Uterine Prolapse — MCQs
A 65-year-old P3+0 female complains of procidentia. She has a past history significant for MI and is diabetic and hypertensive. The patient is not sexually active. Ideal management of prolapse in this patient is:
What is a potential consequence of Birth trauma?
Injury to which of the following muscles that forms the deep support of the perineal body causes cystocele, enterocele and urethral descent?
Gold standard management for vault prolapse is
The most important structure preventing uterine prolapse is:
Which structure can be palpated through the anterior wall of the rectum, directly in front of the rectum in the midline, during a rectal examination of a 27-year-old woman?
What is the treatment for uterine prolapse in nulliparous women?
In uterine prolapse, how do you assess if a pessary ring is properly in place?
A woman who is being investigated for infertility is diagnosed to have a nulliparous prolapse of the uterus. The most appropriate management will be
A 60-year-old woman comes with 3rd degree uterine prolapse. What will be the management?
Uterine Prolapse Indian Medical PG Practice Questions and MCQs
Question 1: A 65-year-old P3+0 female complains of procidentia. She has a past history significant for MI and is diabetic and hypertensive. The patient is not sexually active. Ideal management of prolapse in this patient is:
- A. Cervicopexy
- B. Vaginal hysterectomy
- C. Wait and watch
- D. Le Fort's repair (Correct Answer)
Explanation: ***Le Fort's repair*** - This procedure, a **colpocleisis**, involves partially or completely closing the vagina, making it an ideal choice for elderly, non-sexually active women with significant medical comorbidities who require surgical management of severe prolapse. - The goal is symptom relief with a **minimally invasive** procedure, avoiding a major abdominal surgery that might be risky for a patient with a history of MI, diabetes, and hypertension. *Cervicopexy* - This procedure aims to support the cervix, often done in conjunction with uterine preservation for prolapse. - It is typically performed in younger, sexually active women who wish to retain their uterus, which is not the case for this patient. *Vaginal hysterectomy* - While vaginal hysterectomy is a common procedure for uterine prolapse, in this patient with significant comorbidities and who is not sexually active, a less invasive procedure like Le Fort's repair would be preferred to minimize surgical risks. - This procedure removes the uterus and may be combined with efforts to provide apical support; however, it is a more extensive surgery than colpocleisis. *Wait and watch* - Given the complaint of **procidentia**, which represents severe prolapse, a "wait and watch" approach is inappropriate as it implies significant symptoms and risk of complications, such as ulceration or infection. - This approach is typically reserved for women with **mild to moderate prolapse** and minimal symptoms, or those who decline active treatment, which is not indicated here.
Question 2: What is a potential consequence of Birth trauma?
- A. Uterine prolapse (Correct Answer)
- B. Endometriosis
- C. PID
- D. Abortions
Explanation: ***Uterine prolapse*** - **Birth trauma**, especially due to difficult or prolonged labor, can lead to damage and weakening of the **pelvic floor muscles** and **connective tissues**. - This weakening provides inadequate support for the uterus, potentially resulting in its descent into or out of the vagina, known as **uterine prolapse**. *Endometriosis* - This condition involves the growth of **endometrial-like tissue outside the uterus**, typically in the pelvic cavity. - Endometriosis is thought to be caused by **retrograde menstruation**, genetic factors, or immune system dysfunction, and is not directly caused by birth trauma. *PID* - **Pelvic Inflammatory Disease (PID)** is an infection of the female reproductive organs, usually caused by untreated sexually transmitted infections (STIs). - It primarily affects the uterus, fallopian tubes, and ovaries, and is not a direct consequence of birth trauma. *Abortions* - The term "abortions" refers to the termination of a pregnancy, either spontaneously (**miscarriage**) or induced. - While certain pregnancy complications or uterine abnormalities might lead to recurrent miscarriages, these are generally not a direct result of birth trauma experienced in a *previous* pregnancy; birth trauma itself affects the mother's pelvic structures post-delivery.
