Gynecological Disorders Practice Questions

Q: MC site of injury to the ureter during a hysterectomy is:

Site of crossing by the uterine artery. ***Site of crossing by the uterine artery*** - This is the most common site of ureteral injury during a hysterectomy because the **ureter** and the **uterine artery** cross paths in close proximity. The ureter passes *under* the uterine artery, making it vulnerable to **ligation or transection** during clamping or cutting of the artery. - The phrase "water under the bridge" is a common mnemonic used to remember this relationship, where **water (ureter)** passes under the **bridge (uterine artery)**. *In the ovarian fossa* - While the ureter is in proximity to the ovarian vessels, injury in the ovarian fossa is more common during procedures like **oophorectomy** or **pelvic lymph node dissection**, not typically hysterectomy. - The ureter can be injured here if it's mistaken for a blood vessel during **ligament ligation** or when securing the ovarian pedicle. *At the pelvic brim* - Injury at the pelvic brim is less common during a hysterectomy, though it can occur during procedures that involve **dissection of the great vessels** or extensive pelvic lymphadenectomy. - At this point, the ureter crosses the **iliac vessels**, which might be relevant in procedures like radical hysterectomy with lymph node dissection, but not a standard total hysterectomy. *As it enters the bladder* - Although the terminal portion of the ureter is close to the bladder, injury at its entry point into the bladder during a hysterectomy is not the most common site. - This area is more often at risk during procedures involving the **bladder itself**, such as cystectomy or extensive dissection of the bladder base for endometriosis.

Q: Distending media used in hysteroscopy are all except

Hyskon (32% Dextran 70). ***Hyskon (32% Dextran 70)*** - **CORRECT ANSWER (NOT commonly used as first-line)** - **Hyskon (32% Dextran 70)** is a **viscous, high-molecular-weight dextran solution** that was historically used for hysteroscopy but has **largely fallen out of favor** due to significant complications. - Major concerns include: **anaphylactic reactions**, **pulmonary edema**, **coagulopathy**, **difficulty cleaning equipment**, and **high cost**. - Most modern hysteroscopy centers **avoid Hyskon** and prefer safer alternatives like normal saline or CO2. - While technically a distending medium, it is **rarely used in current practice** due to these safety concerns. *Carbon dioxide* - **Carbon dioxide (CO2)** is a commonly used **gaseous distending medium** for diagnostic hysteroscopy due to its ability to provide **clear visualization** and rapid absorption. - It is typically administered using an **insufflator** that controls flow rate and pressure, minimizing the risk of gas embolism. - Preferred for **diagnostic procedures** but not suitable when bleeding is present. *Glycine* - **Glycine (1.5%)** is an **electrolyte-free, hypotonic solution** commonly used as a distending medium during **operative hysteroscopy** with monopolar electrosurgery. - Its non-conductive properties prevent dispersion of electrical current, making it safe for use with **monopolar electrosurgical instruments**. - Risk of **hyponatremia** with excessive absorption requires monitoring of fluid deficit. *5% dextrose* - **5% dextrose in water (D5W)** is a commonly used **hypotonic, electrolyte-free fluid** for hysteroscopy, especially when **monopolar electrocautery** is employed. - Its non-conductive nature prevents electrical current dissipation, and it is **physiologically well-tolerated** with lower risk of complications. - Can be used for both diagnostic and operative procedures.

Q: Vaginal adenosis is evident in women who had exposure to which of the following in utero?

DES. ***DES*** - **Vaginal adenosis** is a histological finding where glandular epithelial tissue is present in the vagina. It is a well-established consequence of **in utero exposure to diethylstilbestrol (DES)**. - This exposure can also increase the risk of developing **clear cell adenocarcinoma of the vagina or cervix** later in life. *Nickel* - **Nickel** is a common allergen known to cause **contact dermatitis** and, less commonly, respiratory issues. - There is **no established link** between in utero exposure to nickel and the development of vaginal adenosis. *Asbestos* - **Asbestos** exposure is primarily associated with respiratory diseases such as **asbestosis, mesothelioma**, and lung cancer. - It is **not known** to cause reproductive tract abnormalities like vaginal adenosis from in utero exposure. *Cadmium* - **Cadmium** is a heavy metal toxicant associated with kidney damage, bone demineralization, and certain cancers. - While it can be a developmental toxicant, there is **no evidence** linking in utero cadmium exposure to vaginal adenosis.

