A 36-year-old G2P2 woman comes to the office to discuss discontinuing contraception. Six weeks ago, she had her first Depo-Provera injection and now she has unpredictable bleeding. She is frustrated and irritated by these symptoms. She has a history of hypertension but is currently on no medications. Vital signs reveal a blood pressure of 130/90; weight 188 pounds, height 65 inches; BMI 31.4kg/m2. Which of the following is the most appropriate next step in the management of this patient?
a) Offer a different method of contraception b) Reassurance that this is normal initially
c) Begin oral contraceptives as a backup method for contraception d) Perform an endometrial biopsy to assess for endometrial cancer e) Offer add-back estrogen therapy
She should be reassured since initially after Depo-Provera injection there may be unpredictable bleeding. This usually resolves in 2 or 3 months. In general, after 1 year of using Depo-Provera, nearly 50% of users have amenorrhea.
b) Reassurance that this is normal initially
An 18-year-old G0 woman with LMP 14 days ago presents to the office requesting contraception, as she had unprotected intercourse the night before. She has taken oral contraceptives before and wants to know if she can just start them again now. After counseling and a discussion of long-term contraception, as well as emergency contraception, you advise her to take a low dose oral contraceptive. Of the following, which is the most appropriate instruction to give her at this time?
a) If pregnancy occurs, termination is indicated b) Begin taking the pills 72 hours after intercourse
c) Taking 5 pink/active tablets in two doses 12 hours apart has the same efficacy as taking them at the same time d) She should not expect any changes in her next cycle since emergency contraception can be taken at any time during a woman’s cycle
e) Insert the second dose per vagina or take an antiemetic 1-hour before dosing to decrease nausea
Emergency contraceptive pills are not an abortifacient, and they have not been shown to cause any teratogenic effect if inadvertently administered during pregnancy; therefore, termination is not indicated. They are more effective the sooner they are taken after unprotected intercourse, and it is recommended that they be started within 72 hours, and no later than 120 hours. Plan B, the levonorgestrel pills can be taken in one or two doses and cause few side effects. Oral contraceptives need to be taken 12 hours apart. Emergency contraceptive pills may be used anytime during a woman’s cycle, but may impact the next cycle, which can be earlier or later with bleeding ranging from light, to normal, to heavy. Taking an antiemetic one-hour before the dose will decrease her nausea. Bypassing the oral route by inserting the medication per vagina will also have the same result and allow for appropriate absorption.
e) Insert the second dose per vagina or take an antiemetic 1-hour before dosing to decrease nausea
A 35-year-old G3P3 woman requests contraception. Her youngest child is 7 years old. Her periods have been regular since she discontinued breast-feeding 5 years ago. Her past medical history includes depression that is controlled with antidepressants, and a history of deep venous thrombosis. She denies smoking or alcohol use. In the past, oral contraceptive pills have caused her to have severe gastrointestinal upset. What in her history makes her an ideal candidate for progestin-only pills?
a) Depression b) Smoking history
c) Severe nausea on combined oral contraceptives d) Lactation history
e) Deep venous thrombosis
Ideal candidates for progestin-only pills include women who have contraindications to using combined oral
contraceptives (estrogen containing.) Contraindications include a history of thromboembolic disease, women who are lactating, women over age 35 who smoke or women who develop severe nausea with combined oral contraceptive pills. Progestins should be used with caution in women with a history of depression.
e) Deep venous thrombosis
A 24-year-old G1P1 woman comes to the office requesting contraception. Her past medical history is
unremarkable, except for a family history of endometrial cancer. She denies alcohol, smoking and recreational drug use. She is in a monogamous relationship. She wants to significantly decrease her risk of having a gynecological malignancy. Of the following, what is the best method of contraception for this patient? a) Female condoms
b) Male condoms
c) Copper containing intrauterine device d) Combined oral contraceptives e) Cervical cap
Oral contraceptives will decrease a woman’s risk of developing ovarian and endometrial cancer. The earlier, higher dose oral contraceptive pills have been linked to a slight increase in breast cancer, but not the most recent pills. Women who use oral contraceptive pills have slightly higher risk of developing cervical intraepithelial neoplasia, but their risk of developing PID, endometriosis, benign breast changes and ectopic pregnancy are reduced. Both
hypertension and thromboembolic disorders can be a potential side effect from using oral contraceptive pills. Although the mechanism is unclear, an association of tubal ligation and a lower incidence of ovarian cancer in BRCA-1 positive women has been reported. Male condoms and intrauterine devices will not lower her risk of ovarian cancer.
d) Combined oral contraceptives
A 35-year-old G3P3 woman comes to the office to discuss tubal ligation as she desires permanent sterilization. What are the non-contraceptive health benefits of female sterilization?
a) Reduced risk of endometriosis b) Reduced risk of ovarian cancer c) Protection against endometrial cancer d) Reduction in menstrual blood flow
e) Reduced risk of sexually transmitted diseases
Tubal ligation has not been shown to reduce the risk of endometriosis, sexually transmitted diseases or endometrial cancer, nor is there a decrease in menstrual blood flow in women who have undergone a tubal ligation. There is a slight reduction in the risk of ovarian cancer, but the mechanism is not yet fully understood.
b) Reduced risk of ovarian cancer
A 24-year-old G2P2 woman with a history of two prior Cesarean sections desires a tubal ligation for permanent sterilization. She has two daughters, who are 3 and 1 years old. She is very sure she does not desire any more children. She is happily married and a stay-at-home-mom. What is the strongest predictor of post-sterilization regret for this patient?
a) Not working outside the home b) Parity
c) Marital status d) Age
e) Children’s gender
Approximately 10% of women who have been sterilized regret having had the procedure with the strongest predictor of regret being undergoing the procedure at a young age. The percentage expressing regret was 20% for women less than 30-years-old at the time of sterilization. For those under age 25, the rate was as high as 40%. The regret rate was also high for women who were not married at the time of their tubal ligation, when tubal ligation was performed less than a year after delivery, and if there was conflict between the women and their partners.
d) Age
A 32-year-old G3P3 woman comes to the office to discuss permanent sterilization. She has a history of hypertension and asthma (on corticosteroids). She has been married for 10 years. Her blood pressure is 140/94; weight 280 pounds; height 69 inches; and BMI 41.4kg/m2. You discuss with her risks and benefits of contraception. Which of the following would be the best form of permanent sterilization to recommend for this patient?
a) Laparoscopic bilateral tubal ligation b) Mini laparotomy tubal ligation
c) Exploratory laparotomy with bilateral salpingectomy d) Total abdominal hysterectomy
e) Vasectomy for her husband
Both vasectomy and tubal ligation are 99.8% effective. Vasectomies are performed as an outpatient procedure under local anesthetic, while tubal ligations are typically performed in the operating room under regional or general
anesthesia; therefore carrying slightly more risk to the woman, assuming both are healthy. She is morbidly obese, so the risk of anesthesia and surgery are increased. In addition, she has chronic medical problems that make her at increase risk for surgery.
