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

Anatomic location Anterior vaginal wall

– Cystocele– Bladder prolapses

Posterior wall– Rectocele

Apical wall defect– Uterine prolapse– Vaginal vault prolapse (post-hyst)– Enterocele

Causes Age Parity

– Vag parity 3xRR– >2 deliveries4.5RR

Obesity Hx pelvic surgery

Diseases/conditions– Chronic cough– Constipation

Heavy lifting Menopause Inherent quality of

connective tissue

Symptoms Vaginal fullness Pressure Heaviness Discomfort Dysparunia Reducible mass in

introitus Low back pain

Incomplete void Stress incontinence Frequency Urinary hesitancy Splinting Coital laxity

POP PE Lithotomy position first, standing prn Vulvar ulcerations Relaxed genital hiatus Thin walled, smooth bulging mass

– Varying severity 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

Tx Attention to psychosocial aspects Pessary Kegels Estrogen (local) Surgical

Urinary Incontinence 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 3x more common in women (shorter urethra

and greater likelihood of connective tissue, muscle and nerve injuries)

Etiology of UI Gender Age

– In elderly, 30% increase prevalence with each 5-year age increase

Hormonal status Birthing trauma

– Damage to pelvic floor neuromusculature 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

UI History Duration Frequency Severity Social implications

– What do I mean? Use of protective items (pads, diapers,

etc) Mental function

Workup Pelvic exam Q tip test for bladder neck

hypermobility Cough stress test Neuro exam Urodynamic studies

Treatment- Stress UI 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%

Urge UI Involuntary contractions of bladder “Overactive Bladder” Cause unknown Prevalence 10-50%

Treatment As for SUI plus Drugs! Anticholinergics

– Oxybutinin (Ditropan)– Tolterodine (Detrol)

Available in IR, long-acting or patch Increase bladder capacity, decrease

bladder contractions, improve urgency symptoms in 70%

Benign vulvar/vaginal disorders

Infectious causes: already covered, right? But still need to be considered

Atrophic vaginitis Lichen sclerosis Bartholin glands Vulvodynia

Atrophic vaginitis 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– Erythema and edema– Intense pruritis

Lichen sclerosis Chronic- skin is thin, white, shiny Loss of genital landmarks

– Labia minora fusion– Introital stenosis

Pain/dyspareunia from loss of elasticity Increased risk of squamous cell

carcinoma

Lichen sclerosis Tx Steroids Topical high potency for 3 months,

taper to less potent for maintenance

Bartholin’s gland What are the Bartholin glands for?

What can go wrong with them?

Bartholin’s gland cyst Obstruction of the duct of the Bartholin’s

gland retention of secretionscystic dilation

Infection can occur– Sx: pain, tenderness, erythema, dyspareunia

with fluctuant mass Drain with Word catheter or marsupialization Excision if recurrent

Vulvodynia Vulvar pain in absence of relevant physical

findings Sx: burning, raw, irritation, hyperalgesia,

allodynia Prevalence 1.5% 2 types:

– Localized provoked 20-30 yrs Vestibular erythema, tenderness, introital pain

– Generalized unprovoked 40 yrs 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

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

Cervical stenosis etiology Congenital Inflammatory Neoplastic Surgical

– 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

Cervical Polyps Small, pedunculated neoplasms Originate from endocervix Common

– Esp multigravidas over age 20 Mostly benign, but remove and send to

pathology due to malignant change potential

Cervical polyps Asymptomatic or c/o intermenstrual or

postcoital bleeding Sometimes assoc with infertility

– Why? PE: red fragile growth protruding from os

– 2 mm to 3 cm– Not palpable

Remove by grab-n-twist– Larger ones to OR

Adnexal masses Common, usually benign Management dictated by presentation Malignancy must be excluded

– US usually 1st imaging for adnexa– Septations, solid parts and Doppler flow

within lesion are suspicious If likely benign and <6 cm, observe

– Why 6 cm?

Benign ovarian growths 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

Cyst management If fluid-filled, monitor with periodic U/S If not, remove it

– Laparoscopic approach most common Also remove if >6 cm to reduce risk of

torsion Prevention with OCPs Tx pain with NSAIDs

PCOS Polycystic Ovarian Syndrome Common (5-10%) female endocrinopathy Oligo or amenorrhea and anovulation Hyperandrogenism

– What’s that look like? Ultrasonographic evidence of polycystic

ovaries Frequently, infertility Insulin resistance

PCOS 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)

Due Thursday April 15 to me at my next lecture.

Premature Ovarian Failure

Ovaries don’t produce enough estrogen in women < 40– Despite high levels of circulating

gonadotropins Suspect in female <40 with s/s of

estrogen deficiency

S/sx of estrogen deficiency

Atrophic vaginitis Osteopenia/osteoporosis Decreased libido Infertility Menstrual changes

POF Dx High FSH, low estradiol Find cause

– 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

Uterine Disorders Will be covered in Menstrual

Abnormalities lecture

Questions?