Gynecological Disorders Practice Questions

Q: Which of the following is the most common site of bladder injury during abdominal hysterectomy?

Posterior wall. **Explanation:** The bladder is the most frequently injured organ during a hysterectomy, occurring in approximately 1–2% of cases. **Why the Posterior Wall is the Correct Answer:** During an abdominal hysterectomy, the bladder must be separated from the lower uterine segment and cervix. This is achieved by incising the vesicouterine peritoneum and developing the **vesicovaginal space**. The **posterior wall (base)** of the bladder is anatomically adjacent to the anterior surface of the uterus and cervix. Injury most commonly occurs during the **dissection of the bladder flap** or while reflecting the bladder inferiorly, especially if there are adhesions from previous surgeries (like a C-section) or endometriosis. **Analysis of Incorrect Options:** * **Anterior Wall:** This surface faces the pubic symphysis and is generally away from the primary surgical field of a hysterectomy. * **Medial Wall:** The bladder is a midline structure; it does not have a distinct "medial" wall in the context of surgical anatomy. * **Lateral Walls:** While the ureters enter the bladder at the posterolateral angles (trigone), the lateral walls themselves are not the primary site of dissection during the mobilization of the uterus. **NEET-PG High-Yield Pearls:** * **Most common site of injury:** Posterior wall (base). * **Most common timing of injury:** During the dissection of the bladder flap or during the clamping of the vaginal vault. * **Diagnosis:** Intraoperatively, injury is identified by the appearance of urine in the field or by filling the bladder with **methylene blue** or sterile milk. * **Management:** Small injuries (<1 cm) may heal with catheterization; larger injuries require a two-layer closure with absorbable sutures. * **Ureteric Injury:** The most common site for ureteric injury is at the level of the **infundibulopelvic ligament** or where the ureter passes under the **uterine artery** ("water under the bridge").

Q: Recurrent abortion occurs in a woman. USG abdomen shows a non-echoic region in the central part of the uterus. What is the probable diagnosis?

Septate uterus. **Explanation:** The clinical presentation of recurrent abortion combined with specific ultrasonographic findings points toward a Mullerian duct anomaly. **1. Why Septate Uterus is Correct:** A **septate uterus** occurs due to the failure of resorption of the midline uterovaginal septum after the fusion of the Mullerian ducts. On a 2D Ultrasound (USG), the septum appears as a **non-echoic (hypoechoic) or linear region** dividing the central part of the uterine cavity. Because the septum is composed of fibroelastic tissue with poor vascularization, it is the most common Mullerian anomaly associated with **recurrent pregnancy loss (RPL)**, as the embryo cannot implant or sustain growth on poorly vascularized tissue. **2. Why Other Options are Incorrect:** * **Arcuate Uterus:** This is a mild variation where the fundus has a small midline indentation. It is generally considered a normal variant and is not typically associated with recurrent abortions. * **Bicornuate Uterus:** This results from partial failure of fusion of the Mullerian ducts. While it shows two horns, the key diagnostic feature is a **deep fundal cleft (>1cm)**, which distinguishes it from a septate uterus (where the external fundal contour is straight or convex). * **Unicornuate Uterus:** This results from the failure of one Mullerian duct to develop. USG would show a small, laterally displaced uterus ("banana-shaped") rather than a central non-echoic division. **Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Combined Laparoscopy and Hysteroscopy (to differentiate Septate from Bicornuate by viewing the external fundal contour). * **Best Non-invasive Investigation:** 3D Ultrasound or MRI. * **Treatment of Choice:** Hysteroscopic Septal Resection (Metzenbaum procedure). * **Highest Risk of Miscarriage:** Septate uterus (approx. 60-90% risk).

Q: Which of the following lesions is most likely to pursue a benign course?

