Urogynecology Practice Questions

Q: A case of obstructed labor which was delivered by cesarean section complains of cyclical passage of menstrual blood in urine. Which is the most likely site of fistula?

Vesicouterine. ***Vesicouterine*** - **Vesicouterine fistula** is the most likely diagnosis, as menstrual blood collects in the uterus and then passes into the bladder and out with urine (**menouria**). - This type of fistula is a known complication of **cesarean section**, especially after difficult or repeated procedures, due to the close proximity of the bladder and uterus. *Urethrovaginal* - A **urethrovaginal fistula** involves a communication between the urethra and the vagina, leading to urine leakage into the vagina, not menstrual blood in urine. - While it can cause urinary symptoms, it would not explain the cyclical passage of menstrual blood in the urine. *Ureterouterine* - A **ureterouterine fistula** involves a connection between the ureter and the uterus, causing urine to leak into the uterus. - This typically leads to **hydronephrosis** or **pyelonephritis** due to urine reflux, and would not present as menstrual blood in urine. *Vesicovaginal* - A **vesicovaginal fistula** is a communication between the bladder and the vagina, resulting in continuous urinary leakage into the vagina. - This condition causes **stress incontinence** and not the cyclical passage of menstrual blood in urine.

Q: All are causes of prolapse of cervix EXCEPT:

Regular exercise. ***Regular exercise*** - **Regular exercise**, especially core-strengthening exercises, can actually help prevent pelvic organ prolapse by strengthening the **pelvic floor muscles**. - It does not contribute to the weakening of support structures necessary for cervical prolapse. *Menopause* - **Estrogen deficiency** during menopause leads to the thinning and weakening of **pelvic connective tissues** and muscles. - This loss of tissue elasticity and strength renders the pelvic organs more susceptible to prolapse. *Chronic cough* - A **chronic cough** significantly increases **intra-abdominal pressure** repeatedly. - This sustained downward force can strain and weaken the **pelvic floor muscles** and ligaments over time, contributing to prolapse. *Delivery of a big baby* - The **vaginal delivery** of a large baby can cause significant **trauma** and stretching to the **pelvic floor muscles**, ligaments, and fascia. - This physical damage can compromise the structural integrity supporting the cervix and other pelvic organs, increasing the risk of prolapse.

Q: Causes of retention of urine in reproductive age group: a) Cervical fibroid b) Retroverted gravid uterus c) Unilateral hydronephrosis d) Severe UTI e) Posterior urethral valve

ABD. ***Correct: ABD*** - **Cervical fibroid** and **retroverted gravid uterus** can cause extrinsic compression of the urethra or bladder neck, leading to **urinary retention** in women of reproductive age. - **Severe UTI** can cause bladder inflammation and dysfunction, manifesting as acute urinary retention. *Incorrect: ACD* - This option incorrectly includes **unilateral hydronephrosis** as a direct cause of urinary retention. - Unilateral hydronephrosis is typically due to an obstruction higher up in one ureter and does not directly obstruct bladder emptying, though bilateral hydronephrosis *could* occur with lower urinary tract obstruction. *Incorrect: BCD* - This option correctly identifies **retroverted gravid uterus** and **severe UTI** as causes but incorrectly includes **unilateral hydronephrosis**. - It also omits **cervical fibroid**, which is a significant cause of retention in this demographic. *Incorrect: ABC* - This option incorrectly includes **unilateral hydronephrosis**. - Unilateral hydronephrosis affects the upper urinary tract (kidney/ureter) and does not cause bladder outlet obstruction or urinary retention. **Key Points:** - **Cervical fibroid**: Causes mechanical urethral/bladder neck compression - **Retroverted gravid uterus**: Classic cause in 2nd trimester (12-16 weeks) when incarcerated uterus compresses urethra - **Severe UTI**: Causes retention via bladder inflammation, edema, and detrusor dysfunction - **Unilateral hydronephrosis**: Upper urinary tract issue, NOT a cause of urinary retention - **Posterior urethral valve**: Congenital male condition, irrelevant to reproductive age women

Q: All of the following surgeries are done in SUI except

Shirodkar sling. ***Shirodkar sling*** - The **Shirodkar sling** procedure is primarily used for the treatment of **cervical incompetence** in pregnancy, not stress urinary incontinence (SUI). - It involves placing a **cerclage** (suture) around the cervix to reinforce it and prevent preterm birth. *Aldridge sling* - The **Aldridge sling** is a type of **pubovaginal sling**, which is a surgical procedure used to treat SUI. - It involves using a **fascial sling** (often autologous) to support the bladder neck and urethra, increasing outlet resistance. *Kelly's stitch* - **Kelly's stitch**, also known as the **Kelly plication**, is a historical procedure for SUI that involves approximating the **periurethral tissues** anterior to the urethra. - While less common today as a standalone procedure, it aimed to reinforce the bladder neck and improve urethral coaptation. *Marshall Marchetti Krantz* - The **Marshall-Marchetti-Krantz (MMK) procedure** is a well-established **retropubic urethropexy** used for SUI. - It involves suturing the **periurethral tissues** to the **pubic bone** to elevate and stabilize the bladder neck and proximal urethra.

