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OG26.1-2,OG27.1-3 | Genital Trauma and Infections — Graded Quiz
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A 32-year-old woman underwent total abdominal hysterectomy for symptomatic fibroids. On day 8 post-operatively she notices that she is leaking urine continuously despite also feeling the urge to void and voiding normally. Dye test with methylene blue instilled into the bladder is negative (no blue dye at the vaginal vault), but intravenous urography shows contrast dye pooling in the vaginal vault. What is the most likely diagnosis?
Correct. The negative methylene blue test excludes VVF (bladder not the source). The IVU showing contrast dye at the vaginal vault confirms ectopic ureteric drainage — a ureterovaginal fistula. The patient still voids normally because the contralateral ureter continues to fill the bladder normally.
Two-step fistula localisation: (1) Methylene blue dye test — instil into bladder; positive = VVF. (2) IVU or CT urography — if methylene blue negative but leakage continues, demonstrates ureteric injury = UVF. The patient voiding normally despite leakage is the bedside clue for UVF.
The key discriminating finding is the negative methylene blue (bladder is intact, no VVF) combined with contrast dye on IVU pooling vaginally. This confirms the leak is from the ureter, not the bladder. In VVF: methylene blue test is positive (blue dye appears vaginally), and the patient cannot fill or void from the bladder. In UVF: methylene blue negative, IVU positive — the contralateral kidney still fills the bladder so normal voiding continues.
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A 26-year-old primiparous woman sustained a 4th-degree perineal tear during delivery and underwent primary repair. Four months later she reports faecal incontinence and passing flatus vaginally. Examination reveals a defect in the posterior vaginal wall with visible rectal mucosa. Which principle best guides the management of this established rectovaginal fistula?
Correct. Once the acute postoperative inflammation has resolved (typically 3-6 months), delayed secondary repair of the rectovaginal fistula is the appropriate approach. Most obstetric RVFs are repairable by the transvaginal route; permanent colostomy is reserved for failed multiple repairs or very high complex fistulae.
Rectovaginal fistula management principles: (1) Allow 3-6 months for tissue healing post initial injury. (2) Delayed surgical repair is the standard — transvaginal route for low RVFs, transanal or transabdominal for high fistulae. (3) Diverting colostomy protects complex repairs but should not be permanent unless all repair attempts have failed.
Failed primary repair does not mandate permanent colostomy. The principle is: allow all inflammation and oedema to fully resolve, then plan delayed secondary repair. Antibiotics alone will not close an established RVF. Immediate re-repair before resolution would fail again due to poor tissue quality. A proximal diverting colostomy is sometimes used to protect a complex secondary repair, but permanent colostomy is a last resort.
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A 19-year-old woman presents with a 10-day history of a painful, soft, irregular genital ulcer with a necrotic base. She also has a markedly tender unilateral inguinal lymph node that has become fluctuant and is pointing. Gram stain of pus from the lymph node shows Gram-negative coccobacilli in a school-of-fish pattern. What is the recommended treatment for this condition?
Correct. The clinical picture — painful soft necrotic ulcer + tender suppurating bubo + Gram-negative coccobacilli in school-of-fish arrangement — is classic for chancroid (Haemophilus ducreyi). Treatment options include azithromycin 1 g oral single dose (preferred), or ceftriaxone 250 mg IM. Note: the fluctuant bubo should be aspirated (not incised) to prevent sinus formation.
Chancroid (H. ducreyi): painful, soft, ragged, undermined ulcer + tender suppurating inguinal bubo (bubonulus). Gram-stain: Gram-negative coccobacilli in chains/school-of-fish. Rx: azithromycin 1 g single dose or ceftriaxone 250 mg IM. Aspirate fluctuant buboes — do not incise (prevents sinus formation).
