Urogynecology Practice Questions

Q: Cystocoele is prolapse of

Upper 2/3rd of anterior vaginal wall. ***Upper 2/3rd of anterior vaginal wall*** - A **cystocele** specifically refers to the prolapse of the **bladder** through the **upper two-thirds of the anterior vaginal wall**. - The bladder is primarily supported by the **pubocervical fascia** overlying the upper 2/3rd of the anterior vaginal wall. - When this fascial support weakens, the bladder herniates into the vaginal lumen, creating a cystocele. - This is the **classic anatomical definition** found in standard gynecology textbooks. *Lower 2/3rd of anterior vaginal wall* - This option is anatomically incorrect for defining a pure cystocele. - While severe cystoceles can extend downward, the primary defect involves the upper two-thirds where bladder support is located. *Lower 1/3 of anterior vaginal wall* - Prolapse of the lower 1/3 of the anterior vaginal wall is called a **urethrocele**, which involves prolapse of the **urethra**. - A **cystourethrocele** refers to combined prolapse of both bladder and urethra. - This is distinct from a pure cystocele. *Upper 1/3 of anterior vaginal wall* - While the upper third is involved in cystocele, the complete anatomical definition encompasses the **entire upper two-thirds** (upper 2/3rd), not just the upper one-third. - Limiting it to only the upper 1/3 would be incomplete and anatomically imprecise.

Q: Postpartum VVF is best repaired after:

3 months. ***3 months*** - Waiting at least **3 months** for VVF repair allows for complete resolution of **acute inflammation**, **edema**, and infection in surrounding tissues. - This waiting period helps tissues to **regain their normal vascularity** and pliancy, which is crucial for a successful surgical outcome and reduced risk of recurrence. *6 months* - While waiting longer may seem safer, 6 months is generally **unnecessarily long** for most postpartum VVF repairs. - Prolonged waiting can lead to **increased psychological distress** for the patient due to persistent leakage and discomfort. *6 weeks* - Repairing a VVF at 6 weeks postpartum is generally **too early** as the tissues are still highly friable and inflamed. - This early intervention significantly **increases the risk of dehiscence** and failure of the repair due to poor tissue healing. *8 weeks* - Similar to 6 weeks, 8 weeks postpartum is usually **insufficient time** for complete resolution of acute inflammation and edema. - Operating at this stage can still lead to **poor tissue integrity** and a higher chance of a failed repair.

Q: 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:

Le Fort's repair. ***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.

Q: Purandare's cervicopexy is done in :

Elongated cervix. ***Elongated cervix*** - **Purandare's cervicopexy** is a surgical procedure specifically designed to treat **elongated cervix** (cervical elongation) associated with uterine prolapse. - This technique involves fixing the elongated cervix to the anterior abdominal wall to provide support and correct the anatomical defect. - The procedure addresses cervical elongation by suspending the cervix, preventing its descent and associated prolapse symptoms. - It is particularly useful when cervical elongation is a significant component of uterine prolapse. *Congenital prolapse of uterus* - While **congenital prolapse of uterus** is a rare condition requiring surgical management, Purandare's cervicopexy is not the primary procedure specifically designed for this indication. - Congenital prolapse may require various surgical approaches depending on the severity and anatomical findings. *Missed IUD* - A **missed IUD** refers to a situation where an intrauterine device is no longer found in its expected position within the uterus. - Management typically involves retrieval of the IUD, often with instruments, and does not involve cervical suspension procedures. *Incompetent cervix* - An **incompetent cervix** is a condition where the cervix dilates painlessly in the second trimester, leading to preterm birth or pregnancy loss. - The standard treatment is **cervical cerclage**, a stitch placed around the cervix to keep it closed during pregnancy, not cervicopexy which is a suspension procedure for prolapse.