Q: A young nulliparous woman has 3rd degree uterovaginal prolapse without any cystocele or rectocele. There is no stress incontinence. Uterocervical length is 3 inches. All other findings are normal. The best treatment plan for her will be :

Fothergill's operation. ***Fothergill's operation*** - This procedure, also known as **Manchester operation**, is the best option for this patient with **3rd degree uterovaginal prolapse** and **elongated cervix (3-inch uterocervical length)**. - It involves **cervical amputation**, plication of the cardinal ligaments, and anterior colporrhaphy, effectively addressing the prolapse while preserving the uterus. - While it preserves the uterus, **cervical amputation may impact fertility**, so thorough counseling is essential. However, for severe prolapse in a young woman, this offers a balance between surgical correction and uterine preservation. - The absence of cystocele and rectocele makes this focused procedure ideal without requiring extensive vaginal wall repair. *Shirodkar's abdominal sling* - This procedure is primarily used for **cervical incompetence** to prevent preterm delivery, not for uterovaginal prolapse. - It involves placing a stitch around the cervix via an abdominal approach and is typically performed during pregnancy. *Shirodkar's vaginal repair* - There is no standard gynecological procedure known as "Shirodkar's vaginal repair" for uterovaginal prolapse. - The Shirodkar procedure is specifically a type of **cervical cerclage** to prevent pregnancy loss due to cervical incompetence. *Observation and reassurance till child bearing is over* - While conservative management with pessary can be considered for women desiring future pregnancies, a **3rd degree uterovaginal prolapse** is a severe condition that typically requires surgical intervention. - Delaying definitive treatment for severe prolapse can lead to discomfort, ulceration, urinary complications, and progressive pelvic floor dysfunction.

Q: Kamla, a 48 years old lady underwent hysterectomy. On the seventh day, she developed fever, burning micturition and continuous urinary dribbling. She can also pass urine voluntarily. The diagnosis is :

Uretero-vaginal fistula. ***Uretero-vaginal fistula*** - **Post-hysterectomy** onset of continuous urinary dribbling, despite being able to void voluntarily, is highly suggestive of a uretero-vaginal fistula. - The ability to pass urine voluntarily indicates the bladder and urethra are intact, suggesting urine is leaking from a higher point in the urinary tract into the vagina. *Vesico-vaginal fistula* - In a vesico-vaginal fistula, urine would leak continuously from the bladder directly into the vagina, leading to complete and constant incontinence and typically **no ability to pass urine voluntarily** once the bladder is emptied. - This patient can still pass urine voluntarily, which makes a uretero-vaginal fistula more likely where one ureter is leaking but the bladder can still collect and empty urine from the other kidney. *Stress incontinence* - This involves involuntary urine leakage with activities that increase **intra-abdominal pressure** (e.g., coughing, sneezing, laughing). - It does not present as continuous dribbling unrelated to physical exertion and would not typically arise as a new symptom seven days post-hysterectomy in this manner. *Urge incontinence* - Characterized by a sudden, strong need to urinate followed by involuntary leakage, often due to **detrusor overactivity**. - It does not cause continuous urinary dribbling and the patient would not be able to pass significant amounts of urine voluntarily in addition to the continuous leakage.

Q: The appropriate choice for treatment of Nulliparous prolapse is :

Pessary treatment. ***Pessary treatment*** - For **nulliparous women** with prolapse, **conservative management** with a pessary is usually the first-line treatment, especially if they desire future fertility or surgery is not indicated. - Pessaries provide **mechanical support** to pelvic organs, alleviating symptoms without surgical intervention. *Manchester repair* - This procedure involves **cervical amputation**, uterine shortening, and repair of the anterior and posterior vaginal walls. - It is generally performed for **elongated cervix with uterine prolapse**, and is overly aggressive for prolapse in nulliparous women, especially if they wish to preserve fertility. *Ward Mayo's operation* - This refers to a **vaginal hysterectomy with anterior and posterior colporrhaphy**, often accompanied by sacrouterine ligament plication. - It is a **definitive surgical treatment** for advanced prolapse, which is typically not indicated for nulliparous women who have not completed childbearing. *Sling operation* - Sling operations, such as **mid-urethral slings**, are primarily used to treat **stress urinary incontinence**, not uterine or vaginal prolapse itself. - While prolapse can co-exist with incontinence, a sling alone would not address the prolapse in a nulliparous woman.

