Tory Davis, PA-C
Mercy Hospital

 Pelvic Organ Prolapse
 Defects in pelvic support structures result in pelvic relaxation abnormalities
 Classified by anatomical location
 Severity by Stage 0-IV

 Anterior vaginal wall
– Cystocele
– Bladder prolapses
 Posterior wall
– Rectocele
 Apical wall defect
– Uterine prolapse
– Vaginal vault prolapse (post-hyst)
– Enterocele

 Age
 Parity
– Vag parity  3xRR
– >2 deliveries  4.5RR
 Obesity
 Hx pelvic surgery
 Diseases/conditions
– Chronic cough
– Constipation
 Heavy lifting
 Menopause
 Inherent quality of connective tissue

 Vaginal fullness
 Pressure
 Heaviness
 Discomfort
 Dysparunia
 Reducible mass in introitus
 Low back pain
 Incomplete void
 Stress incontinence
 Frequency
 Urinary hesitancy
 Splinting
 Coital laxity

 Lithotomy position first, standing prn
 Vulvar ulcerations
 Relaxed genital hiatus
 Thin walled, smooth bulging mass
– Varying severity
 Observed valsalva
 Check anterior and posterior walls
 Rectovaginal

 Antepatrum, intrapartum, postpartum pelvic floor exercises
 Avoid other reversible/controllable risk factors
 Estrogen therapy p menopause to maintain pelvic tissue tone

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

 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
 3x more common in women (shorter urethra and greater likelihood of connective tissue, muscle and nerve injuries)

 Gender
 Age
– In elderly, 30% increase prevalence with each 5-year age increase
 Hormonal status
 Birthing trauma
– Damage to pelvic floor neuromusculature
 POP

 Stress UI: urinary leakage on effort or exertion
 Urge UI: leakage immediately preceded by sense of urgency “Gotta go!”
 Mixed UI: Likely most common

 Duration
 Frequency
 Severity
 Social implications
– What do I mean?
 Use of protective items (pads, diapers, etc)
 Mental function

 Pelvic exam
 Q tip test for bladder neck hypermobility
 Cough stress test
 Neuro exam
 Urodynamic studies

 Reduce caffeine and alcohol
 Fluid restriction
 Timed voiding
 Kegels
 Biofeedback
 Electric stimulation
 Pessaries
 Surgery

 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%

 Involuntary contractions of bladder

“Overactive Bladder”
 Cause unknown
 Prevalence 10-50%

 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%

 Infectious causes: already covered, right? But still need to be considered
 Atrophic vaginitis
 Lichen sclerosis
 Bartholin glands
 Vulvodynia

 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?

 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

 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

 Steroids
 Topical high potency for 3 months, taper to less potent for maintenance

 What are the Bartholin glands for?
 What can go wrong with them?

 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
 Drain with Word catheter or marsupialization
 Excision if recurrent

 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?)

 Stenosis
 Nabothian cysts
 Polyps
 Already covered: HPV and other STIs, cervical dysplasia

 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

 Congenital
 Inflammatory
 Neoplastic
 Surgical
– Think of this when treating cervical dysplasia: LEEP causes less stenosis than cold-knife cone biopsy

 Don ’t freak out. Benign
 Yellowish translucent raised pearl-like lesions on ectocervix
 1 mm to 3 cm
 Few or multiple

 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

 Asymptomatic or c/o intermenstrual or postcoital bleeding
 Sometimes assoc with infertility
– Why?
 PE: red fragile growth protruding from os
– 2 mm to 3 cm
– Not palpable
 Remove by grab-n-twist
– Larger ones to OR

 Common, usually benign
 Management dictated by presentation
 Malignancy must be excluded
– US usually 1 st imaging for adnexa
– Septations, solid parts and Doppler flow within lesion are suspicious
 If likely benign and <6 cm, observe
– Why 6 cm?

 Follicular cyst- most common. From growth of follicle, often doesn ’t release the egg
– Usually not sx, usually resolve
 Corpus luteum cyst
 Hemorrhagic cyst
 Dermoid cyst- the cyst with teeth

 If fluid-filled, monitor with periodic U/S
 If not, remove it
– Laparoscopic approach most common
 Also remove if >6 cm to reduce risk of torsion
 Prevention with OCPs
 Tx pain with NSAIDs

 Polycystic Ovarian Syndrome
 Common (5-10%) female endocrinopathy
 Oligo or amenorrhea and anovulation
 Hyperandrogenism
– What ’s that look like?
 Ultrasonographic evidence of polycystic ovaries
 Frequently, infertility
 Insulin resistance




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)
 Due Thursday April 15 to me at my next lecture.

 Ovaries don ’t produce enough estrogen in women < 40
– Despite high levels of circulating gonadotropins
 Suspect in female <40 with s/s of estrogen deficiency

 Atrophic vaginitis
 Osteopenia/osteoporosis
 Decreased libido
 Infertility
 Menstrual changes

 High FSH, low estradiol
 Find cause
– Enzyme defects
– Genetic defects
– Autoimmune causes (thyroiditis,
Addison ’s, hypoparathyroid, myasthenia gravis)
– Environmental factors (chemo, smoking, viruses, surgery)

 Desiring pregnancy: IVF plus exogenous hormones to support endometrium
 Not desiring pregnancy: HRT until age
50s
 Either: psychosocial support

 Will be covered in Menstrual
Abnormalities lecture
 Questions?