ABOG Guide to Learning FPMRS: Your Comprehensive Study Blueprint

Preparing for the American Board of Obstetrics and Gynecology (ABOG) subspecialty board certification in Female Pelvic Medicine and Reconstructive Surgery (FPMRS)? Understanding the exam blueprint is your crucial first step. This guide breaks down the key areas you need to master, ensuring you’re well-prepared for the FPMRS qualifying examination. This examination rigorously assesses your knowledge and expertise in the multifaceted field of urogynecology and reconstructive pelvic surgery, ensuring you’re equipped to provide the highest standard of care.

I. Mastering Foundational Knowledge: Diagnosis and Examination

A significant portion of the FPMRS exam focuses on your diagnostic acumen and examination skills. You’ll need to demonstrate proficiency in several key areas:

A. Lower Urinary Tract Dysfunction

Accurate diagnosis is paramount. The exam will test your ability to:

• Diagnose and differentiate: Distinguish between various types of lower urinary tract dysfunctions, such as stress urinary incontinence, urge urinary incontinence, mixed urinary incontinence, overactive bladder, and voiding dysfunction.
• Comprehensive History and Physical Exam: Conduct thorough evaluations, including:
  • POP-Q (Pelvic Organ Prolapse Quantification): Precisely assess and stage pelvic organ prolapse.
  • Myofascial Pelvic Exam: Evaluate pelvic floor muscles for tenderness, tone, and trigger points.
  • Pelvic Muscle Tone, Strength, and Coordination: Assess pelvic floor muscle function using standardized methods like the PERFECT scheme.
  • Pelvic Muscle Spasm and Trigger Points: Identify and understand the role of myofascial pain in pelvic floor disorders.
• Initial Diagnostic Testing: Select, perform, and interpret essential tests:
  • Pad Test: Quantify urinary leakage to assess the severity of incontinence.
  • Post-Void Residual (PVR): Determine bladder emptying efficiency and identify urinary retention.
  • Urinalysis, Culture, and Sensitivities: Diagnose and manage urinary tract infections (UTIs).
  • Cough Stress Test: Assess for stress urinary incontinence by observing leakage with cough provocation.
• Advanced Diagnostic Testing: Master advanced techniques and their interpretation:
  • Urodynamics: Understand and interpret complex urodynamic studies, including cystometry, uroflowmetry, and pressure flow studies, to diagnose complex bladder dysfunction.
  • Cystoscopy: Perform and interpret cystoscopy to visualize the bladder and urethra, identifying abnormalities like bladder stones, tumors, or urethral pathology.
• Voiding Diary Tests: Utilize voiding diaries to gather patient-reported data on voiding frequency, volume, and incontinence episodes.
• Sleep Study Tests: Understand the role of sleep studies in evaluating nocturia and nocturnal polyuria.

B. Interventions and Patient Counseling

Beyond diagnosis, the exam will assess your knowledge of interventions and patient communication:

• Interventions for Lower Urinary Tract Dysfunction: Understand and apply various treatment modalities to address diagnosed conditions.
• Patient Counseling: Effectively counsel patients on:
  • Pathophysiology: Explain the underlying mechanisms of lower urinary tract dysfunction in an understandable way.
  • Diagnostic Testing: Clearly communicate the purpose, process, and implications of recommended diagnostic tests.

II. Non-Surgical Treatment Modalities: Conservative and Minimally Invasive Approaches

The FPMRS exam emphasizes a comprehensive understanding of non-surgical management options. You should be proficient in counseling patients on the efficacy, risks, and benefits of:

A. Conservative Therapies

• Pelvic Floor Physical Therapy (PFPT): Understand the principles and techniques of PFPT in treating various pelvic floor disorders, including urinary and fecal incontinence, and pelvic organ prolapse.
• Pharmacologic Therapy: Be knowledgeable about medications used to treat lower urinary tract symptoms, including:
  • Antimuscarinics and Beta-3 Agonists: For overactive bladder.
  • Alpha-blockers and 5-alpha-reductase inhibitors: For benign prostatic hyperplasia (BPH) and associated lower urinary tract symptoms (LUTS).
  • Topical Estrogen: For genitourinary syndrome of menopause (GSM) and recurrent UTIs.

B. Minimally Invasive Non-Surgical Treatments

• Urethral Bulking Agents: Understand the indications, techniques, and outcomes of urethral bulking for stress urinary incontinence.
• OnabotulinumtoxinA Injection: Be familiar with the use of Botox injections for overactive bladder and urge urinary incontinence, including injection techniques and potential complications.
• Neuromodulation (Posterior Tibial Nerve Stimulation – PTNS): Understand the mechanism, application, and efficacy of PTNS for overactive bladder and fecal incontinence.
• Pessaries: Master the fitting, management, and use of pessaries for pelvic organ prolapse and stress urinary incontinence.

C. Post-Procedural Management of Non-Surgical Treatments

• Monitoring and Adjustment: Know how to monitor the therapeutic effects of non-surgical treatments and adjust treatment plans as needed.
• Complication Management: Be prepared to manage potential complications or side effects associated with each non-surgical treatment modality.

III. Surgical Treatment Options: Invasive and Reconstructive Procedures

Surgical management is a core component of FPMRS. The exam will extensively cover your knowledge of surgical procedures, including counseling, techniques, and complication management.

A. Stress Urinary Incontinence (SUI) Surgery

• Counseling on Surgical Options: Effectively discuss the efficacy, risks, and benefits of surgical treatments for SUI:
  • Retropubic Suspension (e.g., Burch Colposuspension): Understand the principles and outcomes of retropubic suspensions.
  • Midurethral Sling (MUS): Be thoroughly familiar with various MUS types (retropubic, transobturator), their indications, and potential complications.
  • Autologous Fascial Sling: Know the techniques and applications of autologous fascial slings, often considered the gold standard for complex SUI.
  • Neuromodulation (Sacral Neuromodulation – SNM): Understand the role of SNM in refractory urge urinary incontinence and non-obstructive urinary retention.
• Surgical Procedures: Demonstrate knowledge of the surgical techniques for:
  • Retropubic Suspension
  • Midurethral Sling
  • Autologous Fascial Sling
  • Sacral Neuromodulation (SNM) Implantation
• Complication Management: Be prepared to identify and manage complications associated with SUI surgeries, including mesh complications, voiding dysfunction, and infection.

B. Bladder and Ureteral Injury: Diagnosis and Repair

A critical aspect of FPMRS expertise is the ability to recognize and manage iatrogenic injuries to the urinary tract.

• Diagnosis of Bladder Injury: Utilize appropriate diagnostic modalities:
  • Cystoscopy: Directly visualize bladder injuries.
  • CT Urogram: Evaluate for urinary extravasation and ureteral injury.
  • Retrograde Pyelogram: Assess ureteral integrity.
  • Voiding Cystourethrogram (VCUG): Detect bladder leaks and fistulas.
  • Evaluation for Complex Fistula: Recognize and investigate complex fistulas, such as vesicovaginal or vesicouterine fistulas.
• Treatment of Bladder Injury: Master surgical repair techniques:
  • Cystotomy Repair: Repair simple bladder perforations.
  • Vesicovaginal Fistula Repair (Vaginal, Minimally Invasive, Abdominal): Understand different surgical approaches to vesicovaginal fistula repair, based on fistula complexity and location.
  • Uterovaginal Fistula Repair: Know the principles of repairing uterovaginal fistulas.
  • Colovesical Fistula Repair: Understand the management of colovesical fistulas, often requiring multidisciplinary approaches.
  • Interpositional Graft (e.g., Martius flap, omental flap): Utilize interpositional grafts in complex fistula repairs to improve tissue vascularity and healing.
• Diagnosis of Ureteral Injury: Employ diagnostic tools for ureteral injuries:
  • Cystoscopy
  • CT Urogram
  • Retrograde Pyelogram
  • Ureterolysis: Consider ureterolysis to assess ureteral obstruction.
  • Ureteral Catheter/Stent: Utilize ureteral catheters or stents for diagnostic and therapeutic purposes.
• Treatment of Ureteral Injury: Implement appropriate surgical or minimally invasive treatments:
  • Stent Placement: Manage simple ureteral injuries with stent placement.
  • Ureteroneocystostomy (Ureteral Reimplantation): Perform ureteroneocystostomy for distal ureteral injuries.
  • Ureteroureterostomy: Repair ureteroureterostomy for mid-ureteral injuries.
  • Percutaneous Nephrostomy Tube: Utilize percutaneous nephrostomy tubes for urinary diversion in complex ureteral injuries.
  • Boari Flap: Understand the Boari flap technique for long-segment distal ureteral defects.
  • Psoas Hitch: Employ the psoas hitch technique to mobilize the bladder and facilitate ureteral reimplantation.
  • Interpositional Graft: Utilize interpositional grafts for complex ureteral reconstructions.
• Diagnosis of Urethral Injury:
  • Cystoscopy
  • Voiding Cystourethrogram
• Treatment of Urethral Injury:
  • Urethrovaginal Fistula Repair: Repair urethrovaginal fistulas, often utilizing vaginal or perineal approaches.
  • Martius Flap: Employ Martius flaps for urethrovaginal fistula repair to enhance tissue healing and vascularity.

IV. Pelvic Organ Prolapse (POP): Comprehensive Management

Pelvic organ prolapse is a central focus of FPMRS. The exam will cover diagnosis, non-surgical, and surgical management strategies.

A. Diagnosis and Non-Surgical Management

• Diagnosis and Differentiation: Accurately diagnose and differentiate types of pelvic organ prolapse (anterior, posterior, apical).
• Post-Void Residual (PVR) and Urinalysis: Perform and interpret PVR and urinalysis in the context of POP.
• Patient Counseling: Counsel patients on the pathophysiology, indications, and results of additional testing for POP.
• Non-Surgical Treatments:
  • Pelvic Floor Physical Therapy: Counsel patients on the efficacy, risks, and benefits of PFPT for POP.
  • Pessaries: Counsel patients on pessary use, perform fitting, and manage pessary care and complications.

B. Surgical Management of POP

• Counseling on Surgical Options: Discuss the efficacy, risks, and benefits of various surgical approaches:
  • Vaginal Hysterectomy: Understand the role of vaginal hysterectomy in apical prolapse repair.
  • Minimally Invasive (Laparoscopic) and Abdominal Hysterectomy: Know the indications and techniques for minimally invasive and abdominal hysterectomy in POP surgery.
  • Anterior and Posterior Compartment Native Tissue Repairs: Perform and counsel on native tissue repairs for cystocele and rectocele.
  • Vaginal Mesh and Graft Augmented Repairs: Understand the use of mesh and grafts in vaginal prolapse surgery, including associated risks and benefits, and current recommendations.
  • Open Abdominal and Minimally Invasive (Laparoscopic) Sacrocolpopexy: Master sacrocolpopexy techniques for apical prolapse, including open and minimally invasive approaches.
  • Vaginal Native Tissue Apical Suspensions (e.g., Uterosacral Ligament Suspension, Sacrospinous Ligament Fixation): Perform and counsel on native tissue apical suspension procedures.
  • Minimally Invasive (Laparoscopic) Native Tissue Apical Suspensions: Understand minimally invasive approaches to apical suspension.
  • Hysteropexy: Know the indications and techniques for hysteropexy in women desiring uterine preservation.
  • Rectopexy: Understand rectopexy for rectal prolapse.
  • Obliterative Procedures (Colpocleisis): Counsel on and perform obliterative procedures for women who are not sexually active and desire definitive prolapse repair.
• Surgical Procedures: Demonstrate proficiency in performing the surgical procedures listed above.
• Complications of Surgical Treatments: Be prepared to manage complications of POP surgeries, including mesh complications, bleeding, infection, and recurrent prolapse.
• Augmentation of Surgical Materials:
  • Counseling on Mesh and Graft Materials: Discuss different types of mesh and graft materials (allograft, autograft, xenograft, synthetic) with patients.
  • Complication Management: Identify and manage complications related to mesh and graft materials, including erosion, infection, and contracture.
  • Alternatives, Risks, and Benefits: Counsel patients regarding alternatives to mesh, and comprehensively discuss the risks, benefits, and complications associated with mesh and graft use in prolapse surgery.

V. Fecal Incontinence and Defecation Disorders: Diagnosis and Management

Fecal incontinence and defecation disorders are increasingly recognized as important aspects of pelvic floor health. The exam will assess your expertise in this area.

A. Diagnosis and Non-Surgical Management

• Diagnosis and Differentiation: Diagnose and differentiate types of fecal incontinence and defecation disorders, including urge fecal incontinence, passive fecal incontinence, and obstructed defecation.
• Endoanal Ultrasound: Perform and interpret endoanal ultrasound to assess anal sphincter anatomy.
• Pelvic Floor Ultrasound: Utilize pelvic floor ultrasound to evaluate pelvic floor muscle function.
• Anorectal Manometry: Perform and interpret anorectal manometry to assess anal sphincter pressures and rectal sensation.
• Defecography: Obtain and interpret defecography results to evaluate rectal emptying and pelvic floor dynamics during defecation.
• Colonoscopy: Understand the role of colonoscopy in evaluating fecal incontinence and defecation disorders.
• Motility Studies: Interpret motility studies to assess colonic transit and function.
• Fistulogram: Utilize fistulograms to evaluate perianal fistulas.
• CT Tests: Employ CT scans when indicated for complex anorectal conditions.
• Patient Counseling: Counsel patients on the pathophysiology and diagnostic testing for fecal incontinence and defecation disorders.
• Non-Surgical Treatments:
  • Pelvic Floor Physical Therapy: Counsel patients on the efficacy, risks, and benefits of PFPT for fecal incontinence.
  • Pharmacologic Therapy: Be familiar with medications used to manage fecal incontinence, such as antidiarrheals and bulking agents.
  • Bulking Agents: Understand the use of bulking agents for fecal incontinence.
  • Neuromodulation (Posterior Tibial Nerve Stimulation – PTNS): Understand the application of PTNS for fecal incontinence.
  • Pessaries: Utilize pessaries in select cases of fecal incontinence.

B. Surgical Management of Fecal Incontinence

• Surgical Treatment Options:
  • Neuromodulation (Sacral Neuromodulation – SNM): Counsel patients on the efficacy, risks, and benefits of SNM for fecal incontinence. Perform SNM implantation.
  • Rectovaginal Fistula Repair: Counsel patients on rectovaginal fistula repair and perform the procedure when indicated.
  • Anal Sphincteroplasty: Counsel patients on anal sphincteroplasty for anal sphincter defects and perform the procedure.
• Post-Surgical Management: Manage complications or adverse effects of surgical treatments for fecal incontinence.

VI. Congenital Anomalies and Urethral Masses: Specialized Considerations

The FPMRS exam also includes topics related to congenital anomalies and urethral masses, requiring specialized knowledge.

A. Congenital Anomalies

• Diagnosis and Differentiation: Diagnose and differentiate types of congenital urogenital anomalies, such as vaginal agenesis, imperforate hymen, and uterine anomalies.
• Diagnostic Testing: Obtain and interpret results of diagnostic testing for congenital anomalies:
  • Ultrasound
  • MRI
  • Karyotype
  • Hormone Testing
  • Hysteroscopy
• Patient Counseling: Counsel patients on urogenital anomalies, including pathophysiology and diagnostic testing.
• Non-Surgical Treatments: Counsel patients on the timing, efficacy, risks, and benefits of non-surgical treatments, such as expectant management and vaginal dilation.
• Neovagina Surgical Procedures: Counsel on the timing, efficacy, risks, and benefits of neovagina surgical procedures:
  • McIndoe Procedure
  • Laparoscopic Vacchietti Procedure
  • Laparoscopic Davydov Procedure
  • Resection of Septum: Manage vaginal septum resection.
• Complications of Neovagina Surgical Procedures: Manage complications or adverse effects of neovagina surgical procedures.

B. Urethral Masses

• Diagnosis and Exam:
  • Diagnose and differentiate: Distinguish between different types of urethral masses, such as urethral caruncle, urethral diverticulum, and urethral cancer.
  • Pelvic Floor Ultrasound: Utilize pelvic floor ultrasound in the evaluation of urethral masses.
  • Cystoscopy: Perform cystoscopy for diagnostic evaluation.
  • MRI: Obtain and interpret MRI results for urethral masses.
  • Patient Counseling: Counsel patients on urethral mass pathophysiology and diagnostic testing.
• Treatment Options:
  • Counseling: Discuss the efficacy, risks, and benefits of treatment options:
    • Observation
    • Drainage
    • Excision
    • Urethral Reconstruction
    • Concomitant Anti-incontinence Procedure
  • Treatment Implementation: Perform or manage the treatment options listed above.
  • Complication Management: Manage complications or adverse effects of urethral mass treatment.

VII. Urinary Tract Infection (UTI) and Hematuria: Common Urogynecologic Concerns

UTIs and hematuria are frequent presentations in urogynecology. The exam will cover your approach to these conditions.

A. Urinary Tract Infection (UTI)

• Evaluation and Diagnosis: Evaluate and diagnose UTIs, including cystitis and pyelonephritis.
• Management: Manage acute, chronic, and complicated UTIs, including antibiotic selection and management of recurrent UTIs.
• Urogenital Atrophy: Diagnose and treat urogenital atrophy (genitourinary syndrome of menopause – GSM) as a contributing factor to UTIs and other urogenital symptoms.

B. Hematuria

• Diagnostic Testing: Obtain and interpret results of initial diagnostic testing for hematuria:
  • Post-Void Residual
  • Urinalysis, Culture, and Sensitivities
  • Cystoscopy and Biopsy: Perform cystoscopy and bladder biopsy when indicated to evaluate for hematuria etiology.
• Advanced Diagnostic Testing: Obtain and interpret results of advanced diagnostic testing:
  • CT Urogram/IVP (Intravenous Pyelogram)
  • Urine Cytology
  • Renal Ultrasound
• Patient Counseling: Counsel patients on hematuria pathophysiology and diagnostic testing.

VIII. Anatomy and Physiology: The Foundation of FPMRS

A deep understanding of anatomy and physiology is essential for safe and effective FPMRS practice. The exam emphasizes these foundational principles.

A. Surgical Anatomy

• Knowledge Application: Describe and apply knowledge of anatomy to safely perform surgery and avoid complications, focusing on:
  • Vascular and Nerve Supply: Understand the vascular and nerve supply to the pelvic organs.
  • Bladder and Urethra Anatomy: Detailed knowledge of bladder and urethral anatomy.
  • Anatomic Supports of the Pelvic Floor: Understand the ligamentous and fascial supports of the pelvic floor.
  • Ureter Anatomy: Detailed knowledge of ureteral anatomy and course within the pelvis.
  • Anal Sphincter Anatomy: Understand the anatomy of the anal sphincter complex.
  • Rectum Anatomy: Detailed knowledge of rectal anatomy.
  • Small and Large Bowel Anatomy: Understand the relevant anatomy of the small and large bowel in relation to pelvic surgery.

B. Nervous System Anatomy and Physiology

• Central and Peripheral Nervous System: Describe and apply knowledge of central and peripheral nervous system anatomy as it applies to the etiology and treatment of pelvic floor disorders, including urinary tract dysfunction and fecal incontinence.

