BENIGN GYNECOLOGIC LESIONS by nikeborome

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									BENIGN GYNECOLOGIC
      LESIONS
•   VULVA
•   1. urethral caruncle
•   2. cysts
•   3. nevus
•   4. hemangioma
•   5. fibroma
•   6. lipoma
•   7. hidradenoma
•   8. syringoma
•   9. endometriosis
•   10. granular cell myoblastoma
•   11. von Recklinghausen
•   12. hematomas
•   13. dermatologic diseases
•       a. pruritus & vulvodynia
•       b. vulvar vestibulitis
•       c. contact dermatitis
•       d. psoriasis
•       e. seborrheic dermatitis
•       f. lichen planus
•       g. hidradenitis suppurativa
•       h. edema
•   VAGINA
•   1. urethral diverticulum
•   2. inclusion cysts
•   3. dysontogenic cysts
•   4. tampoon problems
•   5. local trauma
•
• UTERUS
• I. CERVIX
•    1. endocervical & cervical polyps
•    2. nabothian cysts
•    3. lacerations
•    4. cervical myomas
•    5. cervical stenosis
•
•   UTERUS
•     II. BODY OF THE UTERUS
•         1. endometrial polyps
•         2. hematometra
•         3. leiomyoma
•   OVUDUCT/FALLOPIAN TUBES
•   1. leiomyomas
•   2. adenomatoid tumors
•   3. paratubal cysts
•   4. torsion
• OVARY
• 1. functional cysts
•     a. follicular cyst
•     b. corpus luteum cysts
•     c. theca lutein cysts
• 2. benign neoplasms of the ovary
•     a. benign cystic teratoma( mature teratoma)
•      b. endometriomas
•      c. transitional cell tumor(Brenner)
•      d. adeofibroma/cystadenofibroma
•      e. torsion
•      f. ovarian remnant syndrome
•      g. fibroma
• VULVA
• 1. Urethral carunle – small fleshy
•    outgrowth of distal edge of urethra
•    may be 1 – 2 cm diameter
•    more in postmenopause
•    sec. to chronic irritation or infection
•    histologically composed of transitional
• and stratified squamous epithelium
• symptoms – dysuria, frequency,urgency
•     point tenderness, ulcerative-hematuria
• approximately – 1 in 40 cases may dev
•     malignant neoplasm
• Urethral caruncle
•    diagnosis – biopsy
•    treatment – cryosurgery
•                 lasertherapy
•                 fulguration
•                 operative excision
• urethral prolapse – disease of premenarche :
  diagnosis in child
• treatment – hot sitz bath, antibiotics
•               topical estrogen
• Diff dx – primary ca of urethra, prolapse urethral
  mucosa
• VULVA
• Cyst
• most common large cyst – cystic
•    dilatation of an obstructed
•     Bartholin’s duct
•    Treatment- not necessary in women
•     less than 40 years old unless infected
•     or enlarges to produce symptoms
•   cyst maybe clear , yellow, blue
•
• Wolffian duct cyst – found near the clitoris
•   and lateral to the hymenal ring. They
•   have thin walls and contain clear serous
•   fluid.
• Epidermal inclusion cyst or sebaceous
• cyst-located beneath the epidermis, or
• the anterior half of the labia majora.
• usually multiple, movable, nontender,
• slow growing, firm to shotty in consistency
• grossly white or yellow
•
• Inclusion cyst – following trauma like
• episiotomy site or obstetric laceration
• Most inclusion cyst of vagina are
• directly related to previous trauma while
• most inclusion cyst of vulva are not
• related to trauma.
• Most of these cysts need no treatment
• if infected – heat applied locally
• and incision and drainage.
