Surgical Management in Urogynecology — MCQs
Urinary incontinence in uterovaginal prolapse is mostly due to:
In young women suffering from 2nd & 3rd degree uterovaginal prolapse, the choice of operation is:
Sacrospinous fixation is for strengthening:
A patient with a non-obstructing carcinoma of the sigmoid colon is being prepared for elective resection. To minimize the risk of postoperative infectious complications, what should be included in your planning?
Gold standard management for vault prolapse is
In Marshall - Marchetti - Krantz (MMK) colposuspension for stress urinary incontinence, Pubocervical fascia is attached to
A 60-year-old woman comes with 3rd degree uterine prolapse. What will be the management?
What is the most appropriate surgical treatment for a 40-year-old married female with uterine prolapse and completed family?
3rd degree genital prolapse in the first trimester of pregnancy is managed by :
Which of the following accurately describes management of Grade 3 pelvic organ prolapse in an elderly woman who is a poor surgical candidate?
Surgical Management in Urogynecology Indian Medical PG Practice Questions and MCQs
Question 1: Urinary incontinence in uterovaginal prolapse is mostly due to:
- A. Detrusor instability
- B. Urge incontinence
- C. True incontinence
- D. Stress incontinence (Correct Answer)
Explanation: ***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 2: In young women suffering from 2nd & 3rd degree uterovaginal prolapse, the choice of operation is:
- A. Vaginal hysterectomy with vault suspension
- B. Uterosacral ligament suspension
- C. Manchester repair (Correct Answer)
- D. Laparoscopic sacrohysteropexy
Explanation: ***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 3: Sacrospinous fixation is for strengthening:
- A. Apical defect (Correct Answer)
- B. Posterior defect
- C. Anterior defect
- D. Lateral defect
Explanation: ***Apical defect*** - **Sacrospinous fixation** is a surgical procedure commonly used to treat **apical prolapse**, which is the descent of the uterus or vaginal vault. - The procedure involves attaching the vaginal apex to the **sacrospinous ligament**, thereby providing support and preventing recurrence of prolapse. *Posterior defect* - A **posterior defect** typically refers to a **rectocele**, a bulge of the rectum into the posterior vaginal wall. - While sometimes co-occurring with apical prolapse, sacrospinous fixation primarily addresses apical support and not directly the rectocele. *Anterior defect* - An **anterior defect** usually describes a **cystocele**, which is the herniation of the bladder into the anterior vaginal wall. - Surgical correction for cystocele often involves **anterior colporrhaphy** or paravaginal defect repair, which are different from sacrospinous fixation. *Lateral defect* - **Lateral defects** in pelvic floor support are less common and typically refer to problems with the **paravaginal attachments**. - These are usually repaired through specific procedures addressing weaknesses in the lateral support structures, not primarily with sacrospinous fixation.
Question 4: A patient with a non-obstructing carcinoma of the sigmoid colon is being prepared for elective resection. To minimize the risk of postoperative infectious complications, what should be included in your planning?
- A. Postoperative administration for 5 to 7 days of parenteral antibiotics effective against aerobes and anaerobes
- B. A single preoperative parenteral dose of antibiotic effective against aerobes and anaerobes may provide initial coverage. (Correct Answer)
- C. Postoperative administration for 2 to 4 days of parenteral antibiotics effective against aerobes and anaerobes
- D. Avoidance of oral antibiotics to prevent emergence of Clostridioides difficile
Explanation: ***Single preoperative parenteral dose of antibiotic effective against aerobes and anaerobes*** - For **elective colorectal surgery**, a single dose of a **broad-spectrum parenteral antibiotic** administered within 60 minutes prior to incision is the standard of care to reduce surgical site infections. - This approach ensures adequate drug levels in the tissues during the period of potential bacterial contamination and is a cornerstone of modern surgical prophylaxis. - Current guidelines (WHO, SCIP) recommend a single preoperative dose, which may be redosed intraoperatively if the procedure is prolonged beyond 3-4 hours. *Avoidance of oral antibiotics to prevent emergence of Clostridioides difficile* - This is **incorrect**. **Oral antibiotics** (such as neomycin and metronidazole) are routinely used preoperatively in conjunction with mechanical bowel preparation for colorectal surgery to reduce intraluminal bacterial load. - The concern for *Clostridioides difficile* infection is generally low with short-term, targeted prophylactic antibiotic regimens compared to broad-spectrum, prolonged use. - The combination of oral and parenteral antibiotics has been shown to further reduce surgical site infections. *Postoperative administration for 5 to 7 days of parenteral antibiotics* - **Prolonged postoperative antibiotic administration** beyond 24 hours in uncomplicated cases is not recommended as it increases the risk of **antibiotic resistance**, *C. difficile* infection, and adverse drug reactions without additional benefit. - The goal of prophylactic antibiotics is to cover the period of contamination during surgery, not to treat presumed ongoing infection postoperatively. *Postoperative administration for 2 to 4 days of parenteral antibiotics* - While administration for up to 24 hours post-operatively may be considered in some high-risk cases, routine **prolonged postoperative antibiotics** (2-4 days) are unnecessary for most elective colorectal resections. - Evidence suggests that continuing antibiotics beyond the immediate perioperative period does not further reduce the incidence of **surgical site infections** in clean-contaminated surgeries.
