Structural Abnormalities + Other

Question 1

a 45-year-old female complaining of pressure in the pelvis and vagina along with discomfort when straining. She also feels that her bladder hasn’t fully emptied after urinating.

Answer 1

Cystocele

Question 2

bulge of the bladder into the vagina

Answer 2

Bladder prolapse (cystocele)

Anterior vaginal prolapse of the posterior bladder wall into the vagina, emerging from the introitus

Question 3

MCC of cystocele

Answer 3

• A cystocele can result from childbirth, constipation, violent coughing, heavy lifting, or other pelvic muscle strain

Question 4

Sx of cystocele

Answer 4

• Symptoms include feeling pressure in the pelvis and vagina, discomfort when straining, and feeling that the bladder hasn’t fully emptied after urinating
  
  • Feels like “sitting on a ball” or “something is falling out”
  • Worse with Valsalva and better with redundancy
• Concurrent urinary incontinence

Question 5

Dx of cystocele

Answer 5

Diagnose with POP-Q (pelvic organ prolapse quantification): quantifies the extent and location of defects, ultrasound or MRI

• Additional testing: Q-tip test, voiding cystourethrogram (VCUG), cystometrogram

Question 6

Tx of cystocele

Answer 6

Treatment includes a flexible ring pessary to support the bladder or surgical repair with mesh augmentation

• Prophylaxis with Kegel exercises: strengthen levator ani and perineal muscles
• Estrogen therapy after menopause maintains tone and vitality of the tissue

Question 7

a 50-year-old female with pelvic pressure reports and a sensation of a mass present in the vagina. She reports chronic constipation and a sensation that the rectum is not completely emptied following a bowel movement. Occasionally, she experiences episodes of fecal incontinence

Answer 7

Rectocele

Question 8

Herniation of rectum into the posterior wall of the vagina

Answer 8

Rectocele

Question 9

MCC of rectocele

Answer 9

• Childbirth and other processes that put pressure on the tissue wall can lead to a rectocele

Question 10

Sx of rectocele

Answer 10

Results in pelvic pressure + bowel symptoms

• Symptoms include a soft bulge of tissue in the vagina that may or may not protrude through the vaginal opening
  
  • Defecatory dysfunction (constipation, straining, incomplete emptying)

Question 11

Dx of rectocele

Answer 11

POP-Q (pelvic organ prolapse quantification): quantifies the extent and location of defects

• Get a colonoscopy to rule out cancer and rectal studies if indicated

Question 12

Tx of rectocele

Answer 12

Kegel exercises, pelvic floor retraining, behavioral changes, bowel regimen, pessary, surgical repair or repair with mesh augmentation

Question 13

a 23-year-old female who comes to the emergency department because of sharp, non-radiating, left lower quadrant pain that has worsened in intensity over the last three hours. She has nausea but denies diarrhea, urinary symptoms, or vaginal discharge. Her temperature is 37°C (98.6°F), pulse is 110/min, respirations are 24/min, and blood pressure is 140/90 mmHg. Pulse oximetry in room air shows an oxygen saturation of 98%. Physical examination shows left lower quadrant tenderness with guarding. Pelvic examination shows left adnexal tenderness without cervical motion tenderness or discharge. A urine pregnancy test is negative. Doppler ultrasound of the left lower quadrant is obtained

Answer 13

Ovarian torsion

Question 14

rotation of the ovary at its pedicle to such a degree as to occlude the ovarian artery and/or vein

Answer 14

Ovarian torsion

Question 15

Sx of ovarian torsion

Answer 15

• Patients with ovarian torsion often present with sudden onset of sharp and usually unilateral lower abdominal pain, in 70% of cases accompanied by nausea and vomiting

Question 16

Dx of ovarian torsion

Answer 16

Abdominal ultrasound with Doppler flow is the diagnostic test of choice

• Doppler flow is not always absent in torsion – the gold standard for the diagnosis of ovarian torsion is laparoscopy

Question 17

Tx of ovarian torsion

Answer 17

The mainstay of the treatment of ovarian torsion includes laparoscopic surgery to uncoil the ovary

Question 18

a 63-year-old, G5P5, Hispanic woman with a three-day history of increased pelvic pressure and a “bulge” that is felt in her vagina when she coughs. Additionally, she complains of incomplete emptying of her bladder, constipation and has noticed a recent worsening of lower back pain

Answer 18

Uterine prolapse

Question 19

Uterus descends toward or into the vagina. It happens when the pelvic floor muscles and ligaments become weak and are no longer able to support the uterus. In some cases, the uterus can protrude from the vaginal opening

Answer 19

Uterine prolapse

Question 20

MCC of uterine prolapse

Answer 20

Caucasian women, after labor/delivery, chronic cough

Question 21

Sx of uterine prolapse

Answer 21

• Vaginal fullness, abdominal pain worse late in the day, after prolonged standing. Relieved by lying down.

