Hampton 20 Appendix 1

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Appendix 1:

Choose ONE best answer for each question

Please do not write any comments next to questions 1. What year of training are you?

a. PGY1 b. PGY2 c. PGY3 d. PGY4

2. You are seeing a 76 year old patient in your office. She is complaining of loss of urine when she plays golf, lifts her grandchildren, and when she has a cold. A student asks you what the most likely explanations for this would be. Your explanation includes all of the following except:

a. loss of urine with increased abdominal pressure b. loss of urine due to decreased anatomic support c. loss of urine due to sacral nerve disruption

d. loss of urine secondary to weak urethral sphincter e. loss of urine without a detrusor muscle contraction

3. When counseling a 78 year old patient about pessary insertion, the following are important points to make except:

a. She should come to the office at least once every three months for pessary management

b. She may use vaginal estrogen cream

c. She may experience increased vaginal discharge

d. The pessary is serving to correct her symptoms, not repair her defect e. She can not have intercourse if she elects pessary management

4. When assessing the anterior, posterior, and apical compartments of the vagina, POPQ measurements are taken in relation to the following structure:

a. The bulbocavernosus muscle b. The perineal body

c. The labia minora d. The hymenal ring e. The labia majora

5. A friend of yours is having pelvic floor symptoms after the birth of her third child.

She heard about kegel exercises but does not know what these are. The following would be a correct explanation for her:

a. Kegels are a good way to increase the strength of the muscles and ligaments in the pelvic floor

b. The three main muscles that you will be focusing on are: puborectalis, pubococcygeous, and coccygeous muscles

c. doing Kegels twice a week is the most efficient way to exercise the pelvic floor

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d. you can use biofeedback which will help you focus on the correct muscles e. if Kegel exercises don’t work for her, a surgeon can help fix her muscles 6. You are teaching a medical student how to evaluate pelvic organ prolapse and urinary incontinence. You state the following:

a. “if your q-tip moves more than 20 degrees you have a diagnosis of hypermobile urethra”

b. “there is a qualitative way to measure prolapse called the POPQ”

c. “you can check the innervation of the pelvic floor, S1-3, with an anal wink test”

d. “don’t touch the bladder when you are checking a post void residual”

e. “you will probably want to break down your speculum to complete your POPQ”

7. A student is confused about apical prolapse and its management. Which of the following statements would be correct:

a. “Removing the uterus decreases the stress on the uterosacral ligaments and improves the outcome of suspension.”

b. “The concepts of apical prolapse repair with and without the uterus in place are very different.”

c. “Uterosacral ligament suspension should be done at the level of the ischial spines or above.”

d. “Abdominal sacral colpopexy is done with a graft material that is placed without tension from the vaginal apex to the sacrum at the level of S2.”

e. “When thinking about options for apical suspension, there is one main ligament that surgeons usually use for suspension.”

8. On the picture, the structure with the star on it is:

a. The pelvic ani muscle b. The coccygeous muscle c. The pubosacral muscle d. The iliococcygeous muscle e. The pubococcygeous muscle

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9. A 54 year old woman comes to your office complaining of incontinence. Which comment is the least contributory to understanding her incontinence:

a. “I am really embarrassed by this – I am not playing tennis anymore.”

b. “I use three pantyliners a day in case I leak urine.”

c. “My urine is often dark.”

d. “I usually leak urine twice a day.”

e. “I dribble urine after I am finished urinating.”

10. A rectocele can occur with weakening or compromise of which tissues:

a. the vaginal epithelium and the rectovaginal connective tissue b. the vaginal epithelium and the coccygeous muscle

c. The coccygeous muscle and the rectovaginal connective tissue d. The levator ani muscles and the rectovaginal connective tissue e. The vaginal epithelium and the levator ani muscles

11. A 79 year old woman is complaining of involuntary loss of urine. It is difficult for her to state when the urine loss occurs, but she notices it especially with

movement. She states that she has trouble starting her stream and feels a dropping sensation in the vagina. She states that she urinates approximately 6 times a day, and does have episodes of enuresis. She admits to several urinary tract infections over the past eight months. She has just had a hip replacement and walks with a walker. The most likely reason for her incontinence is:

a. increased stimulation of the detrusor muscle b. weakened urethral sphincter

c. outflow obstruction d. urinary tract infection

e. difficulty getting to the bathroom

12. The following is a characteristic of point D on the POPQ:

a. it is measured in millimeters b. it exists for all female patients c. it can only have a negative value

d. your measuring instrument would be placed in the posterior fornix e. you must use a speculum to evaluate point D

13. The following is a reason to quantify daily urinary accidents in a patient with urinary incontinence:

a. to manage dosing of anticholinergics b. to assess if she needs urodynamics

c. to obtain a baseline marker for treatment progression d. to see how bothersome her problem is

e. to evaluate the need for pessary use

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14. The two main support systems that contribute to pelvic floor support are:

a. levator ani muscles and the pelvic bones

b. levator ani muscles and connective tissue complexes c. connective tissue complexes and the pelvic bones d. levator ani muscles and urogenital diaphragm e. pelvic bones and urogenital diaphragm

15. An intern asks you a question about anterior vaginal repairs. Which of the following would be a correct statement?

a. “Anterior repairs are usually site specific or midline.”

b. “Most anterior wall defects are due to an autoimmune process of the vesicovaginal connective tissue.”

c. “You can fix anterior wall defects both vaginally and abdominally.”

d. “The gold standard over the past few years has become the TVT.”

e. “Your goal is to create a hammock from the pubic bone to the vaginal apex.”

