Gynecological Disorders Practice Questions

Q: Which of the following is NOT a minimum clinical criterion in the CDC's diagnostic guidelines for pelvic inflammatory disease (PID)?

Elevated white blood cell count. ***Elevated white blood cell count*** - While an elevated **white blood cell (WBC) count** can be seen in PID, it is a **supportive laboratory finding** (additional criterion), not one of the three minimum clinical criteria for diagnosis as per CDC guidelines. - The CDC's minimum clinical criteria are based on direct physical examination findings to broadly identify PID in a clinical setting. *Adnexal tenderness* - **Adnexal tenderness** (tenderness of the ovaries and fallopian tubes) is a **minimum clinical criterion** for diagnosing PID. - This tenderness indicates inflammation in the pelvic organs, which is a hallmark of PID. - Presence of adnexal tenderness alone (in a sexually active woman with pelvic pain and no other identifiable cause) is sufficient to initiate empiric treatment. *Uterine tenderness* - **Uterine tenderness** is a **minimum clinical criterion** for diagnosing PID. - This symptom reflects inflammation of the uterus and surrounding pelvic structures. - Presence of uterine tenderness alone (in appropriate clinical context) warrants empiric treatment. *Cervical motion tenderness* - **Cervical motion tenderness** (also known as "chandelier sign") is a **minimum clinical criterion** for diagnosing PID. - It indicates inflammation of the cervix and potentially the uterus and surrounding pelvic structures. - This finding alone is sufficient to meet diagnostic criteria for empiric treatment.

Q: A 24-year-old woman presents with vaginal discharge, dysuria, and lower abdominal pain. On examination, there is cervical motion tenderness and mucopurulent cervical discharge. What is the diagnostic test of choice?

Nucleic acid amplification test (NAAT). ***Nucleic acid amplification test (NAAT)*** - NAATs are the **most sensitive and specific** tests for detecting *Chlamydia trachomatis* and *Neisseria gonorrhoeae*, common causes of cervicitis, which is suggested by the patient's symptoms (vaginal discharge, dysuria, lower abdominal pain, cervical motion tenderness, mucopurulent discharge). - They can be performed on **non-invasive samples** (e.g., urine, vaginal swabs), making them convenient and preferred for screening and diagnosis. *Culture on modified Thayer-Martin medium* - While **gonococcal culture** on modified Thayer-Martin medium is a specific test, it has **lower sensitivity** compared to NAATs and is more labor-intensive. - It is often reserved for cases where **antibiotic resistance testing** is needed or when NAATs are unavailable. *Wet mount examination* - A **wet mount** can identify motile trichomonads (*Trichomonas vaginalis*), yeast (candidiasis), and clue cells (bacterial vaginosis). - However, it **does not diagnose cervicitis** caused by *Chlamydia* or *Gonorrhea*, which are strongly suspected given the cervical motion tenderness and mucopurulent discharge. *Gram stain of cervical secretions* - A **Gram stain** can identify gram-negative intracellular diplococci suggestive of **gonorrhea**, but its **sensitivity is variable** in women, especially in asymptomatic cases, and it cannot detect chlamydia. - It is **insufficient for definitive diagnosis** of chlamydial infection or as a sole diagnostic tool for gonorrhea due to its lower sensitivity compared to NAATs.

Q: What is the most common vaginal infection in women of reproductive age?

Bacterial vaginosis. ***Bacterial vaginosis*** - **Bacterial vaginosis (BV)** is the most common cause of vaginal symptoms and the most prevalent vaginal infection among women of reproductive age. - It results from an imbalance in the vaginal flora, with an overgrowth of anaerobic bacteria and a decrease in beneficial **Lactobacillus** species. *Candidiasis* - While common, **vulvovaginal candidiasis** (yeast infection) is the second most common cause of vaginal symptoms after bacterial vaginosis. - It is caused by an overgrowth of Candida species, typically **Candida albicans**, and presents with itching, burning, and a "cottage cheese" discharge. *Chlamydial cervicitis* - **Chlamydial cervicitis** is a sexually transmitted infection (STI) affecting the cervix, not primarily the vagina, and is often asymptomatic. - It is a common STI but not the most common vaginal infection, as it primarily involves the **cervix** and may not present with classic vaginal discharge or odor. *Trichomoniasis* - **Trichomoniasis** is a prevalent sexually transmitted infection caused by the parasite *Trichomonas vaginalis*, and while common, it is less frequent than bacterial vaginosis or candidiasis. - It often causes frothy, greenish-yellow discharge, itching, and dyspareunia, but it doesn't hold the top spot for overall vaginal infections.

