DOI: 10.1111/tog.
12220 2016;18:17–23
The Obstetrician & Gynaecologist
http://onlinetog.org
Management of uterine prolapse: is
hysterectomy necessary?
a b
Helen Jefferis MRCOG, Simon Robert Jackson
a
Subspeciality Trainee in Urogynaecology, Department of Urogynaecology, Women’s Centre, John Radcliffe Hospital, Headley Way, Oxford OX3
9DU, UK
b
Consultant Urogynaecologist, Department of Urogynaecology, Women’s Centre, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, UK
*Correspondence: Natalia Price. Email: Natalia.Price@ouh.nhs.uk
Accepted on 1 June 2015
Key content
 Management of uterine prolapse is currently heavily influenced by
patient and surgeon preferences.
 The traditional approach to uterine prolapse is vaginal
hysterectomy. However, this does not address the underlying
deficiency in connective tissue pelvic floor support, and prolapse
recurrence is common.
 Uterine preservation surgery is increasing in popularity, both with
surgeons and patients; there is currently little evidence to show
superior outcome to hysterectomy.
Please cite this paper as: Jefferis H, Jackson SR, Price N. Management of uterine prolapse: is hysterectomy necessary? The Obstetrician & Gynaecologist 2016;18:
17–23. DOI: 10.1111/tog.12220
Introduction
When a woman presents with pelvic organ prolapse, the
management options are doing nothing, offering
conservative treatment such as physiotherapy and vaginal
pessaries, or surgery. Many women will ask for their
gynaecologist’s opinion as to the best course of action. This
will depend on symptomatology, impact on quality of life,
desire for sexual function and medical comorbidities, among
other factors. It is important that gynaecologists are aware of
all available treatment modalities and can counsel
women about the potential benefits and risks. Some
patients will simply require reassurance that there is no
sinister pathology.
Conservative management
Gynaecologists will often recommend lifestyle measures to
patients presenting with symptomatic pelvic organ prolapse.
Of particular interest is the correlation between increasing
body mass index and prevalence of prolapse. Weight loss is
therefore often recommended to patients as part of a
conservative approach to managing prolapse symptoms.
However, one large study1 showed that weight loss was not
ª 2016 Royal College of Obstetricians and Gynaecologists
Review
b,
MD FRCOG, Natalia Price MD MRCOG *
 Fertility preservation remains the one absolute indication for
hysteropexy. Other potential advantages include stronger apical
support and reduced vaginal surgery.
 Colpocleisis remains a valid option for a small cohort of patients.
Learning objectives
 Options for the management of uterine prolapse.
 How to help patients decide on a management plan.
Keywords: colpocleisis / hysteropexy / pelvic organ prolapse /
uterine preservation surgery / vaginal hysterectomy
significantly associated with regression of prolapse, leading
the authors to suggest that the damage obesity causes to the
pelvic floor may be irreversible.
Women are often given advice regarding pelvic floor
muscle training and may receive targeted physiotherapy. A
2014 multicentre randomised controlled trial (RCT)2
comparing individualised pelvic floor muscle training with
no intervention found a statistically significant improvement
in subjective assessment of prolapse symptoms in the
intervention group. No significant improvement in
objective assessment of anatomy, as assessed by the pelvic
organ prolapse quantification system (POP-Q),
was reported.
Women have used mechanical devices to reduce pelvic
organ prolapse since ancient times, and the use of vaginal
pessaries remains a simple and satisfactory treatment. One
study of 100 women using this method3 showed a 92%
satisfaction rate in terms of prolapse symptoms and a 50%
improvement in urinary symptoms.
Studies have shown that older women and those with
comorbidities are most likely to persist with the use of
vaginal pessaries. Women more likely to pursue surgery are
younger, more likely to be sexually active and more likely to
have more advanced prolapse.4 Factors predicting failure of
17
 Management of uterine prolapse
pessary treatment are short vaginal length, deficient perineal
body and a wider vaginal introitus.
The side effects associated with vaginal pessary use are
usually minor and include vaginal discharge, odour and
vaginal erosions. More serious complications such as fistulae
are predominately seen in neglected or forgotten pessaries.
The current debate
Vaginal hysterectomy has long been the standard approach
for the management of uterine prolapse, with the first
successful planned case being credited to Langenback in 1813.