Q: Le Fort's operation is done in:

Elderly menopausal patients with advanced prolapse. ***Elderly menopausal patients with advanced prolapse*** - Le Fort's operation is a **colpocleisis** procedure, involving partial closure of the vagina, and is suitable for elderly patients who are no longer sexually active. - It provides a definitive and durable solution for **advanced pelvic organ prolapse** with a low recurrence rate. *Women under 40 years who are desirous of retaining their menstrual and reproduction function* - This procedure renders a woman unable to have sexual intercourse and potential future vaginal deliveries, making it unsuitable for those desiring to **retain reproductive function**. - It also makes future gynecological examinations and access to the cervix difficult, which is important for **younger women**. *Women over 40 years, those who have completed their families* - While these women may have completed their families, suitability for Le Fort's depends more on whether they are sexually active, as the procedure **obliterates the vaginal canal**. - Other less invasive or reconstructive surgeries would be preferred if **sexual function** is to be preserved. *Young woman suffering from second or third degree prolapse* - Young women with prolapse typically undergo **reconstructive procedures** to preserve their anatomical and functional integrity, including sexual function and future fertility. - Le Fort's operation would be a last resort or generally contraindicated in young women due to its **irreversible nature** and impact on quality of life.

Q: In Marshall - Marchetti - Krantz (MMK) colposuspension for stress urinary incontinence, Pubocervical fascia is attached to

Symphysis pubis. ***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.

Q: A 50-year-old female presents with involuntary loss of urine on coughing or sneezing for 3 years with increasing frequency. Which of the following types of incontinence is the patient suffering from?

Stress incontinence. ***Stress incontinence*** - This is characterized by **involuntary urine leakage** during activities that increase intra-abdominal pressure, such as **coughing, sneezing**, laughing, or exercising. - It often results from **weakening of the pelvic floor muscles** and urethral sphincter, frequently seen in women, especially after childbirth or with aging. *Functional incontinence* - This type involves **involuntary urine loss** due to the inability or unwillingness to reach the toilet in time, often related to **cognitive impairments** or **physical disabilities**. - The urinary tract itself is intact, but external factors prevent timely voiding. *Overflow incontinence* - This occurs when the **bladder does not empty completely** and urine leaks out when the bladder becomes overly full. - It is typically caused by **bladder outlet obstruction** (e.g., enlarged prostate in men) or impaired bladder muscle contraction. *Urgency incontinence* - This is defined by a **sudden, strong urge to urinate** followed by involuntary loss of urine, often before reaching a restroom. - It is caused by **involuntary detrusor muscle contractions** and is commonly associated with overactive bladder syndrome.

Q: In a case of incontinence of urine, dye filled into the urinary bladder does not stain the pad in the vagina, yet the pad is soaked with clear urine. Most likely diagnosis is:

Ureterovaginal fistula. **Ureterovaginal fistula** - If a **dye-filled bladder** does not stain the vaginal pad but clear urine still soaks it, it signifies that the urine is bypassing the bladder and the staining agent. - This scenario strongly suggests a **ureterovaginal fistula**, where urine directly flows from the ureter into the vagina without passing through the bladder. *VVF* - A **vesicovaginal fistula (VVF)** would result in the escape of **dye-filled bladder urine** into the vagina, staining the pad. - The absence of dye on the pad rules out a direct leak from the bladder into the vagina. *Urethrovaginal fistula* - A **urethrovaginal fistula** would also involve urine passing through the bladder and urethra, leading to the **dye staining the vaginal pad**. - The dye would be present in the urine leaking into the vagina, which directly contradicts the clinical presentation. *Urinary stress incontinence* - **Stress incontinence** involves involuntary leakage of urine from the bladder due to increased intra-abdominal pressure, and this urine would also be **dye-stained**. - This diagnosis does not explain why the urine is clear while the bladder is filled with dye.

Q: Le Fort's operation is done in

Elderly menopausal patients with advanced prolapse. ***Elderly menopausal patients with advanced prolapse*** - Le Fort's operation is a **colpocleisis** procedure, which permanently closes the vagina, making it suitable for elderly patients who are no longer sexually active. - It is often reserved for those with **advanced uterine or vaginal prolapse** who are not candidates for more extensive surgeries due to comorbidities. *Women over 40 years, those who have completed their families* - While these patients may have completed their families, Le Fort's operation is a **definitive and irreversible procedure** that is typically reserved for those who are also postmenopausal and have no desire for future sexual activity. - Other less invasive or reconstructive options might be considered for women over 40 who still maintain sexual activity. *Women under 40 years who are desirous of retaining their menstrual and reproduction function* - Le Fort's operation involves **closure of the vagina**, which makes it impossible to retain menstrual or reproductive function. - Younger women would typically be offered **uterine-sparing procedures** or reconstructive surgeries to preserve these functions. *Young woman suffering from second or third degree prolapse* - For young women, even with significant prolapse, the primary goal is often to **preserve fertility, menstruation, and sexual function**. - Le Fort's operation would be contraindicated because it involves **vaginal obliteration**, making it unsuitable for a young woman.

