Urogynaecology

Question 1

You are asked to review a 55 year old woman with overactive bladder symptoms. She has responded poorly to bladder training and is on oxybutynin therapy. Her main complaint is nocturia which is badly affecting her quality of life. What is the best treatment for her continuing symptoms?

a. Darifenacin
b. Desmopressin
c. Mirabegron
d. Tolterodine
e. Transdermal oxybutynin

Answer 1

B - Desmopressin

The use of desmopressin may be considered specifically to reduce nocturia in women with UI or OAB who find it a troublesome symptom. Use particular caution in women with cystic fibrosis and avoid in those over 65 years with cardiovascular disease or hypertension

Question 2

A 46 year old fit and healthy woman has urodynamically confirmed stress urinary incontinence. She has undergone pelvic floor muscle training without improvement. On examination she is noted to have a POP-Q grade 1 anterior vaginal wall prolapse. In view of the effect of her urinary symptoms on her quality of life, she is requesting definitive treatment. What is the most appropriate surgical intervention for her?

a. Anterior colporrhaphy
b. Artificial urinary sphincter
c. Intramural bulking agent
d. Laparoscopic Colposuspension
e. Synthetic mid-urethral tape

Answer 2

E – Synthetic mid-urethral tape

All women with SUI should be referred for pelvic floor exercises in the first instance. If conservative management fails, first line surgical management is a synthetic mid-urethral tape procedure. Anterior colporrhaphy is not indicated since her prolapse is only stage 1 and thus asymptomatic – it also does not treat SUI.

Question 3

A medical student asks for clarity on the relevance of the following documentation from an examination of a woman with prolapse:

Aa 0; Ba 0; C -3; D -4; Bp -5; Ap-3

Which of the following is a standard quantifying tool for the measurement of pelvic organ prolapse?

a. AFS score
b. Baden-Walker halfway scoring system
c. Bristol Female Lower Urinary Tract Symptoms (BFLUTS) score
d. Kings College Health Questionnaire (KHQ)
e. Pelvic Organ Prolapse Quantification System (POP-Q)

Answer 3

E – POP-Q

Question 4

A 32 year old woman had a normal vaginal delivery 6 months ago. She complains of stress urinary incontinence on coughing and sneezing. Abdominal and pelvic examinations were unremarkable and stress incontinence was demonstrable. What is the most appropriate strategy to manage her stress incontinence?

a. No action required as symptoms are likely to improve with time
b. Pelvic floor muscle training
c. Ring pessary
d. Tension free vaginal tape
e. Urodynamics

Answer 4

B – Pelvic floor muscle training
Offer a trial of supervised pelvic floor muscle training of at least 3 months’ duration as first line to women with stress or mixed urinary incontinence

Question 5

A 28 year old nulliparous woman presents with symptoms of overactive bladder (OAB) with urgency urinary incontinence. Her urinalysis is negative and a bladder diary shows a daytime frequency of 12-14 and a nocturnal frequency of 2. She is very concerned as it affected her quality of life. What is the prevalence of OAB in adult females?

a. 5-8%
b. 9-12%
c. 13-16%
d. 17-20%
e. 21-24%

Answer 5

C – 13-16%

Question 6

You see a woman in the urogynecology clinic who complains of stress urinary incontinence. You consider the various mechanisms of this complaint. What nerve is responsible for contraction of the striated muscular layer of the urethra?

a. Pudendal
b. Obturator
c. Genitofemoral
d. Clitoral
e. Vaginal

Answer 6

A - Pudendal

Question 7

You see a woman in the urogynecology clinic who complains of overactive bladder and urge urinary incontinence. You consider the mechanism of this complaint. What nerve is responsible for voluntary control of the detrusor muscle?

a. Pudendal
b. Obturator
c. Genitofemoral
d. Hypogastric
e. Ilioinguinal

Answer 7

A - Pudendal

The detrusor receives somatic, voluntary control from the pudendal nerve, and autonomic control as follows:

