Page 15 of 18
OG26.1-2,OG27.1-3 | Genital Trauma and Infections — Practice Quiz
Click any question card to reveal the correct answer.
A 28-year-old primipara underwent a prolonged obstructed labour for 36 hours before emergency caesarean section. On day 3 postoperatively she develops continuous involuntary leakage of urine. She reports she has no urge to void and has never felt her bladder fill. Which type of fistula is most likely?
Correct. The hallmark of VVF is continuous total urinary incontinence with no bladder filling, no urge to void, and no ability to store urine at all. This is classic pressure-necrosis VVF following prolonged obstructed labour.
In VVF the bladder is bypassed entirely — urine drains directly into the vagina, so the patient has no desire to void and leakage is completely continuous. In UVF one ureter drains ectopically; the contralateral kidney still fills the bladder normally so the patient voids in addition to leaking.
The key discriminating feature is continuous leakage with no urge to void and no bladder filling at all — the bladder never stores urine. In UVF (ureterovaginal), the bladder still fills partially and the patient still voids. Urethrovaginal presents with stress-pattern leakage. This pattern of total incontinence with no sensation of bladder filling points to VVF.
Click to reveal answer
A 24-year-old woman sustains a 3rd-degree perineal tear during vaginal delivery. Which structure is specifically involved in a 3rd-degree perineal tear that distinguishes it from a 2nd-degree tear?
Correct. A 3rd-degree tear involves the anal sphincter complex (external ± internal anal sphincter) but NOT the rectal mucosa. When the rectal mucosa is also breached, it becomes a 4th-degree tear.
OASIS classification: 3rd-degree = external anal sphincter (3a < 50%, 3b ≥ 50%, 3c + internal sphincter); 4th-degree = sphincter complex + rectal mucosa. This distinction is clinically critical as it determines operative repair requirements and risk of anal incontinence.
The defining feature of a 3rd-degree tear is involvement of the external anal sphincter (partial = 3a, >50% = 3b, internal sphincter also = 3c). Involvement of the rectal mucosa in addition upgrades it to 4th-degree. Tears involving only skin and perineal muscles without the sphincter are 1st or 2nd degree.
Click to reveal answer
A woman with a confirmed vesicovaginal fistula following caesarean section presents 10 days after delivery. She is keen for early repair. What is the most appropriate initial management?
Correct. For obstetric VVF, continuous catheter drainage for 6-12 weeks allows small fistulae to close spontaneously, reduces oedema, and allows fibrosis to mature before surgical repair. The traditional principle is to wait approximately 3 months ('3 months rule') for tissue to heal and vascularity to recover.
Initial management of VVF: continuous catheter drainage for up to 3 months — ~15% of small fistulae will close spontaneously. Surgical repair (transvaginal Latzko or transabdominal) is deferred until oedema resolves and the fistula tract matures (classically 3 months, some centres now advocate 6-week repair for post-surgical fistulae if tissues are well-vascularised).
Immediate surgical repair of an acute VVF is generally not advised — the tissues are oedematous, vascular, and inflamed, making watertight closure technically difficult. Continuous Foley drainage is first-line: small fistulae may close spontaneously, and those requiring surgery benefit from delayed repair when tissues are healthier. Colostomy is used for rectovaginal fistulae, not urinary fistulae.
Click to reveal answer
A 22-year-old woman presents with a single painless, clean-based, indurated genital ulcer that appeared 2 weeks ago. Inguinal lymph nodes are mildly enlarged, firm, non-tender, and non-suppurating. Dark-field microscopy of the ulcer exudate shows motile spirochaetes. What is the most likely diagnosis?
Correct. The classic chancre of primary syphilis is a single, painless, clean-based, indurated (cartilage-hard edge) ulcer with non-tender inguinal lymphadenopathy. Dark-field microscopy showing motile spirochaetes is diagnostic of Treponema pallidum.
