Urogynecology Practice Questions

Q: The reference point 'zero' in POPQ (Pelvic Organ Prolapse Quantification) classification is taken as

hymen. ***hymen*** - The **hymen** (or hymenal ring/hymenal caruncles in parous women) is the fixed anatomical reference point (zero point) in the POPQ classification system. - All measurements in POPQ are taken in centimeters relative to the hymenal ring, with **negative values** indicating positions above the hymen and **positive values** indicating descent beyond the hymen. - This landmark was chosen because it is **easily identifiable, reproducible, and remains relatively constant** regardless of the degree of prolapse. *ischial spine* - The **ischial spines** are important anatomical landmarks in the pelvis but are **not** used as the zero reference point in POPQ. - They are used for measuring **total vaginal length (TVL)** - the distance from the hymen to the posterior fornix with the prolapse reduced. - The ischial spines serve as internal palpable landmarks during pelvic examination but not as the measurement reference for prolapse staging. *perineal body* - The **perineal body** is a fibromuscular structure in the perineum and is measured in POPQ (as genital hiatus and perineal body measurements). - However, it is **not the zero reference point** because its position and integrity can be altered by prolapse, childbirth trauma, or surgical procedures. *mid-vagina* - The **mid-vagina** is not a standardized anatomical landmark and is **too variable** to serve as a fixed reference point. - POPQ requires precise, reproducible measurements, which cannot be achieved with such a vague landmark.

Q: What is the most common cause of vault prolapse following hysterectomy ?

Failure to identify and repair enterocele. ***Failure to identify and repair enterocele*** - An **enterocele** is a type of **hernia** in which the peritoneum and small bowel descend into the space between the vagina and rectum. - If an existing **enterocele** is not identified and repaired during hysterectomy, it can **worsen over time** and contribute significantly to **vaginal vault prolapse**. *Obesity* - While **obesity** is a risk factor for pelvic organ prolapse in general due to increased intra-abdominal pressure, it is not considered the most common direct cause of **vault prolapse specifically after hysterectomy**. - It contributes to general weakening of pelvic floor support but is less direct in causing vault collapse than a missed enterocele. *Chronic cough* - **Chronic cough** increases intra-abdominal pressure and is a risk factor for the development or worsening of pelvic organ prolapse. - However, similar to obesity, it's a general contributor to prolapse and not typically the most common direct cause of **vault prolapse** as compared to surgical factors. *Diabetes mellitus* - **Diabetes mellitus** can contribute to overall tissue weakness and neuropathy, potentially affecting pelvic floor support over time. - It is not considered a primary or frequent direct cause of **vaginal vault prolapse** following hysterectomy.

Q: What is the commonest cause of Vulvo-Vaginal Fistula in developing countries ?

Obstructed labour. ***Obstructed labour*** - **Prolonged obstructed labor** causes **ischemic necrosis** of the tissues between the vagina and the bladder or rectum due to continuous pressure from the fetal head, leading to a fistula. - This is the **most common cause** of vulvo-vaginal fistulas in developing countries, often due to limited access to emergency obstetric care like C-sections. *Carcinoma of bladder* - While bladder carcinoma can cause fistulas, they are more typically **vesicovaginal fistulas** and are less common than those resulting from obstructed labor in developing countries. - Fistulas due to malignancy often involve **tissue destruction** and may be associated with prior radiation therapy. *Injury during hysterectomy* - Iatrogenic injury during a **hysterectomy** can lead to a fistula, but this is more common in developed healthcare settings with higher rates of surgical interventions. - This cause is less prevalent globally compared to the widespread issue of obstructed labor in resource-limited regions. *Radiotherapy for treatment of carcinoma cervix* - **Radiotherapy** for cervical carcinoma can cause **radiation-induced necrosis** and lead to fistulas, particularly **rectovaginal** or **vesicovaginal** types. - While a significant cause in cancer patients, it is not the commonest overall cause in developing countries compared to the sheer volume of cases resulting from obstructed labor.

Q: A woman who is being investigated for infertility is diagnosed to have a nulliparous prolapse of the uterus. The most appropriate management will be

Ring pessary. ***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.

Q: Which of the following are the features of backache due to genital prolapse? 1. The pain is experienced on getting up in the morning. 2. The patient complains of a diffuse pain over the sacrum. 3. There is no local tenderness. 4. The pain occurs more commonly among multiparous than nulliparous women. Select the correct answer using the code given below:

2, 3 and 4. ***2, 3 and 4*** - **Diffuse sacral pain** (2) and **lack of local tenderness** (3) are characteristic of backache related to **genital prolapse**, differentiating it from musculoskeletal causes. - **Multiparity** (4) is a significant risk factor for pelvic organ prolapse due to damage to pelvic floor muscles and connective tissues during childbirth. *1 and 2 only* - While diffuse sacral pain is typical, pain experienced primarily on getting up in the morning (1) is more commonly associated with inflammatory conditions like **ankylosing spondylitis** or **degenerative disc disease**, not directly with genital prolapse. - Genital prolapse pain tends to worsen with prolonged standing or activity and be relieved by rest, particularly by lying down. *1, 2 and 3* - The feature of pain on getting up in the morning (1) is inconsistent with typical prolapse-related backache, which usually manifests with activity or prolonged standing. - While diffuse sacral pain (2) and no local tenderness (3) are correct, their combination with an incorrect feature makes this option less accurate. *1 and 4* - Pain on getting up in the morning (1) is not a primary characteristic of backache due to genital prolapse. - While multiparity (4) is a correct risk factor, combining it with an inaccurate pain characteristic makes this option incomplete.

Q: A parous woman notices a bulge at the vulva that diminishes in size following micturition. She also finds it difficult to initiate micturition. What is the likely diagnosis ?