Question 22

Prolapse of the uterus into the vaginal canal - graded by uterine descent:

Answer 22

• 0 degree: No descent
• 1st degree: To the upper vagina/descent between normal and ischial spine
• 2nd degree: To the introitus/between ischial spines and hymen
• 3rd degree: Cervix is outside the introitus/within hymen
• 4th degree (sometimes referred to as procidentia): Uterus and cervix entirely outside the introitus/through the hymen

Question 23

Dx of uterine prolapse

Answer 23

Diagnosis is confirmed by a speculum or bimanual pelvic examination

• Vaginal ulcers are biopsied to exclude cancer
  
  • Simultaneous urinary incontinence requires evaluation

Question 24

Tx of uterine prolapse

Answer 24

Asymptomatic 1st- or 2nd-degree uterine prolapse may not require treatment

• Symptomatic 1st - or 2nd-degree prolapse can be treated with a pessary if the perineum can structurally support a pessary
• Severe or persistent symptoms and 3rd - or 4th-degree prolapse require surgery
  
  • Usually hysterectomy with surgical repair of the pelvic support structures (colporrhaphy) and suspension of the top of the vagina (suturing of the upper vagina to a stable structure nearby)

Question 25

24-year-old nulligravid woman comes to your office with an 18-month history of painful intercourse, difficulty defecating, and dysmenorrhea. These symptoms are cyclical and come and go with her menses. Her menses are regular and heavy, requiring 10 to 15 thick pads on the days of heaviest flow. She denies ever being diagnosed with a sexually transmitted infection (STI). She and her husband have been engaging in regular intercourse without contraception for 1 year in an attempt to conceive. On pelvic examination, you find a normal-sized, immobile, retroverted uterus with nodularity and tenderness on palpation of the uterosacral ligaments.

Answer 25

Endometriosis

Question 26

ctopic endometrial tissue implants are found in extrauterine sites, most commonly the ovaries, fallopian tubes, cul-de-sac, and uterosacral ligaments

Answer 26

Endometriosis

Question 27

“3 D’s” of endometriosis

Answer 27

Dyspareunia, Dyschezia (difficulty in defecating) and Dysmenorrhea

Question 28

Sx of endometriosis

Answer 28

• The “THREE D’S” - Dyspareunia, Dyschezia (difficulty in defecating) and Dysmenorrhea
• History of infertility is also common (30-45% )
• Pelvic pain just before or during menses
  
  • 20% of women with chronic pelvic pain will have endometriosis

Question 29

Dx of endometriosis

Answer 29

Definitive diagnosis is made by laparoscopy (definitive study) and confirmed by biopsy

Question 30

What are PE of endometriosis

Answer 30

• The uterus is fixed and retroflexed on PE. Tender nodularity of cul de sac and uterine ligaments

Question 31

Tx of endometriosis

Answer 31

NSAIDs, OCPs, Danazol, Depo Provera, GnRH agonists, surgical

• Oral contraceptives are first-line medications used in treating endometriosis
  
  • Estrogen-progesterone OCP - ovarian suppression
  • Progesterone analogs (e.g medroxyprogesterone and levonorgestrel) - inhibit the growth of the endometrium
• Gonadotropin-hormone releasing (GnRH) antagonists
  
  • Pituitary gonadotropin hormone suppressed → ↓ estrogen
• Danazol (steroid) - inhibits mid-cycle surges of FSH and LH
• Pain management: Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Surgery options include laparoscopic ectopic endometrial tissue removal and hysterectomy

Question 32

a 33-year-old G1P0 female with difficulty becoming pregnant. She and her husband have been trying to conceive for over 12 months, but have been unsuccessful. She reports menarche at age 15 and has had regular periods since then. Her past medical history includes an abortion at age 20 with dilation and curettage procedure. She has also had a pelvic inflammatory disorder, treated successfully with antibiotics.

