Question 1

A 52 year old woman with urinary urge incontinence is has been treated with oral oxybutynin.
Her symptoms have improved but she is unable to tolerate oral medication.

Options for Questions 1-1

A Offer bladder re-training

Offer vaginal oestrogen

C Offer per-cutaneous sacral nerve stimulation

Offer sublingual oxybutynin

E Offer transdermal oxybutynin

A(Correct answ er: E)

Explanation
Offering OAB drugs
Offer one of the following choices first to women with OAB or mixed UI:
a) oxybutynin (immediate release)
b) tolterodine (immediate release)
c) darifenacin (once daily preparation)
If the first treatment for OAB or mixed UI is not effective or well tolerated, offer another drug with the lowest
acquisition cost.
Offer a transdermal OAB drug to women unable to tolerate oral medication.

Question 2

With respect to pelvic floor muscle training to manage urinary stress incontinence

Options for Questions 2-2

A

Pelvic floor muscle training is more cost-effective

B
than duloxetine as first line treatment

Biofeedback should not be used in combination

with pelvic floor muscle training

Pelvic floor muscle training should not be

performed during menstruation

Pelvic floor muscle training should not be

performed in the antenatal period

Pelvic floor muscle training is not recommended

E in women with moderate severe prolapse
symptoms
A(Correct answ er: A)

Explanation
PELVIC FLOOR MUSCLE TRAINING (PFMT) AND VAGINAL CONES
In women with stress urinary incontinence, vaginal cones are more effective than no treatment over the
short term.
There is no evidence of a difference in effectiveness between cones and PFMT.
Compared with PFMT, cones are associated with more adherence problems.
One study suggested that the training time for using vaginal cones is one-third of that for PFMT, which
would make vaginal cones cheaper than PFMT. However, it is not clear what the appropriate training
regimen should be for women using vaginal cones.
Vaginal cones are not suitable for all women. Cones are inappropriate for use in some circumstances,
such as when there is a moderate to severe prolapse, too narrow or too capacious a vagina causing
difficulty with insertion or misplacement of the cone, untreated atrophic vaginitis, vaginal infection, or during
menstruation or pregnancy.
Evidence does not indicate additional benefit from biofeedback with PFMT in comparison with PFMT
alone in treating UI.
Biofeedback with PFMT is more costly than PFMT alone and therefore is not cost effective.
There are limited data on the use of magnetic therapy for urinary incontinence, and its role in treatment of
women is unclear

 PFMT is more cost effective than duloxetine alone, as first-line treatment for stress urinary incontinence.
Electrical stimulation and/or biofeedback should be considered in women who cannot actively contract pelvic floor
muscles in order to aid motivation and adherence to therapy
Preventive use after pregnancy
Urinary incontinence occurs in 1732% of women post-partum.
PFMT was started 24 or 48 hours after delivery in primi- or multiparous women
At 3 months postpartum, there is
significantly lower prevalence of urinary incontinence in the PFMT group following the 8 week treatment
programme. This difference was not sustained at 1 year
no significant differences in urinary incontinence prevalence between groups following the 4 week
treatment programme
Acohort study reported a significantly lower stress urinary incontinence prevalence in women (41% of
whom had incontinence at baseline) who had undergone a structured 8 week PFMT programmecompared
with usual care, both at the end of the intervention and at 1 year postpartum. No significant differences were
found between groups in leakage index or social activity index.
There is evidence that PFMT used during a first pregnancy reduces the prevalence of urinary
incontinence at 3 months following delivery. The effects in the longer term are inconsistent and the impact of
subsequent pregnancies unknown.

Question 3

Retropubic top-down procedures used in the management of urinary stress incontinence are
associated with

Options for Questions 3-3

A 50-60% continence rates at less than 1 year

3-7% risk of peri-operative tissue injury

C 0.1-0.2% risk of tape erosion

10-17% risk of voiding dysfunction

12-25% risk of de-novo detrusor overactivity

symptoms
A(Correct answ er: B)

Explanation
Retropubic top-down

Long-term continence

Continence < 1 year

81%

2 years: no data

Peri-operative tissue injury

3-7%

3 years: no data

Erosion

No data

5 years: no data

Retention

No data

7 years: no data

Voiding dysfunction

No data

10 years: no data

De-novo detrusor overactivity

symptoms

No data

Question 4

A healthy 57 year old woman presents with vaginal vault prolapse 10 years after vaginal
hysterectomy. Which operation is typically associated with deviation of the vaginal axis?

