O&G SAQs · Urogynaecology — pelvic floor disorders
Stress urinary incontinence and midurethral sling — structured SAQ (15 marks)
FRANZCOG-format structured SAQ on female stress urinary incontinence — diagnosis with mechanism, the conservative ladder that has been completed, the midurethral sling as the next step with the C-Gyn 32 (July 2020, amended March 2022) recommendation reproduced, the retropubic vs transobturator decision, and the mesh-erosion/consent numbers. Per-sub-part marking rubric included.
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FRANZCOGMRCOGABOG
Prompt
A 44-year-old woman (G2P2, both vaginal births, last 6 years ago; BMI 32; no prior continence surgery) presents with a 3-year history of leakage on coughing, sneezing and running. She has reduced her fluid intake, wears three pads a day, and has stopped running. PFMT with a women's health physiotherapist for 14 weeks produced no improvement. Examination reveals a positive cough stress test at a comfortably full bladder, normal post-void residual (45 mL), no prolapse beyond stage 1, and Oxford grade 2 pelvic-floor contraction. Urodynamics are not performed. (a) State the diagnosis, its mechanism and the two urodynamic subcategories you would want to exclude. (4 marks) (b) Outline the conservative options you have tried and the next surgical option to discuss, quoting the relevant RANZCOG statement. (5 marks) (c) The woman asks about a retropubic versus transobturator sling. State the differences in approach, complications and the women for whom each is preferred. (4 marks) (d) The woman wants to know what to consent on. List the complications you must discuss, with the headline numbers. (2 marks)
How this SAQ is marked
Twelve SAQs, 180 marks, two 2-hour papers — roughly 15 marks and 20 minutes each. Marks come from specifics: the named diagnosis with mechanism, the named RANZCOG statement with its three recommendations, the named complications with their headline numbers. Write in short labelled points, not prose paragraphs. Answer the sub-part you are asked.[1]
Reveal model answer and mark schemeShowHide
(a) Diagnosis, mechanism and urodynamic subcategories (4 marks)
One mark per correct element; up to two marks for the diagnosis, one for the mechanism, one for the urodynamic subcategories.[1]
- Diagnosis: Stress urinary incontinence (SUI) — involuntary loss of urine on effort, exertion, coughing or sneezing, confirmed by the positive cough stress test.[1]
- Mechanism: weakness of urethral support (urethral hypermobility) or weakness of the urethral closure mechanism itself (intrinsic sphincter deficiency). The integral theory of Petros and Ulmsten (1990) frames the mid-urethra as the critical zone; a midurethral sling restores the pubourethral backboard.[1]
- Urodynamic subcategories to exclude:
- Urethral hypermobility (Q-tip 30° or more; normal MUCP) — managed by either RP or TO sling.[1]
- Intrinsic sphincter deficiency (ISD) (VLPP under 60 cm H₂O or MUCP under 20 cm H₂O) — favours the retropubic approach because TO fails more often in ISD (Ford 2016 meta-analysis).[6]
- (Bonus point if the candidate names detrusor overactivity as the alternative diagnosis to exclude with mixed or pure urge components.)
(b) Conservative options already tried and the surgical next step (5 marks)
One mark per correct conservative option already deployed; two marks for naming the next surgical step and quoting the position statement.[1][2]
- Lifestyle and behavioural measures — weight loss for BMI 32 (acknowledged contributor), reduction in caffeine and total fluid loading, smoking status, treatment of chronic cough and constipation. Discussed and attempted.[2]
- Supervised pelvic floor muscle training (PFMT) — 14 weeks of supervised PFMT with a women's health physiotherapist, completed before surgical referral. The Cochrane 2018 numbers justify this minimum trial: 56% cure with PFMT vs 6% with no treatment for SUI (RR 8.38, 95% CI 3.68 to 19.07; 4 trials, 165 women; high-quality evidence).[2]
- Continence pessary (incontinence ring or dish) — a non-surgical option she has not yet tried. The Pelvic Floor Disorders Network trial showed 92% successful pessary fitting in women with SUI and POP-Q stage 2 or less. Worth a brief trial before surgery, especially given she would prefer to avoid an operation.
- Surgical next step: midurethral sling (MUS) — the operation of choice for female SUI in Australasia when conservative measures fail.
