Gynecology & Urology Flashcards
Concerning human papillomavirus (HPV) vaccination, which of the following is FALSE?
A. Two HPV vaccines have been developed and approved by the U.S. Food and Drug Administration (FDA).
B. Both vaccines generate high concentrations of neutralizing antibodies to HPV L1 protein.
C. Prospective randomized clinical trials have demonstrated that vaccination prevents nearly 100% of HPV subtype-specific precancerous cell changes.
D. HPV immunizations prevents 90% of all cervical cancers.
D. HPV immunizations prevents 90% of all cervical cancers.
Two human papillomavirus (HPV) vaccines have been developed and approved by the U.S. Food and Drug Administration (FDA).
Vaccination generates high concentrations of neutralizing antibodies to HPV L1 protein, the antigen in both vaccines.
Several randomized clinical trials involving approximately 35,000 young women have shown that both Gardasil and Cervarix prevent nearly 100% of the HPV subtype-specific precancerous cervical cell changes or up to 4 years after vaccination among women who were not infected at the time of vaccination.
Cervical cancer screening continues to play an important role in detection and treatment of cervical intraepithelial neoplasia (CIN) II/III and prevention of cervical cancer in these high-risk patients.
Cervical cancer screening continues to be of great importance since HPV immunization will not prevent approximately 25 to 30% of cervical cancers in HPV-naïve women and does not protect against the development of cancer in women already infected with carcinogenic HPV types. (See Schwartz 10th ed., pp. 1681–1682.
Concerning uterine leiomyomas, all of the following are true EXCEPT
A. Most common pelvic tumor.
B. Has a racial predilection.
C. Classified according to anatomic location.
D. Rarely necessitates hysterectomy.
D. Rarely necessitates hysterectomy.
Leiomyomas, also known colloquially as fibroids, are the most common female pelvic tumor and occur in response to growth of the uterine smooth muscle cells (myometrium).
They are common in the reproductive years, and by age 50, at least 60% of white and up to 80% of black women are (or have been) affected. Leiomyomas are described according to their anatomic location (Fig. 41-1) as intramural, subserosal, submucosal, pedunculated, cervical, and rarely ectopic.
Most are asymptomatic; however, abnormal uterine bleeding caused by leiomyomas is the most common indication for hysterectomy in the United States. (See Schwartz 10th ed., Figure 41-9, pp. 1683–1684.)
Which of the following concerning endometriosis is FALSE?
A. More common in infertile women.
B. Etiology is inflammation-induced.
C. Can involve the thoracic cavity.
D. Can cause increase in serum CA-125.
Answer: B
Endometriosis is especially prevalent in patients suffering from chronic pelvic pain (80%) and infertility (20–50%).
The pathophysiology of endometriosis is poorly understood; etiologic theories explaining dissemination of endometrial glands include retrograde menstruation, lymphatic and vascular spread of endometrial glands, and coelomic metaplasia.
Endometriosis commonly involves the ovaries, pelvic peritoneal surfaces, and uterosacral ligaments.
Other possible sites include the rectovaginal septum, sigmoid colon, intraperitoneal organs, retroperitoneal space, ureters, incisional scars, umbilicus, and even the thoracic cavity.
Endometriosis can also cause increases in serum cancer antigen 125 (CA-125). (See Schwartz 10th ed., pp. 1689–1690.)
Pregnancy-related surgical conditions include all of the following EXCEPT
A. Trauma-related hypovolemia may be compounded by pregnancy-induced decreases in systemic vascular resistance.
B. Gastric motility is decreased, leading to increased risk of aspiration.
C. Increased likelihood of thromboembolic events due to increase in several coagulation actors induced by pregnancy.
D. Fetal autoregulation of blood pressure during all three trimesters of pregnancy.
D. Fetal autoregulation of blood pressure during all three trimesters of pregnancy.
Trauma-related hypovolemia may be compounded by pregnancy-induced decreases in systemic vascular resistance.
Gastric motility is decreased, increasing the risk of aspiration.
Several coagulation factors are also increased in pregnancy, increasing the likelihood or thromboembolic events.
