Urogynecology Practice Questions

Q: With reference to the displacement of uterus, the treatment of choice for genuine stress urinary incontinence is:

TVT‐O mid urethral tape. ***TVT‐O mid urethral tape*** - **TVT-O (tension-free vaginal tape-obturator)** is a minimally invasive surgical procedure that provides support to the mid-urethra, effectively treating genuine **stress urinary incontinence (SUI)**. - This procedure aims to restore the anatomical support mechanisms of the urethra, preventing urine leakage during activities that increase abdominal pressure. *Periurethral injection of bulking agents* - This method involves injecting materials around the urethra to increase its bulk and improve coaptation, but it is generally reserved for patients who are not suitable for surgery or as a secondary treatment, and typically has **lower long-term success rates** compared to tape procedures. - While it can improve continence in some cases, it addresses the issue by increasing urethral resistance rather than restoring proper anatomical support. *Kegel’s perineal exercises* - **Kegel exercises** aim to strengthen the **pelvic floor muscles**, which can be effective for mild SUI by improving urethral support and sphincter function. - However, for genuine SUI, which often involves significant anatomical changes or urethral hypermobility, these exercises are typically used as a **first-line conservative treatment** and may not be sufficient on their own. *Kelly’s plication* - **Kelly's plication**, also known as the **Kelly stitch**, is an older surgical procedure that involves plicating (folding and suturing) the periurethral fascia to provide urethral support. - This procedure has largely been replaced by more effective and less invasive mid-urethral tape procedures like TVT-O due to **higher failure rates** and potential complications.

Q: Regarding 'DeLancey's levels of vaginal support', consider the following pairs:

1, 2 and 3. ***1, 2 and 3*** - DeLancey's levels of vaginal support categorize the anatomical support structures of the vagina into three levels, providing a framework for understanding pelvic organ prolapse. - **Level I** refers to the **apical support** provided by the uterosacral and cardinal ligaments, supporting the uterus and upper vagina. - **Level II** supports the **mid-vagina**, including the paravaginal attachments to the arcus tendineus fascia pelvis (ATFP), providing lateral support. - **Level III** supports the **distal vagina**, including the fusion of the anterior and posterior vaginal walls with the levator ani muscles, perineal body, and urethral support. *2 only* - This option is incomplete as it only recognizes Level II, which supports the mid-vagina, but omits the correct descriptions for Levels I and III, which are also accurately presented. - All three levels described in the table correspond correctly to DeLancey's levels of vaginal support. *1 and 3 only* - This option is incomplete as it misses the correct description for Level II, which accurately states it supports the mid-vagina. - While Level I and Level III are correctly described, a comprehensive understanding requires all three levels. *2 and 3 only* - This option is incomplete because it omits the correct description for Level I, which corresponds to apical support. - Even though Levels II and III are correctly described, all three levels presented in the table are consistent with DeLancey's classification.

Q: Which of the following is NOT a component of Fothergill’s operation as a conservative surgery for uterovaginal prolapse?

Cervicopexy. ***Cervicopexy*** - **Cervicopexy** involves fixing the cervix to a stable structure, which is generally part of reconstructive surgeries for prolapse but isn't a primary component of Fothergill's operation. - Fothergill's operation focuses on excising excess cervical tissue and strengthening the supports, rather than suspending the entire cervix. *Amputation of cervix* - **Cervical amputation** (also known as trachelorrhaphy in some contexts or Sturmdorf sutures) is a key step, where the elongated cervix is amputated to reduce its length and thus improve uterine support. - This step addresses the hypertrophied cervix often seen with uterovaginal prolapse, especially in cases of cervical elongation. *Plication of Mackenrodt's ligaments* - **Plication of Mackenrodt's (cardinal) ligaments** is crucial to shorten and strengthen the main uterine supports, helping to restore the uterus to its normal position. - This tightens the cardinal and uterosacral ligaments, enhancing the anatomical support for the uterus and cervix. *Anterior colporrhaphy* - **Anterior colporrhaphy** is almost always performed concurrently to repair the often present **cystocele** and strengthen the anterior vaginal wall. - This addresses defects in the anterior vaginal wall, preventing or correcting bladder prolapse and further stabilizing the pelvic floor.

