Urogynae

Question 1

The muscles of the levator ani complex are the

a. Puborectalis, ischiococcygeus, pubococcygeus
b. Bulbocavernosus, superficial transverse perinei, ischiocavernosus, bulbospongiosus
c. Puborectalis, pubococcygeus, iliococcygeus
d. Pubococcygeus, iliococcygeus, pubovaginalis

Answer 1

c. Puborectalis, pubococcygeus, iliococcygeus

Question 2

A 50 year old woman presents with an everted vaginal vault 12 years after vaginal hysterectomy. She is sexually active. The PREFERRED treatment would be

a. Control of the prolapse with a pessary
b. Posterior colpoperineorrhaphy
c. Sacrospinous colpopexy or similar procedure
d. Colpocleisis

Answer 2

c. Sacrospinous colpopexy or similar procedure

O

Question 3

In a nulliparous woman without evidence of prolapse, in the upright anatomical position the normal vaginal axis is

a. Upward and backward at 135 degrees
b. Upward and backward at 230 degrees
c. Upward and backward at 310 degrees
d. Upward and backward at 90 degrees

Answer 3

a. Upward and backward at 135 degrees

O

Question 4

The lifetime risk of having an operation for genital prolapse is

a. 1 in 5
b. 1 in 9
c. 1 in 20
d. 1 in 35
e. 1 in 100

Answer 4

b. 1 in 9

O

Lifetime risk of requiring an operation for prolapse or incontinence is 11-19%
7% for POP (RANZCOG)

Question 5

During the performance of a routine abdominal sacrocolpopexy procedure on a woman with a large recurrent enterocele and rectocele, which of the following is MOST CORRECT

a. The most appropriate mesh is a Type 3 polyglactin mesh (multifilament, microporous)
b. The upper end of the mesh should be attached between S1 and S3 at more than one point
c. The procedure should generally include perineorrhaphy
d. The procedure should be supported by a Muscowitz operation

Answer 5

b. The upper end of the mesh should be attached between S1 and S3 at more than one point

O

Question 6

A low urethral closing pressure is associated with:

a) Grand multiparity
b) External Urethral Sphincter Defect
c) Previous incontinence surgery
d) Poor bladder neck support

Answer 6

b) External Urethral Sphincter Defect

*BUT Actually an internal urethral sphincter defect
?Is answer d) instead

Question 7

Regarding benefits and risks of the tension free vaginal tape procedure, which of the following statements is correct?

a. The cure rate on 24 hours pad test at 3 years is 94-96%
b. The risk of needing to perform self catheterisation is 0.5-1%
c. The risk of overactive bladder postoperatively is 12-15%
d. The vaginal erosion rate within 3 years is 10-11%

Answer 7

b. The risk of needing to perform self catheterisation is 0.5-1%

O

No difference in de novo OAB - 10%
Cure rate is 85%
Erosion risk 7%

Question 8

In Australia the MOST COMMON cause of vesicovaginal fistula is

A. Anterior colporrhaphy
B. Radiation
C. Vaginal hysterectomy
D. Abdominal hysterectomy

Answer 8

D. Abdominal hysterectomy

Question 9

A 50 year old woman presents with an everted vagina 12 years after vaginal hysterectomy. She is sexually active. The PREFERRED treatment would be

A. control of prolapse with Protex pessary
B. posterior colpoperineorrhaphy
C. sacrospinous colpopexy or similar procedure
D. colpocleisis

Answer 9

C. sacrospinous colpopexy or similar procedure

Question 10

In a RCT of a new repair technique for rectocoele the most appropriate method for determining the outcome of the procedure is:

A. Sim’s speculum exam by surgeon at 3months
B. Bimanual exam by blinded external observer at 3months
C. Validated pelvic organ prolapse questionnaire assessed by the surgeon at 3months
D. POPQ score by blinded external observer at 3months

Answer 10

D. POPQ score by blinded external observer at 3months

O

Question 11

Which drug exacerbates stress incontinence?

a. Hydralazine
b. Enalapril
c. Propranolol
d. Warfarin

Answer 11

b. Enalapril

ACE-I so cough is a side effect

Question 12

What is not a cause of urinary retention and overflow incontinence?

a. Fibroids
b. Pregnancy
c. HSV
d. Cholinergic agents

Answer 12

d. Cholinergic agents

Question 13

A 60 yo otherwise well woman with symptomatic uterine prolapse. Current treatment advice should be?

a. LAVH
b. Vag hyst
c. Sacrospinous colpopexy
d. HRT
e. Ring pessary

Answer 13

b. Vag hyst

M

Question 14

The five-year success rate of Burch colposuspension for stress incontinence is:

a. 30%
b. 50%
c. 85%
d. 95%

Answer 14

c. 85%

M

Question 15

The 5 year success rate of anterior repair for stress incontinence is:

a) 90%
b) 70%
c) 50%
d) 40%

Answer 15

d) 40%

Question 16

All of the following are appropriate treatments of detrusor instability except:

a) Ileal conduit
b) Sacral nerve desensitisation
c) Permanent IDC
d) Cholinergic agents
e) Hydrodistension of the bladder

