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GROSS B

Correlative Anatomy:

Male and Female Reproductive System Dr. Capulong

MALE
MALE

HYDROCELE

Accumulation

fluid

scrotal sac

within

of

the

of

the

Collection

tunica

albuginea

persistent processus

vaginalis

within

fluid

or

albuginea persistent processus vaginalis within fluid or PROCESSUS VAGINALIS  connection with the anterior

PROCESSUS VAGINALIS

connection with the anterior abdominal wall

usually follows the descend of the testis

Before 36 weeks (age of gestation), the testicles will gradually go down and during BIRTH,
Before 36 weeks (age of gestation), the testicles will
gradually go down and during BIRTH, it is expected that
the testes is already in the scrotal sac. Along with the
descent, there is an infolding of the peritoneal lining
which is called processus vaginalis. As the testis resides
within the scrotal sac, usually, the processus vaginalis
CLOSES so that there will be no communication between
the abdominal cavity and the testicles.

ETIOLOGY

DEVELOPMENTAL

o COMMUNICATING HYDROCELE There are newborns born with fluid already in the scrotal sac because of the failure or non-closure of the processus vaginalis and there is a communication between the abdominal cavity and the scrotal area and this is called COMMUNICATING HYDROCELE.

INFECTION

o Orchitis o Epidydimitis INFECTION Inflammatory reactions edema secretion of fluids cause of hydrocele
o
Orchitis
o
Epidydimitis
INFECTION
Inflammatory reactions
edema
secretion of fluids
cause of hydrocele
NON-COMMUNICATING TYPE

TRAUMA

o Can also cause accumulation of fluid in the scrotal sac

There are also PARASITES that can cause accumulation of fluid in the scrotum(RARE)

STAGES

ACUTE

o

There is initial secretion of fluid within the scrotal sac and usually takes around a few days to a week

o

Gradually, if this is secondary to infection, this will subside especially with antibiotic treatment.

o

But because this is a non-communicating type, this can linger and be the chronic type

CHRONIC

o

More common and usually the etiology is unknown

TYPES

COMMUNICATING NON-COMMUNICATING (+) connection no connection between the between the abdominal cavity abdominal
COMMUNICATING
NON-COMMUNICATING
(+) connection
no connection
between the
between the
abdominal cavity
abdominal cavity
infants
adults

Fluid is around the testis; in between the skin and the investing fascia of scrotum and testicle. The cord structures will go through the inguinal canal. During development, the area by which the testicles are going down is the INGUINAL CANAL. So if the processus vaginalis did not close, then there is communication and that will be the source of the HYDROCELE.

INCIDENCE Infants and children

communicating type

Adult (40 y/o & older) non-communicating type

**Communicating hydrocele is usually related to the inguinal hernia.

CLINICAL MANIFESTATIONS

PAINLESS CYSTIC MASS IN SCROTUM Initially starting very small and if the child is lying down, it is not well-appreciated. But when standing up, because of gravity, fluid will go down to the most dependent portion. There will be appreciation of the enlargement of the scrotal sac.

CYSTIC MASS THAT IS SOFT IN THE MORNING, TENSE IN THE AFTERNOON (COMMUNICATING) This is also due to gravity. The more time that you spend upright, more fluid will go down the scrotal sac.

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DIAGNOSIS

TRANSILLUMINATION TEST (+)

ETIOLOGY

Hereditary

 

o

Put the penlight on the scrotal sac

Drugs: estrogen and progestin

o

See if there would be transillumination

o

Exogenous sources

o

Light will pass through the fluid Normally if there is no fluid there, it will not transilluminate because light will not

o

If the mother had exposure to exogenous hormones during the start of pregnancy.

 

pass though the testis.

o

Since there is an abnormal increase in

TREATMENT

estrogen and progestin, there will be feminization or abnormal (incomplete)

OBSERVATION

 

development of the male reproductive

 

o

Done if child is less than 1 year because

tract.

