PAPER I - 66-Year-Old Postmenopausal Woman, P6L6, Mass at Introitus for 15 Years + Urinary Retention

Q.1. What is your probable diagnosis? (2 marks)

Q.2. Enlist four differential diagnoses (4 marks)

1. Cervical elongation with prolapse - elongated cervix without descent of the uterine body
2. Fibroid polyp - pedunculated submucous fibroid prolapsing through the cervix
3. Prolapsed urethral mucosa (urethral prolapse) - especially in postmenopausal women
4. Cervical/vaginal carcinoma - an ulcerative or fungating mass at the introitus in elderly women must be excluded

Q.3. How would you manage this case? (7 marks)

Immediate/Emergency Management:

• Catheterization - already done (1500 mL drained). Continue catheter drainage to decompress the bladder and allow urethral edema to resolve
• Reduce the prolapse manually if possible (if edema is not severe) after applying hypertonic saline soaks to reduce edema of the prolapsed mass
• Admit the patient

General Measures:

• Treat local ulceration if present (saline douches, estrogen cream locally)
• Correct anemia if present
• Treat any urinary tract infection (urine culture + antibiotics)
• Postmenopausal estrogen deficiency: local/topical estrogen for tissue strengthening
• Pre-operative optimization (treat medical comorbidities, diabetes, hypertension)

Definitive Surgical Management:

• Vaginal hysterectomy with pelvic floor repair (anterior + posterior colporrhaphy) is the operation of choice
• If unfit for surgery: Ring pessary (changed every 3-6 months) with local estrogen cream
• Associated cystocele: Anterior colporrhaphy
• Associated rectocele: Posterior colporrhaphy with perineorrhaphy

Post-operative Care:

• Catheter drainage for 7-10 days
• Perineal hygiene
• Pelvic floor exercises
• Long-term: avoid constipation, heavy lifting

Q.4. Enumerate the various supports of the uterus (7 marks)

A. DIRECT SUPPORTS (Active Supports):

• Levator ani muscle (most important muscular support) - forms a "basin" supporting pelvic organs
• Components: pubococcygeus, iliococcygeus, ischiococcygeus (coccygeus)
• Perineal body

B. LIGAMENTOUS SUPPORTS (Passive Supports):

• Pass from the cervix and upper vagina to the lateral pelvic walls
• Prevents uterine descent and lateral displacement

• Pass from the cervix/upper vagina posteriorly to the sacrum (S2-S4)
• Maintain anteversion and prevent descent

• Pass from the cervix anteriorly to the pubic symphysis
• Support the bladder base

• From the uterine cornua through the inguinal canal to the labium majus
• Maintain anteversion (weak supports, mainly maintain position, not prevent descent)

• Double folds of peritoneum; not true structural supports
• Provide lateral stability

C. INDIRECT SUPPORTS:

• Urogenital diaphragm (deep perineal pouch)
• Perineal body
• Normal axis of the vagina (horizontal upper third normally lies on the levator plate)

Note for Viva:

• Cardinal (Mackenrodt's) ligaments - most important for preventing prolapse
• Levator ani - forms the floor
• Uterosacral ligaments - maintain anteversion/anteflexion

PAPER II / III - 45-Year-Old P1L1, Intermenstrual Bleeding 6 Months + Cauliflower-like Growth 2x2 cm on Cervix

Q.8 / Q.1 / Q.11. Write four differential diagnoses for intermenstrual bleeding (4 marks)

1. Carcinoma cervix (invasive squamous cell carcinoma - most likely given the per speculum finding)
2. Cervical polyp (benign, pedunculated)
3. Cervical ectropion / erosion with contact bleeding
4. Endometrial carcinoma (less likely at 45 years but must exclude)

Q.9 / Q.2 / Q.12. Most probable diagnosis (3 marks)

• 45-year-old woman, P1L1 (low parity - a risk factor)
• Intermenstrual bleeding for 6 months (classic symptom)
• Per speculum: Cauliflower-like growth, 2x2 cm, fragile, bleeding on touch (contact bleeding - hallmark of cervical carcinoma)
• On anterior lip of cervix (squamocolumnar junction most common site)

Q.10 / Q.3 / Q.13. Most important investigations for diagnosis (3-5 marks)

To Confirm the Diagnosis:

1. Cervical biopsy (punch biopsy) - GOLD STANDARD for diagnosis; taken from the suspicious growth/lesion
2. Pap smear (Cervical cytology) - though less useful if obvious lesion is present, still done
3. Colposcopy with directed biopsy - if lesion is not visible to naked eye; identifies transformation zone

Q.4 / Q.14. Further investigations and workup once diagnosis is confirmed (staging workup, 5 marks):

Mandatory:

• Clinical examination (bimanual, per rectal examination for parametrial involvement)
• Colposcopy
• MRI pelvis - for local extension, parametrial involvement, bladder/rectal involvement
• CT scan chest, abdomen, pelvis - for lymph node and distant metastasis
• PET-CT scan - for lymph node metastasis (allowed in FIGO 2018)
• Cystoscopy - if bladder involvement suspected
• Proctoscopy / sigmoidoscopy - if rectal involvement suspected

Routine investigations:

• CBC, LFT, RFT, coagulation profile
• Chest X-ray
• Intravenous urography (IVU) - for ureteral involvement (hydronephrosis = Stage IIIB)
• Barium enema - if rectal involvement suspected

Q.5 / Q.15. Complications possible after radiotherapy for carcinoma cervix (5 marks)

Early Complications (during/weeks after RT):

1. Radiation sickness - nausea, vomiting, malaise, fatigue
2. Radiation cystitis - dysuria, frequency, hematuria
3. Radiation proctitis - diarrhea, tenesmus, rectal bleeding
4. Vaginal mucositis - discharge, soreness
5. Bone marrow suppression - leukopenia, thrombocytopenia

Late Complications (months to years after RT):

1. Vesicovaginal fistula (VVF) - most serious; due to radiation necrosis of bladder wall
2. Rectovaginal fistula (RVF) - radiation necrosis of rectal wall
3. Radiation fibrosis of vagina - vaginal stenosis, dyspareunia
4. Radiation necrosis of the femoral heads
5. Ureteral stricture - hydronephrosis, renal failure
6. Chronic radiation proctitis - rectal stricture, bleeding
7. Chronic radiation cystitis - contracted bladder, hematuria
8. Secondary malignancy (rare)
9. Small bowel obstruction due to adhesions and fibrosis
10. Lymphedema of lower limbs - if pelvic lymph nodes irradiated

Q.6 / Q.12. Screening methods in clinical use for carcinoma cervix (5-7 marks)

1. Pap Smear (Cervical Cytology) - Conventional/Liquid-Based

• Cells scraped from the squamocolumnar junction (transformation zone)
• Cells fixed and stained (Papanicolaou stain)
• Classified by Bethesda System: NILM, ASC-US, LSIL, HSIL, carcinoma
• Sensitivity: 50-80%, Specificity: >98%
• Recommended from age 21 (or 3 years after first intercourse)

2. HPV DNA Testing (Co-testing or Primary screening)

• Detects high-risk HPV types (16, 18, 31, 33, 45, 52, 58)
• Higher sensitivity than Pap smear alone (~95%)
• FDA approved as primary cervical cancer screen (age 25 onwards)
• Co-testing (Pap + HPV) increases sensitivity further

3. VIA (Visual Inspection with Acetic Acid)

• 3-5% acetic acid applied to cervix; abnormal areas turn acetowhite
• Simple, low-cost, no laboratory required, same-visit result
• Recommended in low-resource settings (India, Nepal, WHO guidelines)
• Sensitivity ~80%, Specificity ~90%

4. VILI (Visual Inspection with Lugol's Iodine)

• Lugol's iodine applied; normal squamous cells stain brown (glycogen), abnormal cells remain yellow (iodine non-uptake = "mustard yellow")
• Complements VIA; better specificity

5. Colposcopy (Secondary screening / Triage tool)

• Not a primary screen; used after abnormal Pap/VIA/HPV test
• Magnified examination of cervix; directed biopsy taken

6. HPV Vaccination (Primary Prevention - not a screening method but mentioned here):

• Bivalent (Cervarix): HPV 16, 18
• Quadrivalent (Gardasil): HPV 6, 11, 16, 18
• Nonavalent (Gardasil 9): HPV 6, 11, 16, 18, 31, 33, 45, 52, 58

National Screening Guidelines (India / Nepal):

• Screen-and-treat strategy using VIA in women aged 30-65 years
• Frequency: Every 3-5 years
• Primary HPV testing now recommended by WHO (2021) as the preferred approach

PAPER IV - 45-Year-Old P5L5, Postcoital Bleeding, Foul Discharge, Unhealthy Cervix + VIA Acetowhite + Biopsy: SCC with 6mm Stromal Invasion, No Parametrial/Vaginal Involvement, No Metastasis

Q.19. List the causes of post-coital bleeding (5 marks)

Cervical Causes:

1. Carcinoma cervix (most important cause to exclude)
2. Cervical ectropion / erosion
3. Cervical polyp (benign)
4. Cervicitis (chronic cervicitis, chlamydial, gonorrheal)
5. CIN / HSIL (high-grade squamous intraepithelial lesion)

Vaginal Causes:

1. Atrophic vaginitis (postmenopausal)
2. Vaginal carcinoma
3. Foreign body in vagina

Uterine / Other Causes:

1. Endometrial polyp prolapsing through cervix
2. Bleeding disorder / anticoagulant therapy
3. Pregnancy-related (threatened miscarriage, ectopic - must always exclude)

Q.20. How will you evaluate this patient? (5 marks)

History:

• Duration, frequency, amount of post-coital bleeding
• Associated intermenstrual/postmenopausal bleeding
• Discharge characteristics
• Obstetric/menstrual history
• Sexual history (multiple partners, early coitarche)
• Smoking history
• Previous Pap smear/HPV vaccination history

Examination:

• General examination: pallor (anemia), lymphadenopathy (inguinal, supraclavicular)
• Per speculum: cervix appearance, discharge, biopsy of any lesion
• Bimanual pelvic examination: uterine size, adnexal masses, parametrial thickening
• Per rectal examination: rectal involvement, parametrial induration (rectovaginal septum)

Investigations:

• Pap smear → if abnormal → colposcopy + directed biopsy
• VIA/VILI
• Colposcopy with directed biopsy (GOLD STANDARD)
• CBC, urine analysis
• HPV DNA testing if available

Q.21. Investigations allowed for staging of carcinoma cervix (2 marks)

1. Clinical examination (bimanual pelvic + per rectal)
2. MRI pelvis - for local disease extent
3. CT scan (chest, abdomen, pelvis) - for lymph nodes, distant metastasis
4. PET-CT scan - for lymph node metastasis
5. Cystoscopy (if bladder involvement suspected)
6. Proctoscopy (if rectal involvement suspected)
7. Chest X-ray, IVU (traditional FIGO investigations, still acceptable)

Q.22. Stage of the disease (3 marks)

• Squamous cell carcinoma on biopsy
• Stromal invasion of 6 mm
• Parametrium NOT involved
• Vagina NOT involved
• No radiologic metastasis

• Lesion > 5 mm stromal invasion (so not IA2 which is ≤5 mm)
• Confined to the cervix
• Clinically visible lesion OR lesion > 5 mm depth but ≤ 2 cm in greatest dimension = Stage IB1
• No parametrial (Stage II), no pelvic wall/lower vaginal (Stage III), no distant (Stage IV) involvement

• IA1: Stromal invasion ≤ 3 mm
• IA2: Stromal invasion > 3 mm and ≤ 5 mm
• IB1: Invasive carcinoma > 5 mm depth, ≤ 2 cm in greatest dimension
• IB2: > 2 cm and ≤ 4 cm
• IB3: > 4 cm

Q.23. Management plan for Stage IB1 carcinoma cervix (5 marks)

• Radical hysterectomy (Wertheim's hysterectomy) Type III + bilateral pelvic lymph node dissection - PREFERRED in young/fit patients (preserves ovarian function; better sexual function)
• Radiotherapy (External Beam RT + Brachytherapy) - equally effective; used in poor surgical candidates or when fertility not a concern

• Wertheim's radical hysterectomy + bilateral pelvic lymphadenectomy is the treatment of choice
• If lymph nodes positive on final histology: adjuvant chemoradiation (cisplatin-based)
• If parametrial involvement on final histology: adjuvant chemoradiation

