Vulvar Disorders — MCQs
What is the treatment of choice for Bartholin's cyst?
A female patient presents with multiple sessile lesions on the vulva that do not bleed on touch. What is the most likely diagnosis?
An 18-year-old woman presents for follow-up of an abnormal Pap smear that revealed an abnormality suggestive of HPV infection. Which of the following was the likely cytopathologic finding?
Extramammary Paget's disease of the vulva is most commonly associated with which other cancer?
All are true about lichen planus EXCEPT:
Which of the following precancerous conditions, if treated, has the highest likelihood of not leading to cancer?
What is the most common location for extramammary Paget's disease in women?
A patient with typical cutaneous lesions, slightly elevated red or purple macules often covered by gray or yellow adherent scales. Forceful removal of the scale reveals numerous ‘carpet tack’ extensions. The lesion is:
A 35-year-old prostitute is seen in a community healthcare clinic, with a history of a painless labial sore and swelling of a right inguinal lymph node, which subsided uneventfully over several weeks. Approximately 3 weeks later, she developed fever and a generalized maculopapular skin rash involving the palms of the hands and the soles of the feet. Additionally, she has flattened, broad-based plaques in the anogenital region. What is the most likely diagnosis?
What is the most likely cause of yellow-green watery discharge and pruritus in a female patient?
Vulvar Disorders Indian Medical PG Practice Questions and MCQs
Question 1: What is the treatment of choice for Bartholin's cyst?
- A. Excision
- B. Antibiotic therapy
- C. Marsupialization (Correct Answer)
- D. Cyst drainage
Explanation: ***Marsupialization*** - This procedure involves incising the cyst, draining its contents, and then everting and suturing the edges of the cyst wall to the surrounding skin, creating a permanent-draining pouch. - **Marsupialization** is the treatment of choice because it prevents recurrence by allowing continuous drainage of mucus, unlike simple incision and drainage. *Excision* - Complete surgical excision of the Bartholin's gland or cyst is a more invasive procedure and is typically reserved for cases of **recurrent cysts** after marsupialization or suspected malignancy. - It carries a higher risk of bleeding and infection compared to marsupialization, and can lead to **vaginal dryness** due to loss of glandular secretions. *Antibiotic therapy* - Antibiotics are primarily used if the Bartholin's gland becomes **infected**, leading to an **abscess**, or if there is surrounding cellulitis. - They do not address the underlying blockage of the duct and will not resolve a Bartholin's cyst, which is a collection of mucus due to duct obstruction. *Cyst drainage* - Simple incision and drainage (I&D) provides temporary relief by emptying the cyst contents but has a **high recurrence rate** because the duct often re-occludes. - While it may be used as an initial temporizing measure, it is not the definitive treatment for preventing future episodes of Bartholin's cysts.
Question 2: A female patient presents with multiple sessile lesions on the vulva that do not bleed on touch. What is the most likely diagnosis?
- A. Molluscum
- B. Condyloma acuminata (Correct Answer)
- C. Herpes genitalis
- D. Chancroid
Explanation: ***Condyloma acuminata*** - **Condyloma acuminata**, also known as genital warts, are typically **sessile or pedunculated lesions** with a verrucous (cauliflower-like) appearance, commonly found on the vulva. - These lesions are caused by the **human papillomavirus (HPV)** and generally do not bleed on touch unless traumatized. *Molluscum* - **Molluscum contagiosum** presents as **dome-shaped, pearly papules** with a central umbilication, not sessile lesions. - The lesions are typically smaller and have a characteristic central dimple. *Herpes genitalis* - **Herpes genitalis** presents as painful **vesicles or ulcers** that often rupture and form crusts, not sessile lesions. - These lesions are typically accompanied by pain and itching. *Chancroid* - **Chancroid** is characterized by one or more **painful, soft chancres** with irregular, undermined borders and a grayish base that often bleeds easily. - Ulcers are the hallmark of chancroid, not sessile growths.
Question 3: An 18-year-old woman presents for follow-up of an abnormal Pap smear that revealed an abnormality suggestive of HPV infection. Which of the following was the likely cytopathologic finding?