Adenomyosis. **Explanation:** The question asks to identify the lesion with the most benign course among the given options. **Correct Option: B. Adenomyosis** Adenomyosis is a common, benign gynecological condition characterized by the presence of ectopic endometrial glands and stroma within the myometrium, leading to reactive hypertrophy of the surrounding muscle. While it causes significant morbidity (menorrhagia and dysmenorrhea), it is **not a premalignant condition** and does not carry a risk of malignant transformation. It typically regresses after menopause. **Incorrect Options:** * **A. Vaginal adenosis:** While benign in itself (replacement of squamous epithelium by columnar epithelium), it is a known precursor to **Clear Cell Adenocarcinoma** of the vagina, particularly in women exposed to Diethylstilbestrol (DES) in utero. * **C. Extramammary Paget's disease (Vulva):** This is a rare intraepithelial neoplasia. Unlike mammary Paget’s, it is often a primary lesion, but in approximately 20-30% of cases, it is associated with an underlying invasive adenocarcinoma (vulvar, rectal, or bladder). * **D. Endometrial hyperplasia:** This is a spectrum of lesions. Specifically, **Atypical Endometrial Hyperplasia** (Endometrial Intraepithelial Neoplasia) is a direct precursor to Type I Endometrioid Adenocarcinoma, with a progression risk of nearly 30% if left untreated. **High-Yield Clinical Pearls for NEET-PG:** * **Adenomyosis:** Classically presents as a "globular, symmetrically enlarged, soft/boggy uterus." * **MRI** is the most accurate imaging modality (look for a junctional zone thickness >12 mm). * **Definitive treatment:** Hysterectomy; however, Levonorgestrel-IUS (Mirena) is an effective medical management option. * **Distinction:** Unlike Endometriosis, Adenomyosis is more common in multiparous women in their 40s.

Q: Criteria to diagnose Pelvic Inflammatory Disease (PID) include all of the following except:

Nausea and Vomiting. **Explanation:** Pelvic Inflammatory Disease (PID) is a clinical diagnosis based on the **CDC (Centers for Disease Control and Prevention) criteria**. Because the consequences of missing a diagnosis are severe (infertility, ectopic pregnancy, chronic pain), the diagnostic threshold is kept low. **1. Why Nausea and Vomiting is the correct answer:** Nausea and vomiting are **not** part of the minimum clinical criteria for diagnosing PID. While they may occur in severe cases or if peritonitis develops (e.g., Fitz-Hugh-Curtis syndrome), they are non-specific symptoms. In the context of pelvic pain, nausea and vomiting are more classically associated with **acute appendicitis** or **ovarian torsion**, making them a point of differential diagnosis rather than a diagnostic criterion for PID. **2. Why the other options are incorrect:** According to the CDC, PID is diagnosed if **one or more** of the following **Minimum Clinical Criteria** are present on pelvic examination in a sexually active young woman experiencing pelvic or lower abdominal pain: * **Cervical Motion Tenderness (Option B):** Also known as "Chandelier sign." * **Uterine Tenderness (Option A):** Pain on palpation of the uterus. * **Adnexal Tenderness (Option D):** Pain in the region of the ovaries and fallopian tubes. **Clinical Pearls for NEET-PG:** * **Additional Criteria (to increase specificity):** Oral temperature >101°F (>38.3°C), abnormal cervical/vaginal mucopurulent discharge, presence of abundant WBCs on saline microscopy of vaginal fluid, and elevated ESR/CRP. * **Definitive Criteria:** Histopathologic evidence of endometritis, imaging (USG/MRI) showing thickened fluid-filled tubes, or laparoscopic findings consistent with PID. * **Gold Standard Investigation:** Laparoscopy (though not required for routine diagnosis). * **Most Common Organisms:** *Chlamydia trachomatis* (most common) and *Neisseria gonorrhoeae*.

Q: What is true about genital infections?

