Question deck Flashcards
Which of the following has the highest prevalence?
A) Mayer-Rokitansky-Kuster-Hauser
B) Androgen Insensitivity Syndrome
C) Gonadal agenesis
D) Transverse septum
A
Gidwani G, Falcone T. Congenital Malformations of the Female Genital Tract: Diagnosis and Management. Philadelphia (PA): Lippincott Williams & Wilkins, 1999.
Which of the following dietary modifications have been independently proven to reduce urge urinary incontinence? A) Reduction in caffeine intake to less than 150 mg/day B) Elimination of artificial sweeteners C) Elimination of spicy foods D) A and B E) None of the above
E. Although high caffeine associated with UUI no definitive evidence that reducing eliminates sx
A woman presents with significant apical vaginal prolapse. This implies likely significant loss of support from the following structure: A) Uterosacral ligaments B) Pubocervical fascia C) Prerectal fascia D) Perineal body
A
All of the following statements about the surgical treatment of posterior vaginal prolapse is true except:
A) Site-specific rectocele repair results in a lower risk of postoperative dyspareunia and decreased rates of bowel dysfunction compared to traditional posterior colporrhaphy (midline fascial plication)
B) There is no current evidence that use of synthetic or biologic graft improves outcomes compared to native tissue rectocele repairs (midline fascial plication, site specific rectocele repairs)
C) Transanal rectocele repairs result in lower cure rates than transvaginal approaches
D) Bowel symptoms such as splinting, difficulty emptying and feeling of incomplete evacuation improve or resolve in most women after rectocele repair
A
Maher CM, Feiner B, Baessler K, et al. Surgical management of pelvic organ prolapse in women: the updated summary version Cochrane review. Int Urogynecol J 2011; 22:1445-57.
Paraiso MF, Barber MD, Muir TW, et al. Rectocele repair: a randomized trial of three surgical techniques including graft augmentation. Am J Obstet Gynecol 2006; 195:1762-71.
Gustilo-Ashby AM, Paraiso MF, Jelovsek JE, et al. Bowel symptoms 1 year after surgery for prolapse: further analysis of a randomized trial of rectocele repair. Am J Obstet Gynecol 2007; 197:76 e1-5.
A 64 year-old with a history of diverticulitis undergoes a laparoscopy converted to open laparotomy for a mesh sacral colpopexy, extensive adhesiolysis with enterolysis and cystourethroscopy. The case is converted to a laparotomy due to difficulty visualizing the pelvis due to extensive dense adhesions of the small bowel to the cul-de-sac and adhesions of the rectosigmoid to the vagina and bladder. At the end of the case prior to closure of the abdomen, the best management is to:
A) Inspect the entire bowel.
B) Inspect only the areas of bowel you do not remember seeing when you packed the abdomen.
C) Inspect only the areas of bowel involved in the enterolysis.
D) There is no need to inspect the bowel if no gross spillage of bowel contents was noted intraoperatively.
A
Which of the following have never been shown to be risk factors for urinary tract infections?
A) Coitus
B) Postmenopausal status
C) Douching
D) Family history of UTIs in female relatives
E) Use of spermicides
C
A 42-year-old women presents with complaints of leaking urine daily. She states she voids every 1-2 hours, which is an increase in frequency for her and she, reports most urges to void are sudden, very strong and cannot be deferred. She will leak with any cough or sneeze and has quit playing tennis because of the staining of her clothing with urine that occurs. In addition, she gets up to void at least once every night but can go back to sleep afterwards. What is her diagnosis?
A)
Urinary incontinence, overactive bladder
B)
Mixed incontinence, overactive bladder syndrome
C)
Urge incontinence, overactive bladder
D)
Detrusor overactivity, genuine stress urinary incontinence, urinary frequency
B.
Haylen BT, de Ridder D, Freeman RM, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Int Urogynecol J 2010; 21:5-26.
The ICS/IUGA document defines mixed incontinence as combined stress and urgency incontinence complaint. (Stress incontinence: complaint of involuntary loss of urine on effort or physical exertion and Urgency incontinence: complaint of involuntary loss of urine associated with urgency.). Overactive bladder (OAB) syndrome is defined as urinary urgency, usually accompanied by frequency and nocturia, with or without urgency urinary incontinence, in the absence of urinary tract infection or other obvious pathology.
Which statement regarding fascial sling versus Burch colpopexy for the treatment of SUI is most correct?
A) Autologous fascial sling results in a higher rate of successful treatment of SUI than Burch colposuspension
B) Burch colposuspension results in a higher rate of successful treatment of SUI than autologous fascial sling
C) Postoperative voiding dysfunction has been shown more common after Burch colpopexy than fascial sling.
D) Adverse events, including urinary incontinence, have been shown more common after Burch colposuspension than fascial sling.
A
In a multicenter, randomized clinical trial comparing pubovaginal sling with autologous rectus fascia and Burch colposuspension, women in the sling group had 24-month cumulative rates of success significantly higher than those with Burch (overall 47% versus 38% (P=0.01)), (specific to SUI 66% versus 49% (P
Your patient with a history of fourth degree laceration presents to the office for a third time with complaints of flatus per vagina and intermittent vaginal discharge. You cannot find a fistula tract. Your best next step is:
A) Order a barium enema
B) Take her to the operating room for an exam under anesthesia
C) Perform episioproctotomy in the OR so as to excise the apparent fistula, then repair the perineum
D) Give her a prescription for vaginal metronidazole gel to use as needed
B
A placebo controlled randomized trial evaluating a new drug “No Leak” for overactive bladder is conducted. 300 women with overactive bladder are randomized to either placebo or No Leak and followed for 12 weeks. The primary outcome of the study is the average number of urge urinary incontinence episodes (UUI) per day recorded on a 3-day diary. An important secondary outcome is the proportion of women in each group with dry mouth.
At 12 weeks, the proportion with dry mouth in each group was: Drug No Leak- 34/100 (34%) and Placebo- 15/100 (15%), p = 0.015. Which of the following tests was most likely used to compare the proportion of women with dry mouth between the two groups?
A) Analysis of Variance (ANOVA)
B) Chi-square test
C) Student’s t test
D) Log-rank test
B
A true statement regarding urogenital fistula repair is:
A) It may be advantageous to use interpositional grafts for fistula involving the bladder neck and urethra, fistula after radiation therapy or large fistulae.
B) There is Level 1 evidence that removing the entire fistulous tract increases the success of a repair.
C) The most common complication after a urethrovaginal fistula repair is reported to be a urethral stricture
D) There is Level 1 evidence that using antibiotics perioperatively will reduce the odds of a failed gynecologic vvf repair.
E) A common approach used for urethrovaginal fistula repair is a prone, jacket-knife position
A
Wong MJ, Wong K, Rezvan A, Tate A, Bhatia NN, Yazdany T. Urogenital fistula. Female Pelvic Med Reconstr Surg 2012; 18:71-8.
Pushkar DY, Dyakov VV, Kosko JW, Kasyan GR. Management of urethrovaginal fistulas. Eur Urol 2006; 50:1000-5.
Your patient is diagnosed based on radiologic imaging as having a staghorn calculus. The chemical composition of the renal stone is most likely which of the following?
A) Calcium oxalate
B) Calcium phosphate
C) Stuvite (Magnesium ammonium phosphate)
D) Calcium bicarbonate
E) Uric acid
C
While stones composed of cystine or uric acid can grow into staghorn calculi, these calculi are most commonly composed of struvite.
AUA Clinical Guidelines
If one wanted to compare the association between preoperative Valsalva leak point pressures and post operative scores on the Pelvic Floor Distress Inventory (PFDI), which of the following what would be the most appropriate statistical test to use?
A) Pearson correlation coefficient
B) Chi square
C) Student’s t-test
D) Logistic regression
A
Question 14 of 740
A 55 year old female is planning to undergo an anal sphincteroplasty for fecal incontinence. She asks you to estimate the success rates of fecal continence. The following estimates are most accurate:
A) 11-14% in patients followed after 5 years
B) 28% in patients after a year
C) 41% of patients followed for over 40 months
D) 85% success rate 5 years after surgery
A
A true statement regarding medications used to treat urinary incontinence is:
A) At the dose required to treat SUI, the risk of stroke and severe hypertention is too high to use tricyclic antidepressants.
B) There are Level 1 studies with outcomes at one year, documenting continued success of β3 adrenergic agents.
C) 25% of patients may have nausea if they use an alpha adrenergic agonist
D) Intravesical capsaicin can cause transient pelvic pain.
E) A common side effect of an alpha adrenergic antagonist is urinary incontinence
D
Mariappan P, Alhasso A, Ballantyne Z. et al. Duloxetine, a Serotonin and noradrenaline Reuptake Inhibitor (SNRI) for the Treatment of SUI: A systematic Review. European Urology 2007: 51; 67-84. and Silva W.Andre. Pharmacologic Management of Incontinence and Voiding Dysfunction. Pelvic Medicine and Surgery 2005; 11 (1): 1.
Which of the following blood vessels are NOT part of the posterior branch of the internal iliac artery?
A) Iliolumbar B) Superior Gluteal C) Middle Rectal D) Lateral Sacral
C
Screening for asymptomatic bacteriuria is indicated in which of the following populations?
A) Premenopausal, sexually active women B) Pregnant women C) Diabetic women D) Women in long term nursing facilities E) Women with spinal cord injuries
B
The segment of the vagina most likely to develop prolapse is:
A) Anterior
B) Posterior
C) Apical
D) Uterine
A
Which of the following is true regarding the use of pelvic floor muscle therapy for the treatment of pelvic organ prolapse?
A) Objective and subjective improvements have been noted in pelvic organ prolapse findings between women performing pelvic floor muscle therapy versus those who did not
B) No subjective benefits have been noted in studies of women performing pelvic floor muscle therapy versus those who did not
C) No objective benefits have been noted in studies of women performing pelvic floor muscle therapy versus those who did not
D) Complete cure for Stage 2 pelvic organ prolapse has been noted in a randomized trial of women performing pelvic floor muscle therapy versus those who did not
E) Two stage improvement has been noted in a randomized trial of pelvic floor muscle therapy versus none for the treatment of pelvic organ prolapse
A
Culligan P. Nonsurgical management of pelvic organ prolapse. Obstet Gynecol 2012;119:852-860
According to the 2010 American Urologic Associate Guidelines, all of the following are acceptable treatment regimens for acute pyelonephritis, EXCEPT:
A) Amoxicillin 500mg three times daily for 14 days with initial dose of 3gm fosfomycin
B) Oral ciprofloxacin 500mg twice daily, for 7 days with initial 400mg dose of intravenous ciprofloxacin
C) Oral ciprofloxacin 500mg twice daily, for 7 days without initial 400mg dose of intravenous ciprofloxacin
D) Oral levofloxacin 750mg daily for 5 days
A
A patient with severe urgency and urgency urinary incontinence presents for urodynamic evaluation. A pressure catheter is placed in the bladder and in the vagina and both are zeroed to atmospheric pressure. At the start of infusion, the Pves pressure is 20 cm H2O. At a maximum cystometric capacity of 600mL, the Pves pressure is 60 cm H2O. There is no change in the Pabd pressure. Which of the following statements is correct?
A) The calculated compliance is 15
B) The calculated compliance is 10
C) There is not enough information to calculate compliance
D) The calculated compliance is 30
A
The compliance is calculated by dividing the change in volume over the change in bladder pressure. No the change in bladder pressure should not include pressure recordings that are taken during a detrusor contraction.
A recent study reported outcomes on the rate of progression and regression of symptomatic pelvic organ prolapse in subjects who declined surgical and non-surgical intervention electing observation. In this study all of the following were observed except:
A) The majority of patients were stages 2 and 3
B) The median follow-up time was 16 months and nearly 80% of patients demonstrated no change in leading edge
C) On multivariate analysis, change in leading edge was seen to be independently associated with age
D) 19% of patients demonstrated ≥ 2 cm increase in leading edge
E) 38% of subjects desired the use of a pessary or surgical correction at their last recorded visit
C
Gilchrist AS, Campbell W, Steele H, Brazell H, Foote J, Swift S. Outcomes of observation as therapy for pelvic organ prolapse: A study in the natural history of pelvic organ prolapse. Neurourol Urodyn 2012;doi 10.1002/nau
Which of the following anatomic structures does not significantly contribute to urethral closure pressure in women?
A) Waldeyer’s sheath
B) Longitudinal smooth muscle
C) Circular smooth muscle
D) Striated muscle
E) Vascular submucosal layer
A
Waldeyer’s sheath is a fibromuscular layer surrounding the intravesical portion of the ureter. It is contiguous with the deep muscular layer of the trigone of the bladder. The urethra consists of the following layers: an outer layer of striated muscle, an outer circular smooth muscle layer, an inner longitudinal smooth muscle layer, a vascular submucosa, and a hormonally sensitive mucosa. The striated muscles, smooth muscles, vascular submucosa and mucosa all contribute to urethral closure pressure.
McBride, Li, Gutman (J Pelvic Med Surg 2003; 9:103-123)
Next
Estrogen receptors are found on all of the following except:
A) Trigone
B) Proximal urethra
C) Distal urethra
D) Transitional epithelium
D
Andersson KW, & Wein AJ, Pharmacol Rev, 2004; 56, 581-631
In your institution 3 out of 100 patients sustained a mesh erosion after sacrocolpopexy. Out of the 100 patients, 15 were smokers and 40 underwent concomitant hysterectomy. You hypothesize that smoking and concomitant hysterectomy might be risk factors for mesh erosion. Which is the most appropriate approach to investigate this hypothesis?
A) Case-control study comparing those who had hysterectomy vs. those who did not
B) Case-control study comparing those who smoked vs. those who did not
C) Randomized trial of those undergoing mesh sacrocolpopexy where subjects are randomized to smoking or non-smoking arms
D) Case-control study comparing those with mesh erosion to matched subjects without mesh erosion
D
A case-control study is used to examine risk factors for a rare outcome (ie: outcome that occurs in . The two comparison groups are chosed based on the OUTCOME of interest (ie: mesh erosion) and you compare the proportions of subjects who had various exposures (ie: smoking or hysterectomy). In answers a and b, the two groups are chosen based on exposures, which is not appropriate for a case-control study. A randomized trial would require a large amount of resources in order to examine a rare outcome; in addition it would not be ethical to randomize patients to smoking vs non-smoking groups; thus answer c is not correct. Answer d is the correct answer. A case-control study is appropriate and the two groups are chosen based on the outcome of interest (mesh erosion).
Strauss et al. Evidence-Based Medicine: How to Practice and Teach EBM, 3rd ed, pgs 180-183
Which structure has the largest contribution to anal continence?
A) Internal anal sphincter
B) External anal sphincter
C) Puborectalis muscle
D) Pubococcygeus muscle
A
The anal sphincter complex includes the internal anal sphincter (IAS), the external anal sphincter (EAS), and the puborectalis muscle (PR). The smooth muscle of the IAS is innervated by the autonomic nervous system and is responsible for over half of the resting tone of the sphincter. The striated muscle of the EAS is innervated by the pudendal nerve and is responsible for approximately one third of the resting tone of the sphincter. The PR and levator ani musculature also contribute to resting tone but the largest contribution comes from the IAS.
Walters and Karram; Urogynecology and Reconstructive Pelvic Surgery, 3rd ed., Chapter 24
What is the optimal empiric treatment of acute uncomplicated cystitis?
A) Ciprofloxacin 500 mg twice daily for 3 days
B) Amoxicillin-clavulanate 500 mg/125 mg twice daily for 7 days
C) Cephalexin 500 mg twice daily for 7 days
D) Nitrofurantoin monohydrate/macrocrystals 100 mg twice daily for 5 days
D
Twice daily nitrofurantoin for 5 days is the optimal treatment for acute uncomplicated cystitis based on the 2010 AUA-IDSA UTI Rx Guidelines. Fluoroquinolones are highly efficacious in 3 day regimens but have a propensity for collateral damage and should be reserved for important uses other than acute cystitis. B-Lactam agents, like amoxicillin-clavulanate, in 3-7 day regimens are appropriate choices when other agents cannot be used. Other B-lactams, like cephalexin, are less well studied but may be appropriate in certain settings. B-lactams generally have inferior efficacy and more adverse effects compared to other UTI antimicrobials.
Kalpana Gupta, Thomas M. Hooton, Kurt G. Naber, Bjo ̈rn Wullt, Richard Colgan, Loren G. Miller, Gregory J. Moran, Lindsay E. Nicolle, Raul Raz, Anthony J. Schaeffer, and David E. Soper. International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clinical Practice Guidelines; CID 2011:52, e117.
The differential diagnosis of urethral diverticulum in the setting of a normal IVP includes all of the following except:
A) Skene’s gland cyst
B) Ectopic ureterocele
C) Urethral carcinoma
D) A and C
E) Cystocele
B is the only upper urinary tract abnormality
Scarpero HM, Urol Clin North Am 2011 Feb 38(1) 65-71
Each of the following urodynamic tests require a pressure catheter in the bladder except:
A) Single channel cystometrogram
B) Multi-channel cystometrogram
C) Uroflowmetry
D) Pressure-Flow study
C
Posterior repair with mesh augmentation:
A) Improves both anatomic and symptomatic outcomes
B) Improves anatomic outcomes but does not have a symptomatic benefit
C) Does not have anatomic or symptomatic benefit
D) Has not been studied in randomized trials, so no conclusions can be drawn
C
DA Executive Summary: Surgical Mesh for Treatment of Women WIth Pelvic Organ Prolapse and Stress Urinary Incontinence. Sept 8-9.2011:Accessed April 7, 2013 at http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/MedicalDevices/MedicalDevicesAdvisoryCommittee/ObstetricsandGynecologyDevices/UCM270402.pdf
How much retraction or shrinkage can be expected in 2-dimensional sheet of Amid type I mesh over the first year after implantation:
A) None - retraction is a phenomenon of type II mesh
B) 10%
C) 20%
D) 40%
C
Amid PK, Classification of biomaterials and their related complications in abdominal wall hernia surgery. Hernia 1997; 1: 15-21.
The resting tone of the anus is a result of:
A) External anal sphincter resting tone
B) Internal anal sphincter resting tone
C) Pubococcygeus muscle resting tone
D) Resting tone of both the external and internal anal sphincters
B
Hayden DM, Weiss EG. Fecal incontinence: etiology, evaluation, and treatment. Clinics in colon and rectal surgery. Mar 2011;24(1):64-70
continence tICo. Incontinence. 4 ed. Paris, France: EDITIONS21; 2009
You finish a difficult pelvic floor abdominal surgery that required over an hour of lysis of adhesions involving the small intestines the large intestines, vagina and bladder. You are concerned that there may have been an injury to the colon. What is the most appropriate next step?
A) Palpate the distal rectum and confirm that the bowel wall is intact.
B) Follow the patient closely postoperatively keeping her on a clear liquid diet until she passes flatus
C) Fill the abdomen and pelvis with saline, compress the descending colon and fill the rectum with air to confirm the absence of air bubbles
D) Order an intraoperative colonoscopy.
C
Cholinergic transmission is localized to:
A) Bladder only
B) Trigone only
C) Urethra only
D) External urethral sphincter only
E) Both bladder and external urethral sphincter
E
Fowler CJ, Griffiths D, de Groat WC. The neural control of micturition. Nat Rev Neurosci 2008; 9:453-66.
A 17 year old presents with primary amenorrhea. Breast development was normal. Exam reveals a foreshortened vagina measuring 1cm. To differentiate Mullerian agenesis from Androgen Insensitivity Syndrome and other congenital anomalies, the following work-up is appropriate:
A) MRI, karyotype, and testosterone levels
B) Diagnostic laparoscopy
C) MRI, FSH and LH
D) Retrograde pyelogram and cystoscopy
E) Karyotype
A
Gidwani G, Falcone T. Congenital Malformations of the Female Genital Tract: Diagnosis and Management. Philadelphia (PA): Lippincott Williams & Wilkins, 1999.
A Gartner’s duct cyst is a vestigial remnant of the:
A) Urogenital sinus
B) Paramesonephric duct
C) Mesonephric duct
D) Metanephric duct
E) Sinovaginal bulbs
C
Carlson BM. Human Embryology and Developmental Biology, 4th Ed. Philadelphia (PA): Mosby, Inc., 2009.
The most common presenting symptom of urethral diverticulum is:
A) Discharge per urethra or vagina
B) Dyspareunia
C) Recurrent urinary tract infections
D) Frequency/urgency
D
Frequency/urgency is the most common reported symptom.
Handel LN, Current Urol Rep 2008, 9:383-388
Which of the following statements are true about magnetic resonance imaging?
A) T2 weighted films show fat as white
B) Suspect urethral diverticula show up as white due to spin characteristics of adjacent fat
C) T1 weighted images show urine or fluid media as bright white
D) None of the above
D
Gousse AE, Barbaric ZL, Safir MH, Madjar S, Marumoto AK, Raz S. Dynamic half Fourier acquisition, single shot turbo spin-echo magnetic resonance imaging for evaluating the female pelvis. J Urol 2000; 164:1606-13.
Blander DS, Rovner ES, Schnall MD, Ramchandani P, Banner MP, Broderick GA, Wein AJ. Endoluminal magnetic resonance imaging in the evaluation of urethral diverticula in women. Urology 2001; 57:660-5.
In a patient who has uncontrolled narrow angle glaucoma and severe UUI, the best option would be:
A) Transdermal oxybutynin
B) A β3 adrenergic agonist
C) A selective norephinephrine and serotonin uptake inhibitor
D) An alpha adrenergic agonist
E) A tricyclic antidepressant
b
Gormley EA, Lightner DJ, Burgio KL. Diagnosis and Treatment of OAB (non neurogenic) in adults: AUA /SUFU Guideline. American Urological Association Education and Research, Inc. 2012
and Rios L A, Panhoca R, Mattos D et al. Intravesical Resiniferatoxin for the Treatment of Women with Idiopathic Detrusor Overactivity and urgency Incontinence: A Single Dose, 4 weeks, Double-Blind Randomized Placebo Controlled Trial. Neurourol and Urodynamics 2007: 26; 773-778.
A 47 year old patient with a Stage III anterior pelvic organ prolapse and urodynamic stress incontinence undergoes an uncomplicated anterior repair with mesh augmentation and a transobturator midurethral sling. Postoperatively she trips when beginning to ambulate and is diagnosed with foot drop. Which of the following nerves is most likely to have been injured?
A) Common peroneal nerve
B) Obturator nerve
C) Pudendal nerve
D) Femoral nerve
A
McBride AW, et al. Journal of Pelvic Medicine and Surgery. Volume 9, Number 3, May/June 2003
Which medication is may interact with anti-cholinergics?
A) acetominophen B) tricyclic anti-depressants C) docusate D) senna
B
Gormley EA, Lightner DJ, et al. Diagnosis and Treatment of Overactive Bladder (Non-Neurogenic_ in Adults: AUA/SUFU Guideline. J urol 2012;188:2455-2463.
A 21 year old nulliparous woman is referred to your office for “continuous leakage of urine in her vagina.” Her medical and surgical history are unremarkable. Her work up included a negative tampon test. Office cystoscopy reveals a single left ureteral orifice. Based on these findings, you suspect the patient has which of the following conditions.
A) Vesicovaginal fistula
B) Ectopic ureter
C) Horseshoe kidney
D) Duplicated urinary system
B
Common complications of vaginal pessary use include all of the following except:
A) Vaginal epithelial bleeding
B) Abnormal discharge
C) Urinary incontinence
D) Urinary retention
E) Rectal bleeding
E
Atnip SD. Pessary use and management of pelvic organ prolapse. Obstet Gynecol Clin N Am 2009;36:541-563
Which of the following does not represent one of the possible goals of pelvic floor physical therapy for the treatment of urinary incontinence?
