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Nice incontinence -Urogyn Module part-2

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1)

. An 82-year-old patient presents to the gynaecology outpatient clinic with symptoms of
frequency and urgency. A post-void bladder scan shows 100 mL residual urine. Conservative
management did not help and now you have decided to start her on medical treatment for
overactive bladder (OAB).
Which of the following would you recommend?

2) What is the mode of action of darifenacin?

3)

A 60 year old lady in whom Oxybutinin, Tolteradine or Darifenacin
tablets are ineffective

4)

A 47-year-old woman attends the urogynaecology clinic with symptoms of urgency, urge
incontinence, frequency and nocturia. Conservative and medical treatment has not improved them.
Urodynamic studies suggest an overactive bladder; There is no Significant past medical history and
she is not taking any medication.
What is the appropriate management?

5)

A 60-year-old woman returns to the urogynaecology clinic for a review. She initially presented
with symptoms of urinary leakage and urgency. She has completed a course of bladder training with
no effect. She has myasthenia gravis but is otherwise well.

6)

A foundation year 1 (FYI) doctor is taking a history from a woman who has been referred to the
urogynaecology clinic. She is 50 years old and is complaining of nocturia, urgency and frequency,
with occasional incontinence when she coughs. The doctor is not sure whether this woman needs a
urodynarnics test.
In which of the following circumstances should urodynamic tests be performed?

7)

A 77-year-old woman attends the gynaecology clinic accompanied by her daughter. Her husband
died 10years ago and her daughter is her carer. The patient gives a I-year history of feeling
uncomfortable when she sits down. She has diabetes, hypertension and mild chronic obstructive
pulmonary disease. On examination, she is fran, and procidentia is found. She has tried two ring
pessaries but these were not successful in managing her symptoms.
What is the correct management?

8)

A 40-year-old woman presents with vaginal pressure and bulge, with urinary frequency and
urgency. She has two children born vaginally, aged 9 and 7, who are in primary school. She works as
a lawyer and would like to continue active life. She is sexually active, uses a Mirena intra-uterine
system for contraception and has no medical problems of note. Examination shows her to have
moderate anterior vaginal wall prolapse.
What is the appropriate management?

9)

A66-year-old multiparous woman attends the general gynaecology clinic complaining of
occasional incontinence when coughing and sneezing. She also says there is 'something coming
down the vagina' that is causing a 'dragging' sensation. On examination, there is procidentia.
How will you manage her?

10)

A 60-year-old woman attends the urogynaecology clinic with urinary incontinence associated
with coughing and sneezing. A urine dipstick is negative. A diagnosis of stress urinary incontinence is
made.
What would be considered the first-line treatment?

11)

An 83-yr old woman in poor medical health with urodynamic stress incontinence and normal
voiding parameters

12)

A 67-year-old woman is seen in the gynaecology outpatient clinic. She has tried various
medications for detrusor instability and all failed. She is keen to try the least invasive procedure.
Which of the following options would be most appropriate for her?

A 47-year-old multiparous woman is seen at a 6-month follow-up in the urogynaecology clinic. She
gives a history of arthritis, for which she is taking medication. She is still complaining of frequency.
urgency and urge incontinence. Medical treatment with oxybutynin and tolterodine has not
improved the symptoms. She is really unhappy about this and wants to know what can be done to
improve her symptoms.
What is the next management option?
Nice incontinence and prolapse Answers
23 September 2020 19:26

13) What is the next management option?

14) A 65 year old lady who does not want surgery for Stress Urinary Incontinence (SUI)

15)

A 51-year-old woman with two previous vaginal deliveries is seen in the gynaecology outpatient
clinic complaining of leaking urine on coughing and sneezing for the past three months. She has no
other urinary symptoms and is not on any medications. Abdominal and pelvic examination is normal.
What would you tell her regarding the number of pelvic floor contractions to perform and the
frequency of the exercise programme per day?

