Guve probable diagnosis and dd with explanation Investigations and management . With explanation and reasoning

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cd "/tmp/workspace/attachments/80acb88d-f1d8-4eee-a874-7a1cf0c97903" && python3 -c " from pptx import Presentation from pptx.enum.shapes import MSO_SHAPE_TYPE import os prs = Presentation('SHORT CASES 2.pptx') print(f'Total slides: {len(prs.slides)}') for i, slide in enumerate(prs.slides, 1): print(f'\n=== SLIDE {i} ===') for shape in slide.shapes: if shape.has_text_frame and shape.text_frame.text.strip(): print(f'[{shape.shape_type}] {shape.text_frame.text}') if shape.shape_type == MSO_SHAPE_TYPE.PICTURE: print(f'[IMAGE] {shape.name}') "

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GYNAECOLOGY SHORT CASES - Complete Analysis

CASE 1

65-year-old woman | DM x30 yrs | Post-menopausal x18 yrs | Irregular PV bleeding x4 months | Uterus enlarged to 8 weeks

Probable Diagnosis: Endometrial Carcinoma (Type I - Endometrioid Adenocarcinoma)

Reasoning:

Postmenopausal bleeding (PMB) is endometrial carcinoma until proven otherwise - 10-15% of women with PMB have carcinoma
65 years old + 18 years in menopause = significant estrogen-deprivation period, making any bleeding highly suspicious
Diabetes Mellitus is a classical risk factor for endometrial carcinoma (insulin resistance → hyperinsulinemia → increased IGF-1 → endometrial proliferation; obesity-DM axis elevates unopposed estrogens)
Hypertension (BP 150/100) is another classical triad risk factor
Uterus enlarged to 8 weeks (bulky uterus) suggests intracavitary growth
Fornices free and parametrium likely uninvolved - suggests possibly early stage

The Triad of Endometrial Ca Risk: Obesity + Diabetes + Hypertension (all present here)

Differential Diagnoses

Diagnosis	Supporting Features	Against
Endometrial Polyp	PMB, uterine enlargement	Polyps rarely cause this degree of uterine enlargement
Atrophic Endometritis	PMB in elderly	Usually not associated with uterine enlargement
Hormone-secreting ovarian tumor (Granulosa cell tumor)	PMB, uterine enlargement due to estrogen stimulation	No adnexal mass mentioned
Endometrial Hyperplasia	DM, HT, PMB	Precursor lesion; less likely to enlarge uterus significantly
Pyometra	Elderly, PMB	No fever, not tender
Submucosal fibroid	Uterine enlargement	PMB in postmenopausal makes fibroid less likely (fibroids regress)

Investigations

1. First-line:

Transvaginal Ultrasound (TVS): Endometrial thickness >4 mm in PMB is significant; >8 mm is highly suspicious
Pipelle endometrial biopsy (OPD): Gold standard first step - sensitivity ~90%
Fractional curettage (D&C): If Pipelle inadequate; separates endocervical from endometrial tissue

2. Staging workup (once malignancy confirmed):

MRI pelvis: Best for assessing myometrial invasion depth and cervical involvement (critical for staging)
CT chest/abdomen/pelvis: Lymph node assessment, distant metastasis
CA-125: Elevated in advanced/extra-uterine spread
Cystoscopy/proctoscopy: If bladder/rectal involvement suspected
CBC, LFT, RFT, blood glucose: Pre-operative workup
Chest X-ray: Pre-op + pulmonary mets

FIGO Staging (2023):

Stage I: Confined to uterus
Stage II: Cervical stromal involvement
Stage III: Local/regional spread
Stage IV: Bladder/bowel/distant mets

Management

Surgical (mainstay):

Total Abdominal Hysterectomy + Bilateral Salpingo-oophorectomy (TAH + BSO) with pelvic +/- para-aortic lymph node dissection
Peritoneal washings at surgery

Adjuvant Therapy:

Stage Ia (low grade, no LVSI): Observation only
Stage Ib or higher / high-grade: External beam radiotherapy (EBRT) + vaginal brachytherapy
Advanced stage: Chemotherapy (Carboplatin + Paclitaxel)

Medical control pre-op:

Control blood sugar (DM management)
Control hypertension

CASE 2

Probable Diagnosis: Uterine Leiomyoma (Fibroid Uterus) - likely Intramural type

Reasoning:

