Pelvic organ prolapse — structured SAQ (15 marks)

(a) POP-Q diagnosis and compartment (2 marks)

One mark for the stage, one mark for the compartment. ^[1]

• Diagnosis: Stage III anterior compartment prolapse (Ba at +2 cm, more than 1 cm below the hymen, but not beyond TVL − 2 cm) with apical support preserved (point C at −4 cm). ^[1]
• Compartment: Anterior vaginal wall (cystocele); the apical and posterior compartments are intact at this examination. Perineal body of 2 cm is small for a parous woman and may merit perineorrhaphy if a posterior repair is added. ^[1]

(b) Conservative options already attempted and the next non-operative option (3 marks)

One mark per correct conservative option already deployed; one mark for naming pessary as the next non-operative option; one mark for lifestyle adjuncts. ^[1]

• Lifestyle and behavioural measures: weight, smoking, chronic cough and constipation, fluid loading, lifting. ^[2]
• Supervised pelvic floor muscle training (PFMT): 16 weeks of individualised supervised PFMT completed, as recommended by the Cochrane evidence base. ^[2]
• Topical vaginal oestrogen in a postmenopausal woman — restores epithelium, facilitates pessary use and reduces ulceration. ^[4]
• Pessary is the next non-operative option she has not yet tried: a ring with support is a practical first device. It avoids surgery, addresses the symptom and may unmask occult urinary incontinence that can be managed concurrently. ^[4]

(c) Surgical options, including the apical procedure of choice (5 marks)

One mark for naming the anterior compartment repair; one mark each for the apical options (uterosacral vs sacrocolpopexy vs sacrospinous) with their trade-offs; one mark for selecting uterosacral suspension given her wish to keep the uterus and avoid an abdominal operation. ^[3]

• Anterior colporrhaphy plicates the pubocervical fascia to reduce the anterior bulge; it is a native-tissue procedure and avoids mesh. ^[3]
• Apical procedure of choice — uterosacral ligament suspension (vaginal, mesh-free): addresses apical support without abdominal entry, preserves the uterus when she wishes to keep it, and avoids the mesh-related concerns of sacrocolpopexy. Intra-operative cystoscopy after suture placement is the standard safety step to confirm ureteric patency. ^[3]
• Sacrospinous ligament fixation (vaginal, native tissue): a vaginal alternative but does not preserve the apical anatomy as well as uterosacral suspension and can produce buttock pain; asymmetry and neurovascular proximity are recognised. ^[3]
• Abdominal sacrocolpopexy: the most durable apical support but is abdominal and uses mesh; it is the gold standard for vault prolapse after hysterectomy but not what this patient has requested. ^[3]
• Uterine preservation: valid when she wishes to keep her uterus and malignancy is not suspected; discuss future pregnancy and mode of delivery. ^[3]

(d) Consent — mesh and recurrence (3 marks)

One mark per correct element: mesh regulatory context, exposure/pain discussion and recurrence/expectations. ^[4]

• Mesh context: Transvaginal mesh kits for primary POP are not used in routine ANZ practice after TGA action; abdominal sacrocolpopexy mesh remains the standard apical option when chosen; midurethral slings are a separate category. ^[4]
• Mesh exposure/erosion, dyspareunia, chronic pain and reoperation must be named on the consent form when any mesh is implanted. ^[4]
• Recurrence and reoperation: prolapse repair carries a meaningful rate of recurrence and repeat surgery; quote procedure-specific estimates, document the realistic symptom improvement, and acknowledge that new urinary or bowel symptoms may appear. ^[3]

(e) Follow-up and lifestyle advice (2 marks)

One mark for the review schedule, one mark for lifestyle advice. ^[2]

• Review schedule: six-week wound and voiding review, then at six and twelve months, then as needed; pessary users require a regular removal and cleaning schedule with inspection for ulceration. ^[4]
• Lifestyle: continue PFMT lifelong, address weight, smoking, chronic cough, constipation and heavy lifting; vaginal oestrogen as indicated. ^[2][4]

Common errors that lose marks

• Calling the prolapse “stage II” because the leading edge is “near the hymen”; stage II is at or within 1 cm of the hymen, and +2 cm is stage III. ^[1]
• Treating the anterior wall without checking or supporting the apex; apical loss is the commonest cause of anterior recurrence. ^[3]
• Recommending sacrocolpopexy without acknowledging the patient’s wish to keep her uterus and avoid an abdominal operation. ^[3]
• Failing to mention intra-operative cystoscopy at uterosacral suspension as the safety step for ureteric injury. ^[3]
• Skipping the pessary option when surgery is not yet wanted. ^[4]

Examiner notes

The candidate who scores well demonstrates POP-Q literacy, names the apical options with their trade-offs, picks the operation that matches the patient’s priorities, and writes the consent conversation that a contemporary ANZ unit would actually document. The candidate who scores poorly describes “anterior repair” without apical thought, omits cystoscopy, or describes mesh without explaining that transvaginal mesh kits for primary POP are not in routine use. ^[3][4]