e) Vasectomy for her husband
A 35-year-old G3P3 woman comes to the office because she desires contraception. Her past medical history is significant for Wilson’s disease, chronic hypertension and anemia secondary to menorrhagia. She is currently on no medications. Her vital signs reveal a blood pressure of 144/96. Of the following, what is the ideal
contraceptive for her? a) Progestin-only pill
c) Continuous oral contraceptive
d) Copper containing intrauterine device e) Levonorgestrel intrauterine device
The levonorgestrel intrauterine device has lower failure rates within the first year of use than does the copper
containing intrauterine device. It causes more disruption in menstrual bleeding, especially during the first few months of use, although the overall volume of bleeding is decreased long-term and many women become amenorrheic. The levonorgestrel intrauterine device is protective against endometrial cancer due to release of progestin in the
endometrial cavity. She is not a candidate for oral contraceptive pills because of her poorly controlled chronic
hypertension. The progestin only pills have a much higher failure rate than the progestin intrauterine device. She is not a candidate for the copper-containing intrauterine device because of her history of Wilson’s disease.
e) Levonorgestrel intrauterine device
A 23-year-old G0 woman comes to the office to discuss contraception. Her past medical history is remarkable for hypothyroidism and mild hypertension. She has a history of slightly irregular menses. Her best friend recently got a “patch,” so she is also interested in using a transdermal system (patch.) Her vital signs are: blood pressure 130/84; weight 210 pounds. What is the most compelling reason for her to use a different method of contraception? a) Age b) Hypothyroidism c) Weight d) Unpredictable periods e) Hypertension
The patch has comparable efficiency to the pill in comparative clinical trials, although it has more consistent use. It has a significantly higher failure rate when used in women who weigh more than 198 pounds. The patch (Ortho-Vera) is a transdermal system that is placed on a woman’s upper arm or torso (except breasts). The patch slowly releases Ethinyl Estradiol and Norelgestromin, which establishes steady serum levels for 7 days. A woman should apply one patch in a different area each week for 3 weeks, then have a patch-free week, during which time she will have a withdrawal bleed. Patients should be informed about the risks of using a transdermal delivery system including higher estrogen levels and increased risk of thromboembolic events.
c) Weight
A 37-year-old G3P3 woman presents for a health maintenance exam. She is healthy with no history of medical problems. She had a tubal ligation 2 years ago. She had used combined oral contraceptives previously for a total of 10 years. Her husband has a strong family history of cardiac disease and her grandmother passed away at age 87 from a stroke. She is worried about having a heart attack herself. She has smoked one pack of cigarettes a day for the last 15 years and drinks alcohol 3 times a week. Which of the following is her
strongest risk factor for cardiac disease? a) Past use of oral contraceptives
b) Alcohol consumption c) Maternal family history d) Paternal family history e) Smoking history
Correct!!! Although oral contraceptives are contraindicated in women with coronary vascular disease, past use of the pills does not increase current risk. This woman’s strongest risk is her smoking. Her husband’s family history does not place her at risk. Her grandmother’s history can potentially place her at increased risk but her own smoking is her biggest risk factor. Mild red wine consumption can potentially decrease her risk, and other alcohol consumption does not pose a significant increased risk.
e) Smoking history would be awarded 10 points
A 23-year-old woman with 6 weeks amenorrhea presents with lower abdominal pain and vaginal bleeding. Her temperature is 39°C and the cervix is 1 cm dilated. Uterus is 8-week size and tender. There are no adnexal masses. Urine pregnancy test is positive. What is the most likely diagnosis?
a) Threatened abortion b) Missed abortion c) Normal pregnancy d) Septic abortion e) Ectopic Pregnancy
The patient has a septic abortion. She has fever, bleeding, cervix is open and exam findings consistent with septic abortion. Threatened abortions clinically have vaginal bleeding, positive pregnancy test and a cervical os closed or uneffaced, while missed abortions have retention of a nonviable intrauterine pregnancy for an extended period of time
(i.e. dead fetus or blighted ovum.) A normal pregnancy would have a closed cervix. Ectopic pregnancy would likely present with bleeding, abdominal pain and possibly have an adnexal mass; the cervix would typically be closed.
d) Septic abortion
A 23-year-old woman with 6 weeks amenorrhea presents with lower abdominal pain and vaginal bleeding. Her temperature is 39°C and the cervix is 1cm dilated. Uterus is 8-week size, tender and there are no adnexal masses. Urine pregnancy test is positive. Which of the following is the most appropriate next step in the management of this patient?
a) Single-agent antibiotics b) Observation
c) Laparoscopy plus antibiotics d) Uterine evacuation plus antibiotics
e) Medical termination of pregnancy plus antibiotics
The management of septic abortion is broad spectrum antibiotics and uterine evacuation. Single agent antimicrobials do not provide coverage for the array of organisms that may be involved and therefore are not indicated. A
laparoscopy can be indicated if ectopic pregnancy is suspected, but it is unlikely in this case. Medical termination is not the best option since prompt evacuation of the uterus is indicated in this case.
d) Uterine evacuation plus antibiotics
A 29-year-old G3P0 woman presents for evaluation and treatment of pregnancy loss. Her past medical history is remarkable for 3 early (<14 weeks gestation) pregnancy losses and a deep vein thrombosis 2 years ago. Parental karyotype was normal. Which of the following is the most appropriate next step in the management of this patient?
a) Place a prophylactic cerclage b) Obtain cervical length c) Refer for in vitro fertilization d) Obtain a semen analysis
e) Check antiphospholipid antibodies
Antiphosphospholipid antibodies are associated with recurrent pregnancy loss. The workup for antiphospholipid syndrome includes assessment of anticardiolipin antibody status, PTT, and Russell viper venom time. There are multiple etiologies for recurrent pregnancy loss defined as >2 consecutive or >3 spontaneous losses before 20 weeks gestation. Etiologies include anatomic causes (uterine abnormalities either acquired or inherited,) endocrine
abnormalities such as hyper or hypothyroidism and luteal phase deficiency, parental chromosomal anomalies, immune factors such as lupus anticoagulant and idiopathic factors. Cervical incompetence is diagnosed by history, physical exam and other diagnostic tests, such as ultrasound. The treatment is placement of a cerclage. Semen analysis would not be useful in this workup.
e) Check antiphospholipid antibodies
A 29-year-old G3P0 woman presents for evaluation and treatment of pregnancy loss. Her past medical history is remarkable for 3 early (<16 weeks gestation) pregnancy losses and a deep vein thrombosis 2 years ago. Her work up includes: MRI of pelvis normal, prolonged dilute Russell viper venom test and elevated anticardiolipin antibodies, normal thyroid function and prolactin. She wishes to get pregnant soon. In addition to aspirin, which of the following treatments is appropriate for this patient?
a) No additional treatment b) Corticosteroid
c) Heparin d) Levothroxine e) Bromocriptine
The prolonged dilute Russell viper venom time leads one to suspect that the etiology of recurrent pregnancy loss is due to antiphospholipid antibody syndrome. The treatment is aspirin plus heparin. There is roughly a 75% success rate with combinations therapy versus aspirin alone. There is conflicting evidence regarding steroid use for treatment and heparin is more effective.
c) Heparin
A 25-year-old G1P0 woman at 6 weeks gestational age comes to the office because of undesired pregnancy. You discuss with her the risks and benefits of surgical versus medical abortion using misoprostol and mifepristone. Compared to surgical abortion, which of the following is increased in a woman undergoing a medical abortion?
a) Post abortion pain b) Lower failure rate
c) Long-term psychologic sequelae d) Blood loss
e) Future fertility
In early in pregnancy (less than 49 days) both medical and surgical procedures can be offered. Mifepristone (an antiprogestin) can be administered, followed by misoprostol (a prostaglandin) to induce uterine contractions to expel the products of conception. This approach has proven to be effective (96%) and safe. A surgical termination is required in the event of failure or excessive blood loss. It seems to be more desirable by some patients as they do not have to undergo a surgical procedure; however, it is associated with higher blood loss than surgical abortion. It does not affect future fertility. Any termination of pregnancy, whether medical or surgical, can have psychological sequelae.