Question 3: 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 4: 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 5: The most important structure preventing uterine prolapse is:
- A. Uterosacral ligament
- B. Broad ligament
- C. Cardinal ligament (Correct Answer)
- D. Round ligament
Explanation: ***Cardinal ligament*** - The **cardinal ligaments** (also known as transverse cervical ligaments) are crucial for supporting the uterus and preventing **uterine prolapse** by anchoring the cervix and upper vagina laterally to the pelvic sidewalls [1]. - They provide significant **suspension and stability** to the uterus due to their strong fibrous and muscular composition [1]. *Uterosacral ligament* - These ligaments attach the posterior cervix to the sacrum, primarily preventing **retroversion** of the uterus and providing posterior support [1]. - While they contribute to uterine support, their role in preventing descent is secondary to the cardinal ligaments [1]. *Broad ligament* - The **broad ligament** is a wide fold of peritoneum that drapes over the uterus, fallopian tubes, and ovaries, providing a suspensory role rather than strong structural support [1]. - It contains blood vessels and nerves but offers minimal support against **uterine prolapse** itself. *Round ligament* - The **round ligaments** extend from the uterine horns, through the inguinal canal, and insert into the labia majora, primarily helping to maintain the **anteverted and antiflexed position** of the uterus [2]. - They do not play a significant role in preventing the downward descent or **prolapse** of the uterus.
Question 6: Which structure can be palpated through the anterior wall of the rectum, directly in front of the rectum in the midline, during a rectal examination of a 27-year-old woman?
- A. Bladder
- B. Body of uterus
- C. Cervix of uterus (Correct Answer)
- D. Pubic symphysis
Explanation: Cervix of uterus - The cervix is located posterior to the bladder and inferior to the body of the uterus, making it palpable through the anterior rectal wall via the rectovaginal septum [2]. - Its firm, rounded structure can be felt as a distinct nodule directly anterior to the rectum in the midline during a digital rectal examination. - This is a standard clinical finding in pelvic examination. Bladder - The bladder is anterior to the uterus and cervix; an empty bladder is usually not palpable through the anterior rectal wall. - A distended bladder would be palpable, but it would be a soft, fluctuating mass, not a firm structure like the cervix. Body of uterus - The body of the uterus is superior to the cervix and in the typical anteverted position (normal in ~80% of women), it is angled anteriorly and superiorly, generally beyond the reach of a digital rectal exam for direct palpation through the anterior rectal wall [1]. - In the less common retroverted uterus, the body may be palpable through the posterior fornix of the vagina or through the rectum, but this is not the typical anatomical relationship. Pubic symphysis - The pubic symphysis is a bony joint located at the very anterior aspect of the pelvis, far too anterior and superior to be palpable through the anterior wall of the rectum. - It forms the anterior boundary of the bony pelvis, while the rectum is situated posteriorly within the pelvic cavity.
Question 7: 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 8: In uterine prolapse, how do you assess if a pessary ring is properly in place?
- A. If Bleeding does not occur
- B. If patient feels discomfort
- C. If not expelled after increased abdominal pressure (Correct Answer)
- D. None of the options
Explanation: ***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 9: A woman who is being investigated for infertility is diagnosed to have a nulliparous prolapse of the uterus. The most appropriate management will be
- A. Ring pessary (Correct Answer)
- B. Cervical amputation
- C. Sling operation
- D. Fothergill repair
Explanation: ***Ring pessary*** - A ring pessary can provide **symptomatic relief** for uterine prolapse while allowing the woman to continue trying to conceive and carry a pregnancy. - It is a **non-surgical** and reversible option, making it suitable for women who desire future fertility. *Cervical amputation* - This procedure, such as a **Manchester Fothergill operation**, involves amputation of the cervix and can compromise future fertility and cervical competence during pregnancy. - It is a **definitive surgical treatment** usually reserved for women who have completed childbearing. *Sling operation* - Sling operations, such as sacral colpopexy, involve suspending the uterus or vaginal vault. These are generally performed for **pelvic organ prolapse** in women who are not planning future pregnancies or for more severe prolapse. - These procedures can **interfere with future fertility** and the natural physiological changes during pregnancy and labor. *Fothergill repair* - The Fothergill repair (or Manchester operation) involves **cervical amputation**, anterior colporrhaphy, and posterior colpoperineorrhaphy. It is a surgical procedure aimed at correcting uterine prolapse. - While effective for prolapse, it is **not suitable for women desiring future fertility** due to the cervical amputation and potential impact on pregnancy.
Question 10: 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.
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