11/6- Benign Gynecology Flashcards
Describe the normal physiology of the vagina:
- Role of hormones
- Metabolic content
- Bacterial environment
- pH
- Estrogenized
- Increased glycogen content
- Bacterial flora
- Lactobacilli predominate: produce lactic acid lowering the pH to 3.5-4.5
- Wide variety of aerobic and anaerobic bacteria occur
What are risk factors for vaginal infection?
Anything that alters normal flora of the vagina
- Antibiotics (that allow pathogenic organisms to flourish)
- Douching alters the pH
- Sexual intercourse with semen release raises the pH for 6-8 hrs
- Foreign bodies (e.g. retained tampon)
What are symptoms of vulvovaginitis?
- Vaginal discharge
- Pruritis
- Burning
- “Late” burning (not pain when they urinate, but when it touches skin)
What is on the DDx/etiologies for vulvovaginitis?
- Bacterial vaginosis*
- Candida*
- Trichomoniasis*
- Atrophic vaginitis (post-menopausal women)
- Foreign body vaginitis
- Genital ulcer disease
*most common
In what ways can a wet mount be prepared?
- Components
- Sample of vaginal discharge
- pH paper
- Normal saline
- KOH
- Microscope slide
What is bacterial vaginosis?
- What are typical causes
- Symptoms
- Risk factors
Bacterial vaginosis is the disruption of “normal” flora with characteristic bacteria
- Typical: Gardnerella vaginalis
- Profuse milky white discharge
- Alkaline pH (>4.5, typ 5-6)
- Clue cells (can see them in squamous ep cells)
Risk factors:
- New sexual partners
- Smoking
- IUD
- Douching
What is Candidiasis?
- Etiological cause
- Symptoms
- Risk factors
- Caused by Candida albicans (90% of vulvovaginal candidiasis)
Symptoms:
- Vaginal itching, burning, and irritation
- White odorless vaginal discharge
Risk factors:
- Diabetes
- High dose OCPs
- Antibiotic use
- Immunosuppression
- Pregnancy
What is Trichomoniasis?
- Etiological cause
- Symptoms
- Spread
- Caused by protozoan T. vaginalis
Symptoms:
- Vulvovaginal irritation
- Green yellow frothy vaginal discharge
- Strawberry cervix
- “Musty” odor
- Around 50% of women are asymptomatic!
It’s an STI (not contracted spontaneously… although some proof it can spread via fomites) (pic 515)
Describe how the following vulvovaginal infections are diagnosed (what is seen):
- Candidiasis
- Bacterial vaginosis (BV)
- Trichomoniasis
- Candidiasis: wet mount with pseudohyphae or budding yeast
- Bacterial vaginosis (BV)- Gardnerella:
- Wet mount with “clue cells”
- Positive whiff test
- pH > 4-5
- Trichomoniasis: motile trich on wet mount
Describe how the following vulvovaginal infections are treated:
- Candidiasis
- Bacterial vaginosis (BV)
- Trichomoniasis
- Candidiasis: Fluconazole (po) or other azole (miconazole) for (3-7d, vaginally)
- Vaginal treatment may soothe/treat faster
- Bacterial vaginosis (BV)
- Metronidazole (7d, po) OR
- Clindamycin (7d, pv)
- Trichomoniasis: Metronidazole (po)
What is pelvic organ prolapse?
Protrusion of the pelvic organs into the vaginal canal or beyond the vaginal opening
- Anterior vaginal prolapse (cystocele)
- Posterior vaginal prolapse (rectocele)
- Apical vaginal and uterine prolapse (uterine prolapse)
- Enterocele (small bowel pressing on vagina)
What is complete procedentia?
Uterine prolapse through the vaginal hymen with failure of all the vaginal supports
What causes pelvic organ prolapse (physiology/anatomy)?
- Increased risk
Weakness in the endoplevic fascia investing the vagina along with the ligamentous supports
- Increased risk with pregnancy, labor, and vaginal delivery; also
- Increased intraabdominal pressure (chronic cough, ascites, heavy lifting, habitual straining)
What are symptoms of pelvic organ prolapse?
- Vaginal fullness, vaginal pressure and vaginal bulge
- Anterior vaginal prolapse: stress urinary incontinence, urinary retention
- Posterior vaginal prolapse: straining for bowel movements, splinting
- Complete procedentia: discharge, ulceration, bleeding and rarely carcinoma of the cervix
Describe the stages of prolapse
(This system will tell you how bad/far the prolapse it is, but not what is causing it)
- Stage 1: Most distal portion of the prolapse > 1 cm above the hymen
- Stage 2: Most distal portion of the prolapse is between 1 cm above and 1 cm below the hymen
- Stage 3: Most distal portion of the prolapse is > 1 cm below the hymen
What is the treatment for pelvic organ prolapse?
