Pelvic floor pathology

Pelvic floor relaxation

Classic presentation: Postmenopausal female with vaginal protrusion and urinary incontinence

definition Sturctures involved example

cystocele anterior vaginal wall + bladder

rectocele posterior vaginal wall + rectum

enterocele Pouch of douglas protrusion + intestinal prolapse

 Uterine prolapse
degree description example

1st degree cervix descend half way to introitus

2nd degree cervix at the level of intoitus

3rd degree cervix descend half way outside introitus

4th degree/procidentia The entire uterus is out including anterior

and posterior wall

Classic symptoms include: pelvic pressure, backache, and a mass protruding from the vagina
 Pelvic floor relaxation
feature comments
Risk factors Multiparity, birth traumas, increased intraabdominal pressure (cough, constipation, pregnancy), pelvic
trauma, menopause (estrogen deprivation), connective tissue disorders
diagnosis Pelvic examination to evaluate which organ is involved
Basic approach we treat only if the patient is symptomatic (if no great discomfort, no treatment is necessary)
management Minor degree Surgery of Patients not desiring sexual pathologic ulceration Poor surgical
choice function due to pelvic candidate:
relaxation:
Kegal hysterectomy Lefort procedure (involves Estrogen cream Pessary placement
exercises partial obliteration of the
vagina)
A 44-year-old woman (gravida 5, para 5) comes in complaining that she has
noticed a bulge protruding from her vagina. Her other medical problems
include hypertension, diabetes mellitus, and alcoholism. She stands at work
as a grocery clerk. She has a family history of genital prolapse. On
examination, you notice a uterine prolapse, cystocele, and rectocele. Which
of the following is a major risk factor for her pelvic support disorder?

(A) childbirth
(B) hypertension
(C) diabetes mellitus
(D) positive family history
(E) environmental factors—job
A 44-year-old woman (gravida 5, para 5) comes in complaining that she has
noticed a . Her other medical problems
include hypertension, diabetes mellitus, and alcoholism. She stands at work
as a grocery clerk. She has a family history of genital prolapse. On
examination, you notice a uterine prolapse, cystocele, and rectocele. Which
of the following is a major risk factor for her pelvic support disorder?

(A) childbirth
(B) hypertension
(C) diabetes mellitus
(D) positive family history
(E) environmental factors—job
A 65-year-old woman presents to your office for evaluation of genital
prolapse. She has a history of chronic hypertension, well controlled with a
calcium channel blocker. She has had three full-term spontaneous vaginal
deliveries. The last baby weighed 9 lb and required forceps to deliver the
head. She says she had a large tear in the vagina involving the rectum
during the last delivery. She has a history of chronic constipation and
often uses a laxative to help her have a bowel movement. She has smoked
for more than 30 years and has a smoker’s cough. She entered
menopause at age 52 but has never taken hormone replacement therapy.
Which of the following factors is least important in the subsequent
development of genital prolapse in this patient?

a. Chronic cough
b. Chronic constipation
c. Chronic hypertension
d. Childbirth trauma
e. Menopause
A 65-year-old woman presents to your office for evaluation of genital
prolapse. She has a history of chronic hypertension, well controlled with a
calcium channel blocker. She has had three full-term spontaneous vaginal
deliveries. The last baby weighed 9 lb and required forceps to deliver the
head. She says she had a large tear in the vagina involving the rectum
during the last delivery. She has a history of chronic constipation and
often uses a laxative to help her have a bowel movement. She has smoked
for more than 30 years and has a smoker’s cough. She entered
menopause at age 52 but has never taken hormone replacement therapy.
Which of the following factors is least important in the subsequent
development of genital prolapse in this patient?

a. Chronic cough
b. Chronic constipation
c. Chronic hypertension
d. Childbirth trauma
e. Menopause
A 90-year-old woman comes to your office complaining that she feels as
though she is “sitting on a ball.” On examination, you find that the vagina is
essentially turned inside out, and the entire uterus lies outside the vaginal
introitus. This condition is known as which of the following?

(A) first-degree prolapse

(B) second-degree prolapse
(C) third-degree prolapse
(D) fourth-degree prolapse or procidentia
(E) vaginal evisceration
A 90-year-old woman comes to your office complaining that she feels as
though she is “sitting on a ball.” On examination, you find that the vagina is
essentially turned inside out, and the entire uterus lies outside the vaginal
introitus. This condition is known as which of the following?

(A) first-degree prolapse

(B) second-degree prolapse
(C) third-degree prolapse
(D) fourth-degree prolapse or procidentia
(E) vaginal evisceration
A 90-year-old G5P5 with multiple medical problems is brought into your gynecology clinic
accompanied by her granddaughter. The patient has hypertension, chronic anemia,
coronary artery disease, and osteoporosis. She is mentally alert and oriented and lives in
an assisted living facility. She takes numerous medications, but is very functional at the
current time. She is a widow and not sexually active. Her chief complaint is a sensation of
heaviness and pressure in the vagina. She denies any significant urinary or bowel
problems. On performance of a physical examination, you note that the cervix is just
inside the level of the introitus. Based on the physical examination, which of the following
is the most likely diagnosis?

a. Normal examination
b. First-degree uterine prolapse
c. Second-degree uterine prolapse
d. Third-degree uterine prolapse
e. Complete procidentia
First-degree prolapse involves descent limited to the upper two-thirds of the
vagina/ level of ischeal spines.
Second-degree prolapse is present when the structure is at the vaginal introitus.
Third-degree prolapse, the structure is outside the vagina.
Fourth degree prolapse / Total procidentia - means that the whole uterus would
be located outside the body.
A 90-year-old G5P5 with multiple medical problems is brought into your gynecology clinic
accompanied by her granddaughter. The patient has hypertension, chronic anemia,
coronary artery disease, and osteoporosis. She is mentally alert and oriented and lives in
an assisted living facility. She takes numerous medications, but is very functional at the
current time. She is a widow and not sexually active. Her chief complaint is a sensation of
heaviness and pressure in the vagina. She denies any significant urinary or bowel
problems. On performance of a physical examination, you note that the cervix is just
. Based on the physical examination, which of the
following is the most likely diagnosis?

a. Normal examination
b. First-degree uterine prolapse
c. Second-degree uterine prolapse
d. Third-degree uterine prolapse
e. Complete procidentia
An 86-year-old woman presents to your office for her well-woman examination.
She has no complaints. On pelvic examination performed in the supine and upright
positions, the patient has second-degree prolapse of the uterus. Which of the
following is the best next step in the management of this patient?

a. Reassurance
b. Placement of a pessary
c. Vaginal hysterectomy
d. Le Fort procedure
e. Anterior colporrhaphy
An 86-year-old woman presents to your office for her well-woman examination.
She has no complaints. On pelvic examination performed in the supine and upright
positions, the patient has second-degree prolapse of the uterus. Which of the
following is the best next step in the management of this patient?

a. Reassurance
b. Placement of a pessary
c. Vaginal hysterectomy
d. Le Fort procedure
e. Anterior colporrhaphy
An 81-year-old woman presents to your office complaining that her uterus fell out 2
months ago. She has multiple medical problems, including chronic hypertension,
congestive heart failure, and osteoporosis. She is limited to sitting in a wheelchair
because of her health problems. Her fallen uterus causes significant pain. On physical
examination, the patient is frail and requires assistance with getting on the examination
table. She has complete procidentia of the uterus. Which of the following is the most
appropriate next step in the management of this patient?

