Problems with relaxed Pelvic Muscles Endometriosis, and Toxic Shock Syndrome

Anteflexion The uterus is bent forward on the cervix

Retroflexion The uterus is bent backward on the cervix

Retroversion The uterus is tilted backward

Uterine Prolapse Uterine prolapse is the abnormal position of the uterus in which the uterus protrudes downward PATHOPHYSIOLOGY/ ETIOLOGY The uterus herniates through the pelvic floor and protrudes into vagina (prolapse) Usually due to obstetric trauma and overstretching of musculofascial supports Categorized by degrees

Uterine prolapse-degrees First degree-cervix, without straining or traction is at the vaginal vault Second degree- cervix extends over the perineum and is in the vagina Third degree- the entire uterus(or most of it) protrudes outside of the vagina

Prolapsed Uterus- Clinical Manifestations Backache or abdominal pain Pressure or heaviness in the vaginal region Bloody discharge due to cervix rubbing against clothing or inner thighs Ulceration of the cervix Painful sexual intercourse Difficulty with urination or moving bowels Difficulty walking Symptoms are aggravated by obesity, standing, straining, coughing, or lifting a heavy object, due to increased intra-abdominal pressure

Diagnostics Pelvic examination identifies the condition

Prolapsed Uterus Management Surgical correction is recommended treatment with an anterior and posterior repair; it is effective and permanent Vaginal pessary-a plastic device that is inserted into the vagina as temporary or palliative measure if surgery cannot be done Abdominal sarcopexy- anchor the vagina to the abdominal wall Estrogen cream or ring- to decrease vaginal atrophy

Cystocele and Urethrocele Cystocele is a downward displacement(protrusion) of the bladder into the vagina. Urethrocele is a downward displacement of the urethra into the vagina

Cystocele/Urethrocele Pathophysiology/ Etiology Associated with obstetric trauma to fascia, muscle, and ligaments (results in poor support) Often becomes apparent years later, when genital atrophy associated with aging occurs May also be due to congenital defect or appear after hysterectomy

Clinical Manifestations- Cystocele/ Urethrocele May be asymptomatic in early stages Pelvic pressure or heaviness, backache, nervousness, fatigue Urinary symptoms- urgency, frequency, incontinence, incomplete emptying Aggravated by coughing, sneezing, standing for long periods, and obesity, which increase intra-abdominal pressure Relieved by rest or lying down

Diagnostics-Cystocele/Urethrocele Pelvic exam identifies condition Urinalysis and culture are done to rule out infection

Management- Cystocele/Urethrocele Estrogen therapy after menopause to decrease genital atrophy Surgery- if cystocele is large and interfers with bladder functioning May do anterior vaginal colorrhaphy Complications of surgery include urinary retention, bleeding(requires vaginal packing) Vaginal pessary-plastic device inserted into vagina as temporary treatment to support pelvic organs Prolonged use may lead to necrosis and ulceration Should be removed and cleaned every 1 to 2 months

Rectocele/enterocele Rectocele is displacement(protrusion) of the rectum into the vagina Enterocele is the displacement of intestine into the vagina PATHOPHYSIOLOGY/ETIOLOGY Posterior vaginal wall becomes weakened, allowing displacement Weakening caused by obstetric trauma, childbirth, pelvic surgery, aging

Clinical Manifestations-rectocele/enterocele Pelvic pressure or heaviness, backache, perineal burning Constipation-may have difficulty in fecal evacuation; patient may use fingers into vagina to push feces up so defecation may occur Incontinence of feces and flatus- if tear between rectum and vagina Visible protrusion into vagina Symptoms are aggravated by standing for long periods

Rectocele/enterocele-- diagnostic evaluation Vaginal examination reveals condition May use Sims speculum to uplift cervix and carefully evaluate condition

Rectocele/enterocele management Pessary Estrogen replacement to prevent atrophy Surgery- if rectocele is large enough to interfere with bowel functioning- posterior colporrhaphy Complications of rectocele and enterocele-total fecal incontinence

Vaginal fistula A vaginal fistula is an abnormal, tortuous opening between the vagina and another hollow organ PATHOPHYSIOLOGY/ETIOLOGY Obstetric injury, especially in long labors and in countries with inadequate obstetric care Pelvic surgery-hysterectomy or vaginal reconstructive procedures Carcinoma-extensive disease or complication of treatment such as radiation therapy

Types of Vaginal fistulas 1. Vesicovaginal fistula- is an opening between the bladder and vagina 2. Rectovaginal fistula-is an opening between the rectum and vagina 3. Ureterovaginal fistula- is an opening between the ureter and vagina *** We will look at the manifestations for each one***

Vesicovaginal fistula manifestations Most common type of fistula Constant trickling of urine into the vagina Loss of urge to void because bladder is continuously emptying May cause excoriation and inflammation of the vulva

Rectovaginal fistula manifestations Fecal incontinence and flatus through the vagina; malodorous May present as vulvar cancer

Ureterovaginal fistula-manifestations Are rare Urine in the vagina but patient still voids regularly May cause sever urinary tract infections

Diagnostic Evaluation for vaginal fistulas 1. Methylene blue test-following instillation of this dye in the bladder A. Methylene blue appears in the vagina in vesicovaginal fistula B. Methylene blue does not appear in vagina in ureterovaginal fistula 2. Indigo Carmine test- following a negative methylene blue test, indigo carmine is injected IV. If dye appears in vagina, this indicates ureterovaginal fistula

