Ovarian cysts/Pelvic prolapse Flashcards

1
Q

Ovary

A

Adnexal structure
Produce numerous follicles every month, with one dominant follicle maturing → ovulation
Suspended laterally to the uterus by the utero-ovarian ligament
Covered by the mesovarium (component of the broad ligament)
Connected to the pelvic wall by the suspensory ligament

Blood supply: ovarian artery, a direct branch of the aorta, and the uterine artery

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2
Q

Ovarian Cyst

general and RF

A

Defined as a collection of fluid or semiliquid material, often walled off by a membrane, located in the ovary

Etiology:
Can occur at any age, but more common in reproductive years (endogenous hormone production)

Most are benign

Post-menopausal women with any type of ovarian cyst should undergo evaluation to rule out malignancy

Risk Factors:
Infertility treatment → ovarian hyperstimulation
Tamoxifen → causeexcessive growth of ovarian follicles
Pregnancy – formation in the second trimester due to peak levels of hCG
Cigarette smoking
Tubal ligation

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3
Q

ovarian cysts

categorized as

A

Categorized as:
Functional
Occur as a result of normal physiologic processes
Uncommon after menopause

Neoplastic
Abnormal growth of ovarian cells within the ovary
Subcategorized as
Benign: Women of reproductive age
Malignant: Risk of malignancy increases in the postmenopausal period

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4
Q

ovarian cysts

simple

A

Common
Thin-walled with no evidence of wall thickening or internal walls (septation)
Fluid-filled
Most often benign
Typically disappear without treatment

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5
Q

ovarian cysts

complex

A

Generally large
Irregular borders
Internal septations creating a multilocular appearance
Fluid inside tends to be heterogeneous (solid material and fluid)
Could be part of an ovarian tumor → HIGHER SUSPICION for malignancy

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6
Q

Functional cyst

follicular cysts

A

Most common ovarian mass in women of reproductive age
Follicles that fail to rupture during ovulation and continues to grow because of hormonal stimulation

Characteristics
Simple collections of fluid
Thin-walled
Single or multiple
Variablesize
A few millimeters to 15 cm
Lined with granulosa andtheca cells

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7
Q

functional cyst

Corpus Luteal cyst

A

Corpus luteum that does not dissolve
Followingovulation, the follicle becomes the corpus luteum → secretes progesterone

Pregnancy negative: life span of the corpus luteum is 14 days
Pregnancy positive: corpus luteum continues to secrete progesterone until dissolution at ~14 weeks

Present during pregnancy

Characteristics
Unilateral
Simple or complex
~2‒3 cm size; can be up to 8 cm
Uniloculated cysts, which can contain internal debris

Can hemorrhage into the cyst cavity (hemorrhagic cyst) or rupture into the peritoneum

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8
Q

functional cyst

Clin man

A

Often asymptomatic

Symptoms if present may include:
Pain or pressure:
Unilateral in the lower abdomen
Intermittent or constant
Sharp or dull

Peritoneal irritation
Delayedmenses
Vaginal bleeding

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9
Q

functional cysts

Dx

A

History and exam
Consistent clinical symptoms
Palpable adnexalmasson bimanual examination
Location, shape, size, mobility, and level of tenderness

Imaging – required for definitive diagnosis
Transvaginal ultrasonography

Cancerantigen125 (CA-125) blood test
Only for postmenopausal women
Complex cysts and highCA-125level = ↑ risk of malignancy

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10
Q

functional cysts

managament

surgical indications

A

Typically, no treatment is required unless complications occur
Follicular cysts usually resolve spontaneously within 1–2 menstrual cycles
Resolution occurs after cyst fluid resorption or spontaneous rupture
Cysts that do not resolve require further investigation

Serial transvaginal ultrasounds may be required to monitor cyst changes

Surgical removal indications
Suspectedovarian torsion
Persistent adnexalmass
Suspected malignancy

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11
Q

Neoplastic cysts

general

A

Classified according to the cell of origin:
Epithelial cells
Germ cells
Sexcord-stromal cells
Each has multiple histologic subtypes
Each subtype can be either benign or malignant

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12
Q

Neoplastic Cyst

Epithelial cell tumors

A

Most common type of malignant ovarian tumor

Multiple histological subtypes
Histology (not radiographic appearance) determines if the tumor is benign, borderline, or malignant

Typicallyaffectmiddle-aged and elderly women

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13
Q

Neoplastic Cyst

Germ cell tumor (teratomas)

A

Arise from all 3 germ cell layers
Common in children and adolescents
Usually asymptomatic and discovered incidentally on pelvic exam
Also called “dermoid cysts” because they often contain ectodermal components (teethand hair)
Most often benign
High risk ofovarian torsion

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14
Q

Neoplastic Cyst

Sexcord-stromal tumors

A

Multiple histologic subtypes
Arise from the stroma of the ovary
Common in middle-aged women
Associated with ascites and pleural effusions

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15
Q

neoplastic cysts

Clin man

A

Lower abdominal/pelvicpain
Acute-onset pain associated with ovarian rupture, torsion, or bleeding

Abdominal distention
Abdominal fullness, bloating
Early satiety
Painful intercourse
Irregular periods
Abnormal vaginal bleeding
Urinary frequency
Constipation
Weight loss

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16
Q

neoplastic cyst

Dx and Tx

A

Transvaginal ultrasonography used to determine malignancy risk index:

Benign lesions – simple cyst features
Unilocular
Thin, smooth walls
Fluid-filled
Absence of internal flow

Malignant lesions – complex cyst features
Bilateral
> 10 cm
Solid areas within the tumor
Increased vascularity
Presence ofascites

Management
Surgical removal
Chemotherapy

17
Q

ovarian cysts

Complications

A

Ruptured ovarian cyst
Clinical features
Unilateral lower abdominalpain
Onset ofpainis acute and of moderate to severe intensity

Diagnosis
Pelvic ultrasonography:
Free fluid usually in thepouch of Douglas

Treatment
Laparoscopy or laparotomy

Ovarian torsion

18
Q

Pelvic Organ Prolapse (POP)

General

A

Refers toherniationof one or more pelvic organs into the vaginal canal and potentially all the way through the introitus

Results from weakness and insufficiency of thepelvic floor (ligaments, fascia, and muscles)

Prolapse type is defined by the vaginal wall that is prolapsing and the organs behind that wall

Epidemiology
Peakincidence: women aged 70‒79 years

19
Q

prolapse

RF

A

Multipleparity(risk ↑ with each additional birth)
Vaginal delivery
Advancing age
Menopausal status

Increased intraabdominal pressure:
Chronic cough
Obesity
Chronic straining - Constipation

Connective tissueabnormalities
Hysterectomy ?

20
Q

Compartment Prolapse

Anterior/ posterior/ apical/ procidentia

A

Anterior compartment prolapse:
Herniation of the anterior vaginal wall andbladder
Classically referred to as acystocele

Posterior compartment prolapse:
Herniation of the posterior vaginal wall andrectum
Classically referred to as arectocele

Apical compartment prolapse:
Herniation of the vaginal apex
If theuterusis present, the prolapse is referred to asuterine prolapse
If theuterusis absent, the intestine typically prolapses behind the vaginal cuff, classically known as anenterocele

Procidentia:
Severe form of POP that includesherniationof the anterior, posterior, and apical vaginal compartments through the vaginal introitus

21
Q

prolapse

Vaginal and urinary symptoms

A

Sensations of:
Vaginal fullness
Pressure
Bulge
Symptoms typically worsen with activity, valsalva, and/or at the end of the day

Urinary symptoms:
Incomplete emptying of urine
Difficulty in voiding urine
Urinary incontinence

22
Q

Prolapse

Rectal and pain symptoms

A

Rectal symptoms:
Constipation
Incomplete emptying of stool
Splinting: placing fingers in thevaginaand pushing down in order to evacuate stool
Fecal urgency
Rectal fullness

Painsymptoms:
Dyspareunia
Lower back and pelvic pain that is exacerbated on activity
Vaginal pain if the prolapse is severe anderosionor ulcerations are present

23
Q

prolapse

Dx

A

Based on clinical examination at rest and during valsalva

Visualinspection
Speculum examination
Use only a single blade to examine the anterior and posterior walls separately
Bimanual pelvic examination: helpful in assessing apical prolapse
Rectovaginal examination

Staging
POP-Qstagingsystem recommended by the American Urogynecologic Society (AUGS)
Based on 9 measurements

23
Q

prolapse

Vaginal pessary

A

Medical grade silicone- or latex-based device that is inserted into thevagina

Supports the pelvic organs and restores pelvic anatomy
Multiple shapes
Fit in the office by aclinician

Vaginal estrogencream is often used as an adjunct to prevent vaginal erosions

Complications:
Vaginalerosions
Urinary retention

23
Q

prolapse

conservative/preventative and surgical management

A

Based on stage/grade, symptoms, and overall well-being of the subject

Conservative Management:
Mild POP are asymptomatic and do not require management beyond reducing modifiable risk factors

Weight loss
Reduce straining withdefecation via dietary changes and medications
Avoidsmokingto reduce chronic cough
Kegel exercises: pelvic floor muscle training (primary prevention)
Vaginal pessary

Surgical Management:
Symptomatic individuals if they express a desire
POP causing urinary retention

23
Q

Urethral prolapse

general /PE/ Tx

A

Circumferential protrusion of the distal urethra through the external urethral meatus
Rare condition

Most common in prepubertal girls and postmenopausal women
Vaginal bleeding is the most common presenting symptom

Physical examination: round, often doughnut-shaped protrusion mucosa is observed obscuring urethral opening

Management:
Medical therapy with topical estrogen
Surgical repair

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25
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