Question deck

Question 1

Which of the following has the highest prevalence?
A) Mayer-Rokitansky-Kuster-Hauser

B) Androgen Insensitivity Syndrome

C) Gonadal agenesis

D) Transverse septum

Answer 1

A

Gidwani G, Falcone T. Congenital Malformations of the Female Genital Tract: Diagnosis and Management. Philadelphia (PA): Lippincott Williams & Wilkins, 1999.

Question 2

Which of the following dietary modifications have been independently proven to reduce urge urinary incontinence?
A)
Reduction in caffeine intake to less than 150 mg/day
 B)
Elimination of artificial sweeteners
 C)
Elimination of spicy foods
 D)
A and B
E)
None of the above

Answer 2

E. Although high caffeine associated with UUI no definitive evidence that reducing eliminates sx

Question 3

A woman presents with significant apical vaginal prolapse. This implies likely significant loss of support from the following structure:
A)
Uterosacral ligaments
B)
Pubocervical fascia
 C)
Prerectal fascia
 D)
Perineal body

Answer 3

A

Question 4

All of the following statements about the surgical treatment of posterior vaginal prolapse is true except:
A) Site-specific rectocele repair results in a lower risk of postoperative dyspareunia and decreased rates of bowel dysfunction compared to traditional posterior colporrhaphy (midline fascial plication)

B) There is no current evidence that use of synthetic or biologic graft improves outcomes compared to native tissue rectocele repairs (midline fascial plication, site specific rectocele repairs)

C) Transanal rectocele repairs result in lower cure rates than transvaginal approaches

D) Bowel symptoms such as splinting, difficulty emptying and feeling of incomplete evacuation improve or resolve in most women after rectocele repair

Answer 4

A

Maher CM, Feiner B, Baessler K, et al. Surgical management of pelvic organ prolapse in women: the updated summary version Cochrane review. Int Urogynecol J 2011; 22:1445-57.
Paraiso MF, Barber MD, Muir TW, et al. Rectocele repair: a randomized trial of three surgical techniques including graft augmentation. Am J Obstet Gynecol 2006; 195:1762-71.
Gustilo-Ashby AM, Paraiso MF, Jelovsek JE, et al. Bowel symptoms 1 year after surgery for prolapse: further analysis of a randomized trial of rectocele repair. Am J Obstet Gynecol 2007; 197:76 e1-5.

Question 5

A 64 year-old with a history of diverticulitis undergoes a laparoscopy converted to open laparotomy for a mesh sacral colpopexy, extensive adhesiolysis with enterolysis and cystourethroscopy. The case is converted to a laparotomy due to difficulty visualizing the pelvis due to extensive dense adhesions of the small bowel to the cul-de-sac and adhesions of the rectosigmoid to the vagina and bladder. At the end of the case prior to closure of the abdomen, the best management is to:
A) Inspect the entire bowel.

B) Inspect only the areas of bowel you do not remember seeing when you packed the abdomen.

C) Inspect only the areas of bowel involved in the enterolysis.

D) There is no need to inspect the bowel if no gross spillage of bowel contents was noted intraoperatively.

Answer 5

A

Question 6

Which of the following have never been shown to be risk factors for urinary tract infections?
A) Coitus

B) Postmenopausal status

C) Douching

D) Family history of UTIs in female relatives

E) Use of spermicides

Answer 6

C

Question 7

A 42-year-old women presents with complaints of leaking urine daily. She states she voids every 1-2 hours, which is an increase in frequency for her and she, reports most urges to void are sudden, very strong and cannot be deferred. She will leak with any cough or sneeze and has quit playing tennis because of the staining of her clothing with urine that occurs. In addition, she gets up to void at least once every night but can go back to sleep afterwards. What is her diagnosis?
A)
Urinary incontinence, overactive bladder
B)
Mixed incontinence, overactive bladder syndrome
C)
Urge incontinence, overactive bladder
D)
Detrusor overactivity, genuine stress urinary incontinence, urinary frequency

Answer 7

B.

Haylen BT, de Ridder D, Freeman RM, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Int Urogynecol J 2010; 21:5-26.

The ICS/IUGA document defines mixed incontinence as combined stress and urgency incontinence complaint. (Stress incontinence: complaint of involuntary loss of urine on effort or physical exertion and Urgency incontinence: complaint of involuntary loss of urine associated with urgency.).
Overactive bladder (OAB) syndrome is defined as urinary urgency, usually accompanied by frequency and nocturia, with or without urgency urinary incontinence, in the absence of urinary tract infection or other obvious pathology.

Question 8

Which statement regarding fascial sling versus Burch colpopexy for the treatment of SUI is most correct?

A) Autologous fascial sling results in a higher rate of successful treatment of SUI than Burch colposuspension

B) Burch colposuspension results in a higher rate of successful treatment of SUI than autologous fascial sling

C) Postoperative voiding dysfunction has been shown more common after Burch colpopexy than fascial sling.

D) Adverse events, including urinary incontinence, have been shown more common after Burch colposuspension than fascial sling.

Answer 8

A

In a multicenter, randomized clinical trial comparing pubovaginal sling with autologous rectus fascia and Burch colposuspension, women in the sling group had 24-month cumulative rates of success significantly higher than those with Burch (overall 47% versus 38% (P=0.01)), (specific to SUI 66% versus 49% (P

Question 9

Your patient with a history of fourth degree laceration presents to the office for a third time with complaints of flatus per vagina and intermittent vaginal discharge. You cannot find a fistula tract. Your best next step is:

A) Order a barium enema

B) Take her to the operating room for an exam under anesthesia

C) Perform episioproctotomy in the OR so as to excise the apparent fistula, then repair the perineum

D) Give her a prescription for vaginal metronidazole gel to use as needed

Answer 9

B

Question 10

A placebo controlled randomized trial evaluating a new drug “No Leak” for overactive bladder is conducted. 300 women with overactive bladder are randomized to either placebo or No Leak and followed for 12 weeks. The primary outcome of the study is the average number of urge urinary incontinence episodes (UUI) per day recorded on a 3-day diary. An important secondary outcome is the proportion of women in each group with dry mouth.

At 12 weeks, the proportion with dry mouth in each group was: Drug No Leak- 34/100 (34%) and Placebo- 15/100 (15%), p = 0.015. Which of the following tests was most likely used to compare the proportion of women with dry mouth between the two groups?

A) Analysis of Variance (ANOVA)

B) Chi-square test

C) Student’s t test

D) Log-rank test

Answer 10

B

Question 11

A true statement regarding urogenital fistula repair is:

A) It may be advantageous to use interpositional grafts for fistula involving the bladder neck and urethra, fistula after radiation therapy or large fistulae.

B) There is Level 1 evidence that removing the entire fistulous tract increases the success of a repair.

C) The most common complication after a urethrovaginal fistula repair is reported to be a urethral stricture

D) There is Level 1 evidence that using antibiotics perioperatively will reduce the odds of a failed gynecologic vvf repair.

E) A common approach used for urethrovaginal fistula repair is a prone, jacket-knife position

Answer 11

A

Wong MJ, Wong K, Rezvan A, Tate A, Bhatia NN, Yazdany T. Urogenital fistula. Female Pelvic Med Reconstr Surg 2012; 18:71-8.
Pushkar DY, Dyakov VV, Kosko JW, Kasyan GR. Management of urethrovaginal fistulas. Eur Urol 2006; 50:1000-5.

Question 12

Your patient is diagnosed based on radiologic imaging as having a staghorn calculus. The chemical composition of the renal stone is most likely which of the following?

A) Calcium oxalate

B) Calcium phosphate

C) Stuvite (Magnesium ammonium phosphate)

D) Calcium bicarbonate

E) Uric acid

Answer 12

C
While stones composed of cystine or uric acid can grow into staghorn calculi, these calculi are most commonly composed of struvite.

AUA Clinical Guidelines

Question 13

If one wanted to compare the association between preoperative Valsalva leak point pressures and post operative scores on the Pelvic Floor Distress Inventory (PFDI), which of the following what would be the most appropriate statistical test to use?

A) Pearson correlation coefficient

B) Chi square

C) Student’s t-test

D) Logistic regression

Answer 13

A

Question 14

Question 14 of 740
A 55 year old female is planning to undergo an anal sphincteroplasty for fecal incontinence. She asks you to estimate the success rates of fecal continence. The following estimates are most accurate:

A) 11-14% in patients followed after 5 years

B) 28% in patients after a year

C) 41% of patients followed for over 40 months

D) 85% success rate 5 years after surgery

Answer 14

A

Question 15

A true statement regarding medications used to treat urinary incontinence is:

A) At the dose required to treat SUI, the risk of stroke and severe hypertention is too high to use tricyclic antidepressants.

B) There are Level 1 studies with outcomes at one year, documenting continued success of β3 adrenergic agents.

C) 25% of patients may have nausea if they use an alpha adrenergic agonist

D) Intravesical capsaicin can cause transient pelvic pain.

E) A common side effect of an alpha adrenergic antagonist is urinary incontinence

Answer 15

D

Mariappan P, Alhasso A, Ballantyne Z. et al. Duloxetine, a Serotonin and noradrenaline Reuptake Inhibitor (SNRI) for the Treatment of SUI: A systematic Review. European Urology 2007: 51; 67-84. and Silva W.Andre. Pharmacologic Management of Incontinence and Voiding Dysfunction. Pelvic Medicine and Surgery 2005; 11 (1): 1.

Question 16

Which of the following blood vessels are NOT part of the posterior branch of the internal iliac artery?

A)
Iliolumbar
 B)
Superior Gluteal
C)
Middle Rectal
 D)
Lateral Sacral

Answer 16

C

Question 17

Screening for asymptomatic bacteriuria is indicated in which of the following populations?

 A)
Premenopausal, sexually active women
B)
Pregnant women
 C)
Diabetic women
 D)
Women in long term nursing facilities
 E)
Women with spinal cord injuries

Answer 17

B

Question 18

The segment of the vagina most likely to develop prolapse is:

A) Anterior
B) Posterior
C) Apical
D) Uterine

Answer 18

A

Question 19

Which of the following is true regarding the use of pelvic floor muscle therapy for the treatment of pelvic organ prolapse?

A) Objective and subjective improvements have been noted in pelvic organ prolapse findings between women performing pelvic floor muscle therapy versus those who did not

B) No subjective benefits have been noted in studies of women performing pelvic floor muscle therapy versus those who did not

C) No objective benefits have been noted in studies of women performing pelvic floor muscle therapy versus those who did not

D) Complete cure for Stage 2 pelvic organ prolapse has been noted in a randomized trial of women performing pelvic floor muscle therapy versus those who did not

E) Two stage improvement has been noted in a randomized trial of pelvic floor muscle therapy versus none for the treatment of pelvic organ prolapse

Answer 19

A

Culligan P. Nonsurgical management of pelvic organ prolapse. Obstet Gynecol 2012;119:852-860

Question 20

According to the 2010 American Urologic Associate Guidelines, all of the following are acceptable treatment regimens for acute pyelonephritis, EXCEPT:

A) Amoxicillin 500mg three times daily for 14 days with initial dose of 3gm fosfomycin

B) Oral ciprofloxacin 500mg twice daily, for 7 days with initial 400mg dose of intravenous ciprofloxacin

C) Oral ciprofloxacin 500mg twice daily, for 7 days without initial 400mg dose of intravenous ciprofloxacin

D) Oral levofloxacin 750mg daily for 5 days

Answer 20

A

Question 21

A patient with severe urgency and urgency urinary incontinence presents for urodynamic evaluation. A pressure catheter is placed in the bladder and in the vagina and both are zeroed to atmospheric pressure. At the start of infusion, the Pves pressure is 20 cm H2O. At a maximum cystometric capacity of 600mL, the Pves pressure is 60 cm H2O. There is no change in the Pabd pressure. Which of the following statements is correct?

A) The calculated compliance is 15

B) The calculated compliance is 10

C) There is not enough information to calculate compliance

D) The calculated compliance is 30

Answer 21

A

The compliance is calculated by dividing the change in volume over the change in bladder pressure. No the change in bladder pressure should not include pressure recordings that are taken during a detrusor contraction.

Question 22

A recent study reported outcomes on the rate of progression and regression of symptomatic pelvic organ prolapse in subjects who declined surgical and non-surgical intervention electing observation. In this study all of the following were observed except:

A) The majority of patients were stages 2 and 3

B) The median follow-up time was 16 months and nearly 80% of patients demonstrated no change in leading edge

C) On multivariate analysis, change in leading edge was seen to be independently associated with age

D) 19% of patients demonstrated ≥ 2 cm increase in leading edge

E) 38% of subjects desired the use of a pessary or surgical correction at their last recorded visit

Answer 22

C

Gilchrist AS, Campbell W, Steele H, Brazell H, Foote J, Swift S. Outcomes of observation as therapy for pelvic organ prolapse: A study in the natural history of pelvic organ prolapse. Neurourol Urodyn 2012;doi 10.1002/nau

Question 23

Which of the following anatomic structures does not significantly contribute to urethral closure pressure in women?

A) Waldeyer’s sheath

B) Longitudinal smooth muscle

C) Circular smooth muscle

D) Striated muscle

E) Vascular submucosal layer

Answer 23

A

Waldeyer’s sheath is a fibromuscular layer surrounding the intravesical portion of the ureter. It is contiguous with the deep muscular layer of the trigone of the bladder. The urethra consists of the following layers: an outer layer of striated muscle, an outer circular smooth muscle layer, an inner longitudinal smooth muscle layer, a vascular submucosa, and a hormonally sensitive mucosa. The striated muscles, smooth muscles, vascular submucosa and mucosa all contribute to urethral closure pressure.

McBride, Li, Gutman (J Pelvic Med Surg 2003; 9:103-123)
Next

Question 24

Estrogen receptors are found on all of the following except:

A) Trigone

B) Proximal urethra

C) Distal urethra

D) Transitional epithelium

Answer 24

D

Andersson KW, & Wein AJ, Pharmacol Rev, 2004; 56, 581-631

Question 25

In your institution 3 out of 100 patients sustained a mesh erosion after sacrocolpopexy. Out of the 100 patients, 15 were smokers and 40 underwent concomitant hysterectomy. You hypothesize that smoking and concomitant hysterectomy might be risk factors for mesh erosion. Which is the most appropriate approach to investigate this hypothesis? A) Case-control study comparing those who had hysterectomy vs. those who did not B) Case-control study comparing those who smoked vs. those who did not C) Randomized trial of those undergoing mesh sacrocolpopexy where subjects are randomized to smoking or non-smoking arms D) Case-control study comparing those with mesh erosion to matched subjects without mesh erosion

Answer 25

D A case-control study is used to examine risk factors for a rare outcome (ie: outcome that occurs in . The two comparison groups are chosed based on the OUTCOME of interest (ie: mesh erosion) and you compare the proportions of subjects who had various exposures (ie: smoking or hysterectomy). In answers a and b, the two groups are chosen based on exposures, which is not appropriate for a case-control study. A randomized trial would require a large amount of resources in order to examine a rare outcome; in addition it would not be ethical to randomize patients to smoking vs non-smoking groups; thus answer c is not correct. Answer d is the correct answer. A case-control study is appropriate and the two groups are chosen based on the outcome of interest (mesh erosion). Strauss et al. Evidence-Based Medicine: How to Practice and Teach EBM, 3rd ed, pgs 180-183

Question 26

Which structure has the largest contribution to anal continence? A) Internal anal sphincter B) External anal sphincter C) Puborectalis muscle D) Pubococcygeus muscle

Answer 26

A The anal sphincter complex includes the internal anal sphincter (IAS), the external anal sphincter (EAS), and the puborectalis muscle (PR). The smooth muscle of the IAS is innervated by the autonomic nervous system and is responsible for over half of the resting tone of the sphincter. The striated muscle of the EAS is innervated by the pudendal nerve and is responsible for approximately one third of the resting tone of the sphincter. The PR and levator ani musculature also contribute to resting tone but the largest contribution comes from the IAS. Walters and Karram; Urogynecology and Reconstructive Pelvic Surgery, 3rd ed., Chapter 24

Question 27

What is the optimal empiric treatment of acute uncomplicated cystitis? A) Ciprofloxacin 500 mg twice daily for 3 days B) Amoxicillin-clavulanate 500 mg/125 mg twice daily for 7 days C) Cephalexin 500 mg twice daily for 7 days D) Nitrofurantoin monohydrate/macrocrystals 100 mg twice daily for 5 days

Answer 27

D Twice daily nitrofurantoin for 5 days is the optimal treatment for acute uncomplicated cystitis based on the 2010 AUA-IDSA UTI Rx Guidelines. Fluoroquinolones are highly efficacious in 3 day regimens but have a propensity for collateral damage and should be reserved for important uses other than acute cystitis. B-Lactam agents, like amoxicillin-clavulanate, in 3-7 day regimens are appropriate choices when other agents cannot be used. Other B-lactams, like cephalexin, are less well studied but may be appropriate in certain settings. B-lactams generally have inferior efficacy and more adverse effects compared to other UTI antimicrobials. Kalpana Gupta, Thomas M. Hooton, Kurt G. Naber, Bjo ̈rn Wullt, Richard Colgan, Loren G. Miller, Gregory J. Moran, Lindsay E. Nicolle, Raul Raz, Anthony J. Schaeffer, and David E. Soper. International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clinical Practice Guidelines; CID 2011:52, e117.

Question 28

The differential diagnosis of urethral diverticulum in the setting of a normal IVP includes all of the following except: A) Skene's gland cyst B) Ectopic ureterocele C) Urethral carcinoma D) A and C E) Cystocele

Answer 28

B is the only upper urinary tract abnormality Scarpero HM, Urol Clin North Am 2011 Feb 38(1) 65-71

Question 29

Each of the following urodynamic tests require a pressure catheter in the bladder except: A) Single channel cystometrogram B) Multi-channel cystometrogram C) Uroflowmetry D) Pressure-Flow study

Answer 29

C

Question 30

Posterior repair with mesh augmentation: A) Improves both anatomic and symptomatic outcomes B) Improves anatomic outcomes but does not have a symptomatic benefit C) Does not have anatomic or symptomatic benefit D) Has not been studied in randomized trials, so no conclusions can be drawn

Answer 30

C DA Executive Summary: Surgical Mesh for Treatment of Women WIth Pelvic Organ Prolapse and Stress Urinary Incontinence. Sept 8-9.2011:Accessed April 7, 2013 at http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/MedicalDevices/MedicalDevicesAdvisoryCommittee/ObstetricsandGynecologyDevices/UCM270402.pdf

Question 31

How much retraction or shrinkage can be expected in 2-dimensional sheet of Amid type I mesh over the first year after implantation: A) None - retraction is a phenomenon of type II mesh B) 10% C) 20% D) 40%

Answer 31

C Amid PK, Classification of biomaterials and their related complications in abdominal wall hernia surgery. Hernia 1997; 1: 15-21.

Question 32

The resting tone of the anus is a result of: A) External anal sphincter resting tone B) Internal anal sphincter resting tone C) Pubococcygeus muscle resting tone D) Resting tone of both the external and internal anal sphincters

Answer 32

B Hayden DM, Weiss EG. Fecal incontinence: etiology, evaluation, and treatment. Clinics in colon and rectal surgery. Mar 2011;24(1):64-70 continence tICo. Incontinence. 4 ed. Paris, France: EDITIONS21; 2009

Question 33

You finish a difficult pelvic floor abdominal surgery that required over an hour of lysis of adhesions involving the small intestines the large intestines, vagina and bladder. You are concerned that there may have been an injury to the colon. What is the most appropriate next step? A) Palpate the distal rectum and confirm that the bowel wall is intact. B) Follow the patient closely postoperatively keeping her on a clear liquid diet until she passes flatus C) Fill the abdomen and pelvis with saline, compress the descending colon and fill the rectum with air to confirm the absence of air bubbles D) Order an intraoperative colonoscopy.

Answer 33

C

Question 34

Cholinergic transmission is localized to: A) Bladder only B) Trigone only C) Urethra only D) External urethral sphincter only E) Both bladder and external urethral sphincter

Answer 34

E Fowler CJ, Griffiths D, de Groat WC. The neural control of micturition. Nat Rev Neurosci 2008; 9:453-66.

Question 35

A 17 year old presents with primary amenorrhea. Breast development was normal. Exam reveals a foreshortened vagina measuring 1cm. To differentiate Mullerian agenesis from Androgen Insensitivity Syndrome and other congenital anomalies, the following work-up is appropriate: A) MRI, karyotype, and testosterone levels B) Diagnostic laparoscopy C) MRI, FSH and LH D) Retrograde pyelogram and cystoscopy E) Karyotype

Answer 35

A Gidwani G, Falcone T. Congenital Malformations of the Female Genital Tract: Diagnosis and Management. Philadelphia (PA): Lippincott Williams & Wilkins, 1999.

Question 36

A Gartner's duct cyst is a vestigial remnant of the: A) Urogenital sinus B) Paramesonephric duct C) Mesonephric duct D) Metanephric duct E) Sinovaginal bulbs

Answer 36

C Carlson BM. Human Embryology and Developmental Biology, 4th Ed. Philadelphia (PA): Mosby, Inc., 2009.

Question 37

The most common presenting symptom of urethral diverticulum is: A) Discharge per urethra or vagina B) Dyspareunia C) Recurrent urinary tract infections D) Frequency/urgency

Answer 37

D Frequency/urgency is the most common reported symptom. Handel LN, Current Urol Rep 2008, 9:383-388

Question 38

Which of the following statements are true about magnetic resonance imaging? A) T2 weighted films show fat as white B) Suspect urethral diverticula show up as white due to spin characteristics of adjacent fat C) T1 weighted images show urine or fluid media as bright white D) None of the above

Answer 38

D Gousse AE, Barbaric ZL, Safir MH, Madjar S, Marumoto AK, Raz S. Dynamic half Fourier acquisition, single shot turbo spin-echo magnetic resonance imaging for evaluating the female pelvis. J Urol 2000; 164:1606-13. Blander DS, Rovner ES, Schnall MD, Ramchandani P, Banner MP, Broderick GA, Wein AJ. Endoluminal magnetic resonance imaging in the evaluation of urethral diverticula in women. Urology 2001; 57:660-5.

Question 39

In a patient who has uncontrolled narrow angle glaucoma and severe UUI, the best option would be: A) Transdermal oxybutynin B) A β3 adrenergic agonist C) A selective norephinephrine and serotonin uptake inhibitor D) An alpha adrenergic agonist E) A tricyclic antidepressant

Answer 39

b Gormley EA, Lightner DJ, Burgio KL. Diagnosis and Treatment of OAB (non neurogenic) in adults: AUA /SUFU Guideline. American Urological Association Education and Research, Inc. 2012 and Rios L A, Panhoca R, Mattos D et al. Intravesical Resiniferatoxin for the Treatment of Women with Idiopathic Detrusor Overactivity and urgency Incontinence: A Single Dose, 4 weeks, Double-Blind Randomized Placebo Controlled Trial. Neurourol and Urodynamics 2007: 26; 773-778.

Question 40

A 47 year old patient with a Stage III anterior pelvic organ prolapse and urodynamic stress incontinence undergoes an uncomplicated anterior repair with mesh augmentation and a transobturator midurethral sling. Postoperatively she trips when beginning to ambulate and is diagnosed with foot drop. Which of the following nerves is most likely to have been injured? A) Common peroneal nerve B) Obturator nerve C) Pudendal nerve D) Femoral nerve

Answer 40

A McBride AW, et al. Journal of Pelvic Medicine and Surgery. Volume 9, Number 3, May/June 2003

Question 41

Which medication is may interact with anti-cholinergics? ``` A) acetominophen B) tricyclic anti-depressants C) docusate D) senna ```

Answer 41

B Gormley EA, Lightner DJ, et al. Diagnosis and Treatment of Overactive Bladder (Non-Neurogenic_ in Adults: AUA/SUFU Guideline. J urol 2012;188:2455-2463.

Question 42

A 21 year old nulliparous woman is referred to your office for "continuous leakage of urine in her vagina." Her medical and surgical history are unremarkable. Her work up included a negative tampon test. Office cystoscopy reveals a single left ureteral orifice. Based on these findings, you suspect the patient has which of the following conditions. A) Vesicovaginal fistula B) Ectopic ureter C) Horseshoe kidney D) Duplicated urinary system

Answer 42

B

Question 43

Common complications of vaginal pessary use include all of the following except: A) Vaginal epithelial bleeding B) Abnormal discharge C) Urinary incontinence D) Urinary retention E) Rectal bleeding

Answer 43

E Atnip SD. Pessary use and management of pelvic organ prolapse. Obstet Gynecol Clin N Am 2009;36:541-563

Question 44

Which of the following does not represent one of the possible goals of pelvic floor physical therapy for the treatment of urinary incontinence? A) Increase strength B) Increased endurance C) Coordinate muscle activity D) Decrease hypermobility of bladder neck

Answer 44

D Hay-smith J. Cochrane Database of Systematic Reviews 2008, Issue 4.

Question 45

# Choose the most accurate statement regarding surgical repair of posterior vaginal wall prolapse. A) There are more posterior wall prolapse recurrences with posterior colporrhaphy alone compared to posterior colporrhaphy with a polyglactin mesh B) Synthetic mesh augmentation for posterior colporrhaphy results in improved anatomic outcomes, but with a higher risk of complications C) There is no benefit with synthetic or biologic graft. D) There are more posterior wall prolapse recurrences with posterior colporrhaphy alone compared to posterior colporrhaphy with a biologic graft

Answer 45

C In 2011 the FDA published an executive summary of data which stated that biologic or synthetic grafts do not improve outcomes for posterior vaginal wall prolapse. This is based on the following 3 RCTs: 1. Paraiso et al. compared posterior colporrhaphy, site-specific repair, and site-specific repair with biologic graft. In this study the group with biologic graft had worse anatomic outcomes compared to the other 2 groups. 2. Sand et al compared anterior and posterior repair with vs without polyglactin mesh reinforcement. In this study there were no differences in rectocele recurrence between groups. 3. Carey et al. compared anterior and posterior repairs with synthetic mesh to traditional anterior and posterior colporrhaphies. There were no differences in prolapse recurrence, including the posterior vaginal wall, between mesh and no mesh groups. Paraiso et al. Am J Obstet Gynecol. 2006 Dec;195(6):1762-71. 2. Sand et al. Am J Obstet Gynecol. 2001 Jun;184(7):1357-62; discussion 1362-4. 3. Carey et al. BJOG. 2009 Sep;116(10):1380-6.

Question 46

Weakening of the levator musculature results in: A) No difference in the horizontal orientation of the upper vagina B) Loss of the horizontal orientation of the upper vagina C) Closure of the genital hiatus D) No difference in the genital hiatus

Answer 46

B Levator tone involves the puborectalis muscle, which forms a sling around the vagina and rectum, and helps to maintain a horizontal axis of the upper vagina. Levator tone also helps to maintain closure of the genital hiatus. Weakening of the levator musculature results in loss of the horizontal orientation of the levator plate and enlargement of the genital hiatus. Siddique S. 2003; J Pelvic Med Surg 9(6): 263-272

Question 47

What is the recommended daily dietary fiber intake to prevent or treat constipation? A) 5 - 15 gm B) 15 - 20 gm C) 20 - 35 gm D) 35 -50 gm E) >50 gm

Answer 47

C

Question 48

All of the statements about obesity and pelvic floor surgery are true except: A) There is a higher rate of surgical site infection in patients who are obese vs. non-obese B) Obese patients have increased blood loss C) Vaginal hysterectomy results in higher infection rates D) There are higher operative times in obese patients

Answer 48

C Rogers, RG, Lebkuchner, U, Kammerer-Doak, DN, Thompson, PK, Walters, MD, and Nygaard, IE: Obesity and retropubic surgery for stress incontinence: Is there really an increased risk of intraoperative complications? Am J Obstet Gynecol 2006; 195: 1794-8. Handa, VL, Harvey, L, Cundiff, GW, and Kjerulff, KH: Perioperative Complications of Surgery For Genital Prolapse: Does Concomitant Anti-Incontinence Surgery Increase Complications? Adult Urology 2004;65:483-487. Chen, CCG, Collins, SA, Rodgers, AK, Paraiso, MFR, Walters, MD, and Barber, MD: Perioperative complications in obese women vs normal-weight women who undergo vaginal surgery. Am J Obstet Gynecol 2007; 197: 98.e1-98.e8.

Question 49

What is the mean distance from TVT trocar to the major vessels when the trocar is directed toward the ipsilateral shoulder and directly behind the pubic bone? A) 3.2 to 4.9 cm B) 0.5 to 1.1 cm C) 7.8 to 9.0 cm D) 10.2 to 11.7 cm

Answer 49

A In a cadaveric study of TVT trocar placement, the mean distance from the trocar to obturator vessels was 3.2 cm (range 1.6-4.3 cm), to the superficial epigastric vessels was 3.9 cm (range 0.9-6.70, to the inferior epigastric vessels was 3.9 cm (range 1.9-6.6 cm) and to the external iliac vessels was 4.9 cm (range 2.9-6.2 cm). Muir TW, Tulikangas PK, Fidela Paraiso M and Walters MD: The relationship of tension-free vaginal tape insertion and the vascular anatomy. Obstet Gynecol 2003; 101: 933.

Question 50

Well established major risk factors for development of pelvic organ prolapse include all of the following except: A) Older age B) Vaginal parity C) Diabetes D) Obesity E) Prior Hysterectomy

Answer 50

C Jelovsek JE, Maher C, Barber MD. Pelvic Organ Prolpase. Lancet 2007; 369:1027-38.

Question 51

A 61 year old undergoing midurethral sling is considered at what risk level for Venous Thromboembolism? A) Low Risk B) Modrate Risk C) High Risk D) Highest Risk

Answer 51

C Over 60 years of age with surgery less than 30 min OR major surgery in >40 year old is considered high risk. ACOG practice bulletin #84, Aug 2007 Table 1

Question 52

A 84 year old with urge urinary incontinence has failed several anticholinergic medications. She has rheumatoid arthritis with limited dexterity, but still ives independently. Which is the next best option for management? A) Interstim sacral neuromodulation trial with staged implantation if successful B) Botox injection 100 units intradetrusor C) Percutaneous tibial nerve stimulation D) Increase dose of oxybutinin to 15 then 30 mg daily as tolerated E) Placement of indwelling foley catheter

Answer 52

C Interstim may not be appropriate next line therapy given her age and limited ability to manage the programmer, patients undergoing botox injections should have ability to perform self catheterization. High dose oxybutinin may impair memory in this pateint and indwelling catheters are not recommended. Thus PTNS is likely the next best option of these. Gormley EA, Lightner DJ, Burgio KL, et al. Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline. The Journal of urology 2012;188:2455-63.

Question 53

A 69 year-old woman with uterovaginal prolapse comes to your office for a preoperative evaluation prior to her scheduled robotic assisted laparoscopic supracervical hysterectomy, mesh sacral colpopexy and cystoscopy. The procedure is scheduled for two weeks from today. She had previously been using a pessary for about a year but has decided to proceed with surgery. She has a medical history of hypertension and coronary artery disease. In your review of her medical and surgical history she reveals that since her last visit with you one month ago, she underwent a coronary revascularization procedure with placement of a drug-eluting stent and has been taking clopidogrel and aspirin since the procedure. In addition to consultation with her cardiologist, what is the best option for timing her surgical procedure? A) Reschedule her surgery in one month. At the time of surgery, stop the clopidogrel one week prior to surgery and restart on postoperative day 1 but continue the aspirin perioperatively. B) Reschedule her surgery in one year. At the time of surgery, stop the clopidogrel one week prior to surgery and restart on postoperative day 1 but continue the aspirin perioperatively. C) Reschedule her surgery in one year. At the time of surgery, stop both clopidogrel and aspirin for one week prior to surgery and restart postoperatively. D) Proceed with surgery as planned in two weeks and stop both clopidogrel and aspirin for one week prior to surgery and restart postoperatively. E) Proceed with surgery as planned in two weeks and stop the clopidogrel one week prior to surgery and restart on postoperative day 1 but continue the aspirin perioperatively.

Answer 53

B The American College of Cardiology-American Heart Association guidelines recommend in order to minimize risk of cardiac stent thrombosis, that elective noncardiac surgery be postponed until appropriate antiplatelet therapy has been given. This is 1 month for bare metal stents and 12 months for drug-eluting stents, as long as the patient is not at a high risk of bleeding. Further recommendations include the peri-operative continuation of aspirin if a patient with a cardiac stent undergoes a procedure during which the thienopyridine therapy needs to be discontinued. Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Anesth Analg. 2008;106:685-712

Question 54

The oldest urogynecologic procedure to utilize synthetic mesh is: A) Midurethral sling B) Transvaginal anterior repair C) abdominal sacrocolpopexy D) transvaginal apical suspension E) transvaginal posterior repair

Answer 54

C Urogynecologic Surgical Mesh: Update on the Safety and Effectiveness of Transvaginal Placement for Pelvic Organ Prolapse. FDA Safety Communication2011:Accessed April 6, 2013 at http://www.fda.gov/downloads/MedicalDevices/Safety/AlertsandNotices/UCM262760.pdf.

Question 55

All of the following are proposed theories regarding the etiology of interstitial cystitis/painful bladder syndrome except. A) Mast cell degranulation B) Autoimmune phenomenon C) Glycosaminoglycan deficiency D) Infectious bacteria E) Food borne allergen

Answer 55

E Quilin RB, Erikson, DR. Management of interstitial cystitis/BPS: A urological perspective. Urol Cl N Amer 2012; 39:389-96.

Question 56

A true statement regarding the pathophysiology of neurologic conditions affecting the lower urinary tract is: A) Patients who have a neurologic injury above the level of the brainstem usually present with an acontracile bladder B) Spinal cord lesions between the pontine micturition center and S2 are at greater risk for detrusor areflexia C) Lesions affecting the pelvic plexus can have effect on both parasympathetically and sympathetically innervated functions D) Most spinal cord lesions are complete and have very predictable neurologic sequela E) Urodynamics is of little value in determining management

Answer 56

C Although the pelvic plexus is primarily parasympathetic, interconnections with the sympathetics and therefore its function is also altered. Amis ES and Blaivas JG. Neurogenic Bladder Simplified. In: Radiologic Clinics of North America 1991; 29 (3): 571-580.

Question 57

What percentage of UTI's are caused by bladder instrumentation? A) 10% B) 80% C) 50 % D) 70%

Answer 57

B Lo, E, Nocolle, L, Classen, D et. al: Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals. Infect Cont Hosp EP 2008; 29: S41-S50.

Question 58

Which of the following is a benefit of the uterosacral ligament suspension compared to other vaginal native tissue apical repairs for prolapse? A) It is less likely to result with de novo stress incontinence B) It has fewer complications than other vaginal native tissue repairs C) The anterior vaginal wall is the least likely area to recur with this procedure D) It does not distort the vaginal axis

Answer 58

D Any type of anterior/apical prolapse repair could result in de novo stress incontinence. Thus it is not necessarily less likely with USLS than other procedures. USLS has different types of potential complications than other procedures, but is not reported to have fewer complications. With USLS there is up to 11% risk of ureteral injury, up to 7% risk of nerve injury, amongst other risks. The SSLF has a higher risk of bleeding complications due to close proximity of the pudendal and inferior gluteal vessels. There are also risks of pudendal nerve injury. The ilieococcygeus suspension may result in bleeding with up to a 2% risk of blood transfusion. There are risks of buttock pain, thought to be related to ischemia or necrosis of muscular tissue. In addition, the iliococcygeus suspension results in a shorter vaginal length and thus may not be preferable for all patients. With USLS, the anterior vaginal wall is the most likely area to recur (more likely than the apex). USLS does not distort the vaginal axis and therefore is a benefit to this procedure. Muir TW; J Pelvic Med Surg 2006; 12: 289-305 2. Margulies et al; Am J Obstet Gynecol. 2010 Feb;202(2):124-34

Question 59

A true statement regarding multiple sclerosis is: A) MRI lesions will correlate well with urodynamics findings B) Symptomatology may change over time C) The most likely finding on urodynamic study is detrusor overactivity with sphincter dyssynergia D) The disease is a consequence of cell loss in the cerebrum E) The most likely symptom would be stress urinary incontinence

Answer 59

B The pathologic hallmark of MS are zones of focal inflammatory demyelination or plaques in the white matter of the brain and spinal cord. Lesions can occur at a variety of locations changing lower urinary tract functioning and thus symptomatology. Leboeuf L and Gousse A. Multiple sclerosis. In: Corcos J and Schick E eds. Textbook of the Neurogenic Bladder. London and New York. Martin Dunitz Ltd; 2004: 275-291.

Question 60

Which of the following will NOT help to prevent catheter-associated urinary tract infections in hospitalized patients? A) Use of a silver alloy catheter in hospitalized patients B) Removal of the catheter on postoperative day 1 C) Ensuring that the catheter system remains an open system D) Avoiding unnecessary catheterization E) All of the above will help to prevent catheter-associated urinary tract infections

Answer 60

C Warren JW. Catheter-associated urinary tract infections. Int J Antimicrob Agents 2001;17(4):299-303

Question 61

All of the following are support ligaments of the uterus EXCEPT: A) Uterosacral ligament B) Sacrospinous ligament C) Round ligament D) Cardinal ligament

Answer 61

B Grays Anatomy

Question 62

A 59 year female presents with complaints of SUI and normal pelvic organ support. After urodynamic testing with the transurethral catheter in place, no urodynamic stress incontinence (USI) is demonstrated. The recommended next step is? A) Trial of anticholinergic therapy to rule out urge incontinence as a case of her urinary incontinence B) Remove the catheter and repeat the stress testing C) Schedule a follow up in 6 months and recommend observation D) Schedule a midurethral sling given the patient's symptoms of SUI.

Answer 62

B Clinicians should perform repeat stress testing with the urethral catheter removed in patients suspected of having SUI who do not demonstrate this finding with the catheter in place during urodynamic testing. (Recommendation; Evidence Strength: Grade C) AUA Guidelines - Adult Urodynamics

Question 63

You note a new difficulty cystoscoping a patient immediately after passing midurethral mesh sling trocars and see a trocar in the urethral space. Of the following, the best choice is: A) Remove the trocar, place a suprapubic catheter but not a foley catheter, and not place the sling B) Leave the trocar in place to guide your repair and cut down on the trocar transvaginally to fix the urethrotomy, then place the sling C) Remove the trocar, and proceed with completing the sling, and give an extra dose of antibiotics D) Remove the trocar, confirm hemostasis, leave a foley catheter, and not place the sling

Answer 63

D

Question 64

The principal nerve supply to the anorectum region is through the: A) Perineal nerve B) Pudendal nerve C) Distal rectal nerve D) External anal nerve

Answer 64

B Rao S Diagnosis and Management of Fecal Incontinence. Am J Gastro 2004 Practice Guideline Aug. 1585-1603.

Question 65

A 69-year-old female presents with the complaint that she has a vaginal bulge that can be felt during wiping and washing. On physical exam she has the following findings. What is her diagnosis? Aa +1, Ba+1, C-3 Gh 3, Pb 4, Tvl 9 Ap -2, Bp-2, C-8 A) Stage III pelvic organ prolapse B) Stage II pelvic organ prolapse C) Stage III POPQ exam D) Stage II cystocele E) Stage III cystocele

Answer 65

B Swift SE, Barber MD. Pelvic organ prolapse: defining the disease. Fem Pelv Med Reconstr Surg 2010; 16: 201-203. Haylen BT, de Ridder D, Freeman RM, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Int Urogynecol J 2010; 21:5-26. Bump RC, Mattiasson A, Bø K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 1996; 175:10-7. A bulge that is symptomatic and protrudes beyond the hymen is a good definition for pelvic organ prolapse and has been suggested by the ICS/IUGA terminology document. The exam reveals a Stage II prolpase. The current POPQ document specifically states that terms such as cystocele, rectocele and enterocele not be used and only the stage be reported.

Question 66

65 year old female with history of retropubic urethropexy 10 years prior presents with persistent urgency incontinence, frequency and sensation of incomplete emptying. On examination she has urethral mobility from -5 to 0 degrees, no prolapse, post void residual of 175 mL and a negative urine analysis. She has been on two different anticholinergic medications in the past with little improvement in symptoms. Which is the next best step in the evaluation and treatment of this patient? A) Urodynamic testing with voiding cystometrogram to assess detrusor activity during filling and rule out obstructive voiding as source of her symptoms. B) Trial of sacral neuromodulation with staged implant if > 50% success in urinary symptoms and/or voiding dysfunction C) Percutaneous tibial nerve stimulation once a week for 30 minutes over 12 week therapy D) Injection of botulinum toxin A 100 Units with repeat injection in 2 weeks if unsuccessful E) None of the above

Answer 66

A Given her history of surgery and elevated residual, there should be a high suspicion for obstruction. Neuromodulation is contraindicated for patients with obstuction. PTNS is not approved for retention and botox will not improve voiding dlysfunction.

Question 67

The image to the left demonstrates a large anomolous vessel found at time of robotic sacrocolpopexy, measuring nearly 10 mm located over the area of dissection.. The best approach to expose the site for suture placement and prevent bleeding from this vessel is. A) Use the plasma kinetic advanced bipolar system to cauterize the vessel prior to transection with monopolar scissors B) Use the ultrasonic harmonic scalpel to seal and transect the vessel C) Use monopolar electrocautery to coagulate the vessel then transect with scissors to expose the ligament D) Identify alternate location for placement of sutures or consider aborting or converting to open to isolate and ligate the vessel prior to transection.

Answer 67

D Advanced bipolar systems and ultrasound seal 7 mm and 5 mm vessels respectively. Thus a 1 cm vessel is too large for currently available devices. Traditional bipolar seals 2 to 6 mm, monoplar does not have vessel sealing capability Alkatout I, Schollmeyer T, Hawaldar NA, Sharma N, Mettler L. Principles and safety measures of electrosurgery in laparoscopy. JSLS : Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons 2012;16:130-9. Next

Question 68

Which one of these statements describes a type II error? A) Occurs if an investigator rejects a null hypothesis that is actually true in the population B) Occurs if the investigator fails to reject a null hypothesis that is actually not true C) Is not decreased with increasing sample size D) Is a false positive error

Answer 68

B Source: Browner WS, Newman TB, and Hulley SB (2007). Getting Ready to Estimate Sample Size: Hypothesis and Underlying Principles in S.B. Hulley, S.R. Cummings,W.S. Browner, D. G. Grady, T.B. Newman (Eds.), Designing Clinical Research (pp.55-56). Philadelphia, PA: Lippincott, Williams & Wilkins.

Question 69

In a normally distributed sample, what percent of the total population lies within ± 2 Standard Deviations (SD) of the mean? A) 0.05 B) 0.95 C) 0.68 D) 0.32

Answer 69

B

Question 70

All of the following are true about the success rates and perioperative complications associated with anal sphincteroplasty except: A) Postoperative pain & wound healing issues are common after the procedure. B) Good to excellent results in 66% of patients in the short-term but long-term deterioration with as low as 6% at 10 years post-op. C) Bowel prep or enema should be performed during the preoperative period D) Overlapping technique has better outcomes than the end-to-end technique

Answer 70

D Abrams P, Cardozo L , Khoury S, Wein A. Incontinence. Committee 17 Surgery for Faecal Incontinence. Paris. Health Publication Ltd. 2009. pgs 1387-1417.

Question 71

According to the 2011 American Urological Association Guidelines, all of the following should be considered as first line treatments for treatment of interstitial cystitis/painful bladder syndrome, EXCEPT: A) Education about normal bladder function and possible need for combination therapy to achieve symptom improvement B) Implementation of self-care practices and behavioral modifications that can improve symptoms C) Initiation of oral medications, such as amitriptyline, cimetidine, hydroxyzine or pentosan polysulfate D) Implementation of stress management practices to improve coping techniques and management of stress-induced symptom exacerbations

Answer 71

C

Question 72

A 68 year old female with history of abdominosacrocolpopexy 10 years prior presents with new onset rectal bleeding. She had a normal colonoscopy 4 years prior. Which of the following is the best office procedure for the workup of her complaint. A) Anoscopy B) Colonoscopy C) Cystoscopy D) Procto-sigmoidoscopy E) All of the above

Answer 72

D Anoscopy will likely not identify an erosion at the apex of the vaginal are, colonoscopywas normal 4 years ago and is not an office procedure and requires sedation, cystoscopy will not assess rectal bleeding and thus Proctosigmoidoscopy is the best diagnostic procedure to evaluate her complaints.

Question 73

After a high uterosacral ligament suspension, your patient complains of buttock/posterior thigh pain and numbness of the inferior vulva and. Which nerve is most likely to be involved? A) Pudendal nerve as it exits Alcock's canal B) Obturator nerve as it enters the obturator canal C) Sacral nerve roots as they combine to from the sciatic nerve D) The superior hypogastric plexus near the ganglion

Answer 73

C The pudendal nerve exits Alcock's canal near the ischial tuberosity; this location is not likely to be involved in high USLS. The obturator nerve enters the obturator canal to travel through the obturator foramen, which is also not likely to be injured in high USLS. The sacral nerve roots exit their respective foramina, then combine with L5 nerve roots to form the lumbosacral trunk. The lumbosacral trunk gives rise to the sciatic nerve. A deep USLS stitch could encircle or compress the sacral nerve roots or portions of the lumbosacral trunk. The superior hypogastric plexus and ganglia exist in the presacral space and are unlikely to be involved in high USLS. McBride, Li, Gutman (J Pelvic Med Surg 2003; 9:103-123) & Siddiqui et al. (Obstet Gynecol 2010; 116: 708-13)

Question 74

A 35 year old woman with a remote history of two prior cesarean deliveries presents with 2 months of pain in the distal vagina, extending inferiorly towards the buttocks. She is unable to achieve comfortable vaginal intercourse. On examination you appreciate a punctate lesion on the perineum that appears like granulation tissue; palpation of this area reproduces the patient's pain. Which of the following is least important in her evaluation? A) Rectal exam B) Anoscopy C) Endoanal ultrasonography D) Colonoscopy

Answer 74

C The patient described above likely has a fistula in ano, resulting from a crytoglandular abscess. This type of abscess typically originates on the anterior aspect of the anal canal. Extension of the abscess into the vaginal wall can result in fistula formation. Rectal exam may result in fluid or material extruding from the punctate lesion. Rectal exam may also identify a painful mass consistent with an abscess. Anoscopy can be helpful in delineating the extent of involvement of the rectum and evaluating for co-existing anorectal disease. Colonscopy is also useful to further assess for inflammatory bowel disorders and other infectious processes. Endoanal ultrasonography is most useful in the evaluation of post-obstetric rectovaginal fistulae. In this patient with 2 prior cesarean deliveries that are remote from the onset of symptoms, an obstetric fistula is not likely and thus US would be the least helpful component of the evaluation. Walters and Karram; Urogynecology and Reconstructive Pelvic Surgery, 3rd ed., Chapter 26

Question 75

Which of the following statements is true about the power of the study? A) Power is equal to Type I error B) Power is equal to 1-β error C) Power is equal to the Type II error D) Power is equal to 1-α error

Answer 75

B

Question 76

The most common urodynamic finding in a patient with normal pressure hydrocephalus is: A) Detrusor sphincter dyssynergia B) Impaired detrusor compliance C) Detrusor overactivity D) Detrusor overactivity and detrusor sphincter dyssynergia E) Detrusor areflexia and impaired compliance

Answer 76

C Sakakibara R, Kanda T, Sekido T, et al, Mechanism of Bladder Dysfunction In Idiopathic Normal Pressure Hydrocephalus, Neurourology and Urodynamics 2008, Volume 27, Issue 6, pages 507-510.

Question 77

Compared with anterior colporrhaphy (native tissue repair), the use of transvaginal polypropylene mesh to treat anterior vaginal prolapse is associated with: A) A lower risk of reoperation for pelvic organ prolapse B) A greater improvement in quality of life C) No improvement in anatomic outcomes of the anterior vaginal segment D) A lower risk of postoperative prolapse in the apical and posterior segment E) A 10% mesh exposure rate

Answer 77

E Maher CM, Feiner B, Baessler K, et al. Surgical management of pelvic organ prolapse in women: the updated summary version Cochrane review. Int Urogynecol J 2011; 22:1445-57.

Question 78

Which type of hysterectomy has the LOWEST RATE of resulting vesico-vaginal fistula (1 in 5636 cases)? A) LAVH B) Vaginal hysterectomy C) Abdominal hysterectomy D) Laparoscopic hysterectomy E) Robotic hysterectomy Next

Answer 78

B Härkki-Sirén P, Sjöberg J, Tiitinen A. Urinary tract injuries after hysterectomy. Obstet Gynecol 1998; 92:113-8.

Question 79

A 57-year-old female is undergoing uterosacral vaginal vault suspension at time of vaginal hysterectomy. Upon cystoscopy, no efflux from the right ureter is noted after administration of intravenous indigo carmine dye. All of the following are appropriate next steps except? A) Change table position out of steep Trendelenberg B) Check medical record and examine flank for history of kidney surgery (e.g. nephrectomy) C) Immediate ureteral stent placement D) Remove ipsilateral vaginal vault suspension sutures E) All of the above

Answer 79

C Kim J, Moore CM, Goldman HG, Jones JS, Daneshgari F, Rackley RR, Vasavada SP. Management of ureteral injuries associated with vaginal surgery for pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct 2006; 17:531-5.

Question 80

A 16 year old patient presents with primary amenorrhea. She has normal breast development, sparse pubic hair, tall stature and a 1cm vagina. MRI reveals an absent uterus and no identifiable ovaries. Which of the following laboratory profiles best matches this patient? A) Normal estrogen, karyotype 46 XY B) Normal estrogen, karyotype 46 XX C) Testosterone in or above normal male range, karyotype 46 XY D) Low testosterone and low estrogen, karyotype 47 XXY

Answer 80

C Romao RL, Salle JL, Wherrett DK. Update on the management of disorders of sex development. Pediatr Clin North Am. 2012;59:853-69.

Question 81

The anal sphincter consists of all of the following except: A) A 0.3-0.5 cm thick smooth muscle layer making up the internal anal sphincter B) A 0.6-1 cm thick expansion of striated levator ani muscles making up the external anal sphincter C) A normally open internal anal sphincter and closed external anal sphincter D) Anal mucosal folds and vascular cushions that provide a seal to the anus

Answer 81

C Rao S Diagnosis and Management of Fecal Incontinence. Am J Gastro 2004 Practice Guideline Aug. 1585-1603.

Question 82

According to the 2010 American Urologic Associate Guidelines, in the absence of any contraindications/medication allergies, all of the following are recommended first line microbials for treatment of uncomplicated cystitis, EXCEPT: A) Ciprofloxacin 500mg, twice daily for 3 days B) Fosfomycin trometamol 3mg, single dose C) Pivmecillinam 400mg, twice daily for 5 days D) Nitrofurantion monohydrate 100mg, twice daily for 5 days

Answer 82

A FQ have too much collateral damage

Question 83

All of the following muscles are components of the Levator Ani EXCEPT: A) Pubococcygeus B) Coccygeus C) Iliococcygeus D) Puborectalis

Answer 83

B McBride AW, et al. Journal of Pelvic Medicine and Surgery. Volume 9, Number 3, May/June 2003

Question 84

In 1976 Medical Device Amendments to the Food, Drug and Cosmetic Act (the Act) were enacted and these amendments classified device types into three categories (Class I, II, or III). A class II device type requires special controls, which include all of the following except A) Premarket studies B) Patient registry C) Physician labeling D) Annual reporting

Answer 84

D Annual reporting is only required for Class III devices DA Executive Summary: Surgical Mesh for Treatment of Women WIth Pelvic Organ Prolapse and Stress Urinary Incontinence. Sept 8-9.2011:Accessed April 7, 2013 at http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/MedicalDevices/MedicalDevicesAdvisoryCommittee/ObstetricsandGynecologyDevices/UCM270402.pdf

Question 85

Congenital absence of the uterus and cervix results from agenesis of which structure? A) Paramesonephric ducts B) Wolfian ducts C) Pronephric ducts D) Mesonephric ducts

Answer 85

A

Question 86

When placing the leads for sacral neuromodulation, which foramen is preferentially used? A) S1 B) S2 C) S3 D) S4 E) S5

Answer 86

C

Question 87

59 year old woman undergoes laparoscopic sacrocolpopexy with the port configuration above. Survey of the abdomen after completion of the case notes a thermal bowel injury of transverse colon located distant from operative sites, but near the left upper 3rd arm trocar region. What type of injury would best explain the type of electrosurgical injury? A) Direct coupling injury from electrosurgical instrument B) Direct coupling injury from insulation failure C) Capacitance coupling D) Alternate path burn

Answer 87

C Capacitance coupling is when current is transferred across two devices (i.e. two trocars) that are not touching, but uses tissue as medium. Direct coupling is from loss of insulation of an instrument or if the tip of the energy source touches another metal object that is directly Lipscomb GH, Givens VM. Preventing electrosurgical energy-related injuries. Obstetrics and gynecology clinics of North America 2010;37:369-77. Alkatout I, Schollmeyer T, Hawaldar NA, Sharma N, Mettler L. Principles and safety measures of electrosurgery in laparoscopy. JSLS : Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons 2012;16:130-9.

Question 88

Which of the following is not likely to be seen after routine vaginal delivery without episiotomy and with an intact perineum? A) Decreased tensile strength of the pubococcygeus muscles B) Internal anal sphincter defects C) Fourth degree laceration D) Prolonged pudendal nerve terminal motor latency

Answer 88

C After routine vaginal delivery, MRI studies reveal significant stretch injury and decreased tensile strength of the levator ani muscles, and particularly the pubococcygeus component of the levator ani. Internal anal sphincter defects have been detected by endoanal ultrasonography after routine vaginal deliveries with intact perineal skin. Up to 80% of women can have evidence of denervation after vaginal delivery with 40% showing prolonged pudendal nerve terminal motor latency, most of which recovers by 2 months postpartum. By definition, a fourth degree laceration involves the perineal body, sphincter complex, and rectum. Thus one would not have a fourth degree laceration in the presence of an intact perineum. Walters and Karram; Urogynecology and Reconstructive Pelvic Surgery, 3rd ed., Chapter 13; 2. Lien et al Obstet Gynecol 2004; 103: 31. 3. Sultan et al. NEJM 1993; 329: 1905. Next

Question 89

You are counseling a 44 year-old patient with refractory interstitial cystitis/painful bladder syndrome. She has failed conservative management, multiple medications, bladder instillations and cystoscopy under anesthesia with hydrodistension. You are discussing possible neuromodulation with an Interstim trial. Which of her symptoms is least likely to be improved with a successful response to neuromodulation? A) Urinary urgency B) Urinary frequency C) Bladder pain D) Urinary incontinence

Answer 89

C Neuromodulation is not indicated for bladder pain symptoms alone with interstitial cystitis/painful bladder syndrome and is actually not FDA approved for ICS/PBS. In patients with IC/PBS, neuromodulation is indicated more for urgency and frequency (OAB indication) and is much less effective for pain. Therefore carefuly patient selection is important for neuromodulation trials with IC/PBS. Hanno PM, Burks DA, Clemens JQ, et al. AUA guideline for the diagnosis and treatment of interstitial cystitis/bladder pain syndrome. J Urol. 2011;185:2162-2170

Question 90

A true statement regarding detrusor sphincter dyssynergia is: A) It is responsible for bladder neck obstruction and in combination with an areflexic bladder causes bladder overdistention B) It often occurs in patients with dementia C) It occurs due to changes in the collagen and elastin components of the bladder D) It is best diagnosed by EMG rather than CMG E) It is associated with decreased external urethral sphincter tone

Answer 90

D DSD is a lack of coordination between the detrusor and urethral sphincter due to interruption of the spinobulbar spinal (sacral/brainstem/sacral) pathway that normally coordinates the detrusor and sphincter. The pons coordinates the micturition reflex. Any lesion between the sacral and pontine level may produce discoordinated voiding, which results in increased external sphincter activity during detrusor contraction. It is diagnosed by evaluating the EMG activity during the pressure/flow study. Gajewski J. Spinal cord injury and cerebral trauma. In: Corcos J and Schick E eds. Textbook of the Neurogenic Bladder. London and New York. Martin Dunitz Ltd; 2004: 329-341

Question 91

True statements regarding low bladder compliance include each of the following except: A) Indications for diversion include hydronephrosis and deterioration of renal function B) The upper tract should be evaluated every 6-12 months C) Medical management may improve compliance D) A common complaint in patients is urinary incontinence E) An augmentation cystoplasty is not a therapeutic option

Answer 91

E Treatment of low bladder compliance includes antimuscarinics, augmentation cystoplasty, as well as continent and noncontinent urinary diversion. Stoher M, Blok B, Castro-Diaz D et al. EAU Guidelines on Neurogenic Urinary Tract Dysfunction. European Urology 2009; 56: 81-89.

Question 92

Which compartment(s) of the vagina is/are more prone to prolapse recurrence after unilateral sacrospinous ligament fixation? A) Anterior vaginal wall B) Posterior vaginal wall C) Ipsilateral vaginal apex D) Contralateral vaginal apex

Answer 92

A The anterior vaginal wall is most prone to prolapse recurrence after sacrospinous ligament fixation, regardless if unilateral or bilateral stitches are placed. Muir TW; J Pelvic Med Surg 2006; 12: 289-305

Question 93

Sterile pyuria can be a result of all of the following EXCEPT: A) Chronic interstitial nephritis B) Ureaplasma urealyticum C) Nephrolithiasis D) Acute tubular necrosis E) Renal cell carcinoma

Answer 93

d

Question 94

To avoid complications, a sacrospinous ligament fixation stitch should be placed: A) As close as possible to the ischial spine B) 3 cm medial to the ischial spine, placing the stitch superiorly and slightly behind the ligament C) 3 cm medial to the ischial spine, placing the stitch slightly below the superior edge of the ligament D) Lateral and superior to the ischial spine

Answer 94

C The pudendal nerve and vessels lie directly posterior to the ischial spine; thus one would not want to place the stitch as close as possible to the ischial spine. Superiorly and just behind the sacrospinous ligament lies an abundant vascular supply including the inferior gluteal vessels and hypogastric venous plexus. Thus one would want to avoid placing a stitch superiorly and slightly behind the ligament. The sciatic nerve runs lateral and superior to the ischial spine. The correct answer is C, 3cm medial to the ischial spine, placing the stitch slightly below the superior edge of the ligament. In this area, there is less likelihood of injuring nerves or vessels.

Question 95

Second line treatments for OAB include all of the following except: A) neuromodulation B) darifenacin C) tolterodine D) trospium

Answer 95

A Gormley EA, Lightner DJ, et al. Diagnosis and Treatment of Overactive Bladder (Non-Neurogenic_ in Adults: AUA/SUFU Guideline. J urol 2012;188:2455-2463.

Question 96

Voiding is predominantly a ___________ event. A) Sympathetic B) Parasympathetic C) Somatic D) Skeletal nerve

Answer 96

B Voiding is predominantly a parasympathetic event and involves reflex-coordinated relaxation of the urethra with sustained contraction of the bladder until emptying is complete. Voluntary control of micturition is mediated by the frontal cortex, the pons, and the pudendal nucleus in the ventral horm of the sacral spinal cord. Walters and Karram; Urogynecology and Reconstructive Pelvic Surgery, 3rd ed., Chapter 3

Question 97

You are performing a cystoscopy on a 21 year old nulliparous woman and notice duplicate ureteral orifices on one side of the bladder. Based on Weigert- Meyer's rule, the right lower ureteral orifice drains which portion of the kidney? A) Right lower pole B) Right upper pole C) Left lower pole D) Left upper pole E) None of the above

Answer 97

B Campells Urology

Question 98

A 35 year old female with a C3 spinal cord injury is undergoing video urodynamics. During the study, the patient begins sweating and complains of a severe headache. The best next step should be? A) Give her Tylenol and cool the room down. B) Stop the study and administer steroids for possible allergic reaction to the contrast C) Finish the study as quickly as possible D) Stop the study and decompress her bladder as quickly as possible E) Admit her to the ICU

Answer 98

D Linsenmeyer TA, Bodner, DR, Creasey GH, Green BG, Groah SL, Joseph A et al. Bladder Management for Adults with Spinal Cord Injury: A Clinical Practice Guideline. Washington DC, Paralyzed Veterans of America 2006

Question 99

A 41 year-old woman is scheduled to undergo a stage 1 Interstim procedure for refractory overactive bladder. As part of her surgical "time out," what does not need to be included based upon JCAHO protocol? A) A pre-procedure verification should document a signed consent form. B) The site of the general spinal level of the planned procedure should be marked prior to the procedure with an unambiguous marking. C) The preoperative time out should confirm the patient identity. D) The preoperative time out should confirm the prophylactic antibiotics used. E) The preoperative time out should confirm the correct procedure site and procedure to be done.

