PD II Female GU Pt 1 (A&P, Hx, S&S)

what are the glands of the vestibule?

Skene’s and Bartholin’s (greater vestibular)

where are the Skene’s glands?

paraurethral

where are the Bartholin’s glands?

posterolateral to the vaginal orifice

what is the vagina?

passage connecting uterus and introitus

what is the introitus?

opening of vagina

what are the borders of the vagina?

• anterior = urethra

• posterior = rectum

• inferior = vulva

• superior = cervix

what are rugae?

transverse folds where vaginal mucosa lies

what is the function of the vagina?

intercourse and birthing canal

what are the forcines of the vagina?

• anterior

• posterior

• lateral (2)

where is the anterior fornix?

near vesico-uterine pouch

where is the posterior fornix?

betw posterior vagina and cervix near rectovaginal pouch

what can be palpated from the lateral fornices?

ovaries and fallopian tubes

what is the arterial supply of the vagina?

internal iliac a.

• uterine a.

• vaginal a.

where does the upper 1/3 of the vagina drain into?

inguinal nodes

where does the lower 2/3 of the vagina drain into?

pelvic, sacral, and abdominal nodes

what is the arterial supply of the uterus?

uterine and ovarian a.

where does the uterus drain into?

lumbar nodes

what is the ectocervix?

covering cervical face

what is the endocervix?

in cervical canal (AKA os)

what are the squamous cervical epithelium?

shiny, pink (outer)

what are the columnar cervical epithelium?

deep, red, plushy (inner)

where do the squamous and columnar cervical epithelium meet?

squamocolumnar junction

what is the transformation (transitional) zone?

AKA squamocolumnar junction, where pap smears are obtained

what occurs at the squamocolumnar junction?

area of constant cellular activity

• highly sensitive to irritants, mutagens, and viral agents (HPV)

what is an anteverted/anteversion uterus?

NORMAL POSITION

• forward facing

• right angle to vagina

• posterosuperior to bladder

• anterior to rectum

what is a retroverted/retroversion uterus?

BACKWARD TILTED

• tipped back aiming towards rectum INSTEAD of toward abdomen

what is a retroflexed uterus?

uterus is bent backwards towards rectum

what are the components of the adnexa?

• ovaries

• fallopian/uterine tubes

• supporting ligaments (broad, round, ovarian)

what conditions are related to the adnexa?

masses or tenderness

what are the primary functions of the ovaries?

• production of ova (eggs)

• secretion of hormones

what hormones are secreted from the ovaries?

• estrogen

• progesterone

• testosterone

what hormone is secreted by the hypothalamus?

GnRH

what hormones are secreted from the pituitary?

FSH and LH

what hormone is secreted from the follicle?

estrogen

what is menarche?

1st period

what are the aspects of the menstrual cycle?

• days between day 1 and day 1

• days of bleeding

• regularity

• associated moliminal sxs

what is menopause?

cessation of menses x 1 yr

what does G stand for in the GPA system?

gravida, total number of pregnancies

what does P stand for in the GPA system?

parity, pregnancies > 20 wks

what does A stand for in the GPA system?

abortions (spontaneous or induced termination)

what is a normal menstrual frequency?

> 24 and < 38 days

what is a normal menstrual duration?

< 8 days

what is dysmenorrhea?

painful menses

what is primary dysmenorrhea?

begins shortly after menarche and occurs with every menses

what causes primary dysmenorrhea?

increased endometrial prostaglandin synthesis —> increased tone

how is primary dysmenorrhea treated?

decrease prostaglandins (NSAIDs)

what is secondary dysmenorrhea?

acquired disorder as a result of endometriosis, IUDs, polyps, fibroids, obstruction of flow, etc

how is secondary dysmenorrhea treated?

treat primary cause

what is an imperforate hymen?

blockage of normal vaginal opening

what results from an imperforate hymen?

amenorrhea as a result of a vaginal outlet obstruction

what s/sxs are associated with amenorrhea?

lower abdominal pain, dysuria, bowel movement changes

how is an imperforate hymen treated?

perforation

what causes a painless vaginal chancre?

syphilis

what causes painful vaginal vesicles?

HSV

what causes painful vulva masses?

abscess of Bartholin gland

what causes vaginal venereal warts?

HPV

what is the normal vaginal pH?

