Urogynecology Practice Questions

Q: A 32-year-old lady with intrauterine fetal death after normal vaginal delivery has continuous passage of urine from the vagina. What is the most probable diagnosis?

Vesicovaginal fistula. ***Vesicovaginal fistula*** - The continuous passage of urine from the vagina following delivery, especially in the context of an intrauterine fetal death where prolonged or difficult labor might occur, is highly suggestive of a **vesicovaginal fistula**. - A fistula creates an abnormal connection between the **bladder** and the **vagina**, leading to continuous urine leakage. *Urge incontinence* - Characterized by an **involuntary loss of urine** associated with a sudden, strong desire to void. - This is typically due to an **overactive detrusor muscle** and would not cause continuous leakage, especially not through the vagina itself after a delivery. *Stress incontinence* - Defined by the leakage of urine with activities that **increase intra-abdominal pressure**, such as coughing, sneezing, or laughing. - It results from weakness of the **pelvic floor muscles** or urethral sphincter, not continuous drainage from the vagina. *Bladder rupture* - While a bladder rupture can cause urinary leakage, it usually presents with **acute abdominal pain**, abdominal distension, and possibly **hematuria**, along with urine accumulating in the peritoneal cavity, rather than continuous passage solely from the vagina. - A rupture would likely be an acute, more severe event with systemic symptoms, distinct from the described continuous vaginal leakage of urine.

Q: What is the most common cause of a descending mass per vaginum?

Uterovaginal prolapse. ***Uterovaginal prolapse*** - This is the **most common cause** of a descending mass per vaginum, as it involves the descent of the uterus and/or vaginal walls into or beyond the vaginal introitus. - It is often due to weakening of the **pelvic floor muscles** and **connective tissues**, commonly associated with childbirth, aging, and increased intra-abdominal pressure. *Myoma* - A **myoma** (uterine fibroid) is a benign growth of the uterus that generally presents with symptoms like heavy menstrual bleeding, pelvic pressure, or pain. - While a large submucosal myoma can prolapse through the cervix and into the vagina, it is a **less common cause** of a descending mass per vaginum compared to uterovaginal prolapse itself. *Cervical polyp* - A **cervical polyp** is a benign growth protruding from the cervical canal that can prolapse through the external os. - While it can present as a descending mass, cervical polyps are typically small and **less commonly** present as a significant descending mass compared to uterovaginal prolapse. *Vaginal cyst* - A **vaginal cyst** (e.g., Gartner's duct cyst, inclusion cyst) is a fluid-filled sac within the vaginal wall. - These cysts are usually discovered during a pelvic exam and are less likely to present as a prolapsing, descending mass compared to uterovaginal prolapse.

Q: Moschcowitz repair is done for:

Enterocele. ***Enterocele*** - The **Moschcowitz repair** is a historical procedure designed to repair an **enterocele** by obliterating the cul-de-sac. - It involves placing a series of high **purse-string sutures** in the posterior cul-de-sac peritoneum to elevate it and prevent bowel herniation. *Vault prolapse* - Vault prolapse involves the **prolapse of the vaginal apex** after hysterectomy. - While it can coexist with an enterocele, the Moschcowitz repair specifically targets the **enterocele defect**, not the overall vault support. *Adenomyosis* - **Adenomyosis** is a condition where endometrial tissue grows into the muscular wall of the uterus. - It is managed medically or surgically via **hysterectomy**, and is unrelated to surgical repairs for pelvic organ prolapse. *Chronic inversion of uterus* - **Chronic uterine inversion** is a rare condition where the uterus turns inside out, typically following childbirth. - Management involves **manual or surgical repositioning of the uterus** and is unrelated to the Moschcowitz repair for enterocele.

