LE6 GYNE Flashcards

Question

Question: For Bacterial Vaginosis (Case #8), do we need to treat the sexual partner? A. YES B. NO need

Answer 1

B. NO need Rationale: Bacterial vaginosis is not a true STI, so partner treatment is not required unless symptomatic.

Answer 2

B. Spirochete Rationale: Syphilis is caused by Treponema pallidum, a spirochete bacterium. It is a sexually transmitted infection that progresses through multiple stages if untreated.

Answer 3

C. Syphilis Rationale: Primary syphilis presents as a painless, well-demarcated ulcer (chancre) with associated regional lymphadenopathy.

Answer 4

C. Chlamydia trachomatis Rationale: Lymphogranuloma venereum (LGV), caused by Chlamydia trachomatis, presents with painless genital ulcers followed by suppurative inguinal lymphadenopathy.

Answer 5

C. Condyloma latum Rationale: Condyloma latum are broad, flat, wart-like lesions found in moist intertriginous areas in secondary syphilis.

Answer 6

C. Nucleic acid amplification test (NAAT) Rationale: NAAT is the most sensitive and specific test for diagnosing Chlamydia trachomatis, the causative agent of LGV.

Answer 7

B. Gardnerella vaginalis Rationale: Gardnerella vaginalis is the primary cause of bacterial vaginosis, which presents with clue cells (epithelial cells covered with bacteria) on microscopy.

Answer 8

C. Herpes simplex virus Rationale: Genital herpes presents as painful vesicles on an erythematous base, which progress to ulcerations.

Answer 9

C. Genital herpes Rationale: HSV infection causes recurrent painful vesicles and ulcers in the genital area.

Answer 10

A. Condyloma acuminata Rationale: Human papillomavirus (HPV) causes condyloma acuminata, which appear as cauliflower-like or flat, hyperpigmented lesions.

Answer 11

C. Human immunodeficiency virus (HIV) Rationale: HIV is a retrovirus that causes progressive immune suppression, leading to AIDS.

Answer 12

A. Granuloma inguinale Rationale: Klebsiella granulomatis is the causative agent of granuloma inguinale (donovanosis), characterized by painless, beefy-red ulcers.

Answer 13

D. Lymphogranuloma venereum Rationale: LGV, caused by Chlamydia trachomatis, is characterized by painful inguinal lymphadenopathy (buboes).

Answer 14

A. Syphilis Rationale: Secondary syphilis presents with symmetrical, non-pruritic maculopapular rashes on the palms and soles.

Answer 15

C. Genital herpes Rationale: Herpes simplex virus causes painful genital ulcers with systemic symptoms such as fever and malaise.

Answer 16

A. Chancroid Rationale: Haemophilus ducreyi causes chancroid, characterized by painful ulcers with ragged edges and soft consistency.

Answer 17

A. Syphilis (Treponema pallidum) Rationale: The shallow painless ulcer on the labia minora with tender inguinal lymphadenopathy is characteristic of primary syphilis caused by Treponema pallidum.

Answer 18

C. Gonorrhea Rationale: Gonorrhea, caused by Neisseria gonorrhoeae, presents with mucopurulent discharge and is common in young sexually active individuals. It can lead to pelvic inflammatory disease and is a marker for concomitant Chlamydia trachomatis infection in up to 40% of cases.

Answer 19

B. FTA-ABS Rationale: FTA-ABS detects Treponema pallidum antibodies and is used to confirm syphilis after an initial non-treponemal test (e.g., VDRL or RPR).

Answer 20

B. Endocervix Rationale: The endocervix is the primary site of gonorrhea infection in females. Infection of Bartholin’s glands is also common.

Answer 21

B. Vulva Rationale: LGV, caused by Chlamydia trachomatis, primarily affects the vulva and presents with painless ulcers followed by suppurative inguinal lymphadenopathy (buboes).

Answer 22

C. Granuloma inguinale (Donovanosis) Rationale: Klebsiella granulomatis causes granuloma inguinale, characterized by painless, beefy-red ulcers with a tendency for slow progression.

Answer 23

A. Condyloma acuminata Rationale: Human papillomavirus (HPV) causes condyloma acuminata, which appear as warty lesions. Acetic acid application leads to whitening of the lesions.

Answer 24

B. 6-12 weeks Rationale: Most HIV antibody tests detect infection within 23-90 days after exposure.

Answer 25

C. Chancroid Rationale: Haemophilus ducreyi causes chancroid, characterized by painful soft ulcers with tender inguinal lymphadenopathy (buboes).