• Parasympathetic from S2-4
• Sympathetic from T10-L2

Question 8

A 54 year old woman with known hypertension presents to the gynaecology clinic complaining of stress urinary incontinence. Which of the following drugs, commonly used in the treatment of hypertension may exacerbate stress incontinence?

a. Nifedipine
b. Ramipril
c. Atenolol
d. Methyldopa
e. Doxazocin

Answer 8

E - Doxazocin

Doxazocin is an alpha blocked which relaxes the smooth muscle of the bladder/urethral neck

Question 9

A patient with pelvic organ prolapse is seen in the gynaecology clinic. Her urine dipstick collected at the start of clinic tests positive for leucocytes. She is asymptomatic. What proportion of women who test positive on dipstick testing have an active urinary infection?

a. 85%
b. 60%
c. 40%
d. 33%
e. 25%

Answer 9

D - 33%

Question 10

A 56 year old reports a sensation of incomplete emptying. Her post-void residual is 86ml on bladder scan. What is a normal post-void residual volume?

a. <150ml
b. <100ml
c. <80ml
d. <50ml
e. <10ml

Answer 10

B - <100ml

If a PVR of >100ml is suspected on bladder scan, an in-out catheter is advised to confirm

Question 11

By NICE guidelines on incontinence in women, which of the following does NOT require formal urodynamic testing in advance of surgery?

a. Symptoms suggestive of detrusor over-activity
b. Pure stress incontinence
c. Voiding dysfunction
d. Previous continence surgery
e. Anterior compartment prolapse

Answer 11

B - Pure stress incontinence

Women with anterior compartment prolapse may develop SUI if a repair is performed.

Question 12

A woman with symptoms of hesitancy and poor flow undergoes urodynamic testing. What is considered a normal maximum urinary flow rate (Qmax)?

a. >5ml/s
b. >8ml/s
c. >15ml/s
d. >25ml/s
e. >40ml/s

Answer 12

C - >15ml/s

A normal Qmax on uroflowmetry is >15ml/s - this corresponds to the peak of the ‘Bell-curve’

Question 13

A 60 year old woman is referred to the urogynaecology clinic with a history of anterior compartment prolapse and recurrent urinary tract infection. How many UTIs over a 12 month period are considered diagnostic of ‘recurrent’ UTI?

a. 3 in 12 months
b. 5 in 12 months
c. 6 in 12 months
d. 8 in 12 months
e. 10 in 12 months

Answer 13

A - 3 in 12 months

Question 14

An 89 year old woman is referred to the urogynaecology clinic with a history of overactive bladder - frequency, urge incontinence and nocturia. She is very frail and does not wish to consider surgery. Which of the following drugs is the most appropriate first line management of her symptoms?

a. Duloxetine
b. Mirabegron
c. Oxybutynin
d. Solifenacin
e. Tolterodine

Answer 14

E - Tolterodine

In most women, either oxybutynin, tolterodine or darifenacin is appropriate for OAB - oxybutynin should not be offered to frail, elderly patients however as it crosses the blood-brain barrier and may lead to cognitive impairment

Question 15

What POP-Q marker is used to denote the vaginal vault in a patient, post-hysterectomy?

a. Ap
b. Bp
c. C
d. D
e. V

Answer 15

C - Point C

The vaginal cuff scar following a hysterectomy corresponds to point C on the POP-Q scale

Question 16

A patient is admitted for a vaginal hysterectomy for prolapse. During closure, it is noted that the vault descends to the level of the introitus. What prophylactic measure should be considered to reduce incidence of vault prolapse?

a. Sacrospinous fixation
b. McCall’s culdoplasty
c. Moschowitz procedure
d. Suturing cardinal/uterosacral ligaments to the cuff
e. Sacrocolpopexy

Answer 16

A - Sacrospinous fixation

A few means of minimising the risk of PHVP at primary surgery are described including McCall’s culdoplasty (approximation of the uterosacrals with continuous sutures to obliterate the peritoneum of the posterior cul-de-sac), suturing the cardinal/uterosacrals to the cuff and sacrospinous fixation. Where the vault descends or can be pulled to the introitus at closure, sacrospinous fixation should be considered. While SSF is a highly effective therapy for vault prolapse, with low recurrence rates, there are higher rates of anterior compartment prolapse post-op due to the procedure pre-disposing the anterior compartment to excess intra-abdominal pressure.

