A 65 yo women G3P3 with Stage III Anterior Vaginal Wall Prolapse. The surgical repair that is most likely to resolve her underlying pelvic support defect is?

A 71 yo multiparous woman visits your office with a symptomatic vaginal bulge. She noticed the bulge after her total vaginal hysterectomy 2 years ago, and it has become progressively more bothersome. On examination, she has Stage III pelvic organ prolapse. She has a total vaginal length of 10 cm, and her vaginal cuff protrudes past the hymen; however it is not completely evert. The correct pelvic organ prolapse quantification POP-q assessment of the patient is?

An 87 year old multiparous woman with multiple meducal comorbidities comes to your office for evaluation of POP noted during her recent hospitalization for MI. She reports no typical prolapse symptoms but has urinary incontinence. On exam, her anterior vaginal wall is prolapsed 6 cm beyond the hymen, and her cervix is at the hymen. You obtain a PVR which is 260 mL. UA is negative for nitraites, leukocytes, and blood. The best next step in her management is:

 71-year-old woman is referred to you for symptoms of urinary tract infection, which have improved after a 3-day course of antibiotics. Her dipstick urinalysis is positive for leukocyte esterase and negative for blood. Urine culture is positive for Escherichia coli. She has had three culture-proven urinary tract infections over the past 2 years. She recalls that she had one to two urinary tract infections while in her twenties. She is sexually active with one long-term partner. On pelvic examination, she has no structural abnormalities and has stage 1 pelvic organ support. The best next step in management is:

A 70-year-old woman with a history of chronic obstructive pulmonary disease has had recurrent urinary tract infections every 2 months for the past year. All of her urinary tract infections have been culture proved, and her symptoms have resolved each time with the use of antibiotics. She is not sexually active and has been taking vaginal estrogen for 6 months. She was given a prescription for once-daily trimethoprim–sulfamethoxazole but developed a resistant urinary tract infection after 3 months of therapy. Office-based cystoscopy is negative. Her urine appears cloudy, and she has a postvoid residual urine volume of 100 mL. After ruling out an active urinary tract infection, the best next treatment is

A 32 yo woman G1P1 comes to clinic with urinary incontinence. She hopes to become pregnant within the next year. She reports after delivery of her son 8 month ago, she developed urine leakage with exercise, specifically with running. The leakage interferes with her quality of life. She has no symptoms of urgency urinary incontinence. The best treatment option for her is:

A 44 yo woman G3P3 comes to your office and reports that she leaks urine with coughing, sneezing, and jogging. On examination, she has a positive cough stress test. She is interested in undergoing surgical treatment and recently heard about retropubic mid urethral slings. You counsel her that the most common complication associated with retropubic mid urethral sling procedure is:

A 42 yo woman visits your clinic with urinary incontinence. She first developed urinary leakage with exercise, coughing, and sneezing after delivery of her first child. She has completed her family and desires surgical management. She does not report symptoms of urgency or urgency incontinence. She voids seven times per day, and has no prolapse or vaginal bulge. Her PVR is 55 mL and urine culture is negative. The most important test in evaluation of this patient for surgery is?

A 55 yo woman comes to your office with urgency incontinence. She states that she experiences five or six daily episodes of large volume urine loss associated with an urge to void. She also reports enuresis with involuntary urination at night. She uses six to seven incontinence pads per day. She has tried behavior therapy, including timed voiding and decreasing bladder irritants. She most recently tried two anticholinergic medications with no improvement in symptoms. She decides to try an intradetrusor injection of onabotulinumtoxin A. You counsel her that this is a VERY effective therapy but is accompanied with high rate of UTI and the adverse effect of:

A 65 yo woman has daily episodes of urgency urinary incontinence, despite the fact that she has reduced her fluid intake and performs Kegel exercises correctly. She requires one to two incontinence pads daily. She tried oxybuytynin chloride three times a day with good success initially. However she developed adverse effect s(dry mouth, dry eyes, and constipation), which led her to stop using the medication. Her primary care provider is currently performing a workup for episodic HTN. The next best step is to prescribe:

An 84 yo woman visits your office with urgency urinary incontinence. She reports five to six daily episodes of large volume urine loss associated with urge to void. She wears multiples pads per day and is unable to leave the hos for long periods due to need for frequent pad and clothing changes. She has tried behavior therapy, including timed voiding and decreasing bladder irritants. She has narrow-angle glaucoma and is unable to tolerate anticholinergic medications. Her PVR is 200 mL. She has elected to pursue a trial of SNM. She had a permanent lead placed adjacent to the S3 dorsal root and is working on a daily bladder diary. Her diary today shows > 50% improvement in her urinary leakage episodes. The most appropriate next step is to:

A healthy 35-year-old woman, para 2, comes to your office 6 weeks after uncomplicated placement of a retropubic midurethral sling. She reports urinary frequency, a slow dribbling urinary stream, and a sensation of incomplete bladder emptying. Her stress urinary incontinence symptoms have resolved after surgery. She reports no dysuria or hematuria. Her postvoid residual urine volume is 340 mL and her urine dipstick is negative. She is using self-catheterization. The most appropriate management of her condition is

