Urogynecology Practice Questions

Q: All of the following are abdominal sling surgeries done for uterine preservation in patients of uterine prolapse, EXCEPT?

Manchester. In the management of pelvic organ prolapse, surgeries are broadly classified into those that preserve the uterus and those that involve its removal. **Why Manchester is the Correct Answer:** The **Manchester (Fothergill) operation** is a vaginal surgery, not an abdominal sling procedure. It involves cervical amputation, shortening of the Mackenrodt’s (cardinal) ligaments, and anterior colporrhaphy. It is indicated for uterine prolapse in women who wish to preserve the uterus but do not desire future childbearing (due to the risk of cervical incompetence and mid-trimester abortion following cervical amputation). **Explanation of Incorrect Options (Abdominal Sling Surgeries):** Abdominal sling surgeries are performed to treat **nulliparous prolapse** or prolapse in young women who wish to preserve fertility. They involve using a synthetic mesh or a strip of rectus sheath to anchor the uterus/cervix to a fixed point. * **Shirodkar’s Sling:** The sling is attached to the **promontory of the sacrum** (Sacropexy). * **Khanna’s Sling:** The sling is attached to the **anterior superior iliac spine**. * **Purandare’s Sling:** The sling (rectus sheath) is attached to the **rectus sheath** itself, passing through the internal ring. **High-Yield Clinical Pearls for NEET-PG:** * **Virupaksha’s Sling:** Another abdominal sling where the attachment is to the **pectineal ligament**. * **Best Sling:** Shirodkar’s is often considered the most anatomical as it mimics the direction of the uterosacral ligaments. * **Contraindication:** Manchester operation is generally avoided in women desiring future pregnancy due to high obstetric morbidity. * **Lefort’s Operation:** A "colpocleisis" (obliteration of the vagina) used for frail, elderly patients who are not sexually active.

Q: A patient who has undergone Fothergill's repair for uterine prolapse may experience which of the following complications, except?

First-trimester abortion. **Explanation:** Fothergill’s operation (Manchester repair) involves **amputation of the cervix** and plication of the Mackenrodt’s ligaments. This procedure significantly alters the structural integrity of the cervix, leading to specific obstetric complications in future pregnancies. **1. Why "First-trimester abortion" is the correct answer:** First-trimester abortions (before 12 weeks) are typically caused by chromosomal abnormalities, endocrine imbalances, or immunological factors. Fothergill’s repair affects the mechanical function of the cervix, which does not interfere with early embryonic development or implantation. Therefore, it is **not** a recognized complication of this surgery. **2. Analysis of incorrect options (Complications that DO occur):** * **Cervical Dystocia:** Amputation leads to the formation of rigid, fibrous scar tissue at the external os. During labor, the cervix may fail to dilate effectively, leading to difficult labor (dystocia). * **Premature Labor & PROM:** The removal of a portion of the cervix results in a "shortened cervix" and loss of the cervical sphincter mechanism (cervical incompetence). This inability to hold the weight of the growing conceptus leads to Preterm Premature Rupture of Membranes (PPROM) and mid-trimester miscarriages or premature labor. **Clinical Pearls for NEET-PG:** * **Fothergill’s Repair** is indicated for uterine prolapse in young women who wish to preserve the uterus, particularly when there is **elongation of the supra-vaginal cervix**. * **Obstetric Prognosis:** Because of the high risk of cervical dystocia and preterm birth, pregnancy following Fothergill’s repair is considered high-risk. * **Management:** If a patient becomes pregnant after this repair, a **prophylactic cervical encerclage** (e.g., Shirodkar’s or McDonald’s stitch) is often required to prevent mid-trimester loss.

Q: What is the treatment of choice for second-degree uterine prolapse in a 24-year-old nulliparous woman?