Q: The level of external cervical os in a second degree utero vaginal prolapse is:

Introitus. ***Introitus*** - In a **second-degree uterovaginal prolapse**, the external cervical os descends to the level of the introitus (hymenal ring). - The cervix reaches the vaginal opening but does not extend beyond it, typically becoming visible during straining or examination. - This is the defining characteristic of second-degree prolapse. *Between ischial spines and introitus* - This description refers to a **first-degree uterovaginal prolapse**, where the cervix descends into the lower vagina but remains above the introitus. - The external os has not yet reached the **introitus** and remains within the vaginal canal. *3 cm outside introitus* - This indicates a **third-degree uterovaginal prolapse (procidentia)**, where the cervix and entire uterus descend completely outside the vagina. - The measurement of 3 cm outside the introitus represents significant prolapse beyond the vaginal opening. *At the level of ischial spines* - The **ischial spines** serve as the anatomical zero point in the POP-Q (Pelvic Organ Prolapse Quantification) staging system. - If the external cervical os is at the level of the ischial spines, this represents minimal or no prolapse, as the cervix is in its normal anatomical position high in the vagina.

Q: Treatment of choice in 28 year old nullipara with third degree cervical descent is:

Abdominal cervicopexy. ***Abdominal cervicopexy (Sacrohysteropexy)*** - For a **28-year-old nullipara**, **fertility preservation is paramount** as she may desire future pregnancies. - **Abdominal cervicopexy** (or sacrohysteropexy) suspends the uterus to the sacral promontory using mesh, effectively correcting third-degree uterine prolapse while **preserving the uterus and fertility potential**. - This is the **treatment of choice** in young women with significant pelvic organ prolapse who wish to maintain reproductive capability. - Has high success rates (>90%) with good anatomical outcomes and allows for future vaginal delivery in most cases. *Vaginal hysterectomy with PFR* - While this provides definitive surgical correction of prolapse, it **permanently eliminates fertility**. - This would be inappropriate as first-line treatment for a 28-year-old nulliparous patient unless she explicitly declines uterine preservation. - Reserved for patients who have **completed childbearing** or have additional indications for hysterectomy. *Fothergill's repair (Manchester repair)* - Involves cervical amputation, cardinal ligament shortening, and anterior colporrhaphy. - Although it preserves the uterus, it is **less effective for high-grade prolapse** (third degree) and may compromise fertility due to cervical amputation. - Has largely been replaced by modern uterine suspension procedures like sacrohysteropexy. *Anterior and posterior colporrhaphy* - Repairs **cystocele and rectocele** (vaginal wall defects) but **does not address uterine/cervical descent**. - Would be inadequate as sole treatment for third-degree uterine prolapse, though may be performed as adjunctive procedures.

Q: Surgical treatment of choice for a 20 year old nulliparous woman with uterine prolapse is:

Sacrocolpopexy. ***Sacrocolpopexy (Sacrohysteropexy variant)*** - For a **young, nulliparous woman**, the procedure of choice is **sacrohysteropexy** (also called sacrocervicopexy), which involves attaching the **uterus/cervix** to the **sacrum** using synthetic mesh, providing durable support while preserving the uterus. - This is ideal for young women as it **preserves fertility potential** and maintains vaginal length and sexual function. - The term sacrocolpopexy in this context refers to the uterine-preserving variant, crucial for women desiring future pregnancy. *Le Forte's repair* - This is an **obliterative procedure** primarily used in elderly women who are **no longer sexually active**, involving partial closure of the vagina. - It is absolutely contraindicated in a young, nulliparous woman who desires future sexual function and pregnancy. *Sling surgery* - **Sling surgery** is primarily indicated for **stress urinary incontinence**, not uterine prolapse. - While incontinence can co-exist with prolapse, a sling alone does not address uterine or vaginal apex support. *Abdominal hysterectomy with pelvic floor repair* - **Hysterectomy** removes the uterus and would **eliminate fertility**, which is unacceptable for a young, nulliparous woman desiring children. - Though effective for prolapse, it is an overly aggressive approach; uterine-preserving procedures like sacrohysteropexy are strongly preferred for fertility preservation.

Q: Which of the following is NOT an ideally suited condition for use of ring pessary in case of uterine prolapse?

Late pregnancy. ***Late pregnancy*** - A ring pessary is generally **contraindicated** in late pregnancy due to the risk of inducing uterine contractions, premature rupture of membranes, or infection, and it is not an appropriate long-term solution for prolapse during this period. - The gravid uterus itself acts as a natural support for prolapsed organs, making a pessary less necessary and potentially harmful. *Puerperium* - The **puerperium** can be an ideal time for pessary use, especially if prolapse is noted shortly after delivery. - Tissues are still lax and remodeling, and a pessary can help support the uterus and vagina during this healing phase, potentially preventing more severe prolapse later on. *Patient's unwillingness for surgery* - For patients who **decline surgical intervention**, a ring pessary offers a non-surgical management option for uterine prolapse, providing relief from symptoms. - It allows patients to manage their condition conservatively and is a practical choice given their personal preference. *Patient unfit for surgery* - In cases where a patient has significant comorbidities that make them **unsuitable for surgery** (e.g., severe cardiac disease, advanced age), a ring pessary is a safe and effective alternative. - It provides symptomatic relief without the risks associated with general anesthesia and surgical recovery.

