Venerology — MCQs

Venerology Indian Medical PG Practice Questions and MCQs

Question 61: Which of the following causes genital ulcers?

A. Human papilloma virus
B. Herpes simplex virus
C. Human Immunodeficiency Virus
D. All of the above (Correct Answer)

Explanation: **Explanation:** Genital Ulcer Disease (GUD) is a clinical syndrome characterized by ulcerative lesions on the genitalia, often accompanied by lymphadenopathy. While most commonly associated with classic STIs, several viruses can manifest as ulcers. * **Herpes Simplex Virus (HSV):** HSV-2 (and increasingly HSV-1) is the most common cause of genital ulcers worldwide [1]. It typically presents as painful, grouped vesicles on an erythematous base that rupture to form shallow, "punched-out" ulcers [3]. * **Human Papilloma Virus (HPV):** While HPV is primarily known for causing genital warts (Condyloma acuminata), certain high-risk strains or secondary trauma/infection of a wart can lead to ulceration. Additionally, HPV-related malignancies (Vulvar/Penile intraepithelial neoplasia) can present as chronic, non-healing ulcers. * **Human Immunodeficiency Virus (HIV):** Acute HIV infection (Seroconversion illness) can present with painful mucocutaneous ulcers (aphthous-like) on the mouth or genitals. Furthermore, advanced HIV/AIDS increases the risk of "giant herpetic ulcers" or opportunistic infections that manifest ulceratively. **Clinical Pearls for NEET-PG:** 1. **Painful Ulcers:** Think **H**erpes (HSV) and **C**hancroid (*Haemophilus ducreyi*) [2]. 2. **Painless Ulcers:** Think Syphilis (Chancre), Lymphogranuloma Venereum (LGV), and Granuloma Inguinale (Donovanosis) [2]. 3. **Donovan Bodies:** Pathognomonic for Granuloma Inguinale (safety-pin appearance on Giemsa stain). 4. **School of Fish appearance:** Characteristic of *H. ducreyi* on Gram stain. 5. **Syndromic Management:** In India, the **NACO Kit 1 (Grey)** is used for the management of non-herpetic genital ulcers (covers Syphilis and Chancroid).

Question 62: A 20-year-old young female presented with a relatively painless ulcer of 3 cm on the labia majora with raised margins. Which of the following organisms would have most likely caused this ulcer?

A. Herpes simplex
B. Treponema palladium (Correct Answer)
C. Chlamydia trachomatis
D. Candidal cervicitis

Explanation: ### Explanation The clinical presentation of a **relatively painless, solitary ulcer with raised, indurated margins** on the genitalia is the classic description of a **Chancre**, the hallmark of **Primary Syphilis**. [1] **1. Why Treponema pallidum is correct:** * **Morphology:** The primary chancre caused by *T. pallidum* typically begins as a papule that erodes into a clean-based, painless ulcer. [1] * **Margins:** The margins are characteristically raised and firm (indurated). * **Lymphadenopathy:** It is often associated with painless, non-suppurative bilateral inguinal lymphadenopathy. * **Healing:** Even without treatment, the ulcer usually heals within 3–6 weeks, though the infection progresses to the secondary stage. **2. Why the other options are incorrect:** * **Herpes Simplex (HSV-2):** Causes **painful**, multiple, superficial, vesicular lesions on an erythematous base. [1] They are not indurated. * **Chlamydia trachomatis (L1-L3):** Causes **Lymphogranuloma Venereum (LGV)**. While it starts with a small, painless papule or ulcer, the lesion is transient and often goes unnoticed. The dominant clinical feature is painful, suppurative inguinal lymphadenopathy (the "Groove sign"). [2] * **Candidal cervicitis:** Typically presents with thick, curd-like vaginal discharge and pruritus, not a discrete, indurated ulcer on the labia. **Clinical Pearls for NEET-PG:** * **Painful vs. Painless Ulcers:** Remember the mnemonic **"H is for Hurt"**—**H**erpes and **H**aemophilus ducreyi (Chancroid) are painful; Syphilis and LGV are generally painless. [1] * **Dark-field Microscopy:** The gold standard for diagnosing primary syphilis from ulcer exudate. * **Treatment of Choice:** Benzathine Penicillin G (2.4 million units IM, single dose) remains the first-line therapy.

Question 63: Which statement is true regarding gonococcal urethritis?

A. Symptoms are more severe in females than in males.
B. The rectum and prostate are resistant to gonococci.
C. Most patients present with symptoms of dysuria. (Correct Answer)
D. All of the above.