A 35-year-old woman had a diving accident 2 years ago, resulting in a complete T9 spinal cord injury. Immediately after the accident, she developed acute urinary retention requiring an indwelling urethral catheter. After she recovered from her injuries, she was taught clean intermittent catheterization, which she performed without any issues until 1 year after the accident, at which time she developed urinary incontinence between catheterizations. Her incontinence was controlled with anticholinergic agents for nearly 12 months. However, more recently, she has developed progressively worse leakage between catheterizations. Urodynamic tests demonstrate poor compliance, with detrusor pressure increasing to 50 cm H2O at a volume of 150 mL and a detrusor leak point pressure of 60 cm H2O at a volume of 200 mL. She has no leakage with cough or Valsalva maneuver. Renal ultrasonography reveals mild bilateral hydronephrosis. The best next step in management is à

A 50-year-old woman was diagnosed with multiple sclerosis after an episode of acute urinary retention. She was initially managed with an indwelling catheter for 2 weeks, after which she was taught clean intermittent catheterization. Three months later, she regained the ability to void again and was fully continent. However, over the next 6 months she developed voiding difficulty with periodic leakage in which she totally emptied her bladder in her wheelchair. At her office visit, her postvoid residual urine volume was 400 mL. She returned to the office 1 week later for urodynamic testing. Before emptying her with a catheter, her initial postvoid residual urine volume was 450 mL. Her urodynamic testing demonstrates the tracing illustrated in Figure 43-1 (see color plate). The best next step in management for her is  

A 42 yo woman reports  urinary leaking with exercise, coughing, and sneezing after the delivery of her child 10 years ago. She has had no leakage associated with an urge to void. For the past few years, she has successfully used an incontinence disk but she has decided that she is finished with childbearing and wants to pursue definitive surgical management. She underwent an uncomplicated transobturoator midurethral polypropylene sling procedure. Cystoscopy at the time of the procedure revealed intact bladder and urethra and bilateral urethral efflux. Six months after her sling surgery she was happy that she can now exercise without leaking urine. However, she notes that she has intermittent vaginal spotting between her menses and her partner describes “something scratchy” during intercourse.

What is the best next of action?

A 65 yo sexually active women desires surgical management of her stage III POP. The vaginal bulge interferes with her daily activities, and she sometimes has difficulty emptying her bladder. She does not have symptoms of SUI or UUI. She experiences three episodes of nocturia each night. Her PVR is 175. She wants a procedure that will offer her the best anatomic and functional outcome. The best treatment for her is:

A 57 yo women comes to your office with a 6 mo hx of urinary urgency and frequency + bladder pain. She has been treated for recurrent UTIs but reports negative urine cultures. On exam, she has pain with insertion of the speculum and bladder tenderness on bimanual examination. Otherwise, her pelvic exam is normal. UA is negative.

The most appropriate next step in management is:

A 73 yo has a vaginal bulge for 6 months. She has undergone a previous TVH and BSO. She tried a pessary but was unable to retain due to poor levator muscle and a wide genital hiatus. The patient desires surgical correction and chooses to undergo a sacrospinous ligament suspension. During the procedure, two permanent sutures are placed one fingerbreadth medial to the ischial spinal along the sacrospinous ligament, brisk bleeding is encountered. The bleeding is controlled by application of topical thrombin and prolonged application of manual pressure. The sutures are fixed to the vaginal mucosa in a standard fasion to complete the apical repair. A posterior colporrhaphy and perineorrhaphy then are performed with excellent reduction of the prolapse. In the recovery room, the patient immediately complains of severe right sided buttock pain that radiates down the back of her leg. The best next step in management is:

A 35 yo woman with a history of a spinal cord injury undergoes a cystoscopy as part of her workup for recurrent UTI. On filling the bladder to approximately 400 mL, she suddenly develops a headache and sweating on her face. Her BP is 180/100 mm HG and her HR HR is 45 bpm. Bladder is emptied and the cystoscopy is removed. The symptoms immediately resolve. The patient is likely to have a spinal cord lesion located at

A 58 yo stress continent women has a BMI 22 and Stage III POP. She undergoes an uncomplicated open supracervical hysterectomy, sacrocolpopexy, and Burch colposuspension. The surgery is done in the dorsal lithotomy position through a Pfannenstiel incision using a Balfour retractor and lasts 3 hours. On POD1, she falls as she is trying to get out of bed. She has decreased motor strength of her left quadriceps muscle (2/5) sensory loss over the anterior thigh, and an absent patellar reflex. Based on her symptoms, the nerve that has most likely been injury is

A 65 yo multiparous femoral comes to your office with accidental bowel leakage. She reports several loos stools per day with associated leakage. She has a history of anal sphincter laceration with her first delivery 40 years ago. The intervention that is most likely to eliminate her fecal incontinence is: