Gynecology: Common Lesions of the Vulva, Vagina, C- 123docz.net

Gynecology

Questions

DIRECTIONS (Questions 1 through 36): For each of the multiple choice questions in this section, select the lettered answer that is the one best response in each case.

1. A 63-year-old patient is seen for routine examination. An excoriated 2-cm lesion is found on her left labium majus, which, she states, has been present for at least 3 months. What is the next best step in the management of this patient?

(A) prescribe hydrocortisone cream (B) schedule colposcopy

(D) prescribe Burow’s solution soaks (E) paint the area with toluidine blue stain

2. An 18-year-old woman consults you for a painful swelling of her left labium that has progressively worsened over the past 3 days. She has been treating the discomfort with over-the-counter analgesics and warm sitz baths. On examination, a 6-cm swollen, red, tender, tense cystic mass is present in the base of the left labium majus. What is the most appropriate next step in the care of this patient?

(A) excision of the mass (B) dry heat

(D) intramuscular or intravenous (IV) antibiotics (E) incision and drainage of the mass

3. A 21-year-old G0P0 healthy college student presents to Student Health Center, complaining of severe vulvar puritius. She has a BMI of 24, uses condoms with coitus, and finished her last menses 4 days prior. Last month she was diagnosed with and successfully treated for manila vaginitis. She denies any other symptoms including vaginal discharge. What is the most likely diagnosis?

(A) vaginal trichomoniasis (B) leukemia

(E) hidradenitis suppurativa

4. A 79-year-old woman presents to your office with a 1-cm fleshy outgrowth from her urethra. It has a slightly infected appearance and bleeds on contact. You perform a biopsy, and the report states

“transitional and stratified squamous epithelium with underlying loose connective tissue.” Which of the following is the most likely diagnosis?

(A) urethral leiomyoma (B) hidradenitis suppurativa (C) senile urethritis

(D) urethral caruncle (E) urethral carcinoma

5. A patient consults you with complaints of recurrent, painful, draining vulvar lesions. Examination shows multiple abscesses and deep scars in the labia. A foul-smelling discharge from the lesions is noted. During the review of systems, the patient reports the occasional appearance of similar lesions in the axilla. Which of the following is the most likely diagnosis?

(A) herpetic vulvitis

(B) hidradenitis suppurativa (C) lymphogranuloma venereum (D) granuloma inguinale

(E) secondary syphilis

6. A 20-year-old patient complains of painful vulvar ulcers present for 72 hours. Examination reveals three tender, punched-out lesions with a yellow exudate but no induration. Which of the following is the most likely diagnosis?

(A) chancroid

(B) granuloma inguinale (C) herpes

(D) lymphogranuloma venereum (E) syphilis

7. A 17-year-old girl is seen at a local clinic desiring contraception because she thinks she will soon become sexually active. During her examination, an ulcerative lesion is seen in the vaginal fornix. It has a rolled, irregular edge with a reddish-appearing granular base. The lesion is mildly tender to palpation. This lesion is most likely which of the following?

(A) vaginal intraepithelial neoplasia (B) vulvar carcinoma

(D) an ulcer caused by the use of tampons (E) genital herpes

8. Which of the following is the most common benign neoplasm of the cervix and endocervix?

(A) polyp (B) leiomyoma (C) nabothian cyst (D) endometriosis (E) Gartner’s duct cyst

9. A 15-year-old patient has had menstrual bleeding every 2 to 4 weeks since menarche 1 year ago. The bleeding can be both heavy and light. It sometimes lasts as long as 2 weeks. Which of the following is the next best step in the management of her problem?

(A) obtain a pregnancy test

(B) perform an endometrial biopsy

10. A 47-year-old woman complains of postcoital bleeding, nearly as heavy as menses. Which of the following is the most likely origin of her bleeding?

(A) cervical polyps (B) cervical ectropion (C) cervical carcinoma (D) cervical nabothian cysts (E) cervical infection

11. An obese 63-year-old woman presents with a 3-month history of continuous scanty vaginal bleeding.

She denies the use of hormone replacement therapy. Adequate history and physical examination in the office reveal no other abnormalities. A Pap smear is negative. Which of the following is the next most appropriate step in her management?

(A) begin estrogen replacement therapy (B) sample the endometrium

(E) obtain serum follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol, and prolactin levels

12. A patient being treated for prothrombin deficiency develops abnormal uterine bleeding. An anatomic lesion has been ruled out. Further management to control the bleeding should begin with which of the following?

(A) gonadotropin-releasing hormone (GnRH) antagonists (B) medroxyprogesterone acetate

(E) transdermal estradiol

13. A patient complains of heavy but regular menstrual periods. An anatomic cause of the magnitude of her flow has been ruled out. Which of the following has been shown to be most effective in reducing rather than eliminating her menstrual flow?

(A) tranexamic acid (B) dilation and curettage

(E) ergonovine maleate

14. A patient in her forties presents with dysfunctional bleeding. You want to do an endometrial biopsy.

Because she has no insurance, she would prefer not to have the procedure unless it is likely to show important pathology. An endometrial sampling is likely to be reported as showing endometrial hyperplasia in a patient who is which of the following?

(A) obese

(B) postmenopausal

(E) using a copper intrauterine contraceptive device (IUCD) Questions 15 and 16 apply to the following patient:

A 35-year-old accountant complains of episodic bloating, breast tenderness, dyspareunia, irritability, and depression, which leave her with “only 1 good week a month.” She is currently using condoms and foam for birth control because she “felt terrible” on OCs. Pelvic examination is normal.

15. Which of the following is the best diagnostic course?

(A) begin a prospective diary of symptoms for the next 2 months

(B) obtain a serum progesterone level during the last half of her menstrual cycle (C) obtain a serum estrogen level during the first half of her menstrual cycle (D) perform a transvaginal ultrasound examination of the posterior cul-de-sac (E) begin basal body temperature (BBT) recording

16. She has a normal laboratory and ultrasound evaluation. Her BBT and symptoms calendar are as noted in Figure 18–1 on the following page. Which symptom pattern is most consistent with true premenstrual syndrome (PMS)?

Figure 18–1.

(A) graph A (B) graph B (C) graph C (D) graph D (E) graph E

17. A 33-year-old patient has been diagnosed as having adenomyosis. Which of the following symptoms is most consistent with this diagnosis?

(A) dyspareunia (B) mood swings (C) painful defecation

(D) secondary dysmenorrhea (E) infertility

18. A patient has secondary dysmenorrheal and a fixed pelvis. At laparoscopy, lesions are biopsied that are thought to represent endometriosis. The diagnosis of endometriosis is confirmed histologically by identifying extragenital implants containing which of the following?

(A) endometrial glands and stroma (B) hypertrophic smooth muscle

(E) stromal decidualization

19. Which of the following is the most common indication for treatment of uterine leiomyomata in a 42- year-old woman?

(A) interference with reproductive function (B) rapid enlargement

(D) excessive uterine bleeding (E) impingement on another organ

20. A 45-year-old patient with uterine leiomyomata found on pelvic examination complains of excessive uterine bleeding. Which of the following should be the next step in the management of this patient?

(A) myomectomy (B) hysterectomy (C) ultrasonography (D) endometrial biopsy (E) hysterosalpingography

21. A 26-year-old patient is found to have an 8-week size, irregular uterus. She does not complain of pain or excessive menstrual bleeding. Her Pap smear is normal, and a pregnancy test is negative. Which of the following is the best step in the management of this patient?

(A) continued observation (B) endometrial biopsy (C) cervical conization (D) hysterectomy

(E) pelvic ultrasonography

22. A 23-year-old woman complains of heavy, painful menstrual periods every 2 weeks. On further questioning, you find that every other episode of bleeding is actually very brief, consisting of only 2 days of spotting. At these times, the pain is also only an occasional twinge. During the heavy bleeding, the pain is crampy, nearly constant, located centrally in the pelvis, and lasts 3 days. She reports that this has been her pattern of menstrual pain since her early teens. A BBT curve is biphasic, compatible with normal ovulatory cycles 28 days in length. Her physical examination is normal. In addition to primary dysmenorrhea, which of the following is the most likely diagnosis?