Q: Incontinence in elderly females is most commonly due to:

Detrusor instability. ***Detrusor instability*** - This condition is the most common cause of **urge incontinence** in elderly females, characterized by **involuntary contractions of the detrusor muscle** [1]. - It leads to a sudden, strong urge to urinate that is difficult to postpone, often resulting in **leaking of urine** [1]. *Vesicovaginal fistula* - A **vesicovaginal fistula** is an abnormal connection between the bladder and the vagina, usually caused by trauma or surgery, leading to continuous leakage. - While it causes incontinence, it is a relatively **rare cause** compared to detrusor instability in the general elderly female population. *Outlet obstruction* - **Outlet obstruction** in females is uncommon and typically presents with **overflow incontinence**, not urge incontinence, where the bladder cannot empty properly. - Causes can include severe prolapse or urethral strictures, which are not the most frequent cause of incontinence in this demographic. *True stress incontinence* - **Stress incontinence** occurs when there is leakage of urine due to increased **intra-abdominal pressure** (like coughing, sneezing, or laughing) in the absence of a detrusor contraction. - While common in older women, **detrusor instability (urge incontinence)** becomes more prevalent with advanced age as the primary cause of incontinence [1].

Q: Complications of sling procedures (TVT) for USI are all except:

Obturator nerve injury is about 10%. ***Obturator nerve injury is about 10%*** ✓ **CORRECT ANSWER (NOT a complication of TVT)** - **Obturator nerve injury** is exceedingly rare during **TVT (Tension-free Vaginal Tape)** procedures, which use a retropubic approach through the space of Retzius. - This complication is primarily associated with **TOT (Trans-Obturator Tape)** procedures where the tape passes near the obturator foramen, not with standard retropubic TVT. - The incidence of obturator nerve injury in TVT is essentially negligible (<0.1%), nowhere near 10%. *Overactive bladder in about 7% cases* - **De novo overactive bladder (OAB)** symptoms or worsening of pre-existing OAB can occur in 3-15% of patients after TVT procedures, with 7% being a commonly cited figure. - This occurs due to changes in bladder neck support, urethral kinking, or irritation from the sling material. *Injury to bladder and wound haematoma* - **Bladder injury/perforation** occurs in 2-5% of TVT cases due to the retropubic passage of needles close to the bladder, which is why intraoperative cystoscopy is routinely performed. - **Wound hematoma** can occur at the vaginal or suprapubic incision sites as a common surgical complication from tissue dissection and bleeding. *Sling erosion particularly with polytetrafluoroethylene (Goretex)* - **Sling erosion** into the vagina or urethra is a documented complication of synthetic slings, with rates of 0.5-3% for modern materials. - **Polytetrafluoroethylene (Goretex)**, an older first-generation mesh material, was associated with significantly higher rates of erosion (up to 10%) and infection compared to modern monofilament polypropylene meshes, which is why it has been largely discontinued for sling procedures.

Q: 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

Urethral syndrome. ***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.

Q: The most common type of genital prolapse is:

Cystocele. ***Cystocele*** - A **cystocele** (also known as a bladder prolapse) is the most common type of genital prolapse. - It occurs when the **bladder bulges into the vagina** due to weakened supporting tissues. *Enterocele* - An **enterocele** is the prolapse of the **small intestine into the vagina**, often occurring after a hysterectomy. - While it is a type of prolapse, it is less common than a cystocele. *Procidentia* - **Uterine procidentia** refers to a complete **uterine prolapse** where the entire uterus descends past the vaginal opening. - This is a severe form of prolapse but is less common than a cystocele. *Rectocele* - A **rectocele** occurs when the **rectum bulges into the vagina** due to weakened rectovaginal septum. - Although common, it is still less frequent than a cystocele.

Q: Gold standard management for vault prolapse is

Sacral colpopexy. ***Sacral colpopexy*** - **Sacral colpopexy** is considered the **gold standard** for treating post-hysterectomy vaginal vault prolapse due to its high success rates and durability. - It involves attaching a synthetic mesh from the vaginal apex to the **anterior longitudinal ligament** of the sacrum, effectively suspending the vagina. *Sacrospinous ligament fixation* - While effective for vault prolapse, **sacrospinous ligament fixation** involves unilateral attachment of the vaginal vault to the sacrospinous ligament, which can cause **vaginal axis deviation**. - Its long-term success rates are generally considered slightly lower than sacral colpopexy, although it is still a viable option, especially in cases where an abdominal approach is contraindicated. *LeFort repair* - **LeFort repair** is a **colpocleisis procedure**, meaning it involves partial closure of the vagina, typically reserved for elderly patients who are no longer sexually active and desire a less invasive procedure. - This option is not considered the "best management" in general as it is a **destructive procedure** that restricts future sexual function. *Anterior colporrhaphy* - **Anterior colporrhaphy** is primarily used to repair a **cystocele** (prolapse of the bladder into the vagina) and does not directly address **vaginal vault prolapse**. - While a patient with vault prolapse might also have a cystocele, anterior colporrhaphy alone would not correct the apical support defect.

