Vulvodynia — MCQs
In a patient with a history of burning pain localized to the plantar aspect of the foot, the differential diagnosis must include -
A female patient presents with multiple sessile lesions on the vulva that do not bleed on touch. What is the most likely diagnosis?
Which of the following treatments is used for vulvar atrophy and itching?
Which among the following is not a premalignant lesion of vulva?
All are used in the treatment of hot flushes except
A pregnant female presents with active herpetic lesions on the vulva. What is the most appropriate management?
In cases of spasticity, which drug is least likely to be used?
Which of the following genital infections is associated with preterm labour?
A parous woman complains of itching in the vulva. On examination, there is local redness and swelling and white flakes around the introitus. The most probable diagnosis is
Chronic pelvic pain is defined as pain of greater than ----- months in duration?
Vulvodynia Indian Medical PG Practice Questions and MCQs
Question 1: In a patient with a history of burning pain localized to the plantar aspect of the foot, the differential diagnosis must include -
- A. Peripheral vascular disease
- B. Plantar fibromatosis
- C. Tarsal tunnel syndrome (Correct Answer)
- D. Tarsal coalition
Explanation: ***Tarsal tunnel syndrome*** - This condition involves **compression of the posterior tibial nerve** or its branches as they pass through the tarsal tunnel, leading to **burning pain, numbness, and tingling** on the plantar aspect of the foot [2]. - Symptoms are often exacerbated by activity or prolonged standing and can be reproduced by tapping on the nerve (Tinel's sign). *Peripheral vascular disease* - While it can cause foot pain, it typically presents as **intermittent claudication** (pain with exertion that resolves with rest) or **ischemic rest pain**, often in the toes or forefoot [1]. - The pain is usually described as cramping or aching rather than burning and is associated with signs of **poor circulation** like diminished pulses and cool skin [1]. *Plantar fibromatosis* - This condition, also known as **Ledderhose disease**, involves the formation of benign fibrous nodules within the **plantar fascia**. - It usually presents as **palpable lumps** on the sole of the foot, which may or may not be painful, but burning pain is not a primary or characteristic symptom. *Tarsal coalition* - This is a congenital condition where two or more bones in the midfoot or hindfoot are **abnormally fused**, most commonly the calcaneus and navicular or talus and calcaneus. - It typically causes **pain, stiffness, and flatfoot deformity** that worsens with activity, but burning neuropathic pain is not its primary symptom.
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: Which of the following treatments is used for vulvar atrophy and itching?
- A. Estrogen ointment (Correct Answer)
- B. Antihistamines
- C. Tamoxifen
- D. None of the options
Explanation: ***Estrogen ointment*** * **Estrogen ointment** is the primary treatment for vulvar atrophy and itching because it directly addresses the underlying cause of these symptoms, which is the decline in estrogen levels after **menopause**. * By restoring estrogen to the vulvar tissues, it helps to **thicken the epithelium**, improve blood flow, and increase lubrication, thereby alleviating dryness, itching, and discomfort. *Antihistamines* * **Antihistamines** are used to treat allergic reactions and reduce itching associated with conditions like hives or insect bites, but they do not address the hormonal deficiency causing vulvar atrophy. * While they might temporarily relieve some itching, they do not treat the underlying **tissue thinning** and dryness characteristic of vulvar atrophy. *Tamoxifen* * **Tamoxifen** is a selective estrogen receptor modulator (SERM) primarily used in the treatment and prevention of breast cancer, as it blocks estrogen's effects in breast tissue. * However, in vulvovaginal tissues, **tamoxifen can actually worsen atrophy and dryness** due to its anti-estrogenic effects, making it an inappropriate treatment for vulvar atrophy. *None of the options* * This option is incorrect because **estrogen ointment** is a well-established and effective treatment specifically designed to address vulvar atrophy and associated itching, by restoring estrogen levels to the affected tissues.
Question 4: Which among the following is not a premalignant lesion of vulva?
- A. Paget's disease
- B. Bacterial Vaginosis (Correct Answer)
- C. Bowen's disease
- D. Lichen Sclerosus
Explanation: ***Bacterial Vaginosis*** - This is a common **vaginal infection** caused by an imbalance of normal vaginal bacteria, characterized by specific symptoms like increased discharge and odor. - Bacterial vaginosis is not considered a premalignant lesion and does not increase the risk of developing vulvar cancer. *Paget's disease* - This is a rare form of intraepithelial adenocarcinoma that can occur on the vulva, presenting as a red, itchy, scaly rash. - While it is a **carcinoma in situ**, it has the potential to become invasive, thus considered a premalignant or pre-invasive condition. *Bowen's disease* - This is a form of **squamous cell carcinoma in situ (SCCIS)**, typically appearing as a slow-growing, red, scaly patch on the skin. - It is considered a premalignant lesion because it can progress to invasive squamous cell carcinoma if left untreated. *Lichen Sclerosus* - This is a chronic inflammatory skin condition primarily affecting the anogenital region, leading to thinning, whitening, and scarring of the skin. - Although it is a benign condition, individuals with vulvar lichen sclerosus have an increased risk (3-5%) of developing **vulvar squamous cell carcinoma**, making it a premalignant condition.