The painful soft necrotic ulcer with tender suppurating bubo and gram-negative coccobacilli in school-of-fish pattern = chancroid (Haemophilus ducreyi). Benzathine penicillin is for syphilis. Doxycycline 21 days is for LGV (Chlamydia trachomatis). Dual ceftriaxone + azithromycin is for cervicitis/urethral discharge syndrome. For chancroid: azithromycin 1 g single dose or ceftriaxone 250 mg IM (NACO approved).
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A woman presents with frothy, greenish, malodorous vaginal discharge with vulval pruritus. Wet mount microscopy shows motile pear-shaped flagellated organisms. Speculum examination reveals a 'strawberry cervix.' Under the NACO syndromic management approach, what additional steps must be taken beyond pharmacological treatment?
Correct. Trichomonas vaginalis is a sexually transmitted infection. Syndromic management is not limited to drug treatment — NACO mandates partner notification, partner treatment (metronidazole 2 g single dose for both), and condom promotion. Treating only the patient guarantees re-infection ('ping-pong' phenomenon).
Trichomonas vaginalis: frothy greenish discharge, strawberry cervix (punctate haemorrhages), motile flagellates on wet mount. Treatment: metronidazole 2 g oral single dose (both partners simultaneously). NACO syndromic management always includes partner treatment + condom promotion — treating only the index case causes re-infection.
Syndromic management of STIs always includes three non-pharmacological pillars: (1) Partner notification and treatment (concurrent treatment of partner at the same visit if possible), (2) Promotion of condom use, (3) Counselling on risk reduction. Awaiting culture delays effective treatment and contradicts the syndromic approach. HIV testing is recommended but not a prerequisite for starting treatment.
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A 31-year-old woman with a 5-year history of infertility presents for investigation. Endometrial curettage histology shows a non-caseating granuloma with Langhans giant cells. However, endometrial AFB smear is negative, Lowenstein-Jensen culture at 8 weeks is negative, and TB-PCR is also negative. The clinician still suspects genital tuberculosis. What is the best explanation for the repeatedly negative bacteriological results?
Correct. Genital TB is characteristically paucibacillary — unlike pulmonary TB, the number of mycobacteria in genital specimens is extremely low. Consequently, AFB smear sensitivity is <10%, culture sensitivity is 10-20% even at 8 weeks, and PCR sensitivity (while best available) is still only 60-80%. Histology showing caseating or non-caseating granulomas with Langhans cells is often the most sensitive single test.
Genital TB diagnosis challenge: AFB smear <10% sensitivity; culture 10-20%; PCR 60-80%; histology (caseating granuloma + Langhans giant cells) often most sensitive. No single test is definitive. ECTB diagnostic criteria: combination of histology + menstrual dysfunction + infertility + imaging (HSG beaded/irregular tubes) + response to ATT trial.
Negative bacteriology does NOT exclude genital TB. The disease is paucibacillary by nature — organisms are sparse in the genital tract. Standard Lowenstein-Jensen culture takes up to 8 weeks; liquid culture (MGIT) is faster but availability varies. TB-PCR sensitivity in genital specimens is approximately 60-80%, not 100%. Sarcoidosis can cause non-caseating granulomas, but caseation favours TB; clinical context, imaging, and a positive response to ATT are used for diagnosis.
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A 27-year-old woman with confirmed genital tuberculosis completes a standard ATT regimen (2 months HRZE + 4 months HR). Six months later she has irregular, scanty periods and is found to have intrauterine adhesions on hysteroscopy. What term best describes this endometrial complication of genital tuberculosis?
Correct. Intrauterine adhesions resulting from endometrial tuberculosis are a form of Asherman syndrome (intrauterine synechiae). This is a serious and often irreversible complication — ATT eradicates the infection but cannot reverse the fibrotic adhesions already formed.
Asherman syndrome (intrauterine adhesions/synechiae) from genital TB: presents as oligomenorrhoea/amenorrhoea, infertility, recurrent miscarriage. Diagnosed by hysteroscopy or HSG. ATT cures infection but not the adhesions. Hysteroscopic adhesiolysis ± oestrogen for endometrial regeneration; outcomes depend on extent of adhesions.
