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Gynecology 2.

1a

Benign Neoplasms of the Vulva, Vagina, Cervix and Uterus

OUTLINE
I. Vulva

II.
III.

IV.

a.
Urethral Caruncle
b.
Bartholins Duct Cyst
c.
Skenes Duct Cyst
d.
Epidermal Inclusion Cyst
e.
Nevus or Mole
f.
Hemangiomas
g.
Fibroma
h.
Lipoma
i.
Hidradenoma
j.
Syringoma
k.
Endometriosis
l.
Granular Cell Myoblastoma
m.
Von Reklinhauses Disease
n.
Hematomas
o.
Papillomatosis
Dermatologic Diseases
Vagina
a.
Urethral Diverticulum
b.
Inclusion Cyst
c.
Dysontogenic Cyst
d.
Tampon Problems
e.
Local Trauma

Cervix
a.

V.

b.
c.
Uterus
a.
b.
c.
d.

Endocervical and
Cervical Polyps
Cervical Myomas
Cervical Stenosis
Endometrial Polyps
Hemometra
Myoma
Adenomyoma

LEARNING OBJECTIVES
1. To be able to finish this accursed trans in the middle of Christmas break.
REFERENCES
Unless otherwise stated, everything came from the ppt.
Recording information is italicized
Chapter 18, Comprehensive Gynecology (6th Edition)
* Trans Group/Editors Notes

Dr. Co-Hidalgo
Something AD

Ulcerative lesions, hematuria if they are secondarily infected


may produce point tenderness after contact with
undergarments or intercourse

Sometimes

DIAGNOSIS
Biopsy under local anesthesia, to rule out malignancy but note that
urethral caruncles are NOT precursors for urethral carcinoma
Differential diagnoses include
o Primary carcinoma of the urethra
o Prolapse of the urethral mucosa - If this diagnosis is considered in a
child, urethral prolapse may be the more likely diagnosis. Compared
to caruncles, they do not have a bright red color and is not as
circumscribed grossly

TREATMENT
1. Oral (which may have side effects, hence used less) or topical
estrogen (may be administered as vaginal suppository) and 2. Avoidance
of irritation
If the caruncle does not regress, it may be destroyed by cryosurgery,
laser therapy, fulguration, or operative excision
Following operative destruction, a Foley catheter should be left in place
for 48 to 72 hours.
Follow up is necessary to prevent urethral stenosis
Recurrence may occur. Small asymptomatic caruncles do not need
treatment.
Initially:

EXCISION OF URETHRAL CARUNCLE

I. VULVA
A. URETHRAL CARUNCLE

Figure 1. Urethral Caruncle

A small, fleshy outgrowth of distal edge of the urethra that is soft,


smooth, and friable, bright red ()
Initially appears as eversion of the urethra

May be 1-2 cm in diameter

Believed to arise from an ectropion of the posterior urethral wall


associated with retraction and atrophy of the postmenopausal
vagina

Secondary to chronic irritation or infection

Occur frequently in postmenopausal women, and must be


differentiated from urethral carcinomas
Histologically, composed of transitional and stratified squamous
epithelium with loose connective tissue (*makes sense since it arises
from the urethra)
Generally small, single, and sessile, but may be pedunculated
Divided
histologically into papillomatous, granulomatous, and
angiomatous varieties

CLINICAL MANIFESTATIONS
Many women are asymptomatic
Symptoms attributed to low estrogen levels like dysuria, urinary
frequency or urgency (hence, seen more frequently in post-menopausal
women)

Group 1 | Kuh-h8tr; Vajeana; Renaughn; IKEA

Figure 2. Excision of Urethral Caruncle.


TECHNIQUE:
(1)The patient is placed in the dorsal lithotomy position, and appropriate anesthesia is
administered (general, regional, or local).The vulva and perineum are prepped.
(2) The caruncle is grasped with an Allis clamp and retracted slightly forward. A scalpel
is used to excise some of the vestibular epithelium and to transect the urethra
proximal to the caruncle/ from the base.
(3) The specimen is removed, and the urethral mucosa as well as the vestibular
epithelium is exposed.
(4) The urethral mucosa is closed to the vestibular epithelium with interrupted 3-0
synthetic absorbable sutures. Silk sutures are non-absorbable and may be very painful
upon removal.
(5) The urethral mucosa is sutured to the epithelium of the vestibule.

Page 1 of 11

GYNECOLOGY 2.1a
B. BARTHOLINS DUCT CYST

Figure 3. Bartholins Duct Cyst

MOST COMMON LARGE CYST OF THE VULVA


Occurs in the lower and lateral portion of the labia majora (*makes
sense since this is where the Bartholins ducts are situated)
Cystic dilation of an obstructed Bartholins duct
Resulting cysts may be clear, yellow or blue

CLINICAL MANIFESTATIONS
Asymptomatic or may become infected to produce pain
Very painful. Patients will come to you because they could not walk
properly. If it is infected, they could not even use underwear because the
mere contact with cloth causes pain

TREATMENT
No treatment is necessary for small lesions but if it becomes infected
or enlarges enough to produce symptoms, it has to be treated

MEDICAL
Antibiotics for aerobic and anaerobic organisms. Especially when there
is discharge from the lesion or point of rupture

(3) The wall of the gland is incised


(4) The entire length of the superficial incision is shown
(5) The contents of the abscess are evacuated
(6) A culture is taken of the abscess. The walls are grasped with Allis clamps.
o You may choose to give empiric treatment because the patient may not
tolerate the pain.
o However, once the result of the culture comes out (in 3 days), make the
necessary adjustments or change of antibiotics.
(7) The wall of the abscess is sutured with interrupted 3-0 synthetic absorbable
sutures to the skin of the introitus laterally and to the vaginal mucosa medially
(8) The marsupialization is complete. Generally, no packing of drain is necessary.
o The patient is placed on a regimen of hot sitz baths on the second
postoperative day.
o Laxative and stool softeners are given on the third postoperative day.
o Antibiotic therapy should be directed by the results of the culture.
o Sexual intercourse can usually be resumed in 4 weeks.

