Ovary, vagina Flashcards
(116 cards)
1
Q
1st
A
1st
2
Q
Simple anatomy of the ovaries
A
Outer cortex (contains follicles and theca cells - produce hormones) and inner medulla (contains connective tissue and blood vessels) Cortex covered by germinal epithelium
3
Q
What are ovarian cyst ‘accidents’
A
Acute presentation of ovarian cysts- often don’t present otherwise unless very large
Rupture of cyst, haemorrhage into a cyst or torsion of the pedicle
4
Q
Presentation of ovarian cyst accidents
A
All cause intense pain - haemorrhage into peritoneal cavity can cause hypovolaemic shock
5
Q
What are the 3 types of primary ovarian tumours?
A
Epithelial tumours
Germ cell tumours
Sex cord tumours
Benign and malignant are considered together because benign cyst can undergo malignant change
6
Q
Which ovarian tumour type is more common in postmenopausal women
A
Epithelial tumours
or sex cord tumours
7
Q
Which ovarian tumour type is more common in young premenopausal women
A
Germ cell tumours
8
Q
Which cancers metastasise to the ovaries
A
Breast and GIT cancers
9
Q
Prognosis with ovarian cancer?
A
Poor!
5-year survival rate is below 35% because they present late
10
Q
Highest incidence for ovarian cancer at what age?
A
80-84
11
Q
What are most ovarian cancers?
A
90% are epithelial carcinomas
12
Q
Risk factors for ovarian cancer?
A
Number of ovulations - early menarche, late menopause, nulliparity
13
Q
Protective factors for ovarian cancer?
A
Pregnancy
Lactation
Use of the pill
14
Q
Inheritability of ovarian cancer
A
May be familial (5%) via BRCA 1 and 2 and HNPCC (Lynch syndrome)
15
Q
Screening for ovarian cancer?
A
There is currently no screening program but it is under investigation as prognosis is much better if caught early - would be done with annual TV USS or CA 125 checks
16
Q
When does ovarian cancer present
A
Symptoms are initially vague and/or absent and 70% present with Stage 3-4 cancer
17
Q
Clinical presentation of ovarian cancer x4
A
Abdominal distention (bloating) Feeling full (early satiety) and/or loss of appetite Pelvic or abdominal pain Increased urinary urgency and/or frequency
18
Q
What is the presentation of ovarian cancer similar to?
A
IBS
19
Q
What should you ask with possible ovarian cancer Dx?
A
GIT or breast symptoms because of mets
20
Q
Examination findings in ovarian cancer? x3
A
May reveal cachexia
Abdominal or pelvic mass
Ascites
21
Q
How does ovarian cancer spread?
A
Directly within pelvis and abdomen - transcoelomic spread
22
Q
What is stage 1 ovarian cancer?
A
Disease is macroscopically confined to the ovaries
1a - one ovary - capsule intact
b - two ovaries - capsule intact
c - one or two - capsule not intact or malignant cells in abdominal cavity (ascites)
23
Q
What is stage 2 ovarian cancer
A
Disease spread beyond ovaries but in pelvis
24
Q
Stage 3 ovarian cancer?
A
Disease spread beyond pelvis but confined to abdomen (omentum, small bowel and peritoneum - frequently affected)
25
Stage 4 ovarian cancer
Spread outside of the abdominal cavity - eg. lungs or liver parenchyma
26
Investigations in suspected ovarian cancer
CA 125 levels - should be done in any woman >50 with abdominal symptoms
If >35IU/mL then ultrasound of abdomen/pelvis is done
27
What levels are raised in ovarian germ cell tumours?
AFP and hCG
28
What score is calculated to assess disease risk of ovarian cancer?
Risk of malignancy index - Ultrasound score, menopausal status and serum CA 125 level
29
What score on the RMI requires referral?
>250
30
What is the surgical treatment for ovarian cancer?
Midline laparatomy - hysterectomy, bilateral salpingo-oopherectomy and partial omentectomy
Stage 2 and above the retroperitoneal lymph nodes are removed
31
When is chemotherapy used in ovarian cancer?
Stage 1c and above
32
What is used to monitor response to chemotherapy with ovarian cancer?
Levels of CA 125
33
What is commonly the cause of death with ovarian cancer?
Bowel obstruction or perforation
34
Where does the vulva lymph drainage go to?
Inguinal lymph nodes - these drain to the femoral and then external iliac
35
What are the most common vulval symptoms?
Pruritus, soreness, burning and superficial dyspareunia
36
What can cause vulval symptoms?
```
Candidiasis
Vulval warts
Pubic lice, scabies
Any dermatological disease
Neoplasia - carcinoma or pre-malignant disease
```
37
What is lichen simplex?
Chronic vulval dermatitis
| Chronic inflammatory skin condition of the vulva in women with sensitive skin, dermatitis or eczema
38
Symptoms of lichen simplex?
