Escolar Documentos
Profissional Documentos
Cultura Documentos
Lesions
By Dr Hossam El Sokkary
Lecturer of
obst&gynaecology
Benign Lesions
of the Genital
Tract
Benign Characteristics:
1.
2.
3.
4.
slow-growing
well-circumscribed
not associated with hemorrhage, necrosis or evidence of
widespread dissemination (metastasis)
no constitutional signs and symptoms of weight loss and
anorexia
Topic Objectives
1. To describe and discuss the more
common lesions and conditions of the
female genital tract
2. To discuss their pathophysiology, as well
as their corresponding treatment
Benign
Lesions of the
Vulva
Urethral Caruncle
Urethral Caruncle
believed to arise from an ectropion of the
posterior urethral wall associated with
retraction and atrophy of the
postmenopausal vagina
histologically composed of transitional and
stratified squamous epithelium with loose
connective tissue
Urethral Caruncle
Growth is secondary to chronic irritation
Symptoms may be variable
mostly asymptomatic
dysuria frequency, and urgency
Urethral Caruncle
differential diagnosis
Urethral Caruncle
Treatment
Initially
1. oral or topical estrogen
2. avoidance of irritation
Urethral Prolapse
predominantly in premenarchal
females
Grossly
does not have the bright-red color of
a caruncle
is not as circumscribed in gross
configuration
it may be ulcerated with necrosis or
grossly edematous
Urethral Prolapse
Therapy
1. hot sitz baths
2. antibiotics
3. topical estrogen cream
4. excision of the redundant mucosa
rarely done but may be necessary
Vulvar Cysts
Bartholins duct cyst is the
most common of the large
vulvar cysts
treatment is not necessary
in women younger than 40
unless the cyst becomes
infected or enlarges enough
to produce symptoms
Vulvar Cysts
the most common small vulvar cysts are
epidermal inclusion cysts or sebaceous
cysts
Sebaceous Cysts
located immediately beneath the epidermis
mostly discovered on the anterior half of the
labia majora
multiple, freely movable, round, slow growing,
and nontender with firm consistency
grossly appear white or yellow with caseous
contents on cut section
local scarring of the adjacent skin sometimes
occurs when rupture of the contents of the cyst
produces inflammatory reaction in the
subcutaneous tissue.
Inclusion Cysts
develops when an infolding of squamous
epithelium has occurred beneath the
epidermis in the site of an episiotomy or
obstetric laceration
When found in the vagina most likely
related to previous trauma
Inclusion Cysts
alternative theories of histogenesis
include embryonic remnants
Treatment
excision.
Hemangioma
Hemangioma
Fibroma
Lipoma
benign, slow growing, circumscribed
tumors of fat cells arising from the
subcutaneous tissue of the vulva.
second most frequent benign vulvar
mesenchymal tumor
most lipomas are discovered in the labia
majora and are superficial in location
malignant potential is extremely low
Endometriosis
Endometriosis
commonly present with introital pain and
dyspareunia
classic history - cyclic discomfort and
enlargement of the mass during menses
Treatment
wide excision or laser vaporization depending
on the size of the mass
Hematoma
usually secondary to
blunt trauma - (straddle
injury)
spontaneous hematomas
are rare and usually
occur from rupture of a
varicose vein during
pregnancy or the
postpartum period
Hematoma
Management
usually conservative unless the hematoma is
greater than 10 cm in diameter or is rapidly
expanding
direct pressure may be applied to control the
bleeding
compression and application of an ice pack to
the area
Identification and ligation of bleeders if the
hematoma continues to expand
Dermatologic Lesions
skin of the vulva is susceptible to any
generalized skin disease or involvement
by systemic disease.
most common skin diseases include
contact dermatitis
Psoriasis
seborrheic dermatitis
Tinea cruris
lichen planus
Dermatologic Lesions
Vulvar Edema
may be a symptom of either local or
generalized disease
Most common causes:
secondary reaction to inflammation
lymphatic blockage
Benign
Lesions of the
Vagina
Urethral Diverticulum
Diagnosis:
ascending cystourethrography
cystourethroscopy.
Treatment:
Excisional surgery in acute infection
Inclusion Cyst
most common cystic structures of the vagina
usually discovered in the posterior or lateral
walls of the lower third of the vagina
common in parous women
often results from birth trauma or gynecologic
surgery
majority are asymptomatic
if symptomatic, excisional biopsy is indicated
Tampon Problems
risks with its usage:
vaginal ulcers
toxic shock syndrome from toxins produced by
Staphylococcus aureus
Local Trauma
Coitus is the most frequent etiology
most common injury is a transverse tear
of the posterior fornix
Manifests with profuse or prolonged
vaginal bleeding
Management:
prompt suturing under adequate anesthesia
Benign
Lesions of the
Cervix
Endocervical and
Cervical Polyp
most common benign
neoplastic growth of the
cervix
Seen in multiparous
women in their 40s and 50s
usually secondary to
inflammation
Endocervical and
Cervical Polyp
Symptoms
classic symptom is intermenstrual bleeding
many are asymptomatic
recognized for the first time during a routine
speculum examination
Endocervical and
Cervical Polyp
Management
Polypectomy may be an office procedure
most can be managed by grasping the base of the
polyp with an appropriately sized clamp.
