Asherman's syndrome; Ectropion; Prolapse

Question 1

Define Asherman’s syndrome [1]

Answer 1

Asherman’s syndrome is where adhesions (sometimes called synechiae) form within the uterus, following damage to the uterus.

Question 2

Explain when Asherman’s syndrome occurs and the pathophysiology? [3]

Answer 2

After a pregnancy-related dilatation and curettage procedure, for example in the treatment of retained products of conception (removing placental tissue left behind after birth).

It can also occur after uterine surgery (e.g. myomectomy) or several pelvic infection (e.g. endometritis).

Endometrial curettage (scraping) can damage the basal layer of the endometrium. This damaged tissue may heal abnormally, creating scar tissue (adhesions) connecting areas of the uterus that are generally not connected
- There may be adhesions binding the uterine walls together, or within the endocervix, sealing it shut.

Question 4

Describe the typical presentation of Asherman’s syndrome [4]

Answer 4

Asherman’s syndrome typically presents following recent dilatation and curettage, uterine surgery or endometritis with:
* Secondary amenorrhoea (absent periods)
* Significantly lighter periods
* Dysmenorrhoea (painful periods)

Question 5

What are the options for dx Asherman’s? [4]
Which is the gold standard? [1]

Answer 5

• Hysteroscopy is the gold standard investigation, and can involve dissection and treatment of the adhesions
• Hysterosalpingography, where contrast is injected into the uterus and imaged with xrays
• Sonohysterography, where the uterus is filled with fluid and a pelvic ultrasound is performed
• MRI scan

Question 6

Describe what is meant by a Nabathian cysts

Answer 6

Nabothian cysts are fluid-filled cysts often seen on the surface of the cervix.
- They are usually up to 1cm in size, but rarely can be more extensive.
- They are harmless and unrelated to cervical cancer.

NB: They are also called nabothian follicles or mucinous retention cysts.

Question 7

Describe how Nabothian Cysts occur

Answer 7

The columnar epithelium of the endocervix (the canal) produces cervical mucus.

When the squamous epithelium of the ectocervix slightly covers the mucus-secreting columnar epithelium, the mucus becomes trapped and forms a cyst

. This can happen after childbirth, minor trauma to the cervix or cervicitis secondary to infection.

Question 8

Describe the presentation of nabothian cysts [2]

Answer 8

Nabothian cysts appear as smooth rounded bumps on the cervix, usually near to os (opening). They can range in size from 2mm to 30mm, and have a whitish or yellow appearance.

TOM TIP: It is worth becoming familiar with photographs of nabothian cysts. They are relatively common. They can have a raised and discoloured appearance, creating concern when you first see them. With practice, you will be able to identify them correctly, and the woman can be reassured. Getting a senior opinion if there is any doubt creates a feedback loop that helps you confirm your impression and build your confidence in making the correct diagnosis.

Question 9

Describe what a cervical ectropian is [2]

Answer 9

On the ectocervix there is a transformation zone where the stratified squamous epithelium meets the columnar epithelium of the cervical canal
- Elevated oestrogen levels (ovulatory phase, pregnancy, combined oral contraceptive pill use) result in larger area of columnar epithelium being present on the ectocervix

Question 10

How might a cervical ectoprion present? [3]

Answer 10

This may result in the following features
* vaginal discharge
* post-coital bleeding
* spotting

Question 11

Describe the link between cervical ectropian and cervical cancers [1]

Answer 11

Ectropion is not associated with cervical cancer in any way.
- It is worth getting familiar with distinguishing them from the appearance of cervical cancer. Always ask about smears, and if in doubt, get a senior opinion and consider referring for colposcopy.

Question 12

How do you treat cervical ectropian? [1]

Answer 12

Treatment involves cauterisation of the ectropion using silver nitrate or cold coagulation during colposcopy.

NB: asymptomatic ectropion do not require treatment

Question 13

Pelvic organ prolapse can be classified according to the affected compartments.

What are they? [3]

Answer 13

Anterior compartment:
- cystocele (bladder herniation) and urethrocele (urethral herniation)

Middle compartment:
- uterine prolapse (uterus descent) and vaginal vault prolapse (post-hysterectomy)

Posterior compartment:
- rectocele (rectal herniation) and enterocele (small bowel herniation)

Question 14

Describe what is meant by a vault prolapse [1]

When does it occur? [1]

Answer 14

Vault prolapse occurs in women that have had a hysterectomy, and no longer have a uterus.

The top of the vagina (the vault) descends into the vagina.

Question 15

Define rectocele [1]

Answer 15

Rectoceles are caused by a defect in the posterior vaginal wall, allowing the rectum to prolapse forwards into the vagina.

Question 16

Describe the presentation of rectocele [3]

Answer 16

Rectoceles are particularly associated with constipation. Women can develop faecal loading in the part of the rectum that has prolapsed into the vagina. Loading of faeces results in significant constipation, urinary retention (due to compression on the urethra) and a palpable lump in the vagina.

Question 17

Describe what is meant by a cystocele [1]

What is a urethrocele and a cystourethrocele? [2]

Answer 17

Cystoceles are caused by a defect in the anterior vaginal wall, allowing the bladder to prolapse backwards into the vagina. Prolapse of the urethra is also possible (urethrocele). Prolapse of both the bladder and the urethra is called a cystourethrocele.

Question 18

Describe the typical presentation of prolapse [5]

Answer 18

• A feeling of “something coming down” in the vagina
• A dragging or heavy sensation in the pelvis
• Urinary symptoms, such as incontinence, urgency, frequency, weak stream and retention
• Bowel symptoms, such as constipation, incontinence and urgency
• Sexual dysfunction, such as pain, altered sensation and reduced enjoyment

Question 19

Describe what a Sim’s speculum is and how it is used [2]

Answer 19

A Sim’s speculum is a U-shaped, single-bladed speculum that can be used to support the anterior or posterior vaginal wall while the other vaginal walls are examined. It is held on the anterior wall to examine for a rectocele, and the posterior wall for a cystocele.

Procedure:
* Ask the patient to lie on her left side and bring her knees to her chest
* Insert the blade of the speculum along the posterior wall of the vagina to hold it back
* Ask the woman to cough whilst looking for uterine descent and cystocoele
* Repeat whilst holding back the anterior wall, looking for rectocoele/enterocoele

Question 20

What are the 4 grades of uterine prolapse? [4]

Answer 20

Grade 0: Normal

Grade 1: The lowest part is more than 1cm above the introitus

Grade 2: The lowest part is within 1cm of the introitus (above or below)

Grade 3: The lowest part is more than 1cm below the introitus, but not fully descended

Grade 4: Full descent with eversion of the vagina

Question 21

How do you manage uterine prolapse? [3]

Answer 21

Pelvic floor physiotherapy for stage 1-2 prolapse

Pessary use
- inserted into vagina to provide extra support to the pelvic organs
- oestrogen cream helps prevent vaginal walls from irritation

Surgery:
- Anterior or posterior colporrhaphy: reinforce the pubocervical fascia or the rectovaginal fascia to support structures
- Sacrocolpopexy: Considered for apical prolapse. Attach the vaginal vault or cervix to the sacral promontory using synthetic mesh.

Question 22

For management of associated urinary incontinence, NICE guidelines recommend offering a trial of [] least 3 months before considering surgical options such as midurethral sling procedures

Answer 22

NICE guidelines recommend offering a trial of supervised pelvic floor muscle training for at least 3 months before considering surgical options such as midurethral sling procedures