1
Q
a 45-year-old female complaining of pressure in the pelvis and vagina along with discomfort when straining. She also feels that her bladder hasn’t fully emptied after urinating.
A
Cystocele
2
Q
bulge of the bladder into the vagina
A
Bladder prolapse (cystocele)
Anterior vaginal prolapse of the posterior bladder wall into the vagina, emerging from the introitus
3
Q
MCC of cystocele
A
- A cystocele can result from childbirth, constipation, violent coughing, heavy lifting, or other pelvic muscle strain
4
Q
Sx of cystocele
A
- Symptoms include feeling pressure in the pelvis and vagina, discomfort when straining, and feeling that the bladder hasn’t fully emptied after urinating
- Feels like “sitting on a ball” or “something is falling out”
- Worse with Valsalva and better with redundancy
- Concurrent urinary incontinence
5
Q
Dx of cystocele
A
Diagnose with POP-Q (pelvic organ prolapse quantification): quantifies the extent and location of defects, ultrasound or MRI
- Additional testing: Q-tip test, voiding cystourethrogram (VCUG), cystometrogram
6
Q
Tx of cystocele
A
Treatment includes a flexible ring pessary to support the bladder or surgical repair with mesh augmentation
- Prophylaxis with Kegel exercises: strengthen levator ani and perineal muscles
- Estrogen therapy after menopause maintains tone and vitality of the tissue
7
Q
a 50-year-old female with pelvic pressure reports and a sensation of a mass present in the vagina. She reports chronic constipation and a sensation that the rectum is not completely emptied following a bowel movement. Occasionally, she experiences episodes of fecal incontinence
A
Rectocele
9
Q
MCC of rectocele
A
- Childbirth and other processes that put pressure on the tissue wall can lead to a rectocele
10
Q
Sx of rectocele
A
Results in pelvic pressure + bowel symptoms
- Symptoms include a soft bulge of tissue in the vagina that may or may not protrude through the vaginal opening
- Defecatory dysfunction (constipation, straining, incomplete emptying)
11
Q
Dx of rectocele
A
POP-Q (pelvic organ prolapse quantification): quantifies the extent and location of defects
- Get a colonoscopy to rule out cancer and rectal studies if indicated
12
Q
Tx of rectocele
A
Kegel exercises, pelvic floor retraining, behavioral changes, bowel regimen, pessary, surgical repair or repair with mesh augmentation
13
Q
a 23-year-old female who comes to the emergency department because of sharp, non-radiating, left lower quadrant pain that has worsened in intensity over the last three hours. She has nausea but denies diarrhea, urinary symptoms, or vaginal discharge. Her temperature is 37°C (98.6°F), pulse is 110/min, respirations are 24/min, and blood pressure is 140/90 mmHg. Pulse oximetry in room air shows an oxygen saturation of 98%. Physical examination shows left lower quadrant tenderness with guarding. Pelvic examination shows left adnexal tenderness without cervical motion tenderness or discharge. A urine pregnancy test is negative. Doppler ultrasound of the left lower quadrant is obtained
A
Ovarian torsion
14
Q
rotation of the ovary at its pedicle to such a degree as to occlude the ovarian artery and/or vein
A
Ovarian torsion
15
Q
Sx of ovarian torsion
A
- Patients with ovarian torsion often present with sudden onset of sharp and usually unilateral lower abdominal pain, in 70% of cases accompanied by nausea and vomiting
16
Q
Dx of ovarian torsion
A
Abdominal ultrasound with Doppler flow is the diagnostic test of choice
- Doppler flow is not always absent in torsion – the gold standard for the diagnosis of ovarian torsion is laparoscopy
17
Q
Tx of ovarian torsion
A
The mainstay of the treatment of ovarian torsion includes laparoscopic surgery to uncoil the ovary
18
Q
a 63-year-old, G5P5, Hispanic woman with a three-day history of increased pelvic pressure and a “bulge” that is felt in her vagina when she coughs. Additionally, she complains of incomplete emptying of her bladder, constipation and has noticed a recent worsening of lower back pain
A
Uterine prolapse
19
Q
Uterus descends toward or into the vagina. It happens when the pelvic floor muscles and ligaments become weak and are no longer able to support the uterus. In some cases, the uterus can protrude from the vaginal opening
A
Uterine prolapse
20
Q
MCC of uterine prolapse
A
Caucasian women, after labor/delivery, chronic cough
21
Q
Sx of uterine prolapse
A
- Vaginal fullness, abdominal pain worse late in the day, after prolonged standing. Relieved by lying down.
