GU Flashcards
age 30-50. May be asymptomatic and found on accident
* Breast pain or tenderness worsens during premenstrual phase of cycle.
* Fluctuation in size of masses, Multiple or bilateral.
* Absence of enlarged or tender lymphadenopathy.
Fibrocystic Changes
Imaging
* Mammography
* Ultrasound (Used alone when patient is under 30 years old)
Diagnostic testing
* Core needle biopsy (All suspicious lesions should be biopsied by a General Surgeon)
Treatment
* Mild: NSAIDS
* More severe pain should be referred to primary care for further evaluation.
Patient education
* Avoiding trauma, Wear supportive brassiere night and day
* Decreasing dietary fat intake, eliminating caffeine, Vitamin E, 400IU daily
* Monthly self-breast exam just after menstruation, Risk of not detecting breast cancer is higher.
- Round or ovoid, Rubbery, discrete, relatively moveable.
- Nontender mass 1-5 cm in diameter. Common benign neoplasm occurs most frequently within 20 years after puberty, More frequent and occurs earlier in black women.
Fibroadenoma
Imaging:
Ultrasound (Core needle biopsy is recommended)
Treatment
* All breast masses should be referred to General Surgery for further evaluation and work up, Once confirmed by biopsy, no treatment is usually necessary.
* Excision may be necessary for large or rapidly growing fibroadenomas: Larger than 3-4 cm, Rule out phyllodes tumor (A rare malignant fibroadenoma like tumor)
Produce a mass (with skin or nipple retraction), Ecchymosis.
Commonly Cause
* After fat injections to augment breast size, fill defects after breast surgery (mastectomy).
* Radiation therapy.
* MVA or assault.
Fat Necrosis
Treatment
Core needle biopsy.
Referral
- Age: Most significant risk factor.
- FHx breast or ovarian cancer: Especially bilateral breast cancer or premenopausal.
- Genetics: BRCA 1, BRCA 2, and other mutations.
- Reproductive history: Nulliparous or late first pregnancy (after age 30).
- Menstrual history: Early menarche (under age 12), Late menopause (after age 55).
- Previous medical history: Endometrial
- Early symptoms: single nontender, firm to hard mass with ill-defined margins. painless lump, 90% discovery by patient.
- Late: Skin or nipple retractions, axillary lymphadenopathy, breast enlargement, erythema, edema, pain fixations of mass to skin or chest wall.
Female Breast Carcinoma
Imaging
* Primary lesion: mammography (diagnostic), essential abnormality is only felt by patient.
* Ultrasounds, MRI, not for average risk patient.
* Core needle biopsy: procedure of choice in both palpable and image detected abnormalities.
Treatment
* All breast masses referred to General Surgery for further evaluation and work up.
* Surgical resections, with axillary node dissections. Mastectomy
* Radiations, systemic therapy: chemotherapy, targeted therapy, bisphosphonates.
* Prognosis: more aggressive in young women.
Male, Single nontender, firm to hard mass with ill-defined margins. painless lump,
Hx of Gynecomastia.
Male breast carcinoma
Imaging: Mammography and Ultrasound
Diagnosis: Biopsy (Should be performed on all men with breast masses)
Nipple Discharge
- Serous - most likely benign fibrocystic changes (FCC) like duct ectasia
- Bloody- more likely neoplastic papilloma or carcinoma, mass should be excised.
- Associated mass- more likely neoplastic
- Bilateral- most likely non neoplastic (Endocrine in etiology)
Common causes (in the non-lactating woman) - Duct ectasia: Spontaneous, unilateral, serous or serosanguineous discharge.
- Intraductal papilloma: Spontaneous, unilateral, serous or serosanguineous discharge.
- Carcinoma: Bloody discharge.
Other causes - Milky discharge in the non-lactating woman may occur from hyperprolactinemia: Serum prolactin levels to rule out pituitary tumor, TSH to rule out hypothyroidism.
- Antipsychotic drugs can cause elevated prolactin levels which lead to lactation in men and women.
- Oral contraceptives or estrogen replacement: May cause clear, serous, or milky discharge.
- Breast abscess: Purulent discharge, usually done in hospital setting.
Treatment - Refer to a breast clinic, OB/GYN, or General surgery depending on what type of discharge is present.
