Rectocele and Enterocele — MCQs
Injury to which of the following muscles that forms the deep support of the perineal body causes cystocele, enterocele and urethral descent?
Which of the following is not felt with a digital rectal examination?
All are causes of prolapse of cervix EXCEPT:
What is the treatment for uterine prolapse in nulliparous women?
In gonorrhea, which is not a presenting feature?
What is the last resort treatment for rectal prolapse in childhood?
Not a feature of rectosigmoid endometriosis on MRI
Match List-I with List-II and select the correct answer using the code given below the Lists:
Moschcowitz repair is done for:
A 40 year old lady is examined and found to have uterovaginal prolapse. What is the appropriate surgery to prevent recurrence?
Rectocele and Enterocele Indian Medical PG Practice Questions and MCQs
Question 1: Injury to which of the following muscles that forms the deep support of the perineal body causes cystocele, enterocele and urethral descent?
- A. Sphincter of urethra and anus
- B. Pubococcygeus (Correct Answer)
- C. Bulbospongiosus
- D. Ischiocavernosus
Explanation: ***Pubococcygeus*** - The **pubococcygeus muscle** is a major component of the **levator ani muscle** group, forming the primary support structure of the pelvic floor [1]. Damage to this muscle impairs the support for the bladder, rectum, and uterus, leading to prolapse conditions like **cystocele**, **enterocele**, and **urethral descent**. - Its integrity is crucial for maintaining the position of pelvic organs and proper function of the urinary and defecatory systems, as it directly supports the vagina, rectum, and bladder neck [3]. *Sphincter of urethra and anus* - The **external urethral sphincter** primarily controls voluntary urination, and its injury mainly leads to **stress urinary incontinence**, not necessarily prolapse [2]. - The **external anal sphincter** controls defecation, and its injury would primarily lead to **fecal incontinence**, not cystocele, enterocele, or urethral descent [2]. *Bulbospongiosus* - The **bulbospongiosus muscle** is superficial, supporting the clitoris and compressing erectile tissue in females, and expelling semen/urine in males. - Its injury would primarily affect sexual function and perineal body integrity but is **not a primary cause of pelvic organ prolapse** like cystocele or enterocele [3]. *Ischiocavernosus* - The **ischiocavernosus muscle** is also superficial, maintaining erection of the clitoris/penis by compressing the crura. - Injury to this muscle would mainly disrupt **erectile function** and contribute minimally to pelvic organ support or prolapse.
Question 2: Which of the following is not felt with a digital rectal examination?
- A. Seminal vesicles
- B. Prostate
- C. Rectovesical pouch
- D. Ureter (Correct Answer)
Explanation: ***Ureter*** - The **ureters** are too deep and medially located to be reliably palpated during a **digital rectal examination** (DRE). - They are typically not accessible through the rectal wall due to their anatomical position posterior to the urinary bladder and prostate (in males). *Seminal vesicles* - The **seminal vesicles** are located superior to the prostate and can sometimes be palpated, especially if enlarged or inflamed. - They are adjacent to the posterior surface of the bladder and anterior to the rectum. *Prostate* - The **prostate gland** is directly anterior to the rectum and is the primary structure evaluated during a **DRE**. - Its size, consistency, and any nodules or tenderness can be assessed. *Rectovesical pouch* - The **rectovesical pouch** is the peritoneal reflection between the rectum and the bladder in males. - While not a distinct organ to "feel," pathology within this space (e.g., fluid collections, masses) can sometimes be appreciated as a fullness or mass effect above the prostate via the DRE.
Question 3: All are causes of prolapse of cervix EXCEPT:
- A. Menopause
- B. Chronic cough
- C. Delivery of a big baby
- D. Regular exercise (Correct Answer)
Explanation: ***Regular exercise*** - **Regular exercise**, especially core-strengthening exercises, can actually help prevent pelvic organ prolapse by strengthening the **pelvic floor muscles**. - It does not contribute to the weakening of support structures necessary for cervical prolapse. *Menopause* - **Estrogen deficiency** during menopause leads to the thinning and weakening of **pelvic connective tissues** and muscles. - This loss of tissue elasticity and strength renders the pelvic organs more susceptible to prolapse. *Chronic cough* - A **chronic cough** significantly increases **intra-abdominal pressure** repeatedly. - This sustained downward force can strain and weaken the **pelvic floor muscles** and ligaments over time, contributing to prolapse. *Delivery of a big baby* - The **vaginal delivery** of a large baby can cause significant **trauma** and stretching to the **pelvic floor muscles**, ligaments, and fascia. - This physical damage can compromise the structural integrity supporting the cervix and other pelvic organs, increasing the risk of prolapse.