d) Blood loss
A 36-year-old G2P0 woman at 11 weeks gestational age requests a surgical termination of pregnancy. She had a manual vacuum aspiration last year and would like to undergo the same procedure again. She has chronic hypertension and diabetes well controlled on medications. Vital signs reveal a blood pressure of 120/80 and fasting blood glucose of 100. Which of the following is a contraindication for manual vacuum aspiration of this patient? a) Age b) Parity c) Gestational age d) Chronic hypertension e) Diabetes
Manual vacuum aspiration is more than 99% effective in early pregnancy (less than 8 weeks.) Age, parity and medical illnesses are not contraindications for manual vacuum aspiration. Although the risk of Asherman’s syndrome increases with each subsequent pregnancy termination, this patient may still undergo surgical termination as long as she
understands risks and benefits. Complications of pregnancy termination increase with increasing gestational age. c) Gestational age
A 25-year-old G1 woman at 20 weeks gestation desires termination of the pregnancy. Her prenatal course has been unremarkable except for a chromosomal analysis positive for Trisomy 18. She desires an autopsy of the fetus. Which of the following is the most appropriate next step in the management of this patient?
a) Perform a dilatation and curettage b) Perform a dilatation and evacuation
c) Await fetal demise then start induction of labor
d) Perform an induction with intraamniotic hypertonic saline e) Perform an induction with intravaginal prostaglandins
Both medical and surgical abortions are options for this patient, depending on her personal preferences. However, if she desires an autopsy, she must undergo a medical abortion in order to have an intact fetus. Abortion is legal until viability is achieved (24 weeks gestation) unless a fetal anomaly inconsistent with extrauterine life is identified. A dilatation and curettage is performed if the fetus is less than 16 weeks, while dilatation and evacuation can be performed after 16 weeks by those trained in the procedure. Inductions with hypertonic saline have a high morbidity, so are no longer performed.
e) Perform an induction with intravaginal prostaglandins
A 23-year-old G1P0 woman at 6 weeks gestation undergoes a medical termination of pregnancy. One day later, she presents to the emergency room with bleeding and soaking more than a pad per hour for the last 5 hours. Her blood pressure on arrival is 110/60; heart rate 86. On exam, her cervix is 1cm dilated with active bleeding. Hematocrit on arrival is 29%. Which of the following is the most appropriate next step in the management of this patient?
a) Admit for observation
b) Repeat hematocrit in 6 hours
c) Begin transfusion with O-negative blood d) Give an additional dose of prostaglandins e) Prepare her for a dilatation and curettage
This patient is having heavy bleeding as a complication of medical termination of pregnancy. This is managed best by performing a dilatation and curettage. It is not appropriate to wait 6 hours before making a decision regarding next step in management, or to just admit her for observation. Since the patient is not symptomatic from her anemia, it is not necessary to transfuse her at this time.
A 22-year-old G1P0 woman with LMP 6 weeks ago presents for elective termination of her pregnancy. She is healthy with no medical problems. Her pregnancy thus far has been uncomplicated. An ultrasound performed in the office shows an 8mm endometrial stripe with no intrauterine gestational sac and no adnexal masses. Which of the following is the most appropriate next step in the management of this patient?
a) Obtain a beta-hCG level b) Perform dilation and curettage c) Give patient methotrexate
d) Perform a diagnostic laparoscopy e) Repeat ultrasound in 2 weeks
Even though the patient reports being pregnant, she is asymptomatic with no gestational sac in the uterus. First step in her management is to establish pregnancy by obtaining a beta-hCG level. One should not assume she has an
intrauterine pregnancy and perform a D&C or assume that she has an ectopic pregnancy and treat her with methotrexate or surgery until the pregnancy is confirmed.
a) Obtain a beta-hCG level
A 24-year-old G2P1 woman who underwent an elective termination two days ago presents to the emergency room with abdominal and pelvic pain. She has been feeling nauseated and reports a fever at home to 101.3°F. On presentation, her blood pressure is 100/60; pulse 100; respiration 16; temperature 102°F. Physical
examination reveals diffuse abdominal tenderness and, on pelvic exam, she has marked cervical motion tenderness. In addition to sending a CBC and cultures, which of the following is the most appropriate next step in the management of this patient?
a) Obtain beta-hCG level b) Proceed with a laparoscopy
c) Proceed with a dilatation and curettage d) Begin IV antibiotics
e) Order a hysterosonogram
This patient has postoperative endometritis that could be due to introduction of bacteria into the uterine cavity at the time of dilatation and curettage. It is important to begin antibiotics immediately. After starting antibiotics, an ultrasound should be obtained to look for products of conception. If found, then the patient would require a repeat dilatation and curettage. An hCG level would not be helpful 2 days after the termination. Hysterosonogram is contraindicated when infection is present. There are no indications for laparoscopy in this patient.
d) Begin IV antibiotics
A 32-year-old P0 woman, with a last menstrual period three weeks ago, presents with a 3-month history of a malodorous vaginal discharge. She reports no pruritus or irritation. She has been sexually active with a new partner for the last 4 months. Her past medical history is unremarkable. Pelvic examination reveals normal external genitalia without rash, ulcerations or lesions. Some discharge is noted on the perineum. The vagina reveals only a thin, gray homogeneous discharge. The vaginal pH is greater than 4.5. Which medication is most likely to treat her symptoms and the accompanying saline wet prep?
a) Ceftriaxone b) Doxycycline c) Metronidazole d) Azithromycin e) Penicillin
Bacterial vaginosis is the most common cause of vaginitis. The infection arises from a shift in the vaginal flora from hydrogen peroxide-producing lactobacilli to non-hydrogen peroxide-producing lactobacilli, which allows proliferation of
anaerobic bacteria. The majority of women are asymptomatic; however, patients may experience a thin, gray
discharge with a characteristic fishy odor that is often worse following menses and intercourse. Modified Amsel criteria for diagnosis include three out of four of the following: 1) thin, gray homogenous vaginal discharge; 2) positive whiff test (addition of potassium hydroxide releases characteristic amine odor;) 3) presence of clue cells on saline microscopy; and 4) elevated vaginal pH >4.5. Treatment consists of Metronidazole 500mg orally BID for 7 days, or vaginal Metronidazole 0.75% gel 5-grams QHS for 5 days.
c) Metronidazole
A 64-year-old G2P2 woman presents with a 12-month history of severe vulvar pruritus. She has applied multiple over-the-counter topical therapies without improvement. She has no significant vaginal discharge. She is currently on oral estrogen therapy for osteoporosis. She has severe introital dyspareunia and has stopped having intercourse because of the pain. Her past medical history is significant for allergic rhinitis and hypertension. On pelvic examination, the external genitalia show loss of the labia minora with resorption of the clitoris (phimosis). The vulvar skin appears thin and pale and involves the perianal area. No ulcerations are present. The vagina is mildly atrophic, but appears uninvolved. Which of the following is the most likely diagnosis in this patient?
a) Squamous cell hyperplasia b) Lichen sclerosus
c) Lichen planus d) Candidiasis e) Vulvar cancer
Lichen sclerosus is a chronic inflammatory skin condition that most commonly affects Caucasian premenarchal girls and postmenopausal women. The exact etiology is unknown, but is most likely multifactorial. Patients typically present with extreme vulvar pruritus and may also present with vulvar burning, pain and introital dyspareunia. Early skin changes include polygonal ivory papules involving the vulva and perianal areas, waxy sheen on the labia minora and clitoris, and hypopigmentation. The vagina is not involved. More advanced skin changes may include fissures and erosions due to a chronic itch-scratch-itch cycle, mucosal edema and surface vascular changes and, ultimately, scarring with loss of normal architecture, such as introital stenosis, and resorption of the clitoris (phimosis) and labia minora. Treatment involves use of high-potency topical steroids. There is less than a 5% risk of developing squamous cell cancer within a field of lichen sclerosus.
b) Lichen sclerosus would be awarded 10 points
A 22-year-old P0 woman, presents with a one-month history of profuse vaginal discharge with mild odor. She has a new sexual partner with whom she has had unprotected intercourse. She reports mild to moderate irritation, pruritus and pain. She thought she had a yeast infection, but had no improvement after using an over-the-counter antifungal cream. She is concerned about sexually transmitted infections. Her medical history is significant for lupus and chronic steroid use. Pelvic examination shows normal external genitalia, an erythematous vagina with a copious, frothy yellow discharge and multiple petechiae on the cervix. Vaginal pH is 7. Saline wet mount reveals motile, flagellated organisms and multiple white blood cells. Which of the following is the most appropriate treatment for this patient?
a) Clindamycin b) Azithromycin c) Metronidazole d) Ampicillin e) Doxycycline
This patient has signs and symptoms of trichomoniasis, which is caused by the protozoan, T. vaginalis. Many infected women have symptoms characterized by a diffuse, malodorous, yellow-green discharge with vulvar irritation. However, some women have minimal or no symptoms. Diagnosis of vaginal trichomoniasis is performed by saline microscopy of vaginal secretions, but this method has a sensitivity of only 60% to 70%. The CDC recommended treatment is
metronidazole 2 grams orally in a single dose. An alternate regimen is metronidazole 500mg orally twice daily for seven days. The patient’s sexual partner also should undergo treatment prior to resuming sexual relations.
c) Metronidazole
A 42-year-old G2P2 woman presents with a 2-week history of a thick, curdish white vaginal discharge and pruritus. She has not tried any over-the-counter medications. She is currently single and not sexually active. Her medical history is remarkable for recent antibiotic use for bronchitis. On pelvic examination, the external genitalia show marked erythema with satellite lesions. The vagina appears erythematous and edematous with a thick white discharge. Saline wet prep reveals multiple white blood cells, but no clue cells or trichomonads.
Potassium hydroxide prep shows the following organisms, vaginal pH is 4.0. The cervix appears normal and the remainder of the exam is unremarkable except for mild vaginal wall tenderness. Which of the following is the most appropriate treatment for this patient?
a) Clindamycin b) Azole cream c) Metronidazole d) Doxycycline e) Ciprofloxacin
Vulvovaginal candidiasis (VVC) usually is caused by C. albicans, but is occasionally caused by other Candida species or yeasts. Typical symptoms include pruritus and vaginal discharge. Other symptoms include vaginal soreness, vulvar burning, dyspareunia and external dysuria. None of these symptoms are specific for VVC. The diagnosis is suggested clinically by vulvovaginal pruritus and erythema with or without associated vaginal discharge. The diagnosis can be made in a woman who has signs and symptoms of vaginitis when either: a) a wet preparation (saline or 10% KOH) or Gram stain of vaginal discharge demonstrates yeasts or pseudohyphae; or b) a vaginal culture or other test yields a positive result for a yeast species. Treatment for uncomplicated VVC consists of short-course topical Azole
formulations (1-3 days,) which results in relief of symptoms and negative cultures in 80%-90% of patients who complete therapy.
b) Azole cream
A 52-year-old nulliparous woman presents with long-standing vulvar and vaginal pain and burning. She has been unable to tolerate intercourse with her husband because of introital pain. She had difficulty sitting for prolonged periods of time or wearing restrictive clothing because of worsening vulvar pain. She recently noticed that her gums bleed more frequently. She avoids any topical over-the-counter therapies because they intensify her pain. Her physical examination is remarkable for inflamed gingiva and a whitish reticular skin change on her buccal mucosa. A fine papular rash is present around her wrists bilaterally. Pelvic examination reveals white plaques with intervening red erosions on the labia minora as noted below. A speculum cannot be inserted into her vagina because of extensive adhesions. The cervix cannot be visualized. Which of the following is the most likely diagnosis in this patient?
a) Squamous cell hyperplasia b) Lichen sclerosus
c) Lichen planus d) Genital psoriasis e) Vulvar cancer
Lichen planus is a chronic dermatologic disorder involving the hair-bearing skin and scalp, nails, oral mucous
membranes and vulva. This disease manifests as inflammatory mucocutaneous eruptions characterized by remissions and flares. The exact etiology is unknown, but is felt to be multifactorial. Vulvar symptoms include irritation, burning, pruritus, contact bleeding, pain and dyspareunia. Clinical findings vary with a lacy, reticulated pattern of the labia and perineum, with or without scarring and erosions as well. With progressive adhesion formation and loss of normal architecture, the vagina can become obliterated. Patients may also experience oral lesions, alopecia and extragenital rashes. Treatment is challenging, since no single agent is universally effective and consists of multiple supportive therapies and topical superpotent corticosteroids.
c) Lichen planus
A 27-year-old P0 woman presents with a 3-year history of dyspareunia. She reports a history of always having painful intercourse, but she is now unable to tolerate intercourse at all. She has avoided sex for the last 6 months. She describes severe pain with penile insertion. On further questioning, she reports an inability to use tampons because of painful insertion. She also notes a remote history of frequent yeast infections while she was on antibiotics for recurrent sinusitis that occurred “years” ago. Her medical history is unremarkable, and she is on no medications. Pelvic examination is remarkable for normal appearing external genitalia. Palpation of the vestibule with a Q-tip elicits marked tenderness and slight erythema. A normal-appearing discharge is noted. Saline wet prep shows only a few white blood cells, and potassium hydroxide testing is negative. Vaginal pH is 4.0. The cervix and uterus are unremarkable. Which of the following is the most likely diagnosis in this patient?
a) Vaginal cancer
c) Vulvar vestibulitis d) Contact dermatitis e) Chlamydia infection
Vulvar vestibulitis syndrome consists of a constellation of symptoms and findings limited to the vulvar vestibule, which include severe pain on vestibular touch or attempted vaginal entry, tenderness to pressure and erythema of various degrees. Symptoms often have an abrupt onset and are described as a sharp, burning and rawness sensation. Women may experience pain with tampon insertion, biking or wearing tight pants, and avoid intercourse because of marked introital dyspareunia. Vestibular findings include exquisite tenderness to light touch of variable intensity with or without focal or diffuse erythematous macules. Often, a primary or inciting event cannot be determined. Treatment includes use of tricyclic antidepressants to block sympathetic afferent pain loops, pelvic floor rehabilitation,
biofeedback, and topical anesthetics. Surgery with vestibulectomy is recommended for patients who do not respond to standard therapies and are unable to tolerate intercourse.
c) Vulvar vestibulitis
A 30-year-old G1P1 woman presents with a history of chronic vulvar pruritus. The itching is so severe that she scratches constantly and is unable to sleep at night. She reports no significant vaginal discharge or
dyspareunia. She does not take antibiotics. Her medical history is unremarkable. Pelvic examination reveals normal external genitalia with marked lichenification (increased skin markings) and diffuse vulvar edema and erythema. Saline microscopy is negative. Potassium hydroxide testing is negative. Vaginal pH is less than 4.5. The vaginal mucosa is normal. Which of the following is the most likely diagnosis in this
patient?