Q: Which of the following symptoms can be associated with pelvic organ prolapse? 1. Difficulty in passing urine 2. Incomplete evacuation of urine 3. Urgency and frequency Select the correct answer using the code given below:

1, 2 and 3. ***1, 2 and 3*** - Pelvic organ prolapse can cause **urinary symptoms** due to anatomical distortion affecting the bladder and urethra. - Patients may experience **difficulty in initiating micturition**, the sensation of **incomplete emptying**, **increased urgency**, and **frequency** as common manifestations. *1 and 3 only* - This option is incomplete as it excludes **incomplete evacuation of urine**, which is a frequent symptom of pelvic organ prolapse. - The sensation of incomplete emptying is often due to the physical obstruction or kink in the urethra caused by the prolapsed organ. *2 and 3 only* - This option is incorrect because it dismisses **difficulty in passing urine**, also known as **voiding dysfunction**, which can be a direct result of urethral compression or angulation. - **Voiding dysfunction** is a key symptom that impacts quality of life for women with prolapse. *1 and 2 only* - This choice omits **urgency and frequency**, common irritative symptoms of the bladder often associated with pelvic organ prolapse. - Even without infection, bladder irritation can stem from changes in bladder support and position caused by the prolapse.

Question 1

With reference to the displacement of uterus, the treatment of choice for genuine stress urinary incontinence is:

Accepted Answer

TVT‐O mid urethral tape

Answer

Periurethral injection of bulking agents

Answer

Kegel’s perineal exercises

Answer

Kelly's plication

Question 2

Regarding 'DeLancey's levels of vaginal support', consider the following pairs:

Accepted Answer

1, 2 and 3

Answer

2 only

Answer

1 and 3 only

Answer

2 and 3 only

Question 3

A 40 year old lady is examined and found to have uterovaginal prolapse. What is the appropriate surgery to prevent recurrence?

Accepted Answer

Vaginal hysterectomy with anterior and posterior colporrhaphy and McCall culdoplasty

Answer

Vaginal hysterectomy with McCall culdoplasty

Answer

Abdominal hysterectomy with Moschcowitz operation

Answer

Vaginal hysterectomy with sacrospinocolpopexy

Question 4

A 30 year old lady, mother of 3 children presents with mass descending per vaginum. On examination it is found to have stage 3 prolapse, moderate cystocele, no posterior vaginal wall prolapse. The recommended surgery would be:

Accepted Answer

Manchester operation

Answer

Vaginal hysterectomy

Answer

Rectocele repair

Answer

Cystocele repair

Question 5

Which of the following is NOT a component of Fothergill’s operation as a conservative surgery for uterovaginal prolapse?

Accepted Answer

Cervicopexy

Answer

Amputation of cervix

Answer

Plication of Mackenrodt’s ligaments

Answer

Anterior colporrhaphy

Question 6

The level of external cervical os in a second degree utero
vaginal prolapse is:

Accepted Answer

Introitus

Answer

Between ischial spines and introitus

Answer

3 cm outside introitus

Answer

At the level of ischial spines

Question 7

Treatment of choice in 28 year old nullipara with third degree cervical descent is:

Accepted Answer

Abdominal cervicopexy

Answer

Fothergill’s repair

Answer

Anterior and posterior colporrhaphy

Answer

Vaginal hysterectomy with PFR

Question 8

Surgical treatment of choice for a 20 year old nulliparous woman with uterine prolapse is:

Accepted Answer

Sacrocolpopexy

Answer

Le Forte’s repair

Answer

Sling surgery

Answer

Abdominal hysterectomy with pelvic floor repair

Question 9

Which of the following is NOT an ideally suited condition for use of ring pessary in case of uterine prolapse?

Accepted Answer

Late pregnancy

Answer

Puerperium

Answer

Patient's unwillingness for surgery

Answer

Patient unfit for surgery

Question 10

Which of the following symptoms can be associated with pelvic organ prolapse?

1. Difficulty in passing urine
2. Incomplete evacuation of urine
3. Urgency and frequency

Select the correct answer using the code given below:

Accepted Answer

1, 2 and 3

Answer

1 and 3 only

Answer

2 and 3 only

Answer

1 and 2 only

Urogynecology — MCQs

Urogynecology — MCQs

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