Question 4: What is the treatment for uterine prolapse in nulliparous women?
- A. Anterior colporrhaphy
- B. Posterior colporrhaphy
- C. Sling used involving rectus sheath
- D. Manchester operation (Correct Answer)
Explanation: ***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**.
Question 5: In gonorrhea, which is not a presenting feature?
- A. Discharge
- B. Hematuria (Correct Answer)
- C. Reddened lips of vulva and vagina
- D. Dysuria
Explanation: ***Hematuria*** - **Hematuria**, or blood in the urine, is not a typical presenting feature of uncomplicated gonococcal infection. - While urinary tract infections can cause hematuria, **gonorrhea primarily affects mucous membranes** of the reproductive and urinary tracts, leading to inflammation and purulent discharge rather than bleeding within the urinary system itself. *Discharge* - **Urethral discharge** in men and **vaginal or cervical discharge** in women is a very common symptom of gonorrhea [1]. - The discharge is typically **purulent, thick, and yellowish-green**. *Dysuria* - **Dysuria**, or painful urination, is a frequent symptom, especially in men with **urethritis** due to gonorrhea [1]. - It results from the **inflammation of the urethra** caused by the bacterial infection. *Reddened lips of vulva and vagina* - **Erythema and inflammation of the vulva and vagina** can occur in women with gonococcal cervicitis or vaginitis [1]. - This irritation is a direct result of the **gonococcal infection** of the mucosal surfaces.
Question 6: What is the last resort treatment for rectal prolapse in childhood?
- A. Lahaut's operation
- B. Incision of prolapsed mucosa
- C. Thiersch wiring (Correct Answer)
- D. Ripstein operation
Explanation: ***Thiersch wiring*** - This procedure involves placing a **silver wire or non-absorbable suture** circumferentially around the anus to prevent external prolapse. - It is considered a **last resort** for rectal prolapse in children due to its potential complications and the fact that most childhood prolapses resolve spontaneously or with less invasive measures. - Reserved for cases that fail conservative treatment and minimally invasive options. *Lahaut's operation* - Lahaut's operation involves **injection of sclerosing agents** (sclerotherapy) into the perirectal tissues to induce fibrosis and fixation. - While this is a recognized minimally invasive approach for rectal prolapse, it is **not considered the last resort** in pediatric cases. - Thiersch wiring is typically reserved as the last surgical option when other measures fail. *Incision of prolapsed mucosa* - This is an **unconventional and potentially harmful** approach for rectal prolapse, as it risks severe bleeding, infection, and damage to the rectal tissue. - It does not address the underlying structural issues causing the prolapse and is not a recognized treatment. *Ripstein operation* - The Ripstein procedure (anterior sling rectopexy) is a **rectopexy** technique primarily used for **adult rectal prolapse**. - It involves fixing the rectum to the sacrum with a synthetic mesh and is generally too invasive for pediatric cases, especially when simpler options like Thiersch wiring are available.
Question 7: Not a feature of rectosigmoid endometriosis on MRI
- A. T2 hyperintensity (Correct Answer)
- B. Mushroom cap sign
- C. Fat stranding
- D. Bowel wall thickening
Explanation: ***T2 hyperintensity*** - Endometriotic implants typically demonstrate **T1 hyperintensity** due to the presence of **hemorrhage** within the ectopic endometrial tissue. - On T2-weighted images, endometriosis usually appears **hypointense** or **isointense** due to the phenomenon of **T2 shading**, caused by chronic hemorrhage and fibrosis. *Mushroom cap sign* - This sign is characteristic of **deep infiltrating endometriosis** affecting the rectosigmoid. - It describes the appearance where the fibrotic endometriotic nodule infiltrates the bowel wall, creating a mushroom-like shape due to the **thickened muscularis propria** and overlying mucosal folds. *Fat stranding* - **Fat stranding** in the perirectal or perisigmoid fat is a common feature of **inflammatory conditions** including endometriosis. - It indicates **reactive inflammation** around the endometriotic implants, often seen in cases of deep infiltrating endometriosis. *Bowel wall thickening* - **Bowel wall thickening** is a frequent finding in rectosigmoid endometriosis due to **fibrotic reaction**, **smooth muscle hypertrophy**, and **edema** caused by the infiltrating endometrial tissue. - This thickening can lead to narrowing of the bowel lumen and obstructive symptoms.
Question 8: 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 9: Moschcowitz repair is done for:
- A. Vault prolapse
- B. Adenomyosis
- C. Enterocele (Correct Answer)
- D. Chronic inversion of uterus
Explanation: ***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.
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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