 

we give time for the processus vaginalis

o

Presence of hypospadia is an evidence

SURGERY

to close. (Maybe there is only delay of closure of processus vaginalis)

of feminization especially pernoscrotal or perineal type thus indicating possible intersex problem

 

o

Done if the hydrocele persists for more than 1 year and there is increase in size.

o

More evident in PENOSCROTAL and PERINEAL type

o

if associated with hernia; Ligation

If you have these types of

o

Same ligation for hernia and hydrocele

hypospadias, you should

o

HIGH LIGATION

investigate further regarding the

 

obliterate the connection of the abdominal cavity to the scrotum

sexual orientation of the patient because the usual types are

TIE/LIGATE processus vaginalis

SHAFT or CORONAL.

Ligate just as it comes out of the external inguinal ring

HYPOSPADIA

Clinical condition where the external urethral meatus opens at the VENTRAL side

Abnormal location of the urethral opening

CLASSIFICATION

Abnormal location of the urethral opening CLASSIFICATION GLANDULAR •proximal to the glans CORONAL •at coronal
GLANDULAR •proximal to the glans CORONAL •at coronal sulcus PENILE SHAFT •body of penis
GLANDULAR
•proximal to the glans
CORONAL
•at coronal sulcus
PENILE SHAFT
•body of penis
•Proximal/mid./distal
PENOSCROTAL
•just before scrotal area
PERINEAL
•lowest opening

Very short urethra (The urethra follows the penile shaft.)

MANIFESTATIONS

Difficulty directing urine during voiding

CHORDEE

o

Bowing or dropping of the penis is secondary to the chordee

o

There is an abnormal tissue that pulls down the penis

o

If the penis is bowing there will be difficulty during sexual intercourse and difficult for the female to get pregnant

intercourse and difficult for the female to get pregnant  Failure to obtain satisfactory erection NORMAL

Failure to obtain satisfactory erection

NORMAL ERECT SIZE OF THE PENIS (Varies from one continent to the other)

Blacks

7-8 inches (longest)

Caucasians

4½-5 inches

Asians

3 inches

Stenosis or narrowing of urethral meatus

o

Reason why children with hypospadias will have difficulty in urination

o

More often than not, Hypospadias will be accompanied by other infections (UTI) because of incomplete release of urine due to stenosis

Associated with undescended testis

Ambiguity of genitalia

o Warrants further investigation of genetic sex

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DIAGNOSIS

TREATMENT

Physical examination

Buccal smear and karyotyping

o Karyotyping: especially to identify gender of the patient

Correction wise, it is the same with hypospadias. You need to create a new urethral canal. And if it is in the glans or the penile type, it is much

easier to trim.

Excretory urography

o

o

o

o

Use the prepuce to create a new urethral canal

Trim the prepuce put a catheter

catheter will stay for several weeks (for granulation of tissues) new urethral canal

to assess upper urinary tract for other

anomalies

if the very short urethras will be corrected, then you will dissect the urethra and create a new canal or opening (new urethral meatus), that is why you have to identify if there are other anomalies in the urinary tract

The earlier the hypospadias and epispadias are corrected, the better. The older you do the
The earlier the hypospadias and epispadias are
corrected, the better. The older you do the correction, it
will be much harder because the penis is very sensitive.
When the penis becomes erect and you have a new
canal, the canal will be ruined.

VARICOCELE

you have a new canal, the canal will be ruined. VARICOCELE  Abnormal dilatation of the

Abnormal dilatation of the pampiniform plexus of vein above the testis

When the pampiniform plexus is engorged, the feeling would be having a “bag of worms” (typical presentation of varicocele)

ETIOLOGY

Incompetent valves more on the LEFT side

o Because of inadequate drainage

Renal tumor (very rare)

MANIFESTATION

Dilated veins (bag of worms) in scrotum above testis extending up the spermatic cord

Infertility

is

o Sperm

motility

and

concentration

significantly decreased

Recently, more and more males are afflicted with varicocele, because of incompetent valves (no. 1 cause) but most of them will not undergo operation. But the drawback here is since you have engorgement of the pampiniform plexus, the pooling of blood will change the temp. in the testis. The testis maintains a certain temp. in order for the sperm cells to replicate and live.