EXCISION OF BARTHOLINS DUCT CYST


Usually done to remove well-encapsulated cysts as a whole

SURGICAL
MARSUPIALIZATION
Done when there is a large abscess that makes surgical excision of the
gland difficult
Its purpose is to exteriorize the abscess in such a fashion that it will
become epithelialized from the base
It will close by itself and let it heal open (granulation tissue will eventually
cover it)

Figure 5. Excision of Bartholins Duct Cyst

Figure 4. Marsupialization of cyst


TECHNIQUE:
(1) A thorough bimanual examination should be performed to determine the extent
of the abscess. The patient is placed in a lithotomy position.
(2) The labia are retracted with interrupted 3-0 sutures, and the introitus of the vagina
is exposed. An incision is made over the mucosa of the vagina at its junction with the
introitus down to the wall of the gland.
o If the capsule is still intact, you can remove the mass well. But if it is infected,
the pus will just come out even with just a little puncture.
Group 1 | Kuh-h8tr; Vajeana; Renaughn; IKEA

TECHNIQUE: (*not discussed in detail but part of the ppt)


(1) The patient is placed in the dorsal lithotomy position, and the perineum is
prepped and draped
(2) Careful rectovaginal examination is performed to outline the entire Bartholins
gland cyst or abscess.
(3) To control bleeding, it is essential that the surgeon understand the vascular supply
to the labia and vagina
(4) The labia are retracted laterally with several Allis clamps. For resection of the
Bartholins gland, it is preferable to make the incision over the vaginal mucosa,
directly over the meatus of the gland, rather than over the labia majora. Healing in
this area appears to be faster and less painful for the patient than does healing to an
incision in the skin of the labia
(5) The vaginal mucosa is retracted medially, and the skin of the introitus is retracted
laterally to expose the wall of the gland. Its meatus may be seen if not distorted by
old infection and scarring.
(6) A small Metzenbaum scissors is used to lyse the filmy adhesions between the wall
of the abscess or cyst and the overlying vaginal mucosa and subcutaneous tissue of the
labia majora.
o Either forceps or an Allis clamp is placed on the wall of the cyst. The wall is
retracted to allow adequate dissection and identification of the blood supply to
the gland from branches of the pudendal artery.

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GYNECOLOGY 2.1a
(7) It is important to excise the entire gland. Incomplete removal may lead to a
recurrence of the cyst or abscess.
(8) The last few filmy adhesions to the gland are incised with Metzenbaum scissors,
and the gland is removed.
(9) After removal of the gland, there is frequently bleeding from the wound.
o There will be a big dead space where hematomas may develop if all the bleeders
wont be removed
o Cautery should be done to stop the bleeders but there is a chance that not 100%
of the bleeders will be stopped.
(10) Care must be taken that meticulous hemostasis is carried out throughout the bed
of the gland. Hemostasis frequently requires electrocoagulation and suture ligation.
(11) The bed of the gland should be closed with interrupted 3-0 absorbable suture to
eliminate dead space.
(12) A small closed suction drain is inserted into the wound and sutured into place
with interrupted 5-0 absorbable suture. This prevents the drain from being
prematurely dislodged but allows for easy removal.
(13) The closure of the vaginal mucosa to the skin of the introitus is completed with
interrupted 3-0 Dexon suture.
o The closed suction drain is removed on the third or fourth day when there is no
further drainage (usually within 4-5 days).
o Cultures of the abscess should be made. Frequently, gonococci, streptococci, or
other organisms are found; therefore, preoperative antibiotics are used in most
cases.
o On the third postoperative day, the patient is placed on a regimen of hot sitz
baths and is given a stool softener and laxative.
o Sexual intercourse can usually be resumed in 4 weeks.

C. SKENES DUCT CYSTS


(*Not discussed but part of the ppt)

Rare, small presents as discomfort


Found in routine gynecologic exam
Arise from infection and scarring of the small ducts
Physical compression of the cyst should not produce fluid from the
urethral meatus (unlike in urethral diverticula)

TREATMENT
Asymptomatic = no treatment
Excision with caution not to damage the urethra (*makes sense since the
Skenes glands are very close to the urethra)
D. EPIDERMAL INCLUSION CYST

TREATMENT
Most require no treatment
If cysts become infected, heat can be applied locally or perform Incision
and Drainage (I&D)
Cysts with recurrent infection or with pain should be excised when the
acute inflammation has subsided

E. NEVUS OR MOLE

Figure 7. Vulvar Nevi (A) Intradermal Nevus (B) Compound Nevus

A localized nest or cluster of melanocytes


These undifferentiated cells arise from the embryonic neural crest and
are present from birth
Many nevi are not recognized until they become pigmented at the time
of puberty
Vulvar nevi are one of the most common benign neoplasms in females.
These are generally asymptomatic.
They appear in different colors like blue, brown, or black, some may
be amelatonic
Diameter ranges from a few mm to 2 cm
3 GROUPS: junctional, intradermal, and compound
Although the vulvar area contains approximately 1% of the skin surface
of the body, 5% to 10% of all malignant melanomas in women arise
from this region. This may be because junctional activity is common in
vulvar nevi, or exposure to irritants.
50% of malignant melanoma arises from pre-existing nevus. Family
history is a strong risk factor
Ideally, all vulvar nevi should be excised and examined
Histological exam are especially important for flat junctional and
dysplastic nevus since they have the greatest potential for malignant
transformation
RISK OF DEVELOPING MELANOMA
Table 1. Types of Nevus and Risk of Developing Melanoma
LIFETIME RISK OF DEVELELOPING
TYPE OF NEVUS
MELANOMA
10%
15 times greater
than general population

Figure 6. A hairy vulva (left); Epidermal Inclusion Cyst (Right)

MOST COMMON SMALL VULVAR CYSTS


Found on the anterior half of the labia majora
Discovered more frequently than sebaceous cysts. Both cannot be
differentiated grossly.
Located immediately beneath the epidermis
These cysts are usually multiple, freely movable, round, slow growing,
and non-tender
Firm to shotty (yup) in consistency, and their contents are usually under
pressure
Grossly, they are white or yellow, with caseous cheese-like contents
An inclusion cyst may develop following trauma like episiotomy or
laceration, when an infolding of squamous epithelium has occurred
beneath the epidermis in the sites of an episiotomy
Inclusion cysts may be embryonic remnants and occlusion of
pilosebaceous ducts of sweat glands
Have an epithelial lining of keratinized, stratified squamous epithelium
with a center of cellular debris that grossly resembles sebaceous
material
Group 1 | Kuh-h8tr; Vajeana; Renaughn; IKEA

Congenital JUNCTIONAL nevus


>2 cm diameter
DYSPLASTIC nevus
>5mm diameter, irregular
borders and variegated pigment

EARLY FEATURES OF MALIGNANT MELANOMA: (ABCD)


Table 2. ABCDs of Malignant Melanoma
A
Assymmetry
B
Border Irregularity
C
Color Variegation
*varied in appearance or color; marked with
patches or spots of different colors

Diameter > 6 cm

TREATMENT
Excisional biopsy which is 3 dimensional and adequate in depth and
width
Approximately, 5 to 10 mm of normal skin surrounding the nevus should
be included, and biopsy including the underlying dermis
Nevi that are raised or contain hair RARELY undergo malignant change.
However, if they are frequently irritated or bleed spontaneously, they
should be removed.

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GYNECOLOGY 2.1a
Indications

for biopsy include recent changes in growth or color,


ulceration, bleeding, painm or development of satelite lesions

G. FIBROMA

F. HEMANGIOMA

Figure 9. Fibroma

Figure 8. Hemangioma

Rare malformations of blood vessels, rather than true neoplasms


Discovered initially during childhood and are mostly asymptomatic
Usually single, 1 to 2 cm diameter, flat and soft
Brown, red, or purple
Change in size with compression
NOT ENCAPSULATED
Histologically, the multiple channels of hemangiomas are predominantly
thin-walled capillaries arranged randomly and separated by thin
connective tissue septa
STRAWBERRY

CAVERNOUS

SENILE OR CHERRY

ANGIOKERATOMAS

PYOGENIC
GRANULOMAS

MOST COMMON BENIGN SOLID TUMOR of the VULVA


Can occur in all age groups
Most commonly found in the labia majora
Grow slowly. Varies from few centimeters to a giant fibroma
Arise from deeper connective tissue and should be considered as
dermatofibromas
Smaller fibromas are discovered as subcutaneous nodules, and as they
increase in size and weight they become pedunculated
Large tumors often become cystic after undergoing myxomatous
degeneration.
Low grade potential for becoming malignant
Table 4. Comparison of Large and Small Fibromas
SMALL FIBROMAS
LARGE FIBROMAS
Discovered as subcutaneous nodules
Become cystic after undergoing
myxomatous degeneration.
as they increase in size and weight,
they become pedunculated
Asymptomatic
Produce chronic pressure symptoms
or acute pain when they degenerate

Table 2. Types of Hemangiomas


Congenital, rarely increase in size after age 2
Bright to dark red, elevated, rare
Resolves spontaneously before age 8
You can observe it becomes flattened until they
disappear.
This is more pronounced among newborns

Congenital
May increase in size until age 2 yo
Purple in color
Larger lesions are deeper in location in the
subcutaneous tissue
Resolves spontaneously before age 6
Usually in postmenopausal women
Arise on the labia majora
Multiple, red brown to dark blue
Less than 3 mm diameter
Bigger than cherry angiomas (twice the size)
30-50 yrs old
Rapid growth and tendency to bleed (during
strenuous exercise
Should be differentiated from Kaposis sarcoma
and angiosarcoma
Overgrowth of inflamed granulation tissues
Grow under the hormonal influence of pregnancy
1
cm diameter, mistaken clinically for
melanomas, basal cell carcinomas, vulvar
condylomas or nevi
Treatment: wide and deep excision

DIAGNOSIS

Gross inspection
Excision biopsy

TREATMENT
Asymptomatic hemangiomas and hemangiomas in children rarely require
therapy.
Subtotal resection - In adults, initial treatment of large symptomatic
hemangiomas that are bleeding or infected
Cryosurgery or argon laser if hemangiomas are associated with
troublesome bleeding
Cryosurgery involves single freeze/thaw cycle repeated three times at

TREATMENT
Operative removal if symptomatic or continue to grow
Observation for small fibroma
Surgical excision is the definitive treatment
H. LIPOMA

Figure 10. Lipoma (#mostawkwardhoneymoonever)


SECOND MOST COMMON BENIGN VULVAR MESENCHYMAL TUMOR
Benign, slow-growing, circumscribed tumors of fat cells arising from
subcutaneous tissue of the vulva
Softer and larger than fibromas; more homogenous than fibromas
Majority of lipomas in the vulvar area are smaller than 3cm in diameter
Asymptomatic unless extremely large

TREATMENT
Conservative management for small lesions
Excision for diagnosis/treatment of larger lesions

monthly intervals.

Group 1 | Kuh-h8tr; Vajeana; Renaughn; IKEA

Page 4 of 11

GYNECOLOGY 2.1a
I. HIDRADENOMA

Subcutaneous

lesions are blue, red or purple, depending on their size,


activity and closeness to surface of skin
Pathophysiology may be due to metaplasia, retrograde lymphatic spread
or potential implantation of endometrial tissue during operation
CLINICAL MANIFESTATIONS
Pain and introital dyspareunia are the most common symptoms
The classic history is cyclic discomfort (*since endometrial tissue is
responsive to menstrual cycle), and an enlargement of the mass
associated with menstrual periods.