Severe intractable pruritus, esp. at night
Inflamed labia majora with hypo and hyper-pigmentation
Symptoms exacerbated by chemical or contact dermatitis
Sometimes symptoms are linked to stress
39
Management of lichen simplex
Emollients, steroid creams and antihistamines - used to aim to break itch-scratch cycle
40
How does lichen planus present in the vulva?
Flat, papular, purplish lesions
| Can be erosive and more commonly associated with pain rather than pruritis
41
Treatment of lichen planus
High potency steroid cream
42
How does lichen sclerosus present?
Severe pruritis - worse at night
Uncontrollable scratching can cause trauma with bleeding and skin splitting
Pink-white papules - coalesce to form parchment-like skin with fissures
43
What can happen with lichen sclerosus
Inflammatory adhesions can form potentially causing fusion of the labia and narrowing of the introitus
Vulval carcinoma develops in 5%
44
Treatment of lichen sclerosus
Ultra-potent topical steroids
45
Who is candidiasis more common in?
Diabetics, obese, pregnancy, antibiotics, immunocompromised
46
What are the Bartholin glands?
They are two glands behind the labia minora which secrete lubricating mucus for coitus
47
When do Bartholin cysts arise? What can lead to
If blockage of the duct - cyst forms. If infection occurs (commonly staph.auerus or e.coli) abscess forms
48
Presentation of Bartholin abscess?
Acutely painful and large tender red swelling
49
Treatment of Bartholin abscess
Drainage and then incision is sutured open (marsupialisation) to reduce risk of reformation
50
Details of vaginal cysts
Congenital cysts in vagina
Smooth white appearance - can be mistaken for prolapse
Remove if dyspareunia
51
What is vulval intraepithelial neoplasia (VIN)?
Presence of atypical cells in the vulval epithelium - premalignant disease of the vulva
52
What are the two types of VIN and which is more common?
Usual type VIN and differentiated type VIN - nearly all are usual type VIN
53
Which type of VIN is seen with which age group?
Usual type more common in women 35-55
| Differentiated type more common in older women
54
What is usual type VIN associated with?
HPV, CIN, cigarette smoking and chronic immunosuppression
55
Presentation of usual type VIN
May be multifocal - appearances vary widely
56
What is differentiated type VIN associated with?
Lichen sclerosis
57
Type of lesion in differentiated type VIN
Unifocal in the form of an ulcer or plaque
58
Which VIN type has highest risk of progression to cancer?
Differentiated type VIN
59
What are common symptoms which VIN?
Pruritus or pain
60
Gold standard treatment for VIN?
Local surgical excision to relieve symptoms, confirm histology and exclude invasive disease
61
When is carcinoma of the vulva most common?
After age 60
62
What type of cancers are vulva carcinoma normally?
95% are squamous cell carcinomas
63
What do carcinomas of the vulva usually arise due to?
Usually de novo despite VIN being a pre-malignant stage
64
What is vulval carcinoma associated with?
Lichen sclerosis, immunosuppression, smoking and Pagets disease of the vulva
65
Clinical features of vulval carcinoma?
Pruritus, bleeding or a discharge
| May find a mass - but malignancy often presents late
66
Examination in vulval carcinoma
Will reveal ulcer or mass - most commonly on labia majora or clitoris
Inguinal lymph nodes may be enlarged, hard and immobile
67
How does vulval carcinoma spread?
Superficially and then to deep inguinal lymph nodes
68
How is vulval carcinoma staged?
Surgically and histologically (After surgery)
69
Stage 1a vulval carcinoma?
Tumour confined to vulval perineum
70
Stage 1b vulval carcinoma
Tumour confined to vulval perineum >2cm in size or with stromal invasion >1mm
71
Stage 2 vulval carcinoma
Adjacent spread to lower urethra/vagina or anus
72
Stage 3 vulval carcinoma
Inguinofemoral nodes involved
73
Stage 4 vulval cancer
Invades upper urethra/vagina, rectum. bladder, bone or distant mets
74
Treatment of stage 1a vulval carcinoma
Wide local excision - without inguinal lymphadenopathy
75
Treatment of all other stages of vulval carcinoma
Wide local excision - groin lymphadenectomy = triple incision radical vulvectomy
76
When is radiotherapy used in vulval carcinoma x3
Prior to surgery to shrink large tumours or postoperatively if groin lymph nodes are positive
Or palliatively to treat severe symptoms
77
Details of malignancies of vagina?
Primary carcinoma is 2% of genital tract malignancies - affects older women, generally squamous
Presents with bleeding or discharge - or mass/ulcer
Treatment with intravaginal radiotherapy or occasionally radical surgery
78
What is a urethrocele?
Prolapse of the lower anterior vaginal wall, involving the urethra only
79
What is a cystocele?