- Most discharge is benign especially if bilateral: Duct excision can be offered.
- Follow up: Patient should be reexamined every 3 to 4 months for a year if workup does not show malignancy.
5 days before the onset of menses and subsides within 4 days after menstruation occurs. clear functional impairment with work or personal relationships.
Symptom
* Irritability, Aggressiveness, Depression, Inability to concentrate, Libido change.
* Bloating, Breast pain, Ankle swelling, Skin disorders
PMS/PMDD
Mild to moderate symptoms
* Aerobic exercise
* Reduction of caffeine, salt and alcohol
* Increase in calcium (1200mg/day) and Vitamin D or magnesium, complex carbohydrates.
* Alternative therapies (acupuncture or herbal treatments)
Medications that prevent ovulation such as hormonal contraceptives may lessen symptoms.
Mood symptoms predominate: SSRIs.
- Antibiotics, corticosteroids use, pregnancy, DM. heat, moisture, and occlusive clothing.
- Women: White curd-like discharge, pruritus, vulvovaginal erythema. Not malodorous.
Vulvovaginal candidiasis (yeast infection)
- Antibiotics, corticosteroids use, pregnancy, DM. heat, moisture, and occlusive clothing.
- White curd-like discharge, pruritus, vulvovaginal erythema. Not malodorous.
- Lab: KOH
- Treatment: Antifungal: Fluconazole (Diflucan)
Women: * Frothy, yellow-green discharge, Malodorous and peritus,
* Strawberry cervix: red macular lesion on the cervix.
* * Men: Upwards of 75% of infected males are asymptomatic. Urethritis, clear or mucopurulent urethral discharge, dysuria. urethritis, epididymitis, or prostatitis.
Trichomonas
Lab:
* Wet mount preparation of genital secretion, convenient low cost. sensitivity is low.
* NAAT is recommended due to high sensitivity/specificity.
* Testing for other STDs including HIV should be performed in persons infected with T vaginalis.
Treatment
* Metronidazole 2 g PO in a single dose.
* Metronidazole 500 mg PO BID x7 days.
* No alcohol consumption during treatment to reduce the possibility of a disulfiram-like reaction and for 24 hours after completion of metronidazole.
* Abstain from sex until they and sex partners have been treated, asymptomatic for 7 days.
* Concurrent treatment of all sex partners is critical for symptomatic relief, microbiologic cure, and prevention of transmission and reinfections.
* Retesting for T. vaginalis is recommended for all sexually active women within 3 months following initial treatment regardless of whether they believe their sex partners were treated.
* Testing nucleic acid amplification (NAAT) can be conducted 2 weeks after treatment.
Woemen: * Increased malodorous vignial discharge without obvious vulvitis or vaginitis, NOT STI.
- Lab: Positive whiff test with BV (amine or fishy odor),
Bacterial Vaginosis (BV)
- Treatment: Antibiotic Metronidazole (Flagyl)
Symptoms
* Female: Urethritis: Dysuria, Pyuria, Polyuria. Cervicitis (most frequent): Increased vaginal discharge, Intermenstrual vaginal bleeding, Dyspareunia.
* Males: Urethritis (most frequent): Dysuria (Most common), Mucoid or clear watery discharge, Scant discharge on underwear in the morning. Epididymitis. Prostatitis. Proctitis (MSM): Anorectal pain, Discharge, Rectal bleeding.
Chlamydia
Treatment
* Preferred treatment: Doxycycline 100mg PO BID for 7 days.
* Alternative treatment: Azithromycin 1g single dose (must observe patient taking med).
* Ceftriaxone if concerned for coinfection.
* Abstain from sexual activity for 7 days till completion of antibiotics.
* Encouraged to contact recent sexual partners so they can be treated. * Recommended that patients with laboratory-confirmed chlamydia be retested ~ 3 months after treatment of an initial infection due to partners have not been appropriately treated.
- Female: Most womenare asymptomatic, Urethral: Dysuria, increased vaginal discharge, or vaginal bleeding between periods. Lower abdominal discomfort and Dyspareunia may be present. symptoms are often so mild & nonspecific its mistaken for a bladder or vaginal infection. Rectal Infection. Throat.