Figure 11. Hidradenoma

Rare, small, benign vulvar tumor from APOCRINE sweat glands of the
inner surface of the labia majora and nearby perineum
Found in white women between 30 to 70 yo, most commonly in the
fourth decade of life
Cystic or solid
About 50% are less than 1 cm in diameter and not larger than 2 cm
Has well defined capsules
Arise deep in the dermis
Asymptomatic but sometimes can cause pruritus or bleeding if it
undergoes necrosis
Well-defined and usually sessile, pinkish-gray nodules
Most cases, the surface epithelium is white, but occasionally necrosis of
central indented area occurs, with protrusion of reddish-brown
granulation tissue
Histologically mistaken as adenocarcinoma due to hyperplastic,
adenomatous pattern

TREATMENT
Excisional biopsy is the treatment of choice

J. SYRINGOMA
Very rare, cystic and ASYMPTOMATIC benign tumor
Adenoma of the ECCRINE sweat glands
Appears as small subcutaneous papules, less than 5 mm in diameter
Skin colored or yellow
May coalesce to form cords of firm tissue
Usually located in the labia majora

TREATMENT
Excisional biopsy or cryosurgery

TREATMENT
Wide excision or Laser vaporization
Recurrences are common following inadequate operative removal of all
the involved areas

L. GRANULAR CELL MYOBLASTOMA


Rare, slow growing, solid tumor
Originates from neural sheath (Schwann) cells, sometimes called
Schwannoma
Found in connective tissues throughout the body, most commonly in
tongue
Occurs in any age group
Benign but INFILTRATES the surrounding tissue
Usually painless
Located in the labia majora, but occasionally involve the clitoris
Subcutaneous nodules usually 1 to 5 cm diameter
The overlying skin often has hyperplastic changes that look similar to
invasive squamous cell carcinoma
Grossly, NOT ENCAPSULATED
Irregularly arranged bundles of large, round cells with indistinct borders
and pink cytoplasm

TREATMENT
Wide local excision
Recurrence may occur if excisional biopsy is not adequate and aggressive
enough
Appropriate therapy is second operation with wider margins

M. VON RECKLINGHAUSENS DISEASE


Generalized neurofibromatous and cafe-au-lait spots
Lesions are fleshy, brownish red, polypoid tumors
About 18% of patients with von Recklinghausen's disease have vulvar
involvement.

If symptomatic Excision

DIFFERENTIAL DIAGNOSIS: FOX-FORDYCE DISEASE

TREATMENT

Figure 12. Fox-fordyce Disease

Multiple retention cysts or apocrine glands accompanied by


inflammation of the skin
Produces intense pruritus (*syringomas are asymptomatic).
In contrast, hidradenitis tends to have secondary bacterial infections
leaving syringoma as the other possible diagnosis.
Treated with oral or topical ESTROGENS or topical RETINOIC ACID

K. ENDOMETRIOSIS
Uncommon in the vulva. *Recall that these are ectopically situated
endometrial tissue, so it makes sense that it is uncommon in the vulva.
Firm, small nodules that may be cystic or solid.
Usually found in old healed lacerations, episiotomy site or Bartholin's
duct cyst area of surgery, or along the canal of Nuck.

Group 1 | Kuh-h8tr; Vajeana; Renaughn; IKEA

N. HEMATOMAS
Usually secondary to blunt trauma (straddle injury from a fall, car
accident or physical assault)
Can also occur during recreational activities like bicycle, motorcycle,
water skiing, go-cart riding, etc.
Spontaneous hematomas are rare and usually occur from rupture of a
varicose vein during pregnancy or the postpartum period

TREATMENT
NON-OBSTETRIC HEMATOMAS may be managed conservatively unless
greater than 10cm or rapidly expanding
Drainage and debridement is the treatment for chronic expanding
hematomas
Direct pressure may stop venous bleeding that produces a vulvar
hematoma. Compression and ice pack application may be done.
If the hematoma continues to expand, operative therapy is done to

Page 5 of 11

GYNECOLOGY 2.1a

identify and ligate the damaged vessel


For OBSTETRIC cases, make sure that these are not growing. They
happen immediately postpartum, especially with mediolateral
episiotomy. You may need to do an internal examination before
discharging the patient.
O. PAPILLOMATOSIS/PAPILLARY VULVAR HIRSUTISM

the etiology. The differential diagnosis includes Gartners duct cyst, an


ectopic ureter that empties into the urethra, and Skenes glands cysts.
TREATMENT
Excisional surgery if NOT acutely infected
The most serious consequences of surgical repair of urethral diverticula
are urinary incontinence and urethrovaginal fistula.

B. INCLUSION CYSTS
MOST COMMON CYSTIC STRUCTURE OF THE VAGINA
The cysts are usually discovered in the posterior or lateral walls of the
lower third of the vagina
Vary from 1 to 3 mm in diameter
More common in parous women, and usually result from birth trauma or
gynecologic surgery
Lined by stratified squamous epithelium
Cysts contain thick oily yellow substance, formed by degenerating
epithelial cells

Figure 13. Papillomatosis

Sometimes MISTAKEN as condyloma acuminata


Smooth and soft unlike condylomas
Found distal to the hymenal ring.
DIAGNOSIS

Excisional biopsy
No treatment
DERMATOLOGIC DISEASES

(Not discussed)
Pruritus
Vulvar Syndromes
Contact Dermatitis
Psoriasis
Seborrheic Dermatitis
Lichen Planus
Bechet Syndrome
Hidradenitis Suppurativa
Edema

VAGINA
A. URETHRAL DIVERTICULUM
Permanent, epithelialized, sac-like projection that arises from the
posterior urethra
Present as mass of the anterior vaginal wall
Peak incidence in 4th decade of life
Maybe congenital or acquired
Small, ranging from 3 mm to 3 cm
Lined by epithelium, however there is lack of muscle in the saclike pocket
Assumed that the majority of urethral diverticula result from repetitive
or chronic infections of the periurethral glands
Suburethral infection may cause obstruction of the ducts and glands,
with subsequent production of cystic enlargement and retention cysts.
These cysts may rupture into the urethral lumen and produce a
suburethral diverticulum
CLINICAL MANIFESTATIONS
Nonspecific, similar to lower urinary tract infection: urgency, dysuria,
frequency
The symptoms associated with the urethral diverticulum are extremely
chronic in nature and they have not resolved with multiple courses of
oral antibiotic therapy.
3 Ds of diverticulum: dysuria, dribbling of urine, dyspareunia. However,
less than 10% of women have reported post voiding dribbling.
Classic sign but with poor sensitivity is producing purulent discharge by
compressing the suburethral area during a pelvic exam
Suspect in women with chronic symptoms of lower urinary tract infection
If a woman has a urethral diverticulum and urinary incontinence,
performing a stress urethral pressure profile will help to differentiate

Group 1 | Kuh-h8tr; Vajeana; Renaughn; IKEA

TREATMENT
Excisional biopsy if patient is symptomatic (like dyspareunia or pain)

C. DYSONTOGENETIC CYSTS
Thin walled, soft cysts of embryonic origin
Located at the upper half of the vagina
Mostly asymptomatic, sausage shaped tumors found incidentally during
pelvic examination

Table 3. Embryonic Origin of Dysontogenetic Cysts


Gartner's duct cyst
Mostly found at the anterior lateral wall
Paramesonephricum
Mullerian cyst
Urogenital sinus
Vestibular cyst
Mesonephros

TREATMENT
Small cysts are managed conservatively
Operative excision for chronic symptoms
Rarely, one of these cysts becomes infected, and if operated on during
the acute phase, marsupialization of the cyst is preferred.

D. TAMPON PROBLEMS
tampons for a few days lead to development of epithelial
dehydration and epithelial layering, and some will develop microscopic
ulcers. These minor changes take between 48 hours and 7 days to heal
Macroscopic vaginal ulcers were associated with using of tampons for
prolonged periods. The ulcers had a base of clean granulation tissue
with smooth rolled edges.
Ulcers were secondary to drying and pressure necrosis
"Forgotten" tampons give off an overwhelming odor
Toxic shock syndrome is a related to toxins elaborated by Staphylococcus
aureus.
Wearing

TREATMENT
Conservative management for vaginal ulcers since they heal
spontaneously once foreign body is removed
Biopsy for persistent ulcers
For "forgotten" tampons, patients should be treated with antibiotic
vaginal cream

E. LOCAL TRAUMA
COITUS is the most frequent cause of trauma to the lower genital tract
of adult women (#manaconda)
Predisposing factors to coital injury include virginity, state of postpartum
and postmenopausal vaginal epithelium, pregnancy, intercourse after a
prolonged period of abstinence, hysterectomy, and inebriation

Page 6 of 11

GYNECOLOGY 2.1a
Most

common injury is a transverse tear of the posterior fornix.


prominent symptom is profuse or prolonged vaginal bleeding
Most troublesome but very rare complication is vaginal evisceration
Most

TREATMENT
Prompt suturing
Rule out secondary injury to the urinary and GI tracts

IV. CERVIX
A. ENDOCERVICAL AND CERVICAL POLYPS
MOST COMMON BENIGN LESIONS IN THE CERVIX
Endocervical polyps are most common in multiparous women (40s to
50s). However, cervical polyps can be endo- or ecto-cervical
Cervical polyps are usually single but multiple polyps do occur.
Seen in routine gynecological exam or pap smear
Majority are smooth, soft, reddish purple to cherry red, and fragile
Readily bleed when touched
Polyps whose base is in the ENDOCERVIX usually have a narrow, long
pedicle and occur during the reproductive years. These are usually
secondary to inflammation or abnormal focal responsiveness to
hormonal stimulation.
Polyps that arise from the ECTOCERVIX have a short, broad base and
usually occur in postmenopausal women
Often the polyp seen on inspection is difficult to palpate because of its
soft consistency

Figure 15. Nabothian Cysts. Anechoic; pure black in UTZ

C. CERVICAL MYOMAS
Smooth, firm masses (in contrast to the smooth polyps)
Mostly small and asymptomatic
Usually a solitary growth in contrast with uterine myomas, which in
general, are multiple
Because of the relative paucity of smooth muscle fibers in the cervical
stroma, majority of myomas that appear to be cervical actually arise
from the isthmus of the uterus.

Symptoms,

CLINICAL MANIFESTATIONS
if any, are dependent on the direction of the expanding

myoma
expanding myoma produces symptoms secondary to mechanical
pressure on adjacent organs
May produce dysuria, urgency, urethral or ureteral obstruction,
dyspareunia, or obstruction of the cervix
Pedunculated myomas may prolapse through the cervical external os and
may ulcerate and be infected
If large enough, it may produce distortion of the cervical canal and upper
vagina
The

DIAGNOSIS

Figure 14. Cervical polyp. A large polyp protrudes from the external cervical os. The
surface is red and rough (allegedly), covered by endocervical epithelium.

CLINICAL MANIFESTATIONS
Most are asymptomatic not treated
Commonly presents as intermenstrual bleeding especially after coitus or
after pelvic exam
Often, there is ulceration of the stalks most dependent portion, which
explains the symptom of contact bleeding

TREATMENT
Observe if asymptomatic
If you consider a malignancy do POLYPECTOMY then send to
histopathology

B. NABOTHIAN CYSTS
RETENTION CYSTS of endocervical columnar epithelium occurring
where a tunnel or cleft has been covered by squamous metaplasia
Varies from 3 mm to 3 cm in diameter
Asymptomatic and requires no treatment
Sometimes you can see it during pap smear but most of the time through
vaginal ultrasound
So common that they are considered a normal feature of the adult cervix
Mucous retention cysts are produced by the spontaneous healing
process of the cervix.
o The area of the transformation zone of the cervix is in an almost
constant process of repair, and squamous metaplasia and
inflammation may block the cleft of a gland orifice.
o The endocervical columnar cells continue to secrete, and thus a
mucous retention cyst is formed.
Translucent or opaque white or yellow color
Asymptomatic and no treatment is necessary

Group 1 | Kuh-h8tr; Vajeana; Renaughn; IKEA

Inspection and palpation


TREATMENT
Asymptomatic, small myomas observe
Symptomatic (bleeding) cervical myomas
o GnRH agonist
o Myomectomy
o Hysterectomy (especially if big and will cause more bleeding)

D. CERVICAL STENOSIS
May be acquired or congenital
May be acquired through operative causes, radiation, infection,
neoplasia, or atrophic changes; cone biopsy, cautery, cryocoagulation
It may occur following loop electrocautery excision procedure in women
with low estrogen levels secondary to periodic injections of
medroxyprogesterone, postmenopausal women, those who are breast
feeding
Complications from management of malignancies of cervix
Most often occurs in the region of the internal os

CLINICAL MANIFESTATIONS
Signs and symptoms of dysmenorrhea, pelvic pain, amenorrhea,
infertility
Common symptoms in premenopausal women include dysmenorrhea,
pelvic pain, abnormal bleeding, amenorrhea, and infertility.
The infertility is usually associated with endometriosis, which is
commonly found in reproductive-age women with cervical stenosis.
Postmenopausal women are usually asymptomatic for a long time.
Slowly they develop a hematometra (blood), hydrometra (clear fluid), or
pyometra (exudate)
DIAGNOSIS
Inability to insert a 1-2 mm dilator into the uterine cavity
Fluid in the endometrial cavity during ultrasound

Page 7 of 11

GYNECOLOGY 2.1a
If

obstruction is complete, a soft, slightly tender, enlarged uterus is


appreciated as a midline mass

TREATMENT
Dilation with dilators under ultrasound guidance
If it recurs, monthly laminaria tents are used
After cervical dilation, leave a T tube or latex nasopharyngeal airway as a
stent in the cervical canal for a few days to maintain patency

Does not make a tissue diagnosis


of the most reassuring aspects of sonography is the absence of
adverse clinical effects from the energy levels used in diagnostic studies.
In obese patients, it is superior to perform bimanual examination alone

One

A. ENDOMETRIAL POLYPS
Localized overgrowths of endometrial glands and stroma that projects
beyond the surface of the endometrium
Soft and pliable. Each polyp only has 1 feeding vessel.
Single or multiple
Mostly arise from the fundal part of the uterus
Mostly asymptomatic but may present with abnormal bleeding
Malignancy is related to patients age and most often of lower stage
All age groups, with a peak incidence between 40 and 49

Polyps

Figure 16. Leiomyoma (arrow), originating in cervix and dilating endocervical canal. It
is soft, showing degenerative changes.

are succulent and velvety, with a large central vascular core.

CLINICAL MANIFESTATION
Majority of endometrial polyps are asymptomatic
Most common bleeding patterns include menorrhagia, premenstrual and
postmenstrual staining, scanty postmenstrual spotting
Infertility may be associated with large endometrial polyps

DIAGNOSIS
Hysteroscopy better procedure because you can see the endometrial
directly with the aid of light source.
Hysterosonogram and transvaginal ultrasound are usually requested to
document if there is also a cervical polyp OR if the endometrial polyp is
merely the extension of a cervical polyp.
A well-defined, uniformly hyperechoic mass that is less than 2 cm in
diameter, identified by vaginal ultrasound within the endometrial cavity,
is usually a benign endometrial polyp
2/3 of endometrial polyps consists of immature endometrium that does
not respond to cyclic changes in circulating progesterone. This often
appears as the Swiss Cheese cystic hyperplasia.

Figure 17. Leiomyoma of cervix most likely developing from lateral endocervix and
protruding into broad ligament. Tumor is whitish, firm, and poorly encapsulated.

V. UTERUS
ULTRASOUND
MOST COMMON AND MOST EFFICIENT IMAGING of the pelvic structure
Disadvantage of ultrasound is its poor penetration of bone and air.
Advantages of ultrasound include the real-time nature of the image, the
absence of radiation, the ability to perform the procedure in the office
before, during, or immediately after a pelvic examination, and the ability
to describe the findings to the patient while she is watching.
Become an extremely valuable adjunct to the bimanual examination
Endovaginal ultrasound of an early pregnancy has become a mainstay in
the evaluation of the pregnant woman with first-trimester vaginal
bleeding
Measurement of the endometrial thickness or stripe.
o The normal endometrial thickness is 4 mm or less in a
postmenopausal woman not taking hormones.
o The thickness varies in premenopausal women at different times of
the menstrual cycle and in women taking hormone replacement
In screening of postmenopausal bleeding, remember that:
o Ultrasound does not provide a diagnosisa tissue specimen is
necessary for a diagnosis, and
o All women with bleeding, no matter the endometrial thickness,
need a tissue biopsy.
SONOHYSTEROGRAPHY/SALINE INFUSION SONOGRAPHY
Used to evaluate the endometrial cavity
Performed in the proliferative phase of the cycle when the endometrial
lining is at its lowest level
Indicated for polyps, submucous myomas, septate uterus
Contraindications are active cervical or uterine infection
To locate a missing IUD
Easily accomplished and validated technique for evaluating the
endometrial cavity
Involves instilling saline into the uterine cavity
An alternative to office hysteroscopy

Group 1 | Kuh-h8tr; Vajeana; Renaughn; IKEA

TREATMENT
Dilatation and curettage is a blind procedure, there is a high possibility of
leaving some polyp, so patient will bleed again in the next few months
The optimal management of endometrial polyps is removal by
hysteroscopy with D&C.

Figure 18. Endometrial polyp. Note cystic glands in the polyp (First Pic).

B. HEMATOMETRA
Uterus filled with blood
Secondary to gynatresia (partial or complete obstruction of any part of
lower genital tract)
Obstruction of the isthmus, cervix or vagina maybe congenital or
acquired)

MOST COMMON CAUSES


Table 4. Most Common Causes of Hematometra
CONGENITAL

ACQUIRED LOWER TRACT STENOSIS


Page 8 of 11

GYNECOLOGY 2.1a
Imperforate hymen
Transverse vaginal septum

Senile atrophy of the endocervical canal and


endometrium
Scarring of the isthmus by synechiae
Cervical stenosis associated with surgery
Malignant disease of endocervical canal
Radiation therapy, cryocautery or electrocautery,
endometrial ablation ()

CLINICAL MANIFESTATIONS
depend on patients age, menstrual history, rapidity of
accumulation of blood in the uterine cavity, and the possibility of
infection producing pyometra
Primary amenorrhea for congenital or secondary amenorrhea for
acquired causes
Cyclic lower abdominal pain
Early teenage years - combination of primary amenorrhea and cyclic,
episodic cramping lower abdominal pains
Postmenopausal women - may be entirely asymptomatic
Occasionally the obstruction is incomplete, and there is associated
spotting of dark brown blood
Symptoms