Intrauterine adhesions (synechiae) secondary to endometritis — whether from TB, post-curettage trauma, or infection — constitute Asherman syndrome. This is the endometrial form of structural damage caused by genital TB. The adhesions remain even after ATT; hysteroscopic adhesiolysis may be attempted but pregnancy outcomes remain poor when the endometrium is severely scarred.
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A 23-year-old woman presents to casualty with severe lower abdominal pain, rigidity, rebound tenderness, fever 39.5°C, and tachycardia. She is haemodynamically compromised. Her last menstrual period was 3 weeks ago, serum beta-hCG is negative. Ultrasound shows a complex adnexal mass with internal echoes and free fluid in the pelvis. What is the immediate management priority?
Correct. Haemodynamic compromise + peritonitis + complex adnexal mass after excluding ectopic pregnancy = ruptured tubo-ovarian abscess until proven otherwise. This is a surgical emergency. Stabilise with IV antibiotics and fluids, then proceed to urgent surgical exploration (laparotomy or laparoscopy). Delay in surgery is life-threatening in ruptured TOA.
Ruptured TOA = surgical emergency: (1) IV broad-spectrum antibiotics immediately (clindamycin + gentamicin ± metronidazole), (2) IV fluid resuscitation, (3) Urgent surgical drainage (laparotomy preferred for ruptured/haemodynamically unstable cases). Mortality of untreated ruptured TOA is significant. Unruptured TOA → IV antibiotics, drainage only if failing at 72 hours.
Haemodynamic instability with signs of peritonitis makes expectant management with oral antibiotics inappropriate and dangerous. A ruptured TOA spills infected material into the peritoneal cavity, causing septic peritonitis with rapid deterioration. CT-guided aspiration is appropriate for unruptured, stable TOA — not for haemodynamic compromise. Urgent surgical drainage/debridement under antibiotic cover is the life-saving intervention.
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A 20-year-old woman with no previous sexual partners presents with fever, right upper quadrant pain, and right-sided pleuritic chest pain in addition to lower abdominal pain and cervical motion tenderness. Liver function tests show mildly elevated transaminases. What complication of PID should be considered, and what investigation would best confirm it?
Correct. Fitz-Hugh-Curtis syndrome (perihepatitis) is a recognised complication of PID, caused by spread of infection (usually C. trachomatis or N. gonorrhoeae) to the liver capsule via the peritoneum. It presents as right upper quadrant pain (which can mimic cholecystitis or pleurisy) in a woman with PID. Laparoscopy showing characteristic 'violin-string' or 'fiddle-string' adhesions between the liver capsule and anterior abdominal wall is diagnostic.
Fitz-Hugh-Curtis syndrome: perihepatitis complicating PID; caused by C. trachomatis or N. gonorrhoeae spreading to the liver capsule. Presentation: RUQ pain + pleurisy-like chest pain + signs of PID. Laparoscopy = violin-string adhesions over the liver capsule. Treatment: treat the underlying PID (ceftriaxone + doxycycline + metronidazole).
Right upper quadrant pain in a woman with PID, especially pleuritic in character, should raise suspicion of Fitz-Hugh-Curtis syndrome — perihepatitis from STI (chlamydia most common, also gonorrhoea). Laparoscopy revealing violin-string perihepatitic adhesions is pathognomonic. Cholecystitis would show gallstones/thickened gallbladder wall on ultrasound. Hepatitis B would not cause pleuritic RUQ pain with pelvic signs.
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During the repair of a perineal tear immediately after delivery, the surgeon notes that the internal anal sphincter is torn in addition to a complete external anal sphincter tear, but the rectal mucosa is intact. According to the RCOG/OASIS classification, what degree and subtype is this tear?
Correct. OASIS classification: 3c = complete external anal sphincter tear + involvement of the internal anal sphincter (IAS), but with the rectal mucosa still intact. When the rectal mucosa is also breached, it becomes a 4th-degree tear. 3c has the worst sphincter-function prognosis among 3rd-degree subtypes.
