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MRCOG PART 2 SBAs and EMQs

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Week 1 - Urogynaecology

Week 1 - Urogynaecology Posted by PAUL A.

Question 1

With respect to the epidemiology of pelvic organ prolapse, the proportion of parous women with clinical pelvic organ prolapse is

A.  About 10%

B.  About 30%

C.  About 50%                  

D.  About 70%

E.   Over 90%

 

Question 2

With respect to the epidemiology of pelvic organ prolapse, the proportion of parous women with symptomatic pelvic organ prolapse is

A.  1-2%

B.  4-8%

C.  10-20%               

D.  20-30%

E.   40-58%

 

Question 3

With respect to the long-term effect of vaginal birth on the risk of pelvic organ prolapse

A.  The prevalence of pelvic organ prolapse is not different 20 years after a vaginal birth compared to caesarean section

B.  The prevalence of symptomatic pelvic organ prolapse is not different 20 years after a vaginal birth compared to caesarean section

C.  The prevalence of pelvic organ prolapse is higher 20 years after emergency caesarean section compared to elective caesarean section

D.  Symptomatic pelvic organ prolapse is 2-3 times more common 20 years after vaginal delivery compared to caesarean section         

E.   Symptomatic pelvic organ prolapse is 15-20 times more common 20 years after vaginal delivery compared to caesarean section

 

Question 4

With respect to the effect of vaginal delivery on pelvic floor function

 

A.   Ventouse delivery is associated with a higher long-term risk of pelvic organ prolapse compared to spontaneous vaginal delivery

B.   Episiotomy increases the risk of pelvic organ prolapse following vaginal delivery

C.   Second and third degree perineal tears are not associated with an increased long-term risk of pelvic organ prolapse compared to spontaneous vaginal deliveries without tears              

D.  Current BMI does not affect the risk of pelvic organ prolapse in parous women

E.   Birth weight does not affect the long-term risk of pelvic organ prolapse following vaginal birth

 

Question 5

A 26 year old woman with a low-risk pregnancy attends the antenatal clinic at 39 weeks gestation because the baby is thought to be large for dates. Her height is 156 cm and her booking BMI was 34 kg/m2. Growth scan performed 2 days earlier showed an estimated fetal weight of 4238 g with normal liquor and normal umbilical artery Dopplers. GTT performed at 26 weeks was normal. The woman is particularly concerned about the impact of a vaginal birth on her pelvic floor. She should be informed that

A.   Estimated fetal weight might be inaccurate and should not be used to make clinical decisions

B.   There is no evidence that birth weight affects the risk of long-term pelvic floor dysfunction

C.   Caesarean section is recommended if the estimated fetal weight is above the 95th centile on a customized chart

D.  Her risk long-term pelvic organ prolapse is increased 20-30 fold if the birth weight is over 4000 g

E.   Her risk of long-term pelvic organ prolapse is increased 2 – 3 fold if the birth weight is over 4000 g                 

 

Instructions:

For the statement below, choose the single most appropriate option from the above list of options. Each option may be used once, more than once, or not at all.

Question 6

Using the Pelvic Organ Prolapse Quantification (POP-Q) system, post-hysterectomy vaginal vault prolapse is defined as

A.    Point A at the level of the hymenal ring

B.    Descent of point A

C.   Descent of point B

D.   Point B at the level of the hymenal ring

E.    Descent of point C                          

F.    Point C at the level of the hymenal ring

G.   Descent of point D

H.   Point D less than 2 cm above the hymenal ring

I.      Points A or C less than 2 cm above the hymenal ring

J.     Descent of points A and D

K.    Point A less than 3 cm above the hymenal ring

L.    Point B less than 2 cm above the hymenal ring

 

Instructions:

For the statement below, choose the single most appropriate option from the above list of options. Each option may be used once, more than once, or not at all.

 

Question 7

A 47 year old woman has a total abdominal hysterectomy because of a large fibroid uterus. The risk of her suffering post-hysterectomy vault prolapse is

A.    0.1-0.3%

B.    1-2%              

C.   2-5%

D.   5-7%

E.    6-9%

F.    10-12%

G.   15-18%

H.   20-23%

I.      25-29%

J.     30-33%

K.    Over 35%

 

Instructions:

For the statement below, choose the single most appropriate option from the above list of options. Each option may be used once, more than once, or not at all.

Question 8

A 47 year old mother of 4 children has a vaginal hysterectomy because of symptomatic uterine prolapse. The risk of her suffering post-hysterectomy vault prolapse is

A.    0.1-0.3%

B.    1-2%             

C.   2-5%

D.   5-7%

E.    6-9%

F.    10-12%                                  

G.   15-18%

H.   20-23%

I.      25-29%

J.     30-33%

K.    Over 35%

 

Instructions:

For the scenario below, choose the single most appropriate option from the above list of options. Each option may be used once, more than once, or not at all.

 

Question 9

A healthy 77 year old woman is referred to the gynaecology clinic because of prolapse symptoms. She had a vaginal hysterectomy 20 years ago because of uterine prolapse. She suffers from occasional constipation but has no other urinary or bowel symptoms. Clinical examination confirms vaginal vault prolapse and there is no urinary leakage on straining. Following counselling, she agrees to undergo vault prolapse surgery.