Genital ulcer differential — key discriminators: Syphilis = painless indurated ulcer + non-tender firm nodes; Chancroid = painful soft ragged ulcer + tender suppurating bubo; Herpes = multiple painful shallow vesicular ulcers; LGV = transient ulcer then groove sign (inguinal and femoral nodes separated by Poupart's ligament). Dark-field microscopy is the gold standard for primary syphilis.
The painless, indurated, clean-based nature of this ulcer with non-tender lymphadenopathy is classic for primary syphilis. Chancroid (H. ducreyi) produces a PAINFUL, soft, ragged, necrotic ulcer with tender suppurating lymph nodes. Herpes simplex presents as multiple small vesicles/shallow painful ulcers. LGV typically shows a small transient ulcer followed by prominent tender bubo formation.
Click to reveal answer
Under the NACO syndromic management guidelines, what is the correct first-line treatment for a patient presenting with vaginal discharge syndrome (mucopurulent cervicitis pattern) at a primary health centre?
Correct. NACO recommends dual therapy for cervicitis/urethral discharge to cover both gonorrhoea and chlamydia simultaneously: ceftriaxone (for resistant gonorrhoea — ciprofloxacin is no longer recommended due to widespread resistance) plus azithromycin (for chlamydia). This is a key examination trap.
Critical drug-choice trap: Ciprofloxacin for gonorrhoea is OBSOLETE in India. Current NACO dual therapy = ceftriaxone 250 mg IM (gonorrhoea) + azithromycin 1 g oral (chlamydia) as single-dose simultaneously. Syndromic management treats at first visit without awaiting lab results.
Ciprofloxacin is no longer recommended in India for gonococcal infections due to widespread resistance. Metronidazole alone covers anaerobes/BV/trichomonas but not gonorrhoea or chlamydia. Benzathine penicillin is the treatment for syphilis. For cervicitis/urethral discharge, NACO mandates dual therapy with ceftriaxone + azithromycin to cover both gonorrhoea and chlamydia at one visit.
Click to reveal answer
A 29-year-old woman with primary infertility of 4 years undergoes diagnostic laparoscopy. The surgeon finds bilateral tubal occlusion with peritubal adhesions and caseous nodules at the cornua. Histology of the nodules shows epithelioid granulomas with Langhans giant cells and central caseous necrosis. What is the most common primary site of the original infection in this condition?
Correct. Genital tuberculosis is almost always secondary to haematogenous spread from a primary pulmonary focus (lung is the most common primary site). The blood-borne spread reaches the highly vascular fallopian tubes first, which are the most commonly affected genital site.
Pathogenesis of genital TB: lung primary focus → bacteraemia → fallopian tubes (most common site, ~90-100%) → endometrium → ovaries → cervix (rare) → vulva/vagina (very rare). Haematogenous spread is the rule. Fallopian tube involvement is almost universal in genital TB.
Genital TB is virtually always secondary — it reaches the reproductive tract via haematogenous spread from a primary focus elsewhere. The lung (pulmonary TB or primary complex) is the most common origin, although gastrointestinal or lymph node primary foci can also seed haematogenously. Direct spread from adjacent organs is rare.
Click to reveal answer
A woman is diagnosed with genital tuberculosis on the basis of endometrial curettage showing caseating granulomas. She asks whether anti-tubercular therapy will restore her fertility. What is the most accurate response?
Correct. This is the critical teaching point in genital TB: ATT treats the active infection and prevents further damage, but it CANNOT reverse established tubal fibrosis, adhesions, or endometrial destruction. Fertility outcomes remain poor (10-15% even with IVF in some series), and this must be communicated clearly to the patient.
Key insight: ATT cures the infection but NOT the structural damage. Prognosis for spontaneous fertility after genital TB is poor (~5-10%). IVF may be considered but endometrial TB (Asherman syndrome, thin/fibrosed endometrium) limits IVF success. Always counsel about this distinction.
A common student error is conflating 'cure of infection' with 'restoration of anatomy.' ATT eradicates viable mycobacteria, prevents progression, and reduces contagion risk, but it has no ability to reverse scar tissue, tubal occlusion, or Asherman syndrome that have already formed. IVF is the best assisted reproduction option but is not always successful, especially with severe endometrial involvement.
