Female Reproductive System Flashcards
What are the 3 layers of the uterus
Endometrium - lining of uterus
Myometrium - contain 3 smooth muscle layers
Perimetrium
Function of cervix
- Maintains sterility of structures above it. Prevents bacterial invasion
- narrow external os
- thick cervical mucus
- shedding endometrium
- Guides passage of sperms to the uterus.
Where are the Bartholian’s gland ?
Either side of the vaginal opening
Other name - great vestibular gland
Secrete lubricant fluid during intercourse goes down the great vestibular duct.
Where are the Skenes glands located ? What is it ?
Either side of urethra.
Parautheral gland- another name
Secrete mucus during intercourse
Homologous with male scrotum
What nerve supplies the external genitalia and perineum?
Puodenal nerve - branch of sacral plexus
Origins - nerve root S2 ,3 and 4
Motor function - innervation of pelvic floor muscles
E.g . Levator ani muscles includ
Ilioccocygeus
Puboccocygeus
Puborectalis
Innervation of external anal sphincter ( inferior rectal nerve - branch of puodenal nerve. )and external urethral sphincter . Prevent incontinence.
Sensory - provides innervation to external genitalia.
S2, S3 ,S4 , KEEP POO AND WEE OF THE FLOOR AND GENITALIA .
Clinical significance of the nerve that supplies pelvic floor , external genitalia etc.?
Puodenal nerve block
Anaesthesia for minor vaginal surgeries e.g . Episiotomy.
Puodenal nerve accompanied by internal puodenal artery so need aspirate ( withdraw fluid - check there is no blood) so that the drug is not given into systemic circulation.
What are the sphincter which are involved in urination in females ?
External urethral sphincter
Compressor urethrae - wraps around urethra and contracts pressing urethra against vagina
Urethrovaginalis - wraps around urethra - contracts - compress urethra against vagina.
What are the spaces in the female peritoneal cavity?
Vesicouterine - space byw posterior wall of bladder and anterior wall of uterus
Pouch of Douglas / rectouterine pouch - btw posterior wall of uterus and rectum
Made by relections of peritoneum
Normal position of uterus and abnormal positions?
Normal - anti - flexed , anti - verted
Abnormal - retroverted , retroflexed, ante verted
What is Pelvic organ Prolapse?
0 1 or more of the organs of the Pelvis move out of position and bulge into the vagina.
4 stages with increasing severity
- Stage 1 - more than cm above hymen
- Stage 2 - Btw 1cm above or below hymen
- Stage 3 - More than 1cm below Hymen but 2cm shorter than total vaginal length
- Complete eversion - bascially inside out , uterus etc on the outside of the body.
- Stage 2 -
Different types of Prolapse ?
Cystocele - Anterior prolapse ( Bladder prolapses, dropping and pushes on the wall of the vagina.
- Rectocele - (posterior wall prolapse) Bulging of anterior wall of rectum into the posterior wall of the vagina.
- Uterine prolapse - Uterus slips down into vagina and protrudes out of it.
- Vaginal Vault prolapse - The vault (top of vagina ) drops from normal position and sags down. (can happen after hysterectomy)
Enterocele - Small intestine drops into pelvic cavity and presses on the top of vagina creating a bulge.
Urethocele - Urethra drops down into vagina.
Causes of Pelvic floor prolapse ?
weakened pelvic floor , so organs sag. Caused by :
Increased pressure on pelvic floor :
- pregnancy
* the more
children
you have
the more
at risk
you are
- overweight
- Chronic
constipation.
- Chronic
cough e.g
asthma ,
COPD
Reduced tissue collagen - White women more at risk of prolapse than black as they have weaker/ less collagen - genetic (things like marfan etc effect collagen )
- Hysterectomy - removal of uterus
- Heavy lifting.
- Age - menopause
more at risk -People with:
0 marfan ,
0 Joint hyper-mobility syndrome
0 Ehlers - Danlos syndrome - group of rare group of disorders that affect connective tissue.
Symptoms of Pelvic organ prolaspe ?
Pelvic or vaginal fullness - feel heaviness around lower tummy and genitals.