- A. Fibroids
- B. Koilocytes (Correct Answer)
- C. Donovan bodies
- D. Clear cells
Explanation: ***Koilocytes*** - **Koilocytes** are **pathognomonic cellular changes** indicative of **HPV infection** on a Pap smear [1], [2] - These cells are characterized by an **enlarged nucleus**, often **hyperchromatic**, with a **perinuclear halo** (a clear zone around the nucleus) and cytoplasmic changes [1], [2] - This is the classic cytopathologic finding that confirms HPV infection in cervical cytology [2] *Fibroids* - **Uterine fibroids** are **benign smooth muscle tumors** of the uterus and are not detected by a Pap smear, which screens for cervical cellular abnormalities - They typically present with heavy menstrual bleeding, pelvic pressure, or pain, and are diagnosed via imaging like ultrasound - Fibroids are structural lesions, not cytopathologic findings *Donovan bodies* - **Donovan bodies** are intracellular inclusions found in macrophages and are diagnostic of **granuloma inguinale** (also known as donovanosis) - This is a bacterial sexually transmitted infection caused by *Klebsiella granulomatis* - Associated with genital ulcers and are not related to HPV infection or Pap smear findings *Clear cells* - **Clear cells** are a type of cell seen in specific **adenocarcinomas**, such as **clear cell carcinoma of the vagina or cervix**, which are rare - While these are malignant cells, their presence is not suggestive of HPV infection but rather a specific type of cancer - Clear cell carcinoma has historically been associated with in utero DES (diethylstilbestrol) exposure **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Female Genital Tract, p. 1010. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Female Genital Tract Disease, pp. 466-467.
Question 4: Extramammary Paget's disease of the vulva is most commonly associated with which other cancer?
- A. Vulvar cancer (Correct Answer)
- B. Vaginal cancer
- C. Cervical cancer
- D. Uterine cancer
Explanation: ***Vulvar cancer*** - **Extramammary Paget's disease (EMPD)** frequently presents in the vulvar region and is associated with an underlying **adenocarcinoma** in up to 30% of cases. - The disease involves intraepithelial adenocarcinoma cells that can spread locally and, in some instances, indicates a synchronous or metachronous **internal malignancy**, often of genitourinary or gastrointestinal origin, but primarily vulvar adenocarcinoma in this context. *Vaginal cancer* - While Paget's disease can occur in other anogenital areas, its association with **primary vaginal cancer** is much less common compared to vulvar involvement. - **Vaginal Paget's disease** is rare and usually represents secondary spread from a vulvar primary or an underlying bladder/urethral carcinoma. *Cervical cancer* - **Paget's disease** is not typically associated with **cervical cancer**. Cervical cancers are predominantly squamous cell carcinomas or adenocarcinomas arising from the transformation zone. - While cervical adenocarcinoma can present with similar cells to Paget's, it is a distinct entity and not a common association. *Uterine cancer* - **Uterine cancer**, primarily endometrial carcinoma, has no direct or common association with **Paget's disease**. - Paget's disease primarily affects the skin and can be associated with underlying gland cancers, but these are generally in proximity to the epidermal involvement rather than distant uterine sites.
Question 5: All are true about lichen planus EXCEPT:
- A. Spares oral mucosa (Correct Answer)
- B. Wickham's striae present
- C. Violaceous flat papules
- D. Koebner phenomenon positive
Explanation: ***Spares oral mucosa*** - This statement is incorrect because **lichen planus frequently involves the oral mucosa**, presenting as white reticular lesions, erosions, or plaques. - Oral involvement is common and can be the only manifestation of lichen planus. *Wickham's striae present* - **Wickham's striae** are characteristic **white, lacy reticular patterns** seen on the surface of lichen planus lesions, especially on the oral mucosa and cutaneous papules. - Their presence is a classic diagnostic feature of lichen planus. *Violaceous flat papules* - Cutaneous lesions of lichen planus are typically described as **pruritic, polygonal, planar (flat-topped), purple (violaceous) papules and plaques**. - This classic description helps in the clinical diagnosis of the condition. *Koebner phenomenon positive* - The **Koebner phenomenon**, or isomorphic response, refers to the development of new skin lesions in areas of trauma or injury. - This phenomenon is often observed in lichen planus, where scratching or irritation can precipitate new lesions along the lines of trauma.