a) Lichen simplex chronicus b) Lichen sclerosus
c) Lichen planus d) Candidiasis e) Vulvar cancer
Lichen simplex chronicus, a common vulvar non-neoplastic disorder results from chronic scratching and rubbing, which damages the skin and leads to loss of its protective barrier. Over time, a perpetual itch-scratch-itch cycle develops, and the result is susceptibility to infection, ease of irritation and more itching. Symptoms consist of severe vulvar pruritus, which can be worse at night. Clinical findings include thick, lichenified, enlarged and rugose labia, with or without edema. The skin changes can be localized or generalized. Diagnosis is based on clinical history and findings, as well as vulvar biopsy. Treatment involves a short-course of high-potency topical corticosteroids and antihistamines to control pruritus.
a) Lichen simplex chronicus
A 20-year-old nulliparous woman college student presents with a one-month history of profuse vaginal
discharge and mid-cycle vaginal spotting. She uses oral contraceptives and she feels her irregular bleeding is due to the pill. She is sexually active and has had a new partner within the past 3 months. She reports no fevers or lower abdominal pain. She has otherwise been healthy. On pelvic examination, a thick yellow endocervical discharge is noted. Saline microscopy reveals multiple white blood cells, but no clue cells or trichomonads. Potassium hydroxide testing is negative. Vaginal pH is 4.0. No cervical motion tenderness or uterine/adnexal tenderness is present. Testing for Gonorrhea and Chlamydia is performed, but those results will not be available for several days and the student will be leaving for Europe tomorrow. Which of the following is the most appropriate treatment for this patient?
a) Metronidazole and Erythromycin b) Ceftriaxone and Azithromycin c) Ampicillin
d) Doxycycline
Mucopurulent cervicitis (MPC) is characterized by a mucopurulent exudate visible in the endocervical canal or in an endocervical swab specimen. MPC is typically asymptomatic, but some women have an abnormal discharge or
abnormal vaginal bleeding. MPC can be caused by chlamydia trachomatis or Neisseria gonorrhoeae; however, in most cases neither organism can be isolated. Patients with MPC should be tested for both of these organisms. The results of sensitive tests for C. trachomatis or N. gonorrhoeae (e.g. culture or nucleic acid amplification tests) should
determine the need for treatment, unless the likelihood of infection with either organism is high or the patient is unlikely to return for treatment. Antimicrobial therapy should include coverage for both organisms, such as azithromycin or doxycycline for chlamydia and a cephalosporin or quinolone for gonorrhea. Uncomplicated cervicitis, as in this patient, would require only 125 mg of Ceftriaxone in a single does. Ceftriaxone 250 mg is necessary for the treatment of upper genital tract infection, or pelvic inflammatory disease (PID).
b) Ceftriaxone and Azithromycin
A 37-year-old nulliparous woman, a CEO for a Fortune 500 company, presents with a one-week history of a painful vulvar ulcer. She reports no fevers, malaise or other systemic symptoms. She recently started use of a topical steroid ointment for a vulvar contact dermatitis. She is married and has no prior history of sexually transmitted infections. She reports no travel outside the United States by her husband or herself. Her last Pap smear, 6 months ago, was normal. A vulvar herpes culture later returns positive for herpes simplex virus type 2. A VDRL is nonreactive, and HIV testing is negative. Which of the following is the most likely diagnosis in this patient? a) Primary HSV episode b) Recurrent HSV-1 episode c) Recurrent HSV-2 episode d) Atypical HSV episode e) Contact dermatitis
Two serotypes of HSV have been identified: HSV-1 and HSV-2. Most cases of recurrent genital herpes are caused by HSV-2. Up to 30% of first-episode cases of genital herpes are caused by HSV-1, but recurrences are much less frequent for genital HSV-1 infection than genital HSV-2 infection. Genital HSV infections are classified as initial primary, initial nonprimary, recurrent and asymptomatic. Initial, or first-episode primary genital herpes is a true primary infection (i.e. no history of previous genital herpetic lesions, seronegative for HSV antibodies.) Systemic symptoms of a primary infection include fever, headache, malaise and myalgias, and usually precede the onset of genital lesions. Vulvar lesions begin as tender grouped vesicles that progress into exquisitely tender, superficial, small ulcerations on an erythematous base. Initial, nonprimary genital herpes is the first recognized episode of genital herpes in individuals who are seropositive for HSV antibodies. Prior HSV-1 infection confers partial immunity to HSV-2 infection and thereby lessens the severity of type 2 infection. The severity and duration of symptoms are intermediate between primary and recurrent disease, with individuals experiencing less pain, fewer lesions, more rapid resolution of clinical lesions and shorter duration of viral shedding. Systemic symptoms are rare. Recurrent episodes involve reactivation of latent genital infection, most commonly with HSV-2, and are marked by episodic prodromal symptoms and outbreaks of lesions at varying intervals and of variable severity. Clinical diagnosis of genital herpes should be confirmed by viral culture, antigen detection or serologic tests. Treatment consists of antiviral therapy with Acyclovir, Famciclovir or Valacyclovir.
c) Recurrent HSV-2 episode
A 45-year-old G2P2 woman presents with a 2 month history of vulvar pruritus. She does not have a significant vaginal discharge. Her medical history is significant for HIV diagnosis for 2 years, and a pack of cigarettes a day smoking habit for the last 20 years. Her last Pap smear, 2 years ago, showed LGSIL (low-grade squamous intraepithelial lesion). She underwent colposcopy at that time, which was adequate and consistent with CIN-I/mild dysplasia, and she was subsequently lost to follow-up. Her menstrual history is unremarkable. Pelvic examination is remarkable for a 3cm non-ulcerated, hyperkeratotic lesion on the right labia minora, as well as multiple papillary growths on the posterior fourchette and perineum. The vagina and cervix are grossly normal. In addition to performing a Pap smear, which of the following procedures is most appropriate for this patient? a) Vaginal biopsy b) Vulvar biopsy c) Endometrial biopsy d) Cervical biopsy e) Colposcopy
Genital condylomata, or warts, are typically caused by human papillomavirus (HPV) types 6 or 11. Other HPV types in the anogenital area (e.g. types 16, 18, 31, 33 and 35) have been strongly associated with cervical neoplasia and cancer. Vulvar intraepithelial neoplasia (VIN) is a possibility in this patient, given her history of cervical dysplasia, tobacco use and HIV status. Genital condylomata that do not respond to topical therapies should be biopsied.
