FPRM (Urogyn)

Question 1

65yo with stage III anterior wall vaginal prolapse. What surgical repair is best for her?

Answer 1

Anterior repair with sacrospinous ligament fixation (NOT “midline plication”)
- levator ani = puborectalis, pubococcygeus, iliococcygeus
- level I support = support at apex
- level II = midvaginal
- level III = distal vagina
- apical support -> sacrospinous, uterosacral, and iliococcygeus fascia

Prolog FPMR (Urogyn) - Q2

Question 2

30yo requesting cesarean due to concerns about pelvic floor dysfunction. Cesarean may help in the immediate postpartum with what? (reduced risk of what?)

Answer 2

Urinary incontinence
- pregnancy itself is a risk factor
- studies show decreased risk of incontinence in planned cesareans at 3 months, however not significant at 2 years

Prolog FPMR (Urogyn) - Q3

Question 3

10 days postpartum from forceps + 3rd degree repair now with complete breakdown of wound, no evidence of infection… next best step?

Answer 3

Perform prompt repair in OR (NOT secondary intention)
- Most breakdowns occur in first 2 weeks
- resuture only when infection is resolved -> no edema, induration, or exudate

• OASIS occurs in 2.2-19% of deliveries in US
• Breakdown is uncommon, only 3- 7%
• RF breakdown: smoking, FAVD, ML epis, high BMI, 4th degree

Prolog FPMR (Urogyn) - Q4

Question 4

What does each box represent on a POP-Q? (be able to draw grid with numbers given)

Answer 4

Aa = anterior wall 3cm inside hymen
Ba = anterior wall, most prolapsed point
C = cervix/cuff
gh = genital hiatus
pb = perineal body
tvl = total vaginal length
Ap = posterior wall 3cm in
Bp = posterior wall prolapsed point
D = posterior fornix (gone if they’ve had a hyst)

Top row, left to right: Aa, Ba, C
Middle: gh, pb, tvl
Bottom: Ap, Bp, D

Prolog FPMR (Urogyn) - Q7

Question 5

17yo with vaginal wall cyst. Painless, fluctuant, fluid-filled 6cm mass on left lateral vagina, approx 4cm cephalad to hymenal ring. Most likely diagnosis?

Answer 5

Mesonephric duct remnant (aka Gartner duct cyst)
- remnant of mesonephric or wolffian duct
- commonly found posterior or lateral wall vagina and filled with serous or mucinous fluid

Other answer choices: urethral diverticulum (get MRI to diagnose), bartholin gland (4 and 8 o’clock), pronephric duct remnant (pronephros = kidney development), skene gland (periurethral, analog to male prostate)

Prolog FPMR (Urogyn) - Q1

Question 6

35yo obese Hispanic woman with OP baby delivered by forceps-assisted vaginal delivery with episiotomy. 8.5lb baby. What in her history is the greatest risk of anal sphincter injury?

Answer 6

Forceps-assisted delivery
- 1.5-4 fold higher risk of OASIS than vacuum

• no protective effect from mediolateral episiotomy when used without vacuum extraction
• persistent OP has 2 fold higher risk than OA
• Lithotomy and squatting positions have 2 fold higher risk

Prolog FPMR (Urogyn) - Q5

Question 7

71yo with UTI. 3 episodes over the last 2 years. No structural abnormalities. Next best step in management?

Answer 7

Vaginal estrogen

Recurrent UTI = 2+ in 6 months or 3+ in one year
-Vaginal Ez increases maturation index of vaginal epithelial cells, lower vaginal pH and shifts flora away from Enterobacteriaceae, which protects against UTI

Prolog FPMR (Urogyn) - Q6

Question 8

54yo with mixed urinary incontinence (stress dominant), no prolapse, hypermobile urethra. After sending urine for culture and sensitivity, the best next step in her evaluation is…?

Answer 8

Obtain a postvoid residual volume
- next: surgical treatment may be offered

Point: urodynamic testing not necessary on everyone

Prolog FPMR (Urogyn) - Q8

Question 9

46yo para 2 with leakage of urine when running to bathroom, after sneezing, and when getting out of car on long trip. Wakes up 1-2x/night with strong urge to void and leaks on way to toilet. You obtain urodynamics. Best next step in management?

Answer 9

Fluid intake modulation and timed voiding
- Urge incontinence

SUI: pelvic floor PT, pessary, bulking injection

Prolog FPMR (Urogyn) - Q9

Question 10

62yo obese woman with mixed incontinence. Does not want surgery and wants to try behavioral interventions. Along with pelvic floor muscle exercises, the intervention most likely to reduce leakage is…?

Answer 10

Modest weight loss

Other options: weighted vaginal cones, incontinence pessary, elimination of caffeine
–> interventions = 55-85% effective

• Interestingly, no scientific evidence has demonstrated a significant benefit of caffeine elimination even though it is commonly recommended in clinical practice

Prolog FPMR (Urogyn) - Q10

Question 11

Urinary incontinence with exercise, hoping to become pregnant in the next year… Best treatment option?

Answer 11

Incontinence dish pessary (best for women who have not completed childbearing)

• Stress incontinence prevalence = 16%

Prolog FPMR (Urogyn) - Q11

Question 12

Most common complication associated with a retropubic midurethral sling?

Answer 12

Urinary tract infection (can be associated in 30% of cases)
- Other complications: bladder perforation (5%), voiding dysfunction/retention (3-45%), bleeding (<3%)

Historical procedures:
- Burch retropubic colposuspension: attaches endopelvic fascia at the midurethra to proximal urethra to the bilateral pectineal (Cooper) ligaments
- autologous fascial bladder neck sling: graft from anterior rectus fascia

Slings introduced in 1990s, just as effective with shorter operating times, quicker recovery, and fewer complications

Prolog FPMR (Urogyn) - Q12

Question 13

42yo with SUI, postvoid residual 55mL, negative urine culture. Most important test in evaluation for surgery is…?

Answer 13

Cough stress test
- NOT urodynamic testing for uncomplicated stress incontinence with normal PVR and UA
- cough test maximized in standing position with a full bladder or at 300mL volume

Prolog FPMR (Urogyn) - Q13

Question 14

55yo with urge incontinence, failed other treatments and now trying botox injections. You counsel her on the high rate of UTIs and the adverse effect of…

Answer 14

Urinary retention

Botox:
- injected with 10-20 separate sites
- In a RCT, 100 units led to reduction in urge episodes from 5.0 to 3.3 per day and complete resolution in approx 27% of patients
- approx 33% had UTI, 5% were using catheter at 2 months because of retention

Prolog FPMR (Urogyn) - Q14

Question 15

65yo with urge incontinence, tried oxybutynin chloride TID with good success initially but developed adverse effects (dry mouth, dry eyes, and constipation) which led her to stop. She is currently undergoing workup for episodic hypertension. Next best step is to prescribe…? (medication)

Answer 15

Oxybutynin chloride XL once daily
- sustained release better, start lowest dose

Antimuscarinics: block muscarinic receptors (M2 and M3) on detrusor muscle, prevents acetylcholine binding
- M2 receptors more common in bladder than M3, but M3 most responsible for contractility
- Anticholinergics contraindicated with narrow angle glaucoma

• Oxybutynin = M3 and some M1 affinity (CNS effects with M1)
• Tolterodine, fesoterodine fumarate, solifenacin = M3 affinity
• Mirabegron = B3 agonist, relaxes bladder by mimicking norepinephrine. Can cause hypertension, nasopharyngitis, UTI, headache, and dry mouth (to lesser degree)

Prolog FPMR (Urogyn) - Q15

Question 16

84yo with urge incontinence, pursuing trial of sacral neuromodulation. Had permanent lead placed adjacent to the S3 dorsal root. Bladder diary showed >50% improvement. Next step?

Answer 16

Place a permanent neurostimulator

Sacral neuromodulation: temporary lead along S3 dorsal sacral nerve root
- lead stimulated with external stimulator, confirmed by “bellowing” of the perineum, plantar flexion of great toe. Tested outpatient up to 14 days (stage 1)

Other treatments:
- peripheral tibial nerve stimulation: 12 weekly sessions
- botulinum-A toxin: inhibits calcium-mediated release of acetylcholine vesicles, flaccid muscle paralysis

Prolog FPMR (Urogyn) - Q16

Question 17

POD#2 from TLH, complicated by bleeding at the cuff that was suture ligated. Went home POD#1 after able to void. Was given oral phenazopyridine to confirm fluid was urine and there was orange fluid on her pad. POD#3 had cysto in office that showed 0.5 x 0.5cm defect in bladder posterior to trigone and 1 cm posterior to trigone and medial to right ureteral orifice. Best next step in management is?

Answer 17

CT urography
- concomitant ureteral injuries occur in up to 12% of iatrogenic vesicovaginal fistulas
- Need upper tract imaging (not renal ultrasound) either with CT urogram or retrograde pyelography

Leakage after hyst can be from fistula, peritoneal fluid, seroma, or vaginal discharge

• immediate repair of fistula is not the best next step due to edema and swelling (best to wait 6 weeks for repair)
• for small fistulas can leave foley in for 2-3 weeks but in this case need to identify a concomitant ureteral injury

Prolog FPMR (Urogyn) - Q17

Question 18

A surgical proctor is NOT expected to be able to…
A. Receive compensation
B. teach a new surgeon certain portions
C. complete written eval
D. Recommend termination of the procedure if unsafe

Answer 18

Teach a new surgeon certain portions of the procedure

Proctor vs Preceptor:
- Proctor works for hospital, does not participate directly in patient’s care, should complete a standardized evaluation form, and can sometimes be compensated
- Proctor not responsible for assisting if a complication occurs but can intervene if unsafe and is covered by Good Samaritan Law if they do

• Preceptor: someone who agrees to teach another surgeon how to perform a new surgical procedure, directly involved in patient’s care, and is responsible for the actions of the surgeon he or she is precepting

Prolog FPMR (Urogyn) - Q18

Question 19

77yo undergoing vag hyst, BSO, and uterosacral ligament suspension. No efflux seen from either ureteral orifice on cysto. Next best step?

Answer 19

Give IV fluid bolus
- NOT lasix or removing sutures

• Rate of ureteral obstruction after vag USLS is as high as 11%

Universal intraoperative cystoscopy at time of GYN surgery has been shown to identify a substantial number of otherwise occult injuries to the urinary tract, preventing long term sequelae.

Prolog FPMR (Urogyn) - Q19

Question 20

87yo with prolapse of anterior wall 6cm beyond hymen and cervix at hymen. Postvoid residual volume is 260mL. Next best step?

Answer 20

Prolapse reduction with a pessary
- NOT putting in a catheter due to risk of infection, and because it won’t correct the underlying problem

> 90% with retention result in resolution when prolapse is corrected.

Prolog FPMR (Urogyn) - Q20

Question 21

35yo s/p midurethral sling 6 weeks ago reports sensation of incomplete emptying and postvoid residual is 340mL. Most appropriate management?

Answer 21

Surgical sling lysis

Success of slings = 60-85%
- Urinary retention in 30-45% on day of surgery. Mostly transiet and only 1.5-2.0% require lysis of sling.
-Unlikely to be transient at 6 weeks.

Prolog FPMR (Urogyn) - Q21

Question 22

42yo s/p transobturator midurethral sling, happy with results but reports spotting and “something scratchy” during intercourse. (Figure shows mesh erosion). Next best step in management?

Answer 22

Prescribe estrogen cream

Mesh exposure = displaying, revealing, exhibiting, or making accessible mesh
Mesh extrusion = gradual passage of mesh out of a body structure or tissue

First line treatment for mesh erosion = estrogen cream
If unsuccessful, small areas can be excised

Prolog FPMR (Urogyn) - Q22

Question 23

65yo sexually active woman with stage 3 prolapse, denies incontinence, wanting surgery. PVR 175mL. What surgery is best for her?

Answer 23

Sacrocolpopexy with Burch colposuspension

Abdominal sacrocolpopexy has lower rates of recurrent prolapse than sacrospinous ligament suspension (4% vs 15%)

Approx 40% of stress-continent women undergoing surgery for prolapse will have symptoms after surgery of incontinence

Burch: 2 permanent sutures on either side of the midurethra and urethrovesical junction, then pass each suture through the Cooper ligament (iliopectineal line) to stabilize the urethrovesical junction

*If colpopexy with sling was an option, this would also be correct

Prolog FPMR (Urogyn) - Q23

Question 24

57yo with 6 month hx of urinary urgency and frequency. Pain with insertion of speculum and bladder tenderness on exam. UA negative. Next appropriate step in management?

