Urogynaecology ( Platinum ) – EMQ

Option List:

A. Pessary
B. Sacrospinous fixation
C.  High uterosacral ligament suspension
D.  Sacrocolpopexy
E. Approximation of the uterosacral ligaments using continuous sutures to obliterate the culdesac as high as possible
F. Bursch colposuspension
G. Sacrocolpopexy with mesh repair for SUI
H.  Colpocleisis
I. Colposuspension with sacrocolpopexy
J. Attaching the uterosacral and cardinal ligaments to the vaginal cuff

For each of the following scenario described, choose the most appropriate surgical procedure from the list of options provided. Each option may be used once or more than once or not at all
1. 87 year old woman has undergone a hysterectomy 30 years back and now has presented with vaginal vault prolapse. She is a known hypertensive, diabetic with HbA1c of 8.2 and case of coronary artery disease. On examination, she was found to have stage 3 vault prolapse on POPQ classification. What is the most appropriate surgical management for this woman?

2. 60 year old woman was diagnosed to have complete vaginal vault prolapse. She wishes to have a surgery that would retain her sexual function. While taking an informed consent, she was explained about the risk of occult urinary incontinence manifesting as SUI post-surgery. She wishes to have a surgery which would prevent SUI also, which is the most appropriate option?

3. 56 year old woman is undergoing an abdominal hysterectomy for uterine fibroids. While performing the surgery, the most appropriate procedure done to prevent post hysterectomy vault prolapse is ?

Option List:

A. Oxybutynin
B. Tolteridine
C. Darifenacin
d. Mirabegron
E. Colposuspension
F. Desmopressin
G. Transvaginal sling procedures
H. Oxybutynin with bladder training
I. Mirabegron with bladder training
J. Botulinum toxin A
K. Botulinum toxin B
L. Duloxetine

4. 58 year old woman who had recovered from myasthenic crisis 6 months back. Following this she had presented with symptoms of urgency, urge incontinence and frequency. Urinary dipstick evaluation by the GP showed no evidence of infection, following which 6 weeks of bladder training was advised. The woman did not achieve satisfactory benefit from the bladder training programme. What is the next step of management?

5. 50 year old multiparous women presented with stress urinary incontinence and no history frequency was advised supervised pelvic floor muscle training for 6 months with very little effect. She wishes to have a definitive benefit but is not willing to undergo surgery. The best drug for the management is

6. 60 year old woman multiparous woman with increased frequency, urgency and urge incontinence and nocturia. She was put on oxybutynin which she did not tolerate. So, she was put on transdermal oxybutynin, but the nocturia was a troublesome that makes her use the washroom four to five times. The next best management would be

Option List:

A. Bladder wall injection of botulinum toxin A 100 units
B. Long term indwelling urethral catheterisation
C. Bladder wall injection of Botulinum toxin A 200 units
D. Open colposuspension
E. Indwelling suprapubic catheter
F. Intramural bulking agents
G. Vaginal sacrospinous hysteropexy with sutures
H. Laparoscopic colposuspension
I. Vaginal hysterectomy with or without vaginal sacrospinous fixation with sutures
J. Sacrohysteropexy with mesh
K.  botulinum toxin type A to 200 units

For each of the following clinical scenario, choose the single most appropriate management from the list of options given above. Each option may be used once, more than once or not at all

7. 45 year old P3L3, all delivered by caesarean section, had presented to the GP with complaints of stress urinary incontinence. She has not had any satisfactory relief and wants a permanent relief. She is very unhappy using any mesh. The most appropriate management option is?

8. 49 year old woman has been treated with bladder training along with oxybutynin for overactive bladder. She was reviewed after 4 weeks during which was found to have no benefit. She is distressed that her quality of life is affected and wants a definitive treatment. The best management option would be.

9. 45 year old had presented with stage 3 pelvic organ prolapse with no demonstrable anterior or posterior wall prolapse. she wishes to have a definitive treatment. She wishes to retain her uterus and is not keen on removal of uterus. The best treatment option would be

Option List :

A. Supervised pelvic floor muscle training
B. Intramural bulking agents
C. Bladder training
D. Biofeedback
E. Oxybutinin
F. Desmopressin
G. Botulinum toxin A 100units
H. Top down retro public mid urethral sling
I. Percutaneous sacral nerve stimulation
J. mid-urethral mesh sling trans vaginal tape
K. Botulinum toxin A 200units
L. Augmentation cystoplasty
M. Local MDT review
N. Botulinum toxin A 200units B 200units
O. Darifenacin
P. Mirabegron

Each of the following clinical scenarios below relate to different treatment options for woman with incontinence.

For each patient select the single most appropriate treatment option from the list above. Each option may be used once, more than once or not at all.

