GC116 I Felt A Lump Below Urinary Incontinence In Females; Genital Prolapse
Urinary incontinence in females is the involuntary loss of urine, and genital prolapse is the descent of pelvic organs (such as the uterus, bladder, or rectum) through the vaginal canal due to weakened pelvic floor support.
This lecture (GC 116, Dr. Paulin MA, HKU O&G) covers two intimately linked conditions in women: pelvic organ prolapse (POP) and female urinary incontinence (UI). Both share the same root cause — a weakened or damaged pelvic floor. The lecture systematically builds from anatomy → pathophysiology → risk factors → clinical presentation → examination → investigation → management for both conditions.
Why it matters for exams: This is a classic O&G + Urology crossover topic. Past papers regularly test: (a) identifying the type of incontinence from a clinical vignette, (b) the three levels of pelvic support, (c) first-line investigation for UI, (d) conservative vs surgical management, and (e) the concept of occult stress incontinence masked by prolapse.
Learning Objectives (from the lecture) [1]
- Structure and function of female pelvic floor
- Factors that adversely affect pelvic floor function
- Genital prolapse
- Urinary incontinence
- Summary – the link between prolapse and stress UI
1. Structure and Function of the Female Pelvic Floor
"Pelvic floor" may be used broadly to include all the structures supporting the pelvic cavity rather than the levator ani group of muscles alone. [1]
High Yield – Definition of Pelvic Floor
The pelvic floor is NOT just the levator ani. It includes: peritoneum, pelvic viscera, endopelvic fascia, levator ani muscles, perineal membrane, superficial genital muscles — all connected to the bony pelvis. (Wei 2004) [1]
Why this matters: Students often equate "pelvic floor" with "levator ani." The examiners specifically want you to demonstrate a broader understanding. Prolapse arises from failure of ANY of these layers, not just muscle.
| Function | Explanation |
|---|---|
| Support | Holds pelvic organs (uterus, bladder, rectum) in place against gravity and intra-abdominal pressure |
| Sphincteric | Maintains urinary and faecal continence |
| Sexual | Contributes to vaginal tone and orgasm |
"In all forms of pelvic organ prolapse, the primary problem is in the pelvic floor — NOT in the organ that has been displaced." [1]
This is conceptually crucial. A cystocele is not a "bladder disease"; it is a pelvic floor disease. Treatment targets the floor support, not the bladder itself.
Vaginal support is a combination of:
- Constriction — the tonic contraction of levator ani closing the urogenital hiatus
- Suspension — ligaments and fascia suspending the vagina from the pelvic sidewalls
- Structural geometry — the horizontal orientation of the levator ani creates a "flap-valve" effect under pressure
| Compartment | Structures | Prolapse type |
|---|---|---|
| Anterior | Bladder, urethra | Cystocele, urethrocele |
| Central / Apical | Uterus/cervix (or vault post-hysterectomy) | Uterine prolapse, vault prolapse |
| Posterior | Rectum | Rectocele |
This is the most commonly tested anatomy point from this lecture.
High Yield – Three Levels of Vaginal Support (DeLancey)
| Level | Structure | Function | Effect of Damage |
|---|---|---|---|
| Level I: Suspension | Cardinal and uterosacral ligaments → attach cervix/uterus to pelvic sidewalls; paracolpium supports upper vagina | Suspends uterus and upper vagina | Uterine prolapse or vaginal vault prolapse |
| Level II: Attachment | Paracolpium attaches mid-vagina to pelvic sidewall → forms pubocervical fascia (anterior) and rectovaginal fascia (posterior) | Supports bladder anteriorly and rectum posteriorly | Cystocele, urethrocele, rectocele |
| Level III: Fusion | Distal vagina fuses directly to: urethra (anterior), perineal body (posterior), levator ani (lateral) — no intervening paracolpium | Fixes distal vagina to adjacent structures | Rectocele, urethrocele, perineal deficiency |
How to remember: Think "top → middle → bottom" of the vagina. Level I is at the top (cervix), Level III is at the bottom (introitus).
The constant muscle tone of the pubococcygeal portion is responsible for holding the pelvic floor closed by coapting the urogenital hiatus. The muscle also forms a relatively horizontal shelf on which the pelvic organs are supported. [1]
Why horizontal matters: When standing, intra-abdominal pressure pushes organs down. The levator ani creates a horizontal "shelf" so that pressure pushes organs against the shelf (like pressing a lid onto a box), rather than pushing them through the hiatus. When the levator weakens and the shelf tilts, the hiatus opens and organs prolapse.
