Chapter 7: Benign disorders of Female reproductive tract

pelvic floor disorders

• include

  • urinary incontinence

  • pelvic organ prolapse

  • fecal incontinence

  • and other sensory and emptying abnormalities

• pelvic floor: muscles that hold up pelvic organs

• problems occur why: can get strained and weak; weakness of connective tissue and muscular support of pelvic organs; happen after getting stretched during pregnancy/delivery

Pelvic organ prolapse (POP)

• Happens when structures shift or protrude into or outside of the vaginal canal

• Affects 75% of all women who have a vaginal birth

• 4 Types

  • Cystocele - bladder protrudes vaginal canal

  • Rectocele- rectum sags and protrudes

  • Enterocele - small intestine

  • Uterine prolapse

• Management

• Clinical manifestations, physical exam, lab & diagnostic tests

POP therapeutic management

• kegel exercises

• hormonal replacement therapy

• dietary/lifestyle modifications (rectocele due to constant straining)

• pessaries - assistive devices to hold in place

• colpexin sphere

• surgery: anterior or posterior colporrhaphy; vginal hysterectomy

POP assessment

• health history

  • risk factors: pregnancies/how many deliveries (G&P), UTIs

• Clinical manifestations: asymptomatic; feeling of dragging, lump in vagina, sometimes “coming down”

• Physical: pelvic exam for obvious protrusion; bladder function

• Lab and diagnostic: urinalysis, urine culture, post-void urine volume (>100=bad)

urinary incontinecn

 Involuntary loss of urine

 50% of all women experience urinary incontinence in their lifetime

 Affected by function; pelvic floor issues; neural control; pregnancies

 Estrogen: controls tone of bladder sphincter

 Types

• Urgency

• Stress

• mixed

Therapeutic management of incontinence

• urge

  • bladder training

  • kegel exercises

  • pessary ring

  • pharmacotherapy (anticholinergics)

  • surgery only if other methods fail

• Stress

  • weight loss; smoking cessation; avoidance of constipation; kegel exercise; pessaries; weighted vaginal cones; periurethral injection meds (duloxetine); estrogen replacement therapy; surgery

Assess incontinence

• history; physical exam

• lab tests (urinalysis and urine culture); urodynamic testing

• management

  • discussion of treatment

  • education about good bladder habits

  • support and encouragement

Why people don’t talk about bladder control issues

• UI is inevitable and not amenable to treatment

• may think UI is normal part of aging

• UI is part of being female and “accept it”

• consider a hygiene problem and not a medical condition

Benign growths

• polyps

• uterine fibroids

• genital fistulas

• bartholin cysts

• ovarian cysts

Polyps

 Small benign growth

 Endometrial, Endocervical, Cervical - differentiate between how they appear/bleeding

 Frequently the result of infection, chronic inflammation, abnormal local response to estrogen, or local congestion of cervical vasculature

 Commonly seen near cervical os and uterus

 Endocervical(reddish) more common than cervical

• multiparous women age 40-60

 Endometrial polyps are localized overgrowth of endometrium

• rare in women <20; peaking in fifth decade; gradually declining after menopause

Cervical polyps (grayish) appear after menstruation and/or intercourse; outsideish

 Treatment: removal via forceps; during hysteroscopy; D&C laser vaporization

 Diagnosis:

POLYPS assessment and management

• assessment

  • Endocervical: cherry red due to vascular area

  • Cervical: grayish-white due to connective tissue

  • often asymptomatic

  • mild symptoms: abnormal vaginal bleeding or discharge

  • most frequently metrorrhagia (heavy bleeding period) with endometrial polyps

  • Endometrial polyps detected via UA or hysterectomy

• management

  • explanation

  • rationale for removal

  • follow up care instructions

Uterine fibroids

 Known as Myomas or Leiomyomas

 Benign tumors composed of smooth muscle and fibrous connective tissue

in uterus

 Grow slowly----- When do you think Fibroids would grow most rapidly???

• grow due to high estrogen levels; menstruation or pregnancy

 Classifications

 Fibroids are most common indication for hysterectomy in US

Medical treatment is difficult due to sensations and assessment is similar to menopause

 vaginal, laparoscopic, open surgery

Therapeutic management UF

• goal is to reduce symptoms and tumor size (block estrogen)

• uterine artery embolization to block blood supply to fibroid

• GnRH agonist to stop ovulation and production of estrogen

• surgical: myomectomy, laser surgery, hysterectomy

assessment of UF

• assess

  • health history S/S

  • physical exam; ultrasound for confirmation

• management

  • preoperative teaching

  • aftercare

genital fistulas

 Abnormal opening between genital tract and other organ

 Majority are due to obstetric trauma and genital cutting

 Common types

• Vesicovaginal - bladder to genital tract

• Urethrovaginal - from urethra

• Rectovaginal - from sigmoid colon/rectum

genital fistulas pathophysio

During labor bladder is displaced into abdomen and anterior vaginal wall → bladder & Urethra compressed by the fetal head descending → prolonged/unrelieved compression → ischemia → necrosis → fistula formation

bartholin cysts

 Fluid filled sac-like structures; lubricate vagina

 Occur when the gland becomes blocked

 Bartholin glands are mucus secreting glands near vaginal opening

 Cannot see or feel them unless they are infected

 Treatment

• Sitz bath

• Analgesics

• Antibiotic

ovarian cysts

 Fluid filled sac that grows on the ovary

 Found during pelvic exam or ultrasound

 Common types

• Follicular

• Lutein

• Theca-lutein

• PCOS

tx:

• benign vs solid ovarian malignancy; transvaginal ultrasound, laparoscopy; oral contraceptives(to not ovulate); analgesics

• PCOS: drug and nondrug therapy; lifestyle changes

ovarian cysts assess and managemet

s/s of PCOS; hirutism, alopecia, virilization, menstrual irregularity and infertility

physical exam:

management

• education; referral for surgery; support and reassurance

PCOS

 Anabolic syndrome - affects all hormones (pregnancy + testosterone);

Endocrine condition for women in their reproductive age

 Presence of multiple inactive follicles within ovary that interferes with ovulation

• hormones are off; hard for woman to get pregnant

 Responsible for 70% of Anovulatory Infertility

 Multifaceted disorder; higher chance of gestational diabetes and preeclampsia

 Treatment: Metformin, oral contraception (regulate hormones), clomid; invitrofertilization(IVF)