22
Q
Prolapse of the uterus into the vaginal canal - graded by uterine descent:
A
- 0 degree: No descent
- 1st degree: To the upper vagina/descent between normal and ischial spine
- 2nd degree: To the introitus/between ischial spines and hymen
- 3rd degree: Cervix is outside the introitus/within hymen
- 4th degree (sometimes referred to as procidentia): Uterus and cervix entirely outside the introitus/through the hymen
23
Q
Dx of uterine prolapse
A
Diagnosis is confirmed by a speculum or bimanual pelvic examination
- Vaginal ulcers are biopsied to exclude cancer
- Simultaneous urinary incontinence requires evaluation
24
Q
Tx of uterine prolapse
A
Asymptomatic 1st- or 2nd-degree uterine prolapse may not require treatment
- Symptomatic 1st - or 2nd-degree prolapse can be treated with a pessary if the perineum can structurally support a pessary
- Severe or persistent symptoms and 3rd - or 4th-degree prolapse require surgery
- Usually hysterectomy with surgical repair of the pelvic support structures (colporrhaphy) and suspension of the top of the vagina (suturing of the upper vagina to a stable structure nearby)
25
24-year-old **nulligravid woman** comes to your office with an 18-month history of **painful intercourse, difficulty defecating,** and **dysmenorrhea.** These symptoms are cyclical and **come and go with her menses.** Her menses are regular and heavy, requiring 10 to 15 thick pads on the days of heaviest flow. She denies ever being diagnosed with a sexually transmitted infection (STI). She and her husband have been engaging in regular intercourse without contraception for 1 year in an attempt to conceive. On pelvic examination, you find a normal-sized, immobile, **retroverted uterus with nodularity and tenderness on palpation of the uterosacral ligaments.**
Endometriosis
26
**ctopic endometrial tissue implants are found in extrauterine sites, most commonly the ovaries, fallopian tubes, cul-de-sac, and uterosacral ligaments**
Endometriosis
27
“3 D's” of endometriosis
**Dyspareunia, Dyschezia** (difficulty in defecating) and **Dysmenorrhea**
28
Sx of endometriosis
* **The "THREE D'S" - Dyspareunia, Dyschezia** (difficulty in defecating) and **Dysmenorrhea**
* History of **infertility** is also common (30-45% )
* **Pelvic** **pain just before or during menses**
* 20% of women with chronic pelvic pain will have endometriosis
29
Dx of endometriosis
**Definitive diagnosis** is made by **laparoscopy** **(definitive study)** and **confirmed by biopsy**
30
What are PE of endometriosis
* **The uterus is fixed and retroflexed on PE.** Tender nodularity of cul de sac and uterine ligaments
31
Tx of endometriosis
**NSAIDs, OCPs, Danazol, Depo Provera, GnRH agonists, surgical**
* **Oral contraceptives** are first-line medications used in treating endometriosis
* Estrogen-progesterone OCP - ovarian suppression
* Progesterone analogs (e.g medroxyprogesterone and levonorgestrel) - inhibit the growth of the endometrium
* **Gonadotropin-hormone releasing (GnRH) antagonists**
* Pituitary gonadotropin hormone suppressed → ↓ estrogen
* **Danazol (steroid)** - inhibits mid-cycle surges of FSH and LH
* Pain management: Nonsteroidal anti-inflammatory drugs **(NSAIDs)**
* Surgery options include **laparoscopic** ectopic endometrial tissue removal and **hysterectomy**
32
a 33-year-old G1P0 female with difficulty becoming pregnant. She and her husband have been **trying to conceive for over 12 months**, but have been unsuccessful. She reports menarche at age 15 and has had regular periods since then. Her past medical history includes an abortion at age 20 with dilation and curettage procedure. She has also had a pelvic inflammatory disorder, treated successfully with antibiotics.
