Questions
DIRECTIONS (Question 1): For each of the multiple choice questions in this section, select the lettered answer that is the one best response in each case.
1. A 44-year-old woman (gravida 5, para 5) comes in complaining that she has noticed a bulge protruding from her vagina. Her other medical problems include hypertension, diabetes mel-litus, and alcoholism.
She stands at work as a grocery clerk. She has a family history of genital prolapse. On examination, you notice a uterine prolapse, cystocele, and rectocele. Which of the following is a major risk factor for her pelvic support disorder?
(A) childbirth (B) hypertension (C) diabetes mellitus (D) positive family history (E) environmental factors—job
DIRECTIONS (Questions 2 through 4): The following group of questions is preceded by a list of lettered options. For each question, select the one lettered option that is most closely associated with it. Each lettered option may be used once, multiple times, or not at all.
(A) cystocele (B) rectocele (C) enterocele
(D) complete uterine prolapse (E) urinary tract infection (UTI) (F) hemorrhoid
(G) vaginal vault prolapse
2. A 49-year-old parous woman comes in complaining that over the last several years, it feels as though
“her organs are progressively falling out her vagina.” She also complains of losing urine with coughing, occasional urgency, and sometimes a feeling of incomplete emptying of her bladder with voiding. On further examination, which of the above-mentioned options will you likely find?
3. A 56-year-old woman complains that she is “sitting on a ball.” She says constipation is a significant problem and that sometimes she needs to push stool out of her rectum by inserting a finger in the vagina and pressing on a bulge. On further examination, which of the above-mentioned options will you most likely find?
4. A 68-year-old woman complains of something falling out of her vagina, and she thinks it causes a constant backache. The backache is least symptomatic when she gets up in the morning and worsens as the day goes on. She says she cannot understand why she has this, because 4 years ago she had an abdominal hysterectomy and urethral suspension (Burch procedure) to correct the “falling out” and
some problem with urine loss. Her ability to hold her urine is excellent since the first surgery. Given her history, on examination which of the above-mentioned do you expect to find?
DIRECTIONS (Questions 5 through 23): For each of the multiple choice questions in this section, select the lettered answer that is the one best response in each case.
5. A 90-year-old woman comes to your office complaining that she feels as though she is “sitting on a ball.” On examination, you find that the vagina is essentially turned inside out, and the entire uterus lies outside the vaginal introitus. This condition is known as which of the following?
(A) first-degree prolapse (B) second-degree prolapse (C) third-degree prolapse
(D) fourth-degree prolapse or procidentia (E) vaginal evisceration
6. A 54-year-old postmenopausal woman G4P4 presents with complaint of vaginal fullness and pressure.
Figure 19–1 depicts a visual drawing of your examination findings on pelvic examination, including split speculum examination. The letter A represents which of the following?
Figure 19–1. (A) rectocele
(B) uterine prolapse (C) cystocele
(D) sigmoidocele (E) enterocele
7. An 18-year-old nulliparous woman comes into your office, complaining of a 24-hour history of urinary frequency, urgency, and suprapubic pain. She had intercourse for the first time earlier this week. She is using a diaphragm for birth control. Which of the following statements reflects current knowledge about uncomplicated urinary tract infections?
(A) Cystitis occurs two times more commonly in men than in women.
(B) In a freshly voided, clean-catch urine specimen, leukocyte esterase and nitrites, in combination
have a poor test performance in diagnosing UTI.
(C) Use of a diaphragm helps prevent the development of UTIs.
(D) A teenager is more likely to have asymptomatic bacteriuria than is a postmenopausal woman.
(E) In women who have frequent UTIs related to coitus, infection can be prevented with low-dose postcoital antibiotics.
8. A woman complains of postvoid dribbling of urine when she stands, painful intercourse, and dysuria.
She has no other symptoms. Which of the following is she most likely to have?
(A) a urinary fistula (B) detrusor instability (C) UTI
(D) genuine urinary stress incontinence (E) a urethral diverticulum
9. A 38-year-old multigravid woman complains of the painless loss of urine, beginning immediately with coughing, laughing, lifting, or straining. Immediate cessation of the activity stops the urine loss after only a few drops. Which of the following is this history most suggestive of?