Explanation: Explanation: **Gonococcal Urethritis** is caused by the Gram-negative diplococcus *Neisseria gonorrhoeae*. In males, it typically presents as an acute, symptomatic infection of the anterior urethra. 1. **Why Option C is correct:** Dysuria (painful urination) and a profuse, purulent urethral discharge [1] are the hallmark symptoms of gonococcal urethritis. In males, more than 90% of cases are symptomatic, with dysuria being the most common presenting complaint. 2. **Why Option A is incorrect:** Symptoms are significantly **more severe in males** than in females. In females, the primary site of infection is the endocervix, and the infection is often asymptomatic or presents with mild, non-specific symptoms (vaginal discharge or intermenstrual bleeding). 3. **Why Option B is incorrect:** The rectum and prostate are **not resistant**. *N. gonorrhoeae* can infect any mucosal surface lined with columnar or cuboidal epithelium. Prostatitis is a known local complication in males [3], and proctitis is common in individuals practicing receptive anal intercourse. **High-Yield Clinical Pearls for NEET-PG:** * **Incubation Period:** Short, typically 2–7 days [1] (compared to 7–14 days for Chlamydia). * **Diagnosis:** Gram stain showing **Gram-negative intracellular diplococci** within polymorphonuclear leukocytes (PMNs) is highly sensitive (95%) in symptomatic males. **NAAT** (Nucleic Acid Amplification Test) is the gold standard for screening. * **Treatment:** Due to increasing resistance, the current CDC/WHO recommendation is a single dose of **Ceftriaxone (IM)** [2]. Always co-treat for Chlamydia (e.g., Doxycycline) if it hasn't been ruled out. * **Complications:** If untreated, it can lead to Epididymitis in males and Pelvic Inflammatory Disease (PID) or Fitz-Hugh-Curtis syndrome in females.

Question 64: A 35-year-old male with a history of multiple sex partners presents with urethral discharge. What is the best treatment option?

A. Cefixime + azithromycin (Correct Answer)
B. Ceftriaxone + quinolone
C. Erythromycin
D. Ceftriaxone + doxycycline

Explanation: ### Explanation **Correct Answer: A. Cefixime + azithromycin** The clinical presentation of urethral discharge in a sexually active male is characteristic of **Urethritis** [1]. In clinical practice, especially in resource-limited settings or initial visits, the **Syndromic Management** approach (as per NACO/WHO guidelines) is followed because it is often difficult to distinguish between Gonococcal Urethritis (GU) and Non-Gonococcal Urethritis (NGU) based on symptoms alone [1]. * **Why it is correct:** According to the **NACO guidelines (Kit 1 - Grey)** for urethral discharge, the recommended treatment is a single dose of **Cefixime (400 mg)** to cover *Neisseria gonorrhoeae* and a single dose of **Azithromycin (1 g)** to cover *Chlamydia trachomatis*. This dual therapy ensures coverage for the two most common causative organisms and helps prevent the development of antibiotic resistance [2]. **Analysis of Incorrect Options:** * **B. Ceftriaxone + Quinolone:** While Ceftriaxone is effective against Gonococcus, Quinolones (like Ciprofloxacin) are no longer recommended as first-line therapy due to widespread resistance in *N. gonorrhoeae* [2]. * **C. Erythromycin:** This is a second-line alternative for Chlamydia (often used in pregnancy) but lacks sufficient coverage for Gonococcus. * **D. Ceftriaxone + Doxycycline:** While this is a valid regimen (Ceftriaxone 250mg IM + Doxycycline 100mg BID for 7 days), it is not the preferred "stat" dose combination used in the standard Syndromic Management (Kit 1) which prioritizes single-dose compliance. **Clinical Pearls for NEET-PG:** * **NACO Kit 1 (Grey):** For Urethral/Anorectal/Cervical discharge. Contains Azithromycin (1g) + Cefixime (400mg). * **Incubation Period:** Gonorrhea (2–5 days; rapid onset, purulent discharge) vs. Chlamydia (7–14 days; slow onset, mucoid discharge) [1]. * **Complications:** If left untreated, it can lead to Epididymo-orchitis in males and Pelvic Inflammatory Disease (PID) in females [2]. * **Partner Management:** Always treat the sexual partner(s) simultaneously to prevent "ping-pong" reinfection [2].

Question 65: Tender buboes are used in the diagnosis of which condition?