DIAGNOSIS
Pelvic examination initially reveals a tender globular uterus
Ultrasound confirms the diagnosis
Usually confirmed by vaginal ultrasound or probing the cervix with a
narrow metal dilator, with release of dark brownish black blood from
the endocervical canal.
Sometimes the blood retained inside the uterus becomes secondarily
infected and has a foul odor.
Specimens of the endocervical canal and endometrium obtained via
BIOPSY to rule out malignancy when cause is not obvious
Biopsy is postponed for approximately 2 weeks to diminish the chances
of infection or uterine perforation

TREATMENT
Operative relief of obstruction - perforate the hymen via drainage
Drainage
If the uterus is significantly enlarged or if there is any suspicion that the
retained fluid is infected, drainage should be accomplished first.
Biopsy is done when infection is decreased

C. LEIOMYOMAS OR MYOMAS
Leiomyoma, aka myomas
Benign tumors of muscle cell origin
Maybe single but most are multiple
MOST COMMON GYNECOLOGICAL TUMORS and are present in 30% of
women of reproductive age
MOST COMMON LESIONS WE SEE IN THE UTERUS
Most contain varying amounts of fibrous tissue, which is believed to be
secondary to degeneration of some of the smooth muscle cells.
Highest prevalence occurring during the fifth decade of a womans life
Rare before menarche
Diminish in size during menopause with the reduction of a significant
amount of circulating estrogen
Enlarge during pregnancy and occasionally secondary to oral
contraceptive therapy
Presence of large myomas during pregnancy are symptomatic and causes
so much PAIN, making it difficult to know if the pain is from
degeneration of the myoma or due to preterm labor
Sometimes, instead of having a normal size uterus, it may look larger
than the actual age of gestation. For instance, 20 weeks AOG may look
like 30 weeks AOG.
Smokers have LOWER incidence of myomas due to low estrogen
In the pelvis, majority of myomas are found in the corpus of the uterus

Group 1 | Kuh-h8tr; Vajeana; Renaughn; IKEA

Risk

Factors: increasing age, early menarche, low parity, tamoxifen use,


obesity, and in some studies a high-fat diet
With continued growth, edge of the tumor is compressed and forms a
pseudocapsule
CLINICAL MANIFESTATIONS
Asymptomatic
o Can grow as big as watermelon because patients do not feel anything
unless it is very big
In general, a third of patients will become symptomatic
Prone to grow and become symptomatic in nulliparous women
Pressure from an enlarged mass anterior of bladder
Similar to those of an enlarging pregnant uterus
Anterior myoma pressing on the bladder may produce urinary
frequency and urgency
Pain including dysmenorrhea
Various forms of vascular compromise, either acute degeneration or
torsion of the pedicle, produce severe pelvic pain.
Mild pelvic discomfort is described as pelvic heaviness or a dull,
aching sensation that may be secondary to edematous swelling in the
myoma.
Abnormal bleeding usually happens in submucous myomas
Described as gushing
Menses were longer in duration and heavier

DIAGNOSIS
Pelvic Exam - Upon palpation, an enlarged, firm, irregular uterus may
be felt
Ultrasound
o Real time ultrasound and Doppler
o Sonohysterography
o Color Doppler sonohysteroscopy (Useful in distinguishing polyps
from submucous myomas based on vascularity)
o Office hysteroscopy and saline infusion to be able to identify
submucous and endometrial polyp
Polyps contain a single feeding vessel whereas myomas have several
vessels which arise from the inner myometrium
The eventual fate of some myomas is determined by their relatively poor
vascular supply. This supply is found in one or two major arteries at the
base or pedicle of the myoma.
The arterial supply of myomas is significantly less than that of a similarly
sized area of normal myometrium. Thus, with continued growth,
degeneration occurs because the tumor outgrows its blood supply.
Differential diagnosis include pregnancy, adenomyosis, and an ovarian
neoplasm.

TREATMENT
Observation
o If the myoma is very small (<14 week AOG) during reproductive age,
you do not need to do anything, especially for intramural myoma.
o
If the patient has 3cm myoma but it is a submucous type, then you
should do something.
When the tumor is first discovered, it is appropriate to perform a pelvic
examination at 6-month intervals to determine the rate of growth.
The majority of women will not need an operation, especially those
women in the perimenopausal period, where the condition usually
improves with diminishing levels of circulating estrogens.
Operative therapy is considered if symptoms do not improve with
conservative management
FACTORS AFFECTING TREATMENT
Size and rate of growth of myoma
o If the patient is asymptomatic and is in the reproductive age group, just
observe the patient

Page 9 of 11

GYNECOLOGY 2.1a
o Even if it is 5cm, if asymptomatic then we dont do anything, just
observe unless it grows into 10 to 20 cm
Woman's desire for fertility
MEDICAL MANAGEMENT
An option if the patient still wants to get pregnant. All hormonal.
GnRH Agonist
o Effect makes the patient undergo temporary menopause
o Dose would be monthly injections for 6 months duration
o This will not remove the myoma, just decreases the size of myomas, to
help them during surgery by decreasing the tumor size.
o These are expensive and causes symptoms of menopause
Medroxyprogesterone acetate (Depo Provera)
Danazol
Aromatase inhibitors
Antiprogesterone RU486
With medical treatments, the majority of the reduction in size occurs
within the first 3 months. After cessation of therapy, myomas gradually
resume their pretreatment size. By 6 months after treatment, most
myomas will have returned to their original size.

SURGICAL MANAGEMENT
1. MYOMECTOMY
Most conservative but harder to close because you have a dead space,
problem is hematoma. You must monitor post operatively.
Option for women who wants to preserve their uterus
Table 5. Indications and Contraindications for Myomectomy
INDICATIONS
CONTRAINDICATIONS ()
Nulliparous women (<40 y/o)
Pregnancy
Persistent abnormal bleeding (make
Advanced adnexal disease
sure of the real cause of bleeding
because it might be in another site)
Pain or pressure
Malignancy
Enlargement of an asymptomatic myoma Situation in which enucleation of the
to more than 8 cm who has not
myoma would severely reduce
completed child bearing
endometrial surface so that the
uterus would not be functional

2. HYSTERECTOMY
Most radical, if you are a 50 year old this is okay but if 24 year old with no
family you must consider a more conservative treatment
If the patient no longer desires pregnancy
Table 6. Indications for Hysterectomy
INDICATIONS
Same as myomectomy (*refer to table above)
Myomas with a size of a 14-16 weeks gestation
Rapid growth of a myoma after menopause

Figure 20. Adenomyoma. It has glands. The difference between myoma and
adenomyoma is that the latter has no definite capsule. In ultrasound, you cannot
identify capsules and is described as ill-defined mass.