It should also be recognized that the fetus will be impacted significantly by maternal hypotension, as blood may be shunted away rom the uterus.
Only the third-trimester fetus has any ability to autoregulate in the context of decreased uterine blood flow and oxygen delivery. (See Schwartz 10th ed., p. 1691.)
Typical indications for cesarean delivery include all of the following EXCEPT
A. Questionable fetal status
B. Breech presentation
C. Cephalopelvic disproportion
D. Maternal coagulopathy
D. Maternal coagulopathy
Typical indications for cesarean delivery include nonreassuring fetal status, breech or other malpresentations, triplet and higher order gestations, cephalopelvic disproportion, failure to progress, placenta previa, and active genital herpes. (See Schwartz 10th ed., p. 1693.)
Pelvic floor dysfunction include all of the following EXCEPT
A. Urinary incontinence
B. Pelvic organ prolapse
C. Fecal incontinence
D. Dyspareunia
D. Dyspareunia
Pelvic floor disorders can be categorized, from an urogynecologic perspective, into three main topics: female urinary incontinence and voiding dysfunction, pelvic organ prolapse, and disorders of defecation. (See Schwartz 10th ed., p. 1694.)
All of the following are true concerning stress incontinence EXCEPT
A. Can be due to lack of urethrovaginal support.
B. Can be due to intrinsic sphincter deficiency.
C. Goal of surgical repair is to create a partial urethral
obstruction.
D. Urethral reimplantation is sometimes necessary if
other approaches ail.
D. Urethral reimplantation is sometimes necessary if
other approaches fail.
Stress incontinence is believed to be caused by lack of urethrovaginal support (urethral hypermobility) or intrinsic sphincter deficiency (ISD).
ISD is a term applied to a subset o stress-incontinent patients who have particularly severe symptoms, including urine leakage with minimal exertion.
This condition is often recognized clinically as the low pressure or “drainpipe” urethra.
The urethral sphincter mechanism in these patients is severely damaged, limiting coaptation of the urethra.
Standard surgical procedures used to correct stress incontinence share a common feature: partial urethral obstruction that achieves urethral closure under stress. (See Schwartz 10th ed., p. 1695.)
Concerning vulvar carcinoma, all of the following are true EXCEPT
A. Etiology may be due to an HPV-dependent pathway of carcinogenesis.
B. Approximately 50% are squamous lesions.
C. Hematogenous dissemination is rare.
D. Staging and primary surgical treatment are typically
performed as a single procedure.
B. Approximately 50% are squamous lesions.
Evidence supports an HPV-dependent pathway of carcinogenesis with risk factors similar to vulvar intraepithelial neoplasia (VIN) in the majority of cases.
Vulvar carcinomas are squamous in 90% of cases.
Spread of vulvar carcinoma is by direct local extension and via lymphatic microembolization.
Hematogenous spread is uncommon.
Staging and primary surgical treatment are typically performed as a single procedure and tailored to the individual patient. (See Schwartz 10th ed., p. 1696.)
Which of the following is true concerning endometrial carcinoma?
A. Third most common gynecological malignancy.
B. Equally frequent in menopausal and postmenopausal
women.
C. Risk factors include obesity, smoking.
D. Use of combination oral contraception pills has a protective effect.
C. Risk factors include obesity, smoking.
Endometrial cancer is the most common gynecologic malignancy and fourth most common cancer in women. It is most common in menopausal women in the fifth decade of life; up to 15 to 25% of cases occur prior to menopause, and 1 to 5% occur before age 40.
Risk factors for the most common type of endometrial cancer include increased exposure to estrogen without adequate opposition by progesterone, either endogenous (obesity, chronic anovulation) or exogenous (hormone replacement).
Additional risk factors include diabetes, Lynch II syndrome (hereditary nonpolyposis colorectal cancer), and prolonged use of tamoxifen.
Tamoxifen is a mixed agonist/ antagonist ligand for the estrogen receptor. It is an agonist in the uterus and an antagonistic to the breast and ovary.
Protective factors for endometrial cancer include smoking and use of combination oral contraceptive pills. (See Schwartz 10th ed., pp. 1698–1699.)