Question 5: Gold standard management for vault prolapse is
- A. Sacrospinous ligament fixation
- B. Sacral colpopexy (Correct Answer)
- C. LeFort repair
- D. Anterior colporrhaphy
Explanation: ***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.
Question 6: In Marshall - Marchetti - Krantz (MMK) colposuspension for stress urinary incontinence, Pubocervical fascia is attached to
- A. Pectineal Ligament
- B. Arcus tendineus fascia pelvis
- C. Symphysis pubis (Correct Answer)
- D. Cooper's ligament (Pectineal ligament)
Explanation: ***Symphysis pubis*** - In a Marshall-Marchetti-Krantz (MMK) colposuspension, the **pubocervical fascia** on either side of the urethra is sutured directly to the **periosteum of the symphysis pubis**. - This procedure aims to provide support and elevate the bladder neck and proximal urethra to correct stress urinary incontinence. - The direct attachment to the symphysis pubis is the **defining feature** of the MMK procedure. *Pectineal Ligament* - The pectineal ligament (also known as Cooper's ligament) is the primary anchoring point in **Burch colposuspension**, not MMK. - In the Burch procedure, the paravaginal fascia is sutured to Cooper's ligament, which provides more lateral support compared to MMK. - This is the key anatomical difference between MMK and Burch procedures. *Arcus tendineus fascia pelvis* - The arcus tendineus fascia pelvis (white line) is a thickened band of pelvic fascia extending from the pubic bone to the ischial spine. - It serves as an attachment point for paravaginal fascia and is the target in **paravaginal defect repairs**, not in MMK colposuspension. - While important for pelvic floor support, it is not used as the primary anchoring structure in retropubic bladder neck suspensions. *Cooper's ligament (Pectineal ligament)* - Cooper's ligament is the **same structure** as the pectineal ligament—these terms are synonymous. - It is the defining attachment site in **Burch colposuspension**, where paravaginal tissue is sutured laterally to this ligament. - The MMK procedure, by contrast, uses a more midline approach with attachment directly to the symphysis pubis periosteum.
Question 7: A 60-year-old woman comes with 3rd degree uterine prolapse. What will be the management?
- A. Vaginal hysterectomy with pelvic floor repair (Correct Answer)
- B. Pelvic floor repair
- C. Sacrospinous fixation
- D. Pessary
Explanation: ***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.
Question 8: What is the most appropriate surgical treatment for a 40-year-old married female with uterine prolapse and completed family?
- A. Fothergill's operation
- B. Abdominal Sling operation
- C. Vaginal hysterectomy with pelvic floor repair (Correct Answer)
- D. Ring pessary
Explanation: ***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.
Question 9: 3rd degree genital prolapse in the first trimester of pregnancy is managed by :
- A. Le Fort's repair
- B. Right transvaginal sacrospinous colpopexy
- C. Fothergill's repair
- D. Ring pessary (Correct Answer)
Explanation: ***Ring pessary*** - A ring pessary is a **non-surgical** option often used during pregnancy to support the uterus and prevent further prolapse, especially in the first trimester. - It provides **conservative management**, avoiding surgical risks to both mother and fetus during early pregnancy. *Le Fort's repair* - **Le Fort's repair** is a colpocleisis procedure, typically performed on elderly women who are no longer sexually active, as it surgically obliterates the vaginal canal. It is contraindicated in pregnancy and unlikely to be performed in a woman of childbearing age who is pregnant. *Right transvaginal sacrospinous colpopexy* - This is a **surgical procedure** to correct vaginal vault prolapse by attaching the vaginal apex to the sacrospinous ligament. It is inappropriate for managing prolapse in the first trimester of pregnancy due to surgical risks and potential fetal harm. *Fothergill's repair* - **Fothergill's repair (Manchester repair)** is a surgical procedure that involves cervical amputation, shortening of the cardinal ligaments, and colporrhaphy. This surgery is not suitable during pregnancy due to the risk of miscarriage and is typically reserved for cases of uterocervical elongation causing prolapse in non-pregnant women.
Question 10: Which of the following accurately describes management of Grade 3 pelvic organ prolapse in an elderly woman who is a poor surgical candidate?
- A. Bladder sling
- B. Vaginal hysterectomy
- C. Pessary placement (Correct Answer)
- D. Kegel exercises
Explanation: ***Pessary placement*** - **Pessaries** are a less invasive, effective option for **pelvic organ prolapse** management in patients who are **poor surgical candidates**, helping to support prolapsed organs. - They also serve as a good temporary option to improve symptoms before surgical intervention. *Bladder sling* - A **bladder sling** is a surgical procedure used primarily to treat **stress urinary incontinence**, not pelvic organ prolapse. - This option is unsuitable for a patient who is a **poor surgical candidate**. *Vaginal hysterectomy* - A **vaginal hysterectomy** involves surgical removal of the uterus through the vagina, which is a definitive treatment for **uterine prolapse**. - However, surgical interventions are contraindicated for an **elderly woman** who is a **poor surgical candidate** due to potential risks. *Kegel exercises* - **Kegel exercises** are beneficial for strengthening the **pelvic floor muscles** and preventing the progression of early-stage prolapse or improving mild symptoms. - However, they are generally **insufficient** for managing **Grade 3 pelvic organ prolapse**, which requires more robust support.
Want unlimited practice?
Get full access to all questions, explanations, and performance tracking.
Start For Free