Urogynaecology Test Part 2
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1) Which of the following best describes the mechanism of action of Cyclizine?
Explanation: Cyclizine is type of antihistamine that acts on the H1 receptor.
In pregnancy NICE guidelines advise oral promethazine or oral cyclizine should be used as 1st
line drug management of nausea and vomitting. Both are H1 antagonists.
2) 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.
Mirabegron is recommended as an option for treating the symptoms of
an overactive bladder only for people in whom antimuscarinic drugs are
contraindicated or clinically ineffective, or have unacceptable side effects.
Myasthenia gravis is a contraindication to antimuscarinics.
NICE. Mirabegron for treating symptoms of overactive bladder. NICE Technology Appraisal
Guidance (TA290). June 2013.
3) The structure separating the external and internal anal sphincters.
The anal sphincter complex consists of the external and internal anal sphincters
separated by the conjoint longitudinal coat
4) 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.
If conservative management for stress urinary incontinence has failed, offer one of
NICE. Urinary incontinence in women: management. NICE Clinical Guideline (CG171).
5) A 35 year old woman re-attends 6 days after TAH for menorrhagia
because of persistent leakage of clear fluid from the vagina.
Speculum examination showed the presence of urine in the
vagina and a three swab test showed the presence of dye in the
6) A 72-year-old woman presents to the GP with presence of blood in her urine over the
last 2 months. She has no fever or any other systemic symptoms. Routine urinalysis
shows blood 3+. She feels quite well and has been brought to the GP reluctantly by her
persuasive daughter. The patient apologises for being an encumbrance.
Presence of blood in the urine with no suggestion of urinary infection is a worrying
symptom that needs an immediate referral to the secondary care. Some units have a
dedicated haematuria clinic for this purpose.
7) A 53-year-old woman is referred to the urogynaecology clinic with urinary
incontinence. She has routine urine dipstick testing and is found to have
Urgently refer women with urinary incontinence who have any of the
8) A woman is referred to a urogynaecologist with recurrent UTIs. A urine dipstick
in the clinic is negative.
Measure the postvoid residual volume by a bladder scan or catheterisation in
women with symptoms suggestive of voiding dysfunction or recurrent UTIs.
A bladder scan is used in preference to catheterisation on the grounds of
acceptability and a lower incidence of adverse events.
9) A 60 year old woman developed cervical cancer 12 months
earlier and was treated with combined chemotherapy and
radiotherapy. She now complains of blood in her urine which
occurs all the time
10) A 60-year-old woman has an initial appointment at the gynaecology clinic. Her
presenting symptoms are urinary leakage, urgency and nocturia.
Undertake a urine dipstick test in all women presenting with urinary incontinence
to detect the presence of blood, glucose, protein, leucocytes and nitrites in the urine
11) A 41-year-old woman presents with a long history of probable recurrent urinary tract
infections and has been treated with presumptive antibiotics when she lived abroad.
She has severe pain in the bladder area and also urinary urgency but no leaks. She also
reports occasional haematuria that resolves spontaneously. Serial urine cultures have
always been negative, including for fungus and atypical bacteria.
The symptoms are suggestive of interstitial cystitis. Cystoscopy and a probable biopsy
will help in the diagnosis. These patients are often mistaken for overactive bladder or
12) A 40-year-old woman attends the gynaecology clinic with a history of leakage of
urine on coughing or sneezing following the birth of her last child 2 years ago. A
urine dipstick is negative. A decision is made to commence a course of supervised
pelvic floor muscle training.
Undertake routine digital assessment to confirm pelvic floor muscle contraction
before the use of supervised pelvic floor muscle training for the treatment of
13) A 30-year-old woman presents to the gynaecology outpatient department (OPD) with a
6-month history of urinary urgency – frequency but no urge incontinence or nocturia.
The GP letter states that the urinalysis done last fortnight reported negative.