- sensation of organs falling out (of vagina )
- Bulging of organs into vaginal canal or through vaginal opening
- Stress incontinence - leaking of pee when cough , squeeze
- can have obscured stress incontinence )
- problems peeing - need to go to the toilet more often , or bladder not emptying fully (some urine left).
Rectocele
0 incomplete
defacation -
* Ask
patient
do you
need to
put you
fingers in
you
vagina to
promote
pooing
/bowel
motion?
0 Constipation
- certain prolapses can result in urinary retention (cant pass urine ) and can cause kidney infection / damage which can lead to kidney failure.
How do you assess someone with suspected Prolapse ?
Assessment
- History
- BMI
- Abdominal
and Vaginal
examination
0 Assess
degree of
prolapse
using
POP - Q -
pelvic
organ
prolapse
quantification
system.
0 Assess activity of pelvic floor muscle - bi-manual examination squeeze - insert a finger and ask them to squeeze around them. * some women stay they have been doing pelvic floor exercises but the squeeze test shows they are not doing it properly.
0 rule out pelvic mass or other pathology.
0 Assess vaginal atrophy.
Prolapse assessment
- maximal
valsalva
- sims speculum
- lithotomy position - lying on back , knees bent at 70 dg - knees supported
Management of Prolapse ?
Conservative - fix cause
0 lose weight -
if overweight
(from BMI) - greater than 30kg/m2
0 chronic
cough - refer
to respiratory
specialist ?
0 Physiotherapy
- pelvic floor exercises.
0 Chronic constipation - laxatives.
0 Miminse heavy lifting.
Pessaries
- many different types of pessary device - used for different types and severity of prolapse.
- Surgical
lifestyle changes and pessaries encouraged / used before surgery is considered.
Surgical treatment of certain types of prolapse ?
Rectocele - posterior wall prolapse - posterior wall repair without mesh.
Posterior vaginal repair - tighten the support tissues at the back of the vagina. (the thin tissue btw rectum and vagina has weakened causing the prolapse. )
Uterine prolapse / vaginal vault- Hysterectomy
- uterus sparing surgeries -
0 Vaginal sacrospinous fixation - top of vagina stitched to a ligament of the pelvis on one side of the body
* vagina no longer straight , goes towards the stitched side - can cause pain during intercourse (dyspareunia)
vaginal sacrospinous hysteropexy - the cervix is stitched to a sacrospinous ligament in the pelvis - stitches inseted through cut in vagina
if mesh is used to hold it in place - called Laparoscopic sacro-hysteropexy (using keyhole surgery - uterus lifted up at fixed t bone at the bottom of spine.
Manchester repair neck of the womb (the cervix) is shortened; it involves shortening the cervix (neck of the womb) and supporting the womb in its natural position) .
Anterior prolapse - anterior repair without mesh
How do surgical treat Vaginal vault prolapse?
- vaginal sacrospinous hysteropexy
- Laparoscopic sacro-hysteropexy
How should surgeries for prolapse be followed up?
6-month review after surgery
- if mesh used check for mesh exposure.
What is pessary ?
prosthetic device inserted into the vagina to support internal structures.
many types e.g ring , gellhorne etc.
problems
- need to change every 3 months
* some patients forget e.g dementia - skin can grow around it becomes hard to take out (impaction). - can fall out - if not inserted well or wrong type/ size
- vaginal discharge or vaginal ulceration
What is genital warts ?
STI - sexually transmitted disease.
- Caused by HPV - Human Papilloma virus.
- passed on by direct skin to skin contact during vaginal or anal sex.
(not through kissing or sharing towels etc. )
- passed on by direct skin to skin contact during vaginal or anal sex.
- Lumps / warts around vagina penis or anus.
- common for appearance / reappearance of warts during pregnancy due to changes in the immune system.
Management of Gential warts ?
refer to sexual health specialist :
- vaginal speculum examination in women.
- screening for other coexisting STI is essential (especially in under 25 )
- Proctoscopy - (hollow tube used to inspect the inside of rectum ) - if patient engages in anal sex (receives it - anal receptive sex )
- No need for sexual partner tracing if no other STI’s found.
- if referral t sexual health not possible can be carried out in primary care but have to have the expertise to do these things.
Same for treatment - but diagnosis of external genital warts should be confidently made.
Treatment of Genital warts ?