Young woman (30 yrs), nulliparous
Symmetrical enlargement of uterus to 10 weeks = classic intramural fibroid pattern (subserosal fibroids cause asymmetric; submucosal cause severe bleeding)
Menorrhagia (8 days of heavy flow) is the hallmark of submucous/intramural fibroids
Dysmenorrhoea common with fibroids
Pallor++ = significant iron deficiency anemia from chronic menorrhagia
Mobile uterus, fornices free = no malignant features
Nulliparous status is itself a risk factor for fibroids (protective effect of pregnancy)

Differential Diagnoses

Diagnosis	Supporting Features	Against
Adenomyosis	Menorrhagia, dysmenorrhoea, globular enlargement	Age 30 is young; adenomyosis more common in 35-50 multiparae; symmetrical enlargement can overlap
Endometrial polyp	Menorrhagia	Wouldn't cause uterus to enlarge to 10 weeks
Ovarian cyst/tumor	Pelvic mass	Mass is uterine, not adnexal; fornices free
Pregnancy (early)	Uterine enlargement	LMP and regular cycle given; not pregnant
DUB (Dysfunctional Uterine Bleeding)	Menorrhagia	No structural explanation for uterine enlargement

Investigations

Pelvic Ultrasound (TVS preferred): Confirms fibroid, maps number, size, location (submucosal/intramural/subserosal)
Saline infusion sonohysterography (SIS): Better for submucosal fibroids
MRI pelvis: Gold standard for fibroid mapping (pre-op planning, pre-UAE)
CBC: Assess degree of anemia (likely microcytic hypochromic)
Iron studies: Serum ferritin, TIBC
Thyroid function tests: Rule out hypothyroidism as cause of menorrhagia
Coagulation profile: Rule out bleeding disorder
Pap smear: Cervical cancer screening
Hysteroscopy: Direct visualization + biopsy if needed

Management

Medical (temporary / fertility-preserving):

Iron supplementation: Treat anemia (oral ferrous sulfate 200 mg TDS)
Tranexamic acid: 1g TDS during menstruation (antifibrinolytic)
NSAIDs (Mefenamic acid): For dysmenorrhoea + reduces flow by ~30%
Combined OCP / Progestins: Reduce flow (do not shrink fibroids)
GnRH agonist (Leuprolide/Goserelin): Preoperative - shrinks fibroid by 30-50% via hypoestrogenic state; max 6 months (bone loss risk)
Ulipristal acetate (SPRMs): Selective progesterone receptor modulators - approved in some countries for fibroid treatment

Surgical (definitive):

Myomectomy: Preferred in nulliparous woman wanting to preserve fertility
- Hysteroscopic myomectomy: For submucosal fibroids (Type 0,1,2)
- Laparoscopic myomectomy: For subserosal/intramural fibroids <10 cm
- Open (abdominal) myomectomy: For large/multiple fibroids
Hysterectomy: Definitive; only if family complete and patient declines fertility preservation (not appropriate here at 30, nulliparous)

Interventional:

Uterine Artery Embolization (UAE): Good option for women not wanting surgery; pregnancy outcomes unpredictable - caution in nulliparous

CASE 3

64-year-old postmenopausal (x20 yrs) | P3L3 | Abdominal bloating, lower back pain, early satiety, fatigue x4 months | Weight loss, loss of appetite | Protuberant abdomen, dilated veins, pelvic mass to umbilicus, irregular margins, firm, gross ascites, fluid thrill+ | P/V: left adnexal mass, non-mobile | USG: Left ovarian complex mass 10x8x9 cm with solid components + gross ascites

Probable Diagnosis: Carcinoma Ovary (Epithelial Ovarian Cancer - likely Stage III)

Reasoning:

Postmenopausal woman (age 64) with adnexal mass = malignancy until proven otherwise
Complex ovarian mass with solid components on USG is the most ominous feature
Gross ascites + fluid thrill = peritoneal spread (Stage III)
Non-mobile mass = adhesions/infiltration into surrounding structures
Dilated abdominal veins = venous obstruction or portal hypertension from peritoneal carcinomatosis
Constitutional symptoms: Weight loss, anorexia, fatigue = malignancy
Early satiety = omental infiltration ("omental cake")
Parity (P3) and late menopause slightly reduce risk, but age and postmenopausal status far outweigh this
The classic "silent killer" presentation: insidious onset of vague abdominal symptoms

