ABOG Urogynecology and Reconstructive Pelvic Surgery cheat sheet

Level I support is the cardinal/uterosacral ligament complex suspending the cervix and upper vagina to the sacrum and lateral pelvic wall; failure produces uterine and vault prolapse.

Level II support is the arcus tendineus fasciae pelvis (ATFP) with paravaginal attachments laterally and the pubocervical (anterior) and rectovaginal (posterior) fascia; failure produces cystocele and rectocele.

Level III support is the perineal membrane, levator ani, and perineal body fusing the distal vagina; failure produces urethrocele and perineal descent.

The levator ani comprises pubococcygeus, puborectalis, and iliococcygeus; the puborectalis maintains the anorectal angle and is innervated by direct sacral branches (S3-S4).

The external urethral sphincter is striated, somatic (pudendal nerve), and surrounds the mid-urethra; the internal urethral sphincter is smooth muscle and involuntary.

The urethra is 3-4 cm long; the mid-urethra is the site of maximal resting pressure and the target of midurethral sling placement.

The genitofemoral nerve (L1-L2) supplies the anterior vulva and mons; the pudendal nerve (S2-S4) supplies the posterior vulva, perineum, and external anal sphincter.

Normal pelvic floor muscle resting tone and voluntary contraction (Kegel) contribute to continence; the valsalva leak point pressure reflects the pressure at which leakage occurs with increased abdominal pressure.

POP-Q staging: Stage 0 no prolapse; Stage I leading point >1 cm above hymen; Stage II within 1 cm of hymen; Stage III >1 cm beyond hymen but not complete; Stage IV complete eversion.

The POP-Q reference points are Aa, Ba, C, D, Ap, Bp, gh (genital hiatus), pb (perineal body), and tvl (total vaginal length); C is the cervix or vault, D is the posterior fornix.

Symptomatic anterior compartment prolapse is treated with anterior colporrhaphy or paravaginal repair; recurrence rates are highest in the anterior compartment.

Apical suspension (sacrospinous, uterosacral, or sacrocolpopexy) should be performed for apical prolapse; isolated anterior or posterior repair without apical support risks recurrence.

Sacrocolpopexy (abdominal or laparoscopic) uses mesh to suspend the vault to the anterior longitudinal ligament of the sacrum; it has lower recurrence than vaginal native-tissue repair.

Sacrospinous ligament fixation attaches the vault to the sacrospinous ligament near the ischial spine; risks include pudendal/gluteal pain and buttock pain.

Uterosacral ligament suspension attaches the vault to the uterosacral ligaments; risks include ureteral kinking, so cystoscopy is performed after suture placement.

Obliterative procedures (LeFort colpocleisis) are appropriate for frail, non-sexually-active patients with advanced prolapse; vaginal hysterectomy with colpocleisis is common.

Stress urinary incontinence (SUI) is leakage with increased intra-abdominal pressure (cough, sneeze, exercise) without detrusor contraction; urge incontinence is leakage with a sudden urge.

First-line SUI management is pelvic floor muscle training and behavioral modification; second-line is a midurethral sling (retropubic or transobturator).

Retropubic (TVT) and transobturator (TOT) slings have similar cure rates; retropubic slings have higher rates of bladder perforation and voiding dysfunction, transobturator higher rates of groin pain.

Burch colposuspension and autologous fascia pubovaginal sling are alternatives for SUI; the pubovaginal sling is preferred for intrinsic sphincter deficiency.

Intrinsic sphincter deficiency is suggested by a low Valsalva leak point pressure (<60 cm H2O) and/or low maximal urethral closure pressure (<20 cm H2O).

Anticholinergics and beta-3 agonists (mirabegron) are medical therapy for urge incontinence; onabotulinumtoxinA and sacral neuromodulation are third-line options.

Pessaries are a nonsurgical option for both prolapse and SUI; ring and Gellhorn are common shapes.

Postoperative urinary retention after sling is managed initially with catheter drainage; persistent retention may require sling loosening or urethrolysis.

Urodynamics measures bladder filling (cystometry), voiding (pressure-flow), and urethral function (urethral pressure profilometry) to evaluate lower urinary tract dysfunction.

Detrusor overactivity is involuntary detrusor contractions during filling; it may be neurogenic or idiopathic and correlates with urge incontinence.

Detrusor sphincter dyssynergia is simultaneous detrusor contraction and involuntary sphincter contraction during voiding, seen in upper motor neuron lesions.