Figure 21. Myomas. Appear as hypoechoic masses


3.

UTERINE ARTERY EMBOLIZATION


factors for failure with UAE included younger age at embolization,
bleeding as an indication for therapy, multiple myomas, and the finding
at the time of imaging of collateral ovarian vessels feeding the myoma.
Complications of UAE affect about 5% of patients, such as
postembolization fever; sepsis from infarction of the necrotic
myometrium, which may occur several weeks to a few months post
procedure; and ovarian failure, affecting up to 3% of cases in women
younger than 45 and 15% in women older than 45.
Risk

DIFFERENT TYPES OF MYOMAS

Figure 22. Different Types of Myomas

A. INTRAMURAL
Develops from within the uterine wall
Grows in the myometrium, they dont distort the configuration of the
uterus that much, because it is embedded

If the patient is 55 y/o or postmenopausal who has 4 cm myoma, will


you remove it? NO. Usually after menopause, the myoma will regress or
will remain in size. Unless the patient really wants to remove it, you dont
do any surgical procedure in this case.
Figure 23. Multiple leiomyomas. These are predominantly intramural. The bulging cut
surfaces are clearly shown.

Figure 19. Hysterectomy specimen of myomatous uterus.


Group 1 | Kuh-h8tr; Vajeana; Renaughn; IKEA

B. SUBMUCOSAL
Derive from myometrial cells just below the endometrium
Protrudes into the uterine cavity causing abnormal uterine bleeding
It is inside the endometrial cavity and not that big in size
Usually are the most troublesome clinically - may be associated with
abnormal vaginal bleeding or distortion of the uterine cavity that may
produce infertility or abortion
Page 10 of 11

GYNECOLOGY 2.1a
Rarely,

these may enlarge and pedunculated. The uterus tries to expel it


and the prolapsed myoma protrudes through the external cervical os.

Table 7. Classification of Submucous Myomas (European Society of Hysteroscopy


Classification System)
GRADE
SUBMUCOUS COMPONENT
0
Completely submucous
1
>50% submucous component of intramural myoma
3
<50% submucous component of intramural myoma
*There is no grade 2 in the classification, even in the ppt

Figure 24. Uterus with multiple myomata. Note the large central sub mucosal myoma.

C. SUBSEROSAL
Originate from the serosal surface of the uterus
Can have a broad or pedunculated base
May be intraligamentary
Distorts the configuration of the uterus
Easier to diagnose by pelvic exam - bimanual exam where you can feel
nodulations in the uterus (knobby contour)
Easier to remove or do myomectomies here

Figure 25. Large Subserosal Myoma

D. PARASITIC
These are subserous myomas which have lost blood supply and
parasitize to other organs for their blood supply (e.g. omentum)
D. ADENOMYOSIS
Derived from aberrant glands of the basalis layer of the endometrium
Common, occurring in 60% of hysterectomy specimens in late
reproductive years
Pathogenesis is unknown - theorized to be associated with disruption of
the barrier between the endometrium and myometrium
Makes your uterus big, some will come to you with symptoms of
amenorrhea, some are debilitating
Associated with increased parity, particularly uterine surgeries and
traumas

You cannot do a myomectomy for such because there is no delineation


Results in an asymmetrical uterus
CLINICAL MANIFESTATIONS
50% are asymptomatic
Severity of symptoms depends on the depth of penetration and volume of
disease in the myometrium
CLASSIC SYMPTOMS: secondary dysmenorrhea and menorrhagia (older)
PE findings include a uterus is globular, diffusely enlarged, tender before
and during menstruation due to reaction of the myometrium to the
ectopic endometrium, which are hyperplasia and hypertrophy of
individual muscles
The symptoms of menorrhagia and dysmenorrhea form a spectrum and
are subjective, thus delineating an incidence of associated
symptomatology with adenomyosis is problematic.
They attribute the increase in dysmenorrhea or menstrual bleeding to
the aging process and decreased ability to tolerate the symptoms.
Symptomatic adenomyosis usually presents in women between the ages
of 35 and 50.
DIAGNOSIS
Ultrasound and MRI (expensive)
Both useful to help differentiate between adenomyosis and uterine
myomas in a young woman desiring future childbearing
Findings of poorly de- fined junctional zone markings in the
endometrial-myometrial interface help confirm the diagnosis
Confirmed on histology of hysterectomy specimen
Common incidental finding during autopsy
The standard criterion used in diagnosis of adenomyosis is the finding of
endometrial glands and stroma more than one low-powered field (2.5
mm) from the basalis layer of the endometrium.
MANAGEMENT
There is no satisfactory proved medical treatment for adenomyosis.
Abnormal bleeding and pain may be treated with treated with GnRH
agonists, progestogens, and progesterone-containing IUDs, cyclic
hormones, or prostaglandin synthetase inhibitors
Hysterectomy is the definitive treatment if this therapy is appropriate for
the womans age, parity, and plans for future reproduction.

PATHOLOGIC MANIFESTATIONS
1. DIFFUSE INVOLVEMENT OF BOTH ANTERIOR AND POSTERIOR WALL OF
THE UTERUS
Individual area of adenomyosis are NOT encapsulated
Most of the time it is the posterior wall which is affected so during
ultrasound exam we measure the thickness of the anterior and
posterior wall, posterior is more affected
More common pathologic manifestation
Uterus is uniformly enlarged, usually two to three times normal size
2. FOCAL AREA OR ADENOMYOMA
Area of adenomyosis may have pseudocapsule
Group 1 | Kuh-h8tr; Vajeana; Renaughn; IKEA

Figure 26. Adenomyosis. Remember: not-well-circumscribed & Not encapsulated.

Figure 27. Adenomyosis. The myometrial wall is distorted and thickened by poorly
circumscribed trabeculae that contain pinpoint hemorrhagic cysts.

Be sure to read the second part of this trans

Page 11 of 11