Most likely histotype: Serous adenocarcinoma (most common, ~70% of epithelial ovarian cancers, most aggressive)

Differential Diagnoses

Diagnosis	Supporting Features	Against
Ovarian fibroma/thecoma	Firm mass, ascites (Meigs' syndrome)	Constitutional symptoms, solid components, age makes malignancy more likely
Metastatic ovarian tumor (Krukenberg)	Bilateral adnexal masses, ascites	USG shows left ovarian complex mass; need to exclude primary GI
Tuberculosis (peritoneal TB)	Ascites, weight loss, mass	History of TB, younger age typical; no fever mentioned; USG complex mass with solids - atypical
Ovarian endometrioma	Complex ovarian mass	Post-menopausal, constitutional symptoms, solid components argue against
Pseudomyxoma peritonei	Ascites, ovarian mass	Usually bilateral, jelly-like ascites

Investigations

Tumor Markers:

CA-125: Elevated in ~80% of epithelial ovarian cancers (esp. serous type); also used for monitoring response
HE4 (Human Epididymis Protein 4): Better specificity than CA-125 alone
ROMA score (CA-125 + HE4 + menopausal status): Risk stratification
AFP, beta-hCG, LDH: For germ cell tumors (more relevant in young women but screen anyway)
CEA, CA 19-9: Rule out GI primary / Krukenberg tumor

Imaging:

CT chest/abdomen/pelvis (contrast): Staging - assess peritoneal spread, lymph nodes, liver, lung mets, omental cake
MRI pelvis: Better soft tissue characterization
PET-CT: Optional, for distant metastasis

Other:

Ascitic fluid cytology: Malignant cells confirm peritoneal spread
BRCA1/BRCA2 genetic testing: Counselling + therapeutic implications (PARP inhibitors)
Endoscopy (UGI/colonoscopy): Rule out Krukenberg (gastric/colorectal primary)
CBC, LFT, RFT, albumin: Nutritional status, pre-op
Coagulation profile

Management

FIGO Staging likely Stage III (peritoneal spread beyond pelvis)

Surgical:

Staging laparotomy / Cytoreductive surgery (Debulking):
- TAH + BSO + omentectomy + peritoneal biopsies + pelvic/para-aortic lymph node dissection
- Goal: Optimal cytoreduction (residual disease <1 cm, ideally R0)
- If unresectable upfront: Neoadjuvant chemotherapy (NACT) x3 cycles → interval debulking surgery → 3 more cycles

Chemotherapy:

Standard first-line: Carboplatin (AUC 5-6) + Paclitaxel (175 mg/m²) every 3 weeks x6 cycles
Addition of Bevacizumab (anti-VEGF): For high-risk stage III/IV
PARP inhibitors (Olaparib, Niraparib): Maintenance therapy after response in BRCA-mutated tumors

Palliative:

Drainage of ascites (paracentesis) for symptomatic relief
Nutritional support

CASE 4

Probable Diagnosis: Multiple Uterine Leiomyomas (Multiple Fibroids)

Reasoning:

Uterine size 16 weeks = very large, consistent with multiple fibroids
Irregular uterine contour is classic for multiple fibroids (vs. adenomyosis = uniformly enlarged/globular)
Menorrhagia with clots + dysmenorrhoea + pelvic pain - classic fibroid triad
BPV (Bleeding Per Vaginum) present
Parous woman (P2), age 30 - fibroids very common in reproductive age
Mobile uterus rules out malignancy
Cervix healthy - rules out cervical pathology

Note: P/V shows irregular uterus + 16 weeks size → likely multiple intramural and subserosal fibroids

Differential Diagnoses

Diagnosis	Supporting Features	Against
Adenomyosis	Menorrhagia, dysmenorrhoea, enlarged uterus	Typically globular/smooth enlargement, not irregular; would be softer
Ovarian tumor	Pelvic mass	Mass is uterine, irregular, fornices free - not adnexal
Pregnancy (+ fibroids)	Uterine enlargement	LMP 10 days back, LFT/UPT needed but cycle described as regular
Endometrial carcinoma	Menorrhagia	Age 30, mobile, irregular - fibroids far more likely

Investigations

Same as Case 2 (fibroid workup):