Clue cells are associated with Gardnerella vaginalis.. ### Explanation **Correct Answer: D. Clue cells are associated with Gardnerella vaginalis.** **1. Why the Correct Answer is Right:** Clue cells are the pathognomonic microscopic finding for **Bacterial Vaginosis (BV)**, primarily caused by *Gardnerella vaginalis*. These are vaginal epithelial cells covered with so many coccobacilli that their borders appear stippled or "shaggy." Their presence is one of the four **Amsel’s Criteria** used for diagnosing BV. **2. Why the Other Options are Wrong:** * **Option A:** Thin, frothy, malodorous, greenish-yellow discharge is characteristic of **Trichomoniasis**. In contrast, *Candidal* infection presents with thick, white, "curd-like" or "cottage cheese" discharge. * **Option B:** Metronidazole is the treatment for BV and Trichomoniasis. For **Candidal infection** (a fungal infection), the treatment of choice is antifungal agents like **Fluconazole** or Clotrimazole. Furthermore, partner treatment is not routinely required for Candidiasis as it is not strictly considered an STI. * **Option C:** The drug of choice for *Trichomonas vaginalis* is **Metronidazole** (2g single dose or 500mg BD for 7 days). Tetracyclines are used for infections like Chlamydia or Syphilis (if penicillin-allergic). **3. High-Yield Clinical Pearls for NEET-PG:** * **Amsel’s Criteria (Need 3 out of 4):** 1. Thin homogenous discharge, 2. pH > 4.5, 3. Positive Whiff test (fishy odor with 10% KOH), 4. Clue cells on wet mount. * **Nugent Scoring:** The "Gold Standard" for diagnosing BV (based on Gram stain morphotypes). * **Strawberry Cervix:** Seen in 10% of cases of *Trichomonas vaginalis* due to punctate hemorrhages. * **pH Check:** Vaginal pH is **normal ( 4.5)** in BV and Trichomoniasis.

Q: Per Rectal palpation of the uterus is indicated in which of the following patients?

Virgins. **Explanation:** In gynecological practice, the primary method of pelvic assessment is the **Bimanual Vaginal Examination (P/V)**. However, in specific clinical scenarios where a vaginal examination is contraindicated or impossible, a **Per Rectal (P/R) examination** serves as the standard alternative to assess the pelvic organs (uterus and adnexa). **Why "Virgins" is the Correct Answer:** In patients who have not had sexual intercourse (virgins), the **hymen is intact**. Performing a per-vaginal examination would cause hymeneal rupture and significant physical/psychological distress. Therefore, a per-rectal examination is indicated to palpate the uterus, check for pelvic masses, or assess the pouch of Douglas while maintaining the integrity of the hymen. **Analysis of Incorrect Options:** * **Primigravida (A) & Grand Multipara (C):** These are pregnant or parous women. In these cases, the vaginal introitus is patulous enough to allow a standard per-vaginal examination, which provides superior tactile information compared to a rectal exam. * **Placenta Previa (D):** This is a **strict contraindication** for both P/V and P/R examinations. Any digital examination (vaginal or rectal) can provoke massive, life-threatening hemorrhage by disturbing the placental site. Diagnosis is strictly via ultrasound (Double Setup Examination is now obsolete). **NEET-PG High-Yield Pearls:** * **Indications for P/R in Gynae:** Virgins, vaginal atresia/stenosis, and staging of **Cervical Cancer** (to assess parametrial involvement). * **Mullerian Agenesis (MRKH):** P/R examination is the initial clinical step to confirm the absence of the uterus in a young girl presenting with primary amenorrhea. * **Rectovaginal Examination:** The gold standard for evaluating the **Pouch of Douglas** and rectovaginal septum in suspected endometriosis.

Q: A 38-year-old woman complains of chronic pelvic pain, significantly worse during her menstrual periods. Pelvic examination reveals an enlarged uterus with multiple palpable masses. Ultrasound shows numerous ball-like masses up to 6 cm in diameter within the uterus. In which location are most cases of this type of tumor typically found?