A. Gonorrhoea
B. Herpes
C. Chancroid (Correct Answer)
D. Granuloma venereum

Explanation: **Chancroid** is caused by the Gram-negative coccobacillus *Haemophilus ducreyi*. The clinical hallmark of this condition is the presence of **painful (tender) genital ulcers** [1] accompanied by **painful, fluctuant inguinal lymphadenopathy**, known as **buboes** [1]. These buboes are typically unilateral and, if left untreated, may undergo spontaneous rupture, leading to chronic draining sinuses. **Analysis of Options:** * **Gonorrhoea:** Primarily presents as urethritis (purulent discharge) or cervicitis. While it can cause pelvic inflammatory disease, it does not typically present with tender inguinal buboes. * **Herpes (HSV-2):** Presents with multiple, small, grouped vesicles on an erythematous base that rupture to form shallow, painful ulcers. While lymphadenopathy may be present, it is usually bilateral and non-suppurative, unlike the classic bubo of Chancroid. * **Granuloma venereum (Donovanosis):** Caused by *Klebsiella granulomatis*. It is characterized by **painless**, beefy-red, velvety ulcers [1]. A key feature is "pseudobuboes"—which are subcutaneous nodules rather than true lymphadenopathy. **NEET-PG High-Yield Pearls:** * **The "Pain" Rule:** Chancroid and Herpes are **Painful**; Syphilis and Lymphogranuloma Venereum (LGV) are generally **Painless** (though LGV buboes can become painful later). * **School of Fish Appearance:** Classic Gram stain finding for *H. ducreyi*. * **LGV vs. Chancroid:** Both cause buboes, but LGV (Chlamydia L1-L3) features the **"Groove Sign"** (Poupart’s ligament dividing the nodes) and the initial ulcer is usually evanescent (disappears quickly). * **Treatment of Chancroid:** Single dose of Azithromycin (1g) or Ceftriaxone (250mg IM).

Question 66: Which of the following conditions is NOT transmitted sexually?

A. Syphilis
B. T. vaginalis (Correct Answer)
C. Candida
D. Gonorrhoea

Explanation: The question asks to identify the condition that is **not** primarily considered a sexually transmitted infection (STI). **Why Option B (T. vaginalis) is the Correct Answer (in the context of this specific question):** While *Trichomonas vaginalis* is classically considered an STI [1], in many standardized medical examinations (including some NEET-PG patterns), it is occasionally contrasted with "obligate" STIs. However, there is a **technical discrepancy** in the provided key: *T. vaginalis* is indeed an STI. In clinical practice, **Candida (Option C)** is the condition most frequently cited as **not** being a true STI, as it is a commensal organism that causes opportunistic infection due to changes in vaginal pH or flora. *Note: If this question appeared with this specific key, it likely refers to the fact that Trichomonas can occasionally survive on moist surfaces (fomites like towels), whereas Syphilis and Gonorrhoea are obligate human pathogens requiring direct contact. However, from a strictly medical standpoint, Candida is the least likely to be classified as an STI.* **Analysis of Other Options:** * **A. Syphilis:** Caused by *Treponema pallidum*. It is a classic STI transmitted through direct contact with a chancre. * **C. Candida:** Caused by *Candida albicans*. It is part of the normal vaginal flora [1]. Overgrowth occurs due to antibiotics, pregnancy, or diabetes, rather than sexual transmission. * **D. Gonorrhoea:** Caused by *Neisseria gonorrhoeae*. It is a quintessential STI involving the mucous membranes of the genitourinary tract [1]. **High-Yield Clinical Pearls for NEET-PG:** 1. **Trichomoniasis:** Characterized by a **strawberry cervix** (punctate hemorrhages) and a malodorous, frothy yellowish-green discharge. pH is >4.5 [1]. 2. **Bacterial Vaginosis:** Most common cause of vaginal discharge; features **Clue cells** and a positive Whiff test (fishy odor with KOH). 3. **Candidiasis:** Presents with a thick, **curdy white (cottage cheese)** discharge and intense pruritus. pH is usually normal (<4.5) [1]. 4. **Drug of Choice:** Metronidazole is the DOC for both *Trichomonas* and Bacterial Vaginosis. Fluconazole is used for Candida [1].

Question 67: A male patient presented with agitation, restlessness, and neck stiffness. He had undergone treatment for a penile ulcer 3 years prior. Which laboratory investigation is used for assessing the prognosis of treatment?