Answer 26

B. Pelvic inflammatory disease (PID) Rationale: PID presents with lower abdominal pain, purulent vaginal discharge, and cervical motion tenderness. It is commonly caused by Neisseria gonorrhoeae and Chlamydia trachomatis.

Answer 27

C. Ectopic pregnancy Rationale: PID causes scarring and adhesions in the fallopian tubes, leading to an increased risk of ectopic pregnancy, infertility, and chronic pelvic pain. Severe PID increases the ectopic pregnancy risk to 50%.

Answer 28

B. Tubo-ovarian abscess Rationale: TOA is a severe complication of PID, characterized by an inflammatory mass involving the fallopian tube and ovary. It often requires hospitalization and IV antibiotics.

Answer 29

C. Salpingitis Rationale: The "tobacco pouch" sign represents an enlarged, distended fallopian tube with everted fimbriae, commonly seen in genital tuberculosis and salpingitis.

Answer 30

B. Uterine prolapse Rationale: * Uterine prolapse occurs due to weakened pelvic support structures, leading to descent of the uterus into the vaginal canal. Key signs: * Palpable fleshy mass at the vulva * History of multiple pregnancies (multiparity) * Pelvic pressure and incontinence * Abscesses are usually painful and fluctuant, while carcinomas are typically irregular, firm, and non-reducible.

Answer 31

D. Stage III Rationale: According to the International Continence Society (ICS) staging system: Stage 0: No prolapse is present. Stage I: The most distal portion of the prolapse remains more than 1 cm above the hymen. Stage II: The most distal portion of the prolapse is within 1 cm of the hymen. Stage III: The most distal portion of the prolapse is more than 1 cm below the hymen but does not completely evert the vaginal canal. Stage IV: Complete vaginal eversion. Since the most distal part of the prolapse is 3 cm below the hymen, this classifies it as Stage III.

Answer 32

A. Surgery

Answer 33

D. All of the above Rationale: Normal pelvic organ support is provided by: Level I: Uterosacral and cardinal ligaments (support for the vaginal apex and cervix). Level II: Connective tissue attachments to the arcus tendinous fasciae pelvis (support for the mid-vagina). Level III: Perineal membrane, muscles, and connective tissue attachments (support for the distal vagina).

Answer 34

D. Stage IV Rationale: Stage I: The most distal portion of the prolapse is more than 1 cm above the hymen. Stage II: The prolapse is ≤1 cm proximal or distal to the hymen. Stage III: The prolapse is >1 cm below the hymen but does not completely evert the vaginal canal. Stage IV: Complete eversion of the lower genital tract. Since the mass extends 8 cm beyond the hymen, this is classified as Stage IV pelvic organ prolapse, which represents complete vaginal eversion.

Answer 35

D. Surgery Rationale: Stage IV pelvic organ prolapse requires definitive surgical intervention to restore pelvic anatomy and function. The preferred surgical approach includes vaginal hysterectomy with vaginal vault suspension and anterior-posterior colporrhaphy. Any associated ulcers or infections should be treated first before proceeding with surgery. Since the patient has complete vaginal eversion (Stage IV prolapse), surgery is the only definitive treatment.

Answer 36

A. Cystocele Rationale: The patient’s symptoms of urinary incontinence and the need to push a protruding vulvar mass to urinate strongly suggest a cystocele, which is the herniation of the bladder into the anterior vaginal wall. Key Features of a Cystocele: • Urinary symptoms: Urinary incontinence, difficulty urinating, incomplete bladder emptying • Pelvic pressure or bulging sensation in the vagina • Mass visible at the vulva, especially with straining • Exam findings: • Fleshy mass in the vulvar area • Anterior vaginal wall involvement • Cervix remains in normal position (not significantly prolapsed)

Answer 37

C. Point Aa Rationale: Point Aa is located in the midline of the anterior vaginal wall, 3 cm proximal to the urethral meatus, corresponding to the urethrovesical junction. Since the prolapse in this case involves the anterior vaginal wall, Point Aa is the primary reference point affected in this patient. Point C Most distal part of the cervix (or vaginal apex post-hysterectomy) "Patient had a hysterectomy, and bulging is seen at the vaginal apex." Point D Posterior fornix (Pouch of Douglas), attachment of uterosacral ligaments "Pelvic exam reveals prolapse involving the posterior fornix."