MORE KILLS MALE VARICOCELE ↓TEMPERATURE SPERM INFERTILITY PRESENT CELLS
MORE
KILLS
MALE
VARICOCELE
↓TEMPERATURE
SPERM
INFERTILITY
PRESENT
CELLS

TREATMENT

Determine genetic sex of individual

Repair should be done before school age usually done about 2 years old and up

Reconstructing the urethral using the prepuce can be done in a 1-stage or 2-stage procedure

1-STAGE

2-STAGE

EPISPADIA

CLASSIFICATION

MANIFESTATION

o Due

2-STAGE EPISPADIA CLASSIFICATION MANIFESTATION o Due • Coronal/Glandular type • Penoscrotal/Perineal type to

Coronal/Glandular type

Penoscrotal/Perineal type

to

maldevelopment

of

urethral

mild form of bladder

Because you want to have an elongation of the newly created urethral canal

Before circumcision, identify first if the child will have normal meatus (location wise; no hypospadias)

o If unchecked and proceeded to circumcision, repair of the hypospadias will not be possible because of the removal of the prepuce

Release of chordee (fibrotic tissue or band that holds the shaft of the penis) to obtain erection and be able to void adequately in standing position

Urethral opening is displaced dorsally

GLANDULAR

Dorsum of glans

PENILE

Within the shaft Urethral meatus is broad, gaping and located between pubis and coronal sulcus

PENOPUBIC Located peno-pubic junction with distal dorsal groove extending up to the glans penis

Urinary incontinence

sphincter

Dorsal chordee (resulting to “pataas ang ihi”)

Pubic bones are separated

Epispadia may signify a dystrophy

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Testicular atrophy

IMPROPER CIRCULATION OF BLOOD POOLING OF VENOUS DRAINAGE OF THE TESTIS INADEQUATE BLOOD FLOW TESTICULAR
IMPROPER CIRCULATION OF BLOOD
POOLING OF VENOUS DRAINAGE OF THE TESTIS
INADEQUATE BLOOD FLOW
TESTICULAR ATROPHY

TREATMENT

Varicocelectomy

Undescended testicles

Occurs when one or both the testicles fail to move down into the scrotal sac

During development just prior to delivery, the testicles from its intraabdominal location, will settle down in the scrotal area and this will follow the area of the inguinal canal until its final resting place in the scrotum. Any deviation can cause undescend of the testis:

o

Blockage

o

Infant is delivered prematurely

incomplete descent of testis

o

Hereditary

Most common location: INGUINAL CANAL

Ether TESTICULAR (easiest way) or INGUNAL approach

o

Can be done on an out-patient basis

o

ETIOLOGY

Hormonal factors (testosterone deficiency)

Ligation of the internal spermatic veins at or above the internal inguinal ring

PENILE FRACTURE

Due to the tearing or

rupture of the tunica albuginea covering

the

cavernosa (usually filled up with blood during erection)

corpora

(usually filled up with blood during erection) corpora  Happens when penis is erect  Secondary

Happens when penis is erect

Secondary to vigorous or acrobatic sexual intercourse

o It is as if the glans penis is hitting the sacral bone. The force of trauma of hitting the bone can readily rupture the tunica albunginea

Aggressive masturbation

SURGICAL EMERGENCY

o

because of uncontrollable bleeding due to the fracture; all the blood from the columns, corpora cavernosa, will come out

o

it can also be a cause of death because of necrosis, ischemia and bleeding

In the elderly, it may be secondary to PRIAPISM especially those taking anti-erectile dysfunction medications (Viagra)

CRYPTORCHIDISM

dysfunction medications (Viagra) CRYPTORCHIDISM o Making the reproductive tract development incomplete 

o Making the reproductive tract development incomplete

Prenatal exposure to diethylstilbesterol (exogenous hormone; secondary to intake of the

mother)

Prematurity

o Premature neonates are most commonly affected because testes normally descend into scrotum around 28 weeks gestation

