Gynecological Disorders — MCQs

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?

Q988

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

Q989

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?

Q990

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

Gynecological Disorders Indian Medical PG Practice Questions and MCQs

Question 981: Which of the following statements about bacterial vaginosis is TRUE?

A. Sexual partners should routinely receive treatment
B. It is characterized by a decrease in vaginal pH
C. It results from displacement of lactobacilli by anaerobes (Correct Answer)
D. It is commonly associated with vaginal candidiasis

Explanation: ***It results from displacement of lactobacilli by anaerobes*** - **Bacterial vaginosis (BV)** is characterized by an imbalance in the vaginal microbiota, where the protective **Lactobacillus** species are significantly reduced or replaced. - This reduction allows for the overgrowth of **anaerobic bacteria** like *Gardnerella vaginalis* and *Mycoplasma hominis*, leading to the typical symptoms. *Sexual partners should routinely receive treatment* - **BV** is not considered a sexually transmitted infection, and routine treatment of **male sexual partners** has not been shown to prevent recurrence in women. - Treatment is generally focused on the affected individual to restore the vaginal flora. *It is characterized by a decrease in vaginal pH* - **Bacterial vaginosis** is characterized by an **increase in vaginal pH** (typically >4.5), which is a key diagnostic criterion. - The normal acidic vaginal environment, maintained by lactobacilli, is disrupted, allowing for the proliferation of anaerobic bacteria. *It is commonly associated with vaginal candidiasis* - **Bacterial vaginosis** and **vaginal candidiasis** are two distinct conditions with different etiologies and clinical presentations. - While both can cause vaginal symptoms, they are not commonly associated in a direct causative way; rather, they are independent conditions.

Question 982: A 25-year-old woman presents with vaginal discharge and vulvovaginal irritation. Wet mount shows motile trichomonads. She mentions having a similar infection 2 months ago treated with single-dose metronidazole. What is the most likely explanation for her current infection?

A. Concurrent bacterial vaginosis
B. Reinfection from untreated partner (Correct Answer)
C. Metronidazole resistance
D. Inadequate initial therapy

Explanation: ***Reinfection from untreated partner*** - **Trichomoniasis** is a sexually transmitted infection, and treatment of only one partner often leads to **reinfection** from the untreated partner. - The recurrence of symptoms within a short period (2 months) after successful treatment strongly suggests exposure to the pathogen again. *Concurrent bacterial vaginosis* - While **bacterial vaginosis** can cause discharge, it is a different infection, and its presence does not explain the recurrence of **trichomonads** found on the wet mount. - Co-occurrence is possible, but it doesn't account for the re-emergence of the *Trichomonas* organism. *Metronidazole resistance* - **Metronidazole resistance** in *Trichomonas vaginalis* is rare, especially after an initial successful treatment with a single dose. - Resistance is usually suspected if symptoms persist *despite* adequate treatment, rather than recurring after a period of being symptom-free. *Inadequate initial therapy* - A single-dose regimen of **metronidazole** is typically an effective and standard treatment for trichomoniasis. - If the initial treatment was truly inadequate, symptoms would likely have persisted or returned much sooner, rather than appearing 2 months later.

Question 983: What is the most common cause of persistent vaginal candidiasis despite appropriate antifungal therapy?

A. Azole-resistant C. albicans
B. Underlying diabetes mellitus
C. Non-albicans Candida species (Correct Answer)
D. Concomitant bacterial vaginosis

Explanation: ***Non-albicans Candida species*** - While *Candida albicans* is the most common cause of initial candidiasis, persistent or recurrent infections despite appropriate fluconazole therapy are often due to **non-albicans Candida species** like *C. glabrata* or *C. krusei*. - These species are inherently less susceptible or resistant to fluconazole, necessitating different antifungal treatments. *Azole-resistant C. albicans* - Although possible, **azole resistance in *C. albicans*** is less common than infection by intrinsically resistant non-albicans species as a cause of persistent symptoms after initial standard therapy. - Reduced susceptibility due to prior azole exposure or host factors can contribute, but it's not the primary mechanism behind most refractory cases. *Underlying diabetes mellitus* - **Diabetes mellitus** can predispose individuals to candidiasis and recurrence due to elevated glycogen content in vaginal epithelial cells and impaired immune response. However, it's a risk factor for *developing* candidiasis, not the direct cause of persistent infection despite *appropriate antifungal treatment*. - While diabetes can make infections harder to clear, the persistence after treatment usually points to an issue with the pathogen itself, or the treatment strategy. *Concomitant bacterial vaginosis* - **Bacterial vaginosis (BV)** can coexist with candidiasis, but it's a separate infection caused by an imbalance of vaginal bacteria and would typically not cause persistent candidiasis symptoms *despite antifungal treatment*. - BV symptoms (e.g., "fishy" odor, thin discharge) are distinct from candidiasis (e.g., itching, thick cottage cheese discharge), and treating BV alone would not resolve a fungal infection.