2. Structures Involved in Continence [1]
- Smooth muscles of the bladder neck and urethra
- Urethral connective tissue
- Urethral submucosal vascular plexus — contributes to mucosal coaptation (like a washer sealing a pipe)
- Urethral mucosa — oestrogen-dependent; atrophies after menopause
- Connective tissue supports (endopelvic fascia)
- Muscular supports (levator ani muscles)
- Striated urogenital sphincter
Poor support of the proximal segment of the urethra and bladder neck is the most common cause of stress incontinence. [1]
| Mechanism | Pathophysiology |
|---|---|
| Bladder neck hypermobility | Loss of pelvic floor support → bladder neck descends outside the zone of intra-abdominal pressure → during cough/strain, abdominal pressure no longer transmitted equally to urethra → urine leaks. This is the most common mechanism. |
| Intrinsic sphincter deficiency (ISD) | The urethral sphincter itself is weak despite normal anatomical support → seen after radiation, repeated surgery, neurological damage |
Why does normal anatomy maintain continence? During coughing, intra-abdominal pressure rises. If the bladder neck and proximal urethra are inside the abdominal pressure zone, the pressure increase is transmitted to both bladder AND urethra equally, so the urethra stays closed. When the bladder neck drops below this zone (hypermobility), pressure only increases on the bladder but not the urethra, causing leakage.
"Symptoms of stress, urge, and abnormal emptying mainly derive, for different reasons, from laxity in the vagina or its supporting ligaments, a result of altered connective tissue." (Petros 2007) [1]
The Integral Theory unifies prolapse and incontinence under one framework: restoration of form (structure) leads to restoration of function.
Pathophysiology of idiopathic detrusor overactivity remains a mystery. [1]
Usually idiopathic. Associated with:
- Urethral outflow obstruction
- Poor potty training / childhood nocturnal enuresis
- ?Primary urethral pathology
- ?Altered contractile activity of detrusor cells
Key Point
There are no specific clinical signs in women with detrusor overactivity. The diagnosis is clinical (based on symptoms of urgency) or urodynamic (involuntary detrusor contractions on filling cystometry). You cannot "see" or "feel" detrusor overactivity on examination — this is a common exam trap. [1]
3. Factors That Adversely Affect Pelvic Floor Function
The most common factor is vaginal delivery. Over 90% of patients with prolapse are parous (OR 4.7), and particularly instrumental delivery with a macrosomic baby and a long second stage of labour. [1]
Mechanism: Vaginal birth damages:
- Pelvic floor muscles (direct stretch/tear of levator ani)
- Ligaments and fascia (overstretching of cardinal/uterosacral ligaments)
- Pudendal nerve (traction neuropathy during descent of fetal head) → denervation of pelvic floor muscles
| Factor | Why |
|---|---|
| Menopause (lack of oestrogen) | Oestrogen maintains collagen, vascularity, and mucosal thickness in pelvic tissues. Its loss leads to atrophy. [1][3] |
| Increasing age | Progressive denervation and collagen degeneration |
| Obesity | Chronically raised intra-abdominal pressure |
| Chronic cough/constipation | Repeated straining increases downward force on pelvic floor |
| Occupational stress | Heavy lifting |
| Congenital weakness of connective tissue | e.g., Marfan's syndrome, Ehlers-Danlos |
| Prior hysterectomy | Disrupts Level I support → risk of vault prolapse |
| Racial factor | Whites more prone than Blacks [1] |
4. Genital Prolapse
| Compartment | Type of Prolapse |
|---|---|
| Anterior | Cystourethrocele |
| Middle | Uterine prolapse or vault prolapse |
| Posterior | Rectocele |
Described by the position of the cervix relative to the introital opening during maximal straining:
| Grade | Definition |
|---|---|
| First degree | Cervix descends into the vagina below the ischial spine but NOT as far as the introitus |
| Second degree | Cervix descends to the introital opening or just beyond |
| Third degree | Cervix AND uterine body both beyond the introitus |
The POP-Q is a standardized, quantitative grading system referenced to the hymen (Bump 1996).
