1. Problems with relaxed Pelvic Muscles Endometriosis, and Toxic Shock Syndrome

2. Anteflexion
The uterus is bent forward on the cervix

3. Retroflexion
The uterus is bent backward on the cervix

4. Retroversion
The uterus is tilted backward

5. 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

6. 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

7. 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

8. Diagnostics
Pelvic examination identifies the condition

9. 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

10. 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

11. 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

12. 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

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

14. 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

15. 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

16. 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

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

18. 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

19. 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

20. 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***

21. 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

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

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

24. 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

25. 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

26. 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

27. 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

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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

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

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

38. 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

39. 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

40. 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

41. 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

42. 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