Question 5: All are used in the treatment of hot flushes except
- A. Gabapentin
- B. Clonidine
- C. Tamoxifen (Correct Answer)
- D. Venlafaxine
Explanation: ***Tamoxifen*** - While Tamoxifen is an **anti-estrogen** used in breast cancer treatment, it can actually **cause or worsen hot flushes** as a side effect due to its estrogen receptor modulating effects in the hypothalamus. - It does not alleviate hot flushes and is therefore not used in their treatment in the general sense. *Gabapentin* - **Gabapentin**, an anticonvulsant, is often used off-label to treat hot flushes, particularly in women who cannot or prefer not to use hormone therapy. - It works by reducing the excitability of thermoregulatory neurons in the hypothalamus. *Clonidine* - **Clonidine**, an alpha-2 adrenergic agonist, can be used to treat hot flushes, especially in menopausal women. - It acts on the central nervous system to reduce the frequency and severity of vasomotor symptoms. *Venlafaxine* - **Venlafaxine**, a serotonin-norepinephrine reuptake inhibitor (SNRI), is a recognized non-hormonal treatment for hot flushes. - It is thought to work by modulating neurotransmitter levels that influence the thermoregulatory center in the brain.
Question 6: A pregnant female presents with active herpetic lesions on the vulva. What is the most appropriate management?
- A. Wait & watch
- B. Acyclovir & elective cesarean section (C-section) (Correct Answer)
- C. Acyclovir & allow spontaneous progression of labor
- D. Induction of labor
Explanation: ***Acyclovir & elective cesarean section (C-section)*** - Active **genital herpetic lesions** at the time of delivery pose a significant risk of transmitting **herpes simplex virus (HSV)** to the neonate. - **Acyclovir** can help suppress viral replication, but a **cesarean section** is necessary to prevent direct contact with the lesions during birth, which could lead to severe neonatal HSV infection. *Wait & watch* - This approach is inappropriate due to the high risk of **vertical transmission** of HSV to the neonate if lesions are active during vaginal delivery, potentially causing life-threatening complications. - **Neonatal HSV** can result in significant morbidity and mortality, including neurological damage and disseminated disease. *Acyclovir & allow spontaneous progression of labor* - While **acyclovir** can reduce viral load, it does not completely eliminate the risk of transmission from active lesions during a vaginal birth. - The primary concern is protecting the neonate from direct contact with the **active lesions** in the birth canal. *Induction of labor* - **Induction of labor** does not mitigate the risk of **vertical transmission** from active lesions during a vaginal delivery. - The focus should be on preventing contact with the lesions, not on expediting vaginal birth once active lesions are present.
Question 7: In cases of spasticity, which drug is least likely to be used?
- A. Baclofen
- B. Tizanidine
- C. Amitriptyline (Correct Answer)
- D. Diazepam
Explanation: ***Amitriptyline*** - **Amitriptyline** is a **tricyclic antidepressant** primarily used for treating depression, neuropathic pain, and migraines. - While it has sedative effects, it does not directly act on the mechanisms that reduce muscle tone in spasticity. *Baclofen* - **Baclofen** is a **GABA-B receptor agonist** that reduces the release of excitatory neurotransmitters, effectively decreasing muscle spasticity. - It is one of the most commonly prescribed drugs for spasticity, available in oral and intrathecal forms. *Tizanidine* - **Tizanidine** is an **alpha-2 adrenergic agonist** that works by increasing presynaptic inhibition of motor neurons, thereby reducing muscle tone. - It is frequently used for spasticity associated with multiple sclerosis or spinal cord injury. *Diazepam* - **Diazepam** is a **benzodiazepine** that acts as a GABA-A receptor agonist, enhancing GABA's inhibitory effects on the central nervous system. - It reduces spasticity by causing generalized muscle relaxation, though its sedative properties can be a limiting side effect.
Question 8: Which of the following genital infections is associated with preterm labour?
