11/6- Benign Gynecology Flashcards Preview

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Flashcards in 11/6- Benign Gynecology Deck (49):
1

Describe the normal physiology of the vagina:

- Role of hormones

- Metabolic content

- Bacterial environment

- pH

- Estrogenized

  • Increased glycogen content
  • Bacterial flora

- Lactobacilli predominate: produce lactic acid lowering the pH to 3.5-4.5

- Wide variety of aerobic and anaerobic bacteria occur

2

What are risk factors for vaginal infection?

Anything that alters normal flora of the vagina

- Antibiotics (that allow pathogenic organisms to flourish)

- Douching alters the pH

- Sexual intercourse with semen release raises the pH for 6-8 hrs

- Foreign bodies (e.g. retained tampon)

3

What are symptoms of vulvovaginitis?

- Vaginal discharge

- Pruritis

- Burning

- "Late" burning (not pain when they urinate, but when it touches skin)

4

What is on the DDx/etiologies for vulvovaginitis?

- Bacterial vaginosis*

- Candida*

- Trichomoniasis*

- Atrophic vaginitis (post-menopausal women)

- Foreign body vaginitis

- Genital ulcer disease

*most common

5

In what ways can a wet mount be prepared?

- Components

- Sample of vaginal discharge

- pH paper

- Normal saline

- KOH

- Microscope slide

6

What is bacterial vaginosis?

- What are typical causes

- Symptoms

- Risk factors

Bacterial vaginosis is the disruption of "normal" flora with characteristic bacteria

- Typical: Gardnerella vaginalis

  • Profuse milky white discharge
  • Alkaline pH (>4.5, typ 5-6)
  • Clue cells (can see them in squamous ep cells)

Risk factors:

- New sexual partners

- Smoking

- IUD

- Douching

7

What is Candidiasis?

- Etiological cause

- Symptoms

- Risk factors

- Caused by Candida albicans (90% of vulvovaginal candidiasis)

Symptoms:

- Vaginal itching, burning, and irritation

- White odorless vaginal discharge

Risk factors:

- Diabetes

- High dose OCPs

- Antibiotic use

- Immunosuppression

- Pregnancy 

8

What is Trichomoniasis?

- Etiological cause

- Symptoms

- Spread

- Caused by protozoan T. vaginalis

Symptoms:

- Vulvovaginal irritation

- Green yellow frothy vaginal discharge

- Strawberry cervix

- "Musty" odor

- Around 50% of women are asymptomatic!

It's an STI (not contracted spontaneously... although some proof it can spread via fomites) (pic 515)

9

Describe how the following vulvovaginal infections are diagnosed (what is seen):

- Candidiasis

- Bacterial vaginosis (BV)

- Trichomoniasis

- Candidiasis: wet mount with pseudohyphae or budding yeast

- Bacterial vaginosis (BV)- Gardnerella:

  • Wet mount with "clue cells"
  • Positive whiff test
  • pH > 4-5

- Trichomoniasis: motile trich on wet mount

10

Describe how the following vulvovaginal infections are treated:

- Candidiasis

- Bacterial vaginosis (BV)

- Trichomoniasis

- Candidiasis: Fluconazole (po) or other azole (miconazole) for (3-7d, vaginally)

  • Vaginal treatment may soothe/treat faster

- Bacterial vaginosis (BV)

  • Metronidazole (7d, po) OR
  • Clindamycin (7d, pv)

- Trichomoniasis: Metronidazole (po)

11

What is pelvic organ prolapse?

Protrusion of the pelvic organs into the vaginal canal or beyond the vaginal opening

- Anterior vaginal prolapse (cystocele)

- Posterior vaginal prolapse (rectocele)

- Apical vaginal and uterine prolapse (uterine prolapse)

- Enterocele (small bowel pressing on vagina) 

12

What is complete procedentia?

Uterine prolapse through the vaginal hymen with failure of all the vaginal supports

13

What causes pelvic organ prolapse (physiology/anatomy)?

- Increased risk

Weakness in the endoplevic fascia investing the vagina along with the ligamentous supports

- Increased risk with pregnancy, labor, and vaginal delivery; also

- Increased intraabdominal pressure (chronic cough, ascites, heavy lifting, habitual straining)

14

What are symptoms of pelvic organ prolapse?

- Vaginal fullness, vaginal pressure and vaginal bulge

- Anterior vaginal prolapse: stress urinary incontinence, urinary retention

- Posterior vaginal prolapse: straining for bowel movements, splinting

- Complete procedentia: discharge, ulceration, bleeding and rarely carcinoma of the cervix

15

Describe the stages of prolapse

(This system will tell you how bad/far the prolapse it is, but not what is causing it)

- Stage 1: Most distal portion of the prolapse > 1 cm above the hymen

- Stage 2: Most distal portion of the prolapse is between 1 cm above and 1 cm below the hymen

- Stage 3: Most distal portion of the prolapse is > 1 cm below the hymen

16

What is the treatment for pelvic organ prolapse?