(A) anovulatory bleeding (B) progressive endometriosis (C) chronic constipation

(D) mittelschmerz (E) Halban’s disease

23. A 25-year-old patient with her last menstrual period (LMP) 3 weeks ago is being followed for a 5 cm x 4 cm x 4 cm right ovarian cystic mass. She comes to the emergency department complaining of sudden right-sided low abdominal pain and nausea that has been constant for 2 hours. She had intermittent spasms of pain for a week preceding this episode (when you first felt the cyst). All these pain episodes resolved within minutes. The patient denies fever or recent coitus (none in 6 months). Examination demonstrates a 10 cm x 8 cm x 6 cm right pelvic mass that is very tender. White blood cell (WBC) count is 12,500/mL and temperature is 100.2°F. She has had no prior surgery.

The patient undergoes diagnostic laparoscopy, and a black mass is seen replacing the entire right ovary. Which of the following is the most appropriate management of this patient?

(A) removal of the ovary (B) antibiotic therapy (C) Clostridium antitoxin

(D) reverse torsion and oophoropexy (E) anticoagulation

24. A 58-year-old G2P2 patient presents with complaints of severe vulvar pruritus. She is 10 years postmenopausal. Her examination is consistent with atrophic vulvitis. Which of the following is the most effective treatment of vulvar pruritus associated with atrophic vulvitis?

(A) antihistamines (B) hydrocortisone (C) alcohol injections (D) tranquilizers

(E) topical estrogen therapy

25. A 53-year-old woman is diagnosed with anovulatory dysfunctional bleeding. Which of the following is the most appropriate medical therapy?

(A) orally administered estrogen for the first 25 days of each month (B) vaginal estrogen cream two to three times per week

(E) estrogen 20 mg administered intravenously

26. A 63-year-old patient presents with symptoms of vaginal itching, vaginal dryness, and dys-pareunia.

Which of the following is the most appropriate medical therapy?

(A) orally administered estrogen for the first 25 days of each month (B) vaginal estrogen cream daily

(E) estrogen 20 mg administered intravenously

27. A 19-year-old woman is seen in the emergency department with a history of amenorrhea for 8 weeks, 1 week of unilateral adnexal pain. On physical examination, she is found to have an acute abdomen with tenderness and absent bowel sounds. Laboratory evaluations reveal a hematocrit that is 23%, and a positive pregnancy test. Which of the following is the most likely diagnosis?

(A) ectopic pregnancy

(B) pelvic inflammatory disease (PID) (C) endometriosis

(D) appendicitis

(E) ruptured corpus luteum cyst of the ovary

28. A 23-year-old G1P1 patient is using barrier contraception and is 1 week past onset of her last mense.

She is found to have bilaterally equal adnexal pain; cervical motion tenderness; direct abdominal tenderness; temperature, 101.3°F; and WBC, 12,000/mL. Which of the following is the most likely diagnosis?

(A) ectopic pregnancy (B) PID

(D) urinary tract infection (UTI)

(E) ruptured corpus luteum cyst of the ovary

29. A 16-year-old G0P0 patient reports delayed onset of menses, the sudden onset of severe pain, and syncope. A serum pregnancy test is negative. Her CBC reveals an Hct of 42% and a

WBC of 8,000. Which of the following is the most likely diagnosis?

(A) ectopic pregnancy (B) PID

(E) ruptured corpus luteum cyst of the ovary

30. A 21-year-old patient is seen for a physical examination prior to her return to college. She has been healthy and is using OCs for the past 3 years. On physical examination, you note a 2-mm pigmented flat lesion with irregular margins on the left labia. What is the most appropriate next step in the

management of this lesion?