• Nevus – mole, localized nests or cluster
• of melanocytes
• vulvar nevi – asymptomatic
•    5 – 10 % of all malignant melanomas
•    from vulva
•   50% arise from pre-existing nevi
•   more in 50 year old woman
•   ideally all flat nevi should be excised
•   and examined histologically
•   flat nevi have greater malignant
•   potential
•   S/S
•    A- asymmetry
•   B- border irregularity
•   C- color variegation
•   D- Diameter more than 6 mm

• Hemangiomas – rare malformation of
  blood vessels
• Discovered initially – childhood
• Single, flat, soft, brown to red to purple
• Hemangiomas
• most are asymptomatic
• may ulcerate and bleed
• 5 types
•  1. strawberry – young patients, red
•  2. cavernous – young patients, purple
•     increase in size till 2 years old
• 3. senile – small lesions arise in labia
•    majora, postmenopause, red brown to
•    dark blue
• 4. cherry- postmenopause, red brown-blue
• 5. angiokeratomas – purple or dark red
•    age – 30 – 50 years old, rapid growth
•    bleed on strenuous exercise
•
•   Hemangiomas
•    diagnosis – gross inspection of vascular lesion
•    treatment – with bleeding cryosurgery
•         or argon laser
•   FIBROMA – most common solid benign
•   tumors of the vulva
•   More in labia majora, slow growing
•   Low grade potential for malignancy
•   Smooth surface and distinct contour
•    Treatment – operative removal of fibromas
•     if symptomatic or continue to grow
• LIPOMA – benign, slow growing
  circumscribed tumors of fat cells
• Arising from subcutaneous tissue of the
• vulva it’s a mesenchymal tumor
• more in the labia majora
• Slow growing low malignant potential
• DIAGNOSIS - excision
• HIDRADENOMA
• benign vulvar tumor from apocrine sweat
  glands of inner surface of labia majora and
• nearby perineum
• Age – 30 – 70 years old
• May be solid or cystic
• Tumors are well defined, sessile, pinkish
  gray with well defined capsules
• Asymptomatic
• TREATMENT – excisional biopsy
•   SYRINGOMA
•   Rare, cystic,asymptomatic
•   Small subcutaneous papules
•   More in labia majora
•   Pruritus
•   TREAMENT – excisional biopsy
•                  cryosurgery
•   ENDOMETRIOSIS
•   In the vulva is rare
•   Firm nodule cystic or solid
•   Subcutaneous, lesions are blue, red or
•   purple, found in old OB lacerations
•   Symptoms – vulva – pain, introital
•   dyspareunia, cyclic discomfort with
•   menstruation
•   TREATMENT- wide excision
•                    laser vaporization
•   GRANULOSA CELL MYOBLASTOMA
•   Rare, slow growing,solid tumor,
•   Schwannoma ( neural sheath)
•   Subcutaneous tissue of the vulva
•   Commonly found in the tongue
•   Nodules are pailess
•   Cut surface is yellow
•   TREATMENT – wide excision
•                    excisional biopsy
•   HEMATOMAS
•   Secondary to blunt trauma
•     like straddle injury from fall
•          automobile accident, assault
•   Management for non obstetric hematoma
•    - conservative if meas is less than 10cm
•    - if bleeding is venous
•   TREATMENT- ice pack
•                   operative therapy
•                   drainage and debridement
•   DERMATOLOGIC DISEASES OF THE VULVA
•   a. Pruritus – intense itching, desire to
•       scratch ”itch- scratch cycle”
•    b. Vulvodynia – chronic vulvar discomfort,
•       burning, stinging and rawness.