Diagnostics Con’t. 3. Intravenous pyelogram helps detect the presence and location of fistula and presence of hydroureter and hydronephrosis 4. Cystoscopy- performed to determine number and location of fistulas

Management of Vaginal fistulas Fistulas recognized at the time of delivery should be corrected immediately Treatment of postoperative fistulas may be delayed for 2 to 3 months to allow treatment of infection Surgical closure of opening via vaginal or abdominal route (when patient’s tissues are healthy) Fecal or urinary diversion procedure may be required for large fistulas Rarely, a fistula may heal without surgical intervention

Management of fistulas con’t. Medical approach- A. Prosthesis to prevent incontinence and allow tissue to heal; done for patients who are not surgical candidates B. Prosthesis is inserted into vagina; it is connected to drainage tubing leading to a leg bag

Complications of vaginal fistulas Hydronephrosis Pyelonephritis Possible renal failure with uretervaginal fistula

endometriosis Endometriosis is the abnormal proliferation of uterine endometrial tissue outside the uterus Endometrial cells can be deposited on any or all structures within the pelvic cavity Endometrial cells may also be found outside the pelvic cavity. ]An intact uterus is not needed to have endometriosis

Endometriosis Pathophysiology Peaks in women aged 25 to 45; may occur at any age. Increased risk in siblings, women with shorter menstrual cycles and longer duration of flow. More common in Caucasians, and in women who do not exercise and are obese Responds to ovarian hormonal stimulation-estrogen increases it, progestins decrease it Bleeds during uterine menstruation, resulting in accumulated blood and inflammation and subsequent adhesions and pain Regresses during amenorrhea and oral contraceptive and androgen use

Endometriosis pathophysiology con’t. Theories of origin: May be embryonic tissue remnants that differentiate as a result of hormonal stimulation and spread via lymphatic or venous channels May be transferred via surgical instruments May be due to retrograde menstruation through uterine tubes into peritoneal cavity

Endometriosis- Clinical Manifestations Depends on sites of implantation; may be asymptomatic Pelvic pain-especially during or before menstruation Dyspareunia Painful defecation- if implants are on sigmoid colon or rectum Abnormal uterine bleeding Persistent infertility Hematuria, dysuria, flank pain--- if bladder involved

Endometriosis- Diagnostic Evaluation Pelvic and rectal examinations- tender, fixed nodules or ovarian mass or uterine retrodisplacement; nodules may not be palpable Laparoscopy-for definitive diagnosis to view implants and determine extent of the disease Other studies include ultrasound, CT, and barium enema to determine extent of organ involvement

Endometriosis- Management Medical Danazol(Danocrine)- most commonly used drug; synthetic androgen . Suppresses endometrial growth. Contraindicated in pregnancy. ***Causes masculinizing effects on females*** Progestins-create a hypoestrogenic environment Gonadotropin-releasing hormone antagonist(Lupron) injections over a 6 month period-create hypoestrogenic environment Oral contraceptives-use small amount of estrogen, maximum amount of progestin and androgen effect to decrease implant size

Endometriosis-management surgical Laparoscopic surgery-preferred procedure to remove implants and lyse adhesions; not curative; high recurrence rate CO2 laser laparoscopy- for minimal to moderate disease; vaporizes tissue; may be done at same time as diagnosis; good pregnancy rate Laparotomy-for severe endometriosis or persistent symptoms Presacral neurectomy-to decrease central pelvic pain; preserves fertility Hysterectomy- if fertility is not desired and symptoms are severe; ovaries are preserved if not affected

Endometriosis-complications Infertility Rupture of cyst-mimics ruptured appendix Obstruction of the bowel and ureters Ovarian “Chocolate cysts” darkly pigmented with gelatinous contents

Toxic shock syndrome-(TSS) Is a condition caused by a bacterial toxin (Staphylococcus aureus) in the bloodstream; it can be life-threatening

Tss-pathophysiology Cause is uncertain, but 70% of cases are associated with menstruation and tampon use Research studies suggest that magnesium-absorbing fibers in tampons may account for lower levels of magnesium in the body; this contributes to providing an ideal condition for toxin production by the bacteria

Tss-pathophysiology TSS has been observed in nonmenstruating individuals with conditions such as cellulitis, surgical wound infection, vaginal infections, subcutaneous abscesses, and with the use of contraceptive sponge, diaphragm, and tubal ligation Oral contraceptives may be protective against TSS by increasing lactobacilli in vaginal flora

Tss-clinical manifestations Sudden onset of fever greater than 102 degrees Vomiting and profuse watery diarrhea Rapid progression to hypotension and shock within 72 hours of onset Sometimes, sore throat, headache, and myalgia Rash(similar to sunburn)that develops 1 to 2 weeks after onset of illness and is followed by desquamation, particularly of the palms and soles

Tss-diagnostic evaluation Blood, urine, throat, and vaginal/cervical cultures; possibly cerebrospinal fluid-to detect/rule out infectious organism Tests to rule other febrile illnesses-Rocky Mountain spotted fever, Lyme disease, meningitis, Epstein-Barr or coxsackie virus

Tss-management Fluid and electrolyte replacement to increase blood pressure and prevent renal failure Vasopressor medications (ie,dopamine) as needed Antibiotics(ie, penicillins or cephalosporins) may decrease the rate of relapse The use of steroids and immunoglobins is controversial