Valsalva leak point pressure (VLPP) is the intravesical pressure at which leakage occurs with increased abdominal pressure; low VLPP suggests intrinsic sphincter deficiency.

Maximal urethral closure pressure (MUCP) is measured by urethral pressure profilometry; MUCP <20 cm H2O suggests intrinsic sphincter deficiency.

Post-void residual (PVR) is measured by catheterization or bladder scan; elevated PVR (>150-200 mL) suggests incomplete emptying.

A negative urodynamic study does not exclude SUI; urodynamics is indicated for complex, mixed, or neurogenic incontinence, or before surgical intervention in select cases.

Cystoscopy is indicated for suspected foreign body, fistula, hematuria, or intraoperative evaluation of bladder/ureteral integrity after sling or prolapse surgery.

Overactive bladder (OAB) is urgency, with or without urge incontinence, usually with frequency and nocturia, in the absence of infection or other pathology.

Behavioral therapy (bladder training, timed voiding, fluid/caffeine modification, pelvic floor muscle training) is first-line for OAB.

Antimuscarinics (oxybutynin, tolterodine, solifenacin) and beta-3 agonists (mirabegron) are second-line; anticholinergic side effects include dry mouth, constipation, and cognitive effects.

OnabotulinumtoxinA intradetrusor injection is a third-line option; risk of urinary retention and need for clean intermittent catheterization must be discussed.

Sacral neuromodulation (InterStim) is a third-line option for refractory OAB and non-obstructive retention; test stimulation precedes permanent implantation.

Percutaneous tibial nerve stimulation (PTNS) is a third-line, office-based neuromodulation option for OAB.

Nocturia is evaluated with a bladder diary; causes include nocturnal polyuria, decreased bladder capacity, and sleep disorders.

Urinary tract infection must be excluded before diagnosing OAB; a positive urine culture warrants treatment and reassessment.

Fecal incontinence is the involuntary loss of liquid or solid stool; anal sphincter injury (obstetric), neuropathy, and diarrhea are common causes.

The external anal sphincter is striated and innervated by the pudendal nerve (S2-S4); the internal anal sphincter is smooth muscle and involuntary.

Endoanal ultrasound identifies sphincter defects (obstetric tears); anal manometry measures resting and squeeze pressures.

Conservative management includes dietary fiber, antidiarrheal agents (loperamide), pelvic floor muscle training, and biofeedback.

Sphincteroplasty is offered for a discrete sphincter defect; sacral neuromodulation is an option for refractory fecal incontinence.

A rectal exam and anoscopy are essential for evaluating anorectal disorders; colonoscopy is indicated for alarm symptoms or age-appropriate screening.

Rectal prolapse presents as a full-thickness protrusion; surgical repair (abdominal or perineal) is the definitive treatment.

Obstetric anal sphincter injury (OASIS) increases the risk of later fecal incontinence; recognition and primary repair at delivery are critical.

The pudendal nerve (S2-S4) provides somatic innervation to the external anal sphincter, external urethral sphincter, and perineal skin.

Pudendal neuropathy is associated with prolonged second stage of labor, multiparity, and chronic straining; it contributes to incontinence and prolapse.

Dyssynergic defecation is paradoxical contraction or failure of relaxation of the puborectalis/anal sphincter during defecation; treated with biofeedback.

Anorectal manometry assesses resting and squeeze pressures and the rectoanal inhibitory reflex; balloon expulsion testing evaluates the ability to expel a balloon.

Defecography (fluoroscopic or MRI) evaluates structural and functional defecatory disorders, including rectocele and intussusception.

Slow-transit constipation is distinguished from obstructed defecation by colonic transit studies and defecography.

Biofeedback is first-line therapy for dyssynergic defecation and pelvic floor dyssynergia.

Sacral nerve roots S2-S4 provide parasympathetic innervation to the bladder and rectum; sacral neuromodulation exploits this pathway.

Mesh erosion after sacrocolpopexy presents with vaginal discharge or bleeding; management includes vaginal estrogen and partial mesh excision.

Ureteral injury is a known complication of uterosacral suspension; intraoperative cystoscopy with intravenous indigo carmine or methylene blue confirms ureteral patency.

Bladder perforation during retropubic sling placement is detected by cystoscopy; the sling is repositioned and the bladder drained.

Voiding dysfunction after sling may require sling loosening or urethrolysis; persistent retention is evaluated with urodynamics.

