MRCOG Part 2 – Urogynaecology & Pelvic Floor Problems EMQs

For each scenario, choose the most likely prolapse stage based on the following POP-Q assessment:

• A 47 year old woman presents with a sensation of a bulging lump at the vaginal introitus.  She previously had an total abdominal hysterectomy for large fibroids with significant pressure symptoms. She has tried pelvic floor muscle training but has not had significant benefit.  She is keen to to have definitive treatment with the lowest risk of recurrence. On examination, POP-Q assessment showed:

• A 52 year old woman presents with symptoms of vaginal discomfort and pressure.  She has had increasingly irregular heavy periods for the past year but pelvic ultrasound has not shown any abnormality. She is experiencing hot flushes and night sweats.  She has tried pelvic floor muscle training without benefit.  She is keen to start HRT for her vasomotor symptoms and is concerned that surgery may affect this. On examination, POP-Q assessment shows:

• A 31 year old woman has a planned Caesarean section at 39 weeks for placenta praevia in her first pregnancy.  Post-operatively the urinary catheter is removed 8 hours after delivery.  She passes 120ml of urine at first void but reports a sensation of incomplete bladder emptying and worsening abdominal pain following this.  Bladder scan suggests that there is 400ml of residual urine in the bladder.

• A 31 year old woman has a planned Caesarean section at 39 weeks for placenta praevia in her first pregnancy.  Post-operatively the urinary catheter is removed 8 hours after delivery.  She passes 120ml of urine at first void but reports a sensation of incomplete bladder emptying following this.  Bladder scan suggests that there is 200ml of residual urine in the bladder.  In and out catheter assessment confirms a residual volume of 200ml.

• A 31 year old woman has a planned Caesarean section at 39 weeks for placenta praevia in her first pregnancy.  Post-operatively the urinary catheter is removed 8 hours after delivery.  She passes 120ml of urine at first void but reports a sensation of incomplete bladder emptying and worsening abdominal pain following this.  Bladder scan suggests that there is 400ml of residual urine in the bladder.  In and out catheter assessment confirms a residual volume of 400ml.

• A 31 year old woman has a planned Caesarean section at 39 weeks for placenta praevia in her first pregnancy.  Post-operatively the urinary catheter is removed 8 hours after delivery.  She passes 120ml of urine at first void but reports a sensation of incomplete bladder emptying and worsening abdominal pain following this.  Bladder scan suggests that there is 400ml of residual urine in the bladder. In and out catheter assessment confirms a residual volume of 800ml.

• A 31 year old woman has a planned Caesarean section at 39 weeks for placenta praevia in her first pregnancy.  Post-operatively the urinary catheter is removed 8 hours after delivery. She is unable to pass urine and complains of severe lower abdominal pain. In and out catheter assessment confirms a residual volume of 800ml.

• A 35-year-old woman presents with a 6-month history of persistent severe suprapubic pain associated with urinary urgency and frequency. Urine dipstick testing has been consistently negative and transabdominal ultrasound of the abdomen and pelvis has not shown any abnormality.  She has no significant medical history and denies recreational drugs use.  Her symptoms are debilitating and she is currently off work due to them. Cystoscopy has not shown any significant abnormality.

• A 35-year-old woman is seen in urogynaecology clinic with a 6-month history of persistent severe suprapubic pain associated with urinary urgency and frequency. Urine dipstick testing has been consistently negative and transabdominal ultrasound of the abdomen and pelvis has not shown any abnormality.  She has no significant medical history and denies recreational drugs use.  Her symptoms are debilitating and she is currently off work due to them. Cystoscopy has not shown any significant abnormality.  She has tried conservative measures such as dietary modification and regular analgesia without benefit.

• A 35-year-old woman is seen in urogynaecology clinic with a 6-month history of persistent severe suprapubic pain associated with urinary urgency and frequency. Urine dipstick testing has been consistently negative and transabdominal ultrasound of the abdomen and pelvis has not shown any abnormality.  She has no significant medical history and denies recreational drugs use.  Her symptoms are debilitating and she is currently off work due to them. Cystoscopy confirms the presence of multiple well-demarcated red mucosal lesions at the bladder trigone which bleed on contact.

For each scenario, choose the most likely prolapse stage based on the following POP-Q assessment:

• A 35-year-old woman is seen in urogynaecology clinic with a 6-month history of persistent severe suprapubic pain associated with urinary urgency and frequency. Urine dipstick testing has been consistently negative and transabdominal ultrasound of the abdomen and pelvis has not shown any abnormality.  She has no significant medical history and denies recreational drugs use.  Her symptoms are debilitating and she is currently off work due to them. Cystoscopy has not shown any significant abnormality.  She has tried conservative measures such as dietary modification and regular analgesia without benefit and has tried oral and intravesical pharmacological treatment without significant improvement in her symptoms.

• A 70-year-old woman presents with leakage of urine three years after a transvaginal mesh repair for anterior compartment prolapse.  She is unable to discern whether the leakage occurs from the vagina or the urethra but reports constant uncontrollable leakage of urine.  Clinical examination is suspicious for a vesico-vaginal fistula. Her past medical history includes a permanent pacemaker for complete heart block.