Answer 24

Pelvic floor PT

Painful Bladder Syndrome:
- “unpleasant sensation perceived to be related to the urinary bladder, associated with lower urinary tract symptoms of more than 6 weeks in duration, in the absence of infection or other causes”
- prevalence approx 2.7-6.5%
- symptoms of UTIs with negative cultures
- fail treatment with abx and for overactive bladder and endometriosis
- First line: education, self-care, stress management. Then pelvic floor PT.
- Second line meds: amitriptyline and pentosan polysulfate
- Office cysto and potassium sensitivity test used to be recommended but no longer

Prolog FPMR (Urogyn) - Q24

Question 25

70yo with COPD and recurrent UTIs (all culture proven) now worsening. Taking vaginal estrogen for 6 months. Took daily trimethoprim-sulfamethoxazole for 3 months but developed resistance. Office cysto negative. PVR 100mL. After ruling out active infection, next best treatment is…?

Answer 25

Methenamine hippurate (Hiprex) plus vitamin C
(NOT cranberry pills plus vitamin C)

Daily Macrobid is an ideal suppressive agent (excreted exclusively by kidneys, avoids GI effects) but has risk of chronic interstitial lung disease

Methenamine salts have been shown to inhibit UTI’s by hydrolyzing in the urine into formaldehyde which is bacteriostatic. Given with Vit C to maximize urine acidity. Adverse effects = GI sx and gross hematuria.

• Vaginal estogen proven to reduce UTIs
• Cranberry pills have shown some efficacy over placebo but not as good as antibiotics

Prolog FPMR (Urogyn) - Q25

Question 26

63yo with stage 3 prolapse. Anterior vaginal wall reduces with support of the cervix with a large procto swab. Uterus small and mobile. Best surgical option for her?

Answer 26

Abdominal sacrocolpopexy (NOT just vag hyst, needs apical procedure)

Stage 2 or greater prolapse prevalence = 65% in women age 68yrs

Stage 0 = no prolapse
Stage 1 = 1cm proximal to hymen
Stage 2 = at hymen, +/-1cm
Stage 3 = >1cm below the hymen but protrudes no further than 2cm less than the total vaginal length
Stage 4 = vaginal eversion complete

Prolog FPMR (Urogyn) - Q26

Question 27

Most likely complication after vaginal placement of synthetic mesh?

Answer 27

1 = Mesh exposure (0-30%)

Tx: vaginal estrogen, PFPT, antibiotics
–> surgical excision if fails

2008 “black box” warning with surgical mesh placed through the vagina
2011 modified to address mesh in vagina to fix prolapse only not mesh placed in vagina for SUI.

Prolog FPMR (Urogyn) - Q27

Question 28

45yo with stage 3 prolapse, using pessary but desires surgery. Avid triathlete and sexually active. Wants the most durable repair with quickest recovery time. Best surgery for her?

Answer 28

Laparoscopic sacrocolpopexy

• Better than sacrospinous or uterosacral ligament suspension
• laparoscopic better than open in recovery

Prolog FPMR (Urogyn) - Q28

Question 29

The characteristic of pelvic mesh that results in the lowest rate of mesh extrusion is…

Answer 29

Monofilament (NOT microporous)

Types of mesh based on weave, weight and pore size.
- Type 1: monofilament (polyproylene), macroporous (pore size >75 microns). Macropores allow for host incorporation into the mesh with collagen deposition and angiogenesis
- Type 2: microporous (pore size <10 microns). Increased extrusion rate because fibroblasts and immune cells are unable to penetrate the pores. Higher infection risk.
- Type 3: mutlifilament meshes (polyethylene), rarely used because of increased infection and erosion. Removed from market.

Larger pore size = smaller weight and more elastic the material
Absorbable materials are less likely to become infected

Prolog FPMR (Urogyn) - Q29

Question 30

S/p robotic sacrocolpopexy 4 days ago presenting with nausea, vomiting, and cramping abdominal pain. Tender distended abdomen. Most appropriate initial management strategy is…? (what imaging or surgical procedure)

Answer 30

CT scan with contrast (NOT abdominal flat plate first… won’t determine underlying cause and 4 days postop will still show residual carbon dioxide)

Prolog FPMR (Urogyn) - Q30

Question 31

73yo undergoing sacrospinous ligament suspension, has brisk bleeding during surgery after placing sutures one fingerbreadth medial to ischial spine. Bleeding controlled, but in PACU she complains of severe right-sided buttock pain that radiates down the back of her leg. Best next step?

