Benign disorders of the female reproductive tract

Question 1

Pelvic floor disorders: pelvic floor prolapse (POP)

Answer 1

-Herniation of pelvic organs, protrude in/out of vaginal canal
-Highly associated w/ obesity

Question 2

Pelvic floor disorders

Answer 2

-Group of muscles that form a sling or hammock across pelvis
-Hold uterus, bladder, and bowel in place

Question 3

Pelvic floor disorders: POP types

Answer 3

-Cystocele: bladder drops
-Rectocele: rectum drops
-Enterocele: small intestine drops
-Uterine prolapse: uterus drops (especially in multiparous women)

Question 4

Pelvic floor disorders: POP stages

Answer 4

-0: no descent
-1: prolapsed organ is > 1 cm above hymenal ring
-2: prolapsed organs is 1 cm below hymenal ring
-3: prolapsed organ is 2-3 cm below hymenal ring
-4: prolapsed organ is > 3 cm below hymenal ring

Question 5

Pelvic floor disorders: POP mgmy

Answer 5

-Kegel exercises: strengthen pelvic floor muscles and treats urinary incontinence
-HRT: improves tone and vascularity, given at lowest dose for shortest duration d/t risk for PE, breast cancer, stroke
-Diet and lifestyle
-Pessaries: support device inserted into vagina (long-term use can cause pressure necrosis or fistulas)
-Colporrhaphy and vaginal hysterectomy (tx of choice)

Question 6

Pelvic floor disorders: POP physical exam

Answer 6

-Woman is asked to perform valsalva manuever while examiner notes organ prolapse
-Any urine leakage during exam should be noted
-2 fingers inserted to assess strength (during contraction of pubococcygeal muscles)
-If > 100 mL of retained urine –> referral

Question 7

Pelvic floor disorders: POP how to perform pelvic floor exercises

Answer 7

-Squeeze muscles in rectum
-Stop and start urinary flow to identify pubococcygeus muscle
-Tighten pubococcygeus muscle for 3 counts, then relax
-Contract and relax pubococcygeus muscle rapidly 10x
-Try to bring up entire pelvic floor and bear down 10x
-Repeated these exercises at least 5x/day

Question 8

Pelvic floor disorders: POP diet and lifestyle changes

Answer 8

-High fiber (>25 g/day)
-Wear girdle or abdominal support
-Avoid lifting heavy
-Avoid high-impact activity
-Avoid smoker’s cough

Question 9

Pelvic floor disorders: POP pessary teaching

Answer 9

-Odors reduced by douching w/ dilute vinegar or hydrogen peroxide
-Use estrogen cream for postmenopausal women w/ thin vaginal mucosa

Question 10

Pelvic floor disorders: urinary incontinence (UI)

Answer 10

-Involuntary loss of urine
-Not normal part of aging
-Mgmt: bladder training (q3-5h), pelvic floor exercises, pessary, anticholinergics (oxybutynin, tolterodine, oxybutynin), avoid drinking too much water (1.5 L total daily limit), reduce bladder irritant drinks, control blood glucose, treat chronic cough
-Mgmt for stress incontinence: weighted vaginal cones, periurethral injection, meds (cymbalta, yentreve), ERT, surgery to correct genital prolapse
-Dx: cough stress test, rectal exam, urinalysis

Question 11

Benign growths: polyps

Answer 11

-Small growths that are cherry red if endocervical or grayish white if cerical
-Endocervical polyps more common in multiparous women ages 40-60
-Rarely returned after removal
-Although not cancerous, should still be tested
-Dx: regular pap smear
-Mgmt: forceps removal, removal during hysteroscopy, D&C, laser vaporization, abx

Question 12

Benign growths: uterine fibroids

Answer 12

-Myoma or leiomyomas
-Subserosal: grow outside of uterus, attached by stalk
-Intramural: grow within wall of uterus, most common
-Submucosal: grow below inner uterine surface into uterine cavity
-Grow quickly during childbearing years
-Most common indication for hysterectomy
-Mgmt: birth control pills, GnRH agonists(leuprolide, nafarelin, goserelin), UAE (polyvinyl alc pellets injected into vessels), MRGFUS (coagulative necrosis)
-Surgery tx: myomectomy (removes fibroid alone), laser surgery (destroys fibroids, preserves uterus, may cause scarring and infertility), hysterectomy (removal of uterus, most effective)

Question 13

Benign growths: genital fistulas

Answer 13

-Opening btwn genital organ and another organ
-D/t pregnancy trauma and female genital cutting
-Vesicovaginal: btwn bladder and genital tract
-Urethrovaginal: btwn urethra and vagina
-Rectovaginal: btwn rectum or sigmoid colon and vagina
-Mgmt: small ones heal w/o tx, large ones need surgery

Question 14

Benign growths: bartholin cysts

Answer 14

-Swollen, fluid-filled, sac-like structures when ducts of bartholin gland (secrete vaginal mucus) become blocked
-Abscess forms when cystic fluid becomes infected, ruptures after 2-3 days
-Rule out STIs
-Mgmt: small cysts don’t need tx, large cysts needs word catheter or surgery
-As/s if cyst < 5 cm and not infected

Question 15

Benign growths: ovarian cysts

Answer 15

-Fluid-filled sac that forms on ovary
-Follicular cysts: found on ovaries, resolve on own, < 5 cm, vaginal ultrasound
-Corpus luteum cysts: Corpus luteum fails to degenerate after 14 days, cause pain and delay period, appear after ovulation, resolve on own, pelvic ultrasound
-Theca-lutein cysts: high levels of hCG, rare

Question 16

Benign growths: PCOS

Answer 16

-Follicles have cyst-like appearance
-Ovulation doesn’t occur
-Increased risk for CVD, HTN, obesity, type 2 DM, infertility, cancer, mood disorders
-s/s: 12+ cysts on follicles, weight gain, virilization, alopecia, metabolic syndrome, insulin resistance, acne on face and shoulders
-Dx: 2 of 3 criteria (hyperandrogenism, ovarian dysfxn, detection of PCOS morphology)
-Tx: oral contraceptives for menstrual irregularities, mechanical hair removal for hirsutism, glucophage (metformin) for insulin, ovulation induction agents (clomid) for infertility