Abdominal sling operations. ### Explanation The management of uterine prolapse in young, nulliparous women is focused on **uterine preservation** and maintaining **reproductive function**. **Why Abdominal Sling Operations are the Correct Choice:** In a 24-year-old nulliparous patient, the primary goal is to provide a permanent, strong anatomical correction while preserving the cervix and uterus for future childbearing. **Abdominal sling operations** (e.g., Shirodkar’s abdominal sling, Khanna’s, or Purandare’s) involve using a synthetic mesh or fascia lata to anchor the cervix to the sacral promontory or the anterior rectus sheath. This provides excellent apical support without interfering with the cervical canal or vaginal capacity. **Analysis of Incorrect Options:** * **Fothergill's Repair (Manchester Operation):** This involves amputation of the cervix. It is contraindicated in young women because it leads to cervical incompetence, increased risk of mid-trimester abortions, and cervical dystocia during labor. * **Shirodkar's Procedure:** While Shirodkar described an abdominal sling, the term "Shirodkar's procedure" alone often refers to **cervical cerclage** for cervical incompetence, which is not a treatment for prolapse. * **Le Fort's Repair:** This is a **colpocleisis** (partial vaginal obliteration). It is strictly reserved for elderly, sexually inactive women who are medically unfit for major surgery. **Clinical Pearls for NEET-PG:** * **Treatment of Choice (Young/Nulliparous):** Abdominal Sling Surgery. * **Treatment of Choice (Completed Family/Age <45):** Fothergill’s Repair (if the patient wishes to keep the uterus) or Vaginal Hysterectomy. * **Treatment of Choice (Post-menopausal):** Ward-Mayo’s Operation (Vaginal Hysterectomy with Pelvic Floor Repair). * **Sling Materials:** Synthetic mesh (Mersilene) is now preferred over autologous fascia lata.

Q: In the immediate postoperative period following a hysterectomy, a patient develops leakage of urine. What is the most likely cause?

Bladder injury. **Explanation:** The most common cause of immediate postoperative urinary leakage following a hysterectomy is an unrecognized **bladder injury** (cystotomy). During a hysterectomy, the bladder must be dissected away from the lower uterine segment and cervix (the vesicouterine space). This proximity makes the bladder the most frequently injured organ in the urinary tract during gynecological surgeries. If a perforation occurs and is not identified and repaired intraoperatively, urine will leak into the peritoneal cavity or through the vaginal vault immediately after the procedure. **Analysis of Incorrect Options:** * **Urethral injury:** This is extremely rare during a standard abdominal or vaginal hysterectomy as the urethra is located further down the anterior vaginal wall, away from the primary surgical site of the uterine pedicles. * **Overflow incontinence:** While postoperative urinary retention can occur due to anesthesia or pain, it typically presents with a palpable bladder and "dribbling" rather than continuous leakage. It is a functional issue, not a structural injury. * **Stress urinary incontinence (SUI):** SUI is a chronic condition related to pelvic floor weakness and urethral hypermobility. It presents with leakage during coughing or sneezing, not as a sudden postoperative complication. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of ureteric injury:** At the level of the **isthmus** (where the ureter passes under the uterine artery—"water under the bridge"). * **Timing of presentation:** Bladder injuries (cystotomy) present **immediately** (Day 0-1). Ureterovaginal or Vesicovaginal fistulas (VVF) typically present **7–14 days** postoperatively due to tissue necrosis. * **Diagnostic Test:** If a fistula is suspected, a **Moir’s Blue Test** (Three-swab test) is used to differentiate between VVF (swab turns blue) and ureterovaginal fistula (swab remains white, but wet).

Q: What is the most important structure preventing uterine prolapse?

Cardinal ligament. **Explanation:** The pelvic organs are supported by a complex network of ligaments and the pelvic floor musculature. The primary support of the uterus is divided into three tiers, with the **Cardinal ligament (Mackenrodt’s ligament)** being the most critical. **1. Why Cardinal Ligament is Correct:** The Cardinal ligaments are thick bands of connective tissue located at the base of the broad ligament, extending from the supravaginal portion of the cervix and lateral vaginal fornices to the pelvic side walls. They provide the **primary lateral support** to the uterus, keeping the cervix in a central position and preventing downward protrusion (prolapse). **2. Analysis of Incorrect Options:** * **Round Ligament:** Its primary function is to maintain the uterus in an **anteverted (AV)** and **anteflexed (AF)** position. It does not provide significant vertical support; hence, its laxity leads to retroversion, not prolapse. * **Broad Ligament:** This is a double fold of peritoneum. It is a weak structure that primarily acts as a "cloak" for the adnexa and does not contribute significantly to uterine support. * **Uterosacral Ligament:** While these provide important **posterior support** and pull the cervix backward to maintain anteversion, they are considered secondary to the cardinal ligaments in preventing descent. **NEET-PG High-Yield Pearls:** * **Primary Support (Level 1):** Cardinal and Uterosacral ligaments. * **Secondary Support (Level 2):** Levator ani muscle (specifically the Pubococcygeus part) and pelvic fascia. * **Most important muscular support:** Levator ani. * **Most important ligamentous support:** Cardinal ligament. * **Uterine Position:** Maintained by the Round ligament (AV/AF).