Answer 38

B. Stage 2 Rationale: Stage I: The most distal portion of the prolapse remains more than 1 cm above the hymen. Stage II: The prolapse is ≤1 cm proximal or distal to the hymen. Stage III: The prolapse is >1 cm below the hymen but does not completely evert the vaginal canal. Stage IV: Complete vaginal eversion. Since the mass protrudes 1 cm below the hymen, this is classified as Stage II pelvic organ prolapse.

Answer 39

C. Pessary Rationale: Non-operative management is the first-line treatment for Stage I and II pelvic organ prolapse. Options include: Pessary support (most effective conservative treatment). Large tampons (temporary support). Kegel exercises (strengthen pelvic floor muscles). Estrogen vaginal creams (help maintain tissue integrity). Surgery is typically reserved for Stage III and IV prolapse.

Answer 40

C. Both Rationale: Enterocele involves herniation of the small intestine into the vaginal wall, causing bowel dysfunction. Urethrocele involves urethral descent into the vaginal wall, causing urinary difficulties. Since the patient has both urinary and bowel dysfunction, both conditions must be considered.

Answer 41

C. Transillumination Rationale: Transillumination can help differentiate an enterocele (fluid-filled sac of intestines) from a rectocele (soft tissue of rectum). Rectoceles do not transilluminate, whereas enteroceles often do.

Answer 42

D. All of the above Rationale: McCall Stitch is commonly used during vaginal hysterectomy to prevent enterocele formation. Abdominal sacrocolpopexy is a more definitive surgical repair option for enterocele. Transabdominal reduction may be required for severe enterocele cases.

Answer 43

D. All of the above Rationale: Urethrocele: Descent of the urethra and bladder neck, leading to urinary symptoms such as incontinence or retention. Enterocele: Herniation of the pouch of Douglas containing small intestines into the rectovaginal septum, commonly seen post-hysterectomy. Pelvic organ prolapse (POP): Encompasses multiple forms of prolapse, including urethrocele, cystocele, rectocele, and enterocele.

Answer 44

C. Stage 3 Rationale: Stage I: Prolapse is more than 1 cm above the hymen. Stage II: Prolapse is within 1 cm of the hymen. Stage III: Prolapse is more than 1 cm below the hymen but not completely everted. Stage IV: Complete eversion of the vaginal canal. Since the most distal part of the prolapse is more than 1 cm below the hymen but does not completely evert the vaginal canal, this is classified as Stage III.

Answer 45

B. Stage 1 Rationale: Stage 0: No prolapse. Stage 1: Most distal part of the prolapse remains >1 cm above the hymen. Stage 2: Prolapse is ≤1 cm above or below the hymen. Stage 3: Prolapse extends >1 cm below the hymen but does not completely evert the vaginal canal. Stage 4: Complete eversion of the vaginal canal.

Answer 46

C. Stage 3 Rationale: Stage 3: Prolapse extends >1 cm below the hymen but does not completely evert the vaginal canal. This is distinct from Stage 4, which is complete vaginal eversion.

Answer 47

B. Perineal body Rationale: The perineal body (PB) is the distance between the posterior vaginal wall and rectum. It provides support for the perineum and anal sphincter.

Answer 48

B. Point Bp Rationale: Point Bp is a posterior vaginal wall reference point used in POP-Q (Pelvic Organ Prolapse Quantification). It measures the descent of the posterior vaginal wall in prolapse evaluation.

Answer 49

C. Point D Rationale: Point D represents the posterior fornix in the POP-Q system. It is used to evaluate uterine and vaginal vault prolapse.

Answer 50

A. Stage 0 Rationale: Stage 0: No prolapse is demonstrated. Points Aa, Ap, Ba, and Bp are all at -3 cm. This means the pelvic support structures remain intact.

Answer 51

A. Stage 0 Rationale: No prolapse is present when all these points are at -3 cm, confirming Stage 0 pelvic organ prolapse.

Answer 52

B. Cystocele Rationale: Cystocele is the most common anterior compartment defect, involving prolapse of the bladder into the vagina. Symptoms include urinary incontinence, retention, and urgency.

Answer 53

C. Rectocele Rationale: Rectocele occurs when the rectum bulges into the vaginal wall, often worsening with straining or defecation. Diagnostic methods: History and physical examination Rectovaginal exam (thin rectovaginal septum and bulging of rectum into the vagina).

Answer 54

C. Enterocele Rationale: Enterocele (herniation of small intestine into the rectovaginal septum) can occur after a hysterectomy due to loss of apical vaginal support. Prevention: Incorporating the uterosacral and cardinal ligaments into vault repair prevents vaginal vault prolapse and enterocele formation.