• A 55-year-old woman presents with recurrent urinary tract infections, vaginal spotting and discomfort six years after a transvaginal mesh repair for anterior compartment prolapse. Examination reveals a small area of mesh visible at the vaginal apex.

• A 47 year old woman has a laparoscopic hysteropexy with mesh placement.  Postoperatively, she becomes unwell with abdominal pain, vomiting and abdominal distension.

• A 47 year old woman has a laparoscopic hysteropexy with mesh placement.  Postoperatively, she becomes unwell with abdominal pain, vomiting and abdominal distension.  CT scan shows multiple dilated bowel of small bowel with a transition point at the sacral promontory.

• A 47 year old woman has a abdominal hysteropexy with mesh placement.  At her six month follow up appointment, she reports that she has significant lower back pain since the operation which is affecting her mobility.

• A 47 year old woman has a abdominal hysteropexy with mesh placement.  Post-operatively, she has severe lower back pain, a swinging pyrexia and raised inflammatory markers.  Blood cultures are positive for Staphylococcus aureus.

• A 50-year-old woman presents with urinary urgency, frequency, and nocturia with no stress incontinence symptoms. She has tried lifestyle modifications without success.  Her BMI is 24 and she has no significant past medical history.

• A 50-year-old woman presents with urinary urgency, frequency, and nocturia with no stress incontinence symptoms. She has tried lifestyle modifications without success.  Her BMI is 24 and she has no significant past medical history.  She is commenced on immediate release oxybutynin but reports troublesome symptoms of dry mouth which she finds difficult to tolerate.

• A 62-year-old woman presents with urinary urgency, frequency, and nocturia with no stress incontinence symptoms which did not improve with lifestyle modifications or bladder training.  Her BMI is 24 and she has no significant past medical history.  She has tried a number of pharmacological treatments, including antimuscarinic agents and mirabegron without benefit.  Urodynamic studies shows evidence of detrusor overactivity.

For each scenario, choose the most likely prolapse stage based on the following POP-Q assessment:

• A 62-year-old woman presents with urinary urgency, frequency, and nocturia with no stress incontinence symptoms. She has tried conservative measures without significant benefit.  Her main concern relates to nocturia which she finds particularly distressing and is affecting her quality of life.

• A 60-year-old postmenopausal woman presents with urinary urgency, frequency and vaginal dryness.  She has a BMI of 31 and has a history of hypertension for which she takes amlodipine. Urodynamic studies have not shown evidence of detrusor overactivity.

• A 42-year-old woman presents with leakage of urine during coughing, sneezing, and exercise. Urodynamic testing reveals urine leakage with increased intra-abdominal pressure and no detrusor activity during leakage episodes.

• A 60-year-old woman reports urinary leakage associated with both urgency and physical activity. Urodynamic studies reveal both stress-induced leakage and involuntary detrusor contractions during bladder filling.

• A 45-year-old woman with multiple sclerosis presents with difficulty voiding and episodes of urinary retention. Urodynamic studies reveal simultaneous detrusor contractions with inappropriate external sphincter contraction during voiding.

• A 58-year-old woman presents with urinary urgency, frequency, and nocturia. Urodynamic studies show involuntary detrusor contractions during the filling phase, leading to urinary leakage.

• A 67-year-old woman with a history of previous pelvic radiotherapy for lymphoma presents with a slow urinary stream and incomplete emptying. Urodynamic studies show high detrusor pressures during voiding with poor urinary flow.

For each scenario, choose the most likely prolapse stage based on the following POP-Q assessment:

For each scenario, choose the most likely prolapse stage based on the following POP-Q assessment:

• A 50 year old women presents with a sensation of a vaginal lump on coughing.  She is Para 3, having had three previous vaginal births.  She has no other significant medical or surgical history. She has tried pelvic floor muscle training without significant benefit and wishes to have definitive treatment. On examination, her BMI is 24 and POP-Q assessment showed:

• A 80 year old woman is referred to Urogynaecology clinic following discharge from hospital after her third admission with urinary retention.  On examination, she has a complete procidentia and reports that she has to manually reduce this in order to pass urine.  She has used vaginal shelf pessaries in the past but her mobility has reduced and she now finds it very difficult to manage these.  She is not sexually active and is a resident in a supported living care home.  Her medical history includes osteoarthritis, hypertension and a previous myocardial infarction.

• A 47 year old woman presents with a sensation of a bulging lump at the vaginal introitus.  She previously had a total abdominal hysterectomy for large fibroids with significant pressure symptoms. She has tried pelvic floor muscle training but has not had significant benefit.  She is keen to avoid further surgery at present. On examination, POP-Q assessment showed:

• A 47 year old woman presents with a sensation of a bulging lump at the vaginal introitus.  She previously had an total abdominal hysterectomy for large fibroids with significant pressure symptoms. She has tried pelvic floor muscle training but has not had significant benefit.  She is keen to to have definitive treatment but has read about potential mesh complications and does not wish to have mesh placement. On examination, POP-Q assessment showed: