Urogynecology Practice Questions

Q: Which surgical procedure has the highest incidence of ureteric injury?

Radical hysterectomy. ***Radical hysterectomy*** - This procedure involves extensive dissection to remove the uterus, cervix, and surrounding parametrial tissue, which places the **ureters at high risk of injury** due to their close proximity to the surgical field. - The **ureter** runs directly through the **parametrium** (cardinal and uterosacral ligaments), which are ligated and excised during a radical hysterectomy, making it the procedure with the highest incidence of ureteral injury. *Vaginal hysterectomy* - While ureteric injury can occur, it is generally less common than in radical hysterectomy due to the less extensive dissection and different angle of approach. - The risk is present during clamping and ligating the **uterosacral and cardinal ligaments** but is typically lower than with a radical approach. *Anterior colporraphy* - This procedure primarily involves the anterior vaginal wall and bladder, usually without deep pelvic dissection that would place the ureters at significant risk. - The main risks are typically related to the bladder itself, rather than the ureters, as the dissection is superficial to the ureteral course. *Abdominal hysterectomy* - While there is a risk of ureteric injury, especially during the ligation of the **uterine arteries** and cardinal ligaments, the dissection is less extensive than in a radical hysterectomy. - Standard abdominal hysterectomy involves less parametrial dissection, thus exposing the ureters to a lower, though still present, risk of injury compared to radical procedures.

Q: In Procidentia which of the following is true?

Both uterus and vagina outside the introitus. ***Both uterus and vagina outside the introitus*** - **Procidentia** is defined as the most severe form of **pelvic organ prolapse**, where the **uterus, cervix, and the entire vaginal canal** protrude completely outside the vaginal introitus. - This condition represents a **third-degree uterine prolapse**, signifying the failure of multiple pelvic support structures. *Uterus in vagina cervix outside the introitus* - This description corresponds to a **second-degree uterine prolapse**, where the **cervix** is visible outside the introitus, but the uterine body remains within the vagina. - In **procidentia**, both the uterus and the entire vagina are external. *Uterus and cervix in vagina* - This scenario describes either a normal anatomical position or a **first-degree uterine prolapse** where the cervix has descended but remains within the vagina. - For **procidentia**, there must be complete prolapse beyond the introitus. *None of the options* - This option is incorrect because the first statement accurately defines **procidentia** as the complete prolapse of both the uterus and the vagina outside the introitus.

Q: Cause of decubitus ulcer in uterine prolapse is :

Friction. ***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.

Q: Which of the following cannot be treated by laparoscopy?

Genital prolapse. ***Genital prolapse*** - **Genital prolapse** typically requires **vaginal surgical approaches** such as **anterior/posterior colporrhaphy** and **vaginal hysterectomy** for comprehensive repair of multiple compartment defects. - While **laparoscopic sacrocolpopexy** exists for vault prolapse, it does not address all compartments of complete prolapse and requires advanced laparoscopic expertise compared to established vaginal techniques. *Sterilization* - **Laparoscopic tubal sterilization** is one of the most commonly performed laparoscopic procedures worldwide. - Methods include **Filshie clips**, **Falope rings**, or **electrocautery** to occlude fallopian tubes with minimal morbidity. *Non descent of uterus* - Can be effectively managed with **laparoscopic-assisted vaginal hysterectomy (LAVH)** or **total laparoscopic hysterectomy (TLH)**. - Laparoscopy facilitates **uterine vessel ligation** and dissection of attachments with excellent visualization and minimal invasiveness. *Ectopic pregnancy* - **Laparoscopic surgery** is the **gold standard** for treating ectopic pregnancy when hemodynamically stable. - Procedures include **laparoscopic salpingectomy** or **salpingostomy** with advantages of reduced recovery time and minimal scarring.

Q: Bonney's test is done for:

Stress incontinence. ***Stress incontinence*** - **Bonney's test** is used to assess if **urethral support** can alleviate **stress urinary incontinence (SUI)**. - During the test, the bladder neck is elevated manually or with instruments to mimic surgical correction, and the patient is asked to cough. If leakage stops, it suggests that surgical correction of urethral hypermobility may be beneficial. *Urinary retention* - **Urinary retention** involves the **inability to empty the bladder**, which is not assessed by Bonney's test. - This condition is typically diagnosed by measuring **post-void residual volume**. *Urge incontinence* - **Urge incontinence** is characterized by an **involuntary leakage of urine** accompanied by a sudden, strong desire to void. - This condition is primarily associated with **detrusor overactivity** and is not evaluated by Bonney's test. *Urinary fistula* - A **urinary fistula** is an **abnormal connection** between two epithelialized organs, allowing urine to leak. - Diagnosis involves imaging studies or dye tests to identify the abnormal tract, not Bonney's test.

