Urogynecology Practice Questions

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.

Q: Which among the following simple tests is used to measure/assess urethral hypermobility?

Q tip test. ***Q tip test*** - The **Q-tip test** directly assesses **urethral hypermobility** by measuring the angle of urethral descent during a Valsalva maneuver. - An angle greater than **30 degrees from the horizontal** indicates significant hypermobility. *Voiding diary* - A **voiding diary** is used to record the frequency, volume, and urgency of urination over a specific period. - It helps assess **bladder function** and identify patterns of incontinence, but does not measure urethral mobility. *Office cystometry* - **Office cystometry** measures bladder pressure and volume to evaluate bladder filling and voiding dynamics. - It is primarily used to assess for **detrusor overactivity**, stress incontinence, or outlet obstruction, not urethral hypermobility. *Postvoid residual urine* - **Postvoid residual (PVR) urine** measures the amount of urine left in the bladder after urination. - It helps detect **incomplete bladder emptying**, which can be caused by obstruction or detrusor weakness, but does not assess urethral mobility.

Q: In which condition is a rubber-ring pessary an appropriate management for a woman who is having uterovaginal prolapse?

Old age. ***Old age*** - A rubber-ring pessary is an appropriate management option for uterovaginal prolapse in older women, especially those who are **not candidates for surgery** due to comorbidities or personal preference. - The goal is to **alleviate symptoms** and improve quality of life without invasive interventions. *Early pregnancy* - Uterovaginal prolapse can occur in early pregnancy, but a rubber-ring pessary is generally **not the primary treatment** as the condition often improves spontaneously with uterine growth at around 12-14 weeks. - Additionally, pessaries can increase the risk of **vaginal infections and discomfort** during pregnancy. *Prolapse associated with carcinoma of cervix* - If uterovaginal prolapse is associated with carcinoma of the cervix, the **carcinoma needs to be addressed first**, typically through oncological treatment. - A pessary would **mask symptoms** and is not an appropriate treatment for underlying malignancy. *Active reproductive age* - For women in their active reproductive age, especially those desiring future pregnancies, **surgical correction** is often preferred for uterovaginal prolapse. - While pessaries can provide temporary relief, they might not be suitable for long-term management or for women with a **desire for definitive repair**.

Q: A 50-year old woman complains of leakage of urine. Other than genuine stress urinary incontinence, the most common cause of urinary leakage is ?

Urge incontinence. ***Urge incontinence*** - **Urge incontinence**, characterized by an **involuntary leakage of urine accompanied or immediately preceded by urgency**, is the most common form of urinary incontinence after stress urinary incontinence, especially in older women [1]. - It results from **detrusor overactivity**, leading to sudden, strong urges to void that are difficult to defer. *Vesico vaginal fistula* - A **vesicovaginal fistula** involves an abnormal connection between the bladder and the vagina, leading to continuous and spontaneous leakage of urine into the vagina, which would present differently from typical urge symptoms [1]. - While it causes leakage, it's a relatively rare cause compared to urge incontinence and is often associated with prior surgery or radiation. *Overflow incontinence* - **Overflow incontinence** occurs when the bladder is overfilled and unable to empty properly, leading to continuous leakage of small amounts of urine due to retention [1]. - This is often caused by **bladder outlet obstruction** or **neurogenic bladder**, and the patient might report difficulty voiding or a sensation of incomplete emptying [1]. *Detrusor dyssynergia* - **Detrusor dyssynergia** describes a lack of coordination between the detrusor muscle contraction and external urethral sphincter relaxation, typically seen in neurological disorders [2]. - This condition is a specific type of voiding dysfunction that can lead to incontinence but is not the most common cause of leakage after stress incontinence in the general population.

Q: A 40-year-old G3P3 complains of urge incontinence. Sometimes she gets the urge to void, but passes urine before reaching the washroom. She had three normal spontaneous vaginal deliveries of infants weighing between 3.5 and 3.8 kg. Urine examination is normal. All of the following are appropriate treatments in the management of this patient EXCEPT:

Antidepressants. ***Antidepressants*** - **Tricyclic antidepressants (TCAs)** like imipramine have anticholinergic properties that can help with urge incontinence, but they are **NOT first-line therapy**. - **Anticholinergic medications** (oxybutynin, tolterodine, solifenacin) are the **preferred pharmacological agents** for urge incontinence, not antidepressants. - TCAs have **significant side effects** including sedation, orthostatic hypotension, and cardiac effects, making them less suitable as initial treatment. - They are typically reserved for **refractory cases** or when anticholinergics are contraindicated. *Kegel exercises* - **Pelvic floor muscle training (Kegel exercises)** is recommended as **first-line therapy** for urge incontinence per ACOG guidelines. - While more effective for stress incontinence, they improve overall **pelvic floor function** and bladder control. - They help strengthen the **periurethral and pelvic floor muscles**, which can help suppress detrusor contractions. *Biofeedback* - **Biofeedback** is an effective adjunct to pelvic floor muscle training for urge incontinence. - It helps patients **identify and control pelvic floor muscles** correctly during Kegel exercises. - Provides real-time feedback to improve the efficacy of **behavioral therapy**. *Bladder training* - **Bladder training** is a **cornerstone first-line treatment** for urge incontinence. - Focuses on **scheduled voiding** and gradually increasing the inter-voiding interval. - Helps patients learn to **suppress urgency** and regain bladder control through behavioral modification.