Pelvic Ultrasound/TVS: Confirm multiple fibroids, map locations
MRI pelvis: Pre-op planning for myomectomy/hysterectomy
CBC + iron studies: Assess anemia
Endometrial sampling/biopsy: Rule out endometrial pathology
Hysteroscopy: Assess intracavitary component

Management

Medical (bridge therapy):

GnRH agonist: Preoperative shrinkage (6 months max)
Treat anemia: Iron supplementation, correct hemoglobin pre-operatively
Tranexamic acid + NSAIDs: Control bleeding and pain

Surgical:

Given size (16 weeks), multiple fibroids, parity P2, age 30 - Myomectomy if she desires more children
Abdominal (open) myomectomy preferred for uterus this large (16 weeks) with multiple fibroids
Hysterectomy if family complete and severe symptoms unresponsive

CASE 5

Probable Diagnosis: Vulvovaginal Candidiasis (VVC)

Reasoning:

"Thick curdy (cottage cheese) discharge" is pathognomonic of Candida albicans
Pruritus vulvae - cardinal symptom of VVC
Red vulva with scratch marks = excoriation from intense itching
White flakes with oozing spots on removal = classic candidal plaques/pseudomembrane
Type 2 Diabetes Mellitus - major predisposing factor: hyperglycemia → glycogen accumulation in vaginal epithelium → excellent substrate for Candida overgrowth
No systemic symptoms - consistent with local infection

Differential Diagnoses

Diagnosis	Supporting Features	Against
Bacterial Vaginosis (BV)	Vaginal discharge, vulvitis	BV: thin, grey, fishy-smelling discharge; NO curdy plaques; NO severe pruritus
Trichomonas vaginalis	Discharge, vulvitis	Trichomonal discharge: frothy, greenish-yellow; cervix: strawberry spots; thin discharge
Contact dermatitis	Vulval erythema, itch	No history of topical agent use; no discharge
Vulvar lichen sclerosus	Vulval itching	Elderly women; white atrophic patches; not associated with vaginal discharge
Vulvar intraepithelial neoplasia (VIN)	Pruritus vulvae	No plaques; would not have curdy discharge

Investigations

10% KOH wet mount: Hyphae/pseudohyphae + budding yeast cells = Gold standard bedside diagnosis
Vaginal pH: <4.5 in VVC (alkaline >4.5 suggests BV/Trichomoniasis)
Fungal culture (Sabouraud's dextrose agar): For recurrent/resistant cases - speciate (C. albicans vs non-albicans like C. glabrata, C. krusei)
Fasting/PP blood glucose, HbA1c: Assess diabetic control (crucial - poor control = recurrent infections)
Urine dipstick/urinalysis: Check for glycosuria

Management

Address the predisposing factor FIRST:

Optimize glycemic control (HbA1c target <7%) - Most important step for preventing recurrence

Topical antifungals (first line for uncomplicated VVC):

Clotrimazole 1% cream or 500 mg pessary (single dose or 6-day course)
Miconazole 2% cream or 200 mg pessary x3 days
Apply to vulva + intravaginal

Oral antifungals:

Fluconazole 150 mg single dose orally (convenient; avoid in pregnancy)
For severe/recurrent: Fluconazole 150 mg Day 1, 4, 7 then weekly x6 months

Recurrent VVC (≥4 episodes/year):

Weekly fluconazole 150 mg x6 months (maintenance)
Culture-guided therapy if non-albicans Candida suspected
Boric acid vaginal capsules: For C. glabrata (azole resistant)

General measures:

Loose cotton undergarments
Avoid scented soaps/douching
Dry vulval area after bathing
Partner treatment usually not required unless symptomatic

CASE 6

Probable Diagnosis: Carcinoma Cervix - Stage IIIB (FIGO)

Reasoning:

Fungating growth replacing cervix + bleeds on touch = cervical carcinoma (contact bleeding is hallmark)
Parametrium involved bilaterally up to lateral pelvic wall = Stage IIIB by FIGO (bilateral parametrial involvement OR extension to pelvic wall)
P7 + low socioeconomic status = multiple sexual partners, poor hygiene, no screening, malnutrition - classic high-risk profile
Foul-smelling discharge = tumor necrosis + secondary infection
Pallor+++ = severe chronic blood loss anemia
Edema feet/legs = likely lymphatic obstruction from bilateral parametrial disease → lymphedema; also consider hypoalbuminemia from malnutrition/cachexia
Pulse 100, BP 100/50 = hemodynamic compromise from severe anemia