16. You are counseling a patient regarding pessary use. The following is a correct statement:

a. “We will need to give you a “pessary rest” yearly.”

b. “A pessary will help your pelvic floor defects repair themselves by placing them in their anatomic location.”

c. “You should not see an increase in vaginal infection with pessary use.”

d. “Reasons that fitting may not be successful are a wide introitus and/or stage of prolapse.”

e. “About 50% of women are satisfied with pessary use at one year follow up.”

17. Stress incontinence is attributed to all of the following except:

a. a weakening of the urethral sphincter b. urethral hypermobility

c. intrinsic sphincter deficiency

d. a split in the vesicovaginal connective tissue e. loss of support to the urethra

18. A woman brings her 92 year old mother to see you in your office. She states that her mother has been withdrawn lately, and does not seem to want to go to her usual social activities. She is a well developed, healthy 92 year old who ambulates easily and is well oriented. You detect that she may have some urinary incontinence. She can have any of the following types of incontinence, but the least likely would be:

a. Stress incontinence b. Overflow incontinence c. Functional incontinence d. Urge incontinence e. Mixed incontinence

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19. On the picture, the structure that has the star on it is the insertion point for which two muscles?

a. Internal anal sphincter and ischiocavernosus b. Internal anal sphincter and bulbocavernosus

c. Internal anal sphincter and superficial transverse perineal muscle d. External anal sphincter and ischiocavernosus

e. External anal sphincter and bulbocavernosus

20. When measuring TVL (total vaginal length) on POPQ, you should be sure to:

a. replace the pelvic organs to their correct anatomic position b. take into account the length of the cervix

c. ask the patient to bear down

d. measure vaginal length in relation to the labia minora e. use a speculum

21. Your 83 year old patient is having increased post void residual and pelvic discomfort which you attribute to anterior vaginal wall prolapse. You discuss her options with her. The following would all be aimed at correcting her problem except:

a. pubovaginal sling

b. fitting of a ring pessary with support c. abdominal paravaginal repair

d. anterior repair with graft placement e. anterior colporrhaphy

22. A patient is concerned about her cystocele, but does not want a pessary or surgery. She asks you what the danger is if she ignores her symptoms. You answer all of the following except:

a. “Your symptoms may worsen over time.”

b. “It is OK to do nothing if you understand the risks.”

c. “Kegel exercises may help your symptoms from progressing.”

d. “Urinary incontinence will become a problem for you.”

e. “You may have trouble emptying your bladder.”

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23. I feel like I understand the anatomy of the pelvic floor:

a. completely agree b. somewhat agree c. neutral

d. somewhat disagree e. completely disagree

24. I feel comfortable in the operating room with regard to pelvic anatomy:

25. I feel comfortable diagnosing women with pelvic floor dysfunction:

26. I feel comfortable performing a targeted exam for pelvic floor dysfunction:

27. I feel comfortable with the concepts behind the etiology of pelvic floor dysfunction:

28. I feel comfortable managing women with pelvic organ prolapse:

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29. I feel comfortable with my understanding of the surgical approaches to pelvic organ prolapse:

30. I feel comfortable counseling women with pelvic organ prolapse:

31. I feel comfortable teaching others (medical students/residents) about pelvic floor dysfunction

32. I had a session with the pelvic trainer a. yes – go onto the next questions

b. no – stop questionnaire here

33. The pelvic trainer as a whole was easy to navigate:

a. strongly agree b. somewhat agree c. neutral

d. somewhat disagree e. strongly disagree

34. The modules that I used on the pelvic trainer were easy to navigate:

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35. The interactive anatomy on the pelvic trainer was easy to navigate:

35b. The animations in the modules that I used on the pelvic trainer helped me to understand female pelvic anatomy:

36. The animations in the modules that I used on the pelvic trainer helped me to understand the diagnosis of female pelvic floor dysfunction:

37. The animations in the modules that I used on the pelvic trainer helped me to understand the treatment of female pelvic floor dysfunction:

38. I think that the pelvic trainer will help me counsel patients in the future regarding female pelvic floor dysfunction:

39. The interactive anatomy on the pelvic trainer helped me to understand female pelvic anatomy:

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40.I would like to have used the pelvic trainer for longer than the assigned session:

41.I would use the pelvic trainer on my own time if I had access to it:

42.I think that the pelvic trainer improved my knowledge regarding female pelvic floor dysfunction:

43.I think that the pelvic trainer improved my knowledge regarding female pelvic anatomy:

a. strongly agree b. somewhat agree

c. neutral

44. I think that the pelvic trainer will help me answer questions on board exams:

45. I think that the pelvic trainer will help me take better care of my patients in the future:

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46. I think that the pelvic trainer will help me teach others more effectively in the future: