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| Uterine prolapse |
Uterine prolapse occurs when the integrity of supporting structures is lost. This allows the uterus to descend into the vagina. In advanced cases, complete protrusion with inversion of the vagina occurs. Prior to menopause, the degree and severity of prolapse is usually related to the number of children and the difficulty of childbirth. After menopause, atrophy and loss of tissue integrity further leads to prolapse.
System(s) affected:
- Reproductive
- Renal/Urologic
- Renal/Urologic
- Gastrointestinal
Common among Caucasian races. Less common among Asians and African Americans and particularly uncommon in South African Bantus and West Africans. Approximately 1 in 10 women will experience some degree of prolapse.
SIGNS AND SYMPTOMS:
- Pelvic pressure and low back pain
- As prolapse progresses, eventually a bulging is noticed as a result of protrusion
- Dyspareunia
- Difficulty with urination or defecation
CAUSES:
- Advancing age and vaginal childbirth are the most important factors
- The incidence of prolapse increases with the frequency and difficulty of vaginal deliveries. Less than 2% of prolapse occurs in nulliparous women.
- Other causes of prolapse include connective tissue disorders with lax tissue, i.e., Marfan's syndrome and neurogenic disorders, i.e., multiple sclerosis, cloacal agenesis, chronic constipation, pelvic tumors or ascites and chronic coughing from chronic lung disease
- Patients who have undergone radical vulvectomy with loss of the external supporting structures have a higher rate of prolapse
RISK FACTORS:
- Childbirth, particularly multiple parity
- Advancing age
- Caucasian race
- Various connective tissue and neurogenic disorders
- Conditions resulting in increased intra-abdominal pressure, such as obesity, abdominal or pelvic tumors, pulmonary disease with chronic coughing, chronic constipation
- Occupations requiring heavy lifting
LABORATORY:
- Evaluation of renal function to rule out ureteral obstruction
- Urinalysis to rule out urinary tract infection
PATHOLOGICAL FINDINGS:
- Hyperkeratosis of the cervical and vaginal tissues occur with prolapse beyond the introitus due to chronic irritation and drying. As the irritation becomes more pronounced, bleeding and ulceration occur.
- Degrees of prolapse:
- First degree prolapse - to the ischial spine
- Second degree prolapse - to the introitus
- Third degree prolapse - just beyond the introitus
- Fourth degree prolapse - complete uterine and vaginal inversion involving bladder and bowel
IMAGING:
- Intravenous pyelogram to rule out ureteral obstruction in complete uterine prolapse (optional)
- Pelvic ultrasound or CT scan to rule out other pelvic pathology, if suspected (optional)
DIAGNOSTIC PROCEDURES:
If ulceration or bleeding is present, Pap smears and appropriate cervical and endometrial biopsies should be done to rule out concomitant malignancies
TREATMENT
- Treatment depends on multiple variables including the severity of prolapse, age, sexual activity, associated pelvic pathology and desire for future fertility
- Treatment of first and second degree prolapse is expectant unless patient is symptomatic
- Mildly symptomatic patients and poor surgical candidates - can be treated nonoperatively with perineal (Kegel) exercises, estrogen replacement and vaginal pessaries. Estrogen replacement restores healthy vaginal mucosa and promotes healing.
SURGICAL MEASURES:
- Surgically able patients without additional pelvic pathology - vaginal hysterectomy with or without enterocele, cystocele, rectocele repair and vaginal vault suspension
- For patients who desire to maintain reproductive function - uterine suspension with vaginal repair is an option
- Elderly, non-sexually active women - can be treated with a colpocleisis or vaginal obliteration procedure
ACTIVITY:
Heavy lifting or significant increases in intra-abdominal pressure will lead to worsening of prolapse or recurrence after surgical correction. Lifting should therefore be restricted.
DIET:
Unlimited. Avoid constipation.
PATIENT EDUCATION:
•Kegel exercises when applicable
MEDICATIONS
Estrogen replacement therapy (oral or vaginal cream) can increase the blood supply to the vaginal tissues and in mild cases increase supporting tissue strength to a point where surgery or pessary use may be avoided
Contraindications: Those associated with the use of estrogen. Refer to manufacturer's literature.
Precautions: If estrogen therapy is utilized and the uterus is present, progesterone should be utilized to offset the potential of endometrial carcinoma
Significant possible interactions: Refer to manufacturer's literature
PREVENTION/AVOIDANCE:
- Kegel exercises will increase the strength of the pelvic diaphragm muscles and may provide some pelvic support
- Weight loss and proper management of conditions that would increase abdominal pressure help to prevent prolapse
POSSIBLE COMPLICATIONS
- Ureteral obstruction and renal failure
- Incarceration of bowel herniations
- Pessary use - may not always be effective, and may cause discomfort, ulcers, infection
EXPECTED COURSE AND PROGNOSIS:
- It is expected that as patients age, the incidence and severity of prolapse will increase
- Surgical correction usually successful
ASSOCIATED CONDITIONS:
Cystocele, rectocele, enterocele and vaginal vault prolapse are often associated with uterine prolapse
REFERENCES
•Nichols DH, Randall CL: Vaginal Surgery. 4th Ed. Baltimore, Williams & Wilkins, 1996
•Ryan KJ, Berkowitz R, Barbieri RL: Kistner's Gynecology: Principles and Practice. 6th Ed. Chicago, Year Book Medical Publishers, Inc., 1995
•American College of Obstetricians & Gynecologists (ACOG), 409 12th St., SW, Washington, DC 20024-2188, (800)762-ACOG
•Nichols DH: Gynecologic and Obstetric Surgery. 1st ed. St Louis, MO, CV Mosby, 1993
•Thompson JD, Rock JA: Telinde's Operative Gynecology. 8th ed. Philadelphia, Lippincott-raven, 1997
•Mishell DR, Stenchever MA, et al: Comprehensive Gynecology. 3rd ed. St Louis, CV Mosby, 1997
•Mann WJ, Stovall TG: Gynecologic Surgery. 1st ed. New York, Churchill Livingstone, 1996Labels: Uterine prolapse |
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| Vaginismus |
Involuntary painful contraction of perineal muscles prior to or during vaginal intercourse. The experience of or even the anticipation of pain on vaginal entry causes theses muscles to contract, occluding the vaginal opening and causing further pain when penetration is attempted.
Incidence/Prevalence in USA: 6-8% of women in some studies report complete vaginismus and up to 30% some degree of vaginismus
Predominant age: Postpubertal
Predominant sex: Female
SIGNS AND SYMPTOMS:
•Inability to allow entry for vaginal sexual intercourse secondary to involuntary muscle spasms
•Reluctance or avoidance of pelvic examination
•Relationship discord or difficulty
•Infertility
•Sexual satisfaction may be independent of sexual function!
CAUSES:
•Primary: Often multifactorial
•Negative messages about sex and sexual relations in upbringing may cause phobic reaction
•Poor body image of genital area
•History of sexual trauma, although rates of vaginismus appear to be similar in sexually abused and un-abused populations of women (studies show incidence of sexual abuse of women to be from 12-40%)
•Secondary
•New onset of infection
•Surgical or post delivery scarring
•Endometriosis
•Inadequate vaginal lubrication
RISK FACTORS:
•Previous sexual trauma, but rates appear to be similar in abused and non-abused women
•Often associated with other sexual dysfunctions
DIAGNOSIS
DIFFERENTIAL DIAGNOSIS:
•Dyspareunia
PATHOLOGICAL FINDINGS:
Rarely found in primary vaginismus, but may be varied such as endometriosis or scarring in secondary vaginismus
SPECIAL TESTS:
Psychiatric consultation if not responsive to primary physician's therapy or if primary provider not comfortable with caring for sexual problems
DIAGNOSTIC PROCEDURES:
•General and sexual history
•At some point, a careful pelvic examination to rule out medical cause
TREATMENT
GENERAL MEASURES:
•Can often treat vaginismus successfully without defining/treating its etiologies!!