Key landmarks:
| Point | Location | Range |
|---|---|---|
| Aa | 3 cm proximal to external urethral meatus (anterior wall) | -3 to +3 |
| Ba | Most distal position of upper anterior vaginal wall | -3 (no prolapse) to +tvl |
| C | Most distal edge of cervix or vaginal cuff | — |
| D | Posterior fornix (only in women with cervix) | — |
| Ap | 3 cm proximal to hymen (posterior wall) | -3 to +3 |
| Bp | Most distal position of upper posterior vaginal wall | -3 (no prolapse) to +tvl |
| gh | Genital hiatus (urethral meatus to posterior hymen) | — |
| pb | Perineal body (posterior hymen to mid-anal opening) | — |
| tvl | Total vaginal length | — |
POP-Q Ordinal Stages:
| Stage | Definition |
|---|---|
| 0 | No prolapse |
| I | Most distal part > 1 cm above the hymen |
| II | Most distal part ≤ 1 cm proximal or distal to the hymen |
| III | Most distal part > 1 cm below hymen but no further than tvl − 2 cm |
| IV | Complete eversion; at least tvl − 2 cm |
The most specific symptom is when the woman can see or feel a bulge of tissue that protrudes to or past the vaginal opening. (ACOG 2007) [1]
| Symptom | Compartment | Explanation |
|---|---|---|
| Feeling/seeing a lump | Any | The most specific symptom |
| Urinary symptoms (difficulty voiding, incomplete emptying) | Anterior | Bladder base descent kinks the urethra |
| Bowel symptoms (e.g., splinting — need to push back prolapse to defaecate) | Posterior | Rectocele traps stool in the pouch |
| Pelvic pressure/heaviness | Any | Non-specific — CANNOT assume prolapse treatment will relieve it [1] |
| Back pain | Any | Non-specific [1] |
| May be asymptomatic | Any | Prolapse on examination does not always cause symptoms |
High Yield – Occult Stress Incontinence
Prolapse may MASK incontinence which can present once prolapse has been corrected. [1] This is called occult (latent) stress incontinence. The prolapse kinks the urethra and compresses it, preventing leakage. After surgical repair of the prolapse, the urethra is no longer kinked, and stress incontinence becomes apparent. Always test for occult stress incontinence by reducing the prolapse (e.g., with a pessary or fingers) and performing a cough test. If surgery is indicated, surgery for both conditions may be needed. [1]
Renal damage may occur in the presence of severe genital prolapse as a result of ureteric obstruction. [1]
General:
- Obesity (BMI) — risk factor and affects surgical planning
- Respiratory system — chronic cough?
Abdominal:
- Abdominal/pelvic mass — fibroid or ovarian cyst can worsen prolapse or cause diagnostic confusion
Pelvic examination:
- Lithotomy position — initial assessment
- Sims (left lateral) position — using Sims speculum to retract anterior and posterior vaginal walls sequentially to assess each compartment individually
Pelvic examination checklist: [1]
- Assess degree of descent in each compartment during straining
- Assess condition of vaginal wall (oestrogenization) — pale, thin = atrophic
- Take cervical smear if indicated
- Uterine assessment (bimanual — size, mobility, tenderness)
- Look for adnexal mass
4.7 Management of Genital Prolapse
Nonsurgical treatment using ring pessary for patients who decline surgery, unfit for surgery, or as a temporary measure while awaiting surgery. [1]
Mechanism: The ring sits in the vagina and provides a mechanical support platform for the prolapsed organs.