Q: All of the following operations are done for uterine prolapse except:

Shirodkar. ***Shirodkar*** - The **Shirodkar procedure** is a type of **cervical cerclage** used to address **cervical insufficiency** during pregnancy, to prevent preterm birth. - It involves placing a stitch around the cervix to keep it closed and is **not used for uterine prolapse**. *Abdominocervicopexy* - This procedure involves attaching the **cervix** to the **abdominal wall** using a sling-like material. - It is a recognized surgical technique for correcting **uterine prolapse**, particularly in younger women who wish to retain their uterus. *Khanna* - The **Khanna sling operation** is a specific type of **vaginal sling technique** used to support the uterus or vaginal vault. - It aims to suspend the prolapsed organ to stabilize its position within the pelvis. *Manchester* - The **Manchester operation** (also known as Fothergill's operation) is a classic procedure for **uterine prolapse** when the cervix is elongated. - It involves **cervical amputation**, **repair of the cardinal ligaments**, **anterior colporrhaphy**, and **posterior colpoperineorrhaphy**.

Question 1

Cystocoele is prolapse of

Accepted Answer

Upper 2/3rd of anterior vaginal wall

Answer

Lower 1/3 of anterior vaginal wall

Answer

Lower 2/3rd of anterior vaginal wall

Answer

Upper 1/3 of anterior vaginal wall

Question 2

Postpartum VVF is best repaired after:

Accepted Answer

3 months

Answer

6 months

Answer

6 weeks

Answer

8 weeks

Question 3

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:

Accepted Answer

Le Fort's repair

Answer

Cervicopexy

Answer

Vaginal hysterectomy

Answer

Wait and watch

Question 4

Purandare's cervicopexy is done in :

Accepted Answer

Elongated cervix

Answer

Missed IUD

Answer

Incompetent cervix

Answer

Congenital prolapse of uterus

Question 5

Le Fort's operation is done in:

Accepted Answer

Elderly menopausal patients with advanced prolapse

Answer

Women under 40 years who are desirous of retaining their menstrual and reproduction function

Answer

Women over 40 years, those who have completed their families

Answer

Young woman suffering from second or third degree prolapse

Question 6

In Marshall - Marchetti - Krantz (MMK) colposuspension for stress urinary incontinence, Pubocervical fascia is attached to

Accepted Answer

Symphysis pubis

Answer

Pectineal Ligament

Answer

Arcus tendineus fascia pelvis

Answer

Cooper's ligament (Pectineal ligament)

Question 7

A 50-year-old female presents with involuntary loss of urine on coughing or sneezing for 3 years with increasing frequency. Which of the following types of incontinence is the patient suffering from?

Accepted Answer

Stress incontinence

Answer

Functional incontinence

Answer

Overflow incontinence

Answer

Urgency incontinence

Question 8

In a case of incontinence of urine, dye filled into the urinary bladder does not stain the pad in the vagina, yet the pad is soaked with clear urine. Most likely diagnosis is:

Accepted Answer

Ureterovaginal fistula

Answer

VVF

Answer

Urethrovaginal fistula

Answer

Urinary stress incontinence

Question 9

Le Fort's operation is done in

Accepted Answer

Elderly menopausal patients with advanced prolapse

Answer

Women over 40 years, those who have completed their families

Answer

Women under 40 years who are desirous of retaining their menstrual and reproduction function

Answer

Young woman suffering from second or third degree prolapse

Question 10

All of the following operations are done for uterine prolapse except:

Accepted Answer

Shirodkar

Answer

Abdominocervicopexy

Answer

Khanna

Answer

Manchester

Urogynecology — MCQs

Urogynecology — MCQs

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