BENIGN GYNECLOGIC LESIONS Rowena M. Auxillos, MD,FPOGS, MBA-H ssSTEPS. | DESCRIPTION CONSENT ANESTHESIA Adequate pain relief ASSISTANCE Neonatal support BLADDER Bladder empty CERVIX Fully dicted, membranes ruptured Position, station and pelvic adequacy a DETERMINE hink possible shoulder dystocia EQUIPMENT [Check for functionality and quality * Phantom application "Left blade, left hand, matemal left side, pencil grip and vertical insertion, with right thumb | directing blade Right blade, right hand, matemal right side, pencil grip and vertical insertion with left thumb directing blade FORCEPS "Lock blade and support Check application: 1. Posterior fontanelle 1 cm above plane of shanks 22. Fenestration no more than one fingerbreadih between it and scalp 33. Sagittal suture perpendicular to plane of shanks with occipital sutures 1 cm above respective ‘Applied with contraction and/or maternal expulsive effort GENTLETRACTION fiction in axis of hidttanal HANDLE ELEVATED. [Do not elevate handle too early INCISION Consider episiotomy JAW. Remove forceps when jaw is reachable or delivery assured INSPECT FOR INJURIES/LACERATIONS DOCUMENTATIONMATERNAL ANATOMY External and Internal Generative Organs ewANTERIOR ABDOMINAL WALLBlood Supply PALIN Branches renee cous Bees U ue eel 2 ale Becucen easel CEM EC CIN mT ety cua semen Sen cel eet oatPU cidilerteeColrle hei lare leg) Intercostal nerves (T7.,4) Subcostal nerve (T,») lliohypogastric nerve- skin over suprapubic area llioinguinal nerves (L,) ee ee + can be entrapped.in low transverse incisions closure and Oa ee eeu Re ee eld Seed oa ese acy + medial portion:of the thigh: To dermatome- approximates the level of the umbilicus.Pia aeo nue lattavc Lilet) Intercostal nerves (T7.11) Subcostal nerve (T,2) lichypogastric nerve- skin over suprapubic area llioinguinal nerves (L,) ae el + can be entrapped.in: low transverse incisions closure and PO Meee ee ed Became ey + medial portion:of the thigh: umbilicus.A285 y/o primigravid underwent cesarean section (Pfannensteil) for breech presentation. On the 5" post-op day, she claims numbness on the medial aspect of her Aalto AMA Ancor colin tat saCell eile gan SMU \ ACN 1A) injured during the operation? oO ta teleleENa 1} Hliohypogastric nerve io} Ryeir ice Cua Bp Ulioinguinal Nerveea ie RS elaeR oleate) WiC neces Fibroma Urethral Prolapse: Lipoma AUNT OI Dermatologic Lesions: * Bartholin’s Cyst eCornell ey es saaiia * Sebaceous Cyst * Neurodermatitis Leduc eee lateltrs lo] eA « * Psoriasis + Cutaneuos Candidiasis Sealer aac ileey NSU Endometriosis Hemangioma PM Leoluiy Ata eC) baal oe taller kuakelaAc)CHARACTERISTICS CAUSE SYMPTOMS DAIGNOSIS. ‘TREATMENT URETHRAL CARUNCLE fleshy outgrowth at distal edge of the urethra . postmenopausal ? soft, smooth, friable and bright red and appears as an eversion of the urethra + chronic irritation or infection + mostly asymptomatic + dysuria frequency, and urgency biopsy under local anesthesia + oral or topical estrogen * avoidance of iritation ‘cryosurgery, laser therapy, fulguration, or operative excision Foley cath retention 48-72 H to prevent stenosis Pie eal dal premenarchal fexnales it may be ulcerated with necrosis or grossly edematous. dysuria hot sitz baths Antibiotics: topical estrogen cream excision of the redundant mucosa -rarely done| Majorty are asymptomatic | {CHARACTERISTICS SYMPTOMS: DAIGNOSIS ‘TREATMENT eae) Contains sterile, mucinous fluid Obstructed Bartholin’s duct at 5/7 o'clock Usually asymptomatic if small Inspection/biopsy if postmenopausal 5-7% carcinoma formation None unless large and causing discomfort Firm, smooth, white, yellow papules/nodules on hair-bearing areas asymptomatic Content : white caseous material Excision if recurrently infected Bits of epithelium implanted in the skin during surgery or trauma episiotomyilaceration Asymptomatic if small Inspection/biopsy Excision When pressed, no| fluid from urethral meatus