Likewise, vulvar biopsy is indicated to evaluate the hyperkeratotic lesion in this patient and rule out the possibility of vulvar neoplasia.
b) Vulvar biopsy
A 26-year-old G2P2 woman reports that she is sexually active with a new male partner. She is using oral contraception for birth control and, as such, did not use a condom. She reports the new onset of vulvar burning and irritation. She thought she had a cold or the flu about 10 days ago. Given her history, which of the following is the most likely diagnosis in this patient?
a) Herpes simplex virus b) Human papilloma virus
c) Human immunodeficiency virus d) Molluscum contagiosum e) Trichomonas
The patient is most likely infected with herpes. Herpes simplex virus is a highly contagious DNA virus. Initial infection is characterized by viral like symptoms preceding the appearance of vesicular genital lesions. A prodrome of burning or irritation may occur before the lesions appear. With primary infection, dysuria due to vulvar lesions can cause
significant urinary retention requiring catheter drainage. Pain can be a very significant finding as well. Treatment is centered on care of the local lesions and the symptoms. Sitz baths, perineal care and topical Xylocaine jellies or creams may be helpful. Anti-viral medications, such as Acyclovir, can decrease viral shedding and shorten the course of the outbreak somewhat. These medications can be administered topically or orally. Human papilloma virus is the causative agent for condylomata and cervical dysplasia. It is often asymptomatic, unless vulvar lesions are present causing vulvar itching. In general, human papilloma virus is not associated with generalized symptoms like malaise. Human immunodeficiency virus is an RNA retrovirus transmitted via sexual contact or sharing intravenous needles. Vulvar burning, irritation or lesions are not typically noted with this disease, although generalized malaise can be. HIV can present with many different signs and symptoms therefore risk factors should be considered, and testing offered. Molluscum contagiosum which is caused by Poxviridae is a benign skin disease which presents as a small nodule or dome on the skin with an umbilicated center. It can be transmitted both sexually and from casual contact. Treatment involves local curettage of the lesion or cryotherapy. Trichomonas is a protozoan and is transmitted via sexual contact. It typically presents with a non-specific vaginal discharge. It does not have a systemic manifestation.
a) Herpes simplex virus
A 32-year-old G3P1 woman presents to your office for an annual examination. During the course of your discussion, the patient mentions that she has had an annoying vulvar irritation and slight itch for months. She sometimes notices an odor, but does not experience a specific discharge. She is sexually active with the same male partner for the past 6 months and they occasionally use condoms. On examination, she has a grayish, frothy discharge within the vaginal vault. You perform a wet prep of her vaginal secretions which shows flagellated organisms. Which of the following is the most likely diagnosis in this patient?
a) Yeast, Non-Candida albicans b) Trichomonas
c) Bacterial vaginosis d) Recent intercourse e) Chlamydia
Trichomonas is a flagellated protozoan that can be seen on microscopy. They are slightly larger in size than a polymorphonucleated white blood cell. Pseudohyphae are seen when candida species are present. They are most easily seen after the application of KOH to a wet smear of vaginal secretions. Clue cells are vaginal epithelial cells that appear stippled with adherent bacteria. They are visible on microscopy when vaginal secretions are suspended in saline. They are seen in bacterial vaginosis. Chlamydia and gonorrhea cannot be identified on a wet prep.
b) Trichomonas
A 26-year-old G1P0 woman presents to your office for her first prenatal visit. As part of the routine prenatal evaluation, you offer her testing for sexually transmitted infections. Which of the following sexually
transmitted infections can only be diagnosed using a blood sample? a) Chlamydia
b) Human papilloma virus c) Hepatitis B
d) Syphilis e) Herpes
Hepatitis B screening, done through a blood sample, detects the outer shell of the Dane particle of the virus (HBsAg). Patients who have been immunized should have detectable antibody to Hepatitis B, but will NOT have antigen present. Chlamydia can be detected from urine or endocervical swab. Gonorrhea can also be detected by obtaining an
endocervical swab, and gonorrhea and chlamydia should always be tested as a pair, since the presence of one often means the presence of the other. Human papilloma virus is associated with cervical dysplasia as well as genital warts. The presence of HPV can be detected either through an abnormal Pap smear, by the visualization of condylomatous lesions, by biopsy or by HPV DNA hybridization. The spirochetes of syphilis, obtained from ulcerated lesions, can be visualized under darkfield microscopy during primary and secondary infection. In the latent phase, serologic testing is required and, for screening purposes, either an RPR (rapid plasma regain) or VDRL (venereal disease reference laboratory) test can be ordered. Herpes virus can be diagnosed by culture, as well as antibodies in the blood.
c) Hepatitis B
A 17-year-old G0 sexually active woman presents to the emergency room with pelvic pain that began within the last day. She reports menarche at the age of 15 and coitarche soon thereafter. She has had 4 male partners, including her new boyfriend of a few weeks. Her blood pressure is 100/60, pulse 100, and
temperature 102.5°F. On speculum examination, you note a foul-smelling mucopurulent discharge from her cervical os and she has significant tenderness with manipulation of her uterus. What is the next best step in the management of this patient?
a) Outpatient treatment with oral broad spectrum antibiotics
b) Outpatient treatment with intramuscular and oral broad spectrum antibiotics c) Inpatient treatment, intravenous antibiotics, and dilatation and curettage d) Inpatient treatment, laparoscopy with pelvic lavage
e) Inpatient treatment and intravenous antibiotics
The most likely cause of the symptoms and signs in this patient is infection with a sexually transmitted disease. The most likely organisms are both N. gonorrhoeae and chlamydia, and the patient should be treated empirically for both after appropriate cervical cultures are obtained. Since the patient also has a high fever, inpatient admission is recommended for aggressive intravenous antibiotic therapy in an effort to prevent scarring of her fallopian tubes and possible future infertility.
e) Inpatient treatment and intravenous antibiotics
A 36-year-old G0 woman presents to the emergency department accompanied by her female partner. The patient is febrile and notes severe belly pain. She states that this pain began 2-3 days ago and was associated with diarrhea as well as some nausea. It has gotten progressively worse and she has now developed a fever. Neither her partner, nor other close contacts report any type of viral illness. She had her appendix removed as a teenager. On examination, her temperature is 38.5°C, her abdomen is tender with mild guarding and
rebound, and she has an elevated white count. On pelvic examination, she is exquisitely tender, such that you cannot complete your exam. Pelvic ultrasound demonstrates bilateral 3-4 cm complex masses. What is the most likely underlying pathogenesis of her illness?
a) Diverticulitis
b) A sexually transmitted infection c) Reactivation of an old infection d) Ascending infection
e) Pyelonephritis
Although salpingitis is most often caused by sexually transmitted agents, such as gonorrhea and chlamydia, any ascending infection from the genitourinary tract or gastrointestinal tract can be causative. The infection is polymicrobial consisting of aerobic and anaerobic organisms such as E. coli, Klebsiella, G. vaginalis, Prevotella, Group B
streptococcus and/or enterococcus. Although diverticulitis is a part of the differential diagnosis initially, the specific findings on examination and ultrasound are more suggestive of bilateral tubo-ovarian abscesses. Even though this patient does not have the typical risk factors for salpingitis, the diagnosis should be considered and explained to the patient in a sensitive and respectful manner. The patient should also be questioned separate from her partner regarding the possibility of other sexual contacts.
d) Ascending infection
A 16-year-old G0 woman presents to the emergency department with a two day history of “belly pain.” She is sexually active with a new partner and is not using any form of contraception. Temperature is 100.5°F. On exam, she has lower abdominal tenderness and guarding. On pelvic exam, she has diffuse tenderness over the uterus and bilaterally. Beta hCG <5. What is the most likely diagnosis in this patient?
a) Ectopic pregnancy b) Appendicitis c) Acute Cystitis
d) Intrauterine pregnancy e) Acute salpingitis
can present in much more dramatic fashion with high fever, mucopurulent cervical discharge and severe pain. Important diagnostic criteria include lower abdominal tenderness, uterine/adnexal tenderness and mucopurulent cervicitis.
e) Acute salpingitis
A 16-year-old G0 woman presents to the emergency department with a two-day history of “belly pain” and nausea. She is sexually active with a new partner and is not using any form of contraception. On examination, her temperature is 37.9°C, and she has bilateral lower quadrant pain, with slight rebound and guarding. On pelvic examination, she has purulent cervical discharge and cervical motion tenderness. Her white count is elevated. What is the most appropriate next step in the management of this patient?