OASIS classification must be memorised: 1st = perineal skin ± vaginal mucosa; 2nd = perineal muscles + skin, no sphincter; 3a = <50% EAS; 3b = >50% EAS; 3c = EAS + IAS, rectal mucosa intact; 4th = EAS + IAS + rectal mucosa. Accurate classification determines the repair technique and counselling about future deliveries.
OASIS 3rd-degree subtypes: 3a = less than 50% of external anal sphincter (EAS) thickness torn; 3b = more than 50% of EAS torn; 3c = EAS torn completely + IAS torn, rectal mucosa intact. Adding rectal mucosal breach = 4th degree. This case has complete EAS + IAS torn with intact mucosa = 3c. Grade 3c carries the highest risk of anal incontinence among 3rd-degree injuries.
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A 24-year-old woman presents with a painless inguinal swelling that has been growing for 3 weeks. She recalls a small, transient, painless genital papule 2 months ago that healed spontaneously. On examination there is a unilateral firm inguinal mass with the characteristic appearance of the inguinal ligament dividing the mass into two portions (groove sign). Serology for C. trachomatis is strongly positive. What is the correct treatment?
Correct. Lymphogranuloma venereum (LGV) caused by Chlamydia trachomatis serovars L1-L3 presents with a transient painless genital ulcer followed by the classic inguinal bubo with groove sign (femoral + inguinal nodes separated by Poupart's ligament). Treatment: doxycycline 100 mg twice daily for 21 days (longer course than uncomplicated chlamydia to penetrate intracellular bacteria).
LGV (C. trachomatis L1-L3): phase 1 = transient painless papule/ulcer; phase 2 = inguinal bubo + groove sign (pathognomonic); phase 3 = proctitis/anorectal strictures. Treatment: doxycycline 100 mg BD × 21 days (NOT the 7-day course for urethritis). Aspirate — do not incise — fluctuant buboes.
The groove sign (bilobar inguinal mass divided by the inguinal ligament) is pathognomonic for LGV. Azithromycin 1 g single dose is for uncomplicated chlamydia cervicitis/urethritis — NOT sufficient for LGV which requires 21 days of doxycycline. Ceftriaxone treats gonorrhoea. Metronidazole treats BV/trichomonas. LGV requires a prolonged doxycycline course because the bacteria are intracellular.
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A 25-year-old woman is admitted with moderate PID (fever, adnexal tenderness, no peritonitis, haemodynamically stable). She has no drug allergies. Which inpatient antibiotic regimen is most appropriate according to CDC PID treatment guidelines?
Correct. CDC Regimen A for inpatient PID: cefoxitin (2 g IV 6-hourly) + doxycycline (100 mg oral/IV 12-hourly). Alternatively, CDC Regimen B: clindamycin (900 mg IV 8-hourly) + gentamicin (loading dose 2 mg/kg IV, then 1.5 mg/kg 8-hourly). Both cover the polymicrobial aetiology including N. gonorrhoeae, C. trachomatis, and anaerobes.
CDC inpatient PID regimens: Regimen A = cefoxitin 2g IV 6h + doxycycline 100mg 12h; Regimen B = clindamycin 900mg IV 8h + gentamicin (loading + maintenance). Switch to oral after 24h of clinical improvement. Total treatment duration = 14 days. Add metronidazole to oral step-down for anaerobic cover.
PID is polymicrobial — combination antibiotic therapy is mandatory. Monotherapy with amoxicillin-clavulanate, metronidazole, or azithromycin alone is inadequate. CDC Regimen A = cefoxitin + doxycycline (covers gram-negatives including gonorrhoea + chlamydia + anaerobes). CDC Regimen B = clindamycin + gentamicin (broader anaerobic cover, preferred when TOA suspected). Transition to oral doxycycline 100 mg BD + metronidazole 400 mg BD to complete 14-day total course after clinical improvement.
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