Urogynecology Practice Questions

Q: A 60-year-old woman comes with 3rd degree uterine prolapse. What will be the management?

Vaginal hysterectomy with pelvic floor repair. ***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.

Q: Which is false about stress urinary incontinence?

More common in men. ***More common in men*** - **Stress urinary incontinence (SUI)** is significantly more prevalent in **women** due to anatomical differences and factors like childbirth. - While it can occur in men, especially after prostate surgery, the overall incidence is higher in females. *It is due to weakening of pelvic floor muscles* - Weakening of the **pelvic floor muscles** is a primary cause of SUI, leading to insufficient support for the urethra and bladder neck. - This weakness compromises the ability to maintain urethral closure pressure during activity. *Prostate surgery may be a cause* - **Radical prostatectomy** for prostate cancer is a common cause of SUI in men, as it can damage the urethral sphincter. - Damage to the internal or external urethral sphincter during surgery impairs the ability to control urine flow. *It occurs during increased abdominal pressure* - SUI characteristically involves involuntary urine leakage during activities that increase **intra-abdominal pressure**, such as coughing, sneezing, laughing, or exercising. - This increased pressure overcomes the weakened urethral resistance, leading to urine loss.

Q: What is the preferred treatment for complete prolapse in a woman who has completed her family?

Vaginal hysterectomy. ***Vaginal hysterectomy*** - For women with **complete uterine prolapse** who have completed childbearing, **vaginal hysterectomy** is often the definitive treatment. - This procedure removes the uterus and allows for concurrent **pelvic floor repair** to support the vaginal vault and address any associated cystocele or rectocele. *Sling procedure* - A sling procedure is primarily used to treat **stress urinary incontinence** and involves supporting the urethra or bladder neck. - It does not directly address **uterine prolapse** and would not resolve the main issue of a complete uterine descent. *Le Fort's repair* - **Le Fort's repair (colpocleisis)** is an obliterative procedure that closes off the vagina, typically reserved for elderly women who are not sexually active. - While effective for prolapse, it would be inappropriate for a woman who might wish to maintain **vaginal function**. *Pessary* - A **pessary** is a non-surgical device used for conservative management of prolapse, offering temporary support. - While it can provide symptomatic relief, it is not a **definitive treatment** for complete prolapse in a woman who has completed her family and is seeking a permanent solution.

Q: A patient presents with a history of vaginal prolapse and a painful ulcer on the prolapsed tissue. What is the most likely diagnosis?

Decubitus ulcer. ***Decubitus ulcer*** - A **decubitus ulcer** (pressure sore) is the most likely diagnosis when a patient with a **vaginal prolapse** develops a **painful ulcer** on the prolapsed tissue due to chronic pressure and friction. - The prolapsed tissue is often exposed to constant irritation and lack of proper blood supply, making it susceptible to ulceration. *Carcinoma* - While possible, carcinoma typically presents as a **non-healing lesion** with irregular borders and induration, and is often *not immediately painful* in its early stages. - A definitive diagnosis of carcinoma requires **biopsy and histopathological examination**. *Pressure erosion* - This term is a general description of tissue damage from pressure and can be a precursor to a decubitus ulcer, but **decubitus ulcer** specifically denotes the developed lesion. - It describes the *mechanism of injury* rather than the specific, fully formed ulcer. *Syphilis* - Syphilis causes a **chancre**, which is typically a *painless ulcer* with indurated borders. - It is a sexually transmitted infection, and while it could cause an ulcer, the context of a **vaginal prolapse** points more strongly to a localized pressure injury.

Q: Which type of fistula can present with both normal urinary voiding and continuous urine leakage simultaneously?

Ureterovaginal Fistula. ***Ureterovaginal Fistula*** - With a **ureterovaginal fistula**, urine can still flow from the bladder through the urethra, allowing for **normal voiding**. - Simultaneously, urine directly bypasses the bladder from the ureter into the vagina, causing **continuous leakage** independent of bladder function. *Vesicovaginal Fistula* - A **vesicovaginal fistula** typically leads to continuous urine leakage through the vagina because the bladder contents directly escape. - This often results in **no normal voiding** or significantly reduced voiding as urine does not accumulate in the bladder. *Uretrovaginal Fistula* - A **urethrovaginal fistula** connects the urethra directly to the vagina. - This usually results in **urine leakage during voiding** or when pressure is exerted, rather than continuous leakage with normal bladder emptying. *Vesicoperitoneal Fistula* - A **vesicoperitoneal fistula** involves leakage of urine from the bladder into the peritoneal cavity. - This condition presents with **ascites** and abdominal signs, not vaginal leakage or normal voiding combined with continuous leakage.