a) Methotrexate b) Oral antibiotics
c) Diagnostic laparoscopy d) IV antibiotics
e) No treatment until culture results are back
Although some patients can be treated with an outpatient regimen, this patient should be hospitalized for IV treatment, as she is young, nulliparous, and has nausea so she might not be able to tolerate oral medications. She is also at risk for non-compliance with an outpatient treatment regimen. It is important to treat aggressively in order to prevent the long-term sequelae of acute salpingitis. Her recent sexual contacts should also be informed (by her and/or with her consent) and treated. According to the 2006 CDC recommendations, there are two options for parenteral antibiotics, making sure that both gonorrhea and chlamydia are “covered.” Cefotetan PLUS Doxycycline or Clindamycin PLUS Gentamicin. For outpatient treatment, the 2006 CDC guidelines recommend the following: Cefoxitin or Ceftriaxone and Probenecid 1 gram PLUS Doxycycline; or Ofloxacin with Metronidazole.
d) IV antibiotics
A 32-year-old G0 woman comes to your office because she has been unable to conceive for one year. She has regular menses every 27-34 days. She is currently in a mutually monogamous relationship, reports menarche at the age of 13, with coitarche at the age of 15; she has had 7 sexual partners, including her husband of 3 years. The patient reports that she has had an abnormal Pap smear about 4 years ago, but things have been normal since. She also states that, in her early twenties, she had problems with “female infections” and was on “lots of antibiotics,” but was never hospitalized. She denies any pain with intercourse and she denies any intermenstrual bleeding. Her husband has fathered 2 children from a previous marriage. What is the most likely underlying cause of infertility in this patient?
a) Male factor infertility b) Cervical stenosis c) Ovulatory dysfunction d) Tubal disease e) Endometriosis
Salpingitis can develop in 15-30% of women with inadequately treated gonococcal or chlamydial infections.
Unrecognized salpingitis can result in significant long-term sequelae, such as chronic pelvic pain, hydrosalpinx, tubal scarring and ectopic pregnancy. Given this patient’s history, her inability to conceive is most likely due to the long-term sequelae of a sexually transmitted infection. Her husband has previously fathered two children, thus a varicocele or azoospermia are unlikely. The patient has no risk factors for cervical stenosis. She is having regular cycles; therefore, anovulation and pituitary dysfunction are also less likely. This case emphasizes the importance of aggressive
screening and treatment protocols for sexually transmitted infections, as well as counseling regarding abstinence and safer sex practices.
d) Tubal disease
A 20-year-old G1P0 woman comes in for an annual gynecologic examination and for a refill on her birth control pills. She has heard something about a “new vaccine” to prevent a “pelvic infection or something.” She wants to get more information about preventing sexually transmitted infections, and know if she can get the new vaccine. Against which disease should she be vaccinated?
a) Herpes Simplex Virus-1 (HSV-1) b) Herpes Simplex Virus-2 (HSV-2) c) Hepatitis A
d) Hepatitis C
e) HPV (Human Papilloma Virus)
STIs have a very high prevalence within the population of the United States. HPV is estimated to infect 20 million Americans. There are 3 million new cases of chlamydia every year, and gonorrhea is newly diagnosed 600,000 times a year. Over 50 million adults are infected with herpes simplex virus, with 1.5 million new cases each year. Given that
most men and women with STIs are asymptomatic, the infections are highly communicable and can result in significant long-term sequelae, such as infertility, ectopic pregnancy, liver failure or death, aggressive prevention, screening and treatment is recommended. Of the above STIs, only HPV has a currently approved vaccination that results in
prevention of cervical precancerous and noninvasive cervical cancers associated with HPV Types 16 and 18, the HPV viral types that account for 70% of cervical cancers.
e) HPV (Human Papilloma Virus)
A 19-year-old G0 woman presents to the office with a two-week history of low pelvic pain and cramping. She has a new sexual partner and is on oral contraception, but also uses condoms. She is one week into her cycle. She has noted no vaginal discharge, itch or odor. She denies fevers or chills. She does note that she is on a new diet and has started drinking lots of water. As such, she notes that she is urinating much more
frequently. Her exam is entirely unremarkable. Which of the following is the most appropriate next step in the management of this patient?
a) A pelvic ultrasound b) Pap test
c) Wet prep d) Urinalysis
e) Testing for Chlamydia
Mildly symptomatic or asymptomatic urinary tract infections are common in female patients. Urinary tract infection must be considered in patients who present with low pelvic pain, urinary frequency, urinary urgency, hematuria or new issues with incontinence. In addition, routine screening of pregnant patients for asymptomatic urinary tract infections at each prenatal visit is recommended in order to prevent urinary tract infection, which can cause preterm labor. A pelvic ultrasound is not indicated at this point.
d) Urinalysis
A 76-year-old G3P3 woman presents to your office with worsening urinary incontinence for the past three months. She reports increase in urinary frequency, urgency and nocturia. Her exam shows mild cystocele and rectocele. A urine culture is negative. A post-void residual is 400 cc. Which of the following is the most likely diagnosis in this patient?
a) Genuine stress incontinence b) Detrusor instability
c) Overflow incontinence d) Functional incontinence e) Mixed incontinence
Correct!!! Overflow incontinence is characterized by failure to empty the bladder adequately. This is due to an underactive detrusor muscle (neurologic disorders, diabetes or multiple sclerosis) or obstruction (postoperative or severe prolapse). A normal post-void residual (PVR) is 50-60 cc. An elevated PVR, usually >300 cc, is found in overflow incontinence. Stress incontinence occurs when the bladder pressure is greater than the intraurethral pressure. Overactive detrusor contractions can override the urethral pressure resulting in urine leakage. The mixed variety includes symptoms related to stress incontinence and urge incontinence.
c) Overflow incontinence would be awarded 10 points
A 76-year-old G3P3 presents to the office with worsening stress urinary incontinence for the last 3 months. She reports an increase in urinary frequency, urgency and nocturia. On exam, she has a moderate size cystocele and rectocele. A urine culture is negative. A post-void residual is 50 cc. A cystometrogram shows two bladder contractions while filling. Which of the following is the most likely diagnosis in this patient? a) Genuine stress incontinence
b) Urge incontinence c) Overflow incontinence d) Functional incontinence e) Continuous incontinence
Detrusor overactivity incontinence is also known as urge incontinence. Detrusor instability is due to the overactivity of the bladder muscle. Though the testing may be simple (using a Foley catheter and attached large syringe without the plunger, filling with 50-60 cc of water at a time) or complex (using computers and electronic catheters,) the uninhibited contraction of the bladder with filling makes the diagnosis.
b) Urge incontinence would be awarded 10 points
A 60-year-old G4P4 woman presents with a two-year history of leakage with activity such as coughing,
sneezing and lifting. Her past medical history is significant for vaginal deliveries of infants over 9 pounds. She had a previous abdominal hysterectomy and bilateral salpingo-oophorectomy for uterine fibroids. She is on
vaginal estrogen for atrophic vaginitis. Physical exam shows no anterior, apical or posterior wall vaginal prolapse. Vagina is well-estrogenized. Postvoid residual was normal. Q-tip test showed a straining angle of 60 degrees from the horizon. Cough stress test showed leakage of urine synchronous with the cough.
