PROLOG: Urogynecology

Question 1

Answer 1

Gartner duct: embryonic remnant of mesonephric or wolffian duct

Commonly found along posterior or lateral vagina and are filled with serous or mucinous fluid

Question 2

What are Skene’s glands?

Answer 2

Periurethral glands responsible for lubrication and are the closest female analog to the male prostate gland

Question 3

65 yo woman P3 has stage 3 anterior vaginal wall prolapse. The surgical repair that is most likely to resolve her underlying pelvic support defect is:

Answer 3

Anterior repair with sacrospinous ligament fixation

Question 4

Definition of recurrent UTI

Answer 4

Two or more infections in 6 months or 3 or more infections in 1 year

Question 5

How does vaginal estrogen protect against UTI?

Answer 5

Increase maturation index of vaginal epithelial cells, lower vaginal pH, and shift vaginal flora away from Enterobacter colonization

Question 6

First-line approach to treatment of urgency incontinence

Answer 6

• Behavioral modification, such as modulation of amount and timing of fluid intake
• Timed voiding
• Weight loss

Question 7

What are the principal support mechanisms of the pelvic floor?

Answer 7

Levator ani muscle complex (PR, PC, IC) and the connective tissue attachments of the pelvic organs (endopelvic fascia)

Question 8

What does SSLF involve?

Answer 8

Attaching the vaginal apex to one or both sacrospinous ligaments to treat vaginal vault prolapse

85% success rate

Question 9

Forceps-assisted delivery is associated with a ____-fold higher risk of obstetric anal sphincter injury than vacuum-assisted delivery.

Answer 9

1.5-4

Question 10

Answer 10

• Aa: urethrovesical crease: the midline point on the anterior vaginal wall 3 cm inside the hymen in a woman with no support deficits
• Ba: most prolapsed point on the anterior vaginal wall
• C: cervix or vaginal cuff in a woman with a prior total hyst
• D: posterior fornix (women with a prior total hysterectomy will not have a point “D”)
• gh: external urethral meatus to hymen
• pb: hymen to midanal opening

Question 11

A 32 yo P1 has urinary incontinence. She hopes to become pregnant within the next year. After delivery of her son 8 mo ago, she developed urine leakage with exercise, and specifically with running. The leakage interferes with her QOL. No symptoms of urgency urinary incontinence.

Dx?

The best treatment option for her is?

Answer 11

Stress Urinary Incontinence

Incontinence dish pessary (often are effective temporizing devices for women who have not completed childbearing)

Question 12

A 44 yo P3 reports that she leaks urine with coughing, sneezing, and jogging. On exam, she has a positive cough stress test. She is interested in undergoing surgical treatment and recently heard about retropubic midurethral slings.

You counsel her that the most common complication associated with a retropubic midurethral sling procedure is:

A) bladder perforation

B) hemorrhage

C) neurologic symptoms

D) persistent voiding dysfunction

E) UTI

Answer 12

E) UTI

Question 13

Clinical evaluation of patients with symptoms of SUI

Answer 13

1. Complete physical exam (assessment of vulva, urethra, vagina, uterus, adnexa, pelvic floor muscles, rectum)
2. Screening neurologic exam
3. PVR measurement
4. UA

Question 14

A 42 yo has SUI. She does not report symptoms of urgency or urgency incontinence. She voids 7x day, and has no prolapse or vaginal bulge. Her PVR is 55 mL. Urine culture is neg. The most important test in the evaluation of this patient for surgery is:

A) urodynamic testing

B) cough stress test

C) U/S

D) cystoscopy

E) CT urography

Answer 14

B) cough stress test

Women with persistent bothersome symptoms or who decline conservative treatments may opt for surgical management of their stress urinary incontinence.

Given that this patient has uncomplicated SUI (typical bothersome symptoms, no urgency, no prolapse, normal PVR, negative UC), she does not need urodynamic testing.

A cough stress test demonstrating fluid loss from the urethra with cough is adequate. Cough stress test sensitivity is maximized in the standing position with a full bladder or at 300 mL bladder volume.

Question 15

A 55 yo comes in with urgency incontinence. She has tried behavioral therapy, including timed voiding and decreasing bladder irritants. She most recently tried two anticholinergic medications with no improvement in symptoms.

She decides to try an intradetrusor injection of onabotulinumtoxinA. You counsel her that this is a very effective therapy but is accompanied by a high rate of UTIs and the adverse effect of:

A) dry eye

B) nausea

C) urinary retention

D) leg weakness and numbness

E) psychosis

Answer 15

C) urinary retention

Question 16

65 yo has daily episodes of urgency urinary incontinence, despite the fact that she has reduced her fluid intake and performs Kegel exercises correctly. She tried oxybutynin chloride TID with good success initially. However, she developed adverse effects (dry mouth, dry eyes, constipation), which led her to stop using it. Her PCP is currently performing a workup for episodic HTN. The next best step is to prescribe:

A) Mirabegron QD

B) Oxybutynin chloride XL QD

C) Oxybutynin XL BID

D) Tolterodine tartrate BID

Answer 16

B) oxybutynin chloride XL QD

Oxybutynin is a tertiary amine with M3 affinity, but it has some M1 affinity, which can result in CNS adverse effects.