A) Increase strength
B) Increased endurance
C) Coordinate muscle activity
D) Decrease hypermobility of bladder neck
D
Hay-smith J. Cochrane Database of Systematic Reviews 2008, Issue 4.
Choose the most accurate statement regarding surgical repair of posterior vaginal wall prolapse.
A) There are more posterior wall prolapse recurrences with posterior colporrhaphy alone compared to posterior colporrhaphy with a polyglactin mesh
B) Synthetic mesh augmentation for posterior colporrhaphy results in improved anatomic outcomes, but with a higher risk of complications
C) There is no benefit with synthetic or biologic graft.
D) There are more posterior wall prolapse recurrences with posterior colporrhaphy alone compared to posterior colporrhaphy with a biologic graft
C
In 2011 the FDA published an executive summary of data which stated that biologic or synthetic grafts do not improve outcomes for posterior vaginal wall prolapse. This is based on the following 3 RCTs: 1. Paraiso et al. compared posterior colporrhaphy, site-specific repair, and site-specific repair with biologic graft. In this study the group with biologic graft had worse anatomic outcomes compared to the other 2 groups. 2. Sand et al compared anterior and posterior repair with vs without polyglactin mesh reinforcement. In this study there were no differences in rectocele recurrence between groups. 3. Carey et al. compared anterior and posterior repairs with synthetic mesh to traditional anterior and posterior colporrhaphies. There were no differences in prolapse recurrence, including the posterior vaginal wall, between mesh and no mesh groups.
Paraiso et al. Am J Obstet Gynecol. 2006 Dec;195(6):1762-71. 2. Sand et al. Am J Obstet Gynecol. 2001 Jun;184(7):1357-62; discussion 1362-4. 3. Carey et al. BJOG. 2009 Sep;116(10):1380-6.
Weakening of the levator musculature results in:
A) No difference in the horizontal orientation of the upper vagina
B) Loss of the horizontal orientation of the upper vagina
C) Closure of the genital hiatus
D) No difference in the genital hiatus
B
Levator tone involves the puborectalis muscle, which forms a sling around the vagina and rectum, and helps to maintain a horizontal axis of the upper vagina. Levator tone also helps to maintain closure of the genital hiatus. Weakening of the levator musculature results in loss of the horizontal orientation of the levator plate and enlargement of the genital hiatus.
Siddique S. 2003; J Pelvic Med Surg 9(6): 263-272
What is the recommended daily dietary fiber intake to prevent or treat constipation?
A) 5 - 15 gm
B) 15 - 20 gm
C) 20 - 35 gm
D) 35 -50 gm
E) >50 gm
C
All of the statements about obesity and pelvic floor surgery are true except:
A)
There is a higher rate of surgical site infection in patients who are obese vs. non-obese
B)
Obese patients have increased blood loss
C)
Vaginal hysterectomy results in higher infection rates
D)
There are higher operative times in obese patients
C
Rogers, RG, Lebkuchner, U, Kammerer-Doak, DN, Thompson, PK, Walters, MD, and Nygaard, IE: Obesity and retropubic surgery for stress incontinence: Is there really an increased risk of intraoperative complications? Am J Obstet Gynecol 2006; 195: 1794-8. Handa, VL, Harvey, L, Cundiff, GW, and Kjerulff, KH: Perioperative
Complications of Surgery For Genital Prolapse: Does Concomitant Anti-Incontinence Surgery Increase Complications? Adult Urology 2004;65:483-487. Chen, CCG, Collins, SA, Rodgers, AK, Paraiso, MFR, Walters, MD, and Barber, MD: Perioperative complications in obese women vs normal-weight women who undergo vaginal surgery. Am J Obstet Gynecol 2007; 197: 98.e1-98.e8.
What is the mean distance from TVT trocar to the major vessels when the trocar is directed toward the ipsilateral shoulder and directly behind the pubic bone?
A) 3.2 to 4.9 cm
B) 0.5 to 1.1 cm
C) 7.8 to 9.0 cm
D) 10.2 to 11.7 cm
A
In a cadaveric study of TVT trocar placement, the mean distance from the trocar to obturator vessels was 3.2 cm (range 1.6-4.3 cm), to the superficial epigastric vessels was 3.9 cm (range 0.9-6.70, to the inferior epigastric vessels was 3.9 cm (range 1.9-6.6 cm) and to the external iliac vessels was 4.9 cm (range 2.9-6.2 cm).
Muir TW, Tulikangas PK, Fidela Paraiso M and Walters MD: The relationship of tension-free vaginal tape insertion and the vascular anatomy. Obstet Gynecol 2003; 101: 933.
Well established major risk factors for development of pelvic organ prolapse include all of the following except:
A) Older age
B) Vaginal parity
C) Diabetes
D) Obesity
E) Prior Hysterectomy
C
Jelovsek JE, Maher C, Barber MD. Pelvic Organ Prolpase. Lancet 2007; 369:1027-38.
A 61 year old undergoing midurethral sling is considered at what risk level for Venous Thromboembolism?
A) Low Risk
B) Modrate Risk
C) High Risk
D) Highest Risk
C
Over 60 years of age with surgery less than 30 min OR major surgery in >40 year old is considered high risk.
ACOG practice bulletin #84, Aug 2007 Table 1
A 84 year old with urge urinary incontinence has failed several anticholinergic medications. She has rheumatoid arthritis with limited dexterity, but still ives independently. Which is the next best option for management?
A) Interstim sacral neuromodulation trial with staged implantation if successful
B) Botox injection 100 units intradetrusor
C) Percutaneous tibial nerve stimulation
D) Increase dose of oxybutinin to 15 then 30 mg daily as tolerated
E) Placement of indwelling foley catheter
C
Interstim may not be appropriate next line therapy given her age and limited ability to manage the programmer, patients undergoing botox injections should have ability to perform self catheterization. High dose oxybutinin may impair memory in this pateint and indwelling catheters are not recommended. Thus PTNS is likely the next best option of these.
Gormley EA, Lightner DJ, Burgio KL, et al. Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline. The Journal of urology 2012;188:2455-63.
A 69 year-old woman with uterovaginal prolapse comes to your office for a preoperative evaluation prior to her scheduled robotic assisted laparoscopic supracervical hysterectomy, mesh sacral colpopexy and cystoscopy. The procedure is scheduled for two weeks from today. She had previously been using a pessary for about a year but has decided to proceed with surgery. She has a medical history of hypertension and coronary artery disease. In your review of her medical and surgical history she reveals that since her last visit with you one month ago, she underwent a coronary revascularization procedure with placement of a drug-eluting stent and has been taking clopidogrel and aspirin since the procedure. In addition to consultation with her cardiologist, what is the best option for timing her surgical procedure?
A) Reschedule her surgery in one month. At the time of surgery, stop the clopidogrel one week prior to surgery and restart on postoperative day 1 but continue the aspirin perioperatively.
B) Reschedule her surgery in one year. At the time of surgery, stop the clopidogrel one week prior to surgery and restart on postoperative day 1 but continue the aspirin perioperatively.
C) Reschedule her surgery in one year. At the time of surgery, stop both clopidogrel and aspirin for one week prior to surgery and restart postoperatively.
D) Proceed with surgery as planned in two weeks and stop both clopidogrel and aspirin for one week prior to surgery and restart postoperatively.
E) Proceed with surgery as planned in two weeks and stop the clopidogrel one week prior to surgery and restart on postoperative day 1 but continue the aspirin perioperatively.
B
The American College of Cardiology-American Heart Association guidelines recommend in order to minimize risk of cardiac stent thrombosis, that elective noncardiac surgery be postponed until appropriate antiplatelet therapy has been given. This is 1 month for bare metal stents and 12 months for drug-eluting stents, as long as the patient is not at a high risk of bleeding. Further recommendations include the peri-operative continuation of aspirin if a patient with a cardiac stent undergoes a procedure during which the thienopyridine therapy needs to be discontinued.
Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Anesth Analg. 2008;106:685-712
The oldest urogynecologic procedure to utilize synthetic mesh is:
A) Midurethral sling
B) Transvaginal anterior repair
C) abdominal sacrocolpopexy
D) transvaginal apical suspension
E) transvaginal posterior repair
C
Urogynecologic Surgical Mesh: Update on the Safety and Effectiveness of Transvaginal Placement for Pelvic Organ Prolapse. FDA Safety Communication2011:Accessed April 6, 2013 at http://www.fda.gov/downloads/MedicalDevices/Safety/AlertsandNotices/UCM262760.pdf.
All of the following are proposed theories regarding the etiology of interstitial cystitis/painful bladder syndrome except.
A) Mast cell degranulation
B) Autoimmune phenomenon
C) Glycosaminoglycan deficiency
D) Infectious bacteria
E) Food borne allergen
E
Quilin RB, Erikson, DR. Management of interstitial cystitis/BPS: A urological perspective. Urol Cl N Amer 2012; 39:389-96.
A true statement regarding the pathophysiology of neurologic conditions affecting the lower urinary tract is:
A) Patients who have a neurologic injury above the level of the brainstem usually present with an acontracile bladder
B) Spinal cord lesions between the pontine micturition center and S2 are at greater risk for detrusor areflexia
C) Lesions affecting the pelvic plexus can have effect on both parasympathetically and sympathetically innervated functions
D) Most spinal cord lesions are complete and have very predictable neurologic sequela
E) Urodynamics is of little value in determining management
C
Although the pelvic plexus is primarily parasympathetic, interconnections with the sympathetics and therefore its function is also altered.
Amis ES and Blaivas JG. Neurogenic Bladder Simplified. In: Radiologic Clinics of North America 1991; 29 (3): 571-580.
What percentage of UTI’s are caused by bladder instrumentation?
A) 10%
B) 80%
C) 50 %
D) 70%
B
Lo, E, Nocolle, L, Classen, D et. al: Strategies to Prevent Catheter-Associated
Urinary Tract Infections in Acute Care Hospitals. Infect Cont Hosp EP 2008; 29: S41-S50.
Which of the following is a benefit of the uterosacral ligament suspension compared to other vaginal native tissue apical repairs for prolapse?
A) It is less likely to result with de novo stress incontinence
B) It has fewer complications than other vaginal native tissue repairs
C) The anterior vaginal wall is the least likely area to recur with this procedure
D) It does not distort the vaginal axis
D
Any type of anterior/apical prolapse repair could result in de novo stress incontinence. Thus it is not necessarily less likely with USLS than other procedures. USLS has different types of potential complications than other procedures, but is not reported to have fewer complications. With USLS there is up to 11% risk of ureteral injury, up to 7% risk of nerve injury, amongst other risks. The SSLF has a higher risk of bleeding complications due to close proximity of the pudendal and inferior gluteal vessels. There are also risks of pudendal nerve injury. The ilieococcygeus suspension may result in bleeding with up to a 2% risk of blood transfusion. There are risks of buttock pain, thought to be related to ischemia or necrosis of muscular tissue. In addition, the iliococcygeus suspension results in a shorter vaginal length and thus may not be preferable for all patients. With USLS, the anterior vaginal wall is the most likely area to recur (more likely than the apex). USLS does not distort the vaginal axis and therefore is a benefit to this procedure.
Muir TW; J Pelvic Med Surg 2006; 12: 289-305 2. Margulies et al; Am J Obstet Gynecol. 2010 Feb;202(2):124-34
A true statement regarding multiple sclerosis is:
A) MRI lesions will correlate well with urodynamics findings
B) Symptomatology may change over time
C) The most likely finding on urodynamic study is detrusor overactivity with sphincter dyssynergia
D) The disease is a consequence of cell loss in the cerebrum
E) The most likely symptom would be stress urinary incontinence
B
The pathologic hallmark of MS are zones of focal inflammatory demyelination or plaques in the white matter of the brain and spinal cord. Lesions can occur at a variety of locations changing lower urinary tract functioning and thus symptomatology.
Leboeuf L and Gousse A. Multiple sclerosis. In: Corcos J and Schick E eds. Textbook of the Neurogenic Bladder. London and New York. Martin Dunitz Ltd; 2004: 275-291.
Which of the following will NOT help to prevent catheter-associated urinary tract infections in hospitalized patients?
A) Use of a silver alloy catheter in hospitalized patients
B) Removal of the catheter on postoperative day 1
C) Ensuring that the catheter system remains an open system
D) Avoiding unnecessary catheterization
E) All of the above will help to prevent catheter-associated urinary tract infections
C
Warren JW. Catheter-associated urinary tract infections. Int J Antimicrob Agents 2001;17(4):299-303
All of the following are support ligaments of the uterus EXCEPT:
A) Uterosacral ligament
B) Sacrospinous ligament
C) Round ligament
D) Cardinal ligament
B
Grays Anatomy
A 59 year female presents with complaints of SUI and normal pelvic organ support. After urodynamic testing with the transurethral catheter in place, no urodynamic stress incontinence (USI) is demonstrated. The recommended next step is?
A) Trial of anticholinergic therapy to rule out urge incontinence as a case of her urinary incontinence
B) Remove the catheter and repeat the stress testing
C) Schedule a follow up in 6 months and recommend observation
D) Schedule a midurethral sling given the patient’s symptoms of SUI.
B
Clinicians should perform repeat stress testing with the urethral catheter removed in patients suspected of having SUI who do not demonstrate this finding with the catheter in place during urodynamic testing. (Recommendation; Evidence Strength: Grade C)
AUA Guidelines - Adult Urodynamics
You note a new difficulty cystoscoping a patient immediately after passing midurethral mesh sling trocars and see a trocar in the urethral space. Of the following, the best choice is:
A) Remove the trocar, place a suprapubic catheter but not a foley catheter, and not place the sling
B) Leave the trocar in place to guide your repair and cut down on the trocar transvaginally to fix the urethrotomy, then place the sling
C) Remove the trocar, and proceed with completing the sling, and give an extra dose of antibiotics
D) Remove the trocar, confirm hemostasis, leave a foley catheter, and not place the sling
D
The principal nerve supply to the anorectum region is through the:
A) Perineal nerve
B) Pudendal nerve
C) Distal rectal nerve
D) External anal nerve
B
Rao S Diagnosis and Management of Fecal Incontinence. Am J Gastro 2004 Practice Guideline Aug. 1585-1603.
A 69-year-old female presents with the complaint that she has a vaginal bulge that can be felt during wiping and washing. On physical exam she has the following findings. What is her diagnosis?
Aa +1, Ba+1, C-3
Gh 3, Pb 4, Tvl 9
Ap -2, Bp-2, C-8
A) Stage III pelvic organ prolapse
B) Stage II pelvic organ prolapse
C) Stage III POPQ exam
D) Stage II cystocele
E) Stage III cystocele
B
Swift SE, Barber MD. Pelvic organ prolapse: defining the disease. Fem Pelv Med Reconstr Surg 2010; 16: 201-203.
Haylen BT, de Ridder D, Freeman RM, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Int Urogynecol J 2010; 21:5-26.
Bump RC, Mattiasson A, Bø K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 1996; 175:10-7.
A bulge that is symptomatic and protrudes beyond the hymen is a good definition for pelvic organ prolapse and has been suggested by the ICS/IUGA terminology document. The exam reveals a Stage II prolpase. The current POPQ document specifically states that terms such as cystocele, rectocele and enterocele not be used and only the stage be reported.
65 year old female with history of retropubic urethropexy 10 years prior presents with persistent urgency incontinence, frequency and sensation of incomplete emptying. On examination she has urethral mobility from -5 to 0 degrees, no prolapse, post void residual of 175 mL and a negative urine analysis. She has been on two different anticholinergic medications in the past with little improvement in symptoms. Which is the next best step in the evaluation and treatment of this patient?
A) Urodynamic testing with voiding cystometrogram to assess detrusor activity during filling and rule out obstructive voiding as source of her symptoms.
B) Trial of sacral neuromodulation with staged implant if > 50% success in urinary symptoms and/or voiding dysfunction
C) Percutaneous tibial nerve stimulation once a week for 30 minutes over 12 week therapy
D) Injection of botulinum toxin A 100 Units with repeat injection in 2 weeks if unsuccessful
E) None of the above
A
Given her history of surgery and elevated residual, there should be a high suspicion for obstruction. Neuromodulation is contraindicated for patients with obstuction. PTNS is not approved for retention and botox will not improve voiding dlysfunction.
The image to the left demonstrates a large anomolous vessel found at time of robotic sacrocolpopexy, measuring nearly 10 mm located over the area of dissection.. The best approach to expose the site for suture placement and prevent bleeding from this vessel is.
A) Use the plasma kinetic advanced bipolar system to cauterize the vessel prior to transection with monopolar scissors
B) Use the ultrasonic harmonic scalpel to seal and transect the vessel
C) Use monopolar electrocautery to coagulate the vessel then transect with scissors to expose the ligament
D) Identify alternate location for placement of sutures or consider aborting or converting to open to isolate and ligate the vessel prior to transection.
D
Advanced bipolar systems and ultrasound seal 7 mm and 5 mm vessels respectively. Thus a 1 cm vessel is too large for currently available devices. Traditional bipolar seals 2 to 6 mm, monoplar does not have vessel sealing capability
Alkatout I, Schollmeyer T, Hawaldar NA, Sharma N, Mettler L. Principles and safety measures of electrosurgery in laparoscopy. JSLS : Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons 2012;16:130-9.
Next
Which one of these statements describes a type II error?
A) Occurs if an investigator rejects a null hypothesis that is actually true in the population
B) Occurs if the investigator fails to reject a null hypothesis that is actually not true
C) Is not decreased with increasing sample size
D) Is a false positive error
B
Source: Browner WS, Newman TB, and Hulley SB (2007). Getting Ready to Estimate Sample Size: Hypothesis and Underlying Principles in S.B. Hulley, S.R. Cummings,W.S. Browner, D. G. Grady, T.B. Newman (Eds.), Designing Clinical Research (pp.55-56). Philadelphia, PA: Lippincott, Williams & Wilkins.
In a normally distributed sample, what percent of the total population lies within ± 2 Standard Deviations (SD) of the mean?
A) 0.05
B) 0.95
C) 0.68
D) 0.32
B
All of the following are true about the success rates and perioperative complications associated with anal sphincteroplasty except:
A) Postoperative pain & wound healing issues are common after the procedure.
B) Good to excellent results in 66% of patients in the short-term but long-term deterioration with as low as 6% at 10 years post-op.
C) Bowel prep or enema should be performed during the preoperative period
D) Overlapping technique has better outcomes than the end-to-end technique
D
Abrams P, Cardozo L , Khoury S, Wein A. Incontinence. Committee 17 Surgery for Faecal Incontinence. Paris. Health Publication Ltd. 2009. pgs 1387-1417.
According to the 2011 American Urological Association Guidelines, all of the following should be considered as first line treatments for treatment of interstitial cystitis/painful bladder syndrome, EXCEPT:
A)
Education about normal bladder function and possible need for combination therapy to achieve symptom improvement
B)
Implementation of self-care practices and behavioral modifications that can improve symptoms
C)
Initiation of oral medications, such as amitriptyline, cimetidine, hydroxyzine or pentosan polysulfate
D)
Implementation of stress management practices to improve coping techniques and management of stress-induced symptom exacerbations
C
A 68 year old female with history of abdominosacrocolpopexy 10 years prior presents with new onset rectal bleeding. She had a normal colonoscopy 4 years prior. Which of the following is the best office procedure for the workup of her complaint.
A) Anoscopy
B) Colonoscopy
C) Cystoscopy
D) Procto-sigmoidoscopy
E) All of the above
D
Anoscopy will likely not identify an erosion at the apex of the vaginal are, colonoscopywas normal 4 years ago and is not an office procedure and requires sedation, cystoscopy will not assess rectal bleeding and thus Proctosigmoidoscopy is the best diagnostic procedure to evaluate her complaints.
After a high uterosacral ligament suspension, your patient complains of buttock/posterior thigh pain and numbness of the inferior vulva and. Which nerve is most likely to be involved?
A) Pudendal nerve as it exits Alcock’s canal
B) Obturator nerve as it enters the obturator canal
C) Sacral nerve roots as they combine to from the sciatic nerve
D) The superior hypogastric plexus near the ganglion
C
The pudendal nerve exits Alcock’s canal near the ischial tuberosity; this location is not likely to be involved in high USLS. The obturator nerve enters the obturator canal to travel through the obturator foramen, which is also not likely to be injured in high USLS. The sacral nerve roots exit their respective foramina, then combine with L5 nerve roots to form the lumbosacral trunk. The lumbosacral trunk gives rise to the sciatic nerve. A deep USLS stitch could encircle or compress the sacral nerve roots or portions of the lumbosacral trunk. The superior hypogastric plexus and ganglia exist in the presacral space and are unlikely to be involved in high USLS.
McBride, Li, Gutman (J Pelvic Med Surg 2003; 9:103-123) & Siddiqui et al. (Obstet Gynecol 2010; 116: 708-13)
A 35 year old woman with a remote history of two prior cesarean deliveries presents with 2 months of pain in the distal vagina, extending inferiorly towards the buttocks. She is unable to achieve comfortable vaginal intercourse. On examination you appreciate a punctate lesion on the perineum that appears like granulation tissue; palpation of this area reproduces the patient’s pain. Which of the following is least important in her evaluation?
A) Rectal exam
B) Anoscopy
C) Endoanal ultrasonography
D) Colonoscopy
C
The patient described above likely has a fistula in ano, resulting from a crytoglandular abscess. This type of abscess typically originates on the anterior aspect of the anal canal. Extension of the abscess into the vaginal wall can result in fistula formation. Rectal exam may result in fluid or material extruding from the punctate lesion. Rectal exam may also identify a painful mass consistent with an abscess. Anoscopy can be helpful in delineating the extent of involvement of the rectum and evaluating for co-existing anorectal disease. Colonscopy is also useful to further assess for inflammatory bowel disorders and other infectious processes. Endoanal ultrasonography is most useful in the evaluation of post-obstetric rectovaginal fistulae. In this patient with 2 prior cesarean deliveries that are remote from the onset of symptoms, an obstetric fistula is not likely and thus US would be the least helpful component of the evaluation.
Walters and Karram; Urogynecology and Reconstructive Pelvic Surgery, 3rd ed., Chapter 26
Which of the following statements is true about the power of the study?
A) Power is equal to Type I error
B) Power is equal to 1-β error
C) Power is equal to the Type II error
D) Power is equal to 1-α error
B
The most common urodynamic finding in a patient with normal pressure hydrocephalus is:
A) Detrusor sphincter dyssynergia
B) Impaired detrusor compliance
C) Detrusor overactivity
D) Detrusor overactivity and detrusor sphincter dyssynergia
E) Detrusor areflexia and impaired compliance
C
Sakakibara R, Kanda T, Sekido T, et al, Mechanism of Bladder Dysfunction In Idiopathic Normal Pressure Hydrocephalus, Neurourology and Urodynamics 2008, Volume 27, Issue 6, pages 507-510.
Compared with anterior colporrhaphy (native tissue repair), the use of transvaginal polypropylene mesh to treat anterior vaginal prolapse is associated with:
A) A lower risk of reoperation for pelvic organ prolapse
B) A greater improvement in quality of life
C) No improvement in anatomic outcomes of the anterior vaginal segment
D) A lower risk of postoperative prolapse in the apical and posterior segment
E) A 10% mesh exposure rate
E
Maher CM, Feiner B, Baessler K, et al. Surgical management of pelvic organ prolapse in women: the updated summary version Cochrane review. Int Urogynecol J 2011; 22:1445-57.
Which type of hysterectomy has the LOWEST RATE of resulting vesico-vaginal fistula (1 in 5636 cases)?