Infection/scaring of ducts Discomfort during examination MRlultrasound Excision* Mole * A localized nest or cluster of melanocytes * One of the most common benign neoplasms * Generally asymptomatic * 5% -10% of all malignant melanomas arise from the vulva + 50% of malignant melanomas arise from preexisting nevus + Asymmetry + Border irregularity + Color variegation + Diameter usually greater than 6 mm + High malignant potential + Excisional biopsy : three-dimensional + 5-10 mm of normal skin surrounding the nevus* Rare malformations of blood vessels. * Most common benign solid . overed during childhood * Smooth surface and distinct contour * 60% spontaneously regress in size * Low grade potential malignancy * Asymptomatic * Smaller fibromas : asymptomatic * Become ulcerated and bleed * Large tumors : chronic pressure symptoms or acute pain * Treatment * Excision: symptomatic and/or continue to grow+ Benign, slow growing, * From apocrine sweat circumscribed tumors of fat glands of the inner surface cells b of labia majora + 2-4 most frequent benign * Usually asymptomatic pee elena * Pruritus, bleeding if the tumor tumor undergoes necrosis + Labia majora / superficial * Excisional biopsy : + Malignant potential is low treatment of choice+ Benign skin adnexal neoplasm eccrine * Rare in the vulva origin; rare + Firm, small nodule or nodules + Papules skin colored / yellow + Site * Coalesce to form cords of firm tissue Bordineslediobetsiia feceravart + Hormonally related > Bevan + Treatment: Excisional biopsy + an area of operative removal of a Bartholin's cyst + Pathophysiology + metaplasia + retrograde lymphatic spread + potential implantation of endometrial tissue during operation - = + Treatment: wide excision =« Rare, slow-growing, solid « Benign neural sheath vulvar tumor tumors of Von * Originates from neural Recklinghausen disease sheath (Schwann) (generalized i + Treatment: wide excision neurofibromatosis and café-au-lait spots) + Treatment : excisionHematoma |Seconaary to blunt PEM Rice ua) (Spontaneous hematomas : rare and usually occur from rupture of a varicose vein during pregnancy or Tarew oles LLC F sane BOS eee Nama oe nau Crete) BRUM CW mem eel lesb 1A Be Paes tet eo ete Use eRe UM cae + Identification and figation of bleeders eeA 35 y/o G2P2(2002) consulted because of vulvar,mass which increased in size over a 2-week period. This was accompanied by difficulty in walking and fever. On PE, a 5x5 cm erythematous and tender mass was noted at the 4 o'clock position near the introitus. Which of the following is the most appropriate treatment? SO MNetenecae 2 Nel eclee amend (ee oc) io] Silo ete} B ObservationBenign Lesions of the Vulva Urethrak Caruncle ier ece | AOI ee 169 Dermatologic Lesions Pee sr laa ene cd Peso air lamPl-lgarlaltcy cnc Rees leis (el nae Bee clicele ear) Leeds Bebe latelsrs(o] ec « * Psoriasis + Cutaneuos Candidiasis eee cle} NSU Endometriosis RAC Sie ltt PME Leoluiy Ata eC} taUletk ake) fel ecContact dermatitis ¢ Neurodermatitis * Psoriasis * Seborrheic dermatitis Cutaneuos candidiasis Lichen planus Dermatologic Lesions+ Generalized skin disease : unknown origin. + Spontaneous remissions and exacerbations. * Diagnosis: classic + Two pathophysiologic processes * Primary irritant (nonimmunologic) * Definite allergic (immunologic) * Treatment : withdraw , offeriding substance/ silver scales and application of topical bleeding on gentle steroids scraping of the « A plaques eo ee + Pale/yellow erythema covered by non- adherent oily scale + Treatment: topical and oral anti-fungal agentsHypertrophic, coalesced plaque Inflammatory condition unknown etiology/autoimmune * Three types + Erosive * Classical + Hypertrophic + Diagnosis: punch biopsy + Treatment: oral/topical « steroids a | De Triad of oral aphthous ulcers, genital aphthous ulcers, and uveitis + Multisystemic disease + Diagnosis: exclusion of other vulvar ulcerative disease + Treatment: topical anesthetics Chronic, unrelenting, refractory infection of skin and subcutaneous tissue that contains apocrine glands/foul- smelling discharge * Inflammation : hair follicles + Treatment: topical/oral clindamycinBenign Lesions of the VaginaBenign Lesions of the Vagina Urethral Diverticulum Taree) 0) G19 Tampon Problems Local Trauma *os Asaclike projection arising from the posterior urethra + Symptoms are identical to lower genital tract infection Most common cystic structures + Posterior or lateral walls of the lower 3rd + common in parous women + Risks with usage: + Vaginal ulcers * Toxic shock syndrome from toxins produced by Staphylococcus Aureus + Diagnosis: + Cause: birth trauma or + Treatment: + Voiding gynecologic surgery * Antibiotic vaginal cystourethrograph + Asymptomatic cream + Cystourethroscopy. + If symptomatic, * Treatment: excisional biopsy is + Excisional surgery in treatment of choice acute infectionLocal Trauma Coitus : most frequent etiology Most common injury : ess tear of the posterior fornix ore +: Prompt suturing under adequate anesthesiaBenign Lesions of the Cervix - wal toEndocervical and Cervical Polyp al+ Most common benign neoplastic growth + Common: considered a normal feature of the adult * Multiparous : 40s -50s cervix + Inflammation or to abnormal + Retention cysts focal responsiveness to of endocervical columnar hormonal stimulation cells + Symptoms + Spontaneous healing + Intermenstrual bleeding: process of the cervix classic symptom + Asymptomatic + Recognized for the first * Treatment: not necessary time during a routine speculum examination + Management: Polypectomy Seen post-normal and abnormal deliveries Minor superficial lacerations to extensive full-thickness lacerations Management * Acutely bleeding cervical lacerations : must be sutured Complications * incompetence of the cervix+ Most common benign neoplastic growth + Multiparous : 40s -50s + Inflammation or to abnormal focal responsiveness to hormonal stimusation + Symptoms + Intermenstrual bleeding: classic symptom + Recognized for the first time during a routine speculum examination + Management: Polypectomy + Common: considered a normal feature of the adult cervix + Retention cysts of endocervical columnar cells + Spontaneous healing process of the cervix + Asymptomatic + Treatment: not necessary Seen post-normal and abnormal deliveries Minor superficial lacerations to extensive full-thickness lacerations Management * Acutely bleeding cervical lacerations : must be sutured Complications + incompetence of the cervix+ Region of the intemal os. + Types: + Smooth, firm mass + Small and asymptomatic ral + Pedunculated and protrude through the + Acquired external os of the cervix = Gauses : Diagnosis : inspection and palpation + Operative (iE. Cone biopsy, cautery) Management b sere + Similar to uterine myomas Neopian) + Observation’ expectant management + Alrophic change yg oulcel atens) Nene poor ee + Myomectomy or hysterectomy abnormal bleeding, amenorrhea and infertility + Postmencpausel women are usualy asymptomatic + Diagnosis: inability to introduce a1 to 2 mm dilator into the uterine cavity Management: C L Cervical diators LDAprimigravid delivered at a lying-in clinic and had a 4" degree perineal laceration. What muscle is not lacerated in this kind of OASI? oO lame eC ela Ulg erent le No asettcy © eee @ Superficial Transverse Perineal Muscles. iy becPERINEUM Bulbocavernosus. muscle -~/8 Tronaverse (EAL perineal =) f muscles — & a oi > External anal Internal anal_>= sphincter sphincter — Rectal mucosaYou did a pudendal block in a patient who is about to deliver: Which of the following should guide you when doing this procedure? O The pudendal nerve lies posterolateral to the ischial spines & The pudendal nerve lies in the Alcock’s canal | It has 1 terminal branch which supplies the clitoris =| It lies just beneath the superficial transverse perineal musclesYou did a pudendal block in a patient who is: about to deliver. Which of the following should guide you when doing this procedure? O The pudendal nerve lies posterolateral to the ischial spines The pudendal nerve lies in the Alcock’s canal | it has 1 terminal branch which supplies the clitoris. 