Q: Fourteen weeks pregnancy with third degree prolapse. Best management will be:

Ring pessary. ***Ring pessary*** - A **ring pessary** is the most appropriate management for a **third-degree uterine prolapse** during pregnancy, especially in the second trimester (14 weeks). - It provides **mechanical support** to the uterus, relieving symptoms and potentially allowing the pregnancy to progress without surgical intervention. *No treatment* - Leaving a **third-degree prolapse untreated** during pregnancy can lead to complications such as cervical erosion, infection, miscarriage, or preterm labor, making it an unsuitable option. - The patient would experience significant discomfort and potential obstruction, which needs active management. *Foot end elevation* - While **foot end elevation** can temporarily relieve some pelvic pressure, it is not an effective or sufficient treatment for a **third-degree uterine prolapse**, which requires direct mechanical support. - It does not address the underlying anatomical displacement and would not sustainedly reduce the prolapse. *Sling surgery* - **Sling surgery** is a surgical procedure typically indicated for severe, symptomatic uterine prolapse in non-pregnant individuals or after childbirth, not during pregnancy. - Performing surgery during the **second trimester** carries significant risks to both the mother and the fetus, including potential for miscarriage or preterm labor.

Q: In anterior colporrhaphy, the best method of suture apposing the vaginal flaps is:

Interrupted. ***Interrupted*** - **Interrupted sutures** are preferred in anterior colporrhaphy to allow for drainage and prevent hematoma formation, which can impair healing. - They also distribute tension more evenly across the surgical wound, reducing the risk of wound dehiscence. *Continuous* - **Continuous sutures** are generally avoided in colporrhaphy as they can create a closed space that traps fluid, increasing the risk of infection and hematoma. - If a single point of the suture breaks, the entire closure can unravel, compromising wound integrity. *Interrupted mattress* - While **interrupted mattress sutures** offer strong apposition, they are often more complex and time-consuming to place compared to simple interrupted sutures. - The added bulk and multiple passes through tissue may also increase the risk of tissue ischemia if tied too tightly. *Interlocking* - **Interlocking sutures** are primarily used for hemostasis and are less suitable for mucosal apposition in colporrhaphy. - They tend to create a tighter, more constricting closure that can impede wound drainage and increase tissue tension.

Q: A 52 year old lady presents with constant leakage of urine and dysuria two weeks after a complicated total abdominal hysterectomy. A diagnosis of Vesicovaginal fistula is suspected. The most important test for the diagnosis is:

Triple Swab Test. ***Triple Swab Test*** - The **Triple Swab Test** (also known as the **dye test** or **tampon test**) is the **gold standard diagnostic test** for confirming vesicovaginal fistula. - **Methylene blue** or indigo carmine dye is instilled into the bladder via a catheter, and tampons are placed in the vagina. - If the tampon stains blue, it **confirms the diagnosis** of vesicovaginal fistula by demonstrating direct communication between bladder and vagina. - This is a **simple, non-invasive, and definitive diagnostic test** that directly proves the presence of a fistula. *Cystoscopy* - **Cystoscopy** is important for **evaluation and surgical planning** rather than initial diagnosis. - It allows direct visualization of the **fistula site, size, and proximity to ureteral orifices**, which is crucial for planning repair. - While it can identify the fistula, it is an **invasive procedure** and is typically performed after diagnosis is confirmed, to characterize the fistula before surgical intervention. *Urine culture* - A **urine culture** identifies bacterial infections and guides antibiotic treatment for urinary tract infections. - While UTIs commonly accompany vesicovaginal fistula and cause dysuria, urine culture **does not diagnose the fistula itself**. - It is useful for managing concurrent infection but not for confirming the anatomical defect. *IVP* - **Intravenous Pyelogram (IVP)** is primarily used to assess **upper urinary tract pathology** and ureteral integrity. - It may show contrast leakage but is **not specific for vesicovaginal fistula** and does not provide direct confirmation. - IVP is more useful for ruling out ureteral injury or ureterovaginal fistula rather than diagnosing vesicovaginal fistula.