A) LAVH
B) Vaginal hysterectomy
C) Abdominal hysterectomy
D) Laparoscopic hysterectomy
E) Robotic hysterectomy
Next
B
Härkki-Sirén P, Sjöberg J, Tiitinen A. Urinary tract injuries after hysterectomy. Obstet Gynecol 1998; 92:113-8.
A 57-year-old female is undergoing uterosacral vaginal vault suspension at time of vaginal hysterectomy. Upon cystoscopy, no efflux from the right ureter is noted after administration of intravenous indigo carmine dye. All of the following are appropriate next steps except?
A) Change table position out of steep Trendelenberg
B) Check medical record and examine flank for history of kidney surgery (e.g. nephrectomy)
C) Immediate ureteral stent placement
D) Remove ipsilateral vaginal vault suspension sutures
E) All of the above
C
Kim J, Moore CM, Goldman HG, Jones JS, Daneshgari F, Rackley RR, Vasavada SP. Management of ureteral injuries associated with vaginal surgery for pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct 2006; 17:531-5.
A 16 year old patient presents with primary amenorrhea. She has normal breast development, sparse pubic hair, tall stature and a 1cm vagina. MRI reveals an absent uterus and no identifiable ovaries. Which of the following laboratory profiles best matches this patient?
A) Normal estrogen, karyotype 46 XY
B) Normal estrogen, karyotype 46 XX
C) Testosterone in or above normal male range, karyotype 46 XY
D) Low testosterone and low estrogen, karyotype 47 XXY
C
Romao RL, Salle JL, Wherrett DK. Update on the management of disorders of sex development. Pediatr Clin North Am. 2012;59:853-69.
The anal sphincter consists of all of the following except:
A) A 0.3-0.5 cm thick smooth muscle layer making up the internal anal sphincter
B) A 0.6-1 cm thick expansion of striated levator ani muscles making up the external anal sphincter
C) A normally open internal anal sphincter and closed external anal sphincter
D) Anal mucosal folds and vascular cushions that provide a seal to the anus
C
Rao S Diagnosis and Management of Fecal Incontinence. Am J Gastro 2004 Practice Guideline Aug. 1585-1603.
According to the 2010 American Urologic Associate Guidelines, in the absence of any contraindications/medication allergies, all of the following are recommended first line microbials for treatment of uncomplicated cystitis, EXCEPT:
A) Ciprofloxacin 500mg, twice daily for 3 days
B) Fosfomycin trometamol 3mg, single dose
C) Pivmecillinam 400mg, twice daily for 5 days
D) Nitrofurantion monohydrate 100mg, twice daily for 5 days
A
FQ have too much collateral damage
All of the following muscles are components of the Levator Ani EXCEPT:
A) Pubococcygeus
B) Coccygeus
C) Iliococcygeus
D) Puborectalis
B
McBride AW, et al. Journal of Pelvic Medicine and Surgery. Volume 9, Number 3, May/June 2003
In 1976 Medical Device Amendments to the Food, Drug and Cosmetic Act (the Act) were enacted and these amendments classified device types into three categories (Class I, II, or III). A class II device type requires special controls, which include all of the following except
A) Premarket studies
B) Patient registry
C) Physician labeling
D) Annual reporting
D
Annual reporting is only required for Class III devices
DA Executive Summary: Surgical Mesh for Treatment of Women WIth Pelvic Organ Prolapse and Stress Urinary Incontinence. Sept 8-9.2011:Accessed April 7, 2013 at http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/MedicalDevices/MedicalDevicesAdvisoryCommittee/ObstetricsandGynecologyDevices/UCM270402.pdf
Congenital absence of the uterus and cervix results from agenesis of which structure?
A) Paramesonephric ducts
B) Wolfian ducts
C) Pronephric ducts
D) Mesonephric ducts
A
When placing the leads for sacral neuromodulation, which foramen is preferentially used?
A) S1
B) S2
C) S3
D) S4
E) S5
C
59 year old woman undergoes laparoscopic sacrocolpopexy with the port configuration above. Survey of the abdomen after completion of the case notes a thermal bowel injury of transverse colon located distant from operative sites, but near the left upper 3rd arm trocar region. What type of injury would best explain the type of electrosurgical injury?
A) Direct coupling injury from electrosurgical instrument
B) Direct coupling injury from insulation failure
C) Capacitance coupling
D) Alternate path burn
C
Capacitance coupling is when current is transferred across two devices (i.e. two trocars) that are not touching, but uses tissue as medium. Direct coupling is from loss of insulation of an instrument or if the tip of the energy source touches another metal object that is directly
Lipscomb GH, Givens VM. Preventing electrosurgical energy-related injuries. Obstetrics and gynecology clinics of North America 2010;37:369-77.
Alkatout I, Schollmeyer T, Hawaldar NA, Sharma N, Mettler L. Principles and safety measures of electrosurgery in laparoscopy. JSLS : Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons 2012;16:130-9.
Which of the following is not likely to be seen after routine vaginal delivery without episiotomy and with an intact perineum?
A) Decreased tensile strength of the pubococcygeus muscles
B) Internal anal sphincter defects
C) Fourth degree laceration
D) Prolonged pudendal nerve terminal motor latency
C
After routine vaginal delivery, MRI studies reveal significant stretch injury and decreased tensile strength of the levator ani muscles, and particularly the pubococcygeus component of the levator ani. Internal anal sphincter defects have been detected by endoanal ultrasonography after routine vaginal deliveries with intact perineal skin. Up to 80% of women can have evidence of denervation after vaginal delivery with 40% showing prolonged pudendal nerve terminal motor latency, most of which recovers by 2 months postpartum. By definition, a fourth degree laceration involves the perineal body, sphincter complex, and rectum. Thus one would not have a fourth degree laceration in the presence of an intact perineum.
Walters and Karram; Urogynecology and Reconstructive Pelvic Surgery, 3rd ed., Chapter 13; 2. Lien et al Obstet Gynecol 2004; 103: 31. 3. Sultan et al. NEJM 1993; 329: 1905.
Next
You are counseling a 44 year-old patient with refractory interstitial cystitis/painful bladder syndrome. She has failed conservative management, multiple medications, bladder instillations and cystoscopy under anesthesia with hydrodistension. You are discussing possible neuromodulation with an Interstim trial. Which of her symptoms is least likely to be improved with a successful response to neuromodulation?
A) Urinary urgency
B) Urinary frequency
C) Bladder pain
D) Urinary incontinence
C
Neuromodulation is not indicated for bladder pain symptoms alone with interstitial cystitis/painful bladder syndrome and is actually not FDA approved for ICS/PBS. In patients with IC/PBS, neuromodulation is indicated more for urgency and frequency (OAB indication) and is much less effective for pain. Therefore carefuly patient selection is important for neuromodulation trials with IC/PBS.
Hanno PM, Burks DA, Clemens JQ, et al. AUA guideline for the diagnosis and treatment of interstitial cystitis/bladder pain syndrome. J Urol. 2011;185:2162-2170
A true statement regarding detrusor sphincter dyssynergia is:
A) It is responsible for bladder neck obstruction and in combination with an areflexic bladder causes bladder overdistention
B) It often occurs in patients with dementia
C) It occurs due to changes in the collagen and elastin components of the bladder
D) It is best diagnosed by EMG rather than CMG
E) It is associated with decreased external urethral sphincter tone
D
DSD is a lack of coordination between the detrusor and urethral sphincter due to interruption of the spinobulbar spinal (sacral/brainstem/sacral) pathway that normally coordinates the detrusor and sphincter. The pons coordinates the micturition reflex. Any lesion between the sacral and pontine level may produce discoordinated voiding, which results in increased external sphincter activity during detrusor contraction. It is diagnosed by evaluating the EMG activity during the pressure/flow study.
Gajewski J. Spinal cord injury and cerebral trauma. In: Corcos J and Schick E eds. Textbook of the Neurogenic Bladder. London and New York. Martin Dunitz Ltd; 2004: 329-341
True statements regarding low bladder compliance include each of the following except:
A) Indications for diversion include hydronephrosis and deterioration of renal function
B) The upper tract should be evaluated every 6-12 months
C) Medical management may improve compliance
D) A common complaint in patients is urinary incontinence
E) An augmentation cystoplasty is not a therapeutic option
E
Treatment of low bladder compliance includes antimuscarinics, augmentation cystoplasty, as well as continent and noncontinent urinary diversion.
Stoher M, Blok B, Castro-Diaz D et al. EAU Guidelines on Neurogenic Urinary Tract Dysfunction. European Urology 2009; 56: 81-89.
Which compartment(s) of the vagina is/are more prone to prolapse recurrence after unilateral sacrospinous ligament fixation?
A) Anterior vaginal wall
B) Posterior vaginal wall
C) Ipsilateral vaginal apex
D) Contralateral vaginal apex
A
The anterior vaginal wall is most prone to prolapse recurrence after sacrospinous ligament fixation, regardless if unilateral or bilateral stitches are placed.
Muir TW; J Pelvic Med Surg 2006; 12: 289-305
Sterile pyuria can be a result of all of the following EXCEPT:
A) Chronic interstitial nephritis
B) Ureaplasma urealyticum
C) Nephrolithiasis
D) Acute tubular necrosis
E) Renal cell carcinoma
d
To avoid complications, a sacrospinous ligament fixation stitch should be placed:
A) As close as possible to the ischial spine
B) 3 cm medial to the ischial spine, placing the stitch superiorly and slightly behind the ligament
C) 3 cm medial to the ischial spine, placing the stitch slightly below the superior edge of the ligament
D) Lateral and superior to the ischial spine
C
The pudendal nerve and vessels lie directly posterior to the ischial spine; thus one would not want to place the stitch as close as possible to the ischial spine. Superiorly and just behind the sacrospinous ligament lies an abundant vascular supply including the inferior gluteal vessels and hypogastric venous plexus. Thus one would want to avoid placing a stitch superiorly and slightly behind the ligament. The sciatic nerve runs lateral and superior to the ischial spine. The correct answer is C, 3cm medial to the ischial spine, placing the stitch slightly below the superior edge of the ligament. In this area, there is less likelihood of injuring nerves or vessels.
Second line treatments for OAB include all of the following except:
A) neuromodulation
B) darifenacin
C) tolterodine
D) trospium
A
Gormley EA, Lightner DJ, et al. Diagnosis and Treatment of Overactive Bladder (Non-Neurogenic_ in Adults: AUA/SUFU Guideline. J urol 2012;188:2455-2463.
Voiding is predominantly a ___________ event.
A) Sympathetic
B) Parasympathetic
C) Somatic
D) Skeletal nerve
B
Voiding is predominantly a parasympathetic event and involves reflex-coordinated relaxation of the urethra with sustained contraction of the bladder until emptying is complete. Voluntary control of micturition is mediated by the frontal cortex, the pons, and the pudendal nucleus in the ventral horm of the sacral spinal cord.
Walters and Karram; Urogynecology and Reconstructive Pelvic Surgery, 3rd ed., Chapter 3
You are performing a cystoscopy on a 21 year old nulliparous woman and notice duplicate ureteral orifices on one side of the bladder. Based on Weigert- Meyer’s rule, the right lower ureteral orifice drains which portion of the kidney?
A) Right lower pole
B) Right upper pole
C) Left lower pole
D) Left upper pole
E) None of the above
B
Campells Urology
A 35 year old female with a C3 spinal cord injury is undergoing video urodynamics. During the study, the patient begins sweating and complains of a severe headache. The best next step should be?
A) Give her Tylenol and cool the room down.
B) Stop the study and administer steroids for possible allergic reaction to the contrast
C) Finish the study as quickly as possible
D) Stop the study and decompress her bladder as quickly as possible
E) Admit her to the ICU
D
Linsenmeyer TA, Bodner, DR, Creasey GH, Green BG, Groah SL, Joseph A et al. Bladder Management for Adults with Spinal Cord Injury: A Clinical Practice Guideline. Washington DC, Paralyzed Veterans of America 2006
A 41 year-old woman is scheduled to undergo a stage 1 Interstim procedure for refractory overactive bladder. As part of her surgical “time out,” what does not need to be included based upon JCAHO protocol?
A) A pre-procedure verification should document a signed consent form.
B) The site of the general spinal level of the planned procedure should be marked prior to the procedure with an unambiguous marking.
C) The preoperative time out should confirm the patient identity.
D) The preoperative time out should confirm the prophylactic antibiotics used.
E) The preoperative time out should confirm the correct procedure site and procedure to be done.
D
The JCAHO Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery includes guidelines that a (1) pre-procedure verification should include confirmation of relevant documentation (H&P, signed consent, pre-anesthesia assessment), diagnostic and radiologic tests and required blood products, implants, devices or special equipment. (2) Procedure site should be marked prior to the procedure with an unambiguous marking - this is when the procedure involves more than one possible location and when performing the procedure in an alternate location could harm the patient. The protocol specifically mentions spinal procedures and although may not be “sided” the general spinal level should be marked. (3) A preoperative time-out is performed prior to the procedure with the entire OR team and confirms the patient identity, procedure to be performed and correct procedure site. Antibiotic prophylaxis is not included in the JCAHO protocol although some institutions may include this.
Bladder extrophy results from a defect in which embryologic structure?
A) Cloacal membrane
B) Pronephros
C) Paramesonephric duct
D) Mesonephric duct
A
he area where the somatic mesoderm and the splanchnic mesoderm layers join in the midline is termed the intermediate mesoderm and gives rise to the urogenital system.
What is the recommended first-line antibiotic therapy for uncomplicated cystitis before urine culture results are available?
A) ciprofloxacin 250mg PO BID for 5 days
B) cephalexin 500mg QID PO for 3 days
C) nitrofurantoin monohydrate/macrocrystals 100mg PO for 5 days
D) amoxicillin 500mg PO TID for 7 days
Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis 2011;52(5):e103-120.
While performing a cystoscopy in a patient with interstitial cystitis you diagnose a Hunner’s ulcer. Which of the follow is not a recommended treatment based on AUA guidelines?
A) Fulgeration with laser
B) Injection with DMSO
C) Fulgeration with electrocautery
D) Injection with triamcinolone
B
DMSO is not recommened specifically in cases with a Hunner’s ulcer and is administered in IC as a bladder instillation, not a bladder injection.
AUA Clinical guidelines for treatment of IC.
Urethrovaginal fistula is a difficult complication of urethral diverticulectomy. Which of the following statements are true:
A) Reported urethrovaginal fistula rate after diverticulum repair is 0.9-18.3%
B) A Martius fat pad is often needed
C) Fistulae are commonly associated with undetected carcinoma
D) Prompt surgical intervention is recommended as soon as the diagnosis of fistula is made to minimize the risk of further tissue loss
E) A and B
b
Carcinoma of the urethra is not associated with diverticular repair. Risk of fistula is less than 10%, and repair should be done no less than 3 months after initial urethral surgery.
Handel LN, Current Urol Rep 2008, 9:383-388
Sacral neuromodulation is NOT approved for the treatment of
A) Refractory urge urinary incontinence
B) Neurogenic bladder due to T10 spinal injury
C) Fecal incontinence
D) Idiopathic urinary retention
E) None of the above, it is approved for all A-D
B
Interstim would not be indicated for “neurogenic bladder”. Although many patients with neurogenic bladder have symptoms of overactive bladder, neuromodulation requires an intact neurologic system. It is also contraindicated in those with inadequate response to test stimulation or obstructive urinary retention
Which of the following theories has been proposed as basis for the mechanism of action of mid-urethral slings?
A) Hammock theory
B) Intensification theory
C) Erosion theory
D) McGuire’s theory
E) Integral theory
E
Petros and Ulmsten, Acta Obstet Gynecol Scand Suppl, 1990; 153:7-31
In patients with fecal incontinence, anal manometry results
A) Correlate with symptom severity
B) Predict post-operative success of surgical treatment
C) Both A and B
D) Neither A nor B
D
Several studies have indicated that anal manometry results do not correlate with symptom severity and do not help to predict postoperative success of surgical treatment in fecal incontinence
Hayden DM, Weiss EG. Fecal incontinence: etiology, evaluation, and treatment. Clinics in colon and rectal surgery. Mar 2011;24(1):64-70
Zutshi M, Salcedo L, Hammel J, Hull T. Anal physiology testing in fecal incontinence: is it of any value? International journal of colorectal disease. Feb 2010;25(2):277-282
What is the most implicated mode of pathogenesis in interstitial cystitis/painful bladder syndrome?
A) Increased permeability of the glycosaminoglycan (GAG) layer of the bladder urothelium
B) Mast cell activation
C) Neurogenic upregulation and inflammation
D) Autoimmune factors
E) Multifactorial
E
No single pathologic process has been universally confirmed in patients with IC/PBS and the etiology is multifactorial. Any of the possible etiologies listed in answers A through C may be related to the development of IC/PBS. Women with IC/PBS have been found to have increased C fibers, which carry and release substance P that leads to mast cell activation and production of inflammatory mediators. Detrusor mastocytosis has been found in 20-65% of patients with IC/PBS. Allergies may co-exist. Other proposed theories include pelvic floor dysfunction leading to voiding dysfunction and pain, psychological factors, genetic predisposition, infectious pathogens, and the potential role of estrogen.
Deniseiko Sanses T. Painful Bladder Syndrome/Interstitial Cystitis. Journal of Pelvic Medicine and Surgery. 2007;13:321-336
With respect to anticholinergic therapy, the following is/are true?
A) Anticholinergics are associated with low side effects
B) Anticholinergics are superior to bladder training alone
C) Anticholinergics are the most cost effective approach for management of OAB.
D) Anticholinergics in combination with bladder training are superior to bladder training alone
E) B and D
E
Anticholinergics have high side effect (up to 30%) of dry mouth/constipation, medications alone or in combination with behavior therapy are superior to behavior alone.No data support cost effectiveness of medications.
Rai BP, Cody JD, Alhasso A, Stewart L. Anticholinergic drugs versus non-drug active therapies for non-neurogenic overactive bladder syndrome in adults. Cochrane database of systematic reviews 2012;12:CD003193.
Which of the following is not a characteristic of a case control study?
A) The prevalence of risk factors in sample of subjects who have the disease or condition of interest is compared to that in a separate sample of patients who do not have the disease or condition.
B) It provides data on disease prevalence
C) It is a useful and efficient design for studying rare conditions or diseases
D) It is susceptible to sampling bias and differential measurement bias
B
Designing Clinical Research, 3rd ed. Hulley SB, Cummings SR, Browner WS, et al, eds. Philadelphia: Lippincott Williams & Wilkins, 2007
A 77 year old woman has a recurrent apical prolapse 15 years after undergoing vaginal hysterectomy with a McCall culdoplasty. She is not sexually active and thus has been using a pessary almost continually over the last 10 years. Recently her prolapse is protruding around the pessary. She indicates that she would like the surgical procedure with the lowest likelihood for repeat surgery. Which procedure would you offer?
A) Mesh sacrocolpopexy
B) Vaginal mesh for prolapse
C) LeFort colpocleisis
D) Colpectomy (vaginectomy) colpocleisis
D
When compared to native tissue repairs, the use of mesh in pelvic organ prolapse surgery is associated with increased rates of reoperation. Amongst native tissue repairs, there are reconstructive and obliterative procedures. The obliterative procedures have the lowest rates of prolapse recurrence and low rates of reoperation. This patient has not been sexually active in 10 years and thus is a candidate for an obliterative procedure. She has had a prior hysterectomy and therefore the LeFort colpocleisis technique would not apply. A vaginectomy colpocleisis can be performed in women who are post-hysterectomy, with high success, and low risk of reoperation.
Walters & Ridgeway; Obstet Gynecol 2013; 121 (2)
The prevalence of fecal incontinence in healthy adult female population is approximately:
A) 1-7%
B) 5-12%
C) 11-20%
D) 21-26%
A
Rao S Diagnosis and Management of Fecal Incontinence. Am J Gastro 2004 Practice Guideline Aug. 1585-1603.
What procedures will increase risk of urinary retention after prolapse surgery?
A) Kelly Plication
B) High Grade Cystocele
C) Levator Plication
D) Blood loss over 100 cc
E) all of the above
E
Hakvoort RA, Dijkgraff MG, Burger MP, Emanuel MH, and Roovers, JP: Prediction Short-Term Urinary Retention After Vaginal Prolapse Surgery. Neurourol Urod 28:225-228, 2009.
Which of the following is involved in contraction of the external urethral sphincter?
A) Onuf’s nucleus in the ventral horn of the sacral spinal cord
B) Beta-adrenergic receptors
C) Substantia nigra of the brain
D) M3 muscarinic receptors
A
Voluntary control of the external urethral sphincter is through the through the corticospinal pathway connecting the frontal cortex of the brain with the pudendal nucleus (Onuf’s nucleus) in the ventral horn of the sacral spinal cord. Thus Onuf’s nucleus is involved in contraction of the external urethral sphincter. Beta-adrenergic receptors and M3 muscarinic receptors reside in the bladder wall. Beta-adrenergic receptors allow for relaxation of the detrusor muscle and facilitate storage of urine. M3 muscarinic receptors are parasympathetic receptions that are stimulated for voiding. The substantia nigra of the brain has a high concentration of dopamine receptors and is affected in individuals with Parkinson’s disease. Decreased dopaminergic activity leads to loss of inhibition of the pontine micturition center and increased involuntary voiding.
Walters and Karram; Urogynecology and Reconstructive Pelvic Surgery, 3rd ed., Chapter 3
You are performing anorectal manometry on a patient with constipation. During her attempt to expel a fluid-filled balloon you notice increased surface EMG activity. What may this suggest?
A) Hirshsprung’s disease
B) Slow transit constipation
C) Pelvic floor dyssynergia
D) Enterocele
C
EMG may be performed with needle or surface electrodes. During straining, and when attempting to expel a fluid-filled balloon, EMG should reveal a decrease in electric activity of the pelvic floor muscles. In other words, the muscles should relax to allow passage of stool. If an increase in EMG activity is noted, this is suggestive of pelvic floor dyssynergia. During anorectal manometry, the lack of a recal anal inhibitory reflex is suggestive of Hirschsprung’s disease. Slow transit constipation is best diagnosed with a colonic transit study. Slow transit constipation and enterocele would not result in elevated EMG activity while straining.
Walters and Karram; Urogynecology and Reconstructive Pelvic Surgery, 3rd ed., Chapter 25
A 67 years old female presents complaining of increased daytime urinary frequency and urgency while getting to the bathroom. She often leaks prior to making to the toilet and would like to try a medical therapy. Which of the following statements best describes accurate expectations of anticholinergic use:
A) The patient can expect a reduction in urgency urinary incontinence episodes of 1-4 per day with anticholinergic use.
B) The patient can expect a reduction of 5-9 voids per day.
C) The change in incontinence episodes does not improve patient quality of life
D) Sustained-release oxybutynin appears to be significantly more effective than sustained-release tolterodine.
A
Hartman et al. Treatment of Overactive Bladder in Women. Evidence Report/Technology Assessment Number 187. AHRQ Publication No. 09-E017 August 2009.
Factors that should be taken into consideration during the condition specific
assessment of fecal incontinence include all of the following except:
A) Duration of the problem
B) Relevant medical, surgical, neurological and obstetric history
C) Medication use
D) Age of menarche
E) Incontinence coping strategies
D
National Institute for Health and Clinical Excellence, 2007. Faecal Incontinence: The Management of Faecal Incontinence in Adults. Clinical guidelines No. 49. NICE, London.
After uterosacral ligament suspension a patient wakes up with severe pelvic pain on her left side. It is difficult for her to specifically localize the exact spot of the pain. Which of the following structures is most likely to have been “caught” by one of your sutures?