•   c. Vulvar vestibulitis – unknown etiology
•       pain and burning at introitus
•       not an inflammation
•       allodynia – pain related to nonpainful sti
•       TREAMENT – topical anesthetics
•               surgical removal of skin
• d.Contact dermatitis –
•   site – intertriginous areas
•   red, edematous, inflammed skin
•   weeping eczematoid vesicles
•   TREATMENT – withdraw offending
•    substance
• Burrows solution
• petroleum jelly
• hydrocortisone
• prednisone
•   e. Psoriasis - common generalized
•      unknown etiology
•      chronic
•      spontaneous remission, or
•      exacerbation
•      genetics, multifactorial
•      more in scalp and fingernails
•      red to yellow papules
•      may be 1st clin manifestation of HIV
•      does not involve vagina
•      DIAGNOSIS – classic silver scales
•      and bleeding on scraping of plaques
•      TREATMENT – hydrocortisone,
•       chronic fissures – flourinated corticosteroids
•   f. Seborrheic dermatitis- rare
•      etiology – unknown
•      pale to yellow – red
•      erythematous, edematous
•      oily scales
•      TREATMENT- hydrocortisone cream
•   g. Lichen Planus – chronic eruption
•      of shiny, violaceous papules
•      inner aspects of the vulva
•      etio – local autoimmune cell mediated
•      response
•      s/s – pruritus & pain, burning, scarring
•   DIAGNOSIS – small punch biopsy
•   TREATMENT – topical steroid cream
• h.Hidradenitis suppurativa
•   chronic, unrelenting, refractory infection
•   of skin and subcutaneous tissue
    painful with foul smelling discharge
    more in reproductive age women
    DIAGNOSIS : biopsy
    TREATMENT- antibiotics and
    topical steroids
    options: antiandrogens, isotretinoin
    cyclosporin
    refractory cases – aggressive excision
• VAGINA
• 1. Urethral diverticulum – permanent
•    epithelialized sac- like projection from
•    posterior urethra.
•    suspect in chronic infection or recurrent
•    lower urinary tract symptoms
•    may be congenital or acquired
•    most frequent symptoms- urgency
•    frequency, dysuria,hematuria,
•    3 Ds dysuria, dribbling, dyspareunia
•   VAGINA- URETHRAL DIVERTICULUM
•   DIAGNOSIS- foundation – physician’s
•    awareness
•    voiding cystourethrography
•    cystourethroscopy
•    others: TVS, CT scan, MRI
•           positive pressure urethrography
•   TREATMENT – excisional surgery
•   most serious consequence – urinary
•   incontinence, urethral vaginal fistula
• VAGINA
• 2. Inclusion cyst – common
• located inposterior or lateral walls of the
• lower third of vagina
• more in parous women
• secondary to birth trauma
• asymptomatic
• TREATMENT – excisional biopsy
• VAGINA
• 3. Dysontogenic cysts – thin walled soft
•    cyst of embryonic origin
•    Gartner duct cyst – anterior lateral
•    wall of vagina.
•    Mullerian cyst – upper half of the
•    vagina, multip[le
•    Vestibular cyst - urogenital sinus cyst
•     asymptomatic
•    TREATMENT – if with symptom
•         operative excision
• VAGINA
• 4. Tampoon problems – foreign body
•    “toxic shock syndrome”
•     staph aureus
•     foul vaginal discharge
•     TREATMENT - antibiotics for 7 days
•      vaginal cream for 7 days
• VAGINA
• 5. Local trauma – common due to coitus
•    factors : virginity, postpartum and
•    postmenopausal vaginal epithelialization
•    pregnancy, intercourse after prolonged
•    abstinence, hysterectomy
•    usually – transverse tear in posterior
•    fornix, presents with profuse or prolong
•    vaginal bleeding
•    MANAGEMENT – suturing under anesthesia
•
• UTERUS
• CERVIX
• 1. Endocervical /cervical polyps
•    most common
•    multiparous – 40-50 years old
•    maybe single or multiple
•    bleed when touched, friable
•     endocervix polyp- long pedicle,
•      and narrow
•      more in reproductive years
•      intermenstrual bleeding