Answer 32

Infertility

Question 33

Primary vs secondary infertility

Answer 33

inability to conceive within 12 months of unprotected intercourse

1. Primary: infertility in an absence of previous pregnancy
2. Secondary: infertility after a previous pregnancy

Question 34

MCC of infertility

Answer 34

• Anovulation is the most common cause - amenorrhea and abnormal periods
• Tubal disease
• Male factor
• Unexplained/multifactorial

Question 35

Dx of infertility

Answer 35

Diagnosis is based on PAP, hormonal levels, ultrasound, hysterosalpingogram, semen analysis, ovulation check

Start with more basic tests:

• • Take a detailed history first: type of coitus - when, where, how often
    
    • Ovulation tracking:
      
      • Menstrual diary
      • Luteal phase (day 21) progesterone level - if the progesterone level is less than 3 ng/ml on day 21 then you know that the patient did not ovulate.
      • Basal body temperature: No mid-cycle basal
      • body temperature increase
    • Male factor is diagnosed by semen analysis
    • Labs: TSH, prolactin, LH and FSH in women over 35

Question 36

Tx of infertility

Answer 36

• May require medication such as clomiphene citrate to hyperstimulate ovulation, surgery (lysis of adhesions in tubal disease) or assisted reproductive technologies (i.e in vitro fertilization)
• Metformin increases ovulation and pregnancy rates when PCOS is the cause
  
  • Bromocriptine to treat hyperprolactinemia

Question 37

39-year-old African American woman with abnormally heavy menstrual bleeding along with increased pelvic pressure. She denies pain and is not using any hormonal contraception. She uses multiple sanitary pads per day. On pelvic examination, there is an enlarged uterus with asymmetric contours. The uterus is non-tender to palpation.

Answer 37

Leiomyoma

Question 38

benign smooth muscle cell tumors

Answer 38

Leiomyoma aka uterine fibroids

Question 39

Sx of leiomyoma or uterine fibroids

Answer 39

• polymenorrhea, menorrhagia, intermenstrual bleeding and/or metrorrhagia
• Pelvic pressure and increased abdominal girth. Uterine mass
• Population: Black women, family history

Question 40

Leiomyoma types

Answer 40

• Subserosal: projects into the pelvis, may be pedunculated
• Intramural: within the uterine wall (most common)
• Submucosal: projects into the uterine cavity

Question 41

Dx of leiomyomas

Answer 41

diagnose with ultrasound and/or MRI ⇒ Uterine mass

Question 42

Tx of leiomyomas

Answer 42

treatment is medical or surgical

• Symptomatic medical treatment: NSAIDs, OCPs, Danazol, Leuprolide (also used to shrink fibroids
  pre-operatively)
• Definitive: myomectomy, endometrial ablation, hysterectomy (most common surgical tx)

Question 43

22-year-old nulligravida presents with pelvic pain and irregular menstrual bleeding. She denies sexual activity, and her β-hCG urine test is negative. She has never been on oral contraceptives. On pelvic examination, unilateral tenderness on the left side and a palpable cystic mass approximately 4 to 5 cm in size are present.

Answer 43

Ovarian cyst

Question 44

Sx of ovarian cyst

Answer 44

• The majority of cysts are harmless and cause no symptoms
• Occasionally they may produce bloating, lower abdominal pain, dyspareunia, or lower back pain
• Ovarian cysts may be classified according to whether they are a variant of the normal menstrual cycle (functional) or non-functional

Question 45

3 types of functional ovarian cysts

Answer 45

normal physiologic functioning of ovaries ⇒ follicular (MC) and corpus luteum; 2-3 cm can get as big as 10 cm, clear serous liquid, smooth internal lining

• Follicular cyst (the most common type): a dominant follicle fails to rupture
• Corpus luteum: dominant follicle ruptures but closes again and doesn’t dissolve
• Theca lutein cysts: overstimulation of HCG produced by placenta so only seen in pregnancy

Question 46

3 main complications of ovarian cysts

Answer 46

• Hemorrhagic: more common with follicular and corpus luteal cysts
• Rupture: release contents into peritoneal cavity, frequently after sexual intercourse
• Torsion: ovary twists around suspensory ligament, cuts of blood supply to the ovary (risk if the cyst is > 5 cm)

Question 47

PE findings of ovarian cysts

Answer 47

ruptured = pain, low blood pressure, abdominal or shoulder pain, tachycardia; ovarian torsion = waxing and waning pain, n/v, low-grade fever

Question 48

FIrst imaging study of choice for ovarian torsion vs cyst

Answer 48

Abdominal and pelvic ultrasound

Definitive diagnosis is direct visualization of a torsed ovary during surgery, and prompt operative evaluation is the mainstay of treatment to preserve ovarian function.