Answer 99

D The JCAHO Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery includes guidelines that a (1) pre-procedure verification should include confirmation of relevant documentation (H&P, signed consent, pre-anesthesia assessment), diagnostic and radiologic tests and required blood products, implants, devices or special equipment. (2) Procedure site should be marked prior to the procedure with an unambiguous marking - this is when the procedure involves more than one possible location and when performing the procedure in an alternate location could harm the patient. The protocol specifically mentions spinal procedures and although may not be "sided" the general spinal level should be marked. (3) A preoperative time-out is performed prior to the procedure with the entire OR team and confirms the patient identity, procedure to be performed and correct procedure site. Antibiotic prophylaxis is not included in the JCAHO protocol although some institutions may include this.

Question 100

Bladder extrophy results from a defect in which embryologic structure? A) Cloacal membrane B) Pronephros C) Paramesonephric duct D) Mesonephric duct

Answer 100

A he area where the somatic mesoderm and the splanchnic mesoderm layers join in the midline is termed the intermediate mesoderm and gives rise to the urogenital system.

Question 101

What is the recommended first-line antibiotic therapy for uncomplicated cystitis before urine culture results are available? A) ciprofloxacin 250mg PO BID for 5 days B) cephalexin 500mg QID PO for 3 days C) nitrofurantoin monohydrate/macrocrystals 100mg PO for 5 days D) amoxicillin 500mg PO TID for 7 days

Answer 101

Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis 2011;52(5):e103-120.

Question 102

While performing a cystoscopy in a patient with interstitial cystitis you diagnose a Hunner's ulcer. Which of the follow is not a recommended treatment based on AUA guidelines? A) Fulgeration with laser B) Injection with DMSO C) Fulgeration with electrocautery D) Injection with triamcinolone

Answer 102

B DMSO is not recommened specifically in cases with a Hunner's ulcer and is administered in IC as a bladder instillation, not a bladder injection. AUA Clinical guidelines for treatment of IC.

Question 103

Urethrovaginal fistula is a difficult complication of urethral diverticulectomy. Which of the following statements are true: A) Reported urethrovaginal fistula rate after diverticulum repair is 0.9-18.3% B) A Martius fat pad is often needed C) Fistulae are commonly associated with undetected carcinoma D) Prompt surgical intervention is recommended as soon as the diagnosis of fistula is made to minimize the risk of further tissue loss E) A and B

Answer 103

b Carcinoma of the urethra is not associated with diverticular repair. Risk of fistula is less than 10%, and repair should be done no less than 3 months after initial urethral surgery. Handel LN, Current Urol Rep 2008, 9:383-388

Question 104

Sacral neuromodulation is NOT approved for the treatment of A) Refractory urge urinary incontinence B) Neurogenic bladder due to T10 spinal injury C) Fecal incontinence D) Idiopathic urinary retention E) None of the above, it is approved for all A-D

Answer 104

B Interstim would not be indicated for "neurogenic bladder". Although many patients with neurogenic bladder have symptoms of overactive bladder, neuromodulation requires an intact neurologic system. It is also contraindicated in those with inadequate response to test stimulation or obstructive urinary retention

Question 105

Which of the following theories has been proposed as basis for the mechanism of action of mid-urethral slings? A) Hammock theory B) Intensification theory C) Erosion theory D) McGuire's theory E) Integral theory

Answer 105

E Petros and Ulmsten, Acta Obstet Gynecol Scand Suppl, 1990; 153:7-31

Question 106

In patients with fecal incontinence, anal manometry results A) Correlate with symptom severity B) Predict post-operative success of surgical treatment C) Both A and B D) Neither A nor B

Answer 106

D Several studies have indicated that anal manometry results do not correlate with symptom severity and do not help to predict postoperative success of surgical treatment in fecal incontinence Hayden DM, Weiss EG. Fecal incontinence: etiology, evaluation, and treatment. Clinics in colon and rectal surgery. Mar 2011;24(1):64-70 Zutshi M, Salcedo L, Hammel J, Hull T. Anal physiology testing in fecal incontinence: is it of any value? International journal of colorectal disease. Feb 2010;25(2):277-282

Question 107

What is the most implicated mode of pathogenesis in interstitial cystitis/painful bladder syndrome? A) Increased permeability of the glycosaminoglycan (GAG) layer of the bladder urothelium B) Mast cell activation C) Neurogenic upregulation and inflammation D) Autoimmune factors E) Multifactorial

Answer 107

E No single pathologic process has been universally confirmed in patients with IC/PBS and the etiology is multifactorial. Any of the possible etiologies listed in answers A through C may be related to the development of IC/PBS. Women with IC/PBS have been found to have increased C fibers, which carry and release substance P that leads to mast cell activation and production of inflammatory mediators. Detrusor mastocytosis has been found in 20-65% of patients with IC/PBS. Allergies may co-exist. Other proposed theories include pelvic floor dysfunction leading to voiding dysfunction and pain, psychological factors, genetic predisposition, infectious pathogens, and the potential role of estrogen. Deniseiko Sanses T. Painful Bladder Syndrome/Interstitial Cystitis. Journal of Pelvic Medicine and Surgery. 2007;13:321-336

Question 108

With respect to anticholinergic therapy, the following is/are true? A) Anticholinergics are associated with low side effects B) Anticholinergics are superior to bladder training alone C) Anticholinergics are the most cost effective approach for management of OAB. D) Anticholinergics in combination with bladder training are superior to bladder training alone E) B and D

Answer 108

E Anticholinergics have high side effect (up to 30%) of dry mouth/constipation, medications alone or in combination with behavior therapy are superior to behavior alone.No data support cost effectiveness of medications. Rai BP, Cody JD, Alhasso A, Stewart L. Anticholinergic drugs versus non-drug active therapies for non-neurogenic overactive bladder syndrome in adults. Cochrane database of systematic reviews 2012;12:CD003193.

Question 109

Which of the following is not a characteristic of a case control study? A) The prevalence of risk factors in sample of subjects who have the disease or condition of interest is compared to that in a separate sample of patients who do not have the disease or condition. B) It provides data on disease prevalence C) It is a useful and efficient design for studying rare conditions or diseases D) It is susceptible to sampling bias and differential measurement bias

Answer 109

B Designing Clinical Research, 3rd ed. Hulley SB, Cummings SR, Browner WS, et al, eds. Philadelphia: Lippincott Williams & Wilkins, 2007

Question 110

A 77 year old woman has a recurrent apical prolapse 15 years after undergoing vaginal hysterectomy with a McCall culdoplasty. She is not sexually active and thus has been using a pessary almost continually over the last 10 years. Recently her prolapse is protruding around the pessary. She indicates that she would like the surgical procedure with the lowest likelihood for repeat surgery. Which procedure would you offer? A) Mesh sacrocolpopexy B) Vaginal mesh for prolapse C) LeFort colpocleisis D) Colpectomy (vaginectomy) colpocleisis

Answer 110

D When compared to native tissue repairs, the use of mesh in pelvic organ prolapse surgery is associated with increased rates of reoperation. Amongst native tissue repairs, there are reconstructive and obliterative procedures. The obliterative procedures have the lowest rates of prolapse recurrence and low rates of reoperation. This patient has not been sexually active in 10 years and thus is a candidate for an obliterative procedure. She has had a prior hysterectomy and therefore the LeFort colpocleisis technique would not apply. A vaginectomy colpocleisis can be performed in women who are post-hysterectomy, with high success, and low risk of reoperation. Walters & Ridgeway; Obstet Gynecol 2013; 121 (2)

Question 111

The prevalence of fecal incontinence in healthy adult female population is approximately: A) 1-7% B) 5-12% C) 11-20% D) 21-26%

Answer 111

A Rao S Diagnosis and Management of Fecal Incontinence. Am J Gastro 2004 Practice Guideline Aug. 1585-1603.

Question 112

What procedures will increase risk of urinary retention after prolapse surgery? A) Kelly Plication B) High Grade Cystocele C) Levator Plication D) Blood loss over 100 cc E) all of the above

Answer 112

E Hakvoort RA, Dijkgraff MG, Burger MP, Emanuel MH, and Roovers, JP: Prediction Short-Term Urinary Retention After Vaginal Prolapse Surgery. Neurourol Urod 28:225-228, 2009.

Question 113

Which of the following is involved in contraction of the external urethral sphincter? A) Onuf's nucleus in the ventral horn of the sacral spinal cord B) Beta-adrenergic receptors C) Substantia nigra of the brain D) M3 muscarinic receptors

Answer 113

A Voluntary control of the external urethral sphincter is through the through the corticospinal pathway connecting the frontal cortex of the brain with the pudendal nucleus (Onuf's nucleus) in the ventral horn of the sacral spinal cord. Thus Onuf's nucleus is involved in contraction of the external urethral sphincter. Beta-adrenergic receptors and M3 muscarinic receptors reside in the bladder wall. Beta-adrenergic receptors allow for relaxation of the detrusor muscle and facilitate storage of urine. M3 muscarinic receptors are parasympathetic receptions that are stimulated for voiding. The substantia nigra of the brain has a high concentration of dopamine receptors and is affected in individuals with Parkinson's disease. Decreased dopaminergic activity leads to loss of inhibition of the pontine micturition center and increased involuntary voiding. Walters and Karram; Urogynecology and Reconstructive Pelvic Surgery, 3rd ed., Chapter 3

Question 114

You are performing anorectal manometry on a patient with constipation. During her attempt to expel a fluid-filled balloon you notice increased surface EMG activity. What may this suggest? A) Hirshsprung's disease B) Slow transit constipation C) Pelvic floor dyssynergia D) Enterocele

Answer 114

C EMG may be performed with needle or surface electrodes. During straining, and when attempting to expel a fluid-filled balloon, EMG should reveal a decrease in electric activity of the pelvic floor muscles. In other words, the muscles should relax to allow passage of stool. If an increase in EMG activity is noted, this is suggestive of pelvic floor dyssynergia. During anorectal manometry, the lack of a recal anal inhibitory reflex is suggestive of Hirschsprung's disease. Slow transit constipation is best diagnosed with a colonic transit study. Slow transit constipation and enterocele would not result in elevated EMG activity while straining. Walters and Karram; Urogynecology and Reconstructive Pelvic Surgery, 3rd ed., Chapter 25

Question 115

A 67 years old female presents complaining of increased daytime urinary frequency and urgency while getting to the bathroom. She often leaks prior to making to the toilet and would like to try a medical therapy. Which of the following statements best describes accurate expectations of anticholinergic use: A) The patient can expect a reduction in urgency urinary incontinence episodes of 1-4 per day with anticholinergic use. B) The patient can expect a reduction of 5-9 voids per day. C) The change in incontinence episodes does not improve patient quality of life D) Sustained-release oxybutynin appears to be significantly more effective than sustained-release tolterodine.

Answer 115

A Hartman et al. Treatment of Overactive Bladder in Women. Evidence Report/Technology Assessment Number 187. AHRQ Publication No. 09-E017 August 2009.

Question 116

Factors that should be taken into consideration during the condition specific assessment of fecal incontinence include all of the following except: A) Duration of the problem B) Relevant medical, surgical, neurological and obstetric history C) Medication use D) Age of menarche E) Incontinence coping strategies

Answer 116

D National Institute for Health and Clinical Excellence, 2007. Faecal Incontinence: The Management of Faecal Incontinence in Adults. Clinical guidelines No. 49. NICE, London.

Question 117

After uterosacral ligament suspension a patient wakes up with severe pelvic pain on her left side. It is difficult for her to specifically localize the exact spot of the pain. Which of the following structures is most likely to have been "caught" by one of your sutures? A) the pudendal nerve B) a sacral nerve C) the obturator nerve D) the genitofemoral nerve E) the inferior hypogastric plexus

Answer 117

B Siddiqui NY, Mitchell TR, Bentley RC, Weidner AC. Neural entrapment during uterosacral ligament suspension: An anatomic study of female cadavers. Obstet Gynecol, 2010, 116(3), 708-713.

Question 118

When placing a retropubic midurethral sling using a bottom-up technique in a healthy, normal-weight, 39 year old, she suddenly becomes cardiovascularly unstable and you notice the trocar is deviated sharply lateral. Which vessel has likely been injured? A) Obturator artery B) External iliac artery C) Pudendal artery D) Internal iliac vein

Answer 118

B In a cadaveric study of TVT trocar placement, when trocars were purposefully directed 6 cm lateral to the mid-biceps brachii muscle, the external iliac vessel was found to be 0.6 and 0 cm away from the trocar. Muir TW, Tulikangas PK, Fidela Paraiso M and Walters MD: The relationship of tension-free vaginal tape insertion and the vascular anatomy. Obstet Gynecol 2003; 101: 933.

Question 119

You design a study to determine the incidence and remission of urinary incontinence in the first year after a cerebrovascular accident (CVA). You enroll 100 patients who have had a CVA and evaluate their continence status using validated questionnaires immediately after the CVA and again 6 and 12 months post CVA. This study can best be described as a: A) Retrospective Cohort study B) Prospective Cohort study C) Case Series D) Case Control Study E) Cross-sectional Study

Answer 119

B Designing Clinical Research, 3rd ed. Hulley SB, Cummings SR, Browner WS, et al, eds. Philadelphia: Lippincott Williams & Wilkins, 2007.

Question 120

Which of the following statements is most accurate regarding anorectal testing except: A) Defecography is useful in patients with normal rectal evacuation B) Balloon expulsion test uses a 50ml water-filled balloon and is usually normal in patients with fecal incontinence C) Diagnostic tests such as anorectal manometry, defecography and balloon expulsion test help define underlying mechanisms of fecal incontinence D) The balloon expulsion test may help identify patients with dyssynergic defecation

Answer 120

A Which of the following statements is most accurate regarding anorectal testing except: A) Defecography is useful in patients with normal rectal evacuation B) Balloon expulsion test uses a 50ml water-filled balloon and is usually normal in patients with fecal incontinence C) Diagnostic tests such as anorectal manometry, defecography and balloon expulsion test help define underlying mechanisms of fecal incontinence D) The balloon expulsion test may help identify patients with dyssynergic defecation

Question 121

Which of the following is an inhibitory neurotransmitter in the CNS? A) Glutamic acid B) γ-aminobutyric acid C) Nitric oxide D) Substance P

Answer 121

B Glutamic acid, nitric oxide, substance P, and ATP are excitatory neurotransmitters in the CNS. Inhibitory neurotransmitters include γ-aminobutyric acid, glycine, and opioid peptides. Raz & Rodriguez; Female Urology, 3rd ed., Chapter 3

Question 122

A 45 year female, Gravida 2, Para 2 presents to your office with the complaint of bothersome loss of liquid and solid stool worse over the last year. During her first vaginal delivery she had a "full thickness" tear and reported some loss of stool during the first 6 postpartum weeks that resolved. Rectal examination reveals a weak but intact anal sphincter squeeze. She has tried Kegel exercises off an on at home on her own but this has not helped her enough. You discuss her treatment options and recommend initial management should include: A) Addition of dietary fiber alone B) Education regarding bowel management strategies, supervised anal muscle exercises, and stool consistency management possibly including the addition of dietary fiber C) Sacral neuromodulation D) Loperamide daily

Answer 122

B Abrams P, Cardozo L , Khoury S, Wein A. Incontinence. Committee 16 Conservative and Pharmacological Management of Faecal Incontinence in Adults. Paris. Health Publication Ltd. 2009. pgs 1321-1386

Question 123

A perioperative nerve injury is more commonly encountered with: A) Yellow fin "Allen" stirrups than candy cane stirrups for lithotomy B) A patient with a BMI of 20 kg/m2 than 40 kg/m2 C) Self retaining retractors than manual retraction D) B and C

Answer 123

D Kahn F, Kenton K JPMS Vol 12 number 5, Sept/Oct 2006 Thin patients, retractors, and candy canes are risk factors for injury.

Question 124

# Choose the correct statement with regard to leukocyte esterase and nitrite on urine dipstick. A) Leukocyte esterase has good positive predicative value and nitrite has good positive predictive value for UTI diagnosis B) Leukocyte esterase has good negative predicative value and nitrite has good negative predictive value for UTI diagnosis C) Leukocyte esterase has good negative predictive value and nitrite has good positive predictive value for UTI diagnosis D) Leukocyte esterase has good positive predictive value and nitrtie has good negative predictive value for UTI diagnosis

Answer 124

C On urine dipstick, the 2 most useful components for UTI diagnosis are leukocyte esterace and nitrites. The PPV of leukocyte esterase varies between 19-88% due to multiple causes of pyuria, but the NPV is 97-99%. Nitrite is produced from degradation of dietary nitrite in colonic bacteria (specifically Enterococcus). The PPV of nitrites is 94%, but the NPV is low due to false negatives (ie. lack of dietary nitrate, dilution of nitrite in urine, bacteria lacking nitrate reductase). Heisler CA, Gebhart JB. Urinary Tract Infection in the Adult Female. Pathophysiology, Evaluation and Treatment. J Pelvic Med Surg 2008;14:1-14.

Question 125

Your patient demonstrates bothersome SUI and urethral diverticulum at the 6 o'clock position on the midurethra. Management most likley to result in optimal long term result is: A) Marsupialization of the distal 50% of the urethra combined with a midurethral sling B) Transvaginal excision of the diverticulum and mid urethral mesh sling as a combined procedure C) Retropubic excision of the diverticulum and midurethral mesh sling as a combined procedure D) Transvaginal excision of the diverticulum and an interval mid urethral mesh sling as a second procedure

Answer 125

D Excision of the diverticulum via vaginal approach is the least traumatic and easiest method, but performing a midurethral sling at the same procedure with this diverticulum increases the risk of fistula. Handel LN, Current Urol Rep 2008, 9:383-388

Question 126

True statements regarding the International Continence Society definitions of detrusor overactivity (DO) include each of the following except: A) Phasic DO is defined as a characteristic wave form which may or may not lead to urinary incontinence B) Neurogenic DO is defined as a DO event that is associated with poor compliance C) Terminal DO is a single involuntary detrusor contraction at capacity which cannot be suppressed and results in incontinence D) DO incontinence is incontinence occurring with an involuntary detrusor contraction E) DHIC is defined as detrusor hyperactivity with impaired contractility

Answer 126

B The ICS definition of neurogenic DO is a DO event on UDS in an individual with a relevant neurologic condition Abrams P, Cardozo, L, Fall M, Griffiths D, Rosier P, Ulmsten U, et al. The standardization of terminology of lower urinary tract function: report from the Standardization Sub-Committee of the International Continence Society. Neurourol Urodyn 2002; 21:167-78.

Question 127

For the treatment of OAB symptoms, trospium chloride differs from other antimuscarinics in that: A) It has atropine like effects B) It has a dermal preparation C) The standard dosing is once a week D) It is a tertiary amine E) It has high selectivity for the M3 receptor

Answer 127

A Silva W.Andre. Pharmacologic Management of Incontinence and Voiding Dysfunction. Pelvic Medicine and Surgery 2005; 11 (1): 1.

Question 128

A 66 year-old woman underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy. She developed new onset urinary incontinence postoperatively. You see her for consultation about 2 months after her surgery. She reports almost constant leakage and is not sure whether there are any triggers for her leakage. She denies any urgency, frequency or urge leakage however. She changes her pad 4-5 times daily, and she has to wear a pad at night. Her medical history is significant for osteoporosis. The hysterectomy is her only prior surgery. On speculum exam, you easily visualize a pinpoint dimple in the midline of the anterior vaginal wall 2cm distal from the vaginal cuff. With cough and Valsalva you note spurts of leakage from this area. You perform a cystoscopy and visualize a small mature-appearing fistula in the bladder mucosa above the trigone at the base of the bladder in the midline, quite distal from both ureteral orifices. You note no other abnormalities. You order an IVP to rule out any ureteral involvement and the study is entirely normal. You decide to plan a primary surgical repair. You consider either a vaginal or abdominal approach. Which of the following is true regarding the surgical approach with this patient? A) Both vaginal and abdominal approaches have similar rates of successful closure. B) A vaginal approach has a higher likelihood of successful fistula closure. C) An abdominal approach has a higher likelihood of successful fistula closure. D) An abdominal approach has a higher likelihood of successful fistula closure, but only with a transvesical technique.

Answer 128

A This patient would be an ideal candidate for a vaginal approach as this is a small solitary fistula that is easily visualized. She has no prior attempted repairs and no history of radiation. Vaginal and abdominal approaches have been found to have similar success rates, but a vaginal approach has decreased morbidity. Case series of the vaginal approach for VVF repair have found success rates of 94-100% for primary closure. Case series of abdominal approaches have shown similar success rates of 90-100%. Mueller E, Kenton K, Brubaker L. Modern Management of Genitourinary Fistula. Journal of Pelvic Medicine and Surgery. 2005;11:223-234

Question 129

A 62 year old patient reports right flank pain 1 day after a sacrocolpopexy and bilateral salpingo-oophorectomy for vaginal vault prolapse during which ureteral patency was NOT confirmed. All of the following would be appropriate next steps EXCEPT? A) Cystoscopy with indigo carmine B) Renal ultrasound C) Cystogram with contrast D) Intravenous pyelogram E) CT with intravenous contrast

Answer 129

C All of the listed answers except C allow for some assessment of ureteral patency either directly or indirectly. A cystogram will fill the bladder with contrast and would assess bladder integrity but could be completely normal even with complete occlusion of one or both ureters. Clarke-Pearson and Geller, Obstet Gynecol 2013:121:654-73

Question 130

You are interested in determining if the Valsalva leak point pressures are different between patients with and without postoperative stress incontinence after a midurethral sling. You hypothesize that those with lower preoperative Valsalva leak point pressures are more likely to experience postoperative incontinence. Which of the following statistical tests would be most appropriate? A) Fishers Exact Test B) Chi-Square C) Paired t-test D) Student's t-test

Answer 130

D

Question 131

You are seeing a 32 year-old woman who is a known established patient with a history of painful bladder syndrome and levator myalgia. She had an extensive evaluation including office cystoscopy, urodynamics and CT of the abdomen and pelvis to rule out other causes of her pain. She has been managed for 2 months with behavioral modifications with diet, pelvic floor physical therapy and ibuprofen. Last week she reported an increase in her bladder pain, urgency and frequency. You treated her with 7 days of sulfamethoxazole-trimethoprim DS BID for a presumed UTI. When she came into the office to leave a urine sample she was using phenazopyridine so you did not check a urine dip but sent a urine culture. The urine culture was entirely negative. She is back in your office today reporting her symptoms are basically the same. She has 2 doses of sulfamethoxazole-trimethoprim left. What is the best way to manage her antibiotics? A) Start her on prophylactic sulfamethoxazole-trimethoprim for 3 months B) Extend the course of sulfamethoxazole-trimethoprim to 14 days C) Start her on ciprofloxacin 500mg bid for 7 days D) Start her on prophylactic ciprofloxacin for 3 months E) Stop the antibiotics and discuss other treatment options

Answer 131

E Antibiotic treatment is contraindicated in patients with painful bladder syndrome who have previously been administered antibiotics without efficacy and a negative urine culture. This clinical scenario is a flare of PBS and a urinary tract infection has been ruled out. Long-term antibiotic administration has not been shown to improve PBS symptoms; this has been shown in several observational studies and an RCT comparing antibiotics to placebo for 18 weeks in patients with PBS. Hanno PM, Burks DA, Clemens JQ, et al. AUA guideline for the diagnosis and treatment of interstitial cystitis/bladder pain syndrome. J Urol. 2011;185:2162-2170

Question 132

A 67 year-old woman with uterovaginal prolapse is scheduled to undergo a total vaginal hysterectomy with a uterosacral ligament suspension and cystoscopy. She has a medical history of hypertension. She has no prior surgeries. She takes HCTZ 25mg daily and a multivitamin. She had a documented anaphylactic reaction to penicillin in the past. She is 65 inches tall and weighs 66 kg. The best regimen for perioperative antimicrobial prophylaxis is: A) Cefazolin 1 gram IV B) Cefazolin 2 grams IV C) Clindamycin 600mg IV D) Clindamycin 600mg IV and Gentamicin 100mg IV E) Clindamycin 600mg IV and Ciprofloxacin 200mg IV

Answer 132

D Considering this patient has a history of an immediate anaphylactic reaction to penicillin in the past, cephalosporins should be avoided. Clindamycin 600mg IV alone is not recommended and can be given with either aztreonam 1g IV, gentamicin 1.5 mg/kg, or a quinolone such as ciprofloxacin 400mg IV. Metronidazole 500mg IV can be substituted for the clindamycin. ACOG practice bulletin No. 104: antibiotic prophylaxis for gynecologic procedures. Obstet Gynecol. 2009;113:1180-1189.

Question 133

15. The urogenital sinus becomes which of the following adult female structures? A) Bladder, trigone, membranous urethra B) Bladder, trigone, membranous urethra, vestibule C) Bladder, memgranous urethra D) Bladder, membranous urethra, vestibule E) None of the above

Answer 133

D Campells Urology

Question 134

A true statement regarding spinal cord shock is: A) It is a period of time after a traumatic spinal cord injury where there is increased excitability of spinal cord segments at and below the level of injury B) It is a period of time when performing urodynamics is most valuable C) During this period the detrusor in unable to contract D) The lower urinary tract is usually affected for less than a week E) This condition is treated with nifedipine

Answer 134

C After an acute spinal cord injury, the central synapses between the afferent and efferent arms of the micturition reflex will be inactive. The detrusor will be paralyzed and there will be no conscious awareness of bladder fullness, but the bladder neck and proximal urethra will be closed. The mechanism of spinal shock is unclear and may relate to lack of supraspinal facilitation of the inerneuronal activity due to release of inhbitory transmitters. Gajewski J. Spinal cord injury and cerebral trauma. In: Corcos J and Schick E eds. Textbook of the Neurogenic Bladder. London and New York. Martin Dunitz Ltd; 2004: 329-341.

Question 135

Which of the following is the correct equation best describing the pressure relationships in urodynamics? A) Pdet=Pves-Pabd B) Pves=Pdet-Pabd C) Pdet=Pves-Pura D) MUCP=Pura-Pdet E) MUCP=Pura+Pabd

Answer 135

A Schafer W, Abrams P, Liao L et al, Good Urodynamic Practices: Uro£owmetry, Filling Cystometry, and Pressure-Flow Studies, Neurourology and Urodynamics 2002: 21:261-274

Question 136

Which of the following is not a phase in the Masters and Johnson sexual response cycle? A) Excitation phase B) Plateau phase C) Orgasmic phase D) Rhythmic phase E) Resolution phase

Answer 136

D The Masters and Johnson physiologic response cycle has been used to describe sexual function. The cycle includes the following phases: desire, excitation, plateau, orgasmic, resolution. The usefulness of this model is limited because of initial absent sexual desire, overlapping phases, nongenital sensations that overshadow arousal/excitation, and the fact that orgasm may not be necessary for satisfaction. Thus a more recent circular model of sexual response has been proposed. Siddique S. 2003; J Pelvic Med Surg 9(6): 263-272; Basson R. Obstet Gynecol 2001; 98: 351

Question 137

You are called into the operating room for an intraoperative consultation. During a repeat cesarean section, the obstetrician had difficulty creating the bladder flap due to adhesions and is concerned there may be a cystotomy. All of the following are reasonable methods to assess bladder integrity EXCEPT: A) Instill methylene blue diluted in 300mL of saline through the Foley B) Direct inspection of the bladder with instillation of saline through the Foley C) Cystoscopy with a 70 degree cystoscope D) Cystoscopy with a 0 degree cystoscope

Answer 137

D

Question 138

A women is 3 weeks following a benign abdominal hysterectomy and is diagnosed with a 1 cm. vesico-vaginal fistula (VVF). Which of the following statements is true: A) It will be most effectively treated if the surgeon waits at least 3 months until repair. B) There is Level 1 evidence that an abdominal VVF repair is more likely to be successful than a transvaginal approach. C) Only transvesical repair will allow for interpositional flaps, if necessary. D) There is a high likelihood that the 1 cm size fistula will heal spontaneously. E) Postoperative management will include bladder drainage for 10 -14 days.

Answer 138

E Angioli R, Penalver M, Muzii L, et al. Guidelines of how to manage vesicovaginal fistula. Oncology Hematology 2003; 48: 295- 304.

Question 139

37 yo G4P3 presents with a chief complaint of 10 year h/o bloating, constipation and the feeling of something getting stuck. She occasionally uses perineal decompression to complete a bowel movement. POP reveals: Aa 0, Ba 0, C -3, Gh 3, Pb 4, TVL 9, Ap 0, Bp 0, D -5. Multiple fiber regimens have not been successful and she is desperate for a surgical repair. The appropriate next step is: A) Urodynamics, followed by TVH AP repair B) Posterior repair C) Trial of laxatives D) Further evaluation of constipation

Answer 139

D Locke GR 3rd, Pemberton JH, Phillips SF. AGA technical review on constipation. American Gastroenterological Association. Gastroenterology 2000;119:1766-78.

Question 140

45 year old obese female (BMI 39 kg/m2) with history of depression presents with complaints of 3 times a week stress urinary incotinence. She has no prolapse, urethral mobility to 45 degrees with straining, positive stress test with 350 mL in her bladder and post void residual of 5 mL with negative Urine dip. What treatmentand counseling is most appropriate for this patient? A) Recommend urodynamic testing to assess urethral function and proceed with midurethral sling so that she can begin an exercise program to lose weight. B) Recommend timed voiding drills with biofeedback and a pessary to prevent leakage during exercise. C) Recommended weight loss and counsel her that even 8% reduction in body mass index may result in nearly 50% reduction in leakage episodes. D) Recommend duloxetine 40 mg BID as treatment for her depression as it may also cure her stress urinary leakage.

Answer 140

C Urodynamic testing is not indicated in this patient and surgery is not first line treatment for SUI. Pessary plus biofeedback has not been shown to improve continence rates over biofeedback alone (Richter et al). Large RCT of weight loss has been shown to reduce UI by 47% with just 8% reduction in BMI compared to control group (Subak et al). Clinical trials of duloxetine show 50% reduction in SUI episodes but rare cure rates. Richter HE, Burgio KL, Brubaker L, et al. Continence pessary compared with behavioral therapy or combined therapy for stress incontinence: a randomized controlled trial. Obstet Gynecol 2010;115:609-17.;Subak LL, Wing R, West DS, et al. Weight loss to treat urinary incontinence in overweight and obese women. The New England journal of medicine 2009;360:481-90.

Question 141

Marland pessaries are quite versatile for all of the following reasons except: A) They have a wedge shaped ridge on one side and can be useful when a standard ring with support tends to fall out B) As a space-filling pessary it is used for all prolapse types C) The wedge-shaped side can be placed against the leading edge of prolapse D) The wedge-shaped side can be placed toward the vaginal opening E) The ring aspect of the pessary can be placed against the anterior vaginal wall

Answer 141

B Culligan P. Nonsurgical management of pelvic organ prolapse. Obstet Gynecol 2012;119:852-860

Question 142

You have been asked to evaluate the test characteristics of a new method to diagnose stress incontinence. Of the 1000 participants with the disease, 900 tested positive and 100 tested negative. In the 1000 without stress incontinence, 800 tested positive with the test, and 200 tested negative. From this information one can conclude which of the following? A) The test is more specific than it is sensitive B) The test is more sensitive than it is specific C) The positive predictive value is greater than the negative predictive value. D) The sensitiviy of the test is 80%

Answer 142

B

Question 143

A 52 yo woman with refractory OAB is undergoing the test phase of sacral neuromodulation. Which of the following is not one of the responses that would be expected during stimulation of the S3 nerve? A) Sensation in the labia/vagina B) Dorsiflexion of the little toe C) Sensation in the perineum D) Bellowing of the buttocks

Answer 143

B Carmel ME, Goldman HB. Management of refractory overactive bladder. Expert Rev Obstet Gynecol 2012; 7:605-13.

Question 144

For the uterus to develop embryologically, the following must occur: A) Mullerian Inhibiting Substance (MIS) must be present B) Testosterone must be absent C) SR-Y must be present D) Mullerian Inhibiting Substance (MIS) must be absent

Answer 144

D Carlson BM. Human Embryology and Developmental Biology, 4th Ed. Philadelphia (PA): Mosby, Inc., 20

Question 145

You have a dataset that contains delivery records including route of delivery and fetal head position and that spans 10 years. You would like to determine in patients that are undergoing a vacuum vaginal delivery, whether there is a difference in risks of third degree laceration between those that are delivered occiput anterior and those that are delivered occiput posterior. You determine the rate of 3rd degreelaceration in your sample overall is 13%. What is the most appropriate study design for you to analyse your dataset? A) Retrospective Cohort B) Randomized clinical trial C) Case control D) Prospective Cohort E) Case series

Answer 145

A

Question 146

The most common cause for the development of a urethrovaginal fistula is: A) Radiation therapy for cervical cancer B) Pelvic fracture C) Urethral diverticulectomy D) Abdominal hysterectomy E) Urethral erosion from sling mesh

Answer 146

C

Question 147

Methods to reduce inflammation from mesh include the use of all the following except: A) Porous architecture B) Lightweight, Type I mesh C) Monofilament fibers D) Microporous architecture

Answer 147

D Feedback: D. Microporous architecture. Correct would be macroporous architecture (>75microm) DA Executive Summary: Surgical Mesh for Treatment of Women WIth Pelvic Organ Prolapse and Stress Urinary Incontinence. Sept 8-9.2011:Accessed April 7, 2013 at http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/MedicalDevices/MedicalDevicesAdvisoryCommittee/ObstetricsandGynecologyDevices/UCM270402.pdf

Question 148

You obtain a CT scan as part of a workup for hematuria. The radiologist diagnoses a horseshoe kidney. This congenital anomaly is most likely associated with the anatomical positioning of which structure? A) Left ovarian vein B) Right ovarian artery C) Left renal vein D) Right renal artery E) Inferior mesenteric artery

Answer 148

E This is caused by fusion of the lower poles of both kidneys. Normal ascent to the lumbar area is prevented by the anatomic location of the inferior mesenteric artery. Walters and Karram; Urogynecology and Reconstructive Pelvic Surgery, 3rd ed., Chapter 2; Netter's Atlas

Question 149

An obese 55 year-old woman is undergoing a robotic-assisted laparoscopy mesh sacral colpopexy. Upon placement of the right lower quadrant robotic trocar, you note bleeding into the abdomen directly from the port site and an expanding hematoma within the anterior abdominal wall. This next best step in management would be any of the following options except: A) Remove the trocar and cauterize the bleeding site under direct visualization. B) Remove the trocar and place a Foley balloon to tamponade the bleeding. C) Remove the trocar and ligate the bleeding vessel with an endoscopic ligation device such as an Endo Close™ or Carter-Thomason CloseSure System®. D) The vessel does not need to be ligated, so you can continue with the case.

Answer 149

D This scenario describes an injury to the inferior epigastric artery upon placement of the lower quadrant trocar. Inspection of the anterior abdominal wall is important to visualize these vessels in order to avoid them upon accessory trocar placement during laparoscopy. Any of management options A through C can be used to control the bleeding, which can be brisk. Khan F, Kenton K. Intraoperative Injury in Reconstructive Pelvic Surgery. Journal of Pelvic Medicine and Surgery. 2006;12:241-256

Question 150

According to the 2012 American Urologic Association Guidelines, which of the following should be used in the initial work up of the uncomplicated overactive bladder (OAB) patient: A) Cystoscopy B) Urine culture C) Post-void residual D) Urinalysis

Answer 150

D

Question 151

A 45 year old woman presents for counseling regarding treatment options for her symptomatic stage II apical prolapse. Which of the following statements is MOST correct regarding pelvic floor physical therapy for the treatment of prolapse? A) Based on the available data in the literature, there is evidence that suggests there is some benefit from pelvic floor physical therapy compared to continued observation B) Based on the available data in the literature, there is no evidence that suggests there is benefit when considering the use of pelvic floor physical therapy for the treatment of prolapse C) Based on several randomized control trials, there is good evidence that pelvic floor physical therapy has long-term benefit in the treatment of pelvic organ prolapse D) There is not enough data to make any conclusions regarding the use of pelvic floor physical therapy for the treatment of pelvic organ prolapse

Answer 151

A Hagen S and Stark D. Cochrane Database of Systematic Reviews 2011, Issue 12.

Question 152

According to the International Society for the Study of BPS (ESSIC, or European Society for the Study of Interstitial Cystitis) which of the following histologic description on bladder biopsy is not considered a positive finding associated with interstitial cystitis/painful bladder syndrome? A) Inflammatory infiltrates B) Detrusor mastocytosis C) Intrafascicular fibrosis D) Squamous metaplasia E) Granulation tissue

Answer 152

D Biopsy findings that were accepted as positive signs of BPS were inflammatory infiltrates and/or granulation tissue and/or detrusor mastocytosis and/or intrafascicular fibrosis. van de Merwe JP, Nordling J, Bouchelouche P, et al. Diagnostic criteria, classification, and nomenclature for painful bladder syndrome/interstitial cystitis: an ESSIC proposal. Eur Urol. 2008;53:60-67

Question 153

Which of the following is most associated with a patient's assessment of her own treatment success after surgery for pelvic organ prolapse? A) The absence of prolapse beyond POPQ stage 1 B) The absence of prolapse beyond POPQ stage 2 C) The absence of prolapse beyond the hymen D) The absence of vaginal bulging symptoms E) The absence of a surgical complication

Answer 153

D Barber MD, Brubaker L, Nygaard I, et al. Defining success after surgery for pelvic organ prolapse. Obstet Gynecol 2009; 114(3):600-9.

Question 154

All of the following are true regarding obliterative procedures for pelvic organ prolapse except: A) The have a high success rate for anatomic correction of prolapse. B) Complete colpectomy requires entering enterocele sac to obliterate the cul-de-sac. C) Draining channels are left after LeFort Partial Colpocleisis. D) Levatorplasty and perineoplasty are important additions to obliterative procedures E) all of the above are true

Answer 154

B

Question 155

While performing a synthetic retropubic mid-urethral sling you notice at the time of cystoscopy that the needle has penetrated the bladder. The next step should be: A) Continue to pass the needle through the exit point and re-cystoscope to see if the sling is actually penetrating the bladder B) Remove the needle and abort the procedure C) Remove the needle and re-pass it on the same side and again cystoscope to be sure it does not penetrate the bladder on the second pass D) Remove the needle and call for a urologic consultation to determine if the penetration site needs to be formally repaired

Answer 155

C

Question 156

A 52 year-old woman presents with complaints of worsening urinary urgency and urgency incontinence. Which of the following findings might prompt a cystoscopic evaluation? A) all woman with OAB should have cystoscopy B) a dipstick positive for hematuria C) a history of exposure to Blue Dye #4 D) 3 or more red blood cells/high power field on a properly collected specimen E) 3 or more red blood cells/high power field on 2 of 3 properly collected specimens

Answer 156

D Davis R, Jones JS, Barocas DA, Castle EP, Lang EK, Leveillee RJ, Messing EM, Miller SD, Peterson AC, Turk TM, Weitzel W; American Urological Association. Diagnosis, evaluation and follow-up of asymptomatic microhematuria (AMH) in adults: AUA guideline. J Urol, 2012, 188(6 Suppl):2473-81

Question 157

A) Call for vaginal spotting or bleeding B) Some vaginal pain lasting up to a week is normal C) Some mild vaginal discharge is normal D) The pessary may have metal inside and should be removed prior to obtaining an MRI

Answer 157

D Walters and Karram; Urogynecology and Reconstructive Pelvic Surgery, 3rd ed., Chapter 14 Next

Question 158

The prevalence of fecal incontinence from population-based studies of community dwelling older adults, ≥65 years of age range from 3.0 to 16.9% depending on its definition. Which of the following factors is most highly associated with the presence of fecal incontinence in the older woman? A) Higher Charlson comorbidity score B) History of hysterectomy with bilateral oophorectomy C) Chronic diarrhea D) History of concurrent urinary incontinence E) Poor self perceived health status

Answer 158

D Goode PS, Burgio KL, Halli AD, Jones RW, Richter HE, et al. J Am Geriatr Soc 2005;53:629-635

Question 159

The percentage of Escherichia coli isolated in urine cultures for uncomplicated cystitis is A) 75%-95% B) 55%-75% C) 45%-55% D) <45%

Answer 159

A Gupta K et al. Clinical Infectious Diseases 2011;52(5):e103-e1

Question 160

The Noble-Mengert-Fish procedure... A) Involves a perianal incision and advancement of the mobilized rectal wall to cover the fistula site B) Was originally described to treat rectal carcinoma C) Is indicated for high rectovaginal fistulas D) Includes a diverting colostomy as an initial step

Answer 160

A NMF is a transperineal rectal flap procedure to treat rectovaginal fistula. Novi, JM. JPMS Vol 11(6) Nov/Dec 2005

Question 161

Which of the following statements regarding behavior treatment is most accurate? A) Bladder retraining has been shown to result in greater than 50% reduction in urge and stress incontinence episodes B) Bladder retraining improves nocturia and nocturnal enuresis C) Pelvic floor muscle training is superior to biofeedback therapy for urge urinary incontinence D) Pelvic floor muscle training is superior to estim for treatment of urge urinary incontinence E) C and D

Answer 161

A Fantl et al demonstrated 57% reductions in UI for stress/urge UI, but no improvement in nocturnal symptoms. Systematic reviews have failed to identify PFMT as superior to any other conservative therapy. Fantl JA, Wyman JF, McClish DK, et al. Efficacy of bladder training in older women with urinary incontinence. JAMA : the journal of the American Medical Association 1991;265:609-13; Fitz FF, Resende AP, Stupp L, Sartori MG, Girao MJ, Castro RA. Biofeedback for the treatment of female pelvic floor muscle dysfunction: a systematic review and meta-analysis. Int Urogynecol J 2012;23:1495-516; Fitz FF, Resende AP, Stupp L, Sartori MG, Girao MJ, Castro RA. Biofeedback for the treatment of female pelvic floor muscle dysfunction: a systematic review and meta-analysis. Int Urogynecol J 2012;23:1495-516.

Question 162

A 55 year-old female presents with pelvic pressure and incontinence and has a negative urinalysis but a PVR of 850 ml. Filling cystometry shows absent sensation with filling and no detrusor contraction and the test was stopped at 1000 ml of filling. What is the NEXT most appropriate diagnostic test? A) Brain MRI B) Electroencephalogram C) Lumbo-sacral spine MRI D) No further testing is needed. Teach her clean intermittent self-catheterization.

Answer 162

C Gonzalez RR, Goldfarb DW, Tyagi R, Te AE. Neurologic Disorders. In: Textbook of Female Urology and Urogynecology 3rd Edition, Cardozo L, Staskin D eds. London (UK): Isis Medical Media, Inc., 2010; pp 485-497.

Question 163

The most common urodynamic findings associated with Parkinson's disease include each of the following except: A) Detrusor overactivity B) Detrusor overactivity with impaired contractility C) Normal bladder function D) Outlet obstruction with increased EMG activity E) Stress urinary incontinence

Answer 163

E The pathogenesis of Parkinson's disease involves degeneration of the pigmented dopamine-rick substantia nigra of the brain (an area involved in inhibition of micturition). Sphincter bradykinesia and pseudodysssynergia can be present and results in poorly sustained contractions with outlet obstruction. Winters, JC, Dmochowski RR, Goldman HB, Herndon CD, Kobashi KC, Kraus SR, et al. Urodynamics studies in adults: AUA/SUFU Guidelines. J Urol 2012, 188:2464-72.

Question 164

All of the following statements about sexual function after surgery for pelvic organ prolapse are true except: A) On average, sexual function as measured by validated sexual questionnaires will improve compared to before surgery. B) 30% to 50% of women with symptomatic pelvic organ prolapse will report dyspareunia prior to surgery C) The average postoperative dyspareunia rate after posterior colporrhaphy is 18% D) Performance of a posterior colporraphy at the time of prolapse surgery is associated with worsening sexual function postoperatively.

Answer 164

D Paraiso MF, Barber MD, Muir TW, et al. Rectocele repair: a randomized trial of three surgical techniques including graft augmentation. Am J Obstet Gynecol 2006; 195:1762-71. Komesu YM, Rogers RG, Kammerer-Doak DN, et al. Posterior repair and sexual function. Am J Obstet Gynecol 2007; 197:101 e1-6. Maher C, Baessler K, Barber M, et al. Surgery for Pelvic Organ Prolapse. In: Abrams P, Brubaker L, Cardozo C, Wein A, eds. 5th International Consultation on Incontinence. Paris: Health Publications, Ltd; 2013.

Question 165

Which of the following is least likely to be affected by mesh placed via a transobturator approach? A) Thigh abduction B) Thigh adduction C) Lateral rotation of the thigh D) Medial rotation of the thigh

Answer 165

D From superficial to deep, a trocar or mesh passed through the transobturator approach traverses the following structures: gracilis muscle, adductor longus and brevis muscles, obturator externus muscle, obturator membrane, obturator internus muscle. The gracilis muscle aids with hip adduction and flexion. As the most superficial muscle of the medial thigh, it is often used for flap reconstructive procedures. The adductor longus and brevis muscles aid with thigh adduction. The obturators (externus and internus) aid with thigh abduction and lateral rotation. The muscles that aid with medial (internal) rotation of the thigh are the tensor fascia lata, gluteus medius, and gluteus minimus. None of these latter structures are traversed by trocar or mesh during a transobturator approach and thus medial rotation of the thigh is least likely to be affected with transobturator mesh placement. Walters and Karram; Urogynecology and Reconstructive Pelvic Surgery, 3rd ed., Chapter 2; Netter's Atlas

Question 166

The incidence of overactive bladder is estimated to be: A) 50-100 cases per 1,000 B) 150-200 cases per 1, 000 C) 1-10 cases per 10,000 D) 25-50 cases per 10,000

Answer 166

B Hartman et al. Treatment of Overactive Bladder in Women. Evidence Report/Technology Assessment Number 187. AHRQ Publication No. 09-E017 August 2009.

Question 167

Which of the following is not part of a behavior training program for urinary incontinence? A) Timed voiding drills B) Bedside commode C) Vaginal weighted cones D) Biofeedback E) Pelvic floor muscle excercises

Answer 167

B Voiding diary is usually used as an evaluation measure and a reference to start timed voiding. Bedside commode may be a very effective treatment for patients with limited mobility but is not considered a form of behavioral therapy.

Question 168

Which of the following is not considered correct ICS terminology for description of complex, noninvasive uroflow? A) Continuous smooth B) Continuous intermittent C) Straining D) Fluctuating

Answer 168

C Abrams P, Cardozo, L, Fall M, Griffiths D, Rosier P, Ulmsten U et al, The Standardization of Terminology of Lower Urinary Tract Function: Report from the Standardization Sub-Committee of the International Continence Society. Neurourol Urodyn 2002; 21, 167-178.

Question 169

All of the following may be seen as vaginal masses (are in differential diagnosis of vaginal mass) except? A) Urethral diverticulum B) Skene's gland cysts C) Leiomyomas D) Mullerian duct remnants E) All of the above may be seen

Answer 169

E Sandip Vasavada, MD: Evaluation and Management of Suburethral Diverticula in Walters, MD, Karram, M. Elsevier, Urogynecology and Pelvic Floor Dysfunction, 2nd edition, 2006

Question 170

What urodynamic finding is NOT usually found with myelomeningocele? A) Detrusor overactivity B) Detrusor areflexia C) Bladder neck open D) Poor bladder compliance

Answer 170

A Bauer SB. Neurogenic bladder: etiology and assessment. Pediatr Nephrol 2008; 23:541-551.

Question 171

You are involved in a research study evaluating the outcomes after two different vaginal surgeries for pelvic organ prolapse. You would like to compare the prolapse Stage between the two groups. What type of data is prolapse Stage? A) Continuous B) Dichotomous C) Nominal D) Ordinal

Answer 171

D

Question 172

Which of the following is considered a true statement: A) Both the McCall Culdoplasty and most uterosacral vaginal vault suspension require entrance into the peritoneum B) Severe leg pain and even foot drop can rarely occur when sutures are passed through the SSL complex C) Delayed absorbable sutures are preferred when placing external McCall stitches D) All of the above are correct E) A and C are correct

Answer 172

E

Question 173

Improvements in QOL of PTNS have been demonstrated to be relatively similar to: A) Behavioral therapy B) Anticholinergic medication C) Sacral neuromodulation D) Injection of onabotulinum toxin A

Answer 173

B Peters KM, Macdiarmid SA, Wooldridge LS, et al. Randomized trial of percutaneous tibial nerve stimulation versus extended-release tolterodine: results from the overactive bladder innovative therapy trial. J Urol 2009; 182:1055-61.

Question 174

When considering repair of a vesicovaginal fistula: A) If the fistula was caused by radiation therapy, it may require delay of repair for many months or up to a year. B) Good surgical techniques include having a tension free and layered closure C) Whether repaired vaginally or abdominally recurrent fistulae have a high likelihood of being cured. D) All vesico-vaginal fistula repairs should be delayed until 3-6 months after injury E) All of the above F) A, B, and C

Answer 174

F Angioli R, Penalver M, Muzii L, et al. Guidelines of how to manage vesicovaginal fistula. Crit Rev Oncol Hematol 2003; 48:295-304.

Question 175

Each of the following is a true statement regarding anal sphincteroplasty in the management of FI except A) Using the overlapping sphincter technique, the continence rates do not deteriorate with time B) End to end repairs have similar short term continence rates to overlapping repairs C) The repair may be less effective in patients with sphincter defects >180 degrees D) After an obstetrical injury, the repair may be delayed weeks to months E) The surgery can be performed in the lithotomy or prone, jack-knife position

Answer 175

A Short term improvement of FI is around 66% and reported to decrease over time with rates of 6-10% at 10 years. Abrams P, Andersson K, Birder L et al. Fourth International Consultation on Incontinence Recommendations of the International Scientific Committee: Evaluation and Treament of UI, POP and FI. Neurourology and Urodynamics 2010; 29: 213-240.

Question 176

You are seeing a patient who describes pelvic pressure and inability to completely empty her rectum during bowel movements. She has daily bowel movements associated with a defecatory urge. Your pelvic exam reveals normal posterior vaginal wall support and well coordinated pelvic floor musculature. The levator muscles are supple and seem to appropriately relax with straining. You suspect the patient may have an enterocele that you are not detecting with your clinical exam. Which test might you order to further assess this patient's symptoms? A) Anorectal manometry B) Defecography C) Endoanal ultrasonography D) Colonic transit study E) Electromyography

Answer 176

B Anorectal manometry is useful in the measurement of rest and attempted defecation intrarectal and anal pressures. For those with bowel emptying issues, this test may help to categorize defecation disorders into dyssynergic patterns vs. inadequate expulsion. Though the patient above could have inadequate expulsion, anorectal manometry would not necessarily confirm or exclude an enterocele. Defecography is performed by placing contrast material into the rectum, vagina, and opacifying the small bowel with contrast. The patient is then instructed to defecate while fluroscopic images are obtained. This imaging study can help to delineate rectoceles, enteroceles, sigmoidoceles, and internal rectal intussuception. It is particularly useful with defecatory symptoms do not match exam findings in order to further assess for anatomic changes. Endoanal ultrasonography is used to image the anal sphincter complex, and is mainly utilized in the evaluation of women with fecal incontinence. Colonic transit study is useful in patients who describe slow colon transit, with decreased urge to defecate and infrequent bowel movements. Electromyography (EMG) uses surface electrodes or needles to monitor muscle activity. It is often one component of anorectal manometry as elevated EMG activity during straining is suggestive of pelvic floor dyssynergia. Walters and Karram; Urogynecology and Reconstructive Pelvic Surgery, 3rd ed., Chapter 25 Next

Question 177

When placing a transobturator sling, organize the following layers through which the trocar passes from outside to in A) skin and subcutaneous fat, gracilis muscle, obturator externus muscle, obturator membrane, obturator interus muscle, adductor brevis, periurethral endopelvic fascia B) skin and subcutaneous fat, obturator externus muscle, obturator membrane, obturator interus muscle, gracilis muscle, adductor brevis, periurethral endopelvic fascia C) skin and subcutaneous fat, adductor brevis, gracilis muscle, obturator externus muscle, obturator membrane, obturator interus muscle, periurethral endopelvic fascia D) skin and subcutaneous fat, gracilis muscle, adductor brevis, obturator externus muscle, obturator membrane, obturator interus muscle, periurethral endopelvic fascia

Answer 177

D The helical trocar use to place a transobturator sling follows this path (from outside to in): skin and subcutaneous fat, gracilis muscle, adductor brevis, obturator externus musucle, obturator membrane, obturator interus muscle, periurethral endopelvic fascia and then through the vaginal tunnel. Walters M, Karram M. (2007). Sling Procedures for Stress Urinary Incontinence. (M. Walters & M. Karram, Eds.). In Urogynecology and Reconstructive Surgery, 3 edition. (pg. 196-212). Philadelphia. Mosby Elsevier.

Question 178

Which of the following statements regarding embryogenesis is CORRECT? A) By the 16th day the 3rd layer (mesoderm) forms between the ectoderm and endoderm from cells of the primitive streak. B) The mesoderm fails to separate the endoderm from the ectoderm at two sites: the oropharyngeal membrane and cloacal membrane C) A teratogenic insult will give rise to a host of malformations related to the organ systems actively developing at that particular time. D) The metaphros that gives rise to the kidney forms begins to develop at week 5 of gestation and functions by week 8. E) All of the above

Answer 178

E The area where the somatic mesoderm and the splanchnic mesoderm layers join in the midline is termed the intermediate mesoderm and gives rise to the urogenital system.

Question 179

A 50 year old female with urge urinary incontinence presents for evaluation. She has an uncomplicated medical history, normal physical examination and negative urine analysis. The next best approach in the treament of her symptoms includes: A) Prescription for anticholinergic medications B) Discussion of dietary, behavioral and exercise options with possible anticholinergic medications if desired C) Posterior tibial nerve stimulation D) Discussion of neuromodulation E) All of the above

Answer 179

B 1st line therapy includes behavior modification, exercise and dietary modification with option of medications. PTNS, neuromodulation and botox are considered 3rd line. Gormley EA, Lightner DJ, Burgio KL, et al. Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline. The Journal of urology 2012;188:2455-63.

Question 180

Defecation involves a complex series of events and factors including all except: A) Stool consistency B) Anorectal sensation C) Muscle and neurologic integrity D) Diet E) Hormonal status

Answer 180

E Shah BJ, Chokhavatia S, Rose S. Fecal Incontinence in the Elderly: FAQ. Am J Gastroenterol 2012;107:1635-1646.

Question 181

Which of the following is the most highly M3 receptor selective anticholinergic? A) Darifenacin B) Solifenacin C) Tolterodine D) Trospium E) Oybutynin

Answer 181

A Haab F, Stewart L, Dwyer P. Darifenacin, an M3 selective receptor antagonist, is an effective and well-tolerated once-daily treatment for overactive bladder. Eur Urol 2004;45:420-9; discussion 9.

Question 182

A 72 year old woman with OAB has failed behavioral treatment. You try her on an anticholinergic but she returns complaining of multiple side effects. Which of the following is least likely to be related to the medication: A) Dry mouth B) Constipation C) Dry eyes D) Blurred vision E) Palpitations

Answer 182

E Gormley EA, Lightner DJ, Burgio KL, Chai TC, Clemons JQ, Culkin DJ, et al. Diagnosis and Treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline. J Urol 2012, 188, 2455-2463

Question 183

Which of the following statements regarding Botulinum Toxin is true? A) Blocks the presynaptic release of acetyl choline B) Blocks the detrusor cell's uptake of acetyl choline C) Is comprised of 3 chains, the light chain which internalizes the toxin, the medium chain which transports the toxin to the vesicle and the heavy chain which binds to vesicle and prevents release of acetyl choline D) The toxin permanently binds to the muscarinic receptors thereby competitively inhibiting the acetylcholine molecule from binding

Answer 183

A Which of the following statements regarding Botulinum Toxin is true? A) Blocks the presynaptic release of acetyl choline B) Blocks the detrusor cell's uptake of acetyl choline C) Is comprised of 3 chains, the light chain which internalizes the toxin, the medium chain which transports the toxin to the vesicle and the heavy chain which binds to vesicle and prevents release of acetyl choline D) The toxin permanently binds to the muscarinic receptors thereby competitively inhibiting the acetylcholine molecule from binding

Question 184

With respect to Percutaneous tibial nerve stimulation (PTNS), which of the following statements is most accurate? A) Compared to tolterodine 4mg extended release daily, PTNS is more effective in treatment of urgency, frequency, urge incontinence B) Compared to tolterodine 4 mg extended release daily, PTNS results in better improvements in Quality of Life C) Compared to sham treatment, PTNS results in significant mprovements in global assessment of improvement in OAB symptoms D) Adverse events with PTNS are common E) There are no contraindications to using PTNS for OAB

Answer 184

C Peters et al demonstrated comparable effects between tolterodine and PTNS, with only significant difference in global assessment of improvement. Adverse events are uncommon and only contraindication is presence of a cardiac pace maker or defibrillator. Peters KM, Macdiarmid SA, Wooldridge LS, et al. Randomized trial of percutaneous tibial nerve stimulation versus extended-release tolterodine: results from the overactive bladder innovative therapy trial. The Journal of urology 2009;182:1055-61. Peters KM, Carrico DJ, Perez-Marrero RA, et al. Randomized trial of percutaneous tibial nerve stimulation versus Sham efficacy in the treatment of overactive bladder syndrome: results from the SUmiT trial. The Journal of urology 2010;183:1438-43.

Question 185

A 48 yo woman presents with a 2 year history of worsening urinary urgency and frequency. Her prior physician prescribed behavioral therapeutic techniques but she had no improvement. The minimum basic evaluation for her problem includes which of the following: A) History and Physical Exam B) Post void residual C) Urinalysis D) Voiding Diary E) A and C F) A, C and D

Answer 185

E Gormley EA, Lightner DJ, Burgio KL, Chai TC, Clemons JQ, Culkin DJ, et al. Diagnosis and Treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline. J Urol 2012, 188, 2455-2463

Question 186

A device for potential treatment of a RV fistula in a patient who is not a good surgical candiate for medical indications is called a: A) Seton B) Breton C) Rectal button D) Pelleton

Answer 186

A Novi, JM. JPMS Vol 11(6) Nov/Dec 2005

Question 187

Assuming ability to catheterize post procedure, which of the patients with the following conditions would be the least appropriate to receive Botox injections for urgency incontinence? ``` A) Urinary retention B) Myasthenia gravis C) multiple sclerosis D) Renal insufficiency (GFR ```

Answer 187

B Botox is contraindicated in myesthenia gravis and amyotrophic lateral sclerosis (peripheral motor neuropathy). One may elect to use botox in patients with MS if they have urge incontinence or even If they have retention as long as they can catheterize. Renal insufficiency is not a contraindications, but should obtain clearance from nephrology before injection.