10. Mrs. X, 60 year old, has presented with frequency, dysuria and urgency from 6 weeks.No history of leak during coughing or laughing.This is her first visit to hospital. What is the first line treatment?

11. Mrs. X, 55 year old, has presented with leaking of urine since 6 weeks,she also complains of urgency. There is history of leak during coughing and laughing. Her main symptom is leak during stress. What is the first line of treatment?

12. Mrs.X is a 34 year old woman with urgency, frequency and leaking of urine. Urodynamic studies confirm she has overactive bladder. She is otherwise fit and healthy. She has tried bladder training without any benefit. She doesn’t want Botox A injections as she is quite busy at work. She has been reviewed byLocal MDT team.What is the next appropriate management for her?

13. Mrs.X is 30 year old woman with urgency, frequency and leaking of urine. Urodynamic studies confirm she has overactive bladder. She is otherwise fit and healthy. She has tried bladder training without any benefit. She stopped medicines because of excessive side effects.She was relieved by 100units of Botox A injection which lasted for 4months. Now she has come with recurrence of symptoms. What is next appropriate management to be considered?

14. A 50 year old lady has presented with frequency, urgency and leak. She is otherwise without any comorbidities. She has tried her bladder training which is of little benefit.She was advised to start medicines for her overactive bladder.

15. Ms. Razel, 25 year old fitness trainer presented with leaking of urine during her training sessions. Her symptoms started after last childbirth ; she has tried supervised pelvic floor muscle training with little benefit.She is looking for definitive treatment.

Option List :

A. Stress urinary incontinence
B. Detrusor overactivity
C. Overactive bladder
D. Overactive bladder + stress incontinence
E. Diabetic bladder
F. Urge incontinence
G. Vesicovaginal fistula
H. Bladder pain syndrome
I. Bladder outlier obstruction
J. Detrusor in activity

The following cases indicate various cases of urinary incontinence. Choose the most appropriate diagnosis from the above list. Each answer may be used once, more than once or not at all.

16. 58 years old woman suffering from urinary incontinence, urgency and dribbling of urine. Her urine culture is negative. Her urodynamic studies are as follows:

Bladder capacity: 450 ml
Residual volume: 25 ml
Detruser pressure during the procedure: 50cm of water with leak
Flow rate : 15 mls/sec
First desire to void at 120ml
Incontinence on provocative tests like coughing

17. 58 years old woman post hysterectomy suffering from urinary incontinence, urgency and frequency. Her urine culture is negative. Her urodynamic studies are as follows:
Bladder capacity: 400 ml
Residual volume: 50 ml
Detruser pressure during the procedure stable throughout
Flow rate : 10 mls/sec
Had continuous leakage from the vagina throughout the procedure

18. 58 years old woman suffering from urinary incontinence and urgency. Her urine culture is negative. Her UDS are as follows:

Bladder capacity: 500 ml
Residual volume: 50 ml
Detruser pressure during the procedure: 30cm of water
Flow rate : 20 mls/sec
First desire to void at 90 ml
No incontinence was demonstrated

19. 56 year old woman is undergoing an abdominal hysterectomy for uterine fibroids. While performing the surgery, the most appropriate procedure done to prevent Post hysterectomy vault prolapse is ?

Option List :

A. Oxybutynin
B. Tolteridine
C. Darifenacin
D. Mirabegron
E. Colposuspension
F. Desmopressin
G. Transvaginal sling procedures
H. Oxybutynin with bladder training
I. Mirabegron with bladder training
J. Botulinum toxin A
K. Botulinum toxin B
L. Duloxetine

20. 58 year old woman who had recovered from myasthenic crisis 6 months back. Following this she had presented with symptoms of urgency, urge incontinence and frequency. Urinary dipstick evaluation by the GP showed no evidence of infection, following which 6 weeks of bladder training was advised. The woman did not achieve satisfactory benefit from the bladder training programme. What is the next step of management?

Option List :

A. Bladderwall injection of botulinum toxin A 100 units
B. Long term indwelling urethral catheterisation
C. Bladderwall injection of Botulinum toxin A 200 units
D. Open colposuspension
E. Indwelling suprapubic catheter
F. Intramural bulking agents
G. Vaginal sacrospinous hysteropexy with sutures
H. Laparoscopic colposuspension
I. Vaginal hysterectomy with or without vaginal sacrospinous fixation with sutures
J. Sacrohysteropexy with mesh

For each of the following clinical scenario, choose the single most appropriate management from the list of options given above. Each option may be used once, more than once or not at all

21. 45year old P3L3 all delivered by caesarean section had presented to the GP with complaints of stress urinary incontinence who had not had any satisfactory relief wants a permanent relief. She had been very unhappy using any mesh. The most appropriate management option is?