a. Reassurance
b. Placement of a pessary
c. Vaginal hysterectomy
d. Le Fort procedure
e. Anterior colporrhaphy
An 81-year-old woman presents to your office complaining that her uterus fell out 2
months ago. She has multiple medical problems, including chronic hypertension,
congestive heart failure, and osteoporosis. She is limited to sitting in a wheelchair
because of her health problems. Her fallen uterus causes significant pain. On physical
examination, the patient is frail and requires assistance with getting on the examination
table. She has complete procidentia of the uterus. Which of the following is the most
appropriate next step in the management of this patient?

a. Reassurance
b. Placement of a pessary
c. Vaginal hysterectomy
d. Le Fort procedure
e. Anterior colporrhaphy
A 78-year-old woman with chronic obstructive pulmonary disease, chronic hypertension,
and history of myocardial infarction requiring angioplasty presents to your office for
evaluation of something hanging out of her vagina. She had a hysterectomy for benign
indications at age 48. For the past few months, she has been experiencing the sensation
of pelvic pressure. Last month she felt a bulge at the vaginal opening. Two weeks ago
something fell out of the vagina. On pelvic examination, the patient has total eversion of
the vagina. There is a superficial ulceration at the vaginal apex. Which of the following is
the best next step in the management of this patient?

a. Biopsy of the vaginal ulceration

b. Schedule abdominal sacral colpopexy
c. Place a pessary
d. Prescribe oral estrogen
e. Prescribe topical vaginal estrogen cream
A 78-year-old woman with chronic obstructive pulmonary disease, chronic
hypertension, and history of myocardial infarction requiring angioplasty presents to
your office for evaluation of something hanging out of her vagina. She had a
hysterectomy for benign indications at age 48. For the past few months, she has been
experiencing the sensation of pelvic pressure. Last month she felt a bulge at the vaginal
opening. Two weeks ago something fell out of the vagina. On pelvic examination, the
patient has total eversion of the vagina. There is a superficial ulceration at the vaginal
apex. Which of the following is the best next step in the management of this patient?

a. Biopsy of the vaginal ulceration

b. Schedule abdominal sacral colpopexy
c. Place a pessary
d. Prescribe oral estrogen
e. Prescribe topical vaginal estrogen cream
You are discussing surgical options with a patient with symptomatic pelvic relaxation.
Partial colpocleisis (Le Fort procedure) may be more appropriate than vaginal
hysterectomy and anterior and posterior (A&P) repair for patients in which of the
following circumstances?

a. Do not desire retained sexual function

b. Need periodic endometrial sampling
c. Have had endometrial dysplasia
d. Have cervical dysplasia that requires colposcopic evaluation
e. Have a history of urinary incontinence
You are discussing surgical options with a patient with symptomatic pelvic relaxation.
Partial colpocleisis (Le Fort procedure - Partial colpocleisis ) may be more appropriate
than vaginal hysterectomy and anterior and posterior (A&P) repair for patients in which
of the following circumstances?

a. Do not desire retained sexual function

b. Need periodic endometrial sampling
c. Have had endometrial dysplasia
d. Have cervical dysplasia that requires colposcopic evaluation
e. Have a history of urinary incontinence
 Urinary incontinence
Stress incontinence
Urge incontinence
Overflow incontinence
Note: urinary frequency and urgency is mainly caused by UTI’s, the first step in diagnosis of urinary incontinence will be urinalysis and urine culture to rule out
urinary tract infection
features management
• Most common form of urinary incontinence • weight loss, stop smoking,
• Associated with activity that increase intraabdominal kegal exercise,
pressure (cough laugh, sneeze) • Bladder neck suspension
• Aggrevating factors: Obesity, pregnancy, COPD, status post surgery (Kelly prodedure is
prolapse fixation the older approach with
• Important diagnostic facts: Post void cystometry – normal lower success rates, burch
urethral pressure procedure is highly effective,
Marshall-Marchetti-Krantz
surgery)
• 2nd most common form of urinary incontinence • eliminate aggrevating factors
• Mechanism: unstable bladder due to Inappropriate detrusor (Caffeine, excess water)
muscle contraction (dyssynergia) • Behavioral: Bladder training
• Present as Sudden urge to urinate • anticholinegics (oxybutinine)
• Aggravating factors: Age (>60 years of age), MS, Parkinson’s,
Alzheimer, strokes
• mechanism : bladder gets distended due to lack of sensation • STOP medications
of fullness, until uncontrolled incontinence takes place • Cholinergic (bethanecol)
• Associated with diabetic neuropathy stones, BPH, ibuprofen • Intermittent catheterization
• Important diagnostic fact: inreased post void residual
volume.
 Specific surgeries for urinary incontinence
procedure comments indication
Kelly plication • Suspension of the bladder neck (old Genuine stress incontinence (no rectocele or
procedure yet low rates of success cystocele)
Burch procedure • Bladder neck suspension to the cooper’s Same as Kelly’s plication
ligament through abdominal approach. The
newer version of Kelly plication, highly
effective
Marshall-Marchetti-Krantz • Retropubic attachment of the periurethral Stress incontinence in the presence of cystocele
(MMK) tissue to the symphysis pubis
• Complications Enteroceles may occur in
approximately 5% of women who have
undergone the MMK procedure
Anterior and posterior • Anterior and posterior vaginal wall repair Stress incontinence in the presence of rectocele
colporrhaphy and/or cyctocele
A 53-year-old postmenopausal woman, G3P3, presents
for evaluation of troublesome urinary leakage 6 weeks in
duration. Which of the following is the most appropriate
first step in this patient’s evaluation?

a. Urinalysis and culture

b. Urethral pressure profiles
c. Intravenous pyelogram
d. Cystourethrogram
e. Urethrocystoscopy
A 53-year-old postmenopausal woman, G3P3, presents
for evaluation of troublesome urinary leakage 6 weeks in
duration. Which of the following is the most appropriate
first step in this patient’s evaluation?

a. Urinalysis and culture

b. Urethral pressure profiles
c. Intravenous pyelogram
d. Cystourethrogram
e. Urethrocystoscopy
A 38-year-old multigravid woman complains of the painless loss of urine,
beginning immediately with coughing, laughing, lifting, or straining.
Immediate cessation of the activity stops the urine loss after only a few
drops. Which of the following is this history most suggestive of?

(A) fistula
(B) stress incontinence
(C) urge incontinence
(D) urethral diverticulum
(E) UTI
A 38-year-old multigravid woman complains of the painless loss of urine,
beginning immediately with coughing, laughing, lifting, or straining.
Immediate cessation of the activity stops the urine loss after only a few
drops. Which of the following is this history most suggestive of?