Question 188

During a sacrospinous ligament vault suspension, significant bleeding is encountered while placing the suture through the ligament. You are unable to visualize anything specific to tie off. After packing for a while the bleeding has not abated and she is beginning to get hypotensive. The bleeding vessel probably originates from the: A) Anterior division of internal iliac B) Posterior division of internal iliac C) Perineal artery D) Inferior mesenteric artery

Answer 188

A Grays Atlas of Anatomy, 2008. Page 232

Question 189

Which statement is TRUE about synthetic midurethral slings: A) Transobturator and retropubic approaches are equally effective for patients with ISD B) The quality of evidence in the Cochrane Review on midurethral slings is HIGH C) Transobturator slings have less voiding dysfunction than retropubic slings D) Retropubic bottom-to-top route is equally effective as top-to-bottom route for primary SUI

Answer 189

C Ogah J, Cody DJ, Rogerson L. Minimally invasive synthetic suburethral sling operations for stress urinary incontinence in women: a short version Cochrane review. Neurourol Urodyn 2011;30:284-91.

Question 190

64 year old female presents with mixed urinary incontinence and OAB symptoms. She demonstrates stress incontinence on exam associated with hypermobility but no prolapse. Urinalysis is (+) RBC, negative for nitrate and leukocytes. Spun urine is noted for 10-15 RBC on high-power field with no bacteria or wbc. She is very bothered by her OAB symptoms and incontinence and is eager to be improved. The next best step is: A) Begin course of nitrofurantoin B) Proceed with urodynamics for mixed incontinence indication C) Order CT-Urogram and perform cystoscopy D) Obtain urine for cytology E) Obtain urine for NMP biomarker

Answer 190

C Davis RJ. Jones S,. Barocas DA, et al, Diagnosis, Evaluation and Follow-Up of Asymptomatic Microhematuria (AMH) in Adults: AUA Guideline: Journal of Urology 2012; Volume 188, Issue 6, Supplement , Pages 2473-2481.

Question 191

You are reviewing the voiding diary of a 38 year old female with normal BMI. She thinks that her voided volume is surprisingly high given the amount of fluid she perceives herself to be consuming. What is the definition of polyuria accepted by the International Continence Society (ICS)? A) 24 hour voided volume in excess of 2800 ml (>40mL/kg in a 70kg person) B) Bothersome perception of excessive voiding C) Maximimum cystometric capacity of >500mL D) More than 10 voids per 24 hour period

Answer 191

A The Standardisation of Terminology in Nocturia: Neurourology and Urodynamics 00:179-183 (2002)

Question 192

According to the 2010 American Urologic Associate Guidelines, all of the following are TRUE regarding the treatment of acute cystitis, EXCEPT: A) In some regions, trimethoprim 100mg twice daily for 3 days is considered to be equivalent to trimethoprim-sulfamethoxazole B) Trimethoprim-sulfamethoxazole is an acceptable first line agent for empiric treatment of uncomplicated cystitis if the local resistance of uropathogens does not exceed 5% C) Amoxicillin or ampicillin should not be used for empiric treatment of acute cystitis. D) Nitrofurantoin monohydrate 100mg twice daily for 5 days should be avoided if early pyelonephritis is suspected.

Answer 192

B

Question 193

During the development of the genitourinary system, the metanephros represents which of the following: A) Primative, nonfunctioning kidney B) Primative, functioning kidney C) Permanent functioning kidney D) None of the above

Answer 193

C Campells Urology

Question 194

Which of the statements regarding Botulinum toxin A injection therapy for refractory overactive bladder is true? A) Botulinum toxin A 100 Units is recommended as alternative to initial trial of anticholinergic therapy B) If a patient with idiopathic OAB has inadequate relief with Botulinum toxin A 100 Units at 1 week, then the 200 unit dose should be administerd. C) Botulinum toxin A 200 units is superior to 100 units in the treatment of idiopathic OAB D) Botulinum toxin A injections are associated with urinary retention rates requriring catheterization around 10 - 25% E) Botulinum toxin A injections are associated with 10 - 20% urinary tract infection rates

Answer 194

D Botox is 3rd line therapy (thus should try medications first) and approved for idiopathic OAB at 100 U doses and have rates of retention of 10 - 20% with infection 30-50%. There are no data to support increasing dose of botox from 100 to 200 if failure to achieve satisfactory outcome and FDA recommends waiting at least 8 weeks before repeat injection to decrease development of antibodies. Gormley EA, Lightner DJ, Burgio KL, et al. Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline. The Journal of urology 2012;188:2455-63; Brin MF, Botulinum toxin: chemistry, pharmacology, toxicity, and immunology. Muscle Nerve Suppl. 1997;6:S146.

Question 195

A 36 year old woman with multiple sclerosis and refractory OAB failed treatments with Botox and sacral neuromodulation. A bladder augment was performed. Two years later she presents to the emergency room with the complaint of significant abdominal pain. She had been at a "keg" party the night before. Her abdomen is tender. Appropriate management at this point is a: A) Pain medicine B) CT cystogram C) Bladder irrigation D) Laparoscopy

Answer 195

B Biers SM, Venn SN, Greenwell TJ, The past, present and future of augmentation cystoplasty. BJUI 2012; 109:1280-93.

Question 196

93 year old female with history of dementia is brought in by her daughter with chief complaint of daytime urgency, frequency and nocturia 5 times a night. After complete history and physical examination she is noted on voiding diary to have normal bladder capacity but nocturnal polyuria with more than 1/2 of her daily fluids (1000 mL of fluid) excreted at night? Which is the following is the next best treatment recommendation? A) Restrict fluids to less than 1000 mL per 24 hours B) Prescribe DDAVP 0.1 mL nasal spray before bedtime C) Recommend bedside commonde to prevent falls at night D) Restrict fluids after dinner time and change timing of diuretic medications from late afternoon/early evening E) Prescribe zolpidem to improve sleep

Answer 196

D DDAVP has risk of hyponatremia and seizures especially in the elderly. Fluid restriction alone will not likley change polyuria and may be harmful to this elderly patient,

Question 197

Duplication of the uterus (uterine didelphys) occurs because: A) Lack of regression of mesonephric ducts B) Failure of the vaginal plate to canalize C) Lack of fusion of the paramesonephric ducts D) Failure of the genital tubercle

Answer 197

C Carlson BM. Human Embryology and Developmental Biology, 4th Ed. Philadelphia (PA): Mosby, Inc., 2009.

Question 198

A 17 year old patient presents with primary amenorrhea. She has normal breast development, normal secondary sexual characteristics, normal height and a 2cm vagina. MRI reveals an absent uterus and normal ovaries. The most common associated anomaly is: A) Coarctation of the aorta B) Renal agenesis C) Polydactyly D) Aortic valve atresia

Answer 198

B Gidwani G, Falcone T. Congenital Malformations of the Female Genital Tract: Diagnosis and Management. Philadelphia (PA): Lippincott Williams & Wilkins, 1999.

Question 199

According to the 2012 American Urologic Association Guidelines, which of the following should be considered or used in the initial physical examination of an uncomplicated overactive bladder (OAB) patient, EXCEPT: A) Examination of lower extremities for edema B) Mini-Mental State Examination C) Assess ability of patient to dress independently D) Assessment of post-void residual urine volume

Answer 199

D

Question 200

A 57 year old female has been previously diagnosed with interstitial cystitis on basis of clinical and examination parameters. She has tried and failed multiple therapies including oral medications, cystoscopy with hydrodistention and several instillation protocols. She desires your opinion on next step options. All of the following are plausible next steps in the discussion except. A) Bacillus Calmette Guerin (BCG) instillations weekly B) Supratrigonal cystectomy and augmentation C) Urinary diversion and cystectomy D) Off label use of cyclosporine A orally E) None of the above

Answer 200

A

Question 201

The most common tissue type for a urethral carcinoma arising in a diverticulum is: A) Adenocarcinoma B) Squamous cell carcinoma C) Transitional cell carcinoma D) Mucinous carcinoma

Answer 201

A Adenocarcinoma is most common. Foley CL, BJUI 2001, 108: Supplement 2, 20-23

Question 202

Which of the following are true statements regarding the receptors and mediators involved with medications treating urinary symptoms: A) β3 adrenergic medications act on β3 receptors in the bladder releasing norephiphrine B) Selective norephinephrine and serotonin uptake inhibitors increase the amount of norephinephrine and serotonin present in the somatic nucleus (Onuf's nucleus) in the spinal cord C) Tricyclics antidepressants are thought to have various sites of action including muscarinic receptors in the bladder, serotonin and norephinephrine nerve terminals in Onuf's nucleus and the pontine micturition center. D) Alpha 1 antagonists block norephinephrine activity in the urethra E) All of the above

Answer 202

E Silva WA. Pharmacologic Management of Incontinence and Voiding Dysfunction. Pelvic Medicine and Surgery 2005; 11 (1): 1.

Question 203

Which of the following statements regarding Long term continuation of anticholinergic medications is most accurate? A) Continuation rates for subjects enrolled in clinical trials is between 40 and 50% B) More than half of patients given prescriptions for medications refill their first prescription C) Continuation rates for newer clases of anticholinergic medications (i.e. extended release and transdermal) are higher than for older formulations. D) Long term continuation of anticholinergic medications when measured using medical claims data is between 17 and 57%

Answer 203

D More than half of of patients do NOT refill their prescriptions, continuation rates for clinical trials are high and there is no data comparing real life continuation rates for newer formulations of medications. Sexton CC, Notte SM, Maroulis C, et al. Persistence and adherence in the treatment of overactive bladder syndrome with anticholinergic therapy: a systematic review of the literature. Int J Clin Pract 2011;65:567-85.

Question 204

All of the following statements about power are true EXCEPT: ``` A) Power is equal to 1-β B) Power is equal to 1-α C) The probability of making a type II error is β D) α is also called the level of statistical significance ```

Answer 204

B Browner WS, Newman TB, and Hulley SB (2007). Getting Ready to Estimate Sample Size: Hypothesis and Underlying Principles in S.B. Hulley, S.R. Cummings,W.S. Browner, D. G. Grady, T.B. Newman (Eds.), Designing Clinical Research (pp.51-60). Philadelphia, PA: Lippincott, Williams & Wilkins.

Question 205

Which of the following comments can be said regarding the evidence for use of synthetic mesh in the anterior compartment: A) None of the Level I evidence supports the use of mesh in the anterior compartment B) No level I data show subjective benefit of using mesh C) Most of the Level I data show no subjective benefit of using mesh D) Level I support for synthetic mesh exists only for cases of recurrent prolapse. E) Uterine preservation is a risk factor for recurrence when mesh is used

Answer 205

C Altman D, Väyrynen T, Engh EE, et al. Anterior Colporrhaphy versus Transvaginal Mesh for Pelvic-Organ Prolapse. N Engl J Med 2011; 364: 1826-36.

Question 206

Which of the following is NOT true regarding nerve injury following gynecologic surgery? A) Incidence is approximately 2% B) Most injuries are purely sensory C) The genitofemoral nerve is the most commonly injured nerve D) Most injuries resolve spontaneously in weeks to months

Answer 206

C Bohrer JC, Walters MD, Park A, Polston D, Barber MD. Pelvic nerve injury following gynecologic surgery: a prospective cohort study. Am J Obstet Gynecol 2009;201:531.e1-7.

Question 207

Which of the following biologic materials would be most successful in augmenting anatomic outcomes after anterior colporrhaphy? A) Porcine small intestine submucosa B) Bovine pericardium C) Cadaveric fascia D) Fascia lata

Answer 207

A In general, biologic grafts may improve anatomic outcomes with no change in subjective outcomes. Of the various biologic materials, porcine small intestine submucosa (SIS) shows promise and has been compared in a randomized trial to traditional anterior colporrhaphy (TC). In this study the SIS group had 86.2% anatomic cure compared to 59.3% in TC (p = 0.03). In a randomized trial comparing bovine pericardium to anterior colporrhaphy, anterior colporrhaphy with bovine pericardium reinforcement did not show a statistically significant improvement over colporrhaphy alone. In another RCT, solvent dehydrated fascia lata did not decrease recurrent prolapse after anterior colporrhaphy. Feldner et al. Int Urogynecol J. 2010 Sep;21(9):1057-63. 2. Guerette et al. Obstet Gynecol. 2009 Jul;114(1):59-65. 3. Gandhi et al. Am J Obstet Gynecol. 2005 May;192(5):1649-54.

Question 208

Your patient is s/p hysterectomy with ovaries in situ 10 years ago and presents with abdominal pain. You note a mass at the vaginal apex and drainage coming from a sinus tract at the hysterectomy scar. Your leading diagnosis is: A) Ovarian cyst B) Tubo-ovarian abscess C) Fallopian tube carcinoma D) Diverticulitis

Answer 208

D Diverticulitis is the most common of these choices. Novi, JM. JPMS Vol 11(6) Nov/Dec 2005

Question 209

A 45 year old female with C5 spinal cord injury has neurogenic bladder is found to have urinary incontinence and incomplete emptying. Urodynamics confirms detrusor overactivity and detrusor sphincter dyssynergia. She had good dexterity of her right upper extremity and limited dexterity of the left side. The best surgical option for her is: A) Pubovaginal sling with autologous fascia B) Mid-urethral sling with mesh C) Bladder augmentation with continent catheterizable abdominal stoma D) Transurethral resection of external urethral sphincter E) Urethral dilation

Answer 209

C Linsenmeyer TA, Bodner, DR, Creasey GH, Green BG, Groah SL, Joseph A et al, Bladder Management for Adults with Spinal Cord Injury: A Clinical Practice Guideline, Washington DC, Paralyzed Veterans of America 2006.

Question 210

Which of the following are most likely in a 53 year old woman undergong posterior colporrhaphy? A) Rectal injury B) Dyspareunia C) Ureteral injury D) Recurrent posterior wall prolapse

Answer 210

B Dyspareunia is one worrisome complication that may occur after posterior colporrhaphy. Historically, dyspareunia happened more often with aggressive levator plication, but the goal of any posterior colporrhaphy is essentially to provide some narrowing of the vaginal tube. Thus, dyspareunia could occur even without levator plication. Rectal injury can occur with posterior colporrhaphy, but is infrequent. A traditional posterior colporrhaphy is not performed in close proximity to the ureter and thus ureteral injury would be quite unusual. Though recurrent posterior wall prolapse could happen, in general the posterior vaginal wall is least prone to prolapse recurrence. Walters and Karram; Urogynecology and Reconstructive Pelvic Surgery, 3rd ed., Chapter 20

Question 211

A 41 year old, G3P3 woman with stress urinary incontinence desires nonsurgical management. She is interested in pelvic floor muscle therapy (PFMT) and asks whether adding biofeedback would be helpful. Which of the following statements is most accurate? A) PFMT with biofeedback is as effective as PFMT alone B) Adding biofeedback increases success by 25% C) Adding biofeedback increases success by 50% D) Biofeedback results in worse outcomes

Answer 211

A Shamliyan T, Wyman J, Kane RL. Nonsurgical Treatments for Urinary Incontinence in Adult Women: Diagnosis and Comparative Effectiveness. Rockville (MD); 2012.

Question 212

What is the most common urodynamic finding in a woman with Parkinson's Disease with severe nocturia? A) Detrusor overactivity B) Detrusor areflexia C) Incompetent outlet D) Normal function

Answer 212

A Ragab MM, Mohammed ES. Idiopathic Parkinson's disease patients at the urologic clinic. Neurourol Urodyn 2011; 30:1258-61.

Question 213

Which of following medications is most effective for treatment of stress urinary incontinence A) local vaginal estrogen therapy B) oral estrogen therapy C) duloxetine D) imiprimine E) pseudephedrine

Answer 213

C Although not FDA approved, Duloxetine is approved in Europe for treatment of SUI with reductions in UI episodes of 50+% vs 27-40% for placebo. Local vaginal estrogen therapy MAY be effective in post menopausal women with atrophy, but it is not the "most" effecive of this groupo. ORal estrogens increase UI and imiprimine and pseudephedrine have limited data to support use in SUI.

Question 214

Medications that are high-risk in the geriatric population include all of the following EXCEPT: A) Diphenhydramine B) Diazepam C) Nitrofurantoin D) Cefotetan

Answer 214

D UpToDate. Hospital Management of Older Adults.

Question 215

When rectal filling reaches a point where the rectoanal inhibitory reflex occurs, there is: A) Contraction of the internal anal sphincter and relaxation of the external anal sphincter B) Relaxation of the internal anal sphincter and contraction of the external anal sphincter C) Relaxation of the puborectalis muscle D) Contraction of the puborectalis muscle E) Contraction of the internal and external anal sphincter muscles

Answer 215

B Remes-Troche JM, Rao SC. Expert Rev Gastroenterol Hepatol 2008;2: 323-335.

Question 216

The rectoanal inhibitory reflex enables relaxation of the internal and external anal sphincters in response to rectal distension in order to prepare for defecation A) TRUE B) FALSE

Answer 216

B False. The rectoanal inhibitory reflex relaxes the internal anal sphincter and allows for contraction of the external anal sphincter in response to rectal distension in order to prepare for defecation Hayden DM, Weiss EG. Fecal incontinence: etiology, evaluation, and treatment. Clinics in colon and rectal surgery. Mar 2011;24(1):64-70 E Gutman RE. Colo-Rectal_anal Pathophysiology and Pharmacology. J Pelvic Med Surg. 2003 2003(9):149-158

Question 217

A true statement regarding the treatment of fecal incontinence is A) Therapies are tailored according to the severity of incontinence and impact on quality of life B) Anal sphincteroplasty has durable long term success C) Initial management would include an anal sphincter repair D) Treatments such as rectal plugs, rectal stimulation, anal irrigation are common conservative therapies for non neurogenic FI E) Injection of bulking agents into the sphincter complex should be considered after failed conservative therapy

Answer 217

A Improvement of FI diminishes over time after anal sphincteroplasty repairs, conservative therapy for non neurogenic FI includes bulking agents, dietary changes, PFM exercises with biofeedback, conservative therapy for neurogenic FI includes rectal plugs, rectal stimulation and anal irrigation, bulking agents are currently considered investigational and other surgeries would be considered after failed conservative therapy Abrams P, Andersson K, Birder L et al. Fourth International Consultation on Incontinence Recommendations of the International Scientific Committee: Evaluation and Treatment of UI, POP and FI. Neurourology and Urodynamics 2010; 29: 213-240.

Question 218

A 65 year old female with urgency urinary incontinence has a history of CVA approximately 1 year ago. Which of the following is true regarding urodynamics findings A) Detrusor overactivity is the most likely urodynamic finding B) Usually demonstrates detrusor-sphincter dyssynergia C) Detrusor areflexia is common during initial period after CVA D) A & B are both correct E) A & C are both correct

Answer 218

E Burney T, Senapti M, Desai S et al, Acute Cerebrovascular Accident and Lower Urinary Tract Dysfunction: A Prospective Correlation of the Site of Brain Injury and Urodynamic Findings, Journal of Urology 1996; 156, p1748-1750

Question 219

In which procedure is a suture placed into one uterosacral ligament, reefed across the posterior (cul-de-sac) peritoneum, and then placed through the other uterosacral ligament? A) Uterosacral vaginal vault suspension B) Manchester procedure C) McCall culdoplasty D) LeFort colpocleisis

Answer 219

C The description is for a McCall culdoplasty, where this suture is also affixed to the apex of the vagina. In a uterosacral vaginal vault suspension, separate sutures are placed bilaterally into the uterosacral ligaments at or above the ischial spines and then affixed to the vaginal apex. In the Manchester procedure, the uterus is maintained, the cardinal and uterosacral ligaments are dissected, shortened, and then re-attached to the cervix. A LeFort colpocleisis is an obliterative procedure that does not typically involve the uterosacral ligaments. Walters & Ridgeway; Obstet Gynecol 2013; 121 (2)

Question 220

A study is performed to determine the test characteristics for a new diagnostic test for urinary tract infection (UTI), a rapid PCR test for common uropathogens called RapidUTI. 200 consecutive women with one or more symptoms of urinary tract infection (dysuria, urinary frequency, urinary urgency) presenting to the office for evaluation are enrolled. The urine from all enrolled patients is tested by this new test and a urine culture is collected. Patients are considered as having a UTI if the urine culture demonstrates >100, 000 cfu (criterion or gold standard). The results of the study are summarized below: The positive predictive value of the new test, RapidUTI, is: A) 75% B) 87.5% C) 90% D) 95% Next

Answer 220

C Gala R, Hamilton-Boyles S, Sung VW. SGS Research Handbook - 2nd edition. Fem Pelvic Med Reconst Surg 2011; 17:158-173

Question 221

While performing a pressure flow study on a 45 year old patient, the nurse notes that Pves catheter reading suddenly drops to zero and Pdet recording becomes negative. What is the most likely explanation? A) There is a significant recording artifact and you should rezero the catheters and start over. B) The patient is having a detrusor contraction C) The transurethral catheter fell out D) The vaginal or rectal catheter fell out E) The patient has poor bladder compliance

Answer 221

C Assuming the catheters were zeroed to atmosphere, if the Pves catheter suddenly is recording zero, it is most likely due to the catheter falling out which can occur during the void.

Question 222

A reason to consider avoiding a vaginal Latko repair for a patient with a vesicovaginal fistula includes which of the following? A) The fistula is present near the vaginal apex B) The fistula is a single fistula C) This type of repair is associated with a high failure rate D) The fistula is complicated with multiple connections

Answer 222

D Walters and Karram; Urogynecology and Reconstructive Pelvic Surgery, 3rd ed., Chapter 35

Question 223

A 37 year-old woman reports a 2 month history of urinary urgency, frequency and bladder pain. She reports multiple small volume voids throughout the day and also at night. She has a history of irritable bowel syndrome and a prior laparoscopy for chronic pelvic pain. She takes fluoxetine for depression. She forgot to complete a voiding diary. Her pelvic exam is entirely unremarkable. You are considering the diagnosis of painful bladder syndrome. Regarding a potassium sensitivity test (PST), which statement is true? A) A positive PST is predictive of good response to pentosan polysulfate B) A positive PST is predictive of good response to a tricyclic antidepressant C) A PST is not recommended for routine use in the diagnosis of PBS D) A negative PST rules out PBS E) A positive PST is specific for PBS

Answer 223

C The AUA does not recommend routine use of the PST. The PST is not specific for PBS and one study found that 26% patients meeting NIDDK criteria for PBS have a negative test. The test can be painful, risks inciting a severe flare, and does not allow for the diagnosis of other disorders. PST has not been found to be predictive of improvement with pentosan polysulfate, tricyclic antidepressants combined with hepainoid therapy.

Question 224

Which of the following routes of hysterectomy has the lowest reported rate of ureteral injury? A) Vaginal hysterectomy B) Laparoscopic hysterectomy C) Total abdominal hysterectomy D) Robotic hysterectomy

Answer 224

A

Question 225

Radical hysterectomy may cause each of the following except: A) Autonomic dysfunction to the lower urinary tract B) Detrusor acontractility with impaired sensation C) Lack of coordination between the detrusor and the sphincter D) Stress urinary incontinence E) Loss of bladder compliance

Answer 225

C Extensive dissection of the cardinal and uterosacral ligaments which carry parasympathetic and sympathetic nerves causing an autonomic peripheral neuropathy. Damage to the pelvic plexus can also occur with aggressive posterior dissection. Kershen R and Boone T. Peripheral neuropathies of the lower urinary tract, following pelvic surgery and radiation therapy. In: Corcos J and Schick E eds. Textbook of the Neurogenic Bladder. London and New York. Martin Dunitz Ltd; 2004: 235-244.

Question 226

A 77 year old female presents with a complaint of vaginal bulging. The POP-Q examination reveals: Aa: +3, Ba: +7, C: +7, D: +7, Ap: +3, Bp: +7, TVL: 8.5, GH: 4, PB: 2.5. Which of the following statements is TRUE? A) The patient has a more posterior than anterior vaginal prolapse B) The patient has Stage III Pelvic Organ Prolapse C) The patient has Stage IV Pelvic Organ Prolapse D) The patient would do well with a vaginal anterior and posterior colporrhaphy

Answer 226

C Bump RC, Mattiasson A, Bo K, Brubaker LP. Am J Obstet Gynecol. 1996;175(1):10-17.

Question 227

The reason Intraoperative recognition of a ureteral injury is most important is that it: A) Reduces the risk of renal loss B) Decreases the risk of ureterovaginal fistula C) Reduces postoperative morbidity D) Reduces the risk of readmission

Answer 227

A

Question 228

When comparing tension-free vaginal tape to transobturator tape for the treatment of stress urinary incontinence, which of the following statements is most true? A) Tension-free vaginal tape is associated with greater bladder injury during placement B) Transobturator tape is associated with greater voiding dysfunction postoperatively C) Tension-free vaginal tape is associated with greater neurologic symptoms postoperatively D) Transobturator tape is associated with greater mesh erosions

Answer 228

A In two multi-center randomized trials comparing TVT to TOT for the treatment of stress urinary incontinence, bladder perforation during placement and voiding dysfunction postoperatively were significantly greater in the patients receiving TVT than TOT. Neurological symptoms were most common in the TOT group than TVT in one trial, but not statistically significantly different in one trial. Mesh erosions in both trials were similar between groups, however follow up was not greater than 24 months in both trials. Barber MD, Kleeman S, Karram MM, et al. Transobturator tape compared with tension-free vaginal tape for the treatment of stress urinary incontinence: a randomized controlled trial. Obstet Gynecol 2008;111:611-21. Richter HE, Albo ME, Zyczynski HM, et al. Retropubic versus transobturator midurethral slings for stress incontinence. N Engl J Med 2010;362:2066-76. Albo ME, Litman HJ, Richter HE, et al. Treatment success of retropubic and transobturator mid urethral slings at 24 months. J Urol 2012;188:2281-7.

Question 229

Which is a true statement about vesicovaginal fistula: A) In developed countries, the incidence of VVF is highest after radiation treatment for gynecologic cancers. B) Risk factors that potentially impact wound healing include smoking and diabetes mellitus. C) Vaginal hysterectomy has a higher incidence of vvf than laparoscopic hysterectomy. D) The reported incidence after hysterectomy is 1 in 2,300 surgeries.

Answer 229

B Karram MM. Lower urinary tract fistulas. In: Walters MD and Karram MM, eds. Urogynecology and Reconstructive Pelvic Surgery. 3rd ed. Philadelphia, Pa: Mosby Inc; 2007: 445-460.

Question 230

You are about to perform a cystoscopy under anesthesia with hydrodistension for a patient with interstitial cystitis/painful bladder syndrome. What is the best surgical technique to use? A) High pressure (80 to 100cmH20) and long duration (>10 minutes) B) High pressure (80 to 100cmH20) and short duration (10 minutes) D) Low pressure (60 to 80 cmH20) and short duration (

Answer 230

D Cystoscopy under anesthesia for the treatment of IC/PBS can serve several purposes: 1) diagnostic evaluation to rule out other lesions 2) therapeutic benefit from hydrodistension and fulguration of Hunner's lesions if found, which can be easier to see after distension 3) disease "staging" by determination of bladder capacity under anesthesia. Three observational studies of high pressure/long duration cystoscopy under anesthesia all included at least 1 case of bladder rupture and had variable efficacy from 22 to 67%. Recommendation is for cystoscopy under anesthesia with low pressure/short duration technique. Observational studies have shown efficacy rates 30-54% at one month post-treatment that did decline over time. A high pressure/long duration technique increases the risk of complications without an increase in efficacy. Hanno PM, Burks DA, Clemens JQ, et al. AUA guideline for the diagnosis and treatment of interstitial cystitis/bladder pain syndrome. J Urol. 2011;185:2162-2170

Question 231

In systematic reviews, which of the following anticholinergic medications has the highest efficacy? A) Tolterodine 4mg ER B) Fesoterodine 8 mg C) Trospium 60 mg ER D) Oxybutinin 10 mg ER E) None of the above

Answer 231

E AUA guideline statements indicate there is insufficient eviedence to show superiority of one anticholinergic medication over another. Gormley EA, Lightner DJ, Burgio KL, et al. Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline. The Journal of urology 2012;188:2455-63.

Question 232

A 13 year old premenarchal girl presents with severe pelvic pain. Work-up reveals a thick transverse septum with obstruction. Appropriate treatment options include: A) Drainage of blood and hormonal suppression B) Resection and vaginal reconstruction C) Drain placement D) Vaginal dilation E) A and B F) None of the above

Answer 232

E Gidwani G, Falcone T. Congenital Malformations of the Female Genital Tract: Diagnosis and Management. Philadelphia (PA): Lippincott Williams & Wilkins, 1999.

Question 233

According to the 2012 American Urologic Association Guidelines, all of the following are true concerning the measurement of post-void residual (PVR) urine volume, EXCEPT: A) It should be measured with an ultrasound bladder scanner immediately after the patient voids. B) Urethral catheterization should be used if an ultrasound bladder scanner is unavailable C) Anti-muscarinics should be used with caution in patients with PVR> 250-300ml D) Assessment of PVR is needed in uncomplicated patients receiving anti-muscarinic medications.

Answer 233

D

Question 234

A patient is undergoing an abdominal hysterectomy for benign disease and the surgeon notes a distal ureteral injury (complete transection) with the electrocautery. The patient has no other co-morbidities and is otherwise healthy. All of the following are likely reconstructive options except? A) Ureteroneocystostomy B) Ureteroneocystostomy and psoas hitch C) Ureteroneocystostomy and transecting contralateral superior vesicle pedicle D) Transureteroureterostomy E) End to end ureteroureterostomy F) D and E

Answer 234

F Elliott SP, McAninch JW. Ureteral injuries: external and iatrogenic. Urol Clin North Am. 2006 Feb;33(1):55-66

Question 235

In adult women, which clinical sign or symptom is the most powerful in decreasing the likelihood of UTI when present? A) Absence of dysuria B) History of vaginal discharge C) Absence of back pain D) Vaginal discharge on examination

Answer 235

B Based on a MEDLINE search from 1966 to 2001, Bent et al synthesized the likelihood ratios of predicting UTI. Dysuria (summary positive LR 1.5, 95% CI 1.2, 2.0), frequency (LR 1.8, 95% CI 1.1, 3.0), hematuria (LR 2.0, 95% CI 1.3, 2.9), back pain (LR 1.6, 95% CI 1.2, 2.1) and CVAT (LR 1.7, 95% CI 1.1, 2.5) significantly increased the probability of UTI. Absence of dysuria (summary negative LR 0.5, 95% CI 0.3, 0.7), absence of back pain (LR 0.8, 95% CI 0.7, 0.9), h/o vaginal discharge (LR 0.3, 95% CI 0.1, 0.9), h/o vaginal irritation (LR 0.2, 95% CI 0.1, 0.9), vaginal discharge on exam (LR 0.7, 95% CI 0.5, 0.9) significantly decreased the probability of UTI. Bent S, Nallamothu BK, Simel DL, Fihn SD, Saint S. Does this woman have an acute uncomplicated urinary tract infection? JAMA 2002;287:2701-10.

Question 236

Studies of sacrospinous ligament and ileococcygeous colpopexy show that recurrence of prolapse is most likely to occur in the: A) anterior compartment B) posterior compartment C) apex D) genital hiatus E) cul-de-sac

Answer 236

A Sze EHM, Karram MM. Transvaginal repair of vault prolapse: a review. Obstet Gynecol 1997; 89:466-75.

Question 237

The diagnostic modality which has superiority for visualization of the external anal sphincter is: A) Anal manometry B) MRI C) Endoanal ultrasound D) Defecography E) Proctoscopy

Answer 237

B Malouf AJ, Williams AB, Halligan S, Bartram CI, Dhillon S, Kamm MA. Am J Roentgenol. 2000;175:741-5. Beets-Tan RGH, Morren GL, Beets GL, Kessels AGH, et al. Radiology 2001; 220:81-89

Question 238

Which receptors in the bladder respond to the neurotransmitter ATP? ``` A) Nicotinic B) Muscarinic C) Adrenergic D) Purinergic ```

Answer 238

D Acetylcholine is a neurotransmitter involved in both sympathetic and parasympathetic nerve transmission and interfaces with both nicotinic and muscarinic receptors. Norepinephrine, involved in sympathetic nerve signaling, interfaces with adrenergic receptors. ATP acts on purinergic receptors in the bladder. Walters and Karram; Urogynecology and Reconstructive Pelvic Surgery, 3rd ed., Chapter 3

Question 239

Treatment of nocturnal enuresis or nocturia with polyuria is associated with which of the following adverse events? A) Hyperkalemia and arrythmias B) Hypertension and stroke C) Hypernatremia and altered mental status D) Hypotnatremia and seizures

Answer 239

D DDAVP is associated with salt wasting and low serum osmolarity and hyponatremia. Low levels

Question 240

A 72-year old diabetic patient has been recently hospitalized and was treated with antibiotics. What is the most likely underlying cause of a recent onset of fecal incontinence? A) Cognitive impairment B) Pelvic floor muscle dyssenergia C) Diabetic autonomic neuropathy D) Fecal impaction E) Clostridium difficile infection

Answer 240

E Bliss DZ, Doughty DB, Heitkemper MM. Pathology and management of bowel dysfunction. In: Urinary and Fecal Incontinence Current Management Concepts. 3rd Edition, St Louis, MO: Mosby; 2006:445-451.

Question 241

# Choose the correct order for postoperative complications following transvaginal mesh for prolapse repair as ranked from most to least common A) Graft erosion > dyspareunia > wound granulation B) Graft erosion > wound granulation > dyspareunia C) Wound granulation > graft erosion > dyspareunia D) Dyspareunia > wound granulation > graft erosion E) Dyspareunia > graft erosion > wound granulation

Answer 241

A Abed H, Rahn DD, Lowenstein L, Balk EM, Clemons JL, Rogers RG. Incidence and management of graft erosion, wound granulation, and dyspareunia following vaginal prolapse repair with graft materials: a systematic review. International urogynecology journal. Jul 2011;22(7):789-798

Question 242

A patient presents with a bowel dehiscence after an abdominal sacrocolpopexy. The main abdominal wall defect is due to a separation of the aponeuroses of all of the following muscles EXCEPT: A) Internal oblique muscle B) Rectus muscle C) External oblique muscle D) Transversus abdominus muscle

Answer 242

B McBride AW, et al. Journal of Pelvic Medicine and Surgery. Volume 9, Number 3, May/June 2003

Question 243

A 42 year old female presents with complaints of urgency urinary incontinence and had has no previous therapy. She has no infection and no pelvic organ prolapse. Which of the following statements is correct? A) Prior to starting anticholinergic therapy, multi-channel filling cystometry should be performed. B) Prior to starting posterior tibial nerve stimulation, multichannel filling cystometry should be performed. C) Prior to scheduling Interstim Stage I, multichannel filling cystometry may be performed. D) It is best to perform multichannel filling cystometry between Stage I and II Interstim ther

Answer 243

C Clinicians may perform multi-channel filling cystometry when it is important to determine if altered compliance, detrusor overactivity or other urodynamic abnormalities are present (or not) in patients with urgency incontinence in whom invasive, potentially morbid or irreversible treatments are considered. (Option; Evidence Strength: Grade C) AUA Guidelines - Adult Urodynamics

Question 244

A true statement regarding bladder compliance is: A) It is defined as the change in Pdet/change in volume B) It is influenced by the sympathetic and somatic nervous systems C) It is a measure of the coordination between the detrusor and urethral sphincter D) It may produce a dLPP of 40cmH2O E) It is likely to be abnormal in patients with a stroke

Answer 244

D If bladder compliance is poor, it will be reflected by increasing Pdet. Incontinence occurring at this time would be measured as the detrusor leak point pressure. Detrusor leak point pressures >40 cm H20 has been reported as hazardous to the upper tracts. Winters, JC, Dmochowski RR, Goldman HB, Herndon CD, Kobashi KC, Kraus SR, et al. Urodynamics studies in adults: AUA/SUFU Guidelines. J Urol 2012, 188:2464-72.

Question 245

An 80 year old woman with known history of narrow angle glaucoma and dementia presents with symptoms of urinary urgency, frequency and urge incontinence. Which is the best initial treatment regimen to institute. A) Darifenacin 7.5 mg daily with titration to 15 mg as tolerated B) Biofeedback therapy with behavior modification C) Mirabegron 25 mg daily with titration to 50 mg as tolerated. D) Botulinum toxin A injection 100 Units

Answer 245

C Anticholinergics are contraindicated in patients with narrow angle glaucoma, biofeedback and behavior training will likely not be recalled in this patient with dementia, botox injection is associated with 10-20 % retention rates requiring catheterization. Thus botox may not be best first line therapy.

Question 246

When considering the use of anti-muscarinic agents, all of the following are true, EXCEPT: A) If both immediate and extended release preparations of a medication are available, the extended release formulation should be used due to lower rates of dry mouth B) Most trials that evaluated antimuscarinics for OAB treatment used a PVR of >/=150-200ml as an exclusion criteria. C) The most life-threatening side effect of anti-muscarinic medications is the impaired cognitive function D) Meta-analysis data show similar efficacy for all anti-muscarinic medications

Answer 246

C

Question 247

A 47 year old female is undergoing a complicated abdominal hysterectomy and a distal left ureteral injury is encountered at the just below level of the pelvic brim near the iliac vessels. She has no other pertinent medical history. A consult is called and you discuss reconstructive options with the surgeon. Which of the following is the least likely recommendation for surgical reconstruction of the ureter? A) Transureteroureterostomy B) Ureteral reimplant (ureteroneocystostomy) C) Ureteral reimplant (ureteroneocystostomy) with taking the contralateral superior vesical artery pedicle for improved mobility to the bladder D) Psoas hitch reimplant of the ureter E) Boari flap of the bladder to the ureter to increase length

Answer 247

A Brandes S, Coburn M, Armenakas N, McAninch J. Diagnosis and management of ureteric injury: an evidence-based analysis. BJU Int 2004; 94:277-89.

Question 248

The following statement is true regarding comparisons of anticholinergics for reducing voids per day: A) oxybutynin immediate release is more effective than tolterodine immediate release. B) Tolterodine immediate release is more effective than tolterodine immediate release C) Oxybutynin extended release is more effective than tolterodine immediate release D) Tolterodine extended release is more effective than oxybutynin immediate release and extended release.

Answer 248

C Hartman et al. Treatment of Overactive Bladder in Women. Evidence Report/Technology Assessment Number 187. AHRQ Publication No. 09-E017 August 2009.

Question 249

When considering repair of a vesicovaginal fistula: A) If the fistula was caused by radiation therapy, it may require delay of repair for many months or up to a year. B) Good surgical techniques include having a tension free and layered closure C) Whether repaired vaginally or abdominally recurrent fistulae have a high likelihood of being cured. D) All vesico-vaginal fistula repairs should be delayed until 3-6 months after injury E) All of the above F) A, B, and C

Answer 249

F

Question 250

Level I evidence has shown that when compared to traditional vaginal surgery without mesh, abdominal apical prolapse repair with mesh (sacral colpopexy) results in A) More recurrent prolapse with higher rates of repeat surgery B) More recurrent prolapse with similar rates of repeat surgery C) Less recurrent prolapse with similar rates of repeat surgery D) Less recurrent prolapse with lower rates of repeat surgery

Answer 250

C Maher CM, Feiner B, Baessler K, Glazener CM. Surgical management of pelvic organ prolapse in women: the updated summary version Cochrane review. International urogynecology journal. Nov 2011;22(11):1445-1457

Question 251

Compared to placebo, approximately what percentage improvement is typically seen for anticholinergic medications? A) 20% B) 40% C) 60% D) 80%

Answer 251

B Systematic review by Herbison et al concluded that overall, anticholinergics were superior to placebo with 40% higher cure or improvement rates with 0.6 reduction in incontinence episodes and voids per 24 hrs. Herbison P, Hay-Smith J, Ellis G, Moore K. Effectiveness of anticholinergic drugs compared with placebo in the treatment of overactive bladder: systematic review. Bmj 2003;326:841-4.

Question 252

A healthy 42 year-old woman has undergone a total vaginal hysterectomy, uterosacral ligament suspension. You are performing a cystourethroscopy. The bladder fills nicely and there are no sutures noted within the bladder and no evidence of cystotomy. There is immediate brisk efflux from the left ureter and after 20 minutes you note a sluggish efflux jet from the right ureter. What is the next best step in management? A) Administer 5mg IV furosemide and wait for 20 more minutes for more brisk efflux. B) End the case - even though the efflux from the right ureteral orifice was sluggish you know it is patent. C) Cut the right uterosacral ligament suture and repeat cystoscopy to look for brisk efflux from the right ureter. D) Cut the right uterosacral ligament suture, repeat cystoscopy and place a stent in the right ureter, even if you see brisk efflux. E) Cystoscopically attempt to place a stent in the right ureter.

Answer 252

C Sluggish spill from a ureter on cystoscopy may indicate a partial obstruction. A partial obstruction is likely caused by ureteral kinking from a suture. The suture should be identified and cut. If immediate repeat cystoscopy reveals brisk efflux from that ureter then no further intervention is necessary. A ureteral injury involving incomplete clamping or suture ligation can be remedied by imaging and stent placement only if it is recognized within 30 minutes, so waiting an additional 20 minutes would not be advised. Khan F, Kenton K. Intraoperative Injury in Reconstructive Pelvic Surgery. Journal of Pelvic Medicine and Surgery. 2006;12:241-256

Question 253

Which of the the following considerations is the LEAST important when deciding how and when to repair a vesicovaginal fistula that developed after a hysterectomy? A) Prior radiation exposure B) Size of the fistula C) Whether the patient had a total abdominal hysterectomy versus a total vaginal hysterectomy D) Whether the patient had a total laparoscopic hysterectomy versus a total abdominal hysterectomy E) Proximity to the ureteral orifices

Answer 253

C Generally, when performing both an abdominal and a vaginal hysterectomy, the uterus is detached from the proximal vagina using scissors or a scalpel. Therefore, there is less differentiation between these two routes of hysterectomy. A total laparoscopic hysterectomy generally is performed using monopolar energy to perform the colpotomy. The amount of electrical energy used at the vaginal cuff may influence the decision regarding timing of the repair. Similarly, previous radiation exposure could impact timing and approach such as the use of a interposition flap. Finally, the proximity to the ureteral orifices may dictate the use of ureteral stents and route of surgery.

Question 254

From 2008 to 2010, the most frequent complications reported to the FDA from the use of surgical mesh devices for pelvic organ prolapse included all of the following except A) Mesh erosion B) Infection C) Neuro-muscular problems D) Organ perforation

Answer 254

C Urogynecologic Surgical Mesh: Update on the Safety and Effectiveness of Transvaginal Placement for Pelvic Organ Prolapse. FDA Safety Communication2011:Accessed April 6, 2013 at http://www.fda.gov/downloads/MedicalDevices/Safety/AlertsandNotices/UCM262760.pdf. FDA Executive Summary: Surgical Mesh for Treatment of Women WIth Pelvic Organ Prolapse and Stress Urinary Incontinence. Sept 8-9.2011:Accessed April 7, 2013 at http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/MedicalDevices/MedicalDevicesAdvisoryCommittee/ObstetricsandGynecologyDevices/UCM270402.pdf.

Question 255

All of the following are strategies to minimize confounding in an observational study except: A) Excluding the confounder from the study population (Restriction) B) Stratification C) Blinding D) Matching E) Adjustment using multivariable statistical modeling

Answer 255

C Grimes DA, Schulz KF. Bias and causal associations in observational research. Lancet 2002; 359:248-252.

Question 256

A 43 year-old woman is planning to undergo a mid-urethral sling and cystoscopy. She has no medical problems, no prior surgical history, and takes no medications. She has no known allergies. She is 65 inches tall and weighs 63 kg. What is the best option for DVT prophylaxis? A) Mechanical compression with intermittent pneumatic compression boots B) Mechanical compression with graduated compression stockings C) Unfractionated heparin subcutaneously D) Low molecular weight heparin subcutaneously E) Early ambulation

Answer 256

E When the risk for VTE is very low (

Question 257

The patient whose cystogram is shown is a 42 year old female who complained of heavy menorrhagia, pain related to fibroids and mild stress uirnary incontinence. She underwent a total abdominal hysterectomy 1 week ago but chose to hold on an anti-incontinence procedure because her symptoms were mild. Postoperatively she has noted worsening urinary incontinence. What is the diagnosis? A) Postoperative stress urinary incontinence B) Postoperative vesicovaginal fistula C) Postoperative enterocele D) Postoperative overactive bladder E) Postoperative intrinsic sphincter deficiency

Answer 257

C The cystogram fills the bladder with liquid radioopaque contrast. The cystogram shows a distended bladder to the left of the image with a narrow connection, the vesicovaginal fistula, located at the anterior vaginal cuff and contrast material that was placed in the bladder, filling the vagina.

Question 258

Which of the following pessaries is most recommended for a 62 year old female with stress urinary incontinence and anterior pelvic organ prolapse? A) Incontinence ring B) Cube C) Gelhorn D) Hodge E) Inflatoball

Answer 258

D Walters and Karram; Urogynecology and Reconstructive Pelvic Surgery, 3rd ed., Chapter 14

Question 259

A 51-year-old G3P3 female presents with an anterior vaginal wall mass. Compression of the mass in the mid urethra demonstrates some purulent material that discharges from the urethral meatus. She has also complaints of dysuria, dyspareunia and leakage of urine. A videourodynamics study shows an open bladder neck at rest and stress and leakage per urethra with Valsalva maneuvers. The MRI confirms a large mid to proximal urethral saddlebag diverticulum. She desires surgery to correct this. What is the best surgical option to manage her? A) Incise diverticulum and wait to stage surgical management until discharge subsides B) Urethral diverticulectomy and simultaneous fascia sling C) Urethral diverticulectomy and simultaneous synthetic sling D) Urethral diverticulectomy and periurethral injectable therapy if she has stress incontinence symptoms after surgery E) Spence procedure and fascia sling

Answer 259

B Faerber GJ. Urethral diverticulectomy and pubovaginal sling for simultaneous treatment of urethral diverticulum and intrinsic sphincter deficiency. Tech Urol 1998; 4:192-7.

Question 260

Compliance is best defined as: A) Change in detrusor pressure divided by change in bladder volume (Pdet /Volume) B) Change in bladder volume divided by change in detrusor pressure (Volume/Pdet) C) Change in detrusor pressure divided by change in vesical pressure (Pdet /Pves) D) Change in bladder volume divided by change in vesical pressure ( Volume/Pves)

Answer 260

B Abrams P, Cardozo, L, Fall M, Griffiths D, Rosier P, Ulmsten U et al, The Standardization of Terminology of Lower Urinary Tract Function: Report from the Standardization Sub-Committee of the International Continence Society. Neurourol Urodyn 2002; 21, 167-178.

Question 261

There are more than 23 million Americans with limited English proficiency (LEP). Which of the following statements is true regarding delivery of health care for this population. A) Compared to to English speaking patients, those with LEP have similar risk of medical harm B) Health care providers are encouraged to provide medical interpreters for patients with LEP C) The availability of medical interpreters is a JCAHO safety goal D) Use of family members to translate during consent process is preferred to having a medical interpreter E) All of the above.

Answer 261

C LEP patients have higher medication errors, poor compliance and higher risk of harm than English speaking patients; Health care providers are required by Title VI of the Federal Civil Rights act to provide medical interpreters for patients with LEP, family members have limited ability to translate medical information and have high rates of omission in the process.

Question 262

Which patient is the LEAST appropriate for additional work up with imaging and/or cytoscopy? A) 48 yo woman with UTI unresponsive to appropriate treatment based on culture sensitivities B) 47 yo woman with 4 UTIs in the past 12 months and history of prior midurethral sling C) 35 yo woman with pyelonephritis during pregnancy D) 24 yo woman with persistent infections with the same bacteria E) 50 yo woman with 3 UTIs in the past 12 months

Answer 262

C Recurrent urinary tract infections are defined as 3 episodes in 12 months or 2 in 6 months. In patients with persistent infections with the same bacteria, infections that do not respond to appropriate treatment, or infections with worsening clinical status despite appropriate therapy, imaging of the urinary tract is indicated. In patients with recurrent or persistent UTIs (especially with a history of stones or prior anti-incontinence surgery), cystoscopy can be indicated. Pregnant women are more likely to have UTIs progress to pyelonephritis due to the decreased peristalsis promoting stasis of urine, mechanical obstruction by the enlarged uterus, increased filtration (less drug exposure) and host defense compromise. Grimes CL, Lukacz ES. Urinary tract infections. Female Pelvic Med Reconstr Surg 2011;17:272-8.

Question 263

Which statement is TRUE about treatment success after surgery for SUI? A) Complication rates between retropubic and transobturator synthetic midurethral slings are statistically similar B) Retropubic and transobturator slings have similar cure rates for recurrent SUI with ISD C) In continent women having prolapse surgery vaginally, adding a retropubic TVT had no effect on post-operative rates of urinary incontinence D) Open Burch procedures have lower cure rates for SUI than pubovaginal fascial slings

Answer 263

D Wei JT, Nygaard I, Richter HE, Nager CW, Barber MD, Kenton K, Amundsen CL, Schaffer J, Meikle SF, Spino C; Pelvic Floor Disorders Network. A midurethral sling to reduce incontinence after vaginal prolapse repair. N Engl J Med 2012;366:2358-67. Albo ME, Richter HE, Brubaker L, et al. Burch colposuspension versus fascial sling to reduce urinary stress incontinence. N Engl J Med 2007;356:2143-55.

Question 264

Suspicion of malignancy in a diverticulum is raised if what is observed per urethra upon transvaginal compression? A) Blood B) Pus C) Firmness D) Urine E) A or C are consistent with cancer

Answer 264

E Both blood and a firm mass are signs of cancer or stone in the urethra. Foley CL, BJUI 2001, 108: Supplement 2, 20-23

Question 265

You are performing a hysterectomy and abdominal sacrocolpopexy on a healthy 52 year old female for complete uterine prolapse. When examining the pelvis you notice a pelvic mass overlying the sacrum, extending proximally on either side of midline. What is the most appropriate next step? A) Call for a gynecologic oncology consult for assistance but begin resection of the pelvic mass. B) Resect the mass and proceed as planned. C) Confirm kidneys are in their normal anatomic position and evaluate the position of the ureters. D) Abort the procedure and close the incision as this is most likely a non-resectable presacral osteosarcoma.

Answer 265

C A mass, such as the one described could represent a horseshoe kidney. A horseshoe kidney is a congenital defect that arises from the in utero fusion of the kidneys.

Question 266

A true statement about Botulinum Toxin A for the treatment of UUI include A) Side effects are increased PVR, urinary retention and UTIs. B) The duration of effect after one injection may vary. C) The mechanism of action on smooth muscle may differ than what is known about skeletal muscle D) Doses of onabotulinumtoxin A are equivalent to doses of abobotulinumtoxin A E) All the above F) A, B and C

Answer 266

F Silva W.Andre. Pharmacologic Management of Incontinence and Voiding Dysfunction. Pelvic Medicine and Surgery 2005; 11 (1): 1. and Gormley EA, Lightner DJ, Burgio KL. Diagnosis and Treatment of OAB (non neurogenic) in adults: AUA /SUFU Guideline. American Urological Association Education and Research, Inc. 2012

Question 267

hich is the following are the most common pessaries used? A) Gelhorn pessary B) Hodge pessary C) Ring pessary D) Cube pessary E) Donut pessary Next

Answer 267

C Walters and Karram; Urogynecology and Reconstructive Pelvic Surgery, 3rd ed., Chapter 14

Question 268

Which subtypes of muscarinic receptors have not been identified in the human bladder? A) M1 B) M2 C) M3 D) M4

Answer 268

D M1, M2, and M3 muscarinic receptors have been identified in human bladder. The majority of receptors are M2 but cholinergic activity is mediated by M3. M3 receptors are also found in ocular, salivary, and GI tract glands.

Question 269

# Choose the most accurate statement regarding surgical repair of rectocele. A) Site-specific posterior vaginal wall repair results in less dyspareunia compared to traditional posterior colporrhaphy B) Porcine graft augmentation results in improved anatomic outcomes compared to traditional posterior colporrhaphy C) Porcine graft augmentation results in improved anatomic outcomes compared to site-specific posterior vaginal wall repair D) Prolapse and colorectal symptoms improve, regardless of whether traditional posterior colporrhaphy or site-specific repair is chosen

Answer 269

D Paraiso et a.l performed a randomized trial comparing 3 rectocele repair techniques: traditional posterior colporrhaphy, site-specific repair, and site-specific repair with porcine graft augmentation. After 1 year, those subjects who received graft augmentation had a significantly greater anatomic failure rate (12/26; 46%) than those who received site-specific repair alone (6/27; 22%) or posterior colporraphy (4/28; 14%), P = .02. There was a significant improvement in prolapse and colorectal scales and overall summary scores of the Pelvic Floor Distress Inventory short form 20 (PFDI-20) after surgery in all groups (P

Question 270

Which of the following statements regarding sacral neuromodulation are true? A) Long term reoperation rates for pain or infection are less than 10% B) Long term success rates are typically 80% C) There are major life threating events commonly associated with sacral neuromodulation D) Advances in the battery design have increased longevity of the device. E) Systematic reviews have demonstrated >50% improvement in urgency incontinence of 80% in the short term

Answer 270

E Brazzelli M, Murray A, Fraser C. Efficacy and safety of sacral nerve stimulation for urinary urge incontinence: a systematic review. The Journal of urology 2006;175:835-41. van Kerrebroeck PE, van Voskuilen AC, Heesakkers JP, et al. Results of sacral neuromodulation therapy for urinary voiding dysfunction: outcomes of a prospective, worldwide clinical study. The Journal of urology 2007;178:2029-34.

Question 271

In the geriatric population, it is important to evaluate all of the following EXCEPT: A) Manual dexterity B) Physical function C) Cognition D) Social support E) Living situation

Answer 271

A Erekson EA, Ratner ES, Walke LM, Fried TR. Gynecologic surgery in the geriatric patient. Obstet Gynecol. 2012;119:1262-9.

Question 272

A randomized trial comparing tension-free vaginal tape (TVT) [n=88] to transobturator sling (TOT) [n=82] in women with urodynamic stress incontinence with or without pelvic organ prolapse found that TOT was not inferior to TVT. The Kaplan-Meier survival curve demonstrating the time to development of any recurrent incontinence symptoms (stress or urge) is below: The most appropriate statistical test for comparing time to development of any recurrent incontinence symptoms is: A) Paired t-test B) Wilcoxon sign-rank test C) Log-rank test D) Logistic Regression

Answer 272

C Basic & Clinical Biostatistics, 4th ed. Dawson-Saunders B, Trapp RG, eds. Philadelphia: McGraw-Hill, 2004 Barber M, Kleeman S, Karram M, Paraiso MF, Walters M, Vasavada S, Ellerkmann M. A multi-center randomized trial comparing the transobturator tape with tension-free vaginal tape for the surgical treatment of stress urinary incontinence. Obstet Gynecol 2008; 111:611-21.

Question 273

A 58 year-old woman is seen in consultation for symptoms of urgency, frequency, and bladder pain. She mentions that a doctor told her last month she might have interstitial cystitis. She reports an approximate 2 month history of worsening urinary urgency and frequency with voids every 1-2 hours during the day and nighttime. She noticed a brief episode of gross hematuria one month ago that resolved after 1 day. She denies any back, flank or abdominal pain but reports a vague sensation of pressure with occasional burning in the suprapubic region. She denies any urinary incontinence. She feels a vague sensation of incomplete emptying. Her medical history is fairly unremarkable other than frequent bouts of upper respiratory infections and chronic constipation. She had a vaginal hysterectomy for menorrhagia 8 years ago. She is a smoker. Her pelvic exam is unremarkable; no prolapse, no masses, no atrophy, and PVR 20cc. Urinalysis is 2+ blood and otherwise negative. She had a recent urine culture at her PCP's office that shows mixed flora. What is the best next step in her management? A) Renal ultrasound B) Cystoscopy C) Urodynamics D) Intravenous pyelogram

Answer 273

B Cystoscopy is not necessary for the diagnosis of interstitial cystitis/painful bladder syndrome; however cystoscopy should be considered when the diagnosis is in doubt and when the differential include bladder cancer, stones, urethral diverticula or intravesical foreign bodies. This presentation is concerning for bladder cancer given the irritative symptoms, intermittent gross hematuria and risk factor of smoking.

Question 274

Which of the following least accurate with regards to the guarding reflex for continence? A) External sphincter contraction occurs via somatic nerves B) Internal sphincter contraction occurs via sympathetic nerves C) Detrusor relaxation occurs via sympathetic nerves D) Detrusor activation occurs via parasympathetic nerves E) Responses occur mainly by spinal reflex pathways

Answer 274

D The guarding reflex is present during urine storage. Distention of the bladder produces low level afferent firing. Afferent firing stimulates 1) sympathetic outflow to contract the internal urethral sphincter, 2) sympathetic outflow to relax the detrusor muscle, 3) somatic outflow through the pudendal nerve to contract the external urethral sphincter. These responses occur by spinal reflex pathways. A region in the pons (pontine storage center) augments external urethral sphincter activity. During the guarding reflex, the detrusor is relaxed and not activated; parasympathetic outflow is inhibited. Raz & Rodriguez; Female Urology, 3rd ed., Chapter 3

Question 275

In which scenario would screening for asymptomatic bacteriuria NOT be indicated? A) A 32 year-old healthy woman who is 12 weeks pregnant B) A 64 year-old woman with hypertension and hyperlipidemia who presents to her pre-operative visit for her scheduled prolapse surgery C) A 44 year-old woman with type 2 diabetes mellitus who presents for office scheduled cystoscopy D) A 80 year-old woman with rheumatoid arthritis and systemic lupus erythematous who lives in an assisted living facility and presents for routine medical care E) A 72 year-old healthy woman who presents for scheduled office urodynamic testing

Answer 275

D Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis 2005;40(5):643-654.

Question 276

A colleague asks you about a 74-year old patient who had a Perigee mesh kit placed for anterior compartment prolapse. She is doing well and has no Urogynecologic complaints, but a 1cm vaginal mesh erosion is noted. The best advice to give your colleague is: A) Tell your patient about the erosion, but reassure her that expectant management is safe B) Don't tell the patient about the erosion, as it is asymptomatic and there is no need to stir up trouble in this medicolegal environment C) Tell your patient that the mesh needs to be resected, as type III mesh is associates with sinus tract and abscess formation D) Tell your patient that she should have the mesh erosion oversewn with a biologic graft

Answer 276

A Deffieux X, Thubert T, de Tayrac R, et al. Long-term follow-up of persistent vaginal polypropylene mesh exposure for transvaginally placed mesh procedures Int Urogynecol J 2012; 23:1387-1390.

Question 277

Questionnaires for the diseases of urinary incontinence and pelvic organ prolapse fall into which 3 categories? A) Symptoms, sexual function, impact on social functioning B) Severity, distress, impact on lifestyle C) Symptoms, quality of life, sexual function D) Social functioning, physical well being, sexual health E) Sexual well being, severity, distress

Answer 277

C Barber MD. Symptoms and outcome measures of pelvic organ prolapse. Clin Obstet Gynecol 2005; 48:648-61. This document describes the various types of questionnaires as Symptoms, Quality of life and sexual functioning.

Question 278

A 48 year-old women underwent a laparotomy with a transverse skin incision for an abdominal mesh sacral colpopexy and underwent extensive lysis of adhesions during the procedure. She comes into the office for a postoperative visit approximately 2 weeks after her surgery and is complaining of symptoms including sharp burning pain from the region of the lower right pelvis to the right labia, as well as parasthesias over the lower right Mons and labia. Her symptoms seem to be aggravated by activity but she has not noticed any leg weakness or difficulty walking. What is the most likely nerve injured and most likely mode of injury? A) Femoral nerve injury due to prolonged compression with a self-retaining retractor. B) Lateral femoral cutaneous nerve injury due to prolonged compression with a self-retaining retractor. C) Femoral nerve injury due to hyperflexion of the thigh during prolonged lithotomy position. D) Ilioinguinal nerve entrapped in a wide Pfannenstiel incision. E) Iliohypogastric nerve entrapped in a wide Pfannenstiel incision.

