Transcript Benign GYN Disorders

Benign
Gynecological
Disorders
Tory Davis, PA-C
Mercy Hospital
POP
Pelvic Organ Prolapse
 Defects in pelvic support structures
result in pelvic relaxation abnormalities
 Classified by anatomical location
 Severity by Stage 0-IV
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Anatomic location
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Anterior vaginal wall
– Cystocele
– Bladder prolapses
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Posterior wall
– Rectocele
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Apical wall defect
– Uterine prolapse
– Vaginal vault prolapse (post-hyst)
– Enterocele
Causes
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Age
Parity
– Vag parity 3xRR
– >2 deliveries4.5RR
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Obesity
Hx pelvic surgery
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Diseases/conditions
– Chronic cough
– Constipation
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Heavy lifting
Menopause
Inherent quality of
connective tissue
Symptoms
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Vaginal fullness
Pressure
Heaviness
Discomfort
Dysparunia
Reducible mass in
introitus
Low back pain
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Incomplete void
Stress incontinence
Frequency
Urinary hesitancy
Splinting
Coital laxity
POP PE
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Lithotomy position first, standing prn
Vulvar ulcerations
Relaxed genital hiatus
Thin walled, smooth bulging mass
– Varying severity
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Observed valsalva
Check anterior and posterior walls
Rectovaginal
Prevention
Antepatrum, intrapartum, postpartum
pelvic floor exercises
 Avoid other reversible/controllable risk
factors
 Estrogen therapy p menopause to
maintain pelvic tissue tone
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Tx
Attention to psychosocial aspects
 Pessary
 Kegels
 Estrogen (local)
 Surgical
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Urinary Incontinence
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13 million women
30-40% of US women in lifetime
Up to 70% do not seek treatment
Involuntary loss of urine
– Can be sign, symptom or diagnosed condition
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3x more common in women (shorter urethra
and greater likelihood of connective tissue,
muscle and nerve injuries)
Etiology of UI
Gender
 Age
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– In elderly, 30% increase prevalence with
each 5-year age increase
Hormonal status
 Birthing trauma
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– Damage to pelvic floor neuromusculature
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POP
Types
Stress UI: urinary leakage on effort or
exertion
 Urge UI: leakage immediately
preceded by sense of urgency “Gotta
go!”
 Mixed UI: Likely most common
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UI History
Duration
 Frequency
 Severity
 Social implications
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– What do I mean?
Use of protective items (pads, diapers,
etc)
 Mental function
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Workup
Pelvic exam
 Q tip test for bladder neck
hypermobility
 Cough stress test
 Neuro exam
 Urodynamic studies
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Treatment- Stress UI
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Reduce caffeine and alcohol
Fluid restriction
Timed voiding
Kegels
Biofeedback
Electric stimulation
Pessaries
Surgery
Kegel Exercises
Focused repetitive voluntary
contractions of pelvic floor musculature
 Have pt contract muscles as if to
prevent a fart or to stop urine
 Hold 3-5 seconds, then relax
 50-100 reps daily
 Cure or significant improvement in up
to 75%
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Urge UI
Involuntary contractions of bladder
 “Overactive Bladder”
 Cause unknown
 Prevalence 10-50%
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Treatment
As for SUI plus Drugs!
 Anticholinergics
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– Oxybutinin (Ditropan)
– Tolterodine (Detrol)
Available in IR, long-acting or patch
 Increase bladder capacity, decrease
bladder contractions, improve urgency
symptoms in 70%
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Benign vulvar/vaginal
disorders
Infectious causes: already covered,
right? But still need to be considered
 Atrophic vaginitis
 Lichen sclerosis
 Bartholin glands
 Vulvodynia
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Atrophic vaginitis
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Hypoestrogenic vagina
High pH
Thinned vaginal epithelium
SX: dryness, spotting, serosanguinous
discharge, dyspareunia
Tx: intravaginal estrogen (cream, ring, pv
tablet) Not in women with hx of breast or
endometrial cancer, though, right?
Lichen sclerosis
Benign chronic inflammatory process
 Most common vulvar derm d/o
 Acute phase- red/purple lesions on
non-hair-bearing areas of vulva,
perineum, perianal area in hourglass
pattern
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– Erythema and edema
– Intense pruritis
Lichen sclerosis
Chronic- skin is thin, white, shiny
 Loss of genital landmarks
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– Labia minora fusion
– Introital stenosis
Pain/dyspareunia from loss of elasticity
 Increased risk of squamous cell
carcinoma
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Lichen sclerosis Tx
Steroids
 Topical high potency for 3 months,
taper to less potent for maintenance
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Bartholin’s gland
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What are the Bartholin glands for?