(A) fistula
(B) stress incontinence (C) urge incontinence (D) urethral diverticulum (E) UTI
10. Kegel exercises were designed to do which of the following?
(A) strengthen the abdominal muscles after childbirth
(B) increase the blood flow to the perineum to speed the healing of an episiotomy
(C) improve the tone of the muscles surrounding the bladder base and proximal bladder neck (D) prevent denervation of pelvic muscles after childbirth
(E) decrease the muscle atrophy associated with aging
11. A 10-year-old patient’s mother gives a history of the child constantly wetting herself, requiring the continuous use of diapers since birth. The child is otherwise very healthy and happy and does well in school. Which of the following diagnoses would most closely fit this clinical history?
(A) maternal anxiety
(B) ectopic ureter with fistula to the vagina (C) stress incontinence
(D) urethral diverticula (E) vesicovaginal fistula
12. A 52-year-old postmenopausal woman complains of urinary frequency, urgency, and urge
incontinence. She is otherwise healthy. Which of the following should be included in the behavioral treatment you recommend?
(A) relaxation techniques (B) anticholinergic medication
(C) voiding every hour during the daytime (D) bladder retraining
(E) incontinence pad testing
13. A 35-year-old woman (gravida 4, para 4) complains that she loses urine intermittently and without warning. At other times, she cannot get to the bathroom in time when she first feels the urge to void and also loses urine. She denies dysuria or loss of urine with exercise. Pelvic examination is normal,
except for a first-degree cystocele. Postvoid residual is 150 mL. Of the following options, which is the best plan?
(A) instruct in Kegel exercises
(B) teach clean intermittent self-catheterization
(C) do an intravenous pyelogram (IVP) looking for a urinary fistula (D) perform urodynamic testing looking for a neurogenic bladder (E) give her a trial of anticholinergic medication
14. Which of the following is the most common cause of rectovaginal fistula?
(A) obstetrical delivery (B) irradiation to the pelvis (C) carcinoma
(D) hemorrhoidectomy (E) Crohn’s disease
15. If a rectovaginal fistula is identified, which of the following should initial treatment include?
(A) diverting colostomy (B) bowel resection
(C) rectal pull-through operation (D) vaginal repair of the fistula (E) systemic steroids and antibiotics
16. Fecal incontinence is most likely related to which of the following?
(A) interplay between the pubococcygeus muscle and rectum (B) innervation of the pelvic floor and the anal sphincters (C) normal colonic transit time
(D) nulliparity (E) urinary retention
17. When performing a vaginal hysterectomy for any indication, prevention of future enterocele or vaginal vault prolapse is aided by which of the following?
(A) reattachment of the round ligaments to the vaginal cuff (B) closing the vaginal mucosa
(C) reattachment of the cardinal and uterosacral ligaments to the vaginal cuff (D) complete a purse string suture closure of the cul-de-sac peritoneum (E) placing a vaginal pack for 24 hours postoperatively
Questions 18 through 20 apply to the following patient:
A 30-year-old woman complains of 36 hours of urinary frequency, dysuria, and pelvic pain. She has never had a UTI and has no medical problems.
18. Which of the following is the most likely pathogen?
(A) Escherichia coli
(B) Staphylococcus saprophyticus (C) Klebsiella pneumonia
(D) Proteus mirabilis (E) enterococci
19. Which of the following is the recommended treatment regimen?
(A) 7-day course of tetracycline
(B) 3-day course of trimethoprim-sulfamethoxazole (TMP-SMZ) (C) 7-day course of ciprofloxacin
(D) 3-day course of amoxicillin (E) 7-day course of erythromycin
20. If the patient is pregnant and in the third trimester, which of the following is the appropriate therapy?
(A) 3- to 7-day course of ciprofloxacin (B) 3- to 7-day course of TMP-SMZ
(C) 3- to 7-day course of amoxicillin/clavulanic acid (Augmentin) (D) 3- to 7-day course of nitrofurantoin
(E) 1-day course of nitrofurantoin
Questions 21 and 22 apply to the following patient:
A 49-year-old woman had a radical hysterectomy and lymph node sampling for stage 1B squamous cell cancer of the cervix. A suprapubic catheter was placed at the time of surgery. She is now 8 weeks postoperative and has not been able to void. She is also leaking urine with activity, coughing, and sneezing.