For this patient, tolterodine BID would

Question 17

How do antimuscarinic agents work for urgency incontinence?

Answer 17

Block the M2 and M3 receptors on the detrusor muscle, which prevents the binding of ACh

In the bladder, M2 receptors are more common than M3 recepotrs (70-80% vs 20-30%). However, M3 receptors are thought to be most responsible for initiating bladder contractility.

Question 18

For patients with refractory overactive bladder syndrome (i.e., who have failed conservative therapy or medical or anticholinergic therapy), what are the treatment options?

Question 19

A woman develops leakage per vagina on POD 2 s/p lpsy hyst. Her surgery involved some intraop bleeding at the vaginal cuff, which was controlled with suture ligation, and she went home after she voided on POD 1.

She was prescribed oral phenazopyridine to confirm that the fluid was urine, and there was orange fluid on her pad. She underwent an office cystoscopy on POD 3, which revealed a 0.5-cm x 0.5-cm defect in the bladder posterior to the trigone and 1 cm posterior to the trigone and medial to the R ureteral orifice.

The best next step in management is:

A) indwelling foley for 2-3 weeks

B) renal scan with furosemide

C) CT urography

D) immediate operative repair of fistula

E) renal U/S

Answer 19

C) CT urography

When a vesicovaginal fistula occurs, an evaluation must be done to confirm there is no ureteral injury. For this patient, the important issue is identification of a concomitant ureteral injury, so use of a Foley would not be the best next step.

Question 20

An 87 yo multiparous woman with multiple medical comorbidities comes to your office for evaluation of POP noted during recent hospitalization for MI. She reports no typical prolapse symptoms but has urinary incontinence. On exam, her anterior vaginal wall is prolapsed 6 cm beyond the hymen, and her cervix is at the hymen. You obtain a PVR volume: 260 mL. UA is negative for nitrites, leukocytes, and blood.

The best next step in her management?

A) indwelling Foley

B) antimuscarinic meds

C) prolapse reduction with pessary

D) urodynamic testing

E) colpocleisis and rectus fascial sling

Answer 20

C) prolapse reduction with pessary

Question 21

A healthy 35 yo woman P2, comes to office 6 weeks after uncomplicated placement of retropubic midurethral sling. She reports urinary frequency, a slow dribbling urinary stream, and a sensation of incomplete bladder emptying. Her SUI symptoms have resolved after surgery. She reports no dysuria or hematuria. Her PVR volume is 340 mL and her urine dipstick is negative. She is using self-catheterization. The most appropriate management of her condition is:

A) trial of bethanechol

B) pelvic floor therapy

C) surgical sling lysis

D) recheck PVR volume after 6 weeks of self-cath

E) insertion of suprapubic catheter

Answer 21

C) surgical sling lysis

midurethral sling = first-line procedure for SUI

the described patient’s symptoms and significantly elevated PVR are reflective of clinically significant urinary retention that requires sling lysis in order to avoid long-term sequelae of BOO

Question 22

First-line treatment of mesh erosion

Answer 22

Estrogen cream

Question 23

A 65 yo sexually active woman desires surgical management of her stage III POP. The vaginal bulge interferes with her daily activities and she sometimes has difficulty emptying her bladder. She does not have symptoms of stress or urgency urinary incontinence. She experiences 3 episodes of nocturia each night. Her PVR volume is 175 mL. She wants a procedure that will offer the best anatomic and functional outcome. The best next treatment for this patient is:

A) Sacrocolpopexy with Burch colposuspension

B) Sacrocolpopexy without Burch colposuspension

C) Colpocleisis with rectus fascial sling

D) Colpocleisis without rectus fascial sling

E) SSLF with midurethral sling

Answer 23

A) Sacrocolpopexy with Burch colposuspension

At 2-year follow-up, abdominal sacrocolpopexy was associated with significantly lower rates of recurrent vaginal vault prolapse compared with SSLF. Sacrocolpopexy is associated with less dyspareunia than vaginal SSLF.

Burch colposuspension places two permanent sutures on either side of the midurethra and urethrovesical junction, then passes each suture through the Cooper ligament (iliopectineal line) to stabilize the urethrovesical junction.