A. TPI
B. VDRL (Correct Answer)
C. FTA-ABS
D. Dark field microscopy

Explanation: ### Explanation **Correct Answer: B. VDRL** **Reasoning:** The patient presents with symptoms suggestive of **Neurosyphilis** (agitation, restlessness, neck stiffness) following a history of a penile ulcer (Primary Syphilis) three years ago. In syphilis management, laboratory tests are divided into Treponemal and Non-treponemal tests. [1] **VDRL (Venereal Disease Research Laboratory)** is a non-treponemal test. These tests measure IgG and IgM antibodies against cardiolipin-lecithin-cholesterol antigen. The key clinical utility of VDRL (and RPR) is that the **antibody titers correlate with disease activity.** A successful response to treatment is indicated by a fourfold decline in titers. Therefore, VDRL is the investigation of choice for **monitoring treatment efficacy and assessing prognosis.** In neurosyphilis, CSF-VDRL is highly specific for diagnosis and follow-up. [2] **Why other options are incorrect:** * **A. TPI (Treponema Pallidum Immobilization):** This is a specific treponemal test. While highly specific, it is technically difficult, expensive, and rarely used in modern clinical practice. * **C. FTA-ABS (Fluorescent Treponemal Antibody Absorption):** This is a treponemal test. Treponemal tests remain positive for life (immunological memory) regardless of treatment. Therefore, they **cannot** be used to assess prognosis or treatment response. [1] * **D. Dark field microscopy:** This is used for the direct visualization of *Treponema pallidum* from primary (chancre) or secondary (condyloma lata) lesions. It is a diagnostic tool for early syphilis, not a prognostic one. **NEET-PG High-Yield Pearls:** * **Screening:** VDRL / RPR (Non-treponemal). [1] * **Confirmatory:** FTA-ABS / TPHA (Treponemal). * **Treatment Monitoring:** Fourfold drop in VDRL titer (e.g., 1:32 to 1:8) indicates recovery. * **Prozone Phenomenon:** False negative VDRL due to very high antibody titers (seen in secondary syphilis); requires serum dilution. [1] * **Jarisch-Herxheimer Reaction:** Acute febrile reaction following the first dose of Penicillin due to the release of endotoxins from dying spirochetes.

Question 68: A man presents to a sexually transmitted infection clinic with urethritis and urethral discharge. Gram stain shows numerous pus cells but no microorganisms. The culture is negative on routine laboratory media. What is the most likely causative agent?

A. Chlamydia trachomatis (Correct Answer)
B. Haemophilus ducreyi
C. Treponema pallidum
D. Neisseria gonorrhoeae

Explanation: ### Explanation The clinical presentation of urethritis with a "sterile" Gram stain (pus cells present but no visible organisms) and negative routine cultures is the classic description of **Non-Gonococcal Urethritis (NGU)** [1]. **1. Why Chlamydia trachomatis is correct:** * **Intracellular Nature:** *C. trachomatis* is an obligate intracellular bacterium. It does not have a peptidoglycan layer typical of other bacteria, meaning it **does not take up Gram stain** and is invisible under light microscopy. * **Culture Requirements:** It cannot be grown on routine agar (like Blood or Chocolate agar) because it requires living host cells (cell culture) or specialized molecular techniques like **NAAT (Nucleic Acid Amplification Test)**, which is now the gold standard for diagnosis. * **Epidemiology:** It is the most common cause of NGU worldwide [1]. **2. Why the other options are incorrect:** * **Neisseria gonorrhoeae:** This causes Gonococcal Urethritis. Gram stain would characteristically show **Gram-negative intracellular diplococci** (kidney-bean shaped) within polymorphonuclear leukocytes. It grows readily on Thayer-Martin or Chocolate agar [1]. * **Haemophilus ducreyi:** This is the causative agent of **Chancroid**. It presents with painful genital ulcers and inguinal lymphadenopathy (buboes), not primary urethritis [3]. Gram stain shows a "school of fish" appearance. * **Treponema pallidum:** The causative agent of **Syphilis**. It typically presents with a painless chancre. Treponemes are too thin to be seen on Gram stain (requiring Dark-field microscopy) and do not cause purulent urethral discharge. **Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** NAAT (Nucleic Acid Amplification Test) for both *Chlamydia* and *Gonorrhea*. * **Treatment:** As per CDC/WHO guidelines, urethritis is often treated empirically for both organisms (e.g., Ceftriaxone for Gonorrhea + Doxycycline or Azithromycin for Chlamydia) [2]. * **Incubation Period:** NGU (Chlamydia) has a longer incubation period (7–14 days) compared to Gonorrhea (2–5 days) [1].

Question 69: A 45-year-old lorry driver from Bihar presented with multiple painful, necrotic ulcers on the penis and tender inguinal lymphadenopathy. What is the diagnosis?

