~ Click here for telegram channel link for more notes.Click here to visit our YouTube channel BS ised seasIndex Gynaecology S.N. | Name of the topic ~ Page | No. | “fh fAmenerthoca 20m UTP meArggawra pad [1 | 2. |(Dysmenorrhoed) oom 7s Ve functional uterine bleeding 0 8 40m rr i sm _ 13 ca tomenorthoea “Sm uM 7.__ + Menopause And Climacteric)_to 16 [87 J Oligomenorrhoea’_ 21 as 19 9, | PREMENSTRUAL TENSION SYNOROME (PAfS) 20 J 10,_| POSTMENOPASUAL BLEEDING (Px) _ 22 / Infection and inflammations of female genital tract 24 / Vulval Uleers 26 Vaginitis 27 Monolial Vaginitis 29 Leucorrhoea _ 30 Diseases of Cervix 32 Cervical Erosion ____|33 <_| Pelvic Inflammatory Diseases P| 0] 36 19._ | Salphingitis 40 20. | Chronic Salphingitis * z 41 21. | Oophoritis = 43 k22. "| Pelvic Abscess 44 Parametritis _ 46 __| Cervical Intra epithelial Neoplasia (CIN) 48 | Cervical Cancer (Ca. Cervix) 7 50 Uterine Fibromyoma [Uterine Fibroid] 54 | Cervical Fibromyoma 58 Uterine Polyps — __ [58 Genital Prolapse CRAxe a) [61 ). | Retroversion [s7_| 31._| Genito — Urinary Fistula 70_| - [22.__|Adenomyosis 75 Kv) IFO 33, Congenital Anomalies of F.G.O. 76 ry yL24._[ Infertility eae (xed) 79 PAD. tr 35. | Follicular Cysts. - 85 org £36. [ Endometriosis __ 90 En domartor [37 [Chocolate éyst [a2] * Pies y Pubes vii) eadomun'ts ¢ - a memopawe iw) pLometnrg “yy wisrerosansninastrary — 6) PAUiC ah con 4) Toi chomenos Vagiain © Poach of DoIHY v) one or AA) COW4 0) TB SY ite wey Ea enerGynaecology AMENORRHOEA] It is defined as absence of menstruation, ‘Amenorthoea is not a disease but symptom of disease. gvulat'en L i Arnanonoss 4 Covey 4 Psy SS fie Very ay (Physiological) [Pathological = v Primary Secondary -}> Physiological amenorrhea: Menstruation physiologically absent in .. > Pre pubertal age :- As menstruation is restricted to the child-bearing period of life, so that girl do¢s not menstruate before puber Pregnancy Lactation Post menopausal age Pregnancy is the usual_& comments cause of amenorrhoea in case of ive life of a female & must be investigated. Pathological Amenorrhoea: A] Primary Amenorrhoea:- Cefinitio > “—Menarche does not _appear in a girl who completed 16 years of age.[16 to28 yrs] vvvyv Katiofogy Ce nowy? 3 6 1) Endocrinal:- —— a) Hypothalami 7 > Obesity: wt > 70k, . > Environmental changes:- climate, stress, mental anxiety, —_ ; ows > Anorexia nervosa: wenvosned He Wb oftary ohh 2 Kallman’s syndrome:-due to lack of (GIRICE primary amenorrhoea, sewual ty of infantilism & anosmia (loss of smell) we Tpncaisias C ulater, Rcumuaion 0f waber in Ga weed) >> Head injury, meningitis, - endoerinal cee Rao > Empty sella syndrome:-deficient pituitary tissue ESS _ bee amd ddtae > Pituitary tumour - N\eromno somal 3] Ovarian cos - he Dr Polycystic ovary (early) = 2) Testicular feminisation syndrome:- gonads are testes, external genitalia female & uterus absent. ~ ROIICASHC ova pediicosys - Since 1999 TRs 1 DVEMOM tumourGynaecology i 39 Ovarian tumour. ; Al Thyroid — Hypo or hyper thyraidism. : G ~All Adrenat > Congenital adernogenital syndrome, adrenal tumour ( Al Pancreas: Siventie Grabetes mretitusy ¢ _-H] Nutrition :- 7 mMaltuknNey Gross under nutrition in child hood and adolescence; severe anaemia G anaew a, va JIN] Drugs and diseases + c _ “Testostenmne Anabolic hormonestgeg. > ( qin Sptrserone ne, GnRh analogue, antiepileptic, antipsychatics. ~s Awiepetic € i so ol Beta may TB, mental illness and other serious ilines omy psycholle & 1 1] Chromosomal :- a =e (45 XO) Streak gonad, absent breast, infantile uterus & primary amenorrhea. © Testicular feminisation syndrome. —oveny ke Place, Feats Poseuk Yste wed VJ Utero Vaginal:- “Or Atresia, ch ot ‘Cryptomenorrhoea due co poetforate hymen. Oo Rokitansky syndrome- Ovaries normal, female breasts, absence of uterus and vagina, karyotype — Norinal 46XX. ~~ ap endorettial TB . endometrial LB. Pregnancy, —_ G vee 4 | ‘Secondary Amenorthaea:- G oO Amenorthoea mi r more ina woman with previous normal menstrual function, in absence of pregnancy. { Endocrinal:- ‘Hypothalamie:- 2} Anxiety, mental tension, 4)-Environmental changes oO Aetiology: ENDU| g ¢ fe ¢ nW sc} Obesity d} Pseudocyesis 4 194 ki Ualeh 5a, ca a? Ce) Weight loss asin athletes (fered: So4q pordva) fr Neurological trauma (Head: injury) peu. ( 4) Meningitis, epilepsy - ch 2f Pituitary Xe Cushing syndrome. A Keromegaly c Mediicosys - Since 1999 2 :Free debivey gon ot (0 hese yee 3 Hey Joga poset L 4 | “Gynaecolggy & Sheehan's disease} > pan hypopituitarism develops following postpartum "haemorrhage in childbirth, pituitary vessels get thrombosed. 5 ~*”_Prolatinoma:- Microademoma. & pituitary causing hyper prolactinaemiag_ 3) Ovarian COMMON. in sud d + Polycystic ovarian syndrome. 2. Premature menopause. ~4° Ovarian tumour. aa eal "A Oophorectomy & radiation to oven BL Ba Pitutany yurmove Komen atmynrtd wipoty youd oy q seen crodt 5 ) BY Thyroid:- Hypo & hyperthyroidism. in 5) Pancreas :- Maturity onset DM. Rares POY <5 AF Adrenal :- Hyperplasia or Neoplasia, cushing syndrome] ~ Adquna) _, po on, KLE oyaAMY + overran suneu, Nutrition :- Gross under nutrition and severe anemia. Poop _ll-Drugs & systemic Diseases. —— Drugs:- _ Pevyg esvugerP f0Bestogen, androgen, GnRh analogue antipsychotic drugs, antiepileptic drugs etc. AHS COWS, Aisease :-1.B., mental diseases. / OMAK ePHTA © — Crowmaatied algeus fer oTO) Get fery > Balanced diet >> Afternoon rest \> Drinkingafba ter ~~ Deworming > Exercises, morning walking \F |ron supplementation —4) Tht of anemi ~ SY Inobese — wt loss ete. Treatment of primary amenorrhoe <>” Tit of the cause — Thrab Ht COL For uterine hypoplasia primary health care and cyclical ‘oestrogen ~ agate yert progestogen therapy may help. frmgestos” >” imperforate hymen:- hymenectom ‘ToUBTT undegy TULL __syndrome:-oestrogen dally at bed time for year together for ~ TUsMen’ SHROMIG ondary sexual character starting at 12 years she can not get menses. — -xmPenforad® > Drug amenorrhoea is treated by stopping the drugs if possible, as ES 04 Treatment for secondary amenorrhoea:- > Tab. Medroxyprogesteron acetate(madus) 10mg. taken thrice daily x 7 days. Repeat cycles can be given for 1 week starting from 16 th day menses x 6cycles > Combined oestrogen- progestogen tab. ( tab. Premarin) > Meditation (puja) is suggested ooo. aoe _R Somneten - ahsence of memsrouu'ey / hot diieoe dub AL dassigfcation sittpony of dktecse es Physiotosical Pathological | aanemerrators 0" : OCA 3 parimany qwmonanaws | sec 0M v YA veginavion creo 77 pewlotosy - ST endoosrat §—itubory qvaman Wwyunid an wr et seey Cemmosarsad T pagers vvarovagh ad A) dozens aad Twwengaiion AD Yoewns oF eo, - (imarey) GeO.) Since 1009 en Howmoun syed) ~€) ToeurmanrtGynaecology Cysmenorthoea - Qameal mune EHcoP aut aking HAR Definition:- Is defined as painful menses incapacitating the women. women Jncidence:- 5-10 % girls in their early teens & women in éarly twenties syffer from dysmenorrhoea, ase . i spoamods« srorning wa > Wtloss > Wtgain in. n under. wait / thin girls. > Application of hot water bottle on hynagastrium gives relief to pain ~ 3 Drugs:= AL_ 1 line of t/t:- Aspirin e.g Tab disprin 350mg / ecosprin 325 me twice daily with food Anti prostaglandins ce Geiesamic 2D ponstan) 250 mg for girl ‘below 60 kg & 500 mg for Birl abac 60 kg. Capsule X 3 day. 3) 2nd line t/t ;- Mala D, Ovaral t etc one tab at bed time daily from time daily From 5" day of menses X21 days for 6 cycles. 2} NSAIDS = 4) Surgical dilatation of cervix relieves symptoms <2ySecondary / congestive dysmenorrhoea:- = Poin, ascevaed Means_pain associated with menstruation and is due to pelvic lesion as, volt, endometriosis (severe pelvic pain), adenomyosis, PID & uterine fibroid, BUN hl etiology = Jus. 1 Peladel Belviclesion. yeaior J End ¥ prnexss 97 ‘AMenomesis Salphingo-oophritis, _parametrit alphing 1, ara and___pelvie <> Uterine fibroid J} Age of patient is around 30 yrs. develops sec. dysmenorrhoea ie. lower abdominal fain associated With menses. devedate set: 2} Pain starts 3 —5 days before the start of menses, persists during menses and last ” for days after mense a er, B/D: — ns endomet Caos = 7 Inadenomiei th there can be pair{ with) menorthagia, one "3. InPIO pain appears before and during menses is, pain is very severe not relieved by analgesics with dyspareunia & \Signs:- Underlying cause can be eliciated by examination as follows. \A Per abdomen — Mediicosys - Since 1999 6Gynaecology ~2, Per vaginum sey USG se} Laproscopy “iY Assurance _ 2) Primary health care A) Analgesics A) T[tthe disease, It is a extreme form of spasmodic dysmenorrhoea. Ancidence:- Run in families to recur after pregnancy. fe ‘YF Its characterized by the passage of membranes in the menstural discharge. _A) The membranes may take the form of casts—of the uterine cavity. Microscopically the cast have the structure of the endometrium during nenstruation. _Tit :- Same line of t/t like spasmodic dysmenorrhoea fortunately extremely rare. : . _ o>. . —D tt is a xine Rew @F spamadie Sy smemocro eg HY FoctuMaRWY exinemayy crave Lancdemce- Rum in families * RCW atten Porgnancy LD) noon A mudsue eee sopimodic weer —L scond Cons ve avy Mombnwont ( exnent Aon") Pome . 