Q: Which of the following is TRUE regarding bacterial vaginosis?

It is associated with increased risk of preterm labor. ***It is associated with increased risk of preterm labor*** - **Bacterial vaginosis (BV)** is a common cause of **increased risk of preterm labor** and premature rupture of membranes in pregnant women due to the inflammatory response it triggers. - The imbalance of vaginal flora and presence of certain bacteria can lead to the production of **amniotic fluid-degrading enzymes**, contributing to adverse pregnancy outcomes. *Clue cells are epithelial cells covered with Lactobacilli* - **Clue cells** are in fact **vaginal epithelial cells** covered in **coccobacillary bacteria**, primarily *Gardnerella vaginalis*, not *Lactobacilli*. - The normal flora, largely composed of **Lactobacilli**, is typically **depleted** in bacterial vaginosis. *It is characterized by decreased vaginal pH* - Bacterial vaginosis is characterized by an **increased vaginal pH (typically >4.5)**, not a decreased pH. - The **normal acidic vaginal pH** is maintained by *Lactobacilli* which produce lactic acid; their decrease leads to a higher pH. *Metronidazole treatment should always include male partners* - **Treatment of male partners** for bacterial vaginosis is generally **not recommended**, as BV is not considered a sexually transmitted infection in the same way as chlamydia or gonorrhea. - Recurrence of BV is common, but treatment of male partners has not been shown to significantly prevent recurrence in women.

Q: A 30-year-old woman presents with vaginal discharge and lower abdominal pain for 10 days. Examination reveals cervical motion tenderness and adnexal tenderness. Laboratory tests show elevated WBC count. What is the most appropriate initial antibiotic regimen?

Ceftriaxone plus doxycycline. ***Ceftriaxone plus doxycycline*** - This combination provides broad-spectrum coverage against common causative agents of **Pelvic Inflammatory Disease (PID)**, including *Neisseria gonorrhoeae* (covered by ceftriaxone) and *Chlamydia trachomatis* (covered by doxycycline). - The patient's symptoms of vaginal discharge, lower abdominal pain, cervical motion tenderness, adnexal tenderness, and elevated WBC count are highly suggestive of PID, necessitating empiric treatment for these infections. *Doxycycline plus metronidazole* - While doxycycline is effective against *Chlamydia trachomatis*, metronidazole primarily targets **anaerobic bacteria** and *Trichomonas vaginalis*. - This regimen lacks adequate coverage for **gonococcal infections**, which are a significant cause of PID and require a cephalosporin. *Azithromycin plus metronidazole* - Azithromycin can treat *Chlamydia trachomatis*, but it has **inferior efficacy against gonococcal infections** compared to ceftriaxone. - Metronidazole, as mentioned, addresses anaerobic bacteria but doesn't provide the necessary broad coverage for other common PID pathogens. *Ciprofloxacin plus clindamycin* - Ciprofloxacin has declining efficacy against **gonorrhea** due to increasing resistance and is generally not recommended as first-line therapy for PID without susceptibility testing. - Clindamycin primarily covers anaerobic bacteria and some gram-positive organisms but does not adequately target *Neisseria gonorrhoeae* or *Chlamydia trachomatis*.

Q: What is the preferred management of a uterine septum?