21. What is the most likely reason for voiding difficulty?
(A) spasm of the pelvic floor muscles (B) outflow obstruction
(C) postoperative swelling around the bladder
(D) innervation to the lower urinary tract was transected (E) overdistention of the bladder
22. The most likely etiology of her incontinence is which of the following?
(A) urge incontinence (B) stress incontinence (C) overflow incontinence (D) ureterovaginal fistula (E) urethral diverticulum
23. Which of the following is a normal urologic consequence of aging?
(A) incontinence
(B) elevated postvoid residual from 50 to 100 mL (C) increased daytime diuresis
(D) increased bladder capacity
(E) delayed sensation of first desire to void
DIRECTIONS (Questions 24 through 57): The following groups of questions are preceded by a list
of lettered options. For each question, select the one lettered option that is most closely associated with it. Each lettered option may be used once, multiple times, or not at all.
Questions 24 through 35
Match the description of the pelvic support abnormality with the correct terminology for that abnormality.
(A) cystocele
(B) direct inguinal hernia (C) enterocele
(D) femoral hernia (E) incarcerated hernia (F) incisional hernia
(G) indirect inguinal hernia (H) rectocele (I) Rokitansky’s hernia
(J) sliding hernia (K) Spigelian hernia (L) strangulated hernia (M) umbilical hernia (N) urethrocele
24. Results from injury to the pubourethral ligaments 25. A true hernia into the potential space of the vagina
26. The organ protruding makes up a portion of the wall of the hernia sac
27. Herniation where the vertical linea semilunaris joins the lateral border of the rectus muscle 28. Results from a defect in the posterior levator ani musculofascial attachments
29. The contents of the hernia sac cannot be easily reduced 30. Comes through Hesselbach’s triangle
31. Closes during the first 3 years of life in many people 32. Much more common hernia in the female than the male 33. Associated with absorbable suture material
34. Can be closed more tightly in the female than in the male 35. Acute pain, possible surgical emergency
Questions 36 through 42
Match the type of incontinence with the most appropriate description.
(A) detrusor instability (or overactivity)
(B) genuine stress incontinence (or urodynamic stress incontinence) (C) incontinence
(D) overflow incontinence (E) urethral syndrome
(F) urinary urge incontinence (G) enuresis
(H) sudden onset urinary incontinence, frequency, and urgency 36. Involuntary bladder detrusor contractions leading to urinary loss
37. An inflammatory condition with negative bacterial cultures, sometimes associated with positive chlamydial cultures
38. Involuntary urine loss accompanied by or immediately preceded by a strong desire to void
39. Involuntary loss of urine when intravesical pressure exceeds intraurethral pressure in the absence of a detrusor contraction
40. Incontinence that occurs during sleep
41. Urine loss in association with bladder distention in the absence of bladder contractions 42. All involuntary urine loss
Questions 43 through 51
Match the following urodynamic and urologic tests with their intended purpose.
(A) Bonney or Marshall test (B) cystometrogram
(C) cystoscopy (D) IVP
(E) measurement of residual urine (F) pad test
(G) positive pressure urethrography (H) Q-tip test
(I) urethral pressure profile study (J) urinalysis and/or urine culture (K) standing cough stress test
43. A simple test of urethral hypermobility
44. An indirect test of the neurologic function of the bladder 45. Screens for infection
46. Evaluation of cystocele and overflow incontinence
47. Identifies and quantifies incontinence outside the office setting
48. Identifies noninfectious inflammation, malignancy, and abnormal anatomy 49. A low pressure predicts failure of standard incontinence procedures
50. A means of noninvasively confirming the clinical diagnosis of stress incontinence in the office Questions 51 through 57
Select the most likely diagnosis for each patient with a bladder disorder.