2d seandemy ou Podmawy Pew @ Trakmewr iw ‘ i = Asswrame Drown © 4 poiwt ae DB prorogy!) § © _ IMMOMY Yyealltn cane tewic fenton 2) sRemehe $3 ors ic fenton foneQ 5 . a as Q cxcen Froavagiam : ae endo. adeno. 28 VCP G) psyekalogi cal sh vivue nsarot oly 4 cit exes Omens obssmacon ; wo @ Miwa Fedura &) 919 Caesvinwe ow a) SHOP | Signe @ sigue ay G swe sow ohdowwn Pe . oe agi WO" Mediicosys - Since 1999 RoUMUL toh rey @ veg - 08% ® tlt - ony For Spoamnd’ & das momenta Aopen} copy,Gynaecology — « Dysfunctional uterine bleedin, Definition :- Heavy menses > 80 mi with out any organic cause. C Aetiology:- c Histological Classification : ‘ DUB. qa eo ¢ Puberty gr. Perimeno pauseal gr ( cf ( a) Symp b) Signs 1 js i. © Investigation: 8) casa . Diagnosis:- anne Qe ¢ Management / Treatment:- py a ¢ Cennrty Definition : Defined as excessive menses{more than 80 ml jvhere\fo oiganie cause can be tone ram detested. Bom The type of bleeding may be menorrhagia or metrorrhagia or polymenorrhoea ete. G Sg WO ongayd (Oude py - 1 OME be | — Incidence: 15-20 % females are suffering from D.U.B, o TPL OF BlGxetiology:- | fee “2+ Anvolution:- Common in adloscent & premenopause group. pevymersonnes eo. 2 Ouulatary cycles - adloscomt 4) Excess endometrial prostaglan _ For ESH, LH, prolactin, testosterone etc. 3] Cytology Should be studied to exclude neoplasia. “4S. = To exclude pelvic lesion lude endometrial polyp, : Mediicosys - Since 1999 9AM ots cane abs Diagnosis ~ ules ovemd) al endian wormed 4) att Gynaecology When all other causes are absent & yterus_avaries remain normal, the excessive bleeding is diagr cae AY Surgical t/t sed as D.U.B. janagement of DUB + (olvomem and wunetage stage} D&C:-Is useful in case of perimenopausal group MWR = yecbues, 76) Medical t/t = Baquedd Do8 ) Progesterone :- Is effective to contro! . AY Injection- of testosterone to contral heavy bleeding A) Anaemiais to be treated by iron supplementation A} Severe anemia :- blood transfusion is given as life saving_measure. 73) Primary health care_ —6) Assurance. 064. A) DeRlnaHon g sKodemre. 3g Ahowulaon te ww j Mediicosys - Since 1999 10ove than ge ml) Gynaecology Menorrhy ie Cove than sdays {Blo ~ Befinition:- Defined as excessive noes in ee or aabatin or both causing nore than.80 ml blood loss tr) dn gimnoune = Bete tediny mone than go gu biwod cay \_Jipnotaxis:- Means prolonged durations of mensch NE Daur Fak cyee chau) Aetiology:- Giynaceteoy BT mant Alt) AT Pelvic caus Clinically, the patient are young girl in their early teen who suffer from cyclical monthly pain without the discharge of menstrual bleeding. > In majority haematocolpos:- Collection of menstrual blood in the vagina occurs. It may be and such enormous size as to push up the uterus and the bladder above the pelvic cavity. i) > The amount eventually may reach upto 2.5 lit and an abdomino-pelvic | ‘tumour is produced which is palpable and visible on abdomen examination due to this the urethra becomes elongated to cause retention of urine. JF of eryptomenorthoea:- | Symptoms:- ' a) Retension of urine: This is the most common symptoms b) Attacks of lower abdominal pain for a few days in every month i c) Primary or secondary amenorthoea d) Progressive swelling in the lower abdomen Sings:- a) The patient is usually a young girl (generally 15-18 years) with well developed sec sex character in a case of primary amenorrhoea while the woman is an elderly one in a secondary case. b) Per abdomen:- a. Hypogastric cystic swelling can be felt due to full bladder b. After emptying the bladder, a tensely tender mass occupying the lower abdomen can be felt due to haematocolpos but rarely due té hamatometra and haematosalphix. (Because uterus and fallopian tube offers resistance to distension) Per vagina/ vulvum:: a) On inspection:- a tensely bulging bluish membrane - the imperforate hymen is commonly detected Mediicosys - Since 1999 4 teGynaecology b) The obstruction in the vagina or cervix can be detected by palpation and speculum, examination ©) Per rectum, the vagina is felt tensely cystic filling up the pelvis Treatment:- 1) Hymenectomy :- In haematocolpos the obstructing hymen is incised with a sharp pointed knife under general anaesthesia under strict aseptic precautions In acquired stenosis ~ cervical dilation Artificial vagina is created / made by creating a space between the urethra and bladder in front and the rectum behind until the cervix is reached. ~>o-¢- Mediicosys - Since 1999 15Gynaecology + Menopause and climacteric Definition: Menopause ;- Refers to age of final cessation of menstruation, Climacteric :- Means changes due to cessation of ovarian follicular function. Aetiology:- Menopause occurs as a result of exhaustion of ovum from ovarian follicles and consequent oestrogen deprivation. Timing: > Menopause occurs at an average age of 45 years in India and 51 years in the west. > Genetic makeup, race, climate influence age of menopause. > Premature menopause occurs before 35 years and delayed menopause after 55 years. > Delayed menopause is mainly due to some pelvic pathology (uterine fibroid) or in diabetes mellitus. > Climacteric period gradually starts 2-3 years before and 2-5 years after menopause, Physiofogical changes in menopausal and postmenopausal periods:- Physical > body weight decreases after 65 years. > Skin becomes less elastic and wrinkles appear. > Fat deposition in hip and thighs. > Height diminishes after 65 year. > kyphosis develops due to spinal osteoporosis. Bone effect:- > osteoporosis is the long term significant sequalae af postmenopausal estrogen insufficiency. > Vertebral and forearm fractures become more common in women than men. > Reduction of osteoblast and calcium loss leads to reduction of bone mass. [Measurement of bone mineral density (BMD) of bones is done.) Cardiovascular: > Menstruating women get less ischaemic coronary heart disease due to oestradiol protection, > The incidence rises and equals to that in men 6-10 years after menopause. Endocrinal:- > Because of low negative oestradiol feed back in postmenopause, FSH rises to 50 mlu/mi (50-150) and LH $0 mIU/ml (50-150 miU/ mi > Progesterone secretion from ovary ceases due to failure of ovulation. > Testosterone secretion increased and is also secreted by ovarian stroma > Prolactin level fails. Genital effects:- > In postmenopause progressive atrophy of genital organs with more and more fibrosis occurs. Mediicosys - Since 1999 16Gynaecology > Ovary reduced to 5 gm, fibrotic, furrowed surface, Follicles get exhausted. Stromal hyperplasia produces androgens. > Fallopian tubes shrink > Uterus becomes small and fibrotic. Endometrium atrophies, > Cervix atrophies and flushes with vaginal vault. Vaginal epithelium atropl with loss of rugosity. > Vulva atrophies with narrowing of vaginal orifice. Secondary sex characters:- Breast glandular tissue atrophies, breast becomes flabby and pendulous due to deposition of fat. Pubic and axillary hair become sparse. Sex urge increases at menopause (due to rise in adrenal testosterone) declining after 65 years. Urogenital - atrophic urethritis occurs due to hypooestrogenism. this leat Clinical ids to urinary symptoms and infection to urethra and bladder. features of menopause Symptoms: Signs:- 1) In majority, menopause is asymptomatic other than amenorthoea and minor ailments. 2) Menopausal syndrome: > Hot flushes is the classic symptom. > It comes as recurrent, transient periods of feeling of heat at head and neck flushing, sweating that appears 5-10 times a day lasting for 1-3 minutes. > This can extend to upper chest and back. [Mechanism:- the cause is unclear. Oestrogen withdrawal at menopause, vascular instability and psychological compotent are considered the factors. } . 3) Menstrual pattern before menopause ensues in three forms of menses. a) Progressive scanty menses then cessation. B) Menses come at prolonged interval before ceasing. } Sudden ceasation. 4) Menorthagia and irregular uterine bleeding are not menopausal but due to pelvic pathology. 5) Sleeplessness, anxiety, mood change, forgetfulness. 6) Joint pains, backpain 7) Dyspareunia, 8) Urinary disturbance. 1, These appear gradually, weight increases following menopause. 2. Greying of hair at head, growing of hair on face. Breasts are examined as a routine. 3. Vulva normal immediately after menopause. 4, In geriatric period it shrinks with narrowing of vaginal introitus and sparse pubic hair. 5. Vagina on speculum :-Thin vaginal mucosa with loss of rugosity. %. Cervix:- portio vaginalis atrophies flushing with vaginal vautt Mediicosys - Since 1999 7Gynaecology 7. Uterus:- Body is felt small and hard at postmenopause. 8. Ovaries :- Become impalpable. Investigation:- Elevated serum FSH. Elevated serum LH. Essential laboratory tests, Blood Hb%, postmeal blood glucose, routine urine test, blood lipids every year. Cervical cytology pap stain every 3 years. Treatment of menopaus 1. Patient's education is the first line of treatment educating the woman that menopause is not a disease but natural change of life. 2, She is advised on proper diet, drinking boiled water, afternoon rest, good sleep at night, daily walking, avoiding. Constipation by isafgul, and sex education. 3. In anxiety, tab. Alprazolam (restyl) 0.5 mg at bed time daily for a month and repeated. 4. For sleep. Tab. Diazepam 5 mgm or lorazepam (atevan) 2 mg at bed time for § days in 2 week except weekend is prescribed. 5. Hormone replacement therapy [HRT] ‘A] Short term HRT for 6 to 12 months or more can effectively retieve hot flushes (menopausal syndrome) within 3 months. First line of drug is oestrone sulfate contained in conjugated equine oestrogen - tab. Premarin 0.625 mg (28 tab. In a strip) is taken orally with water at bedtime continuously daily for 6 months or more following, 8] Longterm HRT:- this is advocated for preventive health care in postmenopausal woman. However, the risk of developing breast and endometrial carcinoma has not yet been solved on longterm HRT. Oestrogen is taken for 10 years or more to get benefit. oo ¢- Mediicosys - Since 1999 18mene Gynaecology Oligomenorthoea [> ranges +han ar dows This means infrequent menses at intervals longer than 35 days. Oligomenorrhoea has had more or less same aetiology as that of amenorrhoea. The investigation and treatment of oligomenorthoea are conducted onthe __same__lines__as_ that of ) Hypomenorrhoea This means scanty menstrual loss in duration and amount. Hypomenorrhoea amenorrhoea. occurring regularly can be Constitutional (scanty menses all through) and woman needs only assurance. Hypomenorrhoea with infrequent menses needs investigation and treatment as that of amenorrhoea. Prolonged taking of oral contraceptive pill may cause hypomenorrhoea. Oo ¢- Mediicosys - Since 1999 19Gynaecology Premenstrual tension syndrome (PMS) Is package of symptoms that develop for a week before each menses and pass off at onset of menses. Minimum three cycles symptoms fulfills the definition. Aetiology: Is unknown. It is considered a psychosomatic disorder. Changes in serotinin level in ns is increminated. Clinical features: ‘Woman is usually at third or fourth decade, some thin, some overweight symptoms are breast tenderness (mastalgia), headache, sleeplessness, irritability. Weight gain. The symptoms are related to ovulatory cycles. Urban educated woman gets pms more than rural one. | Treatment: Hy Primary hearth care is given. Thin woman is advised on diet, afternoon rest, | deworming, oral iron-folic acid capsule a day for 4 months for weight gain. Overweight and oH obese woman will have reduction of weight by restricting rice, potato, sweets and daily walking. Vitamin 86 is empirically prescribed. This textbook gives only standard therapy. 1 Thus empirical therapy is not recommended She is put on anxiolytic drug - oral alprazolam (anxit, restyl 0.5 mg) one tablet at bed time daily x 30 days and also during pms for one week before start of menses. Meditation is useful. if she can not sleep, tablet. Diazepam (valium or calmpose 5-10 mg or atevan 2 mg) is taken atbed time daily for 5 days in a week. if breast tenderness pe tab twice daily is taken during premenstrual week for a few cycles. s, tab. Bromocryptine (proctinal, sicryptine) 2.5 mg one Heavy menstruation and abnormal uterine haemorrhage Polymenorrhoea (epimenorrhoea) This means too frequent menstruation at regular intervals of two weeks but less than 3 weeks. Such cyclical bleeding can be normal in amount but when becomes heavy, the condition is called epimenorrhagia. Woman suffers from the symptom when it persists more than 3 cycles. Aetiology: (A) Endocrine disorders :- this is due to anovulation; there is shortening of proliferative phase. This group is caused by endocrinal upset and can be included under dysfunctional uterine haemorrhage. (8) Systemic disorders:- malnutrition and mental anxiety. (C) Pehic disorders :- chronic pelvic inflammatory disease, chocolate cyst of the ovary. Mediicosys - Since 1999 20Gynaecology Glinical features:- It may occur at any time during the menstruating life, but can temporarily develop at premenopause, after abortion and childbirth, The menstrual loss may be normal or profuse, This disorder spontaneously gets corrected. Treatment = 1. The health and anaemia are improved. 2. Hormonal treatment should not be done for a recent case; in them spontaneous cure often happens on primary health care with correction of anaemia. In persistent cases producing anaemia, hormone therapy is useful. Six months cycle control is made by oral contraceptive tablet for 21 days from Sth day of menses, Pelvic treatment:- in cases not responding to medical therapy, pelvic usg ‘by tvs is done to exclude any pathology. Any pelvic cause for the conditions is adequately treated. ooo. Mediicosys - Since 1999 21Gynaecology fpostmenopasual bleeding (PMB) } | eee scier This is irregular bleeding. Per vagina after menopause is being established for six teed y months or longer, Per-vasing afer menotamte oa LAT Oestrogen th withdrawal bleeding following indiscriminate oestrogen ¢ therapy given for menopause can be a cause. However, this is a rare cause in ( India since postmenopausal oestrogen replacement therapy is taken low in ia. ind A AK Cancer of cervix:- endometrium, vagina, vulva and fallopian tubes. Cervical Carcinoma accounts for one-third cases of postmenopausal bleeding in india c Coital bleeding Is a suspicious symptom. © ! Ae Cervical polyp, endometrial polyp. q : malignant ovarian tumour particulary granulosa cell @ ! tumour. _/® Dysfunctional_uterine haemorrhage endometrial hyperplasia and cystic glandular hyperplasia can develop in about 10 per cent cases. : /A# Infections +faginitt (trichomonas, senle},éndometritis\tubercular, senile) and pyometra with bleeding. ! _A6. Injuries. Trauma - decubitus ulcer in procidentia, vaginal passary ulcer, radiation ; “ulcer. Decubitus ulcer is an imp*-Lant causes in the developing countries. i _AA_Goneral diseases - blood dyscrasia or severe hypertension. a LA Cause unknown no definite cause of bleeding from the genital tract can be et detected, Haemorthage from anus or rectum or urinary bladder may be ( mistaken for vaginal bleeding. ( | features _History. Full history is carefully taken on the lines of aetiological factors. (Coitall bleeding suggests carcinoma cervix, Other than vagina any other tract bleeding or any poceue sueems core ; history of oestrogen taking. A oS General health checkup. Thorough systemic examinations are essential. B.p. Is carefully recorded. Pelvic examination. Vaginal speculum and tectal-examination to Mediicosys - Since 1999 22 C ohGynaecology determine the site of bleeding. Vagina shows pale, thin menopausal mucosa. Uterus are felt small Investigation: AZ Gytology. Cervical scrape cytology for pap stain is routinely done in pmb. Endometrial aspiration cytology or brush cytology is also done. 7. High vaginal s 4 Pelvic sonography. Tvs or tas if vagina very narrow is essential step to image pelvic organs, endometrial thickness, any polyp uterine myoma. (Histeroscopylan be performed with biopsy of suspected area, Examination under anaesthesia, cervical biopsy, diagnostic d&c, removal of endometrial WG polyp by polypectomy forceps are done. + 6. Extreme care is taken to avoid uterine perforation while doing d&c. Routine blood and urine testing are done on hb%, tc, de, postmeal blood glucose, urinary infection. : 8. In some cases cystoscopy and sigmoidoscopy are done for bleeding from other tract. Treatment:_ Any causative factor .is treated on the appropriate line and the woman is kept under followup. If no cause can be detected for one episode of bleeding following dilatation and” curettage, woman is carefully followed up. In cases of recurrence of bleeding, total hysterectomy with bilateral salpingo-oophorectomy-is- advisable. Mediicosys - Since 1999 23a hs Gynaecology Infection and inflammations of female genital tract Infections of F.G.0 Infections of f..0 Y Ajof lower genital treat 6] of upper genital treat} sexually transmitted disease in female. ‘A] infection of lower genital treat :- constitute infections of vulva, urethra, vagina, cervix up to internal os. B] infection of upper genital treat.:- constitute infection of fallopian tube, ovary, corpus (body of uterus), pelvic cellular tissues & pelvic peritoneum, It is also cal- -led as pelvic inflammatory disease (pid). Pid are differentiated in A) Acute pid. B) Chronic pid. CJ s.t.ds. in female :- are a) Aids 5} Gonorrhoea ¢) Syphilis) Chlamydia, Infections of lower genital treat, A] Disease of Vulva :- 1) Pruritus Vulva Def” :-It isan itching sensation with desire to scratch the vulva often extending to the surrounding area. Aetiology :- A) Gynecological Causes :- Leucorthocic irrtative discharge from trichomonas vaginitis, monolial vaginitis are the commonest cause. B) Vaginal discharge from other form of vaginitis & cervicitis. C) Discharge of urine in urinary incontinence or that of stool in recto vaginal fistula, D) Chronic vulval dystrophies (leukoplakia, lichen sclerosis) etc are imp. 2) Local iritant :- 1) Unclean hygiene. ii) Chemical irritant like strong soap, dettol sol" or ointments, deodorants, detergents. Tight nylon underwear, imperfectly rinced under cloths. Any parasite from the anus- thread worm, chronic amoebiasis, 3) Alimentary Caus 4) Metabolic Cause 1) Glycosuria. 2) Jaundice. 3) Adiposity. Mediicosys - Since 1999 24Gynaecology 5) Atergic Factor :- Allergic urticaria i.e. Allergy to condom, diaphragm, spermicidal. 6) Dermatological :- Any local or generalised skin lesion like psoriasis, eczema contact dermatitis. . 7) Idiopathic :- Without any obvious cause, psychoneurosis may be responsible. 8) Nutritional :- From iron deficiency anemia, vit-a & vit-bz deficiency, achlor hydria. 9) Radiation vulvitis. Clinical Feature :- 1) The women develop itchy sensation & begins to scratch the vulva. 2) Persistent & prolonged scratching can lead to abrasions, inflammation & irritation with soreness. 3) The patient may loose sleep because of itching & become irritable. Diagnosis Can be made by history, evidence of whole body pruritus or only vulval pruritus. Treatment :- 1) Systemic pruritus is referred to dermatologist. 2) For pruritus vulva :- A) Treat the cause. B) Anti histamics ( tab cetrizine ). C) Sedatives D) Anti fungal drugs.(micconazole tab. & nystatin cream). £) Corticosteriod ointment (wycort). 3) Personal hygiene. 4) Primary health care. $e. Mediicosys - Since 1999 25Gynaecology Vulvat Ulcers Are of following types. A) Traumatic Ulcer: Easly recognised by their appearance, Edges of such ulcers are contused & there is often h/o hurt. Tit Analgesics. Antibiotics, B) Septic Ulcer :- Caused by 1) Ulceration due to non union of perianal tear i) Fissured ulcer on hymen. ll) fissured ulcer due to pruritus. Treatment: Betadine cream. Antibiotics. C) Tuberculous Ulcer :- Appears like thin serpinginous ulcer with undermined edges & thin yellowish discharge at the base. Biopsy shows granuloma formation. T/t + Anti-tubercular. D) Venereal Ulcer 1) Chancroid :- in a small painful ulcer with irregular margin caused by haemophilus ducreyi, gram 4ve bacilli Tit: Antibiot li) Herpes Genitals Ili) Syphilitic Uleer : button (chanere).0 Tit + Antibiotics. E) Malignant Ulcer :- vulval chancres present as non-healing ulcers with raised edges. T/t z= Chemotherapy. F) Dermatological eczematous ulcers on the vulva may develop. By herpes simplex virus multiple superficial painful ulcers appears. appears as deep smooth ulcer with indurated / raised margin like oe Mediicosys - Since 1999 26Gynaecology __-Pefinition:- inflammation of vagina is called as vaginitis. _ _hetiology _A) Bacteria + Gonococci._ ;- Pyogenic bacteria '- Syphilis or other std’s Al Nonspecitic= UP Foreign bodies, A) In ches, 7) Senile <3) iitati A) Parasitic & fungal : (4) Trictiamonas \2}-Monolial/eandidial infections. out of these trichomonal vaginitis & monolial vaginitis is imp. Trichomonas Vaginits:-(Fichgmoniasig)) ischarge from ceruix or by urine or stool in genital fistulae. bout % of lncidences :- This is mgst commonest types sexually transmitted vaginitis, Near the cases'shows this Aetiology :- parasite ;trichomonas :- |s a pear shaped angerohic protozoa, It is slightly bigger than the size of wbc. With four flagella attached to anterior end. It has an undulating membrane, surrounding it’s anterior 2/3" & a fine rod projecting from the post. End. This is actively mobile & can be found in the vagina of a asymptomatic women. nas are foun AT Trichomonas Vaginalis)- found on vagina. 4) TrichomonasBuccalis):- found in mouth, ~£) Trichomonas hominis :- anal canal & rectum. Fig : Trichomonas vaginalis in wet film in-vaginal discharge _ Mode of infection :- This occurs by coital transport from the personal region of the female partner as t. Vaginalis is of bowel origins. Even by infected person’s towels, pond bathing & cloths. Mediicosys - Since 1999 2Gynaecology «Pathotogy : Parasite multiples in vagina at raged oh 5-6 & lowered resistance particularly during menstruation. It is also common during pregnancy . cca agile coh pear ite AY The vaginal discharge is profuse, thin creamy or slightly green in colur, irritating frothy. +2) The vaginal wall are tender, <3) The discharge causes pruritus vulvae, <4) Dysuria, frequently & a low grade urethritis may associated. <5) Abdominal pain, low backache & dyspare y be present. ‘Speculum examination :- \AY_ Vaginal wall is swollen, red, tender, with red papillae which bleeds.an touch , \8) Cervix appears inflamed, red strawberry like. \F Characteristic of discharge is = copious frothy, greenish yellow & offensive. \Anvestigation :- Microscopic examination of vaginal discharge by wet film- for trichomonas. Treatment :- 1) Metronidazole 200mg -t.d.s x 7days. 2) Deworming. 3) For vulval itching ~ surfaz B® ovpinesion - snetemmavion of vagina ® pworoay G@oow'a) Gon-speutie) Gonosive or 4 u 1 Fumgor Uaonacots + eaneain . VYosemie B- @ ody - Tha —syphinis a ‘ asi eee mineme ~O© Twicromons: vavinassy's ¢ ) 3 anddemce 23 peiotosy c fean shape ReKuety mmoboite A ome 1 9 4 3] AY Patmotesy - commu vs ond c Mediicosys - Since 1999 28 ¢ c e @ CGynaecology Monolial Vaginitis Aetiology :- Overgrowth of monalial albicens a fungus of yeast group. The growth is favored with vaginal ph below 4.5. Incidence :-is increases. — during pregnancy. ~ Taking o¢ pills. - Glycosuria, It may be associated trichomonas vaginalis, Mode if infections - Considered as trichomonas. Vaginalis.{exact mode is not known] This fungal infection can also seen in skin of axilla, groin, nail beds. C/f= Symptoms 1) Profuse vaginal discharge thick curdy white, 2) Intense vulval itching, Signs > 1) Redness of the entire vaginal & vulval mucous membrane. 2) Adheret curdy flakes may be seen on the vaginal wall which shows patchy (petechial) hemorrhages on removal of these flakes. 3) Curdy white or thin watery vaginal discharge Is present. Diagnosis :- confirmed by... microscopic demonstration of fungus as refractile long thread like fibers. with bamboo-shoot like buds( mycelia) in exudates. Fig : Monilia Albicans Treatment :- 1) Through cleaning of the vagina is done with cotton swab even anesthesia. 2) Imidazole agents i.e. Canesten or cansoft vaginal tab. Inserted deep into vagina for 6 consecutive night. 3) For vulval itching- surfaz or candid vs cream. 4) Alternatively mycostatin vaginal tab(squibb) is inserted twice daily into vagina for 14days. ooo Mediicosys - Since 1999 29Gynaecology Leucorrhoea Definition:- It is defined as pouring out of vaginal or white discharge per vagina. Aetiology: A] Physiological :~ Normal secretion from vagina, cervix, ses at. A) puberty 8) Ovulation ‘due to hormonal effect. C) Early pregnancy. D) Excess sexual activity. All of the above causes are for temporary duration & needs no treatment. B] Pathological :- 4) li health & sys. Disease 2) genital causes 41] ll health & sys. Disease :- i) Anemia v) Psychological about 1/3" cases, ii) Worms vi) Chronic constipation with sedentary iii) Colitis habit. iv) Endocrinal 2) Genital Causes :- 2/3" cases. 1) Trichomonas vaginitis & candidial vaginitis & other vaginitis -20% 2) Cervical erosion & cervicitis. 3) Genital prolapse. 4) Uterine fibroid, polyp. 5) Cervical carcinoma. 6) Vulval ulcer. 7) Contraceptive (oc, iucd} 8) Unknown causes. Classification of Leucorrhoea :- A) Cervical leucorrhoea 8) Vaginal leucorrhoea ‘A) Cervical Leucorrhoea :- Mucous discharge from the endcervical glands increase in amount & called as cervical leucorrhoea . Chronic cervicitis Cervical erosion Mucous polypi = Ectropion ( cervi Causes partly everted to expose cervical glands due to Mediicosys - Since 1999 30Gynaecology Laceration during child birth.) cn Discharge is mucoid. B) Vaginal Leucorrhoea :- ( non-pathogenic) When the discharge originates in the vagina itself as a transudation through the vaginal wall called as vaginal leucorrhoea. ( acidity of vagina is maintained by Fermentation of glycogen with formation of lactic acid. This is done by doderlein’s bacilli.) Cif 1) White Discharge :- Which can be watery mucoid, mucopus with foul smell, purulent & sticky, viscous, stringy. 2) tis associated with vulval itching. 3) Pt, Become irritable with poor sleep & weight loss. ion & clinical examination :- of patient = - Height - Weight = Anemia - Bp, - Enlarged thyroid - Heart Lungs - liver , spleen examined to rule out sys. Disease. )_ Pelvic exam" :- vaginal, cervical, bimanual. 2) Cervical pap stain cytology. 3) Vaginal/cervical discharge is examined Treatment :- 1) Cause is treated. 2), Primary health care is given 3) Correction of anemia. oo. Mediicosys - Since 1999 31Gynaecology ‘ases of Cervix 1. Cen Definition :- inflammation of cervix is called as cervicitis. Types :- 1) Acute cervicitis 2) Chronic cervicitis. 1) Acute Cervictis :- Causes :- Septic abortion - Puerperal sepsis. - Gonosrhoes. /f = Symptoms 1) Cervixis inflamed i.e. Reddened swollen with oedema. 2) Mucopurulent discharge can be seen in cervical canal. 3) Tenderness of cervix. 4) Sometimes backache. Signs: - An speculum examination cervix is inflamed 2) Chronic Cervicitis :- is most common types. Incidence » Seen in 80% of women with any gynecological complaints. Aetiology: 41) Infection during abortion. 2) Infection during childbirth. 3) Laceration of the cervix during childbirth, 4) Gonococcal infection. 5) Repeated injuries caused by pessaries, tampons & chemical contraceptives. 6) Acute inflammation of cervix may turn in to chronic inflammation. 1) May be symptom less. 2) Complaint of mucus or mucopurulent discharge, 3) Chronic backache. 4) Low abdominal pain. 5) Dyspareunia. 6) Post coital bleeding.(d.d.-cancer} Sings :- cervix- patufous on speculum tender exam", Investigation :- pap'smear to rule out diagnosis of cancer, o$s. Mediicosys - Since 1999 32 «Stu Gs Sk. SaMKaY. Colma Bamba Uas Kyuss Pant Hs von. se fae Ke! salsa bom dank, wd colour Sane nome se “a ge Ki towoh se. woug mMorariasig Gynaecology one Srrawberry, salsa... [Eeniealtrasion)> 15t SteP oP fe cad Foe, ae NO ie Definition:- fall io This is condition of development of reddened area in portio vaginalis around the external os which is a out growth of columnar epithelium replacing squmous epithelium, ay or Oxo] Is conation in which the saumous covering ofthe vaginal portion ofthe cervixis replaced by columnar epithelium. s gre. ¢ gan ware poke We Clinical Types : m 1) Congerital Erosion -n newborn due to mazeral ett rucous 2) Virginal erosion 3) Reproductive age erosion A. Sisaole flat erosion :- 8, Papillary erosion C. Follicular erosion ;- (naboth’s follicle) eG wary) sow Pathology :- Causes AA Cervical erosion basicaly due to estrogen & progesterone 2f/-Associated with cervicitis (chronic) comical, come on : 1] Congenital Erosion : a a) During intrauterine life , vagina & the vaginal portion of the cervix are lined by J transitional epithelium, L b) Towards the end of intrauterine life, columnar epithelium grows down from the cervical canal & in 1/3" of all newborn female children extends to some degree over the «gaol vaginal portion of cervix forming erosion. + paws ) This condition persist for a only few days until the level of oestrogen from the mother falls & the congenital erosion heals spontaneously. But this may reappear under the Influence of oestrogen at puberty & may then persist into adult life. 2} Simple flat Erosion a) Develops in pregnancy, postpartum on tal simple erosion regresses, b) Eroded red area is covered with red columnar epithelium. ig oral contraceptive, on menopause 3] Papillary Erosion :- Associated with cervicitis. a) In chronic cervicitis, pus & mucus are discharged from the canal & irritates the squmous epithelium of cervix. b) After a time epithelium desquamate, columnar epithelium. ave a raw red area & replaced by C) Columnar epithelium proliferates, develops papillae. Papillary projection is clinically seen. Mediicosys - Since 1999 3Gynaecology 4] Follicular Erosion Squmous epithelium regrows towards external os blocks neck of glands causing retension cysts on surface of portio vaginalis & called as naboth’s follicle. Cervical canal We > és Fig: Left: Histology of normal cervix Right: Cervical erosion Hig : Cervical erosion (Papillary type) Clinical features:- ‘Symptoms :- 41) There are commonly no symptoms. 2} Leucorrhoea :- persistent white discharge per vagina, the discharge varies in character from clean pus or mucopurulent. 3) Psychological upset due to persistent vaginal discharge. 1 | | Signs 41} Age - 30-40yrs, parous women, can be rarely seen in virgin & after menopauses. 2). General health :- slight anemia, 3), Vaginal exam” = 1a red granular surface with well defined margin is visible on the vaginal cervix, around the external os. li) in papillary type, papillae are visible on eroded area. li)in follicular erosion, the surface of the portio-vagianalis shows multiple small, pearly white translucent elevations called as naboth’s follicle. Iw) uterus - palpated normal sized. Mediicosys - Since 1999 34 CInvestigations :- 1. Pap smear to rule out cancer. 2. Cervical biopsy. Treatment :- 1) Primary health care. 2) Anemia is corrected. 3) Symptom less cervical erosion needs no treatment. 4) For thin patient weight gain improves leucorrhoea, 5) Surgical treatment == A) Electrocautery. 8) Cryosurgery. C) hysterectomy. $s. Mediicosys - Since 1999 Gynaecology 35ee = Gynaecology (Pelvic inflammatory Diseases [F10) —| __ Fo) io ‘Acute PID.) (Chronic PID Sensi itutes:- 4y Endometritis, ay Salphingitis 3) Dophoritis. <4} Perimetritis > pelvic peritonitis oi Parametritis > pelv - TAR of infection & inflammation of the Upper genital tract}organs typically involvi swh\ene? fallopian tubes, ovaries & surrounding structures is called as P oe a . , ‘eowien NT setactors= one orga A iy i Fe) 8 ‘Multiple sex partner Emu ile wa Zee of contraceptive pill use OF srenous kor oTaeute PD. "UCD users i “area with high prevalenge, 7 -fan- 3. \yau sand — Raiway stamon BC \ Abtiology Microbial agents.) Cstumh orem) AY Primary organisms are sexually transmitted {Ses TA’) “Gonorrhea ~ 30% oe G i =” a ey ectopic. oeyemry 3 Torsion of ovarian pedicle —~ endomuresis A) Endometriosis, Vo ots ‘2 Pelvic peritonitis or even generalised peritonitis. 2) Septicemia = produ: or myocarditis Ay Dyspareunia_ 2) Infertility 3) Chronic PID Mediicosys - Since 1999 37Gynaecology <4} Adhesions, hydrosaiphix, pyosalphix. <4) Chronic pelvic pain and ill-health, +4) Frisk of ectopic pregnancy ~ Vor . 9 wim mucus a _ : Dt [Antibiotics Doxycyclin 100 mg-b.d. i Erythromycin 500 me~4timeaday. qe) are a omen °° vB) (Antiinflammatory and analgesics) uyed OWY Pane ‘ pimp i= vPreventior Oo 7 , Mase i, A} To increase public health awareness. Seu 2) Prevention of STDs with the knowledge of healthy and safer sex. 3) Liberal use of contraceptives, Leucocytosis a 6) Routine urine examination ~S) laparoscopy = helpful to infirm diagnosis and to know the extent of lesion specially in cases of infertility. <_ Differential diagnosis:- Treatment: 1) Endometriosis, 2) Disturbed ectopic pregnancy. 3) Chronic appendicitis. 4) Chronic colitis. 5) Twisted ovarian cyst 6) Chronic cystourethritis. 3) General A) Improvement of general health specially to correct at mia, ~8) Analgesics. <<) Pelvicheat applications. DB Specific: ~2) Antibiotic therapy [ampicillin / tetracyclin or cephalosporin 500 mg thrice daily for 3 weeks} 3) Surgery Ideal surgery should be total hysterectomy with bilateral salphigo- oophrectomy otherwise, the infection may flare up from the residual tissues left behind in conservative surgery. ; ~ridication of surgery:- - Persistence of symptom inspite of treatment. - Recurrent acute attack - General deterioration of health O96. Mediicosys - Since 1999 39ae Gynaecology {Salphingiti « Pefinition:- Infection and inflammation of fallopian tube 1d as salphingitis ( Aetiology:- Same like acute PID zi te Mode of infection: Same like acute PID yO ( \-Fypes:- Two types A} Acute cute slphinglis Rdpwew{ OF {Aiueeee a] cron stings ‘ Tubercubos. SF famerprin the oO Souplung you € col ~ a is again subdivided in two subtypes... stonprocolys ¢ P —a—u—~_wvavrv—em” seprylorer, f doe “Acute Gonococcal salphintitis Acute pyogenic salphingitis 7] |} Sexually transmitted 7) Endogenous organism _ c ‘Infection occurs usually during and 2) Following abortion and child birth. | 3 following menstruation _ an [AT Mode of infection:- By continuity and 4) Through lymphatics and veins pelvic . contiguity cellulites > Tubal affection 7 ¢ “Always bilateral affection 5) May be unialetral ee __ Pathology _ "Pathology : g [AT Endosalphingitis 1) Perisalphingitis “Qtexx WEA | luminal exudation ++ 2) Intra (urinal exudation Less losure of the abdominal ostium by 3) Closure by adhesions may remain patent. 6 phymotic and indrawn fimbriae 2 7 oO | BrPeritoneat coat is less 4) More involvement and such adhesions are : q - more and dense. 7 | [sf Pus becomes sterile by 6 wks. 5) Takes longer time ever ayear. s Restoration of reproductive function is | 6) Restoration may be possible , © likely. _ a oF Gthdian ve Feewoyy © note af : :- Same Uke acute PID = oO oye = ey Fate of acute salphingitis:- ; ot i = ga 1) Complete resolution:- The tubes return to its normal structure and function ¢ e ro” Due to loss of cilia in case of endosalphingitis . 3 Chronic ee tore infection, SAathly. erat ( AS Mediicosys - Since 1999 40 CGynaecology Chronic Salphingitis Chronic salphingitis Pyosalphinx Chronic interstitial ew salphingitis. x ar BP varosalphi + Béfinition:- Collection mucus secr a Patliogen AT It is usually due to the end result of repeated attack of mild endosalphingitis by pyogenic organisms of low virulence. During initial infection, the fimbriae are odematous and indrawn with serous surface adhere together to produce closure of the abdominal ostimum. 3f The uterine ostimum gets closed by congestion ~The secretion (Exudate) accumated to make the tube distended. _SF As the mesosalphinx is fixed the resultant distension makes the tube curled and , looks retort shaped 4f The wall is smooth and shiny containing clear fluid inside. 7% Depending upon diameter of tube the Hydrosalphinx may be... Mild — if diameter <15 mm Moderate — if diameter 15-30. mm Severe - if diameter> 30mm. Diagnosis:- Confirmed by U.S.G. Complicatior i) Xf Formation of tubo-ovariancyst 2 Torsion 3¥ Infection from the gut 1 AY Rupture, , 2] Pyosalphinx: Aetiology:- Same Pathology: 1) The pyogenic organisms, if becomes virulent produce intense inflammatory reaction with secretion of pus, 2) The tube becomes closed at both ends. The abdominal ostium by adhesions of the fimbriae and the uterine end by exudate. 3) Because of intense inflammatory reaction and or escape of pus into the peritoneal cavity, 4) There is dense adhesions with surrounding structure. 5) The inner wall of the tube is replaced in part by granulation tissue. Mediicosys - Since 1999 41Gynaecology 3] Chronic interstitial salphingitis:- Pathology: 1) The tube enlarges mainly due to great thickness of the wall. 2) The distension of the tube by the exudate is unusal, the abdominal ostium may be closed or partially open. 3} The adjacent organs are adherent to the tube. 4) The epithelium is usually intact 5) There is fibrosis of the muscle coat along with inflammatory changes. 