Answer 278

D The femoral nerve can indeed be injured by either thigh hyperflexion during prolonged lithotomy or compression against the pelvic sidewall under a lateral blade of a self-retaining rectractor as the nerve emerges from the border of the psoas muscle prior to exiting the pelvis at the inguinal ligament. However femoral neuropathy typically involves weakness of the quadriceps and iliopsoas muscles. The lateral femoral cutaneous nerve can also be compressed by a self-retaining retractor but gives a syndrome of parasthesia and pain along the anterior and posterior-lateral thigh. Both the ilioinguinal and iliohypogastric nerves are vulnerable to entrapment with a wide Pfannenstiel incision and cause neuropathy symptoms similar to those described here. The ilioinguinal nerve is more medial to the anterior superior iliac spine however and more likely to be injured in this manner. Whiteside JL, Barber MD, Walters MD, et al. Anatomy of ilioinguinal and iliohypogastric nerves in relation to trocar placement and low transverse incisions. Am J Obstet Gynecol. 2003;189:1574-1578; discussion 1578.

Question 279

A true statement regarding medications used to treat urinary incontinence is: A) At the dose required to treat SUI, the risk of stroke and severe hypertention is too high to use tricyclic antidepressants. B) There are Level 1 studies with outcomes at one year, documenting continued success of β3 adrenergic agents. C) 25% of patients may have nausea if they use an alpha adrenergic agonist D) Intravesical capsaicin can cause transient pelvic pain. E) A common side effect of an alpha adrenergic antagonist is urinary incontinence

Answer 279

D Mariappan P, Alhasso A, Ballantyne Z. et al. Duloxetine, a Serotonin and noradrenaline Reuptake Inhibitor (SNRI) for the Treatment of SUI: A systematic Review. European Urology 2007: 51; 67-84. and Silva W.Andre. Pharmacologic Management of Incontinence and Voiding Dysfunction. Pelvic Medicine and Surgery 2005; 11 (1): 1.

Question 280

During a challenging abdominal hysterectomy a laceration is noted in the bladder. The patient has no other risk factors and you are called in to consult to fix this. Appropriate next best step(s) would include A) Open bladder and correct laceration and evaluate ureters B) Simply fix the laceration noted and proceed with remaining parts of hysterectomy procedure C) Place a long term Foley catheter and obtain cystogram in one week D) Observation as bladder laceration is likely extraperitoneal

Answer 280

A Brandes S, Coburn M, Armenakas N, McAninch J. Diagnosis and management of ureteric injury: an evidence-based analysis. BJU Int 2004; 94:277-89.

Question 281

The Martius labial interposition flap is based on what distal most aspect for the vascular pedicle supply? A) Inferior gluteal B) External pudendal artery C) Vaginal artery D) Perineal branch of internal pudendal artery E) B and D

Answer 281

E Elkins TE, DeLancey JO, McGuire EJ. The use of modified Martius graft as an adjunctive technique in vesicovaginal and rectovaginal fistula repair. Obstet Gynecol 1990; 75:727-33.

Question 282

Which of the following statements about clinical evaluation of a young patient with an uncomplicated symptomatic urinary tract infection is incorrect? A) A urine culture should be reserved for recurrent or complicated UTIs or suspected pyelonephritis to confirm the presence of bacteriuria and the antimicrobial susceptibility of the infecting uropathogen. B) A dip U/A has a sensitivity of 75% and Specificity of 82% for predicting a UTI and therefore adds little clinically in an acutely symptomatic patient. C) A formal microscopic urinalysis is helpful and should be considered essential in diagnosising a UTI. D) Cystitis in women usually presents with acute onset dysuria, frequency, urgency, nocturia, and suprapubic discomfort.

Answer 282

C In young women the acute onset urinary dysuria, frequency, urgency, nocturia, and suprapubic discomfort is generally all that is required to make the clinical diagnosis of an uncomplicated UTI. Using an inexpensive in office dip urinalysis is reasonable but withholding therapy in an symptomatic patient in the setting of a negative urinalysis is not clinically prudent. A microscopic urinalysis looking for the presence of leukocytes, bacteria and red blood cells has a very poor ability to predict the presence or absence of a UTI. Approximately 50% of urinary tract infections do not demonstrate hematuria on microscopic exam and bacteria are often unidentifiable in lower colony-count infections. A positive urine culture is considered the Gold Standard for diagnosing a UTI. A result of > 100,000 CFU/ml of one or two organisms is considered the diagnostic criterion for UTI and some feel that > 100 CFU/ml should suffice in a symptomatic patient. A urine culture is performed to confirm the presence of bacteriuria and the antimicrobial susceptibility of the infecting uropathogen and should be reserved for recurrent or complicated UTIs or suspected pyelonephritis Hooten T, Uncomplicated urinary tract infection. NEJM 2012; 366: 1028-1037 Hurlbut TA III, Littenberg B. The diagnostic accuracy of rapid dipstick tests to predict urinary tract infection. Am J Clin Pathol 1991;96:582.

Question 283

In Subsaharan Africa, obstetrical injury is the leading cause of rectovaginal fistula. In the United states, where RVF is a much less common condition, the most common cause of RVF is: A) Inflammatory Bowel Disease (especially Crohn's Disease) B) Iatrogenic (Gynecologic and Colorectal injury) C) Obstetric Injury D) Infectious Process (cryptoglandular abscess)

Answer 283

C Saclarides TJ, Rectovaginal Fistula. Surg Clin N Am 2002; 82: 1261-72.

Question 284

A 60 year old female who originally presented with recurrent UTI is found to have a post void residual of 350 ml. Her medical history is noted for diabetes and she underwent a midurethral sling procedure 3 years ago. Pressure flow study reveals a Qmax of 6 ml/sec associated with a Pdet@Qmax of 45 cm h20. Which of the following is the BEST statement? A) She has a flaccid hypotonic bladder consistent with diabetic cystopathy B) She should have a foley placed and repeat the study in 2 weeks C) She has bladder outlet obstruction D) She would benefit from urecholine E) She would benefit from sacral nerve modulation.

Answer 284

C Defreitas GA, Zimmern PE, Lemack GE, Shariat SF. Refining diagnosis of anatomic female bladder outlet obstruction: comparison of pressure-flow study parameters in clinically obstructed women with those of normal controls. Urology 2004; 64: 675-679.

Question 285

Which one of the following statements best describes the P value? A) It is the probability that the null hypothesis is true. B) It is the probability that the alternative hypothesis is true. C) It is the probability of obtaining the observed difference in the outcome measure, or a larger one, given that no difference exists between treatments in the population. D) It is the probability that the observed difference in the outcome measure was due to random chance.

Answer 285

C Sedgwick P. What is a p value? BMJ 2012; 345:e7767

Question 286

Periurethral glands are: A) Responsible for mucin production which contributes to continence B) Most prominent in the distal two thirds of the female urethra C) Lengthy but minimally branching glandular strucutures D) A and B

Answer 286

D Scarpero HM, Urol Clin North Am 2011 Feb 38(1) 65-71

Question 287

All of the following recommendations are accurate except: A) Endoscopic evaluation of the rectosigmoid region is appropriate for detecting mucosal disease that may contribute to fecal incontinence B) If a patient has coexisting diarrhea it is important to exclude colonic mucosal inflammation, rectal mass or stricture. C) Anorectal manometry with rectal sensory testing is the preferred method for defining functional weakness of the anal sphincter and detecting abnormal sensation D) The ability of the internal sphincter to contract in a reflex case be assessed during abrupt increases in abdominal pressure.

Answer 287

D Rao S Diagnosis and Management of Fecal Incontinence. Am J Gastro 2004 Practice Guideline Aug. 1585-1603.

Question 288

The OPUS Trial (Wei et al 2012) randomized 337 stress-continent women scheduled for prolapse surgery to TVT or sham surgery. The MAIN finding in this study was: A) The number needed to treat with a sling to prevent one case of urinary incontinence was 12 B) Urinary tract infections and bleeding complications were not different between sling and sham groups C) At 12 months, urinary incontinence was present in 27.3% of patients after sling and 43.0% after sham surgery (P

Answer 288

C Wei JT, Nygaard I, Richter HE, Nager CW, Barber MD, et al. A midurethral sling to reduce incontinence after vaginal prolapse repair. N Engl J Med 2012;366:2358-67.

Question 289

In the hallway of your hospital, you are asked to resolve a friendly dispute between a Colorectal and a Gynecologic colleague. They both contend that their own subspecialty is better suited to care for a woman with a delivery-related rectovaginal fistula. Your most accurate statement to settle the discussion is: A) Colorectal is better suited, because there are more studies about transanal advancement flaps B) Gynecology is better suited, because the cause of the injury is so familiar to an OB/Gyn C) Colorectal is better suited, because bowel surgery is more challenging and likely to result in infection, and the colorectal surgeon has more experience D) There is no evidence that one approach is better than the other for this condition

Answer 289

D Tsang CBS, Rothenberger DA, Rectovaginal Fistulas; therapeutic options. Surg Clinics N Am 2009; 77: 95-114

Question 290

When performing a unilateral ureteroneocystostomy which of the following structures may need to be transected? A) The contralateral uterine artery B) The contralateral superior vesical artery C) The ipsilateral superior vesical artery D) The ipsilateral umbilical artery

Answer 290

B Middleton RG: Routine use of the psoas hitch in ureteral reimplantation,J Urol 123:352, 1980.

Question 291

Which of the following is statistically significant with a p value of

Answer 291

B Basic & Clinical Biostatistics, 4th ed. Dawson-Saunders B, Trapp RG, eds. Philadelphia: McGraw-Hill, 2004

Question 292

Parasympathetic activity in the lower urinary tract: A) Results in bladder contraction B) Results in contraction of the bladder neck C) Only occurs during an inflammatory state D) Is associated with relaxation of the bladder E) Occurs via hypogastric nerve

Answer 292

A Fowler CJ, Griffiths D, de Groat WC. The neural control of micturition. Nat Rev Neurosci 2008; 9:453-66.

Question 293

True statements regarding obstetrical anal sphincter tears include each of the following except A) After repair, the patient is at risk for FI with subsequent vaginal deliveries B) Preoperative polyethylene glycol is recommended prior to repair C) An anterior approach sphincteroplasty is the most commonly performed D) A known risk factor for poor surgical outcome is advanced maternal age E) First line therapy includes pelvic floor exercises and biofeedback

Answer 293

D There are no clear predicators for success or failure when evaluating outcomes of obstetrical anal sphincter repair Hull T. Fecal Incontinence. In: In: Walters MD and Karram MM, eds. Urogynecology and Reconstructive Pelvic Surgery. 3rd ed. Philadelphia, Pa: Mosby Inc; 2007: 259-268.

Question 294

Early degeneration of the ureteric bud is most likely to result in which of the following? A) Bladder extrophy B) Renal agenesis C) Pelvic kidney D) Duplicated ureter E) Ectopic ureter

Answer 294

B Walters and Karram; Urogynecology and Reconstructive Pelvic Surgery, 3rd ed., Chapter 2

Question 295

What percent of rectovaginal fistulas in the U.S. are due to obstetric trauma? A) < 5% B) 12 - 14% C) 35 - 49% D) 74 - 88% E) > 95%

Answer 295

D Lowry AC, Thorson AG, Rothenberger DA, Goldberg SM. Repair of simple rectovaginal fistulas. Influence of previous repairs. Dis Colon Rectum 1988; 31:676-8. Baig MK, Zhao RH, Yuen CH, Nogueras JJ, Singh JJ, Weiss EG, Wexner SD. Simple rectovaginal fistulas. Int J Colorectal Dis 2000; 15:323-7.

Question 296

A woman with Stage III pelvic organ prolapse has no clinical symptoms of stress incontinence but leaks with cough with her prolapse reduced. She does not wish to undergo an anti-incontinence procedure at her prolapse surgery. What is her average estimated rate of postoperative SUI if she has surgery for prolapse without an anti-incontinence procedure? A) 12% B) 27% C) 59% D) 82%

Answer 296

C Nager CW, Tan-Kim J. Pelvic organ prolapse and stress urinary incontinence; combined surgical treatment. UpToDate 2011.

Question 297

Match the antimicrobial agent used for uncomplicated acute bacterial cystitis with the potential serious adverse event: (1) trimethoprim-sulfamethoxazole, (2) ciprofloxacin, (3) nitrofurantoin... (i) toxic epidermal necrosis, (ii) Achilles tendon rupture, (iii) pulmonary reactions. A) (1) and (i), (2) and (ii), (3) and (iii) B) (1) and (ii), (2) and (iii), (3) and (i) C) (1) and (iii), (2) and (ii), (3) and (i) D) (1) and (i), (2) and (iii), (3) and (ii) E) (1) and (ii), (2) and (i), (3) and (iii)

Answer 297

A Adverse events associated with trimethoprim-sulfamethoxazole include toxic epidermal necrosis, Stevens-Johnson syndrome, urticarial, headache, pruritus, nausea and vomiting, anorexia, thrombocytopenia, neutropenia, photosensitivity, rash, fever. Adverse events associated with ciprofloxacin Achilles tendon rupture (in patients over 60 yrs), hyperglycemia, hypoglycemia, severe hypersensitivity, headache, restlessness, seizures, confusion and rash. Adverse events associated with nitrofurantoin are pulmonary reactions, hemolytic anemia, hepatitis, peripheral neuropathy, hypersensitivity, vomiting, nausea, anorexia. ACOG Practice Bulletin. Clinical Management Guidelines for Obsterician-Gynecologist. Number 91, March 2008.

Question 298

Which of the following statements regarding release of neurotransmitters or chemical mediators from the urothelium is true? A) Non-cholinergic excitation is mediated via ATP action on muscarinic receptors B) Nitric Oxide has inhibitory effect on lower urinary tract via smooth muscle relaxation C) Acetylcholine induces bladder contractions by activating P2X receptors in detrusor muscle D) Acteylcholine released from efferent nerves or the urothelium acts on only nicotinic ACH receptors to modulate adjacent nerve activity E) Capsaicin released from the urothelium regulates release of chemical mediators involved in local inflammatory response

Answer 298

B Fowler CJ, Griffiths D, de Groat WC, The Neural Control of Micturition, Nature Reviews Neuroscience 2008; 9, 453-466

Question 299

Which excitatory neurotransmitter is an important mediator in spinal reflex pathway signaling? A) Glutamate B) γ-aminobutyric acid C) enkephalins D) ATP

Answer 299

A Spinal reflex pathways controlling bladder and urethral function use glutamatergic transmitter mechanisms. Glutamate is also an important excitatory neurotransmitter in the brain. ATP is an excitatory neurotransmitter, but functions in the brainstem and not the spinal reflex pathways. γ-aminobutyric acid (GABA) and enkephalins are inhibitory neurotransmitters that inhibit micturition reflexes when they are applied to the CNS. Raz & Rodriguez; Female Urology, 3rd ed., Chapter 3

Question 300

An axonal nerve injury should be suspected if A) The patient has weakness, but no sensory loss B) The distribution of the injury fits multiple dermatomes C) The patient has hyperreflexia D) The patient fails to recover in 3-4 weeks

Answer 300

D Kahn F, Kenton K JPMS Vol 12 number 5, Sept/Oct 2006

Question 301

Which of the following is not involved in the development of the genitourinary system: A) Intermediate mesoderm B) Mesothelium of coelomic cavity C) Endoderm of the urogenital sinus D) External ectoderm

Answer 301

D Campells Urology

Question 302

According to the 2012 American Urologic Association Guidelines for evaluation of asymptomatic, microscopic hematuria, indicators of renal parenchymal disease include all of the following, EXCEPT: A) Dysmorphic white blood cells B) Dysmorphic red blood cells C) Proteinuria D) Cellular casts E) Renal insufficiency Next

Answer 302

A

Question 303

According to the 2012 American Urologic Association Guidelines, all of the following should NOT be used in the initial, routine evaluation of the patient with asymptomatic, microscopic hematuria, EXCEPT: A) Blue light cystoscopy B) Urine cytology C) Calculated eGFR, creatinine, and BUN D) Pelvic ultrasound

Answer 303

C

Question 304

A 65 year old woman complains of weakened plantar flexion of the left foot and loss of sensation over the posterior calf and bottom of her foot on postoperative day 1. The nerve most likely injured is: A) Genitofemoral nerve B) Tibial nerve C) Obturator nerve D) Common Peroneal

Answer 304

B Wieslander, C K.; Boreham, M K.; Phelan, J; Schaffer, J I.; Corton, M M. Video: Avoiding nerve injury during gynecologic surgery. J Pel Med Surg. 2005;11:S54.

Question 305

Of Smith, Hodge, and Risser lever-type pessaries, which of the following statements is false? A) These pessaries were originally intended to treat uterine retroversion B) They may be used for uterine prolapse and cystoceles C) They work by being wedged into position behind the pubic bone D) They are very commonly used E) Their open center allows patients to have sexual intercourse without pessary removal

Answer 305

D Culligan P. Nonsurgical management of pelvic organ prolapse. Obstet Gynecol 2012;119:852-860 Clemons JL. Vaginal pessary treatment of prolapse and incontinence. http://www.uptodate.com/contents/vaginal-pessary-treatment-of-prolapse-and-incontinence. Retrieved 12/11/2012

Question 306

Which of the following is associated with a higher risk to the upper tracts? A) A valsalva leak point pressure of > 60 cm H20 B) A detrusor leak point pressure of > 40 cm H20 C) A detrusor leak point pressure of

Answer 306

B

Question 307

You are seeing a 32 year-old woman with interstitial cystitis/painful bladder syndrome for follow-up. You decide to start her on pentosan polysulfate. She should be aware of all of the following possible side effects except: A) Gastro-intestinal upset with diarrhea B) Elevated liver function C) Elevated renal function D) Hair loss E) Abnormal bleeding

Answer 307

C Side effects of pentosan polysulfate (PPS) include elevated LFT's, GI upset, hair loss and abnormal bleeding. PPS has heparin-like activity and should be avoided in patients who take anticoagulation therapies. Deniseiko Sanses T. Painful Bladder Syndrome/Interstitial Cystitis. Journal of Pelvic Medicine and Surgery. 2007;13:321-336

Question 308

Which is NOT true about detrusor areflexia: A) Usually have increased compliance B) Have absent or diminished detrusor contraction C) Storage capacity is increased D) Often due to sacral lesion

Answer 308

A Gonzalez RR, Goldfarb DW, Tyagi R, Te AE. Neurologic Disorders. In: Textbook of Female Urology and Urogynecology 3rd Edition, Cardozo L, Staskin D eds. London (UK): Isis Medical Media, Inc., 2010; pp 485-497.

Question 309

You completed a difficult vaginal hysterectomy and pelvic reconstruction with the patient in lithotomy. On post operative day 1 she falls when trying to walk and has numbness over her involved anterior thigh. The most likely location of injury is: A) The sciatic nerve B) The common peroneal nerve C) The femoral nerve D) The obturator nerve

Answer 309

C Kahn F, Kenton K JPMS Vol 12 number 5, Sept/Oct 2006 Femoral nerve injury and resulting weakness fits the scenario.

Question 310

During a routine postoperative check after an abdominal sacrocolpopexy for advanced vaginal vault prolapse complains of numbness with some parathesia along the right medial thigh. This persists for the next 2 weeks and then resolves. Which of the following nerves is most likely responsible for this? A) Ilioinguinal B) Femoral C) Iliohypograstric D) Sciatic E) Pudendal

Answer 310

C During a routine postoperative check after an abdominal sacrocolpopexy for advanced vaginal vault prolapse complains of numbness with some parathesia along the right medial thigh. This persists for the next 2 weeks and then resolves. Which of the following nerves is most likely responsible for this? A) Ilioinguinal B) Femoral C) Iliohypograstric D) Sciatic E) Pudendal

Question 311

The two pessaries considered the most useful for the treatment of POP are: A) Donut and Gehrung B) Cube and Hodge C) Cube and Donut D) Gelhorn and Ring with Support E) Inflatoball and Donut

Answer 311

D Culligan PJ. Nonsurgical management of pelvic organ prolapse. Obstet Gynecol 2012; 119:852-860.

Question 312

Sacral colpopexy with polypropylene mesh would be the procedure of choice in which individual? A) A 45 year old woman with stage II uterovaginal prolapse and inflammatory bowel disease B) A 75 year old woman with stage III anterior vaginal wall prolapse who is not sexually active C) A 55 year old woman with stage II posterior vaginal wall prolapse D) A 65 year old woman with recurrent stage III apical prolapse and a history of gastro-esophageal reflux disease (GERD)

Answer 312

D Sacral colpopexy with polypropylene mesh is the procedure of choice for those who are more prone to a recurrence of prolapse. This may include younger patients, those with more advanced prolapse, or those who have already had a recurrence after prior prolapse surgery. For those at higher surgical risk or those who are not sexually active, other surgical procedures (e.g. native tissue vaginal repair, vaginal prolapse repair with mesh, colpocleisis) may be considered. Choices A and C involve younger patients, but with less advanced prolapse. Furthermore, the patient in choice A has a history of inflammatory bowel disease and thus is at higher surgical risk, particularly with an abdominally placed mesh. The patient in choice B has more advanced prolapse, but also is older and not sexually active. Thus, colpocleisis may be more appropriate. Of the choices listed, sacral colpopexy with mesh is the procedure of choice for the individual in choice D. Walters & Ridgeway; Obstet Gynecol 2013; 121 (2)

Question 313

All of the following are acceptable first line therapies for an acute urinary tract infection except: A) Nitrofurantoin monohydrate/macrocrystals (100 mg twice daily for 5 days) B) Trimethoprim-sulfamethoxazole (160/800 mg [1 doublestrength tablet] twice-daily for 3 days) C) Fosfomycin trometamol (3 g in a single dose) D) Ciprofloxicin (250 mg bid for 3 days) E) Cephalexin 125-250 mg bid if sulfur allergy and SE with Nitrofurantoin.

Answer 313

D Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis 2011; 52:e103-e120. Hooten T. Uncomplicated urinary tract infection. NEJM 2012; 366: 1028-1037.

Question 314

Antibiotic prophylaxis is recommended for most procedures in FPMRS to reduce postoperative infection. Which of the following statements regading appropriate antibiotic administration is correct? A) Antibiotic prophylaxis is not recommended for Class I (Clean) surgical sites B) Administration of IV antibiotics within 60 minutes before incision is a Joint Commission performance measure C) Redosing of antibiotics should occur for 24 hours postprocedure for surgery lasting longer than 4 hours D) Antibiotic prophylaxis is recommended for urodynamic testing E) A & B are both accurate statements.

Answer 314

E Abx are NOT recommended for class 1 wounds, dosing is within 60 min before incision and is a JC measure, redosing should occur after 3-4 hours or with >1500 EBL at 1/2 dose, No abx recommended for Urodynamics. Darouiche RO, NEJM, 2010; Noorani Br J Surg, 2010; ACOG practice bulletin 104

Question 315

What is the most common pathogen to cause complicated and uncomplicated UTI? A) Pseudomonas B) Klebsiella C) E. Coli D) Enterococcus

Answer 315

C Hooten, TM, Stamm, WE: Diagnosis and Treatment of Uncomplicated Urinary Tract Infection. Infect Dis Clin North Am 1997;11:551-81.

Question 316

When placing a transobturator sling, which anatomical landmark indicates the level at which the helical device will enter (or exit) to pass the sling? A) Clitoris B) Urethral meatus C) Anterior hymenal ring D) Posterior hymenal ring

Answer 316

A transobturator helical device will either enter (if going in to out) or exit (if going out to in) for placement of a transobturator sling. Walters M, Karram M. (2007). Sling Procedures for Stress Urinary Incontinence. (M. Walters & M. Karram, Eds.). In Urogynecology and Reconstructive Surgery, 3 edition. (pg. 196-212). Philadelphia. Mosby Elsevier.

Question 317

The categories for surgical mesh materials include all of the following except A) Non-absorbable synthetic B) Absorbable synthetic C) Non-absorbable biologic D) Composite

Answer 317

C DA Executive Summary: Surgical Mesh for Treatment of Women WIth Pelvic Organ Prolapse and Stress Urinary Incontinence. Sept 8-9.2011:Accessed April 7, 2013 at http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/MedicalDevices/MedicalDevicesAdvisoryCommittee/ObstetricsandGynecologyDevices/UCM270402.pdf

Question 318

A 43 year-old woman underwent a total laparoscopic hysterectomy and bilateral salpingo-oophorectomy for chronic pelvic pain and menorrhagia. She has new onset urinary incontinence that started several days postoperatively. She presents to your office 2 weeks after her surgery and you suspect a urinary tract fistula based on your history and physical. You order an intravenous pyelogram that shows a left sided ureterovaginal fistula. What is the best next step in management? A) Perform a cystoscopy and attempt to place a retrograde ureteral stent. If the stent does not pass then place a percutaneous nephrostomy tube and use this alone for drainage. B) Perform a cystoscopy and attempt to place a retrograde ureteral stent, if successful leave the stent in place and use this alone for drainage. C) Perform a cystoscopy and attempt to place a retrograde ureteral stent. If the stent does not pass then place an anterograde stent and a percutaneous nephrostomy tube. D) Plan for a delayed repair in one month.

Answer 318

C A ureterovaginal fistula diagnosed early can be treated with conservative management. One study found an 82% likelihood of spontaneous closure with stent placement within 1 month. Success rates may be higher with placement of both a ureteral stent and percutaneous nephrostomy tube. If the stent is placed, it should be left in place for about 6 weeks - after 4-6 weeks an IVP or retrograde pyelogram can be performed to assess for persistence of the fistula. This can be repeated after 8 weeks if the fistula does not initially heal and then if at 8 weeks the fistula has still not healed, a surgical repair can be planned. Double J stents are preferred due to less risk of migration. Karram M. Chapter 35: Lower Urinary Tract Fistulas. In: M. Karram and M. Walters. Urogynecology and Reconstructive Pelvic Surgery 3rd Edition. Philadelphia, PA: Mosby Elsevier; 2007: 445-460

Question 319

Which of the following risk factors are most associated with Delirium? A) Uncontrolled post operative pain control B) Age > 60 years C) Use of restraints to prevent removal of IV lines and catheter D) Ketorolac use for pain control E) A and C

Answer 319

E Risk factors for delirium include inadequate pain control, excessive narcotic, use of restraints, sleep deprivation, visual/hearing impairment, dehydration, age >70, hyponatremia, hypoglycemia, poly pharmacy, Erekson EA, Ratner ES, Walke LM, Fried TR. Gynecologic surgery in the geriatric patient. Obstetrics and gynecology 2012;119:1262-9.

Question 320

A 40 year-old woman is in your office for a second opinion. She comes to you with a diagnosis of interstitial cystitis and wants to discuss alternative treatment options. She reports a year of debilitating urgency, frequency and urge urinary incontinence. She reports voiding every hour in the daytime and has a fear of urine leakage. She notes urine leakage when she returns home from work or running errands and when she washes the dishes. She also notes that she has leakage at work when she stands up from sitting at her desk. She works as a receptionist and when at work she only voids 3 times a day when she has her breaks. She wakes up 1-2 times at night to void. She denies any pelvic pain but reports "pressure." Her medical history is unremarkable and she has no prior surgeries. She does not smoke. Her physical exam is unremarkable. She has no evidence of prolapse, no masses on exam and a PVR is 30cc. A urinalysis is entirely negative. She brought a bladder diary with her that shows 2 days of voids every 45 minutes to 1 hour of 20-50cc but 1 day with 5 daytime voids, the first 4 voids are 3 hours apart and range 150-250cc. Her first morning voided volume is 200-350cc. Her 24 hour volumes are approximately 1500cc. She has previously tried dietary modifications, pelvic floor relaxation techniques, bladder instillations, and pentosan polysulfate. None of these interventions have helped her symptoms. What is the most appropriate medication to start? A) Amitriptyline B) Tamsulosin C) Tolterodine D) Cimetidine E) Hydroyzine

Answer 320

C This clinical scenario is more consistent with overactive bladder rather than interstitial cystitis/painful bladder syndrome. Detrusor overactivity can co-exist with IC/PBS in up to 20% of patients, but in this scenario a trial of anticholinergic medication would be most indicated given the lack of bladder pain and the evidence of some normal bladder volumes with associated urge urinary incontinence. Hanno PM, Burks DA, Clemens JQ, et al. AUA guideline for the diagnosis and treatment of interstitial cystitis/bladder pain syndrome. J Urol. 2011;185:2162-2170

Question 321

According to the IUGA/ICS joint terminology and classification system of complications related to prosthese and grafts used in female pelvic floor surgery, a patient with a vaginal mesh exposure less than 1cm in size with extrusion that is painful only during physical exam is category A) 1Ce B) 2Bb C) 2Cd D) 3Bc E) 3Cd

Answer 321

B Haylen BT, Maher C, Deprest J. IUGA/ICS terminology and classification of complications of prosthesis and graft insertion--rereading will revalidate. American journal of obstetrics and gynecology. Jan 2013;208(1):e15.

Question 322

Which of the following statements regarding overactive bladder treatments is true? A) Injection of Botulinum toxin A 100 Units is superior to anticholinergic medication therapy with respect to reduction in incontinence episodes B) Anticholinergic medication therapy is equivalent to Botulinum toxin A 100 Units with respect to absence of leakage on 3 day diary C) Anticholinergic medication therapy is associated with urinary retention requiring intermittent self catheterization D) Injection of Botulinum toxin A 100 units is associated with improved patient satisfaction and quality of life compared to anticholinergic medication E) None of the above

Answer 322

E Botox and medications were similar in primary outcome of UUI reduction, Botox resulted in MORE 3 day dry rates than medication (27 vs. 13%), there was no urinary retention at 2 months in the medication group and quality of life was similar across groups in the ABC study. Visco AG, Brubaker L, Richter HE, et al. Anticholinergic versus botulinum toxin A comparison trial for the treatment of bothersome urge urinary incontinence: ABC trial. Contemporary clinical trials 2012;33:184-96.

Question 323

A diverticulum with a complex configuration would best be imaged preoperatively by: A) MRI B) Voiding cystourethrogram C) Urethroscopy D) IVP

Answer 323

A Handel LN, Current Urol Rep 2008, 9:383-388

Question 324

Randomized clinical trials are considered the highest level of evidence when evaluating two or more therapies or comparing a therapy to placebo. Randomization, when performed appropriately, results in all of the following except: A) Elimination of bias in treatment assignment B) Balances known and unknown confounders between the treatment groups C) Elimination of Measurement Bias D) Facilitates blinding (masking) of identity of treatments from investigators, participants, and assessors, including the possible use of a placebo.

Answer 324

C Designing Clinical Research, 3rd ed. Hulley SB, Cummings SR, Browner WS, et al, eds. Philadelphia: Lippincott Williams & Wilkins, 2007. Schulz KF, Grimes DA. Generation of allocation sequenses in randomized trials: chance, not choice. Lancet 2002; 359:515-9.

Question 325

You are repairing a rectovaginal fistula in the distal posterior vagina and tissue edges are under tension. The best approach is to: A) Close those layers not under tension and allow healing by secondary intent B) Insert a xenograft C) Utilize a bulbocavernosus fat pad graft in the repair D) Use fibrin glue where necessary to bridge the defect

Answer 325

C A Martius fat pad can be useful to fill dead space in a vaginal repair. Novi, JM. JPMS Vol 11(6) Nov/Dec 2005

Question 326

A patient is undergoing a TVT type retropubic synthetic sling and becomes acutely hypotensive with blood emanating from the suprapubic incision. Appropriate next steps would include all of the following except? A) Obtain appropriate blood products in the operating room B) Give epinephrine solution for immediate resuscitation C) Try to visualize the bleeding source D) Prepare for possible open surgery to manage bleeding E) Immediate vascular surgery consult

Answer 326

B Sivanesan K, Abdel-Fattah M, Ghani R. External iliac artery injury during insertion of tension-free vaginal tape: a case report and literature review. Int Urogynecol J Pelvic Floor Dysfunct. 2007 Sep;18(9):1105-8.

Question 327

Which of the following situations would pressure flow studies be most helpful? (>1) A) Evaluation of a patient with primary urgency urinary incontinence B) Evaluation of a patient with refractory, idiopathic urgency incontinence C) Evaluation of a patient with urinary retention 1 month after a Botox injection D) Evaluation of a patient with urinary retention after a midurethral sling

Answer 327

C and D

Question 328

A 57 year old, G3P3 woman with stress-predominant mixed urinary incontinence desires nonsurgical management. She is considering a behavioral and pessary therapy and is open to a combination approach. Which of the following statements is true: A) Combination is superior with 80% improvement in stress incontinence symptoms B) Combination is worse with 30% improvement in stress incontinence symptoms C) Combination therapy does not provide additional benefit. Behavioral provides the best short-term improvement in stress incontinence symptoms (50%) D) Pessary management provides the best improvement in stress incontinence (80%)

Answer 328

C Richter HE, Burgio KL, Brubaker L, Nygaard IE, Ye W, Weidner A, et al. Continence pessary compared with behavioral therapy or combined therapy for stress incontinence: a randomized controlled trial. Obstet Gynecol 2010; 115:609-17.

Question 329

A true statement regarding Botulinum A toxin for the treatment of UUI is A) It is a toxin extracted from red hot chili pepper B) It cleaves a protein on a receptor in the nerve ending C) It blocks a receptor in the detrusor muscle D) It is not available in the US for use E) The most common side effect is suprapubic pain

Answer 329

B Silva W.Andre. Pharmacologic Management of Incontinence and Voiding Dysfunction. Pelvic Medicine and Surgery 2005; 11 (1): 1.

Question 330

Which of the following statement is accurate regarding the rectal angle: A) At rest, the anorectal angle is approximately 90 degrees. B) With voluntary squeeze, the anorectal angle becomes more acute at approximately 70 degrees. C) During defecation the anorectal angle becomes more obtuse to approximately 110-130 degrees. D) All of the above

Answer 330

D Rao S Diagnosis and Management of Fecal Incontinence. Am J Gastro 2004 Practice Guideline Aug. 1585-1603.

Question 331

The most common cancer found within a urethral diverticulum is: A) Transitional cell cancer B) Squamous cell cancer C) Adenocarcinoma D) Sarcoma

Answer 331

C Thomas AA, Rackley RR, Lee U, Goldman HB, Vasavada SP, Hansel DE. Urethral diverticula in 90 female patients: a study with emphasis on neoplastic alterations. J Urol 2008; 180:2463-7.

Question 332

A true statement regarding the use of imipramine, a tricyclic antidepressant, for the treatment of OAB symptoms is: A) There is level 1 evidence supporting use B) It has both antimuscarinic and β3 adrenergic effects. C) It is FDA approved for children with enuresis. D) It is off the market. E) It should be considered first line therapy for OAB.

Answer 332

C Silva W.Andre. Pharmacologic Management of Incontinence and Voiding Dysfunction. Pelvic Medicine and Surgery 2005; 11 (1): 1.

Question 333

A 30 year female presents with 2 days of dysuria. She has no history of recurrent urinary tract infections. Her medical and surgical history is unremarkable. She has no allergies to medications. A urinary dip performed in the office indicates the presence of blood and leukocyte esterase. Which of the following does not represent an appropriate first course of action? A) Empiric treatment with mitrofurantoin monohyrate B) Empiric treatment with trimethroprim-sulfamehtoxazole C) Empiric treatment with ciprofloxacin D) Empiric treatment with fosfomycin trometamol E) Empiric treatment with pivmecillinam

Answer 333

C Gupta K et al. Clinical Infectious Diseases 2011;52(5):e103-e120

Question 334

Which of the following best characterizes the evidence regarding the use of biologic materials compared to native tissue colporrhaphy for anterior compartment prolapse: A) There is no Level I evidence regarding biologic augmenting materials for the anterior compartment B) There is no Level I evidence supporting biologic augmenting materials for the anterior compartment C) Biologic materials have been shown to be detrimental to success rates when used in the anterior compartment D) A minority of RCTs show benefit of biologic augmentation materials

Answer 334

D Yurteri-Kaplan LA, Gutman RE. The Use of Biological Materials in Urogynecologic Reconstruction: A Systematic Review. Plast Reconstr Surg 130 (Suppl. 2): 242S, 2012.)

Question 335

For which study or studies does the patient need to void to demonstrate a urethral diverticulum? A) Voiding cystourethrogram B) T2-weighted MRI C) Double balloon urethrogram D) A and B

Answer 335

A Voiding only occurs during the VCUG. The patient does not void during the other two studies. Handel LN, Current Urol Rep 2008, 9:383-388

Question 336

You would like to perform a study comparing the efficacy of three anticholinergic medications for overactive bladder. You anticipate having 1000 participants in each group. Which of the following tests would be the most appropriate if your primary outcome were the overall score on a validated overactive bladder questionnaire? A) Students t-test B) ANOVA C) Kruskal-Wallis D) Paired t-test

Answer 336

B

Question 337

Which urine culture result, in a healthy non-pregnant woman does NOT meet criteria for definition of UTI? A) Colony count of 10^3 on clean catch without symptoms of UTI B) Colony count of 10^5 on clean catch C) Colony count of 10^2 via catheterized specimen D) Colony count of 10^2 on clean catch with symptoms of UTI

Answer 337

A To diagnose bacteriuria, decreasing the colony count to 1,000-10,000 bacteria per milliliter in symptomatic patients will improve the sensitivity without significantly compromising specificity. ACOG Practice Bulletin. Clinical Management Guidelines for Obsterician-Gynecologist. Number 91, March 2008

Question 338

In a patient who underwent a traditional pubovaginal sling suffers an ilioinguinal nerve entrapment. What constellation of symptoms will she report? A) Weakness of ipsilateral thigh on adduction B) Quadriceps weakness, gait impairment, decreased sensation over anterior thigh and medial calf C) Burning or aching in medial calf D) Pain in medial groin, labia or inner thigh E) Footdrop

Answer 338

D Ilioinguinal nerve injury results in pain the medial groin, labia or inner thigh. Weakness of the ipsilateral thigh on adduction is due to obturator nerve injury. Quadriceps weakness, gait impairment, decreased sensation over the anterior thigh and medial calf is due to femoral nerve injury. Burning or aching in the medial calf is due to saphenous nerve injury. Foot drop is due to common peroneal nerve injury. Walters M, Karram M. (2007). Sling Procedures for Stress Urinary Incontinence. (M. Walters & M. Karram, Eds.). In Urogynecology and Reconstructive Surgery, 3 edition. (pg. 196-212). Philadelphia. Mosby Elsevier.

Question 339

Ms. Smith is 55 years old with several years of urgency urinary incontinence 1-3 times a day. She has tried kegels exercises on her own and now would like to start medications. She would like to know what the chances of her being completely dry are with medications. What is the best estimate for her question? A) 10% B) 20% C) 30% D) 40$

Answer 339

A Complete continence with anticholinergic is rare ranging from 8.5 to 13% Shamliyan T, Wyman JF, Ramakrishnan R, Sainfort F, Kane RL. Benefits and harms of pharmacologic treatment for urinary incontinence in women: a systematic review. Annals of internal medicine 2012;156:861-74, W301-10.

Question 340

You are interested in comparing the percentage of patients with constipation before and after a traditional posterior repair. What is the most appropriate test to use for this purpose? A) Survival analysis B) McNemar's C) Chi square D) Students t-test

Answer 340

B

Question 341

Which of the following occur in atrophic vaginal epithelium? A) Lowered pH B) Increase in glycogen content C) Increase in lactobacilli D) Increase in parabasal cells

Answer 341

D In pre-menopausal women, estrogen stimulation produces copious amounts of glycogen in the vaginal epithelium. Lactobacilli depend on glycogen from sloughed vaginal cells. Lactic acid produced by these bacteria lowers vaginal pH levels to 3.5 to 4.5; this is essential for the body's natural defense against vaginal and urinary tract infections. In postmenopausal women, declining estrogen results in less glycogen and fewer lactobacilli. Thus vaginal pH rises in the setting of urogenital atrophy. Vaginal epithelium consists of layers including the basal layer, 2-3 layers of parabasal cells which are actively proliferating, and differentiated layers of squamous cells. In postmenopausal women with atrophy, cell generation times slow down considerably and there is an increased predominance of parabasal cells that can be seen on a wet mount. Thus the correct answer is D. Bachmann and Nevadunsky; Am Fam Physician. 2000 May 15;61(10):3090-3096.

Question 342

A successful test stimulation trial of sacral neuromodulation for overactive bladder is defined as: A) Reduction in frequency of urination from 18 to 8 per day B) Reduction of leakage episodes from 10 to 6 per week C) Improved quality of life during the test phase of the trial D) Reduction in subjective urgency by 75% E) All of the above

Answer 342

A Successful test stimulation trial is devined as > 50% reduction in incontinence episodes, frequency or pads.

Question 343

Rare complications of pessary include? ``` A) Vesicovaginal fistula B) Rectovaginal fistula C) Bilateral hydronephrosis D) All of the above E) None of the above ```

Answer 343

D Walters and Karram; Urogynecology and Reconstructive Pelvic Surgery, 3rd ed., Chapter 14

Question 344

The surgical safety checklist, as recommended by the World Health Organization contains all of the following EXCEPT: ``` A) Allergies B) Patient identification (2 identifiers) C) Introduction of all team members (name and role in case) D) Confirmation of instrument sterility E) Results of pregnancy test ```

Answer 344

e www.who.int/patientsafety/safesurgery/en/index.html

Question 345

You are performing an office cystoscopy on a 34 year-old woman with symptoms concerning for interstitial cystitis/painful bladder syndrome. You note some diffuse hyperemia along the trigone as well as a circumscribed, reddened mucosal area with small vessels radiating toward a central scar area. She started dietary and behavioral modifications as well as pentosan polysufate 2 months ago. She has had slight relief, but her symptoms are

Answer 345

D The AUA recommends cystoscopy under anesthesia if first or second line treatments have not provided symptom relief. In addition, this patient has a classic Hunner's lesion, and it is recommended that if Hunner's lesions are present that they be fulgurated cystoscopically. Observational studies have shown 70-100% of patients will experience clinically significant relief after fulguration of Hunner's lesions. Up to 46% of patients may require repeat treatments. Hanno PM, Burks DA, Clemens JQ, et al. AUA guideline for the diagnosis and treatment of interstitial cystitis/bladder pain syndrome. J Urol. 2011;185:2162-2170

Question 346

Which of the following most accurately describes how to calculate 24-hour voided volume? A) Discard the 1st void, begin recording for 24 hours at the time of the next void B) Any 24 hour period is acceptable C) Begin urine collection with the first void of the day and end recording just prior to the first void the following morning. D) Record from midnight on 1 day to midnight the following day

Answer 346

A The Standardisation of Terminology in Nocturia: Neurourology and Urodynamics 00:179-183 (2002)

Question 347

Ilioinguinal and/or iliohypogastric nerve injuries are characterized by: A) Suprapubic and inguinal involvement B) Rectus muscle weakness C) Involvement by low transverse abdominal incisions D) A and B E) A and C

Answer 347

E Kahn F, Kenton K JPMS Vol 12 number 5, Sept/Oct 2006 These are sensory-only nerves.

Question 348

Which of the following cannot be obtained from a complex multichannel CMG? A) First sensation B) Maximum capacity C) Compliance D) Maximum flow rate E) Presence of detrusor overactivity

Answer 348

D Abrams P, Cardozo, L, Fall M, Griffiths D, Rosier P, Ulmsten U et al. The Standardization of Terminology of Lower Urinary Tract Function: Report from the Standardization Sub-Committee of the International Continence Society. Neurourol Urodyn 2002; 21, 167-178.

Question 349

The most common urodynamic pattern seen in patients with Multiple Sclerosis is? A) Detrusor overactivity B) Detrusor areflexia C) Sphincter bradykinesia D) Detrusor-sphincter dyssynergia

Answer 349

A Litwiller SE, Frohman EM, and Zimmern PE. Multiple Sclerosis and the Urologist, J Urol 1999; 161, 743-757.

Question 350

In patients with a suspected sphincter defect, evaluation should include which of the following studies A) Anal manometry B) Defecography C) Anal endosonography D) Pudendal nerve terminal motor latency

Answer 350

C This study visualizes the internal and external anal sphincters to assess length, width and any scar tissues or defects that may be present Hayden DM, Weiss EG. Fecal incontinence: etiology, evaluation, and treatment. Clinics in colon and rectal surgery. Mar 2011;24(1):64-70

Question 351

True or false - post coital prophylaxis is as effective as daily suppression in sexually active premenopausal women with recurrent UTI? A) TRUE B) FALSE C) No data to support or refute

Answer 351

A Sexually active premenopausal women with a history of 3 or more documented lower urinary tract infections in the preceding 12 months were assigned to either single oral 125 mg ciprofloxacin immediately after intercourse or single oral 125 mg ciprofloxacin daily at bedtime. Regimens were equally effective (p >0.7) in decreasing the incidence of urinary tract infection and both prophylactic regimens resulted in low incidence of emergent resistant bacterial isolates in urine. Melekos MD, Asbach HW, Gerharz E, Zarakovitis IE, Weingaertner K, Naber KG. Post-intercourse versus daily ciprofloxacin prophylaxis for recurrent urinary tract infections in premenopausal women. J Urol 1997;157:935-9

Question 352

How do beta adrenergic receptors function in the lower urinary tract? A) β3 adrenergic receptor antagonists result in relaxation of the detrusor muscle B) β3 adrenergic receptor agonists result in constriction of the urethra C) β3 adrenergic receptor agonists result in relaxation of the urethra D) β3 adrenergic receptor agonists result in relaxation of the detrusor muscle

Answer 352

D Sympathetic postganglionic fibers in the bladder are noradrenergic. β3 adrenergic receptors exist in the bladder body and around the detrusor muscle. Stimulation of these receptors with norepinephric results in relaxation of smooth muscle and facilitates storage of urine. α1 adrenergic receptors exist in the bladder base and urethral smooth muscle. Stimulation of α1 receptors results in constriction of the urethra and also facilitates urine storage. β3 receptor agonists further facilitate urine storage by relaxing the detrusor smooth muscle. Walters and Karram; Urogynecology and Reconstructive Pelvic Surgery, 3rd ed., Chapter 3

Question 353

All of the items below should be primarily considered for diagnosing overactive bladder except? A) Physical Exam B) urinalysis C) cystoscopy D) Post-void residual

Answer 353

C Gormley EA, Lightner DJ, et al. Diagnosis and Treatment of Overactive Bladder (Non-Neurogenic_ in Adults: AUA/SUFU Guideline. J urol 2012;188:2455-2463.

Question 354

You are seeing a 41 year old woman in consult with what you have confimred is a distal rectovaginal fistula after prior transvaginal repair. Before scheduling surgery you should: A) Delineate the level of the fistula with anal manometry B) Perform methylene blue tampon test C) Obtain colonoscopy with biopsies D) Avoid a bowel prep prior to next repair

Answer 354

C Underlying IBD is associated with failure of RV fistula repair. Novi, JM. JPMS Vol 11(6) Nov/Dec 2005

Question 355

Select the most accurate statement regarding vaginal estrogen and recurrent urinary tract infection. A) Use of topical vaginal estrogen decreases the incidence of recurrent urinary tract infection, decreases vaginal pH, increases vaginal colonization with lactobacilli and decreases vaginal colonization of Enterobacteriaceae. B) Use of topical vaginal estrogen decreases the incidence of recurrent urinary tract infection, decreases vaginal pH, decreases vaginal colonization with lactobacilli and decreases vaginal colonization of Enterobacteriaceae. C) Use of topical vaginal estrogen increases the incidence of recurrent urinary tract infection, increases vaginal pH, increases vaginal colonization with lactobacilli and increases vaginal colonization of Enterobacteriaceae. D) Use of topical vaginal estrogen decreases the incidence of recurrent urinary tract infection, increases vaginal pH, decreases vaginal colonization with lactobacilli and increases vaginal colonization of Enterobacteriaceae. E) Use of topical vaginal estrogen increases the incidence of recurrent urinary tract infection, decreases vaginal pH, increases vaginal colonization with lactobacilli and decreases vaginal colonization of Enterobacteriaceae.

Answer 355

A In a randomized, double-blind, placebo-controlled trial of topically applied intravaginal estriol cream on postmenopausal women with a history of recurrent urinary tract infections, use of topical vaginal estrogen decreases the incidence of recurrent urinary tract infection, decreases vaginal pH, increases vaginal colonization with lactobacilli and decreases vaginal colonization of Enterobacteriaceae. Raz R, Stamm WE. A controlled trial of intravaginal estriol in postmenopausal women with recurrent urinary tract infections. N Engl J Med 1993;329:753-6.

Question 356

Which of the following detect distention in the bladder? ``` A) A-delta fibers B) C-fibers C) Somatic afferent fibers D) Somatic efferent fibers ```

Answer 356

A Afferent pathways detect what is happening in the bladder; efferent pathways bring signals from the CNS to the bladder. There are two types of visceral afferent nerve fibers. A-delta fibers are myelinated and thus transmit signals faster. They detect distention in the bladder. C-fibers are unmyelinated visceral afferent fibers that detect chemical irritants. Somatic afferent fibers involve the pudendal nerve and afferent signals from the urethra. Somatic efferent fibers involve the pudendal nerve and contract the external urethral sphincter. Walters and Karram; Urogynecology and Reconstructive Pelvic Surgery, 3rd ed., Chapter 3

Question 357

Which of the following studies would best assess completion of rectal emptying A) Anal manometry B) Defecography C) Anal endosonography D) Pudendal nerve terminal motor latency

Answer 357

B Defecography assesses anorectal angle during defecation, presence of rectocele or intussusception, extent of perineal descent, and completion of rectal emptying Hayden DM, Weiss EG. Fecal incontinence: etiology, evaluation, and treatment. Clinics in colon and rectal surgery. Mar 2011;24(1):64-70

Question 358

Which of the following is not diagnostic of a catheter associated urinary tract infection? A) 3+ leukocyte esterase on urinalysis in a catheterized urine specimen from a catheterized patient B) Symptoms of UTI in a patient with an indwelling catheter and >10^3 colony-forming units/mL of >1 bacterial species in a single catheter urine specimen C) Symptoms of UTI and >10^3 colony-forming units/mL of >1 bacterial species in a midstream voided urine specimen in a patient whose urethral catheter was removed within the previous 48 hours D) Symptoms of UTI in a patient with a indwelling suprapubic catheter and >10^3 colony-forming units/mL of 1 bacterial species in a single catheter urine specimen

Answer 358

A According to the 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America, pyuria in a catheterized patient is not diagnostic of catheter associated urinary tract evidence. Hooton TM, Bradley SF, Cardenas DD, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis 2010;50:625-63.

Question 359

Which of the following is statistically significant with a p value of

Answer 359

A Basic & Clinical Biostatistics, 4th ed. Dawson-Saunders B, Trapp RG, eds. Philadelphia: McGraw-Hill, 2004

Question 360

A 55 year old G3P3 has uterovaginal prolapse and transvaginal hysterectomy, uterosacral ligament vaginal vault suspension, and anterior and posterior colporrhaphies are planned (estimated case time 2 hours). She is otherwise healthy and has no history of venous thromboembolus. Based on this, the prevention strategy for venous thromboembolus is: A) Low dose unfractionated heparin OR low molecular weight heparin B) No specific prophylaxis C) Low dose unfractionated heparin OR low molecular weight heparin OR intermittent pneumatic compression devices D) Low dose unfractionated heparin OR low molecular weight heparin OR low dose unfractionated heparin/low molecular weight heparin + intermittent pneumatic compression devices

Answer 360

C ACOG Committee on Practice Bulletins--Gynecology. ACOG Practice Bulletin No. 84: Prevention of deep vein thrombosis and pulmonary embolism. Obstet Gynecol 2007;110:429-40.

Question 361

According to ACOG and the AUA, a healthy 37 year old woman undergoing a midurethral sling should have the following VTE prophylaxis strategy: A) No strategy, early and aggressive ambulation B) Graduated compression stockings OR intermittent pneumatic compression devices C) Intermittent pneumatic compression devices D) Intermittent pneumatic compression devices and chemoprophylaxis with low molecular weight heparin or low dose unfractionated heparin

Answer 361

A ACOG Committee on Practice Bulletins--Gynecology. ACOG Practice Bulletin No. 84: Prevention of deep vein thrombosis and pulmonary embolism. Obstet Gynecol. 2007;110:429-40. American Urological Association Best Practice Statement for the Prevention of Deep Vein Thrombosis in Patients Undergoing Urologic Surgery. (2008) (Reviewed and validity confirmed 2011.) http://www.auanet.org/content/media/dvt.pdf

Question 362

A 60 year old G3 P3 with 3 prior cesarean sections, exploratory laparotomy for bowel obstruction and history of diverticulitis present for consultation regarding treatment of her stage 4 uterine prolapse. Which of the following statements is most appropriate in the counseling of this patient? A) She has 5% chance of having omental and bowel adhesions, thus the safest approach is laparoscopic or robotic supracervical hysterectomy with sacrocolpopexy using right upper quadrant entry tecnique. B) Long term pessary use is not recommneded due to relatively young age and risk of erosions. C) Expectant management is the safest option D) Colpocliesis has highest success rates for surgical correction, with least morbidity in women willing to forgo future vaginal intercourse. E) Mechanical bowel preparation should be institued if she elects to proceed with surgery due to higher risk of colorectal injury.

Answer 362

D Up to 50% of patients will have omental adhesions after abdominal surgery with 20% bowel adhesions; long tem pessary use is a reasonable option even in young women, expectant management may not be safe with uterine procidentia due to risks of erosions and ureteral obstruction, there is no data to support mechanical bowel preparation (cochrane review) Fanning J, Valea FA. Perioperative bowel management for gynecologic surgery. American journal of obstetrics and gynecology 2011;205:309-14.; Guenaga KF, Matos D, Wille-Jorgensen P. Mechanical bowel preparation for elective colorectal surgery. Cochrane database of systematic reviews 2011:CD001544.

Question 363

For recurrent urinary tract infections all of the following are acceptable except: A) One nightly tablet nightly of any of the following: 1). TMP-SMX, 40 mg and 200 mg or 80 mg and 400 mg, 2). Nitrofurantoin 50-100mg, 3). Cephalexin 125-250 mg, 4). TMX 100mg. B) If predominantly post coital infections then single dose of antimicrobial agent as soon as feasible after intercourse. C) Fosfamycin 3gm once every ten days. D) Twice weekly Ciprofloxacin 250 mg.

Answer 363

D Because UTI's are a benign condition with spontaneously resolution of symptoms observed in 25 to 42% of women, and only rare cases of progression to pyelonephritis, the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases recommended guidelines for treatment give equal weight to the risk of ecologic adverse effects and drug effectiveness. This was done to prevent the development bacterial resistance to antimicrobials that play a role in the treatment of serious infectious diseases, such as pneumonia and serious skin infections. This is a major reason why the use of ciprofloxacin should never be considered first line therapy even for complicated recurrent UTIs unless other agents are not available. Agents such as nitrofurantion, trimethoprim-sulfamethoxazole, cephlahexin, fosfamycin or trimethoprim are all considered first line agents even for complicated recurrent UTIs. Albert X, Huertas I, Pereiro II, et al. Antibiotics for preventing recurrent urinary tract infection in non-pregnant women. Cochrane Database Syst Rev 2004;CD001209. Hooten T, Uncomplicated urinary tract infection. NEJM 2012; 366: 1028-1037

Question 364

Regarding post-operative revisions or removal of synthetic slings, which statement is TRUE? A) Most sling removals overall are done for urethral pain B) Urethral erosions are more common than vaginal erosions C) Most sling removal or revisions are done for either vaginal mesh erosion or urinary retention D

Answer 364

C Nguyen JN, Jakus-Waldman SM, Walter AJ, White T, Menefee SA. Perioperative complications and reoperations after incontinence and prolapse surgeries using prosthetic implants. Obstet Gynecol 2012;119:539-46. Funk MJ, Siddiqui NY, Pate V, Amundsen CL, Wu JM. Sling revision/removal for mesh erosion and urinary retention: long-term risk and predictors. Am J Obstet Gynecol 2012 Oct 5. [Epub ahead of print]

Question 365

The condition of occult stress urinary incontinence implies which of the following: A) A patient is at high risk to ultimately develop stress incontinence later in life B) the development of stress incontinence such as obesity and chronic obstructive lung disease C) A patient who has advanced prolapse that could be kinking or obstructing the urethra may develop incontinence if the prolapse is surgically corrected D) All of the above are true E) None of the above are true

Answer 365

C Nager CW, Tan-Kim J. Pelvic organ prolapse and stress urinary incontinence; combined surgical treatment. UpToDate 2011.

Question 366

All of the following statements regarding rectal sensation are true except: A) Transient relaxations of the internal anal sphincter allow stool or flatus to from the rectum into the upper anal canal where they may come into contact with specialized sensory nerve endings B) Afferent nerves exist in the upper anal canal which specialize in touch, cold, and friction C) Rectal epithelium shows no organized nerve endings D) All of the above are true

Answer 366

D Rao S Diagnosis and Management of Fecal Incontinence. Am J Gastro 2004 Practice Guideline Aug. 1585-1603.

Question 367

Empiric treatment for uncomplicated cystitis is warranted in which of the following cases: A) A 34 year-old healthy woman presents to the office with urinary frequency and dysuria B) A 24 year-old healthy woman presents to the office with urinary frequency and a urine dipstick is positive for pyuria only C) A 46 year-old healthy woman presents to the office with urinary frequency and a urine dipstick is positive for bacteriuria only D) A 22 year-old healthy woman presents to the office with urinary frequency and a urine dipstick is positive for bacteriuria and pyuria E) All of the above

Answer 367

E Fenwick EA, Briggs AH, Hawke CI. Management of urinary tract infection in general practice: a cost-effectiveness analysis.Br J Gen Pract 2000;50(457):635-639.

Question 368

All of the following statements are true regarding accessory evaluation techniques for the initial work up of an uncomplicated patient presenting with bothersome urinary incontinence except: A) Bladder diaries should be used in the initial assessment of women with UI or OAB. B) 3 days is equivalent to 7 days to determine frequency, nocturia, # daily incontinence episodes. C) Pad tests are not recommended in the routine assessment of women with UI. D) Multichannel urodynamics to assess the bladder capacity and type of incontinence are recommended.

Answer 368

D National Institute for Health and Clinical Excellence: Management of Urinary Incontinence in women 2006. http://www.nice.org.uk/nicemedia/live/10996/30281/30281.pdf The role of a bladder dairy is unquestioned as an initial aid to assess frequency of voids, frequency of incontinent episodes and nocturia. A 3 day voiding dairy is equivalent to a 7 day in determining the aforementioned factors. Pad tests can be helpful in determining if a patient is truly incontinent but will not help in the discrimination of the type of incontinence and are not recommended by the NICE guidelines as discriminatory test in the evaluation of incontinence. Multichannel urodynamics have a limited role in the initial evaluation of an uncomplicated patient. Uncomplicated is difficult to define but would include a subject with no prior failed therapy for incontinence, simple stress or urge incontinence symptoms and no voiding complaints. In addition, the uncomplicated patient should have no neurologic or chronic medical conditions that might compromise their bladder function.

Question 369

All of these conditions are relative contraindications to using anti-muscarinics except: A) diabetes B) narrow angle glaucoma C) impaired gastric emptying D) urinary retention

Answer 369

A Gormley EA, Lightner DJ, et al. Diagnosis and Treatment of Overactive Bladder (Non-Neurogenic_ in Adults: AUA/SUFU Guideline. J urol 2012;188:2455-2463.

Question 370

In statistics, a Type II error is best defined as: A) Rejecting the null hypothesis when, in fact, the null hypothesis is true. B) Not rejecting the null hypothesis when, in fact, the null hypothesis is false. C) Accepting the null hypothesis when, in fact, it is false D) Concluding a statistical comparison is statistically significant when the sample size is too small.

