Vaginal Disorders

Question 1

What is Pelvic Organ Prolapse?

Answer 1

When the muscles and tissues supporting the pelvic organs (the uterus, bladder, or rectum) become weak or loose. This allows one or more of the pelvic organs to drop or press into or out of the vagina.

*In other words, these are vaginal hernias.

Question 2

Name the different types of Pelvic Organ Prolapse?

Answer 2

Cystocele, Uterine Prolapse, (Urethrocele), Rectocele, Enterocele.

Question 3

Define Cystocele?

Answer 3

A hernia of the bladder wall into the vagina, causing soft anterior fullness.

Question 4

Define Urethrocele?

Answer 4

Not a hernia but a sagging of the urethra following it’s detachment from the pubic symphysis during childbirth.

**Often accompanies Cystocele.

Question 5

Define Rectocele?

Answer 5

A herniation of the terminal rectum into the posterior vagina, causing a collapsible pouch-like fullness.

Question 6

Define Enterocele?

Answer 6

A vaginal vault hernia containing small intestine, usually in the posterior vagina and resulting from a deepening of the pouch of Douglas (aka rectouterine pouch).

Question 7

What are the risk factors associated with Pelvic Organ Prolapse?

Answer 7

**Affects up to 50% of women.

1. Prior vaginal childbirth.
2. Genetic predisposition.
3. Advancing age.
4. Prior pelvic surgery.
5. Obesity.
6. Chronic constipation w/straining.
7. Connective Tissue Disorders.

Question 8

What is a Uterine Prolapse?

Answer 8

When the uterus bulges into or out of the vagina; it is sometimes associated with small bowel prolapse (called enterocele), where part of the small intestine, or small bowel, bulges into the vagina.

Question 9

Clinical presentation of pelvic organ prolapse?

Answer 9

TYPICAL Symptoms:

1. Sensation of a BULGE or protrusion of the vagina.
2. Vaginal pressure.
3. Urinary Symptoms – INCONTINENCE, urgency, frequency, retention.
4. Lower back pain.
5. Dyspareunia – painful intercourse.
6. Constipation.

Question 10

Diagnosis of a pelvic organ prolapse?

Answer 10

1. PELVIC Exam.

2. Imaging not necessary.

Question 11

Treatment of pelvic organ prolapse?

Answer 11

1. Nothing.
   - -Is it bothersome for the pt? How old? Still sexually active?
2. Supportive measures:
   - -high-fiber diet, laxatives to improve constipation.
   - -Weight reduction in obese pt’s.
3. Pelvic Floor Exercises – Kegels, Pelvic floor PT, biofeedback.
4. Pessary.
5. Surgery – MC is Hysterectomy, sling, mesh (many complications).

Question 12

What is a pessary?

Answer 12

A pessary is a removable device inserted into the vagina to support the pelvic organs. It affects urethral mobility and closure pressures.

Question 13

What morbidity is associated with urinary incontinence?

Answer 13

• Perineal Candidal Infections.
• Cellulitis.
• Pressure Ulcers (bed-bound pt’s).
• UTI.
• Urosepsis – urinary retention or indwelling catheters.

Question 14

When do you refer a patient that presents with pelvic organ prolapse?

Answer 14

1. Refer to urologist or gynecologist for incontinence evaluation.
2. Refer if nonsurgical therapy is ineffective.

Question 15

What are the types of Urinary Incontinence?

Answer 15

Stress UI, Urge UI, Mixed UI.

Question 16

Define Stress UI?

Answer 16

Complaint of involuntary leakage w/effort, exertion, sneezing or coughing.

Question 17

Define Urge UI?

Answer 17

Complaint of involuntary leakage associated by urgency.

–Urgency is the sudden and compelling desire to void that is difficult to defer or delay urination.

Question 18

Define Mixed UI?

Answer 18

Complaint of involuntary leakage associated w/both urge and exertion; the predominance of SUI or UUI varies.

Question 19

What is the work-up for Urinary Incontinence?

Answer 19

1. Medication review – assess for diuretics, anticholinergics.
2. Bladder irritants – caffeine, alcohol, tobacco.
3. Comorbidities that increase risk:
   - -DM, CVA, Lumber disk disease, functional bowel disorders.
4. Urinalysis w/Culture and Sensitivity if UA normal.
5. BMP to assess GFR and glucose.
6. Post-void residual – US that looks at content of bladder after voiding.
7. Cystometry – measures urine in the bladder, evaluates problems w/filling and voiding.
8. Cystoscopy – only if there is hematuria, urinary retention or some other indication.