(A) follow up in 6–12 months (B) discontinue OCs

(D) wide local excision of lesion with 5 mm margins (E) electrodessication of the lesion

31. A 36-year-old patient presents for evaluation of complaints of chronic vaginal infection. She reports little vaginal discharge, but rather a 1-year history of progressively worsening vulvar discomfort that has escalated to pain sufficient to preclude intercourse and tampon use. Inspection of the vulva

demonstrates focal inflammation, punctation, and ulceration of the perineal and vaginal epithelium. An attempt to perform a bimanual examination of the pelvic organs reveals intense pain and tenderness at the posterior introitus and vestibule. Which of the following is the most appropriate next step in the management of this lesion?

(A) topical anesthetics and antidepressant treatment (B) reduction of dietary oxylates

(D) interferon injections of the vaginal introitus (E) electrodessication of the lesions

32. A 32-year-old G0P0 patient presents complaining of secondary dysmenorrhea that is increasing in severity. The pain is triggered by deep thrusting with coitus. Which of the following is the most common cause of deep-thrust dyspare-unia?

(A) endometriosis (B) depression (C) vaginismus (D) vestibulitis (E) atrophic change

33. Treatments of primary dysmenorrhea are directed toward addressing the cause, which is associated with elevations in which of the following?

(A) estrogen (B) progesterone (C) FSH

(D) prostaglandin F2alpha (E) prostaglandin E2

34. A 20-year-old woman at 12 weeks’ gestation is involved in a serious automobile accident and is brought to the emergency department with multiple traumas. The emergency department physician believes that imaging studies of the abdomen are needed to assess the patient’s acute injuries.

Regarding this imaging, what should you counsel the managing team?

(A) Imaging at this stage of pregnancy should not be carried out.

(B) Imaging should be limited to no more than two views of the abdomen.

(D) Only imaging above the level of the uterine fundus should be carried out.

(E) There are no contraindications to the needed tests.

35. Uterine leiomyomata are thought to arise from which of the following?

(A) embryonic rests

(B) vascular smooth muscle cells

(E) placental remnants

36. On pelvic examination of a 28-year-old mul-tiparous patient, several 3–5 mm yellowish translucent or opaque, raised cystic structures are seen on the surface of the cervix. The patient is asymptomatic.

What is the most appropriate next step in the management of these findings?

(A) excisional biopsy

(B) incision and drainage of cysts (C) oral antibiotic therapy

(D) topical estrogen therapy (E) counseling and reassurance

Answers and Explanations

1. (C) Any vulvar ulcer in a woman of this age should be biopsied and, if benign, evaluated at regular intervals for change. If invasive carcinoma is found, radical vulvectomy and inguinal lymphadenectomy are generally the treatment of choice.

2. (E) The patient described presents a typical history of a Bartholin’s gland abscess. In the acute phase, incision and drainage or by marsupialization is most appropriate. Since the duct of the Bartholin’s gland has become obstructed, allowing the formation of an abscess, a neocystostomy must be created.

This may be done by placing a short catheter with an inflatable bulb (Word catheter) into the abscess and leaving it there for 10 to 14 days, or constructing a new duct by marsupialization of the abscess wall. Simple incision and drainage is ineffective in creating a long-term cure and allows for

reformation of the abscess. The etiology of a Bartholin’s duct abscess is unknown. Rest, hot soaks to the area, analgesics, and antibiotics for associated infection may all help speed healing, but these are not definitive. Cystectomy (or excision of the gland) is used to treat only recalcitrant cases or cases suspected of malignancy and can be very difficult surgery.

3. (C) An accurate and careful history may yield information that will solve the problem of vulvar

pruritus. Obviously, vaginitis, diabetes, and uncleanliness may be contributing factors. A wet prep from the vagina will yield the etiology in many cases. The most common vaginitis to cause vulvar pruritus is Monilia infection. Bacterial vaginosis may cause itching, as may trichomoniasis, but itching is not their major symptom. Systemic diseases, including leukemia, may cause vulvar symptoms, but these are rare.