It remains a safe and readily available surgical solution to
uterine prolapse. Various techniques are described for
reducing the risk of subsequent vaginal prolapse. The
McCall culdoplasty (which involves approximating the
uterosacral ligaments so as to obliterate the peritoneum of
the posterior cul-de-sac as high as possible) is considered
superior to a vaginal Moschowitz procedure, or closure of the
peritoneum of the cul-de-sac in preventing enterocoele
formation.5 Suturing the cardinal and uterosacral ligaments
to the vaginal cuff may also reduce subsequent
vault prolapse.6
While vaginal hysterectomy has served patients and
gynaecologists well for many years, its continued routine
use has been subject to debate. Many gynaecologists argue
that the uterus itself is healthy and the underlying
pathophysiology is a connective tissue deficiency,7 whether
congenital or acquired through childbirth or ageing, and that
uterine prolapse is merely a symptom, not the disease.
Vaginal hysterectomy fails to address this underlying
deficiency in connective tissue, with relatively high
recurrence rates of 10–40% described in the literature.8,9
Recurrence can manifest with vaginal vault eversion, or more
commonly recurrent enterocoele or cystocoele. We know that
cystocoele commonly arises because of loss of apical (type 1)
vaginal support, and until apical support is established, a
cystocoele will recur after surgery. Furthermore,
hysterectomy removes a healthy organ that may play a role
in a woman’s individual and sexual identity.
On the other hand, vaginal hysterectomy has been part of
core gynaecology training for decades; more recently part of
the popular vaginal surgery advanced training skills module
(ATSM). Most gynaecologists are therefore well trained and
comfortable doing the procedure with good outcomes. In
addition, there is evidence that the procedure is associated
with high patient satisfaction rates, which are not
significantly different from uterine preservation.10 Some
uterine preservation procedures have also been associated
with high rates of recurrent anterior wall prolapse.11
Women are increasingly requesting uterine conservation.
This may be because of the wish to preserve fertility, or the
belief that female identity is bound up in the female genital
18
organs. The request frequently arises after women have
conducted an internet literature search and become aware of
alternatives to hysterectomy.
The history of uterine preserving prolapse
surgery
Uterine preservation surgery can be considered when it is
appropriate to offer a surgical remedy for uterine prolapse.
The most obvious indication is fertility preservation in
women who have not yet completed childbearing. However,
this is a small group of patients. Most women requiring
surgery for prolapse have no desire for further children;
indeed the majority are postmenopausal.
In the authors’ experience other more prevalent
indications for uterine preservation include patient request
and superior outcome. The latter is a contentious statement
as clinical data remains sparse and will be discussed in this
article. However, when there is loss of apical support,
traditional vaginal hysterectomy will not correct the defect.
This is most readily apparent when women present with
procidentia; it is self-evident that hysterectomy will not treat
vaginal eversion. The Royal College of Obstetricians
and Gynaecologists (RCOG) Green-top Guideline,
‘Management of Post Hysterectomy Vaginal Vault
Prolapse’,12 recommends sacrospinous fixation if the
vaginal vault is at the introitus at the end of a vaginal
hysterectomy procedure.
The concept of uterine preservation surgery for pelvic
organ prolapse is not new, but it has attracted a resurgence in
interest over recent years. In 1888 Archibald Donald first
described the Manchester repair as an alternative to vaginal
hysterectomy for patients with uterine prolapse, although this
may have been a more useful technique for patients with an
elongated cervix rather than true uterine descent. In 1930
Victor Bonney highlighted the passive role of the uterus in
uterovaginal prolapse, which underpins the theory behind
uterine preservation surgery. Subsequent surgeons have
developed techniques for uterine preservation using a
vaginal, abdominal or laparoscopic approach.
Vaginal approach
In 1966 Williams13 described a technique for transvaginal
uterosacral-cervical ligament plication. He reported on the
outcomes of 20 women undergoing this procedure, with
three ‘failures’ encountered within a 6-month follow-up
period. His method involved a posterior colpotomy with
division of the uterosacral ligaments from the cervix,
plication across the midline and reinsertion into the cervix.
The cardinal ligaments are then plicated anteriorly across
the midline.
