Pelvic organ prolapse — structured oral station (12 minutes)

Opening prompt — "Take me through your assessment and staging."

Model response — say it in this order: ^[1][4]

• "Pelvic organ prolapse is a clinical diagnosis. I examine in semi-lithotomy with a Sims speculum, the patient straining maximally, and record the nine POP-Q points against the hymen — the fixed reference at zero."
• "Points above the hymen are negative; at the hymen is zero; below is positive. Her anterior wall at plus 1 cm and cervix at zero means Stage II (within 1 cm of the hymen), with anterior and apical compartment involvement."
• "I would also grade her pelvic floor muscle strength on the modified Oxford scale, measure the genital hiatus and perineal body, and perform a cough stress test with the prolapse reduced to look for occult stress incontinence."^[1]

Examiner is listening for: the hymen as the reference, the sign convention, the stage justified by measurement, and the occult-incontinence screen. ^[1]

Probe 1 — "Why does the apical compartment matter here?"

• "The anterior bulge is being driven by unrecognised apical descent. DeLancey's Level I support — the cardinal and uterosacral (paracolpium) complex — suspends the upper vagina; when it fails the apex drops and the anterior wall follows."^[4]
• "If I repair the anterior wall alone without restoring apical support, the apex is the next failure. So apical support is always the priority, whichever surgical route I choose."^[9]

Probe 2 — "Outline your management ladder."

• "Observation and lifestyle first — weight, smoking and constipation. Then supervised pelvic floor muscle training, which is first-line for symptomatic mild-to-moderate prolapse: the International Urogynecology Consultation (Bø 2022) gives high-level evidence from 11 RCTs, and PREVPROL showed one-to-one PFMT reduced prolapse symptoms at 2 years."^[7]
• "Then a vaginal pessary — a ring with support, or a Gellhorn for higher stage, with topical vaginal oestrogen. Then surgery for Stage II to IV symptomatic prolapse that has not responded to conservative measures."^[9]

Probe 3 — "She is continent. Do you do anything about her continence at surgery?"

• "I would screen for occult stress incontinence with the prolapse reduced. Reducing the prolapse unkinks the urethra and can unmask occult stress incontinence."
• "In OPUS, continent women randomised to a prophylactic midurethral sling at vaginal prolapse repair had less incontinence at 12 months — 27.3% versus 43.0%, number needed to treat 6.3 — but more bladder perforation 6.7% vs 0%, UTI 31.0% vs 18.3%, major bleeding 3.1% vs 0%, and incomplete emptying 3.7% vs 0%. This is a shared decision about which adverse event she is willing to risk."^[12]

Probe 4 — "She asks whether you will use mesh. What do you say?"

This is a scored domain. Demonstrate it out loud: ^[15]

• "Transvaginal mesh for prolapse is not used. In Australia it was removed from the Register of Therapeutic Goods effective 4 January 2018, and all urogynaecological mesh is now Class III. In the US the FDA ordered manufacturers to stop selling it for prolapse in 2019, and the UK Cumberlege review in 2020 led to specialist centres for those harmed."^[15]
• "If her apical repair is a sacrocolpopexy, that uses abdominally-placed mesh and is a different category — it remains the gold-standard apical repair. I would counsel her specifically on mesh exposure, erosion into bladder or bowel, contraction with pain and dyspareunia, and the chance of needing revision, and document the consent."^[9]

Probe 5 — "She is frightened and asks what this means for her."

• Move to her eye level, use her name, and brief plainly: "Your pelvic floor has dropped, which is common after vaginal births. We have good non-surgical options like a pessary and pelvic floor exercises, and surgery if we need it. I will go through each option and you decide."^[7]
• Acknowledge her fear, address the impact on sex and activity, offer written information, and commit to a follow-up so the decision is shared, not rushed.