Question 6: Which of the following precancerous conditions, if treated, has the highest likelihood of not leading to cancer?
- A. Cervical intraepithelial Neoplasia (Correct Answer)
- B. Ductal carcinoma in situ of breast
- C. Lobular carcinoma in situ of breast
- D. Vaginal intraepithelial neoplasia
Explanation: ***Cervical intraepithelial neoplasia (CIN)*** - CIN has a high success rate with treatment (e.g., **cryotherapy**, **LEEP**), often completely eradicating the dysplastic cells and preventing progression to **invasive cervical cancer**. - The effectiveness of screening via **Pap smears** allows for early detection and intervention, significantly reducing cancer risk. *Ductal carcinoma in situ (DCIS) of breast* - While treatable, DCIS carries a higher risk of recurrence and progression to **invasive breast cancer** in the same or contralateral breast compared to CIN. - Treatment often involves **lumpectomy** with or without radiation, and sometimes **total mastectomy**, reflecting its more serious potential. *Lobular carcinoma in situ (LCIS) of breast* - LCIS is largely considered a **risk indicator** for future invasive cancer in either breast, rather than a direct precursor that inevitably progresses. - Management often involves **close surveillance** or **chemoprevention**, as surgical excision does not prevent cancer development in other areas of the breast. *Vaginal intraepithelial neoplasia (VAIN)* - While treatable, VAIN is less common and often coexists with or follows **cervical or vulvar neoplasia**, indicating a broader field defect due to **HPV**. - Recurrence rates post-treatment can be significant, and patients often require long-term follow-up due to the continued risk of progression.
Question 7: What is the most common location for extramammary Paget's disease in women?
- A. Vulva and perianal area (Correct Answer)
- B. Uterine cervix and endometrium
- C. Breast tissue only
- D. Ovary and fallopian tubes
Explanation: ***Vulva*** - Extramammary Paget's disease predominantly occurs in the **vulvar region**, where it manifests as **red, scaly lesions** [1]. - It is associated with **apocrine gland** involvement and may show underlying malignancy in some cases. *Ovary* - The ovaries are not typical locations for **Extramammary Paget's disease**, as it primarily affects surface epithelium rather than **internal structures**. - Any lesions in the ovaries would raise suspicion for different **pathologies**, such as ovarian tumors, rather than Paget's disease. *Vagina* - Paget's disease does not commonly affect the vagina [1]; it is more associated with **external genitalia** like the vulva. - Vaginal lesions would likely indicate other conditions such as **vaginal carcinoma** or other inflammatory processes. *Uterus* - The uterus is not a site for **Extramammary Paget's disease**; this condition is specific to areas with **apocrine glands**. - Uterine issues are generally related to different diseases, such as **endometrial cancer** or **leiomyoma**. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Female Genital Tract, p. 1004.
Question 8: A patient with typical cutaneous lesions, slightly elevated red or purple macules often covered by gray or yellow adherent scales. Forceful removal of the scale reveals numerous ‘carpet tack’ extensions. The lesion is:
- A. Scleroderma
- B. DLE (Correct Answer)
- C. SLE
- D. Lichen planus
Explanation: ***DLE*** - **Discoid lupus erythematosus (DLE)** lesions are characterized by **erythematous-to-violaceous plaques**, often with **follicular plugging** and a **firmly adherent scale**. - The "carpet tack" sign refers to the painful, prickly projections observed on the undersurface of a removed scale, indicating keratinous plugs within hair follicles, which is highly suggestive of DLE. *Scleroderma* - **Scleroderma** involves **fibrosis** of the skin, leading to hardening and thickening, often preceded by Raynaud's phenomenon. - It does not typically present with elevated red or purple macules with adherent scales or the "carpet tack" sign. *SLE* - **Systemic lupus erythematosus (SLE)** is a multi-system autoimmune disease that can have cutaneous manifestations, but these are often more diffuse (**malar rash**, photosensitivity) or non-scarring. - While DLE can occur in SLE patients, the description specifically points to the localized, scarring nature of DLE rather than the systemic features of SLE itself. *Lichen planus* - **Lichen planus** typically presents with **pruritic, polygonal, planar, purple papules and plaques** (the "6 Ps"). - While it can have scaling, it does not exhibit the "carpet tack" sign or the distinct follicular plugging seen in DLE.