• CERVIX
• ectocervix polyp – short base,
•    postmenopause women
•   histologically – columnar or squamous
•   6 different types
•   1. adenomatous 2. cystic
•    3. fibrous         4. vascular
•   5. inflammatory 6. fibromyomatous
• MANAGEMENT – grasping polyp with
• clamp, chemical cautery, electrocautery
• cryocautery
• CERVIX
• 2. Nabothian cyst
•    retension cyst of endocervical columnar
•    cells
•    multiple cyst, translucent or opaque
•    yellow
• secondary to spontaneous healing of cx
• asymptomatic
• NO TREATMENT
• CERVIX
• 3. Lacerations – in deliveries
•     located at 3 and 9 oclock lacerations
•     may extend to the broad ligament
•     MANAGEMENT – suturing
• 4. Cervical myomas
•    smooth, firm mass, solitary
• arise in isthmus of uterus
• small and asymptomatic
• dyspareunia, dysuria,urgency,ureteral
• and cervical obstruction
• DIAGNOSIS – CERVICAL MYOMA
• inspection and palpation
• TREATMENT- ASYMPTOMATIC
• observe
• persistence of symptoms – GnRH
• myomectomy/hysterectomy
• radiologic catheter embolization
• CERVIX
• 5. Cervical stenosis – internal os
•     acquired or congenital
•     if acquired sec to operative procedure
•    infection, neoplasia,atrophic changes
•    operative proc like cone biopsy,
•    cautery of cervix
•    common symptom in premenopause
•    dysmenorrhea, pelvic pain, abn bleed
•    amenorrhea, infertility
•   Cervical stenosis
•     postmenopause – asymptomatic
•     then slowly they develop hematometra
•     hydrometra, pyometra
•   DIAGNOSIS - inability to introduce a
•    1-2mm cervical dilator in uterine cavity
•   MANAGEMENT – dilation of cx with
•   Dilators under USG guidance, monthly
•   Laminaria tents, leave a T tube or latex
    nasopharyngeal airway as a stent in cx
    canal for few days to maintain patency
• BODY OF THE UTERUS
• 1. Endometrial polyps- localized
  overgrowth of endometrial glands and
• stroma that projects beyond surface of
• endometrium
• soft, pliable, single or multiple
• broad base – sessile
• Pedunculated- slender pedicle
• Etiology – unknown
• associated with endometrial hyperplasia
• BODY OF UTERUS
• endometrial polyp
•   majority are asymptomatic
•   if with s/s – menorrhagia,premenstrual
•   and postmenopausal staining and
•   scanty postmenstrual spotting
•   color – gray or tan
•      occasionally red or brown
•   age – peak – 40 – 49y/o
•   BODY OF UTERUS
•    components of endometrial polyp
•     1. endometrial glands
•      2. endometrial stroma
•      3. central vascular channel
•   malignant transformation 0.5%
•   DIAGNOSIS – hysterectomy
•     vaginal hydrosonography
•     hysteroscopy,hysterosalphingography
•   MANAGEMENT-curettage with removal of polyp
•      hysteroscopy
• BODY OF UTERUS
• 2. Hematometra
•    uterus is distended with blood
•    sec to partial or complete obstruction
•    of lower genital tract
•    obstruction of isthmus of uterus,
•    cervix, or vagina may be congenital or
•    acquired
•
• BODY OF THE UTERUS
• Acquired obstruction
• senile atrophy, scarring by synecchia
•   cervical stenosis sec to surgery,
•   radiation, cryocautery, electrocautery
•   malignant dse of endocervical canal
•   suction curettage
• Symptoms- depends on age
• infection
• cyclic lower abdominal pain
• primary amenorrhea, tender uterus
• DIAGNOSIS HEMATOMETRA
• history taking
• TREATMENT
•    dependent on operative relief
• 3. Leiomyoma- also called myoma
•    benign of muscle origin
•    may also called fibroma or fibromyomas
•    most frequent pelvic tumors
• may be single or multiple
• s/s pain sec large myoma /pressure
•       abn bleeding, dysmenorrhea
•       most – are asymptomatic
•   Leiomyoma
•    3 most common types
•   1. intramural
•   2. subserous- may become parasitic
•   3. submucous- most troublesome
•    special nomenclature – broad lig myoma
•    parasitic myoma