12] It lies just beneath the superficial transverse perineal musclesAnterior rami of S2-S4 *Posteromedial to the ischial celia Hitcee lam eleiol-1arerl| canal(Alcock canal)* PUDENDAL NERVE *3 terminal branches: * Dorsal nerve of fit liKeli cial atc ads) iiclatey ak nerve PERINEUMiS eM alate hol es (er-lc oH eicsel(c) attached to the perineal body and the coccyx «Blood supply > inferior rectal artery «Nerve supply: pudendal nerveINTERNAL GENERATIVE ORGANS Cervix we — External os Vagina abiumBlood Supply to Female 2 Reproductive Tract “Voc tube Arcuate artery ae \ porta—f Y Mesosabpinx \ SSI internal iliac artery ~ Vaginal arteries ©Internal Generative OrgansWhat is the main uterine support? oO Round Ligaments B Infundibulo-pelvic ligaments io} teres toleeclua n @ Transverse Cervical Ligaments.What is the main uterine support? | Round Ligaments. 12} Infundibulo-pelvic ligaments @| Uterosacral ligaments | BUN teeta Belcan)INTERNAL GENERATIVE ORGANS ©)CMabor & SFraccis Cardinal LigamentsIn the management of AUB-Endometrial Polyp, the definitive management to address bleeding and possible malignancy progression would be: oO Endometrial Curettage ie} Fractional Curettage ED tanaso Bim : Rc ewIn the management of AUB-Endometrial Polyp, the definitive management to address bleeding and possible malignancy progression would be: ie} Fractional Curettage 12 TAHBSO © are leit+ Unopposed estrogen * Chronic administration of tamoxifenEndometrial Polyp |Components | + Endometrial glands Ge =iaXelelaa(- leet ieieco] tar) + Central vascular channels IVE Cala Cc Ta SCO) t= 1 Cod eON | fraps ves YEH | bat + Hydrosonography + Hysteroscopy /hysterosalpingography ene | + Removal by curettage or via hysteroscopy =faCueLeoyiitciire) Partial Complete Congenital + imperforate hymen + Transverse vaginal septum Acquired * Senile atrophy of the endocervical canal / endometrium + Scarring of the isthmus + Cervical stenosisRAT elite Benign tumors of muscle cell origin FE decade of a woman's life E most common types Paluch Serose] ehs1< 1100) Dacre eles leet sy msDegeneration of Myoma + Hyaline . eames * Calcific + Cystic + FattySymptoms. Sele Neu Ceea IE We ESO | Most common : pressure from an uterine bleeding | Severity of symptoms : related to the number, location, and size of the myoma Rapid growth after menopause : disturbing symptomFIGO CLASSIFICATION SYSTEM (PALM-COEIN) FOR CAUSES OF ABNORMAL UTERINE BLEEDING [Coagulopathy ee no Onto a Malignancy & Hyperplasis Not yet classified Figure-1: Adopted from Munro et al,[5] F1GO classification system (PALM-COEIN} for causes of abnormal uterine bl eeding in nore gravid wormen of reproductive ageFIGO CLASSIFICATION SYSTEM FOR CAUSES OF ABNORMAL UTERINE BLEEDING LEIOMYOMA | Adenomyosis aeaoee Ovulatory dysfunction eiomyoma Endometrial tLeiomy: Other Malignancy & hyperplasia latrogenic Not yet classified Leiomyoma SM - Submucosal] Peciunculated intracavitary subclassification rat system intramural Contacts endometrium: 100% intramural 22a =e arama oD LS 0% in ural a ~ Subserosal pedunculated z. parasitePedunculated intracavitary <80% intramural Mery Pedunculated oe See Sree Hite ntion, the first refers tothe relationship idometrium, while the second ref ibmucosal and subserosa thin half the diameters in the endometrial and peritoneal cavities 2 respectively TA Jey)A G1P1(1001) presented with an 8 x 8 intramural myoma. The clinician would like to. start her on GnRh agonist prior to the myomectomy. Which of the following is an additional benefit of GnRH use preoperatively? O Increases leiomyoma vascularity 12] (plete ge Neral aint aN(o) Ulta cd 2 Increases uterine