16)

A 32-year-old woman with one child has been referred by her GP with a 1 month history of urine
leakage on running and exercising. She has no urgency, and her frequency is four to six times during
the day and once at night. She has no prolapse or bowel symptoms. She had a spontaneous vaginal
delivery 2 months ago and currently breast feeding. She is planning to have another child in about 2
years.
On examination her BMI was 22. General and abdominal examination was unremarkable. Vaginal
examination showed a no evidence of pelvic organ prolapse. Her cervix was healthy and the uterus
was anteverted and normal size with no adnexal masses. There was no demonstrable stress urinary
incontinence.
Her urine analysis was normal.
What is the most appropriate next management step?

17)

A 55-year-old woman initially presented with urinary leakage on coughing and sneezing. She
completed a course of pelvic floor muscle training with little effect. She wishes to avoid surgical
intervention.

18)

5. A 55-year-old woman presents to the gynaecology outpatients clinic with a 2 year history of
recurrent urinary tract infection. Today she does not report any dysuria or frequency, however she
reports a longstanding sensation of incomplete bladder emptying. She reports no prolapse
symptoms.
Her general and abdominal examination was unremarkable. On vaginal examination she has a grade
II cystocele and no other evidence of prolapse. Her cervix was healthy and the uterus was
anteverted and small. No adnexal masses were felt.
Urine dipstick analyses is NAD.
What is the most appropriate next investigation?

19)

. A 73-yr old woman presents with symptoms of urgency and urge incontinence. She states her
abdomen feels more bloated and she cannot do the top button of her trousers up any more.
Urinalysis is clear.

20)

A 46-year-old woman with a body mass index of 25 kg/m2 attends the urogynaecology clinic,
complaining of an inability to stop herself from urinating when she first feels the desire to micturate.
She has never had any children. She does not drink tea or coffee but drinks 1.5 L of water during the
day. There is no significant past medical history and she is not taking any medication. A urine dipstick
test is negative for leucocytes and nitrites.
What is the correct treatment to offer?

21)

A 60-year-old woman diagnosed with overactive bladder was prescribed oral oxybutynin to be
taken dally. You see her 4 weeks after she started the medication. When you review her symptoms
in the clinic, she says they have not inlproved on this medication.
How should she be managed next?

22)

What proportion of women who use vaginal pessaries to manage pelvic organ prolapse will
report satisfaction in symptom relief?

23)

Which antimuscarinic drug used in the management of an overactive bladder should be avoided
in frail older women?

24)

A 55-yr old woman has been diagnosed with interstitial cystitis. Oral therapy has been unhelpful.
What is the next available management option?

25) What is the mode of action of duloxetine?

26)

A 62-year-old woman is referred to the gynaecology outpatient clinic because of hesitancy of
micturition and dribbling of urine after micturition.
Which of the following initial investigations would you recommend?

27)

A woman attends the urogynaecology clinic with symptoms of stress incontinence that have not
responded to conservative measures. She is keen for surgical intervention but wishes to avoid
synthetic meshes and tapes as she has read adverse reports in the media

28) .Selective serotonin and noradrenergfc reuptake inhibitor E

29)

A39-year-oldpara1patientpresentswithstressincontinencewith no other urinary symptoms.
What would be the first line of management?

30)

You review a 61-year-old patient in the gynaecology outpatient clinic, who is com- plaining of
leaking of urine on coughing or sneezing. Pelvic floor exercises have not helped. You counselled her
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leaking of urine on coughing or sneezing. Pelvic floor exercises have not helped. You counselled her
and booked her for a mid-urethral tape surgery.
The theatre nurse asks you which type of tape do you prefer?

31)

. A woman is seen on the postoperative ward round following the insertion of a transobturator
tape for the treatment of stress urinary incontinence.
Within what timeframe should she be offered a follow-up appointment with a vaginal examination
to exclude erosion?