- Male: Most males are symptomatic, Urethral: Dysuria, White/yellow/green urethral discharge. Epididymitis. Rectal Infection. Throat.
Gonorrhea
Lab: GC/NAAT, gonorrhea culture (requires endocervical or urethral swab specimens), Culture is important due to emergence of antibiotic resistant strains, especially in Southeast Asia.
Patients with evidence of GC infection in the pharynx/anus can be swabbed & cultured for NAAT. (If laboratory has validated the use of NAAT for extra-genital specimens).
Treatment
* 50% of gonorrhea infections are resistant to at least one antibiotic.
* Emergence of fluoroquinolone-resistant N. gonorrhoeae left cephalosporins as the sole remaining class available for treatment of gonorrhea in the U.S.
o Ceftriaxone 500 mg IM in a single dose AND
o Doxycycline 100mg PO BID x 7 days. Alternative: Azithromycin 1g PO in a single dose. STI Screening: Gonorrhea, Chlamydia, HIV, RPR for syphilis, HPV vaccination counseling.
Begins as a painless papule that proceeds to ulcerate into a 1- 2cm painless ulcer with raised margins (chancre). Chancre lasts 3 to 6 weeks and heals regardless of whether a person is treated or not, however, active lesions are infectious. often don’t report primary syphilis because it is painless.
Skin rashes and/or mucous membrane lesions (sores in the mouth, vagina, or anus) mark the second stage of symptoms. diffuse non-pruritic maculopapular eruption on the trunk and extremities that includes the palms and soles. Additional symptoms may include fever, swollen lymph glands, sore throat, patchy hair loss, headaches, weight loss, muscle aches, and fatigue.
Syphilis
Lab: Serologic test (standard used to diagnose syphilis)
* Nontreponemal tests (RPR): serum reactivity to cardiolipin cholesterol lecithin antigen. Nonspecific therefore not definitive. Need to be confirmed with treponemal test.
* Treponemal test (FTA-ABS): More complex and expensive to perform therefore usually used to confirm syphilis.
Treatment
Parental Penicillin G is the standard treatment for all stages of syphilis.
* Primary & Secondary syphilis: Penicillin G benzathine 2.4 million U IM once. PCN allergy: Doxycycline 100mg PO BID x 14 days
* Tertiary syphilis: Penicillin G benzathine 2.4 million U IM once weekly for 3 weeks. Doxycycline 100mg PO BID x 4 weeks.
* Jarisch-Herxheimer reaction: An acute febrile reaction frequently accompanied by headache, myalgia, fever, rigors, diaphoresis, hypotension, and worsening rash if initially present. This can occur within 24 hours after initiation of therapy for syphilis. Typically resolves in 12-24hrs. NSAIDS or antipyretics can help reduce symptom severity.
- Primary: Severe, painful genital ulcers, Dysuria, Fever, Local inguinal lymphadenopathy.
- Recurrent infection: Unilateral small vesicular lesions on erythematous base or ulcerative lesions, may have mild tingling or shooting pains in buttocks and legs prior to recurrent episode.
Herpes simplex virus (HSV)
Lab: Cell culture and PCR are the preferred HSV tests for genital ulcers or other mucocutaneous lesions.
Treatment
Primary Infection Treatment: all patients with first episodes of genital herpes should receive antiviral therapy. can develop severe or prolonged symptoms.
* Acyclovir 400 mg orally TID for 7–10 days
* Valacyclovir 1 g orally BID for 7–10 days
* Famciclovir 250 mg orally TID for 7–10 days
Recurrent Infection Treatment:
* Acyclovir 800 mg orally twice a day for 5 days
* Valacyclovir 1 g orally once a day for 5 days
- Typically asymptomatic, although they may occasionally cause bleeding, pruritus, and pain.
- Patients are generally concerned about the appearance of the lesions, and often cause psychological & psychosexual distress.
- Condyloma acuminata generally occurs in the anogenital region, but lesions may also be present in the oral cavity. Simultaneous lesions in the anogenital region suggest STI.
- Condyloma acuminata lesions: raised, skin-colored, fleshy papules that range in size from 1-5 mm. broad and flat, pedicled, or occasionally have a cauliflower-like appearance.
Human papillomavirus infection (HPV)
Topical therapies:
* Imiquimod cream 5% TID every other day, 6 weeks.
* Podophyllotoxin Solution (0.5% & 0.15%): treat the fleshy papules. Applied BID x 3 days with a 4-day break. 4 weeks. Cryotherapy (Dermatology): Inexpensive, minimally painful, and safe during pregnancy, Liquid NO2 applied to the margin of the lesion 3-5 times for 20 seconds. Weekly treatment for 6-10 weeks.
Surgical excision (Dermatology): Performed for lesions refractory to treatment & for advanced disease. Includes electrosurgery, curettage, scissors excision, and laser therapy. Only surgical
- Periodic painful swelling on either side of the introitus, Dyspareunia
- Fluctuant swelling 1-4 cm in diameter lateral to either labium minus (occlusion)
- Tenderness is evidence of active infection.
Bartholin’s Gland Abscess.
Lab: Purulent drainage culture (Gonorrhea, Chlamydia, Polymicrobial)
Treatment
* Manual aspiration or I&D. Antibiotics are unnecessary unless cellulitis is present.
* STI is suspected but culture is not available, treat for both Gonorrhea and Chlamydia.
* Marsupialization may be required for frequent reoccurrence. Done by OB/GYN.
* Under 40, asymptomatic cysts (no treatment).
* over age 40, biopsy or removal are recommended to rule out vulvar carcinoma.
Most common benign neoplasm of the female genital tract. Discrete, round, firm, often multiple uterine tumors. cause miscarriage and pregnancy complications because they interfere with implantation.
Symptoms
* Frequently asymptomatic
* Pt seek treatment: Pelvic pressure, Abnormal uterine bleeding, Pain.
Leiomyoma of the uterus (fibroid tumor)
Lab: CBC for Iron deficiency anemia.
Imaging
* Transvaginal ultrasound: Confirm presence and monitor for growth.
* MRI with contrast: Assess location.
* Hysterography or hysteroscope:
Treatment
* Emergency measures (surgery): acute torsion, markedly anemic (treat before surgery), LNG IUD can help decrease bleeding.
* Asymptomatic myomas: managed expectantly.
* NSAIDs: decrease menstrual blood loss.
* Hormonal therapies: reduce volume, size, and menstrual blood loss.
* Surgical therapy: definitive treatment and curative.
MEDEVAC for suspected torsion of fibroid and hemorrhage
: Obesity, DM. Unopposed estrogen: Nulliparity, Polycystic ovaries with prolonged anovulation, Unopposed estrogen therapy, Extended use of tamoxifen (estrogen blocker) for the treatment of breast cancer, Family history of colorectal cancer.
Symptoms
* Abnormal uterine bleeding is the presenting sign in 90% of cases, ALL post-menopausal bleeding requires evaluation.
* Pain generally occurs late in the disease, with metastases or infection.
Carcinoma of the endometrium
Lab: Biopsy of endometrial tissue, Pap smear.
Imaging: transvaginal ultrasound, Hysteroscopy.
Treatment
* Surgery: Total hysterectomy, Bilateral salpingo-oophorectomy, Peritoneal washings for cytology, Lymph node sampling.
* Post-operative radiation. Chemotherapy.
* Depth of cancer invasion into the myometriumis the strongest predictor survival outcome.
Signs and symptoms
* Dysmenorrhea, Dyspareunia, Abnormal uterine bleeding.
* Chronic pelvic pain, Infertility.
* Tender nodules in the cul-de-sac or rectovaginal septum
* Cervical motion tenderness, Adnexal mass or tenderness.
Endometriosis
Lab: Definitive diagnosis of endometriosis is made only by histology of lesions removed at surgery. (Laparoscopy)
Imaging: Transvaginal ultrasound (limited value)
Treatment
* NSAIDS. referral
* Hormonal therapy: Inhibit ovulation for 4-9 month preventing cyclic stimulation. (Low dose combined oral contraceptives, Contraceptive patch, Vaginal ring, Progestins, Progestin Intrauterine device).
* Laparoscopic ablation of endometrial implants (reducing pain, promoting ferity)
* Hysterectomy, with bilateral salpingooophorectomy (Definitive therapy for intractable pelvic pain, adnexal masses, or multiple ineffective conservative surgical procedures.)
* Any patient suspected of having endometriosis should be referred to OB/GYN.