blood flaw 2] None of the aboveAG1P1(1001) presented with an 8 x 8 intramural myoma. The clinician would like to. start heron GnRh agonist prior to the myomectomy. Which of the following is an additional benefit of GnRH use preoperatively? O Increases. leiomyoma vascularity 12] [plato greene Col aint aNfo) VLtal cd 2 Increases uterine blood flow None of the above. cyMedical Management v Reduction in the size of the myoma by reducing the level of estrogen ‘ and progesterone (GnRH agonists) » Advantages + Facilitate easier surgery fos vantages eyed + Degeneration of some leiomyomas + Hypoestrogenic side effects(e.g. Trabecular bone loss, vasomotor flushes) ealMedical Management Reduction in the size of the myoma by reducing the level of estrogen and progesterone (GnRH agonists) Advantages « Facilitate easier surgery Disadvantages « Delay in final tissue diagnosis «Degeneration of some leiomyomas + Hypoestrogenic side effects(e.g: Trabecular bone loss, vasomotor flushes) Rd 008 Rowena Auxillos' screenMedical Management Reduction in the size of the myoma by reducing the level of estrogen and progesterone (GnRH agonists) Advantages + Facilitate easier surgery Pec erence eet) Se Pieri en esetee clea (elated Se recuse per cue ie miler ase Mee outta) i pe Pe.Surgical Management: Indications for Surgery 1. Rapidly expanding pelvic mass 2. Persistent abnormal bleeding 3. Pain-or pressure ze . Enlargement of an: asymptomatic myoma >8-cm ina woman who has not yet completed child bearing Cee eee elmer) as | ng Bee a9] 1-112 2. Advanced adnexal disease 3. Malignancy. fetSurgical Management: Indications for Surgery . Rapidly expanding pelvic mass i . Persistent abnormal bleeding . Pain-or pressure . Enlargement of an asymptomatic myoma >8 cm in a woman who has not yet completed child bearing Contraindications to Surgery Break] 1-182 2. Advanced adnexal disease 3. Malignancy.Transcatheter uterine artery embolization iN M Newest modality a Multiple embolic materials Post procedural abdominal and pelvic pain common for the 1st 24 hours Success rates : decreasing menorrhagia and reduction in uterine sizeAdenomatoid Tumors Small, gray-white, circumscribed nodules 1 - ye) Usually unilateral, asymptomatic Do not become malignant ; may be mistaken for low-grade neoplasmParatubal Cysts | Diagnosis is incidental i. | Hydatid cysts of Morgagni: = i jsueletneieveis g ieee Simple Excision ae rt Complications: Torsion | esBenign Lesions of the Ovaries» What is the most dangerous of all complications of Dermoid Cyst? | aol 1@| Infection B pcuaCelagerericdFollicular Cysts Most frequent cystic structure in normal ovaries Results from + Dominant mature follicle's failing to rupture (persistent follicle) * Immature follicle’s failing to undergo the normal process of atresia.Follicular Cysts May be discovered during ultrasound Must be differentiated from a true ovarian neoplasm Management Foledn og * Conservative observation * Cystectomy and oophorectomyCorpus Luteum Cyst At least 3 cm in diameter Associated with normal endocrine function or prolonged secretion of progesterone. Menstrual pattern : normal, delayed menstruation or amenorrhea Asymptomatic / massive intraperitoneal bleeding with rupture.Bpiter mica ea iy Moderate to massive enlargement of the ovaries . Prolonged or excessive stimulation by endogenous or exogenous gonadotrophins : molar pregnancies choriocarcinoma Poe uaiatudeilacaad Cer een eoBhai erica On Hyperreactio Luteinalis + enlargement secondary to the development of multiple luteinized follicular cysts. Luteoma of pregnancy + Not a true neoplasm. * Specific, benign, hyperplastic reaction of ovarian theca lutein cells Symptoms; pressure in the pelvis Confirmed by ultrasound Treatment: conservativeTheca Lutein Cysts Moderate to massive enlargement of the ovaries Prolonged or excessive stimulation by endogenous or exogenous gonadotrophins : i Tee »: molar pregnancies Le ae ape : choriocarcinoma SenMice een icy Hyperreactio Luteinalis * enlargement secondary to the development of multiple luteinized follicular cysts. Luteoma of pregnancy it a true neoplasm * Specific, benign, hyperplastic reaction of ovarian theca lutein cells + Symptoms; pressure in the pelvis * Confirmed by ultrasound * Treatment: conservativeDermoid Cyst Prepubertal females and in teenagers Cul-de-sac or anterior to the broad ligament > Mature cells from all three germ layers Most solid elements arise are contained in a protrusion or nipple in the cyst wall - prominence or tubercle of RokitanskyPreece cis Adult thyroid tissue discovered microscopically in 12% of benign teratomas Struma Ovarii + Thyroid tissue has overgrown other elements and is the predominant tissueDiscovered during a routine pelvic examination abdominal x-ray or ultrasound Management + Cystectomy with preservation normal ovarian tissue Complications + Torsion + Rupture * Infection + Hemorrhage + Malignant degenerationLaboratory Tests and Serum BiomarkersLaboratory Tests and Serum Biomarkers CA-125 CA-125 LDH, AFP, hCG (singular) not measured + <40 y/o with * not used to in complex differentiate premenopausal ovarian mass benign and women with * germ cell malignant simple ovarian tumors adnexal cyst massesLaboratory Tests and Serum Biomarkers Best way to predict malignancy * Risk of Malignancy Index International Ovarian Tumor Analysis ( OTA) Role of serum biomarker * alternative to CA-125Imaging of Adnexal Masses Gray scale high frequency 2D transvaginal ultrasound with color doppler Identify specific diagnosis , Differentiate non-gyne pathologies Differentiate benign from malignant Adjunct to ultrasound Determine extent of diseaseManagement of Adnexal Masses: eating =a 82h) Complete pediatric exam + histor Transabdominal ultrasonography Tumor markers * LDH, AFP, b-HCGManagement of Adnexal Masses: PREMENARCHEAL WOMEN Feto-neonatal cyst + <4 cm: conservative + > 4 cms : cystectomy (torsion/intracystic hemorrhage) Simple Cyst + <10 cm: managed expectantly * >10 cm: surgeryA 25 y/o, G1P1(1001) is being treated for UTI . Transvaginal ultrasound showed a unilocular cyst 6 x 5 cms at the right ovary. (-) FHx of cancer. What is the next best step in the management of this patient? 0 (e) oti} 12) Repeat ultrasound after 2 cycles io} Cystectomy @ Request for tumor markers iJonA 25 y/o, G1P1(1001) is being treated for UTI . Transvaginal ultrasound showed a unilocular cyst 6 x 5 cms at the right ovary. (-) FHx of cancer. What is the next best step in the management of this patient? Observe Repeat ultrasound after 2 cycles lo} Leys ccroicol thd B Request for tumor markersManagement of Adnexal Masses: REPRODUCTIVE -AGED WOMEN Simple ovarian cyst + <5cm : expectant management + 5-7 cms : yearly ultrasound * >7 cms * Further imaging + Surgery OCP in functional ovarian cyst: NOManagement of Adnexal Masses: REPRODUCTIVE -AGED WOMEN SURGICAL MANAGEMENT: * Persistent, asymptomatic ovarian cyst that do not spontaneously resolve after 2-3 cycles > 5-6 cms: OBSERVATION recommended for: + Asymptomatic, CA-125 <200U/mL, TransV UTZ (-) suspicious for cancer + With high risk of surgical morbidity/mortality (advanced age + multiple co-morbidities)Management of Adnexal Masses: REPRODUCTIVE -AGED WOMEN SURGICAL MANAGEMENT indicated for * symptomatic ovarian cyst + suspicion of malignancy (clinical evaluation + result of imaging + serum marker testing) SURGICAL OPTIONS for BENIGN ovarian mass + laparoscopy/laparotomy * OVARIAN CYSTECTOMY:: premenopausal, low pre-op suspicion of malignancy, mass intra-op appears benign, (-) evidence of metastatic diseaseManagement of Adnexal Masses: REPRODUCTIVE -AGED WOMEN ASPIRATION of BENIGN ovarian cyst: NO + Not effective/ high rate of recurrence REFERRAL TO GYNE-ONCOLOGIST * Complex ovarian mass, elevated CA-125, UTZ suggestive of malignancy, ascites, nodular/fixed pelvic mass, evidence of metastasis + Elevated score on formal risk assessment tests (1OTA)Management of Adnexal Masses: POSTMENOPAUSAL WOMEN Role of CONSERVATIVE MANAGEMENT * Surveillance every 3-6 months + low risk for malignancy, CA-125 < 35 IU/ml, asymptomatic, simple, unilateral, unilocular,Management of Adnexal Masses: POSTMENOPAUSAL WOMEN SURGICAL INTERVENTION . Symptomatic * Suspicious / persistent COMPLEX adnexal mass regardless of size « Simple cysts , asymptomatic >7 cmsA38-y/o, G1P1(1001) consulted because of dull hypogastric pain over a period of 3 months. Ultrasound showed bilateral hydrosalpinx measuring 5 X 6 cms. She was medically treated for TOA over a year ago. She is desirous of pregnancy. What is the best advice can you (oie alma oO everett 12 Surgical removal not advisable io Salpingostomy: B PSU ec nagA 38-ylo, G1P1(1001) consulted because of dull hypogastric pain over a period of 3 months. Ultrasound showed bilateral hydrosalpinx measuring 5 X 6 cms. She was medically treated for TOA over a year ago. She is desirous of pregnancy. What is the best advice can you give her? | een iee ern Ope neers Salpingostomy A candidate for IVFManagement of Adnexal Masses: FALLOPIAN TUBE MASSES HYDROSALPINX « Women who want to get pregna * Mild to moderate: SALPINGOSTOMY + Severe (for IVF): LAPAROSCOPIC. SALPINGECTOMY + Severe with extensive adhesions: LAPAROSCOPIC PROXIMAL TUBAL LIGATION/OCCLUSIONManagement of Adnexal Masses: FALLOPIAN TUBE MASSES HYDROSALPINX * Women who want to get pregnant + Mild to moderate: SALPINGOSTOMY + Severe (for IV! Soe oe oe SALPINGECT( + Severe with ae adhesions: LAPAROSCOPIC PROXIMAL TUBAL LIGATION/OCCLUSIONManagement of Adnexal Masses: FALLOPIAN TUBE MASSES Asymptomatic hydrosalpinx + not desirous of pregnancy . * Surgical removal not required ANTIBIOTIC therapy: prevent progressive damage to FT (Chlamydia Trachomatis) * Doxycycline 100 mg BID x 7-10 days * Azithromycin 1 gm PO single doseManagement of Adnexal Masses: FALLOPIAN TUBE MASSES TUBO-OVARIAN ABSCESS + Broad-spectrum antibiotics until clinical improvement 24-48 hours * Clindamycin, Metronidazole, Cefoxitin * Once clinically improved: oral antibiotics x 14 days + SURGICAL INTERVENTION: + Ruptured TOA + Size> 8 cms * No clinical improvement after 48 hours of antibioticsManagement of Adnexal Masses: PARAOVARIAN/PARATUBAL EXPECTANT MANAGEMENT + Asymptomatic simple cysts < 10 cms SURGICAL INTERVENTION + Symptomatic, size, characteristics of mass, risk of malignancy * Cystectomy * Aspiration should be avoided: risk of malignancy + seeding (2-3%) * Recommended surgical approach: LaparoscopyAdnexal masses in Special Populations: PREGNANCY DIAGNOSIS + ULTRASOUND: Primary tool for diagnosis + MRI: distinguish nature of mass + Use of tumor markers: INDIVIDUALIZED. Consider elevations with pregnancyAdnexal masses in Special Populations: PREGNANCY OBSERVE: Benign masses, (-) complications Elective surgical interventions: 14-16 weeks * Multi-disciplinary approach for malignancy Prophylactic tocolytics: NOT routine but should be considered pre-op for preterm laborAdnexal masses in Special Populations: eC A en Re-evaluate adnexal masses diagnosed during pregnancy at 6-8 weeks post-partum Aspiration of benign simple cysts: NOT RCOMMENDED Benign Adnexal masses: CS only for obstetric indicationsAdnexal masses in Special Populations: PREGNANCY Re-evaluate adnexal masses diagnosed during pregnancy at 6-8 weeks post-partum Aspiration of benign simple cysts: NOT RCOMMENDED Benign Adnexal masses: CS only for obstetric indicationsAdnexal masses in EMERGENCY SETTINGS: Sudden onset of severe pain, first trimester bleeding or fever « Emergency or urgent care setting OVARIAN TORSION + Reduction of the torsion with ovarian cystectomyAdnexal masses in EMERGENCY SETTINGS: Sudden onset of severe pain, first trimester bleeding or fever « Emergency or urgent care setting OVARIAN TORSION + Reduction of the torsion with ovarian cystectomy