Q: Bonney's test is used to determine which of the following?

Urinary incontinence due to stress. ***Urinary incontinence due to stress*** - **Bonney's test** is specifically designed to assess whether a patient's **stress urinary incontinence** is correctable by elevating the urethrovesical junction. - A positive result, where urine leakage stops with elevation, suggests that surgical correction to support the urethra may be beneficial. *Uterine prolapse* - While related to pelvic floor dysfunction, **uterine prolapse** is assessed by clinical examination for descent of the uterus, not specifically with Bonney's test. - Its presence is determined by visible or palpable protrusion of the cervix or uterus through the vaginal opening. *Vesicovaginal fistula* - A **vesicovaginal fistula** involves an abnormal connection between the bladder and vagina, leading to continuous urine leakage. - This condition is typically diagnosed using dye tests (e.g., tampon test) or cystoscopy, not Bonney's test. *Ureteric fistula* - A **ureteric fistula** is an abnormal connection involving the ureter, often resulting in continuous urine leakage outside the normal urinary tract. - Diagnosis usually involves imaging studies like IV urography or CT urogram, as Bonney's test is not relevant for this condition.

Q: What is the treatment for uterine prolapse in nulliparous women?

Manchester operation. ***Manchester operation*** - This procedure is sometimes considered for **nulliparous women** with uterine prolapse, particularly if combined with cervical elongation. - It involves **amputation of the cervix** and support of the cardinal ligaments, which can address the prolapse while preserving uterine function. *Sling used involving rectus sheath* - A sling using the rectus sheath is typically employed for **stress urinary incontinence**, not primarily for uterine prolapse. - While it supports the urethra and bladder neck, it does not directly address the descent of the uterus. *Anterior colporrhaphy* - This procedure repairs a **cystocele** (prolapse of the bladder into the vagina) by tightening the anterior vaginal wall. - It does not directly manage **uterine prolapse** itself, though a cystocele can coexist with uterine descent. *Posterior colporrhaphy* - This surgical repair targets a **rectocele** (prolapse of the rectum into the vagina) by tightening the posterior vaginal wall. - Similar to anterior colporrhaphy, it addresses a specific vaginal wall defect rather than the **uterine position**.

Q: What is the most appropriate surgical treatment for a 40-year-old married female with uterine prolapse and completed family?

Vaginal hysterectomy with pelvic floor repair. ***Vaginal hysterectomy with pelvic floor repair*** - For women with **completed family** and symptomatic uterine prolapse, **vaginal hysterectomy** with concurrent **pelvic floor repair** is typically the most definitive and appropriate surgical treatment. - This approach addresses both the uterine prolapse by removing the uterus and the accompanying pelvic floor muscle and fascial defects that contribute to the prolapse. *Fothergill's operation* - **Fothergill's operation**, or Manchester repair, involves **cervical amputation** and uterosacral ligament plication, preserving the uterus. - This procedure is generally reserved for women who desire **future childbearing** or wish to retain their uterus, which is not a priority for this patient with completed family. *Abdominal Sling operation* - The **abdominal sling operation** (e.g., sacral colpopexy) is primarily used for **vaginal vault prolapse** after hysterectomy or in cases of severe prolapse where a more robust suspension is needed. - It is often considered a more complex procedure and may not be the first-line choice for primary uterine prolapse in a patient with completed family, especially when a vaginal approach is feasible. *Ring pessary* - A **ring pessary** is a **non-surgical** management option for uterine prolapse, offering symptomatic relief by physically supporting the uterus. - While it can be an effective initial or long-term management for some patients, the question specifically asks for the "most appropriate **surgical treatment**" in a patient with completed family, implying a definitive solution.

Q: What is the recommended management for a woman with third-degree utero-vaginal prolapse who desires to preserve her fertility?