- Non surgical
- Surgical
Non-surgical:
- Relieve causes of increased intra-abdominal pressure
- Estrogen
- Pelvic floor exercises
- Pessaries
- Require proper fit
- Cleaned and inserted every 6-12 weeks
Surgical (less in elderly):
- Anterior/posterior colporrhaphy
- Vaginal vault suspension
- LeFort colpocleisis (sew up vagina with channels remaining on sides)
- Complete colpocleisis
What is incontinence?
- Prevalence
- Subtypes
Involuntary loss of urine that is objectively demonstrable and is a social/hygiene problem
- 50% of women affected in their lifetime
Subtypes:
- Stress urinary incontinence
- Urge urinary incontinence (overactive bladder)
- Overflow incontinence
Define the following types of incontinence:
- Stress urinary
- Urge urinary (overactive bladder)
- Overflow
- Stress urinary: Involuntary leakage of urine in response to physical exertion, sneezing or coughing (valsalva)
- Urge urinary (overactive bladder): Involuntary leakage of urine accompanied by or immediately preceded by urgency (due to bladder spasm)
- Overflow: Involuntary leakage resulting from detrusor areflexia or a hypotonic bladder as seen with lower motor neuron disease, spinal cord injuries or autonomic neuropathy
Describe Chlamydia cervicitis:
- Etiology
- Found where (anatomically)
- Symptoms (how many asymptomatic)
- Symptoms (specifically)
- Caused by Chlamydia trachomatis
- Chlamydia is #1 bacterial STI (HPV more common)
- Found in urethra, endocervix, endometrium, fallopian tubes and rectum
- Most individuals are asymptomatic
- Symptoms include yellow discharge from a swollen, red, friable cervix and dysuria
How is chlamydia cervicitis diagnosed?
- Screening?
- Prognosis?
- Diagnosed with culture and DNA hydridization and nucleic acid amplification tests
- Can be done on urine, vaginal and cervical swabs
- Screen all females < 25 yo (even if no RFs) and individuals with risk factors
- 30% untreated will progress to PID (pelvic inflammatory disease)
What is the treatment for Chlamydia cervicitis?
- Azithromycin 1 g PO X 1
- Or Doxycycline 100 mg PO BID X 7 days
- Test for other STIs
- HIV as well
- No sex for 7 days after both partners treated
- Test of cure is not needed
Describe Gonorrhea cervicitis
- Etiology
- Location
- Symptoms (how many asymptomatic)
- Symptoms (specifically)
- Cuased by N. Gonorrhoeae
- Found in the throat and urethra, endocervix, endometrium, fallopian tubes and rectum
- Most individuals are asymptomatic
- Symptoms include yellow discharge from a swollen, red, friable cervix and dysuria
- Can cause PID and systemic infxns (more often than Chlamydia)
How is Gonorrhea cervicitis diagnosed?
- Screening?
- Prognosis?
- Diagnosed with culture and DNA hybridization and nucleic acid amplification tests
- Can be done on urine, vaginal and cervical swabs
- Screen all females < 25 yo and individuals with risk factors
- 15% of untreated individuals will progress to PID (pelvic inflammatory disease); can also cause systemic disease (think of endocarditis)
What is the treatment for Gonorrhea cervicitis?
- Ceftriaxone 250 mg IM with Azithromycin 1 g PO X 1
(It’s scary, because getting some resistant strains; why azithromycin was added)
- Test for other STIs
- No sex for 7 days after both partners treated
- Test of cure is not needed
What are symptoms of Pelvic Inflammatory Disease (PID)? Signs?
Symptoms:
- Lower abdominal pain and tenderness
- Abnormal vaginal discharge
Signs:
- Lower abdominal tenderness
- Uterine/adnexal tenderness
- Mucopurulent cervicitis (yellowish discharge)
What conditions lead to PID?
PID develops in 15-30% of inadequately treated gonorrhea and chlamydia patients
What are complications of PID?
(PID causes scarring of tubes)
- Ectopic pregnancy (6x)
- Tubal infertility (14x)
- Chronic pelvic pain (6x)
How is PID diagnosed?
- Less likely to be PID if what
- Clinical diagnosis in sexually active females with uterine/adnexal tenderness or cervical motion tenderness
- Less likely to be diagnosis if no mucopurulent discharge is present or absence of WBCs on wet mount
What are the Mullerian ducts?
- Embryologic origin
- Develop/grow/migrate how
- Become what structures
- The Mullerian ducts (paramesonephric ducts) are epithelium located lateral to the mesonephric ducts
- The Mullerian ducts grow caudally and deviate medially to meet the opposite side
- Proximal Mullerian Duct: fallopian tubes
- Distal Mullerian Duct: uterus, cervix, upper 2/3 of the vagina
- Sinovaginal bulbs arise from the urogenital sinus and join the inferior end of the Mullerian ducts (Mullerian tubercle) forming the rest of the vagina
- The vagina canalizes from cuadal to cephalad (becomes solid with joining of Mullerian duct and sinovaginal bulbs; canalizes afterward)
What are some of the different classes of uterus deformities?