Answer 55

A. True Rationale: Multiparity is a major risk factor for POP due to weakened pelvic support structures from repeated childbirth.

Answer 56

A. True Rationale: Menopause, aging, childbirth history, and heavy physical activity contribute significantly to pelvic floor weakening and prolapse.

Answer 57

A. True Rationale: Obesity increases intra-abdominal pressure, worsening pelvic organ prolapse. Pelvic surgery may weaken supporting ligaments, predisposing to prolapse.

Answer 58

B. False Rationale: Heavy lifting is debated as a risk factor because: It increases intra-abdominal pressure, which may worsen existing prolapse. However, evidence does not consistently link it to new cases of prolapse.

Answer 59

A. True Rationale: Estrogen helps maintain pelvic floor muscle tone. Estrogen deficiency post-menopause leads to pelvic floor muscle weakening, increasing prolapse risk.

Answer 60

A. True Rationale: Pelvic organ prolapse (POP) occurs due to denervation injuries from childbirth, leading to levator ani muscle atrophy and weakening of pelvic support structures.

Answer 61

A. True Rationale: POP results from multiple contributing factors, including: Pregnancy and childbirth trauma (levator ani and connective tissue injury). Menopause and estrogen deficiency (weakened pelvic floor support). Chronic increased intra-abdominal pressure (e.g., obesity, chronic cough, constipation).

Answer 62

A. True Rationale: Stage I POP is when the most distal portion of the prolapse remains more than 1 cm above the hymen. At this stage, prolapse is limited to the upper barrel of the vagina and does not descend near the vaginal opening.

Answer 63

A. True Rationale: ICS staging (POP-Q system) is a standardized, quantitative method for describing pelvic organ prolapse. It provides objective measurements of vaginal support loss at specific anatomical points.

Answer 64

B. False Rationale: The genital hiatus (GH) is measured from the middle of the external urethral meatus to the posterior hymen. It is not measured to the anal opening, as the perineal body separates the genital hiatus from the anal region.

Answer 65

B. Principle of Totality Rationale: The Principle of Totality states that medical interventions can be performed on a body part if they serve the overall well-being of the person. In this case, a hysterectomy is performed to save the patient’s life, even though it results in the loss of reproductive capability. The decision follows the ethical concept that removal of an organ is justified if it benefits the person's overall health.

Answer 66

A. Principle of Non-maleficence Rationale: The Principle of Non-maleficence states that physicians should not cause harm and should refer patients when the care required is beyond their expertise. By referring the patient to a qualified specialist, the general practitioner avoids potential harm that could result from an improperly performed procedure.

Answer 67

C. Principle of Beneficence Rationale: The Principle of Beneficence requires physicians to act in the best interest of the patient, considering factors beyond medical aspects, such as patient preferences, quality of life, and contextual features that affect decision-making.

Answer 68

C. Principle of Autonomy Rationale: The Principle of Autonomy states that patients must receive timely, relevant, and adequate information to make informed choices. Withholding information violates this principle and compromises the patient’s ability to make informed decisions.

Answer 69

B. Deliberative Clinical Management Rationale: Deliberative Clinical Management ensures that treatment recommendations align with medical evidence and ethical principles.

Answer 70

A. When at least one medically reasonable alternative exists Rationale: Physicians should only recommend interventions that have medical validity and ethical justification.

Answer 71

D. Both A & C Rationale: Non-directive counseling provides neutral information, allowing the patient to decide. Shared Decision Making involves a collaborative approach between physician and patient. OB-GYNs often use both approaches in ethical decision-making.

Answer 72

C. Create a culture that supports professional collaboration Rationale: Ethical medical practice involves interdisciplinary teamwork, ensuring the best possible patient care.

Answer 73

B. Texting about lab results Rationale: Texting results to a patient does not breach confidentiality, as long as it maintains privacy and security.

Answer 74

D. All of the above Rationale: Informed consent requires patients to understand their diagnosis, treatment purpose, methods, duration, risks, and alternatives before agreeing.

Answer 75

C. Secure electronic medical records with security protocols Rationale: Patient confidentiality requires secure handling of medical records, including password-protected electronic systems.

Answer 76

A. Yes, if they have parental/guardian written consent Rationale: Minors require parental or guardian consent before receiving contraceptives under legal guidelines.

