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 

Anatomic location 

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 

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

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 

– 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 

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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% 

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 

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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 

– 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?

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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 

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 

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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 

– US usually 1st imaging for adnexa – Septations, solid parts and Doppler flow within lesion are suspicious 

If likely benign and 6 cm to reduce risk of torsion  Prevention with OCPs  Tx pain with NSAIDs 

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 

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

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Suspect in female