Answer 31

Release of sacrospinous sutures

Procedure: vaginal vault attached to the right sacrospinous ligament with sutures in order to avoid the rectum on the patient’s left (performed unilaterally).
- pudendal neurovascular bundle passes behind ischial spine under the lateral aspect of the sacrospinous ligament
- inferior gluteal artery is 2-3cm medial to ischial spine

Pain likely from nerve entrapment 2/2 injury to branches of the sciatic nerve
- classically presents as paresthesia, pain, and improved with local anesthesia
- to avoid entrapment: place sutures vertically rather than horizontal, and in the lateral distal third of the sacrospinous ligament

Prolog FPMR (Urogyn) - Q31

Question 32

13yo with incontinence, renal ultrasound shows duplicated left collecting system and vaginoscopy shows left ureteric opening into the vaginal vault. The embryonic structure that is the result of this abnormal development is….?

Answer 32

Mesonephric duct

• Ectopic ureters are more common in females and associated with duplicated collecting systems in 80%
• males will have hydronephrosis and no incontinence (located superior to external urinary sphincter)

Urinary system develops in 3 stage: 1. pronephros, 2. mesonephros, 3. metanephros
- Pronephros: 4th week gestation
- Mesonephros: 4-5th, forms mesoderm
- ureteric bud develops as outpouching of mesonephric duct near the chloaca
- bladder develops from anterior division of cloaca, the urogenital sinus

Duplication of ureter occurs when the ureteric bud splits and the induced metanephric tissue may be divided.

Weigert-Meyer rule: ectopic ureteric bud arising from an upper renal pole inserts medial and inferior to the lower pole (“upper pole, lower hole”)

Prolog FPMR (Urogyn) - Q32

Question 33

17yo with primary amenorrhea, Tanner stage 4 breasts, normal external genitalia other than vaginal dimple. No uterus on US. Initial lab test to confirm diagnosis?

Answer 33

Testosterone (differentiates vaginal agenesis versus androgen syndromes)

Primary amenorrhea: no menses by age 15

Vaginal agenesis = 46 XX
- Mayer-Rokitansky-Kuster-Hauser syndrome should also be evaluated for renal (25-50%) and skeletal anomalies (10-15%)

AIS = 46 XY
- 2-5% risk of testicular cancer -> bilateral gonadectomy after completion of puberty

Neovagina procedures:
- McIndoe: graft from thigh/buttock and stent at vaginal orifice. 90% success.
- Vecchietti: abdominally; acrylic sphere against the vaginal dimple with traction device. 98% success.

Prolog FPMR (Urogyn) - Q33

Question 34

35yo with hx of spinal cord injury undergoing cystoscopy develops sudden headache, sweating, hypertension, and bradycardia when bladder filled. Immediately resolves when bladder empties. Patient likely has a spinal cord lesion at…? (level)

Answer 34

Cord level T4

Autonomic hyperreflexia: above spinal column T6
- exaggerated sympathetic response
- find and reverse stimulus. Can give alpha-adrenergic blockers, hydralazine, or nitrates for hypertension

Spinal cord level is not the same as spinal column (bony spine) level
- spinal cord level T7-T8 = spinal column level T6
- sacral spinal cord begins at spinal column level T12-L1
- cauda equina begins at spinal column L2

Prolog FPMR (Urogyn) - Q34

Question 35

48yo with 5cm urethral diverticulum and stress incontinence. Maximum urethral closure pressure of 18 cm H2O. Best concomitant anti-incontinence procedure?

Answer 35

Autologous fascial sling
- serves as an additional tissue layer between repaired urethral defect and vaginal epithelium
- avoid foreign body with urethral diverticulum due to fistula formation risk

Retropubic midurethral slings more effective than transobturator sling in patient with maximum urethral closure pressure <20 cm H2O

Autologous slings have higher rates of postop retention. Wouldn’t be unreasonable to repair diverticulum and offer midurethral sling 8 weeks or more postop

Prolog FPMR (Urogyn) - Q35

Question 36

58yo POD#1 from open hyst+colpopexy falls getting out of bed. Decreased motor strength of her left quadriceps muscle, sensory loss over anterior thigh, absent patellar reflex. Nerve most likely injured?