Which of the following is FALSE concerning epithelial ovarian cancer (EOC) risk factors?
A. Risk factors include early menarche.
B. Risk factors include late menopause.
C. Risk factors include previous hysterectomy.
D. Risk factors include nulliparity.
C. Risk factors include previous hysterectomy.
Risk factors for development of epithelial ovarian cancer (EOC) include events that appear to increase the number of lifetime ovulations (eg, early menarche, late menopause, nulliparity), whereas events that decrease the number of ovulations decrease risk (eg, pregnancy, breast eeding, oral contraceptives).
Additionally, a history of tubal ligation for hysterectomy also decreases EOC risk. (See Schwartz 10th ed., p. 1701.)
The objectives of surgery in EOC include which of the following?
A. Establishing histological diagnosis
B. Surgical staging
C. Surgical cytoreduction
D. A, B, and C
D. A, B, and C
The objectives of surgery in EOC are threefold.
The first is to make the histologic diagnosis.
The second is to assess the extent of disease through complete surgical staging.
The third objective is (complete when feasible) surgical cytoreduction for debulking.
(SeeSchwartz10thed.,p.1701.)
A 62-year-old African American male attorney presents to a prostate-screening clinic during National Awareness Week. On careful questioning, he has noted slight urgency, frequency nocturia, and a decrease in the force of micturition.
He is referred to have blood tests to include which of the following?
(A) Carcinoembryonic antigen (CEA) (B) Prostatic acid phosphatase (C) Alkaline phosphatase (D) Prostate-specific antigen (PSA) (E) Lactic dehydrogenase (LDH)
- (D) Prostate-specific antigen (PSA)
According to American Cancer Society, all men over the age of 50 years should undergo annual PSA measurement and digital rectal examination (DRE).
This recommendtion is further supplemented by the guidelines from American Urological Association to start screening 10 years earlier in high-risk individuals (caucasians with family history of prostate cancer and African Americans).
A 62-year-old African American male attorney presents to a prostate-screening clinic during National Awareness Week. On careful questioning, he has noted slight urgency, frequency nocturia, and a decrease in the force of micturition.
- General examination from his urologist is noncontributory. A rectal examination reveals hemorrhoids and a left-sided irregular mass in the prostate. Following normal blood tests, he should have which of the following?
(A) Computed tomography (CT) scan of the pelvis
(B) Magnetic resonance image (MRI) of the prostate
(C) Colonoscopy and biopsy of the prostate under general anesthetic
(D) Biopsy of the nodule
(E) Bone scan
(D) Biopsy of the nodule
At any time during prostate cancer screening, if either the PSA or the DRE is abnormal, recommendation is referral to a urologist to perform TRUS guided biopsy of prostate.
- A 62-year-old postal officer develops minimal urinary symptoms. His PSA level is elevated and continues to increase during a 6-month period of observation. The next step in evaluation, if transrectal ultrasound (TRUS) prostate biopsy (Fig. 9–1) were positive for adenocarcinoma of prostate, would be:
(A) Refer to oncologist for chemotherapy
(B) Metastatic evaluation including CT and bone scans
(C) Repeat PSA and biospy
(D) Evaluation by radiation oncologist
(E) Start hormonal ablation treatment
(B) Metastatic evaluation including CT and bone scans
Typical workup after a positive TRUS biopsy would be evaluating the common metastatic sites (pelvic lymph nodes and bone). CT scan of abdomen and pelvis with and without contrast is performed to also rule out other GU abnormalities (i.e., renal mass, renal stone, and so forth) in addition to pelvic lymphadenopathy.
Bone scan, however, is typically not indicated for PSA
<20 mg/mL.
- Because of positive biopsy findings and negative workup, he undergoes a radical prostatectomy. The pathology report reveals Gleason score 9/10 and involvement of several pelvic lymph nodes. Which is the most likely site for prostatic cancer metastasis?
(A) Liver (B) Kidney (C) Lung (D) Bone (E) Brain
(D) Bone
Bone metastasis is a characteristic feature of prostatic cancer. The lesions are typically osteoblastic on x-ray, and the serum acid phosphatase level becomes elevated.