Click to reveal answer
A 25-year-old woman presents with lower abdominal pain, fever, and abnormal vaginal discharge for 5 days. On examination there is cervical motion tenderness, bilateral adnexal tenderness, and uterine tenderness. High vaginal swab shows pus cells but no organisms on Gram stain. What is the minimum clinical criterion sufficient for empirical treatment of PID according to CDC guidelines?
Correct. The CDC deliberately set the minimum diagnostic threshold for empirical PID treatment very low — ANY ONE of the three pelvic tenderness signs (CMT alone, uterine tenderness alone, or adnexal tenderness alone) in a sexually active woman with no other explanation is sufficient to start treatment. This protects against the harm of delayed treatment and tubal damage.
CDC PID minimum criteria: CMT alone, uterine tenderness alone, or adnexal tenderness alone = treat. The threshold is deliberately low because the cost of missed treatment (tubal damage → infertility, ectopic, chronic pelvic pain) exceeds the cost of over-treatment. Enhanced criteria (fever, elevated WBC/CRP, mucopurulent discharge) increase specificity but are not required.
The CDC minimum criteria for empirical PID treatment are deliberately liberal: ANY ONE of cervical motion tenderness, uterine tenderness, or adnexal tenderness alone is enough to treat empirically in a sexually active woman at risk. Requiring all three, or requiring fever or elevated inflammatory markers, would delay treatment and risk tubal scarring. Laboratory confirmation is NOT required before starting treatment.
Click to reveal answer
A 28-year-old woman with PID is being treated as an outpatient. She fails to improve after 72 hours of oral antibiotics and returns with worsening pain and a tender adnexal mass on ultrasound. What complication should be suspected, and what is the immediate management?
Correct. Failure to respond to outpatient PID antibiotics with a new adnexal mass on ultrasound indicates a tubo-ovarian abscess (TOA). Management is inpatient IV antibiotics (clindamycin + gentamicin is the preferred CDC inpatient regimen); surgical or radiological drainage is indicated if no improvement after 72 hours of IV therapy.
TOA complicates ~15% of PID cases. Initial management: hospitalise + IV antibiotics (clindamycin 900 mg 8-hourly + gentamicin 1.5 mg/kg 8-hourly, or alternative regimens). Surgical drainage if: failure to respond to 72 hours IV antibiotics, TOA >8 cm, threatened rupture. Ruptured TOA = surgical emergency.
An adnexal mass plus failure to respond to outpatient PID treatment = tubo-ovarian abscess until proven otherwise. TOA requires admission for IV antibiotics. Most TOAs (70-80%) respond to IV antibiotics alone; drainage (ultrasound-guided aspiration or surgical) is reserved for those that fail to respond or are large. Ectopic pregnancy should be excluded by serum beta-hCG but the scenario does not suggest an acute haemoperitoneum.
Click to reveal answer
A woman who has had three episodes of PID presents asking about her risk of future problems. Which long-term complication is most directly linked to the number of PID episodes she has had?
Correct. Tubal factor infertility increases directly with the number of PID episodes: approximately 10-12% after 1 episode, 20-25% after 2 episodes, and 40-50% after 3 or more episodes. Each episode adds cumulative scar tissue to the fallopian tube mucosa.
Long-term PID sequelae — cumulative with each episode: (1) Tubal infertility: ~10% after 1 episode, ~25% after 2, ~40-50% after 3+. (2) Ectopic pregnancy: 6-10× increased risk. (3) Chronic pelvic pain: ~18% after 1 episode. Each PID episode reinforces the importance of partner notification and treatment to prevent recurrence.
The major long-term complications of PID are: tubal factor infertility, ectopic pregnancy risk, and chronic pelvic pain — all proportional to number of episodes. Risk of tubal infertility roughly doubles with each additional PID episode. Cervical cancer is caused by HPV and is unrelated to PID episodes. Ovarian cancer and endometrial polyps are not sequelae of PID.
Click to reveal answer