A. Haemophilus ducreyi (Correct Answer)
B. Herpes simplex virus
C. Syphilis
D. Chlamydia trachomatis infection

Explanation: **Explanation:** The clinical presentation of **painful, necrotic ulcers** associated with **tender inguinal lymphadenopathy** (buboes) is the classic hallmark of **Chancroid**, caused by the Gram-negative coccobacillus ***Haemophilus ducreyi*** [2]. **1. Why Option A is Correct:** * **Painful Ulcers:** Unlike syphilis, chancroid presents with extremely painful, "soft" ulcers with ragged, undermined edges and a necrotic/purulent base [2]. * **Bubo Formation:** Inguinal lymphadenopathy in chancroid is typically unilateral, very painful, and prone to suppuration (forming a bubo) [2]. * **Demographics:** Lorry drivers are a high-risk group frequently cited in NEET-PG vignettes for Sexually Transmitted Infections (STIs). **2. Why Other Options are Incorrect:** * **B. Herpes Simplex Virus (HSV):** While painful, HSV presents as multiple small, superficial vesicles on an erythematous base that rupture to form shallow ulcers [1]. It lacks the deep, necrotic character of chancroid. * **C. Syphilis (*Treponema pallidum*):** The primary chancre of syphilis is characteristically **painless**, indurated ("hard"), and clean-based, with painless regional lymphadenopathy [1]. * **D. Chlamydia trachomatis (LGV):** Lymphogranuloma Venereum (serovars L1-L3) typically presents with a transient, painless primary papule/ulcer that heals quickly, followed later by painful "Groove sign" lymphadenopathy [2]. **Clinical Pearls for NEET-PG:** * **School of Fish Appearance:** Classic microscopic finding of *H. ducreyi* on Gram stain (parallel chains). * **Railroad Track Appearance:** Another descriptive term for the arrangement of the bacilli. * **Treatment:** A single dose of **Azithromycin (1g)** or Ceftriaxone (250mg IM). * **Mnemonic:** "Ducreyi makes you **cry**" (because it is painful).

Question 70: Which of the following statements is true about Donovanosis?

A. Caused by Leshmania donovani
B. Amphotericin B is the drug of choice
C. Sodium stibogluconate is the drug of choice
D. Caused by Klebsiella granulomatis (Correct Answer)

Explanation: **Explanation:** **Donovanosis**, also known as **Granuloma Inguinale**, is a chronic, progressive bacterial infection of the genital and perianal skin. 1. **Why Option D is Correct:** Donovanosis is caused by **_Klebsiella granulomatis_** (formerly known as _Calymmatobacterium granulomatis_). It is a Gram-negative, pleomorphic intracellular bacterium. The hallmark of this disease is the presence of **Donovan bodies**—safety-pin-shaped organisms seen within the cytoplasm of large mononuclear cells (macrophages) on a Giemsa or Wright stain. 2. **Why the Other Options are Incorrect:** * **Option A:** _Leishmania donovani_ is the causative agent of **Visceral Leishmaniasis (Kala-azar)**, not Donovanosis. The similarity in names often confuses students, but they are entirely different pathogens. * **Options B & C:** Amphotericin B and Sodium stibogluconate are the mainstays of treatment for **Leishmaniasis**. For Donovanosis, the **drug of choice is Azithromycin** (1g orally once a week or 500mg daily for at least 3 weeks). **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Presentation:** Characterized by **painless, beefy-red, velvety ulcers** that bleed easily on touch (friable). * **Lymphadenopathy:** Unlike Syphilis or LGV, there is **no true lymphadenopathy**. Instead, it presents with **"Pseudobuboes"** (subcutaneous granulation tissue in the inguinal region). * **Diagnosis:** Crushed tissue smear from the ulcer edge showing **Donovan bodies**. * **Complications:** Long-standing cases can lead to "Elephantiasis" of the genitals due to lymphatic scarring or squamous cell carcinoma.

Practice by Chapter

Syphilis

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Gonorrhea

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Chlamydial Infections

Practice Questions

Chancroid and Other Genital Ulcers

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Genital Herpes

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Human Papillomavirus Infections

Practice Questions

HIV and STIs

Practice Questions

Pelvic Inflammatory Disease

Practice Questions

STI Screening and Prevention

Practice Questions

Partner Notification and Treatment

Practice Questions

Sexually Transmitted Enteric Infections

Practice Questions

Special Populations Management

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Venerology — MCQs

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