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What can go wrong with them?
Bartholin’s gland cyst
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Obstruction of the duct of the Bartholin’s
gland retention of secretionscystic
dilation
Infection can occur
– Sx: pain, tenderness, erythema, dyspareunia
with fluctuant mass
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Drain with Word catheter or marsupialization
Excision if recurrent
Vulvodynia
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Vulvar pain in absence of relevant physical
findings
Sx: burning, raw, irritation, hyperalgesia,
allodynia
Prevalence 1.5%
2 types:
– Localized provoked 20-30 yrs
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Vestibular erythema, tenderness, introital pain
– Generalized unprovoked 40 yrs
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Larger area of pain (?neuropathic, pudendal nerve
injury, referred pain?)
Benign Cervical
Disorders
Stenosis
 Nabothian cysts
 Polyps
 Already covered: HPV and other STIs,
cervical dysplasia
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Cervical stenosis
Narrowing of the endocervical canal,
usually at level of internal os
 Partial to full occlusion of the os
 Obstruction of menstrual flow (can
lead to amenorrhea)
 Infertility
 Pelvic pain
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Cervical stenosis
etiology
Congenital
 Inflammatory
 Neoplastic
 Surgical
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– Think of this when treating cervical
dysplasia: LEEP causes less stenosis
than cold-knife cone biopsy
Nabothian cysts
Don’t freak out. Benign
 Yellowish translucent raised pearl-like
lesions on ectocervix
 1 mm to 3 cm
 Few or multiple
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Cervical Polyps
Small, pedunculated neoplasms
 Originate from endocervix
 Common
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– Esp multigravidas over age 20
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Mostly benign, but remove and send to
pathology due to malignant change
potential
Cervical polyps
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Asymptomatic or c/o intermenstrual or
postcoital bleeding
Sometimes assoc with infertility
– Why?
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PE: red fragile growth protruding from os
– 2 mm to 3 cm
– Not palpable
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Remove by grab-n-twist
– Larger ones to OR
Adnexal masses
Common, usually benign
 Management dictated by presentation
 Malignancy must be excluded
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– US usually 1st imaging for adnexa
– Septations, solid parts and Doppler flow
within lesion are suspicious
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If likely benign and <6 cm, observe
– Why 6 cm?
Benign ovarian growths
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Follicular cyst- most common. From
growth of follicle, often doesn’t release
the egg
– Usually not sx, usually resolve
Corpus luteum cyst
 Hemorrhagic cyst
 Dermoid cyst- the cyst with teeth
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Cyst management
If fluid-filled, monitor with periodic U/S
 If not, remove it
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– Laparoscopic approach most common
Also remove if >6 cm to reduce risk of
torsion
 Prevention with OCPs
 Tx pain with NSAIDs
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PCOS
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Polycystic Ovarian Syndrome
Common (5-10%) female endocrinopathy
Oligo or amenorrhea and anovulation
Hyperandrogenism
– What’s that look like?
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Ultrasonographic evidence of polycystic
ovaries
Frequently, infertility
Insulin resistance
PCOS
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Does this topic really belong here?
Please read the Richardson article “Current
Perspectives in Polycystic Ovary Syndrome”
posted on myUNE
Write 1-2 paragraphs on what “system”
PCOS belongs in (Endo vs Women's
Health)
– Defend with supporting evidence from the article
(etiology, clinical features, lab features,
treatment, prognosis, etc)
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Due Thursday April 15 to me at my next
lecture.
Premature Ovarian
Failure
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Ovaries don’t produce enough
estrogen in women < 40
– Despite high levels of circulating
gonadotropins
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Suspect in female <40 with s/s of
estrogen deficiency
S/sx of estrogen
deficiency
Atrophic vaginitis
 Osteopenia/osteoporosis
 Decreased libido
 Infertility
 Menstrual changes
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POF Dx
High FSH, low estradiol
 Find cause
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– Enzyme defects
– Genetic defects
– Autoimmune causes (thyroiditis,
Addison’s, hypoparathyroid, myasthenia
gravis)
– Environmental factors (chemo, smoking,
viruses, surgery)
POF Tx
Desiring pregnancy: IVF plus
exogenous hormones to support
endometrium
 Not desiring pregnancy: HRT until age
50s
 Either: psychosocial support
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Uterine Disorders
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Will be covered in Menstrual
Abnormalities lecture
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Questions?