Sizing: Choose a pessary that gives support to the prolapsed organ but does not cause discomfort to the patient. [1]
Complications: [1]
- Pressure ulcer
- Bleeding
- Infection with discharge
Evidence: Only one RCT identified (Cundiff 2007) — effective for about 60% of women who completed the study. No consensus on type of device, indications, pattern of replacement, or follow-up care. [1]
More definitive. Aim to restore vaginal anatomy/function. Usually done through the vaginal route. Can be done under regional anaesthesia. [1]
Key principle: Nature of surgery depends on the nature of the prolapsed organs. [1]
| Prolapse Type | Surgical Options |
|---|---|
| Anterior (cystocele) | Anterior colporrhaphy (anterior repair) |
| Apical (uterine/vault) | Vaginal hysterectomy ± vault suspension, sacrocolpopexy (abdominal), sacrospinous fixation |
| Posterior (rectocele) | Posterior colporrhaphy (posterior repair) |
| Combined | Combined procedures |
Beware of the common association of stress urinary incontinence which may require surgical treatment on its own. [1]
5. Urinary Incontinence
IUGA/ICS Definition: the complaint of any involuntary leakage of urine. (2010) [1]
- 40.8% reported stress urinary incontinence
- 20.4% had urge incontinence
- 15.9% had mixed incontinence
- Prevalence appears to be rising (21% SUI in 1996 → 40.8% in 2006 survey)
The lecture distinguishes clinical diagnosis from urodynamic diagnosis:
| Clinical Term | Urodynamic Term | Definition |
|---|---|---|
| Stress urinary incontinence (SUI) | Urodynamic stress incontinence (USI) | Clinical: involuntary loss of urine on effort/exertion/sneezing/coughing. Urodynamic: leakage during filling cystometry with ↑ intra-abdominal pressure, in the absence of a detrusor contraction |
| Overactive bladder (OAB) — Dry vs Wet / Urgency urinary incontinence | Detrusor overactivity (DO) | Clinical: involuntary loss of urine associated with urgency. Urodynamic: involuntary detrusor muscle contractions during filling cystometry |
| Mixed UI | — | Combined SUI + UUI symptoms |
| Overflow incontinence | — | Dribbling without recognizable urge or sensation of fullness (large residual volume) |
Exam Trap – Clinical vs Urodynamic Terminology
"Stress urinary incontinence" is a clinical diagnosis based on symptoms. "Urodynamic stress incontinence" is confirmed only by urodynamic studies. You cannot use the term "USI" without having done urodynamics. Similarly, "detrusor overactivity" is a urodynamic diagnosis, while "overactive bladder" is the clinical term. Examiners may test this distinction directly. [1]
Other causes of urinary incontinence: [1]
The lecture provides a comprehensive table for distinguishing types of UI by history:
| Feature | Stress UI | Urgency UI | Mixed UI | Overflow UI |
|---|---|---|---|---|
| Circumstances | Physical activity, ↑ intra-abdominal pressure | Preceded by sudden strong desire to void | Both urgency and exertion | Without recognizable urge/fullness |
| Specific clues | Coughing, sneezing, exercise, walking uphill | Nocturia, frequency; may NOT involve incontinence (dry OAB) | Identify predominant symptom | Dribbling, incomplete emptying |
| Voiding interval | Normal | ↓ interval | ↓ interval | ↑ interval |
| Nocturia | Absent or mild | Often prominent | Variable | — |
Additional history: [1]
- Irritative voiding symptoms:
- Frequency: > 7 voids in daytime
- Urgency: sudden and strong desire to void
- Nocturia: waking at night ≥ 1 time to void
- Relation to genital prolapse, bowel and sexual dysfunction
- Severity and effect on quality of life
- Faecal incontinence (shared pelvic floor pathology)
- Fluid intake — caffeine-containing beverages (caffeine is a bladder irritant)
- Pads for protection, amount of leaking
Cough test (may need reduction of prolapse to detect occult stress incontinence) [1]
- Assess pelvic floor support (each compartment) and function
- Presence of uterine and adnexal pathology
- Neurological examination to assess S2-4 nerve roots — anal tone, perineal sensation, bulbocavernosus reflex
NB: There are no specific clinical signs in women with detrusor overactivity. [1]
| Investigation | Purpose |
|---|---|
| Bladder diary | Records frequency/volume of intake and voids — objective data for diagnosis and monitoring |
| MSU for routine, microscopy ± culture | Rule out UTI (which can cause/worsen urgency and frequency) |
High Yield – First-Line Investigation for UI
The most appropriate first-line investigation for urinary incontinence is MSU for culture (to exclude UTI) + bladder diary. This has been tested directly in the 2020 MCQ (Q85): a 45-year-old lady with urge incontinence → answer was MSU for culture (option A), NOT urodynamics. [7]