•No published controlled studies on success of psychotherapy for vaginismus
•Patient education as noted below on pelvic anatomy and sexual function
•Kegel's exercises to control perineal muscles
•Stepwise vaginal desensitization exercises:
•A) with vaginal dilators (patient inserts/controls), or
•B) with woman's own finger(s) (promotes sexual self-awareness)
•Valsalva can help with vaginal entry
•Advance to husband's fingers with patient's control
•Coitus after achieving largest vaginal dilator or 3 fingers; important to begin with sensate focused exercises/sensual caressing without necessarily a demand for coitus
•A) Female superior at first; passive (non-thrusting); female directed
•B) Later, thrusting may be okay
SURGICAL MEASURES:
Contraindicated
ACTIVITY:
Simple techniques of gentle, progressive, patient-controlled vaginal dilation
DIET:
No special diet
PATIENT EDUCATION:
•Education about pelvic anatomy, nature of the vaginal spasms, normal adult sexual function
•Hand held mirror can help the woman visually learn to tighten and loosen perineal muscles
•Important to teach the partners that the spasms are not under conscious control and are not a reflection on the relationship or a woman's feelings about her partner
•Instruction in techniques for vaginal dilation
•Resources
•American College of Obstetricians & Gynecologists (ACOG), 409 12th St., SW, Washington, DC 20024-2188, (800)762-ACOG
•Valins L. When a Woman's Body Says No to Sex: Understanding and Overcoming Vaginismus. New York: Penguin, 1992.
Contraindications: Anxiolytics, especially benzodiazepines
Precautions: N/A
Significant possible interactions: N/A
ALTERNATIVE DRUGS:
N/A
POSSIBLE COMPLICATIONS:
Precipitation of memory of incest prior to patient's readiness to deal with it
EXPECTED COURSE AND PROGNOSIS:
•Some studies show high degrees of success (58-70%) with behavioral interventions
•History of sexual abuse does not predict outcome negatively or positively
ASSOCIATED CONDITIONS:
•Marital stress, family dysfunction
•Dyspareunia
AGE-RELATED FACTORS:
Vaginismus is generally primary, e.g. happens with first attempt at intercourse
Pediatric: N/A
Geriatric: N/A
Others: N/A
PREGNANCY:
Pregnancy can occur in patients with vaginismus via perineal ejaculation
REFERENCES
•Biswas A: Vaginismus and outcome of treatment: Human Sexuality and Sexual Dysfunction 1995;24:755-758
•Heiman JR: Evaluating sexual dysfunctions: Primary Care of Women. Norwalk, CT, Appleson and Lange, 1995
•Read S, King M, Watson J: Sexual dysfunction in primary medical care. Journal of Public Health Medicine, Oxford University Press 1997;19(4):387-391
•Sarwer D, Durlak J: A field trial of the effectiveness of behavioral treatment for sexual dysfunctions. Journal of Sex and Marital Therapy 1997;23(2):87-97 |
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| Vitiligo |
An acquired, slowly progressive depigmenting condition in small or large areas of the skin due to the disappearance of previously active melanocytes
•Type A is non-dermatomal and widespread. It represents 75% of cases
•Type B is dermatomal or segmental. It represents the remaining 25% of cases
SIGNS AND SYMPTOMS:
•Loss of pigment
•Locally increased sunburning
•Predilection for acral areas and around orifices such as eyes, mouth, anus
•Pruritus (10%)
•Premature graying (35%)
•Koebner's phenomenon (aggravation by trauma)
CAUSES:
Etiology is unclear, but is thought to be an autoimmune reaction to preexisting melanocytes
RISK FACTORS:
•Positive family history
•Autoimmune disorders including hemolytic anemia and adrenal insufficiency
DIFFERENTIAL DIAGNOSIS:
Any condition that causes acquired hypomelanosis, including tinea versicolor, leprosy, lupus erythematosus, pityriasis alba, atopic dermatitis, albinism, alopecia areata, chemical exposure (phenols, arsenic, chloroquine, hydroquinone) steroid exposure, retinoic acid use, tuberous sclerosis, neurofibromatosis, melanocytic nevi (halo nevi), tumor regression of malignant melanoma, piebaldism, hypopituitarism, hyperthyroidism
LABORATORY:
Routine blood and urine studies are usually normal in the absence of associated diseases in adults. In children screen for autoimmune diseases with TSH, CBC, and fasting glucose.
PATHOLOGICAL FINDINGS:
Complete absence of melanocytes in skin biopsy. At the margins one may see a few lymphocytes and large melanocytes with abnormal melanosomes.
DIAGNOSTIC PROCEDURES:
•Examination under Wood's light accentuates the hypopigmented areas, especially in light-skinned individuals
•Skin scraping and a potassium hydroxide (KOH) preparation can be examined microscopically to rule out tinea versicolor
GENERAL MEASURES:
•Sun exposure can accentuate the difference between normal and abnormal skin, so for cosmetic reasons patients may wish to avoid this
•Skin dyes and cosmetics may be used as cover-ups
PATIENT EDUCATION:
•Reassure patient that in absence of associated autoimmune illness the problem is purely cosmetic. Successful cosmetic cover-up is usually quite simple. Some areas offer vitiligo support groups.