Cystometrogram revealed the absence of detrusor instability. The patient failed pelvic muscle exercises and was not interested in an incontinence pessary. Which of the following is the best surgical option for this patient?
a) Retropubic urethropexy b) Needle suspension c) Anterior repair
d) Urethral bulking procedure e) Colpocleisis
Genuine stress incontinence (GSI) is the loss of urine due to increased abdominal pressure in the absence of a detrusor contraction. The majority of GSI is due to urethral hypermobility (straining Q-tip angle >30 degrees from horizon.) Some (<10%) of GSI is due to intrinsic sphincteric deficiency (ISD) of the urethra. Patients can have both hypermobility and ISD. Retropubic urethropexies (Burch and Marshall Marchetti) and sling procedures have the best year success rates for patients with GSI due to hypermobility. Needle suspensions and anterior repairs have lower 5-year success rates for GSI. Urethral bulking procedures are best for patients with ISD, but with little to no mobility of the urethra. Colpocleisis is one option to treat uterine prolapse, and is not indicated for urinary incontinence.
a) Retropubic urethropexy would be awarded 10 points
A 70-year-old G3P3 woman presents with a 4-year history of constant leakage. Her history is significant for abdominal hysterectomy and bilateral salpingo-oophorectomy for endometriosis. She has had four anterior repairs in the past for recurrent cystocele. The leakage started six months after her last anterior repair. Pelvic exam showed no evidence of pelvic relaxation. The vagina was well-estrogenized. Q-tip test revealed a fixed, immobile urethra. Cystometrogram showed no evidence of detrusor instability. Cystourethroscopy showed no evidence of any fistula and revealed a “drain pipe” urethra. Which of the following is the best first treatment for this patient?
a) Retropubic urethropexy b) Needle suspension c) Artificial urethral sphincter d) Urethral bulking procedure e) Sling procedure
Correct!!! This is a classic example of intrinsic sphincteric deficiency. The success rates for retropubic urethropexies, needle suspension and slings are less than 50%. An “obstructive or tight” sling can be performed to increase the success rate, but the voiding difficulties are significant, even requiring prolonged or lifelong self-catheterization. Urethral bulking procedures are minimally invasive and have a success rate of 80% in these specific patients. Artificial sphincters should be used in patients as a last resort.
d) Urethral bulking procedure would be awarded 10 points
A 60-year-old woman presents with complaints of urinary frequency and urge incontinence. Past medical history is unremarkable. She is on no medications. Pelvic exam shows no evidence of pelvic relaxation. Post void residual is normal. Urine analysis is negative. A cystometrogram revealed uninhibited detrusor
contractions upon filling. Which of the following is the best non-surgical treatment for this patient? a) Amitriptyline
b) Oxybutynin
c) Topical (vaginal) estrogen d) Pseudoephedrine
e) Kegel exercises
The patient has the diagnosis of detrusor instability. The parasympathetic system is involved in bladder emptying and acetylcholine is the transmitter that stimulates the bladder to contract through muscarinic receptors. Thus,
anticholinergics are the mainstay of pharmacologic treatment. Oxybutynin is one example. Although the tricyclic antidepressant, amitriptyline, has anticholinergic properties, its side effects do not make it an ideal choice. Vaginal estrogen has been shown to help with urgency, but not urge incontinence. Pseudoephedrine has been shown to have alpha adrenergic properties and may improve urethral tone in the treatment of stress incontinence. Kegel exercises or pelvic muscle training are used to strengthen the pelvic floor and decrease urethral hypermobility for the treatment of stress urinary incontinence.
b) Oxybutynin would be awarded 10 points
A 67-year-old G3P3 woman presents to the office due to severe pelvic protrusion status post hysterectomy. She denies any incontinence. She failed conservative management with a pessary. She underwent a vaginal
surgical repair where the pubocervical fascia was plicated in the midline as well as laterally to the arcus tendineus fascia (white line.) This patient underwent the repair of what defect?
a) Cystocele b) Rectocele c) Uterine prolapse d) Enterocele
e) Urethral diverticulum
Correct!!! Central and lateral cystoceles are repaired by fixing defects in the pubocervical fascia or reattaching it to the sidewall, if separated from the white line. Defects in the rectovaginal fascia are repaired in rectoceles. Uterine prolapse is surgically treated by a vaginal hysterectomy, but this patient already had a hysterectomy. Enteroceles are repaired by either vaginal or abdominal enterocele repairs. Vaginal vault prolapse is treated either by supporting the vaginal cuff to the uterosacral ligaments, sacrospinous ligament or sacrocolpopexy. Urethral diverticulum does not present with severe pelvic protrusion.
a) Cystocele
A 57-year-old G2P2 woman presents to the office with a six-month history of leaking urine, urgency, and nocturia. She describes the amount of urine loss as large and lasting for several seconds. The urine loss occurs when she is standing or sitting and is not associated with any specific activity. What is the most likely cause of this patient’s symptoms?
a) Stress incontinence b) Overflow incontinence c) Urge incontinence d) Mixed incontinence e) Vesicovaginal fistula
This patient has urge incontinence, which is caused by overactivity of the detrusor muscle resulting in uninhibited contractions, which cause an increase in the bladder pressure over urethral pressure resulting in urine leakage. Stress incontinence is caused by an increase in intra-abdominal pressure (coughing, sneezing) when the patient is in the upright position. This increase in pressure is transmitted to the bladder that then rises above the intra-urethral pressure causing urine loss. Associated structural defects are cystocele or urethrocele. Overflow incontinence is associated with symptoms of pressure, fullness, and frequency, and is usually a small amount of continuous leaking. It is not
associated with any positional changes or associated events. Mixed incontinence occurs when increased intra-abdominal pressure causes the urethral-vesical junction to descend causing the detrusor muscle to contract. A vesicovaginal fistula typically results in continuous loss of urine.
c) Urge incontinence
A 56-year-old G3P3 woman presents to the office for her annual health maintenance exam. She is in good health and is not taking any medications. She has been postmenopausal for 3 years. She had an abnormal Pap smear 10 years ago, but results have been normal every year since. She is sexually active with her husband and uses lubricant during intercourse due to mild vaginal dryness. On examination, her cervix was 1 cm above the vaginal introitus and she was noted to have a moderate bladder prolapse. Her uterus is normal in size and she has no adnexal masses, and she was non-tender. In addition to performing a Pap smear and recommending a mammogram, what is the most appropriate next step in the management of this patient? a) Cystocele repair
b) Perform a pelvic ultrasound c) Total hysterectomy
d) Observation e) Topical estrogen
This patient is asymptomatic from her prolapse; therefore, no intervention is necessary at this point. Cystocele repairs and hysterectomies are invasive procedures which are not indicated in this asymptomatic patient. It is not necessary to obtain a pelvic ultrasound, as her uterus is normal in size and she has no adnexal masses. Topical estrogen would not help improve the prolapse, although it might help with her vaginal dryness. She seems to be doing well with the lubricants and it is not necessary to expose her to the estrogen, especially since she still has her uterus, and estrogen treatment alone may increase her risk of endometrial cancer.
d) Observation
A 90-year-old G7P7 woman presents with severe vaginal prolapse. The entire apex, anterior and posterior wall are prolapsed beyond the introitus. She cannot urinate without reduction of the prolapse. Hydronephrosis was noted on ultrasound of the kidneys and it is thought to be related to the prolapse. She has a long-standing history of diabetes and cardiac disease. She is not a candidate for general or regional anesthesia. She has failed a trial of pessaries. Which of the following is the next best step in the management of this patient?