Question 17

A patient returns 2 weeks after undergoing a sacrospinous fixation for PHVP complaining of pain in the buttocks. Injury to what nerve is most likely to account for such a presentation?

a. Gluteal
b. Genitofemoral
c. Ilioinguinal
d. Superior gluteal
e. Pudendal

Answer 17

E - Pudendal

Pudendal nerve injury with SSF is described, and partly predictable owing to the anatomical variations in the manner in which the pudendal nerves crosses the ischial spine. Placement of the SSF sutures 1.5-2cm medial to the spines is recommended to reduce the likelihood of this occurring.

Question 18

Which supportive ligaments of the uterus are approximated during a McCall culdoplasty?

a. Round
b. Uterosacral
c. Infindibulopelvic
d. Cardinal
e. Broad

Answer 18

B - Uterosacral

A McCall’s culdoplasty involves approximation of the utero-sacral ligaments with continuous sutures to obliterate the peritoneum of the posterior cul-de-sac.

Question 19

Which of the following is reduced with subtotal hysterectomy when compared with total?

a. Urinary incontinence
b. Vault prolapse
c. Intra- and immediately post-op complication rates
d. Sexual function
e. Vaginal discharge

Answer 19

C - Intra- and immediately post-op complication rates

There is no evidence that performing sub-total (i.e. with preservation of the cervix) in preference to total hysterectomy in the prevention of PHVP. While sub-total is quicker to performed and associated with few intra- and immediate post-op complications, rates of urinary incontinence and vault prolapse are higher subsequently.

Question 20

6. An 86 year old is brought by her carers to the urogynaecology clinic in a wheelchair with suspected post-hysterectomy vault prolapse. On examination there is complete eversion of the vault beyond the hymenal margin. What surgical treatment option is most appropriate here?

a. Open abdominal sacrocolpoplexy
b. Sacrospinous fixation
c. High uterosacral ligament suspension
d. Laparoscopic Sacrocolpoplexy
e. Colpoclesis

Answer 20

E - Colpoclesis

Colpoclesis involves closure of the vagina – it has a short operating time and may be performed under local anaesthetic. It is a safe and effective procedure in frail women who do not wish to retain sexual function.

Question 21

Which of the following is reduced in sacrospinous fixation when compared with abdominal sacrocolpoplexy?

a. Recurrence of prolapse
b. Dyspareunia
c. Stress-incontinence post-op
d. Operating time
e. Buttock pain post-op

Answer 21

D - Operating time

Sacrospinous fixation is associated with a shorter operating time and early recovery when compared with abdominal Sacrocolpoplexy though higher rates of recurrent vault prolapse, dyspareunia and post-op stress incontinence. Interesting this is not reflected in a significant difference in re-operation or patient satisfaction rates.

Question 22

A 55 year old, sexually active patient attends the gynaecology clinic with the feeling of ‘something coming down’ 6 years after undergoing an abdominal hysterectomy for heavy menstrual bleeding. On examination the vault descends to -2. What first line management is appropriate?

a. Pelvic floor muscle training
b. Shelf pessary
c. Sacrocolpoplexy
d. Sacrospinous fixation
e. Colpoclesis

Answer 22

A - Pelvic floor muscle training

Pelvic floor muscle training is an effective treatment option for women with stage I-II vaginal prolapse, including PHVP. Of the other options listed, a shelf pessary is not suitable for a woman who is sexually active and colpoclesis would certainly not be appropriate in such a case. Sacrocolpoplexy and SSF may be considered for more advanced prolapse.