Infertility
33
Primary vs secondary infertility
**inability to conceive within 12 months of unprotected intercourse**
1. Primary: infertility in an absence of previous pregnancy
2. Secondary: infertility after a previous pregnancy
34
MCC of infertility
* **Anovulation** is the most common cause - amenorrhea and abnormal periods
* Tubal disease
* Male factor
* Unexplained/multifactorial
35
Dx of infertility
Diagnosis is based on PAP, hormonal levels, ultrasound, hysterosalpingogram, semen analysis, ovulation check
**Start with more basic tests:**
* * Take a detailed history first: type of coitus - when, where, how often
* Ovulation tracking:
* Menstrual diary
* **Luteal phase (day 21) progesterone level** - if the progesterone level is less than 3 ng/ml on day 21 then you know that the patient did not ovulate.
* Basal body temperature: **No mid-cycle basal**
* **body temperature increase**
* Male factor is diagnosed by **semen analysis**
* Labs: TSH, prolactin, LH and FSH in women over 35
36
Tx of infertility
* May require medication such as **clomiphene citrate to hyperstimulate ovulation**, surgery (lysis of adhesions in tubal disease) or assisted reproductive technologies (i.e **in vitro fertilization**)
* **Metformin** increases ovulation and pregnancy rates when **PCOS** is the cause
* **Bromocriptine to treat hyperprolactinemia**
37
39-year-old African American woman with **abnormally heavy menstrual bleeding** along with **increased pelvic pressure**. She denies pain and is not using any hormonal contraception. **She uses multiple sanitary pads per day.** On pelvic examination, there is an **enlarged uterus with asymmetric contours.** The uterus is non-tender to palpation.
Leiomyoma
38
benign **smooth muscle cell tumors**
Leiomyoma aka uterine fibroids
39
Sx of leiomyoma or uterine fibroids
* polymenorrhea, menorrhagia, intermenstrual bleeding and/or metrorrhagia
* **Pelvic pressure** and **increased abdominal girth.** Uterine mass
* Population: Black women, family history
40
Leiomyoma types
* **Subserosal:** projects into the pelvis, may be pedunculated
* **Intramural:** within the uterine wall (most common)
* **Submucosal:** projects into the uterine cavity
41
Dx of leiomyomas
diagnose with **ultrasound** and/or MRI ⇒ Uterine mass
42
Tx of leiomyomas
treatment is medical or surgical
* Symptomatic medical treatment: NSAIDs, OCPs, Danazol, Leuprolide (also used to shrink fibroids
pre-operatively)
* Definitive: myomectomy, endometrial ablation, **hysterectomy** (most common surgical tx)
43
22-year-old nulligravida presents with **pelvic pain** and **irregular menstrual bleeding**. She denies sexual activity, and her β-hCG urine test is negative. She has never been on oral contraceptives. On pelvic examination, **unilateral tenderness on the left side** and a **palpable cystic mass** approximately 4 to 5 cm in size are present.
Ovarian cyst
44
Sx of ovarian cyst
* The majority of cysts are harmless and cause **no symptoms**
* Occasionally they may produce **bloating**, **lower abdominal pain**, **dyspareunia**, or **lower back pain**
* Ovarian cysts may be classified according to whether they are a variant of the **normal menstrual cycle (functional)** or **non-functional**
45
3 types of functional ovarian cysts
normal physiologic functioning of ovaries ⇒ follicular (MC) and corpus luteum; 2-3 cm can get as big as 10 cm, clear serous liquid, smooth internal lining
* **Follicular cyst (the most common type):** a dominant follicle fails to rupture
* **Corpus luteum:** dominant follicle ruptures but closes again and doesn't dissolve
* **Theca lutein cysts:** overstimulation of HCG produced by placenta so only seen in pregnancy
46
3 main complications of ovarian cysts
* **Hemorrhagic:** more common with follicular and corpus luteal cysts
* **Rupture:** release contents into peritoneal cavity, frequently after sexual intercourse
* **Torsion:** ovary twists around suspensory ligament, cuts of blood supply to the ovary (risk if the cyst is \> 5 cm)
47
PE findings of ovarian cysts
**ruptured** = pain, low blood pressure, abdominal or shoulder pain, tachycardia; [**ovarian torsion**](https://smartypance.com/lessons/ovary/ovarian-torsion/) = waxing and waning pain, n/v, low-grade fever
48
FIrst imaging study of choice for ovarian torsion vs cyst
**Abdominal and pelvic ultrasound**
Definitive diagnosis is direct visualization of a torsed ovary during surgery, and prompt operative evaluation is the mainstay of treatment to preserve ovarian function.
