MORE GYN! Flashcards
Overflow incontinence is characterized by?
failure to empty the bladder adequately
due to an underactive detrusor muscle (neurologic disorders, diabetes or multiple sclerosis) or obstruction (postoperative or severe prolapse).
n elevated PVR, usually >300 cc, is found in overflow incontinence.
A normal post-void residual (PVR) is ?
50-60 cc.
Stress incontinence occurs when the bladder pressure is greater than the intraurethral pressure.
Genuine stress incontinence (GSI) is the loss of urine due to increased intra-abdominal pressure in the absence of a detrusor contraction.
The majority of GSI is due to urethral hypermobility (straining Q-tip angle >30 degrees from horizon).
underactive detrusor muscle is
neurologic disorders, diabetes or multiple sclerosis
bladder obstruction is
postoperative or severe prolapse
Risk factors for the development of pelvic organ prolapse are
increasing parity increasing age obesity some connective tissue disorders (Ehlers-Danlos syndrome) chronic constipation.
Women with a family history of POP have up to a 2.5 fold increase in prolapse
Retropubic urethropexy
a
Needle suspension
a
Artificial urethral sphincter
Artificial sphincters should be used in patients as a last resort to treat treats intrinsic sphincteric deficiency (hose in the sand)
Urethral bulking procedure
treats intrinsic sphincteric deficiency
Sling procedure
sling that is inserted through a small vaginal incision and attached to another structure in the pelvis for the purpose of supporting the urethra*
Suburethral slings may be either bladder neck or midurethral slings.
Mechanisms of stress incontinence include?
urethral hypermobility and intrinsic sphincteric deficiency (ISD).
Urethral hypermobility is ?
Stress urinary incontinence
like stepping on a hose in sand
-insufficient support of the pelvic floor musculature and vaginal connective tissue to the urethra and bladder neck
- causes the urethra and bladder neck to lose the ability to completely close against the anterior vaginal wall.
-with increases in intra-abdominal pressure
the muscular tube of the urethra fails to close, leading to incontinence
Intrinsic sphincteric deficiency (ISD) is ?
- stress urinary incontinence (SUI)
- loss of urethral tone that normally keeps the urethra closed
- severe urinary leakage even with minimal increases in abdominal pressure.
- can be +/- urethral hypermobility
Urgency incontinence is?
Women with urgency incontinence experience the urge to void immediately with involuntary leakage of urine
detrusor overactivity –> uninhibited (involuntary) detrusor muscle contractions
Overflow incontinence is caused by?
detrusor underactivity or bladder outlet obstruction
symptoms of pressure, fullness, and frequency, and is usually a small amount of continuous leaking.
Vaginal atrophy and loss of urine
low estrogen levels –> atrophy of the urethral mucosal epithelium.
Atrophy results in urethritis, diminished urethral mucosal seal, loss of compliance, and possible irritation, all of which can contribute to incontinence
– Functional incontinence occurs when?
a patient has intact urinary storage and emptying functions but is physically unable to toilet herself in a timely fashion (mobility issues)
detrusor instability is treated via?
anticholinergics are the mainstay of pharmacologic treatment. Oxybutynin is one example
Central and lateral cystoceles are repaired by?
fixing defects in the pubocervical fascia or reattaching it to the sidewall, if separated from the white line.
Defects in the ______ are repaired in rectoceles.
rectovaginal fascia
Uterine prolapse is surgically treated by a ?
vaginal hysterectomy
Vaginal vault prolapse is treated either by?
supporting the vaginal cuff to the uterosacral or sacrospinous ligaments, or by sacrocolpopexy.
Colpocleisis is a procedure where ?
the vagina is surgically obliterated and can be performed quickly without the need for general anesthesia.
Who is at increased risk for molar prego
Asian women in the United States under 20 yo over 40 yo women with two or more miscarriages. Hx of molar (2%)
________ s/s is universal in molar pregnancies.
Vaginal bleeding
Findings of findings of an enlarged uterus and vaginal bleeding, a Beta-hCG value >1,000,000 mIU/mL are ddx for?
molar prego
In the face of discrepancy between dates and uterine size, a pelvic ultrasound is indicated for?
to confirm dates, exclude multiple gestation, uterine abnormalities, and molar pregnancy.
With a Beta-hCG above the __________ an IUP should be easily identified on transvaginal ultrasound.
discriminatory zone (>1500 mIU)
If an IUP is not seen, the ultrasound findings (in conjunction with the Beta-hCG level) should identify a?
mole (multiple internal echoes) or an ectopic (absence of intra-uterine gestation).
__________ is the standard management for molar pregnancies.
Suction curettage
methotrexate is post- GTD may help
Tissue diagnosis is the standard in establishing a diagnosis of almost all malignancies, with the exception of _______________
choriocarcinoma.
DDX of choriocarcinoma
+ Beta-hCG in a reproductive-aged woman
Hx of recent pregnancy .
_____________ is the most common vulvar malignancy and may arise in the setting of chronic irritation from lichen sclerosus.
Squamous cell carcinoma
accounts for approximately 90% of vulvar cancers
The mean age of squamous cell carcinoma is 65 years and _____ is known to increase the risk of development of vulvar cancer
smoking- especially in the setting of HPV infection.
_________ represents 5% of vulvar cancer
Melanoma
Vulvar intraepithelial neoplasia s/s
- itchy
- multicentric brown-pigmented papules on the perineum, perianal region and labia minora.
- No induration or groin adenopathy is noted.
___________ most likely arise from the Bartholin gland
Primary vulvar adenocarcinomas
*other histologies such as squamous cell, transitional, adenosquamous, and adenoid cystic carcinomas can also arise from this location
VIN III should be treated with ___________
local superficial excision
radical surgery if it carcinoma (which is not VIN3, just almost)
Trichloroacetic acid (TCA) treats?
genital warts
Paget’s is an in situ carcinoma of the vulva is acs w/ ?
is a adenocarcinoma
association with breast cancer is significant, but not as high as Paget’s disease of the nipple.
Paget’s looks like?
vulva is fiery red mottled background with whitish hyperkeratotic areas
Recommends that management options for ASCUS
include performing HPV DNA testing or repeat cytology at 12 months following the abnormal Pap test result.
ASCUS w/ + HPV
If HPV is positive, or if repeat cytology at 12 months reveals ASCUS or higher, then colposcopy should be performed
ASCUS w/ - HPV
If the HPV testing is negative then routine screening can be resumed at three years.
________ is an area of columnar epithelium that has not yet undergone squamous metaplasia.
Ectropion
It appears as a reddish ring of tissue surrounding the external os.
________ can represent dysplasia but, in most cases, is less concerning than the above vascular changes like ____________
Acetowhite epithelium is dysplasia
atypical vessels and Punctations and mosaicism represent new blood vessels are more dangerous
Cervical conization refers to?
an excision of a cone-shaped sample of tissue from the mucous membrane of the cervix.
Carcinoma in situ vs Microinvasive cervical cancer
In microinvasive cancer, they invade less than 3 mm
Carcinoma in situ (CIS) represents abnormal cells involving the entire epithelium to the basement membrane.
Cervical conization is indicated in this patient who has a positive
endocervical curettage
Cryotherapy will not provide a pathologic specimen to rule out invasive cancer, but can be used to treat cervical dysplasia once cancer has been completely ruled out and the entire lesion can be visualized.
Cryotherapy will not provide a pathologic specimen to rule out invasive cancer, but can be used to treat cervical dysplasia once _______________
cancer has been completely ruled out and the entire lesion can be visualized.