Question 984: A 23-year-old woman presents with vulvovaginal itching, burning, and thick white discharge. Microscopy shows budding yeast with pseudohyphae. She reports recurrent episodes. What is the most appropriate management?

A. Fluconazole 150mg orally as single dose
B. Topical clotrimazole for 7 days
C. Weekly fluconazole 150mg for 6 months (Correct Answer)
D. Metronidazole 500mg orally twice daily for 7 days

Explanation: ***Weekly fluconazole 150mg for 6 months*** - The patient's history of **recurrent episodes** of vulvovaginal candidiasis, coupled with the presence of **budding yeast and pseudohyphae**, indicates a need for **prophylactic treatment**. - **Weekly fluconazole** for an extended period (e.g., 6 months) is the recommended regimen for **recurrent vulvovaginal candidiasis**, aiming to suppress future outbreaks. *Fluconazole 150mg orally as single dose* - A **single dose of fluconazole** is typically effective for **uncomplicated, sporadic vulvovaginal candidiasis**. - It is insufficient to prevent recurrence in a patient with a history of **recurrent candidiasis**. *Topical clotrimazole for 7 days* - **Topical antifungals** like clotrimazole are effective for **acute episodes of candidiasis**, particularly when symptoms are mild or localized. - Similar to a single oral dose, a 7-day course of topical treatment is generally not adequate for **preventing recurrence** in chronic cases. *Metronidazole 500mg orally twice daily for 7 days* - **Metronidazole** is an antibiotic used to treat **bacterial vaginosis** and **trichomoniasis**, which are caused by bacteria and parasites, respectively. - It has **no antifungal activity** and would be ineffective against vulvovaginal candidiasis.

Question 985: Which of the following is NOT a complication of untreated trichomoniasis?

A. Ectopic pregnancy (Correct Answer)
B. Infertility in women
C. Preterm delivery
D. Increased susceptibility to HIV infection

Explanation: ***Ectopic pregnancy*** - While other **sexually transmitted infections (STIs)** like chlamydia and gonorrhea are significant risk factors for **ectopic pregnancy** due to fallopian tube damage, trichomoniasis is not directly associated with it. - The inflammatory response from *Trichomonas vaginalis* primarily affects the **lower genital tract** (vagina, cervix, urethra) and does not typically lead to the kind of **tubal scarring** associated with ectopic gestations. - Unlike ascending infections that cause PID, trichomoniasis remains localized to lower genital structures. *Infertility in women* - Untreated trichomoniasis can lead to **chronic cervicitis** and **endometritis**, which may contribute to female infertility. - The persistent inflammation can affect the **cervical mucus quality** and create a hostile environment for sperm. - Studies have demonstrated associations between *Trichomonas vaginalis* infection and reduced fertility rates. *Preterm delivery* - Studies have linked untreated *Trichomonas vaginalis* infection during pregnancy to an increased risk of **preterm birth** and **low birth weight**. - The inflammation caused by the parasite can contribute to **premature rupture of membranes (PROM)** and uterine contractions. - Maternal trichomoniasis is considered a modifiable risk factor for adverse pregnancy outcomes. *Increased susceptibility to HIV infection* - Trichomoniasis causes **genital inflammation** and microscopic lesions, which can disrupt the natural protective barriers of the genital tract. - These disruptions make individuals more vulnerable to acquiring **HIV infection** if exposed, as the virus can more easily enter the bloodstream through damaged tissues. - Co-infection with trichomoniasis increases HIV viral shedding, further facilitating transmission.

Question 986: What is the most common clinical manifestation of Trichomonas vaginalis infection in women?

