is **not directly a recognized risk factor** for stress urinary incontinence. - Risk factors for stress urinary incontinence primarily involve factors that increase **intra-abdominal pressure** or weaken pelvic floor support. *Obesity* - **Increased intra-abdominal pressure** due to excess weight places constant strain on the pelvic floor muscles and urethral sphincter. - This persistent pressure can lead to weakening of the supporting structures, predisposing to **stress urinary incontinence**. *Smoking* - Smoking is associated with chronic cough, which repeatedly increases **intra-abdominal pressure**, potentially leading to pelvic floor muscle weakness. - It also affects **collagen synthesis**, which can weaken connective tissues supporting the bladder and urethra. *Pregnancy* - The growing uterus during pregnancy places significant **mechanical stress** on the pelvic floor muscles and ligaments. - **Hormonal changes** during pregnancy can also relax connective tissues, further contributing to pelvic floor laxity.
Question 6: A 55-year-old woman has recurrent urinary retention after a hysterectomy done for a large fibroid. The most likely cause is:
- A. Injury to the bladder neck
- B. Injury to the hypogastric plexi (Correct Answer)
- C. Atrophic and stenotic urethra
- D. Lumbar disc prolapse
Explanation: ***Injury to the hypogastric plexi*** - The **hypogastric plexi** (superior and inferior) contain sympathetic and parasympathetic fibers crucial for bladder control, with parasympathetic fibers primarily responsible for bladder contraction during micturition. - Damage to these nerves during pelvic surgery, such as a hysterectomy, can lead to **detrusor areflexia** or hypocontractility, resulting in urinary retention. *Injury to the bladder neck* - Injury to the **bladder neck** itself typically causes **stress urinary incontinence** or voiding dysfunction due to obstruction, rather than complete retention from inability to contract the bladder. - While it can impact bladder function, it doesn't primarily explain recurrent retention characterized by the inability to empty the bladder. *Atrophic and stenotic urethra* - An **atrophic and stenotic urethra** would primarily cause symptoms of **obstructive voiding**, such as weak stream, hesitancy, or incomplete emptying, but not typically complete, recurrent urinary retention as a direct consequence of a hysterectomy. - This condition is more related to estrogen deficiency or chronic irritation, and would likely pre-date or develop independently from the hysterectomy. *Lumbar disc prolapse* - **Lumbar disc prolapse** can cause urinary retention if it leads to **cauda equina syndrome**, characterized by severe neurological deficits like saddle anesthesia, bowel/bladder dysfunction, and lower extremity weakness. - However, isolated recurrent urinary retention as the *most likely* cause after a hysterectomy, without other neurological signs, points away from a disc issue.
Question 7: Cystocoele is prolapse of
- A. Lower 1/3 of anterior vaginal wall
- B. Lower 2/3rd of anterior vaginal wall
- C. Upper 1/3 of anterior vaginal wall
- D. Upper 2/3rd of anterior vaginal wall (Correct Answer)
Explanation: ***Upper 2/3rd of anterior vaginal wall*** - A **cystocele** specifically refers to the prolapse of the **bladder** through the **upper two-thirds of the anterior vaginal wall**. - The bladder is primarily supported by the **pubocervical fascia** overlying the upper 2/3rd of the anterior vaginal wall. - When this fascial support weakens, the bladder herniates into the vaginal lumen, creating a cystocele. - This is the **classic anatomical definition** found in standard gynecology textbooks. *Lower 2/3rd of anterior vaginal wall* - This option is anatomically incorrect for defining a pure cystocele. - While severe cystoceles can extend downward, the primary defect involves the upper two-thirds where bladder support is located. *Lower 1/3 of anterior vaginal wall* - Prolapse of the lower 1/3 of the anterior vaginal wall is called a **urethrocele**, which involves prolapse of the **urethra**. - A **cystourethrocele** refers to combined prolapse of both bladder and urethra. - This is distinct from a pure cystocele. *Upper 1/3 of anterior vaginal wall* - While the upper third is involved in cystocele, the complete anatomical definition encompasses the **entire upper two-thirds** (upper 2/3rd), not just the upper one-third. - Limiting it to only the upper 1/3 would be incomplete and anatomically imprecise.
Question 8: A 60-year-old woman comes with 3rd degree uterine prolapse. What will be the management?