Answer 370

B Basic & Clinical Biostatistics, 4th ed. Dawson-Saunders B, Trapp RG, eds. Philadelphia: McGraw-Hill, 2004

Question 371

During voluntary squeeze the anorectal angle goes from a resting angle of ____ degrees to an angle of ____ degrees A) 70, 110 B) 90, 110 C) 90, 70 D) 110, 90 E) 110, 70

Answer 371

C

Question 372

Pelvic floor surgery may impact an elderly patient's functional status and capacity for independent living. Which if the following assessments and interventions have NOT been shown to decrease falls in older adults? A) Assessment social situation and identification of family support for postoperative recovery B) Home visits by therapist or nurse to identify safety concerns and remove tripping hazards C) Assessment of postural hypotension and modification of medications likely to contribute (i.e. antihypertensives) D) Balance and gait assessment with "get up and go" test with occupational therapy referral E) Medication review with identification and modification of those with adverse effects such as sedation

Answer 372

A B through E all have level I evidence supporting decrease fall risk in the elderly. A makes sense, but not supported by the literature. Erekson EA, Ratner ES, Walke LM, Fried TR. Gynecologic surgery in the geriatric patient. Obstetrics and gynecology 2012;119:1262-9.

Question 373

A 47-year-old women presents with complaints of leaking urine. It occurs most commonly with cough and sneeze on a daily basis. It has been happening for several months and she desires treatment. What is her current complaint? A) Mixed incontinence B) Urodynamic stress incontinence C) Genuine stress urinary incontinence D) Stress loss E) Urinary incontinence and stress incontinence

Answer 373

E Haylen BT, de Ridder D, Freeman RM, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Int Urogynecol J 2010; 21:5-26. Urinary incontinence is the complaint of involuntary loss of urine. Stress incontinence is the complaint of involuntary loss of urine on effort or physical exertion.

Question 374

Phenotypic sexual differentiation of the embryo depends on all of the following EXCEPT: A) Presence or absence of Y chromosome. B) Presence or absence of SR-Y protein (testis determining factor) C) Functioning testosterone receptors D) Presence of paramesonephric ducts at 6 weeks

Answer 374

D Carlson BM. Human Embryology and Developmental Biology, 4th Ed. Philadelphia (PA): Mosby, Inc., 2009.

Question 375

40 year old G0 presents with complaint of vaginal bulge, incontinence and dysuria. Urine analysis is negative. The most appropriate next test for evaluation of her complaint is: A) Urodynamic testing B) Voiding cystourethrography C) MRI D) Retrograde positive pressure urethrography E) All of the above

Answer 375

C Image represents suburethral diverticulum. Rcommended imaging for this is MRI. VCUG and PPU are not recommended. http://www.uptodate.com/contents/urethral-diverticulum-in-women

Question 376

Medications that have been associated with an alteration of anal sphincter tone include all of the following EXCEPT: A) Calcium channel blockers B) Nitrates C) β-adrenergic blockers D) Anticholinergic medications E) Botulinum toxin injection

Answer 376

D National Institutes for Health and Clinical Excellence (2007), Clinical Guideline No. 49, NICE, London

Question 377

A 55 year old female presents to your office reporting bothersome loos of liquid and solid stool almost daily. She reports urgency to get to the bathroom which is worse with liquid stool. She wears a pad daily and is embarassed to go to social events due to the "possible need" to have to get to a bathroom. Physical examination reveals a normal digital rectal examination. She requests treatment and you are most likely to recommend: A) Increasing dietary fiber B) Supervised pelvic floor muscle exercises with biofeedback C) Starting loperamide 2-4 mg daily to improve stool consistency D) Referral for screening colonoscopy to rule out bowel malignancy

Answer 377

C Abrams P, Cardozo L , Khoury S, Wein A. Incontinence. Committee 16 Conservative and Pharmacological Management of Faecal Incontinence in Adults. Paris. Health Publication Ltd. 2009. pgs 1321-1386.

Question 378

80 year old female with limited mobility, living in an assisted care facility. She has multiple medical problems including diabetes, hypertension, heart failure and recent history of stroke. She presents with complaints of urinary urgency, frequency, and nocturia. She is not bothered by bulge or pressure and has been told she has prolapse in the past, but declined surgery. On examination she has stage 3 uterine prolapse, urethral hypermobility to 90 degrees, occult stress urinary incontinence and a post void residual of 500 mL with negative UA. Which is the most appropriate next step in her evaluation and treatment? A) Placement of chronic indwelling foley catheter for her incontinence and retention as she is not bothered by her prolapse. B) Placement of a pessary and reassess voiding ability with retrograde fill and post void residual C) Urodynamic testing to assess for occult stress incontinence and intrinsic sphincter dysfunction as well as obstruction. D) Schedule colpocliesis and midurethral sling surgery to reduce likely obstruction from her prolapse and treat her occult stress urinary incontinence

Answer 378

B Chronic indwelling foley catheters are never recommended (AUA guidelines), urodynamics may be necessary if she is medically cleared for surgery but of little utility as a first line approach. Surgery would not be recommended without trial of conservative therapy with a pessary. Should the pessary resolve her retention but she remain incontinent a bulking injection may be less risky.

Question 379

Which bowel agent would be preferred for long-term use in a patient with chronic renal insufficiency and severe constipation? ``` A) magnesium citrate B) magnesium hydroxide C) sodium phosphate and biphosphate D) polyethylene glycol E) bisacodyl ```

Answer 379

D Magnesium citrate, magnesium hydroxide (milk of magnesia), and sodium phosphate and biphosphate (Phospho-soda) should be used with caution in patients with renal impairment because they may cause electrolyte abnormalities. Polyethylene glycol powder (MiraLax) does not cause a net ion gain or loss and thus is safe for patients with renal insufficiency. Bisacodyl (Dulcolax) is a stimulant laxative; long term use may lead to cathartic colon syndrome (dilated and atonic colon) and thus these agents are preferred only for short-term use. Walters and Karram; Urogynecology and Reconstructive Pelvic Surgery, 3rd ed., Chapter 25

Question 380

A 27-year-old female known to a primary care practice calls the nurse with a 2 day history of increasing urinary frequency, urgency, nocturia and dysuria. This followed an act of coitus. Your presumptive diagnosis is an acute urinary tract infection. Which of the flowing is true? A) You can call in a prescription for an antibiotic based on symptoms alone with a high degree of safety and efficacy. B) She should come by your office to have a clean catch dip urinalysis done and it must be positive for any one or all of the following (heme, leuks, nitrites) before initiating antibiotic therapy. C) In order to meet the CDC guidelines for diagnosing a urinary tract infection she must have the above symptoms and a positive urine culture (a positive urine dip does not meet the CDC criteria for a UTI). D) A microscopic urinalysis has very high sensitivity ad specificity for diagnosing a UTI and should always be obtained to confirm the diagnosis. E) The patient possibly has a post coital vulvar lesion/laceration and should be seen and examined before the diagnosis of a urinary tract infection can be made with any degree of certainty.

Answer 380

A Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis 2011; 52:e103-e120. Gupta K, Hooton TM, Roberts PL, Stamm WE. Patient-initiated treatment of uncomplicated recurrent urinary tract infections in young women. Ann Intern Med 2001; 135:9-16.

Question 381

Complications to pessary use include? A) Vaginal discharge B) Vaginal odor C) Vaginal erosions D) Vaginal spotting E) All of the above

Answer 381

E Walters and Karram; Urogynecology and Reconstructive Pelvic Surgery, 3rd ed., Chapter 14

Question 382

Level I evidence supports that new onset stress urinary incontinence occurs more frequently following mesh augmented anterior repair compared to traditional anterior repair without mesh A) TRUE B) FALSE

Answer 382

A Altman D, Vayrynen T, Engh ME, Axelsen S, Falconer C. Anterior colporrhaphy versus transvaginal mesh for pelvic-organ prolapse. The New England journal of medicine. May 12 2011;364(19):1826-1836

Question 383

Which of the following statements regarding sacral neuromodulation are true? A) Staged interstim lead wire trials lead to higher rates of IPG placement than percutaneous nerve evaluation B) Percutaneous nerve evaluation interstim trials requires fluroscopy for optimal placement C) Bilateral tined lead placement during the test phase results in improved success rates over unilateral placement D) Lead migration is the leading cause of failed Percutaneous nerve evaluation testing

Answer 383

A IPG implant rates range from 40-50% for PNE and 70-90% for staged. PNE does not require fluroscopy and there is no conclusive evidence that bilateral tined leads is superior to unilateral. Lead migration from PNE may be one reason for lower implant rates, but it is also only a unipolar node and limited range of programming options. Baxter C, Kim JH. Contrasting the percutaneous nerve evaluation versus staged implantation in sacral neuromodulation. Current urology reports 2010;11:310-4.

Question 384

Level 1 evidence shows the following mesh exposure rates within the first 12 months after anterior vaginal repair with synthetic mesh: A) 3-16% B) 18-25% C) 26-35% D) 36-45% E) 46-50%

Answer 384

A There are 2 RCTs (Level 1 evidence) that specifically address the question of anterior repair with synthetic mesh. In the study by Altman et al, the risk of repeat surgery for mesh erosion was 3.2% at 12 months. In the study by Iglesia et al, the risk was 15.6% by 3 months, and this rate did not change when the same patients were followed for 12 months. A Cochrane review of RCTs published in 2010 shows a 10% (30/293) risk of mesh erosion for anterior repairs with polypropylene mesh. Altman et al. N Engl J Med. 2011 May 12;364(19):1826-36. 2. Iglesia et al. Am J Obstet Gynecol. 2012 Jan;206(1):86.e1-9. 3. Maher et al. Cochrane Database Syst Rev. 2010 Apr 14;(4):CD004014.

Question 385

The prevalence of overactive bladder in women is estimated to be: A) 5% B) 15% C) 40% D) 65%

Answer 385

B Hartman et al. Treatment of Overactive Bladder in Women. Evidence Report/Technology Assessment Number 187. AHRQ Publication No. 09-E017 August 2009.

Question 386

The pudendal nerve is the primary innervation to the anorectum and arises from: ``` A) L5-S2 B) S1-S3 C) S2-S4 D) S3-S5 ```

Answer 386

C continence tICo. Incontinence. 4 ed. Paris, France: EDITIONS21; 2009

Question 387

Each of the following is a true statement regarding fecal diversion for FI except A) It is considered the last resort for therapy B) It is a surgery that is associated with poor quality of life C) It is indicated in patients who are physically or mentally incapacitated D) It is considered a safe and effective operation E) Colostomy is an example of a typical diversion

Answer 387

B In a refractory FI population, fecal diversion is a procedure that can improve QOL in a very difficult population Hayden D and Weiss E. Fecal Incontinence: Etiology, Evaluation, and Treatment. Clin Colon Rectal Surg 2011; 24: 64-70.

Question 388

A woman with multiple sclerosis who had an enterocystoplasty 15 years ago presents to the emergency room after a night of binge drinking complaining of abdominal pain. Which of these following radiologic tests is mandatory? A) pelvic ultrasound B) CT cystogram C) CT with and without contrast D) MRI of the pelvis E) retrograde urethrogram

Answer 388

B The chief concern is rupture of the augmented portion of the bladder. A CT cystogram is the most sensitive, easily obtained diagnostic study. Biers SM, Venn SN, Greenwell TJ. The past, present and future of augmentation cystoplasty. BJUI, 2011, 109, 1280-1293.

Question 389

The urodynamic study that attempts to measure bladder compliance is: A) Pressure flow study B) Filling cystometry C) Pelvic floor electromyography D) Urethral pressure profilometry E) Valsava leak point pressure

Answer 389

B Hashim H, Abrams P. Cystometry. In: Textbook of Female Urology and Urogynecology 3rd Edition, Cardozo L, Staskin D eds. London (UK): Isis Medical Media, Inc., 2010; pp 267-275.

Question 390

Which of the following is false about a Skene's gland cyst or abscess? A) It communicates with the urethra B) The abscess usually distorts the distal urethra and meatus C) Most patients have absent Skene's glands D) All are false E) A and C

Answer 390

E Sandip Vasavada, MD: Evaluation and Management of Suburethral Diverticula in Walters, MD, Karram, M. Elsevier, Urogynecology and Pelvic Floor Dysfunction, 2nd edition, 2006

Question 391

Which of the following statements regarding preprocedure counseling for Botox injections is most accurate? A) Rates of urinary retention may be as high as 90% B) Urinary tract infection is rare C) Side effects of muscle weakness and respiratory depression are rare D) Therapeutic effects typically last from 12 to 14 months

Answer 391

C Retention rates are generally 25% or less, UTIs are common and therapeutic effect is 8-12 months. Sahai A, Dowson C, Khan MS, Dasgupta P. Repeated injections of botulinum toxin-A for idiopathic detrusor overactivity. Urology 2010;75:552-8.

Question 392

Which of the following statements about lower urinary tract infections is correct? A) Approximately 50% are due to E. Coli B) Staphylococcus saprophyticus is the second most common pathogen to E. Coli. C) Proteus is almost always secondary to urinary tract instrumentation such s an indwelling Foley Catheter. D) If Candida albicans is present on a culture result it is always a contaminant from a vulvovaginal yeast infection, as Candida cannot grow in the bladder.

Answer 392

B Staph saprophyticus is the second most common pathogen for lower urinary tract infections. E. Coli is the most common but accounts for 75-90% of infections. Other common pathogens in urinary tract infections include: Klebsiella, Enterobacter, Serratia, Proteus, Pseudomonas, Providencia, and Morganella species. Pseudomonas is almost always secondary to urinary tract instrumentation. Candida albicans and other fungal organisms can cause UTIs in patients with DM, indwelling urinary catheters or in the immunocompromised. Hooten T, Uncomplicated urinary tract infection. NEJM 2012; 366: 1028-1037

Question 393

The origin of the clitoris is: A) The genital tubercle B) The urogenital groove C) The tunica vaginalis D) The distal vaginal plate

Answer 393

A Carlson BM. Human Embryology and Developmental Biology, 4th Ed. Philadelphia (PA): Mosby, Inc., 2009.

Question 394

45 yo G3P2 presents with the complaint of dyspareunia which began sometime after her TVH BSO 5 years ago. She denies hot flashes and is not on HRT. She does not complain of vaginal dryness. Pelvic exam is unremarkable without signs of atrophy. The next step should be. A) Pelvic floor physical therapy B) Trial of vaginal lubricants C) Trial of vaginal estrogen cream D) Referral to psychiatry

Answer 394

B Tan O, Bradshaw K, Carr B. Management of vulvovaginal atrophy-related sexual dysfunction in postmenopausal women: an up-to-date review. Menopause 2012;19:109-17.

Question 395

All of the following are characteristics of a cohort study except: A) They are the best way to determine incidence and natural history of a disorder B) It allows calculation of Relative Risk (RR) C) It can be performed prospectively, retrospectively or ambidirectionally D) They are subject to incidence-prevalence bias (Neyman bias) E) Selection bias is avoided

Answer 395

E Grimes DA, Schulz KF. Cohort studies: marching towards outcomes. Lancet 2002; 359:341-45.

Question 396

When considering the use of anti-muscarinic agents, all of the following are true, EXCEPT: A) Anti-muscarinics should be used with caution in patients taking solid oral forms of potassium chloride. B) Anti-muscarinics should be used with caution in patients taking oral psyllium C) Anti-muscarinics should be used with caution in patients taking oral benztropine D) Anti-muscarinics should be used with caution inpatients using ipratropium inhalers

Answer 396

B

Question 397

Which of the following is true about the reduction cough stress test? A) It is highly sensitive and specific in identifying who will develop post prolapse surgery stress incontinence. B) It is commonly only done on subjects with pelvic organ prolapse who do not have complaints of urinary incontinence. C) It has the best predictive value if done with a pessary. D) It is commonly done on subjects with pelvic organ prolapse who complain of urinary incontinence. E) It is done by having the patient cough with a symptomatically full bladder.

Answer 397

B Wei JT, Nygaard I, Richter HE, et al. Midurethral sling to reduce incontinence after vaginal prolapse repair. N Engl J Med 2012; 366:2358-67.. Brubaker L, Cundiff GW, Fine P, et al. Abdominal sacrocolpopexy with Burch to reduce urinary stress incontinence. NEJM 2006; 354:1557-66. In both of these trials the reduction cough stress test was defined and its role in predicting who would and who would not develop post operative stress urinary incontinence has been questioned.

Question 398

A 60 year-old woman with a history of microscopic hematuria is scheduled to undergo diagnostic cystoscopy as part of her evaluation. Antibiotic prophylaxis is not recommended if: A) The patient takes chronic corticosteroid use. B) The patient has an active UTI. C) The patient has mitral valve prolapse. D) The patient is a smoker. E) Antibiotic prophylaxis is never indicated in this situation.

Answer 398

C Simple cystoscopy and urodynamics procedures generally do not require antibiotic prophylaxis; however prophylaxis should be considered in the presence of clinical risk factors for infection. Risk factors include advanced age, urinary tract anomalies, poor nutritional status, smoking, chronic corticosteroid use, immunodeficiency, external catheters, colonized endogenous/exogenous material, distant coexistent infection, prolonged hospitalization. An active UTI should be treated with therapeutic antibiotics. Wolf JS, Jr., Bennett CJ, Dmochowski RR, et al. Best practice policy statement on urologic surgery antimicrobial prophylaxis. J Urol. 2008;179:1379-1390.

Question 399

A 34-year old primipara whose delivery was complicated by a third-degree perineal laceration, subsequently underwent a layered-closure type surgical repair of a rectovaginal fistula by another surgeon in a different subspecialty. She is dissatisfied with the outcome of the reparative procedure when she presents to you for further evaluation. The most likely cause of her dissatisfaction is: A) Recurrence of the fistula B) Vulvar asymmetry C) Failure of the procedure to correct her anal incontinence D) Frustration with the obstetrical events leading up to her perineal injury

Answer 399

C Tsang CBS, Madoff RD, Wong WD, Anal Sphincter Integrity and Function Influences Outcome in Rectovaginal Fistula Repair. Dis Colon Rectum 1998; 41: 1141-1146.

Question 400

The best test for multi-planar imaging of a suspect urethral diverticulum is? A) Voiding cystourethrogram B) Positive Pressure Urethrography (PPUG) C) Transvaginal ultrasonography D) MRI (magnetic resonance imaging) E) CT scan

Answer 400

D The best test for multi-planar imaging of a suspect urethral diverticulum is? A) Voiding cystourethrogram B) Positive Pressure Urethrography (PPUG) C) Transvaginal ultrasonography D) MRI (magnetic resonance imaging) E) CT scan

Question 401

Select the most accurate statement regarding prevention of recurrent urinary tract infection in non-pregnant women. A) Continous antibiotic prophylaxis for 6-12 months DOES NOT reduce the rate of UTI during prophylaxis compared to placebo B) Continous antibiotic prophylaxis for 6-12 months reduces the rate of UTI during prophylaxis compared to placebo C) Continuous daily cranberry juice intake for 6-12 months reduces the rate of UTI D) Continuous daily cranberry powder intake for 6-12 months reduces the rate of UTI

Answer 401

B Although evidence that cranberry juice may decrease the number of symptomatic UTIs over a 12 month period previously existed for women with recurrent UTIs, the addition of 14 further studies in the most recent Cochrane review suggests cranberry juice is less effective than previously indicated. Some small studies demonstrated a small benefit for women with recurrent UTIs, but no statistically significant differences existed when the results of a much larger study were included. Given the large number of dropouts/withdrawals from studies (mainly attributed to the acceptability of consuming cranberry products, particularly juice, over long periods), and the evidence that the benefit for preventing UTI is small, cranberry juice is not currently recommended by the Cochrane reviewers for prevention of UTIs. Powders need further study with standardized methods to ensure the potency before being evaluated in clinical studies or recommended for use. The most recent Cochrane review of antibiotic prophylaxis for recurrent UTI, demonstrated that continuous antibiotic prophylaxis for 6-12 months reduced the rate of UTI during prophylaxis when compared to placebo. Jepson RG, Williams G, Craig JC. Cranberries for preventing urinary tract infections. Cochrane Database Syst Rev 2012;10:CD001321. Albert X, Huertas I, Pereiro, II, Sanfelix J, Gosalbes V, Perrota C. Antibiotics for preventing recurrent urinary tract infection in non-pregnant women. Cochrane Database Syst Rev 2004:CD001209

Question 402

List the following pathogens in order of most common to least common cause of UTI in healthy, sexually active women. (1) Staphlococcus saprophyticus, (2) Escherichia coli, (3) Candida species, (4) Proteus mirabilis. A) 2, 3, 1, 4 B) 2, 1, 4, 3 C) 1, 2, 4, 3 D) 3, 2, 1, 4

Answer 402

B Escherichia coli causes approximately 80 -85% of UTIs in healthy, sexually active women. Staphylococcus saprophyticus is the next most common cause. Other bacteria, including proteus mirabilis is more commonly implicated in complicated UTIs. Fungi, most commonly Candida species may cause UTI is patients with concurrent morbidity such as DM, chronic urinary catheterization, renal transplant and immunocompromised status. Heisler CA, Gebhart JB. Urinary Tract Infection in the Adult Female. Pathophysiology, Evaluation and Treatment. J Pelvic Med Surg 2008;14:1-14.

Question 403

Your 62 year old patient complains of parathesias over the mons and labia majora on post-operative day #1 after an attempted laparoscopic sacrocolpopexy that was converted to open sacrocolpopexy for dense abdominal adhesions. Which nerve is most likely to have been injured? A) Lateral femoral cutaneous B) Sciatic C) Pudendal D) Genitofemoral E) Obturator

Answer 403

D Clarke-Pearson and Geller, Obstet Gynecol 2013:121:654-73

Question 404

A common side effect from diphenoxylate hydrochloride (lomotil) for the treatment of FI may be A) Joint pain B) Hematuria C) Dizziness D) Muscle pain

Answer 404

C Wright J, Gebrich A, Albright T. The Management of Anal Incontinence. JPMRS 2006; 12 (3)

Question 405

The best management for a cancer within a urethral diverticulum is? A) Excision and observation B) No definitive recommendation can be made and each case and must be individualized C) Radical excision and postoperative radiation therapy D) Excision followed by platinum based chemotherapy E) Radical cystourethrectomy and urinary diversion

Answer 405

B Thomas, AA et al. J Urol. 2008 Dec;180(6):2463-7

Question 406

The following are common postoperative complications in older women EXCEPT: A) Delirium B) Falls C) Bowel perforation D) Electrolyte imbalances E) Surgical site infections

Answer 406

C Erekson EA, Ratner ES, Walke LM, Fried TR. Gynecologic surgery in the geriatric patient. Obstet Gynecol 2012;119:1262-9.

Question 407

The urine dip stick is the most common office test for urinary tract infection (UTI). It is most accurate for detecting a UTI when the presence of either nitrite or leukocyte esterace is considered a positive result, with a sensitivity of 75% and a specificity of 85%. The specificity of a diagnostic test is defined as: A) The likelihood that a person with the disease will be correctly identified B) The likelihood that a person without the disease will be correctly identified C) The likelihood that a person with a positive test has the disease D) The likelihood that a person with a negative test does not have the disease

Answer 407

B Gala R, Hamilton-Boyles S, Sung VW. SGS Research Handbook - 2nd edition. Fem Pelvic Med Reconst Surg 2011; 17:158-173

Question 408

All of the following are clinical predictors of increased perioperative cardiovascular risk (myocardial infarction, heart failure, death) EXCEPT: A) Ischemic heart disease B) Congestive heart failure C) Cerebrovascular disease D) Insulin-dependent diabetes E) Wheel-chair dependence F) Serum Creatinine >2.0 mg/dL

Answer 408

E Eagle KA, Berger PB, Calkins H, Chaitman BR, Ewy GA, Fleischmann KE, et al. ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery---executive summary a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Circulation 2002; 105:1257-67.

Question 409

Biologic or artificial grafts add which of the following attributes to the surgical outcomes of posterior colporrhaphy compared to non-graft repairs? A) Cost B) Improved durability C) Improved functional outcomes D) Worse short-term and long-term morbidities E) More than one of the above

Answer 409

A Paraiso MF, Barber MD, Muir TW, Walters MD. Rectocele repair: a randomized trial of three surgical techniques including graft augmentation. Am J Obstet Gynecol 2006; 195:1762-71.

Question 410

Which of the following statements is true regarding abdominal sacral colpopexy: A) Vaginal Mesh erosion is estimated to occur in 12-15 % of cases. B) There are now multiple Level 1 studies that have compared an open to robotic approach noting no significant difference. C) There is Level 1 evidence noting less pain with RSC when compared to LSC. D) There is Level 1 evidence that laparoscopic sacral colpopexy provides superior outcomes to transvaginal mesh repair for women with Stage 2-4 vaginal vault prolapse. E) All the above are correct

Answer 410

C Maher et al; Am J Obstet gynecol; 204(4); 360 e361-367

Question 411

Proper fitting of a ring pessary is BEST described by the following statement. A) The ring pessary rests in the between the anterior and posterior vaginal fornix B) The ring pessary rests in the posterior fornix and against the posterior aspect of the pubic symphysis C) The ring pessary rests in the anterior fornix and against the posterior vaginal wall D) The ring pessary functions by occupying a spacer large than the genital hiatus

Answer 411

B Cundiff GW and Addison WA. Obstet Gynecol Clin North Am. 1998;25:907, 921, viii.

Question 412

In the one randomized controlled trial that exists comparing outcomes between conventional laparoscopic and the robot-assisted laparoscopic sacral colpopexy, it was found that robotic-assisted surgery was associated with: A) reduce operating times B) reduced costs C) increased post-operative pain D) increased mesh erosion E) reduced rates of recurrence

Answer 412

C Paraiso MF, Jelovsek JE, Frick A, Chen CC, Barber MD. Laparoscopic compared with robotic sacrocolpopexy for vaginal prolapse: a randomized controlled trial. Obstet Gynecol 2011; 118:1005-13.

Question 413

Bowel symptoms commonly associated with the presence of a rectocele includes all of the following except: A) Splinting the perineum to defecate B) Feeling of incomplete evacuation C) Hard, infrequent stools D) Hard straining

Answer 413

C Gustilo-Ashby AM, Paraiso MFR, Jelovsek JE, Walters MD, Barber MD. Bowel symptoms one year after surgery for prolapse: further analysis of a randomized trial of rectocele repair. Am J Obstet Gynecol 2007; 197:76-8.

Question 414

You are called for an intraoperative consultation for a cystotomy during an abdominal hysterectomy that involves the posterior dome of the bladder and extends inferiorly towards the trigone. All of the following are important considerationsregarind approach to surgical repair EXCEPT: A) Whether the cystotomy was created during sharp dissection or electrosurgery B) The proximity of the ureteral orifices to the cystotomy C) Whether the repair is water tight after the first layer closure D) The patient's baseline creatinine level E) Evaluation of bilateral ureteral spill

Answer 414

D

Question 415

Which of the following surgical procedures DOES NOT contribute support to the anterior vaginal wall? A) Paravaginal defect repair B) Abdominal sacral colpopexy C) Uterosacral ligament suspension D) Halban's procedure

Answer 415

D The paravaginal defect repair re-establishes lateral support of the vagina, and in doing so, contributes support to the anterior vaginal wall. Apical surgeries for prolapse contribute some support to the anterior vaginal wall since anterior and apical prolapse are linked. Thus, both the abdominal sacral colpopexy and uterosacral ligament suspensions contribute to anterior vaginal wall support. The Halban's procedure is one where the posterior cul-de-sac is obliterated by placing permanent sutures from the posterior vagina, proceeding longitudinally over the cul-de-sac peritoneum, and then over the inferior sigmoid serosa. This procedure aims to obliterate the posterior cul-de-sac, and does not contribute to anterior vaginal wall support. Walters and Karram; Urogynecology and Reconstructive Pelvic Surgery, 3rd ed., Chapter 17; 2. Rooney et al. Am J Obstet Gynecol. 2006 Dec;195(6):1837-40. Next

Question 416

Which of the following is a true statement regarding vesicovaginal fistula (VVF) is: A) In developed countries, the incidence of VVF is highest after radiation treatment for gynecologic cancers. B) Risk factors that potentially impact wound healing include smoking and diabetes mellitus. C) Vaginal hysterectomy has a higher incidence of VVF than laparoscopic hysterectomy. D) The reported incidence after hysterectomy is 1 in 2,300 surgeries.

Answer 416

B Karram MM. Lower urinary tract fistulas. In: Walters MD and Karram MM, eds. Urogynecology and Reconstructive Pelvic Surgery. 3rd ed. Philadelphia, Pa: Mosby Inc; 2007: 445-460.

Question 417

A 72 year old female reports that she has the sense that she does not completely empty her bladder and her stream starts and stops several times during a void and her stream is significantly slower since she underwent a TOT midurethral sling 7 months ago? Her symptoms are best described as: A) Hesitancy, Urinary retention, Voiding abnormality B) Slow stream, Intermittency, Feeling of incomplete (bladder) emptying C) Dysuria, Spraying, Position-dependent micturition D) Reduced bladder sensation, Intermittency, straining to void

Answer 417

B Haylen et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunctionInt Urogynecol J 2010; 21:5-26. The patient reports the following symptoms as defined by the IUGA/ICS standardization of terminology report: Slow stream: complaint of a urinary stream perceived as slower compared to previous performance or in comparison with others. Intermittency: complaint of urine flow that stops and starts on one or more occasions during voiding. Feeling of incomplete (bladder) emptying: complaint that the bladder does not feel empty after micturition. She does not report the following: Hesitancy: complaint of a delay in initiating micturition. Urinary Retention: complaint of the inability to pass urine despite persistent effort. Voiding abnormality: describes a set of symptoms and not a specific symptom Dysuria: complaint of burning or other discomfort during micturition. Discomfort may be intrinsic to the lower urinary tract or external (vulvar dysuria). Spraying (splitting) of urinary stream: complaint that the urine passage is a spray or split rather than a single discrete stream. Position-dependent micturition: complaint of having to take specific positions to be able to micturate spontaneously or to improve bladder emptying, e.g., leaning forwards or backwards on the toilet seat or voiding in the semi-standing position. Reduced bladder sensation: complaint that the definite desire to void occurs later to that previously experienced despite an awareness that the bladder is filling. Straining to void: complaint of the need to make an intensive effort (by abdominal straining, Valsalva, or suprapubic pressure) to either initiate, maintain, or improve the urinary stream. The patient does describe intermittency (complaint of urine flow that stops and starts on one or more occasions during voiding) but the other two symptoms in this answer are incorrect.

Question 418

All of the following statements about use of transvaginal mesh or graft for treatment of anterior vaginal prolapse is true except: A) Placement of absorbable polyglactin mesh improves anatomic outcomes compared with anterior colporrhaphy alone B) Placement of biologic graft results in improved subjective outcomes compared with anterior colporrhaphy alone C) Placement of polypropylene mesh is associated with improved anatomic outcomes compared with anterior colporrhaphy alone D) Placement of polypropylene mesh is not associated with improvements in quality of life or decreased reoperations for pelvic organ prolapse compared with anterior colporrhaphy alone.

Answer 418

B Maher CM, Feiner B, Baessler K, et al. Surgical management of pelvic organ prolapse in women: the updated summary version Cochrane review. Int Urogynecol J 2011; 22:1445-57.

Question 419

Which is an acceptable treatment for Painful Bladder Syndrome? A) Long term antibiotics B) Intravesical lidocaine C) Intravesical resiniferatoxin D) Systemic oral glucocorticoids E) Intravesical BCG

Answer 419

B Hanno PM, Burks DA, Clemens JQ, Dmochowski RR, Erickson D, et al. AUA guideline for the diagnosis and treatment of interstitial cystitis/bladder pain syndrome. J Urol 2011; 185:2162-70.

Question 420

Which of the following statements regarding transvaginal uterosacral ligament suspension is most accurate? A) If prolapse recurs, it is more likely to recur in the anterior vaginal wall than the apex B) If prolapse recurs, it is more likely to recur in the apex than the anterior vaginal wall C) If prolapse recurs, it is more likely to recur in women with preoperative Stage 2 prolapse compared to those with preoperative Stage 3 prolapse D) If prolapse recurs, it is more likely to recur in the apex than the posterior vaginal wall

Answer 420

A In a systematic review and meta-analysis of transvaginal uterosacral ligament suspension, in the anterior, apical, and posterior compartments, the pooled rates for a successful outcome were 81.2% (95% CI, 67.5-94.5%), 98.3% (95% CI, 95.7-100%), and 87.4% (95% CI, 67.5-94.5%). In the anterior compartment, women with preoperative stage 2 prolapse were more likely than those with preoperative stage 3 prolapse to have a successful anatomic outcome (92.4% vs 66.8%; P = .06). Thus prolapse is more likely to recur in the anterior vaginal wall compared to the apex. The apex is least likely to recur and thus statements B and D are least correct. Of the options listed, A is the most accurate choice. Margulies et al; Am J Obstet Gynecol. 2010 Feb;202(2):124-34 Next

Question 421

What is the correct definition of Bias? A) Random error B) Confounding C) Systematic error D) Cause-effect

Answer 421

C Newman TB, Browner WS, and Hulley SB (2007). Enhancing Causal Inference in Observational Studies in S.B. Hulley, S.R. Cummings,W.S. Browner, D. G. Grady, T.B. Newman (Eds.), Designing Clinical Research (pp.127-143). Philadelphia, PA: Lippincott, Williams & Wilkins.

Question 422

Recommended surgeries for neurogenic fecal incontinence include each of the following except A) Antegrade Continence Enema (ACE) B) Graciloplasty C) Artifical sphincter D) Neuromodulation E) Rectal Slings

Answer 422

E Rectal slings are not considered a recommended surgery at this time Abrams P, Andersson K, Birder L et al. Fourth International Consultation on Incontinence Recommendations of the International Scientific Committee: Evaluation and Treatment of UI, POP and FI. Neurourology and Urodynamics 2010; 29: 213-240.

Question 423

Which of the following is NOT one of the principles of surgical correction of rectovaginal fistula repair? A) Watertight seal of rectal mucosa and vaginal epithelium B) Interpose a layer of fresh, vascularized tissue C) Tension-free closure of all tissue layers D) Interrupt the continuity of the fistula tract

Answer 423

A Nichols DH, Repair of Rectal Fistula and of Old Complete Perineal Laceration. In: Nichols DH and Clarke-Pearson DL, editors. Gynecologic, Obstetric, and Related Surgery, 2nd ed. Mosby, Inc, St. Louis (MO). 2000. P. 518-547.

Question 424

A 29 year-old patient with interstitial cystitis/painful bladder syndrome is in your office for a follow-up. She has tried dietary and behavioral modifications along with ibuprofen, phenazopyridine, and pentosan polysulfate. She has had some relief of her urgency and frequency but only minimal relief of her pain. She describes rare mild urinary incontinence and this is associated with exercise, but is not common or bothersome. You repeat a pelvic exam and there are no masses, no prolapse noted. On digital vaginal exam she has a tender contracted band posteriorly noted on the right and left. Palpation of this band reproduces her pain. You prompt her to perform a pelvic floor contraction and she has difficulty with coordination. What is the best next therapy? A) Pelvic floor physical therapy with pelvic floor strengthening exercises B) Pelvic floor physical therapy with pelvic floor relaxation techniques C) Tolterodine D) Cimetidine E) Bladder instillations

Answer 424

B This patient has evidence of levator spasm on exam and pelvic floor relaxation is the best treatment option. Pelvic floor strengthening could make the pain worse. Hanno PM, Burks DA, Clemens JQ, et al. AUA guideline for the diagnosis and treatment of interstitial cystitis/bladder pain syndrome. J Urol. 2011;185:2162-2170

Question 425

Which of the following is a component of normal apical vaginal support (DeLancey level 1)? A) endopelvic fascia B) sacrotuberous ligament C) arcus tendineus fascia pelvis D) perineal membrane E) cardinal ligament

Answer 425

E Items A and C are involved in Level 2 support, D is involved in Level 3 support, B is not involved in vaginal support Corton, M. Anatomy of pelvic floor dysfunction, Obstet Gynecol Clin N Amer, 2009, 36, 401-419.

Question 426

The characteristic of a questionnaire that assesses how well it measures what it is intended to measure it best described as? A) Responsiveness B) Validity C) Reproducibility D) Reliability

Answer 426

B The characteristic of a questionnaire that assesses how well it measures what it is intended to measure it best described as? A) Responsiveness B) Validity C) Reproducibility D) Reliability

Question 427

Which of the following is statistically significant with a p value of

Answer 427

B Basic & Clinical Biostatistics, 4th ed. Dawson-Saunders B, Trapp RG, eds. Philadelphia: McGraw-Hill, 2004

Question 428

Which of the following procedures requires entrance into the peritoneal cavity: A) Uterosacral Colpopexy B) Sacrospinous Colpopexy C) McCall Culdoplasty D) Illiococcygeus Suspension E) Manchester Procedure F) C and E

Answer 428

F Margulies et al; AJOG 2010 202(2): 124-134 Webb et al; Obstet Gynecol;1998; 92;281-5

Question 429

Management of large urethral diverticulectomy should include: A) Intraoperative cystoscopy with ureteral assessment B) Foley catheter, but not usually suprapubic catheter C) A and B D) Suprapubic catheter, but not foley catheter E) A and D

Answer 429

C Scarpero HM, Urol Clin North Am 2011 Feb 38(1) 65-71

Question 430

Investigators performed a randomized trial to compare the efficacy of two different drugs for overactive bladder (Drug A and Drug B) to placebo. 300 patients with overactive bladder were randomized to one of three groups: Drug A, Drug B or Placebo for 12 weeks. The primary outcome of the study was the average number of urge incontinence episodes per day on a 7-day bladder diary after 12 weeks of therapy. At 12 weeks, the number of urge incontinence episodes per day in each group was: Drug A 2.3 + 4.0; Drug B 3.4 + 3.2; Placebo 4.4 + 4.0; p

Answer 430

B Basic & Clinical Biostatistics, 4th ed. Dawson-Saunders B, Trapp RG, eds. Philadelphia: McGraw-Hill, 2004.

Question 431

A patient is undergoing an abdominal surgery complicated by a ureteral injury. You note that the distance from the bladder to the injury site is 15cm. Which of the following is the most likely the surgical approach that would be performed? A) Psoas hitch B) Boari Flap C) Ureteroneocystostomy D) Ureteroureterostomy

Answer 431

B

Question 432

A 80 year old women presents to your clinic for pessary fitting for stage III apical prolapse. Based on the current available evidence, which pessary has the highest rate of successful placement? A) Ring with support pessary B) Gellhorn pessary C) Donut pessary D) Cube pessary E) None of the above

Answer 432

A Clemons JL et al. Am J Obstet Gynecol. 2004;190(2):345-50

Question 433

Which aspects of vaginal delivery do not place patients at an increased risk of future fecal incontinence A) Forceps-assisted delivery B) Induced labor C) Primiparity D) Protracted labor

Answer 433

B Hayden DM, Weiss EG. Fecal incontinence: etiology, evaluation, and treatment. Clinics in colon and rectal surgery. Mar 2011;24(1):64-70

Question 434

A 19 year old female with myelomeningocele complains of urinary incontinence despite performing intermittent catheterization every 6 hours. The best next step is? A) Increase frequency of catheterization to q 4hours B) Perform renal sonogram and urodynamics C) Decrease frequency of catheterization to reduce her infections D) Perform a pubovaginal sling with autologous fascia

Answer 434

B Bauer SB. Neurogenic Bladder: Etiology and Assessment. Pediatr Nephrol 2008; 23:541-51.

Question 435

Women with cognitive impairment may have limited options for management of incontinence. Prompted voiding is one conservative technique that has been shown to be effective. Which of the following best describes this technique? A) Timed voiding with endurance and muscle strengthening exercises done at the time of toileting B) Monitoring by caregivers for patient desire to void or leakage, reminders to patient to toilet on a scheduled basis and positive feedback when patient remains continence and attempts to void. C) Setting alarm clock to remind patient to void on specified interval and increasing that interval by 15 min every day. D) Caregiver reminding patient to void on a set interval based on bladder diary or standard interval of every two to 3 hours.

Answer 435

B A is called Functional Incidental Training, B is correct, C & D is called "habit trainig" or scheduled voiding.

Question 436

Which of the following statements are true regarding the diagnoses of overactive bladder? A) Urodynamics should be performed at initial consultation B) Bladder ultrasound is part of the initial work-up C) Cystoscopy should be performed D) Urinalysis should be performed

Answer 436

D Gormley EA, Lightner DJ, et al. Diagnosis and Treatment of Overactive Bladder (Non-Neurogenic_ in Adults: AUA/SUFU Guideline. J urol 2012;188:2455-2463.

Question 437

According to the 2012 American Urologic Association Guidelines for evaluation of asymptomatic, microscopic hematuria, which of the following is acceptable alternative for detailed evaluation of the upper urinary collecting system for patients with relative or absolute contraindications to multiphasic computed tomography urography? A) Magnetic resonance urography with contrast B) Magnetic imaging with retrograde pyelograms C) Non-contrast CT D) Renal ultrasound with retrograde pyelograms

Answer 437

B According to the 2012 American Urologic Association Guidelines for evaluation of asymptomatic, microscopic hematuria, which of the following is acceptable alternative for detailed evaluation of the upper urinary collecting system for patients with relative or absolute contraindications to multiphasic computed tomography urography? A) Magnetic resonance urography with contrast B) Magnetic imaging with retrograde pyelograms C) Non-contrast CT D) Renal ultrasound with retrograde pyelograms

Question 438

A 79 year old women presents to your clinic for pessary fitting for stage IV apical prolapse. Based on the current available evidence, which pessary has the highest rate of successful placement for this patient? A) Ring pessary B) Gellhorn pessary C) Donut pessary D) Cube pessary E) None of the above

Answer 438

B Clemons JL et al. Am J Obstet Gynecol. 2004;190(2):345-50

Question 439

Normal clitoral sensation is dependent on which of the following? A) pudendal nerve B) hypogastric nerve C) cavernosal nerve D) genitofemoral nerve E) perineal nerve

Answer 439

A The dorsal genital/clitoral nerve is derived from the pudendal nerve Ginger VAT, Yang C. Functional anatomy of the female sex organs. Cancer and Sexual Health, Current Clin Urology, 2011, 13-23

Question 440

Which of the following conditions is associated with the lowest chance of success in the treatment of behavioral therapy with timed voiding? A) Age >65 B) Diabetes C) Cardiac disease D) Dementia E) > 3 urgency urinary incontinence episodes per day

Answer 440

D Behavioral therapy and in particular timed voiding requires that the patient is cognitively intact, is able to appreciate her urge to void, have the ability to record voiding times, and increase her voiding interval. Davila GW, Guerette N. Current treatment options for female urinary incontinence--a review. Int J Fertil Womens Med 2004;49:102-12.

Question 441

In which situation might one perform an iliococcygeus suspension? A) If the surgeon is planning to perform a sacrospinous ligament fixation but happens to enter the peritoneal cavity B) In women having a transvaginal colpopexy where the vagina is not long enough to reach the sacrospinous ligament. C) In young, sexually active women, who wish for a native tissue apical repair D) Instead of a sacrospinous ligament fixation, if a more durable repair is desired.

Answer 441

B An iliococcygeus repair is one where the vagina is affixed to the fascia of the iliococcygeus muscle, just below (caudad) to the ischial spine. This procedure is useful in women with a shortened vaginal length where the vagina may not reach the sacrospinous ligament. It is an extraperitoneal procedure and thus would not necessarily be performed upon entry into the peritoneal cavity. It does not achieve as much vaginal length as SSLF or USLS and thus may be less ideal for sexually active women who want to preserve vaginal length. It is not shown to necessarily be more durable than any other native tissue vaginal repairs. In addition to instances where the vagina is foreshortened, this technique may also be applied if the posterior apex needs additional support during a rectocele repair. Walters & Ridgeway; Obstet Gynecol 2013; 121 (2)

Question 442

Which of the following is a major predictor of perioperative cardiac events according to the ACC/AHA? A) Diabetes mellitus B) History of cerebrovascular disease C) Renal insufficiency (Cr > 2.0) D) Cardiac arrythmia E) All of the above

Answer 442

D Major predictors of cardiac events include unstable coronary syndrome(recent MI, unstable angina), heart failure class IV, arrhythmias, severe heart valve disease (mitral or aortic stenosis). Diabetes, renal insufficiency, cerebrovascular disease, prior MI, mild angina are considered intermediate risk factors. Uptodate: http://www.uptodate.com/contents/estimation-of-cardiac-risk-prior-to-noncardiac-surgery Next

Question 443

Which of the following procedures is associated with lowest median cure/dry rate for stress incontinence at 12-23 months? A) Open retropubic urethropexy B) Laparoscopic retropubic urethropexy C) Cadaveric sling D) Autologous fascia sling E) Synthetic mid urethral sling

Answer 443

C AUA Guidelines, Appendix A18 - Outcome Graphs

Question 444

All of the treatments for overactive bladder are first line therapy in the treatment except: A) behavioral therapy B) anti-cholinergics C) pelvic floor muscle training D) bladder control strategies

Answer 444

B Gormley EA, Lightner DJ, et al. Diagnosis and Treatment of Overactive Bladder (Non-Neurogenic_ in Adults: AUA/SUFU Guideline. J urol 2012;188:2455-2463.

Question 445

A 48 year old female presents for urodynamics for evaluation of female stress incontinence. During the uroflowmetry, she is unable to void. A post void residual is checked and is found to be 110mL. Which of the following conclusions would be the most accurate? A) The patient is nervous and likely the cause of her inability to void B) The patient has a voiding dysfunction and should be addressed prior to evaluation of her incontinence C) The patient recently voided and therefore was unable to void during the uroflowmetry D) The patient should be taught intermittent self-catheterization and record both her voided volumes and residual volumes for 3 days to confirm normal voiding prior to further evaluation or treatment of her stress incontinence.

Answer 445

C

Question 446

Which of the following statements about uncomplicated lower urinary tract infections in young women is correct? A) Because simple acute UTIs are a benign condition the recommended guidelines for treatment give equal weight to the risk of ecologic adverse effects (developing bacterial resistence) and drug effectiveness. B) They always require therapy because they do not resolve spontaneously and will lead to upper tract disease. C) They are the result of enterobactericae that have an altered virulence and therefore require aggressive therapy to completely clear these altered bacteria from the host. D) Therapy with Ciprofloxacin should be considered first line as this antimicrobial has demonstrated consistent efficacy against common pathogens and there is almost no chance of bacteria developing resistance.

Answer 446

A Because simple acute UTI's are a benign condition with spontaneously resolution of symptoms observed in 25 to 42% of women, and only rare cases of progression to pyelonephritis, the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases recommended guidelines for treatment give equal weight to the risk of ecologic adverse effects and drug effectiveness. This was done to prevent the development bacterial resistance to antimicrobials that play a role in the treatment of serious infectious diseases, such as pneumonia and serious skin infections. This is a major reason why the use of ciprofloxacin should never be considered first line therapy for either uncomplicated acute infections or complicated recurrent UTIs unless other agents are not available. Simple acute UTIs may be the result of periurethral colonization by bacteria with altered virulence but even in these circumstances the patient can spontaneously resolve the infection and therefore aggressive antimicrobial therapy is not warranted. Hooten T, Uncomplicated urinary tract infection. NEJM 2012; 366: 1028-1037 Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis 2011;52(5):e103-e120

Question 447

Which investigative study can demonstrate urethral diverticula and does not involve radiation exposure? A) Voiding cystourethrogram B) Micturition study during UDS C) T2-weighted MRI without gadolinium D) Double balloon urethrogram

Answer 447

C Only the MRI does not require radiation. The micturition study can only show a diverticulum if fluroscopy is used. Foley CL, BJUI 2001, 108: Supplement 2, 20-23

Question 448

Which statement about methenamine salts and their use in urinary tract infections is NOT true? A) Methenamine hippurate may be effective in preventing UTI in patients with normal urinary tract anatomy B) Methenamine salts produce formaldehyde which acts as a bacteriostatic agent C) Methenamine salts are well tolerated and adverse effects are generally mild D) Methenamine hippurate is most effective in spinal cord injured patients with neuropathic bladder in preventing UTI

Answer 448

D A 2012 Cochrane review on the use of methenamine hippurate for the prevention of UTI, demonstrated methenamine hippurate may be effective for preventing UTI in patients without renal tract abnormalities, particularly when used for short-term prophylaxis. It does not appear to work in patients with neuropathic bladder or in patients who have renal tract abnormalities. Methenamine salts are well tolerated and adverse effects, including minor gastrointestinal upsets, dysuria, abdominal cramps, anorexia, rash and stomatitis are generally mild. Lee BS, Bhuta T, Simpson JM, Craig JC. Methenamine hippurate for preventing urinary tract infections. Cochrane Database Syst Rev 2012;10:CD003265.

Question 449

45 year old with neurogenic bladder due to multiple sclerosis presents with complaints of urge urinary incontinence. She has normal post void residual and no evidence of detrusor sphincter dysenergia on urodynamic testing. Which treatment is FDA approved for treatment of her incontinence? A) Botulinum toxin A 100 units with repeat injection if insufficient response in 2 weeks B) Neuromodulation with Interstim stage 1 trial and implantation of IPG if successful C) Percutaneous tibial nerve stimulation D) Botulinum toxin A 200 units E) All of the above

Answer 449

D Botox 200 unitis is only option of these choices that is FDA approved for neurogenic bladder.

Question 450

According to the IUGA/ICS joint terminology and classification system of complications related to prosthese and grafts used in female pelvic floor surgery, if a patient has an abscess they are division A) A B) B C) C D) D

Answer 450

D Haylen BT, Maher C, Deprest J. IUGA/ICS terminology and classification of complications of prosthesis and graft insertion--rereading will revalidate. American journal of obstetrics and gynecology. Jan 2013;208(1):e15.

Question 451

In a 72-year-old post menopausal women which of the following is correct regarding her vaginal flora and risk of recurrent urinary tract infections? A) Her vaginal pH is in the 4.5 - 5 range but her flora is skewed to a predominantly Enterobacteriaceae. B) Her risk of recurrent urinary tract infections is as high as 75-80%. C) Topical estrogen therapy is a highly effective for preventing recurrent urinary tract infections in this population. D) The vaginal flora tends to be of a very virulent nature and these patients are at high risk of pyelonephritis. E) For recurrent urinary tract infections fluroquilone suppression should be considered first line therapy.

Answer 451

C Perrotta C, Aznar M, Mejia R, Albert X, Ng CW. Estrogens for preventing recurrent urinary tract infection in postmenopausal women. Cochrane Database Syst Rev 2008; (2):CD005131. Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis 2011; 52:e103-e120.

Question 452

A 78 year old female is referred to you from her primary care physician who during a routine screening annual examination noted pelvic organ prolapse that protuded several centimeters beyond the introitus. The patient is otherwise asymptomatic. She is voiding normally without any urinary incontience. She is having normal bowel movements. Her physical examination confirms Stage III anterior and uterine prolapse but is otherwise normal. Which of the following is the most appropriate next steps? A) Offer the patient a minimally invasive hysterectomy and sacrocolpopexy to minimize her recovery period. B) Schedule urodynamic testing with barrier reduction to evaluate for occult stress incontinence C) Offer the patient a vaginal hysterectomy, native tissue vault suspension and prophylactic mid urethral sling D) Offer the patient observation with the option to return in a few months to see if she has developed any bothersome symptoms related to her pelvic organ prolapse. E) Offer the patient the patient a pessary that she is able to place and remove herself

Answer 452

D

Question 453

A urethral diverticulum is best stated as being: A) Outpouching of mucosa from the urethra B) A defect in the periurethral fascia C) Due to repeated infection of the periurethral glands D) Most patients have a history of urinary tract infections in the past E) All of the above

Answer 453

E Sandip Vasavada, MD: Evaluation and Management of Suburethral Diverticula in Walters, MD, Karram, M. Elsevier, Urogynecology and Pelvic Floor Dysfunction, 2nd edition, 2006

Question 454

Important surgical principles for rectovaginal fistula surgery include: A) Adequate blood supply to enhance healing B) Wide mobilization of tissue planes C) Closure in multiple layers without tension D) All of the above

Answer 454

D Novi, JM. JPMS Vol 11(6) Nov/Dec 2005

Question 455

Which of the following is true about urinary tract infections in pregnancy? A) They are less likely to progress to pyelonephritis B) Asymptomatic bacteriuria occurs in up to 50% of pregnancies C) Asymptomatic bacteriruia is associated with premature rupture of membranes and preterm labor D) Pregnant women should be placed on suppressive antibiotic therapy at the start of pregnancy to prevent urinary tract infection E) Ciprofloxacin is first-line therapy in pregnant patients requiring suppressive therapy

Answer 455

C Smaill F, Vazquez, JC. Antibiotics for asymptomatic bactteriuria in pregnancy. Cochrane Database Syst Rev 2007;(2):CD000490.

Question 456

For repair of anterior vaginal wall prolapse, which of the following statements is most accurate? A) There are similar anterior wall prolapse recurrences with standard anterior repair and anterior repair with a polyglactin mesh inlay B) There are similar anterior wall prolapse recurrences with standard anterior repair and anterior repair with a polypropylene mesh overlay C) There are similar anterior wall prolapse recurrences with standard anterior repair and anterior repair with an armed transobturator mesh D) There are similar anterior wall prolapse recurrences with standard anterior repair and anterior repair with a porcine dermis mesh inlay E) None of the above

Answer 456

E In a Cochrane Database Systematic Review by Maher et al, standard anterior repair was found to have more recurrent cystoceles than all of the following: polyglactin mesh inlay, porcine dermis inlay, polypropylene mesh overlay, armed transobturator mesh. "For anterior vaginal wall prolapse, standard anterior repair was associated with more recurrent cystoceles than when supplemented with a polyglactin mesh inlay (RR 1.39, 95% CI 1.02 to 1.90) or porcine dermis mesh inlay (RR 2.72, 95% CI 1.20 to 6.14); but data on morbidity and other clinical outcomes were lacking. Standard anterior repair was associated with more anterior compartment failures on examination than for polypropylene mesh repair as an overlay (RR 2.14, 95% CI 1.23 to 3.74) or armed transobturator mesh (RR 3.55, 95% CI 2.29 to 5.51)." However, subjective outcomes and complications may be different amongst the different approaches.

Question 457

A 58 year-old woman underwent an uncomplicated abdominal mesh sacral colpopexy and Burch retropubic suspension. She has a suprapubic catheter for postoperative bladder drainage. Which of the following statements is true? A) A transurethral Foley catheter would be clearly superior. B) A transurethral Foley catheter would increase her rate of urinary tract infection. C) A transurethral Foley catheter would increase her rate of catheter-related complications. D) A transurethral Foley catheter would reduce the length of her hospital stay.

Answer 457

B No route of catheterization has been found to be clearly superior among postoperative patients, including those having urogynecologic procedures. Suprapubic catheters have been shown to decreased risk of UTI but have been associated with increased risk of catheter-related complications compared to transurethral catheters. There is no difference in hospital stay. Healy EF, Walsh CA, Cotter AM, et al. Suprapubic compared with transurethral bladder catheterization for gynecologic surgery: a systematic review and meta-analysis. Obstet Gynecol. 2012;120:678-687.

Question 458

Which of the following non-antibiotic therapies has shown efficacy in preventing recurrent urinary tract infections? A) Cranberry juice or cranberry extract tablets. B) Probiotics given vaginally via capsules C) Probiotics given orally via capsules D) Topical estrogen in post menopausal women E) D-mannose (an adhesion blocker)

Answer 458

D Zhang L, DeBusscher J, Foxman B. Cranberry juice fails to prevent recurrent urinary tract infection: results from a randomized placebo-controlled trial. Clin Infect Dis 2011;52:23-30. Barrons R, Tassone D. Use of Lactobacillus probiotics for bacterial genitourinary infections in women: a review. Clin Ther 2008; 30:453-68. Perrotta C, Aznar M, Mejia R, Albert X, Ng CW. Estrogens for preventing recurrent urinary tract infection in postmenopausal women. Cochrane Database Syst Rev 2008; (2):CD005131.

Question 459

The cavernous nerve, responsible for clitoral engorgement during sexual activity, is derived from: A) The pudendal nerve B) The dorsal nerve of the clitoris C) The superior hypogastric plexus D) The inferior hypogastric plexus E) The sciatic nerve

Answer 459

D Ginger VAT, Yang C. Functional Anatomy of the Female Sex Organs. Cancer and Sexual Health, Current Clinical Urology, 2011, 13-23.

Question 460

A 69 year old female presents to your office and reports bothersome symptoms. After recording her complaints you note the following POPQ exam results: Aa +3, Ba+4, C-3 Gh 3, Pb 4, Tvl 10 Ap -2, Bp-2, C-8 Which of the following symptoms are those most commonly reported (being present in >/= 80% of patients) in patients with the above exam? A) A vaginal bulge that can be seen or felt. B) Urinary incontinence, urinary urgency, and incontinence. C) A feeling of incomplete rectal evacuation and back pain. D) Anal incontinence and splinting to have a bowel movement.

Answer 460

A Barber Symptoms and outcome measures of pelvic organ prolapse. Clin Obstet Gynecol 2005; 48: 648-661. The patient has a stage III POPQ exam that represents an anterior vaginal wall prolapse. These patients will most likely have the bothersome complaint of a vaginal bulge, which is the only consistent symptom, associated with pelvic organ prolapse. Urinary symptoms may be present but generally improve as patient's prolapse get worse and they are not consistently seen in patients with prolapse. Difficulty evacuating bowels is most common with posterior vaginal wall prolapse and this patient has good posterior support. Pain is inversely related to prolapse with less pain in subjects with greater degrees of prolapse.

Question 461

Which of the following are true about the Prevalence of a disease: A) It is a function of the Incidence and duration/natural history of a disease B) It can be calculated from a Cross-sectional study design C) It is defined as the number of existing patients with disease in a population divided by the total population at risk D) Both a and c are true E) a, b and c are true

Answer 461

E Designing Clinical Research, 3rd ed. Hulley SB, Cummings SR, Browner WS, et al, eds. Philadelphia: Lippincott Williams & Wilkins, 2007.

Question 462

A 45 year old, G2P2 woman with stress urinary incontinence desires nonsurgical management. She is considering a continence pessary. Which of the following choices best estimates the likelihood she would be "much better" or "very much better" within 3 months. A) 20% B) 40% C) 60% D) 80%

Answer 462

B Richter HE, Burgio KL, Brubaker L, Nygaard IE, Ye W, Weidner A, et al. Continence pessary compared with behavioral therapy or combined therapy for stress incontinence: a randomized controlled trial. Obstet Gynecol 2010; 115:609-17.

Question 463

_____________ is a rare complication of mesh sacrocolpopexy that should be considered in women with back pain after this procedure. A) Osteomyelitis B) Herniated disc C) Spinal stenosis D) Bowel obstruction

Answer 463

A Sacral osteomyelitis has been reported after mesh sacrocolpopexy. This presumably occurs when mesh is being sutured to the anterior longitudinal ligament of the sacrum. Depending on where these sutures are placed in relation to the promontory, sutures could be in close proximity to the L5-S1 disc space. Herniated disc and spinal stenosis are clinical etiologies of back pain, but have not been reported as complications of mesh sacrocolpopexy. Though bowel obstruction can occur after sacrocolpopexy, it would be unusual to present with back pain, and more commonly presents with nausea/vomiting, and GI symptoms. Walters & Ridgeway; Obstet Gynecol 2013; 121 (2)

Question 464

93 year old female with history of dementia is brought in by her daughter with chief complaint of daytime urgency, frequency and nocturia 5 times a night. After complete history and physical examination, the next best step in her evaluation and treatment is? A) Prescription for solifenacin 5 mg and titrate to 10 mg as tolerated B) Recommend a bedside commode to prevent falls at night C) Recommend biofeedback and timed voiding drills D) Obtain a 3 day voiding diary E) A and B

Answer 464

D Given complaints of nocturia 5 times a night, one should assess for nocturnal polyuria. Anticholinergic medications in this age group should be initiated with caution and after addressing functional issues. Timed voiding and biofeedback may be of little benefit in this patient with dementia.

