Urogynecology and Pelvic Floor Disorders
What this domain tests
Urogynecology questions test quantification of prolapse, discrimination of urinary incontinence types, conservative versus surgical management, and recognition of fistula and sphincter injury.
Core rules
- POP-Q. Six points (Aa, Ba, C, D, Ap, Bp) plus genital hiatus, perineal body, and total vaginal length. Stage 0 = no prolapse; stage I = leading edge >−3 cm; stage II = −1 to +1 cm; stage III = >+1 cm but not complete; stage IV = complete eversion.
- Incontinence types. Stress = leakage with cough or effort; urge = leakage with urgency; mixed = both. A cough stress test with a full bladder supports stress incontinence. Urodynamics is reserved for complex cases, prior surgery, or unclear diagnosis.
- Conservative care. Pelvic floor muscle training for at least 3 months, weight loss, pessary. These come before surgery in uncomplicated stress incontinence.
- Surgery. Retropubic or transobturator midurethral sling for stress incontinence; anterior or posterior colporrhaphy for prolapse; sacrospinous fixation for apical prolapse; mesh erosion presents with discharge or bleeding.
- OAB. Bladder training, then antimuscarinics or mirabegron; avoid anticholinergics in frail elderly patients.
- Obstetric anal sphincter injury. Third/fourth-degree tears need primary repair, antibiotics, and laxatives; document and follow up.
Worked example
A 58-year-old leaks on coughing, has no urgency, and has a cystocele at Ba +2. Start pelvic floor training and a pessary; if she remains symptomatic and wants surgery, a midurethral sling is appropriate after confirming stress-predominant leakage.
Traps
Confusing stage I and stage II POP-Q; operating on urge incontinence with a sling; repairing a vesicovaginal fistula too early (wait 6–12 weeks); missing an occult sphincter tear after forceps delivery.