A) the pudendal nerve
B) a sacral nerve
C) the obturator nerve
D) the genitofemoral nerve
E) the inferior hypogastric plexus
B
Siddiqui NY, Mitchell TR, Bentley RC, Weidner AC. Neural entrapment during uterosacral ligament suspension: An anatomic study of female cadavers. Obstet Gynecol, 2010, 116(3), 708-713.
When placing a retropubic midurethral sling using a bottom-up technique in a healthy, normal-weight, 39 year old, she suddenly becomes cardiovascularly unstable and you notice the trocar is deviated sharply lateral. Which vessel has likely been injured?
A) Obturator artery
B) External iliac artery
C) Pudendal artery
D) Internal iliac vein
B
In a cadaveric study of TVT trocar placement, when trocars were purposefully directed 6 cm lateral to the mid-biceps brachii muscle, the external iliac vessel was found to be 0.6 and 0 cm away from the trocar.
Muir TW, Tulikangas PK, Fidela Paraiso M and Walters MD: The relationship of tension-free vaginal tape insertion and the vascular anatomy. Obstet Gynecol 2003; 101: 933.
You design a study to determine the incidence and remission of urinary incontinence in the first year after a cerebrovascular accident (CVA). You enroll 100 patients who have had a CVA and evaluate their continence status using validated questionnaires immediately after the CVA and again 6 and 12 months post CVA. This study can best be described as a:
A) Retrospective Cohort study
B) Prospective Cohort study
C) Case Series
D) Case Control Study
E) Cross-sectional Study
B
Designing Clinical Research, 3rd ed. Hulley SB, Cummings SR, Browner WS, et al, eds. Philadelphia: Lippincott Williams & Wilkins, 2007.
Which of the following statements is most accurate regarding anorectal testing except:
A) Defecography is useful in patients with normal rectal evacuation
B) Balloon expulsion test uses a 50ml water-filled balloon and is usually normal in patients with fecal incontinence
C) Diagnostic tests such as anorectal manometry, defecography and balloon expulsion test help define underlying mechanisms of fecal incontinence
D) The balloon expulsion test may help identify patients with dyssynergic defecation
A
Which of the following statements is most accurate regarding anorectal testing except:
A) Defecography is useful in patients with normal rectal evacuation
B) Balloon expulsion test uses a 50ml water-filled balloon and is usually normal in patients with fecal incontinence
C) Diagnostic tests such as anorectal manometry, defecography and balloon expulsion test help define underlying mechanisms of fecal incontinence
D) The balloon expulsion test may help identify patients with dyssynergic defecation
Which of the following is an inhibitory neurotransmitter in the CNS?
A) Glutamic acid
B) γ-aminobutyric acid
C) Nitric oxide
D) Substance P
B
Glutamic acid, nitric oxide, substance P, and ATP are excitatory neurotransmitters in the CNS. Inhibitory neurotransmitters include γ-aminobutyric acid, glycine, and opioid peptides.
Raz & Rodriguez; Female Urology, 3rd ed., Chapter 3
A 45 year female, Gravida 2, Para 2 presents to your office with the complaint of bothersome loss of liquid and solid stool worse over the last year. During her first vaginal delivery she had a “full thickness” tear and reported some loss of stool during the first 6 postpartum weeks that resolved. Rectal examination reveals a weak but intact anal sphincter squeeze. She has tried Kegel exercises off an on at home on her own but this has not helped her enough. You discuss her treatment options and recommend initial management should include:
A) Addition of dietary fiber alone
B) Education regarding bowel management strategies, supervised anal muscle exercises, and stool consistency management possibly including the addition of dietary fiber
C) Sacral neuromodulation
D) Loperamide daily
B
Abrams P, Cardozo L , Khoury S, Wein A. Incontinence. Committee 16 Conservative and Pharmacological Management of Faecal Incontinence in Adults. Paris. Health Publication Ltd. 2009. pgs 1321-1386
A perioperative nerve injury is more commonly encountered with:
A) Yellow fin “Allen” stirrups than candy cane stirrups for lithotomy
B) A patient with a BMI of 20 kg/m2 than 40 kg/m2
C) Self retaining retractors than manual retraction
D) B and C
D
Kahn F, Kenton K JPMS Vol 12 number 5, Sept/Oct 2006
Thin patients, retractors, and candy canes are risk factors for injury.
Choose the correct statement with regard to leukocyte esterase and nitrite on urine dipstick.
A) Leukocyte esterase has good positive predicative value and nitrite has good positive predictive value for UTI diagnosis
B) Leukocyte esterase has good negative predicative value and nitrite has good negative predictive value for UTI diagnosis
C) Leukocyte esterase has good negative predictive value and nitrite has good positive predictive value for UTI diagnosis
D) Leukocyte esterase has good positive predictive value and nitrtie has good negative predictive value for UTI diagnosis
C
On urine dipstick, the 2 most useful components for UTI diagnosis are leukocyte esterace and nitrites. The PPV of leukocyte esterase varies between 19-88% due to multiple causes of pyuria, but the NPV is 97-99%. Nitrite is produced from degradation of dietary nitrite in colonic bacteria (specifically Enterococcus). The PPV of nitrites is 94%, but the NPV is low due to false negatives (ie. lack of dietary nitrate, dilution of nitrite in urine, bacteria lacking nitrate reductase).
Heisler CA, Gebhart JB. Urinary Tract Infection in the Adult Female. Pathophysiology, Evaluation and Treatment. J Pelvic Med Surg 2008;14:1-14.
Your patient demonstrates bothersome SUI and urethral diverticulum at the 6 o’clock position on the midurethra. Management most likley to result in optimal long term result is:
A) Marsupialization of the distal 50% of the urethra combined with a midurethral sling
B) Transvaginal excision of the diverticulum and mid urethral mesh sling as a combined procedure
C) Retropubic excision of the diverticulum and midurethral mesh sling as a combined procedure
D) Transvaginal excision of the diverticulum and an interval mid urethral mesh sling as a second procedure
D
Excision of the diverticulum via vaginal approach is the least traumatic and easiest method, but performing a midurethral sling at the same procedure with this diverticulum increases the risk of fistula.
Handel LN, Current Urol Rep 2008, 9:383-388
True statements regarding the International Continence Society definitions of detrusor overactivity (DO) include each of the following except:
A) Phasic DO is defined as a characteristic wave form which may or may not lead to urinary incontinence
B) Neurogenic DO is defined as a DO event that is associated with poor compliance
C) Terminal DO is a single involuntary detrusor contraction at capacity which cannot be suppressed and results in incontinence
D) DO incontinence is incontinence occurring with an involuntary detrusor contraction
E) DHIC is defined as detrusor hyperactivity with impaired contractility
B
The ICS definition of neurogenic DO is a DO event on UDS in an individual with a relevant neurologic condition
Abrams P, Cardozo, L, Fall M, Griffiths D, Rosier P, Ulmsten U, et al. The standardization of terminology of lower urinary tract function: report from the Standardization Sub-Committee of the International Continence Society. Neurourol Urodyn 2002; 21:167-78.
For the treatment of OAB symptoms, trospium chloride differs from other antimuscarinics in that:
A) It has atropine like effects
B) It has a dermal preparation
C) The standard dosing is once a week
D) It is a tertiary amine
E) It has high selectivity for the M3 receptor
A
Silva W.Andre. Pharmacologic Management of Incontinence and Voiding Dysfunction. Pelvic Medicine and Surgery 2005; 11 (1): 1.
A 66 year-old woman underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy. She developed new onset urinary incontinence postoperatively. You see her for consultation about 2 months after her surgery. She reports almost constant leakage and is not sure whether there are any triggers for her leakage. She denies any urgency, frequency or urge leakage however. She changes her pad 4-5 times daily, and she has to wear a pad at night. Her medical history is significant for osteoporosis. The hysterectomy is her only prior surgery. On speculum exam, you easily visualize a pinpoint dimple in the midline of the anterior vaginal wall 2cm distal from the vaginal cuff. With cough and Valsalva you note spurts of leakage from this area. You perform a cystoscopy and visualize a small mature-appearing fistula in the bladder mucosa above the trigone at the base of the bladder in the midline, quite distal from both ureteral orifices. You note no other abnormalities. You order an IVP to rule out any ureteral involvement and the study is entirely normal. You decide to plan a primary surgical repair. You consider either a vaginal or abdominal approach. Which of the following is true regarding the surgical approach with this patient?
A) Both vaginal and abdominal approaches have similar rates of successful closure.
B) A vaginal approach has a higher likelihood of successful fistula closure.
C) An abdominal approach has a higher likelihood of successful fistula closure.
D) An abdominal approach has a higher likelihood of successful fistula closure, but only with a transvesical technique.
A
This patient would be an ideal candidate for a vaginal approach as this is a small solitary fistula that is easily visualized. She has no prior attempted repairs and no history of radiation. Vaginal and abdominal approaches have been found to have similar success rates, but a vaginal approach has decreased morbidity. Case series of the vaginal approach for VVF repair have found success rates of 94-100% for primary closure. Case series of abdominal approaches have shown similar success rates of 90-100%.
Mueller E, Kenton K, Brubaker L. Modern Management of Genitourinary Fistula. Journal of Pelvic Medicine and Surgery. 2005;11:223-234
A 62 year old patient reports right flank pain 1 day after a sacrocolpopexy and bilateral salpingo-oophorectomy for vaginal vault prolapse during which ureteral patency was NOT confirmed. All of the following would be appropriate next steps EXCEPT?
A) Cystoscopy with indigo carmine
B) Renal ultrasound
C) Cystogram with contrast
D) Intravenous pyelogram
E) CT with intravenous contrast
C
All of the listed answers except C allow for some assessment of ureteral patency either directly or indirectly. A cystogram will fill the bladder with contrast and would assess bladder integrity but could be completely normal even with complete occlusion of one or both ureters.
Clarke-Pearson and Geller, Obstet Gynecol 2013:121:654-73
You are interested in determining if the Valsalva leak point pressures are different between patients with and without postoperative stress incontinence after a midurethral sling. You hypothesize that those with lower preoperative Valsalva leak point pressures are more likely to experience postoperative incontinence. Which of the following statistical tests would be most appropriate?
A) Fishers Exact Test
B) Chi-Square
C) Paired t-test
D) Student’s t-test
D
You are seeing a 32 year-old woman who is a known established patient with a history of painful bladder syndrome and levator myalgia. She had an extensive evaluation including office cystoscopy, urodynamics and CT of the abdomen and pelvis to rule out other causes of her pain. She has been managed for 2 months with behavioral modifications with diet, pelvic floor physical therapy and ibuprofen. Last week she reported an increase in her bladder pain, urgency and frequency. You treated her with 7 days of sulfamethoxazole-trimethoprim DS BID for a presumed UTI. When she came into the office to leave a urine sample she was using phenazopyridine so you did not check a urine dip but sent a urine culture. The urine culture was entirely negative. She is back in your office today reporting her symptoms are basically the same. She has 2 doses of sulfamethoxazole-trimethoprim left. What is the best way to manage her antibiotics?
A) Start her on prophylactic sulfamethoxazole-trimethoprim for 3 months
B) Extend the course of sulfamethoxazole-trimethoprim to 14 days
C) Start her on ciprofloxacin 500mg bid for 7 days
D) Start her on prophylactic ciprofloxacin for 3 months
E) Stop the antibiotics and discuss other treatment options
E
Antibiotic treatment is contraindicated in patients with painful bladder syndrome who have previously been administered antibiotics without efficacy and a negative urine culture. This clinical scenario is a flare of PBS and a urinary tract infection has been ruled out. Long-term antibiotic administration has not been shown to improve PBS symptoms; this has been shown in several observational studies and an RCT comparing antibiotics to placebo for 18 weeks in patients with PBS.
Hanno PM, Burks DA, Clemens JQ, et al. AUA guideline for the diagnosis and treatment of interstitial cystitis/bladder pain syndrome. J Urol. 2011;185:2162-2170
A 67 year-old woman with uterovaginal prolapse is scheduled to undergo a total vaginal hysterectomy with a uterosacral ligament suspension and cystoscopy. She has a medical history of hypertension. She has no prior surgeries. She takes HCTZ 25mg daily and a multivitamin. She had a documented anaphylactic reaction to penicillin in the past. She is 65 inches tall and weighs 66 kg. The best regimen for perioperative antimicrobial prophylaxis is:
A) Cefazolin 1 gram IV
B) Cefazolin 2 grams IV
C) Clindamycin 600mg IV
D) Clindamycin 600mg IV and Gentamicin 100mg IV
E) Clindamycin 600mg IV and Ciprofloxacin 200mg IV
D
Considering this patient has a history of an immediate anaphylactic reaction to penicillin in the past, cephalosporins should be avoided. Clindamycin 600mg IV alone is not recommended and can be given with either aztreonam 1g IV, gentamicin 1.5 mg/kg, or a quinolone such as ciprofloxacin 400mg IV. Metronidazole 500mg IV can be substituted for the clindamycin.
ACOG practice bulletin No. 104: antibiotic prophylaxis for gynecologic procedures. Obstet Gynecol. 2009;113:1180-1189.
- The urogenital sinus becomes which of the following adult female structures?
A) Bladder, trigone, membranous urethra
B) Bladder, trigone, membranous urethra, vestibule
C) Bladder, memgranous urethra
D) Bladder, membranous urethra, vestibule
E) None of the above
D
Campells Urology
A true statement regarding spinal cord shock is:
A) It is a period of time after a traumatic spinal cord injury where there is increased excitability of spinal cord segments at and below the level of injury
B) It is a period of time when performing urodynamics is most valuable
C) During this period the detrusor in unable to contract
D) The lower urinary tract is usually affected for less than a week
E) This condition is treated with nifedipine
C
After an acute spinal cord injury, the central synapses between the afferent and efferent arms of the micturition reflex will be inactive. The detrusor will be paralyzed and there will be no conscious awareness of bladder fullness, but the bladder neck and proximal urethra will be closed. The mechanism of spinal shock is unclear and may relate to lack of supraspinal facilitation of the inerneuronal activity due to release of inhbitory transmitters.
Gajewski J. Spinal cord injury and cerebral trauma. In: Corcos J and Schick E eds. Textbook of the Neurogenic Bladder. London and New York. Martin Dunitz Ltd; 2004: 329-341.
Which of the following is the correct equation best describing the pressure relationships in urodynamics?
A) Pdet=Pves-Pabd
B) Pves=Pdet-Pabd
C) Pdet=Pves-Pura
D) MUCP=Pura-Pdet
E) MUCP=Pura+Pabd
A
Schafer W, Abrams P, Liao L et al, Good Urodynamic Practices: Uro£owmetry, Filling Cystometry, and Pressure-Flow Studies, Neurourology and Urodynamics 2002: 21:261-274
Which of the following is not a phase in the Masters and Johnson sexual response cycle?
A) Excitation phase
B) Plateau phase
C) Orgasmic phase
D) Rhythmic phase
E) Resolution phase
D
The Masters and Johnson physiologic response cycle has been used to describe sexual function. The cycle includes the following phases: desire, excitation, plateau, orgasmic, resolution. The usefulness of this model is limited because of initial absent sexual desire, overlapping phases, nongenital sensations that overshadow arousal/excitation, and the fact that orgasm may not be necessary for satisfaction. Thus a more recent circular model of sexual response has been proposed.
Siddique S. 2003; J Pelvic Med Surg 9(6): 263-272; Basson R. Obstet Gynecol 2001; 98: 351
You are called into the operating room for an intraoperative consultation. During a repeat cesarean section, the obstetrician had difficulty creating the bladder flap due to adhesions and is concerned there may be a cystotomy. All of the following are reasonable methods to assess bladder integrity EXCEPT:
A) Instill methylene blue diluted in 300mL of saline through the Foley
B) Direct inspection of the bladder with instillation of saline through the Foley
C) Cystoscopy with a 70 degree cystoscope
D) Cystoscopy with a 0 degree cystoscope
D
A women is 3 weeks following a benign abdominal hysterectomy and is diagnosed with a 1 cm. vesico-vaginal fistula (VVF). Which of the following statements is true:
A) It will be most effectively treated if the surgeon waits at least 3 months until repair.
B) There is Level 1 evidence that an abdominal VVF repair is more likely to be successful than a transvaginal approach.
C) Only transvesical repair will allow for interpositional flaps, if necessary.
D) There is a high likelihood that the 1 cm size fistula will heal spontaneously.
E) Postoperative management will include bladder drainage for 10 -14 days.
E
Angioli R, Penalver M, Muzii L, et al. Guidelines of how to manage
vesicovaginal fistula. Oncology Hematology 2003; 48: 295- 304.
37 yo G4P3 presents with a chief complaint of 10 year h/o bloating, constipation and the feeling of something getting stuck. She occasionally uses perineal decompression to complete a bowel movement. POP reveals: Aa 0, Ba 0, C -3, Gh 3, Pb 4, TVL 9, Ap 0, Bp 0, D -5. Multiple fiber regimens have not been successful and she is desperate for a surgical repair. The appropriate next step is:
A) Urodynamics, followed by TVH AP repair
B) Posterior repair
C) Trial of laxatives
D) Further evaluation of constipation
D
Locke GR 3rd, Pemberton JH, Phillips SF. AGA technical review on constipation. American Gastroenterological Association. Gastroenterology 2000;119:1766-78.
45 year old obese female (BMI 39 kg/m2) with history of depression presents with complaints of 3 times a week stress urinary incotinence. She has no prolapse, urethral mobility to 45 degrees with straining, positive stress test with 350 mL in her bladder and post void residual of 5 mL with negative Urine dip. What treatmentand counseling is most appropriate for this patient?
A) Recommend urodynamic testing to assess urethral function and proceed with midurethral sling so that she can begin an exercise program to lose weight.
B) Recommend timed voiding drills with biofeedback and a pessary to prevent leakage during exercise.
C) Recommended weight loss and counsel her that even 8% reduction in body mass index may result in nearly 50% reduction in leakage episodes.
D) Recommend duloxetine 40 mg BID as treatment for her depression as it may also cure her stress urinary leakage.
C
Urodynamic testing is not indicated in this patient and surgery is not first line treatment for SUI. Pessary plus biofeedback has not been shown to improve continence rates over biofeedback alone (Richter et al). Large RCT of weight loss has been shown to reduce UI by 47% with just 8% reduction in BMI compared to control group (Subak et al). Clinical trials of duloxetine show 50% reduction in SUI episodes but rare cure rates.
Richter HE, Burgio KL, Brubaker L, et al. Continence pessary compared with behavioral therapy or combined therapy for stress incontinence: a randomized controlled trial. Obstet Gynecol 2010;115:609-17.;Subak LL, Wing R, West DS, et al. Weight loss to treat urinary incontinence in overweight and obese women. The New England journal of medicine 2009;360:481-90.
Marland pessaries are quite versatile for all of the following reasons except:
A) They have a wedge shaped ridge on one side and can be useful when a standard ring with support tends to fall out
B) As a space-filling pessary it is used for all prolapse types
C) The wedge-shaped side can be placed against the leading edge of prolapse
D) The wedge-shaped side can be placed toward the vaginal opening
E) The ring aspect of the pessary can be placed against the anterior vaginal wall
B
Culligan P. Nonsurgical management of pelvic organ prolapse. Obstet Gynecol 2012;119:852-860
You have been asked to evaluate the test characteristics of a new method to diagnose stress incontinence. Of the 1000 participants with the disease, 900 tested positive and 100 tested negative. In the 1000 without stress incontinence, 800 tested positive with the test, and 200 tested negative. From this information one can conclude which of the following?
A) The test is more specific than it is sensitive
B) The test is more sensitive than it is specific
C) The positive predictive value is greater than the negative predictive value.
D) The sensitiviy of the test is 80%
B
A 52 yo woman with refractory OAB is undergoing the test phase of sacral neuromodulation. Which of the following is not one of the responses that would be expected during stimulation of the S3 nerve?
A) Sensation in the labia/vagina
B) Dorsiflexion of the little toe
C) Sensation in the perineum
D) Bellowing of the buttocks
B
Carmel ME, Goldman HB. Management of refractory overactive bladder. Expert Rev Obstet Gynecol 2012; 7:605-13.
For the uterus to develop embryologically, the following must occur:
A) Mullerian Inhibiting Substance (MIS) must be present
B) Testosterone must be absent
C) SR-Y must be present
D) Mullerian Inhibiting Substance (MIS) must be absent
D
Carlson BM. Human Embryology and Developmental Biology, 4th Ed. Philadelphia (PA): Mosby, Inc., 20
You have a dataset that contains delivery records including route of delivery and fetal head position and that spans 10 years. You would like to determine in patients that are undergoing a vacuum vaginal delivery, whether there is a difference in risks of third degree laceration between those that are delivered occiput anterior and those that are delivered occiput posterior. You determine the rate of 3rd degreelaceration in your sample overall is 13%. What is the most appropriate study design for you to analyse your dataset?
A) Retrospective Cohort
B) Randomized clinical trial
C) Case control
D) Prospective Cohort
E) Case series
A
The most common cause for the development of a urethrovaginal fistula is:
A) Radiation therapy for cervical cancer
B) Pelvic fracture
C) Urethral diverticulectomy
D) Abdominal hysterectomy
E) Urethral erosion from sling mesh
C
Methods to reduce inflammation from mesh include the use of all the following except:
A) Porous architecture
B) Lightweight, Type I mesh
C) Monofilament fibers
D) Microporous architecture
D
Feedback:
D. Microporous architecture. Correct would be macroporous architecture (>75microm)
DA Executive Summary: Surgical Mesh for Treatment of Women WIth Pelvic Organ Prolapse and Stress Urinary Incontinence. Sept 8-9.2011:Accessed April 7, 2013 at http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/MedicalDevices/MedicalDevicesAdvisoryCommittee/ObstetricsandGynecologyDevices/UCM270402.pdf
You obtain a CT scan as part of a workup for hematuria. The radiologist diagnoses a horseshoe kidney. This congenital anomaly is most likely associated with the anatomical positioning of which structure?
A) Left ovarian vein
B) Right ovarian artery
C) Left renal vein
D) Right renal artery
E) Inferior mesenteric artery
E
This is caused by fusion of the lower poles of both kidneys. Normal ascent to the lumbar area is prevented by the anatomic location of the inferior mesenteric artery.
Walters and Karram; Urogynecology and Reconstructive Pelvic Surgery, 3rd ed., Chapter 2; Netter’s Atlas
An obese 55 year-old woman is undergoing a robotic-assisted laparoscopy mesh sacral colpopexy. Upon placement of the right lower quadrant robotic trocar, you note bleeding into the abdomen directly from the port site and an expanding hematoma within the anterior abdominal wall. This next best step in management would be any of the following options except:
A) Remove the trocar and cauterize the bleeding site under direct visualization.
B) Remove the trocar and place a Foley balloon to tamponade the bleeding.
C) Remove the trocar and ligate the bleeding vessel with an endoscopic ligation device such as an Endo Close™ or Carter-Thomason CloseSure System®.
D) The vessel does not need to be ligated, so you can continue with the case.
D
This scenario describes an injury to the inferior epigastric artery upon placement of the lower quadrant trocar. Inspection of the anterior abdominal wall is important to visualize these vessels in order to avoid them upon accessory trocar placement during laparoscopy. Any of management options A through C can be used to control the bleeding, which can be brisk.