Question 20

What lumbar disk disease is associated with Urinary Incontinence?

Answer 20

Cauda Equina Syndrome.

Question 21

Treatment for UI?

Answer 21

Lose weight, eat more fiber, Kegels, Bladder training, avoid irritants, stop smoking, fluid restriction,.

Topical estrogens, Antimuscarinics (Tolterodine or Oxybutynin), Beta-3 Agonist (Mirabegron), Botox injections, Nerve stimulation (Tibial and Sacral).

Question 22

Why will nerve stimulation of the Tibial nerve be beneficial in UI?

Answer 22

The posterior tibial nerve is a distal branch of the sciatic nerve that originates in the pelvis (L5-S3 spinal roots) and descends towards the lower extremities. Stimulation of the posterior tibial nerve delivers retrograde neuromodulation to the sacral nerve plexus that controls bladder function.

Question 23

An umbrella term for inflammation of the vaginal canal or surrounding structures?

Answer 23

Vaginitis.

Question 24

What are the 3 main causes of Vaginitis?

Answer 24

1. Candidiasis Infection.
2. Bacterial Vaginosis infection.
3. Trichomonas infection.

Question 25

Clinical presentation of Candidiasis?

Answer 25

• Thick, white discharge (cottage cheese like).
• Pruritus/irritation – very uncomfortable infection.
• NO smell or “Bready” smell.

Question 26

What are the risk factors for Candidiasis?

Answer 26

Uncontrolled BG, pregnancy, recent Abx use.

Question 27

Diagnosis of Candidiasis?

Answer 27

Diagnosed w/KOH wet prep.

–low light; shows HYPHAE and spores.

Question 28

Treatment for Candidiasis?

Answer 28

1. Topical -azoles:
   - -Tx options b/t 1 and 14 days.
2. Oral Fluconazole:
   - -single dose.
3. Pregnant pt’s or resistant cases should be treated w/14-day topical regimen or 2 doses of oral, 3 days apart.

Question 29

Clinical presentation of Bacterial Vaginosis (BV)?

Answer 29

1. Thin, grey discharge; sometimes frothy.
2. Pruritus – depends on the pt.
3. Bad smell.

Question 30

Risk factors for BV?

Answer 30

Unprotected sex, douching, tampons.

*Anything that changes the pH of the vaginal canal.

Question 31

Diagnosis of BV?

Answer 31

1. KOH wet prep will show CLUE cells.
2. AMSEL criteria for BV:
   - -pH > the normal of 4.5.
   - - (+) “Whiff Test” - an amine-like (fishy) odor is present if a drop of discharge is alkalinized w/10% potassium hydroxide.
   - -Discharge.
   - -Clue cells.

Question 32

Treatment of BV?

Answer 32

METRONIDAZOLE

• -Topical BID x5 days.
• -PO 500 mg BID x7 days.

Question 33

What is important to tell your pt’s who are taking Metronidazole?

Answer 33

NO Alcohol!!

Question 34

Type of vaginitis caused by a sexually transmitted protozoal Flagellate that infects the vagina, skene ducts and lower urinary tract?

Answer 34

Trichomonas Vaginalis (Vaginitis) – an STI.

Question 35

Clinical presentation of Trichomonas?

Answer 35

1. Yellow-green, frothy discharge.
2. Foul, malodorous smell.
3. Can infect the Skene ducts.
4. Appearance of “STRAWBERRY CERVIX.”

Question 36

What is “Strawberry Cervix?”

Answer 36

Classic for Trichomonas; red macular lesions on the cervix in severe cases.

Question 37

What are the risk factors for Trichomonas?

Answer 37

1. Younger age (<25 yrs).

2. Unprotected sex.

Question 38

Diagnosis of Trichomonas?

Answer 38

Wet prep shows MOTILE organisms with FLAGELLA.

–Flagella are slender, thin-like structures.

Question 39

Treatment for Trichomonas?

Answer 39

METRONIDAZOLE – PO only.

–2 grams once OR 500 mg x7 days.

Question 40

Treatment of resistant or recurrent vaginitis?

Answer 40

1. Candidiasis – get a culture to guide further Tx.
2. BV – try Doxycycline; then boric acid suppositories.
3. Trichomonas – retreat w/one-time dose then contact the CDC.

Question 41

Prevention of Vaginitis?

Answer 41

• *Control the risk factors:

- -control BG, good hygiene, practice safe sex and know your partners.