(A) fistula
(B) stress incontinence
(C) urge incontinence
(D) urethral diverticulum
(E) UTI
healthy 59-year-old woman with no history of urinary incontinence
undergoes vaginal hysterectomy and anteroposterior repair for uterine
prolapse, large cystocele, and rectocele. Two weeks postoperatively, she
presents to your office with a new complaint of intermittent leakage of
urine. What is the most likely cause of this complaint following her surgery?

a. Detrusor instability
b. Overflow incontinence
c. Rectovaginal fistula
d. Stress urinary incontinence
e. Vesicovaginal fistula
healthy 59-year-old woman with no history of urinary incontinence
undergoes vaginal hysterectomy and anteroposterior repair for uterine
prolapse, large cystocele, and rectocele. Two weeks postoperatively, she
presents to your office with a new complaint of intermittent leakage of
urine. What is the most likely cause of this complaint following her surgery?

a. Detrusor instability
b. Overflow incontinence
c. Rectovaginal fistula
d. Stress urinary incontinence
e. Vesicovaginal fistula
A 44-year-old woman complains of urinary incontinence. She loses urine when she
laughs, coughs, and plays tennis. Urodynamic studies are performed in the office
with a multiple-channel machine. If this patient has genuine stress urinary
incontinence, which of the following do you expect to see on the cystometric
study?

a. An abnormally short urethra

b. Multiple uninhibited detrusor contractions
c. Total bladder capacity of 1000 cc
d. Normal urethral pressure profile
e. First urge to void at 50 cc
A 44-year-old woman complains of urinary incontinence. She loses urine when she
laughs, coughs, and plays tennis. Urodynamic studies are performed in the office
with a multiple-channel machine. If this patient has genuine stress urinary
incontinence, which of the following do you expect to see on the cystometric
study?

a. An abnormally short urethra

b. Multiple uninhibited detrusor contractions
c. Total bladder capacity of 1000 cc
d. Normal urethral pressure profile
e. First urge to void at 50 cc
Kegel exercises were designed to do which of the following?

(A) strengthen the abdominal muscles after childbirth

(B) increase the blood flow to the perineum to speed the healing of an episiotomy
(C) improve the tone of the muscles surrounding the bladder base and proximal
bladder neck
(D) prevent denervation of pelvic muscles after childbirth
(E) decrease the muscle atrophy associated with aging
Kegel exercises were designed to do which of the following?

(A) strengthen the abdominal muscles after childbirth

(B) increase the blood flow to the perineum to speed the healing of an episiotomy
(C) improve the tone of the muscles surrounding the bladder base and proximal
bladder neck
(D) prevent denervation of pelvic muscles after childbirth
(E) decrease the muscle atrophy associated with aging
A 76-year-old woman presents for evaluation of urinary incontinence. She had a
hysterectomy for fibroid tumors of the uterus at age 48. After complete evaluation, you
determine that the patient has genuine stress urinary incontinence. On physical
examination, she has a hypermobile urethra, but there is no cystocele or rectocele. There
is no vaginal vault prolapse. Office cystometrics confirms genuine stress urinary
incontinence. Which of the following surgical procedures should you recommend to this
patient?

a. Kelly plication
b. Anterior and posterior colporrhaphy
c. Burch procedure
d. Abdominal sacral colpopexy
e. Le Fort colpocleisis
A 76-year-old woman presents for evaluation of urinary incontinence. She had a
hysterectomy for fibroid tumors of the uterus at age 48. After complete evaluation, you
determine that the patient has genuine stress urinary incontinence. On physical
examination, she has a hypermobile urethra, but there is no cystocele or rectocele. There
is no vaginal vault prolapse. Office cystometrics confirms genuine stress urinary
incontinence. Which of the following surgical procedures should you recommend to this
patient?

a. Kelly plication
b. Anterior and posterior colporrhaphy
c. Burch procedure
d. Abdominal sacral colpopexy
e. Le Fort colpocleisis
A 46-year-old woman presents to your office complaining of something bulging from her
vagina for the past year. It has been getting progressively more prominent. She has
started to notice that she leaks urine with laughing and sneezing. She still has periods
regularly every 26 days. She is married. Her husband had a vasectomy for contraception.
After appropriate evaluation, you diagnose a second-degree cystocele. She has no uterine
prolapse or rectocele. Which of the following is the best treatment plan to offer this
patient?

a. Anticholinergic medications
b. Antibiotic therapy with Bactrim
c. Le Fort colpocleisis
d. Surgical correction with a bladder neck suspension procedure
e. Use of vaginal estrogen cream
A 46-year-old woman presents to your office complaining of something bulging from her
vagina for the past year. It has been getting progressively more prominent. She has
started to notice that she leaks urine with laughing and sneezing. She still has periods
regularly every 26 days. She is married. Her husband had a vasectomy for contraception.
After appropriate evaluation, you diagnose a second-degree cystocele. She has no
uterine prolapse or rectocele. Which of the following is the best treatment plan to offer
this patient?

a. Anticholinergic medications
b. Antibiotic therapy with Bactrim
c. Le Fort colpocleisis
d. Surgical correction with a bladder neck suspension procedure (MMK)
e. Use of vaginal estrogen cream
A 63-year-old woman is undergoing a total abdominal hysterectomy (TAH) for atypical
endometrial hyperplasia. She mentioned to her doctor 2 weeks prior to the surgery that she has
had problems with leakage of urine with straining and occasional episodes of urinary urgency. A
urine culture at that visit is negative. She has had preoperative cystometrics done in the doctor’s
office showing loss of urine during Valsalva maneuvers along with evidence of detrusor
instability. The doctor has elected to do a retropubic bladder neck suspension following the TAH.
A Marshall-Marchetti-Krantz procedure (MMK) is done to attach the bladder neck to the pubic
symphysis. The patient does well after her surgery and is released from the hospital on
postoperative day 3. Which of the following should her doctor advise her prior to her discharge?

a. Urinary retention is very common after an MMK procedure and often requires long-term self-
catheterization.
b. She has a 5% risk of enterocele formation.
c. The MMK procedure is highly effective, with greater than 90% long-term cure rate.
d. Osteitis pubis occurs in approximately 10% of patients after an MMK, but is easily treated with
oral antibiotics.
e. She will not need any additional treatment for her bladder dysfunction
A 63-year-old woman is undergoing a total abdominal hysterectomy (TAH) for atypical
endometrial hyperplasia. She mentioned to her doctor 2 weeks prior to the surgery that she has
had problems with leakage of urine with straining and occasional episodes of urinary urgency. A
urine culture at that visit is negative. She has had preoperative cystometrics done in the doctor’s
office showing loss of urine during Valsalva maneuvers along with evidence of detrusor
instability. The doctor has elected to do a retropubic bladder neck suspension following the TAH.
A Marshall-Marchetti-Krantz procedure (MMK) is done to attach the bladder neck to the pubic
symphysis. The patient does well after her surgery and is released from the hospital on
postoperative day 3. Which of the following should her doctor advise her prior to her discharge?

a. Urinary retention is very common after an MMK procedure and often requires long-term self-
catheterization.
b. She has a 5% risk of enterocele formation.
c. The MMK procedure is highly effective, with greater than 90% long-term cure rate.
d. Osteitis pubis occurs in approximately 10% of patients after an MMK, but is easily treated with
oral antibiotics.
e. She will not need any additional treatment for her bladder dysfunction
A 50-year-old woman complains of leakage of urine. After genuine stress
urinary incontinence, which of the following is the most common cause of
urinary leakage?

a. Detrusor dyssynergia
b. Unstable bladder
c. Unstable urethra
d. Urethral diverticulum
e. Overflow incontinence
A 50-year-old woman complains of leakage of urine. After genuine stress
urinary incontinence, which of the following is the most common cause of
urinary leakage?

a. Detrusor dyssynergia (both detrusor and urethra contract simultaniosly)

b. Unstable bladder
c. Unstable urethra
d. Urethral diverticulum
e. Overflow incontinence
A 65-year-old woman complains of leakage of urine. Which of the following is the
most common cause of this condition in such patients?

a. Anatomic stress urinary incontinence

b. Urethral diverticulum
c. Overflow incontinence
d. Unstable bladder
e. Fistula
A 65-year-old woman complains of leakage of urine. Which of the following is the
most common cause of this condition in such patients?

