Urogynecology and Pelvic Reconstructive Surgery
What the exam tests
Pelvic organ prolapse, urinary incontinence, and fistula. The exam tests classification, conservative versus surgical management, and counselling.
Core rules
- Prolapse is described by POP-Q stages 0–IV; stage II is 1 cm above to 1 cm below the hymen.
- Stress incontinence is leakage with cough or exertion; urge incontinence follows urgency. Mixed symptoms are common.
- First-line management: pelvic floor muscle training for at least 3 months, weight loss, and treating constipation.
- Pessaries are suitable for women who decline surgery or are unfit for it.
- Surgery: anterior or posterior repair, sacrospinous fixation, or sacrocolpopexy for apical prolapse; midurethral sling for stress incontinence after failed conservative care.
- Mesh use requires explicit counselling about erosion and pain.
Worked example
A 55-year-old para 3 complains of urine loss when coughing; examination shows a cystocele to the hymen and a positive cough test. There is no urgency. Diagnosis: stress urinary incontinence with stage II anterior prolapse. Start supervised pelvic floor training for 12 weeks, treat constipation, and review. If symptoms persist, offer a midurethral sling after urodynamics if the diagnosis is unclear. The reasoning: conservative treatment comes first; surgery is not offered for urge-predominant symptoms.
Traps
Operating on overactive bladder; forgetting to exclude urinary tract infection; not examining for prolapse; and ignoring postvoid residual in women with voiding difficulty.