32)

A 36-year-old multiparous woman presents with urinary incontinence on coughing and sneezing.
She has tried physiotherapy but this has not helped. Which of the following is licensed for use in the
management of stress urinary incontinence?

33)

A 40-yr old multiparous woman was referred by her GP die to prolapse and mixed urinary
incontinence. On examination she has a grade 1 cystocele and rectocele (POPQ classification). No
stress incontinence is demonstrable. Her bladder diary is suggestive of frequency and urgency. What
is the most appropriate initial management option?

34)

A 46-yr old woman who has had 3 previous vaginal delivery presents with a 2 yr
deteriorating history of leakage of urine on coughing, sneezing, and during exercise. On
examination a moderate cystocele and rectocele is observed

35) Anticholinergic plus calcium channel blocker J

36)

A45-year-old woman with four children attends the urogynaecology clinic with urgency, and
incontinence when coughing or sneezing and during lntercourse. There is no signfficant past medical
history and she is not taking any medication. Her body mass index is 35 kglm2 and she drinks three
cups of tea everyday.
What is your initial management plan?

37)

Ms. XY is 60 years old. She presents with symptoms suggestive of an overactive blad- der. Urine
dip is negative for leucocytes and nitrites. She does not smoke or consume caffeine. Examination
reveals no prolapse. Conservative therapies and OAB drugs have failed to improve her symptoms.
After an MDT discussion, a decision is reached to try botulinum toxin A. Which of the following is an
appropriate starting dose of the toxin?

38)

A 90-year-old woman with hypertension and type 2 diabetes presents with worsening
uterovaginal prolapse that is not being controlled with shelf pessaries

39)

A 58-yr old woman presents with a 9 month history of urinary frequency, urgency, and
pelvic pain. Investigations including urodynamic have been normal

40)

A 56-yr old woman with urodynamic stress incontinence and no previous surgery; her family is
complete and there is no prolapse on examination.

41) A 50 year old lady with urgency, frequency and intractable nocturia

42)

A fit and healthy 52-year-old patient with confirmed detru- sor overactivity has tried three
different medical treatments (Oxybutynin, Solifenacin, Mirabegron).
The procedure that should be offered to the patient is

43) Uroselective, M3 muscarinic acetylcholine receptor antagonist

44)

Which invasive treatment for an overactive bladder is suitable for women who are unable to
perform clean intermittent catheterisation?

45)

An 84-year-old patient presents with symptoms of urgency, urgency incontinence and nocturia.
The patient is taking several different medications for other medical conditions. A diagnosis of
overactive bladder is made.
The general practitioner has already tried Oxybutynin but the patient had side effects (central
nervous system) and this was stopped.
Which anticholinergic medication would you now consider?

46)

You review a 49-year-old woman in the gynaecology outpatient clinic with symptoms of
frequency and urgency of micturition. She is a para 1, delivered vaginally 15 years ago. Her BMI is 27
and she smokes 15 cigarettes a day. She drinks four cups of coffee daily.
Which of the following lifestyle interventions is the most important to improve her symptoms?

47)

A 72-year-old patient presents to the gynaecology outpatient clinic with symptoms of frequency
and urgency. A post-void bladder scan shows 75 mL residual urine. Conservative management did
not help and now you have decided to start her on medical treatment for OAB.
How soon after commencing medical treatment does she need a review?

48)

You review a woman in the urogynaecology outpatient clinic. You decided to start her on
anticholinergic therapy as she has symptoms of overactive bladder that has failed to respond to
lifestyle modification and bladder retraining.
How long will it take before she can expect to see the full benefits of taking this medication?

49)

A 60-year-old woman presents to the gynaecology outpatient clinic with a 6 month history of
urinary urgency, day time frequency every hour and night time frequency of three to four times. She
has no urge or stress urinary incontinence. She has had three proven urinary tract infections over
the past 6 months. She is postmenopausal and is not on HRT. She has had two vaginal deliveries in
the past.
Her general and abdominal examination was unremarkable. Vaginal examination showed atropic
external genitalia with a grade 1 cystocele and a grade 1 rectocele. There was no uterine descent.
Her cervix was healthy and the uterus was anteverted and small. No adnexal masses felt.
Urine analysis showed + of RBC and + of leukocytes.
What is the most appropriate next management step?