a. Anatomic stress urinary incontinence

b. Urethral diverticulum
c. Overflow incontinence
d. Unstable bladder
e. Fistula
A 40-year-old G3P3 comes to your office for a routine annual GYN examination. She
tells you that she gets up several times during the night to void. On further
questioning, she admits to you that during the day she sometimes gets the urge to
void, but sometimes cannot quite make it to the bathroom. She attributes this to
getting older and is not extremely concerned, although she often wears a pad when
she goes out in case she loses some urine. This patient is very healthy otherwise and
does not take any medication on a regular basis. She still has regular, monthly
menstrual periods. She has had three normal spontaneous vaginal deliveries of infants
weighing between 7 and 8 lb. An office dipstick of her urine does not indicate any
blood, bacteria, WBCs, or protein. Her urine culture is negative. Based on her office
presentation and history, which of the following is the most likely diagnosis?

a. Urinary stress incontinence

b. Urinary tract infection
c. Overflow incontinence
d. Bladder dyssynergia
e. Vesicovaginal fistula
A 40-year-old G3P3 comes to your office for a routine annual GYN
examination. She tells you that she gets up several times during the night
to void. On further questioning, she admits to you that during the day she
sometimes gets the urge to void, but sometimes cannot quite make it to
the bathroom. She attributes this to getting older and is not extremely
concerned, although she often wears a pad when she goes out in case she
loses some urine. This patient is very healthy otherwise and does not take
any medication on a regular basis. She still has regular, monthly menstrual
periods. She has had three normal spontaneous vaginal deliveries of
infants weighing between 7 and 8 lb. An office dipstick of her urine does
not indicate any blood, bacteria, WBCs, or protein. Her urine culture is
negative. Based on her office presentation and history, which of the
following is the most likely diagnosis?

a. Urinary stress incontinence

b. Urinary tract infection
c. Overflow incontinence
d. Bladder dyssynergia
e. Vesicovaginal fistula
A 38-year-old woman presents to your office complaining of urinary incontinence.
Her symptoms are suggestive of urge incontinence. She admits to drinking several
large glasses of iced tea and water on a daily basis because her mother always
told her to drink lots of liquids to lower her risk of bladder infections. Urinalysis
and urine culture are negative. After confirming the diagnosis with physical
examination and office cystometrics, which of the following treatments should
you recommend to the patient as the next step in the management of her
problem?

a. Instruct her to start performing Kegel exercises.

b. Tell her to hold her urine for 6 hours at a time to enlarge her bladder capacity.
c. Instruct her to eliminate excess water and caffeine from her daily fluid intake.
d. Prescribe an anticholinergic.
e. Schedule cystoscopy.
A 38-year-old woman presents to your office complaining of urinary
incontinence. Her symptoms are suggestive of urge incontinence. She
admits to drinking several large glasses of iced tea and water on a daily
basis because her mother always told her to drink lots of liquids to lower
her risk of bladder infections. Urinalysis and urine culture are negative.
After confirming the diagnosis with physical examination and office
cystometrics, which of the following treatments should you recommend
to the patient as the next step in the management of her problem?

a. Instruct her to start performing Kegel exercises.

b. Tell her to hold her urine for 6 hours at a time to enlarge her bladder
capacity.
c. Instruct her to eliminate excess water and caffeine from her daily fluid
intake.
d. Prescribe an anticholinergic.
e. Schedule cystoscopy.
A 52-year-old postmenopausal woman complains of urinary frequency, urgency,
and urge incontinence. She is otherwise healthy. Which of the following should be
included in the behavioral treatment you recommend?

(A) relaxation techniques

(B) anticholinergic medication
(C) voiding every hour during the daytime
(D) bladder retraining
(E) incontinence pad testing
A 52-year-old postmenopausal woman complains of urinary frequency, urgency,
and urge incontinence. She is otherwise healthy. Which of the following should be
included in the behavioral treatment you recommend?

(A) relaxation techniques

(B) anticholinergic medication
(C) voiding every hour during the daytime
(D) bladder retraining
(E) incontinence pad testing
A 45-year-old woman with previously documented urge incontinence continues to
be symptomatic after following your advice for conservative self-treatment. Which
of the following is the best next step in management?

a. Prescribe Ditropan (oxybutynin chloride).

b. Prescribe Estrogen therapy.
c. Schedule a retropubic suspension of the bladder neck.
d. Refer her to a urologist for urethral dilation.
e. Schedule a voiding cystourethrogram.
A 45-year-old woman with previously documented urge incontinence continues to
be symptomatic after following your advice for conservative self-treatment. Which
of the following is the best next step in management?

a. Prescribe Ditropan (oxybutynin chloride).

b. Prescribe Estrogen therapy.
c. Schedule a retropubic suspension of the bladder neck.
d. Refer her to a urologist for urethral dilation.
e. Schedule a voiding cystourethrogram.
 Other pelvic floor pathologies
disorder Comments
Fecal incontinence • A continuous or recurrent uncontrolled passage of fecal material
• “continence” requires: normal stool consistency and volume, intact innervation of the pelvic floor
and anal sphincters, and coordination of the puborectalis muscle, rectum, and anal sphincters
• The most common cause of fecal incontinence is obstetric trauma with inadequate repair
• Other causes include: senility, central nervous system (CNS) disease, rectal prolapse, diabetes,
chronic diarrhea, and inflammatory bowel disease.
• Management: . Surgical repair of a defect (if obstetric trauma) bulk-forming and antispasmodic
agents, Biofeedback and electrical stimulation of the rectal sphincter

Rectovaginal fistula • A consequence of obstetrical trauma (other causes include radiation and IBD’s)
• Presentation: passage of flatus through the vagina with or without fecal passage
• Management: vaginal surgical repair of fistula
Ectopic ureter • a congenital anatomic defect by which a ureter is opened to the vagina
• Manifest as unctrollable dribbling of urine in the pediatric female patient
• Diagnosis: physical examination, intravenous dye injection, IVP.
Urethral diverticulum • A small outpouching of the urethra
• Presentation: dysuria, dyspareunia (painful sexual intercourse and urine to dribble after voiding),
palpable mass on the anterior vaginal wall under the urethra
• Diagnosis: on physical examination, urethrogram, urethroscopy
A postmenopausal woman is undergoing evaluation for fecal incontinence.
She has no other diagnosed medical problems. She lives by herself and is
self-sufficient, oriented, and an excellent historian. Physical examination is
completely normal. Which of the following is the most likely cause of this
patient’s condition?

a. Rectal prolapse
b. Diabetes
c. Obstetric trauma
d. Senility
e. Excessive caffeine intake
A postmenopausal woman is undergoing evaluation for fecal
incontinence. She has no other diagnosed medical problems.
She lives by herself and is self-sufficient, oriented, and an
excellent historian. Physical examination is completely normal.
Which of the following is the most likely cause of this patient’s
condition?

a. Rectal prolapse
b. Diabetes
c. Obstetric trauma
d. Senility
e. Excessive caffeine intake
Fecal incontinence is most likely related to which of the following?

(A) interplay between the pubococcygeus muscle and rectum

(B) innervation of the pelvic floor and the anal sphincters
(C) normal colonic transit time
(D) nulliparity
(E) urinary retention
Fecal incontinence is most likely related to which of the following?

(A) interplay between the pubococcygeus muscle and rectum

(B) innervation of the pelvic floor and the anal sphincters
(C) normal colonic transit time
(D) nulliparity
(E) urinary retention
Which of the following is the most common cause of rectovaginal
fistula?