Answer 77

B. Provide an affidavit stating the reason for refusal Rationale: Physicians with moral objections should document their stance in an affidavit for legal protection.

Answer 78

A. Beneficence and Autonomy Rationale: Beneficence supports contraception as a preventive health measure. Autonomy allows patients to make informed reproductive choices.

Answer 79

C. Respect the patient’s decision and not perform BTL Rationale: Sterilization requires explicit informed consent from the patient. Even if medically advisable, the patient has full autonomy over her reproductive choices.

Answer 80

D. Explanation that sterilization procedures have an insignificant failure rate Rationale: No sterilization method is 100% effective; the failure rate must be discussed as part of informed consent.

Answer 81

A. Give emergency contraception and discuss future strategies. Rationale: Emergency contraception (EC) is effective if given within 72 hours of unprotected intercourse. EC is not illegal and is available in the Philippines, though it depends on the OB-GYN whether they choose to prescribe it.

Answer 82

B. Principle of Double Effect Rationale: The principle of double effect applies when a treatment has both good and bad effects. The treatment is directed toward the pathologic organ (cervix) and not intended to harm the fetus, even if it may indirectly lead to fetal loss. The act itself is not intrinsically evil, and the bad effect (fetal harm) does not outweigh the good effect (life-saving cancer treatment for the mother).

Answer 83

D. The act itself is not intrinsically evil. Rationale: The principle of double effect states that an action can be morally permissible even if it has negative side effects, as long as: The act itself is not intrinsically evil. The bad effect does not cause the good effect. The bad effect does not outweigh the good effect. There is a proportionate reason to tolerate the bad effect.

Answer 84

C. Obtain valid informed consent and seek approval from the hospital ethics committee. Rationale: Cesarean section on maternal request (CSMR) requires ethical considerations, especially in the absence of medical indications. The OB-GYN must discuss risks and benefits with the patient and obtain valid informed consent. Ethics committee approval may be necessary to ensure that the decision aligns with hospital policies and ethical standards.

Answer 85

A. Beneficence Rationale: Beneficence requires that physicians consider all aspects of patient well-being, including professional, personal, financial, and legal factors, to ensure the best possible care.

Answer 86

B. Autonomy Rationale: Autonomy requires that patients receive timely, relevant, and adequate information about their medical condition and treatment. Withholding information may lead to uninformed decisions that could negatively impact the patient.

Answer 87

B. Deliberative clinical management Rationale: Deliberative clinical management ensures that treatment recommendations are based on evidence, ethical principles, and patient-centered care.

Answer 88

A. When at least one medically reasonable alternative exists Rationale: Physicians should only recommend treatments that have medical validity and ethical justification.

Answer 89

A. Directive counseling Rationale: Directive counseling occurs when a physician recommends a specific treatment option based on clinical evidence and medical ethics.

Answer 90

A. Creating a culture that supports professional collaboration Rationale: Interdisciplinary teamwork ensures high-quality patient care and ethical decision-making.

Answer 91

A. Patient texting the doctor their lab test results Rationale: Communicating via text for medical results is not a breach of ethics, as long as privacy and security are maintained.

Answer 92

A. Diagnosis, purpose, method, and duration of treatment Rationale: Informed consent ensures that the patient understands the diagnosis, procedure, risks, benefits, and alternatives before agreeing to treatment.

Answer 93

A. Electronic medical records require security protocols Rationale: Patient confidentiality mandates secure handling of medical records to protect personal health information.

Answer 94

A. If the student presents a written consent form from a parent or guardian Rationale: Minors require parental/guardian consent before receiving contraceptives, in accordance with legal guidelines.

Answer 95

A. Obtain a DOH affidavit stating the refusal and reasonA. Non-maleficence Rationale: Physicians with moral objections must document their stance in an affidavit for legal protection.

Answer 96

A. Non-maleficence Rationale: Non-maleficence ensures that contraceptive choices prioritize patient safety and well-being, minimizing potential harm.

Answer 97

A. Do not perform bilateral tubal ligation Rationale: Sterilization requires explicit written informed consent from the patient. Even if medically advisable, autonomy dictates that the patient has full control over her reproductive choices.

Answer 98

A. Explanation that sterilization procedures have an insignificant failure rate Rationale: No sterilization method is 100% effective. Failure rates, though low, must be disclosed as part of informed consent.

Answer 99

A. Give emergency contraception and discuss future contraceptive strategies Rationale: Emergency contraception (EC) is effective within 72 hours of unprotected intercourse. EC is not illegal in the Philippines, and it is at the discretion of the OB-GYN whether to prescribe it.