< 4.5

what is leukorrhea?

vaginal discharge

what bacteria is predominant in a healthy vagina?

lactobacilli

during what part of the menstrual cycle are vaginal secretions clear and elastic?

estrogen surge

during what part of the menstrual cycle are vaginal secretions thicker and white?

Luteal phase

what is the most common cause of candida vaginitis?

Candida albicans

what risk factors are associated with candida vaginitis?

• antibiotics/steroids

• diabetes

• OCP

• immunosuppression

• douching

• tight clothing

what s/sxs are associated with candida vaginitis?

• white, curd-like “cottage cheese” discharge

• no odor

• pruritis

• dysuria

• dyspareunia

how does candida vaginitis present on exam?

• inflammed vulva/vagina mucosa

• +/- friability with thick adherent white discharge

how is candida vaginitis diagnosed?

KOH prep with branching/pseudohyphae

how is candida vaginitis treated?

antifungal (oral, topical, intravaginal)

• -AZOLE!!

what is bacterial vaginosis?

elusive pathogenesis, polymicrobial anaerobic overgrowth

what is the most common cause of bacterial vaginosis?

Gardnerella vaginalis

what risk factors are associated with bacterial vaginosis?

• multiple sex partners

• frequent intercourse

• after douching

how is bacterial vaginosis diagnosed?

Gram stain and Amsel criteria (3/4)

what are the Amsel criteria?

• homogenous, non-clumping VD

• amine (fishy) odor when potassium hydroxide solution is added to vaginal secretions

• presence of clue cells (> 20%) on microscopy

• vaginal pH > 4.5

in what pathologies can the “whiff" test” be positive?

BV and trich

what are clue cells?

stippled appearance due to adherent coccobilli and fuzzy, obscured borders

how is BV treated?

• metronidazole (Flagyl or Metrogel) (PO or topical/vaginal)

• clindamycin (Cleocin or Clindesse) (PO or topical/vaginal)

what risks are increased with BV?

• pregnancy complications

• STIs

what is a common side effect of clindamycin?

C. diff infections

what is a common side effect of metronidazole?

disulfuram rxn

what are the signs/symptoms of trichomonas?

• vulvovaginitis (dysuria, dyspareunia)

• leukorrhea (yellow/gray/green, frothy, odor)

how does trichomonas present on exam?

• vaginal erythema

• “strawberry cervix” (punctate erythema on cervical face)

how is trichomonas diagnosed?

• wet mount

• culture

• detected on pap smears

what is seen on a positive trich wet mount?

motile trichomonads (single celled parasite with 2-5 plagellae)

how does gonococcal cervicitis present?

• green, yellow, no odor, adherent

• pus from cervical os

what is vulvitis?

external genital pruritus, burning, redness, rash

what is vaginitis?

inflammation of the vagina

what is vulvovaginitis?

vaginal irritation, pain, and pruritus

what can cause vaginal itching?

• candidiasis

• glucosuria (DM, DM rx, renal tubule acidosis)

• vulvar leukoplakia

• external irritant

• psychosomatic

what treatment should be AVOIDED for vaginal itching?

talcum powder on vulva

what can cause abdominal pain?

• complication of pregnancy

• acute inflammation

• chronic inflammation

what acute inflammation can cause abdominal pain?

• infections

• ovulatory (mittelschmerz)

• IUD

what chronic inflammation can cause abdominal pain?

• structural/functional disorder

• infections

what is dyspareunia?

pain during or after intercourse

what physiologic causes can cause dyspareunia?

• infection

• tumors (rectovaginal septum, uterus, ovaries)

• atrophic vaginitis

• inadequate lubrication

• vaginismus

what is vaginismus?

severe pelvic pain and spasm when labia is merely touched

what psychogenic causes can cause dyspareunia?

• fear of pregnancy

• penetration anxiety

what can cause general changes in hair distribution?

• dermatologic alopecia

• dieting, stress

• infection

• idiopathic, autoimmune

• thyroid disease

what is hirsutism?

excess hair on face, trunk, or limbs (male pattern)

what condition is associated with hirsutism?

PCOS

what s/sxs are associated with PCOS?

• amenorrhea

• oligomenorrhea

• infertility

• acne

• obesity

• aconthosis nigricans

what is virilization?

excessive hirsutism with receding temporal hair, deep voice, or clitoral enlargement