(A) obstetrical delivery

(B) irradiation to the pelvis
(C) carcinoma
(D) hemorrhoidectomy
(E) Crohn’s disease
Which of the following is the most common cause of rectovaginal
fistula?

(A) obstetrical delivery

(B) irradiation to the pelvis
(C) carcinoma
(D) hemorrhoidectomy
(E) Crohn’s disease
If a rectovaginal fistula is identified, which of the following
should initial treatment include?

(A) diverting colostomy

(B) bowel resection
(C) rectal pull-through operation
(D) vaginal repair of the fistula
(E) systemic steroids and antibiotics
If a rectovaginal fistula is identified, which of the following
should initial treatment include?

(A) diverting colostomy

(B) bowel resection
(C) rectal pull-through operation
(D) vaginal repair of the fistula
(E) systemic steroids and antibiotics
A 10-year-old patient’s mother gives a history of the child constantly wetting
herself, requiring the continuous use of diapers since birth. The child is
otherwise very healthy and happy and does well in school. Which of the
following diagnoses would most closely fit this clinical history?

(A) maternal anxiety

(B) ectopic ureter with fistula to the vagina
(C) stress incontinence
(D) urethral diverticula
(E) vesicovaginal fistula
A 10-year-old patient’s mother gives a history of the child
constantly wetting herself, requiring the continuous use of
diapers since birth. The child is otherwise very healthy
and happy and does well in school. Which of the following
diagnoses would most closely fit this clinical history?

(A) maternal anxiety

(B) ectopic ureter with fistula to the vagina
(C) stress incontinence
(D) urethral diverticula
(E) vesicovaginal fistula
A woman complains of postvoid dribbling of urine when she stands,
painful intercourse, and dysuria. She has no other symptoms. Which of
the following is she most likely to have?

(A) a urinary fistula

(B) detrusor instability
(C) UTI
(D) genuine urinary stress incontinence
(E) a urethral diverticulum
A woman complains of postvoid dribbling of urine when she stands,
painful intercourse, and dysuria. She has no other symptoms. Which of
the following is she most likely to have?

(A) a urinary fistula - contineus

(B) detrusor instability
(C) UTI
(D) genuine urinary stress incontinence
(E) a urethral diverticulum
A 30-year-old G3P3 is being evaluated for urinary urgency, urinary frequency,
and dysuria. She also complains of pain with insertion when attempting
intercourse. She frequently dribbles a few drops of urine after she finishes
voiding. She has had three full-term spontaneous vaginal deliveries. Her last
baby weighed more than 9 lb. She had multiple sutures placed in the vaginal
area after delivery of that child. She also has a history of multiple urinary tract
infections since she was a teenager. On pelvic examination, she has a 1-cm
tender suburethral mass. With palpation of the mass, a small amount of blood-
tinged pus is expressed from the urethra. Which of the following is the most
likely cause of this patient’s problem?

a. Urethral polyp
b. Urethral fistula
c. Urethral stricture
d. Urethral eversion
e. Urethral diverticulum
A 30-year-old G3P3 is being evaluated for urinary urgency, urinary frequency, and
dysuria. She also complains of pain with insertion when attempting intercourse.
She frequently dribbles a few drops of urine after she finishes voiding. She has had
three full-term spontaneous vaginal deliveries. Her last baby weighed more than 9
lb. She had multiple sutures placed in the vaginal area after delivery of that child.
She also has a history of multiple urinary tract infections since she was a teenager.
On pelvic examination, she has a 1-cm tender suburethral mass. With palpation of
the mass, a small amount of blood-tinged pus is expressed from the urethra.
Which of the following is the most likely cause of this patient’s problem?

a. Urethral polyp
b. Urethral fistula
c. Urethral stricture
d. Urethral eversion
e. Urethral diverticulum
Premalignany and malignant
disorders of the ovary
 Benign Ovarian disorders
disorder comments
Functional/physiologic cyst In the process of normal ovulation, a follicle develops to maturity and then ruptures to release an
ovum; this is followed by formation and subsequent involution of the corpus luteum
An incidental finding in an asymptomatic patient should be managed conservatively with recheck
after 1-2 menstrual cycles
Follicular cyst The most common ovarian mass, due to failure of rupture of functional follicle or previously
raptured follicle (mainly unilateral).
A rupture may cause sterile peritonitis
Diagnosis: Ultrasound
Corpus luteum cyst The most common ovarian mass in pregnancy, due to accumulation of corpus luteum during
pregnancy, mainly unilateral, may hemorrhage (may be confused with the amniotic sac)
Theca lutein cysts Most common cause of ovarian enlargement in the pediatric population. Mass due to
gonadotropin stimulation, usually bilateral, strong association with choriocarcinoma and moles
Chocolate cyst Blood containing cyst from ovarian endometriosis, varies with the menstrual cycle
Ooophoritis May be a complication of mumps or PID
Stromal hyperthecosis An uncommon ovarian mass, Occurs primarily in postmenopausal women, may cause virilization.
Associated with acanthosis nigricans and insulin resistance
A 25-year-old woman presents to you for routine well-woman examination. She
has had two normal vaginal deliveries and is healthy. She smokes one pack of
cigarettes per day. She has no gynecologic complaints. Her last menstrual period
was 3 weeks ago. During the pelvic examination, you notice that her left ovary is
enlarged to 5 cm in diameter. Which of the following is the best recommendation
to this patient?

a. Order CA-125 testing

b. Schedule outpatient diagnostic laparoscopy
c. Return to the office in 1 to 2 months to recheck the ovaries
d. Schedule a CT scan of the pelvis
e. Admit to the hospital for exploratory laparotomy
A 25-year-old woman presents to you for routine well-woman examination. She
has had two normal vaginal deliveries and is healthy. She smokes one pack of
cigarettes per day. She has no gynecologic complaints. Her last menstrual period
was 3 weeks ago. During the pelvic examination, you notice that her left ovary is
enlarged to 5 cm in diameter. Which of the following is the best recommendation
to this patient?

a. Order CA-125 testing

b. Schedule outpatient diagnostic laparoscopy
c. Return to the office in 1 to 2 months to recheck the ovaries
d. Schedule a CT scan of the pelvis
e. Admit to the hospital for exploratory laparotomy
You are called to the operating room by the general surgeons at a local children’s
hospital. A 4-year old girl with acute abdominal pain was thought to have
appendicitis; instead, she has a large right ovary. What is the most likely diagnosis?

(A) germ cell tumor

(B) epithelial stromal tumor
(C) sex cord-stromal tumor
(D) nonneoplastic follicle or theca lutein cyst
(E) metastatic tumor
You are called to the operating room by the general surgeons at a local children’s
hospital. A 4-year old girl with acute abdominal pain was thought to have
appendicitis; instead, she has a large right ovary. What is the most likely diagnosis?