6) This hinders the tubal motility and favours ectopic pregnancy. 4] Salphingitissthmica nodosa. CMbortbariy saplercptuy ) AY itis elated to tubercular infection, although it may be the residue of any form of chronic interstitial salphingtis PF There is infiltration of the tubal mucosa directly into muscularis resembling adenomyosis of the uterus, ~ prea Corp SY Nicked eve apnerance:- Reveals ane ar two nodes XS tageas2cm AF Microscopically:- There is thickening of the muscularis in which tubal epithelium {MONSKOPTE lined spaces are scattered. oO ~ edd spaces are scattered.» C/F of chronic salphingitis:- SInvestigation:- Same like chronic PID Management:- -OO4. a (Avasory OF Pemaeke goviitad saauts } Tiherwlaris coupler @) oer + chaawic gaamwiemay imple of FT pordivaing Factor © pemotoay TyPICal AYYPI Ca @ — Pateoomecis 2 Souplunigirs 1st Mera Waetsig TT AMBIN S” gored Formate’ Gerr u or Kod tub dagawd, > RU Souphuvgity ~ CIP of crown'c tap 200 Brel eredig LOUey ab omy, LY FAQ) es MRO ty a © TRUM seiicosys See 959 2 aN mam DAUM IN cou oETR OD puntwbenua,, dienyyGynaecology Oophori Inflammation of ovaries is called as oophoritis. itis always associated with inflammation of fallopian tube hence synonymously itis calied as salphingo-oophoritis Mode of infecti 1) Directly from the exudate containing the ovarian surface. 2) Blood borne ~ mumps 3) Through the rent of the ovulation producing interstitial oophoritis. Aetiology like PID - Same ( Primary organism, secondary organism. Pathology: 1) If the organisms are virulent, an abscess is formed and two-ovarian abscess results, 2) The ovaries may be adherent to the tubes, intestine, omentum and pelvic peritoneum to form T.0. Mass (Tubo-ovarian mass) 3) Direct affection of ovaries without tubal involvement may be due to mumps or influenza C/fz- Same like PIO T/ts- Same like PID Mediicosys - Since 1999 Ba Gynaecology (Pelvic Abscess ENcrstea Puy sy 7 the Pouch of douglas pefinition:-Encysted pus in the pouch of douglas i called as pelvic abscess. Aetiology: in Pelvic cause: Com > Post abortal and puerperal sepsis > Acute salphingits > Perforation of infected uterus such as attempted uterine curettage in septic abortion or pyomet > Infection of pelvic haematocele usually following disturbed tubal pregnancy. v Post operative pelvic peritonitis. Extra pelvic causes:- Rare, <> Appendicit <> Diverticulitis > Ruptured gall bladder ~> Perforated peptic uleer etc and high temp with chills and.tigors _ ~2) Rectal tenesmus frequent passage of loose mucoid stool 3) Pain lower abdomen ~A) Difficulty or even retension of urine. <2) face is red with anxious look DY Pulse rate raised \3) Per abdomen:- _a)-Tenderness -b) Rigidity _S/-A mass may be felt in supra pubic region which is tender, irregular, soft ete. Mediicosys - Since 1999 44Gynaecology 4) Per vaginum:: ~a)" The vagina is hot and tender _ _-+) The uterus is pushed anteriorly 2} The movement of cervix is painful _ <5) Rectal examin: Anvestigations:- Jy Blood examinations:-TLCT, DLC neutrophils? Dy Bacteriological :- Swabs are taken from high vagina, endocervical canal and from, the pus. Culture is done and antibiotics sensitivity is checked. 4) US.G.- diagnosis of pelvic abscess is confirmed by U.S,G and culdacente Fate:- ~X} Complete resolution: fs unlikely. ~2) Generalised peritonitis ~3) Abscess may burst Tht _Ar Antibiotics 2} Surgery. post colpotomy_ -$0- ObscOR7—> — enedstad PUE bh he — Pouch of douglas @ sexinavion OD Aewotoay > eRe Bived | Baemororiial og panic come XIE Fee Crone) ee eee Comman) came, dlagnesi * wa! sate OF foune +B fost ehontal and > APpemdis Hs. gbsiem pucn perod seesis Gi) sivern' wes orngioms H) “ncabe sabahinalls ii) gymnund gall — i) ploman'e cay Belles 1) post oteranive Fertonaxd |) PERC wrest fewre fentonit’s OQ Celia Fo) is oye sy pad witnamated 100% sMinpioma = St gWe i, passe ate radbed a YL 7 Cnaoa ¢Mediicosys - Since 1999 (tex 4, ) (ter 5 os (rains, ee ~ wiv rome "REY emer ero = POU wh LOLA ado meeGynaecology Parametritis j Definition: Inflammation of the pelvic cellular tissue is called as parametrtis. Aetiology:- Infection occurs following... a) Delivery and abortion b) Acute infection of cervix, uterus tubes ( ¢) Caesarean section or hystrectomy ‘ d) Secondary to pelvic peritonitis f e) Cacervix 3 | a fe Causative organism are:- : | - Anaerobic streptococci © | = Staphylococci ¢ i - E.coli a { Pathology: 1 1) There is intense hyperemia with exudation of serous fluid, lymph and neutrophils R | 2) The exudate may form an abcess a | 3) The pus may be localized or may have extrapelvic extension along the tract of 2 i | blood vessels and ureter © | 4) The abscess thus sprade towards the perinephric region, to the buttocks, to the © ¢ thigh, above the inguinal ligament 5) Rarely the abscess may burst into the pelvic organs. ¢ 6) The cellulitis usually confined to one side but may extent to the other side either ( anteriorly or posteriorly. Fate of pelvic celtulites tv T Jy 4 Resolution Abscessess Pelvic Chronic | thrombophebitis q v v C Mediicosys - Since 1999 46Gynaecology Localised Extra pelvic Burst into rectum or extension beritoneal cavity | Perinephric region Buttocks Femoral triangle Above injuinal ligament Cit A) Acute:- 1) The onset in slow, appears about 7-10 days following initial infection 2) Fever ~202°F 3) Dull — aching pain deep in the pelvis, Sign:- 1) Pulse rate - Raised 2) Tenderness on lower abdomen 3) Hot, Tender vagina 4) Indurated tender mass extends to the lat pelvic wall 5) An abcess formation is featured by spiky rise of temp, toxic look and fluctuant swelling Chrot i Cit. 1) Deep seated pelvic pain may be localized to one side 2) Dyspareunia. 3) The uterus is fixed to an indurated and tender mass Tit Acute :- Same like acute PID Chronic:- Same like chronic PID Mediicosys - Since 1999 47Gynaecology i >) Definition: This is a pre malignant cervical lesion of squamous epithelium in which there is transformation of cervical squamous epithelium to pre malignant dysplasia cells. Richard 1967 From USA gave the term CIN; whereas squamous intra epithelial lesion {SIL}, a new name is also given since 1990. Section 3 ignant tumours of female genit Cervical Intra epithelial Neoplasia (CIN) Grades: 1) CIN grade | ;- Low grade:- Lower one third of squamous epithelial layer becomes dysplastic (Mild dysplascia) This is reversible, can show regression to normal in 30-50% 2) CIN Grade I! :- Lower 2/3 of squamous epithelial Jayer becomes dysplastic (Moderate dysplasia) 3) CIN grade Il:- Entire squamous epithelial cells becomes dysplastic (Severe dysplasia.) 4) Carcinoma in situ (CiS):- Is grade II! CIN with cellular atypia and malignant cells change. , CIN is @ continuous process with progression of CIN grades to invasive cervical cancers cin cnt Fo Fig:- Cervical intraepithetiat neoplasia Epidemiology :- Same as cervical Carcinoma. CF Symptoms:- Lesion is asymptomatic ign:- Cervix on speculum examination shows no lesion. Mediicosys - Since 1999 48 £Gynaecology Diagnosis:- Made by 1) PAP sme Shows presence of dysplastic call Og i ee) Fig:- PAP Smear 1) By colposcopic examination. 2) Punch biopsy tissue histology. Treatment:- : 1) Expectant treatment for CIN grade | 2) For grade 1! and Ili surgical treatment is done called as cervical conisation, excision by knife is done around external os under general anesthesia. Removal cervical cone o oe. Since 1999 49Gynaecology This is primary malignant epithelial growth invading cervix. This is the most rin woman and also in genital tr: . Sommanesteancer in TT RGUNOL. AgRoTmal ynCoW ADE) gaDLOr) invading Ciscidenca] wn Cevore 15-25,/ 1,00,000 women inEurope_.4 commoner camcey iN womew amd 119.4 43.5 / 1,00,000 women in India _ ado iy mewtw Inu, (anton Extract aetiology.is non known Risk factors are:- UST Sperm factor: is prime cause. Early sexual intercourse in teenaged (< 16 years) is “jrost Important; married woman gets more than in single. ~10),Child bearing Vaginal delivervin grand multiparty. ‘\-71)STDs and prostitution with multiple sexual partners favors. : |_2aWiral infection :- HPV type 16,18, 31,33 are responsible to cause cervical dysphasia ‘and invash cinoma. 1B}Habits;- Tobacco smoking favours cancer where as vegetarian diet i.e. vegetables Ura) Poverty. 