First line for soft , non -keratinized lesion
- Podophylltoxin - solution or cream
- Imiquimod - for non and keratinized genital and perianal (around anus) warts. - no internal use
- Sinecatechin 10 % ointment external genital warts aged over 18 and immunocompromised.
- These are self - applied creams - patient should be shown how to apply and how to locate warts. Cannot be used during pregnancy
Specialist appilication - TCA - Trichloroacetic acid
* first line along with Podophyllotoxin - for soft keritanized warts.
First line for kertinized warts.
Kertinized warts - respond well to :
- cyrotherapy -
freezing wart
- excision - TCA - electrocautery (removal of wart by burning via low - voltage electrified probe ) - anesthesia used * these are ablative therapies - removal / destruction of body part or tissue.
NO TREATMENT
- sometimes treatment not indicated , can clear up within 6 months.
What is Bartholin’s Cyst/ Duct cyst ?
Painful swelling in Bartholin’s gland.
Duct obstructed so fluid backs up into the gland.
* can be linked to STI or some bacterial infections - not always.
Abscess can form if cyst is infection and collection of pus develops.
Abcess - red , swollen, tender and hot. Patient may have a fever.
Symptoms of Bartholin’s cyst ?
soft painless lump
- if cyst grows - noticable and uncomfotable when walking , sit down or have sex.
- pain in skin around vagina.
Abccess formation - red, hot , tender swollen. fever (38)
Treatment of Bartholin’s cyst ?
If linked to bacterial infection - Antibiotic given (no further treatment may be needed )
Painful cyst
- soak in warm water /warm compress several times a day for 10-15 mins. - pain relief - antibiotics
Large, painful abcess - if not responded to treatment for painful cyst.
- Word balloon catheter insertion -
- small incision in abscess and drain fluid ,
- word balloon catheter ( thin tube with balloon at the end) fitted into empty cyst/abscess.
- Balloon filled with sterile fluid and increases in size filling cyst / Ab
- Catheter stays in for 3 -4 weeks and epithelialisation (new cells grow around it ) occurs.
Marsupialisation - for recurrent abscesses.
- small incision in cyst/ Abscess and fluid drained
- edges of surrounding skin sewed to create small kangaroo pouch to collect any further fluid draining - prevent abscess coming back.
- special gauze applied to prevent bleeding. Cut should heal by itself.
What is Acne Inversa / hidradenitis suppurativa ?
Long term skin condition - very painful
- boil- like lumps , areas of leaking pus, abscess scarring.
Can happen in groin / armpit - areas of apocrine sweat glands.
(around anus ,on bum and under breats can also be affected )
Blockage of aprocrine sweat glands - secretions cannot escape so tubes swell , burst or become infected.
Smoking and obesity worsen symptoms.
- most common during puberty . less common before puberty and after menopause (can happen at any age tho)
Patient can also have acne and ingrown hairs. ( Acne inversa can be mistaken for these things )
Treatment of Hidradenitis suppurativa.
- warm flannel , painkillers (NSAID) , antibiotics, surgery , steriod injection.
- Clindamycin - Antibiotic lotion given for affected skin - reduce spread of bacteria on the skin
- Oral Tetracycline - given as well to prevent further attacks
- Doxycycline
- lymecycline
After lack of response:
1. (Clindamycin + rifampicin ) - can also be given - Not tetracyclines
Clindamycin - linomycin class
Rifampcin - rifamycins
- Still no response
- Acitretin - Vitamin A derivative - Retiniods
- unclog pores allow other medicated cream in . prevent dead cells clogging pores.
(NOT USED IN PREGNANT WOMEN )
- unclog pores allow other medicated cream in . prevent dead cells clogging pores.
Acitretin and pregnancy and side effects , blood donation .
Do not g=take/ give if patient is pregnant or plans to become pregnant.
Can harm fetus
Patient needs to have 2 negative pregnancy results and has to be on 2 acceptable forms of birth control.
* (not need if
patient has
has a
hysterectomy )
- Do not consume anything that contains alcohol during treatment and 2 months after.
- combines with alcohol forming a substance harmful to fetus - stays in blood for a long time.