Answer 100

B. Principle of Double Effect Rationale: The Principle of Double Effect applies when a treatment has both beneficial and harmful effects. The intent is to treat the pathology (cervical cancer), not to harm the pregnancy, even though fetal loss may occur as an indirect consequence.

Answer 101

A. The act itself is intrinsically evil Rationale: The Principle of Double Effect states that an action must not be intrinsically evil and that the bad effect must not outweigh the good effect.

Answer 102

A. Autonomy Rationale: Patients have the right to make informed decisions regarding their treatment, especially in complex cases like cancer in pregnancy.

Answer 103

A. Obtain valid informed consent and seek approval from the ethics committee Rationale: Cesarean section on maternal request (CSMR) requires ethical consideration when there is no medical indication. The OB-GYN must discuss risks and benefits and obtain ethics committee approval if needed.

Answer 104

D. Doctor’s personal opinion on treatment choice Rationale: Informed consent is an ongoing process that involves disclosure of information, voluntary decision-making, and patient understanding.

Answer 105

B. Justice Rationale: Justice ensures fairness in medical treatment, including equal access to healthcare services.

Answer 106

A. Non-directive Rationale: Non-directive counseling allows the patient to explore all options without physician bias.

Answer 107

A. Conscientious objector Rationale: A conscientious objector is a healthcare provider who refuses to perform certain legal medical services due to personal ethical or religious beliefs.

Answer 108

A. Secure consent from parents or guardians before any procedure Rationale: Minors (<18 years) require parental/guardian consent for medical procedures, as required by law.

Answer 109

A. Encourage male partners to share responsibility Rationale: Both partners share responsibility in ensuring safer sex and contraception use to prevent unplanned pregnancy and sexually transmitted infections (STIs).

Answer 110

A. Assess the patient and perform completion curettage Rationale: Dilation and curettage (D&C) is performed to remove remaining uterine tissue after a miscarriage or abortion to prevent complications such as infection and hemorrhage. Ethical responsibility dictates that the physician must provide medical care, regardless of personal or legal considerations regarding the abortion.

Answer 111

A. Non-maleficence Rationale: Non-maleficence is the obligation of a physician not to harm the patient and to minimize avoidable risks in medical care.

Answer 112

A. Health status of the fetus Rationale: When managing a brain-dead pregnant woman, the health and viability of the fetus must be assessed to determine if continued pregnancy is medically feasible.

Answer 113

B. Stage II Rationale: Stage I: Cancer is confined to the uterus. Stage II: Cancer extends outside the uterus but is limited to genital structures such as the adnexa (ovaries, fallopian tubes), cervix, or vagina. Stage III: Cancer spreads beyond the genital structures but remains within the pelvis. Stage IV: Cancer spreads to distant organs outside the pelvis.

Answer 114

B. Prolapse Rationale: Pelvic organ prolapse (POP) occurs when weakened pelvic floor muscles cause descent of pelvic organs. A fleshy, reducible mass in an elderly multigravida strongly suggests pelvic organ prolapse rather than a cyst, abscess, or malignancy.

Answer 115

C. Stage III Rationale: Stage I: Prolapse >1 cm above the hymen. Stage II: Prolapse ≤1 cm proximal or distal to the hymen. Stage III: Prolapse >1 cm below the hymen but does not completely evert the vaginal canal. Stage IV: Complete vaginal eversion. Since the most distal part of the mass is 3 cm below the hymen, this is classified as Stage III pelvic organ prolapse.

Answer 116

C. Surgery Rationale: Stage III prolapse usually requires surgical intervention as conservative treatments (pessaries, Kegel exercises) are less effective. Surgical options include vaginal hysterectomy with vaginal vault suspension and anterior-posterior colporrhaphy.

Answer 117

D. All of the above Rationale: The pelvic support system is made up of multiple structures, including: Perineal muscles (support vaginal and rectal walls). Cardinal ligaments (support the uterus and upper vagina). Pelvic fascia (provides connective tissue support).

Answer 118

D. Stage IV Rationale: Stage IV is characterized by complete vaginal eversion. Since the mass extends 8 cm beyond the hymen, this is classified as Stage IV pelvic organ prolapse.

Answer 119

C. Surgery Rationale: Stage IV prolapse requires definitive surgical correction to restore pelvic anatomy and prevent complications. Surgical options include vaginal hysterectomy with vaginal vault suspension and anterior-posterior colporrhaphy.