1-45) Unhygienic condition. ar MMe sumoion oF SAUMOU aynd - ae Govwnnars epiteeli um ane Cervical transformation zone squamous metastatic epithelium develops 85%, * equamp —_Rest arises from other parts of ectocervical squamous epithelia. MFO © cpiyaabivitypess a a) (Naked eye types: 2 Beophitic80%)- growth from etorery Stage I A = Pre clinical carcinoma of the cervix, that is those lesions diagnosed only by microscopy. > IAs Minimal microscopic stromal invasion. > Iz Lesion detected microscopically can be measured. The upper limit shoukt not exceed the depth of 5.0 mm from the base of epithelium either surface or glandular and the horizontal sprade must not be exceed 7.0 mm. > Lesions of greater dimension than stage IAr whether seen lly or not. 27 Stage I:- Carcinoma invades beyo Jjout not to pelvic wall or > IIA = Carcinoma extending to upper 2/3 vagina without parametrial involvement. > IIB :- Carcinoma extending to parametrium. tage Ill:- Carcinoma extending to lower 1/3 of vagina with or without extension to pelvic wall. > Ill Ax Carcinoma extending to lower 1/3 of vagina without extension to pelvic walt. > III B= Carcinoma extends to pelvic wall and or hydronephrosis or non functioning kidney 5),Stage IV:- Carcinoma extends to bladder or rectum mucosa or distant metastasis beyond pelvi > IVA: Tumour spade to adjacent organ. > IVB: Extra pelvic spade to distant organ, (22st secommented for £160 staging: 4 Complete physical examination, under anaesthesia if necessary 2. Chest X-ray L& Ercretory urogram Cystoscopy 5. Proctosigmoidoscopy LS. Qytology (from biospy) 4 Histopathology A Endocervical curettage \_-9> _Cone biopsy \-407C.T-scan of abdomen & pelvis _-Li-Bone scan ete. Mediicosys - Since 1999 SIM 2 ¢ (clinical featur ‘Symptoms:- The 4 main symptoms are_ Os 1] Haemorrhage 2] Discharge 3] Cachexia 4] Pain i nee mormeee rene 05 / SF reenonton the typical haemorrhages in Ca cervix is superimposed upon normal menstrual bleeding i... Gynaecology Aroita), V~ Coital bleeding bleeding Bleeding on strain, exertions a GBieedin gy 4 “post menopausal bleeding — fost ote . .4C Bleeding follows digital examination 7 OY ee i Slee duns 1 Discharge + Offensive vaginal discharge is present apes gital CAAMUNIE ‘ay Cachexia:- Patient is cachectic, anaemic with oedema on legs. «AT Pain :- Pelvic pain of varying degrees is press 2d with backache, pretwmy OF _— Mmichunaen s}Bladder_symptoms:- Increased frequency of micturation, dysuria, haematuria or dxtsumiq “ingantinence of urine due to vesicovaginal fistula. | Mawmnatwia 6} Rectum symptoms] Diarrhoed, j fpainful defecation|because of proctitis and obstruction, Ancor Wyus” bleeding per rectum. . Hy rgrtus Because of Vaginal discharge ty veniged| pane BeEaUEE OF vaginal discharge] Push 3) Cervix bleeds on touch, if digital examination of cervix is followed by profuse vaginal bleeding it cewix bleeds indicate caulifiower type growth. aaa ‘on pouch b) itis friable. > grote , 6) Cervix is fixed and lost its mobility due to infitr > Pxed ond becausecfoarametitis. 40sh its mobil) There is induration of cervix & other surrounding structures. us tp (witlea Wen > parame ps E oF PBlagnosis. confirmed by:- | Ye isto bata, 1 Cervical wedge biopsy istry oF a7 pap smear poe Smear, 4 Cytology, histology : =— * 37” Through physical examination y V6Vaginal, bimanual, speculum examination ie Eomalentons: jon of the parametruium or i Ava ovagina) Fistuly Nauunnnage Vato While, rectovaginal fistula —] Sepsis | —_ nr S Pyometra TZ. Aduonizg 7. Pye Lae Pyelonephritis Muley, \ ese of deat we Urzemia_ <6 Haemorrhage Mediicosys - Since 1999 52Gynaecology c. Sepsis. d. Cachexia._ e. Metastases. Trpétment:- i Grimary surgery :- Abdominal radical hysterectomy. (Wertheim operation) the surgery includes removal of the uterus, tubes and ovaries of both side, varying length of adjacent vagina, paramaterum, cervical nodes, ete. Primary radiotherapy_ AY Combination of both ‘ > faim: SUT AT Chemotherapy > eimamy era rag Proptfylaxis:- — > combination of beth Bf Direct — chomotn rene + ‘Bezeoning by PAP smear cytology |. + (Peoples education z- Awareness) Bi] Indirect: All risk factors of Ca Mediicosys - Since 1999 53Gynaecology Benign Tumours of the Genital Tract Uterine Fibromyoma [Uterine Fibroi Deyn BEfinition:- This is a benign growth from the muscular layer of uterus (smooth) Qapwty Uncidence:- 5-20% woman aged over 30 years ye al] Myomas generally ceggeto.grow after menopause and rarely found munuler \xeT oF before puberty. loner. = Oren bP Incidence is more in women having granulosa ~ cell tumour and polycystic qvatian disease. coy. JA Size of myomas increasés during pregnancy and during tr oral contraceptive nt with pa jology;- Not exactly know estrogen :- Tmourlis oestrogen dependent because concentration af estrogen receptor is higher in myomas ands it develops during reproductive age. / pf Heredity:- It runs in families. —eoe ‘At corporeal :- Corporealfibromyoma ph Atcervical :- Cervical fibromyoma Corporeal fibromyoma Tipes:- Fibromyoma (g') 1 —-se.b27059 (ramus) (suse J (dasmas) _Bubmue g A EWGOMUG yy (atramural:- Uterine myomas arise in the smooth muscle cells Of the myometrial tissue (60-70 %} —— __ A bserous:- If the tumour grows outwards towards the peritoneal surface ie es : bers. grow underneath the periténeum called as subserous or subperitoneal tumour (15-20%) submucus-( endoradviam ) When tumour grows inwards and present underneath endometrium is called sur} a pne™? 2% submucus fibromyoma ‘ a 0 It may sessile or pendunculated 5uhl D ge B Aw ° ) pe Mediicosys - Since 1999 54Gynaecology Interstitial (intramural) Subserous (pedunculated) Subserous Fig:- Various types of body fibroid Pathological changes:- Grossly:- _ fs oY Frequently fiple sfhericaltumou}infmuscle layer, Fem in constancy] 2) Cut section shows characteristic pale_white (pinkish white) with wRorled trabeculation. 3) The capsule consists of connective tissue which fixes the tumour to the myometrium, Microscopically: 1) The tumour consists of bundle of plain muscle cells separated by varying amount of fibrous strands 2}, Bundle of fibrous connective tissue present (intervening) between muscle tissue. jecondary Changes:- D4) Hyaline degeneration:- Commonest type. The affected muscle part become ~~~ “structurally, glassy, eosinophilic, uniform ie homogenous. 2)_Cystic degeneration:- When hyaline material under go liquifaction, the tumour becomes soft, irregular spaces filled with fluid called as cystic degeneration. _CF__ 3) Calcification:- calcium salt may be deposited in the tumour called as calcification. ! “tis commonly seen in post menopausal women. RO __4) Red degeneration:- the myoama becomes tense, tender and causes severe co a abdominal pain with constitutional upset and fever. ; 9 The tumour is purple-red in colour and develops a fishy odur. It is typically seen during pregnancy. Pye Microscopically:- The red discolorisation is due to diffusion of blood pigments = from the thrombosed vessels. ;- Is rare in uterine fibroid. \_S}7Atrophy:- There is shrinkage in the size of the tumour which becomes firmer and fibrotic as a result of { sed blood supply, due to menopause. Mediicosys - Since 1999 —Gynaecology 7) Infection:- Occurs commonly in submucus type. ( 8) Malignant changes:- Occurs in less than0.5 % of fibromyomas. & a} 17 Symptomless in early stage ¢ _2¥ Menstrual distu _3Y Menorthagia:- due to: a, T sed endometrial surface b. Endometrial hyperplasia c. T sed vascularity g _f Polymenorrhoea:- Menstrual cycle becomes too frequent less than 3 weeks. ( + Sy Bysmenorrhoea. ¢ Paln:- Spasmodic dysmenorrhoea uecurs with intramural and submucus_myomas. “Pain can be severe if a submucus myomatous polyp protrudes into uterine cavity as a polyp. _A#)_ Pressure symptoms:- Pressure symptoms are due to large tumours. : AT Feeling of lump in tower abdomen i 4 Tarinary frequency, urgency Aovton of Anaem : Weakness, palpitation, tachycardia and dyspnoea sya ens: Ss padpouone AP Sings of anaemia are present 5 } A persbiomen- 2 sod eured 9 — 2 anspusy 1. Alump is palpated arising out of the pelvis. 2, The surface of lump may be smooth or nodular. © 3. Lump shows dullness.on percussion ‘Bimanual examination:- © Confirms that uterus is enlarged with nodularity, oO \ vestigation: | Af Pelvic US.G. :- Hysteroscopy | Laproscopy . 7 Fj Lab test:- 1. Blood Hb% 2. Blood glucose level 3, ABO-Rh Group 4, Other blood and urine test ¢ VAP Cervical PAP smear is mandatory. ce Mediicosys - Since 1999 56 ( rrGynaecology Multipie fibromyoma uterus $e Mediicosys - Since 1999 7Gynaecology Cervical Fibromyoma Incidence:- 1-2% of uterine fibromyomas Type: According to location 1) At portio-vaginalis:- The myomas may project into the vagina and becomes polypoidat 2) At cervix:- a, Anterior:- Pushing bladder up b. Posterior:~ Pushing / pressing rectum ._ Lateral- Pushing ureter below and laterally. 4. Central :- Uterus rides on tumaur C/F:- 1). No menstrual disorder occurs but pressure symptoms like. a. T frequency of uterine b. Retension of urine c. Retension of rectum d. Difficulty In defecation on straining Signs:- Perabdomen The uterus and appendages are felt separate Per vaginum Cervix expanded with a tumour Investigation: 1) usG 2) Urine analysis 3) Culture ~ for infection Tite 1). Small supra vaginal cervical fibroid producing no symptom so require no treatment 2) Hysterectomy: In large fibroid Poo. Mediicosys - Since 1999 58Gynaecology Uterine Polyps jon: This is a pendunculated growth arising in uterine cavity from corpus or cervix, Types:- Uterine polyps Ll t t T qT Mucus Fibroid Placental Malignant A] Mucus polyp: 1) This is the commonest type 2) It is a overgrowth of endocervical or endometrial mucosa due to hormonal stimuli. i) Pathology (Structural features) of mucus polyp + ) a. Arises singly or multiple b. Pea sized, bright red, pendunculated hanging from external os. ©. Histology: Squamous hyperplasia d. Malignant changes are rare. ii) Cf Incidence:-Elderly woman; commonly 30-40, rarely postmenopausal symptoms:- a. menorrhagia b, Coital bleeding c. Leucorrhoea lilInvestigation and diagnosis:~ e. Speculum examination f. Blood group and Hb% iv)Treatment: 1) Under general anaesthesia; polypectomy — removal of polyp 2) D&C B] Fibroid polyp:- Fibroid polyp results from expulsion of submucus fibroid from its bed into the uterine cavity and then protrude into vagina. a. Pathology:- 1, Moderate to large that fills up whole vagina usually single pendunculated pale white firm polyp protrudes in uterine cavity, cervix or in vagina. 