Question 465

The urogenital system originates from which embryologic structure? A) Ectoderm B) Endoderm C) Intermediate mesoderm D) Somites

Answer 465

C The area where the somatic mesoderm and the splanchnic mesoderm layers join in the midline is termed the intermediate mesoderm and gives rise to the urogenital system.

Question 466

Rare potential risks of urethral injection of bulking agents for treatment of intrinsic sphincter deficiency include the following: A) Tissue necrosis at the injection site B) Suburethral abscess C) Urethral prolapse D) A,B and C E) A and B

Answer 466

D More common risks of urethral injection of bulking agents for treatment of ISD include pain during injection, urinary retention and voiding dysfunction. Rare complications include suburethral abscess, tissue necrosis at the injection site, urethral prolapse, delayed hypersensitivity with systemic arthralgia, osteitis pubis, pseudocyts or collagen polyps, urethral diverticulum and vesicovaginal fistula. Bent A. (2007). Urethral Injection of Bulking Agents for Intrinsic Sphincter Deficiency. (M. Walters & M. Karram, Eds.). In Urogynecology and Reconstructive Surgery, 3 edition. (pg. 227-233). Philadelphia. Mosby Elsevier.

Question 467

What are the risk factors for post-surgical urinary tract infections? A) Failure of Voiding trial B) Longer Operating Room Times C) History of Recurrent UTI D) Concomitant Procedures E) All of the Above

Answer 467

E Nygaard I, Brubaker L, Chai, TC, Markland AD, Menefee SA, Sirls L, Sutkin G, et al: Risk factors for urinary tract infection following incontinence surgery, Int Urogynecol J 22:1255-1265, 2011. And Falagas, M E. Urinary tract infections after pelvic floor gynecological surgery: prevalence and effect of antimicrobial prophylaxis. A systematic review.International Urogynecology Journal And Pelvic Floor Dysfunction Volume: 19 Issue: 8 (2008-08-01) p. 1165-1172.

Question 468

What is the most common procedure currently performed in the United States in women to treat stress urinary incontinence? A) Sling B) Burch procedure C) Collagen injection D) Needle suspension E) Kelly plication

Answer 468

A In a large health care commercial claims database analysis, based upon CPT codes, the most common SUI surgery in the US in women between 2000 and 2009 was sling (198.3 per 100,000 person- years, 95% CI 192.8-203.9), followed by Burch (25.9 per 100,000 person-years, 95% CI 24.8-27.2), then collagen (11.2 per 100,000 person-years, 95% CI 10.7-11.7) and finally laparoscopic SUI procedures, needle suspensions, total vaginal hysterectomy plus colpourethrocystopexies, and Kelly plications at lower rates and relatively uncommon. Jonsson Funk M, Levin PJ, Wu JM. Trends in the surgical management of stress urinary incontinence. Obstet Gynecol 2012;119:845-51. PMID: 3310349.

Question 469

While placing a left lower laparoscopic port at the time of a laparoscopic hysterectomy and sacrocolpopexy under direct vision, you observe a significant amount of bleeding coming from the abdominal wall at the location where the trocar is being introduced. Which of the following next steps is most appropriate? A) Remove the trocar immediately and apply external pressure to the abdominal wall B) Abort the procedure and call vascular surgery for assistance C) Place a Foley catheter through the trocar and incision, inflate the bulb and pull up to help tamponade the bleeder D) Make a laparotomy incision and proceed with the planned surgery

Answer 469

C A large Foley catheter balloon can provide temporary tamponade and reduce blood loss while the surgeon addresses the best next step such as suture ligation of the bleeding vessel superior and inferior to the site of injury.

Question 470

When comparing retropubic midurethral sling to single-incision mini sling (in the "U" configuration), which of the following statements is NOT true? A) Patients receiving retropubic midurethral sling are more likely to have a bladder perforation during placement B) Subjective stress urinary incontinence cure rates are similar at 1 year postoperatively C) At one year, postoperative stress urinary incontinence severity is worse following retropubic midurethral sling when compared to mini-sling D) Bothersome urge urinary incontinence is equally as likely postoperatively after retropubic midurethral sling and mini-sling.

Answer 470

C In a multicenter, randomized trial comparing retropubic midurethral sling (TVT) to single incision mini-sling in the "U" configuration (TVT-SECUR), patients receiving TVT were more likely to have a bladder perforation during placement (4.8% compared with 0.8%; P = .046). One year after surgery, subjective cure was seen in 55.8% (72 of 129) of those who received a mini- sling and in 60.6% (77 of 127) of those who received TVT, mean difference of 4.8% (95% CI, 16.7% to 7.2%). This did not meet predetermined non-inferiority limits, but no significant differences in subjective cure were noted using standard superiority testing (P = .43). Incontinence severity 1 year after surgery was greater in the mini-sling group (mean Incontinence Severity Index score +/- SD: 2.2 +/- 2.7 compared with 1.5 +/-1.9; P=015), due to a higher proportion "severe" incontinence in the mini-sling group postoperatively (16% compared with 5%; P=025. Bothersome urge incontinence symptoms were seen in 25% of mini-sling and 29% TVT, respectively (P=.54). Barber MD, Weidner AC, Sokol AI, et al. Single-incision mini-sling compared with tension-free vaginal tape for the treatment of stress urinary incontinence: a randomized controlled trial. Obstet Gynecol 2012;119:328-37.

Question 471

Which of the following is a true statement regarding urogenital fistula repair: A) It may be advantageous to use interpositional grafts for fistula involving the bladder neck and urethra, fistula after radiation therapy or large fistulae. B) There is Level 1 evidence that removing the entire fistulous tract increases the success of a repair. C) The most common complication after a urethrovaginal fistula repair is reported to be a urethral stricture. D) There is Level 1 evidence that using antibiotics perioperatively will reduce the odds of a failed gynecologic vesicovaginal fistula repair. E) A common approach used for urethrovaginal fistula repair is a prone, jacket-knife position.

Answer 471

A Wong MJ, Wong K, Rezvan A, Tate A et al. Urogenital Fistula Female Pelvic Medicine and Reconstructive Surgery 2012: 18 (2): 71-78 and Pushkar D Y, Dyakov VV et al. Management of Urethrovaginal Fistulas. European Urology 2006: 50; 1000-1005.

Question 472

The purported mechanism of action of biofeedback training to treat fecal incontinence includes all of the following except: A) Increased resting anal canal pressures B) Reinforcing heightened sensitivity to less and less rectal distention C) Improved EAS strength, speed or endurance D) Enhancing voluntary anal contraction in response to rectal filling

Answer 472

A Incontinence. Committee 16 Conservative and Pharmacological Management of Faecal Incontinence in Adults. Paris. Health Publication Ltd. 2009. pgs 1321-1386.

Question 473

A 55 year-old female presents with pelvic pressure and incontinence and has a negative urinalysis but a PVR of 850 ml. Filling cystometry shows absent sensation with filling and no detrusor contraction and the test was stopped at 1000 ml of filling. Which condition is NOT in her differential diagnosis? A) Brain tumor B) Spinal stenosis C) Disk herniation D) Diabetes

Answer 473

A

Question 474

Researchers want to assess whether there is an association between smoking and urinary incontinence. Of the following, which is the best study design to assess for this association? A) Case-series B) Cross-sectional study C) Randomized controlled trial D) Prospective cohort study E) Crossover trial

Answer 474

D Designing Clinical Research, 3rd ed. Hulley SB, Cummings SR, Browner WS, et al, eds. Philadelphia: Lippincott Williams & Wilkins, 2007

Question 475

According to the 2012 American Urologic Association Guidelines, all of the following are true concerning the use of behavioral therapies to treat OAB, EXCEPT: A) Behavioral therapies are usually 20% less effective in OAB symptom improvement when compared with anti-muscarinic therapies B) An 8% weight loss can reduce overall urinary incontinence episodes by almost 50% C) A reduction in urinary urgency and frequency can be seen with a 25% reduction in fluid intake. D) When doing bladder training (incremental voiding schedules done with distraction) and behavioral training (pelvic floor muscle training with urge suppression techniques), typical mean improvements range from 50-80%

Answer 475

A

Question 476

During placement of a transobturator sling your device wanders too laterally on the right side and damages structures in the obturator canal. Unfortunately, the nerve in that area is severed. Post-operatively what right lower extremity complaint might the patient be expected to have? A) inability to curl the toes B) inability to feel the bottom of their feet C) constant inner thigh pain D) inability to move the thigh medially E) inability to lift their leg

Answer 476

D Obturator nerve injury causes loss of thigh adduction. Drake RL, Vogl AV, Mitchell AWM, Tibbits. Grays atlas of anatomy. Philadelphia. Elsevier. 2008.

Question 477

Which of the following statements is false? A) Urethral diverticulae usually occur in the 3rd to 5th decade of life B) The majority of urethral diverticulae are congenital and enlarge over time, leading to clinical symptoms C) Most patients present with non specific symptoms and diagnosis is delayed D) Diverticula of the urethra usually arise from the periurethral glands in the posterolateral distal urethra

Answer 477

B Most diverticulae are acquired, not congenital. Handel LN, Current Urol Rep 2008, 9:383-388

Question 478

Which of the following statements regarding the surgical safety checklist are true? A) Identification of correct patient and consent is mandatory after induction of anesthesia B) Surgical site marking is required for all surgical procedures C) Confirmation of antibiotic dosing immediately after incision D) Address any patient specific concerns

Answer 478

D ID and consent must be BEFORE anesthesia, No site marking for midlline or implausible laterality (i.e. sling), Antibiotics must be within 60 min before incision. http://who.int/patientsafety/safesurgery/tools_resources/SSSL_Checklist_finalJun08.pdf

Question 479

A post-void residual should be checked in all woman with OAB and the following conditions/complaints except? A) multiple sclerosis B) straining to void C) previous anti-incontinence surgery D) over the age of 45 E) cauda equina syndrome

Answer 479

D Gormley EA, Lightner DJ, Burgio KL, Chai TC, Clemons JQ, Culkin DJ, et al. Diagnosis and Treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline. J Urol 2012, 188, 2455-2463 Available on AUA website: http://www.auanet.org/content/clinical-practice-guidelines/clinical-guidelines.cfm Retrieved Dec 10, 2012

Question 480

A 26 year old G1P0 requests information regarding the role of pelvic floor physical therapy during her pregnancy for the prevention of urinary incontinence. Which of the following statements BEST describes the current available data. A) Based on the current randomized trials, there appears to be no short term or long term benefit of pelvic floor physical therapy in the prevention of urinary incontinence B) Based on the current randomized trials, there appears to be some short and long term benefit of pelvic floor physical therapy in the prevention of urinary incontinence C) Based on the current randomized trials, there appears to be some short evidence for intense pelvic floor physical therapy in the prevention of urinary incontinence D) Based on the current randomized trials, while there does not appear to be any short term benefit, long term data suggests some benefit in pelvic floor physical therapy in the prevention of urinary incontinence

Answer 480

C Hay-smith J. Cochrane Database of Systematic Reviews 2008, Issue 4.

Question 481

Which of the following has been shown to best correlate as a biomarker for interstitial cystitis/painful bladder syndrome? A) Glycosaminoglycan (GAG) B) Anti-proliferative factor (APF) C) Hyaluronic acid levels D) Vascular endothelial growth factor (VEGF) E) All of the above

Answer 481

B Keay S, Zhang CO, Hise MK, et al. A diagnostic in vitro urine assay for interstitial cystitis. Urology 1998; 52: 974-8.

Question 482

Which of the following therapies is considered second line therapy for the treatment of OAB A) Use of biofeedback for pelvic floor muscle training B) Percutaneous tibial nerve stimulation C) Mirabegron 25 mg daily D) Botulinum toxin 100 Units E) B and C

Answer 482

C Medication therapy is considered 2nd line therapy by AUA guidelines. PTNS and botox are 3rd line and biofeedback is first line. Gormley EA, Lightner DJ, Burgio KL, et al. Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline. The Journal of urology 2012;188:2455-63.

Question 483

A 77 year old woman presents with a confirmed diagnosis of severe urgency urinary incontinence. She has severe dementia, wears adult diapers continuously and resides in a nursing home. She has normal mobility. The best initial treatment option includes: A) Bladder retraining and pelvic floor muscle exercises B) Electrical stimulation to help identify pelvic floor muscles C) Prompted voiding by care providers D) Intradetrusor botulinum toxin injections

Answer 483

C Hagglund D. A systematic literature review of incontinence care for persons with dementia: the research evidence. J Clin Nurs 2010; 19:303-12.

Question 484

Which of the following antibiotics is currently associated with the highest rate of bacterial resistance in the United States? A) Nitrofuratoin monohydrate/macrocystals B) Rocephin C) Trimethoprim-sulfamethoxazole D) Ciprofloxacin E) Amoxicillin

Answer 484

C Gupta K, Hooton TM, Stamm WE. Increasing antimicrobial resistance and the management of uncomplicated community-acquired urinary tract infections. Ann Intern Med 2001;135(1):41-50.

Question 485

In women without symptoms of stress urinary incontinence undergoing sacrocolpopexy for prolapse repair, which of the following statements is most correct? A) If urodynamic data preoperatively do not suggest stress urinary incontinence, Burch procedure at the time of sacrocolpopexy has not been demonstrated to decrease postoperative stress urinary incontinence B) Burch procedure at the time of sacrocolpopexy reduces the risk of postoperative stress urinary incontinence C) Any benefits obtained with Burch procedure at the time of sacrocolpopexy, with regard to postoperative stress urinary incontinence, have not been found to persist after the first 6 weeks D) When a Burch procedure is performed at the time of abdominal sacrocolpopexy, the risk of sexual dysfunction postoperatively increases

Answer 485

B In a multicenter randomized trial of prophylactic Burch procedure at the time of abdominal sacrocolpopexy, at three months postop 23.8% of the Burch group and 44.1% of the control group had stress incontinence (P

Question 486

Which of the following will not be able to have genetically related children (even with the assistance of advanced reproductive technology)? ``` A) Androgen Insensitivity Syndrome B) Mayer-Rokitansky-Kuster-Hauser C) Gonadal agenesis D) Uterine didelphys E) A and B F) A and C ```

Answer 486

F Romao RL, Salle JL, Wherrett DK. Update on the management of disorders of sex development. Pediatr Clin North Am. 2012;59:853-69.

Question 487

According to the 2011 American Urological Association Guidelines, all of the following should be considered as second line treatments for treatment of interstitial cystitis/painful bladder syndrome, EXCEPT: A) Cystoscopy under anesthesia with short-duration, low pressure hydrodistension B) Use of oral medications, such as amitriptyline, cimetidine, hydroxyzine, or pentosan polysulfate C) Manual physical therapy D) Use of intravesical DMSO, heparin, or lidocaine

Answer 487

A

Question 488

Continence pessaries may be used for treatment of stress urinary incontinence. Which of the following statements are true? A) Pessary is superior to behavior therapy after 3 months of treatment B) Pessary results in improved dry rates over behavior therapy C) About 50% of women remain satisfied with pessary treatment at 1 year. D) More women are satisfied with pessary use than behavior therapy

Answer 488

C ATLAS study showed that at 3 months, overall improvement was similar between pessary and behavior (40-50%). Complete continence was less than 50% and lower in the pessary group. Patient satisfaction was 75% for behavior and 63% for pessary. Richter HE, Burgio KL, Brubaker L, et al. Continence pessary compared with behavioral therapy or combined therapy for stress incontinence: a randomized controlled trial. Obstet Gynecol 2010;115:609-17.

Question 489

Which muscle overlies the sacrospinous ligament? A) Puborectalis B) Pubococcygeus C) Coccygeus D) Iliococcygeus E) Piriformis

Answer 489

C

Question 490

A 59 year old female presents with a complaint of a vaginal bulge for several months. She is found to have Stage IV vaginal vault prolapse and has no complaints of stress incontinence. She is interested in surgical therapy for her prolapse. Which of the following statements are correct? A) The patient should counseled against an anti-incontinence procedure because this has not been shown to be beneficial at the time of prolapse repair B) Stress testing should be performed with prolapse reduction to assess for occult stress incontinence C) Urodynamic testing should be performed while standing D) If reduction testing is to be performed, manual reduction is preferred.

Answer 490

B In women with high grade POP but without the symptom of SUI, clinicians should perform stress testing with reduction of the prolapse. Multi- channel urodynamics with prolapse reduction may be used to assess for occult stress incontinence and detrusor dysfunction in these women with associated LUTS. (Option; Evidence Strength: Grade C). Manual reduction is not recommnded as this can result in inaccurate assessment of VLPP. AUA Guidelines - Adult Urodynamics

Question 491

The gynecologist is doing an outside-in transobturator sling for a 50 year-old woman with stress urinary incontinence. The helical trocar passes around the ischiopubic ramus but will NOT pass through which anatomic structure: A) Obturator canal B) Obturator internus muscle C) Peri-urethral endopelvic fascia D) Obturator foramen E) Gracilis muscle

Answer 491

A Whiteside JL, Walters MD. Anatomy of the obturator region: relations to a trans-obturator sling. Int Urogynecol J Pelvic Floor Dysfunct 2004;15:223-6.

Question 492

Which of the following statements is true regarding anticholinergic overactive bladder medications? A) Once daily oral preparations are superior in efficacy to multi dose preparations B) Transdermal preparations have lowest reported dry mouth rates C) Behavioral training improves ability to discontinue medication D) Compliance with therapy is equivalent across all anticholinergic formulations E) A and C

Answer 492

B Efficacy is similar across all preparations, transdermal has lowest dry mouth, behavior training does NOT improve medication discontinuation rates and compliance is better with extended release. Burgio KL, Kraus SR, Menefee S, Borello-France D, Corton M, Johnson HW, et al. Behavioral therapy to enable women with urge incontinence to discontinue drug treatment: a randomized trial. Ann Intern Med 2008 Aug 5;149(3):161-9.; Gormley EA, Lightner DJ, Burgio KL, et al. Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline. The Journal of urology 2012;188:2455-63.

Question 493

A 45 year old woman is post-operative day 1 after robotic sacral colpopexy. She complains of numbness over her anterior thigh and cannot stand from a seated position. She most likely has suffered an injury to the: ``` A) Obturator nerve B) Femoral nerve C) Lateral femoral cutaneous nerve D) Sciatic nerve ```

Answer 493

B Wieslander, C K.; Boreham, M K.; Phelan, J; Schaffer, J I.; Corton, M M. Video: Avoiding nerve injury during gynecologic surgery. J Pel Med Surg. 2005;11:S54.

Question 494

Which of the following is TRUE about Urethral Bulking for SUI: A) Durasphere EXP, Coaptite, Macroplastique are more effective than Contigen B) Transurethral and periurethral methods of bulking have similar effectiveness C) Total continence occurs in only about 20% of cases D) Repeat injections are usually required and the effects are additive up to 5 injections

Answer 494

B Kirchin V, Page T, Keegan PE, Atiemo K, Cody JD, McClinton S. Urethral injection therapy for urinary incontinence in women. Cochrane Database Syst Rev 2012 Feb 15;2:CD003881.

Question 495

A 58 year old female presents for urodynamic evaluation for mixed urinary incontinence and urinary frequency. The urodynamic study reveals no detrusor overactivity, Pves at the start of fill of 22 cm H2O, Pabd at the start of fill of 23 cm H2O. Valsalva leak point pressures at 300mL that was positive at 120 cm H2O and cough leak point pressure that was positive at the same volume at 110 cm H2O. At capacity (400mL), Pves pressure was 52 cm H2O and Pabd pressure was 24 cm H2O. Which of the following would be the most appropriate next step? A) Check serum creatinine and order a renal ultrasound B) Offer the patient a mid-urethral sling for a diagnosis of urodynamic stress incontinence C) Begin anticholinergic therapy for overactive bladder D) Offer a pessary for treatment of stress incontinence

Answer 495

A The urodynamic evaluation indicates signficantly reduced bladder compliance of

Question 496

In a patient who has uncontrolled narrow angle glaucoma and severe UUI, the best option would be: A) Transdermal oxybutynin B) A β3 adrenergics agonist C) A selective norephinephrine and serotonin uptake inhibitor D) An alpha adrenergic agonist E) A tricyclic antidepressant

Answer 496

B Gormley EA, Lightner DJ, Burgio KL. Diagnosis and Treatment of OAB (non neurogenic) in adults: AUA /SUFU Guideline. American Urological Association Education and Research, Inc. 2012 and Rios L A, Panhoca R, Mattos D et al. Intravesical Resiniferatoxin for the Treatment of Women with Idiopathic Detrusor Overactivity and urgency Incontinence: A Single Dose, 4 weeks, Double-Blind Randomized Placebo Controlled Trial. Neurourol and Urodynamics 2007: 26; 773-778.

Question 497

According to the 2012 American Urologic Association Guidelines, all of the following are true concerning evaluation of asymptomatic, microscopic hematuria, EXCEPT: A) If patients are s discretion B) One must consider: menstruation, infection, vigorous exercise, medical renal disease, trauma, viral illness C) If patients are taking anticoagulation, further urologic and nephrologic evaluation is not needed D) The initial evaluation of asymptomatic microscopic hematuria should include a radiologic evaluation with multiphase computed tomography urography

Answer 497

C

Question 498

The vagina is derived from: A) The urogenital sinus B) The mesonephric ducts C) The paramesonephric ducts D) A and C E) All of the above

Answer 498

D Carlson BM. Human Embryology and Developmental Biology, 4th Ed. Philadelphia (PA): Mosby, Inc., 2009.

Question 499

A patient has a complex pelvic surgery and the surgeon is worried about a bladder injury after surgery. All of the following are important principles in the evaluation of this patient except? A) Use of water soluble contrast material to distend the bladder under x-ray guidance B) Distend bladder to at least 300 cc C) Use of oblique films to evaluate urethra and outlet D) Obtain a post-drainage film to evaluate for extravasation E) CT cystography may be a useful adjunct for multiplanar imaging of this patient

Answer 499

D | Bodner DR, Selzman AA, Spirnak JP. Evaluation and treatment of bladder ruptureSemin Urol. 1995 Feb;13(1):62-5.

Question 500

In women with post-hysterectomy vaginal vault prolapse, which statement in the most accurate? A) Level I data show that abdominal sacrocolpopexy and vaginal sacrospinous ligament fixation are both highly effective in the treatment of apical prolapse B) Level I data show that abdominal sacrocolpopexy is far more effective than vaginal sacrospinous ligament fixation for treatment of apical prolapse C) Level I data show that vaginal sacrospinous ligament fixation is far more effective than abdominal sacrocolpopexy for treatment of apical prolapse D) Level I data show that vaginal sacrospinous ligament fixation with vaginal mesh is far more effective than abdominal sacrocolpopexy for treatment of apical prolapse E) Level I data show that abdominal sacrocolpopexy and vaginal sacrospinous ligament fixation with mesh are both highly effective in the treatment of apical prolapse

Answer 500

A There are few randomized controlled trials (Level I data) that address this question. Benson et al. published a prospective study in 1996 which showed that ASC was more effective that SSLF for apical prolapse; in their population at least 50% of women had a uterus at the time of the procedure. In 2004 Maher et al published an RCT (Level I evidence) on ASC vs vaginal SSLF and concluded that both procedures are highly effective in the treatment of post-hysterectomy vaginal vault prolapse. Thus "A" is the most correct answer. There are no Level I data comparing SSLF with mesh (vaginal mesh) to abdominal sacral colpopexy. Maher et al. AJOG 2004; 190 (20-6)

Question 501

Which receptor in the detrusor muscle is predominantly responsible for contraction during normal micturation? A) M1 B) M2 C) M3 D) M4 E) M5

Answer 501

C M3 receptors are predominant receptor involved in normal bladder contraction. M2 may be upregulated or responsible in pathologic bldder contractions such as after urinary obstruction. Other subtypes are present but in low concentrations. Thus most anticholinergic drug development is aimed at selective blockade of M3 or M2. Andersson KE, Arner A. Urinary bladder contraction and relaxation: physiology and pathophysiology. Physiol Rev 2004;84:935-86.

Question 502

Commonly used interpositional flaps/grafts used for vesicovaginal fistula repairs include each of the following except: A) Omentum B) Peritoneum C) Gracilis muscle D) Collagen impregnated mesh E) Labial fat

Answer 502

D

Question 503

Strothers L, Chopra A, Raz S. Vesicovaginal Fistula. In: Raz S, ed. Female Urology. 2nd ed. Philadelphia, PA:W.B. Saunders Company 1996. p. 490-506. The great majority of neural control of colorectal function is mediated by: A) Extrinsic spinal sensory neurons B) Sympathetic autonomic neurons C) Parasympathetic autonomic neurons D) Enteric motor neurons

Answer 503

D Brookes SJ, Dinning PG, Gladman MA. Neuroanatomy and physiology of colorectal function and defaecation: from basic science to human clinical studies. Neurogastroenterol Motil 2009;21 Suppl 2:9-19. Next

Question 504

According to the IUGA/ICS joint terminology and classification system of complications related to prosthese and grafts used in female pelvic floor surgery, complications are classified by all of the following except: A) Category B) Time C) Site D) Severity E) All are included

Answer 504

D Severity. Complications are classified by category, time and site Haylen BT, Maher C, Deprest J. IUGA/ICS terminology and classification of complications of prosthesis and graft insertion--rereading will revalidate. American journal of obstetrics and gynecology. Jan 2013;208(1):e15.

Question 505

Which of the following diagnostic tests is most useful in evaluating a patient complaining of fecal incontinence with a suspected anal-sphincter disruption: A) Anorectal manometry B) Anal sonography C) Barium proctography D) MRI

Answer 505

B

Question 506

A) Darifenacin B) Solifenacin C) Tolterodine D) Trospium

Answer 506

D Trospium has been reported to have rates of dry mouth as low as 8.7%. Staskin D, Sand P, Zinner N, Dmochowski R. Once daily trospium chloride is effective and well tolerated for the treatment of overactive bladder: results from a multicenter phase III trial. The Journal of urology 2007;178:978-83; discussion 83-4.

Question 507

Radiographic imaging of the urinary tract should be considered under which of the following circumstances? A) A 35 year old patient with poor response to antimicrobial therapy and a persistent infection despite adequate therapy. B) A 25 year old patient with an episode of pyelonephritis in pregnancy who is now post partum. C) A 42 year old patient who has had one urinary tract infection each year for the past 5 years. D) A 10 year old girl with a recent UTI.

Answer 507

A In women with routine uncomplicated UTIs the role of imaging is limited. However, if patients have persistent UTI with the same organism that does not respond to appropriate therapy then an abscess or stone could be the cause and imaging of the upper tracts with either U/S or CT is appropriate. If subjects have two or more episodes of pyelonephritis, especially outside of pregnancy, then the upper tracts require evaluation with imaging. Hooten T, Uncomplicated urinary tract infection. NEJM 2012; 366: 1028-1037

Question 508

Risk factors associated with an unsuccessful pessary fitting trial include which of the following? A) Short vaginal length B) Prior hysterectomy C) Wide vaginal introitus D) Short vaginal length and prior hysterectomy E) Short vaginal length and wide vaginal introitus

Answer 508

E

Question 509

AUA Guidelines state that a clinican may perform multi-channel urodynamics in patients with both symptoms and physical findings of stress incontinence in which patient population? A) Elderly B) Patients considering a trial of a continence pessary C) Patients considering invasive, potentially morbid or irreversible treatments D) Patients considering observation to help inform decision making

Answer 509

C Clinicians may perform urodynamics in patients with both symptoms and physical findings of stress incontinence who are considering invasive, potentially morbid or irreversible treatments. (Option; Evidence Strength: Grade C) AUA Guidelines - Adult Urodynamics

Question 510

A 62 year old healthy patient presents with complaints of an occasional vaginal bulge and pressure. You are concerned that the patient may have an enterocele. Which of the following is the least helpful in diagnosing an enterocele? A) Rectovaginal examination during strain B) Defecography C) Anorectal manometry D) MRI

Answer 510

C

Question 511

Each of the following is a true statement regarding the use of the artificial anal sphincter for FI except: A) The cuff is placed around the anal canal and is constantly inflated to create anal continence B) It is indicated in those who have failed prior anal sphincteroplasty C) It is reported to improve FI symptoms by 85% D) It has less than 10% complication rate

Answer 511

D Artifical anal sphincters have a high complication rate ranging from 20-100%. Complications include infection, erosion, and malfunctioning of the device Hayden D and Weiss E. Fecal Incontinence: Etiology, Evaluation, and Treatment. Clin Colon Rectal Surg 2011; 24: 64-70.

Question 512

According to the 2012 American Urologic Association Guidelines, evaluation of persistent asymptomatic, microscopic hematuria after an initial negative workup could include all of the following, EXCEPT: A) Yearly urinalysis B) Repeat evaluation every 3-5 years C) No further follow up D) Yearly urine cytology

Answer 512

D

Question 513

A patient complains of urinary incontinence 2 weeks after a TAH, a speculum exam reveals a pool of urine at the apex. The best next step would be: A) Order a renal ultrasound B) Order an IVP C) Order a CT scan D) Obtain a Trattner catheter urethrogram E) Perform a "tampon test" placing methylene blue dye in the bladder

Answer 513

E Strothers L, Chopra A, Raz S. Vesicovaginal Fistula. In: Raz S, ed. Female Urology. 2nd ed. Philadelphia, PA:W.B. Saunders Company 1996. p. 490-506.

Question 514

The advantage of MRI over other imaging modalities in the evaluation of suspect urethral diverticulum is: A) Offers multiplanar imaging B) The study does not expose the patient to radiation C) Does not require a patient to void during the study D) Study is typically done without a catheter E) All of the above

Answer 514

E Blander, D et al. Urology 2001 Apr 57(4); 660-65

Question 515

A 55 year old female is 9 days post-op status post an abdominal hysterectomy with BSO. She if referred to you due to non-stress, non-urge vaginal leakage that began 2 days ago and is constant and of moderate amount. You note fluid in the vagina. You place Methylene blue stained saline in the bladder but no blue is noted vaginally. What is the most appropriate next step? A) Reassure the patient to return in 6 weeks if not improved B) Obtain a CT scan with IV contrast to evaluate for a ureterovaginal fistula C) Recommend vaginal tampons to help absorb the leakage D) Instruct the patient regarding Kegels

Answer 515

B A ureterovaginal fistula can present several days after the surgery, would present with vaginal leakage but would not demonstrate blue in the vagina if Methylene blue is only placed in the bladder.

Question 516

Your patient has a duplicated right collecting system. The drooping lily sign is found in the right kidney on excretory pyelography. Which of the following is a correct statement? A) The right lower pole moeity is obstructed B) The right upper pole moeity is obstructed C) The right lower pole moeity is displaced medially D) The right lower pole moeity is displaced superiorly

Answer 516

B The Drooping Lily Sign is a deformity seen on IV urography of a duplex kidney, with the forcing of the lower collecting system and ureter outward and downward to resemble the shape of a drooping lily. It is caused by obstruction and dilation of the upper (often non-opacified) collecting system.

Question 517

A 27 year old female presents to your office with complaints of urge, frequency and pelvic pain symptoms lasting for a few weeks. An appropriate Initial workup should include all of the following except. A) Urinalysis B) Urine culture C) Mycoplasma and ureaplasma cultures D) Potassium sensitivity test E) Physical examination

Answer 517

D

Question 518

Urge-related fecal incontinence is usually caused by changes in which anal sphincter A) External B) Internal C) Both D) Neither

Answer 518

A Disruption or weakness of the EAS mscule causes urge-related or diarrhea-associated fecal incontinence. In contrast, damage to the IAS muscle or the anal endovascular cushions may lead to a poor seal and an impaired sampling reflex Incontinence tICo. Incontinence. 4 ed. Paris, France: EDITIONS21; 2009

Question 519

The most common time for a rectovaginal fistula to present after a course of radiation therapy is: A) Immediately after completion B) 1 month after completion C) 6-24 months after completion D) 6 years after completion

Answer 519

C Novi, JM. JPMS Vol 11(6) Nov/Dec 2005

Question 520

Each of the following are true statements regarding the success of biofeedback in patients with FI except: A) Most studies are small with short term follow up B) Predictors for success include low rectal sensation threshold and low urgency threshold C) Patients with a decreased rectal capacity have decreased success D) Rectal balloons are successful at retraining the rectal sensory threshold E) Patients with denervation to the pelvic floor are the optimal candidates for biofeedback therapy

Answer 520

E Risk factors for poor responses to biofeedback for FI include neurologic impairment of the pelvic floor, passive incontinence (or no sensation) or high rectal sensitivity thresholds Hayden D and Weiss E. Fecal Incontinence: Etiology, Evaluation, and Treatment. Clin Colon Rectal Surg 2011; 24: 64-70

Question 521

A 55 year old female presents with stress urinary incontinence, which is confirmed on physical exam. She denies any symptoms of OAB or urge incontinence. She denies any voiding complaints or problems with UTI's. She is interested in surgical options. Which of the following is the next best step? A) Obtain CMG, PFS with EMG B) Obtain UA and PVR C) Obtain CMG and PFS only D) Obtain uroflow and PVR E) Obtain CMG and PVR

Answer 521

B Winters, JC, Dmochowski RR, Goldman HB, Herndon CD, Kobashi KC, Kraus SR, et al, Urodynamics Studies in Adults: AUA/SUFU Guidelines, Journal of Urology 2012, 188, 2464-72

Question 522

Which of the following vaginal procedures to correct pelvic organ prolapse have been reported to have the highest reported risk of ureteral injury? A) Total vaginal hysterectomy B) Anterior repair C) Uterosacral ligament repair D) Sacrospinous ligament suspension

Answer 522

C Barber et al AJOG 2000

Question 523

A 67 years old female presents complaining of increased daytime urinary frequency and urgency while getting to the bathroom. She often leaks prior to making to the toilet and would like to try a therapy. Which of the following statements best describes accurate expectations of treatments for overactive bladder: A) There appears to be an added benefit for reducing incontinence episodes or voids per day by adding behavioral treatments to pharmacologic approaches for reduction in incontinence. B) Extended release formulations of anticholinergics appear to be more effective than immediate release formulations. C) Combining anticholinergic use with sacral neuromodulation appears to be more effective than sacral neuromodulation alone. D) Patients who have received prior treatment with anticholinergics appear to be less responsive to future anticholinergic treatment.

Answer 523

A Hartman et al. Treatment of Overactive Bladder in Women. Evidence Report/Technology Assessment Number 187. AHRQ Publication No. 09-E017 August 2009.

Question 524

Which of the following statements about the Weigert-Meyer rule is correct? A) The upper pole inserts lateral to the lower pole ureter. B) The upper pole inserts superior to the lower pole ureter. C) The upper pole inserts medial to the lower pole ureter D) The lower pole inserts inferior to the lower pole ureter.

Answer 524

C The Weigert-Meyer rule states that the Upper Pole Moiety inserts medial and inferiorly to the lower pole moeity. The lower pole moeity inserts laterally and superiorly. Berrocal, et al Anomalies of the Distal Ureter, Bladder, and Urethra in Children: Embryologic, Radiologic, and Pathologic Features RadioGraphics 2002; 22: 1139.

Question 525

A 42 year old G3P3 female presents with a 10-month history of urinary incontinence occurring daily with activities such as laughing, coughing or sneezing. She is bothered by this and is wearing pads almost continuously. She voids once every 3-4 hours during the day and gets up 0-1 times at night. After a complete physical exam including a POPQ the patients is asked to void and a dip u/a of her voided specimen is negative. You contemplate doing a I&O cath for a post void residual. Which of the following are true regarding post void residual determinations? A) An abnormal PVR is one that is =25% of voided volume. B) Ultrasound determinations are not as accurate and clean catheterization results, generally underestimating the post void residual. C) A single abnormal value is diagnostic of a voiding disorder and requires video urodynamics to evaluate. D) PVR do not need to be routinely done during the incontinence evaluation and should be reserved for women with symptoms suggestive of a voiding disorder.

Answer 525

D National Institute for Health and Clinical Excellence: Management of Urinary Incontinence in women 2006. http://www.nice.org.uk/nicemedia/live/10996/30281/30281.pdf The determination of a post void residual is generally a well tolerated and low morbidity procedure, however, it is not necessary in women unless they complain of a voiding abnormality. The complaint of stress urinary incontinence does not qualify as a voiding abnormality. Ultrasound determinations are equivalent to catheterized specimens and a single abnormal value is not diagnostic of a voiding abnormality and can occur sporadically in up to 10% of normal patients. Therefore, an invasive and expensive video urodynamic study should be reserved for subjects with persistently elevated and symptomatic post void residuals. An abnormal PVR value is difficult to determine but it is generally accepted to be one that is >/= 100 cc's ot >/= 25% of the voided volume.

Question 526

The urodynamic relationship between change in bladder volume and change in detrusor pressure describes what? A) Desire to void B) Urgency C) Bladder compliance D) Voiding E) Leak point pressure

Answer 526

C Hashim H, Abrams P. Cystometry. In: Textbook of Female Urology and Urogynecology 3rd Edition, Cardozo L, Staskin D eds. London (UK): Isis Medical Media, Inc., 2010; pp 267-275.

Question 527

A 28 year old healthy nulliparous female is referred to you for a vaginal cystic mass. She is relatively asymptomatic with the exception of some mild occasional vaginal pressure and discomfort during intercourse. Upon examination you observe and palpate a 2x4 centimeter soft cystic mass along the left lateral and proximal vaginal wall. The remainder of the vaginal and bimanual examination is completely normal. If this cystic mass were due to an embryologic remnant, which of the following would most likely be the origin? ``` A) Paramesonephric duct B) Mesonephric duct C) Metanephric duct D) Mullerian duct ```

Answer 527

B Nephrogenic cords develop from the intermediate mesoderm beginning in the cephalad portions of the embryo. Three sets of bilateral ducts and tubes develop: the pronephros, the mesonephros and the metanephros. The first, the pronephros, forms in the cranial portion of the embryo at the beginning of the 4th week after conception. The tubules associated with the pronephric duct have not excretory function. They regress by the end of the 4th week. Late in the 4th weeks, the second set of tubes known as the mesonephros develops along with its mesonephric tubules. The mesonephric tubules are associated with tufts of capillaries or glomeruli. Therefore, the mesonephros serves as the fetal kidney, producing urine for 2-3 weeks before degenerating. As new mesonephric tubules form, the more cranial tubules degenerate. Mesonephric ducts may persist as Gartner's duct cysts or Cysts of Morgagni.

Question 528

Which of the following is not an exclusion criteria or relative exclusion criteria of the diagnosis if interstitial cystitis, according the NIH-NIDDK diagnostic criteria? A) Symptom duration

Answer 528

A Inclusion criteria include (Category A) at least one cystoscopic finding of either glomerulations or Hunner's lesions AND (Category B) at least one symptom of bladder pain or urinary urgency. Exclusion criteria include bacterial cystitis in past 3 months, urinary frequency 350cc while awake, absence of intense urge at 150cc medium fill during cystometry, detrusor overactivity, history of urinary tract stone or tumors, genital herpes, prior uterine/cervical/vaginal or urethral cancer, chemical cystitis, Tb, RTX cystitis. Relative exclusion criteria include age

Question 529

Each of the following is a true statement regarding medication for stress incontinence except: A) At doses previously studied for SUI, alpha adrenergics have significant cardiovascular side effects. B) Serotonin and norepinephrine reuptake inhibitors are not FDA approved for SUI. C) Serotonin and norepinephrine reuptake inhibitors have an FDA "black box warning" for suicide risk . D) Alpha adrenergic drugs have their mechanism of action on the skeletal muscle of the uretha. E) Serotonin and norepinephrine reuptake inhibitors act at the level of Onuf's nucleus

Answer 529

D Reference: Schuessler B, Baessler K. Pharmacologic Treatment of SUI: Expectations for Outcome. Urology 2003; 62: 31-38. Mariappan P, Alhasso A, Ballantyne Z, Grant A, N'Dow J et al. Duloxetine, a Serotonin and Noradrenaline Reuptake Inhibitor for the Treatment of SUI: A Systematic Review. European Urol 2007; 51: 67- 74.

Question 530

Question 530 of 740 A common neurologic physical examination finding associated with a neurologic injury is: A) Ataxia with poor leg coordination with a pudendal motor nerve injury B) Loss of bulbocavernous reflex with a T5 injury C) Detrusor sphincter dyssynergia with a cauda equine lesion D) Increased deep tendon reflexes with a CNS disease E) Decreased anal sphincter tone with a cerebellar lesion

Answer 530

D This is an historic positive physical finding in patients with CNS disease and it is thought to be due to pyramidal tract abnormalities. Stoher M, Blok B, Castro-Diaz D et al. EAU Guidelines on Neurogenic Urinary Tract Dysfunction. European urology 2009; 56: 81-89.

Question 531

Question 531 of 740 Which of the following is least likely to contribute to the normal vaginal microenvironment? A) Vaginal adventitia B) Vaginal epithelium C) Microbial flora D) Host-microbe interactions E) Microbe-microbe interactions

Answer 531

A There are multiple components to the vaginal microenvironment. These include the vaginal epithelium, microbial flora which interact with the host (epithelium) and with each other (microbe-microbe interactions). For example, superior tissue adherence of nonpathogenic lactobacilli gives rise to the concept of a healthy, adherent biofilm. The vaginal adventitia exists in the deepest layer of the vagina and surrounds the muscularis. Thus this layer is least likely to contribute to the microenvironment in the vagina. Siddique S. 2003; J Pelvic Med Surg 9(6): 263-272

Question 532

Question 532 of 740 Which of the following is thought to result in bladder contraction? A) ATP B) Noradrenaline C) Acetylcholine D) ATP and Acetylcholine E) Nitric Oxide and Noradrenaline

Answer 532

D Andersson KE, Arner A. Urinary Bladder Contraction and Relaxation: Physiology and Pathophysiology. Pharmacol Rev 2004; 84, 935-986.

Question 533

Question 533 of 740 You are asked by a colleague for a postoperative consultation on a 62 year old female who has undergone a vaginal hysterectomy and uterosacral ligament suspension. There was sluggish spill on the left during the surgery but the decision had been made not to replace the suspension sutures. Now, 2 days after the surgery, the patient has left flank pain, a low grade temp but normal urine output. All of the following are reasonable next steps EXCEPT? A) Left percutaneous nephrostomy and attempt at placing a single J antegrade ureteral stent B) Return to the operating room for cystoscopy and attempt at placing a retrograde left ureteral straight stent. C) Return to the operating room for cystoscopy and attempt at placing a retrograde left double J ureteral stent. D) Return to the operating room and removal of the left sided uterosacral ligament suture, reassessment of ureteral patency, and placement of a double J ureteral stent.

Answer 533

B A straight uteral stent is useful in various situations including confirming ureteral patency, injection of retrograde due and to help with intraoperative ureteral identification. However, a straight ureteral stent is not indicated as an indwelling ureteral stent as normal ureteral peristalsis will act to expel the stent. A single J or double J ureteral stent is placed such that an end of the stent with a "pig tail" rests in the renal pelvis and resists expulsion resulting from ureteral peristalsis.

Question 534

The following statement(s) are true about urethral diverticular surgery: A) It is best to set suture lines on top of each other to minimize the risk of stricture B) Repair is best performed during the time of active infection to maximize likelihood of localizing the diverticulum C) A Martius fat pad can be useful to close dead space D) Repair is best performed after lower urinary tract infection has been treated so as to minimize bleeding and friability and facilitate dissection E) C and D

Answer 534

E It is best to treat any infection before attempting diverticular repair. Foley CL, BJUI 2001, 108: Supplement 2, 20-23; Scarpero HM, Urol Clin North Am 2011 Feb 38(1) 65-71

Question 535

Question 535 of 740 During a sacrocolpopexy, significant bleeding is noted during the presacral space. The bleeding could be coming from all of the following EXCEPT: A) Middle sacral artery B) Left common iliac C) Presacral venous plexus D) Aberant obturator artery E) Middle rectal artery

Answer 535

D

Question 536

Question 536 of 740 In a patient with detrusor overactivity and detrusor sphincter dyssynergia, correct statements include each of the following except: A) A renal ultrasound would aid in guiding therapy B) A treatment option is anticholinergic therapy with intermittent self catheterization C) Botox injections can be used in both the bladder and urethra D) Upper extremity dexterity will determine management decision E) Baclofen is considered first line therapy

Answer 536

E Baclofen has been found useful in the treament of skeletal spasticity, however effective oral doses to treat DSD are associated with severe side effects. At the present time intrathecal baclofen pump for DSD has been evaluated in a few small case reports and would not be considered first line therapy. Stoher M, Blok B, Castro-Diaz D et al. EAU Guidelines on Neurogenic Urinary Tract Dysfunction. European urology 2009; 56: 81-89

Question 537

Question 537 of 740 Each of the following is generally considered a true statement regarding vesicovaginal fistula and urethrovaginal fistula repair except: A) It is important to mobilize the surrounding tissue during the repair. B) Postoperatively, suprapubic catheter drainage affords a better success rate than transurethral bladder drainage. C) Total fistula track removal is unnecessary. D) The repair should include a layered closure. E) Interpositional vascularized tissue may be used when necessary.

Answer 537

B Strothers L, Chopra A, Raz S. Vesicovaginal Fistula. In: Raz S, ed. Female Urology. 2nd ed. Philadelphia, PA:W.B. Saunders Company 1996. p. 490-506.

Question 538

Question 538 of 740 A 40 year-old woman with severe refractory interstitial cystitis/painful bladder syndrome is considering a urinary diversion with cystectomy for treatment. She has failed conservative measures and multiple medications including pentosan polysulfate, amitriptyline, cimetidine, as well as serial bladder instillations. She received only brief and slight relief from several cystoscopic procedures under anesthesia with hydrodistension. Her bladder capacity under anesthesia was 200cc. Hunner's lesions were never noted so she did not have fulguration. She underwent a stage 1 Interstim and had no relief of her symptoms. She declined intradetrusor Botox injections as she was not able to successfully learn to self-catheterize and did not want to risk urinary retention. Her current symptoms include urgency, frequency every 30-60 minutes during the day and night with small volumes and bladder pain. Her pain is somewhat controlled with a combination of fentanyl patches, oxycodone, ibuprofen and phenazopyridine. What aspect of her history is associated with a better response to cystectomy/urinary diversion? A) No evidence of Hunner's lesions on cystoscopy B) Nocturia C) Presence of neuropathic pain D) Small bladder capacity under anesthesia

Answer 538

D Small bladder capacity under anesthesia and the absence of neuropathic pain are associated with a better response with cystectomy/urinary diversion. Hanno PM, Burks DA, Clemens JQ, et al. AUA guideline for the diagnosis and treatment of interstitial cystitis/bladder pain syndrome. J Urol. 2011;185:2162-2170

Question 539

Question 539 of 740 When evaluating literature regarding outcomes after surgery for anterior vaginal wall prolapse, which statement is the most accurate? A) Outcomes (failure rates) are most affected by the materials used in the repair B) Outcomes (failure rates) are most affected by the surgeon's training C) Outcomes (failure rates) are most affected by the definitions used in the study D) Outcomes (failure rates) are most affected by whether procedures are performed in an academic vs. community hospital setting

Answer 539

C Surgical outcomes reported in the literature are highly influenced by the outcome definitions that are used. For example, in a study by Weber et al. assessing anterior colporrhaphy, only 39% were considered to have a successful outcome if a strict anatomic outcome was used (anterior vaginal wall at POP-Q stage 0 or 1). The same study was later re-analyzed by Chmielewski et al. and a more clinically relevant outcome was used with success was defined as (1) no prolapse beyond the hymen, (2) the absence of prolapse symptoms (visual analog scale ≤ 2), and (3) the absence of retreatment. Using this composite outcome definition, 88% of the same subjects were now classified as having a successful outcome. This highlights the importance of which outcome definitions are used in surgical literature regarding prolapse. Weber et al. Am J Obstet Gynecol. 2001 Dec;185(6):1299-304; discussion 1304-6. 2. Chmielewski et al. Am J Obstet Gynecol. 2011 Jul;205(1):69.e1-8.

Question 540

Question 540 of 740 According to the 2012 American Urologic Association Guidelines for evaluation of asymptomatic, microscopic hematuria, all are correct concerning urine sample collection, EXCEPT: A) Transurethral catheterization should be performed, if possible B) A random, midstream clean-catch collection is usually sufficient C) One should obtain a new specimen if a significant number of squamous cells are present D) Urine specimens collected as the first void of the morning should be avoided

Answer 540

A

Question 541

Question 541 of 740 Which of the following are not necessary to ensure a successful ureteral reconstruction? A) Tension free repair B) Internal stent drained repair C) External drainage near anastomosis D) Non absorbable suture repair E) Well vascularized spatulated anastomosis

Answer 541

D Png JC, Chapple CR. Principles of Ureteric Reconstruction. Curr Opin Urol. 2000 May;10(3):207-12

Question 542

For posterior vaginal wall prolapse, which of the following statements in most accurate? A) The vaginal approach is preferred to the transanal approach because of less blood loss B) The vaginal approach is preferred to the transanal approach because of a lower rate of recurrent rectocele C) Graft augmentation with porcine dermis results in improved anatomic outcomes compared to traditional posterior colpoprrhaphy D) Polypropylene mesh augmentation results in improved anatomic outcomes compared to traditional posterior colporrhaphy

Answer 542

B In a Cochrane review, for posterior vaginal wall prolapse, the vaginal approach was associated with a lower rate of recurrent rectocele or enterocele, or both, than the transanal approach (RR 0.24, 95% CI 0.09 to 0.64); although there was a higher blood loss and post-operative narcotic use. No data exist on efficacy or otherwise of polypropylene mesh in the posterior vaginal compartment. In another systematic review of grafts in prolapse surgery, data regarding graft use for posterior and apical compartments were insufficient to determine efficacy. Thus it is not accurate to say that biologic or synthetic mesh/grafts result in improved outcomes compared to traditional posterior colporrhaphy. Maher et al. Cochrane Database Syst Rev. 2010 Apr 14;(4):CD004014. 2. Sung et al. Obstet Gynecol. 2008 Nov;112(5):1131-42

Question 543

Question 543 of 740 Match the procedure to its attachment sites: (1) paravaginal repair, (2) Pereyra needle suspension, (3) Marshall, Marchetti, and Krantz (MMK) procedure, (4) Burch colposuspension with (i) urethrovaginal tissue to Cooper's ligament (pectineal ligament), (ii) urethrovaginal tissue to periosteum of the pubic symphysis, (iii) periurethral tissue to rectus fascia, (iv) endopelvic fascia of anterolateral vagina to arcus tendineus A) 1 with iv, 2 with iii, 3 with i, 4 with ii B) 1 with iv, 2 with iii, 3 with ii, 4 with i C) 1 with i, 2 with ii, 3 with iv, 4 with iii D) 1 with ii, 2 with I, 3 with iii, 4 with iv

Answer 543

B (1) paravaginal repair with (iv) endopelvic fascia of anterolateral vagina to arcus tendineus; (2) Pereyra needle suspension with (iii) periurethral tissue to rectus fascia; (3) Marshall, Marchetti, and Krantz (MMK) procedure with (ii) urethrovaginal tissue to periosteum of the pubic symphysis; (4) Burch colposuspension with (i) urethrovaginal tissue to Cooper's ligament (pectineal ligament) Walters M. (2007). Retropubic Operations for Stress Urinary Incontinence. (M. Walters & M. Karram, Eds.). In Urogynecology and Reconstructive Surgery, 3 edition. (pg. 227-233). Philadelphia. Mosby Elsevier.

Question 544

Question 544 of 740 Fusion of the inferior poles of developing kidneys ultimately form what is commonly referred to as a horseshoe kidney. During ascent of the kidneys, the final position of a horseshoe kidney is at the level of which of the following: A) Hypogastric artery B) Inferior mesenteric artery C) Superior mesenteric artery D) Bifurcation of the aorta

Answer 544

B Campells Urology

Question 545

Question 545 of 740 A women is 3 weeks following a benign abdominal hysterectomy and is diagnosed with a 1 cm. vesico-vaginal fistula (VVF). A true statement is: A) It will be most effectively treated if the surgeon waits at least 3 months until repair. B) There is Level 1 evidence that an abdominal VVF repair is more likely to be successful than a transvaginal approach C) Only transvesical repair will allow for interpositional flaps, if necessary D) There is a high likelihood that the 1 cm size fistula will heal spontaneously. E) Postoperative management will include bladder drainage for 10 -14 days

Answer 545

E Angioli R, Penalver M, Muzii L, et al. Guidelines of how to manage vesicovaginal fistula. Crit Rev Oncol Hematol 2003; 48:295-304.

Question 546

Question 546 of 740 Which of the following is the most common pathogen found in uncomplicated urinary tract infections in premenopausal healthy women? A) Pseudomonas aeruginosa B) Klebsiella pneumoniae C) E. coli D) Ureaplasma urealyticum E) Staphylococcus saprophyticus

Answer 546

C Fihn SD. Clinical practice. Acute uncomplicated urinary tract infection in women. N Engl J Med 2003;349(3):259-266.

Question 547

Question 547 of 740 A patient with cognitive impairment and a history of chronic constipation presents you with a history of daily fecal incontinence of soft-formed stools, not associated bowel urgency. On examination, you note a strong circumferential anal contraction on digital exam. What type of bowel dysfunction is most likely? A) Impaired rectal sphincter B) Sensory dysfunction C) Fecal impaction D) Irritable bowel syndrome E) All of the above

Answer 547

B Doughty DB, Jensen LL. Assessment and management of the patient with fecal incontinence and related bowel dysfunction. In: Urinary and fecal incontinence current management concepts. 3rd Edition, St Louis, MO: Mosby; 2006:458-460.

Question 548

Question 548 of 740 Choose the best treatment regimen for healthy, non-pregnant patients suspected of having pyelonephritis, but not requiring hospitalization. A) 3 day course of oral Trimethoprim-sulfamethoxazole 160/800 mg twice daily B) 7 day course of oral Ciprofloxacin 500 mg twice daily C) 5 day course of oral Nitrofurantoin 100 mg twice daily D) 3 day course of IV Vancomycin 1 g twice daily E) 7 day course of oral Ampicillin 500 mg four times daily

Answer 548

B 3 day course of trimethoprim-sulfamethoxazole and 5 day course of nitrofurantoin are appropriate for acute uncomplicated lower urinary tract infection, not pyelonephritis. IV vancomycin (MRSA-active agent) is not recommended as empirical therapy due to MRSA being an uncommon cause of pyelonephritits. Due to rising rates of ampicillin resistance among gram-negative organisms, it is only recommended when Enterococcus is suspected. The 2010 IDSA guidelines recommend oral ciprofloxacin 500 mg twice daily for 7 days for patients with pyelonephritis not requiring hospitalization. Kalpana Gupta, Thomas M. Hooton, Kurt G. Naber, Bjo ̈rn Wullt, Richard Colgan, Loren G. Miller, Gregory J. Moran, Lindsay E. Nicolle, Raul Raz, Anthony J. Schaeffer, and David E. Soper. International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clinical Practice Guidelines; CID 2011:52, e117.

Question 549

Question 549 of 740 When using a transurethral method for injection of urethral bulking agents for intrinsic sphincter deficiency, what is the optimal location for injection? A) At the urethral meatus at 3 o'clock and 9 o'clock B) At the urethral meatus at 12 o'clock C) Between 1 and 2 cm distal to the bladder neck at 12 o'clock D) Between 1 and 2 cm distal to the bladder neck at 3 o'clock and 9 o'clock

Answer 549

D Various transurethral injection sites are known, including 3 o'clock and 9 o'clock, 4 o'clock and 8 o'clock and circumferential at 3 o'clock, 6 o'clock, 9 o'clock and 12 o'clock. The selected site may be as much as 2 cm distal to the bladder neck but the needle bevel extends 1 cm from the hub, and the site of injection ends up 1 cm distal to the bladder neck. The theory on how injectable materials treat incontinence is by achieving mucosal coaptation, such that injection at just 12 o'clock is not the optimal way to achieve this. Bent A. (2007). Urethral Injection of Bulking Agents for Intrinsic Sphincter Deficiency. (M. Walters & M. Karram, Eds.). In Urogynecology and Reconstructive Surgery, 3 edition. (pg. 227-233). Philadelphia. Mosby Elsevier.

Question 550

Question 550 of 740 A 56 yr old with Stage 3 uterine prolapse presents for discussion of her surgical options. She recently had a negative pap smear (no evidence of vulvovaginal atrophy) but has had infrequent episodes of Postmenopausal bleeding. On examination, her uterus is normal size without any cervical elongation. Pelvic ultrasound shows an endometrial stripe of 1 mm. She is very interested in a uterine preserving procedure without the use of mesh. Choose the correct statement: A) Historically, a Manchester procedure was performed in this situation. B) Due to her history of PMB uterine preservation would require a histologic assessment of her endometrium. C) You should discourage a uterine preserving procedure due to a 13% incidence of uterine pathology secondary to her PMB even if her workup was completely negative. D) You should clearly state that the long term outcome with a uterine preserving procedure would be suboptimal to hysterectomy with repair. E) All the above are correct.

Answer 550

C Frick et al; Am J Obstet Gynecol202(5); 507e501-504

Question 551

In a sacrocolpopexy, which of the following vessels is at highest risk for injury when placing sutures in the presacral space? ``` A) Right external iliac artery B) Right common iliac vein C) Left common iliac artery D) Left common iliac vein ```

Answer 551

D The middle sacral vessels and sacral venous plexus are likely to be the most vulnerable to injury during suture placement in the presacral space. However, there are also great vessels in close proximity to the presacral space. Cadaveric studies show that the left common iliac vein is closest in location to the presacral space near the promontory and thus, the left common iliac vein is at the highest risk for injury when considering the various common, external, and internal iliac arteries and veins. 1. Flynn et al. Am J Obstet Gynecol. 2005 May;192(5):1501-5. 2. Wieslander et al. Am J Obstet Gynecol. 2006 Dec;195(6):1736-41.

Question 552

Question 552 of 740 A patient has the following findings on POPQ examination: Aa = +3, Ba = +3, C=-8.5, TVL = 10, D=-9.5, Ap = -3, Bp = -3, GH = 3, PB = 2. Which of the following statements is correct? A) The patient has uterovaginal pelvic organ prolapse B) The patient has anterior vaginal prolapse C) The patient has a foreshortened vagina D) The patient has a rectocele E) The patient's posterior pelvic organ prolapse is more pronounced than her anterior pelvic organ prolapse

Answer 552

B Bump RC, Mattiasson A, Bo K, Brubaker LP. Am J Obstet Gynecol. 1996;175(1):10-17.

Question 553

Question 553 of 740 Q2. When biofeedback is used to treat fecal incontinence: A) It may include perfusion manometry, surface electromyography, intraanal EMG, and transanal ultrasound B) It should increase the resting anal canal pressures and increase rectal sensitivity C) It has been proven to be better than pelvic floor muscle training or behavioral therapy D) It requires 6 months of training to be effective and no home program is necessary

Answer 553

A Biofeedback improves external anal sphincter, improves rectal sensation and enhances the coordination of the external anal sphincter in response to rectal filling Hayden D and Weiss E. Fecal Incontinence: Etiology, Evaluation, and Treatment. Clin Colon Rectal Surg 2011; 24: 64-70.

Question 554

Question 554 of 740 Involuntary detrusor contractions are during a urodynamic study on a 35 year old female with multiple sclerosis. The best terminology for this is: A) Detrusor instability B) Detrusor hyperactivity C) Neurogenic detrusor overactivity D) Detrusor hyperreflexia E) Phasic Detrusor overactivity

Answer 554

C Abrams P, Cardozo, L, Fall M, Griffiths D, Rosier P, Ulmsten U et al, The Standardization of Terminology of Lower Urinary Tract Function: Report from the Standardization Sub-Committee of the International Continence Society, Neurourology & Urodynamics 2002; 21, 167-178.