The polyp is avulsed with a twisting motion and sent
to the pathology for microscopic evaluation.
if bleeding ensues, the base may be treated with
chemical cautery, electrocautery, or cryocautery
Nabothian Cysts
so common that they are
considered a normal
feature of the adult cervix
retention cysts of
endocervical glands
occurring due to
obstruction of the gland
duct
asymptomatic
Cervical Lacerations
Management
Acutely bleeding cervical lacerations should be sutured
Complications
extensive cervical lacerations especially those involving the
endocervical stroma may lead to incompetence of the cervix
during a subsequent pregnancy
Cervical Myomas
smooth, firm masses similar to myomas of the
uterus
may become pedunculated and protrude
through the external os of the cervix
diagnosis is by inspection and palpation
management
observation/ expectant management
medical therapy with GnRH agonists
myomectomy or hysterectomy
Cervical Stenosis
most often occurs in the region of the
internal os
may be divided into congenital or acquired
causes of acquired cervical stenosis:
Operative (i.e. cone biopsy, cautery)
Radiation
Infection
Neoplasia
Cervical Stenosis
Symptoms
in premenopausal women: dysmenorhea,
pelvic pain, amenorrhea and infertility
postmenopausal women are usually
asymptomatic
diagnosis is established by inability to
introduce a 1 to 2 mm dilator into the uterine
cavity
Benign
Lesions of the
Uterus
Endometrial Polyp
localized overgrowths of
endometrial glands and stroma
that project beyond the surface of
the endometrium
most arise from the fundus of the
uterus
may vary from a few millimeters to
several centimeters in diameter
may have a broad base or be
attached by a slender pedicle.
Endometrial Polyp
peak incidence between ages 40 and 49
associated with endometrial hyperplasia
unopposed estrogen may be the cause
May be associated with chronic administration
of tamoxifen
Endometrial Polyp
Components
1. endometrial glands
2. endometrial stroma
3. central vascular
channels
Endometrial Polyp
malignant transformation
has been estimated to be as
high as 0.5%
Diagnosis:
Hydrosonography
hysteroscopy and/or
hysterosalpingography
management - removal by
curettage or via the
hysteroscope.
Leiomyoma
benign tumors of muscle cell
origin
often referred to as fibroids or
myomas
most frequent tumors of the
pelvis
highest prevalence occurring
during the fifth decade of a
womans life
majority are found in the
corpus of the uterus
Leiomyoma
classified into subgroups
by their relative anatomic
relationship and position to
the layers of the uterus.
3 most common types
a.intramural
b.subserous
c.submucous
Leiomyoma
submucosal tumors
associated with abnormal vaginal bleeding or
distortion of the uterine cavity that may produce
infertility or abortion
Leiomyoma
Etiology
each tumor results from an original single
muscle cell (monoclonal theory)
somatic mutation of normal myometrium
to leiomyomas influenced by estrogen.
Leiomyoma
never before menarche
most diminish in size following
menopause with the reduction of a
significant amount of circulating estrogen.
often enlarge during pregnancy and
occasionally enlarge secondary to oral
contraceptive therapy.
Leiomyoma
pathology
grossly, has a lighter color than the
normal myometrium
on cut surface it has a glistening, pearlwhite appearance, with the smooth
muscle arranged in a trabeculated or
whorled configuration
histologically there is a proliferation of
mature smooth muscle cells; the
nonstriated muscle fibers are arranged
interlacing bundles.
Leiomyoma
Types of Degeneration
1. Hyaline
2. Calcific
3. Cystic
4. Fatty
5. Red degeneration
6. Necrosis
7. Malignant - 0.3% and 0.7%
Leiomyoma
symptoms
most common are pressure from an enlarging
pelvic mass, pain and abnormal uterine bleeding
severity of symptoms is usually related to the
number, location, and size of the myomas
majority are asymptomatic
rapid growth after menopause is a disturbing
symptom
Leiomyoma
diagnosis
1. pelvic examination
2. Ultrasound
management
if small, symptomatic, judicious observation is made
at first discovery, a pelvic examination at 6 month
intervals to determine the rate of growth should be done
women with abnormal bleeding and leiomyomas should
be investigated thoroughly for concurrent problems such
as endomterial hyperplasia
surgery when persistently symptomatic
Leiomyoma
Medical Management
e.g.GnRh agonists
Advantages
1. Facilitate easier surgery
2. induction of amenorrhea
Disadvantages
1. degeneration of some leiomyomas, necessitating piece-meal
enucleation at myomectomy
2. hypoestrogenic side effects (e.g. trabecular bone loss, vasomotor
flushes)
3. cost
Leiomyoma
Surgical Management
Indications for Surgery
1. rapidly expanding pelvic mass
2. persistent abnormal bleeding
3. pain or pressure
4. enlargement of an asymptomatic
myoma to more than 8 cm in a
woman who has not yet
completed child bearing
Adenomyosis
growth of glands and
stroma into the uterine
myometrium to a depth
of at least 2.5 mm from
the basalis layer
sometimes known as
internal endometriosis
pathogenesis remains
unknown.
