Williams Gynecology, Second Edition (Schorge,Williams Gynecology), 2nd Edition

Pelvic Organ Prolapse

24–1. Which of the following are risk factors for the development of pelvic organ prolapse?

a. Spina bifida

b. Hypoestrogenism

c. Prior hysterectomy

d. All of the above

24–2. Compared with selective use, elective episiotomy during the second stage of labor has been associated with all EXCEPT which of the following?

a. Periurethral tears

b. Anal sphincter laceration

c. Increased postpartum pain

d. Postpartum anal incontinence

24–3. Which statement is true regarding measurements taken for the Pelvic Organ Prolapse Quantification (POP-Q) examination?

a. All are taken at rest, except for total vaginal length, which is obtained during Valsalva.

b. Point D is omitted in the absence of a cervix.

c. GH is measured from the midline of the posterior hymenal ring to the mid-anal opening.

d. Point Aa corresponds to the most distal portion of any part of the upper/proximal anterior vaginal wall.

24–4. As shown in this image of vaginal prolapse, when the leading edge of bulge is approximately even with the plane of the hymen or within 1 cm distal to the hymen, a patient is said to have which stage of prolapse?


Reproduced, with permission, from Buckley RG, Knoop KJ: Gynecologic and obstetric conditions. In Knoop KJ, Stack LB, Storrow AB, et al (eds): The Atlas of Emergency Medicine, 3rd ed. New York, McGraw-Hill, 2010, Figure 10-17.

a. Stage I

b. Stage II

c. Stage III

d. Stage IV

24–5. Pelvic organ support is maintained in part by the levator ani muscle, which is composed of all EXCEPT which of the following?

a. Puborectalis

b. Iliococcygeus

c. Pubococcygeus

d. Obturator internus

24–6. Using the Baden-Walker Halfway System, decent of the prolapse to the level of the hymen is considered which of the following?

a. Grade 1

b. Grade 2

c. Grade 3

d. Grade 4

24–7. Which description of levels of vaginal support is accurate?

a. Level I support describes the upper/proximal vaginal support via lateral attachments to the arcus tendineus fascia pelvis.

b. Level II support describes midvaginal support via the cardinal and uterosacral ligaments.

c. Level III support describes attachment of the distal vagina to surrounding structures, namely, the perineal body and the superficial and deep perineal muscles.

d. Level IV describes the global support of an intact “endopelvic fascia.”

24–8. Which of the following is the symptom that is reliably associated with prolapse and usually worsens as prolapse progresses?

a. Pelvic pain

b. Constipation

c. Anal incontinence

d. Sensation of pelvic pressure

24–9. Patients with this type of prolapse most commonly complain of which of the following?


Photograph contributed by Dr. Marlene Corton.

a. Dyspareunia

b. Constipation

c. Anal incontinence

d. The need for digital decompression of the bulge for defecation

24–10. An anterior vaginal wall prolapse is noted that has sagging lateral vaginal sulci, but rugae are still present. This suggests which type of anatomic defect?

a. Central

b. Midline

c. Transverse

d. Paravaginal

24–11. An enterocele may definitively be diagnosed during examination by which of the following methods?

a. Assessing the vaginal apex with a bivalve speculum

b. Observing small bowel peristalsis behind the vaginal wall

c. Displacing the posterior vaginal wall with a split speculum

d. All of the above

24–12. Which of the following is true of the ring pessary?

a. It is an example of a space-filling pessary.

b. It works by creating suction between the vaginal walls and the pessary.

c. It is most effective for patients with stage III or IV prolapse.

d. It is appropriately fitted when positioned behind the pubic symphysis anteriorly and the cervix posteriorly.

24–13. Which of the following is true of this pessary type?


a. It is a space-filling pessary.

b. It creates a diameter larger than the genital hiatus.

c. It is often used for moderate to severe prolapse or procidentia.

d. All of the above

24–14. All EXCEPT which of the following statements regarding pessary management are correct?

a. Ideally, the pessary is removed once every 4 to 6 months, washed with soap and water, and replaced the next morning.

b. Ulcerations or abrasions on the vaginal wall may be from an ill-fitting pessary or from the initial prolapse itself.

c. Pelvic pain with a pessary indicates its size is too large.

d. Urinary leakage may occur due to new support of the vaginal wall.

24–15. Options for management of foul odors associated with pessary use include all EXCEPT which of the following?

a. Warm water douches

b. Broad-spectrum antibiotics

c. Increased frequency of removal and washing

d. Use of Trimo-San gel (Milex Products, Chicago, IL)

24–16. Which characteristics describe the typical operative candidate for the obliterative procedure demonstrated in the image?