Hysteroscopic resection of septum. ***Hysteroscopic resection of septum*** - **Hysteroscopic resection of a uterine septum** is the preferred management due to its minimally invasive nature and high success rates in improving reproductive outcomes. - This procedure allows direct visualization and precise removal of the septal tissue, preserving the healthy uterine musculature. *Laparoscopic resection of septum* - While laparoscopic approaches are minimally invasive, directly resecting a uterine septum laparoscopically is generally **not the primary method**. - Laparoscopy is often used for diagnostics or in conjunction with hysteroscopy for guidance, but not typically for primary septal resection alone. *Uterine metroplasty* - **Uterine metroplasty** is a broader term for surgical reconstruction of the uterus, typically reserved for more complex uterine anomalies like a **bicornuate uterus**. - It involves more extensive surgical remodeling of the uterine cavity and is generally **more invasive** than hysteroscopic septal resection. *Laparotomy and resection* - **Laparotomy** involves a large abdominal incision and is a more invasive surgical approach with a longer recovery period. - It is generally **reserved for very complex uterine malformations** or cases where hysteroscopic or laparoscopic approaches are not feasible or have failed.

Q: Which of the following is NOT typically associated with uterine didelphys?

Endometriosis. ***Endometriosis*** - **Endometriosis** is a condition where tissue similar to the lining of the uterus grows outside the uterus; it is not typically associated with specific Müllerian anomalies like uterine didelphys. - While both conditions can cause pelvic pain or infertility, there isn't a direct causal link or increased prevalence of endometriosis specifically due to uterine didelphys. *Premature labor* - **Uterine didelphys** involves two separate uteri, each with its own cervix, which can lead to a smaller uterine cavity in each horn, increasing the risk of **premature labor**. - The abnormal uterine shape and reduced cavity size can compromise the ability to carry a pregnancy to term. *Transverse lie* - The presence of **two separate uterine horns** in uterine didelphys can significantly alter the shape of the uterine cavity, making it difficult for the fetus to assume a regular **longitudinal lie**. - This anatomical variation often predisposes to **malpresentation**, such as **transverse lie**, where the baby lies horizontally across the uterus. *Repeated abortion* - Uterine didelphys is associated with a higher incidence of **repeated abortions** due to various factors including the smaller size of each uterine cavity, potential cervical incompetence, and altered blood supply. - The structural abnormalities can prevent proper implantation or adequate growth of the fetus, leading to recurrent pregnancy losses.

Q: The patient presented with a retroverted uterus, dysmenorrhea, and dyspareunia. What is the next step of the investigation?

USG. ***USG*** - **Transvaginal ultrasound (TVS)** is the initial imaging modality of choice for evaluating uterine position, assessing for causes of dysmenorrhea and dyspareunia (e.g., **endometriosis**, adenomyosis, fibroids), and can visualize the retroverted uterus. - It is **non-invasive**, readily available, and provides good resolution of pelvic organs, making it suitable for first-line investigation. *HSG* - **Hysterosalpingography (HSG)** is primarily used to assess **fallopian tube patency** in cases of infertility. - It will **not provide detailed information** about the uterine position or other pelvic pathologies contributing to pain. *Laparotomy* - **Laparotomy** is a major surgical procedure involving a large abdominal incision, typically reserved for **definitive diagnosis and treatment** of significant pelvic pathology when less invasive methods are insufficient. - It is **not an initial investigatory step** for symptoms like dysmenorrhea and dyspareunia. *Diagnostic Laparoscopy* - **Diagnostic laparoscopy** is a minimally invasive surgical procedure that allows direct visualization of pelvic organs, often used to **confirm endometriosis** or other pathologies. - While it offers definitive diagnosis, it is an **invasive procedure** and usually performed **after initial non-invasive imaging** (like USG) has been completed.

Q: What are clue cells?