Question 24

A 57 yo woman comes to your office with a 6-month history of urinary urgency and frequency + bladder pain. She has been treated for recurrent UTI but reports negative urine cultures. On exam, she has pain with insertion of the speculum and bladder tenderness on bimanual exam. Otherwise, her pelvic exam is normal. Her UA is negative. The most appropriate next step:

A) office cystoscopy

B) potassium sensitivity test

C) pelvic floor PT

d) pentosan polysulfate
e) amitriptyline

Answer 24

C) pelvic floor PT

Painful bladder syndrome is an unpleasant sensation (pain, pressure, or discomfort) perceived to be related to the urinary bladder, associated with lower urinary tract symptoms of more than 6 weeks in duration, in the absence of infection or other identifa

Question 25

Treatment for recurrent UTI

Answer 25

Methenamine hippurate + vitamin C

Question 26

A 52-year-old woman is undergoing a midurethral retropubic synthetic sling placement for SUI. Immediately after trocar placement, gross hematuria is noted in the Foley catheter. With the use of a 70-degree lens, cystoscopy is performed and reveals bilateral perforations of the sling trocars. The passers then are removed. Repeat cystoscopy reveals ongoing brisk bleeding from the left-sided trocar site, resulting in red-colored urine. The best next step is:

(A) abandon the sling procedure

(B) replace the sling

(C) continuous bladder irrigation for 48 hours

(D) abdominal repair by cystotomy

Answer 26

(B) replace the sling

Should a trocar be seen in the bladder, the surgeon should then empty the bladder and repass the trocars.

Question 27

During a laparoscopic salpingo-oophorectomy, you use a bipolar electrosurgical energy source to secure the blood supply to the ovary within the infundibulopelvic ligament before transecting it. The correct term for the electrosurgical function you perform with the bipolar device is

(A) cauterization

(B) fulguration

(C) vaporization

(D) coagulation

Answer 27

(D) coagulation: as the tissue is heated, the collagen and elastin found in the blood vessel walls denature, formating a hemostatis coagulum.

A - cauterization: conduction of heat via direct current from a probe heated to a very high temperature (ex: branding cattle, grill lines on a steak)

B - fulguration: process of creating a superficial coagulum (dry patch of dead tissue) by applying intermittent energy to a tissue surface using a monopolar electrode without direct tissue contact (ex; rollerball attachment to stop cervical bleeding after LEEP)

C - vaporization: when electrosurgical current is applied in a very concentrated way at high voltage, the intense heat delivered to the tissue causes the fluid inside cells to vaporize and the cells to burst. A high voltage is required to push the current through the vapor. Performed on cutting mode, which delivers continuous current without direct contact with the tissue. avoids eschar or coagulum, creating a clean wound with minimal necrotic tissue at wound borders

Question 28

A 65-year-old multiparous female comes to your office with accidental bowel leakage. She reports several loose stools per day with associated leakage. She has a history of anal sphincter lacera-

tion with her first delivery 40 years ago. The intervention incontinence is

(A) overlapping anal sphincteroplasty

(B) loperamide

(C) sacral neuromodulation

(D) biofeedback
(E) posterior levatorplasty

Answer 28

(B) loperamide

The best intervention for this patient, however, is to control stool consistency and motility with the use of loperamide, an opioid receptor agonist that stimulates receptors in the myenteric plexus of the large intestine to decrease smooth muscle tone. This results in increased time for substances to stay in the intestine, allowing for more water to be absorbed out of the fecal matter. Loperamide also decreases colonic mass movements and suppresses the gastrocolic reflex. Once the patient’s stool consistency is improved, biofeedback then would be recommended for continued fecal inconti- nence management.

Question 29

A 48-year-old woman, para 1, with a symptomatic 5-cm urethral diverticulum requests surgical management. She also reports bothersome stress urinary incontinence. Office cystometry demon- strates urinary leakage with cough and Valsalva, 200 mL bladder volume, and maximum urethral closure pressure of 18 cm H2O. The best concomitant anti-incontinence procedure for this patient is

(A) periurethral bulking injection

(B) retropubic midurethral sling
(C) transobturator midurethral sling

(D) laparoscopic Burch urethropexy

(E) autologous fascial sling

Answer 29

(E) autologous fascial sling

Surgical repair of symptomatic urethral diverticula involves a multilayer closure with or without an interposition flap to avoid urethral stricture or urethro- vaginal fistula formation. In a patient with known stress urinary incontinence, an autologous sling can serve as an additional tissue layer between the repaired urethral defect and the vaginal epithelium, thus decreasing the risk of fistula formation. In the described patient, the native tissue autologous fascial sling would be the best anti-incontinence procedure for her (Fig. 35-1; see color plate). Autologous slings are prepared using the patient’s fascial tissue. Traditionally, the rectus fascia and tensor fascia lata have been used to fashion the slings.