Q: Most common complication of vaginoplasty is

Restenosis. ***Restenosis (Correct Answer)*** - **Restenosis** (narrowing or closure of the vaginal canal) is the **most common complication** of vaginoplasty, occurring in 10-15% of cases - Particularly prominent in **neovaginal construction** procedures - Results from **fibrosis and scar tissue formation** during healing - Requires **regular dilation** or further surgical intervention to maintain patency - Prevention involves strict adherence to post-operative dilation protocols *Vaginal bleeding* - Minor post-operative bleeding is expected and manageable with conservative measures - Severe or prolonged hemorrhage is uncommon and not the most frequent complication - Less persistent than restenosis, which requires ongoing management *Dysmenorrhea* - Refers to painful menstruation, not directly related to vaginoplasty - Vaginoplasty primarily involves vaginal reconstruction and does not affect the uterus or menstrual cycle - Not a recognized complication of the procedure *Ectopic pregnancy* - Not possible after vaginoplasty alone, as the procedure involves vaginal construction/reconstruction only - Does not establish functional fallopian tubes or affect reproductive tract anatomy relevant to conception - Unrelated to the scope of vaginoplasty complications

Q: All of the following are true about the isthmus EXCEPT:

Measures 20 mm in length. ***Measures 20 mm in length*** - The uterine **isthmus** is a narrow region connecting the **corpus** to the **cervix**, and its length is not typically 20 mm. - While it lengthens during pregnancy to form part of the **lower uterine segment**, a standard, non-pregnant measurement of 20 mm is incorrect. *Forms lower uterine segment* - During **pregnancy**, the isthmus undergoes significant stretching and thinning to form the **lower uterine segment**, facilitating childbirth. - This anatomical change is crucial for the passage of the fetus and is distinct from its non-pregnant state. *Present between cervical mucosa and endometrial mucosa* - The **isthmus** is located anatomically between the main body of the uterus (containing **endometrial mucosa**) and the cervix (containing **cervical mucosa**). - It marks a transition zone in the uterine lining, reflecting its intermediate position. *Mucosa similar to endometrium* - The mucosal lining of the **isthmus** is often described as resembling the **endometrial mucosa** due to its responsiveness to hormonal changes. - However, it has specific characteristics that distinguish it from both the fundal endometrium and the cervical lining, making it a unique transitional area.

Q: Treatment of choice in a perimenopausal woman with bleeding PV due to multiple fibroids is:

TAH. ***TAH*** - A **Total Abdominal Hysterectomy (TAH)** is the treatment of choice for a perimenopausal woman with significant **bleeding due to multiple fibroids**. At this stage, fertility preservation is generally not a primary concern, and removing the uterus permanently resolves the fibroid-related symptoms. - This approach effectively eliminates the source of bleeding and recurrence of fibroids, providing a definitive solution to her problem. *Vaginal hysterectomy* - **Vaginal hysterectomy** is generally preferred for cases of **uterine prolapse** or smaller uteri, and it may be challenging for **multiple, large fibroids** and a uterus that is significantly enlarged. - The approach is limited for extensive fibroids and may not be feasible if the uterus is too bulky or fixed. *Enucleation of fibroids* - **Myomectomy (enucleation of fibroids)** is primarily performed in women who desire to **preserve fertility** or the uterus. In a perimenopausal woman with severe bleeding, a definitive procedure is often preferred. - While it removes the fibroids, it carries a risk of **fibroid recurrence** and may not fully address the symptoms as effectively as a hysterectomy in this age group. *TAH with BSO* - **TAH with Bilateral Salpingo-Oophorectomy (BSO)** involves removal of the ovaries, which would induce **surgical menopause**. While it can be considered, it is not the initial treatment of choice unless there are coexisting **ovarian pathologies** or a strong family history of ovarian cancer. - Removing healthy ovaries in a perimenopausal woman could exacerbate menopausal symptoms by rapidly lowering hormone levels, which might be avoided if not strictly indicated.

