K Urogyne review

Question 1

Which one of the following is NOT a risk factor for urinary incontinence:
A. Race
B. Menopause
C. Prior hysterectomy
D. COPD
E. Vaginal delivery of an infant weighing > 4 kg

Answer 1

C. Prior hysterectomy

• pre & post-op urodynamic studies show clinically insignificant differences
• evidence does not support avoidance of clinically indicated hysterectomy to prevent UI
• evidence does not support performance of supracervical hysterectomy to prevent UI

Question 2

List the three muscles that make up the urogenital sphincter complex. Which one maintains a state of resting contraction, and which two contract swiftly when continence is challenged by increased intra-abdominal pressure?

Answer 2

Sphincter urethrae - wraps circumferentially around urethra & maintains tonic contraction
Urethrovaginal sphincter, compressor urethrae - arch over the urethra & insert into anterior vaginal wall, contract swiftly when continence is challenged

Question 3

What is the mechanism by which hypoestrogenism contributes to UI?

Answer 3

Hypoestrogenism results in decreased prominence of the submucosal venous plexus, which contributes to urethral coaptation

Question 4

Describe the location & function (including the ligand) of each of the following receptors in the bladder:

A. Muscarinic
B. Alpha
C. Beta

Answer 4

A. Parasympathetic - acetylcholine binds receptors in bladder dome leading to detrusor contraction resulting in urine voiding
B. Sympathetic - epinephrine binds receptors in bladder base & urethra leading to muscle contraction resulting in urine storage
C. Sympathetic - epinephrine binds receptors in bladder dome leading to muscle relaxation resulting in urine storage

Question 5

List three risk factors for intrinsic urogenital sphincter deficiency.

Answer 5

Pelvic surgery resulting in urethral denervation, prior radiation therapy, diabetic neuropathy, neuronal degenerative disease, hypoestrogenism, birth trauma

Question 6

Which spinal levels mediate the bulbocavernosus & anocutaneous reflexes?
A. S1-3
B. T12-S2
C. S2-4
D. T10-T12
E. T10-S2

Answer 6

C. S2-4

Question 7

Define the leak point pressure. What value is suggestive of intrinsic sphincter deficiency?

Answer 7

Leak point pressure = intra-abdominal pressure at which urine leakage occurs
LPP < 60 cm H2O suggests ISD

Question 8

List three characteristics of women unlikely to benefit from pelvic floor muscle strengthening for treatment of UI.

Answer 8

Severe incontinence
Prolapse beyond the hymen
Prior failed physiotherapy
Prior prolonged second stage of labour
Obesity
High degree of psychological distress
Poor general physical health

Question 9

Which antimuscarinic would you recommend for a woman with known liver disease?
A. Tolterodine
B. Solifenacin
C. Fesoterodine
D. Trospium
E. Darifenacin

Answer 9

D. Trospium - predominantly renal metabolism, whereas for all others there is a greater element of hepatic metabolism

Question 10

Define stage IV prolapse (POP-Q).

Answer 10

Complete eversion with the most significant prolapse protruding to at least (Total Vaginal Length - 2).

Question 11

Define DeLancey’s second level of vaginal support. With failure of this level of support, what sort of prolapse would you expect to see?

Answer 11

Mid-vagina is supported by paravaginal attachments to the arcus tendineus fascia pelvis anteriorly and arcus tendineus rectovaginalis posteriorly.

Failure would result in anterior vaginal wall prolapse.

Question 12

List the three muscles of the levator ani in order from lateral to medial.

Answer 12

Iliococcygeus, pubococcygeus, puborectalis.

Question 13

List three physical exam findings suggestive of enterocele.

Answer 13

Apical posterior wall descent
Visualization of peristalsis behind the vaginal wall
Palpation of small bowel between examining fingers on rectovaginal exam

Question 14

What are the two mechanisms by which space-filling pessaries work?

Answer 14

Suction to vaginal walls

Diameter > genital hiatus

Question 15

If using a mesh to augment prolapse reconstruction, which is preferred?
A. Microporous monofilament
B. Macroporous monofilament
C. Microporous multifilament
D. Macroporous multifilament

Answer 15

B. Macroporous multifilament

• Macroporous mesh allows tissue ingrowth & collagen infiltration, while microporous mesh increases risk of infection (small pores permit bacteria but not macrophages)
• Multifilament mesh contains intrafibrous pores that can harbour bacteria

Question 16

Describe the dovetail sign. What is its clinical significance?

Answer 16

Absent anterior radial spikes around the anus - signifies disruption of the EAS.

Question 17

A 65 y/o G0 woman presents w/ a chief complaint of malodorous vaginal discharge. You diagnose a recto-vaginal fistula. What test must be done prior to proceeding with surgical repair?
A. Biopsy of fistula tract
B. CT enterography
C. Barium enema
D. FOBT
E. Sigmoidoscopy

Answer 17

A. Biopsy of fistula tract - unless RVF is clearly secondary to obstetric injury, biopsy to rule out malignancy & inflammatory disease is mandatory.

Question 18

You diagnose a 32 y/o G3P3 woman w/ a recto-vaginal fistula. What test must be done prior to proceeding with surgical repair?
A. Biopsy of fistula tract
B. Endoanal US
C. Barium enema
D. Sigmoidoscopy
E. CT enterography

Answer 18

B. Endoanal US - obstetric RVFs are typically found in the distal third of the vagina, and options for repair include episioproctotomy vs fistulotomy w/ purse-string repair or tension-free layered closure. Episioproctotomy is avoided if the EAS is intact, and this is best assessed by endoanal US.

Question 19

Which route of hysterectomy is associated with the highest incidence of genitourinary fistula?
A. Abdominal
B. Vaginal
C. Laparoscopic
D. Supracervical

Answer 19

C. Laparoscopic

Question 20

What are two predictors of successful surgical repair of a genitourinary fistula?

Answer 20

First attempt at repair
Obstetric fistula
Healthy surrounding tissue