GYN (part 2)- Exam 2 Flashcards
Pelvic Organ Prolapse
* What is cystocele?
* What is urethrocele?
* What is rectocele?
* Prolapse of what?
- Cystocele – hernia of the bladder wall into the vagina
- Urethrocele – sagging of the urethra following its detachment from the pubic symphysis during childbirth
- Rectocele – herniation of the terminal rectum into the posterior vagina
- Prolapse of the Uterus
What are the stages of the uterine prolapse?
What are the risk factors of any prolapse (7)?
- Vaginal birth
- Genetic predisposition
- Aging
- Prior pelvic surgery
- Connective tissue disorders
- Obesity
- Straining from chronic constipation, chronic cough
Lifetime risk of needed surgery is 15-19%
Clinical presentation of prolapse
* Senstation of what?
* What type of incontinence?
* Feeling of incomplete what?
* Bowel Movements?
* Difficult or painful what?
- Sensation of a bulge or protrusion in the vagina
- Urinary or fecal incontinence
- Feeling of incomplete bladder emptying
- Constipation
- Difficult or painful intercourse
Treatment of prolapse:
* What is the primary step? ⭐️
* What are some supportive measures?
* Limit what?
* Incontinence may be improved with what?
- Weight reduction in obese patients is primary step and has been shown to reduce stress incontinence ⭐️
- Supportive measures – high-fiber diet, laxatives for constipation
- Limit straining and lifting
- Incontinence may be improved with pelvic floor exercises
Pessaries:
* What are they?
* Reduce what?
* Typically used by who?
- Vaginal insert designed to support areas of prolapse
- Reduce discomfort of cystocele, rectocele, enterocele
- Typically used in patients who do not want to undergo surgery or for whom the risk of surgery outweighs the possible benefit.
Surgical correction of prolapse
* What is most common?
* Combined with what?
* For many years, what was incorporated?
* What may be effective and appropriate for older women?
- Vaginal or abdominal hysterectomy most common
- Combined with tacking or suspension of pelvic structures
- For many years, mesh was incorporated into a suspension network-now considered too high risk
- Vaginal excision may be effective and appropriate for older women
Vaginal discharge
* What is the normal pH?
* What if the pH above or less than 4.5?
* Measurement of pH is less useful at the extremes of age because why?
- The pH of the normal vaginal secretions is 4.0 to 4.5
- A pH above 4.5 in a premenopausal woman with abnormal discharge suggests infections such as bacterial vaginosis or trichomoniasis
- A pH less or 4.5 in a premenopausal woman with abnormal discharge suggests candida
- Measurement of pH is less useful at the extremes of age because the pH of normal vaginal secretions in premenarchal and postmenopausal women is 4.7 or more
Normal Vaginal Discharge
* The majority of normal vaginal secretions consist of what?
* What is the color?
* How much is produced per day?
* What is the smell?
- The majority of normal vaginal secretions consist of mucus from the cervix
- White to off-white in color
- Normally around 1.5mg of vaginal fluid is produced per day
- Normal discharge is odorless
Vulvovaginitis
* What is it?
* What are the common complaints? (3)
Spectrum of conditions that cause vaginal or vulvar symptoms
Common complaints:
* Itching
* Burning with urination or sexual activity
* Abnormal discharge
Vulvovaginitis
* What are the MCCs? (3)
- Bacterial vaginosis
- Vulvovaginal candidiasis
- Trichomoniasis
Vulvovaginitis
* What is the clinical evaluation? (5)
Diagnostic Tests: Vulvovaginitis
* How is the microscopy done?
⭐️
- Vaginal discharge is sampled with a cotton-tipped swab, mixed with one to two drops of 0.9 percent normal saline solution on a glass slide and examined under a microscope
- Performed to look for candidal buds or hyphae, motile trichomonads or clue cells
- The addition of 10% potassium hydroxide (KOH) to the wet mount of vaginal discharge destroys cellular elements, thus it is particularly helpful in diagnosing candida vaginitis.
- Smelling (“whiffing”) the slide immediately after applying KOH is useful for detecting the fishy (amine) odor of bacterial vaginosis. Fishy smell only when applied KOH.
Vulvovaginal Candidiasis “ Yeast Infection”
* What is it?
* What are risk factors? (5)
* What is the most prominent symptom?
- Fungal infection usually caused by Candida albicans
- Risk factors – broad-spectrum antibiotics, pregnancy, diabetes, immune compromise, silk underwear
- Pruritis may be severe, and is most prominent symptom
Vulvovaginal Candidiasis
* How is the discharge?
* What is the ph and smell?
* Dx how? What else is available?
- Thick, adherent curd like white discharge in vaginal vault
- Not malodorous and pH is normal (<4.5)
- Diagnosed by clinical appearance or KOH prep of slide with microscopy
- PCR testing available
What is this?
Branched hyphae and budding yeast of Candida albicans (spaghetti & meatballs)
What is this?
Cervical Candidiasis
Treatment: Vulvovaginal Candidiasis
* What are the different choices? (5) ⭐️
Typically will respond to a 1-3 day regimen of topical azole⭐️ or one-time dose of oral fluconazole
* In pregnant patient, oral azoles are contraindicated in first trimester
* Clotrimazole, 1% vaginal cream or supp. x7days
* Miconazole, 2% vaginal cream or supp. x7days
* Nystatinis another option but requires prolonged therapy (7 to 14 days). Takes time but it works. Can be used for peds (doesn’t burn).
DO TOPICAL FIRST
Treatment: Vulvovaginal Candidiasis
* If complicated or recurrent, what is the treatment?
If complicated or recurrent (>4x/year) or in setting of immune compromise, uncontrolled DM or corticosteroid treatment – extend duration to 7-14 days of a topical regimen or 2 doses of oral fluconazole followed by once a week maintenance therapy for 6 months
Trichomonas vaginalis
* What is it?
* What is a sxs?
* what is the discharge?
* What is seen on the cervix?
- Sexually transmitted flagellated protozoa
- Pruritis
- Frothy clear/white/yellow-green thin malodorous discharge
- Red macular lesions on the cervix in severe cases
Trichomonas vaginalis
* Vaginal _
* What is seen with microscopic exam? What is positive?
* What is available?
- Vaginal erythema
- Motile organisms with flagella seen by microscopic examination of swab of vaginal area, prepped with saline
- Whiff test may be slightly positive with KOH prep
- Rapid diagnostic tests are available
Treatment: trich
* Who should be treated?
* What is the txt? ⭐️
* How long of abstinence?
- Highly recommended that both partners be treated simultaneously.
- Metronidazole 500mg PO twice daily for seven days or tinidazole 2 grams PO as a single dose
- Advise 5 days of abstinence upon treatment onset
Treatment: Trich
* What is the txt in preg patients?
Metronidazole: 2 g orally (single dose) OR
* Extend to 2g PO QD x 7 days in resistant infections
Avoid tinidazole or metrogel
Treatment of asymptomatic patients is not indicated
* In pregnancy, asymptomatic patients do not have to be treated until 37th week gestation
BV
* What is it?
* Not what?
* What is a risk factor?
* What is the discharge like?
- Polymicrobial disease. Gardnerella most common
- NOT a sexually transmitted infection, only overgrowth of anaerobic bacteria
- Sexual activity is a risk factor
- Malodorous discharge, typical without vaginitis