Pelvic Inflammatory Disease — MCQs
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?
Dilatation & curettage (D&C) is contraindicated in-
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 teenage patient presents with dysmenorrhea and chronic pelvic pain. Upon further investigation, she is found to have a transverse vaginal septum. What is the most likely diagnosis?
Violin string adhesion is seen in ?
Which of the following is not a complication of pelvic inflammatory disease?
Which of the following are risk factors for developing pelvic inflammatory disease in females? 1. Use of oral contraception pills 2. Multiple sexual partners 3. Lower socioeconomic status 4. Genetic predisposition
Which of the following are risk factors for Pelvic Inflammatory Disease (PID)? 1. Multiple sexual partners 2. IUD use 3. Genetic predisposition 4. Sexually active teenagers Select the correct answer using the code given below.
Which of the following are risk factors for Pelvic Inflammatory Disease (PID)? 1. Use of contraceptive pills 2. IUD use 3. Genetic predisposition 4. Sexually active teenagers Select the correct answer using the code given below.
An infertile woman presents with yellow or green vaginal discharge, a Bartholin cyst and proctitis. What is the most probable diagnosis?
Pelvic Inflammatory Disease Indian Medical PG Practice Questions and MCQs
Question 1: 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?
- A. Ceftriaxone plus doxycycline (Correct Answer)
- B. Doxycycline plus metronidazole
- C. Azithromycin plus metronidazole
- D. Ciprofloxacin plus clindamycin
Explanation: ***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*.
Question 2: Dilatation & curettage (D&C) is contraindicated in-
- A. Pelvic inflammatory disease (PID) (Correct Answer)
- B. Endometriosis
- C. Ectopic pregnancy
- D. Abnormal uterine bleeding
Explanation: ***Pelvic inflammatory disease (PID)*** - D&C is **contraindicated** in PID due to the high risk of **spreading pre-existing infection** from the cervix or vagina into the sterile uterine cavity and beyond. - This procedure can worsen the infection, potentially leading to **sepsis**, **tubo-ovarian abscesses**, or chronic pain. *Endometriosis* - D&C is not typically contraindicated in **endometriosis**, as it is sometimes used diagnostically to rule out other causes of abnormal uterine bleeding, though it isn't a treatment for endometriosis itself. - Endometriosis involves the presence of **endometrial tissue outside the uterus**, and a D&C performed on the uterus does not directly exacerbate this condition. *Ectopic pregnancy* - D&C is not contraindicated in **ectopic pregnancy**; however, it is not the primary treatment. - A D&C may be performed if the diagnosis of ectopic pregnancy is uncertain and to rule out an **intrauterine pregnancy** or retained products of conception. *Abnormal uterine bleeding* - D&C is frequently indicated and can be both **diagnostic and therapeutic** for abnormal uterine bleeding, especially to investigate causes like polyps, fibroids, or endometrial hyperplasia. - It helps in obtaining tissue for **histopathological examination** to guide further management.
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?
- 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 4: A teenage patient presents with dysmenorrhea and chronic pelvic pain. Upon further investigation, she is found to have a transverse vaginal septum. What is the most likely diagnosis?
- A. Dermoid cyst
- B. Tubo-ovarian abscess
- C. Endometriosis (Correct Answer)
- D. Hematocolpos/Hematometra
Explanation: ***Endometriosis*** - This condition is characterized by the presence of **endometrial-like tissue outside the uterus**, which responds to hormonal changes, leading to chronic pelvic pain and dysmenorrhea. - While a transverse vaginal septum isn't a direct cause of endometriosis, this presentation of chronic pain and dysmenorrhea in a teenager strongly suggests endometriosis, and the septum might be an incidental finding or a contributing factor to pain due to outflow obstruction in some cases. *Dermoid cyst* - A dermoid cyst (mature cystic teratoma) is a benign ovarian tumor that typically causes pelvic pain due to its size or torsion, and it does not usually cause dysmenorrhea. - It would not be directly associated with the presence of a transverse vaginal septum. *Tubo-ovarian abscess* - A tubo-ovarian abscess is an inflammatory mass involving the fallopian tube and ovary, typically presenting with acute-onset severe pelvic pain, fever, and leukocytosis. - While it causes pelvic pain, it is usually acute and infectious in nature, and not inherently linked to dysmenorrhea or a transverse vaginal septum. *Hematocolpos/Hematometra* - **Hematocolpos** (blood in the vagina) or **hematometra** (blood in the uterus) results from an outflow obstruction, such as an imperforate hymen or a transverse vaginal septum. - While a transverse vaginal septum could lead to hematocolpos, the primary symptoms would be cyclical abdominal pain progressing from menarche, an abdominal mass, and **amenorrhea** (absence of menstruation), rather than dysmenorrhea (painful menstruation) which implies some menstrual flow.