Mechanical interference with the passage of the testes into the scrotum

o Mass/tissue blocking inguinal canal

Deficiency of gonadotropin

DIAGNOSIS

Differentiate from retractile testis

CRYPTORCHIDISM •undescended testis •testis is completely absent in scrotum
CRYPTORCHIDISM
•undescended testis
•testis
is
completely
absent in scrotum
RETRACTILE TESTIS •testis goes down and up •secondary to hyperfunctioning of cremaster muscle (pulls the
RETRACTILE TESTIS
•testis goes down and up
•secondary to hyperfunctioning
of cremaster muscle (pulls the
testis up and down)
•during cold temperatures, testis
is not present in scrotum
•but during warm temperatures,
testis is present

How to test:

1. Insert fingers into scrotal area

2. Palpate in the inguinal canal. If you palpate a round structure in the inguinal canal, probably that’s the testis.

3. Instruct the patient to bear down so that the testis will go down OR ask patient to stand up.

4. If you cannot still identify, you can do other tests

o

ULTRASOUND

Abdominal cavity and inguinal area to check for the location of the testis

o

CT SCAN

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COMPLICATIONS

TESTICULAR CANCER

o

7 years old and up: you have to correct it already

o

20 y/o with undescended testis: chances of acquiring testicular cancer is higher

MALE INFERTILITY

o Adequate temp. for spermatogenesis is not maintained

TESTOSTERONE LEVEL IS LOW

TREATMENT

ORCHIDOPEXY: permanently putting the testis in

the scrotum

1. Identify first the location of testis

2. If testis is in the ingunal canal, extract the testis, pull it down

3. if testicles are short, dissect it

4. Free the vas deferens so it can go down

5. Once the testis is in the scrotum, suture the testis

The concern for surgery is the TESTICULAR CANCER and not the infertility

PHIMOSIS

is the TESTICULAR CANCER and not the infertility PHIMOSIS  Inability of the foreskin to be

Inability of the foreskin to be retracted due to a very small opening of the foreskin

Usually cause frequent UTI in children

TREATMENT: circumcision

This is the only indication for circumcision of newborns and children

If there is no phimosis and no UTI, the recommendation would be circumcision at an age wherein the child is desirous of having circumcision and the foreskin is completely retracted beyond the glans penis.

o

If these conditions are not present, usually we can delay the circumcision.

o

Circumcision should be a decision from the child and not the parents.

Coronal Circumcision

Removal of the foreskin

Not done anymore because when you remove the foreskin, you expose the penis to stimulation. Excessive stimulation can cause premature ejaculation

There is a higher incidence of premature ejaculation to males circumcised coronally rather than those who underwent DORSAL SLIT because the foreskin will protect the penis from excessive stimulation

German cut”

PARA PHIMOSIS

excessive stimulation  “ G erman cut” PARA PHIMOSIS is retracted beyond the glans and inability

is

retracted beyond the glans and inability of the foreskin to return back to the tip of the penis When a child out of curiosity is retracting the foreskin wherein the opening is still small. When the foreskin is forcefully pulled down and unable to return back.

When

the

foreskin

Can cause ischemia of the glands

Emergency surgical circumcision to release foreskin and correct the ischemia

PROSTATE DISEASES

PROSTATITIS

infection of the prostate

treated with antibiotics and correct the problem

more common to those who lack sexual activity

BPH (BENIGN PROSTATIC HYPERTROPHY)

medial lobe is the most common affected

Usual manifestation is difficulty in urination (due to hypertrophy compression of urethra)

Treatment with medications, TURP

PROSTATE CANCER

posterior lobe most common lobe affected

Diagnosis:

o

Digital Rectal Examination (DRE)

Gold standard for checking the prostate gland

By doing this, you can feel for the posterior lobe of the prostate

(+) CA: Stony hard prostate

(-) CA: rubbery, well- circumscribed feeling of a benign prostate

o

Transrectal Ultrasound followed by biopsy

o

Prostate Specific Antigen (PSA)

Usually for 50y/o and up

Screening

Non specific (can also be elevated in even in prostatitis)

o

Elevated PSA + (+) DRE can detect early prostate cancer

o

Must

correlate it with physical

examination

Example:

Patient with stony hard prostate + elevated PSA What is the next step to do?

