Vulvar lesions: Classification: Red lesions: Candidiasis Contact dermatitis Vulvodynia Systemic skin disorders: Psoriasis Dermatosis White lesions: Dystrophies: Lichen sclerosis (↓ skin growth) Vulvar hyperplasia (↑ skin growth) Vulvar intraepithelial neoplasia Vitiligo Dark lesions: Nevi Malignant melanoma Ulcers: Genital herpes Syphilis Lymphogranuloma venereum (LGV) Granuloma inguinale Human immunodeficiency virus Carcinoma (see large tumors) Small tumors: Condylomata Sebaceous cysts Inclusion cysts Fibroepithelial polyps Bartholin abscess Carcinoma (see large tumors) Large tumors: Fibroma Lipoma Large condylomata Carcinoma Red lesions: Candidiasis: Note: Not an STD Normal flora in vagina – controlled by the microclimate of the vagina, which is hormone dependant Sx – involvement includes labia minora & majora: Severe pruritis Burning Whitish discharge (thin or thick) Oedematous Red Tender to touch Cx – recurrences after medical treatment, due to: Systemic antibiotics – prolonged/repeated use DM Corticosteroid use e.g. asthma COC’s esp. high dose oestrogen types ↓ Immunity e.g. HIV Candida species other than C. Albicans.
Vaginal discharge: Classification of vaginal discharge: Diffuse discharge Physiological Infectious Vaginitis Trichomonas Candida spp. Bacterial vaginosis Endocervicitis: Neisseria gonohorrhoea Chlamydia trachomatis Atrophic Irritants & allergens Localized discharge Foreign body Fistula Neoplasia Cervical discharge Physiological Pathological Endocervicitis Neoplasia Physiological vaginal discharge: Characteristics: Fluctuates with menstrual cycles (with regards to amount & consistency) No malodorous, irritating or blood stained Clear or white Non-homogenous/flocculating pH < 5 Whiff test is negative No vulvar ulcers, rash, erythema, CET Epithelial cells & lactobacilli on wet mount smear Ax: Oestrogen → stimulation of lactobacilli → ↑ lactic acid formation (from glycogen in the discharge) → ↓ pH → infection non-friendly environment. (The rest of the discharge consists of endocervical mucus, exfoliated epithelial cells & vaginal transudate) Mx: Atrophic vaginosis: General: Postmenopausal Sx’s of genital atrophy Ax: ↓ Oestrogen (MP) → ↓ discharge & glycogen → non-flourishing lactobacilli → ↑ pH → 2˚ bacterial Ix Sx: ↓ SC fat → less prominent labia majora Introitus narrows Epithelium → pale & shiny ↓ Vaginal rugae ± Small bleedings Cx → smaller with smaller diameter; ↓ intravaginal portion; no endocervical mucus ± Urethral mucosa prolapse (may be small) Dx: Vaginal pH ↑ → 6.5-7.0 On wet mount – more pus cells (polymorphs) than epithelial cells AND no lactobacilli Mx:
Pelvic masses: Classification: Benign disease: Female internal genitalia: Uterus Pregnancy Myomata Ovaries Solid benign tumors Functional cysts Fallopian tubes ± ovarian involvement Extra-uterine pregnancy Inflammatory masses Endometritis Other pelvic organs: Bladder – full bladder Bowel Faecal impaction Diverticulosis Chronic inflammatory masses Retroperitoneal organs Pelvic kidney Massively enlarged LN’s Psoas muscle abscess Malignant disease: Female internal genitalia Uterus CxCA Endometrial CA Sarcoma Ovaries Ovarian CA Other pelvic organs: Bowel Rectal CA Retroperitoneal organs Sarcomas or soft-tissues Gynaecological US – indications: Bleeding in early pregnancy Suspected ovarian cysts PMB PID IVF Urinary incontinence Suspected congenital abnormalities of uterus/vagina Myomatous uterus: Dx: Hx: Painless OR Doscomfort; backache; heavy-feeling; pressure Sx’s of bladder/bowel ↑ Blood loss during menstruation (usually cyclical) → Dysmoenorrhoea & anaemia Ex: ± Anaemia Distension; lower abdominal pelvic mass (rarely fills abdomen like term pregnancy) Cervix displaced & small Uterus ± enlarged/globular OR single palpable myomata (soild; non-tender; mobile) ± Fill whole pelvis & hollow of sacrum → determined on PR
Delayed menarche with adequate 2˚ sexual development Congenital abnormalities of the genital tract Androgen insensitivity syndrome Poor feedback of hypothalamo-pituitary-ovarian axis Delayed puberty with inadequate or absent 2˚ sexual characteristics Hypothalamic or pituitary dysfunction (serious) Ovarian failure/dysgenesis Delayed puberty with virilisation Adrenal hyperplasia Androgen producing tumors Heraphroditism Mx: R/F Adolescent with excessive uterine bleeding: Pathogenesis: Immature HPO axis → anovulatory cycles (≈1-2yr) → irregular cycles, which may be heavy. Other symptoms e.g. pain seldomly present Other causes: Bleeding disorder; genital tumor; pregnancy complications Dx: Pregnancy test FBC – leukaemia; thrombocytopenia ESR VWF – Hx of bleeding (dental-work/IJ) since birth Mx: Gynaecological tumors in children: Mx: R/F Ovarian tumors: Types: Older children: Germ-cell tumors Young children/adults: Benign cystic teratoma: Growing cystic abdominal mass → ± torsion; ± rupture; ± bleed All complications will cause much pain & shock Precocious puberty: Granulosa cell tumors Androgen producing tumors Mx: R/F
Male & female sterilization – the great snip & tie: Female sterilization by tubal ligation: Selection criteria: Mature & autonomous (can make an informed decision) If not capable of the above, a request fro sterilization has to be made to the minister of health (e.g. mentral retardation) Informed of options Decision must be unhurried Postponed if: Divorce At time of delivery Had a miscarriage Young No gynaecological problems i.e. normal menstruation; not pregnant; normal cervical cytology Types – 2 common types: Laparoscopic using clips (filshie clips) or silastic rubber band (Fallope rings) – if not pregnant; under GA/local anaesthesia Modified – under GA/epidural anaesthesia; using polyglactin/polyglycolic sute material to tie tube off: At C/S OR D1/D2 of puerperium (4-5cm subumbilical transverse incision) OR Interval procedure – if laparoscopic equipment & expertise aren’t available (6-8cm suprapubic transverse incision) Cx: Anaesthetic risks; laparoscopic risks; slight haemorrhage; wound Ix Failure to ligate tube Ectopic pregnancy Post-tubal ligation syndrome – excessive abnormal uterine bledding, pain & dysmenorrhoea (Ax unknown) Failure rate due to – improper tube identification; incomplete ligation/occlusion; reanastamosis (RARE!) Reversal – possible if tubes were ligated & not cauterized/buried & if long enough wide-lumen sections are available; absence of adhesions. Success achieved in 2/3 of patients Mechanism – performed with microscope Male sterilization by vasectomy: Selection group: Voluntary Men with hereditary disease in their side of family Note: Not advised to have vasectomy are men in unstable relationships; under financial or social pressure Important considerations: Man/couple must use contraception for 12wk after procedure After 12wk semen analysis should be preformed When 2 analyses show azoospermia (no sperm) = SUCCESS If persistent sperm → R/F urologist Cx: Recanalisation (small risk) Circulating anti-sperm anti-bodies → decreased successful reversal even if perfectly re-anastamosed Spermatogenesis can continue for years after procedure