- Non surgical

- Surgical

Non-surgical:

- Relieve causes of increased intra-abdominal pressure

- Estrogen

- Pelvic floor exercises

- Pessaries

  • Require proper fit
  • Cleaned and inserted every 6-12 weeks

Surgical (less in elderly):

- Anterior/posterior colporrhaphy

- Vaginal vault suspension

- LeFort colpocleisis (sew up vagina with channels remaining on sides)

- Complete colpocleisis

17

What is incontinence?

- Prevalence

- Subtypes

Involuntary loss of urine that is objectively demonstrable and is a social/hygiene problem

- 50% of women affected in their lifetime

Subtypes:

- Stress urinary incontinence

- Urge urinary incontinence (overactive bladder)

- Overflow incontinence

18

Define the following types of incontinence:

- Stress urinary

- Urge urinary (overactive bladder)

- Overflow

- Stress urinary: Involuntary leakage of urine in response to physical exertion, sneezing or coughing (valsalva)

- Urge urinary (overactive bladder): Involuntary leakage of urine accompanied by or immediately preceded by urgency (due to bladder spasm)

- Overflow: Involuntary leakage resulting from detrusor areflexia or a hypotonic bladder as seen with lower motor neuron disease, spinal cord injuries or autonomic neuropathy

19

Describe Chlamydia cervicitis:

- Etiology

- Found where (anatomically)

- Symptoms (how many asymptomatic)

- Symptoms (specifically)

- Caused by Chlamydia trachomatis

- Chlamydia is #1 bacterial STI (HPV more common)

- Found in urethra, endocervix, endometrium, fallopian tubes and rectum

- Most individuals are asymptomatic

- Symptoms include yellow discharge from a swollen, red, friable cervix and dysuria

20

How is chlamydia cervicitis diagnosed?

- Screening?

- Prognosis?

- Diagnosed with culture and DNA hydridization and nucleic acid amplification tests

  • Can be done on urine, vaginal and cervical swabs

- Screen all females < 25 yo (even if no RFs) and individuals with risk factors

- 30% untreated will progress to PID (pelvic inflammatory disease)

21

What is the treatment for Chlamydia cervicitis?

- Azithromycin 1 g PO X 1

  • Or Doxycycline 100 mg PO BID X 7 days

- Test for other STIs

  • HIV as well

- No sex for 7 days after both partners treated

- Test of cure is not needed

22

Describe Gonorrhea cervicitis

- Etiology

- Location

- Symptoms (how many asymptomatic)

- Symptoms (specifically)

- Cuased by N. Gonorrhoeae

- Found in the throat and urethra, endocervix, endometrium, fallopian tubes and rectum

- Most individuals are asymptomatic

- Symptoms include yellow discharge from a swollen, red, friable cervix and dysuria

- Can cause PID and systemic infxns (more often than Chlamydia)

23

How is Gonorrhea cervicitis diagnosed?

- Screening?

- Prognosis?

- Diagnosed with culture and DNA hybridization and nucleic acid amplification tests

  • Can be done on urine, vaginal and cervical swabs

- Screen all females < 25 yo and individuals with risk factors

- 15% of untreated individuals will progress to PID (pelvic inflammatory disease); can also cause systemic disease (think of endocarditis)

24

What is the treatment for Gonorrhea cervicitis?

- Ceftriaxone 250 mg IM with Azithromycin 1 g PO X 1

(It's scary, because getting some resistant strains; why azithromycin was added)

- Test for other STIs

- No sex for 7 days after both partners treated

- Test of cure is not needed

25

What are symptoms of Pelvic Inflammatory Disease (PID)? Signs?

Symptoms:

- Lower abdominal pain and tenderness

- Abnormal vaginal discharge

Signs:

- Lower abdominal tenderness

- Uterine/adnexal tenderness

- Mucopurulent cervicitis (yellowish discharge)

26

What conditions lead to PID?

PID develops in 15-30% of inadequately treated gonorrhea and chlamydia patients

27

What are complications of PID?

(PID causes scarring of tubes)

- Ectopic pregnancy (6x)

- Tubal infertility (14x)

- Chronic pelvic pain (6x)

28

How is PID diagnosed?

- Less likely to be PID if what

- Clinical diagnosis in sexually active females with uterine/adnexal tenderness or cervical motion tenderness

- Less likely to be diagnosis if no mucopurulent discharge is present or absence of WBCs on wet mount

29

What are the Mullerian ducts?

- Embryologic origin

- Develop/grow/migrate how

- Become what structures

- The Mullerian ducts (paramesonephric ducts) are epithelium located lateral to the mesonephric ducts

- The Mullerian ducts grow caudally and deviate medially to meet the opposite side

  • Proximal Mullerian Duct: fallopian tubes
  • Distal Mullerian Duct: uterus, cervix, upper 2/3 of the vagina

- Sinovaginal bulbs arise from the urogenital sinus and join the inferior end of the Mullerian ducts (Mullerian tubercle) forming the rest of the vagina

- The vagina canalizes from cuadal to cephalad (becomes solid with joining of Mullerian duct and sinovaginal bulbs; canalizes afterward)

30

What are some of the different classes of uterus deformities?