Order for a Transrectal Ultrasound (probe is put on the rectum so it can readily identify the enlargement in the prostate) followed by a biopsy (insertion of a needle; getting a sample of the prostate gland).

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INGUINAL HERNIA

Most common location: INGUINAL AREA

Most common type of hernias are groin or inguinal types (75%)

INCARCERATION: the incomplete indirect hernia becomes complete and the scrotum cannot reduce its size because the intraabdominal contents are now located in the scrotum.

INGUNAL HERNIA

 

STRANGULATION:

there

is

vascular

compromise.

Indirect type

(There are times that it can be

patent processus vaginalis (PPV)

incarcerated

 

but

not

young patients

compromised.)

 

same cause as hydrocele

This

is

an

emergency.

If

scrotum becomes enlarged

uncorrected,

it

will

cause

ischemia.

 

Direct type

weakness in the abdominal wall musculature (floor)

FEMORAL HERNIA

older patients

bulge is within the inguinal canal and does not go down in the scrotum

DIRECT •Post. wall •Less common •Older •Smaller •Hesselbach's Triangle •Medial to inferior
DIRECT
•Post. wall
•Less common
•Older
•Smaller
•Hesselbach's Triangle
•Medial to inferior
epigastric vessels
•Lower risk
INDIRECT •Deep ring •70% •Congetinal •Scrotal •Deep ring •Lateral to inferior epigastric vessels
INDIRECT
•Deep ring
•70%
•Congetinal
•Scrotal
•Deep ring
•Lateral to inferior
epigastric vessels
•Incarceration,
Strangulation

The defect for direct type would be on the posterior wall because of the weakness of the muscle. In the indirect type, the defect is in the deep inguinal ring where the processus vaginalis will come out.

70% would be of the indirect type; and the direct type is less common and is usually seen in older patients. Usually, the indirect type is congenital and it has a scrotal component (scrotum also becomes big especially if this is a complete type of indirect inguinal hernia). In direct, there is no enlargement of the scrotum.

In the indirect type, the hernia comes from the deep ring; whereas, the direct type, it is from the Hesselbach’s triangle.

In the indirect type, the hernia will be lateral to the inferior epigastric vessels; whereas, the direct type will be medial to the inferior epigastric vessels.

The indirect type has a higher incidence of incarceration and strangulation; whereas, the direct type has a lower incidence.

hernia protrudes through femoral canal

manifestation would be below inguinal ligament

Females > Males

SLIDING HERNIA (PANTALOON’S HERNIA)

Part of the processus vaginalis is accompanied

by an organ

part of sac: viscera

LEFT SIDE: sigmoid colon or bladder

RIGHT SIDE: cecum or bladder

RICHTER’S HERNIA: involves the bladder only

VASECTOMY

surgical sterilization that involves ligation and resection of part of vas deferens

bilateral cutting of the continuation of the vas deferens

can be done on an out-patient basis

1. Make a small incision on the scrotum

2. Feel for the vas deferens

3. Cut

only done if patient is 100% sure that he decides

not to bear a child anymore

there would be degeneration of sperm cells

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FEMALE
FEMALE

BARTHOLINS CYST

Bartholins gland’s homologue is the Cowper’s Gland. The bartholin’s gland usually secrete a fluid or
Bartholins gland’s homologue is the Cowper’s Gland.
The bartholin’s gland usually secrete a fluid or mucoid
discharge to lubricate the vaginal opening. At times, this
can be blocked and the problem would be the
abnormal accumulation of the fluid within the gland itself.
This will present as a swelling in between the labia majora
and minora.

blockage of the Bartholins glands causing fluid accumulation

may be secondary to infection (or inadvertent pulling of hair in the area of the labia)

Treatment:

o

Antibiotics

o

Draining (if unresponsive to antibiotics)

o

MARSUPIALIZATION

Procedure of choice for these kind of cysts

opening up of the cyst draining the content suture around the edges

for delaying the closure of the wound to promote adequate drainage

If only incision and drainage is used, after a few hours, it is already closed and the cycle will repeat itself.