Adenomyosis
Pathology
1. diffuse involvement of the anterior and
the posterior alls of the uterus, with
the posterior being more often
involved
2. there is a focal area of the lesion adenomyoma.
results in a asymmetric uterus
where there is usually a
pseudocapsule.
Criteria for diagnosis
a finding of active or proliferative
glands, (2.5 mm) from the basalis
layer of the endometrium.
Adenomyosis
Diagnosis
majority of women are asymptomatic
May present with secondary
dysmennorhea and menorrhagia. severity
of symptoms increases proportionally with
depth of invasion and penetration.
Usually presents with uterine enlargement
palpated through pelvic examination
Ultrasound is helpful in diagnosis.
Adenomyosis
Treatment
no satisfactory
proven medical
treatment for
adenomyosis.
Hysterectomy is the
definitive treatment
Benign
Lesions of the
Ovaries
Follicular Cysts
most frequent cystic structure
in normal ovaries
arises from temporary
variation of a normal
physiologic process
may result from either
Follicular Cysts
Management
Conservative observation
majority disappear spontaneously by either reabsorption of the cyst
fluid or silent rupture within 4 to 8 weeks on initial diagnosis
persistent ovarian mass necessitates operative intervention to
differentiate it from a true neoplasm of the ovary
cystectomy and oophorectomy
Management
Conservative if unruptured
With persistent bleeding - treatment is
cystectomy.
Dermoid Cyst
Benign cystic teratoma
most common ovarian neoplasm
in prepubertal females and in
teenagers
vary from a few millimeters to 25
cm in diameter, may be single or
multiple
usually discovered either in the
cul-de-sac or anterior to the
broad ligament
Dermoid Cyst
composed of mature
cells, usually, from all
three germ layers
most solid elements
arise are contained in a
protrusion or nipple
(mamila) in the cyst
wall termed the
prominence or tubercle
of Rokitansky
Dermoid Cyst
adult thyroid tissue is discovered
microscopically in approximately 12% of
benign teratomas
Struma ovarii
teratoma in which the thyroid tissue has
overgrown other elements and is the
predominant tissue
Dermoid Cyst
management
cystectomy with preservation of as much normal ovarian tissue as
possible
Complications
1. Torsion
2. Rupture
3. Infection
4. Hemorrhage
5. malignant degeneration
Endometrioma
areas of ovarian
endometriosis that become
cystic
usually associated with
endometriosis in other areas
of the pelvic cavity
large chocolate cysts of the
ovary may reach 15 to 20 cm
Endometrioma
the most common symptoms
associated
1. pelvic pain
2. Dyspareunia
3. infertility
Endometrioma
management
medical therapy is rarely successful in
treating ovarian endometriosis
surgical therapy is complicated by
formation of de novo and recurrent
adhesions
Fibroma
Fibroma
management
Exploratory operation
in postmenopausal women, often a bilateral salpingooophorectomy and total abdominal hysterectomy are
performed
Cystadenoma
Cystadenoma
Management
postmenopausal women: bilateral salpingooophorectomy and total abdominal hysterectomy
in younger women: simple excision of the tumor and
inspection of the contralateral ovary is appropriate
Torsion
Symptoms
Acute abdominal and pelvic pain
fever
Torsion
management
conservative operation for young women
laparoscope or via laparotomy
Endometriosis
Etiology of
Endometriosis
1. RETROGRADE MENSTRUATION
pelvic endometriosis is secondary to implantation of endometrial cells
shed during menstruation
2. METAPLASIA
arises from the metaplasia of coelomic epithelium or proliferation of
embryonic rests.
4. IATROGENIC DISSEMINATION
5. IMMUNOLOGIC CHANGES
the altered function of the immune-related cells are directly involved on
the pathogenesis of endometriosis
6. GENETIC PREDISPOSITION
Endometriosis
PATHOLOGY
ovaries are the most common
site
grossly exhibit wide variation in
color, shape, size and
associated inflammatory and
fibrotic changes.
Endometriosis
Signs and Symptoms
Classic symptoms include cyclic pelvic pain and
infertility.
Pelvic pain is often inversely proportional to the
amount of endometriosis.
cyclic pelvic pain is related to the sequential swelling
and the extravasations of blood and menstrual debris
in to the surrounding tissue and mediated by
prostaglandins and cytokines
Dyspareunia
GI and urinary symptoms
classic pelvic findings of a retroverted uterus with
scarring and tenderness posterior to the uterus
Endometriosis
Diagnosis
1. Ultrasound
2. Laparoscopy
Endometriosis
Goals of Management
1. relief of pain
2. promotion of fertility
Primary long term goal in management is
to prevent progression of the disease
process
Endometriosis
Medical Management
primary goal of hormonal treatment is
induction of amenorhea.
DOES NOT provide a long lasting cure of the
disease
Endometriosis
Medications for Endometriosis
1. Danazol
2. GnRH Agonists*
3. Oral contraceptives
4. Medroxyprogesterone acetate (DMPA)
Endometriosis
SURGICAL THERAPY
Thank you!