- men should talk to doctor if taking this medication and partner is pregnant or plans to be . A small amount of Aretretin can be found in semen but not known if it causes harm.
Do not give blood while on this.
Acitretin may cause liver damage
- yellowing of skin ,eyes
- dark urine
- nausea , vomiting
- pain in in upper right stomach.
- loss of appetite
*report these symptoms to GP
Still no response
3. Adalimumab - (injection under skin) reduced inflammation - ANTI -TNF (tumour necrosis factor)
*if there is a reduction of more than 25 % in absecess and nodule count discontinue and give INFLIXIMAB - IV infusion (anti -tnf ) instead
No response
- Surgery - removal of affected areas
St johns wort and hormonal contraceptives ?
St johns wart interferes with action of hormonal contraceptive.
What are Ectopic pregnancies ?
Fertilised egg implants himself outside the wound.
usually happens in the Fallopian tubes.
- can’t save pregnancy - medicine or operation to remove it.
Symptoms of ectopic pregnancy ?
Missed period - usual of normal preg
Tend to develop btw 4th and 12th week .
- tummy pain - low down on one side
(e. g. right iliac pain with radiation down right thigh) - pain in tip of shoulder
- vaginal bleeding / brown watery discharge
- discomfort when pooing or weeing.
Risk of ectopic pregnancy ?
Can cause fallopian tube rupture.
medical emergency - life threating
- signs
- sharp intense
pain in tummy - very
dizzing/fainting - sick , pale
- sharp intense
Treatment
Surgery to repair fallopian tube.
management of suspected ectopic pregnancy ?
Signs of haemodynamic instability - (perfusion failure characterised by circulatory shock and advanced heart failure )
- Hypotension - Tachycardia - Shock - Pallor - collaspe
- give IV fluids - emergency abulance transfer to hospital
If no need for abulance and transfer (no in immediate danger )
- arrange pregnancy test - urine .
- pregnancy confirmed - gentle abdominal exam
- abdominal pain and tenderness strongly suspect
ectopic pregnancy- no abdominal P or T do gentle pelvic exam - presence of Pelvic T or cervical motion tenderness ( chandlier’s sign - unpleasant sensation or response elicited by movement of cervix by clinicians hand) - indicative of inflammatory processes)
- abdominal pain and tenderness strongly suspect
- Arrange immediate admission to early pregnancy unit or out of hours gynecology for diagnosis and treatment . (i f the tenderness and pain is present - either during abdominal exam or pelvic )
* Pelvic exam -do not palpate for adnexal (adnexa of uterus - adjoining region to the uterus -Fallopian tube , ovary) mass or pelvic mass - increases risk f rupture of ectopic pregnancy.
Diagnosis - Transvaginal ultrasound - identify location of pregancy and whether there is a fetal pole and heartbeat.
MRI - second line diagnostic tool.
Treatment of ectopic pregnancy?
Expectant management - watch and see if ectopic pregnancy is able to resolve itself with medication or surgery. Patients with minimal symptoms and clinically stable includ PUL (pregancy of unknown location)
Medical management - Drug treatment - Methotrexate .
1st line treatment for women who: 0 No significant pain.
0 An
unruptured
ectopic
pregnancy
with an
adnexal mass
smaller than
35 mm with
no visible
heartbeat.
0 Serum hCG
level less
than 1500
IU/L.
0 No
intrauterine
pregnancy
(as
confirmed
on an
ultrasound
scan).
And can follow up.
Surgery - Salpingectomy (removal of fallopian tube) or Salpingotomy (incision into fallopian tube to remove ectopic pregancy ) via laparoscopy (keyhole surgery in abdomen and peritoneum - small incision made in abdomen to allow surgeon to put laparscope inside and look at the inside of the tummy or by open surgery - (cutting the skin so that doctor has full view of structures , organs)
1st line - if woman has :
0 Significant pain.
0Adnexal mass of 35 mm or larger.
0 Fetal heartbeat visible on an ultrasound scan.
0 Serum hCG level of 5000 IU/L or more.
and cannot attend follow up after methotrexate treatement.
Monitor Serum HCG 0 to see if it has gone down to acceptable level after treatment.
*Anti-D immunoglobulin is offered to all rhesus-negative women who have had surgical removal of an ectopic pregnancy.