Q: The disadvantage of Marshall-Marchetti-Krantz procedure compared with other surgical alternatives for treatment of stress urinary incontinence includes

Osteitis pubis. ***Osteitis pubis*** - **Osteitis pubis** is a known, though rare, complication specifically associated with the Marshall-Marchetti-Krantz (MMK) procedure due to the sutures placed in the periosteum of the pubic symphysis, leading to inflammation. - This complication presents as **groin pain** and tenderness over the symphysis pubis, and it is less common with modern sling procedures or colposuspension techniques. *Increased incidence of urinary tract infections* - While **urinary tract infections (UTIs)** can occur after any pelvic surgery, there is no evidence to suggest that the MMK procedure specifically carries a higher incidence compared to other stress urinary incontinence (SUI) surgeries. - Post-surgical catheterization and manipulation can increase UTI risk universally regardless of the specific surgical approach. *Urinary retention* - **Urinary retention** is a potential complication of many SUI surgeries, including MMK, due to over-correction or urethral obstruction. - However, newer procedures like mid-urethral slings have also been associated with significant rates of transient or persistent urinary retention, suggesting it's not a unique disadvantage of MMK. *High failure rate* - The **failure rate** of MMK, while debated and variable across studies, is generally comparable to or sometimes better than some older SUI procedures. - Modern tension-free vaginal tape (TVT) and other sling procedures have often superseded MMK due to less invasiveness or similar efficacy, not necessarily a universally higher failure rate of MMK.

Q: In uterine prolapse, how do you assess if a pessary ring is properly in place?

If not expelled after increased abdominal pressure. ***If not expelled after increased abdominal pressure*** - A properly fitted pessary should remain in place even with increased **intra-abdominal pressure**, such as during coughing, straining, or Valsalva maneuvers, indicating stable support for the uterus. - This assesses the pessary's ability to mechanically support the **pelvic organs** and prevent prolapse recurrence during daily activities. *If Bleeding does not occur* - While bleeding after pessary insertion can indicate trauma or irritation, the absence of bleeding alone does not confirm proper fit or efficacy in preventing **prolapse**. - Bleeding can occur due to various reasons, and it is not a direct measure of the pessary's ability to maintain its position or provide support. *If patient feels discomfort* - Discomfort can indicate either an improperly fitted pessary (too large causing pressure, or too small causing rubbing) or an initial adjustment period. - However, the absence of discomfort does not guarantee the pessary will stay in place during activities that increase **abdominal pressure**, which is crucial for prolapse management. *None of the options* - This option is incorrect because the ability of the pessary to remain in place during increased abdominal pressure is a key indicator of its proper fit and effectiveness.

Question 1

Which surgical procedure has the highest incidence of ureteric injury?

Accepted Answer

Radical hysterectomy

Answer

Vaginal hysterectomy

Answer

Anterior colporraphy

Answer

Abdominal hysterectomy

Question 2

In Procidentia which of the following is true?

Accepted Answer

Both uterus and vagina outside the introitus

Answer

Uterus in vagina cervix outside the introitus

Answer

Uterus and cervix in vagina

Answer

None of the options

Question 3

Cause of decubitus ulcer in uterine prolapse is :

Accepted Answer

Friction

Answer

Trauma

Answer

Intercourse

Answer

Venous congestion

Question 4

Which of the following cannot be treated by laparoscopy?

Accepted Answer

Genital prolapse

Answer

Non descent of uterus

Answer

Ectopic pregnancy

Answer

Sterilization

Question 5

Bonney's test is done for:

Accepted Answer

Stress incontinence

Answer

Urinary retention

Answer

Urge incontinence

Answer

Urinary fistula

Question 6

Fourteen weeks pregnancy with third degree prolapse. Best management will be:

Accepted Answer

Ring pessary

Answer

No treatment

Answer

Foot end elevation

Answer

Sling surgery

Question 7

In anterior colporrhaphy, the best method of suture apposing the vaginal flaps is:

Accepted Answer

Interrupted

Answer

Continuous

Answer

Interrupted mattress

Answer

Interlocking

Question 8

A 52 year old lady presents with constant leakage of urine and dysuria two weeks after a complicated total abdominal hysterectomy. A diagnosis of Vesicovaginal fistula is suspected. The most important test for the diagnosis is:

Accepted Answer

Triple Swab Test

Answer

Urine culture

Answer

Cystoscopy

Answer

IVP

Question 9

The disadvantage of Marshall-Marchetti-Krantz procedure compared with other surgical alternatives for treatment of stress urinary incontinence includes

Accepted Answer

Osteitis pubis

Answer

Increased incidence of urinary tract infections

Answer

Urinary retention

Answer

High failure rate

Question 10

In uterine prolapse, how do you assess if a pessary ring is properly in place?

Accepted Answer

If not expelled after increased abdominal pressure

Answer

If Bleeding does not occur

Answer

If patient feels discomfort

Answer

None of the options

Urogynecology — MCQs

Urogynecology — MCQs

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