Urogynecology (Tests, Surgeries, Etc)

Question 1

POP-Q

Answer 1

gold standard for measuring prolapse;
Stage 0: no prolapse
Stage 1: distal point is greater than 1cm above distal to hymen
Stage 2: distal point is equal or less than 1 cm above or below hymen
Stage 3: distal point is greater than 1 cm below hymen protruding 3/4 of vaginal length
Stage 4: complete eversion of the tvl (greater than 2cm)

Question 2

Surgery for anterior prolapse or cystocele

Answer 2

anterior repair with or without mesh (vaginal), paravaginal repair; colposuspension, paravaginal (suprapubic)

Question 3

Surgery for Apical or Uterine Prolapse

Answer 3

Vaginal hysterectomy, vault repair, sacrospinous fixation, bilateral iliococcygeal hitch (Vaginal)
Sacrohysteropexy, sacrocolpopexy (suprapubic)

Question 4

Surgery for posterior wall prolapse or rectocele

Answer 4

levator plication, fascial repair with or without mesh, transanal repair (vaginal), mesh interposition, sacrocolpopexy with mesh interposition (suprapubic)

Question 5

Indication for ring pessary

Answer 5

useful in treatment of uterine prolapse (stage 1 or 2)–cystocele, SUI

Question 6

platform pessary

Answer 6

folded then placed in vagina; aids in reduction of prolapse equally in vagina; able to have intercourse with in place

Question 7

Gellhorn pessary

Answer 7

For patients with severe uterine or vaginal prolapse; useful for large prolapse of anterior wall. difficult to self insert

Question 8

inflatable pessary

Answer 8

doughnut shaped device with stem; requires manual dexterity (all prolapse)

Question 9

cube pessary

Answer 9

six concave surfaces create suction effect and hold pessary in place; useful in patients with vaginal eversion and complete vaginal prolapse (all prolapse)

Question 10

smith-hodge pessary

Answer 10

elevates the bladder neck into a retropubic position; help predicts likelihood of incontinence after surgery for correction of prolapse (small cystocele, enterocele, sui)

Question 11

Colplexin

Answer 11

sphere shaped device that is easily inserted; use with PF exercises

Question 12

DeLancey I Classification & Symptoms

Answer 12

Classification: Superior vaginal & uterine supor, cardinal and uterosacral ligaments; uterus and upper vaginal region
Sxs: Cervix first prolapse, pelvic heaviness, back pain; “drooping” cystocele which causes voiding dysfunction

Question 13

DeLancey II Classification & Symptoms

Answer 13

Mid vaginal suspensory mechanism–main support for urethra, bladder, rectum (pubocervical fascia and rectovaginal fascia) Muscle connections; ATFP/ATLA
Sxs: Cystocele (SUI, voiding dysfunction), rectocele (FI, incomplete evacuation) ** Not typically back pain

Question 14

DeLancey III Classification & Symptoms

Answer 14

lowest portion of vagina; no paracolpium to support; fuses with LA mm, urethra and perineum; ant ligaments to maintain continence
Sxs: Severe leakage from pubo-urethral ligament and laxity of “hammock”, gaping at introitus, perineal body is broad and inferior

Question 15

Pfanenstiel Incision

Answer 15

RA mm separated from fascia using blunt or sharp dissection or electrocautery; leads to pain inthe abdominal skin superior to incision;
** Also, may have direct nerve injury of ilioinguinal nerve at superficial inguinal ring

Question 16

Maylard incision

Answer 16

used in hysterectomy 2/2 cervical CA; direct trauma to RA mm at incision line that is 3-5 cm above insertion into pubis

Question 17

Lateral Femoral Cutaneous Nerve Entrapment

Answer 17

travels posterior psoas, QL, ant iliacus, under inguinal ligament; innervates ant and lat thigh

Question 18

Cherny Incision

Answer 18

same place as pfannenstiel, but cuts at pubic symphysis then reattaches

Question 19

Midline Incision

Answer 19

used for more extensive abdominal explorations, vertical through linea alba (diverts around umbilicus)

Question 20

paramedian incision

Answer 20

verticle to the L or R of the umbilicus

Question 21

McBurney incision

Answer 21

Appendix

Question 22

Ilioinguinal Nerve Entrapment

Answer 22

*ilioinguinal nerve: superficial inguinal ring–> pain in inguinal distribution radiating to perineum and medial thigh; pain increases with hip ext; pain with palpation medial to ASIS.

