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how should a pelvic exam be done?
lithotomy position
what is the appropriate order of a pelvic exam?
external
internal
bimanual
what is done during the speculum/internal exam?
+/- pap smear and culture
what is noted during the bimanual exam?
uterus position, size, shape, tenderness
adnexa ovaries, masses, tenderness
what is done during the rectovaginal exam?
+/- stool testing
what is Lichen sclerosis?
uniform smooth, red, shiny, friable skin associated with pruritis, bleeding, and dyspareunia
what is cervical motion tenderness?
pain with movement of the cervix
what is the screening test for cervical cancer?
Pap smear
what is a Pap smear?
sampling of transformation/transitional zone
what are the primary types of cervical cancer?
squamous cell (MC)
adenocarcinoma
what risk factors are associated with cervical cancer?
sexual activity at young age, multiple partners, STI hx
failure to do proper screening, immune status, smoking
HPV (oncogenic strains 16/18)
what is cervical intraepithelial neoplasia (CIN)?
precancerous condition in which abnormal cells grow on the surface of the cervix
when should the first screening be done?
@ 21, regardless of sexual activity
how often should screening be done between ages 21 and 29?
every 3 years (+HPV is Pap abnormal)
how often should screening be done between ages 30 and 65?
every 5 years (Pap + HPV) OR every 3 years (Pap only)
how often should screening be done post hysterectomy?
no screening if hysto was for benign reason
how often should screening be done after age 65?
well screened —> can end
poorly screened —> continue
how often should screening be done if high risk or prev HPV pos?
every 6 mo - 1 year
what patients are considered high risk?
Hx HPV or cervical/Pap abnormalities
Hx immunosuppresion
Hx DES (synthetic estrogen) exposure
what risk is increased in DES exposed mothers?
breast cancer
what risk is increased in DES exposed daughters?
cervical changes (adenosis)
clear cell adenocarcinoma of cervix/vagina
what risk is increased in DES exposed sons?
epididymal cysts
how does a retention/Nabothian cyst present?
benign, translucent yellow/clear nodule
how does a cervical polyp present?
protrudes through os
what cervical surface variation is present?
retention/Nabothian cyst
what cervical surface variation is present?
cervical polyp
what is ectopy (erythroplasia)?
normal physiological change seen during pregnancy and puerperium
how does a postmenopausal cervix present?
stenotic os, pale face, +/- petechiae
what cervical surface variation is present?
ectopy (erythroplasia)
what cervical surface variation is present?
postmenopausal cervix
what cervical surface variation is present?
mucupurulent cervicitis
what is mucupurulent cervicitis?
sexually transmitted infection
what cervical surface variation is present?
carcinoma
what causes cervical os stenosis?
congenital
menopause
cancer or cancer tx
post op cervical procedure
what s/sxs are associated with cervical os stenosis?
menstrual irregularities
infertility
abdominal fullness
how is cervical os stenosis treated?
IF SYMPTOMATIC!!
dilation +/- stent
what is the most common STI in the US?
human papilloma virus (HPV)
what are the mucosal strains of HPV?
6, 11
what are the oncogenic strains of HPV?
16, 18… 31, 33, 45, 52, 58
how is HPV transmitted?
vaginal, anal, oral contact
how is HPV prevented?
vaccine (Gardasil 9)
what lesions are associated with HPV?
vaginal warts - CONDYLOMA ACUMINATA
cauliflower-like growths (flesh colored)
vulva, vagina, cervix, perineum, anus (area of contact)
how is HPV diagnosed?
inspection
Pap smear
colposcopy
biopsy
what is uterine prolapse?
condition where the uterus slips from its normal position and descends from the pelvic cavity into the vagina
what causes uterine descent/prolapse?
secondary to weakness of pelvic floor muscles
who most commonly experiences uterine descent/prolapse?
multiparous woman
what is 1st degree uterine descent/prolapse?
cervix in vagina
what is 2nd degree uterine descent/prolapse?
cervix in introitus
what is 3rd degree uterine descent/prolapse?
cervix and vagina outside introitus
what is rectocele prolapse?
rectum in posterior vagina
what is cystocele prolapse?
bladder to anterior vagina
how does pelvic organ prolapse manifest?
asxs
feeling a bulge (like something is falling out)
excess pressure
urinary
defecatory
sexual dysfunction
what is the most common tumor in females?
fibroids
are fibroids benign or malignant?
benign
what are other terms for fibroids?
myxoma, leiomyomata
how do fibroids appear on exam?
firm, irregular, vary in size
what are the s/sxs of fibroids?
secondary dysmenorrhea
increased volume of flow
+/- anemia
how do ovarian cysts and tumors present?
+/- pain
how does a ruptured tubal/ectopic pregnancies present?
severe UL abdominal pain, nausea, amenorrhea +/- shock
what is ovarian torsion?
rotation of ovary occludes ovarian artery and/or vein
what side is most common for ovarian torsions?
right
what risk factors are associated with ovarian torsion?
pregnancy
increased length of ovarian ligaments
enlarged ovaries
tumors
what s/sxs are associated with ovarian torsion?
acute onset, unilateral abdominal pain
nausea, vomiting, fever, chills (with necrosis)
how is ovarian torsion diagnosed?
doppler ultrasound
how is ovarian torsion treated?
surgery (within 6 hours)
what are Bartholin cysts/abscesses?
inflammation, trauma, cancer causes obstruction of duct
retention of secretions causes cyst +/- infection
what microbes commonly cause Bartholin cysts/abscesses?
Staph/Strep, E. coli, STDs
what s/sxs are associated with Bartholin cysts?
non tender, smaller swelling of labia
what s/sxs are associated with Bartholin abscesses?
very tender, larger, difficulty ambulating due to pain
how are Bartholin cysts/abscesses treated?
I&D +/- wound catheter
marsupialization (DEFINITIVE)
PO Abx PRN
warm sitz baths
what is pelvic inflammatory disease (PID)?
spectrum of inflammatory disorders of upper genital tract, including any condition of…
cervicitis
endometritis
salpingitis, oophoritis, tubo-ovarian abscess
peritonitis
what is the most common etiology of pelvic inflammatory disease (PID)?
STI (Gonorrhea and Chlamydia) or BV (G. vaginalis)
how does PID present?
lower abdominal pain
vaginal discharge
fever/chills
hematuria
painful intercourse
irregular menses
extreme cervical motion tenderness (Chandelier sign)
what complications are associated with PID?
infertility
ectopic pregnancy
chronic pelvic pain
liver adhesions (Fitz Hugh Curtis syndrome)
what is pilonidal disease?
pore/sac fills with fluid/debris then forms sinus tract
where is pilonidal disease located?
midline superficial to coccyx or lower sacrum
what occurs if pilonidal disease becomes infected?
pilonidal abscess
how is pilonidal disease treated?
I&D, warm soaks, Abx only if cellulitis
excision (marsupialization)