Prolapse of the upper anterior vaginal wall, involving the bladder
80
What is a cystourethrocele?
Prolapse of the upper anterior wall + bladder often also has associated prolapse of urethra
81
What is apical prolapse?
Term used to describe prolapse of the uterus, cervix and upper vagina
82
What is a enterocele?
Prolapse of the upper posterior wall of the vagina
| Resulting pouch usually contains loops of small bowel
83
What is a rectocele?
Prolapse of the lower posterior wall of the vagina, involving the anterior wall of the rectum
84
What must be used when the measurements of a prolapse exam are explained?
The condition of the examination must be explained, eg. position of the patient, at rest/straining and whether traction is employed
85
What is 0 on ISC Pelvic Organ Prolapse (POP) scoring system?
No descent of pelvic organs during straining
86
What is 1 on ISC POP score?
Leading surface of the prolapse does not descend below 1cm above the hymenal ring
87
What is 2 on ISC POP score?
Leading edge of the prolapse extends from 1cm above to 1cm below the hymenal ring
88
What is 3 on ISC POP score?
Prolapse extends 1cm or more below the hymenal ring but without complete vaginal eversion
89
What is 4 on ISC POP score?
Vagina completely everted (complete procidentia)
90
Risk factors for prolapse x5
```
Vaginal delivery and pregnancy
Abnormal collagen disorders
Menopause
Chronic increased abdominal pressure
Pelvic surgery
```
91
What factors associated with pregnancy increase the risk of prolapse? x3
Large infants
Prolonged second stage
Instrumental delivery
92
Why is menopause associated with prolapse
Thought to be due to the deterioration of collagenous connective tissue which occurs following oestrogen withdrawal
93
Which factors associated with increased abdominal pressure increase risk of prolapse? x5
```
Obesity
Chronic cough
Constipation
Heavy lifting
Pelvic mass
```
94
Clinical features of prolapse
Dragging sensation or sensation of a lump are common
| Usually worse at the end of the day or standing up
95
Clinical features of a severe prolapse
Can interfere with intercourse, can ulcerate and cause bleeding or discharge
96
Clinical features of a cystourethrocele
Can cause urinary frequency and incomplete bladder emptying
| Stress incontinence is common
97
Examination of a prolapse
Abdomen exam to exclude pelvic masses
| Sim's speculum - asking patient to bear down
98
How to differentiate between a rectocele and enterocele on examination
Finger in the rectum will be seen to bulge into a rectocele but not in an enterocele
99
Symptoms of rectocele
Occasional difficulty in defacaeting
100
Investigations with prolapse
US if pelvic mass is suspected
101
Management of prolapse
Weight reduction
Smoking is discourage
Physiotherapy might help mild to moderate and reduce stress incontinence
102
Non-surgical management of prolapse
Pessaries - in women who is unwilling or unfit for surgery
| - act like an artificial pelvic floor placed in vagina behind symphysis pubis and in front of sacrum
103
Two types of pessary for prolapse?
Most common - ring pessary
| Shelf pessary - more effective for severe forms of prolapse
104
How often are pessaries changed?
6-9 months
105
What is needed with pessaries
Postmenopausal women may require oestrogen replacement, topical oestrogen or HRT to prevent vaginal ulceration
106
Surgical treatment for uterine prolapse
Vaginal hysterectomy - traditional surgical treatment for uterovaginal prolapse but doesn't treat underlying problem
Hysteropexy - uterus and cervix attached to sacrum using a bifurcated non-absorbable mesh
107
Surgical treatment for vaginal vault prolapse
Sacrocolpopexy - fixes vault to sacrum using a mesh
| Sacrospinous fixation suspends the vault to the sacrospinous ligament
108
Surgical treatment for vaginal wall prolapse
Anterior and posterior repairs - used for the relevant prolapse
109
Surgical treatment for urodynamic stress incontinence
Tension-free vaginal tape or
| Trans-obturator tape procedures
110
What is the most common ovarian cyst and details?
Follicular cyst - due to non-rupture of dominant follicle
| Commonly regresses after several menstrual cycles
111
Other physiological ovarian cyst?
Corpus luteum cyst - when corpus luteum doesn't break down, may fill with blood or fluid and form cyst - more likely to present with intraperitoneal bleeding than follicular cysts
112
Most common benign ovarian tumour in young women
Dermoid cyst - aka mature cystic teratoma- contains appendages etc
113
What is Rokitansky protuberance
Collection of appendages, hair, teeth etc in ovarian teratoma
114
What sort of tumour is dermoid cyst
Germ cell tumour - aka the ovarian tumour that occurs in young women
115
Most common types of benign ovarian epithelial tumour
Serous cystadenoma (most common) - resembles serous carcinoma which is most common type of ovarian cancer
116
Other benign epithelial ovarian tumour
Mucinous cystadenoma
| - typically large and may become massive and rupture