Rectal mucosa free → Stage IIIB (not Stage IVA which would require bladder/rectal mucosal involvement)

Histology: Squamous cell carcinoma (~80% of cervical cancers) most likely

Differential Diagnoses

Diagnosis	Supporting Features	Against
Cervical polyp	PV bleeding, visible cervical lesion	Polyps don't cause fungating growth replacing entire cervix
Cervicitis/STI	Discharge, PV bleeding	Would not replace entire cervix with fungating mass
Endometrial carcinoma extending to cervix	PV bleeding, elderly	Cervical mass is primary here; endometrial ca invades FROM above
Metastatic deposit on cervix	Rare presentation	No primary site identified

Investigations

Diagnostic:

Colposcopy-directed biopsy / Punch biopsy from growth: Histopathological confirmation (most important)
Pap smear: Low yield with fungating growth; biopsy preferred
Cystoscopy: Rule out bladder involvement (Stage IVA)
Proctoscopy/sigmoidoscopy: Rectal mucosa - already done (free)
IVP (Intravenous Pyelogram) or CT urogram: Ureteric obstruction/hydronephrosis (very common in Stage III) - can cause renal failure

Staging/Systemic:

MRI pelvis: Best for parametrial assessment, tumor volume
CT chest/abdomen/pelvis: Lymph node status, distant mets
PET-CT: If available - most accurate for nodes and distant disease
CBC: Degree of anemia
RFT (serum creatinine, BUN): Bilateral hydronephrosis may cause renal impairment
LFT, albumin: Nutritional status
Chest X-ray

Management

Stage IIIB Cervical Cancer - Primary treatment: Concurrent Chemoradiation (CCRT)

Radiotherapy:

External Beam Radiation Therapy (EBRT): Whole pelvis - 45-50 Gy in 25 fractions
Brachytherapy (intracavitary): Boost to cervix/parametria - high dose rate (HDR) brachytherapy

Concurrent Chemotherapy (radiosensitizer):

Cisplatin 40 mg/m² weekly during EBRT (standard of care, improves survival significantly)
Alternative: 5-FU + Mitomycin C (if cisplatin contraindicated)

Supportive/Pre-treatment:

Blood transfusion: Correct severe anemia (Hb <8g/dL) before initiating RT (anemia reduces radiosensitivity - important!)
Nutritional support: High protein diet, supplements
Ureteric stenting or nephrostomy: If hydronephrosis/renal impairment present
Broad-spectrum antibiotics: For infected/necrotic tumor
Pain management: Adequate analgesia

Prognosis: Stage IIIB - 5-year survival ~30-40%

Note: Surgery (radical hysterectomy) is NOT appropriate for Stage IIIB - CCRT is standard

CASE 7

Probable Diagnosis: Third-Degree Uterovaginal Prolapse (Procidentia) with Cystocele and Rectocele

Reasoning:

Cervix lying outside the introitus = Third degree (complete/procidentia) by traditional classification; Stage III-IV by POP-Q
Cystocele (anterior vaginal wall prolapse) + Rectocele (posterior vaginal wall prolapse) = complete pelvic floor failure
Dragging sensation = classic symptom of prolapse (heaviness, bearing-down sensation)
"Something coming out P/V" = classic description of procidentia
Risk factors all present:
- Para 4 with prolonged labour (pelvic floor damage)
- Rapid succession of pregnancies
- Low socioeconomic status (heavy physical labour, malnutrition)
- Chronic cough (perpetually raised intra-abdominal pressure)
- Menopause (hypoestrogenism → atrophy of pelvic supportive tissues)
Small red ulcers on cervical lips (decubitus ulcers) = due to chronic exposure and friction outside the introitus

Differential Diagnoses

Diagnosis	Supporting Features	Against
Cervical fibroid polyp	Something coming out P/V	Would be smooth, pedunculated; cystocele/rectocele absent
Hypertrophied elongated cervix	Cervix outside introitus	No cystocele/rectocele; uterus would be in normal position
Inversion of uterus (chronic)	Mass at introitus	Extremely rare; different examination findings
Large Bartholin's cyst	Vulval swelling	Not uterocervical origin

Investigations

Pre-operative workup:

Urine analysis + culture: Urinary tract infection very common with cystocele (residual urine)
Urodynamic studies: Assess bladder function, rule out urge/stress incontinence (important pre-op)
TVS: Uterine size, ovaries, rule out other pathology
Cervical biopsy: From ulcerated area - rule out cervical malignancy
Pap smear: Cervical cancer screening
CBC: Assess anemia
RFT, LFT: Pre-op
ECG, Chest X-ray: Pre-op assessment (esp. with chronic cough)
Spirometry: If chronic cough suggests COPD (treat before surgery)
Blood sugar, Hb%

Management

Definitive (Surgical):

Vaginal Hysterectomy + Pelvic Floor Repair - Gold standard:
- Vaginal hysterectomy (remove uterus vaginally)
- Anterior colporrhaphy - repair cystocele
- Posterior colpoperineorrhaphy - repair rectocele + perineum
- Vault suspension (McCall's culdoplasty or sacrospinous ligament fixation) - prevent vault prolapse post-hysterectomy

Pre-operative preparation:

Treat decubitus ulcers: Estrogen cream applied to prolapsed cervix/vaginal epithelium for 4-6 weeks to improve tissue quality before surgery
Treat UTI if present
Correct anemia
Treat chronic cough (physiotherapy, bronchodilators)
Weight loss if obese

For elderly/unfit patients not suitable for surgery:

Ring pessary (Shelf pessary): Mechanical support - inserted in vagina to hold prolapse; requires regular changing (every 3-6 months); Estrogen cream alongside

Post-operative care:

Avoid heavy lifting
Pelvic floor exercises (Kegel's)
Treat chronic cough

CASE 8

Probable Diagnosis: Carcinoma Cervix - Stage IB1 (FIGO 2018)

Reasoning:

Post-coital bleeding = #1 presenting symptom of early cervical carcinoma
Fungating growth from posterior lip, 3 cm, bleeds on touch = classic cervical carcinoma appearance
Parametrium free = confined to cervix - FIGO Stage IB
Tumor 3 cm = Stage IB1 (FIGO 2018: IB1 = >2cm ≤4cm, clinically visible lesion confined to cervix)
Vagina healthy = no vaginal extension (not Stage II)
Young woman (28 yrs), parous - consistent with HPV-related cervical carcinoma

Note: Although young (28 yrs) for carcinoma, P2 with history of early sexual activity/multiple partners implied by young age + parous status can harbor HPV infection leading to carcinoma

Differential Diagnoses

Diagnosis	Supporting Features	Against
Cervical ectropion (erosion)	Young woman, PV bleeding, red area on cervix	Ectropion is velvety/smooth; doesn't form a 3 cm fungating mass
Cervical polyp	PV bleeding, cervical lesion	Polyp is pedunculated, smooth; doesn't cause 3 cm fungating mass
Cervicitis (STI)	Bleeding on touch	Discharge would be prominent; not a 3 cm mass
Nabothian cyst	Cervical lesion	Cystic, not fungating, not bleeding

Investigations

Colposcopy: Assess extent, guide biopsy
Punch biopsy from growth: Histopathological diagnosis (essential before treatment)
LLETZ/Cone biopsy: If needed for depth of invasion assessment
MRI pelvis: Best for local staging (parametrial, vaginal, nodal assessment)
CT chest/abdomen/pelvis: Distant disease assessment
PET-CT: Lymph node staging
CBC, coagulation profile, RFT, LFT: Pre-op
HPV typing: Research/epidemiological purpose
Cystoscopy, proctoscopy: Staging

Management

Stage IB1 (3 cm, confined to cervix, parametrium free):

Option 1 - Surgical (preferred for young patients):

Radical (Wertheim's) Hysterectomy + Bilateral Pelvic Lymph Node Dissection
- Removes uterus + upper 1/3 vagina + parametria + uterosacral ligaments + pelvic lymph nodes
- Advantages in young woman: Ovaries can be conserved (avoid premature menopause), better bladder/bowel function, definitive pathological staging
- If adverse pathological features (positive nodes, positive margins, parametrial involvement): Post-op adjuvant chemoradiation

Option 2 - Concurrent Chemoradiation (CCRT):

Equally effective to surgery for IB1
EBRT + brachytherapy + weekly Cisplatin
Used if patient is poor surgical candidate

Fertility-sparing (if patient desires more children - discuss):