50)

. A 50-year-old patient is having an anterior repair for pelvic organ prolapse. At the end of the
operation, blood stained urine is noted.
What is the appropriate next step in her management?

51)

A 36-year-old woman attends GOPD with episodes of very frequent incontinence during
exercise. This is having a significant impact on her quality of life as she is now avoiding exercise. She
reports a day time frequency of 10 and occasional episodes of urgency but no urgency incontinence.
She has completed her family and has no significant past medical history.
Which investigation or treatment would you first discuss with the woman?

52) Which one of the following is a risk factor for pelvic organ prolapse?

53)

An elderly woman with cognitive disability and limited mobility is distressed with frequent
bedding and clothing changes due to urinary incontinence contamination.
The preferred management plan would be:

54)

A 49-yr old woman with 3 children born by vaginal delivery presents with leaking on exercise,
coughing and sneezing with occasional urgency. She has tried pelvic floor exercise with little
improvement in her symptoms and seeks definitive treatment. On examination there is minimal
prolapse and urinalysis is clear

55)

You see a woman in the gynaecology outpatient clinic. She has symptoms of frequency and
urgency of micturition. You asked her to keep a bladder diary.
Over what length of time should a bladder diary be undertaken?
A. Two days.
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56)

. A 38-year-old patient is suffering with stress incontinence. Her BMI is 32 kg/m2 and the patient is
interested in lifestyle manage- ment for her incontinence.
What is the most important lifestyle change that you would recommend?

57)

A 52-year-old patient presents with a history suggestive of an overactive bladder, but also
complains of fecal incontinence.
The patient has tried conservative measures and various anticholinergics with no significant benefit.

Urodynamic testing confirms detrusor overactivity and some void- ing dysfunction.
What is the best surgical option for this patient?

58) Competitive muscarinic receptor antagonist which is a prodrug

A 60-year-old woman presents with a vaginal bulge of 6 months duration. She has no urinary or
bowel symptoms. She had a coronary artery by-pass graft 3 months ago.
She was slightly dyspnoeic on supine position during examination. Her abdominal examination was
unremarkable. Vaginal examination findings are shown below.

59) What is the most appropriate next management step?

60)

A 62-yr old postmenopausal woman presents with an 8 months history of dysuria and vulval
pain. On examination, a pink exophytic lesion is observed at the urethral meatus

61)

A 45-year-old woman presents with urinary frequency and urgency and a diagnosis of idiopathic
detrusor overactivity is made. This has not responded to conservative measures and she is ready to
proceed with surgical intervention

62) 12.Anticholinergic plus muscuIotrophic plus local anaesthetic

63)

A 44-yr old woman with urge incontinence and severe detrusor overactivity on urodynamic
assessment. This is unresponsive to conservative therapy and anticholinergic medication

64)

A 55-year-old woman attends the urogynaecology clinic with urinary incontinence associated
with urgency. A urine dipstick is negative. A diagnosis of urgency urinary incontinence is made
What would be considered the first-line treatment?

65)

A 28-yr old woman presents ten days after an anterior colporrhaphy for cystocele. She
complaints of feeling constantly damp vaginally and is having to wear pads continuously.

66)

Ms. XY is 55 years old. She suffers from symptoms of an overactive bladder. Bladder retraining
has not helped her. Her recent urine analysis is negative for infection.
What is next step in her management?