Question 555

Question 555 of 740 A 62 year-old woman complains of symptoms of OAB. She has tried behavioral therapy and is not interested in pelvic floor exercises. You decide to treat her with medication. All of the following are well known side effects of the common medications used to treat this problem except for? A) dry eyes B) dry mouth C) constipation D) nasal drip E) hypertension

Answer 555

D Items A, B and C are common anticholinergic side effects; Item E is a side effect warning for mirabegron. reference - product inserts

Question 556

Question 556 of 740 According to AUA Guidelines for Adult Urodynamics, surgeons considering invasive therapy in patients with SUI should do which of the following? A) Assess PVR urine volume B) Routinely perform stress testing with and without a transurethral catheter in place C) Perform the urodynamic testing with the patient standing D) Perform a urethral pressure profile with pressure transmission ratios in at least areas of the urethra

Answer 556

A Guideline statement #2. Surgeons considering invasive therapy in patients with SUI should assess PVR urine volume. (Expert Opinion) AUA Guidelines - Adult Urodynamics

Question 557

Question 557 of 740 Which of the following muscles are least likely to be plicated during a posterior colporrhaphy with perineorrhaphy? A) Ischiocavernosus B) Bulbospongiosus C) Transverse perinei D) Levator ani

Answer 557

A The ischiocavernosus muscles travel under the inferior pubic ramus, between the pubis and ischial tuberosity. Therefore these muscles are not in a location where they are likely to be plicated during a posterior colporrhaphy. The bulbospongiosus and transverse perinei muscles are often intentionally re-approximated in the midline during a perineorrhaphy. Some surgeons may also choose to plicate the levator ani muscles during posterior colporrhaphy. Walters and Karram; Urogynecology and Reconstructive Pelvic Surgery, 3rd ed., Chapters 2 and 20

Question 558

Question 558 of 740 In which patient is single dose fosfomycin for treatment of a urinary tract infection most appropriate? A) A sexually active 21 yr old with 3 days of UTI symptoms and a history of cloacal extrophy B) A sexually active 21 yr old with 10 days of UTI symptoms and a presumed normal urinary tract C) A sexually active 21 yr old with 3 days of UTI symptoms and a presumed normal urinary tract D) A non-sexually active 70 yr old with 3 days of UTI symptoms and a presumed normal urinary tract

Answer 558

C Fosfomycin tromethamine 3 g dose (powder) single dose can be used for the treatment of uncomplicated acute bacterial cystitis. If used, single-dosed therapy should be reserved for young, sexually active women with normal urinary tract who have had symptoms for no more than 1 week. ACOG Practice Bulletin. Clinical Management Guidelines for Obsterician-Gynecologist. Number 91, March 2008.

Question 559

Question 559 of 740 A true statement about Botulinum Toxin A for the treatment of UUI include: A) Side effects are increased PVR, urinary retention and UTIs. B) The duration of effect after one injection may vary. C) The mechanism of action on smooth muscle may differ than what is known about skeletal muscle D) Doses of onabotulinumtoxin A are equivalent to doses of abobotulinumtoxin A E) All the above F) A, B and C

Answer 559

F Silva W.Andre. Pharmacologic Management of Incontinence and Voiding Dysfunction. Pelvic Medicine and Surgery 2005; 11 (1): 1. and Gormley EA, Lightner DJ, Burgio KL. Diagnosis and Treatment of OAB (non neurogenic) in adults: AUA /SUFU Guideline. American Urological Association Education and Research, Inc. 2012

Question 560

Question 560 of 740 The majority of sympathetic innervation of the lower urinary tract comes from: A) Pelvic plexus B) Hypogastric nerve C) Pudendal nerve D) Onuf's nerve E) Alcock's plexus

Answer 560

B Fowler CJ, Griffiths D, de Groat WC. The neural control of micturition. Nat Rev Neurosci 2008; 9:453-66.

Question 561

Question 561 of 740 True statements regarding long term indwelling transurethral catheter management in neurogenic bladder include each of the following except: A) Bladder stone formation is common B) Oncologic surveillance by cytology/ cystoscopy is necessary C) Urethral erosion may occur D) Catheter change every 2 weeks is required E) Bladder wall fibrosis results in low bladder compliance

Answer 561

D Data are insufficient to recommend routine catheter change (e.g. every 2-4 weeks) to prevent catheter associated infections, encrustations, or any other catheter assoicated problem. Hooton TM, Bradley SF, Cardenas D et al. Diagnosis, Prevention, and Treatment of Catheter-Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. IDSA Guidelines 2010; 50: 625-663.

Question 562

Question 562 of 740 Urodynamic testing is most valuable in which patient with overactive bladder symptoms? A) 50 year old with urinary urgency, frequency and rare urine leakage B) 50 year old with history of prolapse and incontinence surgery with gradually increasing urinary frequency and urgency over the last year. C) 60 year old with new onset large volume urinary incontinence with no urgency or other exacerbating factors D) 80 year old with history of dementia who has failed darifenacin treatment

Answer 562

C Urodynamics are not generally needed to make the diagnosis of OAB except in the setting of inconsistent symptoms (mixed urinary incontinence) or sudden onset of symptoms concerning for possible neurogenic etiology.

Question 563

Question 563 of 740 A true statement regarding the use of sacral neuromodulation in the management of FI is A) It has similar reported success rates at one year as it does for the treatment of urgency urinary incontinence B) It has a well known mechanism of action for treating FI C) It has been shown to work better if the lead is placed in S4 v. S3 D) It requires a shorter testing period than is needed when used to treat urinary symptoms E) It has been shown to improve quality of life but has not been shown to reduce the number of FI episodes

Answer 563

A Sacral neuromodulation, InterStim therapy, has been FDA approved for FI. Success rates are similar to rates for UUI and it is still recommended that the lead is placed in S3. A longer testing period is recommended for FI to confirm a >50% improvement in symptoms. Hayden D and Weiss E. Fecal Incontinence: Etiology, Evaluation, and Treatment. Clin Colon Rectal Surg 2011; 24: 64-70

Question 564

Botulinum Toxin Type A acts by: A) Competitive inhibition with acetylcholinesterase B) Inhibiting vesicle docking to prevent acetylcholine release C) Blocking the production of acetylcholine D) Activation of acetylcholine receptors on the postsynaptic nerve terminals

Answer 564

B Inhibiting vesicle docking to prevent acetylcholine release by cleaving SNAP-25. Schiavo G, Santucci A, Dasgupta BR, et al. Botulinum neurotoxins serotypes A and E cleave SNAP-25 at distinct COOH-terminal peptide bonds. FEBS letters. Nov 29 1993;335(1):99-103

Question 565

Question 565 of 740 Proposed mechanisms of action for medications used to treat fecal incontinence include each of the following except A) Inhibition of the excitatory effects of serotonin receptors on neuronal pathways in the bowel B) Binding to bile salts in the small intestine C) Increased alpha adrenergic activity in the smooth muscle of the internal anal sphincter D) Hydroscopic properties that reabsorb fluid from stool E) All of the above are proposed mechanisms of action for medications used to treat fecal incontinence

Answer 565

E alosetron(serotonin receptor antagonist), cholestryramine (bile acid sequestrants),phenelephrine gel (alpha adrenergic agents),and kaopectate (hydroscropic agent) have all been used to treat FI. Wright J, Gebrich A, Albright T. The Management of Anal Incontinence. JPMRS 2006; 12 (3)

Question 566

Question 566 of 740 Which of the following disorders is potentially related to nocturia? A) Restless leg syndrome B) Chronic obstructive pulmonary disease C) Obstructive sleep apnea D) Insomnia E) All of the above

Answer 566

E The Standardisation of Terminology in Nocturia: Neurourology and Urodynamics 00:179-183 (2002)

Question 567

Question 567 of 740 A patient presents to you with a painful area of drainage from the perineal skin. You examine her and note a fistulous tract in a prior obstetrical scar that extends to the mid anus, as well as another inflammatory lesion on the perineal skin that you cannot probe. Your next step is: A) Evaluate for inflammatory bowel disease B) Go to the OR and perform episioproctotomy with reconstruction to repair the fistula C) Incise and drain the area you could not probe D) Go to the OR to excise both fistulous tracts and perform RV fistula repair

Answer 567

A This presentation is likely enough to be Crohn's disease that this diagnosis should be ruled out before any attempt at surgical treatment of the perineum should be undertaken. Novi, JM. JPMS Vol 11(6) Nov/Dec 2005

Question 568

Question 568 of 740 A 60 year-old underwent an apical suspension procedure with a concomitant hysterectomy. She sustained a left ureteral injury intraoperatively. What was the least likely mode of hysterectomy? A) supracervical hysterectomy via laparotomy B) total abdominal hysterectomy C) vaginal hysterectomy D) laparoscopic assisted vaginal hysterectomy E) total laparoscopic hysterectomy

Answer 568

C According to a study examining 142 urinary tract injuries the ureteral injury rate following hysterectomy was: 13.9 of 1000 after laparoscopic, 0.4 of 1000 after total abdominal, 0.3 of 1000 after supracervical abdominal, and 0.2 of 1000 after vaginal hysterectomy. Harkki-Siren P, Sjoberg J, Tiitinen A. Urinary tract injuries after hysterectomy. Obstet Gynecol. 1998;92:113-118

Question 569

Question 569 of 740 Which of the following statements about a normal or Gaussian distribution are true: A) When its mean is 0 and standard deviation 1, it is known as the Standard Normal Distribution or Z Distribution. B) The mean +/- 1 standard deviation includes approximately 33% of all values in the distribution. C) The mean +/- 2 standard deviation includes approximately 96% of all values in the distribution. D) a and c are true E) a, b, and c are true

Answer 569

D Basic & Clinical Biostatistics, 4th ed. Dawson-Saunders B, Trapp RG, eds. Philadelphia: McGraw-Hill, 2004

Question 570

Which statement below best describes patients eligible for non-surgical treatment for symptomatic POP? A) Women greater than 80 years of age B) Women with Stage 1 and 2 prolapse C) Most women with prolapse D) Women with significant medical comorbidities E) Women with anterior compartment defects

Answer 570

C Kapoor DS, Thakar R, Sultan AH, Oliver R. Conservative versus surgical management of prolapse: what dictates patient choice. Intl Urogynecol J 2009;20:1157-1161.

Question 571

The vaginal epithelial incision that best preserves integrity of that tissue layer relative to closure after urethral diverticulum repair is: A) Transverse at the mid urethra B) The inverted U C) Midlin sagittal D) Transverse at the location of the largest loculation of the diverticulum

Answer 571

B Scarpero HM, Urol Clin North Am 2011 Feb 38(1) 65-71

Question 572

A placebo controlled randomized trial evaluating a new drug "No Leak" for overactive bladder is conducted. 300 women with overactive bladder are randomized to either placebo or No Leak and followed for 12 weeks. The primary outcome of the study is the average number of urge urinary incontinence episodes (UUI) per day recorded on a 3-day diary. An important secondary outcome is the proportion of women in each group with dry mouth. At 12 weeks, the number of UUI/day in each group was: Drug No Leak 2.3+4.0; Placebo 4.4+4.0; p s t test D) Log-rank test

Answer 572

C Basic & Clinical Biostatistics, 4th ed. Dawson-Saunders B, Trapp RG, eds. Philadelphia: McGraw-Hill, 2004

Question 573

A 46 year old female is referred to you for urgency, frequency. She states that her symptoms have been present for over a year. She has a distant history of a vaginal hysterectomy and underwent a retropubic sling 3 years ago. Her urinalysis shows microscopic hematuria with 10 RBC/HPF. What is the most appropriate next step? A) Begin anticholinergic therapy B) Begin behavioral therapy C) Perform a diagnostic cystoscopy D) Schedule a Botox bladder injection

Answer 573

C Mesh in the bladder is a known complication after retropubic slings. The combination of irritative voiding symptoms and microscopic hematuria are indications for a diagnostic cystoscopy to evaluate for mesh in the bladder or urethra.

Question 574

Question 574 of 740 The true statement for patients performing prolonged clean intermittent self catheterization (CISC) is: A) Prophylactic antibiotics will decrease the risk for symptomatic UTIs B) Single use catheters decrease the risk of symptomatic UTI's compared with multi-use catheters C) Pyuria accompanying asymptomatic bacteria is an indication for antibiotic treatment D) Gross hematuria does not require further evaluation as it is most likely due to catheter trauma E) More frequent CISC may be necessary in patients experiencing incontinence between catheterization

Answer 574

E Patients with neurogenic bladder requiring CISC may experience overflow incontinence if CISC is not performed on a regular basis. Hooton TM, Bradley SF, Cardenas D et al. Diagnosis, Prevention, and Treatment of Catheter-Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. IDSA Guidelines 2010; 50: 625-663

Question 575

Question 575 of 740 A vesicovaginal fistula is diagnosed 10 days after a laparoscopic hysterectomy. The factor most likely to be related to a successful outcome is: A) Scheduling the patient for immediate repair. B) The fistula is repaired abdominal and not vaginally. C) The vaginal cuff is well healed and not inflamed/ edematous. D) She reports that she only leaks when she is on her feet and not lying down. E) She starts on oral antibiotics and she takes them until her VVF repair.

Answer 575

C

Question 576

Question 576 of 740 Urinary incontinence is most likely to be prevented by which of the following interventions? A) Pelvic floor muscle exercises with biofeedback B) Drinking plenty of fluids to prevent dehydration C) Hormone replacement therapy at the time of menopause D) Elective cesarean delivery E) None of the above

Answer 576

A Only pelvic floor exercises have been shown in prospective trials to prevent onset of urinary incontinenece Diokno AC, Sampselle CM, Herzog AR, et al. Prevention of urinary incontinence by behavioral modification program: a randomized, controlled trial among older women in the community. The Journal of urology 2004;171:1165-71.

Question 577

Question 577 of 740 Which of the following staements regarding behavior therapy for the treatment of urgency urinary incontinence is true? A) Anticholinergic therapy alone is superior to behavior therapy alone B) Anticholinergic therapy in conjunction with behavior therapy is superior to behavior therapy alone C) Anticholinergic therapy in conjuction with behavior therapy is superior to anticholinergic therapy alone D) A and B E) B and C

Answer 577

E One RCT showed behavior therapy with biofeedback to be superior to oxybutinin (Burgio), Combined therapy is superior to behavior alone or drug alone (Burgio 2008 & 2000) Burgio KL, Locher JL, Goode PS, et al. Behavioral vs drug treatment for urge urinary incontinence in older women: a randomized controlled trial. JAMA : the journal of the American Medical Association 1998;280:1995-2000: Burgio KL, Kraus SR, Menefee S, et al. Behavioral therapy to enable women with urge incontinence to discontinue drug treatment: a randomized trial. Ann Intern Med 2008;149:161-9.; Burgio KL, Locher JL, Goode PS. Combined behavioral and drug therapy for urge incontinence in older women. J Am Geriatr Soc 2000;48:370-4.

Question 578

Question 578 of 740 A true statement regarding a β3 adrenergic agent for the treatment of UI is A) It acts on receptors in the urethra releasing acetylcholine B) The effects are via the parasympathetic nervous system C) It is instilled into the bladder D) It has been proven to be superior to antimuscarinics E) It should be used with caution in those with hypertension

Answer 578

E Nitti V, Auerbach S, Martin N, Calhoun A, Lee M et al. Results of a Randomized Phase III Trial of Mirabegron in Patients with OAB. J Urol 2012 December 13 doi: doi:pii: S0022-5347(12)05849-1. 10.1016/j.juro.2012.10.017.

Question 579

Question 579 of 740 Common side-effects associated with pessary use include all of the following except: A) Vaginal discharge B) Vaginal abrasions C) Odor D) Difficult removal E) Vesicovaginal fistula

Answer 579

E Clemons J. Vaginal pessary treatment of prolapse and incontinence. UpToDate®, www.uptodate.com , 2012. Arias BE, Ridgeway B, Barber MD. Complications of neglected vaginal pessaries: case presentation and literature review. Intl Urogynecol J 2008; 19:1173-1178.

Question 580

Question 580 of 740 All of the following are true regarding vaginal apical suspension procedures except: A) Buttock pain that occurs after sacrospinous ligament suspension is best managed expectantly as it usually resolves over time. B) The most common segment of the vagina to recur after sacrospinous ligament suspension is the anterior segment. C) Ureteral kinking or injury requiring a post-operative intervention occurs in 1-11% of cases after a vaginal uterosacral vault suspension. D) The most common complication after a transvaginal mesh apical supension is vaginal mesh erosion/exposure. E) All of the above are correct.

Answer 580

C Margulies (2010);Am J Obstet Gynecol 202 (2) ; 124-134

Question 581

Question 581 of 740 When performing an office simple cystometrogram on a 42 year female with complaints of stress urinary incontinence during running you note that the after instilling 375mL of normal saline, the miniscus suddenly rises and overflows the syringe. The most likely explanation for this is: A) The patient has an uninhibited detrusor contraction B) The patient has poor bladder compliance and requires upper tract evaluation. C) The patient has urodynamic stress incontinence D) The patient has recently taken an anticholinergic invalidating the cystometrogram. E) The syringe is being held higher than the location of the bladder resulting in this finding.

Answer 581

A An office cystometrogram retrogradely fills the bladder with fluid. In a normal bladder, the fluid should instill easily as the bladder is compliant. While a poorly compliant bladder may not allow for a significant amount of fluid to be instilled, the sudden rise that is described resulting in overflow of the syringe is most likely due to a detrusor contraction and the increase in PVes pressure. This could also be explained if the syringe were moved suddenly LOWER than the location of the bladder.

Question 582

Question 582 of 740 Which of the following is not a urodynamic diagnosis based on the ICS Terminology? A) Urodynamic stress incontinence B) Increased sensation C) Terminal detrusor overactivity D) Female stress incontinence

Answer 582

D ICS Terminology

Question 583

Question 583 of 740 Which of the following has NOT been shown to increase the risk of urinary tract infection? A) Sexual activity B) Urethra-to-anus distance C) Hormonal status D) Use of spermicide combined with diaphragm for contraception E) Voiding habits before or after intercourse

Answer 583

B Unmarried sexually active 24-year-old women having intercourse 3 times a week were found to be 2.6 times higher than similar 24-year-olds not having intercourse. Women who use spermicide and diaphragm for contraception have also been found to be at increased risk of UTI. Urethra-to-anus distance in women with UTIs were statistically significant shorter in distance. Hormonal status may also be a factor as women over 60 years have a 10% to 15% incidence of recurrent UTIs. Voiding habits before or after intercourse, douching, wiping patterns, tub bathing, underwear type, bacterial vaginosis, sexually transmitted diseases (STDs), or number of lifetime sexual partners has not been associated with increased UTI. Heisler CA, Gebhart JB. Urinary Tract Infection in the Adult Female. Pathophysiology, Evaluation and Treatment. J Pelvic Med Surg 2008;14:1-14.

Question 584

Question 584 of 740 The following statement is true regarding antimuscarinic medications used to treat UUI: A) Amongst the oral antimuscarinics, those with M3 selectivity have a lower rate of dry mouth than those without M3 selectivity. B) Oxybutynin should have the least effect on cognitive function C) ER formulations have lower rates of dry mouth than IR formulations of both oxybutynin and tolterodine D) There is compelling evidence that anticholinergics such as fesoterodine and solifenacin succinate are more effective than ER formulations of oxybutynin and tolterodine.

Answer 584

C Madhuvrata P, Cody JD, Ellis G, et al. Which antichoninergic drug for overactive bladder symptoms in adults. The Cochrane Collaboration. Wiley Publishers. 2012 and Gormley EA, Lightner DJ, Burgio KL. Diagnosis and Treatment of OAB (non neurogenic) in adults: AUA /SUFU Guideline. American Urological Association Education and Research, Inc. 2012

Question 585

Question 585 of 740 Which of the following anticholinergic medications is available in a transdermal route of delivery? A) Tolterodine B) Darifenacin C) Oxybutynin

Answer 585

C Dmochowski, et al. Efficacy and safety of transdermal oxybutynin in patients with urge and mixed urinary incontinence. J Urol. 2002 Aug;168(2):580-6. Next

Question 586

Question 586 of 740 The incidence of GI injury is increased at total radiation doses of: A) 1,000 cGy B) 10,000 cGy C) 5,000 cGy D) 100 cGy

Answer 586

C A commonly accepted threshold for gastrointestinal injury after radiation is 5,000 cGy total dose. Novi, JM. JPMS Vol 11(6) Nov/Dec 2005

Question 587

Question 587 of 740 A woman complains of urinary retention after a proctectomy. The area/nerve that was traumatized that led to the retention is likely the: A) The pudendal nerve B) The superior hypogastric plexus C) The inferior hypogastric plexus D) The pelvic nerve E) C or D

Answer 587

E Grays Atlas of Anatomy, 2008. Page 260

Question 588

Question 588 of 740 Nocturia is defined as: A) Waking up due to the need to urinate two of more times because of the need to urinate. B) Complaint of interruption of sleep one or more times because of the need to micturate. Each void is preceded and followed by sleep. C) Bothersome nighttime voiding that occurs at least two time per night. D) Waking during the night to void associated with urgency and frequency during the nighttime hours.

Answer 588

B

Question 589

Question 589 of 740 All of the following are contraindications to transureteroureterostomy except? A) History of recurrent stone disease B) Previous ureteral tumor history C) Prior history of radiation therapy and retroperitoneal fibrosis D) Short ureter that precludes a tension free repair E) All of the above

Answer 589

D?? Png JC, Chapple CR. Principles of Ureteric Reconstruction. Curr Opin Urol. 2000 May;10(3):207-12 D absolute, others relative

Question 590

Question 590 of 740 Which of the following findings on cystoscopy is most diagnostic for interstitial cystitis/painful bladder syndrome? A) Glomerulations B) Hunner's lesion C) Normal cystoscopy D) Hypervascularity along the trigone E) Mucosal petechiae

Answer 590

B The AUA has no agreed upon findings that are diagnostic on cystoscopy for IC/PBS. The only consistent finding that leads to a diagnosis is a Hunner's lesion, which is a circumscribed, reddened mucosal area with small vessels radiating toward a central scar area with a fibrin deposit, which was first described in 1918. Glomerulations, petechiae, mucosal bleeding and hypervascularity can all be seen in IC/PBS, as well as several other conditions and are not specific for IC/PBS. The cystoscopy can be normal as well and does not rule out IC/PBS. The International Society for the Study of BPS (ESSIC, European Society for the Study of Interstitial Cystitis) defines sub-types based upon cystoscopic and biopsy findings, including the presence or absence of Hunner's lesions. Interstitial cystitis (IC) with Hunner's lesions is called classic IC as opposed to non-lesion IC in which Hunner's lesions are not found. According to ESSIC, for the documentation of positive signs for the diagnosis of BPS, hydrodistension at cystoscopy was a prerequisite and if indicated a biopsy (to document histologic details of BPS). Cystoscopic features that were accepted as positive signs of BPS were glomerulations grade 2-3 (based upon increased submucosal bleeding following hydrodistension) or Hunner's lesions or both. 1. Hanno PM, Burks DA, Clemens JQ, et al. AUA guideline for the diagnosis and treatment of interstitial cystitis/bladder pain syndrome. J Urol. 2011;185:2162-2170 2. van de Merwe JP, Nordling J, Bouchelouche P, et al. Diagnostic criteria, classification, and nomenclature for painful bladder syndrome/interstitial cystitis: an ESSIC proposal. Eur Urol. 2008;53:60-67

Question 591

Question 591 of 740 Your patient is not a surgical candidate for rectovaginal fistula repair because of surgical co morbidities. You advise her that her small, high vaginal fistula: A) Could have fecal leakage elimated with loop ileostomy B) Has a 90% likelihood of successful closure via use of fibrin glue C) Could be blocked and easily managed with a seton D) May be successfully managed by intentional mild constipation

Answer 591

D

Question 592

In the PESSRI trial, all of the following statements are true except: A) The ring with support pessary performed better than the Gellhorn pessary for the treatment of POP B) The participants were primarily white and postmenopausal C) There was no difference in baseline POPDI and POPIQ scores between groups D) There were statistically significant improvements in both the PFDI and PFIQ scores, in both pessary groups at 12 weeks E) The predominant compartment with prolapse was the anterior compartment

Answer 592

A Cundiff GW, Amundsen CL, Bent AE, Coates KW et al. The PESSRI study: symptom relief outcomes of a randomized crossover trial of the ring and Gellhorn pessaries. Am J Obstet Gynecol 2007;196:405.e1-405.e8.

Question 593

Question 593 of 740 All of the following are appropriate treatment options for neurogenic detrusor overactivity except: A) Anticholinergic medications B) Botulinum toxin bladder injection C) Augmentation cystoplasty D) Bethanecol

Answer 593

D Stohrer M, Blok B, Castro-Diaz D, Chartier-Kastler E, Del Popolo G, Kramer G et al. EAU Guidelines on Neurogenic Lower Urinary Tract Dysfunction. Eur Urol 2009; 56:81-8.

Question 594

Question 594 of 740 Nocturnal polyuria is defined as: A) Nocturnal urine volume >20-30% of total24h urine volume but is age dependent B) Total nocturnal void volume >500mL C) Voiding >1 time per night D) Bothersome nighttime voiding

Answer 594

A The Standardisation of Terminology in Nocturia: Neurourology and Urodynamics 00:179-183 (2002)

Question 595

Question 595 of 740 65 year old Caucasian G6P1, 5 Sab with stage 3 uterovaginal prolapse is scheduled for vaginal hysterectomy with vault suspension and anterior repair. During her preop visit she explains that her sister had DVT and PE during pregnancy. Which of the following statements about her preoperative evaluation are correct? A) She has 2 fold higher risk of bleeding and should have type and cross of 2 units of blood available B) She should receive graduated or intermittent compression stockings for DVT prophylaxis C) The most likely inherited thrombophilia is Factor V Leiden mutation D) She should receive full dose anticoagulation preoperatively E) All of the above

Answer 595

C Recurrent abortions and family history of venous thromboembolism suggest an inherited thrombophilia. Factor V Leiden mutations occur in 5% of the population, thus the most common heritible defect. She is athighest risk for VTE given age >60 and molecular hypercoagulable state requiring low dose heparin or low molecular weight heparin with or without compression stockings for prophylaxis. ACOG practice bulletin #84 2007, Martlew VJ. Peri-operative management of patients with coagulation disorders. Br J Anaesth 2000;85:446-55.

Question 596

A 65 year old female with no prior history of gynecologic problems, normal pap smear 1 year ago and not on hormone therapy. She has stage 3 uterovaginal prolapse and has failed a pessary trial. She reports 2 episodes of spotting for several days on a pad within the last 3 months. She now desires uterine preserving surgical management. Which of the following preoperative testing modalities is the most important test to perform prior to surgical intervention? A) Urodynamic testing to rule out occult stress urinary incontinence B) Abdominal ultrasound to assess endometrial thickness C) Pap smear with HPV testing D) Cystourethroscopy to rule out bladder pathology E) Endometrial biopsy to rule out endometrial pathology

Answer 596

E Occult SUI can be assessed without urodynamics, transvaginal ultrasound is recommened for assessement of endometrial stripe, HPV testing is not indicated at 65 with normal pap smears, cystourethroscoy is indicated for hematuria thus a microanalysis of urine would be recommended first. Endometrial biopsy is recommended to rule out endometrial pathology.

Question 597

Question 597 of 740 You and your colleagues perform a prospective cohort study evaluating a new transurethral injectable bulking agent. 100 patients with stress urinary incontinence are enrolled and a 3-day bladder diary is collected prior to and six-months after the procedure. The mean number of stress urinary incontinence per day (+/- standard deviation) prior to performing the procedure is 4.5+/-2.3. Six months after the procedure the mean number of stress urinary incontinence episodes per day (+/- standard deviation) as recorded on the bladder diary was 2.1+/-2.3. The most appropriate statistical test to determine if there was a significant improvement (p

Answer 597

D Basic & Clinical Biostatistics, 4th ed. Dawson-Saunders B, Trapp RG, eds. Philadelphia: McGraw-Hill, 2004

Question 598

Question 598 of 740 A patient describes fecal staining after her first vaginal delivery. Two years later, her second delivery required vacuum extraction and resulted in distal RV fistula. Your preop workup for fistula repair should include: A) Barium enema B) Endo anal ultrasound C) Defecography D) Urodynamics

Answer 598

B Her prior history and symptoms indicate that evaluation of the anal sphincters is appropriate prior to fistula repair. Novi, JM. JPMS Vol 11(6) Nov/Dec 2005; Brubaker LT, Saclarides TJ. Female Pelvic Floor: Disorders of Function and Support

Question 599

Question 599 of 740 A 47 year old female presents to your office with the complaint of fecal incontinence especially with loose stools. The best recommended treatment option is: A) Increased dietary fiber B) Loperamide C) Diphenoxylate-atropine D) Amitriptyline

Answer 599

B Wald A N Engl J Med 2007; 356:1648-55

Question 600

Question 600 of 740 During placement of the lead for sacral neuromodulation you are not sure if you are getting the appropriate motor responses. You decide to place the test needle one level higher to compare responses. When you test the needle you now see leg rotation. Which foramen was your needle probably in initially? A) S1 B) S2 C) S3 D) S4 E) S5

Answer 600

C S2 stimulation causes leg movement, S3 bellowing of perianal muscles and dorsiflexion of large toe, and S4 just bellowing of perianal muscles. Amend B, Khalil M, Kessler TM, Sievert KD. How does sacral modulation work best? Placement and programming techniques to maximize efficacy. Curr Urol Rep. 2011, 12(5):327-35.

Question 601

Question 601 of 740 Which of the following is a characteristic of a case control study? A) The prevalence of risk factors in sample of subjects who have the disease or condition of interest is compared to that in a separate sample of patients who do not have the disease or condition. B) It is not susceptible to sampling bias and differential measurement bias C) It provides data on disease prevalence D) Cases are defined as patients who have a specific risk factor or undergo an intervention while controls are patients without the risk factor or who did not undergo the intervention.

Answer 601

A Schulz KF, Grimes DA. Case-control studies: research in reverse. Lancet 2002; 359: 431-34

Question 602

Question 602 of 740 During a Burch urethropexy, sutures are attached from the vagina to which ligament? A) Obturator ligament B) Sacrospinous ligament C) Carter's ligament D) Iliopectineal ligament E) Obturator fascia

Answer 602

D Walters and Karram; Urogynecology and Reconstructive Pelvic Surgery, 3rd ed.; Netter's Atlas

Question 603

Question 603 of 740 Obstetrical risk factors associated with the development of fecal incontinence include all of the following except: A) Operative vaginal delivery B) Previous hemorroidectomy C) Anal dilation D) Perineal massage during crowning

Answer 603

D Rao S Diagnosis and Management of Fecal Incontinence. Am J Gastro 2004 Practice Guideline Aug. 1585-1603.

Question 604

Question 604 of 740 Which statement regarding the rectal anal inhibitory reflex (RAIR) is the most accurate? A) The RAIR occurs when relaxation of the rectum leads to reflexive internal sphincter relaxation B) The RAIR occurs when distention of the rectum leads to reflexive internal sphincter relaxation C) The RAIR occurs when distention of the rectum leads to reflexive internal sphincter constriction D) The RAIR occurs when relaxation of the rectum leads to reflexive internal sphincter constriction

Answer 604

B The RAIR occurs when distention of the rectum leads to reflexive internal sphincter relaxation. Presence of this reflex allows for defecation with a full rectum. In patients with Hirschsprung's disease, this reflex does not occur. The RAIR is assessed during anorectal manometry. Walters and Karram; Urogynecology and Reconstructive Pelvic Surgery, 3rd ed., Chapter 25

Question 605

Question 605 of 740 A 57 year old, woman is being treated for severe nocturnal polyuria with DDAVP. She has been using this therapy very effectively for 3 months without any problems. She calls the office complaining of nausea and vomiting. A) Encourage her to drink plenty of fluids to prevent dehydration. B) Recommend she be seen immediately for evaluation including electrolyte assessment. C) Follow up in 3 days if symptoms persist. D) Call in an antiemetic and recommend bland diet for 2 days.

Answer 605

B Weiss JP, Zinner NR, Klein BM, Norgaard JP. Desmopressin orally disintegrating tablet effectively reduces nocturia: results of a randomized, double-blind, placebo-controlled trial. Neurourol Urodyn 2012; 31:441-7.

Question 606

Question 606 of 740 Four months after a proctectomy a woman complains of constant urine leakage. She notes she has to strain to void. During her exam her post-void residual is noted to be 624 mL The structure most likely injured during her surgery is? A) superior hypogastric plexus B) inferior hypogastric plexus C) lower hypogastric plexus D) third sacral nerve E) fourth sacral nerve

Answer 606

B The inferior hypogastric plexus lies lateral to the rectum and is where most autonomic supply to the pelvic organs (including the bladder) passes. Drake RL, Vogl AV, Mitchell AWM, Tibbits. Grays atlas of anatomy. Philadelphia. Elsevier. 2008.

Question 607

Question 607 of 740 A 55 year-old woman underwent a total laparoscopic hysterectomy one month ago. You are seeing her in consultation for new onset urine leakage since her surgery. She reports small spurts of urine leakage throughout the day and night. The leakage does not seem to be related to urgency, coughing, laughing, or sneezing. She is unsure if activity brings on the leakage but she has noticed the leakage seems to be worse in certain positions. You are concerned for a possible vesicovaginal fistula. On your speculum exam you do not visualize any fistula tract in the vaginal epithelium, any notable dimple or area of suspicion for a fistula, but the vaginal cuff still seems to be healing and suture remnants along the cuff closure are still visible. You perform a diagnostic test by retrograde filling the bladder with 300cc of normal saline mixed with an ampule of indigo carmine. When you repeat her speculum exam you still do not visualize an area suspicious for a fistula or any leakage of blue-stained fluid. You place a tampon and have her ambulate and do some provocative maneuvers for 30 minutes. When you remove the tampon it seems to be slightly wet but there is no blue staining. The next best step in management includes any of the following except: A) Repeat the tampon test after administration of phenazopyridine 100mg orally B) Intravenous pyelogram C) Retrograde pyelogram D) Renal ultrasound

Answer 607

D EXCEPT The suspicion in this patient would be for a ureterovaginal fistula given the recent hysterectomy, convincing history for a urinary tract fistula and thus far a negative exam for a vesicovaginal fistula. Either an intravenous or retrograde pyelogram would investigate the integrity of the ureters. If the concern were still high for a vesicovaginal fistula then an IVP would not be ideal as the radio-opaque bladder can obscure any contrast filling in the vagina. A renal ultrasound may show hydronephrosis due to partial obstruction of the ureter involved in the ureterovaginal fistula; however renal ultrasounds can miss up to 20% of ureteral injuries. Karram M. Chapter 35: Lower Urinary Tract Fistulas. In: M. Karram and M. Walters. Urogynecology and Reconstructive Pelvic Surgery 3rd Edition. Philadelphia, PA: Mosby Elsevier; 2007: 445-460

Question 608

Question 608 of 740 75 year old female presents with history of overactive bladder for 10 years. She has been on tolterodine 4 mg with good urge control, but is now undergoing workup for memory loss. Which of the following therapies may be appropriate alternatives to her current regimen? A) Oxybutinin 10 mg extended release formulation B) Oxybutinin 3% gel transdermal preparation C) Solifenacin 5 mg with titration to 10 mg as tolerated D) Trospium XR 60mg E) C or D

Answer 608

D Darifenacin has limited ability to cross blood brain barrier and randomized trials comparing to Oxybutinin have shown negative impact on memory. Although, not shown at 10 mg doses or with transdermal preparation Darifenacin or Trospium may be safer options in those with memory impairment. Trospium is a quartenary amine and does not cross the blood brain barrier. No studies of solifenacin have shown safety with respect to memory and this medication does not have chemical properties that limit crossing of the blood brain barrier. Gormley EA, Lightner DJ, Burgio KL, et al. Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline. The Journal of urology 2012;188:2455-63.

Question 609

Question 609 of 740 A true statement regarding the use of posterior tibial nerve stimulation for the treatment of FI is A) It has a proposed mechanism of action via the femoral nerve B) It has been recently FDA approved for FI C) It may be equally effective in patients with intact anal sphincters as in those with an anal sphincter defect D) It is performed as a staged procedure E) It requires local anesthesia

Answer 609

C PTNS is being evaluated for FI and is not yet FDA approved for this indication. Preliminary studies show similar success in patients with a disruptive anal sphincter as with those with an intact anal sphincter. It is an office procedure performed without anesthesia. Hotouras H, Thata M, Allison M. Percutaneous tibial nerve stimulation in females with fecal incontinence: the impact of sphincter morphology and rectal sensation on clinical outcome. Int J Colorectal Disease 2012; 27: 927=930.

Question 610

Which of the following is considered a C-fiber afferent neurotoxin? A) Resinaferatoxin B) Botulinum toxin A C) Enkephalin D) Substance P

Answer 610

A Capsaicin and resinaferatoxin are C-fiber afferent neurotoxins. Botulinum toxin A is not specific to C-fibers. Enkephalin is an inhibitory neurotransmitter and substance P is an excitatory neurotransmitter. Raz & Rodriguez; Female Urology, 3rd ed., Chapter 3

Question 611

Question 611 of 740 Which of the following is true regarding paravaginal defect repair? A) The procedure requires an abdominal approach B) The goal of the procedure is to improve anterior vaginal wall prolapse by attaching the lateral vaginal walls to the arcus tendineus fascia pelvis (ATFP) C) Level 1 data shows that it results in better anatomic outcomes than anterior colporrhaphy D) If heavy bleeding occurs, it is likely as a result of injury to the inferior gluteal artery

Answer 611

B A paravaginal defect repair can be performed via abdominal, laparoscopic, or vaginal approaches. The goal of the procedure is to improve anterior vaginal wall prolapse by attaching the lateral vaginal walls to the arcus tendineus fascia pelvis (ATFP). Prior to 2013 there were no comparative studies assessing this procedure. However, in 2013 Minassian et al published an RCT comparing anterior colporrhaphy with polyglactin mesh to abdominal PVDR. At 2 years, objective failure rates for the vaginal and abdominal groups were 32% and 40%, respectively, P = 0.56, showing no difference between the two procedures. PVDR requires entry into the retropubic space which typically involves accessory vessels and collateral blood supply related to the obturator artery. The inferior gluteal artery is located superior and just behind the mid-portion of the sacrospinous ligament and thus is prone to injury during SSLF, and not PVDR. Muir TW; J Pelvic Med Surg 2006; 12: 289-305 2. Minassian et al. Neurourol Urodyn. 2013 Mar 18:0. doi: 10.1002/nau.22396. [Epub ahead of print]

Question 612

Question 612 of 740 The following neurologic disorders are associated with fecal incontinence accept: A) Multiple sclerosis B) Parkinson's Disease C) Dementia D) Cauda equine lesions E) Diabetic neuropathy

Answer 612

B Rao S Diagnosis and Management of Fecal Incontinence. Am J Gastro 2004 Practice Guideline Aug. 1585-1603.

Question 613

Question 613 of 740 Physiologic changes that take place during the normal aging process include all of the following EXCEPT: A) Decreased insulin resistance B) Decreased surface area of lung tissue C) Decreased muscle mass D) Decreased immune function

Answer 613

A Erekson EA, Ratner ES, Walke LM, Fried TR. Gynecologic surgery in the geriatric patient. Obstet Gynecol. 2012;119:1262-9.

Question 614

Question 614 of 740 Which of the following structures most directly evolves into the adult kidney? A) Wolffian duct B) Mesonephros C) Metanephros D) Pronephros

Answer 614

C

Question 615

The most common causative uropathogen responsible for community-acquired uncomplicated cystitis is: A) Escherichia coli B) Proteus mirabilis C) Klebsiella penumoniae D) Staphylococcus saprophyticus E) Enterobacteriacaea

Answer 615

A Gupta K et al. Clinical Infectious Diseases 2011;52(5):e103-e1

Question 616

Question 616 of 740 The following features can be assessed or identified by digital rectal examination except: A) anal-canal tone B) contraction of the external anal sphincter C) contraction of the puborectalis D) disruption of the internal anal sphincter

Answer 616

D Wald A N Engl J Med 2007; 356:1648-55

Question 617

Question 617 of 740 A women is referred to you for evaluation of a Stage 2 posterior vaginal wall prolapse (protruding to the level of the hymen). During the interview, the woman states that she has always had one bowel movement per week, and does not perceive a daily urge to defecate. What is your advice? A) Proceed with posterior colporrhaphy to improve defecatory function, but avoid a levator plication as it will likely result in more postoperative pain. B) A traditional posterior colporrhaphy is more likely to improve her defecatory function compared to a site-specific posterior repair C) A site-specific repair is more likely to improve her defecatory function compared to a traditional posterior colporrhaphy D) Her defecatory symptoms are unlikely to be improved by rectocele repair

Answer 617

D The woman describes slow-transit constipation. Repair of a posterior wall vaginal prolapse may aid outlet defecatory symptoms (constipation related to stool trapping or bulge), but slow-transit defecatory symptoms are unlikely to be improved by rectocele repair, regardless of the type of techniques chosen. Walters and Karram; Urogynecology and Reconstructive Pelvic Surgery, 3rd ed., Chapter 20

Question 618

Question 618 of 740 According to data from the CARE Trial, which type of mesh carries the highest risk of erosion after sacrocolpoexy? A) Woven polyester (Mersilene) B) Polypropylene (Prolene) C) Expanded polytrafluoethylene (EPTFE, Gore-Tex) D) None, all types were found to have equal risk of mesh erosion

Answer 618

C Cundiff GW, Varner E, Visco AG, et al. Risk factors for mesh/suture erosion following sacral colpopexy. American journal of obstetrics and gynecology. Dec 2008;199(6):688 e681-685

Question 619

Question 619 of 740 You are seeing a 54 year old woman with stage 3 anterior vaginal wall prolapse. While obtaining her history, she mentions that she does not desire hysterectomy. What is the most appropriate course of action? A) Counsel her on surgical repair of the anterior vaginal wall only, since she does not desire hysterectomy even if she has uterine prolapse B) Assess for concomitant uterine prolapse, since addressing an apical defect will improve outcomes of surgical repair for the anterior vaginal wall C) Tell her that in order to surgically address her prolapse, she will need to reconsider her desires regarding hysterectomy D) Tell her that she is not a candidate for surgical repair unless she first fails pessary management

Answer 619

B Data shows that advanced anterior vaginal wall prolapse is highly correlated with apical prolapse. Thus for a patient with stage 3 anterior prolapse it would be most appropriate to assess for concomitant apical defects in order to maximize outcomes after surgical repair. Even if the patient does not desire hysterectomy, there are multiple surgical options that involve hysteropexy and can address the apical defect without removing the uterus. Although all patients should be offerred non-surgical (pessary) management when counseling about prolapse, it is not required that a woman first fail pessary management in order to be a candidate for surgical repair. Rooney et al. Am J Obstet Gynecol. 2006 Dec;195(6):1837-40. 2. Elliott et al J Urol. 2013 Jan;189(1):200-3.

Question 620

Gonadectomy in patients with Androgen Insensitivity Syndrome is: A) Recommended after puberty B) Recommended at diagnosis, regardless of age C) Not recommended D) Recommended after child-bearing completed

Answer 620

A Romao RL, Salle JL, Wherrett DK. Update on the management of disorders of sex development. Pediatr Clin North Am. 2012;59:853-69.

Question 621

Question 621 of 740 In patients with loose stool FI, each of the following are effective conservative management strategies except: A) Avoidance of broccoli, cabbage, fruit and caffeine B) Reduction in daily fluid intake C) Scheduled defecation D) Use of synthetic cellulose E) Avoidance of laxatives

Answer 621

B Fluid quanity has not been shown to influence either diarrhea/FI or constipation. Wright J, Gebrich A, Albright T. The Management of Anal Incontinence. JPMRS 2006; 12 (3)

Question 622

Question 622 of 740 Which of the following reflexes cannot be assessed during a routine pelvic exam? A) Bulbocavernosus reflex B) Clitoral-anal reflex C) Anal wink reflex D) Rectal anal inhibitory reflex

Answer 622

D This question refers to sacral reflexes that evaluate the spinal cord reflex arc of the pudendal nerve. The bulbocavernosus reflex is assessed by applying a stimulus to the dorsal clitoral nerve and identifying reflex contraction of the bulbocavernosus muscle. The clitoral-anal reflex is another name for this since clitoral stimulation could also result in anal sphincter contraction. The anal wink reflex is elicited similarly but the stimulus is applied to the perianal region. The rectal anal inhibitory reflex (RAIR) is assessed during anorectal manometry and occurs when distention of the rectum results in reflex relaxation of the internal anal sphincter. RAIR cannot be assessed during a routine pelvic exam. Walters and Karram; Urogynecology and Reconstructive Pelvic Surgery, 3rd ed., Chapter 11

Question 623

A study is performed to determine the test characteristics for a new diagnostic test for urinary tract infection (UTI), a rapid PCR test for common uropathogens called RapidUTI. 200 consecutive women with one or more symptoms of urinary tract infection (dysuria, urinary frequency, urinary urgency) presenting to the office for evaluation are enrolled. The urine from all enrolled patients is tested by this new test and a urine culture is collected. Patients are considered as having a UTI if the urine culture demonstrates >100, 000 cfu (criterion or gold standard). The results of the study are summarized below: The sensitivity of the new test, RapidUTI, is: A) 75% B) 87.5% C) 90% D) 95%

Answer 623

A Gala R, Hamilton-Boyles S, Sung VW. SGS Research Handbook - 2nd edition. Fem Pelvic Med Reconst Surg 2011; 17:158-173

Question 624

Anorectal nerve "sampling" is a process which involves: A) Contraction of the internal anal sphincter B) Krause end-bulbs C) Digital rectal examination D) None of the above

Answer 624

B It has been suggested that bowel contents are periodically sensed by anorectal "sampling," the process by which transient relaxation of the IAS allows the stool contents from the rectum to come into contact with specialized sensory organs, such as the Krause end-bulbs, Golgi-Mazzoni bodies and genital corpuscles, and the sparse Meissner's corpuscles and Pacinian corpuscles in the upper anal canal. Incontinence: 4th International Consultation on Incontinence, Paris 4th Edition 2009

Question 625

Question 625 of 740 You and your colleagues are planning a research study to compare a new continence pessary to pelvic muscle exercises with biofeedback for primary treatment of urinary incontinence. The primary outcome measure that you have chosen to compare these to treatments in your study is the mean number of urinary incontinence episodes (UIE) as measured by 7-day bladder diary 3 months after initiating treatment. To determine the appropriate sample size for your study you need all of the following information except: A) Power B) Alpha C) The estimated mean UIE for your two treatment groups D) Kappa statistic E) The standard deviation expected for the two treatment groups

Answer 625

D Gala R, Hamilton-Boyles S, Sung VW. SGS Research Handbook - 2nd edition. Fem Pelvic Med Reconst Surg 2011; 17:158-173

Question 626

Question 626 of 740 According to the 2011 American Urological Association Guidelines, all of the following are necessary for diagnosing interstitial cystitis/painful bladder syndrome, EXCEPT: A) Assessment of baseline voiding symptoms and pain levels B) Office cystoscopy or cystoscopy under anesthesia C) History and physical examination D) Laboratory evaluation, including urinalysis, urine culture, urine cytology

Answer 626

B

Question 627

An 81 year-old underwent a vaginal hysterectomy with vaginectomy and colpocleisis and cystoscopy, with an EBL of 800cc. Operative time was over 4 hours. She has a known history of type 2 diabetes mellitus, coronary artery disease with a prior MI, peripheral vascular disease and mild chronic renal insufficiency. Her preoperative American Society of Anesthesiologists (ASA) classification was 3. Postoperatively she had symptomatic anemia with a hemotocrit of 22% and required a blood transfusion on postoperative day 1, which was complicated by pulmonary edema requiring furosemide for diuresis. The patient's risk factors for these postoperative complications include all of the following except: A) Length of surgical procedure B) History of peripheral vascular disease C) History of coronary artery disease D) ASA classification E) Age

Answer 627

D In a study of 267 urogynecologic surgical patients over 75 years of age, the most common perioperative complications were blood loss or blood transfusion, pulmonary edema and postoperative CHF. Significant risk factors for these complications included length of operative time, coronary artery disease, and peripheral vascular disease and did not include ASA class or Charlson Comorbidity Index. Stepp KJ, Barber MD, Yoo EH, et al. Incidence of perioperative complications of urogynecologic surgery in elderly women. Am J Obstet Gynecol. 2005;192:1630-1636.

Question 628

Risk factors for nerve injury during surgery include all of the following except: ``` A) thin physique B) lithotomy position C) smokers D) operating room time greater than half an hour ```

Answer 628

D Barnett, JC, Hurd, WW, Rogers, RM, Williams, NL, and Shapiro, SA. Laparoscopic positioning and nerve injuries: J Minim Invas Gyn 2007; 14: 664-672.

Question 629

Question 629 of 740 The minimum evaluation necessary before initiating anticholinergic treatment for overactive bladder includes which of the following? A) History and physical examination to rule out contraindications to treatment B) Urine culture C) post void residual by bladder scan or catheterization D) Use of validated symptom questioinnaire to determine bother from symptoms E) All of the above

Answer 629

A Only history, physical and UA are minimum evaluation recommendations per AUA guidelines. Other assessments may be excluded if minimum evaluation is normal. Gormley EA, Lightner DJ, Burgio KL, et al. Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline. The Journal of urology 2012;188:2455-63.

Question 630

Question 630 of 740 Which f the following facets of the past medical history could negatively impact a patients continence and should be factored into the decision process when deciding how to proceed with the evaluation and management of an incontinent patient? A) Remote prior hysterectomy if performed for a benign condition. B) Coexisting mild autoimmune diseases such as rheumatoid arthritis and Hasimoto's thyroiditis. C) Neurologic diseases specifically to include Multiple Sclerosis, spinal cord lesions and stroke. D) Patient medications specifically to include ACE inhibitors and/or statins.

Answer 630

C National Institute for Health and Clinical Excellence: Management of Urinary Incontinence in women 2006. http://www.nice.org.uk/nicemedia/live/10996/30281/30281.pdf Prior hysterectomy for benign conditions is not a risk factor for urinary incontinence and while important for a complete history and physical exam will not alter decisions regarding either the evaluation or management of urinary incontinence. Incontinence following a hysterectomy (within 1-3 weeks ) may suggest a bladder injury and fistula but is not a consideration if perfomed remote from the onset of the incontinence. Coexisting mild autoimmune conditions may limit dexterity but in the initial evaluation should not be a major factor that leads to alterations in the initial decisions regarding evaluation and management. If the disease is severe and limits mobility then it should be considered when making therapeutic decisions but will not effect evaluation of the incontinent female. Neurologic diseases can have a profound effect on the type and severity of incontinence as well as any therapy. They should be explored and well documented in any initial history and physical exam. Medications can have a profound effect on continence but the medications listed while common will have minimal if any effect on continence.

Question 631

Question 631 of 740 A 75 year old women presents to your clinic with uterovaginal prolapse and occasional non-bothersome stress urinary incontinence. Her POP-Q examination reveals stage III prolapse of her anterior and apical compartment. What would be the most appropriate first line treatment in this patient? A) Vaginal hysterectomy, McCall's culdoplasty and midurethral sling B) Vaginal hysterectomy, intraperitoneal colpopexy, and midurethral sling C) Vaginal hysterectomy, LeForte Colpocleisis D) Sacrospinous hysteropexy E) Pessary

Answer 631

E

Question 632

According to the American College of Obstetrics and Gynecology and the American Urological Association, antibiotic prophylaxis is appropriate for the following surgical procedures: Correct answer: F) You chose: E) ``` A) Tension free vaginal tape (TVT) B) Anterior colporrhaphy C) Total vaginal hysterectomy D) Diagnostic laparoscopy E) All of the above F) a, b, c G) a, b ```

Answer 632

F ACOG Committee on Practice Bulletins--Gynecology ACOG practice bulletin No. 104: antibiotic prophylaxis for gynecologic procedures. Obstet Gynecol 2009; 113:1180-9.

Question 633

Question 633 of 740 A 42 year told patient presents with complaints of urinary urgency, usually accompanied by frequency and nocturia, with urgency urinary incontinence. Her urine culture is negative and you find no other reason for her complaints. Which of the following diagnoses is most correct? A) Urinary leakage B) Detrusor instability C) Detrusor overactivity D) Overactive bladder syndrome E) Urinary urgency

Answer 633

D OAB Syndrome is defined as urinary urgency, usually accompanied by frequency and nocturia, with or without urgency urinary incontinence, in the absence of urinary tract infection or other obvious pathology. ICS Terminology

Question 634

Question 634 of 740 Women with which of the following risk factors are less likely to improve with anticholinergic use for overactive bladder: A) Baseline severity of urge urinary incontinence episodes B) Patients with sensory urgency noted on urodynamics C) Women with detrusor instability compared to women without detrusor instability D) Detrusor activity in response to washing hands or running water

Answer 634

D Hartman et al. Treatment of Overactive Bladder in Women. Evidence Report/Technology Assessment Number 187. AHRQ Publication No. 09-E017 August 2009.

Question 635

Question 635 of 740 Which of the following overactive bladder medications have mixed pharmacologic actions? A) Tolterodine B) Trospium C) Solifenacin D) Mirabegron E) Oxybutinin

Answer 635

E Tolterodine, trospium and solifenacin are antimuscarinic compounds, mirabegron is beta receptor agonist. Oxybutinin has mixed smooth muscle relaxant and anticholinergic properties. Thuroff JW, Abrams P, Andersson KE, et al. EAU guidelines on urinary incontinence. European urology 2011;59:387-400. (table 3)

Question 636

Question 636 of 740 Which of the following medications demonstrate level 1 evidence to support use in the treatment of overactive bladder? A) Oxybutinin B) Estradiol C) Terazosin D) Imiprimine E) A, B & C

Answer 636

A Of these options, only oxybutinin has level 1 evidence to support use in OAB. Athough commonly used, all others are level 2 or 3 with no RCTs.

Question 637

Question 637 of 740 Compared to anterior vaginal wall repair using native tissue, anterior repair with _______________ leads to improved anatomic outcomes. A) Biologic graft B) Absorbable synthetic mesh C) Non-absorbable synthetic mesh D) A and C E) A, B and C

Answer 637

E E. A, B and C . This finding is limited to anatomic outcomes. No consistent improvement in quality of life was noted. Further, the authors state that this finding needs to be balanced with increased operative time, greater blood loss, and risk of mesh/graft exposure or erosion. Maher CM, Feiner B, Baessler K, Glazener CM. Surgical management of pelvic organ prolapse in women: the updated summary version Cochrane review. International urogynecology journal. Nov 2011;22(11):1445-1457.

Question 638

You wish to perform a randomized trial. Which of the following statements provides guidelines for the conduct, analysis, and reporting of randomized trials? A) CONSORT B) STROBE C) MOOSE D) PRISMA

Answer 638

A The CONSORT statement provides guidelines for conducting, analyzing, and reporting randomized trials. The STROBE statement provides guidelines for observational studies. The MOOSE statement provides guidelines for meta-analysis of observational studies. The PRISMA statement provides guidelines for reporting of systematic reviews and meta-analyses. www.consort-statement.org; www.strobe-statement.org; www.prisma-statement.org

Question 639

Question 639 of 740 During a laparoscopic procedure, you notice that the Foley bag is filled with air. What is the most appropriate next step? A) Evaluate for a cystotomy B) Reduce the inflation pressure by at least 3mm Hg and check for crepitus C) Administer intravenous indigo carmine and evaluate for a ureteral injury D) Replace Foley catheter with a new catheter that is not cracked

Answer 639

A

Question 640

Question 640 of 740 After an autologous fascial sling the patient immediately complains of burning pain in the upper thigh and labia majora. The nerve that was most likely caught in one of the sutures is: A) Iliohypogastric B) Iliococcygeous C) Ilioinguinal D) Genitofemoral

Answer 640

C

Question 641

Question 641 of 740 A true statement regarding the evaluation of a urogenital fistula is: A) An MRI provides the best evaluation of the condition of the local tissues. B) If urethroscopy does not diagnosis a suspected urethrovaginal fistula, a Tratner catheter may aid in the diagnosis C) A renal ultrasound is better than an intravenous urography for diagnosing concomitant ureteral injury D) A positive IV indigo carmine test diagnoses a vesicovaginal fistula E) A voiding cystourethrogram is the best diagnostic tool for identifying a vesicovaginal fistula

Answer 641

B Karram MM. Lower urinary tract fistulas. In: Walters MD and Karram MM, eds. Urogynecology and Reconstructive Pelvic Surgery. 3rd ed. Philadelphia, Pa: Mosby Inc; 2007: 445-460.

Question 642

Question 642 of 740 Which of the following is TRUE about Burch colposuspension? A) After 5 years, approximately 70% of patients can expect to be dry B) Two sutures are equivalent to 1 suture on each side of the urethra in terms of cure rates C) Adding a hysterectomy to a Burch colposuspension improves the rate of cure for SUI D) Synthetic midurethral slings have a higher cure rates for SUI than Burch colposuspension

Answer 642

A Lapitan MC, Cody JD. Open retropubic colposuspension for urinary incontinence in women. Cochrane Database Syst Rev 2012; 6:CD002912.

Question 643

Question 643 of 740 Odds ratio is best described by what type of study? A) Prospective randomized controlled trial B) Retrospective chart review C) Case control study D) Descriptive study

Answer 643

C Newman TB, Browner WS, Cummings SR, Hulley SB (2007). Designing Cross-sectional and Case-Control Studies in S.B. Hulley, S.R. Cummings,W.S. Browner, D. G. Grady, T.B. Newman (Eds.), Designing Clinical Research (pp.109-121). Philadelphia, PA: Lippincott, Williams & Wilkins.

Question 644

Question 644 of 740 Diffuse bleeding is noted from the presacral space during presacral dissection at the time of sacrocolpopexy. Which energy modality should be used to control bleeding with the least risk of thermal injury to adjacent structures? A) Monopolar vaporization B) Monopolar fulguration C) Monopolar desiccation D) Traditional bipolar cautery E) Ultrasonic coagulation

Answer 644

D Monpolar results in most amount of thermal spread, ultrasonic technology if for vessel sealing and not diffuse bleeding. Bipolar has 2-6 mm of thermal spread

Question 645

Question 645 of 740 The following statement is generally considered true regarding antimuscarinic medications used to treat UUI: A) Among oral antimuscarinics, those with M3 selectivity have a lower rate of dry mouth than those without M3 selectivity. B) Oxybutynin should have the least effect on cognitive function based on the molecular properties of the drug. C) ER formulations of both oxybutynin and tolterodine have lower rates of dry mouth than their IR formulations. D) There is compelling evidence that anticholinergics such as fesoterodine and solifenacin succinate are more effective than ER formulations of oxybutynin and tolterodine.

Answer 645

C Madhuvrata P, Cody JD, Ellis G, et al. Which antichoninergic drug for overactive bladder symptoms in adults. The Cochrane Collaboration. Wiley Publishers. 2012 and Gormley EA, Lightner DJ, Burgio KL. Diagnosis and Treatment of OAB (non neurogenic) in adults: AUA /SUFU Guideline. American Urological Association Education and Research, Inc. 2012

Question 646

Question 646 of 740 Which of the following is associated with a greater risk of upper GU tract problems? A) VLPP >40 B) VLPP 100 D) DLPP>40 E) DLPP<40

Answer 646

D McGuire EJ, Woodside JR, Borden TA Weiss RM, Prognostic value of urodynamic testing in myelodysplastic patients. J Urol 1981; 126: 205-209

Question 647

Question 647 of 740 According to AUA Guidelines for Adult Urodynamics, when making the diagnosis of urodynamic stress incontinence, which of the following are true? A) Assessment of urethral function must be performed B) Assessment of urethral function is discouraged C) Assessment of urethral function should be performed D) Assessment of urethral function may be performed

Answer 647

C Although not a universal finding, poor urethral function, as suggested by lower cough leak point pressure (CLPP), VLPP/ALPP,and/or MUCP tends to predict less optimal outcomes with some types of therapy. AUA Guidelines - Adult Urodynamics

Question 648

Question 648 of 740 Each of the following statements regarding ureteroneocystomy is true EXCEPT: A) They are highly successful with success rates over 90% B) A psoas hitch is often performed at the same time to reduce tension on the anastomosis C) A Boari flap is often used when repairing the most distal ureteral injuries D) A double-J ureteral stent is utilized to protect the anastomotic connection

Answer 648

C A psoas hitch is often performed at the time of a ureteroneocystostomy to reduce tension on the anastomosis and can be used for distal ureteral injuries. If the injury site is more proximal, and the distal end of the ureter can not reach the bladder without tension, a Boari flap may be necessary. Cambell-Walsh Urology, 9th Edition

Question 649

What is the correct description of confounding? A) Another variable in the study is associated with the predictor and a cause of the outcome B) The outcome is actually the cause of the predictor C) The outcome is due to random error D) The outcome is due to systematic error

Answer 649

A Newman TB, Browner WS, and Hulley SB (2007). Enhancing Causal Inference in Observational Studies in S.B. Hulley, S.R. Cummings,W.S. Browner, D. G. Grady, T.B. Newman (Eds.), Designing Clinical Research (pp.127-143). Philadelphia, PA: Lippincott, Williams & Wilkins.