(A) germ cell tumor

(B) epithelial stromal tumor
(C) sex cord-stromal tumor
(D) nonneoplastic follicle or theca lutein cyst
(E) metastatic tumor
 Ovarian tumors, the facts
feature comments
incidence • Increases with age until the 7th decade of life
• Each 1st degree family relative with ovarian cancer increase the risk for development of
malignancy in 4-5% in an individual
General rule Ovaries in postmenopausal patients are not palpable, if it does, suspect malignancy
presentation Most pathognomonic symptoms: urinary urgency and bloating
histology The majority of ovarian tumors (65%) arise from epithelial cells (serous, mucinous)
And 25% arise from germ cells.
(The different types of ovarian tumors in the next slide)
Protecting factors OCP’s, pregnancy, breast-feeding (inhibit ovulation)
diagnosis Best initial diagnostic step: Pelvic examination: a palpable abdominal or pelvic mass
Ultrasound: >10 cm mass, solid mass, papillary vegetations
CA-125: secreted by many tissues (pleura, peritoneum, pericardium), it has
minor importance on detecting a new malignancy, yet helpful in tumor progression and recurrence
after treatment.
Special pathologies Lynch syndrome type II – a mismatch repair defect with multiple malignancies in: endometrium,
ovaries, stomach and colon
 origin
Germ cell tumors
Types of ovarian neoplasms
Ovarian tumors
Dysgerminoma
Choriocarcinoma
Endodermal sinus (yolk sac) tumor
teratoma
Epithelial cell tumors Serous cystadenoma
Serous cystadenocarcinoma
Mucinous cystadenoma
Comments
Most common Malignant germ cell tumor, composed of
primordial germ cells and intervening connective tissue
infiltrated by lymphocytes. Coexist with other germ cell tumors.
Equivalent to male seminoma, tumor marker is LDH
rare, Malignant and aggressive, can develop in pregnancy in the mother
or the infant, tumor marker is hCG.
Aggressive ovarian tumor, tumor marker is AFP
Most common ovarian germ cell tumor (90%), contains cell from 2-3
germ laters.
• The “mature form” (dermoid cyst”) – most common
benign germ cell tumor, usually unilateral, yet bilateral in 10-15%
of cases
• The “immature form” containing embryonal tissue,
2nd most common malignant germ call tumor, highly
aggressive, occurs mainly in the first 2 decades of life
20% of ovarian. Bilateral in 33% of cases, benign. Lined with cells similar
to fallopian tube epithelium.
50% of ovarian tumors - tumors – most common of epithelial,
bilateral in 33% of cases, malignant. tumor marker CA-125
Benign tumor, composed of Multilocular cyst lined by mucous secreting
 origin Ovarian tumor comments

Sex cord-stromal origin Fibroma Bundles of spindle shaped fibroblasts. benign

Meig’s syndrome – triad of ovarian fibroma, ascites and
right sided pleural effusion

thecoma Estrogen secreting, demonstrates round lipid containing

cells in addition to fibroblasts.

Granulosa cell tumor Estrogen secreting tumor, by that causing precocious

puberty in children, and endometrial hyperplasia and
carcinoma in adults, contains “call-Exner bodies”

Sertoli-leydig cell tumor (a.k.a Androgen secreting tumor associated with virilism
adrenoblastoma, arrhenoblastoma) (musculinization), contains “crystals of Reinke”

Metastatic Tumor comments

Krukenberg tumor Gi malignancy that metastasizes to ovaries, causing a mucin secreting “signet cells” adenocarcinoma

Vaginal tumor The most common origin of metastasis to the ovaries

Which of the following statements accurately reflects the natural history of ovarian epithelial
carcinoma?

(A) The incidence of ovarian carcinoma increases with age until the seventh decade of life.
(B) Elderly women are less likely than younger women to have disease diagnosed at an advanced
stage.
(C) Most women with ovarian cancer do not have any symptoms prior to dissemination of
disease.
(D) Seventy-five percent of all ovarian tumors in women older than 50 years are malignant.
(E) Twenty-five percent of all ovarian tumors in women between 20 and 40 years of age are
malignant.
Which of the following statements accurately reflects the natural history of ovarian epithelial
carcinoma?

(A) The incidence of ovarian carcinoma increases with age until the seventh decade of life.
(B) Elderly women are less likely than younger women to have disease diagnosed at an advanced
stage.
(C) Most women with ovarian cancer do not have any symptoms prior to dissemination of
disease.
(D) Seventy-five percent of all ovarian tumors in women older than 50 years are malignant.
(E) Twenty-five percent of all ovarian tumors in women between 20 and 40 years of age are
malignant.
A 54-year-old healthy woman comes for an annual examination. Her last menstrual
period (LMP) was 4 years ago. The physical examination is normal. Pelvic examination
shows vaginal atrophy and a small, mobile uterus. The right ovary is 2.5 x 4.5 cm in
diameter. The left ovary is nonpalpable. Vaginal ultrasonography shows that the right
ovary is similar in size to that of a premenopausal ovary. What should you advise this
patient?

(A) The ovaries of a postmenopausal woman are usually palpable.

(B) The right ovary of a postmenopausal woman is usually palpable by right-handed
examiners.
(C) A palpable ovary in a postmenopausal woman is suspicious for malignancy.
(D) The right ovary is still producing significant amounts of estrogen
(E) The vaginal ultrasound is an unnecessary diagnostic test.
A 54-year-old healthy woman comes for an annual examination. Her last menstrual
period (LMP) was 4 years ago. The physical examination is normal. Pelvic examination
shows vaginal atrophy and a small, mobile uterus. The right ovary is 2.5 x 4.5 cm in
diameter. The left ovary is nonpalpable. Vaginal ultrasonography shows that the right
ovary is similar in size to that of a premenopausal ovary. What should you advise this
patient?

(A) The ovaries of a postmenopausal woman are usually palpable.

(B) The right ovary of a postmenopausal woman is usually palpable by right-handed
examiners.
(C) A palpable ovary in a postmenopausal woman is suspicious for malignancy.
(D) The right ovary is still producing significant amounts of estrogen
(E) The vaginal ultrasound is an unnecessary diagnostic test.
A 24-year-old woman presents with new-onset right lower quadrant pain, and you
palpate an enlarged, tender right adnexa. Which of the following sonographic
characteristics of the cyst in this patient suggests the need for surgical exploration
now instead of observation for one menstrual cycle?

a. Lack of ascites
b. Unilocularity
c. Papillary vegetation
d. Diameter of 5 cm
e. Demonstration of arterial and venous flow by Doppler imaging
A 24-year-old woman presents with new-onset right lower quadrant pain, and you
palpate an enlarged, tender right adnexa. Which of the following sonographic
characteristics of the cyst in this patient suggests the need for surgical exploration
now instead of observation for one menstrual cycle?

a. Lack of ascites
b. Unilocularity
c. Papillary vegetation
d. Diameter of 5 cm
e. Demonstration of arterial and venous flow by Doppler imaging
Which of the following is a cornerstone for detection of ovarian neoplasia?

(A) CA-125
(B) human chorionic gonadotropin (hCG)
(C) pelvic examination
(D) pelvic ultrasound
(E) alpha-fetoprotein
Which of the following is a cornerstone for detection of ovarian neoplasia?

(A) CA-125
(B) human chorionic gonadotropin (hCG)
(C) pelvic examination
(D) pelvic ultrasound
(E) alpha-fetoprotein
Which of the following statements reflects CA-125?
(A) It is a circulating antigenic marker for germ cell ovarian carcinoma.
(B) It is found in normal fetal and adult ovaries.
(C) It is secreted by mesothelial cells of the pleura, pericardium, and peritoneum.
(D) It is not useful in monitoring tumor progression.
(E) It is never elevated in the sera of women with benign diseases.
Which of the following statements reflects CA-125?
(A) It is a circulating antigenic marker for germ cell ovarian carcinoma.
(B) It is found in normal fetal and adult ovaries.
(C) It is secreted by mesothelial cells of the pleura, pericardium, and peritoneum.
(D) It is not useful in monitoring tumor progression.
(E) It is never elevated in the sera of women with benign diseases.
A 56-year-old healthy woman develops vague complaints and presents to her
primary care physician. Which of the following accurately describes symptoms that
could be associated with a diagnosis of ovarian cancer?