Answer 120

A. Urethrocele Rationale: Urethrocele occurs when the urethra and bladder neck prolapse into the vaginal wall, leading to urinary incontinence or retention. Symptoms: Difficulty urinating unless manually repositioning the prolapse. Anterior vaginal wall involvement, distinguishing it from rectocele (posterior wall prolapse).

Answer 121

A. Aa Rationale: Point Aa is located in the midline of the anterior vaginal wall, 3 cm proximal to the urethral meatus, corresponding to the urethrovesical junction. Because the prolapse involves the anterior vaginal wall, Point Aa is the primary reference point affected. 🔹 QUICK IDENTIFICATION TIPS FOR CASES ✅ Anterior bulge? → Think Aa/Ba (anterior vaginal wall prolapse) ✅ Posterior bulge? → Think Ap/Bp (posterior vaginal wall prolapse) ✅ Cervical prolapse? → Look at Point C ✅ Post-hysterectomy apex prolapse? → Check Point C & D ✅ Rectovaginal symptoms (splinting, constipation)? → Consider PB involvement 🔹 High-yield clinical clues: If the bulge worsens with straining → assess Aa, Ba, Ap, Bp. If anterior prolapse + urinary incontinence → consider urethral hypermobility (stress incontinence). If posterior prolapse + constipation → suspect rectocele.

Answer 122

B. Stage 2 Rationale: Stage 1: Prolapse remains >1 cm above the hymen. Stage 2: Prolapse is ≤1 cm above or below the hymen. Stage 3: Prolapse extends >1 cm below the hymen but does not completely evert the vaginal canal. Stage 4: Complete vaginal eversion. Since the most distal part of the prolapse is 1 cm below the hymen, this is classified as Stage II pelvic organ prolapse.

Answer 123

B. Pessary Rationale: Stage I and II prolapse are often managed conservatively. A pessary is the first-line treatment, providing mechanical support to the pelvic organs, reducing symptoms, and avoiding surgery.

Answer 124

A. Cystocele and enterocele Rationale: Cystocele: Occurs when the bladder protrudes into the vaginal wall, causing urinary incontinence or retention. Enterocele: Involves herniation of the small intestine into the vaginal wall, leading to bowel dysfunction. Since the patient experiences both urinary and bowel incontinence, both conditions must be considered.

Answer 125

B. Transillumination Rationale: Enterocele contains loops of small intestine, which can be transilluminated. Rectoceles do not transilluminate because they consist of the rectum and surrounding soft tissue.

Answer 126

D. All of the above Rationale: McCall stitch: Used to prevent enterocele formation during vaginal hysterectomy. Abdominal sacrocolpopexy: Definitive surgical repair for advanced pelvic organ prolapse. Transabdominal reduction: May be necessary in severe enterocele cases.

Answer 127

A. Pelvic organ prolapse, urethrocele, enterocele Rationale: Pelvic organ prolapse (POP): Protrusion of pelvic organs into the vaginal wall due to weakened support structures. Urethrocele: Prolapse of the urethra into the anterior vaginal wall, affecting urination. Enterocele: Herniation of the small intestine into the vaginal wall, leading to bowel dysfunction.

Answer 128

C. Stage III Rationale: Stage I: Prolapse remains >1 cm above the hymen. Stage II: Prolapse is ≤1 cm above or below the hymen. Stage III: Prolapse extends >1 cm below the hymen but does not completely evert the vaginal canal. Stage IV: Complete vaginal eversion. Since the mass descends 2.5 cm below the hymen, this is classified as Stage III pelvic organ prolapse.

Answer 129

A. Stage I Rationale: Stage I: Prolapse remains more than 1 cm above the hymen. Stage II: Prolapse is ≤1 cm above or below the hymen. Stage III: Prolapse is >1 cm below the hymen but does not completely evert the vaginal canal. Stage IV: Complete vaginal eversion.

Answer 130

C. Stage III Rationale: Stage III: Prolapse is more than 1 cm below the hymen but does not reach the total vaginal length minus 2 cm. This stage represents moderate to severe pelvic organ prolapse, where surgical intervention is often considered.

Answer 131

B. Perineal body Rationale: The perineal body (PB) is the fibromuscular structure located between the posterior vaginal wall and rectum, providing support for the perineum and anal sphincter.