Q: The recommended non-surgical treatment of stress incontinence is:

Pelvic floor muscle exercises. ***Pelvic floor muscle exercises*** - **Pelvic floor muscle exercises** (Kegel exercises) are considered the **first-line non-surgical treatment** for stress urinary incontinence. - They aim to strengthen the **pelvic floor muscles**, which support the urethra and bladder, improving urethral closure pressure. *Electrical stimulation* - **Electrical stimulation** is a passive treatment method that involves using a probe to deliver electrical currents to the pelvic floor muscles. - It is typically used as a **secondary treatment** when active pelvic floor muscle training is difficult or ineffective, as it does not actively engage the patient in muscle control. *Bladder training* - **Bladder training** is a behavioral therapy primarily used for **urge incontinence** or mixed incontinence, not specifically stress incontinence. - It involves learning to suppress sudden urges to urinate and gradually increasing the time between voids to regain bladder control. *Vaginal cone/weights* - **Vaginal cones or weights** are devices inserted into the vagina that patients hold in place by contracting their pelvic floor muscles. - While they can be used to **improve pelvic floor muscle strength**, they are often considered an **adjunctive or secondary treatment**, not the primary recommended non-surgical approach.

Q: Cystocoele is prolapse of

Upper 2/3rd of anterior vaginal wall. ***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 1

A 32-year-old lady with intrauterine fetal death after normal vaginal delivery has continuous passage of urine from the vagina. What is the most probable diagnosis?

Accepted Answer

Vesicovaginal fistula

Answer

Urge incontinence

Answer

Stress incontinence

Answer

Bladder rupture

Question 2

What is the most common cause of a descending mass per vaginum?

Accepted Answer

Uterovaginal prolapse

Answer

Myoma

Answer

Cervical polyp

Answer

Vaginal cyst

Question 3

Moschcowitz repair is done for:

Accepted Answer

Enterocele

Answer

Vault prolapse

Answer

Adenomyosis

Answer

Chronic inversion of uterus

Question 4

Incontinence in elderly females is most commonly due to:

Accepted Answer

Detrusor instability

Answer

Outlet obstruction

Answer

Vesicovaginal fistula

Answer

True stress incontinence

Question 5

Complications of sling procedures (TVT) for USI are all except:

Accepted Answer

Obturator nerve injury is about 10%

Answer

Overactive bladder in about 7% cases

Answer

Injury to bladder and wound haematoma

Answer

Sling erosion particularly with polytetrafluoroethylene (Goretex)

Question 6

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

Accepted Answer

Urethral syndrome

Answer

Asymptomatic bacteriuria

Answer

Cystitis

Answer

Vulvovaginitis

Question 7

The most common type of genital prolapse is:

Accepted Answer

Cystocele

Answer

Enterocele

Answer

Procidentia

Answer

Rectocele

Question 8

Gold standard management for vault prolapse is

Accepted Answer

Sacral colpopexy

Answer

Sacrospinous ligament fixation

Answer

LeFort repair

Answer

Anterior colporrhaphy

Question 9

The recommended non-surgical treatment of stress incontinence is:

Accepted Answer

Pelvic floor muscle exercises

Answer

Electrical stimulation

Answer

Bladder training

Answer

Vaginal cone/weights

Question 10

Cystocoele is prolapse of

Accepted Answer

Upper 2/3rd of anterior vaginal wall

Answer

Lower 1/3 of anterior vaginal wall

Answer

Lower 2/3rd of anterior vaginal wall

Answer

Upper 1/3 of anterior vaginal wall

Urogynecology — MCQs

Urogynecology — MCQs

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