(A) there are no identifiable symptoms in women with ovarian cancer

(B) symptoms are usually present for years prior to a diagnosis
(C) shortness of breath and cough
(D) diarrhea
(E) urinary urgency and bloating
A 56-year-old healthy woman develops vague complaints and presents to her
primary care physician. Which of the following accurately describes symptoms that
could be associated with a diagnosis of ovarian cancer?

(A) there are no identifiable symptoms in women with ovarian cancer

(B) symptoms are usually present for years prior to a diagnosis
(C) shortness of breath and cough
(D) diarrhea
(E) urinary urgency and bloating
A 38-year-old nulliparous woman presents requesting a bilateral salpingo-
oophorectomy. Her mother died of ovarian cancer at the age 64, and her sister at
the age 48. There is no family history of other cancers. You advise her that her risk
of developing ovarian cancer is what percentage?

(A) 1–2%
(B) 7%
(C) 20%
(D) 30–40%
(E) >50%
A 38-year-old nulliparous woman presents requesting a bilateral salpingo-
oophorectomy. Her mother died of ovarian cancer at the age 64, and her sister at
the age 48. There is no family history of other cancers. You advise her that her risk
of developing ovarian cancer is what percentage?

(A) 1–2%
(B) 7%
(C) 20%
(D) 30–40%
(E) >50%
Which of the following statements is true?

(A) A site-specific defect transmitting the trait for only ovarian carcinoma is
common.
(B) A BRCA1 gene mutation increases her lifetime risk of ovarian cancer to 10%.
(C) Lynch type II cancer syndrome includes ovarian malignancy.
(D) Fifty percent of ovarian cancer is hereditary.
(E) A BRCA2 mutation increases the risk of ovarian cancer by 70%.
 Lynch syndrome II
• Lynch I syndrome is s mismatch repair gene deficiency include
multiple colon cancers
• Cancer family syndrome, all features of lynch syndrome I with early
onset of cancinoma at other sites including endometrium,
ovaries, and stomach (also TCC)
 A reminder from “breast” practice
BRCA 1 (chromosome 17) BRCA 2 (chromosome 13)
Breast cancer (negative receptors) Breast cancer (positive receptors)
Ovarian cancer (40%) Ovarian cancer (20%)
Male breast cancer
Colon cancer, gastric cancer
Endometrial
Pancreatic cancer
Gallbladder cancer
melanoma
Prostate cancer (both)

* Note: prophylactic mastectomy (simple) reduce the risk for breast cancer in BRCA carriers by 90% but do not
eliminate it
Which of the following statements is true?

(A) A site-specific defect transmitting the trait for only ovarian carcinoma is
common.
(B) A BRCA1 gene mutation increases her lifetime risk of ovarian cancer to 10%.
(C) Lynch type II cancer syndrome includes ovarian malignancy.
(D) Fifty percent of ovarian cancer is hereditary.
(E) A BRCA2 mutation increases the risk of ovarian cancer by 70%.
Ovarian neoplasms most commonly arise from which of the following cell lines?

(A) ovarian epithelium

(B) ovarian stroma
(C) ovarian germ cells
(D) ovarian sex cords
(E) metastatic disease
Ovarian neoplasms most commonly arise from which of the following
cell lines?

(A) ovarian epithelium

(B) ovarian stroma
(C) ovarian germ cells
(D) ovarian sex cords
(E) metastatic disease
Which of the following postmenopausal women is most protected from ovarian
epithelial carcinoma?

(A) a married woman using perineal talc powder

(B) an unmarried woman with a history of breast cancer
(C) a nun with a history of late menopause
(D) a nulliparous woman with a history of regular menses
(E) a multiparous woman who used OCPs and now postmenopausal
Which of the following postmenopausal women is most protected from ovarian
epithelial carcinoma?

(A) a married woman using perineal talc powder

(B) an unmarried woman with a history of breast cancer
(C) a nun with a history of late menopause
(D) a nulliparous woman with a history of regular menses
(E) a multiparous woman who used OCPs and now postmenopausal
A 35-year-old woman desiring fertility undergoes exploratory laparotomy for a 12-cm pelvic
mass. At surgery, a large, lobulated, right ovarian mass is observed. It has a smooth external
capsule and a bluishgray appearance. The uterus, fallopian tubes, and left ovary appear normal.
Abdominal exploration is negative for metastatic disease. A right salpingo-oophorectomy is
performed. The tumor is opened intraoperatively and found to be divided by septa into lobules.
Frozen section of the tumor shows a mucinous cystadenoma of low malignant potential. One
would base the remainder of the surgical intervention at this time on which of the following
statements regarding mucinous cystadenoma of low malignant potential?

(A) Spread of the tumor outside the ovary occurs 30–40% of the time in the form of
intraperitoneal
growth of mucin-producing cells.
(B) It has 1–2% incidence of bilaterality.
(C) It has a 5-year survival rate of 60%.
(D) It typically occurs in postmenopausal women.
(E) It comprises atypical epithelial proliferation without stromal invasion.
A 35-year-old woman desiring fertility undergoes exploratory laparotomy for a 12-cm pelvic
mass. At surgery, a large, lobulated, right ovarian mass is observed. It has a smooth external
capsule and a bluishgray appearance. The uterus, fallopian tubes, and left ovary appear normal.
Abdominal exploration is negative for metastatic disease. A right salpingo-oophorectomy is
performed. The tumor is opened intraoperatively and found to be divided by septa into lobules.
Frozen section of the tumor shows a mucinous cystadenoma of low malignant potential. One
would base the remainder of the surgical intervention at this time on which of the following
statements regarding mucinous cystadenoma of low malignant potential?

(A) Spread of the tumor outside the ovary occurs 30–40% of the time in the form of
intraperitoneal
growth of mucin-producing cells.
(B) It has 1–2% incidence of bilaterality.
(C) It has a 5-year survival rate of 60%.
(D) It typically occurs in postmenopausal women.
(E) It comprises atypical epithelial proliferation without stromal invasion.
A 65-year-old woman has abdominal distention of 3 months’
duration. Abdominal percussion causes a wavelike movement
of fluid around a central tympanitic area. Pelvic examination
shows a right adnexal mass. It is 8 cm in size, nodular, and
fixed in the pelvis. The left ovary is nonpalpable. Blood
chemistries, urinalysis, cervical Pap smear, mammography, and
chest X-ray are normal. Stool guaiac examination and
gastrointestinal studies are also normal. A serum CA-125 level
is 250 U/mL (normal, <35 U/mL). Which of the following is the
most likely diagnosis?

(A) gonadoblastoma
(B) Meigs’ syndrome
(C) Krukenberg’s tumors
(D) serous cystadenocarcinoma
(E) endodermal sinus tumor
A 65-year-old woman has abdominal distention of 3 months’
duration. Abdominal percussion causes a wavelike movement
of fluid around a central tympanitic area. Pelvic examination
shows a right adnexal mass. It is 8 cm in size, nodular, and
fixed in the pelvis. The left ovary is nonpalpable. Blood
chemistries, urinalysis, cervical Pap smear, mammography, and
chest X-ray are normal. Stool guaiac examination and
gastrointestinal studies are also normal. A serum CA-125 level
is 250 U/mL (normal, <35 U/mL). Which of the following is the
most likely diagnosis?