Behavioural therapy: smoking cessation, weight reduction, reduce caffeine intake, fluid intake advice. [1]
"8 glasses of water is a myth!" [1]
Why these work:
- Weight reduction → decreases chronic intra-abdominal pressure
- Caffeine reduction → caffeine is a diuretic and bladder irritant
- Smoking cessation → reduces chronic cough (which worsens SUI)
- Fluid advice → excessive fluid = more urine = more leakage; too little = concentrated irritating urine
Urodynamics confirms whether the leakage was related to USI and/or detrusor overactivity. [1]
Components:
- Measurement of pressure–flow relationship between bladder and urethra
- Storage/filling phase AND voiding phase
- Cystometry — evaluates storage function and bladder sensation during filling
When to do urodynamics: Not first-line. Reserved for:
- Diagnostic uncertainty (e.g., mixed symptoms)
- Before surgical intervention
- Failed initial conservative treatment
6. Management of Urodynamic Stress Incontinence [1]
| Approach | Details |
|---|---|
| Behavioural therapy | As above (weight, caffeine, smoking, fluid) |
| Pelvic floor exercise (Kegel) ± biofeedback | Strengthen levator ani → improve urethral support. 3 sets of 8-12 contractions, hold 8-10s, TDS, for ≥ 15-20 weeks [5] |
| Pharmacotherapy | Not first line for SUI. Duloxetine (SNRI) can increase urethral sphincter activity but is not licensed in HK [5] |
Surgery aims to: (a) restore the bladder neck back to the intra-abdominal pressure zone, (b) increase outflow resistance, or (c) attain both. [1]
| Procedure | Mechanism |
|---|---|
| Mid-urethral sling (tension-free vaginal tape, TVT) | A polypropylene mesh tape placed under the mid-urethra; provides a backboard for urethral compression during ↑ abdominal pressure |
| Trans-obturator tape (TOT) | Similar to TVT but exits through obturator foramen — lower risk of bladder perforation |
| Burch colposuspension | Sutures from lateral vaginal walls to iliopectineal ligaments → lifts bladder neck |
| Transurethral injection | Bulking agents (e.g., silicone, collagen) injected around mid-urethra to improve coaptation |
| Artificial urinary sphincter | Inflatable cuff around urethra — patient deflates it to void (more common in males) |
7. Management of Detrusor Overactivity [1]
- Pelvic floor exercise
- Behavioural therapy: deferment technique and bladder retraining — gradually increase voiding intervals using distraction and timed voiding schedules
| Drug Class | Examples | Mechanism |
|---|---|---|
| Anti-muscarinic agents | Oxybutynin, tolterodine, solifenacin | Block M3 muscarinic receptors on detrusor muscle → reduce involuntary contractions |
| Beta-3 adrenoceptor agonist | Mirabegron | Activates β3 receptors on detrusor → promotes relaxation during filling |
Side effects of anti-muscarinics: Dry mouth, constipation, blurred vision, cognitive impairment (especially in elderly — cross BBB) → mirabegron avoids these.
- Botulinum toxin injection into detrusor
- Percutaneous sacral nerve stimulation
- Augmentation cystoplasty (last resort)
High Yield – Lecture Summary Slide
"Weakened pelvic floor support is the basic pathophysiology. Vaginal childbirth is an important risk factor. Common association of prolapse and urinary incontinence in an elderly woman. Remember the possibility of occult stress incontinence in case of severe prolapse. Conservative management is available but rarely curative. If surgery is indicated, surgery for BOTH conditions may be needed." [1]
Role of Primary Care [1]
Patients usually do not volunteer incontinence symptoms due to:
- Embarrassment
- Accept as part of normal ageing and childbirth
- Not aware that treatment is available
- Symptom not troublesome enough
Always take note of the symptom and refer if indicated. [1]
9. Integration with Related Lectures
Urogenital atrophy from oestrogen deficiency causes: vaginal dryness, dyspareunia, prolapse, urgency, frequency, dysuria, UTI, incontinence, voiding difficulties. Topical oestrogen is a key adjunct treatment for UI in postmenopausal women.
Aetiological causes of UI include: congenital (duplex ureter below sphincter), infection, iatrogenic (post-prostatectomy), birth injury (VVF, stress incontinence), neoplastic.
- Suprasacral spinal cord lesion: Spinal shock → AROU → later becomes hyperreflexic (urge incontinence / detrusor-sphincter dyssynergia)
- Sacral cord / cauda equina lesion: Hyporeflexic/areflexic bladder → overflow incontinence
Posterior urethral valves (male) → bilateral hydronephrosis → requires urgent investigation. VUR → recurrent UTI → reflux nephropathy.