(Don't memorize)

- Hypoplasia/agenesis

- Unicornate (to one side with/out horn)

- Didelphus (two uteri but one vagina)

- Bicornate (split uterus)

- Septate (full/partial divide)

- Arcuate

- DES drug related 

31

What are some common presentations of uterine/vaginal malformations?

- Primary Amenorrhea

- Acute or chronic pelvic pain

- Abnormal vaginal bleeding

- Foul smelling vaginal discharge (often worse at the time of menses)

- Incidental finding of physical exam

- Recurrent abortions

- Infertility

32

How are Mullerian anomalies diagnosed?

- Physical Exam: look for imperforate hymen, vaginal dimple, blind vaginal pouch, abdominal masses secondary to hematocolpos/hematometria

- Ultrasound: transabdominal, transvaginal, transperineal

- MRI: “considered the gold standard”, should be used for all complex anomalies

- Hysterosalpingogram/Sonohysterogram (saline/dye used to image)

- Examination under anesthesia: bimanual, rectoabdominal exam

- Diagnostic Laparoscopy, Hysteroscopy, Vaginoscopy

33

What are some urinary tract anomalies related to these Mullerian structures?

- Most common associated anomaly including ipsilateral renal agenesis (so check Mullerian structures if child only has 1 kidney), duplex collecting systems, renal duplication, horseshoe-shaped kidneys

- Incidence of associated genital abnormalities in female patients with renal anomalies is estimated to be 25%-89%

34

What is imperforate hymen? Results?

- Lack of canalization distally

- Purple hue if period flow backed up behind

35

What is the most common obstructive anomaly?

Imperforate hymen

36

How is imperforate hymen diagnosed?

- Can be diagnosed on physical exam, may present with a mucocolpos, hematocolpos

- Can be repaired in infancy, childhood, or adolescence

- Beware that it may be difficult to differentiate between an imperforate hymen and vaginal atresia in the unestrogenized state of childhood

- Do not just puncture a hematocolpos/ mucocolpos without definitive repair since this may allow for an ascending infection

37

What is the most common gynecologic complaint?

Pelvic pain (i.e. dysmenorrhea)

- Acute or chronic

- Cyclic or constant

38

What is on the DDx for acute pelvic pain?

- Gynecologic

- Non gynecologic

Gynecologic

- Adnexal

  • Torsion
  • Hemorrhagic cysts

- Acute infections

  • Endometritis
  • PID

- Pregnancy complications

  • Ectopic pregnancy
  • Miscarriage

Non-Gynecologic:

- GI

  • Appendicitis
  • Enteritis
  • Intestinal obstruction

- GU

  • Cystitis
  • Ureteral stones

- Other

  • Pelvic thrombophlebitis
  • Vascular aneurysm

39

What is on the DDx for chronic pelvic pain?

- Gynecologic

- Non gynecologic

(Chronic is > 6 mo)

Gynecologic

- Endometriosis

- Adenomyosis

- PID

- Fibroids

Non gynecologic

- GI

  • Constipation
  • Irritable bowel disease

- GU

  • Interstitial Cystitis

- Musculoskeletal

- Psychological

40

What are the types of dysmenorrhea? Describe.

(Dysmenorrhea = cramps)

- Primary dysmenorrhea: no pathologic explanation

- Secondary dysmenorrhea: attributable to structural/functional abnormalities

41

What are causes of secondary dysmenorrhea?

- Endometriosis

- Adenomyosis

- Fibroids

- IUD

- Cervical stenosis

- Transverse vaginal septum

- Imperforate hymen

42

What is endometriosis?

- Prevalence

Endometrial glands/stroma that have implanted outside the uterine cavity and walls

- 5-15% of women have some degree of this disease

43

What are the theories behind the origin of endometriosis?

- Retrograde menstruation

- Mullerian metaplasia

- Lymphatic spread

(Probably an interaction; can get this in places not connected to abdomen [lymphatic] or if haven't had a period yet)

44

Where can endometriosis occur?

- Most commonly?

- Can be located throughout pelvis and abdomen

- Most common site of involvement is ovary

45

What is seen here?

"Powder-burn" lesions of endometriosis

46

What is seen here?

"Chocolate cyst" of endometriosis (has endometrionic blood within)

47

What are presenting symptoms of endometriosis?

- Dysmenorrhea/ Pelvic pain

- Dyspareunia

- Dyschezia (pain with bowel movement)

- Worsens during luteal phase, improves during menses (sometimes)

- Asymptomatic in some women

- Infertility (result of severe scarring)

48

What is done for the definitive diagnosis of endometriosis?

Characteristic gross or histological findings obtained at the time of surgery

- So can suspect with clinical history but only confirm with biopsy

49

What is the treatment for endometriosis?

- Surgical

- Medical

Surgical

- Total abdominal hysterectomy with bilateral salpingoophorectomy

- Laparoscopic or laparotomy with destruction and removal of endometrial implants

  • Excision versus laser ablation

Medical

- First line therapy

  • NSAIDs
  • Oral contraceptives and progestins

- Second line therapy:

  • GnRH agonist (puts you into menopause)
  • Danazol