- A 79-year-old man is examined for severe pain in the iliac crest. Metastatic disease from prostatic cancer is confirmed. What is the treatment offered initially to most patients with metastatic prostatic cancer?
(A) Cortisone and pituitary ablation
(B) Radical prostatectomy
(C) Luteinizing releasing hormone (LRH) agonist (Leuprolide)
(D) Local irradiation and testosterone
(E) Hyperthermia
(C) Luteinizing releasing hormone (LRH) agonist (Leuprolide)
Previously, androgen ablation was achieved by bilateral orchiectomy. However, total androgen ablation is accomplished by oral administration of antiandrogens for 2 weeks followed by injection of LRH angonist.
- During her eighth month of pregnancy, a 29-year-old woman is noted to have polyhydramnios. Further testing shows anencephalus. Polyhydramnios in this patient is caused by which of the following?
(A) Impairment of the fetus’s swallowing mechanism
(B) Tumor of the fetus’s brain
(C) A secretory peptide from the placenta
(D) Excess antidiuretic hormone (ADH) from the fetus
(E) Renal agenesis
(A) Impairment of the fetus’s swallowing mechanism
Anencephalus is due to failure of the cephalic part of the neural tube to close off. This condition happens in 1/1000 pregnancies, is four times more common in whites than blacks, and is four times more common in females than males.
- Several weeks after lifting a heavy object, a previously healthy 34-year-old man continues to complain of heaviness in his left groin. Which of the following statements is true of testicular cancer?
(A) It is the most common solid tumor in men over 50 years of age.
(B) It is not associated with a higher incidence of infertility.
(C) It presents as a painless mass in the scrotum in more than 70% of patients.
(D) It accounts for 10% of malignant tumors in men.
(E) It rarely metastasizes.
(C) It presents as a painless mass in the scrotum in more than 70% of patients.
Testicular cancer accounts for 1–2% of all malignant tumors in men. There are two categories of testicular tumors—lymphomas (which occur in individuals <10 or >50 years of age) and nonhematogenous tumors, that is
germ cell and nongerm cell tumors (which occur in 15–35 year old individuals). Typically, the patient presents few weeks or months after a vague recollection of heavy activity or local trauma.
- During a workup for infertility, a 34-year-old man is noted to have a solid tumor in the anterior aspect of his right testis. What is the most likely diagnosis?
(A) Torsion of the testis
(B) Cyst of the epididymis
(C) Lipoma of the cord
(D) Cancer of the testis
(E) Epididymo-orchitis
(D) Cancer of the testis
Nonhematogenous testicular tumors are divided into two categories—germ cell tumors (seminoma, nonseminoma, i.e., embryonal, choriocarcinoma, teratoma, teratocarcinoma, yolk sac tumors) and nongerm cell tumors (Leydig cell or Sertoli cell).
There is no mass within the testis with torsion.
Epididymitis presents within painful tender testis.
- Improved survival after lymphadenectomy for testicular tumors occurs after which of the following?
(A) Seminoma
(B) Embryonal cell carcinoma
(C) Leydig cell tumor
(D) Sertoli cell tumor
(E) Lymphoma
(B) Embryonal cell carcinoma
Embryonal cell carcinoma should be treated by retroperitoneal lymph node dissection (RPLND), if tumor is not spread beyond peritoneal cavity. About 30% of patients will have lymph node metastasis at the time of diagnosis.
Seminoma and embryonal cell carcinomas account for about 70% of all testicular tumors.
- A 38-year-old woman presents with shortness of breath and abdominal distention. Workup reveals presence of ascites and hydrothorax. What is the name of this condition?
(A) Brenner tumor
(B) Dysgerminoma
(C) Wolffian duct remnant
(D) Krukenberg’s tumor
(E) Meigs’s syndrome
(E) Meigs’s syndrome
This patient is suffering from Meigs’s syndrome.
Treatment would be removal of a benign ovarian fibroma.
Brener tumor is a fibroepithelial tumor of the ovary with low-malignant potential.
Dysgerminomas contain germ cells and infiltration with lymphocytes.