Q: Sacrospinous fixation is for strengthening:

Apical defect. ***Apical defect*** - **Sacrospinous fixation** is a surgical procedure commonly used to treat **apical prolapse**, which is the descent of the uterus or vaginal vault. - The procedure involves attaching the vaginal apex to the **sacrospinous ligament**, thereby providing support and preventing recurrence of prolapse. *Posterior defect* - A **posterior defect** typically refers to a **rectocele**, a bulge of the rectum into the posterior vaginal wall. - While sometimes co-occurring with apical prolapse, sacrospinous fixation primarily addresses apical support and not directly the rectocele. *Anterior defect* - An **anterior defect** usually describes a **cystocele**, which is the herniation of the bladder into the anterior vaginal wall. - Surgical correction for cystocele often involves **anterior colporrhaphy** or paravaginal defect repair, which are different from sacrospinous fixation. *Lateral defect* - **Lateral defects** in pelvic floor support are less common and typically refer to problems with the **paravaginal attachments**. - These are usually repaired through specific procedures addressing weaknesses in the lateral support structures, not primarily with sacrospinous fixation.

Q: 3rd degree genital prolapse in the first trimester of pregnancy is managed by :

Ring pessary. ***Ring pessary*** - A ring pessary is a **non-surgical** option often used during pregnancy to support the uterus and prevent further prolapse, especially in the first trimester. - It provides **conservative management**, avoiding surgical risks to both mother and fetus during early pregnancy. *Le Fort's repair* - **Le Fort's repair** is a colpocleisis procedure, typically performed on elderly women who are no longer sexually active, as it surgically obliterates the vaginal canal. It is contraindicated in pregnancy and unlikely to be performed in a woman of childbearing age who is pregnant. *Right transvaginal sacrospinous colpopexy* - This is a **surgical procedure** to correct vaginal vault prolapse by attaching the vaginal apex to the sacrospinous ligament. It is inappropriate for managing prolapse in the first trimester of pregnancy due to surgical risks and potential fetal harm. *Fothergill's repair* - **Fothergill's repair (Manchester repair)** is a surgical procedure that involves cervical amputation, shortening of the cardinal ligaments, and colporrhaphy. This surgery is not suitable during pregnancy due to the risk of miscarriage and is typically reserved for cases of uterocervical elongation causing prolapse in non-pregnant women.

Q: Risk factors for stress urinary incontinence are all except

Hypertension. ***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 1

A case of obstructed labor which was delivered by cesarean section complains of cyclical passage of menstrual blood in urine. Which is the most likely site of fistula?

Accepted Answer

Vesicouterine

Answer

Urethrovaginal

Answer

Ureterouterine

Answer

Vesicovaginal

Question 2

All are causes of prolapse of cervix EXCEPT:

Accepted Answer

Regular exercise

Answer

Menopause

Answer

Chronic cough

Answer

Delivery of a big baby

Question 3

Causes of retention of urine in reproductive age group:
a) Cervical fibroid
b) Retroverted gravid uterus
c) Unilateral hydronephrosis
d) Severe UTI
e) Posterior urethral valve

Accepted Answer

ABD

Answer

ACD

Answer

BCD

Answer

ABC

Question 4

All of the following surgeries are done in SUI except

Accepted Answer

Shirodkar sling

Answer

Aldridge sling

Answer

Kelly's stitch

Answer

Marshall Marchetti Krantz

Question 5

A young nulliparous woman has 3rd degree uterovaginal prolapse without any cystocele or rectocele. There is no stress incontinence. Uterocervical length is 3 inches. All other findings are normal. The best treatment plan for her will be :

Accepted Answer

Fothergill's operation

Answer

Shirodkar's abdominal sling

Answer

Shirodkar's vaginal repair

Answer

Observation and reassurance till child bearing is over

Question 6

Kamla, a 48 years old lady underwent hysterectomy. On the seventh day, she developed fever, burning micturition and continuous urinary dribbling. She can also pass urine voluntarily. The diagnosis is :

Accepted Answer

Uretero-vaginal fistula

Answer

Vesico-vaginal fistula

Answer

Stress incontinence

Answer

Urge incontinence

Question 7

The appropriate choice for treatment of Nulliparous prolapse is :

Accepted Answer

Pessary treatment

Answer

Manchester repair

Answer

Ward Mayo's operation

Answer

Sling operation

Question 8

Sacrospinous fixation is for strengthening:

Accepted Answer

Apical defect

Answer

Posterior defect

Answer

Anterior defect

Answer

Lateral defect

Question 9

3rd degree genital prolapse in the first trimester of pregnancy is managed by :

Accepted Answer

Ring pessary

Answer

Le Fort's repair

Answer

Right transvaginal sacrospinous colpopexy

Answer

Fothergill's repair

Question 10

Risk factors for stress urinary incontinence are all except

Accepted Answer

Hypertension

Answer

Obesity

Answer

Smoking

Answer

Pregnancy

Urogynecology — MCQs

Urogynecology — MCQs

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