A bladder diary helps to ascertain the type and quantity of the ingested fluids and
the association with urinary symptoms. As she does not have urinary leakage, dry
overactive bladder may be managed with a symptom diary for confirmation of
diagnosis and patient feedback with lifestyle recommendations before commencing
14) A woman attends a general gynaecology clinic and has routine urinalysis by
dipstick. She has no symptoms, but the urine tests positive for both leucocytes and
If women do not have symptoms of a UTI but their urine tests positive for both
leucocytes and nitrites, do not offer antibiotics without the results of a midstream
15) The structure accounting for the majority of the resting anal pressure
The internal anal sphincter is innervated by the sympathetic (L5) and
parasympathetic (S2–S4) nerves and accounts for 50–85% of the resting anal
16) A 38-year-old woman presents with urinary leakage on coughing and sneezing. She has
completed her family. She has had two normal deliveries. She also admits that she has
difficulty holding on due to urinary urgency and frequents the toilet at least seven times
a day but not at night. Anticholinergics have not been helpful so far.
Urodynamics helps to ascertain treatment plan if conservative measures have
not been helpful.
17) 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.
Restrict augmentation cystoplasty for the management of idiopathic detrusor
overactivity to women whose condition has not responded to conservative
management and who are willing and able to self-catheterise.
18) 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.
10.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
Do not routinely offer duloxetine as a second-line treatment for women with
stress urinary incontinence, although it may be offered as second-line therapy
if women prefer pharmacological to surgical treatment or are not suitable for
surgical treatment. If duloxetine is prescribed, counsel women about its adverse
19) A 40-year-old woman with no significant past medical history presents with a
10-month history of pelvic pain mainly located to the suprapubic area. She has
urinary urgency and frequency but no leakage. The symptoms persist through her
cycle. She suffers with constipation but not diarrhoea.
The widespread definition for bladder pain syndrome is that proposed by the
European Society for the Study of BPS (ESSIC) in 2008 as ‘pelvic pain, pressure
or discomfort perceived to be related to the bladder, lasting at least 6 months, and
accompanied by at least one other urinary symptom, for example persistent urge
to void or frequency, in the absence of other identifiable causes’.
RCOG. Management of bladder pain syndrome. RCOG GTG No. 70. December 2016.
20) A healthy 57 years old woman complains of a vaginal lump 20
years after total anbdominal hysterectomy for a large fibroid
uterus. Clinical examination showed marked vault prolapse.
21) A 48-year-old woman presents to clinic with complex symptoms. She has urinary
urgency and frequency but also dysuria and postmicturition dribble. A full
gynaecological history also reveals dyspareunia. An initial pelvic examination is
A urethral diverticulum may present with multiple symptoms. The historical
classical triad of dysuria, postvoid dribbling and dyspareunia is only seen in
a minority of patients. Lower urinary tract symptoms, namely frequency and
urgency, are present in 40–100% of cases.
Archer R, Blackman J, Stott M, Barrington J. Urethral diverticulum. The Obstetrician &
22) A 45 year old woman complained initially of urinary frequency
urgency and urge incontinence and also leaked urine on
coughing or straining. She was treated medically initially and her
symptoms of urinary frequency and urgency have largely
resolved. Over the last 6 months, she is finding that urinary
leakage on coughing and straining is increasingly affecting her
23) The most caudal component of the levator ani complex.
The puborectalis muscle is the most caudal component of the levator ani complex
and is situated cephalad to the deep component of the external anal sphincter,
from which it is almost inseparable.
24) A 55-year-old woman who previously had insertion of a tension-free vaginal tape
for the treatment of stress incontinence attends with new symptoms of urinary
leakage with physical exertion or coughing. She is requesting further surgery.
After undertaking a detailed clinical history and examination, perform
multichannel filling and voiding cystometry before surgery in women who have
had previous surgery for stress incontinence.
25) A 90-year-old woman with hypertension and type 2 diabetes presents with
worsening uterovaginal prolapse that is not being controlled with shelf pessaries.
Colpocleisis is often reserved for elderly patients, in particular those with comorbidities that may render them unsuitable for the longer operating times and
more invasive procedures associated with reconstructive surgery
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