 

A.    Discuss risks and benefits of urodynamic studies

B.    Recommend urodynamic studies with prolapse reduced

C.   No indication for urodynamic studies                 

D.   Recommend urodynamic studies without prolapse reduction

E.    Recommend urodynamic studies with + without prolapse reduction

F.    Recommend prophylactic surgery for stress urinary incontinence

G.   Discuss risks and benefits of prophylactic stress incontinence surgery

H.   Recommend prophylactic stress incontinence surgery if an abdominal operation is planned

I.      Recommend prophylactic stress incontinence surgery if a vaginal operation is planned

J.     Recommend urodynamic studies if an abdominal operation is planned

 

Instructions:

For the statement below, choose the single most appropriate option from the above list of options. Each option may be used once, more than once, or not at all.

 

Question 10

McCall culdoplasty involves

 

A.    Excision of redundant vaginal wall at the vault

B.    Amputation of the cervix with plication of the transverse cervical ligaments

C.   Approximating the cardinal ligaments and attaching them to the vaginal vault

D.   Attaching the round ligaments to the posterior vaginal wall

E.    Closure of the vagina in elderly women who are not sexually active

F.    Approximation of the utero-sacral ligaments with obliteration of the pouch of Douglas               

G.   Formation of a skin bridge in the vagina

H.   Repair of anterior compartment defect using non-absorbable mesh

I.      Occlusion of the introitus using absorbable sutures

J.     Repair of posterior compartment defect using non-absorbable mesh

 

Instructions:

For the statement below, choose the single most appropriate option from the above list of options. Each option may be used once, more than once, or not at all.

 

Question 11

With respect to the surgical treatment or prevention of post-hysterectomy vaginal vault prolapse, the Moschcowitz procedure involves

A.    Closure of the parietal pelvic peritoneum

B.    Attachment of the utero-sacral ligaments to the vaginal vault

C.   Attachment of the transverse cervical ligaments to the vaginal vault

D.   Obliteration of the pouch of Douglas using concentric purse-string sutures                     

E.    Obliteration of the utero-vesical pouch using concentric purse-string sutures

F.    Excision of redundant vaginal wall at the vault

G.   Approximating the cardinal ligaments and attaching them to the vaginal vault

H.   Attaching the round ligaments to the posterior vaginal wall

I.      Closure of the vagina in elderly women who are not sexually active

J.     Formation of a skin bridge in the vagina

K.    Repair of anterior compartment defect using non-absorbable mesh

L.    Repair of posterior compartment defect using non-absorbable mesh

 

Instructions:

For the scenario below, choose the single most appropriate option from the above list of options. Each option may be used once, more than once, or not at all.

 

Question 12

A healthy 79 year old woman is undergoing vaginal hysterectomy because of symptomatic uterine prolapse. She is sexually active. Which procedure should be used to reduce the risk of vault prolapse?

A.    Moschcowitz culdoplasty

B.    Closure of the parietal pelvic peritoneum

C.   The Manchester procedure

D.   The Fothergill procedure

E.    McCall culdoplasty              

F.    Sacro-spinous fixation

G.   Sacro-colpopexy

H.   Anterior colporrhaphy

I.      Anterior and posterior colporrhaphy

J.     Colpocliesis

K.    Closure of the visceral pelvic peritoneum

 

Instructions:

For the scenario below, choose the single most appropriate option from the above list of options. Each option may be used once, more than once, or not at all.

 

Question 13

A healthy 47 year old woman is due to undergo abdominal hysterectomy because of a large fibroid uterus. She is up-to-date with her smears and the last test was negative. She enquires about the benefits and disadvantages of sub-total hysterectomy. Sub-total hysterectomy is associated with

 

A.    A lower risk of post-hysterectomy vault prolapse

B.    No significant difference in the risk of vaginal prolapse

C.   A lower risk of urinary incontinence

D.   No significant difference in the risk of urinary incontinence

E.    A higher risk of vaginal prolapse              

F.    A higher risk of bowel injury

G.   No significant difference in long-term outcomes

H.   A higher risk of fecal incontinence

I.      Longer operating time

J.     A lower risk of enterocele

 

Instructions:

For the scenario below, choose the most appropriate first line treatment option from the above list of options. Each option may be used once, more than once, or not at all.

 

Question 14

A healthy 79 year old woman attends the gynaecology clinic because of a 3 year history of prolapse symptoms. She had a vaginal hysterectomy for uterine prolapse 20 years ago. There are no urinary symptoms and she is sexually active. Clinical examination confirms stage II vaginal vault prolapse.

 

A.    Anterior and posterior colporrhaphy

B.    Ring pessary

C.   Hodge pessary

D.   Gellhorn pessary

E.    Pelvic floor muscle training                       

F.    Vaginal cone

G.   Manchester procedure

H.   Fothergill procedure

I.      Sacro-spinous fixation

J.     Abdominal sacro-colpopexy

 

Instructions:

For the scenario below, choose the single most appropriate option from the above list of options. Each option may be used once, more than once, or not at all.