67) An 85 year old frail lady with Overactive Bladder (OAB)

68) A 60 year old lady with poor bladder contractility

69)

A 64-year-old woman who has four normal deliveries presents to clinic with a history of leaking
urine on coughing, sneezing. On examination, she has demonstrable stress incontinence. She does
not give history of any other urinary symptoms.
The following is the next step in management:

70)

A 30-year-old woman presents with moderate uterine and moderate anterior and posterior
vaginal wall prolapse 6 weeks after her first delivery. This delivery was a prolonged one, ending with
Neville Barnes forceps delivery, during which an episiotomy was made. She described suffering from
bulge and pressure per vagina, especially on looking after her baby, as well as urinary frequency and
urgency. She is sexually active and has no other medical problems.
What is the appropriate management option for her?

71)

A 56-year-old woman undergoes urodynamic assessment. During the test, there is no change to
detrusor activity; however, she experiences urinary leaking on coughing. The diagnosis is therefore
most likely to be:

72)

A 65-year-old woman is prescribed mirabegron (Betmiga, Astellas Pharma) for detrusor
overactivity.
What type of drug is mirabegron?

73)

A 55-year-old patient presents with a history of urinary symptoms of urgency, increased
frequency and nocturia. The patient states that she does not have symptoms of hesitancy and feels
as though she empties her bladder completely.
What would be the first line of management?

74)

An 80-year-old hypertensive lady has Overactive bladder symptoms. The single best option for
drug therapy:

75)

A 53-year-old para 2 presents with a 12-month history of leaking on sneezing. She tried pelvic
floor exercise for six months with no improvement. On examination, there was no evidence of
uterovaginal prolapse.
What is the most appropriate surgical intervention?

76)

A 39-year-old patient presents with symptoms of leakage of urine upon coughing, sneezing and
during exercise. The symptoms started following the birth of her second child 18 months ago. What
would be the first line of management?
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would be the first line of management?

77)

A 27-year-old woman attends for cystometry. She reports a 2 year history of urgency and a
daytime frequency of 9–12, with two episodes of nocturia per night. She reports incontinence
episodes with coughing and laughing. She has no significant past medical history and has no known
allergies. She has had no previous treatment for her overactive bladder.
General abdominal examination is unremarkable. Vaginal examination does not demonstrate any
prolapse. Her cervix appears healthy. Saline cystometry is performed and demonstrates provoked
detrusor overactivity but no urodynamic stress incontinence.
What is the most appropriate first line treatment in this woman?

78)

Which derangement of acid–base balance is associated with augmentation cystoplasty for the
treatment of an overactive bladder?

79)

A 57-year-old woman who has had two children presents with the sensation of something
coming down with no urinary symptoms. She complains of chronic constipation. On examination,
she has stage 2-3 posterior vaginal wall prolapse with no associated uterine descent. The anterior
vaginal wall is well supported. What is the most appropriate treatment?

80)

A 38-year-old patient is suffering with symptoms of an overac- tive bladder. Her BMI is 25 kg/m2
and the patient is interested in lifestyle changes.
What is the most important lifestyle change that you would rec- ommend?

81)

. A 60-yr old woman who underwent TVT-O two years ago has attended for follow-up with
recurrent stress incontinence. Conservative management has failed and clinically stress incontinence
is demonstrable. She is now requesting further surgical treatment. What is the next line of
management?

82)

A 62-year-old woman who is otherwise fit and well presents with urgency, urinary leakage and
nocturia. The urgency and leakage are improved with transdermal oxybutynin, but the nocturia
remains troublesome with her needing to go to the toilet four or five times per night.

83)

A 59-yr old nullip woman presents with recurrent dysuria and frequency worsening over the past
six months. She smokes 20 cigarettes per day. Repeated MSUs at her GP have never demonstrated
infection. Urinalysis demonstrates ++ haematuria. You have sent repeat MSU for microscopy,
culture, and sensitivity.

84)

Ms. XY is 60 years old. She presents with symptoms suggestive of an overactive bladder. Urine
dip is negative for leucocytes and nitrites. She does not smoke or consume caffeine. Examination
reveals no prolapse. Which of the following is the most appropriate advice?

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