UWise - Objectives 35-39 Flashcards
(113 cards)
1
Q
What is the most common cause of vaginal infection?
A
Bacterial vaginosis
2
Q
What is the pathophysiology of BV?
A
A shift in the vaginal flora from hydrogen peroxide-producing lactobacilli to non-hydrogen peroxide-producing lactobacilli allows proliferation of anaerobic bacteria
3
Q
How do patients with BV present?
A
The majority are asymptomatic; however, patients may experience a thin, gray discharge with a characteristic fishy odor that is often worse following menses and intercourse.
4
Q
How is BV diagnosed with the Amsel criteria?
A
3 of the 4:
- Thin, gray homogenous vaginal discharge
- Positive whiff test (KOH leads to characteristic amine odor)
- Presence of clue cells on saline microscopy
- Elevated pH >4.5
5
Q
How is BV treated?
A
- Metronidazole 500 mg orally BID for 7 days
2. Vaginal metronidazole 0.75% gel QHS for 5 days
6
Q
Lichen sclerosus is a chronic inflammatory skin conditions that most commonly affects what populations?
A
Caucasian premenarchal girls and postmenopausal women
7
Q
How do patients with lichen sclerosus present?
A
Extreme vulvar pruritis +/- vulvar burning, pain, and introital dyspareunia
8
Q
How does early lichen sclerosus appear on physical exam?
A
Early skin changes include polygonal ivory papules involving the vulva and perianal areas, waxy sheen on the labia minora and clitoris, and hypopigmentation
The vagina is not involved.
9
Q
How does lichen sclerosus appear on physical exam later in the disease?
A
More advanced skin changes may include fissures and erosions due to a chronic itch-scratch-itch cycle, mucosal edema, and surface vascular changes
Scarring with loss of normal architecture, such as introital stenosis and resorption of the clitoris (phimosis) and labia minora, may occur
10
Q
How is lichen sclerosus treated?
A
High-potency topical steroids
11
Q
What is the risk of developing squamous cell cancer within a field of lichen sclerosus?
A
<5%
12
Q
How does squamous cell hyperplasia of the vulva appear?
A
Pink-red appearance with an overlying white keratin
13
Q
How does lichen planus of the vulva appear?
A
Similar to lichen sclerosus, but typically has papules that have a dusky pink appearance and, in severe cases, can lead to erosions
14
Q
How does vulvar cancer typically appear?
A
Friable growth or ulceration
15
Q
How does vulvovaginal candidiasis present?
A
Pruritis and thick white cottage cheese-like discharge, vaginal soreness, vulvar burning, dyspareunia, external dysuria (none of these symptoms are specific)
16
Q
How is vulvovaginal candidiasis diagnosed?
A
- Wet prep (saline or 10% KOH) or Gram stain of vaginal discharge demonstrates yeast or pseudohyphae (may be negative in up to 50% of cases)
- Vaginal culture or other test yields a positive result for yeast species
17
Q
How is VC treated?
A
Short-course topical azole formulations (1-3 days), which results in relief of symptoms and negative cultures in 80-90% of patients who complete therapy.
18
Q
Lichen planus is a chronic dermatologic disorder involving what parts of the body?
A
Hair-bearing skin and scalp, nails, oral mucous membranes, and vulva
19
Q
What is the etiology and pathophysiology of lichen planus?
A
Etiology is unknown, but is thought to be related to cell-mediated immunity.
Inflammatory mucocutaneous eruptions characterized by remissions and flairs
20
Q
How does lichen planus present?
A
Irritation, burning, pruritis, contact bleeding, pain, and dyspareunia of the vulva
21
Q
How does lichen planus appear on physical exam?
A
Lacy, reticulated pattern of the labia and perineum, with or without scarring and erosions. With progressive adhesion formation and loss of normal architecture, the vagina can become obliterated. Patients may also experience oral lesions, alopecia, and extragenital rashes.
22
Q
How is lichen planus treated?
A
No single agent is universally effective, so treatment consists of multiple supportive therapies and topical high potency corticosteroids
23
Q
What is the classic appearance of lichen sclerosus?
A
Thinned out appearance with loss of normal architecture over time
24
Q
How does genital psoriasis appear?
A
Scaly lesions that are well-dermacated
25
What is vestibulodynia syndrome?
Constellation of symptoms and findings limited to the vulvar vestibule, which include severe pain on vestibular touch or attempted vaginal entry, tenderness to pressure and erythema of various degrees. Symptoms often have an abrupt onset and are described as sharp, burning, and raw. Women may experience pain with tampon insertion, biking or wearing tight pants, and avoid intercourse because of marked introital dyspareunia.
26
What are some of the vestibular findings of vestibulodynia syndrome?