Question 5: Violin string adhesion is seen in ?
- A. Ruptured ectopic pregnancy
- B. Endometriosis
- C. PCOS
- D. Fitz-Hugh-Curtis syndrome (Correct Answer)
Explanation: ***Fitz-Hugh-Curtis syndrome*** - **Fitz-Hugh-Curtis syndrome** is a perihepatitis characterized by inflammation of the liver capsule and adjacent peritoneal surfaces. - The classic "violin string" adhesions are **fibrinous adhesions** that form between the liver capsule and the anterior abdominal wall or diaphragm. *Ruptured ectopic pregnancy* - A ruptured ectopic pregnancy typically presents with acute abdominal pain and **hypovolemic shock** due to hemoperitoneum. - While it can cause pelvic adhesions, "violin string" adhesions are not a characteristic finding; the primary concern is **intra-abdominal hemorrhage**. *Endometriosis* - **Endometriosis** involves the presence of endometrial-like tissue outside the uterus, causing pain, inflammation, and adhesions, especially in the pelvis. - While it does lead to adhesions, these are usually **dense and diffuse pelvic adhesions**, not the specific "violin string" pattern associated with the liver capsule. *PCOS* - **Polycystic ovary syndrome (PCOS)** is an endocrine disorder characterized by hormonal imbalances, anovulation, and polycystic ovaries. - It primarily affects **ovarian function** and metabolism and does not directly cause adhesions in the abdominal cavity.
Question 6: Which of the following is not a complication of pelvic inflammatory disease?
- A. Ectopic
- B. Pyometra (Correct Answer)
- C. Endometritis
- D. Infertility
Explanation: ***Pyometra*** - **Pyometra** is a collection of pus in the uterine cavity, typically caused by cervical stenosis (from surgery, radiation, or postmenopausal atrophy) or cervical malignancy, and is **not a recognized complication of Pelvic Inflammatory Disease (PID)**. - While PID involves ascending infection causing **endometritis** (inflammation of the endometrial lining), it does not typically lead to pyometra, which requires obstruction at the cervical level. - Pyometra is not listed among standard PID complications in major obstetrics and gynecology textbooks. *Ectopic pregnancy* - **Ectopic pregnancy** is a well-recognized complication of PID due to damage and scarring of the **fallopian tubes**, which impairs the normal transit of a fertilized egg to the uterus. - The inflammation and adhesions caused by PID create an environment that can trap the embryo outside the uterus, most commonly in the fallopian tube. - Risk of ectopic pregnancy increases 6-10 fold after PID. *Infertility* - **Infertility** is a common long-term consequence of PID, resulting from scarring and damage to the fallopian tubes, ovaries, and surrounding structures. - Tubal factor infertility occurs in approximately 10-20% of women after one episode of PID, with the risk increasing with recurrent infections. - This damage can obstruct the passage of eggs and sperm, or impair tubal function necessary for conception. *Endometritis* - **Endometritis** is an inflammation of the lining of the uterus and is a **direct component** of PID, not just a complication. - PID involves the ascension of infection from the cervix through the endometrium to the fallopian tubes and potentially to the ovaries and peritoneum. - Endometritis represents the uterine involvement in the spectrum of upper genital tract infection that defines PID.
Question 7: Which of the following are risk factors for developing pelvic inflammatory disease in females? 1. Use of oral contraception pills 2. Multiple sexual partners 3. Lower socioeconomic status 4. Genetic predisposition
- A. 1, 2 and 4
- B. 1, 2 and 3 (Correct Answer)
- C. 2, 3 and 4
- D. 1, 3 and 4
Explanation: ***1, 2 and 3*** - **Multiple sexual partners** is a well-established major risk factor for PID as it significantly increases exposure to sexually transmitted infections (STIs), particularly *Chlamydia trachomatis* and *Neisseria gonorrhoeae*, which are the primary causative organisms of PID. - **Lower socioeconomic status** is associated with increased PID risk due to reduced access to healthcare services, delayed diagnosis and treatment of STIs, and barriers to preventive care. - **Use of oral contraception pills** has a controversial relationship with PID. While OCPs do not prevent STIs and may be associated with behavioral factors (reduced condom use), the direct relationship remains debated. Some evidence suggests OCPs may actually provide modest protection against ascending infection by thickening cervical mucus. However, this option represents the best available answer among the choices given. *1, 2 and 4* - This incorrectly includes **genetic predisposition**, which is not an established risk factor for PID. PID is primarily an infectious disease driven by behavioral and socioeconomic factors, not genetic susceptibility. *2, 3 and 4* - This incorrectly includes **genetic predisposition** as a risk factor for PID, which lacks evidence-based support. - It also excludes oral contraception pills, making this option incomplete even considering the controversial role of OCPs. *1, 3 and 4* - This incorrectly includes **genetic predisposition** and critically excludes **multiple sexual partners**, which is the most significant and well-established behavioral risk factor for PID. - Missing this key risk factor makes this option clearly incorrect.