Answer 36

Femoral

Nerve injuries:
- Neuropraxia: compression/stretching of nerve and vascular supply. Least severe.
- Axonotmesis: axon injured, Wallerian degeneration, can regenerate but slowly
- Neurotmesis: transection, most severe

Risk factors with persistent neuropathy: prolonged surgical time, steep tburg, low or high BMI, smoking within 20days of procedure, self-retaining retractors

• Femoral: anterior rami L2-L4, motor to anterior thigh and sensation to anterior and medial leg -> from retractor
• Obturator: posterior rami L2-L4, adductor muscles
• Sciatic: anterior rami L4-S4, motor and sensation to hamstrings -> hyperflexion of thigh in stirrups
• Common peroneal: from sciatic. Compressed in stirrups. Foot drop.
• Ilioinguinal: L1-L2, suprapubic sensation -> low-transverse incisions

Prolog FPMR (Urogyn) - Q36

Question 37

65yo with accidental bowel leakage, several loose stools per day, and hx of sphincter laceration with delivery 40 years ago. Intervention to most likely eliminate her fecal incontinence is?

Answer 37

Loperamide
- Control stool consistency and motility first (NOT sacral neuromodulation)

Advancing age is greatest RF for accidental bowel leakage
Other RF: loose stool/diarrhea (3 fold inc), T2DM, BMI > 30, multiple chronic medical problems .

Prolog FPMR (Urogyn) - Q37

Question 38

30yo with gas and stool per vagina 4 weeks after 4th degree repair. 7mm rectovaginal fistula above the anal sphincter complex. Most appropriate management?

Answer 38

Mobilization of fistula tract and layered closure
- early surgical intervention using a simple layered approach as long as no active infection is present
- pinpoint fistulas (<4mm) have up to a 40% chance of spontaneous closure, expectant management is advisable
- larger than >5mm rarely close without surgical intervention

Prolog FPMR (Urogyn) - Q38

Question 39

48yo undergoes 6 hour complicated robotic procedure in steep trendelenburg. POD#1 she is unable to pick up her coffee cup but denies pain. Best next step?

Answer 39

Physical therapy

Brachial plexus injury from steep Tburg with arms fixed to sides and sliding cephalad
- most have complete recovery
-Presentation = motor and sensory weakness, unilateral

Prolog FPMR (Urogyn) - Q39

Question 40

82yo with nighttime urgency and frequency, “running to the bathroom”. No daytime symptoms. In addition to a voiding dairy, best next step?

Answer 40

Bedside commode for nighttime use

Nocturia = 2+ episodes of urge to void at night
- can be from fluid intake in the evening, CHF, venous insufficiency, reduction of prolapse. BPH in men.
Nocturnal polyuria = 35% of 24hr urine volume is voided at night

Fracture in this age is associated with 50% mortality rate in the first year after fracture

Prolog FPMR (Urogyn) - Q40

Question 41

80yo s/p colpocleisis 1 year ago now having intermittent fecal incontinence, incomplete bowel evacuation, and rectal fullness. Most likely finding on physical exam?

Answer 41

Rectal prolapse (NOT posterior wall prolapse)
- Colpocleisis success rate 90-100%, recurrent prolapse is uncommon

Rectal prolapse: 0.5%.
- Consider colonoscopy to look for lead point mass
2 transperineal procedures: Altemeier and Delorme techniques

Prolog FPMR (Urogyn) - Q41

Question 42

35yo with complete T9 spinal cord injury 2 years ago. Initially had urinary retention and catheter, then was taught to intermittently cath. Started developing incontinence between cath’s. Urodynamic testing: detrusor pressure increasing to 50 cm H2O at a volume of 150mL and leak point pressure of 60 cm H2O at a volume of 200mL. Bilateral hydronephrosis on US. Next step in management?

