Gynecology APGO uWise Flashcards
Dysmenorrhea + Dyspareunia
What else?
Endometriosis
- nodularity on uterosacral ligament
Endometrial glands embedded in wall of uterus
Adenomyosis
Oligomenorrhea in an overweight patient?
Polycystic ovarian syndrome
Inability to conceive for 1 year + Dysmenorrhea + dyspareunia Palpable, tender adnexal mass Complex ovarian cyst Simple cyst
Endometriosis = endometrial glands outside the uterine cavity
Complex ovarian cyst
Endometrioma
- chocolate cyst
Conservative management for endometriosis?
OCP’s
NSAIDs
Treatment for severe endometriosis w/ failed conservative medical management (OCP’s)?
Surgery to manage symptoms
- conservative: ablation, excision
- definitive (total hysterectomy/BSO)
So in young pt who desires pregnancy, laser ablation if no adnexal masses and ovaries are not enlarged.
Why OCP’s for conservative treatment of endometriosis?
Get - feedback to pituitary-hypothalamic axis
- this stops stimulation of ovary
- this suppresses sex hormone production (E)
- Estrogen normally stimulates endometrial tissue and we want this suppressed
Danazol
- indications?
- SE’s?
- synthetic androgen
- used to treat endometriosis
SE: androgenic side effects Dan the Man
- used to treat endometriosis
- wt gain + hair + ache + lipid levels
GnRH
- indications?
Can only be used short-term
- control pelvic pain in endometriosis pt only if unresponsive to other hormone treatments
- have more side effects that OCP’s when treating endometriosis
Test/procedure to confirm endometriosis?
Diagnostic laparoscopy
Biopsies
Complex ovarian cyst
- how differentiate?
- ) Symptoms of endometriosis? (dysmenorrhea + dyspareunia)
- ) Mid-cycle: think hemorrhagic cyst
- ) Obese + oligomenorrhea: think PCOS
Complex ovarian cyst
- 48yo smoker
- next best step?
Repeat U/S in 2 months
- if mid cycle will resolve on it’s own
OCP’s are contraindicated in 35+ smoker
Ovarian mass w/ sudden onset severe pain + nausea
Ovarian torsion
Severe RLQ pain + nausea + tachycardia + ovarian mass + free fluid in pelvis + hematocrit 29%…next step?
Surgical exploration
- likely ovarian torsion
- already did U/S
- ovarian torsion requires immediate surgical attention
Endometriosis + unable to conceive for 18 months + otherwise negative workup…next step to help fertility?
1.) Clomiphene citrate: stimulate ovulation
2.) Intrauterine insemination is also option
If these fail…in vitro fertilization or adoption
Urinary frequency, urgency, nocturia
Mild cystocele + rectocele
Post-void volume = 400cc
Overflow incontinence: failure to empty bladder adequately
1.) Underactive detrusor (DM, MS, neuro)
2.) Obstruction (postop, severe prolapse)
Normal post-void residual = 50-60cc
What is mixed urinary incontinence?
Stress incontinence
Urge incontinence
Risk factors for pelvic organ prolapse?
Increased age, obesity, CT disorders (Ehlers-Danlos) + chronic constipation + vaginal delivery
Also: family hx of prolapse!
Urinary leakage w/ cough, sneeze, lift Vaginal deliveries infants > 9lbs Previous hysterectomy + BSO Post-void volume = normal Q-tip test = straining angle 60 degrees Pt failed kegel exercises
Stress incontinence - increased and pressure in absence of detrusor contraction
Most due to urethral hypermobility
Straining Q-tip > 30 degrees from horizon
Very occasionally due to sphincter deficiency of urethra
Surgery for stress incontinence?
Retropubic urethropexy: tension free vaginal tape or sling procedure best 5-year rates.
Intrinsic sphincter deficiency; best first treatment?
Urethral bulking procedure
- constant leaking of urine
- previous cystocele repairs
Treat stress incontinence?
Urethral bulking procedure/injection
- reduces diameter of urethra, creating resistance to leakage
Sling procedure: voiding difficulties are significant
Pseudoephedrine: improve urethral tone
Kegel: strengthen pelvic floor m. and decrease urethral hyper mobility
Uninhibited detrusor contractions upon bladder filling. Treatment?
Oxybutynin:
- ACh transmits parasympathetic signal for bladder emptying via muscarinic receptors
- Anticholinergics = mainstay of medical management
Treat pelvic protrusion:
Symptoms of vaginal pressure + heaviness
(large pelvic prolapse)
- ) Pessary: ring to support = initial treatment
- ) Pubocervical fascia plicated in midline and laterally to acrus tendineus fascia (white line) to fix:
- white line = fix cystocele
Urgency, nocturia + large urine loss for several seconds.
Post-residual volume - 50cc
Urine loss standing or sitting, not activity related
Urge incontinence:
- overactive detrusor muscle
- get uninhibited contractions
- increase in bladder pressure over urethral pressure = leakage
Associated defects related to urge incontinence?
Structura/ mechanical defects of:
- cystocele
- urethrocele
Asymptomatic pelvic prolapse
NO intervention necessary
Observation
90yo w/ apex/ant/post vaginal prolapse Cardiac + DM Hydronephrosis due to prolapse Can't urinate w/o reduction of prolapse Best next step?
Colpocleisis
- removal of ant/post vaginal wall
- small vaginal canal will exist
For women who are no longer sexually active
Two ways to treat Gon/Chla IV?
- ) Cefotetan/xitin + Doxycycline
2. ) Clindamycin + Gentamicin
Outpatient treatment of Gon/Chla?
Ceftriaxone (3rd gen) + Doxycycline +/- Metronidazole
What does metronidazole cover?
Anaerobic + protozoal infections
- treat C. diff assoc diarrhea
- great against H. pylori & Gardnerella v.
Acute cystitis in healthy, non-pregnancy women cause?
E. coli in 85% of cases
Also: Staph saprophyticus, Klebsiella, Enterococcus, Proteus.
Young F cramping + low pelvic pain
Urinating much more frequently
UTI: do urine analysis
What does Clindamycin cover?
Treats anaerobes + streptococcal + staphylococcal infections.
Causes C. diff.
Doxycycline covers?
Chronic bronchitis
Weird bacteria: H. flu, Moraxella, Legionella, Mycoplasma, Chlamydia
How reduce risk of ovarian cancer in young female?
OCP’s
- five years continuous use reduces risk by 1/2
- but total risk is 1% per female if no family hx
How screen pt for ovarian cancer?
BRCA1 & 2 mutations typically seen in hereditary ovarian cancers. So if mom has breast cancer, test mom for BRCA1/2. BRCA covers breast & ovarian cancers.
Unilocular simple cyst without evidence of blood, soft tissue elements or excrescences
+/- symptoms
Fluctuates w/ cycle
Functional ovarian cyst
- Serous cyst adenoma’s are typically much larger than functional ovarian cysts
- Mucinous cystadenoma are multilocular and quite large