Hidradenitis suppurativa causes vulvar pain and suppurative lesions, but generally not itching. The most likely sources of pruritus of those listed are feminine hygiene products. These agents very commonly cause a contact dermatitis that can result in skin changes and itching.

4. (D) Small, fleshy, polypoid growths from the urethra are most likely urethral caruncles. They not only are most common in postmenopausal women but also occur in children. Topical estrogen cream will usually allay any symptoms. In postmenopausal women, a biopsy must be done prior to treatment in order to rule out the main differential diagnosis, urethral carcinoma. When these caruncles are found in children, prompt recognition will prevent these lesions from being misinterpreted as evidence of sexual abuse.

5. (B) Hidradenitis suppurativa is a refractory infection of the apocrine sweat glands, usually caused by staphylococci or streptococci. Treatment early in the disease consists of drainage and antibiotic therapy. Severe chronic infections may not respond to medical therapy and require extensive surgery.

Multiple, recurrent, infected-appearing ulcers occurring bilaterally on the labia should suggest hidradenitis suppurativa. Herpetic vulvitis presents as a maculopapular rash with vesical formation.

Lymphogranuloma venereum and granuloma inguinale are both uncommon sexually transmitted diseases (STDs) and present with limited but characteristic ulcers (Table 18–1). Secondary syphilis generally does not present with vulvar symptoms, but rather with a “money spot” rash over the torso, palms, and soles of the feet.

6. (A) Very painful punched-out lesions with a yellow exudate but no induration surrounded by an erythematous halo should suggest chancroid. Each of the other conditions listed present with

significantly different symptoms and findings (see Table 18–1).

TABLE 18–1. Minor Sexually Transmitted Diseases

7. (D) Tampon ulcers may cause vaginal discharge or spotting but may also be asymptomatic. When seen on examination, they have the characteristic appearance described in the question; rolled-edge ulcers with a granular base. They are found in the vaginal fornices and go away after the discontinuation of tampon use. A herpetic lesion does not have this appearance. A syphilitic lesion is also unlikely if the woman has not been sexually active, but it would be wise to screen with a rapid plasma reagin (RPR) or Venereal Disease Research Laboratory (VDRL) test or a direct treponemum antibody testing. The other diseases mentioned are less likely because they are sexually transmitted or are extremely unlikely in a woman this age.

8. (A) Benign endocervical or cervical polyps have been reported in up to 4% of patients in some series.

They are most common in multiparous women in the 40- to 50-year-old age group. The main clinical symptom is intermenstrual bleeding. Though uncertain, their etiology is thought to be some type of inflammation. Nabothian cysts arise at areas of active metaplasia of the cervix, resulting in a squamous cell covering of a mucus-secreting gland. This causes a mucus-filled cyst on the cervix, but they do not involve the endocervical canal. Gartner’s duct cysts are lateral on the vaginal wall and represent remnants of the Wolffian duct.

9. (E) Reproductive-age bleeding is most likely to be pregnancy-related. Contraceptive-induced bleeding (breakthrough, IUD, etc.) is also common etiology in the reproductive-age woman. Perimenopausal women are most likely to suffer from benign neoplasia in the form of polyps or leiomyomata.

Postmenopausal women are at the greatest risk for cancer, especially endometrial cancer—the most common gynecologic malignancy.

10. (C) Organic lesions, such as endocervical polyp, cervical ectropion, and infection, may all be the origin of bleeding in a woman of this age. Though rare, the most significant bleeding is generally found with cervical lesions associated with carcinoma. Bleeding from cervical polyps may be heavy, but when sufficient to cause heavy post-coital bleeding, they will generally cause bleeding at other times as well. In contrast, cervical carcinoma may present with heavy postcoital bleeding alone in the early stages of its growth. Therefore, malignancy must always be ruled out. Nabothian cysts of the cervix are not associated with abnormal bleeding.

11. (B) Amenorrhea for at least 6 months establishes the diagnosis of menopause. Uterine bleeding thereafter must be aggressively investigated to rule out neoplasia. Assessment of the endometrium can

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