Khan F, Kenton K. Intraoperative Injury in Reconstructive Pelvic Surgery. Journal of Pelvic Medicine and Surgery. 2006;12:241-256
According to the 2012 American Urologic Association Guidelines, which of the following should be used in the initial work up of the uncomplicated overactive bladder (OAB) patient:
A) Cystoscopy
B) Urine culture
C) Post-void residual
D) Urinalysis
D
A 45 year old woman presents for counseling regarding treatment options for her symptomatic stage II apical prolapse. Which of the following statements is MOST correct regarding pelvic floor physical therapy for the treatment of prolapse?
A) Based on the available data in the literature, there is evidence that suggests there is some benefit from pelvic floor physical therapy compared to continued observation
B) Based on the available data in the literature, there is no evidence that suggests there is benefit when considering the use of pelvic floor physical therapy for the treatment of prolapse
C) Based on several randomized control trials, there is good evidence that pelvic floor physical therapy has long-term benefit in the treatment of pelvic organ prolapse
D) There is not enough data to make any conclusions regarding the use of pelvic floor physical therapy for the treatment of pelvic organ prolapse
A
Hagen S and Stark D. Cochrane Database of Systematic Reviews 2011, Issue 12.
According to the International Society for the Study of BPS (ESSIC, or European Society for the Study of Interstitial Cystitis) which of the following histologic description on bladder biopsy is not considered a positive finding associated with interstitial cystitis/painful bladder syndrome?
A) Inflammatory infiltrates
B) Detrusor mastocytosis
C) Intrafascicular fibrosis
D) Squamous metaplasia
E) Granulation tissue
D
Biopsy findings that were accepted as positive signs of BPS were inflammatory infiltrates and/or granulation tissue and/or detrusor mastocytosis and/or intrafascicular fibrosis.
van de Merwe JP, Nordling J, Bouchelouche P, et al. Diagnostic criteria, classification, and nomenclature for painful bladder syndrome/interstitial cystitis: an ESSIC proposal. Eur Urol. 2008;53:60-67
Which of the following is most associated with a patient’s assessment of her own treatment success after surgery for pelvic organ prolapse?
A) The absence of prolapse beyond POPQ stage 1
B) The absence of prolapse beyond POPQ stage 2
C) The absence of prolapse beyond the hymen
D) The absence of vaginal bulging symptoms
E) The absence of a surgical complication
D
Barber MD, Brubaker L, Nygaard I, et al. Defining success after surgery for pelvic organ prolapse. Obstet Gynecol 2009; 114(3):600-9.
All of the following are true regarding obliterative procedures for pelvic organ prolapse except:
A) The have a high success rate for anatomic correction of prolapse.
B) Complete colpectomy requires entering enterocele sac to obliterate the cul-de-sac.
C) Draining channels are left after LeFort Partial Colpocleisis.
D) Levatorplasty and perineoplasty are important additions to obliterative procedures
E) all of the above are true
B
While performing a synthetic retropubic mid-urethral sling you notice at the time of cystoscopy that the needle has penetrated the bladder. The next step should be:
A) Continue to pass the needle through the exit point and re-cystoscope to see if the sling is actually penetrating the bladder
B) Remove the needle and abort the procedure
C) Remove the needle and re-pass it on the same side and again cystoscope to be sure it does not penetrate the bladder on the second pass
D) Remove the needle and call for a urologic consultation to determine if the penetration site needs to be formally repaired
C
A 52 year-old woman presents with complaints of worsening urinary urgency and urgency incontinence. Which of the following findings might prompt a cystoscopic evaluation?
A) all woman with OAB should have cystoscopy
B) a dipstick positive for hematuria
C) a history of exposure to Blue Dye #4
D) 3 or more red blood cells/high power field on a properly collected specimen
E) 3 or more red blood cells/high power field on 2 of 3 properly collected specimens
D
Davis R, Jones JS, Barocas DA, Castle EP, Lang EK, Leveillee RJ, Messing EM, Miller SD, Peterson AC, Turk TM, Weitzel W; American Urological Association. Diagnosis, evaluation and follow-up of asymptomatic microhematuria (AMH) in adults: AUA guideline. J Urol, 2012, 188(6 Suppl):2473-81
A) Call for vaginal spotting or bleeding
B) Some vaginal pain lasting up to a week is normal
C) Some mild vaginal discharge is normal
D) The pessary may have metal inside and should be removed prior to obtaining an MRI
D
Walters and Karram; Urogynecology and Reconstructive Pelvic Surgery, 3rd ed., Chapter 14
Next
The prevalence of fecal incontinence from population-based studies of community dwelling older adults, ≥65 years of age range from 3.0 to 16.9% depending on its definition. Which of the following factors is most highly associated with the presence of fecal incontinence in the older woman?
A) Higher Charlson comorbidity score
B) History of hysterectomy with bilateral oophorectomy
C) Chronic diarrhea
D) History of concurrent urinary incontinence
E) Poor self perceived health status
D
Goode PS, Burgio KL, Halli AD, Jones RW, Richter HE, et al. J Am Geriatr Soc 2005;53:629-635
The percentage of Escherichia coli isolated in urine cultures for uncomplicated cystitis is
A) 75%-95%
B) 55%-75%
C) 45%-55%
D) <45%
A
Gupta K et al. Clinical Infectious Diseases 2011;52(5):e103-e1
The Noble-Mengert-Fish procedure…
A) Involves a perianal incision and advancement of the mobilized rectal wall to cover the fistula site
B) Was originally described to treat rectal carcinoma
C) Is indicated for high rectovaginal fistulas
D) Includes a diverting colostomy as an initial step
A
NMF is a transperineal rectal flap procedure to treat rectovaginal fistula.
Novi, JM. JPMS Vol 11(6) Nov/Dec 2005
Which of the following statements regarding behavior treatment is most accurate?
A) Bladder retraining has been shown to result in greater than 50% reduction in urge and stress incontinence episodes
B) Bladder retraining improves nocturia and nocturnal enuresis
C) Pelvic floor muscle training is superior to biofeedback therapy for urge urinary incontinence
D) Pelvic floor muscle training is superior to estim for treatment of urge urinary incontinence
E) C and D
A
Fantl et al demonstrated 57% reductions in UI for stress/urge UI, but no improvement in nocturnal symptoms. Systematic reviews have failed to identify PFMT as superior to any other conservative therapy.
Fantl JA, Wyman JF, McClish DK, et al. Efficacy of bladder training in older women with urinary incontinence. JAMA : the journal of the American Medical Association 1991;265:609-13; Fitz FF, Resende AP, Stupp L, Sartori MG, Girao MJ, Castro RA. Biofeedback for the treatment of female pelvic floor muscle dysfunction: a systematic review and meta-analysis. Int Urogynecol J 2012;23:1495-516; Fitz FF, Resende AP, Stupp L, Sartori MG, Girao MJ, Castro RA. Biofeedback for the treatment of female pelvic floor muscle dysfunction: a systematic review and meta-analysis. Int Urogynecol J 2012;23:1495-516.
A 55 year-old female presents with pelvic pressure and incontinence and has a negative urinalysis but a PVR of 850 ml. Filling cystometry shows absent sensation with filling and no detrusor contraction and the test was stopped at 1000 ml of filling.
What is the NEXT most appropriate diagnostic test?
A) Brain MRI
B) Electroencephalogram
C) Lumbo-sacral spine MRI
D) No further testing is needed. Teach her clean intermittent self-catheterization.
C
Gonzalez RR, Goldfarb DW, Tyagi R, Te AE. Neurologic Disorders. In: Textbook of Female Urology and Urogynecology 3rd Edition, Cardozo L, Staskin D eds. London (UK): Isis Medical Media, Inc., 2010; pp 485-497.
The most common urodynamic findings associated with Parkinson’s disease include each of the following except:
A) Detrusor overactivity
B) Detrusor overactivity with impaired contractility
C) Normal bladder function
D) Outlet obstruction with increased EMG activity
E) Stress urinary incontinence
E
The pathogenesis of Parkinson’s disease involves degeneration of the pigmented dopamine-rick substantia nigra of the brain (an area involved in inhibition of micturition). Sphincter bradykinesia and pseudodysssynergia can be present and results in poorly sustained contractions with outlet obstruction.
Winters, JC, Dmochowski RR, Goldman HB, Herndon CD, Kobashi KC, Kraus SR, et al. Urodynamics studies in adults: AUA/SUFU Guidelines. J Urol 2012, 188:2464-72.
All of the following statements about sexual function after surgery for pelvic organ prolapse are true except:
A) On average, sexual function as measured by validated sexual questionnaires will improve compared to before surgery.
B) 30% to 50% of women with symptomatic pelvic organ prolapse will report dyspareunia prior to surgery
C) The average postoperative dyspareunia rate after posterior colporrhaphy is 18%
D) Performance of a posterior colporraphy at the time of prolapse surgery is associated with worsening sexual function postoperatively.
D
Paraiso MF, Barber MD, Muir TW, et al. Rectocele repair: a randomized trial of three surgical techniques including graft augmentation. Am J Obstet Gynecol 2006; 195:1762-71.
Komesu YM, Rogers RG, Kammerer-Doak DN, et al. Posterior repair and sexual function. Am J Obstet Gynecol 2007; 197:101 e1-6.
Maher C, Baessler K, Barber M, et al. Surgery for Pelvic Organ Prolapse. In: Abrams P, Brubaker L, Cardozo C, Wein A, eds. 5th International Consultation on Incontinence. Paris: Health Publications, Ltd; 2013.
Which of the following is least likely to be affected by mesh placed via a transobturator approach?
A) Thigh abduction
B) Thigh adduction
C) Lateral rotation of the thigh
D) Medial rotation of the thigh
D
From superficial to deep, a trocar or mesh passed through the transobturator approach traverses the following structures: gracilis muscle, adductor longus and brevis muscles, obturator externus muscle, obturator membrane, obturator internus muscle. The gracilis muscle aids with hip adduction and flexion. As the most superficial muscle of the medial thigh, it is often used for flap reconstructive procedures. The adductor longus and brevis muscles aid with thigh adduction. The obturators (externus and internus) aid with thigh abduction and lateral rotation. The muscles that aid with medial (internal) rotation of the thigh are the tensor fascia lata, gluteus medius, and gluteus minimus. None of these latter structures are traversed by trocar or mesh during a transobturator approach and thus medial rotation of the thigh is least likely to be affected with transobturator mesh placement.
Walters and Karram; Urogynecology and Reconstructive Pelvic Surgery, 3rd ed., Chapter 2; Netter’s Atlas
The incidence of overactive bladder is estimated to be:
A) 50-100 cases per 1,000
B) 150-200 cases per 1, 000
C) 1-10 cases per 10,000
D) 25-50 cases per 10,000
B
Hartman et al. Treatment of Overactive Bladder in Women. Evidence Report/Technology Assessment Number 187. AHRQ Publication No. 09-E017 August 2009.
Which of the following is not part of a behavior training program for urinary incontinence?
A) Timed voiding drills
B) Bedside commode
C) Vaginal weighted cones
D) Biofeedback
E) Pelvic floor muscle excercises
B
Voiding diary is usually used as an evaluation measure and a reference to start timed voiding. Bedside commode may be a very effective treatment for patients with limited mobility but is not considered a form of behavioral therapy.
Which of the following is not considered correct ICS terminology for description of complex, noninvasive uroflow?
A) Continuous smooth
B) Continuous intermittent
C) Straining
D) Fluctuating
C
Abrams P, Cardozo, L, Fall M, Griffiths D, Rosier P, Ulmsten U et al, The Standardization of Terminology of Lower Urinary Tract Function: Report from the Standardization Sub-Committee of the International Continence Society. Neurourol Urodyn 2002; 21, 167-178.
All of the following may be seen as vaginal masses (are in differential diagnosis of vaginal mass) except?
A) Urethral diverticulum
B) Skene’s gland cysts
C) Leiomyomas
D) Mullerian duct remnants
E) All of the above may be seen
E
Sandip Vasavada, MD: Evaluation and Management of Suburethral Diverticula in Walters, MD, Karram, M. Elsevier, Urogynecology and Pelvic Floor Dysfunction, 2nd edition, 2006
What urodynamic finding is NOT usually found with myelomeningocele?
A) Detrusor overactivity
B) Detrusor areflexia
C) Bladder neck open
D) Poor bladder compliance
A
Bauer SB. Neurogenic bladder: etiology and assessment. Pediatr Nephrol 2008; 23:541-551.
You are involved in a research study evaluating the outcomes after two different vaginal surgeries for pelvic organ prolapse. You would like to compare the prolapse Stage between the two groups. What type of data is prolapse Stage?
A) Continuous
B) Dichotomous
C) Nominal
D) Ordinal
D
Which of the following is considered a true statement:
A) Both the McCall Culdoplasty and most uterosacral vaginal vault suspension require entrance into the peritoneum
B) Severe leg pain and even foot drop can rarely occur when sutures are passed through the SSL complex
C) Delayed absorbable sutures are preferred when placing external McCall stitches
D) All of the above are correct
E) A and C are correct
E
Improvements in QOL of PTNS have been demonstrated to be relatively similar to:
A) Behavioral therapy
B) Anticholinergic medication
C) Sacral neuromodulation
D) Injection of onabotulinum toxin A
B
Peters KM, Macdiarmid SA, Wooldridge LS, et al. Randomized trial of percutaneous tibial nerve stimulation versus extended-release tolterodine: results from the overactive bladder innovative therapy trial. J Urol 2009; 182:1055-61.
When considering repair of a vesicovaginal fistula:
A) If the fistula was caused by radiation therapy, it may require delay of repair for many months or up to a year.
B) Good surgical techniques include having a tension free and layered closure
C) Whether repaired vaginally or abdominally recurrent fistulae have a high likelihood of being cured.
D) All vesico-vaginal fistula repairs should be delayed until 3-6 months after injury
E) All of the above
F) A, B, and C
F
Angioli R, Penalver M, Muzii L, et al. Guidelines of how to manage vesicovaginal fistula. Crit Rev Oncol Hematol 2003; 48:295-304.
Each of the following is a true statement regarding anal sphincteroplasty in the management of FI except
A) Using the overlapping sphincter technique, the continence rates do not deteriorate with time
B) End to end repairs have similar short term continence rates to overlapping repairs
C) The repair may be less effective in patients with sphincter defects >180 degrees
D) After an obstetrical injury, the repair may be delayed weeks to months
E) The surgery can be performed in the lithotomy or prone, jack-knife position
A
Short term improvement of FI is around 66% and reported to decrease over time with rates of 6-10% at 10 years.
Abrams P, Andersson K, Birder L et al. Fourth International Consultation on Incontinence Recommendations of the International Scientific Committee: Evaluation and Treament of UI, POP and FI. Neurourology and Urodynamics 2010; 29: 213-240.
You are seeing a patient who describes pelvic pressure and inability to completely empty her rectum during bowel movements. She has daily bowel movements associated with a defecatory urge. Your pelvic exam reveals normal posterior vaginal wall support and well coordinated pelvic floor musculature. The levator muscles are supple and seem to appropriately relax with straining. You suspect the patient may have an enterocele that you are not detecting with your clinical exam. Which test might you order to further assess this patient’s symptoms?
A) Anorectal manometry
B) Defecography
C) Endoanal ultrasonography
D) Colonic transit study
E) Electromyography
B
Anorectal manometry is useful in the measurement of rest and attempted defecation intrarectal and anal pressures. For those with bowel emptying issues, this test may help to categorize defecation disorders into dyssynergic patterns vs. inadequate expulsion. Though the patient above could have inadequate expulsion, anorectal manometry would not necessarily confirm or exclude an enterocele. Defecography is performed by placing contrast material into the rectum, vagina, and opacifying the small bowel with contrast. The patient is then instructed to defecate while fluroscopic images are obtained. This imaging study can help to delineate rectoceles, enteroceles, sigmoidoceles, and internal rectal intussuception. It is particularly useful with defecatory symptoms do not match exam findings in order to further assess for anatomic changes. Endoanal ultrasonography is used to image the anal sphincter complex, and is mainly utilized in the evaluation of women with fecal incontinence. Colonic transit study is useful in patients who describe slow colon transit, with decreased urge to defecate and infrequent bowel movements. Electromyography (EMG) uses surface electrodes or needles to monitor muscle activity. It is often one component of anorectal manometry as elevated EMG activity during straining is suggestive of pelvic floor dyssynergia.
Walters and Karram; Urogynecology and Reconstructive Pelvic Surgery, 3rd ed., Chapter 25
Next
When placing a transobturator sling, organize the following layers through which the trocar passes from outside to in
A) skin and subcutaneous fat, gracilis muscle, obturator externus muscle, obturator membrane, obturator interus muscle, adductor brevis, periurethral endopelvic fascia
B) skin and subcutaneous fat, obturator externus muscle, obturator membrane, obturator interus muscle, gracilis muscle, adductor brevis, periurethral endopelvic fascia
C) skin and subcutaneous fat, adductor brevis, gracilis muscle, obturator externus muscle, obturator membrane, obturator interus muscle, periurethral endopelvic fascia
D) skin and subcutaneous fat, gracilis muscle, adductor brevis, obturator externus muscle, obturator membrane, obturator interus muscle, periurethral endopelvic fascia
D
The helical trocar use to place a transobturator sling follows this path (from outside to in): skin and subcutaneous fat, gracilis muscle, adductor brevis, obturator externus musucle, obturator membrane, obturator interus muscle, periurethral endopelvic fascia and then through the vaginal tunnel.
Walters M, Karram M. (2007). Sling Procedures for Stress Urinary Incontinence. (M. Walters & M. Karram, Eds.). In Urogynecology and Reconstructive Surgery, 3 edition. (pg. 196-212). Philadelphia. Mosby Elsevier.
Which of the following statements regarding embryogenesis is CORRECT?
A) By the 16th day the 3rd layer (mesoderm) forms between the ectoderm and endoderm from cells of the primitive streak.
B) The mesoderm fails to separate the endoderm from the ectoderm at two sites: the oropharyngeal membrane and cloacal membrane
C) A teratogenic insult will give rise to a host of malformations related to the organ systems actively developing at that particular time.
D) The metaphros that gives rise to the kidney forms begins to develop at week 5 of gestation and functions by week 8.
E) All of the above
E
The area where the somatic mesoderm and the splanchnic mesoderm layers join in the midline is termed the intermediate mesoderm and gives rise to the urogenital system.
A 50 year old female with urge urinary incontinence presents for evaluation. She has an uncomplicated medical history, normal physical examination and negative urine analysis. The next best approach in the treament of her symptoms includes:
A) Prescription for anticholinergic medications
B) Discussion of dietary, behavioral and exercise options with possible anticholinergic medications if desired
C) Posterior tibial nerve stimulation
D) Discussion of neuromodulation
E) All of the above
B
1st line therapy includes behavior modification, exercise and dietary modification with option of medications. PTNS, neuromodulation and botox are considered 3rd line.
Gormley EA, Lightner DJ, Burgio KL, et al. Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline. The Journal of urology 2012;188:2455-63.
Defecation involves a complex series of events and factors including all except:
A) Stool consistency
B) Anorectal sensation
C) Muscle and neurologic integrity
D) Diet
E) Hormonal status
E
Shah BJ, Chokhavatia S, Rose S. Fecal Incontinence in the Elderly: FAQ. Am J Gastroenterol 2012;107:1635-1646.
Which of the following is the most highly M3 receptor selective anticholinergic?
A) Darifenacin
B) Solifenacin
C) Tolterodine
D) Trospium
E) Oybutynin
A
Haab F, Stewart L, Dwyer P. Darifenacin, an M3 selective receptor antagonist, is an effective and well-tolerated once-daily treatment for overactive bladder. Eur Urol 2004;45:420-9; discussion 9.
A 72 year old woman with OAB has failed behavioral treatment. You try her on an anticholinergic but she returns complaining of multiple side effects. Which of the following is least likely to be related to the medication:
A) Dry mouth
B) Constipation
C) Dry eyes
D) Blurred vision
E) Palpitations
E
Gormley EA, Lightner DJ, Burgio KL, Chai TC, Clemons JQ, Culkin DJ, et al. Diagnosis and Treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline. J Urol 2012, 188, 2455-2463
Which of the following statements regarding Botulinum Toxin is true?
A) Blocks the presynaptic release of acetyl choline
B) Blocks the detrusor cell’s uptake of acetyl choline
C) Is comprised of 3 chains, the light chain which internalizes the toxin, the medium chain which transports the toxin to the vesicle and the heavy chain which binds to vesicle and prevents release of acetyl choline
D) The toxin permanently binds to the muscarinic receptors thereby competitively inhibiting the acetylcholine molecule from binding
A
Which of the following statements regarding Botulinum Toxin is true?
A) Blocks the presynaptic release of acetyl choline
B) Blocks the detrusor cell’s uptake of acetyl choline
C) Is comprised of 3 chains, the light chain which internalizes the toxin, the medium chain which transports the toxin to the vesicle and the heavy chain which binds to vesicle and prevents release of acetyl choline
D) The toxin permanently binds to the muscarinic receptors thereby competitively inhibiting the acetylcholine molecule from binding
With respect to Percutaneous tibial nerve stimulation (PTNS), which of the following statements is most accurate?
A) Compared to tolterodine 4mg extended release daily, PTNS is more effective in treatment of urgency, frequency, urge incontinence
B) Compared to tolterodine 4 mg extended release daily, PTNS results in better improvements in Quality of Life
C) Compared to sham treatment, PTNS results in significant mprovements in global assessment of improvement in OAB symptoms
D) Adverse events with PTNS are common
E) There are no contraindications to using PTNS for OAB
C
Peters et al demonstrated comparable effects between tolterodine and PTNS, with only significant difference in global assessment of improvement. Adverse events are uncommon and only contraindication is presence of a cardiac pace maker or defibrillator.
Peters KM, Macdiarmid SA, Wooldridge LS, et al. Randomized trial of percutaneous tibial nerve stimulation versus extended-release tolterodine: results from the overactive bladder innovative therapy trial. The Journal of urology 2009;182:1055-61.
Peters KM, Carrico DJ, Perez-Marrero RA, et al. Randomized trial of percutaneous tibial nerve stimulation versus Sham efficacy in the treatment of overactive bladder syndrome: results from the SUmiT trial. The Journal of urology 2010;183:1438-43.
A 48 yo woman presents with a 2 year history of worsening urinary urgency and frequency. Her prior physician prescribed behavioral therapeutic techniques but she had no improvement. The minimum basic evaluation for her problem includes which of the following:
A) History and Physical Exam
B) Post void residual
C) Urinalysis
D) Voiding Diary
E) A and C
F) A, C and D
E
Gormley EA, Lightner DJ, Burgio KL, Chai TC, Clemons JQ, Culkin DJ, et al. Diagnosis and Treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline. J Urol 2012, 188, 2455-2463
A device for potential treatment of a RV fistula in a patient who is not a good surgical candiate for medical indications is called a:
A) Seton
B) Breton
C) Rectal button
D) Pelleton
A
Novi, JM. JPMS Vol 11(6) Nov/Dec 2005
Assuming ability to catheterize post procedure, which of the patients with the following conditions would be the least appropriate to receive Botox injections for urgency incontinence?
A) Urinary retention B) Myasthenia gravis C) multiple sclerosis D) Renal insufficiency (GFR
B
Botox is contraindicated in myesthenia gravis and amyotrophic lateral sclerosis (peripheral motor neuropathy). One may elect to use botox in patients with MS if they have urge incontinence or even If they have retention as long as they can catheterize. Renal insufficiency is not a contraindications, but should obtain clearance from nephrology before injection.