IX. Perioperative Management and Surgical Safety: Ensuring Optimal Patient Outcomes

Beyond surgical technique, the FPMRS exam assesses your perioperative management skills and commitment to patient safety.

A. Preoperative Assessment and Management

• Preoperative Testing: Identify and perform appropriate preoperative testing based on:
  • Patient Comorbidities: Consider comorbidities like immunosuppression, diabetes, and cardiovascular disease.
  • Patient Population: Tailor preoperative assessment to specific populations, such as geriatric patients.
• Perioperative Anticoagulation: Manage perioperative anticoagulation, including VTE (venous thromboembolism) prevention and management of chronic anticoagulation.

B. Intraoperative and Postoperative Management

• Patient Positioning: Position patients appropriately to decrease adverse outcomes during surgery.
• Intraoperative Techniques for Injury Minimization: Utilize intraoperative techniques to minimize vascular, visceral, and urinary tract injuries.
• Intraoperative Injury Management: Manage intraoperative injuries, including vascular, bowel, urinary tract, and nerve injuries.
• Postoperative Complication Management: Manage postoperative medical and surgical complications.
• Prolonged Urinary Catheterization: Manage prolonged urinary catheterization, including indications, risks, and removal protocols.

X. Professionalism, Ethics, and Patient-Centered Care: Beyond Technical Skills

The FPMRS exam emphasizes the importance of professionalism, ethics, and patient-centered care, recognizing that these are integral to high-quality medical practice.

A. Ethics and Professionalism

• Practice Review and Health Disparities: Systematically engage in practice review to identify and address health disparities.
• Shared Clinical Decision Making: Incorporate patient, family, and cultural considerations in shared clinical decision-making.
• Psychological, Sexual, and Social Implications: Consider the psychological, sexual, and social implications of various treatment options when providing patient care.

B. Patient Safety

• Practice Analysis for Safety Improvement: Systematically analyze practice for safety improvements, utilizing root cause analysis and other quality improvement methodologies.
• Procedural Briefings and Debriefings: Incorporate standard use of procedural briefings, “time outs”, and debriefings in clinical practice to enhance patient safety.
• Sentinel Event Review and Reporting: Participate in the review of sentinel events, reportable events, and near misses.
• Universal Protocols: Implement universal protocols, such as bundles and checklists, to help ensure patient safety.

C. Interpersonal Communication Skills

• Communication Regarding Adverse Outcomes: Communicate effectively with patients and families regarding adverse outcomes and medical errors, demonstrating transparency and empathy.
• Sensitivity and Responsiveness to Diversity: Demonstrate sensitivity and responsiveness when communicating with a diverse patient population, including diversity in gender, age, culture, race, religion, disabilities, and sexual orientation.
• Comprehensive Referral Information: Provide comprehensive information when referring patients to other professionals, ensuring seamless transitions of care.

D. Systems-Based Practice

• Cost Awareness and Risk-Benefit Analysis: Incorporate considerations of cost awareness and risk-benefit analysis in patient care decisions.
• Multidisciplinary Teams: Provide care within multidisciplinary teams to promote safety and optimize patient outcomes.

E. Patient-Based Learning and Improvement

• Quality Improvement Activities: Design or participate in practice or hospital quality improvement activities, demonstrating a commitment to continuous learning and improvement.

F. Evidence-Based Medicine

• Evidence-Based Practices and Guidelines: Incorporate evidence-based practices and national guidelines to improve practice patterns and patient outcomes.
• Enhanced Recovery After Surgery (ERAS) Protocols: Implement evidence-based protocols to enhance recovery after surgery (ERAS), optimizing postoperative care and reducing complications.

By thoroughly understanding and preparing for each of these areas outlined in this ABOG FPMRS exam guide, you will significantly enhance your readiness for the qualifying examination and your future practice in Female Pelvic Medicine and Reconstructive Surgery. Good luck with your studies!