(A) gonadoblastoma
(B) Meigs’ syndrome
(C) Krukenberg’s tumors
(D) serous cystadenocarcinoma
(E) endodermal sinus tumor
A 41-year-old woman undergoes exploratory laparotomy for a persistent
adnexal mass. Frozen section diagnosis is serous carcinoma. Assuming
that the other ovary is grossly normal, what is the likelihood that the
contralateral ovary is involved in this malignancy?

a. 5%
b. 15%
c. 33%
d. 50%
e. 75%
A 41-year-old woman undergoes exploratory laparotomy for a persistent
adnexal mass. Frozen section diagnosis is serous carcinoma. Assuming
that the other ovary is grossly normal, what is the likelihood that the
contralateral ovary is involved in this malignancy?

a. 5%
b. 15%
c. 33%
d. 50%
e. 75%
A 10-year-old girl presents with abdominal pain. During the emergency
department workup, an adnexal mass is found. You suspect a germ cell tumor. In
preoperative discussion, her parents are told that the most common germ cell
tumor is which of the following?

(A) dysgerminoma
(B) endodermal sinus tumor
(C) embryonal carcinoma
(D) choriocarcinoma
(E) mature teratoma
A 10-year-old girl presents with abdominal pain. During the emergency
department workup, an adnexal mass is found. You suspect a germ cell tumor. In
preoperative discussion, her parents are told that the most common germ cell
tumor is which of the following?

(A) dysgerminoma
(B) endodermal sinus tumor
(C) embryonal carcinoma
(D) choriocarcinoma
(E) mature teratoma
A 19-year-old woman with an ovarian mass is thought to have a dermoid or
teratoma based on ultrasound findings and gross examination at removal by
laparoscopy. At her postoperative visit the pathology returns with the finding of an
immature teratoma. Which of the following statements reflects current knowledge
about immature teratomas?

(A) They are the most common malignant germ cell tumor.
(B) They are commonly bilateral.
(C) They produce alpha-fetoprotein.
(D) They commonly occur during the first two decades of life.
(E) They contain malignant squamous cell elements.
A 19-year-old woman with an ovarian mass is thought to have a dermoid or
teratoma based on ultrasound findings and gross examination at removal by
laparoscopy. At her postoperative visit the pathology returns with the finding of an
immature teratoma. Which of the following statements reflects current knowledge
about immature teratomas?

(A) They are the most common malignant germ cell tumor.
(B) They are commonly bilateral.
(C) They produce alpha-fetoprotein.
(D) They commonly occur during the first two decades of life.
(E) They contain malignant squamous cell elements.
A 17-year-old girl is seen by her primary care physician for the evaluation of left lower
quadrant pain. The physician felt a pelvic mass on physical examination and ordered a
pelvic ultrasound. You are consulted because an ovarian neoplasm is identified by the
ultrasound. Which of the following is the most common ovarian tumor in this type of
patient?

a. Germ cell
b. Papillary serous epithelial
c. Fibrosarcoma
d. Brenner tumor
e. Sarcoma botryoides
A 17-year-old girl is seen by her primary care physician for the evaluation of left lower
quadrant pain. The physician felt a pelvic mass on physical examination and ordered a
pelvic ultrasound. You are consulted because an ovarian neoplasm is identified by the
ultrasound. Which of the following is the most common ovarian tumor in this type of
patient?

a. Germ cell
b. Papillary serous epithelial
c. Fibrosarcoma
d. Brenner tumor
e. Sarcoma botryoides
A 21-year-old woman presents with left lower quadrant pain. An anterior 7-cm firm
adnexal cyst is palpated. Ultrasound confirms a complex left adnexal mass with solid
components that appear to contain bone and teeth. What percentage of these tumors
are bilateral?

a. Less than 1%
b. 2% to 3%
c. 10% to 15%
d. 50%
e. Greater than 75%
A 21-year-old woman presents with left lower quadrant pain. An anterior 7-cm firm
adnexal cyst is palpated. Ultrasound confirms a complex left adnexal mass with solid
components that appear to contain bone and teeth. What percentage of these tumors
are bilateral?

a. Less than 1%
b. 2% to 3%
c. 10% to 15%
d. 50%
e. Greater than 75%
A 26-year-old nulliparous woman is seen in the emergency department for acute
abdominal pain. Her vital signs are blood pressure, 90/50 mm Hg; pulse, 120 bpm; and
temperature, afebrile. Abdominal examination shows right lower quadrant tenderness
with rebound. Pelvic examination demonstrates a painful 10-cm right adnexal mass. A
serum pregnancy test is negative. A hematocrit is 24% (normal, 35– 45%). Exploratory
laparotomy confirms a hemoperitoneum. A smooth right ovarian tumor is bleeding from
its ruptured capsule. Inspection of the uterus, fallopian tubes, and left ovary is normal. A
right salpingo-oophorectomy is performed. Frozen section of the tumor shows primitive
germ cells with intervening connective tissue infiltrated by lymphocytes. The tumor is
most likely which of the following?

(A) dysgerminoma
(B) endodermal sinus tumor
(C) choriocarcinoma
(D) embryonal carcinoma
(E) mature teratoma
A 26-year-old nulliparous woman is seen in the emergency department for acute
abdominal pain. Her vital signs are blood pressure, 90/50 mm Hg; pulse, 120 bpm; and
temperature, afebrile. Abdominal examination shows right lower quadrant tenderness
with rebound. Pelvic examination demonstrates a painful 10-cm right adnexal mass. A
serum pregnancy test is negative. A hematocrit is 24% (normal, 35– 45%). Exploratory
laparotomy confirms a hemoperitoneum. A smooth right ovarian tumor is bleeding from
its ruptured capsule. Inspection of the uterus, fallopian tubes, and left ovary is normal. A
right salpingo-oophorectomy is performed. Frozen section of the tumor shows primitive
germ cells with intervening connective tissue infiltrated by lymphocytes. The tumor is
most likely which of the following?

(A) dysgerminoma
(B) endodermal sinus tumor
(C) choriocarcinoma
(D) embryonal carcinoma
(E) mature teratoma
Which of the following statements reflects current understanding about
dysgerminoma?

(A) It occurs in women of all ages with equal frequency.

(B) It has a bilaterality rate of less than 1%.
(C) It is usually resistant to radiotherapy.
(D) It can occur in combination with other germ cell elements.
(E) It has a poor survival rate following unilateral adnexectomy for stage I disease
Which of the following statements reflects current understanding about
dysgerminoma?

(A) It occurs in women of all ages with equal frequency.

(B) It has a bilaterality rate of less than 1%.
(C) It is usually resistant to radiotherapy.
(D) It can occur in combination with other germ cell elements.
(E) It has a poor survival rate following unilateral adnexectomy for stage I disease
A 48-year-old woman is taken to surgery for a solid pelvic mass of 6x7 cm and marked
ascites. At laparotomy the adnexa is removed and sent for frozen section examination.
The report returns as metastic adenocarcinoma to the ovary. Although uncommon,
metastatic tumors to the ovary most often originate from which of the following?

(A) breast
(B) stomach
(C) large intestine
(D) uterus
(E) vagina
A 48-year-old woman is taken to surgery for a solid pelvic mass of 6x7 cm and marked
ascites. At laparotomy the adnexa is removed and sent for frozen section examination.
The report returns as metastic adenocarcinoma to the ovary. Although uncommon,
metastatic tumors to the ovary most often originate from which of the following?

(A) breast
(B) stomach
(C) large intestine
(D) uterus
(E) vagina