Answer 42

Ileocystoplasty

6-12 weeks after injury bladder is atonic and doesn’t empty (need catheter). Over time, patients develop detrusor dysfunction where bladder contracts against closed sphincter, resulting in urinary retention and overflow incontinence.
- Initial mgmt: intermittent cath and anticholinergics

Leakage between caths: detrusor overactivity or poor bladder compliance

Detrusor leak point pressure: lowest value of pressure where leakage is observed
- pressures increasing to over 40 cm H2O before leakage are at risk for upper tract damage

Ileocytoplasty = opening bladder widely and patching to U-shaped segment of ileum to restore capacity

Prolog FPMR (Urogyn) - Q42

Question 43

50yo with multiple sclerosis with periodic incontinence. PVR in office 400mL. Best next step in management?

Answer 43

Clean intermittent catheterization and anticholinergic agent

Neurologic lesions above the pons (micturition center) typically result in detrusor overactivity with external sphincter synergy
- increased detrusor tone with increase in sphincter tone at the same time

Advise to cath 5x/day and bladder volume shouldn’t exceed 500cc

Prolog FPMR (Urogyn) - Q43

Question 44

52yo undergoing midurethral retropubic synthetic sling. After trocar placed, gross hematuria noted. Cytoscopy showed bilateral perforations of the sling trocars. Next best step?

Answer 44

Replace the sling

Cysto: 0 or 30 degree scope best for urethra, 70 degree for bladder

Trocar passage through bladder generally is of no consequence

Prolog FPMR (Urogyn) - Q44

Question 45

58yo with vaginal bulge, splinting to defecate, sexually active, with POP-Q showing posterior compartment prolapse. Best surgery for her?

Answer 45

Posterior colporrhaphy
- success rate 76-96%

Graft use not recommended in posterior compartment

Prolog FPMR (Urogyn) - Q45

Question 46

45yo 5 months after robotic assisted laparoscopic sacrocolpopexy with worsening back pain, tenderness on spine, and increased enhancement on MRI. Most likely microbial pathogen associated with her vertebral discitis is…?

Answer 46

2 = candida

Staph aureus

MC organism isolated in vertebral osteomyolitis after sacrocolpopexy.

Prolog FPMR (Urogyn) - Q46

Question 47

74yo undergoes TVH, BSO, and uterosacral ligament suspension. Postop has pain and numbness in left buttock that radiates down back of thigh to popliteal fossa. No motor compromise. Most likely cause of her pain is…?

Answer 47

Entrapment of sacral nerve roots

USLS: If sutures are placed too lateral or too deeply can entrap sacral nerve branches -> pain and numbness in S2-S4 distribution

Prolog FPMR (Urogyn) - Q47

Question 48

The correct term for the electrosurgical function you perform with the bipolar device is….?

Answer 48

Coagulation

“Cauterization” = conduction of heat via direct current from probe heated to a very high temperature. (Ex: branding cattle)

Vaporization = continuous current without direct contact to tissue, on cutting mode. Clean wound with minimal necrotic tissue at borders.

Coagulation = wide surface, amount of heat generated is too low to vaporize the tissue. Desiccation, forms coagulum.

Fulguration = superficial coagulum by applying intermittent energy to the tissue surface using monopolar electrode without direct tissue contact (rollerball after LEEP)

Prolog FPMR (Urogyn) - Q48

Question 49

57yo undergoing TVH and uterosacral ligament suspension. BMI 37, otherwise healthy, no hx of VTE or smoking, taking HRT. Her perioperative thromboprophylaxis should be…

Answer 49

Intermittent pneumatic compression devices

Other correct choices (considered high risk for VTE):
- unfractionated heparin 5K units Q8 hours
- LMWH 40mg daily
- graduated compression stockers
- SCDs

Low risk = surgery <30 minutes in patients <40 yrs with no risk factors
Moderate = surgery <30 min with risk factors; <30min 40-60yrs with no risk factors; major surgery <40yrs
High = <30 min in patients >60yrs or with risks; major surgery >40yrs or with risks
Highest = major surgery in patients older than 60+prior VTE, cancer, or hypercoagulable state

Prolog FPMR (Urogyn) - Q49

Question 50

42yo with stress incontinence despite trying pessary. Wants definitive management with the treatment that has the highest success rate with shortest recovery time. Most appropriate treatment…?

Answer 50

Midurethral sling
- as effective as Burch and fascial slings but shorter operative times, quicker recovery, and fewer postop complications

Prolog FPMR (Urogyn) - Q50