- A. Human Papilloma Virus
- B. Monilial vaginitis
- C. Bacterial vaginosis (Correct Answer)
- D. Trichomonas vaginalis
Explanation: ***Bacterial vaginosis*** - Bacterial vaginosis (BV) is strongly associated with an increased risk of **preterm labor** and **premature rupture of membranes** due to the production of proteases and phospholipases by anaerobic bacteria. - The imbalance of vaginal flora, particularly the overgrowth of anaerobic bacteria, can lead to ascending infection and inflammation of the **chorioamniotic membranes**. - BV has the **strongest and most consistent** evidence linking it to preterm birth among genital infections. *Human Papilloma Virus* - HPV infection is primarily known for causing **genital warts** and increasing the risk of **cervical dysplasia** and cancer. - It is not directly linked to an increased risk of preterm labor. *Monilial vaginitis* - Monilial vaginitis, or **vulvovaginal candidiasis** (yeast infection), is a common cause of vaginal discomfort, itching, and discharge. - While uncomfortable, it is not consistently associated with an increased risk of preterm labor or other adverse pregnancy outcomes. *Trichomonas vaginalis* - *Trichomonas vaginalis* infection is a sexually transmitted infection that can cause **vaginitis**, cervicitis, and urethritis. - While some studies suggest a possible association with adverse pregnancy outcomes, the evidence is **inconsistent and significantly weaker** compared to bacterial vaginosis, making BV the most established cause of preterm labor among these options.
Question 9: A parous woman complains of itching in the vulva. On examination, there is local redness and swelling and white flakes around the introitus. The most probable diagnosis is
- A. Trichomoniasis
- B. Gonorrhoea
- C. Candidiasis (Correct Answer)
- D. Pyogenic vulvovaginitis
Explanation: ***Candidiasis*** - The symptoms of **itching**, **redness**, **swelling** of the vulva, and **white flakes** (often described as "cottage cheese-like") around the introitus are highly characteristic of vulvovaginal **candidiasis (yeast infection)**. - This condition is common, especially in parous women, and is caused by an overgrowth of *Candida* species. *Trichomoniasis* - Typically presents with a **foamy, greenish-yellow discharge**, a **foul odor**, and often **punctate hemorrhages** on the cervix (strawberry cervix). - While it can cause itching and irritation, the presence of **white flakes** is not a characteristic feature. *Gonorrhoea* - Often **asymptomatic** in women or presents with **purulent vaginal discharge**, **dysuria**, and **pelvic pain**. - It does not typically cause **white flakes** around the introitus and the discharge is usually not itchy initially. *Pyogenic vulvovaginitis* - This is a general term for bacterial vulvovaginitis that would present with signs of **bacterial infection**, such as a **malodorous discharge** and significant inflammation. - While it can cause redness and swelling, the description of **white flakes** is not specific to pyogenic infections and points more towards a fungal etiology.
Question 10: Chronic pelvic pain is defined as pain of greater than ----- months in duration?
- A. 1 month
- B. 3 months
- C. 6 months (Correct Answer)
- D. 12 months
Explanation: **Explanation:** **Chronic Pelvic Pain (CPP)** is defined as non-cyclical pain lasting for **6 months or longer**, localized to the anatomic pelvis, anterior abdominal wall at or below the umbilicus, lumbosacral back, or the buttocks. It must be of sufficient severity to cause functional disability or lead to medical consultation. * **Why 6 months is correct:** This duration is the standard diagnostic criterion established by the American College of Obstetricians and Gynecologists (ACOG) and the Royal College of Obstetricians and Gynaecologists (RCOG). The 6-month threshold distinguishes chronic pain from acute or subacute conditions, indicating that the pain has persisted beyond the normal tissue healing time and may involve central sensitization. * **Why other options are incorrect:** * **1 month:** This is considered **acute pain**, often associated with immediate surgical emergencies (e.g., ectopic pregnancy, torsion) or infections (PID). * **3 months:** While some international pain societies are moving toward a 3-month definition for general chronic pain, in the specific context of **Obstetrics and Gynecology exams (NEET-PG/INI-CET)**, the 6-month criteria remains the gold standard. * **12 months:** This is unnecessarily long and would delay essential diagnostic workups for conditions like endometriosis or malignancy. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause:** Endometriosis is the most frequent organic cause of CPP. * **Multidisciplinary approach:** CPP often lacks a single identifiable cause (up to 40-60% of laparoscopies for CPP are normal); it frequently involves a "carnival of symptoms" including IBS, interstitial cystitis, and psychological factors. * **Red Flags:** Unexplained weight loss, postmenopausal bleeding, or a palpable pelvic mass require immediate investigation to rule out malignancy.
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