A. Frothy, yellow-green vaginal discharge (Correct Answer)
B. Dysuria
C. Strawberry cervix
D. Vulvar burning and itching

Explanation: ***Frothy, yellow-green vaginal discharge*** - **Frothy, yellow-green vaginal discharge** is the most characteristic and common symptomatic manifestation of *Trichomonas vaginalis* infection, occurring in 50-70% of symptomatic cases. - This discharge results from inflammation and gas production by the motile trophozoites, and is often accompanied by a **foul, fishy odor**. - The frothy nature and yellow-green color make this discharge highly distinctive for trichomoniasis. *Dysuria* - **Dysuria** (painful urination) can occur with *Trichomonas vaginalis* infection but is less specific and less common than the characteristic discharge. - Dysuria is usually secondary to vulvar inflammation and urethral involvement rather than a primary manifestation. - This symptom can be present in various urinary tract infections and other sexually transmitted infections. *Strawberry cervix* - **Strawberry cervix** (colpitis macularis) refers to punctate hemorrhages on the cervix, creating a strawberry-like appearance. - While this is a specific sign of trichomoniasis, it is only visible in approximately 2-5% of cases and requires colposcopic examination. - This makes it much less common than the characteristic vaginal discharge as a clinical manifestation. *Vulvar burning and itching* - **Vulvar burning and itching** are common symptoms in trichomoniasis due to local inflammation. - However, these symptoms are also prevalent in other vaginal infections such as candidiasis and bacterial vaginosis, making them less specific. - The frothy, yellow-green discharge remains more distinctive and frequently reported as the primary manifestation of symptomatic trichomoniasis.

Question 987: 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?

A. Bacterial vaginosis - Clindamycin therapy
B. Mycoplasma genitalium cervicitis - Doxycycline followed by Moxifloxacin therapy (Correct Answer)
C. Cervical ectopy - Cryotherapy
D. Trichomoniasis - Metronidazole therapy

Explanation: ***Mycoplasma genitalium cervicitis - Doxycycline followed by Moxifloxacin therapy*** - The patient's symptoms of **dyspareunia**, **post-coital bleeding**, and **mucopurulent cervical discharge**, along with **increased polymorphonuclear leukocytes** on microscopy and **negative NAAT for chlamydia and gonorrhea**, are highly suggestive of *Mycoplasma genitalium* cervicitis. - **Current first-line treatment** is **Doxycycline 100mg twice daily for 7 days followed by Moxifloxacin 400mg daily for 7 days** due to high rates of macrolide resistance (30-40% failure with azithromycin monotherapy). - This extended dual regimen has significantly higher cure rates and reduces development of further resistance. *Bacterial vaginosis - Clindamycin therapy* - **Bacterial vaginosis** typically presents with a **fishy odor**, thin, greyish-white discharge, and **vaginal itching/burning**, which are not the primary symptoms here. - Microscopy would show **clue cells** and a shift in vaginal flora, not necessarily increased polymorphonuclear leukocytes from an endocervical sample as the primary finding. *Cervical ectopy - Cryotherapy* - **Cervical ectopy** (or cervical eversion) is a normal physiological variant where columnar epithelium extends onto the ectocervix, and while it can cause **post-coital bleeding** and **mucopurulent discharge**, it is usually a diagnosis of exclusion after ruling out infection. - The presence of **increased polymorphonuclear leukocytes** points more strongly towards an infectious etiology rather than a physiological variation, and **cryotherapy** is not indicated for infection. *Trichomoniasis - Metronidazole therapy* - **Trichomoniasis** typically presents with a **frothy, yellow-green vaginal discharge**, **vaginal itching**, and a **"strawberry cervix"** on examination, which are not described. - While it can cause inflammation and discharge, the specific symptom complex and negative NAAT for common STIs make *Mycoplasma genitalium* a more probable diagnosis given the context.

Question 988: Which of the following is NOT a minimum clinical criterion in the CDC's diagnostic guidelines for pelvic inflammatory disease (PID)?

A. Adnexal tenderness
B. Uterine tenderness
C. Cervical motion tenderness
D. Elevated white blood cell count (Correct Answer)

Explanation: ***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.

Question 989: 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?

A. Culture on modified Thayer-Martin medium
B. Wet mount examination
C. Gram stain of cervical secretions
D. Nucleic acid amplification test (NAAT) (Correct Answer)

Explanation: ***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.

Question 990: What is the most common vaginal infection in women of reproductive age?

A. Bacterial vaginosis (Correct Answer)
B. Candidiasis
C. Chlamydial cervicitis
D. Trichomoniasis

Explanation: ***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.

Practice by Chapter

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