Vaginal epithelial cells lined by bacteria. ***Vaginal epithelial cells lined by bacteria*** - **Clue cells** are definitive diagnostic features of **bacterial vaginosis**, identified on microscopy. - They are specifically **vaginal epithelial cells** that appear "cluey" or stippled due to their surface being obscured by numerous adherent bacteria, primarily *Gardnerella vaginalis*. *Uterine endothelial cells lined by bacteria* - The **endometrium** (uterine lining) is composed of epithelial cells, not typically referred to as endothelial cells in this context, and is not where clue cells are found. - Presence of bacteria adherent to uterine cells would suggest an **endometritis** or other uterine infection, not bacterial vaginosis. *Cervical epithelial cells lined by bacteria* - While bacteria can adhere to **cervical epithelial cells**, especially in the presence of infection, these are not typically called **clue cells**. - **Clue cells** are characteristic of the vaginal environment and are specifically associated with bacterial vaginosis. *Abdominal cells lined by bacteria* - **Abdominal cells** are not relevant to the definition of clue cells, which are found in the vaginal canal. - The presence of bacteria on abdominal cells would indicate a completely different pathology, such as a **peritoneal infection**.

Question 1

A 25-year-old woman with recurrent urinary tract infections presents with dyspareunia, post-coital bleeding, and mucopurulent cervical discharge. Nucleic acid amplification test for C. trachomatis and N. gonorrhoeae is negative. Microscopy shows increased polymorphonuclear leukocytes from endocervical sample. What is the most likely diagnosis and appropriate management?

Accepted Answer

Mycoplasma genitalium cervicitis - Doxycycline followed by Moxifloxacin therapy

Answer

Bacterial vaginosis - Clindamycin therapy

Answer

Cervical ectopy - Cryotherapy

Answer

Trichomoniasis - Metronidazole therapy

Question 2

Which of the following is NOT a minimum clinical criterion in the CDC's diagnostic guidelines for pelvic inflammatory disease (PID)?

Accepted Answer

Elevated white blood cell count

Answer

Adnexal tenderness

Answer

Uterine tenderness

Answer

Cervical motion tenderness

Question 3

A 24-year-old woman presents with vaginal discharge, dysuria, and lower abdominal pain. On examination, there is cervical motion tenderness and mucopurulent cervical discharge. What is the diagnostic test of choice?

Accepted Answer

Nucleic acid amplification test (NAAT)

Answer

Culture on modified Thayer-Martin medium

Answer

Wet mount examination

Answer

Gram stain of cervical secretions

Question 4

What is the most common vaginal infection in women of reproductive age?

Accepted Answer

Bacterial vaginosis

Answer

Candidiasis

Answer

Chlamydial cervicitis

Answer

Trichomoniasis

Question 5

Which of the following is TRUE regarding bacterial vaginosis?

Accepted Answer

It is associated with increased risk of preterm labor

Answer

Clue cells are epithelial cells covered with Lactobacilli

Answer

It is characterized by decreased vaginal pH

Answer

Metronidazole treatment should always include male partners

Question 6

A 30-year-old woman presents with vaginal discharge and lower abdominal pain for 10 days. Examination reveals cervical motion tenderness and adnexal tenderness. Laboratory tests show elevated WBC count. What is the most appropriate initial antibiotic regimen?

Accepted Answer

Ceftriaxone plus doxycycline

Answer

Doxycycline plus metronidazole

Answer

Azithromycin plus metronidazole

Answer

Ciprofloxacin plus clindamycin

Question 7

What is the preferred management of a uterine septum?

Accepted Answer

Hysteroscopic resection of septum

Answer

Laparoscopic resection of septum

Answer

Uterine metroplasty

Answer

Laparotomy and resection

Question 8

Which of the following is NOT typically associated with uterine didelphys?

Accepted Answer

Endometriosis

Answer

Premature labor

Answer

Transverse lie

Answer

Repeated abortion

Question 9

The patient presented with a retroverted uterus, dysmenorrhea, and dyspareunia. What is the next step of the investigation?

Accepted Answer

USG

Answer

HSG

Answer

Laparotomy

Answer

Diagnostic Laparoscopy

Question 10

What are clue cells?

Accepted Answer

Vaginal epithelial cells lined by bacteria

Answer

Uterine epithelial cells lined by bacteria

Answer

Cervical epithelial cells lined by bacteria

Answer

Abdominal cells lined by bacteria

Gynecological Disorders — MCQs

Gynecological Disorders — MCQs

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