Reproduced, with permission, by Schaffer JI, Hoffman BL: Surgeries for female pelvic reconstruction. In Schorge JO, Schaffer JI, Halvorson LM, et al (eds): Williams Gynecology, 1st ed. New York, McGraw-Hill, 2008, Figure 42-23.1.

a. Desiring future fertility

b. Desiring future coital activity

c. Medically compromised or elderly patient

d. Abnormal uterine bleeding requiring concomitant hysterectomy

24–17. Compared with reconstructive procedures for prolapse correction, colpocleisis generally has which of the following characteristics?

a. Is technically more difficult

b. Requires greater operative time

c. Has a less successful long-term anatomic outcome

d. None of the above

24–18. A vaginal reconstructive procedure for prolapse correction may be preferable to an abdominal route for which of the following reasons?

a. A prior vaginal approach has failed.

b. A short total vaginal length is present.

c. A higher risk of recurrent prolapse is expected.

d. A quicker return to daily activities is desired.

24–19. Performing an abdominal sacrocolpopexy or uterosacral ligament suspension addresses the detachment defect of anterior wall prolapse and should offer an improved repair over traditional anterior colporrhaphy alone.

a. Central

b. Midline

c. Transverse

d. Paravaginal

24–20. In the procedure depicted in this image, the fibromuscular layer of the anterior vaginal wall is reattached to which of the following?


Reproduced, with permission, from Schaffer JI, Hoffman BL: Surgeries for female pelvic reconstruction. In Schorge JO, Schaffer JI, Halvorson LM, et al (eds): Williams Gynecology, 1st ed. New York, McGraw-Hill, 2008, Figure 42-14.3.

a. Cardinal ligaments

b. Uterosacral ligaments

c. Arcus tendineus fascia pelvis

d. Iliopectineal (Cooper) ligament

24–21. For this patient, which of the following is essential during reconstructive surgeries to correct this degree of prolapse?


Photograph contributed by Dr. Marlene Corton.

a. Perineorrhaphy

b. Apical resuspension

c. Burch colposuspension

d. Paravaginal defect repair

24–22. Effective procedures for addressing prolapse at the vaginal apex include all EXCEPT which of the following?

a. Simple hysterectomy

b. Abdominal sacrocolpopexy

c. Sacrospinous ligament fixation

d. Uterosacral ligament vault suspension

24–23. Which of the following statements regarding sacrospinous ligament fixation are true?

a. Requires an intraperitoneal approach

b. May be performed unilaterally or bilaterally

c. Results in buttock pain or vascular injury in 10 to 15 percent of cases

d. Supports the apex well but results in frequent recurrent prolapse of the posterior vaginal wall

24–24. Regarding repair of posterior vaginal wall prolapse, all EXCEPT which of the following are correct?

a. To achieve its high 76 to 96 percent anatomic cure rate, posterior colporrhaphy requires addition of biologic or synthetic mesh materials.

b. Concurrent levator muscle plication narrows the genital hiatus but may increase dyspareunia.

c. Site-specific repairs discretely close fibromuscular defects that may be midline, lateral, distal, or superior.

d. Site-specific repairs have anatomic success rates comparable to those of traditional colporrhaphy.

24–25. In the surgery pictured here, with plication of tissues of the distal posterior vaginal wall, which of the following is true?


Reproduced, with permission, from Schaffer JI, Hoffman BL: Surgeries for female pelvic reconstruction. In Schorge JO, Schaffer JI, Halvorson LM, et al (eds): Williams Gynecology, 1st ed. New York, McGraw-Hill, 2008, Figure 42-16.1.

a. Level III support is being reestablished.

b. The risk of posterior wall prolapse recurrence is decreased.

c. Overly aggressive plication may narrow the introitus and lead to entry dyspareunia.

d. All of the above

24–26. Compared with type II or III mesh materials, type I mesh has which of the following characteristics?

a. Has smaller pore size of less than 1 μm

b. Has a higher rate of associated infection

c. Allows better tissue ingrowth, angiogenesis, and flexibility

d. Is harvested from another part of the body (e.g., rectus abdominis fascia)

24–27. Which statement correctly describes xenografts?

a. Synthetic, multifilament mesh material

b. Biologic graft from a human other than the patient

c. Biologic graft such as porcine dermis or bovine pericardium

d. Synthetic mesh with pore sizes less than 10 μm in at least one dimension

Chapter 24 ANSWER KEY