• Radical trachelectomy + pelvic lymphadenectomy

Q.24. Complications of radical hysterectomy (Wertheim's) (5 marks)

Intraoperative:

1. Hemorrhage (injury to iliac vessels, vesical plexus)
2. Ureteral injury (transection, ligation) - most common intraoperative injury
3. Bladder injury
4. Bowel injury
5. Obturator nerve injury

Early Postoperative:

1. Urinary retention / bladder dysfunction (most common complication - due to denervation of bladder; requires prolonged catheterization for 7-10 days)
2. Urinary tract infection
3. Hemorrhage
4. Wound infection/dehiscence
5. Venous thromboembolism (DVT, pulmonary embolism)
6. Ileus / Bowel obstruction
7. Lymphocyst formation
8. Fistula formation (early) - vesicovaginal or ureterovaginal

Late Complications:

1. Vesicovaginal fistula - 1-2% incidence
2. Ureterovaginal fistula - ureteral devascularization
3. Lymphedema of lower limbs - pelvic lymphadenectomy
4. Bladder hypotonia / chronic retention
5. Vault prolapse
6. Adhesions/intestinal obstruction
7. Sexual dysfunction (vaginal shortening, dyspareunia)
8. Premature menopause (if ovaries removed)
9. Ureteral stricture (late)

Q.25. Advantages and disadvantages of surgery vs radiotherapy in carcinoma cervix (5 marks)

PAPER (Last Image) - 45-Year-Old P6L6, AUB + Unhealthy Cervix + Pap Smear Suggestive of Invasive Cancer + Biopsy: SCC

Q.7. Differential diagnosis for abnormal uterine bleeding in a 45-year-old (4 marks)

1. Dysfunctional uterine bleeding (DUB) - anovulatory cycles in perimenopause
2. Carcinoma cervix (high suspicion given unhealthy cervix)
3. Endometrial carcinoma - must exclude with endometrial sampling
4. Uterine fibroids (leiomyoma) - especially submucosal

Q.8. Screening methods for cervical cancer (4 marks)

1. Pap smear (Cervical cytology) - conventional/liquid-based cytology
2. VIA (Visual Inspection with Acetic Acid) - low-resource settings
3. VILI (Visual Inspection with Lugol's Iodine)
4. HPV DNA testing - high sensitivity; now WHO-preferred primary screen
5. Colposcopy - triage/secondary tool after abnormal primary screen

Q.9. National guidelines on screening for cervical cancer (3 marks)

India (National Cancer Screening Guidelines - NHM):

• Target population: Women aged 30-65 years
• Method: VIA (Visual Inspection with Acetic Acid) as primary screen in resource-limited settings
• Strategy: Screen-and-treat (VIA positive → cryotherapy on same visit if eligible)
• Frequency: Once every 5 years (or at minimum, 3 times in a lifetime at 30, 40, and 50 years)
• HPV testing being integrated in secondary/tertiary care settings

WHO (2021) Global Strategy:

• HPV DNA testing as the preferred primary screening test
• Threshold: 70% coverage of women screened twice by age 35 and 45
• Target: 90-70-90 strategy (90% vaccinated, 70% screened, 90% treated)

Nepal:

• VIA-based screening recommended, integrated into national health system
• Target age: 30-60 years
• Cervical cancer screening camps at district hospitals

Q.10. Next step when Pap smear shows features of invasive cancer (2 marks)

• Pap smear is a screening test, NOT diagnostic
• When Pap smear is suggestive of invasive cancer, colposcopy is performed and punch biopsy from suspicious areas (acetowhite, abnormal vascular patterns) is the mandatory next step
• Histological confirmation is required before staging and treatment planning
• If no colposcope available: Wedge/cone biopsy of the cervix

Q.11. Further management plan after biopsy shows SCC of cervix (4 marks)

1. Clinical staging examination (under anesthesia for EUA - examination under anesthesia)
2. Investigations for staging: MRI pelvis, CT chest/abdomen/pelvis, cystoscopy if needed, PET-CT if available
3. Multidisciplinary team (MDT) discussion: Gynecologic oncologist, radiation oncologist, medical oncologist
4. Treatment based on stage:
   • Early stage (IA-IIA): Radical hysterectomy + PLND or chemoradiation
   • Advanced stage (IIB onwards): Concurrent chemoradiation (cisplatin weekly + EBRT + brachytherapy)