 

Question 15

A healthy 82 year old woman has been referred to the gynaecology clinic because of prolapse symptoms. She had an abdominal hysterectomy 40 years ago because of heavy menstrual bleeding. She is not sexually active. Clinical examination confirms stage IV vaginal vault prolapse. The woman does not wish to have surgery.

 

A.    Ring pessaries are ineffective in women with vault prolapse

B.    Gellhorn pessaries are ineffective in women with vault prolapse

C.   Ring pessaries are more effective than Gellhorn pessaries in women with vault prolapse

D.   Gellhorn pessaries are more effective than ring pessaries in women with vault prolapse

E.    Ring and Gellhorn pessaries are effective in women with vault prolapse              

F.    The woman should be advised that surgery is the only effective treatment

G.   A ring pessary should not be used if the woman is likely to become sexually active

H.   A Gellhorn  pessary can be used even in sexually active women

I.      The Hodge pessary has been shown to be more effective than the Gellhorn pessary

Pessaries are contra-indicated in post-menopausal women  

 

Instructions:

For the scenario below, choose the single most appropriate option from the above list of options. Each option may be used once, more than once, or not at all.

 

Question 16

A 76 year old woman is referred to the gynaecology clinic with prolapse symptoms. She had a vaginal hysterectomy 30 years ago because of uterine prolapse. She has no urinary or bowel symptoms and is sexually active. Clinical examination confirms vaginal vault prolapse. With respect to the choice of operative procedure

 

A.    Anterior and posterior colporrhaphy should be recommended if a specialist urogynaecologist is not available

B.    The McCall culdoplasty has been shown to be the most effective procedure

C.   Open abdominal sacro-colpopexy is associated with lower recurrence rates compared to vaginal sacro-spinous fixation                       

D.   Open abdominal sacro-colpopexy is associated with higher rates of dyspareunia compared to vaginal sacro-spinous fixation

E.    Open abdominal sacro-colpopexy is associated with higher rates of post-operative stress urinary incontinence compared to vaginal sacro-spinous fixation

F.    Open abdominal sacro-colpopexy is associated with higher re-operation rates compared to vaginal sacro-spinous fixation

G.   Open abdominal sacro-colpopexy is associated with lower patient satisfaction compared to vaginal sacro-spinous fixation

H.   Sacro-spinous fixation should be recommended if the woman has a short vagina

I.      Sacro-spinous fixation should be recommended if the woman has a history of dyspareunia

J.     Abdominal sacro-colpopexy should not be offered if the woman plans to continue sexual activity

 

Instructions:

For the scenario below, choose the single most appropriate option from the above list of options. Each option may be used once, more than once, or not at all.

 

Question 17

A healthy 66 year old woman is referred to the gynaecology clinic with prolapse symptoms. She had a vaginal hysterectomy 15 years ago because of uterine prolapse. She has no urinary or bowel symptoms and is sexually active. Clinical examination confirms vaginal vault prolapse. Following counselling, the woman is undergoing open abdominal sacro-colpopexy. During the operation, the vaginal vault is attached to

 

A.    The Cardinal ligament

B.    The transverse cervical ligament

C.   The sacro-spinous ligament

D.   The ilio-pectineal ligament

E.    The anterior longitudinal ligament                       

F.    The posterior longitudinal ligament

G.   The sacro-tuberous ligament

H.   The inter-spinous ligament

I.      Scarpa’s fascia

J.    The periosteum of the symphysis pubis 

 

Instructions:

For the scenario below, choose the single most appropriate option from the above list of options. Each option may be used once, more than once, or not at all.

 

Question 18

A healthy 78 year old woman has undergone vaginal sacro-spinous fixation because of vaginal vault prolapse. At her follow-up appointment 6 weeks later, she complains of right buttock pain. She should be informed that

A.    Buttock pain on the right is unlikely to be related to the operation

B.    1 in 2 women with right buttock pain will need further surgery to remove sutures

C.   Buttock pain usually resolves in 6-12 months in most women

D.   Buttock pain usually resolves in 2-3 months in most women                       

E.    Buttock pain that is present at 6 weeks is likely to become long-term pain

F.    The sutures need to be removed to treat buttock pain

G.   Local anaesthetic injection is the recommended treatment

H.   5 in 10 women with buttock pain need further surgery to remove sutures

I.      Buttock pain is a recognised risk factor for recurrent prolapse

J.     About 1 in 100 women experience buttock pain after the operation

 

 

prolapse Posted by rasheeda B.

1c 2b 3a 4b 5b 6e 7b 8f 9c 10 f 11d 12 e 13e 14j 15e 16c 17e 18d

ANSWERS Posted by PAUL A.

Answers

 

1)   C

2)   C

3)   D

4)   C

5)   E

6)   E

7)   B

8)   F

9)   C

10)                  F

11)                  D

12)                  E

13)                  E

14)                  E

15)                  E

16)                  C

17)                  E

18)                  D