Rectal 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:
In Procidentia which of the following is true?
A 57-year-old man presents to the office with complaints of perianal pain during defecation and perineal heaviness for 1 month. He also complains of discharge around his anus, and bright red bleeding during defecation. The patient provides a history of having a sexual relationship with other men without using any methods of protection. The physical examination demonstrates edematous verrucous anal folds that are of hard consistency and painful to the touch. A proctosigmoidoscopy reveals an anal canal ulcer with well defined, indurated borders on a white background. A biopsy is taken and the results are pending. What is the most likely diagnosis?
What is the treatment for uterine prolapse in nulliparous women?
In gonorrhea, which is not a presenting feature?
Risk factors for stress urinary incontinence are all except
Investigation of choice for lumbar prolapsed disc -
A 60-year-old woman comes with 3rd degree uterine prolapse. What will be the management?
A young male patient presents with complete rectal prolapse and no history of previous surgeries. The surgery of choice is:
Rectal prolapse occurs due to all EXCEPT:
Rectal 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: In Procidentia which of the following is true?
- A. Both uterus and vagina outside the introitus (Correct Answer)
- B. Uterus in vagina cervix outside the introitus
- C. Uterus and cervix in vagina
- D. None of the options
Explanation: ***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.
Question 3: A 57-year-old man presents to the office with complaints of perianal pain during defecation and perineal heaviness for 1 month. He also complains of discharge around his anus, and bright red bleeding during defecation. The patient provides a history of having a sexual relationship with other men without using any methods of protection. The physical examination demonstrates edematous verrucous anal folds that are of hard consistency and painful to the touch. A proctosigmoidoscopy reveals an anal canal ulcer with well defined, indurated borders on a white background. A biopsy is taken and the results are pending. What is the most likely diagnosis?
- A. Anal cancer (Correct Answer)
- B. Polyps
- C. Anal fissure
- D. Hemorrhoids
- E. Proctitis
Explanation: ***Anal cancer*** - The patient's presentation with **perianal pain**, **bleeding**, **discharge**, and **edematous verrucous anal folds** (suggesting a lesion) are highly suspicious for anal cancer. His history of unprotected sexual relationships with men is a significant risk factor for **HPV infection**, which is a leading cause of anal squamous cell carcinoma. - The proctosigmoidoscopy findings of an **anal canal ulcer with well-defined, indurated borders** and a white background further point towards a malignant lesion, making anal cancer the most likely diagnosis. *Polyps* - While polyps can cause bleeding, they typically do not present with **indurated, painful verrucous lesions** or an ulcer with defined borders. - Polyps are usually soft and less likely to cause the severe perianal pain and perineal heaviness described. *Anal fissure* - An anal fissure is a **linear tear** in the anal canal, causing sharp pain during defecation and bright red blood. - It would not typically present with **edematous verrucous anal folds**, perineal heaviness, or an indurated ulcer as seen on proctosigmoidoscopy. *Hemorrhoids* - Hemorrhoids commonly cause **bright red bleeding** and can cause discomfort or heaviness. - However, they usually appear as swollen vascular cushions and do not typically present as **indurated, painful verrucous lesions** or an ulcer with defined borders. *Proctitis* - Proctitis is an inflammation of the rectum, causing rectal pain, tenesmus, and bleeding, often due to **inflammatory bowel disease** or **infections**. - While it can cause some of the symptoms, it wouldn't typically manifest as a distinct **indurated, verrucous lesion** or an ulcer with firm borders, which are more indicative of a mass.
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: Risk factors for stress urinary incontinence are all except
- A. Obesity
- B. Hypertension (Correct Answer)
- C. Smoking
- D. Pregnancy
Explanation: ***Hypertension*** - While hypertension is a significant health concern, it is **not directly a recognized risk factor** for stress urinary incontinence. - Risk factors for stress urinary incontinence primarily involve factors that increase **intra-abdominal pressure** or weaken pelvic floor support. *Obesity* - **Increased intra-abdominal pressure** due to excess weight places constant strain on the pelvic floor muscles and urethral sphincter. - This persistent pressure can lead to weakening of the supporting structures, predisposing to **stress urinary incontinence**. *Smoking* - Smoking is associated with chronic cough, which repeatedly increases **intra-abdominal pressure**, potentially leading to pelvic floor muscle weakness. - It also affects **collagen synthesis**, which can weaken connective tissues supporting the bladder and urethra. *Pregnancy* - The growing uterus during pregnancy places significant **mechanical stress** on the pelvic floor muscles and ligaments. - **Hormonal changes** during pregnancy can also relax connective tissues, further contributing to pelvic floor laxity.