Answer 16

d) Cholinergic agents

Use ANTI-cholinergic agents

Question 17

51 yo woman presents with enterocele 3 yrs after Burch. Cause of this is mainly due to:

a) big babies
b) change in vaginal axis
c) menopause

Answer 17

b) change in vaginal axis

The normal axis of the vagina is almost horizontal. Because the vagina is a tubular structure, pulling up on the anterior vagina also elevates the posterior vagina. This can pull the posterior vagina up out of its normal position, opening the rectouterine pouch of Douglas and thereby predisposing patients to enterocele formation, uterine prolapse and vaginal vault eversion

Question 18

A 50 yo with stress incontinence and cystourethrocele. Which surgical management is most likely to be effective?

a) Retropubic urethropexy
b) Anterior repair with Kelly sutures
c) Aldridge sling
d) Sacrospinous fixation of periurethral ligaments

Answer 18

a) Retropubic urethropexy

This has the highest success rates of surgical treatment of GSI, with the Burch being treatment of choice. MMK involves placing sutures from the pubocervical fascia directly into the pubic symphysis. Success rates are comparable but advantages of the Burch include correction of
co-existing cystocoele, lack of osteitis pubis and firmer point of fixation

Question 19

Which of the following are true about vesico-vaginal fistulas?

a) site can be accurately localised with an IVU
b) characteristically appear by day 3 post hysterectomy
c) are usually situated above the trigone of the bladder
d) are common following appropriately repaired crush injuries of the bladder
e) large fistula causes a large urine leak

Answer 19

c) are usually situated above the trigone of the bladder

Mostly occur after TAH, typically day 10 post op. Use tampon test and methylene dye into bladder to diagnose (IVU will diagnose urethral fistula)

Question 20

Which of the following is not associated with detrusor instability?

a) genitourinary stress incontinence
b) dementia
c) multiple sclerosis
d) interstitial cystitis
e) autonomic neuropathy

Answer 20

a) genitourinary stress incontinence

Urge incontinence is not caused by failure of urethral support or closure, but rather by uninhibited contractions of detrusor muscles

Question 21

Drugs which worsen stress incontinence, correct option:

a) amiodarone
b) phenoxybenzamine
c) phenylephedrine
d) tolbutamide

Answer 21

b) phenoxybenzamine

Alpha and Beta agonist

Question 22

What is true of incontinence?

a) 25% of nursing home residents are affected
b) Incontinence is often the trigger for institutionalisation of elderly folk
c) Incontinence is a normal part of ageing
d) Kegel’s exercise will obtain 80% rate of complete cure in older women
e) Estrogen has been proven in RCT to improve GSI

Answer 22

b) Incontinence is often the trigger for institutionalisation of elderly folk

Kegel’s exercise according to Novak’s has been shown to cure 32% of patients with GSI and improve the remaining 68%.
50-60% of nursing home patients have urinary incontinence

Question 23

Concerning the investigation of urodynamics. Select the incorrect option:

a) GSI does not occur with bladder pressure below 30cm water
b) Urodynamics cannot distinguish between functional and neuropathic detrusor instability
c) In order to calculate detrusor pressure, it is necessary to measure intravaginal or rectal pressure

Answer 23

a) GSI does not occur with bladder pressure below 30cm water

Urethral closing pressure <20cmH20

Question 24

Sexually active 27 year old has 2/52 hx of urgency and dysuria. Came to casualty, MSU collected and commenced on Cefalexin. There was no growth on the MSU. Her symptoms persist. Next?

a) repeat MSU
b) Quantitative analysis of urine WBC
c) Urethroscopy
d) Chlamydia swabs of urethra and cervix

Answer 24

d) Chlamydia swabs of urethra and cervix

Question 25

Which of the following is the commonest cause of urinary incontinence?

a) Genito urinary stress incontinence
b) Detrusor instability
c) Detrusor-urethral dysenergia
d) Neurogenic bladder
e) Drug therapy

Answer 25

a) Genito urinary stress incontinence

Question 26

Post-op Burch colposuspension, patient complains of severe pain in one groin. Cause?

a) Space of Retzius haematoma
b) Ilioinguinal nerve damage
c) Pubic bone trauma
d) UTI

Answer 26

b) Ilioinguinal nerve damage

Space of Retzius: area between the bladder and symphysis pubis
- can get haematomas

But UNILATERAL groin pain more consistent with ilioinguinal nerve injury

Question 27

A primiparous patient has a normal vaginal birth including 4h continuous lumbar epidural anaesthesia. She was catheterised twice in labour with an in-out catheter. 6 hours after delivery she was unable to void. An indwelling catheter was inserted and drained 1500mLs. The catheter was left in overnight and removed the next day. She voided small amounts during the day, 50-100mL at a time. A second indwelling catheter was inserted and drained 700mL. The cause of the urinary retention was:

a) Urethral spasm
b) Urethral trauma
c) Detrusor failure
d) Parasympathetic blockade caused by the epidural anaesthesia

Answer 27

c) Detrusor failure

Question 28

A woman had midcavity forceps under epidural for prolonged stage 2. 4 hrs after delivery the bladder was noted to be distended, she voided 200ml of urine and the residual was 700 ml. She was able to void 100-200 ml at each time. 12 hrs later, IDC was inserted and noted residual of 1000ml. Which of the following is correct?

a) urethral dysfunction
b) detrusor dystonia
c) parasympathetic block secondary to epidural
d) probanthine should be started
e) bethenacol 25mg qid

Answer 28

b) detrusor dystonia