49
Dx of ovarian cyst
**Transvaginal** **ultrasound****/abdominal**
* **MRI:** If ultrasound indeterminate for surgical resection evaluation
* Labs: **Serum CA-125** (in menopausal, postmenopausal individuals) ⇒Assists in ruling out ovarian cancer
* Histologic analysis via **ultrasound-guided aspiration** (definitive)
50
Tx of ovarian cysts
* **Most resolve** in **one month**
* **Follow-up imaging** in women of reproductive age for incidentally discovered simple cysts on ultrasound is **not needed until 5 cm**, as these are usually normal ovarian follicles
* For simple cysts greater than **5 cm but less than 7 cm** in premenopausal females, cysts should be **followed yearly**
51
What dx need to be done for suspected rape
Rape constitutes both a **psychiatric emergency** and a **legal situation**; all procedures should be documented, clothing saved, and samples are taken
**Cultures** from the **vagina**, the **anus**, and usually, the **pharynx for gonorrhea** and **Chlamydia**, **RPR** for syphilis, **hepatitis** antigens, **HIV**, **urinalysis,** **pregnancy test** for menstrual-aged women (regardless of contraceptive status)
52
Tx for suspected rape
* **Rocephin** 250 mg followed by oral **doxycycline** twice daily x 7 days
* **Tetanus toxoid** if indicated
* The patient should be given the option of **emergency contraception**
* **Counseling:** As soon as possible after the event, and preferably before leaving the emergency department, the patient should talk to a mental health professional and follow-up counseling should be scheduled
53
What type of urinary incontinence is this **“**(**detrusor overactivity) -** frequent small amounts of urine**”**
Urge incontinence
54
What type of urinary incontinence **Occurs at night and disrupts sleep**
Urge incontinence
55
Tx of urge incontinence
**Bladder-training exercises**
If this is unsuccessful, medications include **anticholinergics (oxybutynin)** and **TCAs (imipramine)**
56
What type of urinary incontinence is this : **(weakness of pelvic floor) -** urine leakage due to abrupt increases in intra-abdominal pressure (eg, with coughing, sneezing, laughing, bending, or lifting).
Stress incontinence
57
Women after **multiple deliveries and no urine loss at night** have what type of urinary incontinence?
Stress incontinence
58
Tx of stress incontinence
* Treated with **Kegel exercises** to strengthen pelvic floor musculature
* Vaginal **estrogens**
* Use of a **pessary**
* **Surgery** (there are various options, and a popular option is a **mid-urethral sling**)
59
What type of urinary incontinence is this: **(impaired detrusor contractility) -** occurs when urinary retention leads to bladder distention and overflow of urine through the urethra
Overflow incontinence
60
**Diabetic patients** and patients with **neurologic disorders with** **Elevated postvoid residual volume**
**What type of incontinence?**
Overflow
61
Tx of overflow incontinence
* Treated with **intermittent self-catheterization** is the best management
* **cholinergic agents** (bethanechol) to increase bladder contractions
* **α-blockers** (terazosin, doxazosin) to decrease sphincter resistance
62
patients who have normal voiding systems, but who have difficulty reaching the toilet because of physical or mental disabilities
Functional incontinence
63
Increased urinary volume and the inability to timely urinate
Functional incontinence
64
Tx of functional incontinence
* Treatment includes **scheduled voiding times**
65
Stress and urge incontinence is considered:
Mixed incontinence
66
Tx of mixed incontinence
**Lifestyle modifications** and **pelvic floor exercises** are first-line
* If unresponsive to first-line treatments then therapy is based on the predominant symptoms