Question 49

Dx of ovarian cyst

Answer 49

Transvaginal ultrasound/abdominal

• MRI: If ultrasound indeterminate for surgical resection evaluation
• Labs: Serum CA-125 (in menopausal, postmenopausal individuals) ⇒Assists in ruling out ovarian cancer
• Histologic analysis via ultrasound-guided aspiration (definitive)

Question 50

Tx of ovarian cysts

Answer 50

• Most resolve in one month
• Follow-up imaging in women of reproductive age for incidentally discovered simple cysts on ultrasound is not needed until 5 cm, as these are usually normal ovarian follicles
• For simple cysts greater than 5 cm but less than 7 cm in premenopausal females, cysts should be followed yearly

Question 51

What dx need to be done for suspected rape

Answer 51

Rape constitutes both a psychiatric emergency and a legal situation; all procedures should be documented, clothing saved, and samples are taken

Cultures from the vagina, the anus, and usually, the pharynx for gonorrhea and Chlamydia, RPR for syphilis, hepatitis antigens, HIV, urinalysis, pregnancy test for menstrual-aged women (regardless of contraceptive status)

Question 52

Tx for suspected rape

Answer 52

• Rocephin 250 mg followed by oral doxycycline twice daily x 7 days
• Tetanus toxoid if indicated
• The patient should be given the option of emergency contraception
• Counseling: As soon as possible after the event, and preferably before leaving the emergency department, the patient should talk to a mental health professional and follow-up counseling should be scheduled

Question 53

What type of urinary incontinence is this “(detrusor overactivity) - frequent small amounts of urine”

Answer 53

Urge incontinence

Question 54

What type of urinary incontinence Occurs at night and disrupts sleep

Answer 54

Urge incontinence

Question 55

Tx of urge incontinence

Answer 55

Bladder-training exercises

If this is unsuccessful, medications include anticholinergics (oxybutynin) and TCAs (imipramine)

Question 56

What type of urinary incontinence is this : (weakness of pelvic floor) - urine leakage due to abrupt increases in intra-abdominal pressure (eg, with coughing, sneezing, laughing, bending, or lifting).

Answer 56

Stress incontinence

Question 57

Women after multiple deliveries and no urine loss at night have what type of urinary incontinence?

Answer 57

Stress incontinence

Question 58

Tx of stress incontinence

Answer 58

• Treated with Kegel exercises to strengthen pelvic floor musculature
  
  • Vaginal estrogens
  • Use of a pessary
    
    • Surgery (there are various options, and a popular option is a mid-urethral sling)

Question 59

What type of urinary incontinence is this: (impaired detrusor contractility) - occurs when urinary retention leads to bladder distention and overflow of urine through the urethra

Answer 59

Overflow incontinence

Question 60

Diabetic patients and patients with neurologic disorders with Elevated postvoid residual volume

What type of incontinence?

Answer 60

Overflow

Question 61

Tx of overflow incontinence

Answer 61

• Treated with intermittent self-catheterization is the best management
  
  • cholinergic agents (bethanechol) to increase bladder contractions
    
    • α-blockers (terazosin, doxazosin) to decrease sphincter resistance

Question 62

patients who have normal voiding systems, but who have difficulty reaching the toilet because of physical or mental disabilities

Answer 62

Functional incontinence

Question 63

Increased urinary volume and the inability to timely urinate

Answer 63

Functional incontinence

Question 64

Tx of functional incontinence

Answer 64

• Treatment includes scheduled voiding times

Question 65

Stress and urge incontinence is considered:

Answer 65

Mixed incontinence

Question 66

Tx of mixed incontinence

Answer 66

Lifestyle modifications and pelvic floor exercises are first-line

• If unresponsive to first-line treatments then therapy is based on the predominant symptoms