Q: A female patient presents with post-void dribbling, recurrent urinary tract infections, and a tender anterior vaginal wall mass. Her MRI pelvis is shown in the image. What is the most likely diagnosis?

Urethral diverticula. ***Urethral diverticula*** - The classic triad of **post-void dribbling**, **recurrent UTIs**, and a **tender anterior vaginal wall mass** is pathognomonic for urethral diverticulum. - MRI typically shows a **fluid-filled cystic structure** adjacent to the urethra, which matches the clinical presentation. *Vesicovaginal fistula* - Presents with **continuous urinary leakage** into the vagina, not post-void dribbling. - Typically associated with **obstetric trauma** or surgical complications, causing constant wetness rather than a palpable mass. *Post-partum hemorrhage* - Occurs within **24 hours of delivery** and involves **excessive bleeding**, not urinary symptoms. - Characterized by **blood loss >500ml** (vaginal delivery) or **>1000ml** (cesarean), unrelated to urinary tract pathology. *Pelvic organ prolapse* - Involves **descent of pelvic organs** (bladder, uterus, rectum) into or beyond the vaginal introitus. - Symptoms include **pelvic pressure** and **bulging sensation**, not the specific triad of urethral diverticulum.

Question 1

Childbirth trauma leading to urinary incontinence is seen least in females with which type of pelvis?

Accepted Answer

Anthropoid pelvis

Answer

Android pelvis

Answer

Gynaecoid pelvis

Answer

Platypelloid pelvis

Question 2

All of the following are abdominal sling surgeries done for uterine preservation in patients of uterine prolapse, EXCEPT?

Accepted Answer

Manchester

Answer

Khanna

Answer

Shirodkar

Answer

Purandare

Question 3

A patient who has undergone Fothergill's repair for uterine prolapse may experience which of the following complications, except?

Accepted Answer

First-trimester abortion

Answer

Cervical dystocia

Answer

Premature labor

Answer

Premature rupture of membranes

Question 4

What is the treatment of choice for second-degree uterine prolapse in a 24-year-old nulliparous woman?

Accepted Answer

Abdominal sling operations

Answer

Fothergill's repair

Answer

Shirodkar's procedure

Answer

Le Fort's repair

Question 5

In the immediate postoperative period following a hysterectomy, a patient develops leakage of urine. What is the most likely cause?

Accepted Answer

Bladder injury

Answer

Urethral injury

Answer

Overflow incontinence

Answer

Stress urinary incontinence

Question 6

What is the most important structure preventing uterine prolapse?

Accepted Answer

Cardinal ligament

Answer

Round ligament

Answer

Broad ligaments

Answer

Uterosacral ligament

Question 7

A 55-year-old woman presents with chronic pelvic discomfort, lower back pain, constipation, difficulty with walking, and impaired coitus. Pelvic examination reveals that the uterine cervix lies low within the vaginal canal but does not protrude through the introitus. For minor degrees of this condition, Kegel exercises are sometimes prescribed. How are Kegel exercises performed?

Accepted Answer

Contracting muscles to interrupt the stream of flowing urine

Answer

Closing the glottis and increasing abdominal pressure

Answer

Pressing the knees together

Answer

Tensing the buttocks

Question 8

What is the best treatment for severe stress incontinence without prolapse?

Accepted Answer

Tension-free vaginal tape

Answer

Pelvic floor exercises

Answer

Kelly's repair

Answer

Burch colposuspension

Question 9

A female patient presents with post-void dribbling, recurrent urinary tract infections, and a tender anterior vaginal wall mass. Her MRI pelvis is shown in the image. What is the most likely diagnosis?

Accepted Answer

Urethral diverticula

Answer

Vesicovaginal fistula

Answer

Post-partum hemorrhage

Answer

Pelvic organ prolapse

Question 10

What is the treatment for genuine stress incontinence?

Accepted Answer

Colposuspension

Answer

Anterior colporrhaphy

Answer

Posterior colporrhaphy

Answer

Pelvic floor exercises

Urogynecology — MCQs

Urogynecology — MCQs

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