ECTOPIC PREGNANCY

happens if you have fertilization and the mature ova is implanted in another location other than the uterine cavity

disorders of early pregnancy

Most common site: FALLOPIAN TUBE (>90%)

rarely in the ovary or abdominal cavity

associated with PID (pelvic inflammatory diseases) and endometriosis

o

increases the risk of ectopic pregnancy

o

causes scarring and blockage of the tube difficulty in migration of the fertilized ova

o

it stops or hinder the normal migration of the fertilized ova

but 50% occur with no known cause

may end in:

ova  but 50% occur with no known cause  may end in: 1: very seldom;

1: very seldom; 2 and 3: more common

Medical emergency if it is ruptured because of the uncontrollable bleeding

o Patients can go into hypotension because of hemoperitoneum

DIAGNOSIS

(+) pregnancy test

ULTRASOUND: very sensitive for this; shows the site of the ectopic pregnancy

High HCG, sonography and endometrial biopsy

showing decidual reaction but no chorionic villi

CLASSIFICATION

decidual reaction but no chorionic villi CLASSIFICATION  Tubal – most common  Ovarian  Cervical

Tubal most common

Ovarian

Cervical

Abdominal

o

NOT compatible to life

o

will present as a normal pregnancy

o

mother doesn’t have any abdominal signs and symptoms because there will be no obstruction of the tube

o

ONLY clinical manifestation is when ultrasound is done, THE uterine cavity is EMPTY despite the positivity of the pregnancy test initially

o

When you scan the abdominal cavity, it may be lodged/implanted in the mesentery

o

The implant must be surgically removed

Interstitial pregnancy in the intramural part

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INTERSTITIAL TUBAL ECTOPIC

2.5% of all tubal pregnancy

Early rupture doesn’t occur because of the bigger space where the fetus can develop

However, because of the blood supply (coming from the ovarian and uterine arteries) rupture of this type of ectopic is most likely fatal

Often diagnosis is late

TREATMENT

Surgical removal

SALPHINGOSTOMY:

1. Initially, you can do a small incision within the

fallopian tube (if located in the f.tube)

2. Remove the product of conception

3. Leave it as is because it usually seals off.

Minimal handling of the tube: Better. This is to avoid any scarring.

BUT if there would be repeated incidence of tubal pregnancy especially on the same side:

SALPHINGECTOMY (removal of fallopian tube).

UTERINE PROLAPSE

(removal of fallopian tube). UTERINE PROLAPSE  Abnormal displacement of uterus secondary to laxity of

Abnormal displacement of uterus secondary to laxity of ligaments that holds the uterus in place (most important: UTEROSACRAL ligament; also cardinal ligament);

another cause is relaxation of muscles because of multiple deliveries (multiparous)

Usually passes through the vaginal canal

CAUSES

Loss of muscle tone

MULTIPARITY (major factor), injury during childbirth

Other factors

o

Obesity

o

Chronic coughing or straining

o

Constipation

intraabdominal pressure will push the uterus down the vaginal canal

This is not associated with body builders because if they are body builders but did not experience pregnancy, the pelvis is not tested and the ligaments were not subjected to the strain of labor.

PELVIC SUPPORT PROBLEMS

There can be organs accompanying the uterus as it slides down.

CYSTOCELE

o Posterior portion of the bladder slides together with the uterus

RECTOCELE

o Anterior

down

portion

of

the

rectum

slides

ENTEROCELE

o Portions of the small bowel goes down

uterine

and

slide

together

with

the

prolapse

STAGES OF UTERINE PROLAPSE

1ST DEGREE •CERVIX DROOPS TO THE VAGINA 2ND DEGREE •CERVIX STICKS TO OPENING OF VAGINA
1ST DEGREE
•CERVIX DROOPS TO THE
VAGINA
2ND DEGREE
•CERVIX STICKS TO
OPENING OF VAGINA
•FISH-MOUTH APPEARANCE
OF CERVIX between the
folds of labia minora
3RD DEGREE
•CERVIX IS OUTSIDE OF
VAGINA
•ENTIRE CERVIX & UTERUS
4TH DEGREE
COMES OUT OF VAGINA

