Ovarian cysts/Pelvic prolapse Flashcards
Ovary
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
Ovarian Cyst
general and RF
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
ovarian cysts
categorized as
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
ovarian cysts
simple
Common
Thin-walled with no evidence of wall thickening or internal walls (septation)
Fluid-filled
Most often benign
Typically disappear without treatment
ovarian cysts
complex
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
Functional cyst
follicular cysts
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
functional cyst
Corpus Luteal cyst
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
functional cyst
Clin man
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
functional cysts
Dx
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
functional cysts
managament
surgical indications
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
Neoplastic cysts
general
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
Neoplastic Cyst
Epithelial cell tumors
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
Neoplastic Cyst
Germ cell tumor (teratomas)
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
Neoplastic Cyst
Sexcord-stromal tumors
Multiple histologic subtypes
Arise from the stroma of the ovary
Common in middle-aged women
Associated with ascites and pleural effusions
neoplastic cysts
Clin man
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
neoplastic cyst
Dx and Tx
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
ovarian cysts
Complications
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
Pelvic Organ Prolapse (POP)
General
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
prolapse
RF
Multipleparity(risk ↑ with each additional birth)
Vaginal delivery
Advancing age
Menopausal status
Increased intraabdominal pressure:
Chronic cough
Obesity
Chronic straining - Constipation
Connective tissueabnormalities
Hysterectomy ?
Compartment Prolapse
Anterior/ posterior/ apical/ procidentia
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
prolapse
Vaginal and urinary symptoms
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
Prolapse
Rectal and pain symptoms
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
prolapse
Dx
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
prolapse
Vaginal pessary
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
prolapse
conservative/preventative and surgical management
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
Urethral prolapse
general /PE/ Tx
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