•   Grossly – solid pearly, white mass
•     histo- whorled configuaration of cells
•      with pseudocapsule
• Leiomyomas
• growth dependent on
  estrogen/progesterone
• tends to enlarge during pregnancy
• tends to decrease in size on menopause
• Myoma may degenerate into
• 1. hyaline
• 2. myxomatous
• 3. calcific  5. fatty
• 4. cystic    6. red degeneration
•   Leiomyoma
•   mildest degeneration – hyaline
•   acute degeneration – red & carneous
•   carneous – occurs during pregnancy
•   DIAGNOSIS- pelvic exam ,USG,CT scan
•    MRI
•   MANAGEMENT - small/asymptomatic
•    observe
•   Myomectomy & or hysterectomy
•   Leiomyoma
•   Classic indications for myomectomy
•   1. rapidly expanding pelvic mass
•   2. persistent abnormal vaginal bleeding
•   3. pain or pressure
•   4. enlargement of asymptomatic myoma
•   To more than 8 cm in a woman who has
    not completed childbearing
•   Leiomyoma
•    contraindications to myomectomy
•   1. pregnancy
•   2. advanced adnexal dse
•   3. malignancy
•   4. situation in which enucleation of myoma
    may result in severe reduction of
    endometrial surface – uterus not functional
• Leiomyoma
• Hysterectomy
• done with completed family size
• size 14 to 16 weeks gestation
• rapid growth of myoma after menopause
• Medical management
• Danazol, medroxyprogesterone acetate
• antiprogesterone RU 486
• OVIDUCT/FALLOPIAN TUBES
• 1. Leiomyoma
•    tubal may be single or multiple
•    usually in interstitial portion
•    usually coexist with uterine myoma
•    smooth, firm mobile, nontender
•    maybe subserosal interstitial,
•    submucosal
•    majority are asymptomatic
• OVIDUCT
• 2. Adenomatoid tumors
•    most prevalent benign tumors of FT
•    small, gray white, circumscribed
•    nodules, 1-2 cm diameter
• usually unilateral do ot become malig
• TREATMENT- EXCISION

•
• OVIDUCT
• 3. Paratubal cyst- are incidental
  discoveries
• Small, asymptomatic, slow growing
• 40-50 years old
• When they are near the fimbrial end
• they are called Hydatid cyst of Morgagni
• Generally they produce a dull pain
• During pregnancy grow rapidly
• TREATMENT – SIMPLE EXCISION
• OVIDUCT
• 4. Torsion
•    acute torsion is a rare event
•    predisposing factor – pregnancy
•    usually accompanies torsion of ovary
•    right tube is frequently involved
• MANAGEMENT – explore lap
• OVARY
• 1. Functional cyst
•    a. Follicular cyst – most frequent
•       multiple from few mm to 15 cm
•       physiologic, not neoplastic
•       translucent, thin walled, filled with
•       watery, clear to straw color fluid
•       majority are asymptomatic
•       Initial MGT. – observe
•       persistent ovarian mass – excision
•       cystectomy
• OVARY
• 2. Corpus luteum cyst
•    less common
•    clinically more important
•    all corpora lutea are cystic with
•    gradual reabsorption of a limited amt
•    of hemorrhage which may form a cavity
•    clinically they a re not term corpus
•    luteum cyst unless they are of 3 cm dia
•    corpus luteum assoc with normal
•    endocrine function or prolong sec of
•    progesterone
• OVARY
• CORPUS LUTEUM CYST
• assoc menstrual pattern
• normal, delayed, amenorrhea
• most are small ave dia 4 cm
• asymptomatic if it ruptures it may cause
• intraperitoneal bleeding
• DIAGNOSIS - USG
• MANAGEMENT- Cystectomy is the
• choice
• OVARY
• 3. Theca lutein cysts
•    least common
•    almost always bilateral
•    dia from 1 to 10 cm
•    hyperreactio luteinalis – condition of
•    ovarian enlargement sec to dev of multi
•    luteinized follicular cysts
•    found in 50% of molar preg
•    10% in chorio carcinoma
• OVARY
• Theca lutein cells
•    cyst are also found in multiple pregnancies,
  diabetes, Rh sensitization
• Grossly the total ovarian size may be 20 to 30
  cm diameter
• Bilateral enlargement due to hundreds of thin
  walled locules producing honeycombed
  appearance.