2, Structure:- Fibroid:- Present as the core > Endometrium:- As a covering capsule pedicle is made up of covering mucus memb. 3, Histology:- Fibromyoma b. C/Fe 1. Incidence:- Childbearing (30-40) rarely menopausal 2. Symptoms: a) Leucorrhoea Mediicosys - Since 1999 - 59Gynaecology b) Metrorthagia <) Dysmenorrhoea d) Menorrhagia e) Postmenopausual bleeding f) Something coming down g) Retension of urine ~in 3. Sign: a) Patient becomes anaemic b) Presence of fibroid polyp Seen Per speculum examination Diagnosis and investigation: Speculum examinatio 1) Shows slippery lump (polyp) with a pedicle in the vagina or in a cervical canal or uterine cavity, 2) Hanging polyp becomes infected 3) Hb% and ABO,Rh groups Treatment 1) Polypectomy:- Removal of polyp C] Placental polyp:- When bits of placenta are left out and remains attached after abortion or childbirth, it gets organized in blood clot and called as placental polyp. i. Structure :- It is single sessile but uncapsulated ii, Cf Symptoms: 1) Spotting bleeding 2) Heavy bleeding at interval Signs: 1) Patulous as 2) Uterus bulky Treatment:- D&C D] Malignant polyp:- Rare type it isa uterine sarcoma or endometrial carcinoma or mesodermal mixed tumour, Incidence:- 1) Late years of life:- Menopasual Postmenopasual 2} karly years too:- Infancy, childhuod, reproductive age Sarcoma batryoidi:-Is the common malignant polyp. Itis cystic grape like malignant growth Occurs in uterus (Corpus) :- During postmenopausal years, & In cervix:- During infancy, childhood and reproductive age, Cit 1) Vaginal bleeding 2), Leucorrhoea. Investigation:- Biopsy of malignant polyp Th = 1) Removal of polyp 2) Appropriate t/t of cancer is done. $6. Mediicosys - Since 1999 60Wk FC Pixed @) Section 4 - Others Genital Prolapse, Befiniti Herniation of the pelvic organs through vagina is call | prolapse. eURPOMs OF UrOT US Genital prolapse is grouped according to age group as. Jn virgins — (congenital) :- Uterine prolapse due to development defect of uterine support following in young virgins. - wl, in reproductive age group: Acquired genital prolapse due to child birth, trauma. to pelvic supports following poor intranatal care. Atl. Climacteric:- Menopausal atrophy of pelvic supports that leads to atonicity and asthenia (most imp), Gynaecology asthenia (mostimp)y A &tiology and prolapse:- Ai Predisposing factors byAgeravating factors AT Predisposing factor HW) Acquire J Vaginal delivery with consequent injury to the supporting structures is the chief cause. . The injury is caused By: xeon Over stretching of Mackenrodt’s and uterosacral ligaments - due to «> Premature bearing down efforts prior to full dilation of cerwix (common in India in women who are delivered at home by dais) > -Apptcation of forceps or ventouse tration port full dilation of cervix, > Down wards pressure on the uterine fundus in an attempt to deliver the placenta. > Prolonged labour (2™ stage). eebig Over stretching of endopelvic fascial sheaths of vagina. Ste stething of perineum = Due to Ir Prolonged station of the head on the perineum <2 Avoidance or delay in episiotomy. _3-Imperfect repair of the perineal injuries. #} Sub involution of supporting structures:- In—Ii nourished, asthenic women. <2} Early resumption of activities which greatly increase intra abdominal pressure & SE «4 Repeated child births at frequent intervals. Persistent over fil of the bladder in the puerperium leads to stretching of the pubocéFvical fascia and prolapse, ive KA ond _beCongenital:- Olochomem mou 7% Congenital weskness of the supporting structures is responsible {oUt for Tulliparous prolapsd of prolapse following vaginal delivery. a pulp: psd of prolaps gi Care \_Bhtggravating factors:- dag pbtes 4. Postmenopausal atrophy {atanicity and asthemia) imped 2. Increased intra — abdominal pressure as in chronic cough and constipation sey 3. Increased weight of the uterus as in fibroid or myohyperplasia. Med ~ Meaicosys - Since 1999 Pew 61> Back, ediicosys - Since TPachau : Plow, fetare®Gynaecology + Asthenia and under nutrition _5._Traction by anterior vaginal wall polyp or cervical polyp. Raised intra abdominal pressure:- -¥ Chronic cough :- Due to chronic bronchitis, asthma _¥ Constipation ® Extras:- Hard domestic work, prolonged breast feeding are also factors. pe I types:~ Types of genital prolapse vO OU Vaginal Uterine + 4 Tee + Cexd RRY Anterior wall \ == Post wali Utero vaginal Vaginal uterine Cystocele Urethyo —_cysto Relaxed cele urliocele Ferineum” poy : == Primary Secondary + at i Enterocele, Goliowing) : i I : Tt tL Vaginal Abdominal hysterectomy HYStevectortiy . aan inal prolapse: | . Anterior wall:- upper 2/3 _ «i Bustocele s The cystocele is formed by laxity and descend 2/3" of the anterior vaginal wall. As bladder base is closely related there is herniation ‘of the bladder through ant vaginal wall a Urethencale Lower 3a arose When there is laxity of Jags third of the anterior vaginal wall, the urethra herniates through it called as urethrocele, wit If urethral herniation occurs along with bladder it is called as cystourethrocele. peisomeioees Mediicosys - Since 1999 62Gynaecology Fig:- Cystocele yb} Post vaginal wall:- UF Relaxed perineum :- Torn perineal body produces gaping introitus with bulge of the lower part of the posterior vaginal wall. 2} Rectocele:- Lower 2/3 ‘There is laxity of the lower 2/3 of post. vaginal wall as result, there is herniation of the rectum through the lax area called rectocele. - Rectocele == } Vault Protapse:- Jy nterocele:- Laxity of the upper third of the post vaginal wall results in herniation of the pouch of Douglas. It may contain omentum of gut hence called as enterocele. AF Secondary vault prolapse:- This may occurs following either vaginal or abdominal hysterectomy. Mediicosys - Since 1999 63Gynaecology ary rolapse:- These are of 2 types J} Uternvaginal:- Where primary decent of uterus causes inversion of the vagina:- In this type there is no rectocele or cystocele 2Vagino uterine prolapse :- Commonest here primary vaginal prolapse drags uterus down. This is associated with rectocele, cystocele and relaxed perineum. Degrees of uterine prolapse:- aAirst degre The cervix and uterine body de: from its normal position (Normally external as lies at the plane of ichial spines into the vagina ) brSecond degree :- The cervix descends at or outside the vaginal introitus but the body of the uterus lies within the vagina. «Third degree (Complete procidentia) Popularly termed procindentia whole of the uterus descends outside the vaginal introitus and vagina is almost inverted. al icatior 77 Descent of the cervix in-the vagina. \% Decent of the cervixin the introitus 2° Decent of the cervix outside the introitus. Procidentia :- All of the uterus outside the Introitus ite au AF "Something coming down” per vaginum or“ falling of the womb” on straining or even standing is the characteristic symptom in any type of genital prolapse. Mediicosys - Since 1999 64Gynaecology In procidentia, there may be difficulty in walking due to mass__—_protruding JF Sacral_or lumbosacral backache due to stretching may be present which is relived on rest. _3) White discharge per vaginum may be due to associated cervicitis, mild degree vaginitis and decubitus ulcer. Sometimes due to decubitus ulcer there is blood stained di _B}-Menorrhagia is not common occurs in case of decubitus ulcer ‘Frequency of micturition during day when the patient is up and about the bladder sags down. If the frequency occurs during day and night, itis due to cystitis in cystocele. _ AV difficulty in emptying the bladder:~ Leads to chronic retention ‘Stress incontinence :- Is rare. AY Oitficuty | in completely emptying the bowel. Bowel is emptied after pushing up ) the rectocele by fingers through vagina. She passes stool.on standing, Constipation. of the pelvic cellular tissues Signs:- ~a}“Age:- Patient is of child-bearing or post menopause age and aimost always a parous woman, ° ~-bf General health «Is normal or poor, asthenic, she is often anaemic : _sb Per abdgmen:- Abdomen lax. Per vaginum ) apsfection: ‘The patient lies on her back and strain down on coughing The finding are as follows:- ) «2 -tarity of the perineum S_-Bulging of the ant vaginal walls ~ ‘Lower part = urethrocele Upper part: Cystocele ete <> Descent of cervix in the vagina for 1" degree prolapse > Cervix can be visualized at or outside the vaginal introitus in 2” and 3" degree b)eM Palpation:- Grip test:- Is done to diagnose 2 degree uterine prolapse from 3“ degree _ Procedure® the protruding uterine prolapse is gripped by thumb in front ~ Base of t and two fingers on the back. ine corpus can be grippe. in'3* degree :- Uterine fundus lies bel «gp7héeystocele, urethrocele can be felt.as bulging Mediicosys - Since 1999 65 respe sof vaginal wall NaH ng f os sopra