Exquisite tenderness to light touch of variable intensity with or without focal or diffuse erythematous macules
27
How is vestibulodynia syndrome treated?
TCAs to block sympathetic afferent pain loops
Pelvic floor rehabilitation
Biofeedback
Topical anesthetics
Surgery with vestibulectomy (only for patients who do not respond to standrad therapies and are unable to tolerate intercourse)
28
How does contact dermatitis appear?
Characteristic erythema
29
How does vaginal cancer typically present?
Bleeding and/or a mass
30
What is lichen simplex chronicus?
A common vulvar non-neoplastic disorder resulting from chronic scratching and rubbing, which damages the skin and leads to loss of its protective barrier. Over time, a perpetual itch-scratch-itch cycle develops, and the result is susceptibility to infection, ease of irritation, and more itching
31
What are the symptoms of lichen simplex chronicus?
Severe vulvar pruritus, which can be worse at night
32
How does lichen simplex chronicus appear?
Thick, lichenified, enlarged, and rugose labia with a leather-like appearance, with or without edema
33
What are some etiologies of lichen simplex chronicus?
Environmental factors such as excessive heat and feminine hygiene products, and conditions such as yeast infections or lichen sclerosus
34
How is lichen simplex chronicus diagnosed?
Clinical history and findings, as well as vulvar biopsy and cultures
35
How is lichen simplex chronicus treated?
Short-course of high-potency topical corticosteroids and antihistamines to control pruritis
36
___ is characterized by a mucopurulent exudate visible in the endocervical canal or in an endocervical swab specimen.
Mucopurulent cervicitis
37
What causes MPC?
C. trachomatis or N. gonorrhoeae; in most cases neither can be isolated
38
How is MPC treated?
Azithromycine or doxycycline for chlamydia and a cephalosporin or quinolone for gonorrhea
39
How does the dose of ceftriaxone vary for uncomplicated cervicitis vs. PID?
125 mg vs. 250 mg
40
Most cases of recurrent genital herpes are caused by ___.
HSV-2
41
Up to 30% of first-episode cases of genital herpes are caused by ___.
HSV-1
42
How are genital HSV infections classified?
1. Initial primary (first-episode): true primary infection - no history of previous genital herpetic lesions and seronegative for HSV Ab
2. Initial non-primary: first recognized episode in individuals who are seropositive for HSV Ab
3. Recurrent - reactivation of latent genital infection; episodic prodromal symptoms and outbreaks of lesions at varying intervals and of varying severity
4. Asymptomatic
43
How does genital herpes present?
Systemic symptoms of a primary infection include fever, headache, malaise, and myalgias, and usually precede the onset of genital lesions. A prodrome of burning or irritation may occur before the lesions appear.
Vulvar lesions begin as tender grouped vesicles that progress into exquisitely tender, superficial, small ulcerations on an erythematous base. Dysuria may result due to vulvar lesions; this may cause significant urinary retention.
Ulcerations and "kissing lesions" (mirror image lesions on opposing skin surfaces); typically lasts for 7-10 days
44
How is genital herpes diagnosed?
Viral culture, antigen detection, or serologic tests
45
How is genital herpes treated?
Acyclovir, famciclovir, or valacyclovir
46
How is vulvodynia treated?
Estrogen cream and clobetasol (high-potency steroid)
47
How id vulvodynia diagnosed?
Exclude all other causes of vulvar pain
48
What can cause contact dermatitis of the vulva?
Adult wipes, scented toilet tissue, lubricants, laundry detergents, latex and sanitary napkins
49
How is contact dermatitis treated?
Discontinue the inciting product + short course of steroids
50
How does primary syphilis appear?
Painless papule at the site of inoculation; this ulcerates and forms the chancre. Left untreated 25% of patients will develop the systemic symptoms of secondary syphilis, which include low-grade fever, malaise, headache, generalized lymphadenopathy, rash, anorexia, weight loss, and myalgias.
51
How does trichomonas present?
Non-specific yellow or greenish vaginal discharge; no systemic manifestation
52
___% of hepatitis B cases worldwide are acquired from sexual transmission.
38
53
How should hepatitis B exposure be managed?
Initiate prophylaxis as soon as possible, but not later than 7 days after blood contact and within 14 days after sexual exposure.
HBsAG positive source: If pt is unvaccinated, give 1 dose HBIG and the HBV series.
HBsAG negative or unknown source: give HBV series only
If vaccinated and non-responder, then give HBIG plus HBV or HBIG 2x
54
What is the incubation period for Hepatitis B?
6 weeks to 6 months
55
What can cause salpingitis?
Sexually transmitted agents such as gonorrhea and chlamydia (most common); any ascending infection from the GU or GI tract can be causative (typically polymicrobial, consisting of aerobic and anaerobic organisms)
56
What are important diagnostic criteria of acute salpingitis?
Lower abdominal tenderness, uterine/adnexal tenderness, mucopurulent cervicitis
57
Discuss the rates of tubal infertility after 1, 2, and 3 episodes of PID.
1: 12%
2: 25%
3: 50%
58
What are possible long-term sequelae of inadequately treated gonococcal or chlamydial infections?
Chronic pelvic pain, hydrosalpinx, tubal scarring, ectopic pregnancy
59
___ must be considered in patients who present with low pelvic pain, urinary frequency, urinary urgency, hematuria, or new issues with incontinence.
UTI
60
What are antibiotic options for treating pyelonephritis inpatient?
IV aminoglycoside PLUS either amp, piperacillin or first-gen cehpalosporins, aztrenoam, third-gen cephalosporins, pip-tazo, or an FQ
61
In stable patients with mild uncomplicated pyelo, what is first-line treatment? What is an acceptable alternative?
FQ such as ciproflaxacin; TMP-SMX (Bactrim)
62
Define overflow incontinence.
Failure to empty the bladder adequately
63
List causes of overflow incontinence.
1. Underactive detrusor muscle (neurologic disorders, DM, MS)
2. Obstruction (postoperative or severe prolapse)
64
What is considered a normal post-void residual?
50-60 cc
65
Define stress incontinence.
Loss of urine due to increased intra-abdominal pressure in the absence of a detrusor contraction (Bladder pressure > intra-urethral pressure)
66
Define urge incontinence.
Overactive detrusor contractions increase the bladder pressure and override the intra-urethral pressure, leading to urine leakage
67
Define mixed incontinence.
Symptoms related to stress and urge incontinence; occurs when increased intra-abdominal pressure causes the urethral-vesical junction to descend, causing the detrusor muscle to contract
68
What are the causes of stress incontinence?
1. Majority - urethral hypermobility (straining Q-tip angle >30 degrees from the horizon)
2. <10% - Intrinsic sphincteric deficiency (ISD) of the urethra
(Can have both)
69
What procedure has the best 5-year success rate for patients with stress incontinence due to hypermobility?
Mid-urehtral sling
70
What procedure is best for patients with stress incontinence due to ISD but little to no mobility of the urethra?
Urethral bulking procedures
- Minimally invasive
- 80% success rate
71
List treatment options of detrusor overactvity.
1. Beta-3 adrenergic agonists (Mirabegron) - cause relaxation of detrusor
2. Tolterodine (Detrol)
72
Mirabegron should be avoided in patients with what comorbidities?
Severe HTN, ESRD, liver disease
73
True or false - vaginal estrogen has been shown to help with urgency, but not urge incontinence.
True
74
Tolterodine (Detrol) is contraindicated in patients with what disease?
Narrow-angle glaucoma
75
How are Kegel exercises used in the setting of incontinence?
Strengthen the pelvic floor and decrease urethral hypermobility in the setting of stress urinary incontinence
76
How are central and lateral cystoceles repaired?
Fixing defects in the pubocervical fascia or reattaching it to the sidewall, if separated from the white line
77
How are rectoceles repaired?
Fixing defects in the rectovaginal fascia
78
How is uterine prolapse treated?
Vaginal hysterectomy
79
How are enteroceles repaired?
Vaginal or abdominal enterocele repairs
80
How is vaginal vault prolapse treated?
Supporting the vaginal cuff to the uterosacral or sacrospinous ligaments or sacrocolpopexy (cuff to sacral promonotry using interposed mesh); colpocleisis (surgical obliteration of the vagina) is an option where general anesthesia is not needed, indicated for a patient with high surgical morbidity
81
How does overflow incontinence present?
Pressure, fullness, frequency, small amount of continuous leaking; not associated with any positional changes or events
82
How does stress incontinence present?
Occurs with increases in intra-abdominal pressure when the patient is in the upright position; may have associated strucbtural defects such as cystocele or urethrocele
83
List 5 risk factors for pelvic organ prolapse.
1. Obesity
2. Age
3. Parity
4. Chronic constipation
5. Connective tissue disorders
84
True or false - Kegel exercises and chondroitin sulfate have not been shown to improve pelvic organ prolapse.
True
85
Presentation of endometriosis?
Dysmenorrhea, dyspareunia
Nodularity along the back of the uterus along the uterosacral ligaments (suggestive)
86
Endometriosis is present in about ___% of infertile women.
30
87
What is the gold standard in the diagnosis of endometriosis?
Surgery
88
What are the conservative and definitive surgical options to treat endometriosis?
Conservative - lap ablation or excision of implants, excision of endometriomas
Definitive - total hysterectomy/BSO
89
What is the MOA of OC's in treating endometriosis?