Options for Questions 4-4

A Abdominal sacro-colpopexy

Sacro-spinous fixation

C Ileo-coccygeus fixation

Laparoscopic sacro-colpopexy

E Colpocliesis
A(Correct answ er: B)

Explanation
Surgical treatment
1) Abdominal sacro-colpopexy

2) Sacro-spinous fixation
There is currently no evidence to recommend one procedure over the other
Operating surgeon should be experienced in both procedures
Sacro-spinous fixation requires adequate vaginal length to reach the sacro-spinous ligament
Vaginal procedure may be appropriate in the presence of vaginal wall prolapse. However, prolapse may also be
reduced abdominally or laparoscopically
Vaginal procedure more suitable for frail women because of morbidity associated with abdominal incision
Abdominal procedure appropriate if woman is undergoing laparotomy for other reasons and is more suitable for
sexually active women as sacro-spinous fixation results in deviation of the vaginal axis and may be associated with
dyspareunia. Sacro-spinous fixation may cause vaginal narrowing and shortening especially if combined with anterior
/ posterior repair
3) Ileo-coccygeus fixation is currently not recommended
4) Vaginal utero-sacral ligament suspension is effective but associated with a risk of ureteric injury and should be
used with caution
5) Laparoscopic sacro-colpopexy appears to be as effective as open procedures but requires operative laparoscopic
skills and longer operating times.
6) Colpocleisis should be considered in women who do not wish to retain sexual function. Short operating time and
low risk of morbidity makes this a useful option in women who are unfit for major surgery.

Question 5

Mirabegron

Options for Questions 5-5

A Has a worse side-effect profile than tolterodine
C

Has a lower discontinuation rate due to sideeffects than tolterodine

Has a worse side-effect profile than oxybutynin

Causes less dry mouth than tolterodine

E Does not have any cardiovascular side-effects

A(Correct answ er: D)

Explanation
Adverse effects
Incidence of adverse effects 39.2% compared with 36.4% for the placebo group and 48.4% for the tolterodine group
Adverse events are mild or moderate. Headache (6.9%) and GI disorders (13.8%) are the most common in the
mirabegron group, but their incidence lower compared with the tolterodine group (9.4%, 23.4% respectively).
Treatment-related dizziness and palpitations more common with mirabegron compared with placebo and
tolterodine.
Discontinuation rates caused by adverse effects 4.6% and 7.7% with mirabegron 100 mg and 150 mg, respectively,
1.5% with placebo and 3.1% with tolterodine.

Question 6

Which one is an anti-phospholipid antibody?

Options for Questions 6-6

A Anti-Ro antibodies

Anti-beta-2 glycoprotein-I antibodies

C Rheumatoid factor

Anti-nuclear antibodies

E Anti-smooth muscle antibodies

A(Correct answ er: B)

Explanation

Antiphospholipid syndrome refers to the association between anti-phospholipid antibodies (lupus anticoagulant,
anticardiolipin antibodies and anti-B2 glycoprotein-I antibodies) and adverse pregnancy outcome or vascular
thrombosis

Question 7

A 23 year old woman with sickle cell disease attends the antenatal clinic at 16 weeks gestation.
Her risk of suffering a stillbirth is

Options for Questions 7-7

A 0.2%

1%

C 5%

8%

E 12%
A(Correct answ er: B)

Explanation
Fetal risks of maternal sickle cell disease
Miscarriage
IUGR / small for gestation age (21% of neonates are below 10th centile)
Pre-term delivery (27% delivered before 37 weeks)
Stillbirth (1%)
Increased perinatal mortality (6x)??No fetal haemoglobinopathy

Question 8

A 34 year old woman with sickle cell disease attends for pre-conception counseling. To assess
her for chronic complications

Options for Questions 8-8

A

Liver function tests should be done if not

undertaken in the last 3 months

Screening for pulmonary hypertension should be

D
done using ECG

Iron chelation is not recommended before

conception

Renal function tests should be done if not

undertaken in the last 12 months
Screening for iron overload is done using serum
ferritin and transferrin levels

A(Correct answ er: B)

Explanation
Pre-conception assessment of chronic complications
Investigations
FBC, B12, folate & ferritin. Liver & renal function tests if not performed in the last year ( sickle
nephropathy / abnormal LFT)
Red cell antibodies
Urine dpistix for proteinuria
Retinal screening for proliferative retinopathy.
Screen for pulmonary hypertension with echocardiography if not done in the last year.
Screening for iron overload in women who have been multiply transfused in the past or who have a high
ferritin level using cardiac magnetic resonance imaging. Aggressive iron chelation before conception is
advisable in women who are significantly iron loaded.
Haemoglobinopathy status of the partner with referral for genetic counselling if positive
Screen for Hep B and rubella immunity

Question 9

A 35 year old woman has colposcopy and diathermy loop excision for CIN 2. She should be
advised to abstain from vaginal intercourse for

Options for Questions 9-9

A 1 week

2 weeks

C 4 weeks

6 weeks

E 8 weeks