UTERINE PROCIDENTIA:

when there is total exit of the uterus from the vaginal canal

CLINICAL MANIFESTATIONS

Protruding mass within the vaginal canal

Feeling of “something is going to fall out” especially when in an erect position or during walking

Varying degrees of dysuria and constipation depending upon the combination of the prolapsed whether cystocele or rectocele

Urinary incontinence

TREATMENT

1 ST /2 ND DEGREE: anchor the uterus in its normal place

Keep in recumbent position

Replace the uterus to its normal position and

location hold it in place

Vaginal hysterectomy (for severe cases)

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VAGINAL FISTULA

VAGINAL FISTULA  Abnormal connection between vaginal canal and another organ TYPES  RECTOVAGINAL

Abnormal connection between vaginal canal and another organ

TYPES

RECTOVAGINAL

 

o

abnormal communication between the

 

posterior vaginal wall and the anterior rectum

 

o

feces will be observed coming out of the vagina

o

Early sign: AIR (flatus) coming out of vagina

o

When you insert a catheter into the vagina, it will go out of the rectum

VESICOVAGINAL

 

o

communication between the vagina and the bladder

o

urine will be coming out of the vagina

VESICOUTERINE

URETHROVAGINAL

o Very uncommon

ETIOLOGY

Complication of difficult vaginal deliveries and episiotomies/episiorrhapy

o

When a mother deliveries a big baby and she sustained 4 th degree laceration

(worst lacearation; the laceration went all the way into the rectum and you have to repair the rectum);

o

if the rectum is not repaired, there will an abnormal communication between the posterior vaginal wall and the anterior rectum.

o

Several weeks after it is healed, the feces will be observed coming out of the vagina (RECTOVAGINAL FISTULA)

Complications of surgeries whether normal delivery or hysterectomy

Tumors of vagina or cervix

Following radiation for treatment of rectal cancer

o

Because part of the treatment is RADIATION and it makes tissues very brittle and they stick together

o

The moment there is adhesion of the rectum and vagina, there can be abnormal communications between the two areas.

CLINICAL MANIFESTATIONS

Abnormal vaginal discharge fluid or fecaloid

o

Fluid: BLADDER

o

Fecaloid: RECTUM

Frequent bouts of UTI

Varying degrees of fecal incontinence

DIAGNOSIS

Physical examination: IE (internal examination)

Bi-manual Examination

1. One finger is inserted in the rectum, and the other hand is inserted in the vagina

2. Palpate for the lines of the suture that you made

If you can palpate the suture line in the rectum, it means you have to correct your repair

The repair must be SEROMUSCULAR ONLY and it will not involve the mucosa.

Because if you suture through all the layers of the rectum, it will involve the mucosa and the suture can be palpated like strings of a guitar.

Urinalysis for UTI

Contrast studies to determine the extent and location of fistula

o X-rays and insert dyes; then follow the tract of the dye so you can localize the location of the fistula Example:

both the vaginal and rectum took the dye

TREATMENT

Best treatment is prevention

o

That is why you have patients in labor to

strain properly

o

Do an adequate episiotomy

Repair of defect created

Put intervening normal tissue ion between

o OMENTUM: good tissue to be used in repairs in order to prevent adherence and prevent formation another fistula

Be careful in doing surgeries because fistulas are IATROGENIC (surgeon-induced if the proper technique is not done) except for radiation treatment because it is a complication.

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Bernabe, Maria Katrina (2013)

MYOMA

MYOMA  Abnormal outgrowths of myometrial tissues  They can be located in several areas within

Abnormal outgrowths of myometrial tissues

They can be located in several areas within the uterus

Usually benign

Respond to hormonal changes

o That is why in uncomplicated myomas, it is advised that patients wait for their menopausal years because during menopause, the myoma will also shrink.

However, with patients presenting with bleeding or pain because of a very large myoma, we do not wait for the menopause and we schedule them for operation.