Question 650

Question 650 of 740 Which of the following statements about the urethra is true? A) Normal length is typically 5-6 cm B) Epithelium is mainly cuboidal and transitions to squamous at the bladder neck C) Is composed of inner longitudinal and outer circular layers D) The compressor urethra extends from the bladder neck to proximal urethra and is responsible for passive continence E) The only muscle content consists of skeletal muscle

Answer 650

C Cundiff GW. The pathophysiology of stress urinary incontinence: a historical perspective. Rev Urol 2004; 6 Suppl 3:S10-8.

Question 651

Question 651 of 740 A 42 year old patient 2 days after a retropubic midurethral sling calls the office with fever to 100.5, mild nausea and vomiting and diffuse abdominal pain for the previous 12 hours. She if voiding spontaneously. Which of the following would be the most appropriate next steps? A) Begin ibuprofen 600mg PO tid x 5 days to reduce inflammation. B) Have the patient present for a physical examination and more thorough assessment C) Call in an antibiotic to treat a urinary tract infection. D) Have the patient observe her symptoms and schedule a follow up visit in 1 week if not improved.

Answer 651

B

Question 652

Question 652 of 740 When considering route of sacrocolpopexy, which of the following statements is most accurate? A) Comparative studies have shown faster operating times in robotic sacrocolpopexy compared to laparoscopic sacrocolpopexy B) Comparative studies have shown similar one-year outcomes, regardless of the route of sacrocolpopexy (eg: abdominal, laparoscopic, robotic) C) Comparative studies have shown superior short-term outcomes after robotic sacrocolpopexy compared to other routes D) There are no comparative studies that assess different routes of sacrocolpopexy

Answer 652

B To date, the only RCT comparing route of sacrocolpopexy is by Paraiso et al, which compares robotic to laparoscopic sacrocolpopexy. This study shows longer operating times in the robotic group, and more postoperative pain in the robotic group. However, one year outcomes (anatomic and functional) were similar between groups. Other comparative cohort studies have shown similar short-term and one-year outcomes between abdominal, laparoscopic, and robotic sacrocolpopexy. The robotic approach has not been demonstrated to have faster operating times compared to laparoscopy or superior outcomes compared to other approaches. Thus B is the most accurate answer. Paraiso et al. Laparoscopic compared with robotic sacrocolpopexy for vaginal prolapse: a randomized controlled trial. Obstet Gynecol. 2011 Nov;118(5):1005-13 2. Antosh et al. Short term outcomes of robotic versus conventional laparoscopic sacal colpopexy. Female Pelvic Med Reconstr Surg. 2012 May-Jun;18(3):158-61. 3. Paraiso et al. Laparoscopic and abdominal sacrocolpopexies: a comparative cohort study. Am J Obstet Gynecol. 2005 May;192(5):1752-8. 4. Siddiqui et al. Symptomatic and anatomic 1-year outcomes after robotic and abdominal sacrocolpopexy. Am J Obstet Gynecol. 2012 May;206(5):435.e1-5

Question 653

Question 653 of 740 You are interested in performing a study to determine the prevalence of urinary incontinence in women with multiple sclerosis. Of the following, which is the most appropriate study design to answer this research question? A) Case-control study B) Randomized controlled trial C) Cross-sectional study D) Cross over study

Answer 653

C Designing Clinical Research, 3rd ed. Hulley SB, Cummings SR, Browner WS, et al, eds. Philadelphia: Lippincott Williams & Wilkins, 2007.

Question 654

Question 654 of 740 A surgical colleague routinely asks you to place ureteral catheters for almost all of his abdominal pelvic surgeries so he minimizes ureteral injury risk. You are discussing this with him. The most accurate statement you can say concerning this is: A) Ureteral catheters can identify help prevent ureteric injury B) Ureteral catheters cannot even induce injury in their placement C) Ureteral catheters may only allow better identification of a ureteric injury D) One should routinely place ureteral catheters for all pelvic surgeries

Answer 654

C Bothwell WN, Bleicher RJ, Dent TL. Prophylactic ureteral catheterization in colon surgery. A five-year review. Dis Colon Rectum 1994; 37:330-4.

Question 655

Question 655 of 740 During sneeze-induced stress conditions in rats, the major rise in urethral pressure occurred: A) In the proximal urethra, mediated by parasympathetic nerves B) In the proximal urethra, mediated by sympathetic nerves C) In the middle urethra, mediated by somatic nerves D) In the middle urethra, mediated by visceral nerves

Answer 655

C During sneeze-induced stress conditions in rats, the major rise in urethral pressure occurred in the middle urethra and was mediated by efferent pathways in the pudendal nerve to the external urethral sphincter (somatic efferents). Raz & Rodriguez; Female Urology, 3rd ed., Chapter 3

Question 656

Question 656 of 740 Which of the following are true statements regarding the receptors and mediators involved with medications treating urinary symptoms: A) β3 adrenergic medications act on β3 receptors in the bladder releasing norephiphrine B) Selective norephinephrine and serotonin uptake inhibitors increase the amount of norephinephrine and serotonin present in the somatic nucleus (Onuf's nucleus) in the spinal cord C) Tricyclics antidepressants are thought to have various sites of action including muscarinic receptors in the bladder, serotonin and norephinephrine nerve terminals in Onuf's nucleus and the pontine micturition center. D) Alpha 1 antagonists block norephinephrine activity in the urethra E) All of the above

Answer 656

E Silva WA. Pharmacologic Management of Incontinence and Voiding Dysfunction. Pelvic Medicine and Surgery 2005; 11 (1): 1.

Question 657

Question 657 of 740 A 66 year-old patient underwent a laparoscopic supracervical hysterectomy, bilateral salpingo-oophorectomy, mesh sacral colpopexy with extensive adhesiolysis and enterolysis and cystoscopy. She calls into the office on postoperative day 6 complaining of acutely worsening abdominal pain, chills and fever to 101 and nausea with 1 episode of emesis this morning. You decide to advise her to go immediately to the emergency room for evaluation, as you are concerned for a possible bowel injury. What is the least likely mechanism of thermal injury to the bowel in this patient? A) The electric current of the monopolar scissors arced to the nearby bowel from the fimbriae of one of the fallopian tubes during the hysterectomy. B) The electric current arced from the monopolar scissors to the nearby fenestrated grasper retracting the bowel during the sacral dissection. C) Thermal spread extended to the nearby bowel from the bipolar instrument when coagulating a vascular pedicle during enterolysis. D) An interruption in the insulating sheath of the monopolar scissors caused electric current to pass through the nearby bowel adjacent to the shaft of the instrument during the hysterectomy. E) The electric current passed through the nearby bowel to complete the electric current cycle from the bipolar instrument to the return electrode grounding pad during enterolysis.

Answer 657

E With monopolar surgery, the electric current cycle is completed from the instrument to a grounding electron reservoir via the path of least resistance, which is generally the return electrode grounding pad (example: conventional Bovie®). In bipolar surgery the electric current is confined between the two electrodes of the surgical instrument (example: LigaSure™). Soderstrom R, Brill A. Chapter 15: Principles of Electrosurgery as Applied to Gynecology. In: H. Jones (ed.). TeLinde's Operative Gynecology 10th Edition. Philadelphia, PA: Lippincott Williams & Wilkins; 2008: 280-297

Question 658

Question 658 of 740 Select the factor that is LEAST likely to directly impact on baseline anal sphincter resting tone: A) Rectal compliance B) Pudendal nerve innervation C) Internal anal sphincter function D) External anal sphincter function E) Puborectalis muscle function

Answer 658

A Rao SSC. Clin Gastroenterol Hepatol 2010;8:910-919.

Question 659

Question 659 of 740 Which of the following urodynamic measurements is most suggestive of intrinsic sphincter deficiency: A) MUCP=40 B) MUCP=10 C) DLPP=30 D) VLPP=110 E) Pura=40

Answer 659

B McGuire EJ, Fitzpatrick CC, Wan J, Bloom D, Sanvordenker J, Ritchey M, et al, Clinical assessment of urethral sphincter function, The Journal of Urology 1993; 150, 1452-1454

Question 660

Question 660 of 740 A true statement regarding the evaluation and treatment of patients with neurogenic fecal incontinence is A) The physical examination will provide the precise diagnosis of the neurogenic bowel dysfunction B) Assessment of fine motor skills, balance and ability to transfer to toilet will help tailor treatment C) Those with a peripheral nerve injury will likely benefit from digital rectal stimulation therapy D) Suprasacral spinal cord injured patients have sphincteric incompetence E) Transrectal fluid enemas are considered 2nd line therapy

Answer 660

B Various neurologic conditions can be associated with fecal incontinence and evaluating functional and environmental factors may help with treatment Abrams P, Andersson K, Birder L et al. Fourth International Consultation on Incontinence Recommendations of the International Scientific Committee: Evaluation and Treatment of UI, POP and FI. Neurourology and Urodynamics 2010; 29: 213-240. Next

Question 661

``` Question 661 of 740 Which of the following class of pharmacologic agents could be a treatment for stress urinary incontinence? ``` A) Alpha adrenergic agonist B) Alpha adrenergic antagonist C) Beta adrenergic agonist D) Beta adrenergic antagonist

Answer 661

A Alpha adrenergic agonists stimulation would result in increased urethral contraction. Alpha antagonists may worsen SUI. Beta receptors mediate bladder storage and thus would not improve stress urinary incontinence.

Question 662

Question 662 of 740 What is the best imaging study for assessment of urethral diverticulum? A) IVP B) MRI C) CT-Urogram D) Voiding cysto-urethrogram

Answer 662

B Huber L, Siddighi S. Urogynecology and Female Pelvic Reconstructive Surgery, New York, McGraw Hill 2006, p77-83.

Question 663

Question 663 of 740 In women with uncomplicated stress urinary incontinence, prior to proceding with surgical treatment, which of the following is the LEAST critical component of the office evaluation? A) Positive result on provocative stress test B) Normal postvoiding residual volume C) Urodynamic testing with fluroscopy D) Confirmation of absence of bladder infection

Answer 663

C In a multicenter, randomized trial of women with uncomplicated, demonstrable stress urinary incontinence undergoing midurethral sling, when preoperative office evaluation with urodynamic tests was compared with preoperative office evaluation only, treatment success at 12 months, preoperative office evaluation alone was not inferior to evaluation with urodynamic testing. Nager CW, Brubaker L, Litman HJ, et al. A randomized trial of urodynamic testing before stress-incontinence surgery. N Engl J Med 2012;366:1987-97. PMID: 3386296.

Question 664

Question 664 of 740 Which symptom or sign is NOT a finding in autonomic dysreflexia? A) Sweating B) Flushing C) Hypertension D) Tachycardia

Answer 664

D Clinical Practice Guideline: Bladder management for adults with spinal cord injury: a clinical practice guideline for health-care providers. J Spinal Cord Med 2006; 29:527-73.

Question 665

Question 665 of 740 With respect to surgical intervention in elderly women, which if the following statements is true? A) Women 80 years and above have a 13.6 fold increased odds of death from surgery compared to those under 60 B) Delerium may occur in 17% of elderly women undergoing surgery C) Untreated pain is a leading cause of delerium in elderly patients D) Elderly patients are at high risk of falls and fractures. E) All of the above

Answer 665

E Erekson EA, Ratner ES, Walke LM, Fried TR. Gynecologic surgery in the geriatric patient. Obstetrics and gynecology 2012;119:1262-9.Sung VW, Weitzen S, Sokol ER, Rardin CR, Myers DL. Effect of patient age on increasing morbidity and mortality following urogynecologic surgery. American journal of obstetrics and gynecology 2006;194:1411-7.

Question 666

Question 666 of 740 Ectopic ureters are thought to be caused by which of the following embryologic mechanism? A) Ureteric bud arising too low on the nephric duct B) Ureteric bud arising too high on the nephric duct C) Failure of the ureteric bud to induce metanephric meschyme D) Failure of the ureteric bud to form

Answer 666

B Campells Urology

Question 667

Question 667 of 740 A 54-year old woman with a history of radiation for endometrial cancer 2 years prior presents with an enterovaginal fistula at the midvagina. She is interested in surgical repair. The single most important part of the preoperative evaluation and planning is: A) Ultrasound to assess the integrity of the sphincter B) Planning of a temporary diverting colostomy C) Biopsy of the fistula D) MRI to determine what part of the bowel is communicating E) Colonscopy to assess for Inflammatory Bowel Disease

Answer 667

C Saclarides TJ, Rectovaginal Fistula. Surg Clin N Am 2002; 82: 1261-72

Question 668

Question 668 of 740 You are seeing a 40 year-old woman in consultation for urinary incontinence. You diagnose her with a urethrovaginal fistula. What procedure in her prior surgical history is the least likely to have caused the urethrovaginal fistula? A) urethral diverticulectomy B) Burch retropubic urethropexy C) mid-urethral mesh sling D) anterior colporrhaphy E) outlet forceps delivery

Answer 668

E Case series have shown that the procedures most associated with urethrovaginal fistula are urethral diverticulectomy, anterior colporrhaphy, and stress incontinence procedure. Obstetric procedures are rarely associated with urethrovaginal fistulas, accounting for

Question 669

Question 669 of 740 According to the 2011 American Urological Association Guidelines, all the following are considered treatments that should NOT be offered for treatment of interstitial cystitis/painful bladder syndrome, EXCEPT: A) Long-term oral antibiotic administration B) High-pressure, long duration hydrodistension C) Intravesical instillation of resiniferatoxin D) Intradetrusor botulinum toxin A administration

Answer 669

D Explanation: Intradetrusor botulinum toxin A administration can be offered as a fifth line treatment if other treatments have been ineffective in attaining symptom control. Patients must be willing to accept the possibility that post-treatment intermittent self-catheterization may be necessary.

Question 670

Question 670 of 740 A 61 year old undergoing midurethral sling should receive which prophylaxis regimen for prevention of DVT? A) Low molecular weight heparin 5000 U or 40 mg enoxaparin daily until 2 weeks post op B) Intermittent pneumatic compression device C) Graduated compression stockings D) Early and aggressive mobilization

Answer 670

B Because she is >60, needs intermittent compression device or low dose unfractionated heparin (5000 q 8 hr) or low molecular weight heparin (i.e. enoxaparin 40 mg daily) ACOG practice bulletin #84, AUG 2007 Table 1

Question 671

Question 671 of 740 Which of the following scenarios are contraindications to medical therapy for urinary incontinence therapy? A) Solifenacin in a 50 year old woman with wide angle glaucoma B) Mirabegron in a 65 woman with supraventricular tachycardia C) Imiprimine in a 45 year old woman on selegiline, a MAO inhibitor, for major depression D) Oxybutinin in a 70 year old woman with history of heart failure E) None of the above

Answer 671

C Selegiline is an MAO inhibitor and is contraindicated with Tricyclic antidepressants. Antimuscarinics are contraindicated in NARROW angle glaucoma and SVT, gastric emptying problems and relatively contraindicated in urinary retention, mirabegron is contraindicated in uncontrolled hypertension Package inserts for medications.

Question 672

The most common cause of rectovaginal fistula in the US is: ``` A) Crohn's disease B) Childbirth injury C) Ulcerative colitis D) Pelvic radiation ```

Answer 672

B 90% of US rectovaginal fistulae are due to childbirth related vaginal injury. Novi, JM. JPMS Vol 11(6) Nov/Dec 2005

Question 673

Question 673 of 740 A 29 year old female Gravida 1 Para 1 who presents to your office 12 weeks after a vaginal delivery complicated by a fourth degree tear reporting continued leaking of solid stool at least 2 to 3 times per week. Digital examination reveals a healed perineum, normal sensation but a weak voluntary anal sphincter squeeze strength and duration. You decide to perform an endoanal ultrasound which shows a defect in the external anal sphincter from the 9 to 3 o'clock position. The most likely treatment plan should include: A) Postanal repair B) Overlapping sphincteroplasty C) Sacral neuromodulation D) Kegel muscle exercises

Answer 673

B Abrams P, Cardozo L , Khoury S, Wein A. Incontinence. Committee 17 Surgery for Faecal Incontinence. Paris. Health Publication Ltd. 2009. 1387-1417.

Question 674

Question 674 of 740 Failure of the ureteric bud to invade into the condensing blastema of metaneprhic mesenchyme prevents which of the following structures to develop? A) Ureter B) Urethra C) Bladder D) Trigone E) Kidney

Answer 674

E Campells Urology

Question 675

Question 675 of 740 78 year old with long standing history of urinary incontinence has been on multiple anticholinergic medications. She continues to have urinary frequencya and unconscious urine loss and on examination has decreased peripheral lower extremity sensation, absent bulbocavernosus and anal reflexes but normal perineal sensation. She has no prolapse and has a positive stress test. She voids only 100 mL and has a post void residual of 750 mL. Urodynamics show delayed sensation, no detrusor overactivity and an atonic bladder during voiding phase. What is the next best treatment strategy? A) Clean intermittent self catheterization 4 times a day with measured voids and residuals. B) Placement of indwelling foley catheter to decompress the bladder C) Trial of neuromodulation with Sacral neuromodulation (Interstim) D) Stop anticholinergic medications and see if atony resolves in 1 week E) Begin trial of tamulosin 0.4 mg once daily to facilitate urethral relaxation and decrease retention.

Answer 675

A Indwelling foley catheters are not recommended due to higher rates of infection. Although interstim is approved for retention a complete workup of her atony and neurologic findings would be appropriate before proceeding with implantation procedures. It is unlikely that anticholinergics alone are causing her level of urinary retention and to resolve her urine leakage from overflow and immediately treat the retention she needs to learn CISC. Flomax is not indicated for urinary retention in women and given atony on urodynamics this is an unlikely etiology.

Question 676

Question 676 of 740 An advantage of bilateral uterosacral ligament colpopexy is that it does not: A) require post-procedure cystoscopy B) result in post-operative dyspareunia C) create any significant distortion of the vaginal axis D) increase the risk of post-procedure stress urinary incontinence E) require opening the peritoneal cavity

Answer 676

C Shull BL, Bachofen C, Coates KW, Kuehl TJ. A transvaginal approach to repair of apical and other associated sites of pelvic organ prolapse with uterosacral ligaments, Am J Obstet Gynecol 2000; 183:1365-73; discussion 1373-4.

Question 677

Question 677 of 740 The physical examination in a woman with fecal incontinence should include all of the following except: A) Abdominal examination B) Vaginal examination C) Anorectal examination D) A provocative stress test E) Assessment of motor and sensory innervation

Answer 677

D Omotosho TB, Rogers RG. Evaluation and Treatment of Anal Incontinence, Constipation, and Defecatory Dysfunction. Obstet Gynecol Clin N Am 2009;36:673-697.

Question 678

Question 678 of 740 Which of the following statements from the AUA IC guidelines is false? A) Patients should be counseled to the nature of IC and its diagnosis and therapy options B) Patients undergoing cystoscopy and hydrodistention should have this done for a minimum of 10 minutes at 80-100cm H20 pressure C) If a patient has a severe and fibrotic bladder on early evaluation, one can proceed directly to more invasive surgical therapy such as cystectomy and diversion D) BCG intravesical therapy for interstitial cystitis is not suggested E) B and C

Answer 678

E Hanno PM, Burks DA, Clemens JQ, et al. AUA guideline for the diagnosis and treatment of interstitial cystitis/bladder pain syndrome. J Urol 2011; 185:2162-70.

Question 679

Question 679 of 740 A 28 year-old woman presents to the office with complaints of urinary frequency and dysuria, what colony count on a clean catch urine culture is adequate to initiate antibacterial therapy? A) 10 CFU/mL B) 100 CFU/mL C) 1,000 CFU/mL D) 10,000 CFU/mL E) 100,000 CFU/mL

Answer 679

C American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No 91: treatment of urinary tract infections in nonpregnant women. Obstet Gynecol 2008;111:785-794.

Question 680

Question 680 of 740 Your patient has a rectovaginal fistula. Historical elements that increase the risk of fistula include: A) Posterior vaginal permanent mesh B) Forceps vaginal delivery C) Ulcerative colitis D) A and B E) All of the above

Answer 680

D Ulcerative colitis is not associated with RV fistula because it is not a transmural inflammation. Novi, JM. JPMS Vol 11(6) Nov/Dec 2005, Choi JM, FPMRS 2012, 18:366-371

Question 681

Question 681 of 740 Which of the following blood vessel follows a path that includes leaving the pelvis through Alcock's canal? A) Inferior vesical artery B) Inferior rectal artery C) Pudendal artery D) Obturator artery

Answer 681

C

Question 682

Question 682 of 740 65 year old obese G2P2 s/p TVH, USLVS, A&P repair with TVT sling and cystourethroscopy on POD#1 she complains of inability to walk, ankle weakness and numbness of top of foot and lateral lower leg. She has normal patellar reflexes and normal hip extension and knee flexion. What nerve is most likley involved in this injury? A) Sciatic Nerve B) Femoral Nerve C) Peroneal nerve D) Tibial nerve E) Lateral Femoral Cutaneous Nerve

Answer 682

C Sciatic nerve injury would have pain down back of leg and weak hip extension, Femoral would have absent patellar reflexes and weak knee extension, Lateral femoral cutaneous would be numb lateral thigh w/o weakness and tibial would be absent Tibial would be foot drop with posterior calf numbness. Wieslander CKB, M.K.; Phelan, J; Schaffer, J.I.; Corton, M.M. . Video: Avoiding nerve injury during gynecologic surgery. J Pel Med Surg 2005;11:S54.

Question 683

Question 683 of 740 Which of the following are true regarding pudendal nerve terminal motor latency (PNTML) studies? A) The use of PNTML testing is mainly limited by the high cost of the study B) The use of PNTML testing is mainly limited by the availability of trained personnel C) The use of PNTML testing is mainly limited by difficulty in learning the protocol D) The use of PNTML testing is mainly limited by the inability to measure the distance over which a stimulus travels and the lack of prognostic value

Answer 683

D PNTML is a type of nerve conduction study that can be performed in any electromyography laboratory. The method is relatively easy to learn. It is mainly limited by the fact that nerve conduction studies rely on knowledge of both a) the time it takes for a stimulus to generate an action potential and b) the distance over which the stimulus travels. This distance should include only the studied nerve and not the neuromuscular junction or muscle. In measuring PNTML, the distance over which the stimulus travels is difficult to measure because of the inaccessible and circuitous route of the pudendal nerve. In addition, the stimulus must travel through the neuromuscular junction and muscle. Thus it is difficult to ascertain if "prolonged latency" relates to different distances, neuromuscular junction transmission, muscle mass, or true nerve damage, which limits it's prognostic value. Walters and Karram; Urogynecology and Reconstructive Pelvic Surgery, 3rd ed., Chapter 11

Question 684

Question 684 of 740 36 yo G3P3 presents with pain and bleeding during intercourse. She denies urinary or fecal incontinence. Her history is significant for an unrepaired 4th degree laceration 9 years ago. Examination reveals a cloaca. The mechanism which allows her to remain fecally continent is: A) Intact rectoanal inhibitory reflex (RAIR) B) Increased internal anal sphincter pressure C) Increased puborectalis tone D) Increased anorectal angle

Answer 684

C Bent AE, Cundiff GW, Swift SE. Ostergards urogynecology and pelvic floor dysfunction. 6th ed. Lippincott Wiliams & Wilkins 2008, 357-369.

Question 685

Question 685 of 740 Which of the following causes of incontinence in the elderly is the least likely to be reversible? A) Delirium B) Infection C) Dementia D) Atrophic urethritis E) Stool impaction

Answer 685

C The pneumonic DIAPPERS indicates reversible causes of incontinence in the elderly. These include: Delirium, Infection, Atrophic urethritis, Pharmacalogical, Psychiatric, Endocrine, Restricted Mobility, Stool impaction. Dementia is a risk factor for detrusor overactivity and urgency incontinence but is not reversible. Dunn et al. J Pelvic Med & Surgery 2004; 10(2): 43-51

Question 686

Question 686 of 740 Stress urinary incontinence is determined by which of the following? A) Multichannel urodynamic testing B) Single chanel urodynamic testing C) Obtaining a careful history from the patient D) Q-tip testing E) Pad weigh testing

Answer 686

C Stress incontinence is the complaint of involuntary loss of urine on effort or physical exertion ICS Terminology

Question 687

The following suggests a developmental anomaly of the urogenital tract EXCEPT: A) Primary amenorrhea B) Delayed development of secondary sexual characteristics C) Cyclic abdominal and pelvic pain D) Menorrhagia E) Dyspareunia

Answer 687

D Gidwani G, Falcone T. Congenital Malformations of the Female Genital Tract: Diagnosis and Management. Philadelphia (PA): Lippincott Williams & Wilkins, 1999.

Question 688

Question 688 of 740 Relative risk and incidence are best described by what type of study? A) Case control Study B) Cohort study C) Meta- analysis D) Retrospective chart review

Answer 688

B Source: Newman TB, Browner WS, Cummings SR, Hulley SB (2007). Designing Cross-sectional and Case-Control Studies in S.B. Hulley, S.R. Cummings,W.S. Browner, D. G. Grady, T.B. Newman (Eds.), Designing Clinical Research (pp.109-121). Philadelphia, PA: Lippincott, Williams & Wilkins.

Question 689

Question 689 of 740 In randomized trials, allocation concealment is important because it: A) Investigators may look more aggressively for a particular outcome if they know which treatment the subject received B) Minimizes intentional or unintentional recruitment bias C) Allows for intention to treat analyses D) Minimizes recall bias

Answer 689

B "Blinding" of investigators in a method to prevent them from knowing which treatment a subject received, and thus prevents investigators from looking more aggressively for particular outcomes with particular subjects. Allocation concealment occurs when the person who is enrolling a participant into a clinical trial is unaware whether the next participant to be enrolled will be allocated to the intervention or control group. This minimizes intentional or unintentional recruitment bias because investigators cannot preferentially enroll subjects with a more favorable prognosis when they know that they will be assigned to a specific group. Intention-to-treat analysis is a method of analyzing any randomized trial (regardless of how subjects are recruited). In intention-to-treat analyses patients are analyzed based on their randomization assignment, regardless of whether they completed or received that treatment. Recall bias occurs when recalling information from the past. If a subject is asked to complete information (e.g. a quesionnaire or data form) regarding events from the past, this may be subject to recall bias. Strauss et al. Evidence-Based Medicine: How to Practice and Teach EBM, 3rd ed.

Question 690

Question 690 of 740 True statements regarding autonomic dysreflexia include each of the following except: A) It is an exaggerated parasympathetic response that can be evoked from any stimulation below the level of injury B) Patients more prone to experience this condition have spinal cord injuries above T5 C) The dysreflexia occurs due to lack of inhibitory impulses from the brainstem D) It may require treatment with nifedipine E) Signs and symptoms can include bradycardia and headache

Answer 690

A This syndrome is secondary to loss of supraspinal inhibitory control of a thoraolumbar smpathetic outflow and results from massive discharge of the sympathetic system. Amis ES and Blaivas JG. Neurogenic Bladder Simplified. In: Radiologic Clinics of North America 1991; 29 (3): 571-580.

Question 691

Question 691 of 740 28 year old female with a T7 Spinal cord injury currently manages her bladder with intermittent catheterization q 3-4 hours and oxybutynin ER 20 mg daily. Work-up including urodynamics confirmed detrusor overactivity and detrusor sphincter dyssynergia. She tried higher doses of oxybutynin which helped but did not resolve her incontinence plus she could not tolerate the side effects. The next best option would be: A) Botulinum toxin detrusor injection of 200 units B) Adding tamsulosin to oxybutynin ER 20mg C) Adding bethanecol to oxybutynin ER 20mg D) Botulinum toxin detrusor injection of 100 units E) Interstim implant for Sacral nerve modulation therapy

Answer 691

A Ginsberg D, Gousse A, Keppenne V, et al, Phase 3 Efficacy and Tolerability Study of Onabotulinumtoxin A for Urinary Incontinence From Neurogenic Detrusor Overactivity, Journal of Urology, 2012, Volume 187, , Pages 2131-2139

Question 692

Question 692 of 740 In the Colpopexy and Urinary Reduction Efforts (CARE) trial, which of the following was NOT associated with a higher risk of mesh erosion? A) Concurrent smoking B) Concurrent hysterectomy C) Polypropylene mesh D) Expanded polytrafluoroethylene mesh

Answer 692

C In the CARE trial, mesh erosion was associated with concurrent smoking (OR 5.2) and concurrent hysterectomy (OR 4.9). Expanded polytrafluoroethylene mesh was also associated with a higher risk of mesh erosion (OR 4.2). Polypropylene mesh is the most commonly used mesh material for colpopexy and was not associated with an elevated risk of erosion compared to other materials. Cundiff et al. Am J Obstet Gynecol. 2008 Dec;199(6):688.e1-5

Question 693

Question 693 of 740 Strategies to help reduce confounders during the analysis phase include everything except A) Stratification B) Statistical Adjustment C) Propensity Scores D) Suppression

Answer 693

D Newman TB, Browner WS, and Hulley SB (2007). Enhancing Causal Inference in Observational Studies in S.B. Hulley, S.R. Cummings,W.S. Browner, D. G. Grady, T.B. Newman (Eds.), Designing Clinical Research (pp.127-143). Philadelphia, PA: Lippincott, Williams & Wilkins.

Question 694

Question 694 of 740 Which of the following study designs provides the weakest level of evidence? A) Case-control B) Case series C) Retrospective Cohort D) Randomized Controlled Trial

Answer 694

B

Question 695

Question 695 of 740 During a Burch urethropexy, bleeding was encountered in the left retropubic space. While attempting to provide adequate exposure, large retractors were necessary to achieve hemostasis. Unfortunately, a compression injury occurred. The following day the patient noticed that she was unable to adduct her left leg. Which of the following nerves was most likely to be injured? A) Pelvic nerve B) Obturator nerve C) Pudendal nerve D) Genitofemoral nerve E) Ilioinguinal nerve

Answer 695

B McBride AW, et al. Journal of Pelvic Medicine and Surgery. Volume 9, Number 3, May/June 2003

Question 696

Question 696 of 740 The variable that is most consistently associated with unsuccessful pessary fitting is: A) Stage 4 prolapse B) Presence of a rectocele C) Small genital hiatus D) Previous hysterectomy E) Intravaginal estrogen usage

Answer 696

D Clemons J. Vaginal pessary treatment of prolapse and incontinence. UpToDate®, www.uptodate.com , 2012.

Question 697

Question 697 of 740 You perform an uncomplicated transobturator mesh sling in a 52 year healthy female with pure stress incontinence. Which of the following statements is true? A) A cystoscopy is recommended to confirm that both the bladder and urethra are intact. B) Randomized trials have shown that continence rates are lower than with retropubic slings C) Cystoscopy is only indicated after retropubic slings. D) The risk of hemorrhage is higher than with a retropubic sling

Answer 697

A

Question 698

Question 698 of 740 Which of the following is considered a COMPLEX rectovaginal fistula by the Tsang classification? A) Low (distal) vagina B) Size 2.0 cm C) After 4th degree obstetric laceration D) Associated with Crohn's Disease E) Associated with Bartholin abscess

Answer 698

D Tsang CB, Rothenberger DA. Rectovaginal fistulas. Therapeutic options. Surg Clin North Am 1997; 77: 95-114.

Question 699

Question 699 of 740 Urodynamic patterns considered to result in high risk for upper urinary tract deterioration in patients with neurogenic bladders include each of the following except: A) Decreased compliance B) Detrusor sphincter dyssynergia C) High detrusor leak point pressure D) Detrusor areflexia and decreased compliance E) Detrusor overactivity

Answer 699

E A detrusor overactivity event is a frequent event in neurogenic and in non neurogenic patients and alone is not considered a condition that would place patients at high risk for upper tract deterioration. Winters, JC, Dmochowski RR, Goldman HB, Herndon CD, Kobashi KC, Kraus SR, et al. Urodynamics studies in adults: AUA/SUFU Guidelines. J Urol 2012, 188:2464-72.

Question 700

In what year did the FDA first approve the use of mesh for a urogynecologic surgical procedure ``` A) 1994 B) 1996 C) 1998 D) 2000 E) 2002 ```

Answer 700

B Urogynecologic Surgical Mesh: Update on the Safety and Effectiveness of Transvaginal Placement for Pelvic Organ Prolapse. FDA Safety Communication2011:Accessed April 6, 2013 at http://www.fda.gov/downloads/MedicalDevices/Safety/AlertsandNotices/UCM262760.pdf. FDA Executive Summary: Surgical Mesh for Treatment of Women WIth Pelvic Organ Prolapse and Stress Urinary Incontinence. Sept 8-9.2011:Accessed April 7, 2013 at http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/MedicalDevices/MedicalDevicesAdvisoryCommittee/ObstetricsandGynecologyDevices/UCM270402.pdf.

Question 701

Question 701 of 740 Which of the following is an anorectal complication of traumatic vaginal delivery? A) Anal ulcer B) Anorectal abscess C) Anal sphincter disruption D) Rectovaginal fistula E) All of the Above

Answer 701

E Venkatesh KS, Ramanujam PS, Larson DM, Haywood MA. Anorectal complications of vaginal delivery. Dis Colon Rectum 1989; 32:1039-41.

Question 702

Question 702 of 740 On anal endosonography, the external anal sphincter fibers appear hyperechoic in comparison to the internal anal sphincter fibers. A) TRUE B) FALSE

Answer 702

A AW McBride JL, R Gutman. Anatomy of the Pelvis. Journal of Pelvic Medicine and Surgery. 2003;9(3):20

Question 703

Question 703 of 740 For recurrent urinary tract infections all of the following are acceptable except: A) One nightly tablet nightly of any of the following: 1). TMP-SMX, 40 mg and 200 mg or 80 mg and 400 mg, 2). Nitrofurantoin 50-100mg, 3). Cephalexin 125-250 mg, 4). TMX 100mg. B) If predominantly post coital infections then single dose of antimicrobial agent as soon as feasible after intercourse. C) Self-diagnosis and self-treatment with refills on agents appropriate for treating acute cystitis. D) Fosfamycin 3 gm once every ten days. E) Twice weekly Ciprofloxacin 250 mg.

Answer 703

E Albert X, Huertas I, Pereiro II, et al. Antibiotics for preventing recurrent urinary tract infection in non-pregnant women. Cochrane Database Syst Rev 2004;CD001209. Hooten T. Uncomplicated urinary tract infection. NEJM 2012; 366: 1028-1037. Gupta K, Hooton TM, Roberts PL, Stamm WE. Patient-initiated treatment of uncomplicated recurrent urinary tract infections in young women. Ann Intern Med 2001;135:9-16.

Question 704

Question 704 of 740 A 68 year-old woman underwent an uncomplicated robotic-assisted supracervical hysterectomy, mesh sacral colpopexy, mid-urethral sling, posterior colporrhaphy with perineoplasty and cystourethroscopy. She stays in the hospital overnight and on postoperative day 1 she undergoes a void trial. When the nurse calls you with the results of the void trial, she mentions that the patient had difficulty walking when she tried to ambulate to the bathroom. On examination you notice she has difficulty dorsi-flexing and everting her left foot. She has no problems inverting her left foot. As she ambulates, she flexes her left thigh higher than the right thigh while walking. The patient tells you that her left foot "feels limp" and she feels some tingling on the top of the foot and lateral calf. What could have helped to prevent this nerve injury? A) Minimize hyperflexion of the thigh to avoid femoral nerve compression at the inguinal ligament. B) Minimize hyperextension of the knee to avoid sciatic nerve stretch injury. C) Minimize excessive external rotation of the hips to avoid sciatic nerve stretch injury. D) Minimize external pressure to the medial aspect of the knee as the peroneal nerve wraps around the fibula. E) Minimize external pressure to the lateral aspect of the knee as the peroneal nerve wraps around the fibula.

Answer 704

E The femoral nerve can certainly be injured by compression at the inguinal ligament during prolonged lithotomy with hyperflexion of the hip; however the clinical syndrome of femoral neuropathy involves weakness of the quadriceps and iliopsoas muscles. The common peroneal nerve and tibial nerves are the distal branches of the sciatic nerve. The sciatic nerve can be injured in lithotomy by stretch injury with knee extension, or with excessive external rotation of the hips. Sciatic and peroneal neuropathy symptoms are similar however this patient has isolated peroneal symptoms without any tibial neuropathy symptoms. Tibial neuropathy symptoms include weakness of plantar flexion and foot inversion along with sensory deficits of the toe and plantar surface of the foot. The peroneal nerve is vulnerable to injury in lithotomy with excessive pressure at the lateral aspect of the knee as the nerve wraps around the neck of the fibula. Irvin W, Andersen W, Taylor P, et al. Minimizing the risk of neurologic injury in gynecologic surgery. Obstet Gynecol. 2004;103:374-382.

Question 705

``` Question 705 of 740 Regarding synthetic (permanent) versus biologic augmenting materials, which of the following statements is NOT supported by evidence: ``` A) Synthetic mesh is superior to biologic graft for use in sacrocolpopexy B) Biologic grafts have a lower erosion rate than synthetic meshes C) Biologic grafts have a lower rate of reoperation for erosion than synthetic meshes D) Biologic grafts reduce recurrence of posterior vaginal prolapse E) B and D are both unsupported by evidence

Answer 705

E Abed H, Rahn DD, Lowenstein L, et al. Incidence and management of graft erosion, wound granulation, and dyspareunia following vaginal prolapse repair with graft materials: a systematic review. Int Urogynecol J 2011; 22:789-798.

Question 706

Question 706 of 740 In a normally distributed sample, what percent of the total population lies within ± 1 Standard Deviation (SD) of the mean? A) 0.05 B) 0.95 C) 0.68 D) 0.32

Answer 706

C

Question 707

Question 707 of 740 Which of the following contributes to rugae in the vagina? A) Collagen B) Estrogen C) Progesterone D) Lactic Acid

Answer 707

B Rugae are present in the vaginal epithelium when the vagina is supported by estrogen. With the lack of estrogen, rugae may disappear, as seen in women with urogenital atrophy. Siddique S. 2003; J Pelvic Med Surg 9(6): 263-272

Question 708

Question 708 of 740 A true statement regarding medications the medications used for loose stool fecal incontinence is A) Bulking agents decrease peristalsis causing symptoms of increased abdominal bloating B) It is unsafe to take more than 30 grams of fiber supplements/day C) Loperamide works by slowing colonic transit but is not an opiate D) Risks of opium derivatives include addiction and anticholinergic side effects E) Loperamide is less effective than fiber supplementation alone

Answer 708

D Loperamide is an opiate however it is over the counter since it does not cross the blood brain barrier and therefore not considered addictive. Other opium derivative medications such as lomotil do cross the blood brain barrier and therefore require a prescription and can be addictive and have additional anticholinergic side effects. Wright J, Gebrich A, Albright T. The Management of Anal Incontinence. JPMRS 2006; 12 (3)

Question 709

Question 709 of 740 Which of the following is true regarding prevention of postoperative infection after prolapse surgery A) Administration of antibiotics immediately after incision decreases infection by 25% B) Iodine preparation is superior to chlorhexidine-alcohol preparation for clean-contaminated surgery C) Shaving hair around the surgical site results in higher post operative infection than clipping D) Bowel preparation before prolapse surgery decreases risk of postoperative infection E) Pessaries should remain in place until time of surgery.

Answer 709

C abx are supposed to be BEFORE incision, BV and pessary increase risk of cuff cellulitis, shaving increases infection, bowel prep not noted to decrease infection, chlorhexidine/alcohol abdominal prep is superior to iodine for clean contminated surgery (9.5 vs. 16%) ACOG Bulletin, #104 May 2009, Darouiche RO, NEJM, 2010; Noorani Br J Surg, 2010

Question 710

Question 710 of 740 When performing an abdominal paravaginal defect repair, the pubocervical fascia is attached to which structure? A) Arcus tendineus levator ani B) Obturator membrane C) Periurethral membrane D) Arcus tendineus fascia pelvis

Answer 710

D McBride AW, et al. Journal of Pelvic Medicine and Surgery. Volume 9, Number 3, May/June 2003

Question 711

Question 711 of 740 During voiding, the pontine micturition center does all of the following EXCEPT: A) Stimulates parasympathetic outflow to bladder B) Stimulates parasympathetic outflow to internal urethral sphincter smooth muscle C) Inhibits sympathetic outflow to the urethral outlet D) Inhibits pudendal outflow to the urethral outlet E) Increases somatic outflow to the urethral outlet

Answer 711

E During voiding, intense bladder firing activates the spinobulbospinal reflex pathways which pass through the pontine micturition center (PMC). The PMC stimulates parasympathetic outflow to the bladder causing contraction of the detrusor muscle. In addition, the combination of increased parasympathetic outflow to the internal urethral smooth muscle with inhibition of sympathetic and somatic (pudendal) outflow results in relaxation of the urethra. E is incorrect because during voiding the PMC inhibits somatic outflow to the urethral outlet. Raz & Rodriguez; Female Urology, 3rd ed., Chapter 3

Question 712

Question 712 of 740 All of these statements are correct regarding type I error EXCEPT: A) Occurs if an investigator rejects a null hypothesis that is false B) Occurs if an investigator rejects a null hypothesis that is actually true C) Is when a false postive occurs D) Can be reduced by increasing the sample size

Answer 712

A EXCEPT Browner WS, Newman TB, and Hulley SB (2007). Getting Ready to Estimate Sample Size: Hypothesis and Underlying Principles in S.B. Hulley, S.R. Cummings,W.S. Browner, D. G. Grady, T.B. Newman (Eds.), Designing Clinical Research (pp.55-56). Philadelphia, PA: Lippincott, Williams & Wilkins.

Question 713

Question 713 of 740 A patient who has a history of radiation for rectal cancer 10 years ago presents with rectovaginal fistula. You should: A) Biopsy the fistula tract B) Counsel her about an increased risk of breakdown of repair and repair it in the OR C) Treat with estrogen cream first D) Treat with antibiotics only

Answer 713

A Recurrent malignancy is associated with fistula after radiation. Novi, JM. JPMS Vol 11(6) Nov/Dec 2005

Question 714

Question 714 of 740 Changes in vaginal physiology associated with menopause include all of the following except: A) Decreased vaginal ph B) Decreased vaginal vascularity and elasticity C) Decreased vaginal secretions D) Shifting of maturation index to basal, parabasal cells

Answer 714

A Hoffman B, Schorge J, Schaffer J, Halvorsen L, Bradshaw B, Cunningham G. Williams Gynecology. 2nd ed. McGraw Hill 2012, 554-574.

Question 715

Question 715 of 740 Which of the following choices best describes the range of possible Ba? A) -3 to +3 B) -TVL to +TVL C) -3 to +TVL D) -TVL to +3

Answer 715

C Point Ba: a point that represents the most distal (i.e., most dependent) position of any part of the upper anterior vaginal wall from the vaginal cuff or anterior vaginal fornix to point Aa. By definition, point Ba is at -3 cm in the absence of prolapse and would have a positive value equal to the position of the cuff in women with total posthysterectomy vaginal eversion. Bump RC, Mattiasson A, Bo K, Brubaker LP. Am J Obstet Gynecol. 1996;175(1):10-17.

Question 716

Several epidemiologic studies have suggested an association between urinary incontinence and obesity. It is, however, unclear if this association represents a cause-effect relationship. All of the following are criteria commonly used to judge causality except: ``` A) Temporal sequence B) Strength of association C) Biologic Plausibility D) Dose-response relationship (biologic gradient) E) Precision of association ```

Answer 716

E Grimes DA, Schulz KF. Cohort studies: marching towards outcomes. Lancet 2002; 359:341-45.

Question 717

Question 717 of 740 Imperforate hymen occurs after: A) Failure of the vaginal plate development B) Failure of urogenital sinus and sinovaginal bulb fusion C) Failure of perinatal hymenal membrane degeneration D) Failure of mesonephric duct fusion

Answer 717

C Carlson BM. Human Embryology and Developmental Biology, 4th Ed. Philadelphia (PA): Mosby, Inc., 2009.

Question 718

Which of the following symptoms is not a component of overactive bladder syndrome? A) Urinary urgency B) Nocturia C) Hematuria D) Urinary urgency incontinence E) Urinary frequency

Answer 718

C

Question 719

Question 719 of 740 Which of the following are true statements about patients undergoing sling surgery? A) a trocar passage into the bladder requires immediate exploration B) most sling trocar injuries are extraperitoneal C) bowel injury has not been reported with antegrade sling passage D) current AUA Stress urinary incontinence guidelines suggest cystoscopy always be performed even during TOT and other minimally invasive sling procedures E) B and D

Answer 719

E Dmochowski RR, Blaivas JM, Gormley EA, et al. Update of AUA guideline on the surgical management of female stress urinary incontinence. J Urol 2010; 183:1906-14.

Question 720

Question 720 of 740 Investigators performed a randomized trial to compare the efficacy of two different drugs for overactive bladder (Drug A and Drug B) to placebo. 300 patients with overactive bladder were randomized to one of three groups: Drug A, Drug B or Placebo for 12 weeks. The primary outcome of the study was the average number of urge incontinence episodes per day on a 7-day bladder diary after 12 weeks of therapy. At 12 weeks, the number of urge incontinence episodes per day in each group was: Drug A 2.3 + 4.0; Drug B 3.4 + 3.2; Placebo 4.4 + 4.0; p

Answer 720

A Basic & Clinical Biostatistics, 4th ed. Dawson-Saunders B, Trapp RG, eds. Philadelphia: McGraw-Hill, 2004.

Question 721

Question 721 of 740 The triad of cognitive decline, gait disturbance, and urinary incontinence is suggestive of: A) Alzheimer's dementia B) Multiple sclerosis C) Normal pressure hydrocephalus D) Spinal cord injury

Answer 721

C The triad of new onset cognitive decline, gait disturbance and UI may suggest normal pressure hydrocephalus, and thus warrants evaluation with MRI. Alzheimer's dementia does not necessarily result in gait disturbance. MS can have variable lesions, but does not typically present with cognitive decline. Spinal cord injury may result in gait disturbance and UI but also would not necessarily be associated with cognitive decline. Dunn et al. J Pelvic Med & Surgery 2004; 10(2): 43-51

Question 722

Question 722 of 740 Which of the following factors is least important when considering the use of a vascular flap to augment a surgical repair of a recurrent vesicovaginal fistula? A) fistula size B) history of prior unsuccessful repair C) history of pelvic radiation D) location near the bladder neck or urethral fistula E) whether the planned surgical approach is transvaginal or transabdominal

Answer 722

E Vascular flaps can be used both vaginally (Martius bulbocavernosus flap, gracilis muscle, bladder mucosa, peritoneum) and abdominally (omentum, rectus muscle, bladder mucosa, peritoneum). Augmentation with a vascular flap should be considered with a particularly large defect, history of radiated tissue, a prior unsuccessful repair, or location at the bladder neck or adjacent to the urethra. Mueller E, Kenton K, Brubaker L. Modern Management of Genitourinary Fistula. Journal of Pelvic Medicine and Surgery. 2005;11:223-234

Question 723

Question 723 of 740 A 77 year old female presents with a complaint of vaginal bulging. The POP-Q examination reveals: Aa: +3, Ba: +7, C: +7, D: +7, Ap: +3, Bp: +7, TVL: 8.5, GH: 4, PB: 2.5. Which of the following statements is TRUE? A) The patient has a more posterior than anterior vaginal prolapse B) The patient has Stage III Pelvic Organ Prolapse C) The patient has Stage IV Pelvic Organ Prolapse D) The patient would do well with a vaginal anterior and posterior colporrhaphy

Answer 723

C Bump RC, Mattiasson A, Bo K, Brubaker LP. Am J Obstet Gynecol. 1996;175(1):10-17.

Question 724

Question 724 of 740 According to the 2012 American Urologic Association Guidelines for evaluation of asymptomatic, microscopic hematuria, all are correct, EXCEPT: A) Dilute urine can cause red blood cells to lyze, reducing the number of red blood cells seen on microscopy. B) At least 2 microscopic fields under 400x magnification need to be examined to perform urine microscopy. C) A positive dipstick merits microscopic examination of the urine, but does not warrant full evaluation unless three or greater red blood cells/HPF are seen D) Patients should discard the initial 10ml of urine in the toilet to collect a true mid stream urine specimen

Answer 724

B

Question 725

Question 725 of 740 In women with a congenital anomaly (Mullerian agenesis or Androgen Insensitivity Syndrome), vaginal dilation or vaginal reconstruction is appropriate: A) At diagnosis of anomaly B) At puberty C) Prior to going to college D) When the patient is considering sexual activity and is mature enough to commit to dilator use

Answer 725

D Gidwani G, Falcone T. Congenital Malformations of the Female Genital Tract: Diagnosis and Management. Philadelphia (PA): Lippincott Williams & Wilkins, 1999.

Question 726

Question 726 of 740 In women without symptoms of stress urinary incontinence undergoing vaginally approached prolapse repair, which of the following statements is most correct? A) Rates of major bleeding complications or vascular complications are NOT increased with the addition of a sling procedure at the time of vaginal prolapse repair B) Sling procedure at the time of vaginal prolapse repair reduces the risk of postoperative stress urinary incontinence C) Any benefits obtained with sling procedure at the time of vaginal prolapse repair, with regard to postoperative stress urinary incontinence, have not been found to persist after the first 6 weeks D) Addition of sling procedure at the time of vaginal prolapse repair, does NOT increase the rate of voiding dysfunction postoperatively

Answer 726

B In a multicenter, randomized trial comparing midurethral sling to sham procedure at the time of vaginal prolapse repair in women with no symptoms of stress urinary incontinence, at 3 months, the rate of SUI was 23.6% in the sling group and 49.4% in the sham group (P

Question 727

Question 727 of 740 When performing surgical repair of cystocele with a vaginal approach: A) There is no benefit with synthetic mesh B) Synthetic mesh may improve outcomes, but is associated with more complications than non-mesh procedures C) Mesh complication rates are similar to procedures where mesh is placed abdominally D) Synthetic mesh should be considered mainly in patients who are not sexually active

Answer 727

B Level 1 data shows that synthetic mesh may improve objective and subjective outcomes (less failure with mesh), with no differences in quality of life or dyspareunia. However there may be more complications with mesh procedures, with unique complications related to mesh. The FDA Safety Communication, updated in 2012, specifically highlighted that mesh placed abdominally for prolapse repair may result in lower rates of mesh complications compared to transvaginal prolapse surgery with mesh. For patients who are not sexually active, obliterative procedures may be preferred, depending on patient goals. In those who are sexually active, mesh procedures may still be performed, provided that appropriate counseling is provided regarding potential mesh complications. Maher et al. Cochrane Database Syst Rev. 2010 Apr 14;(4):CD004014. 2. Walters & Ridgeway; Obstet Gynecol 2013; 121 (2)

Question 728

Question 728 of 740 The following physical finding is associated with denervation of the anal sphincter: A) anal deformity B) prolapsed hemorrhoids C) patulous anus D) dermatitis resulting from frequent soiling

Answer 728

C Wald A N Engl J Med 2007; 356:1648-55

Question 729

Question 729 of 740 All of the following are prophylactic treatment options for recurrent urinary tract infections EXCEPT: A) Daily antibiotics B) Full-dosed prolonged antibiotics C) Sorbitol D) Postcoital antibiotics E) Probiotics

Answer 729

B Hooton TM. Recurrent urinary tract infection in women. Int J Antimicrob Agents 2001;17(4):259-268.

Question 730

Question 730 of 740 Which of the following best describes the relationship between ovarian and uterine development? A) Uterine development depends on functional ovaries B) They develop at the same time and are interdependent C) They are completely separate processes D) They occur simultaneously as long as SR-Y is present

Answer 730

C Carlson BM. Human Embryology and Developmental Biology, 4th Ed. Philadelphia (PA): Mosby, Inc., 2009.

Question 731

The most consistently sensitive and specific study to evaluate for urethral diverticulum preoperatively is: A) Voiding cystourethrogram B) MRI C) Perineal ultrasound D) Retrograde positive pressure urethrography (double balloon urethrogram)

Answer 731

B Foley CL, BJUI 2001, 108: Supplement 2, 20-23; Scarpero HM, Urol Clin North Am 2011 Feb 38(1) 65-71

Question 732

Question 732 of 740 All of the following regarding sympathetic innervation of the lower urinary tract are true except: A) Promotes bladder relaxation or storage via beta adrenergic activity B) Promotes bladder neck closure via alpha adrenergic activity C) Promotes improved compliance by via M2 receptors D) Originates from mainly T10-L2 E) Noradrenaline is the major neurotransmitter

Answer 732

C Fowler CJ, Griffiths D, de Groat WC, The Neural Control of Micturition, Nature Reviews Neuroscience 2008; 9, 453-466.

Question 733

Question 733 of 740 The uterus arises from the: A) Paramesonephric ducts B) Urogenital sinus C) Mesonephric tubules D) Pronephric ducts E) Mesonephric ducts

Answer 733

A Carlson BM. Human Embryology and Developmental Biology, 4th Ed. Philadelphia (PA): Mosby, Inc., 2009.

Question 734

Question 734 of 740 You are seeing a patient with Stage 3 anterior vaginal wall prolapse. Which of the following are least likely to improve after prolapse surgery? A) Urgency incontinence B) Stress urinary incontinence C) Voiding difficulty D) Symptoms of an external bulge

Answer 734

B Prolapse surgery is most likely to improve bulge symptoms. Regarding urinary symptoms, outcomes related to UUI may be difficult to predict, but there are some observational data suggesting that urgency incontinence may improve after prolapse surgery. For women with a stage 3 (external) bulge, voiding difficulty would likely improve after surgery. Women with a stage 3 anterior prolapse tend to have some kinking of the urethra and stress urinary incontinence may be unmasked or worsened with prolapse surgery. Thus B is the best answer. Walters and Karram; Urogynecology and Reconstructive Pelvic Surgery, 3rd ed., Chapter 19; Miranne et al Int Urogynecol J. 2012 Dec 11. [Epub ahead of print]

Question 735

Question 735 of 740 A 31 year-old woman with interstitial cystitis/painful bladder syndrome is in your office for a follow-up. She had an extensive diagnostic evaluation, all of which was entirely normal. She has tried dietary and behavioral modifications, pelvic floor physical therapy, ibuprofen as needed and phenazopyridine as needed. The ibuprofen and phenazopyridine have helped her symptoms slightly but the physical therapy and dietary and behavioral modifications have not really helped much. What is the best next treatment option? A) Pentosan polysulfate B) Cystoscopy under anesthesia with hydrodistension C) Continue the current regimen for 3 more months D) Neuromodulation with Interstim E) Urinary diversion

Answer 735

A First line management includes stress management, pain management, education and behavioral modifications. Second line therapy then includes medications such as pentosan polysulfate, amitriptyline, cimetidine, hydroxyzine, or bladder instillations. Therapeutic cystoscopy is third line, neuromodulation is fourth line, cyclosporine or intradetrusor Botox are fifth line and urinary diversion is the last line of therapy for severe refractory patients. Multiple therapies can certainly be combined at any given time for improved effect.

Question 736

Which of the following do not innervate the lower urinary tract? A) Sacral parasympathetic nerves B) Thoracolumbar sympathetic nerves C) Cervical sympathetic nerves D) Sacral somatic nerves

Answer 736

C The innervation of the lower urinary tract is derived from three sets of peripheral nerves: Sacral parasympathetic (ie: pelvic nerves S2-4), thoracolumbar sympathetic (ie: hypogastric nerves and sympathetic chain), and sacral somatic nerves (pudendal nerve). Raz & Rodriguez; Female Urology, 3rd ed., Chapter 3

Question 737

Question 737 of 740 65 year old obese G2P2 s/p TVH, USLVS, A&P repair with TVT sling and cystourethroscopy on POD#1 she complains of inability to walk, ankle weakness and numbness of top of foot and lateral lower leg. She has normal patellar reflexes and normal hip extension and knee flexion. What is the most likely cause of the injury in the the patient described above? A) Compression of knee on candy cane stirrup B) Inadvertent straightening of leg during case C) Hyperflexion of the thigh D) Malpositioned retractors

Answer 737

A Peroneal nerve runs lateral to knee and provides sensory function to lateral calf and motor to lower foot. B is sciatic injury, C is femoral and D is not really relevant to vaginal surgery but most common cause of femoral nerve injury during abdominal surgery. Wieslander CKB, M.K.; Phelan, J; Schaffer, J.I.; Corton, M.M. . Video: Avoiding nerve injury during gynecologic surgery. J Pel Med Surg 2005;11:S54.

Question 738

Question 738 of 740 Which of the following is a true statement regarding the evaluation of a urogenital fistula: A) An MRI provides the best evaluation of the condition of the local tissues. B) If urethroscopy does not diagnosis a suspected urethrovaginal fistula, a Tratner catheter may aid in the diagnosis. C) A renal ultrasound is better than an intravenous urography for diagnosing concomitant ureteral injury. D) A positive IV indigo carmine test diagnoses a vesicovaginal fistula. E) A voiding cystourethrogram is the best diagnostic tool for identifying a vesicovaginal fistula.

Answer 738

B Karram MM. Lower urinary tract fistulas. In: Walters MD and Karram MM, eds. Urogynecology and Reconstructive Pelvic Surgery. 3rd ed. Philadelphia, Pa: Mosby Inc; 2007: 445-460.

Question 739

Question 739 of 740 Each of the following are components of Overactive Bladder Syndrome except? A) Urinary urgency B) Urinary frequency C) Microscopic hematuria D) Urgency urinary incontinence E) Nocturia

Answer 739

C

Question 740

Question 740 of 740 A 79 year-old woman is scheduled to undergo a LeFort colpocleisis and cystoscopy under spinal anesthesia. She has a medical history of coronary artery disease, a prior myocardial infarction with congestive heart failure. Her prior surgical history includes an implantable cardiac defibrillator (ICD). Which of the following is not an acceptable option for management of electrocautery technique during the case? A) Use a monopolar device with caution to position the patient return electrode grounding pad away from the ICD such that the current does not pass through or near the ICD generator or leads. B) Use a monopolar device with caution to position the patient return electrode grounding pad closer to the ICD such that the current passes over a wider area and dissipates the electrons. C) Use a bipolar or harmonic device if possible. D) Use short intermittent bursts of monopolar energy at the lowest feasible energy level.

Answer 740

B The American Society of Anesthesiologists Task Force on Perioperative Management of Patients with Cardiac Implantable Electronic Devices recommends any of options A, C, D, and E for management of electrocautery in patients with ICDs. If the return pad were positioned closer to the ICD then the current would pass closer to the ICD generator and leads which could lead to interference with the device. The literature is limited to case series and small observational studies. Practice advisory for the perioperative management of patients with cardiac implantable electronic devices: pacemakers and implantable cardioverter-defibrillators: an updated report by the american society of anesthesiologists task force on perioperative management of patients with cardiac implantable electronic devices. Anesthesiology. 2011;114:247-261.