Q: A multiparous woman with a history of LSCS presents with cyclical hematuria and normal menstruation. The most likely diagnosis is:

Bladder endometriosis. ***Bladder endometriosis*** - This is the **correct diagnosis** given the presentation of **cyclical hematuria with normal menstruation**. - **Bladder endometriosis** involves endometrial tissue growing in the bladder wall, which responds to hormonal changes during the menstrual cycle. - It leads to **cyclical hematuria concurrent with menstruation**, while the patient continues to have normal vaginal menstrual bleeding. - **Risk factors** include previous pelvic surgery such as LSCS, which can lead to endometrial tissue implantation. *Vesicouterine fistula* - A **vesicouterine fistula** (Youssef syndrome) is an abnormal communication between the bladder and uterus, often a complication of uterine surgery like LSCS. - It presents with **menouria** - cyclical hematuria with **amenorrhea** (absence of vaginal menstruation), as menstrual blood drains directly into the bladder. - This patient has **normal menstruation**, which rules out vesicouterine fistula. *Both bladder endometriosis and vesicouterine fistula* - While both can occur after LSCS, they are **distinguished by the presence or absence of menstruation**. - The presence of **normal menstruation** in this case points specifically to bladder endometriosis, not both conditions. *Urinary tract infection* - While UTIs can cause hematuria, it is typically **non-cyclical** and often accompanied by symptoms like dysuria, frequency, and urgency. - The key differentiating factor here is the **cyclical nature** of the hematuria synchronized with the menstrual cycle, which is not characteristic of UTI.

Question 1

MC site of injury to the ureter during a hysterectomy is:

Accepted Answer

Site of crossing by the uterine artery

Answer

In the ovarian fossa

Answer

At the pelvic brim

Answer

As it enters the bladder

Question 2

Compared with other mullerian duct defects, a transverse vaginal septum is associated with lower rate of

Accepted Answer

Renal anomalies

Answer

Ectopic pregnancy

Answer

Retrograde menstruation

Answer

Endometriosis

Question 3

A 25-year-old female patient presented with complaints of feeling of mass per abdomen. On examination, a mass was found on left adnexal region with multiple solid cystic areas. The patient was operated and the mass was removed, which has been shown below. What is the true statement regarding the condition?

Accepted Answer

Specimen shows multiple solid cystic areas suggestive of dermoid cyst.

Answer

Specimen shows cystic areas suggestive of serous cyst adenoma

Answer

Specimen shows Dysgerminoma

Answer

Specimen shows Choriocarcinoma

Question 4

Distending media used in hysteroscopy are all except

Accepted Answer

Hyskon (32% Dextran 70)

Answer

Carbon dioxide

Answer

Glycine

Answer

5% dextrose

Question 5

To minimize ureteric damage, the following preoperative and operative precautions may be taken except:

Accepted Answer

Cystoscopy

Answer

Ureter should not be dissected off the peritoneum for a long distance

Answer

Bladder should be pushed downwards and outwards while the clamps are placed near the angles of vagina

Answer

Direct visualization during surgery

Question 6

Vaginal adenosis is evident in women who had exposure to which of the following in utero?

Accepted Answer

DES

Answer

Nickel

Answer

Asbestos

Answer

Cadmium

Question 7

Most common complication of vaginoplasty is

Accepted Answer

Restenosis

Answer

Vaginal bleeding

Answer

Dysmenorrhea

Answer

Ectopic pregnancy

Question 8

All of the following are true about the isthmus EXCEPT:

Accepted Answer

Measures 20 mm in length

Answer

Forms lower uterine segment

Answer

Present between cervical mucosa and endometrial mucosa

Answer

Mucosa similar to endometrium

Question 9

Treatment of choice in a perimenopausal woman with bleeding PV due to multiple fibroids is:

Accepted Answer

TAH

Answer

Vaginal hysterectomy

Answer

Enucleation of fibroids

Answer

TAH with BSO

Question 10

A multiparous woman with a history of LSCS presents with cyclical hematuria and normal menstruation. The most likely diagnosis is:

Accepted Answer

Bladder endometriosis

Answer

Vesicouterine fistula

Answer

Urinary tract infection

Answer

Both bladder endometriosis and vesicouterine fistula

Gynecological Disorders — MCQs

Gynecological Disorders — MCQs

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