Radical trachelectomy + pelvic lymph node dissection: Removes cervix but preserves uterine body; for tumors ≤2 cm (Stage IB1 ≤2cm)
This patient's tumor is 3 cm, so standard radical hysterectomy is more appropriate

CASE 9

Probable Diagnosis: Trichomonas vaginalis Infection (Trichomoniasis)

Reasoning:

"Thin frothy greenish discharge" = classic description of Trichomonas vaginalis (flagellated protozoan)
Foul smell = due to anaerobic metabolism of T. vaginalis
Multiple punctate haemorrhagic spots on vaginal walls = "strawberry spots" / colpitis macularis - pathognomonic for Trichomoniasis
Burning micturition = T. vaginalis can colonize urethra → urethritis
Cervix healthy = helps differentiate from cervical pathology
Recently married = sexually transmitted infection (Trichomonas is an STI); new sexual partner exposure

Differential Diagnoses

Diagnosis	Supporting Features	Against
Bacterial Vaginosis (BV)	Foul-smelling discharge	BV: thin grey homogeneous discharge, fishy odor (not frothy green); no strawberry spots; pH >4.5; clue cells
Candida vaginitis	Vaginal discharge, burning	Candida: thick, curdy, white discharge; NO frothy discharge; intense pruritus > burning; NO strawberry spots
Gonorrhoea (N. gonorrhoeae)	STI, discharge	Gonococcal: mucopurulent cervical discharge; primarily cervicitis; rarely vaginal frothy discharge
Chlamydia	STI, urethritis	Usually cervicitis; minimal/no vaginal discharge; no strawberry spots
Urinary Tract Infection	Burning micturition	UTI: no vaginal discharge/lesions; urine findings

Investigations

Wet mount preparation (normal saline): Motile trichomonads (pear-shaped, flagellated organisms with tumbling motility) - Gold standard bedside test (but sensitivity only 60-70%)
Vaginal pH: >4.5 (alkaline) in trichomoniasis
Whiff test (KOH): May be mildly positive (less so than BV)
NAAT (Nucleic Acid Amplification Test): Most sensitive and specific (>95%) - swab from vaginal/cervical secretions
Culture in Diamond's medium: Gold standard culture; less practical
Pap smear: May reveal trichomonads incidentally
Screen for other STIs: HIV, syphilis (VDRL), hepatitis B, gonorrhea, chlamydia (NAAT) - STI co-infection common
Partner evaluation: Essential for contact tracing

Management

Metronidazole (Nitroimidazole) - Drug of choice:

Metronidazole 2g orally single dose (preferred - better compliance)
OR Metronidazole 400-500 mg BD x7 days (alternative)
OR Tinidazole 2g single dose (better tolerated, fewer GI side effects, alternative)

CRITICAL: Partner treatment is MANDATORY

Sexual partner must be treated simultaneously with the same regimen
Even if asymptomatic (Trichomonas is sexually transmitted)
Avoid sexual intercourse until both partners complete treatment and are asymptomatic

Counselling:

Safe sex (condoms reduce transmission)
STI screening for other infections
Test-of-cure not routinely needed; re-test if symptoms persist
Avoid alcohol during metronidazole and 48 hours after (disulfiram-like reaction)

CASE 10

30-year-old Neha | Dribbling of urine x7 months | Vaginal delivery 7 months back at home, forceps application, prolonged labour (2 days), stillbirth, baby 3.5 kg | P/S: Small hole 0.5 cm x 1 cm at junction of anterior vaginal wall and cervix | Urine dribbling out

Probable Diagnosis: Vesico-Vaginal Fistula (VVF) - Obstetric

Reasoning:

Continuous/dribbling urine = pathognomonic of VVF (leakage through fistulous tract bypasses bladder sphincter control)
Hole at junction of anterior vaginal wall and cervix = fistulous opening visualized directly on P/S
Prolonged labour (2 days) = sustained pressure necrosis of bladder base/trigone between fetal head and maternal pubic symphysis → ischemic necrosis → sloughing → fistula formation (most common mechanism of obstetric fistula)
Instrumental delivery (forceps): Additional direct trauma
Home delivery by local practitioner = no access to emergency Caesarean section; poor obstetric care
Stillbirth + large baby (3.5 kg) = obstructed labour features
Onset 7 months back coincides exactly with delivery = obstetric fistula