Manchester operation. ***Manchester operation*** - The **Manchester operation (also known as Fothergill's operation)** is the **recommended fertility-preserving procedure** for women with third-degree uterovaginal prolapse who wish to retain their uterus. - It involves **amputation of the elongated/hypertrophied cervix**, **anterior colporrhaphy**, **posterior colpoperineorrhaphy**, and **plication of the cardinal (Mackenrodt's) ligaments** anteriorly to the cervical stump. - This procedure **restores anatomical support** while **preserving the uterus and fertility potential**, making it ideal for younger women desiring future pregnancy. *Fothergill's repair* - **Fothergill's repair is synonymous with Manchester operation** - they are the **same procedure**. - Both terms refer to the fertility-preserving surgical approach for uterovaginal prolapse. - This option would also be correct, but since "Manchester operation" is listed separately, it appears the question intends to distinguish them (though medically they are identical). *Le Fort's repair (Colpocleisis)* - **Le Fort's colpocleisis** involves **partial obliteration of the vaginal canal** by suturing the anterior and posterior vaginal walls together. - This procedure is suitable only for **elderly women who have completed childbearing and are not sexually active**. - It renders a woman **unable to have intercourse or carry a pregnancy**, making it completely unsuitable for women desiring fertility. *Shirodkar's Modified Sling Operation* - The **Shirodkar's operation** is a **cervical cerclage procedure** used for **cervical incompetence** to prevent second-trimester pregnancy loss. - It involves placing a **purse-string suture around the cervix** to provide mechanical support during pregnancy. - This procedure **does not treat uterine prolapse** and is unrelated to pelvic organ prolapse management.

Q: Urinary incontinence in uterovaginal prolapse is mostly due to:

Stress incontinence. ***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 1

A 60-year-old woman comes with 3rd degree uterine prolapse. What will be the management?

Accepted Answer

Vaginal hysterectomy with pelvic floor repair

Answer

Pelvic floor repair

Answer

Sacrospinous fixation

Answer

Pessary

Question 2

Which is false about stress urinary incontinence?

Accepted Answer

More common in men

Answer

It is due to weakening of pelvic floor muscles

Answer

Prostate surgery may be a cause

Answer

It occurs during increased abdominal pressure

Question 3

What is the preferred treatment for complete prolapse in a woman who has completed her family?

Accepted Answer

Vaginal hysterectomy

Answer

Pessary

Answer

Sling procedure

Answer

Le Fort's repair

Question 4

A patient presents with a history of vaginal prolapse and a painful ulcer on the prolapsed tissue. What is the most likely diagnosis?

Accepted Answer

Decubitus ulcer

Answer

Carcinoma

Answer

Pressure erosion

Answer

Syphilis

Question 5

Which type of fistula can present with both normal urinary voiding and continuous urine leakage simultaneously?

Accepted Answer

Ureterovaginal Fistula

Answer

Vesicovaginal Fistula

Answer

Uretrovaginal Fistula

Answer

Vesicoperitoneal Fistula

Question 6

Bonney's test is used to determine which of the following?

Accepted Answer

Urinary incontinence due to stress

Answer

Uterine prolapse

Answer

Vesicovaginal fistula

Answer

Ureteric fistula

Question 7

What is the treatment for uterine prolapse in nulliparous women?

Accepted Answer

Manchester operation

Answer

Anterior colporrhaphy

Answer

Posterior colporrhaphy

Answer

Sling used involving rectus sheath

Question 8

What is the most appropriate surgical treatment for a 40-year-old married female with uterine prolapse and completed family?

Accepted Answer

Vaginal hysterectomy with pelvic floor repair

Answer

Fothergill's operation

Answer

Abdominal Sling operation

Answer

Ring pessary

Question 9

What is the recommended management for a woman with third-degree utero-vaginal prolapse who desires to preserve her fertility?

Accepted Answer

Manchester operation

Answer

Le fort's repair

Answer

Fothergill's repair

Answer

Shirodkar's Modified Sling Operation

Question 10

Urinary incontinence in uterovaginal prolapse is mostly due to:

Accepted Answer

Stress incontinence

Answer

Detrusor instability

Answer

Urge incontinence

Answer

True incontinence

Urogynecology — MCQs

Urogynecology — MCQs

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