Vaginal Disorders Flashcards
What is Pelvic Organ Prolapse?
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.
Name the different types of Pelvic Organ Prolapse?
Cystocele, Uterine Prolapse, (Urethrocele), Rectocele, Enterocele.
Define Cystocele?
A hernia of the bladder wall into the vagina, causing soft anterior fullness.
Define Urethrocele?
Not a hernia but a sagging of the urethra following it’s detachment from the pubic symphysis during childbirth.
**Often accompanies Cystocele.
Define Rectocele?
A herniation of the terminal rectum into the posterior vagina, causing a collapsible pouch-like fullness.
Define Enterocele?
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).
What are the risk factors associated with Pelvic Organ Prolapse?
**Affects up to 50% of women.
- Prior vaginal childbirth.
- Genetic predisposition.
- Advancing age.
- Prior pelvic surgery.
- Obesity.
- Chronic constipation w/straining.
- Connective Tissue Disorders.
What is a Uterine Prolapse?
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.
Clinical presentation of pelvic organ prolapse?
TYPICAL Symptoms:
- Sensation of a BULGE or protrusion of the vagina.
- Vaginal pressure.
- Urinary Symptoms – INCONTINENCE, urgency, frequency, retention.
- Lower back pain.
- Dyspareunia – painful intercourse.
- Constipation.
Diagnosis of a pelvic organ prolapse?
- PELVIC Exam.
2. Imaging not necessary.
Treatment of pelvic organ prolapse?
- Nothing.
- -Is it bothersome for the pt? How old? Still sexually active? - Supportive measures:
- -high-fiber diet, laxatives to improve constipation.
- -Weight reduction in obese pt’s. - Pelvic Floor Exercises – Kegels, Pelvic floor PT, biofeedback.
- Pessary.
- Surgery – MC is Hysterectomy, sling, mesh (many complications).
What is a pessary?
A pessary is a removable device inserted into the vagina to support the pelvic organs. It affects urethral mobility and closure pressures.
What morbidity is associated with urinary incontinence?
- Perineal Candidal Infections.
- Cellulitis.
- Pressure Ulcers (bed-bound pt’s).
- UTI.
- Urosepsis – urinary retention or indwelling catheters.
When do you refer a patient that presents with pelvic organ prolapse?
- Refer to urologist or gynecologist for incontinence evaluation.
- Refer if nonsurgical therapy is ineffective.
What are the types of Urinary Incontinence?
Stress UI, Urge UI, Mixed UI.
Define Stress UI?
Complaint of involuntary leakage w/effort, exertion, sneezing or coughing.
Define Urge UI?
Complaint of involuntary leakage associated by urgency.
–Urgency is the sudden and compelling desire to void that is difficult to defer or delay urination.
Define Mixed UI?
Complaint of involuntary leakage associated w/both urge and exertion; the predominance of SUI or UUI varies.
What is the work-up for Urinary Incontinence?
- Medication review – assess for diuretics, anticholinergics.
- Bladder irritants – caffeine, alcohol, tobacco.
- Comorbidities that increase risk:
- -DM, CVA, Lumber disk disease, functional bowel disorders. - Urinalysis w/Culture and Sensitivity if UA normal.
- BMP to assess GFR and glucose.
- Post-void residual – US that looks at content of bladder after voiding.
- Cystometry – measures urine in the bladder, evaluates problems w/filling and voiding.
- Cystoscopy – only if there is hematuria, urinary retention or some other indication.
What lumbar disk disease is associated with Urinary Incontinence?
Cauda Equina Syndrome.
Treatment for UI?
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).
Why will nerve stimulation of the Tibial nerve be beneficial in UI?
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.
An umbrella term for inflammation of the vaginal canal or surrounding structures?
Vaginitis.
What are the 3 main causes of Vaginitis?
- Candidiasis Infection.
- Bacterial Vaginosis infection.
- Trichomonas infection.
Clinical presentation of Candidiasis?
- Thick, white discharge (cottage cheese like).
- Pruritus/irritation – very uncomfortable infection.
- NO smell or “Bready” smell.
What are the risk factors for Candidiasis?
Uncontrolled BG, pregnancy, recent Abx use.
Diagnosis of Candidiasis?
Diagnosed w/KOH wet prep.
–low light; shows HYPHAE and spores.
Treatment for Candidiasis?
- Topical -azoles:
- -Tx options b/t 1 and 14 days. - Oral Fluconazole:
- -single dose. - Pregnant pt’s or resistant cases should be treated w/14-day topical regimen or 2 doses of oral, 3 days apart.
Clinical presentation of Bacterial Vaginosis (BV)?
- Thin, grey discharge; sometimes frothy.
- Pruritus – depends on the pt.
- Bad smell.
Risk factors for BV?
Unprotected sex, douching, tampons.
*Anything that changes the pH of the vaginal canal.
Diagnosis of BV?
- KOH wet prep will show CLUE cells.
- 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.
Treatment of BV?
METRONIDAZOLE
- -Topical BID x5 days.
- -PO 500 mg BID x7 days.
What is important to tell your pt’s who are taking Metronidazole?
NO Alcohol!!
Type of vaginitis caused by a sexually transmitted protozoal Flagellate that infects the vagina, skene ducts and lower urinary tract?
Trichomonas Vaginalis (Vaginitis) – an STI.
Clinical presentation of Trichomonas?
- Yellow-green, frothy discharge.
- Foul, malodorous smell.
- Can infect the Skene ducts.
- Appearance of “STRAWBERRY CERVIX.”
What is “Strawberry Cervix?”
Classic for Trichomonas; red macular lesions on the cervix in severe cases.
What are the risk factors for Trichomonas?
- Younger age (<25 yrs).
2. Unprotected sex.
Diagnosis of Trichomonas?
Wet prep shows MOTILE organisms with FLAGELLA.
–Flagella are slender, thin-like structures.
Treatment for Trichomonas?
METRONIDAZOLE – PO only.
–2 grams once OR 500 mg x7 days.
Treatment of resistant or recurrent vaginitis?
- Candidiasis – get a culture to guide further Tx.
- BV – try Doxycycline; then boric acid suppositories.
- Trichomonas – retreat w/one-time dose then contact the CDC.
Prevention of Vaginitis?
- *Control the risk factors:
- -control BG, good hygiene, practice safe sex and know your partners.