Question 23

A 59 year old present to her GP complaining that she is getting up 3 or 4 times a night to pass urine. Whenever she is out during the day, she finds herself having to go to the toilet often though tends to pass only small volumes of urine at a time. She doesn’t report any leaking and has never had any accidents because she didn’t get there in time. How would you classify this patient’s symptoms?

a. Stress urinary incontinence
b. Urge urinary incontinence
c. Mixed urinary incontinence
d. Overactive bladder
e. Nocturnal enuresis

Answer 23

D - Overactive bladder

Question 24

A 64 year old patient is seen in the urogynaecology clinic complaining that she is unable to cough, sneeze or laugh without leaking urine. She also reports occasional accidents when she cannot get to the toilet on time and that when she needs to go ‘it has to be now’. How would you classify this patient’s symptoms?

a. Stress urinary incontinence
b. Urge urinary incontinence
c. Mixed urinary incontinence
d. Overactive bladder
e. Idiopathic detrusor overactivity

Answer 24

C - Mixed urinary incontinence

Question 25

A patient is seen in the gynaecology outpatient clinic reporting that she recently has had to wear a pad all day and at night as she finds that she tends to leak urine if she cannot get to the toilet in time. What is the first line investigation in this patient?

a. Urine dipstick testing
b. Urine microscopy and sensitivity
c. Bladder scanning for post-void residual
d. Urodynamic studies
e. Cystoscopy

Answer 25

A - Urine dipstick testing

Question 26

A 46 year old Para 5 is seen in the urogynaecology clinic referred with symptoms suggestive of mixed urinary incontinence. Urine tested in clinic was clear for infection. What is your next line investigation?

a. Urodynamics
b. Bladder diary
c. Cystoscopy
d. Scan for bladder capacity
e. Post-void residual using Foley catheter

Answer 26

B - Bladder diary

Question 27

For how long should bladder diaries be completed in order to gain an accurate assessment of patient’s reporting urinary symptoms?

a. 24 hours
b. 3 days
c. 7 days
d. 2 weeks
e. 1 month

Answer 27

B - 3 days

Question 28

A patient with symptoms of leaking urine each time she coughs or sneezes is referred for a trial pelvic floor muscle training. How long should this trial last before re-assessing her symptoms?

a. 3 months
b. 6 months
c. 12 months
d. 18 months
e. 24 months

Answer 28

A - 3 months

Question 29

Which of the following describes the optimum pelvic floor muscle exercising regimen in women with stress urinary incontinence?

a. 8 contractions, 3 times a day
b. 5 contraction, 5 times a day
c. 3 contractions, 4 times a day
d. 10 contraction, 5 times a day
e. 12 contractions, 2 times a day

Answer 29

A - 8 contractions, 3 times a day

Question 30

A 38 year old patient is seen in the urogynaecology clinic with daytime urge incontinence. She has no other gynaecological symptoms nor history of note and her BMI is within normal limits at 24. On examination there is good pelvic floor muscle tone. She informed you that she has been doing regular pelvic floor exercises as instructed by a physiotherapist since the birth of her son 4 years earlier. What is most appropriate first line management in this case?

a. Urodynamic studies
b. Trial of anti-cholinergic drugs
c. Desmopressin
d. Intravesicular Botox
e. Bladder training

Answer 30

E - Bladder training

Question 31

What is the standard dose of Botox A used to treat proven detrusor overactivity in patients with overactive bladder?

a. 50 units
b. 100 units
c. 200 units
d. 500 units
e. 1000 units

Answer 31

C - 200 units

A lower dose may be used in patients unwilling to intermittently self catheterise though accepting of a possible lower success rate

Question 32

How often can Botox therapy be repeated in women who report improvement and request to continue with this treatment?