Answer 132

B. Point Bp Rationale: Point Bp is a posterior vaginal wall reference point in the Pelvic Organ Prolapse Quantification (POP-Q) system, used to assess posterior compartment prolapse. 🔹 QUICK IDENTIFICATION TIPS FOR CASES ✅ Anterior bulge? → Think Aa/Ba (anterior vaginal wall prolapse) ✅ Posterior bulge? → Think Ap/Bp (posterior vaginal wall prolapse) ✅ Cervical prolapse? → Look at Point C ✅ Post-hysterectomy apex prolapse? → Check Point C & D ✅ Rectovaginal symptoms (splinting, constipation)? → Consider PB involvement 🔹 High-yield clinical clues: If the bulge worsens with straining → assess Aa, Ba, Ap, Bp. If anterior prolapse + urinary incontinence → consider urethral hypermobility (stress incontinence). If posterior prolapse + constipation → suspect rectocele.

Answer 133

C. Point D Rationale: Point D is used in ICS staging to assess uterine and vaginal vault prolapse, representing the posterior fornix location. 🔹 QUICK IDENTIFICATION TIPS FOR CASES ✅ Anterior bulge? → Think Aa/Ba (anterior vaginal wall prolapse) ✅ Posterior bulge? → Think Ap/Bp (posterior vaginal wall prolapse) ✅ Cervical prolapse? → Look at Point C ✅ Post-hysterectomy apex prolapse? → Check Point C & D ✅ Rectovaginal symptoms (splinting, constipation)? → Consider PB involvement 🔹 High-yield clinical clues: If the bulge worsens with straining → assess Aa, Ba, Ap, Bp. If anterior prolapse + urinary incontinence → consider urethral hypermobility (stress incontinence). If posterior prolapse + constipation → suspect rectocele.

Answer 134

B. Uterosacral ligaments Rationale: Level I support is pro2. Level II normal support of the pelvic organs is provided by which anatomic structure(s)? A. Perineal muscles B. Uterosacral ligaments C. Arcus tendineus D. Endopelvic tissuesvided by the uterosacral and cardinal ligaments, which suspend the uterus and vaginal apex to the sacrum and pelvic sidewalls.

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C. Arcus tendineus Rationale: Level II support comes from the arcus tendineus fascia pelvis, which anchors the mid-vagina to the pelvic sidewalls.

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C. Mid-vagina Rationale: Level II support stabilizes the mid-vagina by attaching it to the arcus tendineus fascia pelvis, preventing vaginal wall descent.

Answer 137

A. Vaginal birth Rationale: Vaginal birth (parity) is the strongest risk factor due to direct trauma to pelvic floor muscles, nerves, and connective tissue, leading to weakened pelvic support.

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C. Stage III Rationale: Stage III: Prolapse extends more than 1 cm below the hymen but does not reach total vaginal length minus 2 cm. Stage IV: Complete vaginal eversion.

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B. Stage I Rationale: Stage I: Prolapse remains more than 1 cm above the hymen. The cervix is 2 cm above the hymen, which qualifies as Stage I POP.

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A. Pessary Rationale: Mild prolapse (Stage I-II) is managed conservatively using pessaries, pelvic floor exercises, and estrogen therapy. Surgery is reserved for more severe cases (Stage III-IV) or persistent symptoms.

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C. Cystocele Rationale: Cystocele occurs when the pubocervical fascia weakens, allowing the bladder to protrude into the anterior vaginal wall.

Answer 142

A. Enterocele Rationale: Enterocele (herniation of the small intestine into the vaginal canal) can be prevented by suturing the uterosacral ligaments during pelvic reconstructive surgery.

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A. Aa Rationale: Point Aa: Located 3 cm proximal to the urethral meatus; represents anterior vaginal wall descent.

Answer 144

A. Fetal heart rate at 120 bpm Rationale: A viable fetus with a detectable heart rate may be delivered via emergency C-section in a brain-dead mother. Maternal death beyond a certain time frame (e.g., 60 minutes) reduces the likelihood of a successful fetal outcome.

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B. Family planning Rationale: Family planning ensures optimal maternal health, reduces unplanned pregnancies, and improves pregnancy outcomes. Abstinence and marriage are personal choices, but contraception and birth spacing are evidence-based approaches for safe motherhood.

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B. False Rationale: The Professional Responsibility Model emphasizes that a physician is a professional who prioritizes patient care over financial gain. Entrepreneurship should not override ethical responsibilities in medical practice.

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A. Timely, irrelevant, adequate information Rationale: Informed consent must include timely, relevant, and adequate information for the patient to make an informed decision. The inclusion of "irrelevant" information negates the principle of providing necessary details.