The concept of sacrospinous hysteropexy was first
described by Richardson14 in 1989. The cervix or
ª 2016 Royal College of Obstetricians and Gynaecologists

uterosacral ligament is transfixed to the sacrospinous
ligament using either permanent or delayed absorbable
sutures. In 2001 Maher15 reported a small comparison
study between sacrospinous hysteropexy and vaginal
hysterectomy with sacrospinous vault fixation, with no
differences in objective or subjective outcomes at follow-up.
Other studies have suggested that sacrospinous hysteropexy
has a shorter operative time and less blood loss than vaginal
hysterectomy.16 One study also reported fewer postoperative
incidences of overactive bladder symptoms in the
sacrospinous hysteropexy group.17 Dietz et al.11 described
an increased risk of anterior compartment prolapse following
sacrospinous hysteropexy, with an incidence of up to 40%.
Sacrospinous hysteropexy, is the most studied vaginal
technique for uterine preservation prolapse surgery;
however, in general, the studies assessing it are of poor
quality, with small numbers, short follow-up periods,18 a lack
of controls and limited functional outcome data.
The technique of posterior vaginal slingplasty was first
described in 2001,19 using a mesh kit to create ‘neo-
uterosacral ligaments’. One prospective comparison study
quoted a 91.4% patient satisfaction rate post-surgery,20 but
cumulative data suggest a high incidence of mesh
complications with up to a 21% mesh erosion rate.21
Abdominal approach
Several methods for open abdominal hysteropexy have been
described, including transfixing the uterus to the anterior
abdominal wall and ventral fixation to the pectineal
ligaments. Most techniques use the sacral promontory as
the fixation point, giving rise to the term
‘abdominal sacrohysteropexy’.
Abdominal suture sacrohysteropexy was described as early
as 1957,22 with the uterine fundus being fixed to the sacral
promontory with silk sutures. More recent techniques have
utilised a variety of synthetic meshes to aid fixation. In 1993,
Addison23 first described a technique for resuspending the
uterus to the sacrum using MersileneTM (Ethicon US, LLC,
USA) polyester fibre mesh. Leron and Stanton24 followed-up
13 women undergoing abdominal sacrohysteropexy and
found it to be a safe and effective surgery for the
management of uterine prolapse. Farkas et al.25 described a
technique for uterine suspension using a ‘wrap-around’ insert
of Gore-Tex (W.L. Gore & Associates, Inc., Newark, USA)
for women with prolapse secondary to bladder exstrophy.
Roovers et al.10 reported on a comparison between
sacrohysteropexy and vaginal hysterectomy with vault
fixation; recurrence was higher in the abdominal surgery
group (22%) than in the vaginal hysterectomy group (2.5%).
Constantini et al.26, however, found no subjective or
objective difference in functional outcomes when
comparing a group of patients undergoing
sacrohysteropexy with those undergoing hysterectomy with
ª 2016 Royal College of Obstetricians and Gynaecologists
Jefferis et al.
sacrocolpopexy. Sacrohysteropexy was associated with a
shorter operative time and hospital stay and a reduction in
intraoperative blood loss. It is difficult to interpret data
reporting comparisons between abdominal sacrohysteropexy
and hysterectomy because of variations in surgical techniques
and differences in mesh type, size, shape and
attachment points.
Laparoscopic approach
While initial experience with abdominal hysteropexy was
obtained via laparotomy, open abdominal surgery has now,
in many units, been largely replaced with laparoscopic
techniques. The laparoscope confers better vision than
laparotomy, allowing a magnified, high definition view.
Furthermore, the long instruments allow better pelvic access,
particularly behind the uterus, than conferred by laparotomy.
General advantages of laparoscopic compared with open
surgery are reduced hospital stay, reduced need for analgesia,
quicker recovery and minimal blood loss. There is a
suggestion that adhesion formation is also reduced.
The main disadvantage of laparoscopic surgery is the
initial increase in operating time while the surgeon learns the
laparoscopic techniques. Focused training and use of skills
laboratories and laparoscopic simulators can help to address
this issue. As a new generation of surgeons develop, trained
from the outset in laparoscopic techniques, such concerns
will become obsolete. In fact, many skilled laparoscopic
surgeons find that if they are in a situation where open
surgery is required, the operating times are slower and
visualisation of the anatomy is poorer.
Several laparoscopic uterine suspension procedures have
been described using different methods. Laparoscopic
ventrosuspension involves suturing the round ligaments to
the rectus sheath. However, the round ligament is not
particularly robust, and perhaps, as expected, it has been
shown to have poor outcomes, with one case series of nine
women reporting recurrent prolapse in all but one patient
within 6 months.27 Chen et al.28 used mesh to suspend the
uterus by attachment to the anterior abdominal wall. While
they reported good outcomes, all patients experienced
significant pain or dragging sensations over the mesh
attachment site.
Laparoscopic uterosacral ligament plication was first
described by Wu et al.29 in 1997, with good results in a
small case series. Maher et al.30 modified this technique to
include reattachment of the uterosacral ligaments to the
cervix and closure of the pouch of Douglas, with an objective
success rate of 79% in 43 women at 12 months.
Recent techniques have focused on use of the sacral
promontory as a point of fixation. Krause et al.31 followed-
up 81 women undergoing laparoscopic sacral suture
hysteropexy, placing sutures through the posterior aspect of
the cervix and transfixing to the sacral promontory via the
19
 Management of uterine prolapse
right uterosacral ligament. Objective correction of prolapse
was seen in 94% of patients at a mean of 20.3 months
follow-up.
Cutner et al.32 developed the technique of laparoscopic
uterine sling suspension. The peritoneum is opened over the
sacral promontory and the rectum is reflected laterally.
A tunnel is created by blunt dissection underneath the
peritoneum from the sacral promontory to the insertion of
the uterosacral ligament complex into the cervix on either
side. MersileneTM tape on a needle is placed through the
cervix, through the uterosacral ligaments and through the
peritoneal tunnels on each side, before being bilaterally
tacked to the sacral promontory to suspend the uterus. This
technique aims for the sling to resemble newly created
uterosacral ligaments.
The theoretical advantage is that this type of repair, by
augmenting weak connective tissue with prosthetic material,
provides stronger apical support resulting in lower
recurrence rates. It allows the patient to retain their fertility
and, by avoiding vaginal surgery, there is a lower potential for
dyspareunia and sexual dysfunction. However, evidence is
lacking to support this technique as it has not been evaluated
in clinical trials.
Authors’ technique; the Oxford
hysteropexy
The laparoscopic polypropylene cervical encirclage
hysteropexy was modified in Oxford from previously
described open abdominal surgery techniques. The authors’
experience with hysteropexy has shown that mesh, when
attached to the posterior aspect of the cervix, or to the
cervical stump following hysterectomy, has a high avulsion
rate. Therefore, a method of complete cervical encirclage was
developed using a bifurcated polypropylene mesh.33 The
technique has evolved; initially the abdominal polypropylene
was not completely peritonealised; previous reports from
open abdominal surgery suggested this was unnecessary.
However, it subsequently became apparent that exposed
intraperitoneal polypropylene causes marked bowel
adhesions, thus complete peritonealisation was adopted.
Furthermore, a 3 cm width strip of polypropylene was
initially used, but this resulted in several instances of
recurrent cervical descent because of mesh stretching.
Subsequently, a 5 cm wide strip of polypropylene was used.
Other units within the UK have now adopted this Oxford
hysteropexy technique; it is not exclusive to Oxford. The
aims of this technique are outlined in Box 1.
A four-port laparoscopic technique is used with a 10 mm
umbilical, two 5 mm lateral and a 12 mm suprapubic port
inserted. After identifying the sacral promontory, the
peritoneum is incised with bipolar graspers and monopolar
scissors to identify a safe window of periosteum for mesh
20
Box 1. Aims of hysteropexy
 To restore and reinforce uterine support by suspending the uterus
from the sacral promontory using type 1 polypropylene mesh. Two
strong attachment points are used: the cervix and the anterior
longitudinal ligament overlying the sacral promontory.
 To restore vaginal length without compromising calibre.
By restoring apical support a reduction in anterior prolapse is seen,
consistent with the importance of restoring level 1 support in
cystocoele repair. A reduction in enterocoele is also seen.
fixation. A peritoneal relaxing incision is then used, medial to
the right ureter, to retract it from the surgical site; this is then
extended into the pelvis, lateral to the rectum. The right
uterosacral ligament is identified and the peritoneum is
opened over this, where the uterosacral ligaments insert into
the cervix. A flap of peritoneum is mobilised to facilitate
reperitonealisation. The vesico-uterine peritoneum is incised
to reflect the bladder away and bilateral avascular windows
are created in the broad ligament, lateral to the uterine
arteries, at the level of the internal os.