During a sacrospinous ligament vault suspension, significant bleeding is encountered while placing the suture through the ligament. You are unable to visualize anything specific to tie off. After packing for a while the bleeding has not abated and she is beginning to get hypotensive. The bleeding vessel probably originates from the:
A) Anterior division of internal iliac
B) Posterior division of internal iliac
C) Perineal artery
D) Inferior mesenteric artery
A
Grays Atlas of Anatomy, 2008. Page 232
Which statement is TRUE about synthetic midurethral slings:
A) Transobturator and retropubic approaches are equally effective for patients with ISD
B) The quality of evidence in the Cochrane Review on midurethral slings is HIGH
C) Transobturator slings have less voiding dysfunction than retropubic slings
D) Retropubic bottom-to-top route is equally effective as top-to-bottom route for primary SUI
C
Ogah J, Cody DJ, Rogerson L. Minimally invasive synthetic suburethral sling operations for stress urinary incontinence in women: a short version Cochrane review. Neurourol Urodyn 2011;30:284-91.
64 year old female presents with mixed urinary incontinence and OAB symptoms. She demonstrates stress incontinence on exam associated with hypermobility but no prolapse. Urinalysis is (+) RBC, negative for nitrate and leukocytes. Spun urine is noted for 10-15 RBC on high-power field with no bacteria or wbc. She is very bothered by her OAB symptoms and incontinence and is eager to be improved. The next best step is:
A) Begin course of nitrofurantoin
B) Proceed with urodynamics for mixed incontinence indication
C) Order CT-Urogram and perform cystoscopy
D) Obtain urine for cytology
E) Obtain urine for NMP biomarker
C
Davis RJ. Jones S,. Barocas DA, et al, Diagnosis, Evaluation and Follow-Up of Asymptomatic Microhematuria (AMH) in Adults: AUA Guideline: Journal of Urology 2012; Volume 188, Issue 6, Supplement , Pages 2473-2481.
You are reviewing the voiding diary of a 38 year old female with normal BMI. She thinks that her voided volume is surprisingly high given the amount of fluid she perceives herself to be consuming. What is the definition of polyuria accepted by the International Continence Society (ICS)?
A) 24 hour voided volume in excess of 2800 ml (>40mL/kg in a 70kg person)
B) Bothersome perception of excessive voiding
C) Maximimum cystometric capacity of >500mL
D) More than 10 voids per 24 hour period
A
The Standardisation of Terminology in Nocturia: Neurourology and Urodynamics 00:179-183 (2002)
According to the 2010 American Urologic Associate Guidelines, all of the following are TRUE regarding the treatment of acute cystitis, EXCEPT:
A) In some regions, trimethoprim 100mg twice daily for 3 days is considered to be equivalent to trimethoprim-sulfamethoxazole
B) Trimethoprim-sulfamethoxazole is an acceptable first line agent for empiric treatment of uncomplicated cystitis if the local resistance of uropathogens does not exceed 5%
C) Amoxicillin or ampicillin should not be used for empiric treatment of acute cystitis.
D) Nitrofurantoin monohydrate 100mg twice daily for 5 days should be avoided if early pyelonephritis is suspected.
B
During the development of the genitourinary system, the metanephros represents which of the following:
A) Primative, nonfunctioning kidney
B) Primative, functioning kidney
C) Permanent functioning kidney
D) None of the above
C
Campells Urology
Which of the statements regarding Botulinum toxin A injection therapy for refractory overactive bladder is true?
A) Botulinum toxin A 100 Units is recommended as alternative to initial trial of anticholinergic therapy
B) If a patient with idiopathic OAB has inadequate relief with Botulinum toxin A 100 Units at 1 week, then the 200 unit dose should be administerd.
C) Botulinum toxin A 200 units is superior to 100 units in the treatment of idiopathic OAB
D) Botulinum toxin A injections are associated with urinary retention rates requriring catheterization around 10 - 25%
E) Botulinum toxin A injections are associated with 10 - 20% urinary tract infection rates
D
Botox is 3rd line therapy (thus should try medications first) and approved for idiopathic OAB at 100 U doses and have rates of retention of 10 - 20% with infection 30-50%. There are no data to support increasing dose of botox from 100 to 200 if failure to achieve satisfactory outcome and FDA recommends waiting at least 8 weeks before repeat injection to decrease development of antibodies.
Gormley EA, Lightner DJ, Burgio KL, et al. Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline. The Journal of urology 2012;188:2455-63; Brin MF, Botulinum toxin: chemistry, pharmacology, toxicity, and immunology. Muscle Nerve Suppl. 1997;6:S146.
A 36 year old woman with multiple sclerosis and refractory OAB failed treatments with Botox and sacral neuromodulation. A bladder augment was performed. Two years later she presents to the emergency room with the complaint of significant abdominal pain. She had been at a “keg” party the night before. Her abdomen is tender. Appropriate management at this point is a:
A) Pain medicine
B) CT cystogram
C) Bladder irrigation
D) Laparoscopy
B
Biers SM, Venn SN, Greenwell TJ, The past, present and future of augmentation cystoplasty. BJUI 2012; 109:1280-93.
93 year old female with history of dementia is brought in by her daughter with chief complaint of daytime urgency, frequency and nocturia 5 times a night. After complete history and physical examination she is noted on voiding diary to have normal bladder capacity but nocturnal polyuria with more than 1/2 of her daily fluids (1000 mL of fluid) excreted at night? Which is the following is the next best treatment recommendation?
A) Restrict fluids to less than 1000 mL per 24 hours
B) Prescribe DDAVP 0.1 mL nasal spray before bedtime
C) Recommend bedside commonde to prevent falls at night
D) Restrict fluids after dinner time and change timing of diuretic medications from late afternoon/early evening
E) Prescribe zolpidem to improve sleep
D
DDAVP has risk of hyponatremia and seizures especially in the elderly. Fluid restriction alone will not likley change polyuria and may be harmful to this elderly patient,
Duplication of the uterus (uterine didelphys) occurs because:
A) Lack of regression of mesonephric ducts
B) Failure of the vaginal plate to canalize
C) Lack of fusion of the paramesonephric ducts
D) Failure of the genital tubercle
C
Carlson BM. Human Embryology and Developmental Biology, 4th Ed. Philadelphia (PA): Mosby, Inc., 2009.
A 17 year old patient presents with primary amenorrhea. She has normal breast development, normal secondary sexual characteristics, normal height and a 2cm vagina. MRI reveals an absent uterus and normal ovaries. The most common associated anomaly is:
A) Coarctation of the aorta
B) Renal agenesis
C) Polydactyly
D) Aortic valve atresia
B
Gidwani G, Falcone T. Congenital Malformations of the Female Genital Tract: Diagnosis and Management. Philadelphia (PA): Lippincott Williams & Wilkins, 1999.
According to the 2012 American Urologic Association Guidelines, which of the following should be considered or used in the initial physical examination of an uncomplicated overactive bladder (OAB) patient, EXCEPT:
A) Examination of lower extremities for edema
B) Mini-Mental State Examination
C) Assess ability of patient to dress independently
D) Assessment of post-void residual urine volume
D
A 57 year old female has been previously diagnosed with interstitial cystitis on basis of clinical and examination parameters. She has tried and failed multiple therapies including oral medications, cystoscopy with hydrodistention and several instillation protocols. She desires your opinion on next step options. All of the following are plausible next steps in the discussion except.
A) Bacillus Calmette Guerin (BCG) instillations weekly
B) Supratrigonal cystectomy and augmentation
C) Urinary diversion and cystectomy
D) Off label use of cyclosporine A orally
E) None of the above
A
The most common tissue type for a urethral carcinoma arising in a diverticulum is:
A) Adenocarcinoma
B) Squamous cell carcinoma
C) Transitional cell carcinoma
D) Mucinous carcinoma
A
Adenocarcinoma is most common.
Foley CL, BJUI 2001, 108: Supplement 2, 20-23
Which of the following are true statements regarding the receptors and mediators involved with medications treating urinary symptoms:
A) β3 adrenergic medications act on β3 receptors in the bladder releasing norephiphrine
B) Selective norephinephrine and serotonin uptake inhibitors increase the amount of norephinephrine and serotonin present in the somatic nucleus (Onuf’s nucleus) in the spinal cord
C) Tricyclics antidepressants are thought to have various sites of action including muscarinic receptors in the bladder, serotonin and norephinephrine nerve terminals in Onuf’s nucleus and the pontine micturition center.
D) Alpha 1 antagonists block norephinephrine activity in the urethra
E) All of the above
E
Silva WA. Pharmacologic Management of Incontinence and Voiding Dysfunction. Pelvic Medicine and Surgery 2005; 11 (1): 1.
Which of the following statements regarding Long term continuation of anticholinergic medications is most accurate?
A) Continuation rates for subjects enrolled in clinical trials is between 40 and 50%
B) More than half of patients given prescriptions for medications refill their first prescription
C) Continuation rates for newer clases of anticholinergic medications (i.e. extended release and transdermal) are higher than for older formulations.
D) Long term continuation of anticholinergic medications when measured using medical claims data is between 17 and 57%
D
More than half of of patients do NOT refill their prescriptions, continuation rates for clinical trials are high and there is no data comparing real life continuation rates for newer formulations of medications.
Sexton CC, Notte SM, Maroulis C, et al. Persistence and adherence in the treatment of overactive bladder syndrome with anticholinergic therapy: a systematic review of the literature. Int J Clin Pract 2011;65:567-85.
All of the following statements about power are true EXCEPT:
A) Power is equal to 1-β B) Power is equal to 1-α C) The probability of making a type II error is β D) α is also called the level of statistical significance
B
Browner WS, Newman TB, and Hulley SB (2007). Getting Ready to Estimate Sample Size: Hypothesis and Underlying Principles in S.B. Hulley, S.R. Cummings,W.S. Browner, D. G. Grady, T.B. Newman (Eds.), Designing Clinical Research (pp.51-60). Philadelphia, PA: Lippincott, Williams & Wilkins.
Which of the following comments can be said regarding the evidence for use of synthetic mesh in the anterior compartment:
A) None of the Level I evidence supports the use of mesh in the anterior compartment
B) No level I data show subjective benefit of using mesh
C) Most of the Level I data show no subjective benefit of using mesh
D) Level I support for synthetic mesh exists only for cases of recurrent prolapse.
E) Uterine preservation is a risk factor for recurrence when mesh is used
C
Altman D, Väyrynen T, Engh EE, et al. Anterior Colporrhaphy versus Transvaginal Mesh for Pelvic-Organ Prolapse. N Engl J Med 2011; 364: 1826-36.
Which of the following is NOT true regarding nerve injury following gynecologic surgery?
A) Incidence is approximately 2%
B) Most injuries are purely sensory
C) The genitofemoral nerve is the most commonly injured nerve
D) Most injuries resolve spontaneously in weeks to months
C
Bohrer JC, Walters MD, Park A, Polston D, Barber MD. Pelvic nerve injury following gynecologic surgery: a prospective cohort study. Am J Obstet Gynecol 2009;201:531.e1-7.
Which of the following biologic materials would be most successful in augmenting anatomic outcomes after anterior colporrhaphy?
A) Porcine small intestine submucosa
B) Bovine pericardium
C) Cadaveric fascia
D) Fascia lata
A
In general, biologic grafts may improve anatomic outcomes with no change in subjective outcomes. Of the various biologic materials, porcine small intestine submucosa (SIS) shows promise and has been compared in a randomized trial to traditional anterior colporrhaphy (TC). In this study the SIS group had 86.2% anatomic cure compared to 59.3% in TC (p = 0.03). In a randomized trial comparing bovine pericardium to anterior colporrhaphy, anterior colporrhaphy with bovine pericardium reinforcement did not show a statistically significant improvement over colporrhaphy alone. In another RCT, solvent dehydrated fascia lata did not decrease recurrent prolapse after anterior colporrhaphy.
Feldner et al. Int Urogynecol J. 2010 Sep;21(9):1057-63. 2. Guerette et al. Obstet Gynecol. 2009 Jul;114(1):59-65. 3. Gandhi et al. Am J Obstet Gynecol. 2005 May;192(5):1649-54.
Your patient is s/p hysterectomy with ovaries in situ 10 years ago and presents with abdominal pain. You note a mass at the vaginal apex and drainage coming from a sinus tract at the hysterectomy scar. Your leading diagnosis is:
A) Ovarian cyst
B) Tubo-ovarian abscess
C) Fallopian tube carcinoma
D) Diverticulitis
D
Diverticulitis is the most common of these choices.
Novi, JM. JPMS Vol 11(6) Nov/Dec 2005
A 45 year old female with C5 spinal cord injury has neurogenic bladder is found to have urinary incontinence and incomplete emptying. Urodynamics confirms detrusor overactivity and detrusor sphincter dyssynergia. She had good dexterity of her right upper extremity and limited dexterity of the left side. The best surgical option for her is:
A) Pubovaginal sling with autologous fascia
B) Mid-urethral sling with mesh
C) Bladder augmentation with continent catheterizable abdominal stoma
D) Transurethral resection of external urethral sphincter
E) Urethral dilation
C
Linsenmeyer TA, Bodner, DR, Creasey GH, Green BG, Groah SL, Joseph A et al, Bladder Management for Adults with Spinal Cord Injury: A Clinical Practice Guideline, Washington DC, Paralyzed Veterans of America 2006.
Which of the following are most likely in a 53 year old woman undergong posterior colporrhaphy?
A) Rectal injury
B) Dyspareunia
C) Ureteral injury
D) Recurrent posterior wall prolapse
B
Dyspareunia is one worrisome complication that may occur after posterior colporrhaphy. Historically, dyspareunia happened more often with aggressive levator plication, but the goal of any posterior colporrhaphy is essentially to provide some narrowing of the vaginal tube. Thus, dyspareunia could occur even without levator plication. Rectal injury can occur with posterior colporrhaphy, but is infrequent. A traditional posterior colporrhaphy is not performed in close proximity to the ureter and thus ureteral injury would be quite unusual. Though recurrent posterior wall prolapse could happen, in general the posterior vaginal wall is least prone to prolapse recurrence.
Walters and Karram; Urogynecology and Reconstructive Pelvic Surgery, 3rd ed., Chapter 20
A 41 year old, G3P3 woman with stress urinary incontinence desires nonsurgical management. She is interested in pelvic floor muscle therapy (PFMT) and asks whether adding biofeedback would be helpful. Which of the following statements is most accurate?
A) PFMT with biofeedback is as effective as PFMT alone
B) Adding biofeedback increases success by 25%
C) Adding biofeedback increases success by 50%
D) Biofeedback results in worse outcomes
A
Shamliyan T, Wyman J, Kane RL. Nonsurgical Treatments for Urinary Incontinence in Adult Women: Diagnosis and Comparative Effectiveness. Rockville (MD); 2012.
What is the most common urodynamic finding in a woman with Parkinson’s Disease with severe nocturia?
A) Detrusor overactivity
B) Detrusor areflexia
C) Incompetent outlet
D) Normal function
A
Ragab MM, Mohammed ES. Idiopathic Parkinson’s disease patients at the urologic clinic. Neurourol Urodyn 2011; 30:1258-61.
Which of following medications is most effective for treatment of stress urinary incontinence
A) local vaginal estrogen therapy
B) oral estrogen therapy
C) duloxetine
D) imiprimine
E) pseudephedrine
C
Although not FDA approved, Duloxetine is approved in Europe for treatment of SUI with reductions in UI episodes of 50+% vs 27-40% for placebo. Local vaginal estrogen therapy MAY be effective in post menopausal women with atrophy, but it is not the “most” effecive of this groupo. ORal estrogens increase UI and imiprimine and pseudephedrine have limited data to support use in SUI.
Medications that are high-risk in the geriatric population include all of the following EXCEPT:
A) Diphenhydramine
B) Diazepam
C) Nitrofurantoin
D) Cefotetan
D
UpToDate. Hospital Management of Older Adults.
When rectal filling reaches a point where the rectoanal inhibitory reflex occurs, there is:
A) Contraction of the internal anal sphincter and relaxation of the external anal sphincter
B) Relaxation of the internal anal sphincter and contraction of the external anal sphincter
C) Relaxation of the puborectalis muscle
D) Contraction of the puborectalis muscle
E) Contraction of the internal and external anal sphincter muscles
B
Remes-Troche JM, Rao SC. Expert Rev Gastroenterol Hepatol 2008;2: 323-335.
The rectoanal inhibitory reflex enables relaxation of the internal and external anal sphincters in response to rectal distension in order to prepare for defecation
A) TRUE
B) FALSE
B
False. The rectoanal inhibitory reflex relaxes the internal anal sphincter and allows for contraction of the external anal sphincter in response to rectal distension in order to prepare for defecation
Hayden DM, Weiss EG. Fecal incontinence: etiology, evaluation, and treatment. Clinics in colon and rectal surgery. Mar 2011;24(1):64-70
E Gutman RE. Colo-Rectal_anal Pathophysiology and Pharmacology. J Pelvic Med Surg. 2003 2003(9):149-158
A true statement regarding the treatment of fecal incontinence is
A) Therapies are tailored according to the severity of incontinence and impact on quality of life
B) Anal sphincteroplasty has durable long term success
C) Initial management would include an anal sphincter repair
D) Treatments such as rectal plugs, rectal stimulation, anal irrigation are common conservative therapies for non neurogenic FI
E) Injection of bulking agents into the sphincter complex should be considered after failed conservative therapy
A
Improvement of FI diminishes over time after anal sphincteroplasty repairs, conservative therapy for non neurogenic FI includes bulking agents, dietary changes, PFM exercises with biofeedback, conservative therapy for neurogenic FI includes rectal plugs, rectal stimulation and anal irrigation, bulking agents are currently considered investigational and other surgeries would be considered after failed conservative therapy
Abrams P, Andersson K, Birder L et al. Fourth International Consultation on Incontinence Recommendations of the International Scientific Committee: Evaluation and Treatment of UI, POP and FI. Neurourology and Urodynamics 2010; 29: 213-240.
A 65 year old female with urgency urinary incontinence has a history of CVA approximately 1 year ago. Which of the following is true regarding urodynamics findings
A) Detrusor overactivity is the most likely urodynamic finding
B) Usually demonstrates detrusor-sphincter dyssynergia
C) Detrusor areflexia is common during initial period after CVA
D) A & B are both correct
E) A & C are both correct
E
Burney T, Senapti M, Desai S et al, Acute Cerebrovascular Accident and Lower Urinary Tract Dysfunction: A Prospective Correlation of the Site of Brain Injury and Urodynamic Findings, Journal of Urology 1996; 156, p1748-1750
In which procedure is a suture placed into one uterosacral ligament, reefed across the posterior (cul-de-sac) peritoneum, and then placed through the other uterosacral ligament?
A) Uterosacral vaginal vault suspension
B) Manchester procedure
C) McCall culdoplasty
D) LeFort colpocleisis
C
The description is for a McCall culdoplasty, where this suture is also affixed to the apex of the vagina. In a uterosacral vaginal vault suspension, separate sutures are placed bilaterally into the uterosacral ligaments at or above the ischial spines and then affixed to the vaginal apex. In the Manchester procedure, the uterus is maintained, the cardinal and uterosacral ligaments are dissected, shortened, and then re-attached to the cervix. A LeFort colpocleisis is an obliterative procedure that does not typically involve the uterosacral ligaments.
Walters & Ridgeway; Obstet Gynecol 2013; 121 (2)
A study is performed to determine the test characteristics for a new diagnostic test for urinary tract infection (UTI), a rapid PCR test for common uropathogens called RapidUTI. 200 consecutive women with one or more symptoms of urinary tract infection (dysuria, urinary frequency, urinary urgency) presenting to the office for evaluation are enrolled. The urine from all enrolled patients is tested by this new test and a urine culture is collected. Patients are considered as having a UTI if the urine culture demonstrates >100, 000 cfu (criterion or gold standard). The results of the study are summarized below:
The positive predictive value of the new test, RapidUTI, is:
A) 75%
B) 87.5%
C) 90%
D) 95%
Next
C
Gala R, Hamilton-Boyles S, Sung VW. SGS Research Handbook - 2nd edition. Fem Pelvic Med Reconst Surg 2011; 17:158-173
While performing a pressure flow study on a 45 year old patient, the nurse notes that Pves catheter reading suddenly drops to zero and Pdet recording becomes negative. What is the most likely explanation?
A) There is a significant recording artifact and you should rezero the catheters and start over.
B) The patient is having a detrusor contraction
C) The transurethral catheter fell out
D) The vaginal or rectal catheter fell out
E) The patient has poor bladder compliance
C
Assuming the catheters were zeroed to atmosphere, if the Pves catheter suddenly is recording zero, it is most likely due to the catheter falling out which can occur during the void.
A reason to consider avoiding a vaginal Latko repair for a patient with a vesicovaginal fistula includes which of the following?
A) The fistula is present near the vaginal apex
B) The fistula is a single fistula
C) This type of repair is associated with a high failure rate
D) The fistula is complicated with multiple connections
D
Walters and Karram; Urogynecology and Reconstructive Pelvic Surgery, 3rd ed., Chapter 35
A 37 year-old woman reports a 2 month history of urinary urgency, frequency and bladder pain. She reports multiple small volume voids throughout the day and also at night. She has a history of irritable bowel syndrome and a prior laparoscopy for chronic pelvic pain. She takes fluoxetine for depression. She forgot to complete a voiding diary. Her pelvic exam is entirely unremarkable. You are considering the diagnosis of painful bladder syndrome. Regarding a potassium sensitivity test (PST), which statement is true?
A) A positive PST is predictive of good response to pentosan polysulfate
B) A positive PST is predictive of good response to a tricyclic antidepressant
C) A PST is not recommended for routine use in the diagnosis of PBS
D) A negative PST rules out PBS
E) A positive PST is specific for PBS
C
The AUA does not recommend routine use of the PST. The PST is not specific for PBS and one study found that 26% patients meeting NIDDK criteria for PBS have a negative test. The test can be painful, risks inciting a severe flare, and does not allow for the diagnosis of other disorders. PST has not been found to be predictive of improvement with pentosan polysulfate, tricyclic antidepressants combined with hepainoid therapy.
Which of the following routes of hysterectomy has the lowest reported rate of ureteral injury?
A) Vaginal hysterectomy
B) Laparoscopic hysterectomy
C) Total abdominal hysterectomy
D) Robotic hysterectomy
A
Radical hysterectomy may cause each of the following except:
A) Autonomic dysfunction to the lower urinary tract
B) Detrusor acontractility with impaired sensation
C) Lack of coordination between the detrusor and the sphincter
D) Stress urinary incontinence
E) Loss of bladder compliance
C
Extensive dissection of the cardinal and uterosacral ligaments which carry parasympathetic and sympathetic nerves causing an autonomic peripheral neuropathy. Damage to the pelvic plexus can also occur with aggressive posterior dissection.
Kershen R and Boone T. Peripheral neuropathies of the lower urinary tract, following pelvic surgery and radiation therapy. In: Corcos J and Schick E eds. Textbook of the Neurogenic Bladder. London and New York. Martin Dunitz Ltd; 2004: 235-244.
A 77 year old female presents with a complaint of vaginal bulging. The POP-Q examination reveals: Aa: +3, Ba: +7, C: +7, D: +7, Ap: +3, Bp: +7, TVL: 8.5, GH: 4, PB: 2.5. Which of the following statements is TRUE?
A) The patient has a more posterior than anterior vaginal prolapse
B) The patient has Stage III Pelvic Organ Prolapse
C) The patient has Stage IV Pelvic Organ Prolapse
D) The patient would do well with a vaginal anterior and posterior colporrhaphy
C
Bump RC, Mattiasson A, Bo K, Brubaker LP. Am J Obstet Gynecol. 1996;175(1):10-17.
The reason Intraoperative recognition of a ureteral injury is most important is that it:
A) Reduces the risk of renal loss
B) Decreases the risk of ureterovaginal fistula
C) Reduces postoperative morbidity
D) Reduces the risk of readmission
A
When comparing tension-free vaginal tape to transobturator tape for the treatment of stress urinary incontinence, which of the following statements is most true?