Q: Chassar Moir technique is used in

Vesico vaginal fistula. ***Vesico vaginal fistula*** - The Chassar Moir technique is a surgical approach specifically designed for the repair of **vesicovaginal fistulae**, which are abnormal communications between the bladder and the vagina. - This technique primarily utilizes a **transvaginal approach** to close the fistula, often involving excision of the tract and multi-layered closure. *Enterocoele repair* - Enterocoele repair involves addressing a herniation of the **peritoneum and small bowel** into the rectovaginal space. - While it's a pelvic floor repair, it's distinct from fistula repair; various techniques like sacrocolpopexy or colporrhaphy are used, not typically the Chassar Moir. *Urethrocoele* - A urethrocoele (or urethrocele) is a **herniation of the urethra** into the vagina, usually due to weakening of pelvic floor support. - Its repair focuses on supporting the urethra, often through anterior colporrhaphy, and not directly related to the Chassar Moir technique. *Stress incontinence* - Stress urinary incontinence is the involuntary leakage of urine with physical activity, often due to **urethral hypermobility** or **intrinsic sphincter deficiency**. - Surgical treatments include mid-urethral slings or colposuspension, which are entirely different procedures from the Chassar Moir technique for fistula repair.

Q: A 55-year-old woman has recurrent urinary retention after a hysterectomy done for a large fibroid. The most likely cause is:

Injury to the hypogastric plexi. ***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.

Q: A lady underwent vaginal hysterectomy for Carcinoma cervix. Following the surgery after her urethral catheter was removed, she complained of urinary incontinence. On examination she had normal voiding as well as continuous incontinence. Methylene blue dye was instilled in her bladder through her urethra and she was given oral Phenazopyridine dye. After some time her pads were checked and it showed yellow staining at the top most pad, while the middle or bottom pads were unstained. She is likely to have:

Ureterovaginal fistula. ***Ureterovaginal fistula*** - The **yellow staining** on the topmost pad, resulting from oral **Phenazopyridine** excreted by the kidneys, indicates that the urine is bypassing the bladder and leaking into the vagina directly from a ureter. - The **negative methylene blue test** (no blue staining) rules out bladder involvement, confirming that the leak is from a higher part of the urinary tract (ureter). *Vesicouterine fistula* - This type of fistula involves a communication between the **bladder and the uterus**, which is not relevant in a patient who has undergone a hysterectomy. - The presence of continuous incontinence with a normal voiding pattern would not typically be seen with this type of fistula, especially after hysterectomy. *Vesicovaginal fistula* - If a vesicovaginal fistula were present, the patient's pads would show **blue staining** from the methylene blue instilled into the bladder, indicating a direct leak from the bladder into the vagina. - The absence of blue staining in the pads rules out this diagnosis. *Urethrovaginal fistula* - A urethrovaginal fistula would involve a connection between the **urethra and the vagina**, typically leading to leakage of urine from the urethra. - While it causes incontinence, the specific finding of **yellow staining from oral Phenazopyridine** without blue staining from bladder instillation points away from a urethral source.

Q: 3 pad test is done for:

Stress incontinence. ***Stress incontinence*** - The **3-pad test (pad weighing test)** is a standardized, objective method to **quantify urinary incontinence**, particularly stress incontinence - The test involves weighing absorbent pads before and after a specified period (1-hour test or 24-hour test) to measure the exact amount of urine leakage - **Stress incontinence** is the most common indication, where involuntary urine leakage occurs during activities that increase intra-abdominal pressure (coughing, sneezing, laughing, exercise) - The test helps **grade severity** (mild 100g) and **monitor treatment response** - It provides objective documentation of incontinence severity for clinical decision-making *Urinary fistula* - A urinary fistula is an abnormal communication between the urinary tract and another structure (vesicovaginal, ureterovaginal fistula) - While severe continuous leakage occurs, diagnosis is made by **clinical examination**, **dye tests** (methylene blue test, double dye test), **speculum examination**, and **imaging** (cystoscopy, IVP) - The pad test is not the primary diagnostic method for fistulas, though it may show continuous heavy leakage *Rectovaginal fistula* - This is an abnormal connection between the rectum and vagina, causing passage of stool or gas through the vagina - The 3-pad test specifically measures **urine loss**, not fecal incontinence - Not relevant for rectovaginal fistula assessment *Urethrocoele* - A urethrocoele is a herniation or prolapse of the urethra into the anterior vaginal wall - This is a **structural/anatomical diagnosis** made by pelvic examination - While patients may have associated stress incontinence, the pad test measures the leakage, not the anatomical defect itself - Diagnosis is clinical, not based on pad testing