11. Likely Exam Questions
Stem: 45-year-old lady with urinary incontinence for 2 months, frequency, urgency, incontinence with urge sensation but NOT with coughing/sneezing. Most appropriate first-line investigation?
- Answer: A. Midstream urine for culture — to exclude UTI before further workup.
Stem: Which statement BEST describes stress urinary incontinence?
- Answer: A. It is a more common problem in female. (Not B: UTI association is with OAB/urgency. Not C: SUI is worse with activity, not at night. Not D: that describes urgency UI.)
Stem: 80-year-old man with long-standing hesitancy, frequency, straining, incomplete emptying, wets the bed.
- Answer: B. Overflow incontinence — chronic retention from BPH → continuous dribbling
Testing causes of retention: post-biopsy acute prostatitis, spinal fracture → neurologic, BPH → overflow.
-
"A 65-year-old woman presents with a lump at the vaginal introitus. She is also experiencing difficulty passing urine. Describe how you would examine this patient."
- Markscheme: General (BMI, respiratory), abdominal (mass), pelvic exam in lithotomy AND Sims position, assess each compartment during straining, assess vaginal oestrogenization, cough test WITH prolapse reduction to detect occult SUI, neurological exam S2-4.
-
"List three levels of pelvic support and the prolapse that results from damage to each level."
- Level I (cardinal/uterosacral ligaments) → uterine/vault prolapse; Level II (paracolpium/pubocervical and rectovaginal fascia) → cystocele/rectocele; Level III (fusion to urethra/perineal body/levator ani) → urethrocele/perineal deficiency.
-
"A 70-year-old woman with procidentia is found to have hydronephrosis. Explain the mechanism."
- Severe prolapse → ureteric kinking at the level of the cardinal ligament or bladder base → obstruction → hydronephrosis → potential renal damage.
-
"Differentiate stress UI from urgency UI in terms of history, pathophysiology, and first-line management."
-
"What is occult stress incontinence and why is it clinically important?"
- Stress incontinence masked by prolapse (kinking of urethra). Important because it may become apparent AFTER prolapse surgery → must test for it pre-operatively by reducing prolapse and doing a cough test. May need combined surgery.
Active Recall - Lecture Notes
High Yield Summary
Pelvic floor = all structures supporting pelvic cavity (not just levator ani). Three functions: Support, Sphincteric, Sexual. DeLancey's three levels of support: Level I (cardinal/uterosacral ligaments → uterine/vault prolapse), Level II (paracolpium/fascia → cystocele/rectocele), Level III (direct fusion → urethrocele/perineal deficiency). Vaginal delivery is the single most important risk factor (OR 4.7). Most specific symptom of prolapse is seeing/feeling a bulge. Prolapse can MASK stress incontinence (occult SUI) — always reduce prolapse and cough test before surgery. First-line investigation for UI: MSU C/ST + bladder diary (NOT urodynamics). SUI management: pelvic floor exercises → surgery (TVT/colposuspension). OAB/UUI management: bladder retraining → anti-muscarinics (oxybutynin/tolterodine/solifenacin) or mirabegron → surgery only in refractory cases. Conservative treatment of prolapse: ring pessary (~60% effective). Surgery for prolapse depends on the compartment affected. If both prolapse and SUI present, surgery for BOTH may be needed.
[1] Lecture slides: GC 116. I felt a lump below urinary incontinence in females; genital prolapse.pdf [2] Senior notes: Block C - I felt a lump below_ urinary incontinence in females; genital prolapse.pdf [3] Lecture slides: GC 114. Climacteric symptoms menopause and related illness; amenorrhoea.pdf (p41) [4] Lecture slides: GC 209. Urinary incontinence and overactive bladder.pdf (p22) [5] Senior notes: Ryan Ho Urogenital.pdf (p159-164) [6] Senior notes: Ryan Ho Neurology.pdf (p53, p168) [7] Past papers: 2020 Fourth Summative Assessment MCQ paper.pdf (Q54, Q85) [8] Senior notes: Adrian Lui Pediatrics Notes.pdf (p336) [9] Past papers: 2024 Fourth Summative MCQ.pdf (Q62) [10] Past papers: 2023 Fourth Summative MCQ.pdf (Q22-24)
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