A) Tension-free vaginal tape is associated with greater bladder injury during placement
B) Transobturator tape is associated with greater voiding dysfunction postoperatively
C) Tension-free vaginal tape is associated with greater neurologic symptoms postoperatively
D) Transobturator tape is associated with greater mesh erosions
A
In two multi-center randomized trials comparing TVT to TOT for the treatment of stress urinary incontinence, bladder perforation during placement and voiding dysfunction postoperatively were significantly greater in the patients receiving TVT than TOT. Neurological symptoms were most common in the TOT group than TVT in one trial, but not statistically significantly different in one trial. Mesh erosions in both trials were similar between groups, however follow up was not greater than 24 months in both trials.
Barber MD, Kleeman S, Karram MM, et al. Transobturator tape compared with tension-free vaginal tape for the treatment of stress urinary incontinence: a randomized controlled trial. Obstet Gynecol 2008;111:611-21.
Richter HE, Albo ME, Zyczynski HM, et al. Retropubic versus transobturator midurethral slings for stress incontinence. N Engl J Med 2010;362:2066-76.
Albo ME, Litman HJ, Richter HE, et al. Treatment success of retropubic and transobturator mid urethral slings at 24 months. J Urol 2012;188:2281-7.
Which is a true statement about vesicovaginal fistula:
A) In developed countries, the incidence of VVF is highest after radiation treatment for gynecologic cancers.
B) Risk factors that potentially impact wound healing include smoking and diabetes mellitus.
C) Vaginal hysterectomy has a higher incidence of vvf than laparoscopic hysterectomy.
D) The reported incidence after hysterectomy is 1 in 2,300 surgeries.
B
Karram MM. Lower urinary tract fistulas. In: Walters MD and Karram MM, eds. Urogynecology and Reconstructive Pelvic Surgery. 3rd ed. Philadelphia, Pa: Mosby Inc; 2007: 445-460.
You are about to perform a cystoscopy under anesthesia with hydrodistension for a patient with interstitial cystitis/painful bladder syndrome. What is the best surgical technique to use?
A) High pressure (80 to 100cmH20) and long duration (>10 minutes)
B) High pressure (80 to 100cmH20) and short duration (10 minutes)
D) Low pressure (60 to 80 cmH20) and short duration (
D
Cystoscopy under anesthesia for the treatment of IC/PBS can serve several purposes: 1) diagnostic evaluation to rule out other lesions 2) therapeutic benefit from hydrodistension and fulguration of Hunner’s lesions if found, which can be easier to see after distension 3) disease “staging” by determination of bladder capacity under anesthesia. Three observational studies of high pressure/long duration cystoscopy under anesthesia all included at least 1 case of bladder rupture and had variable efficacy from 22 to 67%. Recommendation is for cystoscopy under anesthesia with low pressure/short duration technique. Observational studies have shown efficacy rates 30-54% at one month post-treatment that did decline over time. A high pressure/long duration technique increases the risk of complications without an increase in efficacy.
Hanno PM, Burks DA, Clemens JQ, et al. AUA guideline for the diagnosis and treatment of interstitial cystitis/bladder pain syndrome. J Urol. 2011;185:2162-2170
In systematic reviews, which of the following anticholinergic medications has the highest efficacy?
A) Tolterodine 4mg ER
B) Fesoterodine 8 mg
C) Trospium 60 mg ER
D) Oxybutinin 10 mg ER
E) None of the above
E
AUA guideline statements indicate there is insufficient eviedence to show superiority of one anticholinergic medication over another.
Gormley EA, Lightner DJ, Burgio KL, et al. Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline. The Journal of urology 2012;188:2455-63.
A 13 year old premenarchal girl presents with severe pelvic pain. Work-up reveals a thick transverse septum with obstruction. Appropriate treatment options include:
A) Drainage of blood and hormonal suppression
B) Resection and vaginal reconstruction
C) Drain placement
D) Vaginal dilation
E) A and B
F) None of the above
E
Gidwani G, Falcone T. Congenital Malformations of the Female Genital Tract: Diagnosis and Management. Philadelphia (PA): Lippincott Williams & Wilkins, 1999.
According to the 2012 American Urologic Association Guidelines, all of the following are true concerning the measurement of post-void residual (PVR) urine volume, EXCEPT:
A) It should be measured with an ultrasound bladder scanner immediately after the patient voids.
B) Urethral catheterization should be used if an ultrasound bladder scanner is unavailable
C) Anti-muscarinics should be used with caution in patients with PVR> 250-300ml
D) Assessment of PVR is needed in uncomplicated patients receiving anti-muscarinic medications.
D
A patient is undergoing an abdominal hysterectomy for benign disease and the surgeon notes a distal ureteral injury (complete transection) with the electrocautery. The patient has no other co-morbidities and is otherwise healthy. All of the following are likely reconstructive options except?
A) Ureteroneocystostomy
B) Ureteroneocystostomy and psoas hitch
C) Ureteroneocystostomy and transecting contralateral superior vesicle pedicle
D) Transureteroureterostomy
E) End to end ureteroureterostomy
F) D and E
F
Elliott SP, McAninch JW. Ureteral injuries: external and iatrogenic. Urol Clin North Am. 2006 Feb;33(1):55-66
In adult women, which clinical sign or symptom is the most powerful in decreasing the likelihood of UTI when present?
A) Absence of dysuria
B) History of vaginal discharge
C) Absence of back pain
D) Vaginal discharge on examination
B
Based on a MEDLINE search from 1966 to 2001, Bent et al synthesized the likelihood ratios of predicting UTI. Dysuria (summary positive LR 1.5, 95% CI 1.2, 2.0), frequency (LR 1.8, 95% CI 1.1, 3.0), hematuria (LR 2.0, 95% CI 1.3, 2.9), back pain (LR 1.6, 95% CI 1.2, 2.1) and CVAT (LR 1.7, 95% CI 1.1, 2.5) significantly increased the probability of UTI. Absence of dysuria (summary negative LR 0.5, 95% CI 0.3, 0.7), absence of back pain (LR 0.8, 95% CI 0.7, 0.9), h/o vaginal discharge (LR 0.3, 95% CI 0.1, 0.9), h/o vaginal irritation (LR 0.2, 95% CI 0.1, 0.9), vaginal discharge on exam (LR 0.7, 95% CI 0.5, 0.9) significantly decreased the probability of UTI.
Bent S, Nallamothu BK, Simel DL, Fihn SD, Saint S. Does this woman have an acute uncomplicated urinary tract infection? JAMA 2002;287:2701-10.
Studies of sacrospinous ligament and ileococcygeous colpopexy show that recurrence of prolapse is most likely to occur in the:
A) anterior compartment
B) posterior compartment
C) apex
D) genital hiatus
E) cul-de-sac
A
Sze EHM, Karram MM. Transvaginal repair of vault prolapse: a review. Obstet Gynecol 1997; 89:466-75.
The diagnostic modality which has superiority for visualization of the external anal sphincter is:
A) Anal manometry
B) MRI
C) Endoanal ultrasound
D) Defecography
E) Proctoscopy
B
Malouf AJ, Williams AB, Halligan S, Bartram CI, Dhillon S, Kamm MA. Am J Roentgenol. 2000;175:741-5.
Beets-Tan RGH, Morren GL, Beets GL, Kessels AGH, et al. Radiology 2001; 220:81-89
Which receptors in the bladder respond to the neurotransmitter ATP?
A) Nicotinic B) Muscarinic C) Adrenergic D) Purinergic
D
Acetylcholine is a neurotransmitter involved in both sympathetic and parasympathetic nerve transmission and interfaces with both nicotinic and muscarinic receptors. Norepinephrine, involved in sympathetic nerve signaling, interfaces with adrenergic receptors. ATP acts on purinergic receptors in the bladder.
Walters and Karram; Urogynecology and Reconstructive Pelvic Surgery, 3rd ed., Chapter 3
Treatment of nocturnal enuresis or nocturia with polyuria is associated with which of the following adverse events?
A) Hyperkalemia and arrythmias
B) Hypertension and stroke
C) Hypernatremia and altered mental status
D) Hypotnatremia and seizures
D
DDAVP is associated with salt wasting and low serum osmolarity and hyponatremia. Low levels
A 72-year old diabetic patient has been recently hospitalized and was treated with antibiotics. What is the most likely underlying cause of a recent onset of fecal incontinence?
A) Cognitive impairment
B) Pelvic floor muscle dyssenergia
C) Diabetic autonomic neuropathy
D) Fecal impaction
E) Clostridium difficile infection
E
Bliss DZ, Doughty DB, Heitkemper MM. Pathology and management of bowel dysfunction. In: Urinary and Fecal Incontinence Current Management Concepts. 3rd Edition, St Louis, MO: Mosby; 2006:445-451.
Choose the correct order for postoperative complications following transvaginal mesh for prolapse repair as ranked from most to least common
A) Graft erosion > dyspareunia > wound granulation
B) Graft erosion > wound granulation > dyspareunia
C) Wound granulation > graft erosion > dyspareunia
D) Dyspareunia > wound granulation > graft erosion
E) Dyspareunia > graft erosion > wound granulation
A
Abed H, Rahn DD, Lowenstein L, Balk EM, Clemons JL, Rogers RG. Incidence and management of graft erosion, wound granulation, and dyspareunia following vaginal prolapse repair with graft materials: a systematic review. International urogynecology journal. Jul 2011;22(7):789-798
A patient presents with a bowel dehiscence after an abdominal sacrocolpopexy. The main abdominal wall defect is due to a separation of the aponeuroses of all of the following muscles EXCEPT:
A) Internal oblique muscle
B) Rectus muscle
C) External oblique muscle
D) Transversus abdominus muscle
B
McBride AW, et al. Journal of Pelvic Medicine and Surgery. Volume 9, Number 3, May/June 2003
A 42 year old female presents with complaints of urgency urinary incontinence and had has no previous therapy. She has no infection and no pelvic organ prolapse. Which of the following statements is correct?
A) Prior to starting anticholinergic therapy, multi-channel filling cystometry should be performed.
B) Prior to starting posterior tibial nerve stimulation, multichannel filling cystometry should be performed.
C) Prior to scheduling Interstim Stage I, multichannel filling cystometry may be performed.
D) It is best to perform multichannel filling cystometry between Stage I and II Interstim ther
C
Clinicians may perform multi-channel filling cystometry when it is important to determine if altered compliance, detrusor overactivity or other urodynamic abnormalities are present (or not) in patients with urgency incontinence in whom invasive, potentially morbid or irreversible treatments are considered. (Option; Evidence Strength: Grade C)
AUA Guidelines - Adult Urodynamics
A true statement regarding bladder compliance is:
A) It is defined as the change in Pdet/change in volume
B) It is influenced by the sympathetic and somatic nervous systems
C) It is a measure of the coordination between the detrusor and urethral sphincter
D) It may produce a dLPP of 40cmH2O
E) It is likely to be abnormal in patients with a stroke
D
If bladder compliance is poor, it will be reflected by increasing Pdet. Incontinence occurring at this time would be measured as the detrusor leak point pressure. Detrusor leak point pressures >40 cm H20 has been reported as hazardous to the upper tracts.
Winters, JC, Dmochowski RR, Goldman HB, Herndon CD, Kobashi KC, Kraus SR, et al. Urodynamics studies in adults: AUA/SUFU Guidelines. J Urol 2012, 188:2464-72.
An 80 year old woman with known history of narrow angle glaucoma and dementia presents with symptoms of urinary urgency, frequency and urge incontinence. Which is the best initial treatment regimen to institute.
A) Darifenacin 7.5 mg daily with titration to 15 mg as tolerated
B) Biofeedback therapy with behavior modification
C) Mirabegron 25 mg daily with titration to 50 mg as tolerated.
D) Botulinum toxin A injection 100 Units
C
Anticholinergics are contraindicated in patients with narrow angle glaucoma, biofeedback and behavior training will likely not be recalled in this patient with dementia, botox injection is associated with 10-20 % retention rates requiring catheterization. Thus botox may not be best first line therapy.
When considering the use of anti-muscarinic agents, all of the following are true, EXCEPT:
A) If both immediate and extended release preparations of a medication are available, the extended release formulation should be used due to lower rates of dry mouth
B) Most trials that evaluated antimuscarinics for OAB treatment used a PVR of >/=150-200ml as an exclusion criteria.
C) The most life-threatening side effect of anti-muscarinic medications is the impaired cognitive function
D) Meta-analysis data show similar efficacy for all anti-muscarinic medications
C
A 47 year old female is undergoing a complicated abdominal hysterectomy and a distal left ureteral injury is encountered at the just below level of the pelvic brim near the iliac vessels. She has no other pertinent medical history. A consult is called and you discuss reconstructive options with the surgeon. Which of the following is the least likely recommendation for surgical reconstruction of the ureter?
A) Transureteroureterostomy
B) Ureteral reimplant (ureteroneocystostomy)
C) Ureteral reimplant (ureteroneocystostomy) with taking the contralateral superior vesical artery pedicle for improved mobility to the bladder
D) Psoas hitch reimplant of the ureter
E) Boari flap of the bladder to the ureter to increase length
A
Brandes S, Coburn M, Armenakas N, McAninch J. Diagnosis and management of ureteric injury: an evidence-based analysis. BJU Int 2004; 94:277-89.
The following statement is true regarding comparisons of anticholinergics for reducing voids per day:
A) oxybutynin immediate release is more effective than tolterodine immediate release.
B) Tolterodine immediate release is more effective than tolterodine immediate release
C) Oxybutynin extended release is more effective than tolterodine immediate release
D) Tolterodine extended release is more effective than oxybutynin immediate release and extended release.
C
Hartman et al. Treatment of Overactive Bladder in Women. Evidence Report/Technology Assessment Number 187. AHRQ Publication No. 09-E017 August 2009.
When considering repair of a vesicovaginal fistula:
A) If the fistula was caused by radiation therapy, it may require delay of repair for many months or up to a year.
B) Good surgical techniques include having a tension free and layered closure
C) Whether repaired vaginally or abdominally recurrent fistulae have a high likelihood of being cured.
D) All vesico-vaginal fistula repairs should be delayed until 3-6 months after injury
E) All of the above
F) A, B, and C
F
Level I evidence has shown that when compared to traditional vaginal surgery without mesh, abdominal apical prolapse repair with mesh (sacral colpopexy) results in
A) More recurrent prolapse with higher rates of repeat surgery
B) More recurrent prolapse with similar rates of repeat surgery
C) Less recurrent prolapse with similar rates of repeat surgery
D) Less recurrent prolapse with lower rates of repeat surgery
C
Maher CM, Feiner B, Baessler K, Glazener CM. Surgical management of pelvic organ prolapse in women: the updated summary version Cochrane review. International urogynecology journal. Nov 2011;22(11):1445-1457
Compared to placebo, approximately what percentage improvement is typically seen for anticholinergic medications?
A) 20%
B) 40%
C) 60%
D) 80%
B
Systematic review by Herbison et al concluded that overall, anticholinergics were superior to placebo with 40% higher cure or improvement rates with 0.6 reduction in incontinence episodes and voids per 24 hrs.
Herbison P, Hay-Smith J, Ellis G, Moore K. Effectiveness of anticholinergic drugs compared with placebo in the treatment of overactive bladder: systematic review. Bmj 2003;326:841-4.
A healthy 42 year-old woman has undergone a total vaginal hysterectomy, uterosacral ligament suspension. You are performing a cystourethroscopy. The bladder fills nicely and there are no sutures noted within the bladder and no evidence of cystotomy. There is immediate brisk efflux from the left ureter and after 20 minutes you note a sluggish efflux jet from the right ureter. What is the next best step in management?
A) Administer 5mg IV furosemide and wait for 20 more minutes for more brisk efflux.
B) End the case - even though the efflux from the right ureteral orifice was sluggish you know it is patent.
C) Cut the right uterosacral ligament suture and repeat cystoscopy to look for brisk efflux from the right ureter.
D) Cut the right uterosacral ligament suture, repeat cystoscopy and place a stent in the right ureter, even if you see brisk efflux.
E) Cystoscopically attempt to place a stent in the right ureter.
C
Sluggish spill from a ureter on cystoscopy may indicate a partial obstruction. A partial obstruction is likely caused by ureteral kinking from a suture. The suture should be identified and cut. If immediate repeat cystoscopy reveals brisk efflux from that ureter then no further intervention is necessary. A ureteral injury involving incomplete clamping or suture ligation can be remedied by imaging and stent placement only if it is recognized within 30 minutes, so waiting an additional 20 minutes would not be advised.
Khan F, Kenton K. Intraoperative Injury in Reconstructive Pelvic Surgery. Journal of Pelvic Medicine and Surgery. 2006;12:241-256
Which of the the following considerations is the LEAST important when deciding how and when to repair a vesicovaginal fistula that developed after a hysterectomy?
A) Prior radiation exposure
B) Size of the fistula
C) Whether the patient had a total abdominal hysterectomy versus a total vaginal hysterectomy
D) Whether the patient had a total laparoscopic hysterectomy versus a total abdominal hysterectomy
E) Proximity to the ureteral orifices
C
Generally, when performing both an abdominal and a vaginal hysterectomy, the uterus is detached from the proximal vagina using scissors or a scalpel. Therefore, there is less differentiation between these two routes of hysterectomy. A total laparoscopic hysterectomy generally is performed using monopolar energy to perform the colpotomy. The amount of electrical energy used at the vaginal cuff may influence the decision regarding timing of the repair. Similarly, previous radiation exposure could impact timing and approach such as the use of a interposition flap. Finally, the proximity to the ureteral orifices may dictate the use of ureteral stents and route of surgery.
From 2008 to 2010, the most frequent complications reported to the FDA from the use of surgical mesh devices for pelvic organ prolapse included all of the following except
A) Mesh erosion
B) Infection
C) Neuro-muscular problems
D) Organ perforation
C
Urogynecologic Surgical Mesh: Update on the Safety and Effectiveness of Transvaginal Placement for Pelvic Organ Prolapse. FDA Safety Communication2011:Accessed April 6, 2013 at http://www.fda.gov/downloads/MedicalDevices/Safety/AlertsandNotices/UCM262760.pdf.
FDA Executive Summary: Surgical Mesh for Treatment of Women WIth Pelvic Organ Prolapse and Stress Urinary Incontinence. Sept 8-9.2011:Accessed April 7, 2013 at http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/MedicalDevices/MedicalDevicesAdvisoryCommittee/ObstetricsandGynecologyDevices/UCM270402.pdf.
All of the following are strategies to minimize confounding in an observational study except:
A) Excluding the confounder from the study population (Restriction)
B) Stratification
C) Blinding
D) Matching
E) Adjustment using multivariable statistical modeling
C
Grimes DA, Schulz KF. Bias and causal associations in observational research. Lancet 2002; 359:248-252.
A 43 year-old woman is planning to undergo a mid-urethral sling and cystoscopy. She has no medical problems, no prior surgical history, and takes no medications. She has no known allergies. She is 65 inches tall and weighs 63 kg. What is the best option for DVT prophylaxis?
A) Mechanical compression with intermittent pneumatic compression boots
B) Mechanical compression with graduated compression stockings
C) Unfractionated heparin subcutaneously
D) Low molecular weight heparin subcutaneously
E) Early ambulation
E
When the risk for VTE is very low (
The patient whose cystogram is shown is a 42 year old female who complained of heavy menorrhagia, pain related to fibroids and mild stress uirnary incontinence. She underwent a total abdominal hysterectomy 1 week ago but chose to hold on an anti-incontinence procedure because her symptoms were mild. Postoperatively she has noted worsening urinary incontinence. What is the diagnosis?
A) Postoperative stress urinary incontinence
B) Postoperative vesicovaginal fistula
C) Postoperative enterocele
D) Postoperative overactive bladder
E) Postoperative intrinsic sphincter deficiency
C
The cystogram fills the bladder with liquid radioopaque contrast. The cystogram shows a distended bladder to the left of the image with a narrow connection, the vesicovaginal fistula, located at the anterior vaginal cuff and contrast material that was placed in the bladder, filling the vagina.
Which of the following pessaries is most recommended for a 62 year old female with stress urinary incontinence and anterior pelvic organ prolapse?
A) Incontinence ring
B) Cube
C) Gelhorn
D) Hodge
E) Inflatoball
D
Walters and Karram; Urogynecology and Reconstructive Pelvic Surgery, 3rd ed., Chapter 14
A 51-year-old G3P3 female presents with an anterior vaginal wall mass. Compression of the mass in the mid urethra demonstrates some purulent material that discharges from the urethral meatus. She has also complaints of dysuria, dyspareunia and leakage of urine. A videourodynamics study shows an open bladder neck at rest and stress and leakage per urethra with Valsalva maneuvers. The MRI confirms a large mid to proximal urethral saddlebag diverticulum. She desires surgery to correct this. What is the best surgical option to manage her?
A) Incise diverticulum and wait to stage surgical management until discharge subsides
B) Urethral diverticulectomy and simultaneous fascia sling
C) Urethral diverticulectomy and simultaneous synthetic sling
D) Urethral diverticulectomy and periurethral injectable therapy if she has stress incontinence symptoms after surgery
E) Spence procedure and fascia sling
B
Faerber GJ. Urethral diverticulectomy and pubovaginal sling for simultaneous treatment of urethral diverticulum and intrinsic sphincter deficiency. Tech Urol 1998; 4:192-7.
Compliance is best defined as:
A) Change in detrusor pressure divided by change in bladder volume (Pdet /Volume)
B) Change in bladder volume divided by change in detrusor pressure (Volume/Pdet)
C) Change in detrusor pressure divided by change in vesical pressure (Pdet /Pves)
D) Change in bladder volume divided by change in vesical pressure ( Volume/Pves)
B
Abrams P, Cardozo, L, Fall M, Griffiths D, Rosier P, Ulmsten U et al, The Standardization of Terminology of Lower Urinary Tract Function: Report from the Standardization Sub-Committee of the International Continence Society. Neurourol Urodyn 2002; 21, 167-178.
There are more than 23 million Americans with limited English proficiency (LEP). Which of the following statements is true regarding delivery of health care for this population.
A) Compared to to English speaking patients, those with LEP have similar risk of medical harm
B) Health care providers are encouraged to provide medical interpreters for patients with LEP
C) The availability of medical interpreters is a JCAHO safety goal
D) Use of family members to translate during consent process is preferred to having a medical interpreter
E) All of the above.
C
LEP patients have higher medication errors, poor compliance and higher risk of harm than English speaking patients; Health care providers are required by Title VI of the Federal Civil Rights act to provide medical interpreters for patients with LEP, family members have limited ability to translate medical information and have high rates of omission in the process.
Which patient is the LEAST appropriate for additional work up with imaging and/or cytoscopy?
A) 48 yo woman with UTI unresponsive to appropriate treatment based on culture sensitivities
B) 47 yo woman with 4 UTIs in the past 12 months and history of prior midurethral sling
C) 35 yo woman with pyelonephritis during pregnancy
D) 24 yo woman with persistent infections with the same bacteria
E) 50 yo woman with 3 UTIs in the past 12 months
C
Recurrent urinary tract infections are defined as 3 episodes in 12 months or 2 in 6 months. In patients with persistent infections with the same bacteria, infections that do not respond to appropriate treatment, or infections with worsening clinical status despite appropriate therapy, imaging of the urinary tract is indicated. In patients with recurrent or persistent UTIs (especially with a history of stones or prior anti-incontinence surgery), cystoscopy can be indicated. Pregnant women are more likely to have UTIs progress to pyelonephritis due to the decreased peristalsis promoting stasis of urine, mechanical obstruction by the enlarged uterus, increased filtration (less drug exposure) and host defense compromise.