A bifurcated polypropylene type 1 macroporous non-
absorbable mesh (ProLiteTM; Atrium Medical Corporation,
USA) is brought through the broad ligament windows. This
is transfixed to the anterior cervix using non-dissolvable,
non-absorbable polyester 2-0 sutures (Ethibond; Ethicon
US, LLC, USA). The mesh is attached to the sacral
promontory under moderate tension using two to three
5 mm helical fasteners (Pro-TackTM; Covidien, CT, USA). The
mesh is then completely reperitonealised using Monocryl
(Ethicon US, LLC, USA) sutures.
Outcomes after laparoscopic hysteropexy
Outcome data post-laparoscopic hysteropexy is sparse. We
performed a prospective observational study34 and reported
outcomes following laparoscopic sacrohysteropexy in 140
women. Follow-up time varied between 1 and 4 years, with
89% of women reporting that their prolapse was ‘very much’
or ‘much’ better. There was significant improvement
(P<0.001) in all parameters of ICIQ-VS (International
Consultation on Incontinence Questionnaire – Vaginal
Symptoms) and POP-Q scores post-surgery. Four percent of
women experienced further apical prolapse, of which half
underwent further surgical intervention. This compares
favourably with the risk of vault prolapse following vaginal
hysterectomy.35 The rate of serious complications was 4%, and
comprised bowel adhesions (prior to the modified
reperitonealisation technique), broad ligament vascular
injury and one pulmonary embolus. When asked, 92% of
women said they would recommend the operation to a friend.
ª 2016 Royal College of Obstetricians and Gynaecologists

As this is still a relatively new technique, more outcome
data over a longer time frame are needed to enable
comparison with more traditional approaches. The
outcomes of the Vault or Uterine prolapse surgery
Evaluation (VUE) study (a randomised, multicentre trial
comparing uterine preservation surgery with vaginal
hysterectomy) are awaited and are likely to produce the
best available evidence on this debate. However, the fact that
all surgical hysteropexy techniques (vaginal, abdominal and
laparoscopic) are incorporated into one uterine preservation
arm may pose a challenge for the power of the study and the
generalisability of the results.
Hysterectomy or uterine preservation?
Vaginal hysterectomy eliminates the possibility of uterine or
cervical pathology, and there are incidences of unexpected
pathology being detected at pathological examination of the
removed uterus.36 Careful patient selection is needed if
uterine preservation is planned – any abnormal or
postmenopausal bleeding would certainly warrant further
investigation in advance of hysteropexy. Contraindications to
uterine preservation include the presence of cervical
dysplasia, abnormal uterine bleeding and possibly large
fibroids or uterine anomalies. In these cases hysterectomy
would be more appropriate.
The main contraindication to hysterectomy is the desire to
retain fertility, although the majority of women being treated
for prolapse will be postmenopausal so this factor may not be
relevant. Another situation where uterine preservation is
recommended is in the presence of congenital anomalies such
as bladder exstrophy.37
Current mesh debate
The use of type 1 mesh is well established in pelvic
reconstruction surgery and has common usage in
sacrocolpopexy and mid-urethral slings. However, the
medical community has become aware of complications,
such as with hip and breast implants, which have attracted a
high media profile – in many cases associated with litigation,
particularly in the USA and Scotland. The use of mesh for
prolapse and incontinence in gynaecology is now under
intense scrutiny. This has been secondary to a realisation that
vaginal mesh extrusion rates are higher than
previously thought.
Certainly the use of transvaginal mesh for vaginal prolapse
appears to have a relatively high complication rate, with mesh
erosion reported in up to 10% of cases.38 This is secondary to
mesh lying adjacent to the vaginal wall that has been
weakened by a surgical incision and subsequent scarring.
With an abdominal approach, the mesh extrusion rate is
considerably less, as the vaginal incision is avoided.
ª 2016 Royal College of Obstetricians and Gynaecologists
Jefferis et al.