Question 7: Investigation of choice for lumbar prolapsed disc -
- A. CT Scan
- B. Myelogram
- C. X-ray
- D. MRI (Correct Answer)
Explanation: ***MRI*** - An **MRI** provides the best visualization of **soft tissues**, including the intervertebral discs, spinal cord, and nerve roots, making it the **gold standard** for diagnosing lumbar prolapsed disc. - It can accurately show the **degree of disc herniation**, its impact on neural structures, and associated edema, which are crucial for treatment planning. *CT Scan* - While a **CT scan** provides good bony detail and can show disc herniation, its ability to visualize soft tissues is inferior to MRI for this specific condition. - It involves **ionizing radiation** and may miss subtle nerve root compression or spinal cord abnormalities apparent on MRI. *Myelogram* - A **myelogram** involves injecting contrast dye into the spinal canal and then performing X-rays or CT scans to outline the spinal cord and nerve roots. - Though effective in showing **nerve compression**, it is an **invasive procedure** with potential complications and has largely been replaced by MRI as a first-line diagnostic investigation. *X-ray* - **X-rays** primarily visualize **bony structures** and are useful for detecting fractures, spinal alignment issues, or severe degenerative changes. - They **cannot directly visualize intervertebral discs** or nerve compression, making them unsuitable for diagnosing a prolapsed disc.
Question 8: 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 9: A young male patient presents with complete rectal prolapse and no history of previous surgeries. The surgery of choice is:
- A. Delorme's procedure
- B. Anterior resection
- C. Abdominal rectopexy (Correct Answer)
- D. Goodsall's procedure
Explanation: ***Abdominal rectopexy*** - **Abdominal rectopexy** is considered the surgery of choice for **complete rectal prolapse** in young, fit patients due to its superior long-term results in terms of recurrence rates. - This procedure involves addressing the prolapse via an abdominal approach, often by fixing the rectum to the sacrum, and may include sigmoid resection if there is a redundant colon. *Delorme's procedure* - This is a **perineal approach** that involves plication of the prolapsed rectal mucosa and muscle. - It is generally favored in **elderly** or **frail patients** due to its lower morbidity, but it has a higher recurrence rate compared to abdominal approaches. *Anterior resection* - **Anterior resection** is primarily a procedure for removing a diseased segment of the **left colon or rectum**, typically for cancer or diverticular disease. - While it may be combined with rectopexy if a redundant sigmoid colon is present, it is not the primary or sole treatment for rectal prolapse itself. *Goodsall's procedure* - **Goodsall's rule** is a principle used to predict the internal opening of an anal fistula based on the external opening's location, and **Goodsall's procedure** is not a named surgical technique for rectal prolapse. - This option appears to be a distractor, as there is no specific surgical procedure for rectal prolapse named after Goodsall.
Question 10: Rectal prolapse occurs due to all EXCEPT:
- A. Whooping cough
- B. Fistula-in-Ano (Correct Answer)
- C. Marasmus
- D. Obstetric trauma
Explanation: The image displays a prominent **rectal prolapse**, characterized by the eversion of the rectal wall through the anus. This condition can be caused by various factors that increase intra-abdominal pressure or weaken the pelvic floor. ***Fistula-in-Ano*** - A **fistula-in-ano** is an abnormal connection between the anal canal and the perianal skin, typically resulting from an anal abscess. - While it can be associated with inflammatory bowel disease or local infection, it is a **separate pathological entity** that does not cause rectal prolapse. - Fistula-in-ano does not directly increase intra-abdominal pressure or weaken the pelvic floor muscles, and thus is **not a cause of rectal prolapse**. *Whooping cough* - **Whooping cough (pertussis)** leads to severe, paroxysmal coughing fits, which significantly increase **intra-abdominal pressure**. - This sustained increase in pressure, especially in children, can contribute to the development or worsening of **rectal prolapse**. *Obstetric trauma* - **Obstetric trauma**, particularly during childbirth, can cause significant damage to the **pelvic floor muscles** and ligaments. - Weakening of these supporting structures is a major predisposing factor for **rectal prolapse**, especially in multiparous women. *Marasmus* - **Marasmus** is a severe form of protein-energy malnutrition seen in children, characterized by significant weight loss and muscle wasting. - While less direct than other causes, it can contribute to rectal prolapse through chronic malnutrition, diarrhea, and weakened pelvic tissues in pediatric populations.
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