Grimes CL, Lukacz ES. Urinary tract infections. Female Pelvic Med Reconstr Surg 2011;17:272-8.
Which statement is TRUE about treatment success after surgery for SUI?
A) Complication rates between retropubic and transobturator synthetic midurethral slings are statistically similar
B) Retropubic and transobturator slings have similar cure rates for recurrent SUI with ISD
C) In continent women having prolapse surgery vaginally, adding a retropubic TVT had no effect on post-operative rates of urinary incontinence
D) Open Burch procedures have lower cure rates for SUI than pubovaginal fascial slings
D
Wei JT, Nygaard I, Richter HE, Nager CW, Barber MD, Kenton K, Amundsen CL, Schaffer J, Meikle SF, Spino C; Pelvic Floor Disorders Network. A midurethral sling to reduce incontinence after vaginal prolapse repair. N Engl J Med 2012;366:2358-67.
Albo ME, Richter HE, Brubaker L, et al. Burch colposuspension versus fascial sling to reduce urinary stress incontinence. N Engl J Med 2007;356:2143-55.
Suspicion of malignancy in a diverticulum is raised if what is observed per urethra upon transvaginal compression?
A) Blood
B) Pus
C) Firmness
D) Urine
E) A or C are consistent with cancer
E
Both blood and a firm mass are signs of cancer or stone in the urethra.
Foley CL, BJUI 2001, 108: Supplement 2, 20-23
You are performing a hysterectomy and abdominal sacrocolpopexy on a healthy 52 year old female for complete uterine prolapse. When examining the pelvis you notice a pelvic mass overlying the sacrum, extending proximally on either side of midline. What is the most appropriate next step?
A) Call for a gynecologic oncology consult for assistance but begin resection of the pelvic mass.
B) Resect the mass and proceed as planned.
C) Confirm kidneys are in their normal anatomic position and evaluate the position of the ureters.
D) Abort the procedure and close the incision as this is most likely a non-resectable presacral osteosarcoma.
C
A mass, such as the one described could represent a horseshoe kidney. A horseshoe kidney is a congenital defect that arises from the in utero fusion of the kidneys.
A true statement about Botulinum Toxin A for the treatment of UUI include
A) Side effects are increased PVR, urinary retention and UTIs.
B) The duration of effect after one injection may vary.
C) The mechanism of action on smooth muscle may differ than what is known about skeletal muscle
D) Doses of onabotulinumtoxin A are equivalent to doses of abobotulinumtoxin A
E) All the above
F) A, B and C
F
Silva W.Andre. Pharmacologic Management of Incontinence and Voiding Dysfunction. Pelvic Medicine and Surgery 2005; 11 (1): 1. and Gormley EA, Lightner DJ, Burgio KL. Diagnosis and Treatment of OAB (non neurogenic) in adults: AUA /SUFU Guideline. American Urological Association Education and Research, Inc. 2012
hich is the following are the most common pessaries used?
A) Gelhorn pessary
B) Hodge pessary
C) Ring pessary
D) Cube pessary
E) Donut pessary
Next
C
Walters and Karram; Urogynecology and Reconstructive Pelvic Surgery, 3rd ed., Chapter 14
Which subtypes of muscarinic receptors have not been identified in the human bladder?
A) M1
B) M2
C) M3
D) M4
D
M1, M2, and M3 muscarinic receptors have been identified in human bladder. The majority of receptors are M2 but cholinergic activity is mediated by M3. M3 receptors are also found in ocular, salivary, and GI tract glands.
Choose the most accurate statement regarding surgical repair of rectocele.
A) Site-specific posterior vaginal wall repair results in less dyspareunia compared to traditional posterior colporrhaphy
B) Porcine graft augmentation results in improved anatomic outcomes compared to traditional posterior colporrhaphy
C) Porcine graft augmentation results in improved anatomic outcomes compared to site-specific posterior vaginal wall repair
D) Prolapse and colorectal symptoms improve, regardless of whether traditional posterior colporrhaphy or site-specific repair is chosen
D
Paraiso et a.l performed a randomized trial comparing 3 rectocele repair techniques: traditional posterior colporrhaphy, site-specific repair, and site-specific repair with porcine graft augmentation. After 1 year, those subjects who received graft augmentation had a significantly greater anatomic failure rate (12/26; 46%) than those who received site-specific repair alone (6/27; 22%) or posterior colporraphy (4/28; 14%), P = .02. There was a significant improvement in prolapse and colorectal scales and overall summary scores of the Pelvic Floor Distress Inventory short form 20 (PFDI-20) after surgery in all groups (P
Which of the following statements regarding sacral neuromodulation are true?
A) Long term reoperation rates for pain or infection are less than 10%
B) Long term success rates are typically 80%
C) There are major life threating events commonly associated with sacral neuromodulation
D) Advances in the battery design have increased longevity of the device.
E) Systematic reviews have demonstrated >50% improvement in urgency incontinence of 80% in the short term
E
Brazzelli M, Murray A, Fraser C. Efficacy and safety of sacral nerve stimulation for urinary urge incontinence: a systematic review. The Journal of urology 2006;175:835-41.
van Kerrebroeck PE, van Voskuilen AC, Heesakkers JP, et al. Results of sacral neuromodulation therapy for urinary voiding dysfunction: outcomes of a prospective, worldwide clinical study. The Journal of urology 2007;178:2029-34.
In the geriatric population, it is important to evaluate all of the following EXCEPT:
A) Manual dexterity
B) Physical function
C) Cognition
D) Social support
E) Living situation
A
Erekson EA, Ratner ES, Walke LM, Fried TR. Gynecologic surgery in the geriatric patient. Obstet Gynecol. 2012;119:1262-9.
A randomized trial comparing tension-free vaginal tape (TVT) [n=88] to transobturator sling (TOT) [n=82] in women with urodynamic stress incontinence with or without pelvic organ prolapse found that TOT was not inferior to TVT. The Kaplan-Meier survival curve demonstrating the time to development of any recurrent incontinence symptoms (stress or urge) is below:
The most appropriate statistical test for comparing time to development of any recurrent incontinence symptoms is:
A) Paired t-test
B) Wilcoxon sign-rank test
C) Log-rank test
D) Logistic Regression
C
Basic & Clinical Biostatistics, 4th ed. Dawson-Saunders B, Trapp RG, eds. Philadelphia: McGraw-Hill, 2004
Barber M, Kleeman S, Karram M, Paraiso MF, Walters M, Vasavada S, Ellerkmann M. A multi-center randomized trial comparing the transobturator tape with tension-free vaginal tape for the surgical treatment of stress urinary incontinence. Obstet Gynecol 2008; 111:611-21.
A 58 year-old woman is seen in consultation for symptoms of urgency, frequency, and bladder pain. She mentions that a doctor told her last month she might have interstitial cystitis. She reports an approximate 2 month history of worsening urinary urgency and frequency with voids every 1-2 hours during the day and nighttime. She noticed a brief episode of gross hematuria one month ago that resolved after 1 day. She denies any back, flank or abdominal pain but reports a vague sensation of pressure with occasional burning in the suprapubic region. She denies any urinary incontinence. She feels a vague sensation of incomplete emptying. Her medical history is fairly unremarkable other than frequent bouts of upper respiratory infections and chronic constipation. She had a vaginal hysterectomy for menorrhagia 8 years ago. She is a smoker. Her pelvic exam is unremarkable; no prolapse, no masses, no atrophy, and PVR 20cc. Urinalysis is 2+ blood and otherwise negative. She had a recent urine culture at her PCP’s office that shows mixed flora. What is the best next step in her management?
A) Renal ultrasound
B) Cystoscopy
C) Urodynamics
D) Intravenous pyelogram
B
Cystoscopy is not necessary for the diagnosis of interstitial cystitis/painful bladder syndrome; however cystoscopy should be considered when the diagnosis is in doubt and when the differential include bladder cancer, stones, urethral diverticula or intravesical foreign bodies. This presentation is concerning for bladder cancer given the irritative symptoms, intermittent gross hematuria and risk factor of smoking.
Which of the following least accurate with regards to the guarding reflex for continence?
A) External sphincter contraction occurs via somatic nerves
B) Internal sphincter contraction occurs via sympathetic nerves
C) Detrusor relaxation occurs via sympathetic nerves
D) Detrusor activation occurs via parasympathetic nerves
E) Responses occur mainly by spinal reflex pathways
D
The guarding reflex is present during urine storage. Distention of the bladder produces low level afferent firing. Afferent firing stimulates 1) sympathetic outflow to contract the internal urethral sphincter, 2) sympathetic outflow to relax the detrusor muscle, 3) somatic outflow through the pudendal nerve to contract the external urethral sphincter. These responses occur by spinal reflex pathways. A region in the pons (pontine storage center) augments external urethral sphincter activity. During the guarding reflex, the detrusor is relaxed and not activated; parasympathetic outflow is inhibited.
Raz & Rodriguez; Female Urology, 3rd ed., Chapter 3
In which scenario would screening for asymptomatic bacteriuria NOT be indicated?
A) A 32 year-old healthy woman who is 12 weeks pregnant
B) A 64 year-old woman with hypertension and hyperlipidemia who presents to her pre-operative visit for her scheduled prolapse surgery
C) A 44 year-old woman with type 2 diabetes mellitus who presents for office scheduled cystoscopy
D) A 80 year-old woman with rheumatoid arthritis and systemic lupus erythematous who lives in an assisted living facility and presents for routine medical care
E) A 72 year-old healthy woman who presents for scheduled office urodynamic testing
D
Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis 2005;40(5):643-654.
A colleague asks you about a 74-year old patient who had a Perigee mesh kit placed for anterior compartment prolapse. She is doing well and has no Urogynecologic complaints, but a 1cm vaginal mesh erosion is noted. The best advice to give your colleague is:
A) Tell your patient about the erosion, but reassure her that expectant management is safe
B) Don’t tell the patient about the erosion, as it is asymptomatic and there is no need to stir up trouble in this medicolegal environment
C) Tell your patient that the mesh needs to be resected, as type III mesh is associates with sinus tract and abscess formation
D) Tell your patient that she should have the mesh erosion oversewn with a biologic graft
A
Deffieux X, Thubert T, de Tayrac R, et al. Long-term follow-up of persistent vaginal polypropylene mesh exposure for transvaginally placed mesh procedures Int Urogynecol J 2012; 23:1387-1390.
Questionnaires for the diseases of urinary incontinence and pelvic organ prolapse fall into which 3 categories?
A) Symptoms, sexual function, impact on social functioning
B) Severity, distress, impact on lifestyle
C) Symptoms, quality of life, sexual function
D) Social functioning, physical well being, sexual health
E) Sexual well being, severity, distress
C
Barber MD. Symptoms and outcome measures of pelvic organ prolapse. Clin Obstet Gynecol 2005; 48:648-61.
This document describes the various types of questionnaires as Symptoms, Quality of life and sexual functioning.
A 48 year-old women underwent a laparotomy with a transverse skin incision for an abdominal mesh sacral colpopexy and underwent extensive lysis of adhesions during the procedure. She comes into the office for a postoperative visit approximately 2 weeks after her surgery and is complaining of symptoms including sharp burning pain from the region of the lower right pelvis to the right labia, as well as parasthesias over the lower right Mons and labia. Her symptoms seem to be aggravated by activity but she has not noticed any leg weakness or difficulty walking. What is the most likely nerve injured and most likely mode of injury?
A) Femoral nerve injury due to prolonged compression with a self-retaining retractor.
B) Lateral femoral cutaneous nerve injury due to prolonged compression with a self-retaining retractor.
C) Femoral nerve injury due to hyperflexion of the thigh during prolonged lithotomy position.
D) Ilioinguinal nerve entrapped in a wide Pfannenstiel incision.
E) Iliohypogastric nerve entrapped in a wide Pfannenstiel incision.
D
The femoral nerve can indeed be injured by either thigh hyperflexion during prolonged lithotomy or compression against the pelvic sidewall under a lateral blade of a self-retaining rectractor as the nerve emerges from the border of the psoas muscle prior to exiting the pelvis at the inguinal ligament. However femoral neuropathy typically involves weakness of the quadriceps and iliopsoas muscles. The lateral femoral cutaneous nerve can also be compressed by a self-retaining retractor but gives a syndrome of parasthesia and pain along the anterior and posterior-lateral thigh. Both the ilioinguinal and iliohypogastric nerves are vulnerable to entrapment with a wide Pfannenstiel incision and cause neuropathy symptoms similar to those described here. The ilioinguinal nerve is more medial to the anterior superior iliac spine however and more likely to be injured in this manner.
Whiteside JL, Barber MD, Walters MD, et al. Anatomy of ilioinguinal and iliohypogastric nerves in relation to trocar placement and low transverse incisions. Am J Obstet Gynecol. 2003;189:1574-1578; discussion 1578.
A true statement regarding medications used to treat urinary incontinence is:
A) At the dose required to treat SUI, the risk of stroke and severe hypertention is too high to use tricyclic antidepressants.
B) There are Level 1 studies with outcomes at one year, documenting continued success of β3 adrenergic agents.
C) 25% of patients may have nausea if they use an alpha adrenergic agonist
D) Intravesical capsaicin can cause transient pelvic pain.
E) A common side effect of an alpha adrenergic antagonist is urinary incontinence
D
Mariappan P, Alhasso A, Ballantyne Z. et al. Duloxetine, a Serotonin and noradrenaline Reuptake Inhibitor (SNRI) for the Treatment of SUI: A systematic Review. European Urology 2007: 51; 67-84. and Silva W.Andre. Pharmacologic Management of Incontinence and Voiding Dysfunction. Pelvic Medicine and Surgery 2005; 11 (1): 1.
During a challenging abdominal hysterectomy a laceration is noted in the bladder. The patient has no other risk factors and you are called in to consult to fix this. Appropriate next best step(s) would include
A) Open bladder and correct laceration and evaluate ureters
B) Simply fix the laceration noted and proceed with remaining parts of hysterectomy procedure
C) Place a long term Foley catheter and obtain cystogram in one week
D) Observation as bladder laceration is likely extraperitoneal
A
Brandes S, Coburn M, Armenakas N, McAninch J. Diagnosis and management of ureteric injury: an evidence-based analysis. BJU Int 2004; 94:277-89.
The Martius labial interposition flap is based on what distal most aspect for the vascular pedicle supply?
A) Inferior gluteal
B) External pudendal artery
C) Vaginal artery
D) Perineal branch of internal pudendal artery
E) B and D
E
Elkins TE, DeLancey JO, McGuire EJ. The use of modified Martius graft as an adjunctive technique in vesicovaginal and rectovaginal fistula repair. Obstet Gynecol 1990; 75:727-33.
Which of the following statements about clinical evaluation of a young patient with an uncomplicated symptomatic urinary tract infection is incorrect?
A) A urine culture should be reserved for recurrent or complicated UTIs or suspected pyelonephritis to confirm the presence of bacteriuria and the antimicrobial susceptibility of the infecting uropathogen.
B) A dip U/A has a sensitivity of 75% and Specificity of 82% for predicting a UTI and therefore adds little clinically in an acutely symptomatic patient.
C) A formal microscopic urinalysis is helpful and should be considered essential in diagnosising a UTI.
D) Cystitis in women usually presents with acute onset dysuria, frequency, urgency, nocturia, and suprapubic discomfort.
C
In young women the acute onset urinary dysuria, frequency, urgency, nocturia, and suprapubic discomfort is generally all that is required to make the clinical diagnosis of an uncomplicated UTI. Using an inexpensive in office dip urinalysis is reasonable but withholding therapy in an symptomatic patient in the setting of a negative urinalysis is not clinically prudent.
A microscopic urinalysis looking for the presence of leukocytes, bacteria and red blood cells has a very poor ability to predict the presence or absence of a UTI. Approximately 50% of urinary tract infections do not demonstrate hematuria on microscopic exam and bacteria are often unidentifiable in lower colony-count infections.
A positive urine culture is considered the Gold Standard for diagnosing a UTI. A result of > 100,000 CFU/ml of one or two organisms is considered the diagnostic criterion for UTI and some feel that > 100 CFU/ml should suffice in a symptomatic patient. A urine culture is performed to confirm the presence of bacteriuria and the antimicrobial susceptibility of the infecting uropathogen and should be reserved for recurrent or complicated UTIs or suspected pyelonephritis
Hooten T, Uncomplicated urinary tract infection. NEJM 2012; 366: 1028-1037
Hurlbut TA III, Littenberg B. The diagnostic accuracy of rapid dipstick tests to predict urinary tract infection. Am J Clin Pathol 1991;96:582.
In Subsaharan Africa, obstetrical injury is the leading cause of rectovaginal fistula. In the United states, where RVF is a much less common condition, the most common cause of RVF is:
A) Inflammatory Bowel Disease (especially Crohn’s Disease)
B) Iatrogenic (Gynecologic and Colorectal injury)
C) Obstetric Injury
D) Infectious Process (cryptoglandular abscess)
C
Saclarides TJ, Rectovaginal Fistula. Surg Clin N Am 2002; 82: 1261-72.
A 60 year old female who originally presented with recurrent UTI is found to have a post void residual of 350 ml. Her medical history is noted for diabetes and she underwent a midurethral sling procedure 3 years ago. Pressure flow study reveals a Qmax of 6 ml/sec associated with a Pdet@Qmax of 45 cm h20. Which of the following is the BEST statement?
A) She has a flaccid hypotonic bladder consistent with diabetic cystopathy
B) She should have a foley placed and repeat the study in 2 weeks
C) She has bladder outlet obstruction
D) She would benefit from urecholine
E) She would benefit from sacral nerve modulation.
C
Defreitas GA, Zimmern PE, Lemack GE, Shariat SF. Refining diagnosis of anatomic female bladder outlet obstruction: comparison of pressure-flow study parameters in clinically obstructed women with those of normal controls. Urology 2004; 64: 675-679.
Which one of the following statements best describes the P value?
A) It is the probability that the null hypothesis is true.
B) It is the probability that the alternative hypothesis is true.
C) It is the probability of obtaining the observed difference in the outcome measure, or a larger one, given that no difference exists between treatments in the population.
D) It is the probability that the observed difference in the outcome measure was due to random chance.
C
Sedgwick P. What is a p value? BMJ 2012; 345:e7767
Periurethral glands are:
A) Responsible for mucin production which contributes to continence
B) Most prominent in the distal two thirds of the female urethra
C) Lengthy but minimally branching glandular strucutures
D) A and B
D
Scarpero HM, Urol Clin North Am 2011 Feb 38(1) 65-71
All of the following recommendations are accurate except:
A) Endoscopic evaluation of the rectosigmoid region is appropriate for detecting mucosal disease that may contribute to fecal incontinence
B) If a patient has coexisting diarrhea it is important to exclude colonic mucosal inflammation, rectal mass or stricture.
C) Anorectal manometry with rectal sensory testing is the preferred method for defining functional weakness of the anal sphincter and detecting abnormal sensation
D) The ability of the internal sphincter to contract in a reflex case be assessed during abrupt increases in abdominal pressure.
D
Rao S Diagnosis and Management of Fecal Incontinence. Am J Gastro 2004 Practice Guideline Aug. 1585-1603.
The OPUS Trial (Wei et al 2012) randomized 337 stress-continent women scheduled for prolapse surgery to TVT or sham surgery. The MAIN finding in this study was:
A) The number needed to treat with a sling to prevent one case of urinary incontinence was 12
B) Urinary tract infections and bleeding complications were not different between sling and sham groups
C) At 12 months, urinary incontinence was present in 27.3% of patients after sling and 43.0% after sham surgery (P
C
Wei JT, Nygaard I, Richter HE, Nager CW, Barber MD, et al. A midurethral sling to reduce incontinence after vaginal prolapse repair. N Engl J Med 2012;366:2358-67.
In the hallway of your hospital, you are asked to resolve a friendly dispute between a Colorectal and a Gynecologic colleague. They both contend that their own subspecialty is better suited to care for a woman with a delivery-related rectovaginal fistula. Your most accurate statement to settle the discussion is:
A) Colorectal is better suited, because there are more studies about transanal advancement flaps
B) Gynecology is better suited, because the cause of the injury is so familiar to an OB/Gyn
C) Colorectal is better suited, because bowel surgery is more challenging and likely to result in infection, and the colorectal surgeon has more experience
D) There is no evidence that one approach is better than the other for this condition
D
Tsang CBS, Rothenberger DA, Rectovaginal Fistulas; therapeutic options. Surg Clinics N Am 2009; 77: 95-114
When performing a unilateral ureteroneocystostomy which of the following structures may need to be transected?
A) The contralateral uterine artery
B) The contralateral superior vesical artery
C) The ipsilateral superior vesical artery
D) The ipsilateral umbilical artery
B
Middleton RG: Routine use of the psoas hitch in ureteral reimplantation,J Urol 123:352, 1980.
Which of the following is statistically significant with a p value of
B
Basic & Clinical Biostatistics, 4th ed. Dawson-Saunders B, Trapp RG, eds. Philadelphia: McGraw-Hill, 2004
Parasympathetic activity in the lower urinary tract:
A) Results in bladder contraction
B) Results in contraction of the bladder neck
C) Only occurs during an inflammatory state
D) Is associated with relaxation of the bladder
E) Occurs via hypogastric nerve
A
Fowler CJ, Griffiths D, de Groat WC. The neural control of micturition. Nat Rev Neurosci 2008; 9:453-66.
True statements regarding obstetrical anal sphincter tears include each of the following except
A) After repair, the patient is at risk for FI with subsequent vaginal deliveries
B) Preoperative polyethylene glycol is recommended prior to repair
C) An anterior approach sphincteroplasty is the most commonly performed
D) A known risk factor for poor surgical outcome is advanced maternal age
E) First line therapy includes pelvic floor exercises and biofeedback
D
There are no clear predicators for success or failure when evaluating outcomes of obstetrical anal sphincter repair
Hull T. Fecal Incontinence. In: In: Walters MD and Karram MM, eds. Urogynecology and Reconstructive Pelvic Surgery. 3rd ed. Philadelphia, Pa: Mosby Inc; 2007: 259-268.
Early degeneration of the ureteric bud is most likely to result in which of the following?
A) Bladder extrophy
B) Renal agenesis
C) Pelvic kidney
D) Duplicated ureter
E) Ectopic ureter
B
Walters and Karram; Urogynecology and Reconstructive Pelvic Surgery, 3rd ed., Chapter 2
What percent of rectovaginal fistulas in the U.S. are due to obstetric trauma?
A) < 5%
B) 12 - 14%
C) 35 - 49%
D) 74 - 88%
E) > 95%
D
Lowry AC, Thorson AG, Rothenberger DA, Goldberg SM. Repair of simple rectovaginal fistulas. Influence of previous repairs. Dis Colon Rectum 1988; 31:676-8.
Baig MK, Zhao RH, Yuen CH, Nogueras JJ, Singh JJ, Weiss EG, Wexner SD. Simple rectovaginal fistulas. Int J Colorectal Dis 2000; 15:323-7.
A woman with Stage III pelvic organ prolapse has no clinical symptoms of stress incontinence but leaks with cough with her prolapse reduced. She does not wish to undergo an anti-incontinence procedure at her prolapse surgery. What is her average estimated rate of postoperative SUI if she has surgery for prolapse without an anti-incontinence procedure?
A) 12%
B) 27%
C) 59%
D) 82%
C
Nager CW, Tan-Kim J. Pelvic organ prolapse and stress urinary incontinence; combined surgical treatment. UpToDate 2011.