Recurrence after native-tissue prolapse repair is highest in the anterior compartment; reoperation rates increase with time.

Sacrocolpopexy mesh erosion risk is reduced by avoiding tension and ensuring peritoneal coverage of the mesh.

Graft infection or abscess after mesh placement may require removal of the mesh; synthetic mesh in contaminated fields is avoided.

Postoperative pelvic pain after sacrospinous fixation may reflect nerve injury or suture placement; evaluation includes exam and imaging.

Graft types include autologous (fascia lata, rectus fascia), allograft (cadaveric fascia), xenograft (porcine/bovine dermis), and synthetic mesh (polypropylene).

Type I macroporous polypropylene mesh is the preferred synthetic for pelvic floor reconstruction because it allows tissue ingrowth and resists infection.

Synthetic mesh is avoided in the anterior vaginal wall in some settings due to erosion and dyspareunia risk; native tissue is preferred for transvaginal repair.

Autologous fascia is preferred in contaminated fields and for pubovaginal slings in intrinsic sphincter deficiency.

Mesh erosion rates are higher with transvaginal mesh kits than with abdominal sacrocolpopexy; vaginal estrogen may help with erosion.

Allografts and xenografts carry theoretical disease transmission risk and are resorbed over time, reducing durability.

Graft selection considers infection risk, durability, cost, and patient factors; synthetic mesh is contraindicated in active infection.

The FDA has issued safety communications regarding transvaginal mesh for prolapse; abdominal sacrocolpopexy mesh remains an accepted use.

Preoperative assessment includes medical comorbidity optimization, VTE risk assessment, and antibiotic prophylaxis (typically cefazolin) within 60 minutes of incision.

Vaginal surgery is often performed under regional (spinal) or general anesthesia; regional anesthesia reduces postoperative nausea and VTE risk.

Venous thromboembolism prophylaxis is selected by Caprini risk score; mechanical prophylaxis is used for low-risk patients, pharmacologic for higher risk.

Enhanced recovery after surgery (ERAS) protocols include preoperative carbohydrate loading, multimodal analgesia, and early ambulation.

Surgical safety checklist (WHO) reduces errors by confirming patient identity, procedure, site, and allergies before incision.

Perioperative glycemic control and smoking cessation reduce surgical site infection and wound complications.

Positioning for vaginal surgery (lithotomy) requires attention to nerve injury, especially the common peroneal nerve at the fibular head.

Postoperative urinary retention is common after pelvic surgery; early voiding trials and bladder scanning guide catheter management.

Mullerian anomalies include imperforate hymen, transverse vaginal septum, and Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome (vaginal agenesis with normal ovaries).

MRKH syndrome presents with primary amenorrhea and normal secondary sexual characteristics; karyotype is 46,XX and ovaries are functional.

Obstructed hemivagina with ipsilateral renal anomaly (OHVIRA) presents with cyclic pelvic pain and a pelvic mass; renal ultrasound is indicated.

Congenital urethral anomalies and epispadias are associated with bladder exstrophy spectrum; management is complex and often multidisciplinary.

Spina bifida and spinal cord injury patients have neurogenic bladder; urodynamics guides management to protect the upper tracts.

Neurogenic bladder management includes clean intermittent catheterization, anticholinergics, and botulinum toxin; upper tract surveillance is essential.

Pregnancy and pelvic floor disorders: obstetric anal sphincter injury and prolonged second stage increase risk of later prolapse and incontinence.

Elderly and frail patients require individualized surgical planning; obliterative procedures may be preferred over reconstructive surgery.

Sensitivity = true positives / (true positives + false negatives); specificity = true negatives / (true negatives + false positives).

Positive predictive value depends on prevalence; a highly sensitive test is useful for ruling out disease (SnNout), a highly specific test for ruling in (SpPin).

A randomized controlled trial minimizes confounding; intention-to-treat analysis preserves randomization benefits.

A p-value <0.05 conventionally indicates statistical significance; confidence intervals convey precision and clinical relevance.

Number needed to treat (NNT) = 1 / absolute risk reduction; it quantifies clinical benefit.

Systematic reviews and meta-analyses synthesize evidence; heterogeneity (I-squared) assesses variability across studies.

Levels of evidence range from Level I (RCTs, systematic reviews) to Level V (expert opinion); GRADE rates quality and strength of recommendations.

Bias types include selection, information, and confounding; blinding and randomization reduce bias in clinical trials.