• DIAGNOSIS - palpation / USG
• TREATMENT – CONSERVATIVE
• regress gradually
• COX- rupture
• OVARY
• 4. Benign cystic teratoma (dermoids,
•    mature teratoma)
• Teratoma – monstrous growth
•    maybe benign or malignant
•    malignant variety – immature teratoma
•    1-2% of dermoids
• most common ovarian tumors
• 25 – 50 years old women
• size from few mm to 25 cm diameter
• may be single or multiple, unilocular
• OVARY
• BENIGN CYSTIC TERATOMA
•   arise from single germ cell after first
  meiotic division
• Grossly cyst wall are smooth, shiny,
  opaque,white color
• Maybe composed of ectoderm, endoderm,
• Mesoderm materials, like hair, nails, brain
• Cartilage etc.
• DIAGNOSIS- palpation/USG
• MANAGEMENT – explorelap/cystectomy
• OVARY
• 5. Endometriomas – separate topic
• 6. Fibroma of the ovary most common benign
  tumor of the ovary
• Size vary from small nodules to huge pelvic
  tumors weighing 50 pounds
• Extremely slow growing tumors
• Usually unilateral average age 48 years old, s/s
  abdominal enlargement, pressure,
• ascites
• no change in menstrual pattern
• Meigs syndrome – ascites hydrothorax, fibroma
• OVARY
• Fibroma
• usually are solid, heavy,well
  encapsulated, grayish white
• On cut surface demonstrate a
  homogenous white or yellowish white solid
  tissue with a trabeculated or whorled
  appearace similar to myoma of the uterus
• Histologially – connective tissues
• DIAGNOSIS - palpation/ USG
• MANAGEMENT - explorelap
• OVARY
• 7. Transitional cell tumor – Brenner tumors
•    rare, small, smooth, solid, fibroepithelial
•    tumors generally asymptomatic
•    benign, low malignant potential
•    90% are discovered accidentally
•    during surgery
•    sometimes assoc with postmenopausal
•    vaginal bleeding, endometrial hyperplsia
• OVARY
• Brenner
• histologically it has 2 components
• 1. solid masses
•   2. nests of epithelial cells and a
  surrounding fibrous stroma
•   the pale epithellial cells have a coffee
  bean appearing nucleus
• MANAGEMENT – explorelap with simple
  excision
• OVARY
• 8. adenofibroma/cystadenofibroma
•    closely related
•    benign tumors, firm consists of fibrous
•    stroma and epithelial components
•    epithelial – serous histologically
•    maybe mucinous, and endometroid or
•    clear cell.
•    small – asymptomatic
•    large – pressure symptoms, rupture
•    management - TAHBSO
• OVARY
• 9. Torsion of the ovary or both oviduct
•    and the ovary is uncommon
•    cause of acute lower abdominal and
•    pelvic pain
•    most in reproductive years
•    ave age mid 20s
•    s/s acute severe, unilateral, lower abdominal
  and pelvic pain to an abrupt change in position,
  assoc with vomiting
• fever with necrosis of adnexal torsion
• DIAGNOSIS- pelvic exam/ USG
• Management - Explorelap
•
• OVARY
• 10. Ovarian remnant syndrome
• chronic pelvic pain sec to a small area of
• functioning ovarian tissue following
  intended removal of both ovaries
• most women have endometriosis
• pain is cyclic and exacerbated following
• coitus
• masses are small 3 cm in dia
• located retroperitoneally near ureter
• OVARY
• Ovarian remnant syndrome
• DIAGNOSIS
•   PELVIC EXAM/ HISTORY/ USG
•   MRI/ PREMENOPAUSAL FSH LEVEL
•   to women who has had BSO
• MANAGEMENT – surgical removal of the
•   ovarian remnant
• VAGINA
• .
• .

								
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