(A) acute cystitis
(B) acute urethritis (often due to Chlamydia) (C) interstitial cystitis
(D) painful bladder syndrome of unknown etiology (E) postural diuresis
(F) sensory urgency (G) urethral diverticulum (H) urethral syndrome (I) vaginitis
51. An 18-year-old woman with acute onset frequency, dysuria, suprapubic pain, and a new sexual partner. Office leukocyte esterase dipstick is positive.
52. An 18-year-old woman with frequency, urgency, and suprapubic pain. The pain increases with bladder filling and is temporarily relieved with voiding. Multiple urine cultures over 6 months have been negative, and antibiotics have not improved her symptoms. Cystoscopy under anesthesia is negative.
53. An 80-year-old woman with nocturia three to five times a night that disrupts her sleep. She voids every 2 to 3 hours during the daytime. Her medical history is complicated by mild congestive heart failure and hypertension.
54. An 18-year-old woman with frequency, urgency, nocturia, and suprapubic pain. She voids every 30 minutes, because it temporarily reduces her symptoms. Urine cultures have been negative. Cystoscopy under anesthesia reveals petechial hemorrhages after bladder distention.
55. An 80-year-old woman with frequency, urgency, and nocturia. Urine culture is negative, and postvoid residual is 30 mL. Office cystometrics shows no uninhibited detrusor contractions.
56. An 18-year-old woman with acute onset frequency, urgency, dysuria, vaginal discharge, and a new sexual partner. Microscopic urine evaluation shows pyuria. Urine culture is negative.
57. An 18-year-old woman with acute onset of vaginal discharge, external dysuria, and a new sexual partner. No pyuria is seen on microscopic urine evaluation.
Answers and Explanations
1. (A) Risk factors for pelvic support disorders are increasing parity, increases in intra-abdominal pressure (chronic coughing or straining at stool and possibly obesity), pelvic trauma from radical surgery or pelvic fractures, aging, estrogen deprivation, heredity, or connective tissue disorders.
Women who delivered large infants had assisted delivery with either vacuum or forceps, or had lacerations are all at increased risk of future support disorders and incontinence.
2. (A) The sensation of pressure, fullness, or falling out is probably the most common symptom of anterior vaginal prolapse or cystocele formation. Mild urine loss with coughing, sneezing, straining (urinary stress incontinence), some urinary urgency, and incomplete emptying are also common complaints.
Rectocele will be associated with complaints of difficulty voiding.
3. (B) The sensation of pressure, fullness, or falling out is probably the most common symptom of any uterovaginal prolapse. The rectal symptoms that she has with defecation, however, are pathognomonic for a rectocele. When symptoms are this severe, the treatment of choice is surgical repair.
4. (C) The sensation of pressure, fullness, or falling out is probably the most common symptom of any uterovaginal prolapse, as we have seen in the preceding examples. The point to be made here is that this patient has supposedly had a repair of her prolapse and incontinence. Two things contribute to the development of an en-terocele: (1) she has had a prior hysterectomy and (2) she has had a
transabdominal urethral suspension, which contributes to enterocele formation in approximately one in six to seven patients. The history of symptoms worsening throughout the day and getting better with rest is characteristic for genital prolapse and especially so for any enterocele. The most common treatment for enterocele is surgical repair. Pessaries or exercises are of little value with severe prolapse. The pessary is unlikely to be retained in the vagina.
5. (D) Uterovaginal prolapse describes the position of the cystocele, rectocele, enterocele, or uterus. It is usually described as a “degree” of prolapse. First-degree prolapse is when the leading edge of the prolapsed organ (cervix or vagina) extends below the ischial spines (or into the distal one-third of the vagina); second-degree prolapse is just to the vaginal introitus; third-degree prolapse is when the organ readily passes through the introitus; and fourth-degree (or total procidentia) is when the entire body of the pro-lapsing organ (uterus or vagina) lies outside the vaginal introitus. The more advanced the prolapse, the more difficult is the therapeutic task of restoring comfort and/or function.
