11/6- Benign Gynecology Flashcards Preview

a_GYNGU > 11/6- Benign Gynecology > Flashcards

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

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


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)


What are symptoms of vulvovaginitis?

- Vaginal discharge

- Pruritis

- Burning

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


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


In what ways can a wet mount be prepared?

- Components

- Sample of vaginal discharge

- pH paper

- Normal saline


- Microscope slide


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


- Douching


What is Candidiasis?

- Etiological cause

- Symptoms

- Risk factors

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


- Vaginal itching, burning, and irritation

- White odorless vaginal discharge

Risk factors:

- Diabetes

- High dose OCPs

- Antibiotic use

- Immunosuppression

- Pregnancy 


What is Trichomoniasis?

- Etiological cause

- Symptoms

- Spread

- Caused by protozoan T. vaginalis


- 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)


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


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)


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) 


What is complete procedentia?

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


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)


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


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


What is the treatment for pelvic organ prolapse?

- Non surgical

- 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


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


- Stress urinary incontinence

- Urge urinary incontinence (overactive bladder)

- Overflow incontinence


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


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


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)


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


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)


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)


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


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


- Lower abdominal pain and tenderness

- Abnormal vaginal discharge


- Lower abdominal tenderness

- Uterine/adnexal tenderness

- Mucopurulent cervicitis (yellowish discharge)


What conditions lead to PID?

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


What are complications of PID?

(PID causes scarring of tubes)

- Ectopic pregnancy (6x)

- Tubal infertility (14x)

- Chronic pelvic pain (6x)


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


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)


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 


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


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


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%


What is imperforate hymen? Results?

- Lack of canalization distally

- Purple hue if period flow backed up behind


What is the most common obstructive anomaly?

Imperforate hymen


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


What is the most common gynecologic complaint?

Pelvic pain (i.e. dysmenorrhea)

- Acute or chronic

- Cyclic or constant


What is on the DDx for acute pelvic pain?

- Gynecologic

- Non gynecologic


- Adnexal

  • Torsion
  • Hemorrhagic cysts

- Acute infections

  • Endometritis
  • PID

- Pregnancy complications

  • Ectopic pregnancy
  • Miscarriage


- GI

  • Appendicitis
  • Enteritis
  • Intestinal obstruction

- GU

  • Cystitis
  • Ureteral stones

- Other

  • Pelvic thrombophlebitis
  • Vascular aneurysm


What is on the DDx for chronic pelvic pain?

- Gynecologic

- Non gynecologic

(Chronic is > 6 mo)


- Endometriosis

- Adenomyosis


- Fibroids

Non gynecologic

- GI

  • Constipation
  • Irritable bowel disease

- GU

  • Interstitial Cystitis

- Musculoskeletal

- Psychological


What are the types of dysmenorrhea? Describe.

(Dysmenorrhea = cramps)

- Primary dysmenorrhea: no pathologic explanation

- Secondary dysmenorrhea: attributable to structural/functional abnormalities


What are causes of secondary dysmenorrhea?

- Endometriosis

- Adenomyosis

- Fibroids


- Cervical stenosis

- Transverse vaginal septum

- Imperforate hymen


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


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)


Where can endometriosis occur?

- Most commonly?

- Can be located throughout pelvis and abdomen

- Most common site of involvement is ovary


What is seen here?

"Powder-burn" lesions of endometriosis


What is seen here?

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


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)


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


What is the treatment for endometriosis?

- Surgical

- Medical


- Total abdominal hysterectomy with bilateral salpingoophorectomy

- Laparoscopic or laparotomy with destruction and removal of endometrial implants

  • Excision versus laser ablation


- First line therapy

  • NSAIDs
  • Oral contraceptives and progestins

- Second line therapy:

  • GnRH agonist (puts you into menopause)
  • Danazol