Differential Diagnoses

Diagnosis	Supporting Features	Against
Urethrovaginal Fistula	Urinary leakage P/V	Located at urethra; this fistula is at anterior vaginal wall/cervix junction = VVF
Ureterovaginal Fistula	Continuous urinary leakage	Usually post-surgical (hysterectomy); ureteral injury; examine for ureteric jet
Stress Urinary Incontinence	Post-partum, urine leakage	SUI is leakage on effort/cough, not constant dribbling; no fistulous opening on examination
Rectovaginal Fistula (RVF)	Obstetric, fistula	Feces/gas through vagina; opening on posterior wall; this is anterior + urine

Investigations

Confirm VVF and assess anatomy:

Dye test (Methylene blue/Evans blue dye): Instill dye into bladder via catheter → observe vagina for blue staining = confirms VVF
- Three swab test: If upper swab stained blue = VVF; lower swab = urethrovaginal fistula
- If swab yellow but not blue = ureterovaginal fistula (consider IV indigo carmine)
Intravenous Pyelogram (IVP) / CT urogram: Rule out concurrent ureterovaginal fistula (10-15% of obstetric fistulas have ureteral involvement); assess upper urinary tract
Cystoscopy: Localize fistula in relation to ureteric orifices (critical for surgical planning)
Examination under anaesthesia (EUA): Full assessment of fistula size, site, surrounding tissue
MRI pelvis: Complex fistula assessment; tissue quality evaluation
Urine culture: Treat UTI before surgery
RFT, CBC: Pre-op; assess renal function

Management

Timing of repair:

Classically wait 3 months after delivery before surgical repair to allow:
- Edema/inflammation to resolve
- Necrotic tissue to fully separate
- Surrounding tissue to soften
This patient is 7 months post-partum - surgical repair can proceed now

Surgical repair:

Vaginal approach (Colpocleisis/Fistula repair - Latzko's operation or layered closure): Preferred for most VVF
- Latzko partial colpocleisis: Good for post-hysterectomy VVF at vault
- Layered vaginal repair: For obstetric fistulas; good access for low/mid-vaginal fistulas
Abdominal approach (O'Connor's procedure): For high/complex fistulas, failed vaginal repair, or when bladder reconstruction needed
- Open bladder, repair from inside (bivalve technique)
Principles of repair:
- Wide mobilization of fistula edges
- Excision of fibrotic fistula tract
- Tension-free, layered, watertight closure
- Interposition flap (Martius flap - labial fat pad) for complex/recurrent fistulas
Post-op: Continuous bladder drainage (Foley catheter) x14-21 days; strict bed rest initially; high fluid intake

Pre-operative:

Treat local infection/vaginitis
Estrogen cream to improve vaginal tissue quality
Nutritional optimization
Psychological support (fistula causes severe social isolation and depression)

Physiological repair in small fistulas:

Continuous catheterization for 6-8 weeks (for very small, fresh fistulas < 2-3 weeks old) - allows spontaneous closure in ~20%

Summary Table

Case	Age	Key Features	Probable Diagnosis	FIGO/Stage
1	65F	PMB, DM, HT, uterus 8wks	Endometrial Carcinoma	Likely Stage I-II
2	30F	Menorrhagia, dysmenorrhoea, symmetrical 10 wks uterus, nulliparous	Uterine Leiomyoma (Fibroid)	-
3	64F	Postmenopausal, complex ovarian mass, ascites, constitutional symptoms	Carcinoma Ovary (Epithelial)	Stage III
4	30F	P2, menorrhagia, irregular uterus 16 wks	Multiple Uterine Fibroids	-
5	35F	DM, pruritus vulvae, curdy discharge, white plaques	Vulvovaginal Candidiasis	-
6	58F	P7, PMB, fungating cervical growth, bilateral parametrial involvement to pelvic wall	Carcinoma Cervix	FIGO Stage IIIB
7	50F	P4, procidentia, cystocele, rectocele, chronic cough	3rd Degree Uterovaginal Prolapse	-
8	28F	Post-coital bleeding, 3 cm cervical mass, parametrium free	Carcinoma Cervix	FIGO Stage IB1
9	26F	Recently married, frothy green discharge, strawberry spots vagina	Trichomonas vaginalis	-
10	30F	Prolonged obstructed labour, forceps delivery, dribbling urine, hole at anterior vaginal wall	Vesico-Vaginal Fistula (Obstetric)	-

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