(Don’t memorize)
- Hypoplasia/agenesis
- Unicornate (to one side with/out horn)
- Didelphus (two uteri but one vagina)
- Bicornate (split uterus)
- Septate (full/partial divide)
- Arcuate
- DES drug related
What are some common presentations of uterine/vaginal malformations?
- Primary Amenorrhea
- Acute or chronic pelvic pain
- Abnormal vaginal bleeding
- Foul smelling vaginal discharge (often worse at the time of menses)
- Incidental finding of physical exam
- Recurrent abortions
- Infertility
How are Mullerian anomalies diagnosed?
- Physical Exam: look for imperforate hymen, vaginal dimple, blind vaginal pouch, abdominal masses secondary to hematocolpos/hematometria
- Ultrasound: transabdominal, transvaginal, transperineal
- MRI: “considered the gold standard”, should be used for all complex anomalies
- Hysterosalpingogram/Sonohysterogram (saline/dye used to image)
- Examination under anesthesia: bimanual, rectoabdominal exam
- Diagnostic Laparoscopy, Hysteroscopy, Vaginoscopy
What are some urinary tract anomalies related to these Mullerian structures?
- Most common associated anomaly including ipsilateral renal agenesis (so check Mullerian structures if child only has 1 kidney), duplex collecting systems, renal duplication, horseshoe-shaped kidneys
- Incidence of associated genital abnormalities in female patients with renal anomalies is estimated to be 25%-89%
What is imperforate hymen? Results?
- Lack of canalization distally
- Purple hue if period flow backed up behind
What is the most common obstructive anomaly?
Imperforate hymen
How is imperforate hymen diagnosed?
- Can be diagnosed on physical exam, may present with a mucocolpos, hematocolpos
- Can be repaired in infancy, childhood, or adolescence
- Beware that it may be difficult to differentiate between an imperforate hymen and vaginal atresia in the unestrogenized state of childhood
- Do not just puncture a hematocolpos/ mucocolpos without definitive repair since this may allow for an ascending infection
What is the most common gynecologic complaint?
Pelvic pain (i.e. dysmenorrhea)
- Acute or chronic
- Cyclic or constant
What is on the DDx for acute pelvic pain?
- Gynecologic
- Non gynecologic
Gynecologic
- Adnexal
- Torsion
- Hemorrhagic cysts
- Acute infections
- Endometritis
- PID
- Pregnancy complications
- Ectopic pregnancy
- Miscarriage
Non-Gynecologic:
- GI
- Appendicitis
- Enteritis
- Intestinal obstruction
- GU
- Cystitis
- Ureteral stones
- Other
- Pelvic thrombophlebitis
- Vascular aneurysm
What is on the DDx for chronic pelvic pain?
- Gynecologic
- Non gynecologic
(Chronic is > 6 mo)
Gynecologic
- Endometriosis
- Adenomyosis
- PID
- Fibroids
Non gynecologic
- GI
- Constipation
- Irritable bowel disease
- GU
- Interstitial Cystitis
- Musculoskeletal
- Psychological
What are the types of dysmenorrhea? Describe.
(Dysmenorrhea = cramps)
- Primary dysmenorrhea: no pathologic explanation
- Secondary dysmenorrhea: attributable to structural/functional abnormalities
What are causes of secondary dysmenorrhea?
- Endometriosis
- Adenomyosis
- Fibroids
- IUD
- Cervical stenosis
- Transverse vaginal septum
- Imperforate hymen
What is endometriosis?
- Prevalence
Endometrial glands/stroma that have implanted outside the uterine cavity and walls
- 5-15% of women have some degree of this disease
What are the theories behind the origin of endometriosis?
- Retrograde menstruation
- Mullerian metaplasia
- Lymphatic spread
(Probably an interaction; can get this in places not connected to abdomen [lymphatic] or if haven’t had a period yet)
Where can endometriosis occur?
- Most commonly?
- Can be located throughout pelvis and abdomen
- Most common site of involvement is ovary
What is seen here?
“Powder-burn” lesions of endometriosis
What is seen here?
“Chocolate cyst” of endometriosis (has endometrionic blood within)
What are presenting symptoms of endometriosis?
- Dysmenorrhea/ Pelvic pain
- Dyspareunia
- Dyschezia (pain with bowel movement)
- Worsens during luteal phase, improves during menses (sometimes)
- Asymptomatic in some women
- Infertility (result of severe scarring)
What is done for the definitive diagnosis of endometriosis?
Characteristic gross or histological findings obtained at the time of surgery
- So can suspect with clinical history but only confirm with biopsy
What is the treatment for endometriosis?
- Surgical
- Medical
Surgical
- Total abdominal hysterectomy with bilateral salpingoophorectomy
- Laparoscopic or laparotomy with destruction and removal of endometrial implants
- Excision versus laser ablation
Medical
- First line therapy
- NSAIDs
- Oral contraceptives and progestins
- Second line therapy:
- GnRH agonist (puts you into menopause)
- Danazol