- A. Vaginal hysterectomy with pelvic floor repair (Correct Answer)
- B. Pelvic floor repair
- C. Sacrospinous fixation
- D. Pessary
Explanation: ***Vaginal hysterectomy with pelvic floor repair*** - A **3rd degree uterine prolapse** means the cervix and uterus protrude beyond the introitus, requiring surgical intervention in most cases. - **Vaginal hysterectomy** addresses the prolapsed uterus, and **pelvic floor repair** (e.g., anterior/posterior colporrhaphy) simultaneously reinforces weakened pelvic support structures to prevent recurrence. - This is the **most definitive surgical management** for complete uterine prolapse in a postmenopausal woman. *Pelvic floor repair* - While important for addressing fascial defects, **pelvic floor repair alone** is insufficient for 3rd-degree uterine prolapse where the uterus itself is significantly descended. - This option would leave the **prolapsed uterus** unaddressed, making long-term surgical success unlikely. *Sacrospinous fixation* - **Sacrospinous fixation** is a procedure primarily used for **vaginal vault prolapse** (post-hysterectomy) or as part of apical suspension, by attaching the vaginal apex to the sacrospinous ligament. - While it can be used for **uterine-sparing procedures** (sacrospinous hysteropexy), it is not the primary or sole management when the standard approach is vaginal hysterectomy with repair. *Pessary* - A **pessary** is a non-surgical option appropriate for patients who are **not surgical candidates** (significant comorbidities, elderly frail patients) or those who **decline surgery**. - While it can provide symptomatic relief even for 3rd-degree prolapse, it requires regular follow-up and is generally considered a **conservative/temporizing measure** rather than definitive management when surgery is feasible.
Question 9: Match List-I with List-II and select the correct answer using the code given below the Lists:
- A. A→4 B→1 C→2 D→3
- B. A→4 B→2 C→1 D→3
- C. A→3 B→2 C→1 D→4
- D. A→3 B→1 C→2 D→4 (Correct Answer)
Explanation: ***A→3 B→1 C→2 D→4*** - This option correctly matches each pelvic floor abnormality description with its corresponding condition. - **Cystocele** involves the descent of the bladder into the upper two-thirds of the anterior vaginal wall, **Urethrocele** describes the descent of the urethra into the lower one-third of the anterior vaginal wall, **Enterocele** refers to the descent of small bowel into the upper one-third of the posterior vaginal wall, and **Rectocele** involves the descent of the rectum into the lower one-third of the posterior vaginal wall. *A→4 B→1 C→2 D→3* - This option incorrectly matches the descent of the upper 2/3 of the anterior vaginal wall with a **rectocele** and the descent of the upper 1/3 of the posterior vaginal wall with a **cystocele**. - A **rectocele** involves the posterior vaginal wall, not the anterior, and a **cystocele** involves the anterior vaginal wall, not the posterior. *A→4 B→2 C→1 D→3* - This option incorrectly matches the descent of the upper 2/3 of the anterior vaginal wall with a **rectocele** and misidentifies other associations. - The pattern of descent and wall involvement for **urethrocele**, **enterocele**, and **cystocele** is not consistently maintained here according to the definitions. *A→3 B→2 C→1 D→4* - This option incorrectly associates the descent of the lower 1/3 of the anterior vaginal wall with an **enterocele**, and the descent of the upper 1/3 of the posterior vaginal wall with a **urethrocele**. - An **enterocele** involves the small bowel protruding into the posterior vaginal wall, and a **urethrocele** involves the urethra descending into the anterior vaginal wall.
Question 10: A 40 year old lady is examined and found to have uterovaginal prolapse. What is the appropriate surgery to prevent recurrence?
- A. Vaginal hysterectomy with McCall culdoplasty
- B. Abdominal hysterectomy with Moschcowitz operation
- C. Vaginal hysterectomy with anterior and posterior colporrhaphy and McCall culdoplasty (Correct Answer)
- D. Vaginal hysterectomy with sacrospinocolpopexy
Explanation: ***Vaginal hysterectomy with anterior and posterior colporrhaphy and McCall culdoplasty*** - This combination addresses **multiple compartments of pelvic organ prolapse**, including the uterus, anterior vaginal wall (cystocele), posterior vaginal wall (rectocele), and vaginal vault (enterocele/cuff prolapse). - **McCall culdoplasty** suspends the vaginal vault, and **anterior/posterior colporrhaphy** repairs defects in the bladder and rectal supports, significantly reducing recurrence rates. *Vaginal hysterectomy with McCall culdoplasty* - While **McCall culdoplasty** is excellent for preventing **vaginal vault prolapse** after hysterectomy, it doesn't directly address associated **cystocele** or **rectocele**. - A prolapse often involves multiple compartments, and addressing only the uterine component may lead to **recurrence** in the anterior or posterior vaginal walls. *Abdominal hysterectomy with Moschcowitz operation* - **Abdominal hysterectomy** is generally reserved for cases where a vaginal approach is not feasible or other abdominal procedures are required; it has a **longer recovery** and higher morbidity compared to vaginal approaches for prolapse. - The **Moschcowitz operation** is a type of culdoplasty, but an open abdominal approach for uncomplicated uterovaginal prolapse is less preferred than vaginal repairs due to increased invasiveness and potential for greater discomfort and recovery time. *Vaginal hysterectomy with sacrospinocolpopexy* - **Sacrospinocolpopexy** is a durable procedure, especially for **vaginal vault prolapse**, and often uses mesh for suspension. - While highly effective for vault suspension, it typically requires a **laparoscopic or abdominal approach** for mesh placement and often requires additional procedures to manage associated anterior and posterior wall defects, making a combined vaginal approach with anterior/posterior colporrhaphy and McCall culdoplasty more comprehensive for overall uterovaginal prolapse.
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