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

CHAPTER 26
Genitourinary Fistula and Urethral Diverticulum

26–1. What is the most common type of genitourinary fistula?

a. Vesicovaginal

b. Vesicouterine

c. Ureterovaginal

d. Urethrovaginal

26–2. Which of the following is the correct sequence of events in wound healing?

a. Angiogenesis → fibrosis → remodeling

b. Angiogenesis → remodeling → fibrosis

c. Fibrosis → remodeling → angiogenesis

d. Remodeling → angiogenesis → fibrosis

26–3. All EXCEPT which of the following anatomic communications have been described?

a. Vesicocervical

b. Ureterouterine

c. Urethrouterine

d. Ureterocervical

26–4. All EXCEPT which of the following are examples of complicated vesicovaginal fistulas?

a. Concurrent pelvic malignancy

b. Prior pelvic radiation therapy

c. Posthysterectomy fistula distant from the vaginal cuff

d. High posthysterectomy fistula with normal vaginal length

26–5. According to the more comprehensive fistula classification system introduced by Goh in 2004, how would one classify a 2-cm diameter fistula with moderate-to-severe surrounding fibrosis located 5 cm from the external urethral meatus?

a. Type1ai

b. Type1bii

c. Type3aii

d. Type2ciii

26–6. In developing countries, most genitourinary fistulas (approximately 90 percent) are attributable to which of the following?

a. Malignancy

b. Pelvic surgery

c. Obstetric trauma

d. Sexual trauma or foreign body

26–7. In developed countries, most genitourinary fistulas (approximately 90 percent) are attributable to which of the following?

a. Malignancy

b. Pelvic surgery

c. Obstetric trauma

d. Sexual trauma or foreign body

26–8. Which of the following diagnostic tools or techniques would help identify a ureterovaginal fistula?

a. Cystourethroscopy

b. Intravenous pyelogram

c. Voiding cystourethrogram

d. “Three-swab” or tampon test with diluted solution of methylene blue instilled (retrograde) into the bladder

26–9. This image is of a normal female voiding cystourethro-gram. This modality, when viewed laterally, may help in the diagnosis of all EXCEPT which of the following?

Image

Reproduced, with permission, from Gash JR, Noe J: Radiology of the urinary tract. In Chen MYM, Pop TL, Ott DJ (eds): Basic Radiology, 2nd ed. New York, McGraw-Hill, 2011, Figure 9-14.

a. Urethral diverticulum

b. Vesicovaginal fistula

c. Ureterouterine fistula

d. Urethrovaginal fistula

26–10. Spontaneous healing of a genitourinary fistula via continuous bladder drainage using an indwelling urinary catheter is more likely to happen in which of the following settings?

a. The fistula is large, greater than 2 cm.

b. The fistula is small, 2 to 3 mm.

c. The fistula is related to pelvic radiation.

d. The catheter is left in place for a minimum of 8 weeks.

26–11. Compared with an abdominal (transperitoneal) approach for genitourinary fistula repair, the route of surgery depicted in this figure is associated with which of the following?

Image

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 42-10.3.

a. Greater blood loss

b. Greater operative time

c. Less overall morbidity

d. Increased duration of hospitalization

26–12. Indications for an abdominal approach to genitourinary fistula repair include which of the following?

a. Recurrent fistula

b. Complex or large fistula

c. Concomitant ureteric fistula or fistula in close proximity to ureteral orifices

d. All of the above

26–13. If intervening tissues for surgical closure of a fistula are poorly vascularized and weak, which of the following would be an appropriate intervention?

a. Use synthetic graft material to reinforce the repair

b. Consider an abdominal approach with an omental interpositional flap

c. Abort the procedure in favor of conservative management with a long-term indwelling urinary catheter

d. All of the above

26–14. In developed countries, urethrovaginal fistulas are most commonly attributed to which of the following?

a. Obstetric trauma

b. Pelvic infection

c. Prior hysterectomy

d. Prior anterior colporrhaphy or urethral diverticulectomy

26–15. Which of the following statements regarding urethral diverticula is correct?

a. They commonly are associated with urethral cancer.

b. They may be associated with infectious urethritis.

c. They are identified almost exclusively in reproductive-aged women.

d. They develop with equal frequency in men and women.

26–16. Which of the following statements is true regarding calculi that develop within urethral diverticula?

a. They result from stagnation of urine and precipitation of salts.

b. They are usually composed of calcium oxalate or calcium phosphate.

c. They are associated with approximately 10 percent of urethral diverticula.

d. All of the above

26–17. Urethral cancers related to urethral diverticula are usually which histologic type?

a. Sarcomas

b. Adenocarcinomas

c. Squamous cell carcinomas

d. Transitional cell carcinomas

26–18. A predominance of paraurethral glands are found along the which portion of the urethra?

a. Distal third

b. Middle third

c. Proximal third

d. At the bladder neck

26–19. The communication point between the diverticular ostium and the urethra most commonly occurs at which location?

a. Midurethra

b. Distal urethra

c. Proximal urethra

d. Mid- and distal urethra with approximately equal frequency

26–20. Among women presenting with symptomatic urethral diverticula, which of the following statements is correct?

a. Urinary retention is the most common complaint.

b. The mass is soft and pliable and is almost always nontender.

c. Associated urinary incontinence or postvoid dribbling is rare, occurring in less than 10 percent of patients.

d. Dyspareunia may be either with entry or deeper penetration, depending on whether the diverticulum is distal or proximal.

26–21. Cystourethroscopy for the detection of urethral diver-ticula is best performed with which of the following endoscopes?

a. 0-degree rigid telescope

b. 30-degree rigid telescope

c. 70-degree rigid telescope

d. 120-degree rigid telescope

26–22. Use of cystourethroscopy for the diagnosis of urethral diverticula is beneficial for all EXCEPT which of the following?

a. May be performed as an office-based procedure

b. Generally allows for identification of diverticular ostium location

c. Allows for exclusion of other pathology such as lower urinary tract calculi

d. Allows for characterization of diverticular size and circumferential extent

26–23. A 51-year-old G3P3 woman presents with voiding difficulties and recurrent bladder infections. A voiding cystourethrogram is performed, and a large, irregular urethral diverticulum is identified (arrow). Which of the statements is true regarding this diagnostic modality?

Image

Reproduced, with permission, from Gerst SR, Hricak H: Radiology of the urinary tract. In Tanagho EA, McAninch JW (eds): Smith’s General Urology, 17th ed. New York, McGraw-Hill, 2008, Figure 6-13B.

a. Is no longer available in most hospital centers

b. Is painful for patients and complicated to perform

c. Requires exposure of the patient to ionizing radiation

d. Is more sensitive for detection of diverticula compared with positive-pressure urethrography

26–24. Which of the following is true regarding magnetic resonance imaging of periurethral pathology?

a. Requires ionizing radiation and contrast exposure

b. Is generally less expensive than other imaging modalities

c. Has limited utility in identifying location, extent, and internal characteristics of masses

d. Has comparable or superior sensitivity for detecting urethral diverticula compared with other imaging modalities

26–25. The procedure depicted here places patients at risk for which of the following?

Image

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 42-9.3.

a. Urinary leakage

b. Urethral stenosis

c. Urethrovaginal fistula

d. All of the above

Reference:

Goh JT: A new classification for female genital tract fistula. Aust N Z J Obstet Gynaecol 44:502, 2004

Chapter 26 ANSWER KEY

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