Intramural location within the fundus or body of the uterus. ### Explanation **1. Understanding the Diagnosis** The clinical presentation of a 38-year-old woman with chronic pelvic pain, dysmenorrhea, an enlarged uterus, and "ball-like masses" on ultrasound is classic for **Uterine Leiomyomas (Fibroids)**. These are benign monoclonal tumors of smooth muscle cells. **2. Why Option B is Correct** Leiomyomas are the most common pelvic tumors in women. Based on their anatomical location, they are classified as intramural, submucosal, or subserosal. * **Intramural fibroids**, located within the thick muscular wall of the uterus, are the **most common type** overall. * The majority of these tumors (approx. 95%) occur in the **corpus (fundus or body)** of the uterus because this area contains the highest concentration of smooth muscle fibers. **3. Why Other Options are Incorrect** * **Options A & C (Cervix):** Cervical fibroids are relatively rare, accounting for only about 1–2% of all uterine leiomyomas. * **Option D (Submucosal):** While submucosal fibroids are clinically significant because they cause heavy menstrual bleeding (menorrhagia) and infertility, they are less common than the intramural variety. **4. NEET-PG High-Yield Pearls** * **Most common symptom:** Menorrhagia (heavy menstrual bleeding). * **Most common type:** Intramural. * **Most symptomatic type:** Submucosal (even small ones cause significant bleeding). * **Degenerations:** **Red degeneration** (carneous degeneration) is most common during pregnancy due to rapid growth and ischemia. **Hyaline degeneration** is the most common overall. * **Investigation of choice:** Transvaginal Ultrasound (TVS). Saline Infusion Sonography (SIS) is superior for submucosal types. * **Medical Management:** GnRH agonists (used pre-operatively to reduce tumor size).

Question 1

A 36-year-old female presents with heavy menstrual bleeding. She has one child of 7 years. USG shows a single 3x3 cm submucosal fibroid. Hemoglobin is 10.5 gm/dl. What is the best treatment option for her?

Accepted Answer

Hysteroscopic myomectomy

Answer

GnRH injection

Answer

Uterine Artery Embolization (UAE)

Answer

Laparoscopic myomectomy

Question 2

Which of the following is the most common site of bladder injury during abdominal hysterectomy?

Accepted Answer

Posterior wall

Answer

Anterior wall

Answer

Medial wall

Answer

Lateral wall

Question 3

Recurrent abortion occurs in a woman. USG abdomen shows a non-echoic region in the central part of the uterus. What is the probable diagnosis?

Accepted Answer

Septate uterus

Answer

Arcuate uterus

Answer

Bicornuate uterus

Answer

Unicornuate uterus

Question 4

Which of the following lesions is most likely to pursue a benign course?

Accepted Answer

Adenomyosis

Answer

Vaginal adenosis

Answer

Extramammary Paget's disease

Answer

Endometrial hyperplasia

Question 5

Criteria to diagnose Pelvic Inflammatory Disease (PID) include all of the following except:

Accepted Answer

Nausea and Vomiting

Answer

Uterine tenderness

Answer

Cervical motion tenderness

Answer

Adnexal tenderness

Question 6

What is true about genital infections?

Accepted Answer

Clue cells are associated with Gardnerella vaginalis.

Answer

Thin frothy secretions are associated with candidal infection.

Answer

Patients and partners are given metronidazole for candidal infection.

Answer

Tetracycline is the drug of choice for Trichomonas vaginalis.

Question 7

Per Rectal palpation of the uterus is indicated in which of the following patients?

Accepted Answer

Virgins

Answer

Primigravida

Answer

Grand multipara

Answer

Placenta previa

Question 8

Which type of fibroid typically presents with a "Lantern on top of St Paul's Cathedral" appearance?

Accepted Answer

Cervical fibroid

Answer

Submucosal fibroid

Answer

Subserosal fibroid

Answer

Interstitial fibroid

Question 9

What is the classical symptom of an endocervical polyp?

Accepted Answer

Intermenstrual bleeding

Answer

Cervical prolapse

Answer

Dyspareunia

Answer

Dysmenorrhea

Question 10

A 38-year-old woman complains of chronic pelvic pain, significantly worse during her menstrual periods. Pelvic examination reveals an enlarged uterus with multiple palpable masses. Ultrasound shows numerous ball-like masses up to 6 cm in diameter within the uterus. In which location are most cases of this type of tumor typically found?

Accepted Answer

Intramural location within the fundus or body of the uterus

Answer

Intramural location within the cervix of the uterus

Answer

Submucosal location within the cervix of the uterus

Answer

Submucosal location within the fundus or body of the uterus

Gynecological Disorders — MCQs

Gynecological Disorders — MCQs

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