structural anomalies Flashcards
What is pelvic organ prolapse
This is the descent of pelvic organs into the vagina. This is the result of weakness and lengthening of the ligaments and muscles surrounding the uterus.
What is a uterine prolapse
This is where the uterus itself descends in the vagina.
What is a rectocele
- defect in the posterior vaginal wall – where the rectum prolapses into the vagina
- assoc with constipation
What is the presentation of a rectocele
Women can often become faecally loaded in the part of the rectum that had prolapsed into the vagina, resulting in constipation, urinary retention (due to compression on the urethra) and a lump in the vagina.
What is the management of a rectocele
Women can use their fingers to press the lump backwards (correcting the anatomical position of the rectum) in order to defecate.
What is a Cystocele
- defect in the anterior vaginal wall – where the bladder prolapses into the vagina
- can also be prolapse of the urethra (called a urethrocele) or both the bladder and the urethra (cystourethrocele).
What are the risk factors for uterine prolapse
Multiple vaginal childbirths Traumatic vaginal childbirths Advanced age (and post-menopause) Obesity Chronic Constipation (particularly rectoceles
What is the presentation of a uterine prolapse
- urinary, bowel or sexual dysfunction.
- Feeling of “something coming down” in the vagina
- Dragging or heavy sensation in the pelvis
- Women may have identified a lump or a mass in the vagina, and often will already be pushing it back up themselves.
- The prolapse will become worse on straining or bearing down.
What are the management options for a uterine prolapse
Conservative management
Vaginal pessary
Surgery
What conservative management is advised for uterine prolapse
- Physiotherapy (pelvic floor exercises)
- Lifestyle changes for associated stress incontinence (reduced caffeine intake, incontinence pads etc)
- Treat associated symptoms such as stress incontinence (e.g. with anticholinergic mediations like solifenacin or oxybutynin)
- Vaginal oestrogen cream
What is a vaginal pessary
- There are many types of pessary (e.g. ring, gellhorn, cube, donut and hodge)
- They fit inside the vagina and provide support for the uterus
- Women often have to try a few types before finding the correct comfort and symptom relief
- Pessaries should be removed and cleaned / changed periodically (e.g. every 4 months)
- They can cause vaginal irritation / erosion over time, oestrogen cream can help this
What is the surgical management for a uterine prolapse
- consider the pros and cons of surgery and the persons co-morbidities
- hysterectomy for uterine prolapse
- Surgery can be very successful in correcting the problem
- controversy about mesh repairs and the potential complications (including chronic pain) associated with the use of mesh.
- There are other complications (e.g. infection, bleeding, damage to bladder / bowel etc)
What are the features of polycystic ovarian syndrome
Weight gain Hirsuitism Infrequent or absent ovulation resulting in oligomenorrhoea or amenorrhoea and poor fertility Acanthosis nigricans Impaired glucose tolerance
What is the hormone profile of a patient with PCOS
LH is raised
LH to FSH ratio is raised
Insulin can be raised
Testosterone can be raised
What is the Rotterdam criteria
Requires two of three to make a diagnosis
- Infrequent or absent ovulation
- Hyperandrogenism (e.g. hirsutism)
- Polycystic ovaries on ultrasound (or ovarian volume >10mls)
What is the general management of PCOS
Weight loss
Combined oral contraceptive pill
What is insulin resistance
- High levels of insulin result in higher levels of androgens (such as testosterone). I
- Insulin promotes the release of androgens from the ovaries and adrenal glands
- Very common in patients with PCOS
- Metformin can help improve fertility
How do you manage infertility in PCOS
Step wise approach
- Weight loss
- Metformin
- Clomifene
How do you mange hirstuitism in woman with PCOS
Co-cyprindiol (Dianette): - Has an anti-androgenic effect - Contraceptive - Increased risk of VTE Topical eflornithine
What is female genital mutilation
- Involves surgically changing female genitals for non-medical reasons.
- This is illegal as per the Female Genital Mutilation Act 2003.
- It is a legal requirement to report any discovered cases of FGM to the police.
Where is FGM most prevelant
- Common cultural practice in many African countries.
- Somalia has the highest levels of FGM of any country.
- Other countries with high rates are Ethiopia, Sudan and Eritrea.
- It is also found in Yemen, Kurdistan, Indonesia and various parts of South and Western Asia.
What are the different types of FGM
Removal of the clitorus.
Removal of the clitoris and labia minora.
Narrowing or closing the vaginal orifice.
Other unnecessary procedures to the female genitalia.
What is a bicornate uterus
- where there are two “horns” to the uterus
- associated with adverse pregnancy outcomes, however successful pregnancy is generally expected
What are the complications of a bicornate uterus
Miscarriage
Premature birth
Malpresentation
What is vaginal agenesis
- vagina fails to develop, probably due to failure of the Mullerian ducts to develop
- associated with an absent uterus and cervix.
- Ovaries typically remain in place so the female sexual hormones are unaffected unless it is caused by androgen insensitivity syndrome.
What is a Transverse Vaginal Septae
- error in development where a septum (wall) forms transversely across the vagina.
- can either be perforate (with a hole) or imperforate (completely sealed).
How does a perforate transverse vaginal septae present
girls will still menstruate but can present with difficulty with intercourse or tampon use.
How does an imperforate transverse vaginal septae present
Like an imperforate hymen
How do you diagnose and manage and transverse vaginal septae
examination, ultrasound or MRI. Treatment is with surgical correction.
What are the main complications of a transverse vaginal septae
stenosis or the vagina or recurrence.
What is an imperforate hymen
where the hymen at the opening of the vagina is completely formed without any opening.
How does an imperforate hymen present
typical or more intense cyclical pelvic pain / cramping that would normally be associated with menstruation but without any vaginal bleeding.
How do you diagnose and manage an imperforate hymen
simple examination and treatment is with surgical incision to create an opening in the hymen.
What can happen as a result of not treating an imperforate hymen
menses could be backed up and retrograde menstruation could occur out of the fallopian tubes. This could lead to endometriosis
What investigations should be done in all pre-menopausal woman with complex looking cysts
- CA-125
- αFP
- βHCG
With suspicion of malignancy until proven otherwise