Cystocele. ***Cystocele*** - A **cystocele** (bladder prolapse) presents as a bulge in the vagina, which can reduce in size after urination if some urine is expelled. - **Difficulty initiating micturition** (voiding dysfunction) is common as the prolapsed bladder neck can obstruct the urethra. *Uterine prolapse* - This condition involves the **uterus descending** into the vaginal canal. - While it can cause a vulvar bulge, the symptoms described (diminishing with micturition, difficulty with initiation) are not typical for isolated uterine prolapse. *Fibroid polyp* - A **fibroid polyp** is a benign tumor that can protrude through the cervix and vagina, causing a vulvar mass. - It typically does not fluctuate with micturition or cause difficulty in initiating urination. *Vaginal cyst in the pouch of Douglas* - A **vaginal cyst** in the pouch of Douglas (e.g., an enterocele) is a herniation of the small bowel through the vaginal wall. - While it can cause a bulge, it would not typically diminish in size specifically with micturition or primarily cause difficulty in initiating urination.

Q: A woman of child-bearing age develops a second-degree uterine prolapse with supravaginal elongation of the cervix. What will be the most appropriate management?

Fothergill's operation. ***Fothergill's operation*** - This procedure, also known as **mancuni operation**, is ideal for women of childbearing age with **second-degree uterine prolapse** and **supravaginal elongation of the cervix**. - It involves **cervical amputation**, anterior colporrhaphy, and posterior colpoperineorrhaphy, effectively correcting the prolapse while preserving the uterus for future pregnancies. *Sling operation* - A sling operation (e.g., sacrocolpopexy) is primarily used for **vaginal vault prolapse** after hysterectomy, or for severe uterine prolapse when preservation of the uterus is not a priority. - It involves suspending the uterus or vagina using synthetic mesh or biological material, which is not the first-line for this specific presentation in a woman desiring future fertility. *Vaginal hysterectomy and pelvic floor repair* - This approach is typically chosen for women who have **completed childbearing** or do not desire future pregnancies, as it involves removal of the uterus. - While it effectively corrects prolapse, it is not the most appropriate management for a woman of childbearing age who may wish to conceive. *Amputation of the cervix* - While cervical amputation is a component of Fothergill's operation, performing only **cervical amputation in isolation** would not adequately address the entire prolapse or offer sufficient pelvic floor support. - This option is incomplete as a definitive management strategy for uterine prolapse with supravaginal elongation.

Q: Match List-I with List-II and select the correct answer using the code given below the Lists:

A→3 B→1 C→2 D→4. ***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 1

Which of the following are correct regarding pathology of stress urinary incontinence?

1. Hypermobility of urethra
2. Descent of bladder neck and proximal urethra below pelvic diaphragm
3. Lowered urethral pressure
4. Increased detrusor activity

Accepted Answer

1, 2 and 3

Answer

2 and 4

Answer

3 and 4

Answer

1, 2 and 4

Answer

1 and 2

Question 2

The reference point 'zero' in POPQ (Pelvic Organ Prolapse Quantification) classification is taken as

Accepted Answer

hymen

Answer

perineal body

Answer

ischial spine

Answer

mid-vagina

Question 3

What is the most common cause of vault prolapse following hysterectomy ?

Accepted Answer

Failure to identify and repair enterocele

Answer

Obesity

Answer

Chronic cough

Answer

Diabetes mellitus

Question 4

What is the commonest cause of Vulvo-Vaginal Fistula in developing countries ?

Accepted Answer

Obstructed labour

Answer

Carcinoma of bladder

Answer

Injury during hysterectomy

Answer

Radiotherapy for treatment of carcinoma cervix

Question 5

A woman who is being investigated for infertility is diagnosed to have a nulliparous prolapse of the uterus. The most appropriate management will be

Accepted Answer

Ring pessary

Answer

Cervical amputation

Answer

Sling operation

Answer

Fothergill repair

Question 6

Which of the following are the features of backache due to genital prolapse?

1. The pain is experienced on getting up in the morning.
2. The patient complains of a diffuse pain over the sacrum.
3. There is no local tenderness.
4. The pain occurs more commonly among multiparous than nulliparous women.

Select the correct answer using the code given below:

Accepted Answer

2, 3 and 4

Answer

1 and 2 only

Answer

1, 2 and 3

Answer

1 and 4

Question 7

A 20-year-old young woman, who was delivered two months ago at home by a nurse, presents with a complaint of something protruding through the vulva. The clinical examination reveals a cystocele, rectocele, and the cervix 1 cm above the introitus. The most appropriate management will be

Accepted Answer

Anterior colporrhaphy, posterior colporrhaphy and perineal repair

Answer

Sling operation

Answer

Fothergill's operation

Answer

Vaginal hysterectomy

Question 8

A parous woman notices a bulge at the vulva that diminishes in size following micturition. She also finds it difficult to initiate micturition. What is the likely diagnosis ?

Accepted Answer

Cystocele

Answer

Uterine prolapse

Answer

Fibroid polyp

Answer

Vaginal cyst in the pouch of Douglas

Question 9

A woman of child-bearing age develops a second-degree uterine prolapse with supravaginal elongation of the cervix. What will be the most appropriate management?

Accepted Answer

Fothergill's operation

Answer

Sling operation

Answer

Vaginal hysterectomy and pelvic floor repair

Answer

Amputation of the cervix

Question 10

Match List-I with List-II and select the correct answer using the code given below the Lists:

Accepted Answer

A→3  B→1  C→2  D→4

Answer

A→4  B→1  C→2  D→3

Answer

A→4  B→2  C→1  D→3

Answer

A→3  B→2  C→1  D→4

Urogynecology — MCQs

Urogynecology — MCQs

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