Question 9: A 35-year-old prostitute is seen in a community healthcare clinic, with a history of a painless labial sore and swelling of a right inguinal lymph node, which subsided uneventfully over several weeks. Approximately 3 weeks later, she developed fever and a generalized maculopapular skin rash involving the palms of the hands and the soles of the feet. Additionally, she has flattened, broad-based plaques in the anogenital region. What is the most likely diagnosis?
- A. Primary chancre
- B. Chancroid (Haemophilus ducreyi)
- C. Secondary syphilis (Condylomata lata) (Correct Answer)
- D. Genital warts caused by HPV (Condylomata acuminata)
Explanation: ***Secondary syphilis (Condylomata lata)*** - The constellation of a **painless labial sore** (primary syphilis), followed by **generalized maculopapular rash** involving palms/soles, fever, and **condylomata lata** (broad-based plaques) is classic for **secondary syphilis**. - **Condylomata lata** are characteristic moist, fleshy, broad-based lesions found in intertriginous areas in secondary syphilis, distinct from genital warts. *Primary chancre* - This option refers only to the initial **painless labial sore**, which is the primary stage of syphilis. - The patient's subsequent symptoms (rash, fever, condylomata lata) indicate progression beyond the primary stage. *Chancroid (Haemophilus ducreyi)* - Chancroid typically presents with **painful genital ulcers** and sometimes painful inguinal lymphadenopathy. - It does not cause a generalized maculopapular rash on palms/soles or condylomata lata. *Genital warts caused by HPV (Condylomata acuminata)* - **Condylomata acuminata** are caused by Human Papillomavirus (HPV) and are typically flesh-colored to brownish, **verrucous (warty) lesions**, not flattened, broad-based plaques. - HPV infection does not cause a preceding painless sore, fever, or a generalized maculopapular rash involving palms and soles.
Question 10: What is the most likely cause of yellow-green watery discharge and pruritus in a female patient?
- A. Candida
- B. Bacterial vaginosis
- C. Chlamydia trachomatis
- D. Trichomonas vaginalis (Correct Answer)
Explanation: ***Trichomonas vaginalis (Correct)*** - The characteristic presentation of **yellow-green, frothy, watery vaginal discharge** with associated **pruritus** is highly suggestive of **trichomoniasis**. - Other clinical findings may include **dyspareunia**, **dysuria**, and a **"strawberry cervix"** on speculum examination. - Trichomoniasis is a sexually transmitted infection caused by the protozoan *Trichomonas vaginalis*. *Candida (Incorrect)* - **Candidiasis** (yeast infection) typically presents with **thick, white, cottage cheese-like discharge** and severe pruritus, often described as a burning sensation. - The discharge is usually not watery or yellow-green, and the characteristic fishy odor is absent. - pH is typically normal (<4.5), unlike trichomoniasis where pH is elevated (>4.5). *Bacterial vaginosis (Incorrect)* - **Bacterial vaginosis** is characterized by a **thin, gray-white discharge** with a **fishy odor**, especially after intercourse or with alkalinization. - The discharge is not typically yellow-green or frothy. - Pruritus may be present but is usually less prominent than with candidiasis or trichomoniasis. *Chlamydia trachomatis (Incorrect)* - **Chlamydia** infection is often **asymptomatic** in women (up to 70% of cases), but when symptoms occur, they may include **mucopurulent cervical discharge**, intermenstrial bleeding, or lower abdominal pain. - It does not typically cause the **profuse, frothy, yellow-green discharge** with significant pruritus described in this clinical presentation. - Chlamydia primarily causes cervicitis rather than vaginitis.
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