a. 3 months
b. 6 months
c. 12 months
d. 2 years
e. 3 years

Answer 32

B - 6 months

Question 33

You are assisting with a vaginal hysterectomy for prolapse. During the procedure your consultant explains that she is approximating the uterosacral ligaments as high as possible so as to obliterate the peritoneum of posterior cul-de-sac as high as possible in a bid to prevent subsequent vault prolapse. How is this technique better known?

a. Colposuspension
b. McCall culdoplasty
c. Moschowitz procedure
d. Vaginal sacrocolpopexy
e. Manchester repair

Answer 33

B - McCall Culdoplasty

TOG 2016

Question 34

A 78 year old woman is admitted for vaginal hysterectomy for uterine prolapse. Following the hysterectomy, the vaginal vault is noted to descend to the introitus. What additional procedure should be performed (in keeping with the RCOG Green Top Guideline) to correct this?

a. Vaginal sacrocolpopexy
b. Abdominal sacrocolpopexy
c. McCall culdoplasty
d. Moschowitz procedure
e. Sacrospinous fixation

Answer 34

E - Sacrospinous fixation

TOG 2016

Question 35

A diagnosis of Fowler’s syndrome (FS) is made in a 25-year-old student with polycystic ovary syndrome. What treatment is most effective in restoring voiding in this patient?

a. Anticholinergics
b. Botulinum toxin
c. Intermittent self-catheterisation
d. Physiotherapy
e. Sacral neuromodulation

Answer 35

E - Sacral neuromodulation

The only treatment that has been found to restore voiding in women with FS is sacral neuromodulation. Injection of botulinum into the urethral sphincter have been shown to be effective in managing urinary retention resulting from this condition.

TOG StratOG Resource

Question 36

You suspect that a 20-year-old who presents with urinary retention suffers from Fowler’s syndrome (FS). What test will you perform to confirm the diagnosis?

a. A maximum urethral resting value of 80 mmHg
b. Concentric needle EMG of the striated urethral sphincter
c. Demonstration of painful withdrawal of a urethral catheter
d. Frequency and volume charts (voiding diary)
e. Routine cystometry

Answer 36

B - Concentric needle EMG of the striated urethral sphincter

The maximum urethral closure pressure is typically found to have a measured resting value in excess of 100 cm of water in women with FS. Routine cystometry will demonstrate a large bladder capacity without the usual sensations during the filing phase and filling is often stopped by the urodynamicist at 500 ml on grounds of safety, although the women’s actual functional capacity is much greater. Concentric needle EMG of the striated urethral sphincter is the test used to make a diagnosis.

TOG StratOG Resource

Question 37

A 32 year old woman with a history of polycystic ovarian syndrome and fibromyalgia presents to the emergency gynaecology unit in urinary retention of >1 litre. Subsequent urological and neurological follow up investigations fail to elicit a cause, though urethral sphincter volume is noted to be increased and sphincter electromyography is abnormal. Urinalysis is normal. What is the most likely diagnosis?

a. Fowler’s syndrome
b. Multiple sclerosis
c. Urethral cyst
d. Bladder tumour
e. Interstitial cystitis

Answer 37

A - Fowler’s syndrome

TOG 2018

Question 38

A young women with recurrent admissions in urinary retention is investigated extensively and a diagnosis of Fowler’s Syndrome (abnormally urethral sphincter relaxation) is made. Which of the following treatments has been shown to be most effective in restoring normal voiding in women with Fowler’s Syndrome?

a. Augmentation cystoplasty
b. Intra-urethral heparin injection
c. Intra-vesicular Botox A injection
d. Urethral bulking
e. Sacral neuromodulation

Answer 38

E - Sacral Neuromodulation

TOG 2018

Question 39

A patient with uterovaginal prolapse wishes to undergo surgical repair though is reluctant to consider a hysterectomy. Instead, a uterine-sparing procedure where the round ligaments are sutured to the rectus sheath is performed. How is this procedure better known?

a. Manchester repair
b. Moschowitz procedure
c. Oxford repair
d. Hysteropexy
e. Ventrosuspension

Answer 39

E - Ventrosuspension

TOG 2018