Disease characterized by fibroid (benign tumors) in the uterus

Most common benign tumors in women

Composed of smooth cells

Become malignant in fewer than 0.1% of patients

Myomas can degenerate into sarcomas (rare)

ETIOLOGY

Growth related to estrogen stimulation because the fibroids often enlarged with pregnancy and shrink with menopause

Begins as a simple proliferation of smooth muscle cells; hypertrophy hyperplasia

PATHOPHYSIOLOGY

Fibroids vary greatly in size and usually appear firm, surrounded by a pseudocapsule composed of compressed but otherwise normal uterine myometrium

The uterine cavity may become larger, increasing the endometrial surface; this can

cause increased uterine bleeding

The ovary in size from very small to almost occupying the entire uterus.

Can simulate the age of gestation of a pregnant woman that is why when you examine a patient with myoma, you correlate the size with the age of gestation

TYPES

you correlate the size with the age of gestation TYPES INTRAMURAL • Found in the uterine

INTRAMURAL

Found in the uterine wall

Surrounded by myometrium More prone to BLEEDING

• Surrounded by myometrium • More prone to BLEEDING SUBMUCOSAL • Located directly under the endometrium,

SUBMUCOSAL

Located directly under the endometrium, involving the endometrial cavity

under the endometrium, involving the endometrial cavity SUBSEROSAL • Found on the outer surface (under the

SUBSEROSAL

Found on the outer surface (under the serosa) of the uterus Predisposed to TORSION (pedicle twisting) extreme abdominal pain

to TORSION (pedicle twisting)  extreme abdominal pain WANDERING or PARASITIC • A pedunculated leiomyoma that

WANDERING or PARASITIC

A pedunculated leiomyoma that twist on its pedicle,

breaks off, then attaches to the other tissues,

particularly the omentum In the pelvic area, aside from the uterus and fallopian tube, you have the mesentery of the recto- sigmoid area and the omentum going down Whenever you see implants that look like a part of the endometrium or muscle looking, when you remove it, that can be a parasitic type f myoma.

when you remove it, that can be a parasitic type f myoma. INTRALIGAMENTARY • Implants on

INTRALIGAMENTARY

Implants on the pelvic ligaments, may displace the uterus or involve the ureter myoma located within the broad ligament

the ureter • myoma located within the broad ligament CERVICAL • Occurs infrequently and may obstruct

CERVICAL

Occurs infrequently and may obstruct the cervical

canal usually goes out of the cervical os

DIAGNOSIS

BIMANUAL EXAMINATION

o

One hand on top of abdominal cavity and the other hand doing the internal examination

o

Push the fundus of uterus while during IE

o

IE: Guide will be the FORNIX

1. Touch the cervical os and check for smoothness and orientation

2. Put your fingers on the fornix

3. Touch the right and left adnexa

4. While doing so, push the fundus of the uterus and move it so that the ovaries will be pushed down to your fingers and you can palpate it

ULTRASONOGRAPHY

o

For nulliparous patients with no sexual contact yet

ABDOMINAL

(for

general

 

purposes)

or TRANSRECTAL

(better) ULTRASOUND

 

o

Already with sexual contact:

TRANSVAGINAL

Best

Because you can look at the adnexa

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Bernabe, Maria Katrina (2013)

Endometrial biopsy

Laparascopy

Surgery depending upon the myoma

o

MYOMECTOMY

Removal of myoma only

o

HYSTERECTOMY

If entire uterus is involved

o

OPEN LAPAROSCOPY

If subserous or intramural

COMPLICATIONS

Recurrent spontaneous abortion

o If you have a big myoma, you can have spontaneous abortion because that will

impinge on the implantation site of the mature ova

Preterm labor

Anemia secondary to excessive bleeding

o Especially if INTRAMURAL type

Bladder compression

o It Impinges on the bladder

Infection

Bowel obstruction

TUBAL LIGATION

Counterpart of hysterectomy of the males

Done if:

o

there is desire to not have any pregnancies anymore especially for multiparous women

o

women who have medical complications (e.g. cardiac problems)

Surgical sterilization hat involves ligation or resection of part of fallopian tube

Usual techniques:

o

POMEROY

clamp fallopian tube then cut

problem here is there are reports of migration and recanalization because they are adherent to each other

o

PARKLAND

remove part of fallopian tube then ligate

decreased incidence of migration and recanalization

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Bernabe, Maria Katrina (2013)