- RANZCOG statement: Position statement on midurethral slings (C-Gyn 32, July 2020, amended March 2022). Recommendation 1 (Evidence-based, Grade A): "MUS surgery is a recommended surgical procedure for SUI in routine cases." The Good Practice Point requires local credentialling, written information (including from the ACSQHC), audit and patient-reported outcomes.[1]
(c) Retropubic vs transobturator — approach, complications, preferred women (4 marks)
One mark per correct comparison element; max four.[1][4]
| Element | Retropubic (RP) | Transobturator (TO) |
|---|---|---|
| Approach | Vaginal incision with two suprapubic exit points just above the pubic bone; tape passes through the retropubic space | Vaginal incision with two groin exit points lateral to the labia; tape passes through the obturator membrane |
| Effectiveness | Similar short-term subjective cure (Cochrane 2017 RR 0.98, 95% CI 0.96–1.00) | Similar short-term subjective cure |
| ISD | More effective | Higher failure rate — avoid in ISD |
| Visceral injury (bladder perforation, major vessel) | Higher | Lower |
| Voiding dysfunction postoperatively | Higher | Lower |
| Postoperative pain | Suprapubic; lower rate | Groin; higher rate; may become chronic |
| Mesh exposure | Approximately 2% | Approximately 2% |
| Complete mesh removal | Usually possible | More difficult, often incomplete |
- RP preferred (routine): ISD; any woman in whom you want the routine option (C-Gyn 32, ACSQHC).[1]
- TO preferred: extensive previous abdominal surgery where retropubic adhesions raise the bowel/vascular injury risk; inability to cease anticoagulation (lower visceral injury risk); ISD is the contraindication to TO. C-Gyn 32 specifies TO only in exceptional circumstances with multidisciplinary discussion.[1]
(d) Consent — complications to discuss, with headline numbers (2 marks)
One mark per correct complication with its headline figure.[1]
- Mesh exposure / erosion: approximately 2% for both RP and TO.[1]
- Chronic pain: up to 5% (Federal Court of Australia ruling Gill v Ethicon 2019).[1]
- Severe pain requiring sling removal: approximately 1 in 150 (around 0.7%).[1]
- Voiding dysfunction needing sling loosening or division: approximately 0.6% (Laurikainen 2006, 9,040 TVTs nationwide) — and she must be told that sling release can leave her with recurrent SUI.[5]
- De novo urge incontinence or worsening of overactive bladder symptoms: 5–15%.[1]
- Bleeding; damage to bladder and urethra; bowel and major vessel perforation; recurrence of SUI after sling release; dyspareunia (and partner symptoms); failure of primary procedure. [1]
- Audit: her case will be logged on the UGSA database, the IUGA database, or the Australian Pelvic Floor Procedures Registry; adverse events reportable to the TGA in Australia or MEDSAFE in New Zealand.[1]
References6ShowHide
- [1]Ford AA, Rogerson L, Cody JD, Aluko P, Ogah JA Mid-urethral sling operations for stress urinary incontinence in women Cochrane Database Syst Rev, 2017.PMID 28756647
- [2]Dumoulin C, Cacciari LP, Hay-Smith EJC Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women Cochrane Database Syst Rev, 2018.PMID 30288727
- [3]Labrie J, Berghmans BL, Fischer K, Milani AL, van der Wijk I, Smalbraak DJ, et al Surgery versus physiotherapy for stress urinary incontinence N Engl J Med, 2013.PMID 24047061
- [4]Richter HE, Albo ME, Zyczynski HM, Kenton K, Norton PA, Sirls LT, et al; Urinary Incontinence Treatment Network Retropubic versus transobturator midurethral slings for stress incontinence N Engl J Med, 2010.PMID 20479459
- [5]Laurikainen E, Kiilholma P A nationwide analysis of transvaginal tape release for urinary retention after tension-free vaginal tape procedure Int Urogynecol J Pelvic Floor Dysfunct, 2006.PMID 16132161
- [6]Ford AA, Ogah J Retropubic or transobturator mid-urethral slings for intrinsic sphincter deficiency-related stress urinary incontinence in women: a systematic review and meta-analysis Int Urogynecol J, 2016.PMID 26220506