Sacrocolpopexy mesh extrusion rates of 2–11% have
been reported.39,40
The Medicines and Healthcare Products Regulatory
Agency (MHRA) and the RCOG12 have both issued
guidance for urogynaecologists surrounding the use of
mesh in prolapse and incontinence surgery.41
In the authors’ experience, no cases of vaginal mesh
extrusion were seen in a series of 700 women undergoing
Oxford hysteropexy, even after up to 8 years of follow-up.42
One explanation would be the fact that the polypropylene
mesh does not approximate to the vaginal wall and lies at
the level of the internal os. Following initial concerns
regarding adhesions of the bowel to the mesh, the technique
has been modified to completely reperitonealise the mesh.
Subsequent to this modification, no further bowel adhesions
or other mesh complications have been reported.
Fertility following uterine preservation
surgery
Theoretically one advantage of hysteropexy is retention of
reproductive potential. It may therefore be the preferred
approach for younger patients who have not completed
their families. However, patients must be counselled that
data for pregnancy outcomes following the procedure are
scarce and the impact of the pregnancy on the surgery, and
indeed the effect of the surgery on the pregnancy, are
unknown. In some techniques, such as the Oxford
hysteropexy, the mesh encircles the cervix and vaginal
birth is therefore not possible; in effect the mesh acts as a
cervical suture. There is also concern that uterine blood flow
may be compromised as the mesh potentially constricts the
uterine arteries, although it is likely that a rich collateral
supply is formed.
In the authors’ experience, three patients have
subsequently conceived following an Oxford hysteropexy:
one patient has been followed through to delivery in
conjunction with her obstetrician. Uterine artery Doppler
studies at 23 weeks of gestation showed no compromise to
blood flow. Serial growth scans showed a normally grown
fetus and the patient underwent elective caesarean delivery at
39 weeks of gestation, delivering a healthy infant of normal
birthweight. The patient has since required surgical
correction of anterior vaginal wall prolapse, although it is
not clear whether this is related to her pregnancy or whether
she would have had recurrence of prolapse anyway. The other
two patients were in early pregnancy at the time of writing
and will be reported on in the near future.
Obliterative procedures
Obliterative, rather than reconstructive, surgery aims to close
off a portion of the vaginal canal, thereby reducing the
21
 Management of uterine prolapse
prolapsing viscera back into the pelvis. Colpocleisis (from the
Greek kolpos meaning folds, and cleisis meaning closure) was
first reported by Gerardin in 1823. The technique in use
today is a modification of that described by Lefort in 1877.
Epithelium is removed from the anterior and posterior
vaginal walls, with subsequent imbrication to create a tissue
septum providing a platform of support. Bilateral drainage
channels are usually left to allow passage of vaginal and
cervical secretions.
By definition, obliterative procedures result in loss of
sexual function; accordingly they are used for a cohort of
patients for whom this is not an issue. For example,
colpocleisis is often reserved for elderly patients, in
particular those with comorbidities that may render them
unsuitable for the longer operating times and more invasive
procedures associated with reconstructive surgery.
Studies suggest that colpocleisis is a successful and
acceptable procedure. One large retrospective case series43
reported an anatomical success rate of 98% and a patient
satisfaction rate of 92%. One disadvantage is the loss of access
to the cervix and uterus in the event of future pathology. It is
therefore important to assess individual risk prior to surgery.
Conclusion
While vaginal hysterectomy is adopted by the majority of
gynaecologists as the preferred approach for surgical
treatment of uterine prolapse, there is an increasing move
towards alternative techniques. However, robust evidence to
support a change in practice is lacking. The change in
practice is currently being driven by patient preference and
clinical expert opinion (evidence level 4). Gynaecologists
must be aware of all treatment modalities to facilitate patient
choice and be able to counsel women about their options. It
may not be appropriate for all units to offer specialised
surgery because this requires adequate training, experience
and patient numbers.
Uterine preservation surgery is increasing in popularity
with both surgeons and patients. Fertility is preserved, and
this remains the one absolute indication for hysteropexy.
Other theoretical advantages include stronger apical support,
reduced vaginal surgery and associated vaginal dysfunction
and psychological wellbeing. More good quality data are
needed to enable clinicians to make evidence-based decisions
regarding choice of prolapse surgery.
Disclosure of interests
There are no conflicts of interest.
Contribution to authorship
NP and HJ researched and wrote the article. SJ reviewed the
article for surgical detail and approved the final version
for publication.
22
Supporting Information
Single Best Answer questions are available for this article at
https://stratog.rcog.org.uk/tutorial/tog-online-sba-resource
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