Etiolog: Lower abdominal incision, cherny incision, pregnancy, iliac bone harvesting, UI sx 18 mo post-op, femoral catheter, orchiectomy, tearing of lower EO aponeurosis

Also common in vulvar pain, instability of Tsp & Lsp, constipation

Question 23

Iliohypogastric Nerve Entrapment

Answer 23

*iliohypogastric n: will affect motor function of IO and TrA; sensation at posterolateral gluteal skin and pubic skin; Tracks trhough psoas, QL, Transversus, IO and EO; Entrapment when surgical incision extends laterally to less than 3cm from AS iliac incision

Question 24

Genitofemoral Nerve Entrapment

Answer 24

*genitofemoral n: will affect function of genital branch (cremaster), skin of scrotum, mons pubis, labia majora and upper ant thigh; Travels through psoas, under ilioinguinal ligament

Trapped by lateral retractors, pfannensteil, cherny OR biopsies, C/s, intrapelvic trauma, retroperitoneal hematoma, pregnancy, trauma to inguinal lig

S/s: groin pain, worse with IR/ER of hip, prolonged walking light touch

Question 25

Obturator Nerve Entrapment

Answer 25

L2, L3, L4 anteriorly fuse to form;
Etiology: pelvic trauma and fx between head of fetus and bony structures; between tumor and bony pelvis, obturator canal during sx or with total hip malposition of LE for long periods, abnormal positioning of LE of newborn with delivery;

S/s: difficulty with ambulation, unstable LE in anterior branch entrapment, medial aspect of thigh; weakness worse with Exercises; Severe loss of ADD and IR occur;
** Recognize early; treat with ES, stretching, Massage; Surgical intervention

Question 26

Femoral Nerve Entrapment.

Answer 26

femoral n: injured 2/2 retractors (stretch and compression); wknss in iliacus, pectinus and ant compartment mm; skin on and thigh and med leg; Travels under psoas ant iliacus and under inguinal lig; Common with hyper hip flexion during delivery;

Question 27

Problems after Hysterectomy

Answer 27

Pain in the vaginal scar, disruption of nerves (orgasm!); with radical hysterectomy (2/2 cancer–pt may have bladder nerves disrupted)

Question 28

Retropubic colposupsensions

Answer 28

For SUI (Burch, Marshall-Marchetti-Krantz)
- suspension of the periurethral vaginal wall to structures in or on the bony pelvis
- access space of retzius
- can damage femoral, obturator, pudendal and perineal nn.
Voiding dysfunction
*Open burch is used for young women desiring fertility, complications from mesh in past, combined with otheropen repairs

Question 29

Needle Procedures

Answer 29

Pereyra, Raz, Gittes, Stamey

Sutures placed periurethrally to anchor tissue and improve suspension

Question 30

Pubovaginal Slings

Answer 30

Fascial slings; for women who don’t want foreign substance; more women had UTIs, voiding dysfunction and UUI after sx compared to Burch

Question 31

TVT & TOT

Answer 31

TOT may have less overcorrection/urgency/dysuria; Less risk for bladder damage but impacts OI mm

Question 32

Urethral bulking

Answer 32

cure/improvement in 70-80% of pts (total in 40%), repeat may be required

Question 33

Anterior Colporrhaphy & repair with graft

Answer 33

incision anteriorly, defect is folded over or removed then stitched back together; improved with use of mesh or graft

Question 34

Posterior vaginal repair: graft, colporhaphy

Answer 34

midline fascial plication; dyspareunia and defecatory dysfunction common after

Rectocele specific repair had same oucomes; graft does not improve outcomes

Transvaginal approach preferred to rectal

Question 35

Obliterative Procedures

Answer 35

Colpocleisis;
Risks: Bowel dysfunction, Regret
Uterus is only removed if pathological

Question 36

Sacrocolpopexy

Answer 36

Vaginal vault is tacked to sacral prominence; performed abdominally
sacrospinous ligament fixation for vaginal vault prolapse