6. (E) The marked prolapse in Figure l9-l shows an enterocele protruding posterior to the uterus. The figure also shows a uterine prolapse. Enterocele is definitively diagnosed by observing and palpating small bowel peristalsis behind the vaginal wall. A recotvaginal examination is critical for
confirmation. A sigmoidocele is not seen as no sigmoid colon is depicted in the picture; instead, small bowel is depicted.
7. (E) Low-dose postcoital antibiotic use has been shown to be effective at reducing frequency of
postcoital UTIs. UTIs are rare in men less than 50 years of age. In contrast, 40% to 50% of women will have a UTI in their lifetime. The use of diaphragms and spermicides has been associated with
recurrence of UTIs. The vaginal flora is altered by the spermicide. Older women, particularly elderly
with chronic neurologic illness or functional impairments, will often have asymptomatic bacteriuria.
The presence of both leukocyte esterase, a surrogate for the WBC count, and nitrates, a metabolic product of bacteria have a very high predictive value for a positive UTI.
8. (E) A small outpouching of the urethra can contain enough urine to dribble after voiding. Such a
diverticulum may be very difficult to demonstrate. A specialized urethrogram, urethroscopy, magnetic resonance imaging (MRI), or examination by a very experienced examiner may allow diagnosis to be made. If suspicion is strong enough, surgical exploration is indicated. The classic history is dribbling, dysuria, and dys-pareunia. A urinary fistula usually leads to continuous incontinence. Detrusor
instability is a urodynamic diagnosis with incontinence symptoms associated with a strong urge to void.
UTIs usually also have symptoms of frequency and dysuria.
9. (B) Stress incontinence is precipitated by anything that increases intra-abdominal pressure. The patient is able to suppress this loss after a few drops in most cases. Patients with mild stress incontinence lose only a small spurt of urine that stops when not straining.
10. (C) Kegel first described these isometric exercises to improve the strength of the levator ani and pubococcygeus muscles after childbirth. These exercises can improve the condition in many women with mild stress incontinence. The exercises may work better to prevent stress incontinence, if done regularly and properly, than to cure it. The addition of pelvic floor physical therapy with biofeedback can help women strengthen these muscles, particularly those having trouble contracting these muscles.
11. (B) With any congenital incontinence, anatomic defects must be considered. If the child is neu- rologically normal, an ectopic ureter (one that opens into the vagina) is the most likely cause. A congenital vesicovaginal fistula is unlikely. A test that would help delineate the etiology of this problem would be an intravenous dye (indigo carmine or methylene blue) study with follow-up examination to see where the dye is extruded. An IVP might also be helpful.
12. (D) Behavioral therapy benefits many patients and encompasses bladder retraining, pelvic muscle rehabilitation, and timed/prompted voiding. Bladder retraining involves increasing the time between voiding episodes gradually so that the patient relearns to suppress the micturition reflex. Eventually, this leads to a larger functional bladder capacity and fewer incontinence episodes. Medications could be helpful for this patient, but that is not a behavioral treatment. Timed voiding is a behavioral
treatment, but it is generally used for neurologically impaired patients, and voiding every hour would not be appropriate for treating this patient.
13. (D) The urgency and unheralded loss of urine are classic symptoms of a neurologically abnormal bladder. The different types of incontinence that could cause this problem must be distinguished from one another, as the treatments are different. Standard urodynamic testing should be performed.
14. (A) The most common cause of rectovaginal fistula is obstetrical delivery. This is mainly due to a breakdown of a repaired third- or fourth-degree laceration. Fistulas can occur after complicated
gynecologic surgery, pelvic radiation, and inflammatory conditions such as Crohn’s disease. Symptoms include passing flatus per vagina with or without fecal passage. Air can enter the vagina under other circumstances and be passed later, such as when a patient gets up from a knee-chest position. Some patients will also present with recurrent bladder or vaginal infections, bleeding, or pain. Spontaneous fis-tulization has not been reported.