Q: In young women suffering from 2nd & 3rd degree uterovaginal prolapse, the choice of operation is:

Manchester repair. ***Manchester repair*** - For **young women** with 2nd and 3rd degree uterovaginal prolapse, **Manchester repair** (Fothergill's operation) is the traditional procedure of choice as it **preserves fertility** while effectively treating the prolapse. - The procedure involves **amputation of the elongated cervix** and **plication of the cardinal ligaments** anteriorly, providing excellent support while maintaining the uterus for future childbearing. - This is particularly suitable for young women who have not completed their family, addressing both the anatomical defect and fertility preservation. *Vaginal hysterectomy with vault suspension* - This is an effective and definitive treatment for uterovaginal prolapse but involves **removal of the uterus**, making it unsuitable as the first choice for young women who may desire future fertility. - This procedure is more appropriate for women who have completed their family or in whom uterine preservation is not a priority. *Laparoscopic sacrohysteropexy* - While this modern procedure preserves the uterus and fertility, it is a **more complex and expensive** minimally invasive approach that may not be widely available in all centers. - Though increasingly used, it is not traditionally considered the standard first-line procedure in examination contexts, where Manchester repair remains the classical fertility-preserving option for young women. *Uterosacral ligament suspension* - This procedure is primarily used for **vaginal vault prolapse** after hysterectomy or as a component of prolapse repair, not as a standalone treatment for uterovaginal prolapse with the uterus in situ. - It does not address the cervical elongation and uterine descent that typically accompany 2nd and 3rd degree uterovaginal prolapse in young women.

Question 1

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

Question 2

Which among the following simple tests is used to measure/assess urethral hypermobility?

Accepted Answer

Q tip test

Answer

Voiding diary

Answer

Office cystometry

Answer

Postvoid residual urine

Question 3

In which condition is a rubber-ring pessary an appropriate management for a woman who is having uterovaginal prolapse?

Accepted Answer

Old age

Answer

Early pregnancy

Answer

Prolapse associated with carcinoma of cervix

Answer

Active reproductive age

Question 4

A 50-year old woman complains of leakage of urine. Other than genuine stress urinary incontinence, the most common cause of urinary leakage is ?

Accepted Answer

Urge incontinence

Answer

Vesico vaginal fistula

Answer

Overflow incontinence

Answer

Detrusor dyssynergia

Question 5

A 40-year-old G3P3 complains of urge incontinence. Sometimes she gets the urge to void, but passes urine before reaching the washroom. She had three normal spontaneous vaginal deliveries of infants weighing between 3.5 and 3.8 kg. Urine examination is normal. All of the following are appropriate treatments in the management of this patient EXCEPT:

Accepted Answer

Antidepressants

Answer

Kegel exercises

Answer

Biofeedback

Answer

Bladder training

Question 6

Chassar Moir technique is used in

Accepted Answer

Vesico vaginal fistula

Answer

Enterocoele repair

Answer

Urethrocoele

Answer

Stress incontinence

Question 7

A 55-year-old woman has recurrent urinary retention after a hysterectomy done for a large fibroid. The most likely cause is:

Accepted Answer

Injury to the hypogastric plexi

Answer

Injury to the bladder neck

Answer

Atrophic and stenotic urethra

Answer

Lumbar disc prolapse

Question 8

A lady underwent vaginal hysterectomy for Carcinoma cervix. Following the surgery after her urethral catheter was removed, she complained of urinary incontinence. On examination she had normal voiding as well as continuous incontinence. Methylene blue dye was instilled in her bladder through her urethra and she was given oral Phenazopyridine dye. After some time her pads were checked and it showed yellow staining at the top most pad, while the middle or bottom pads were unstained. She is likely to have:

Accepted Answer

Ureterovaginal fistula

Answer

Vesicouterine fistula

Answer

Vesicovaginal fistula

Answer

Urethrovaginal fistula

Question 9

3 pad test is done for:

Accepted Answer

Stress incontinence

Answer

Rectovaginal fistula

Answer

Urethrocoele

Answer

Urinary fistula

Question 10

In young women suffering from 2nd & 3rd degree uterovaginal prolapse, the choice of operation is:

Accepted Answer

Manchester repair

Answer

Vaginal hysterectomy with vault suspension

Answer

Uterosacral ligament suspension

Answer

Laparoscopic sacrohysteropexy

Urogynecology — MCQs

Urogynecology — MCQs

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