Negative feedback to the pituitary-hypothalamic axis, which stops stimulation of the ovary resulting in ovarian supression of sex hormone production, such as estrogen. Since estrogen stimulates endometrial tissue located outside of the uterus, endometriosis can be suppressed by OCPs, especially when prescribed in a continuous fashion
90
What are other medical treatment options for endometriosis?
1. GnRH agonists (negative feedback, but only short term; more side effects)
2. Danazol (synthetic androgen, androgenic side effects)
3. NSAIDs
91
When is laparoscopy indicated in patients with endometriosis?
When medical treatment is failed and/or planning pregnancy in the near future (allows both diagnosis of endo and tubal occlusion and the opportunity for treatment of endo)
92
How should a patient with known endometriosis and inability to conceive with an otherwise negative workup for infertility be managed?
Ovarian stimulation with or without intrauterine insemination
93
True or false - endometriosis is a benign lesion.
True - in an asymptomatic patient who is not concerned about fertility, no further treatment is necessary
94
What accounts for >90% of the diagnoses in women with discernible laparoscopic abnormalities?
Endometriosis and adhesions
95
True or false - laparoscopic evaluation of chronic pelvic pain in adolescents should be deferred based on age.
False - laparoscopic evaluation of chronic pelvic pain in adolescents should not be deferred based on age.
96
What is interstitial cystitis?
Chronic inflammatory condition of the bladder, which is clinically characterized by recurrent irritative voiding symptoms of urgency and frequency in the absence of objective evidence of another disease that could cause the symptoms; pelvic pain is reported by up to 70% of women with IC; women may also experience dyspareunia
97
Discuss the etiology of interstitial cystitis.
Unknown, but may have an AI and even hereditary component; may be more common in women who also have endo
98
What is IBS?
Common functional bowel disorder of uncertain etiology characterized by a chronic, relapsing pattern of abdominal and pelvic pain and bowel dysfunction with constipation or diarrhea. It is one of the most common disorders associated with chronic pelvic pain.
99
How is IBS diagnosed?
Rome II Criteria:
At least 12 weeks (need not be consecutive) in the preceding 12 months of abdominal discomfort or pain that has two or three features: 1. Relief with defecation, 2. Onset associated with a change in frequency of stool, or 3. Onset associated with a change in stool form or appearance
100
True or false - chronic pelvic pain may be associated with a history of abuse.
True
101
What is pelvic congestion syndrome?
Cause of chronic pelvic pain in the setting of pelvic varicosities, leading to chronic dilation with stasis and vascular congestion
102
Describe the pain associated with pelvic congestion syndrome.
Variable intensity and duration, worse premenstrually and during pregnancy, aggravated by standing, fatigue, and coitus; pelvic "fullness" or "heaviness," which may extend to the vulvar area and legs. Associated symptoms include vaginal discharge, backache, and urinary frequency. Menstrual cycle defects and dysmenorrhea are common
103
What are the nerves at risk in nerve entrapment syndrome?
Iliohypogastric nerve (T12, L1) and ilioinguinal (T12, L1) nerve
104
Describe the course of the iliohypogastric nerve and ilioinguinal nerve.
Exit the spinal column at the 12th vertebral body, pass laterally through the psoas muscle before piercing the transversus abdominus muscle to the anterior abdominal wall. Once at the ASIS, the iliohypogastric courses medially between the internal and external obliques, becoming cutaneous 1 cm superior to the superficial inguinal ring.
105
What is the innervation of the iliohypogastric?
Cutaneous sensation to the groin and the skin overlying the pubis
106
What is the innervation of the ilioinguinal nerve?
Cutaneous sensation to the groin, symphysis, labium, and upper inner thigh
107
When are the iliohypogastric and ilioinguinal nerves susceptible to injury?
Low transverse incision is extended beyond the lateral border of the rectus abdominus muscle, into the internal oblique muscle
108
Damage to the ___ nerve, which can occur during lymph node dissection, would result in the inability to adduct the thigh.
Obturator
109
Hysterectomy done for chronic pelvic pain has only a ___% chance of improvement in symptoms.
50
110
What is the best predictor of successful elimination of chronic pelvic pain via hysterectomy?
Tenderness confined to the uterus
111
Tenderness on flexion of abdominal muscles (Carnet's sign) is highly suggestive of what?
Abdominal wall pain (vs. visceral pain)
112
Cyclic pain that corresponds to menstrual cycles increases the chance that pain is due to a ___ lesion.
Gynecologic
113
Pain that is constant, refractory to hormonal manipulation and reproducible with palpation of somatic structures is suggestive of ___ or ___. How can it be managed?
Neuromuscular pain or fibromyalgia; PT and exercise