•Information available through National Vitiligo Foundation, P.O. Box 6337, Tyler TX 75711; (903)531-0074
DRUG(S) OF CHOICE:
•Localized vitiligo: Begin with a mid-potency steroid cream applied daily for 3-4 months. If no response, advance to high potency steroids. Clobetasol propionate (Temovate) cream applied qd for 2 months (qod on the face). Treatment may be resumed following a 1 to 4 month respite. Alternatively topical psoralens applied in a 1% solution followed in 90 minutes by ultraviolet exposure (UVA). Caution for subsequent exposure to light (sunburn).
•Widespread vitiligo: Oral systemic steroids, e.g., betamethasone 5 mg given 2 days in a row, then held the remainder of the week. This pattern continued for 2-4 months minimizes side effects and is effective in arresting the disease in many patients. Oral trimethylpsoralen or methoxsalen (Oxsoralen-Ultra, 8-MOP) and UVA over a 12-24 month period. Alternatively depigmenting the remaining normal skin with hydroquinone (Benoquin) 20% cream may be elected.
Contraindications:
•Absolute contraindications to use of psoralen compounds: Idiosyncratic reaction to psoralens, photosensitive disease (e.g., systemic lupus erythematosus, albinism, porphyria), invasive squamous cell carcinoma, melanoma, aphakia
•Relative contraindications to use of psoralen compounds: Cardiac disease, hepatic dysfunction, multiple basal cell carcinomas, prior radiation therapy, prior arsenic therapy
Precautions:
•Watch for skin atrophy and telangiectasias when using topical steroids, especially on the face
•Watch for photosensitizers with UVA treatment
•Severe burns possible with topical psoralens. Partially avoided with - 1:10 or 1:50 dilution of psoralens.
•Psoralen plus UVA (PUVA) cannot be used for children less than 12 years of age due to immaturity of the ocular lens
•Patients undergoing PUVA therapy should have a screening ophthalmologic examination to rule out subclinical retinal pigmentary disease that is frequently associated with vitiligo
Significant possible interactions: Other photosensitizers, e.g., tetracyclines and retinoic acid
ALTERNATIVE DRUGS:
Patients with unresponsive localized vitiligo may be candidates for mini-grafting with or without PUVA therapy
FOLLOW UP
PATIENT MONITORING:
•With PUVA therapy, CBC, liver, renal function tests, and an ANA should be done every 6 months.
•With topical steroids, follow at monthly intervals to avoid steroid-atrophy of the skin.
PREVENTION/AVOIDANCE:
•While undergoing all therapies, avoid excessive sun exposure
POSSIBLE COMPLICATIONS:
•Phototoxic reactions ranging from mild to severe with PUVA
•Skin atrophy and telangiectasias with topical steroids
•Contact dermatitis can occur with use of depigmenting agents and cosmetic covers
EXPECTED COURSE AND PROGNOSIS:
•Only 5% spontaneously repigment
•Best results are with PUVA therapy where 70% have repigmentation of head and neck area, less in other body areas. Lower percentages respond to topical therapy
•There is no response in at least 20% of cases, especially long-standing cases
•Once repigmentation occurs it usually persists.
ASSOCIATED CONDITIONS:
•Addison's disease
•Alopecia areata
•Chronic mucocutaneous candidiasis
•Diabetes mellitus
•Hypoparathyroidism
•Melanoma
•Pernicious anemia
•Polyglandular autoimmune syndrome
•Thyroid disorders (hyper- and hypothyroidism) - 30% of patients with vitiligo
•Uveitis
•Halo nevi
PREGNANCY:
•Treatment with topical or oral psoralens is contraindicated
SYNONYMS:
•Hypomelanosis
•Depigmentation
REFERENCES
•Habif T: Clinical Dermatology. 3rd Ed. St Louis, Mosby, 1996
•Fitzpatrick TB, et al: Color Atlas and Synopsis of Clinical Dermatology. 3rd Ed. New York, McGraw-Hill, 1997
•Goldstein A, Goldstein B: Practical Dermatology. 2nd ed. St. Louis, Mosby, 1997.Labels: Depigmentation, Hypomelanosis |
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