Q.12. Preventive methods for cervical cancer (3 marks)

Primary Prevention:

1. HPV Vaccination:
   • Bivalent (Cervarix): HPV 16, 18 - protects against 70% of cervical cancers
   • Quadrivalent (Gardasil): HPV 6, 11, 16, 18
   • Nonavalent (Gardasil 9): 9 HPV types - protects against ~90% of cervical cancers
   • Recommended: Girls 9-14 years (before sexual debut) - 2 doses; 15 and above - 3 doses
2. Safe sexual practices: Barrier contraception (condoms) reduce HPV transmission
3. Avoid early coitarche and multiple sexual partners
4. Cessation of smoking
5. Circumcision of male partners (reduces HPV transmission)

Secondary Prevention:

1. Regular cervical cancer screening (Pap smear/VIA/HPV testing as above)
2. Treatment of premalignant lesions (CIN): LEEP, cryotherapy, cone biopsy

Tertiary Prevention:

1. Early detection and treatment of invasive carcinoma

Q.13. Complications of radiotherapy in carcinoma cervix (5 marks)

Acute Complications:

1. Radiation sickness (nausea, vomiting, fatigue, anorexia)
2. Radiation cystitis - dysuria, hematuria, frequency
3. Radiation proctitis - diarrhea, rectal bleeding, tenesmus
4. Radiation vaginitis - discharge, soreness
5. Myelosuppression (leukopenia, anemia, thrombocytopenia)
6. Skin reaction (radiodermatitis) in EBRT field

Late Complications:

1. Vesicovaginal fistula (VVF) - most feared; requires surgical repair
2. Rectovaginal fistula (RVF)
3. Ureterovaginal fistula - with ureteral stricture → hydronephrosis
4. Vaginal stenosis and fibrosis - dyspareunia, inability to have intercourse
5. Chronic radiation cystitis - contracted bladder, persistent hematuria
6. Chronic radiation proctitis - rectal stricture, obstruction, bleeding
7. Radiation necrosis of femoral head - avascular necrosis
8. Lymphedema of lower limbs
9. Small bowel radiation enteritis - obstruction, fistula
10. Secondary malignancy (radiation-induced sarcoma - rare)

Summary of All Answers Covered

Paper I - Uterovaginal Prolapse (P6L6, Postmenopausal, 66 years)

• Q1.1: Diagnosis = 3rd degree uterovaginal prolapse (Procidentia) + acute urinary retention
• Q1.2: 4 differentials listed (cervical elongation, fibroid polyp, urethral prolapse, Ca cervix)
• Q1.3: Management - emergency catheterization, edema reduction, vaginal hysterectomy + pelvic floor repair
• Q1.4: Supports of uterus - categorized into pelvic floor (levator ani), Mackenrodt's/cardinal ligaments, uterosacral, pubocervical, round, broad ligaments

Papers II, III - Carcinoma Cervix (Cauliflower growth, 45 y/o)

• Differentials for intermenstrual bleeding
• Diagnosis = Invasive carcinoma cervix
• Investigations for diagnosis (biopsy = gold standard) + staging workup (MRI/CT/PET as per FIGO 2018)
• Complications of radiotherapy (acute + late - VVF, RVF, cystitis, proctitis, stenosis, fistulas)
• Screening methods (Pap smear, VIA, VILI, HPV DNA testing, colposcopy)

Paper IV - SCC Cervix with Staging

• Causes of post-coital bleeding
• Patient evaluation
• FIGO 2018 staging investigations
• Stage = IB1 (6mm invasion, confined to cervix, no parametrial/vaginal involvement)
• Management = Wertheim's radical hysterectomy + PLND
• Complications of radical hysterectomy
• Surgery vs Radiotherapy comparison table

Paper (Last Image) - Screening + Prevention

• AUB differentials, screening guidelines (national + WHO)
• Next step after abnormal Pap = colposcopy + biopsy
• Prevention (HPV vaccine, safe sex, smoking cessation, screening)
• Radiotherapy complications (10 late complications listed)