Krukenberg’s tumor is metastasis of a primary alimentary tract adenocarcinoma to the ovary.
- A 41-year-old man requests information concerning vasectomy for sterilization. In this procedure, which of the following statements is true?
(A) The incidence of sexual dysfunction is not influenced in those with dependent personalities.
(B) The success rate in reestablishing continuity of the vas deferens is greater than 80% at 10 years.
(C) The failure rate occurs in 1/400 patients.
(D) Recanalization of the vas deferens does not occur.
(E) The procedure is difficult and requires laparotomy.
(C) The failure rate occurs in 1/400 patients.
The failure rate of 1/400 patient has been reported. Since there is no alteration in the level of testosterone production, there is no reported sexual dysfuntion attributed to vasectomy. The success rate for reversal of vasectomy greatly depends on the time since the vasectomy was performed. Failure rates for vasovasostomy has been reported to be >80% after 10 years.
- A 6-month-old boy was born with hypospadias. This condition is due to failure in the development of which of the following?
(A) Urogenital fold
(B) Müllerian system
(C) Genital tubercle
(D) Urachus
(E) Vitelline duct
(A) Urogenital fold
Embryologically, the genital tubercule develops into the penis. The edge of the cloacal membrane forms the urogenital fold and by the process of invagination forms the urethral groove and finally the penile urethera.
The severity of hypospadias depends on the location of the anomalous opening onto the penile urethra.
The mildest degree is where the opening is on the glans and the most severe form at the penoscrotal junction.
- A 64-year-old woman notes an ulcer on her left labia majora. Biospy reveals squamous cell carcinoma. What is the treatment?
(A) Wide local excision
(B) Radiotherapy
(C) Preoperative radiotherapy followed by wide local excision
(D) Wide excision and unilateral groin dissection
(E) Radical vulvectomy and bilateral groin dissection
(E) Radical vulvectomy and bilateral groin dissection
Similar to penile cancer, radical vulvectomy and bilateral groin dissection have improved survival in patients with carcinoma of the vulva.
The deep and superficial nodes are removed.
If the lymph nodes are not involved, the cure rate exceeds 70%.
The overall survival is approximately 50%.
Radiotherapy has not offered additional benefit pregnancy.
- A 6-year-old healthy appearing girl is brought for evaluation of bloody vaginal discharge. The most likely diagnosis is:
(A) Squamous cell carcinoma
(B) Sarcoma botryoides
(C) Carcinosarcoma
(D) Clear cell adenocarcinoma
(E) Lymphoma
(B) Sarcoma botryoides
Sarcoma botryoides usually occurs as a grape-like polypoid mass in the vagina of young girls.
Clear-cell adenocarcinoma occurs at an older age, in the second decade of life. It is associated with the administration of DES to patient’s mother’s during pregnancy.
Squamous carcinoma is the most common tumor of the vagina in postmenopausal patients. However, malignant tumors of the vagina are rare in children.
- A healthy appearing, 8-year-old boy is evaluated for an abdominal mass, felt by his mother during a bath. What is the most likely diagnosis?
(A) Lymphoma
(B) Rhabdomyoscarcoma
(C) Wilms’ tumor
(D) Neuroblastoma
(E) Renal cell carcinoma
(C) Wilms’ tumor
Typically Wilms’ tumor is noted in well appearing children in the second half of their first decade of life. These masses are usually felt or visually noted by parents during routine daily activities. Children with neuroblastoma are usually younger and appear quite sick.
Although unlikely, renal cell carcinoma has been reported in children and diagnosis is only based on final pathology results.
Lymphoma should be ruled out based on CT scan findings and subsequent needle-guided biopsy, since
treatment is usually nonsurgical.
- In repair of a third-degree perineal laceration, which structure shown in Fig. 9–2 is least likely to be divided?
(A) Bulbocavernosus muscle (B) Vaginal mucosa (C) Superficial transverse perineal lmuscle (D) External anal sphincter (E) Ischiocavernosus muscle
(E) Ischiocavernosus muscle
Ischiocavernous muscle is NOT involved in third degree perineal lacerations.
This muscle originates at the ischial tuberosity and inserts at the base of the clitoris.
- A 24-year-old man had been treated for gonorrhea 2 months previously. He developed an ulcerative lesion in the glands of the penis that is noted to be condylomata lata. The etiology of condylomata lata is which of the following?
(A) Mixture of organisms (B) Haemophilus ducreyi (C) Herpesvirus hominis, type II (D) Treponema pallidum (E) Neisseria gonorrhoeae
(D) Treponema pallidum
Condylomata lata are a manifestation of secondary syphilis.
The treatment is intramuscular injection of penicillin. They are distinguished from condylomata acuminata; in that the latter are velvety and filiform in appearance and are result of infection with human papilloma virus (HPV).
- A 23-year-old woman has a cesarean section in which a Pfannenstiel incision (Fig. 9–3) is used. In the Pfannenstiel incision, which of the following is TRUE?
(A) The recti and fascia are separated transversely.
(B) The recti and fascia are separated vertically.
(C) Fascia lata graft is used.
(D) A prosthetic graft is used.
(E) The upper abdomen can readily be explored.
(B) The recti and fascia are separated vertically.
In the Pfannenstiel incision, the rectus muscles and the peritoneum are separated in a vertical fashion after the skin is incised transversely.
- What is the most common cause of failure of radiotherapy for stage II cervical carcinoma?
(A) Liver metastasis (B) Bone metastasis (C) Para-aortic node metastasis (D) Resistance of the central tumor (E) Undifferentiated tumor histology
(C) Para-aortic node metastasis
In stage II cervical cancer, the incidence of nodal involvement is 25%–40%.
Most tumors are not radioresistant, and distant metastasis (i..e., a more advanced stage) are a late complication of more advanced stages of the disease.
- Twelve years after menopause, a 60-year-old woman undergoes laparotomy for an ovarian carcinoma. The ovarian tumor that is most likely to respond to radiotherapy is which of the following?
(A) Dysgerminoma (B) Krukenberg’s tumor (C) Arrhenoblastoma (D) Granulosa cell tumor (E) Brenner tumor
(A) Dysgerminoma
Dysgerminoma (like seminoma in men) is very radiosensitive.
The Krukenberg’s tumor is a metastatic tumor to the ovary and is not treated by radiation.
The other tumors are best treated by surgery.
The Brenner tumor is most often a benign tumor.
Arrhenoblastomas and granuloso-cell tumors are hormone-producing tumors.
- A 24-year-old woman has been unsuccessful becoming pregnant. She is admitted with abdominal pain; her blood pressure is 90/60 mm Hg, her pulse rate is 102 beats per minute (bpm), and her hematocrit (HCT) is 28%. Features of ectopic pregnancy include which of the following?
(A) Elevated blood pressure on assuming an erect position
(B) Pulsus paradoxus
(C) Tenderness below the right subcostal margin (Murphy’s sign)
(D) Pain referred to the supraclavicular region
(E) Ecchymosis around the umbilicus
(E) Ecchymosis around the umbilicus
Free bleeding in the peritoneal cavity results in pain referred to the right supraclavicular region due to diaphragmatic irritation.
Patients who present with abdominal pain and (usually) a history of missed menstruation should undergo a pregnancy test after hospital admission.
- After undergoing a partial cystectomy for carcinoma of the rectum, a 76-year-old woman develops a vesicovaginal fistula. The repair will have a higher chance of success if which of the following occurs?
(A) Scar tissue is not excised
(B) The bladder wall is closed under tension
(C) Repair is performed more than 6 months after the causative operation
(D) Repair is performed within 7–14 days of the onset of symptoms
(E) Urethral catheters removed within 7 days
(C) Repair is performed more than 6 months after the causative operation
Repair of vesicovaginal fistula is recommended after enough time has passed, to allow a reduction in the inflammatory reaction and even spontaneous closure to occur. To promote spontaneous closure, a Foley catheter is inserted for bladder drainage.
It is advised to perform meticulous repair, excision of previous fistulous tract, and tension-free anastomosis.
Frequently an omental interposition helps to separate overlapping suture lines.