Question 8: Which of the following are risk factors for Pelvic Inflammatory Disease (PID)? 1. Multiple sexual partners 2. IUD use 3. Genetic predisposition 4. Sexually active teenagers Select the correct answer using the code given below.
- A. 1, 2 and 3
- B. 1, 2 and 4 (Correct Answer)
- C. 1, 3 and 4
- D. 2, 3 and 4
Explanation: ***1, 2 and 4*** - **Multiple sexual partners** is a well-established risk factor for PID as it increases exposure to sexually transmitted infections (STIs), particularly *Chlamydia trachomatis* and *Neisseria gonorrhoeae*, which are the primary causative organisms of PID. - **IUD use** increases the risk of PID, particularly during the first 3 weeks after insertion when the insertion procedure can introduce vaginal flora into the upper genital tract. The risk returns to baseline after this initial period. - **Sexually active teenagers** are at higher risk due to biological factors (cervical ectopy with larger area of columnar epithelium susceptible to infection) and behavioral factors (multiple partners, inconsistent condom use, higher rates of STIs). *1, 2 and 3* - This option incorrectly includes **genetic predisposition** as a primary risk factor for PID. - PID is predominantly an **infectious disease** caused by ascending infection from the lower genital tract, not directly linked to genetic predisposition. *1, 3 and 4* - This option incorrectly includes **genetic predisposition** while correctly identifying multiple sexual partners and sexually active teenagers. - Genetic factors are not established risk factors for PID compared to behavioral and infectious causes. *2, 3 and 4* - This option incorrectly includes **genetic predisposition** and omits multiple sexual partners, which is one of the most important behavioral risk factors for PID. - The primary risk factors are related to sexual behavior and STI exposure, not genetics.
Question 9: Which of the following are risk factors for Pelvic Inflammatory Disease (PID)? 1. Use of contraceptive pills 2. IUD use 3. Genetic predisposition 4. Sexually active teenagers Select the correct answer using the code given below.
- A. 2 and 4 (Correct Answer)
- B. 1, 2 and 4
- C. 1, 3 and 4
- D. 2, 3 and 4
Explanation: ***2 and 4*** - **IUD use** is a recognized risk factor for PID, particularly within the first few weeks after insertion, as it can introduce bacteria into the uterus. - **Sexually active teenagers** are at higher risk due to biological factors such as an immature cervix and higher rates of sexually transmitted infections (STIs). *1, 2 and 4* - While IUD use and sexually active teenagers are risk factors, **oral contraceptive pills** are known to *reduce* the risk of PID, not increase it, as they thicken cervical mucus, which may act as a barrier to ascending infection. - Therefore, including contraceptive pills as a risk factor makes this option incorrect. *1, 3 and 4* - This option correctly identifies sexually active teenagers as a risk, but incorrectly includes **contraceptive pills** as a risk factor and introduces **genetic predisposition**, which is not a primary or established risk factor for PID. - PID is primarily an inflammatory response to infection, not a genetically inherited condition. *2, 3 and 4* - This option correctly identifies IUD use and sexually active teenagers as risk factors, but incorrectly includes **genetic predisposition**. - There is no strong evidence to suggest a direct genetic predisposition to developing PID, as it is largely an acquired infectious disease.
Question 10: An infertile woman presents with yellow or green vaginal discharge, a Bartholin cyst and proctitis. What is the most probable diagnosis?
- A. Trichomoniasis
- B. Gonorrhoea (Correct Answer)
- C. Syphilis
- D. Candidiasis
Explanation: ***Gonorrhoea*** - This presentation, including **yellow/green vaginal discharge**, a **Bartholin cyst**, and **proctitis**, is highly suggestive of **gonorrhoea**. - *Neisseria gonorrhoeae* can cause inflammation in these specific areas and is a known cause of **infertility** due to pelvic inflammatory disease. *Trichomoniasis* - Characterized by a **frothy, foul-smelling, yellow-green discharge** and often involves **cervical petechiae** (strawberry cervix). - While it causes vaginal discharge, **Bartholin cysts** and **proctitis** are not typical features. *Syphilis* - The primary stage presents as a **painless chancre**, secondary syphilis involves a **rash** and **lymphadenopathy**, and tertiary syphilis has severe organ involvement. - It does not typically present with the specific combination of **Bartholin cyst**, vaginal discharge, and **proctitis**. *Candidiasis* - Causes a **thick, white, "cottage cheese-like" discharge** associated with significant **pruritus** and **vaginal irritation**. - It does not typically lead to **Bartholin cysts** or **proctitis**.
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