First 1/2 of Chp 41
What are two types of pathology specific to the vagina? Explain each.
1. Gartner's Duct Cyst- Most common cystic lesion of the vagina; incidental finding.
2. Imperforate Hymen- pediatric issue; most common congenital abnormality. The hymen traps fluid. *referred to as Cervical Stenosis when postmenopausal*.
What type of cyst is external to the vagina?
Bartholin Duct Cyst
How can you differentiate between a Gartner's Duct cyst and a Bartholin Duct cyst?
A Gartner's duct cyst is visualized endovaginally within the vagina and is very inferior sonographically. A bartholin duct cyst is external to the opening of the vagina, and is visualized thru translabial scanning.
________ masses are rare in the vagina.
When is the vaginal cuff seen? What is the upper limit size of a normal vaginal cuff? If vaginal cuff is larger than the upper limit, what should it be regarded as?
Vaginal cuff is seen in a hysterectomy patients after surgery (Posthysterectomy). The upper size limit of a normal vaginal cuff is 2.1cm. If it is larger than this (or has a visual mass or high echogenicity) it should be regarded with suspicion for malignancy. (esp. in patients with a previous hx of cancer).
Nodular areas in the vaginal cuff may be due to what?
What are the four stages of vaginal malignancies?
Stage 1: Superficial vaginal tumors
Stage 2: extravaginal tumors
Stage 3: invasion of the musculature of the pelvic side wall
Stage 4: Involvement of the urinary bladder
The rectouterine recess is also known as what? (2)
Pouch of douglas; posterior cul-de-sac
The rectouterine recess is most _____ & ________ reflection of the peritoneal cavity.
posterior & inferior
The rectouterine recess (aka: pouch of douglas or posterior cul-de-sac) is a common location for _________ or __________ fluid.
physiologic or pathologic
What is the most common pathology of the cervix?
Nabothian cysts are also known as _________.
Epithelial Inclusion Cyst
_________ are the most common cervical pathology finding. They usually measure ______cm, and are mostly of no clinical significance. Songraphically, they have characteristics of a _____. However, they also can be hemorrhagic-- they will look _____ and have __________.
Nabothian cysts (epithelial inclusion cysts); > 2cm; cyst
Nabothian cysts usually result from ___________.
What type of symptoms result from nabothian cysts?
What is a cervical polyp?
They are benign, and are found amongst ___________ age.
hyperplastic protrusion of epithelium of cervix.
Late middle age.
Cervical polyps can be _______ or ________ based.
Symptom of cervical polyps?
Pedunculated or broad based.
Cervical leiomyomas are _____. When small, patients are _______. When large, it can cause a ______ or ________ obstruction.
Rare; asymptomatic; bowel or bladder obstruction
What is used to determine leiomyoma vs. polyp?
Cervical Stenosis is acquired. It is a(n) ________ at the internal or external os. what 5 things can cause this obstruction?
Cervical Stenosis sonographically appears at a ______-filled uterus. It could be: hydrometra, pyometra, or hematometra (define each)
obstruction; radiation therapy, cone biopsy, postmenopasual cx atrophy, chronic infection, cyrosurgery, or cancer.
fluid; water/fluid filled, puss-filled, blood-filled
Describe the symptomatic differences between a postmenopausal pt and a premenopasual pt with cervical stenosis.
Postmenopausal- may be asymptomatic
Premenopausal- oligomenorrhea, amenorrhea, dysmenorrhea, or infertility.
What is a precursor to cervical cancer/carcinoma?
Cervical cancer/carcinoma is the ______ most common GYN malignancy. __________ is the most common type of cervical cancer.
Cervical Cancer is found amongst women in their __________ years, causing ______ or _________.
Third; Squamous cell
Childbearing; Vaginal discharge or bleeding
What are the risk factors (6) for Cx CA?
What are the signs and symptoms of Cx CA? (4)
HPV infection; early sexual promiscuity; low socioeconomic status; smoking; BCP's; women in 3rd or 4th decade of life (30's-40's).
Early- asymptomatic; discharge (may be odorous), metorrhagia or postcoital bleeding, palpable pelvic mass
Describe the sono appearance of Cx CA. (4)
What approach is best?
Normal; enlarged, bulky Cx; Solid, retrovesical mass (may not be differentiated from leiomyoma); hydro, pyo, or hematometra (Cx stenosis)
Translabial or tranperineal
Areas of _____ echogenicity or ___________ areas with _________ borders/outline = _________.
increased; hypoechoic; irregular
What will be the visual difference with color on a mass to determine malignant vs benign?
Benign= there may be SOME flow
What is a mucinous endocervical type of minimal deviation adencarcinoma? Where multiple cystic areas are seen within a solid cervical mass.
________ cysts do not have an associated mass.
What are the two main objectives when evaluating the uterus?
1) Assess structural anatomy (UT shape, echogenicity)
2) Assess endometrium
What are the six Mullerian UT anomalies?
Double UT double vagina (UT Didelphys), Bicornuate, Bicornuate w/ rudimentary left horn, septate, unicornuate, and arcuate.
What is the Class I Mullerian Anomaly?
Diagnosed by development of: _______, ________, or ___________.
Vaginal atresia (pediatric)
Hyrdocolpos, hydrometrocolpos, or hematometrocolpos
What is the Class II Mullerian Anomaly?
It is related to ____ and _________. Sonographically a _____ and _______ (cigar shaped) UT deviated to one side is demonstrated.
Infertility, pregnancy loss; long and slender
What is the Class III Mullerian Anomaly?
Complete duplication of _____, ______, and ______.
Not usually associated with ________ problems. Generally does not require treatment.
Uterus, cervix, and vagina
What is the class IV Mullerian Anomaly?
Duplication of ______ with one common _______.
Bilobed ______ cavity has wide-spaced cavities. _____ incidence of fertility complications, usually not treated.
What is the class VI Mullerian Anomaly?
UT is _____ in size and shape externally; however, cavity is ______ shaped with ______ contour.
Related to exposure to drug diethylstilbestrol (DES) in utero
normal; T-shaped; irregular
With a septate uterus, there is ____ fundus.
It is associated with ______ because of implantation on septum and lack of adequate ___________. However it is treatable, the septum can be removed ____________.
infertility; blood supply; hysterscopically
What are the most common gynecologic/ pelvic tumors?
They are found in the ____ and occur in approximately _______% of women over age of _____. They're more common in ____________ women.
Leimyomas (aka fibroids, myomas)
Uterus; 20-30%; 30; african american
Myoma tumors are composed of ______-shaped smooth muscle cells arranged in a _____-like pattern with variable amounts of ______ connective tissue.
It can degenerate into a number of different histologic subtypes, degeneration occurs when myomas outgrow their blood supply; calcifications
spindle-shaped; whorl-like; fibrous
Myomas have _____ muscle cell composition.
_____ occurs after atrophy or degenerative changes.
Clinically, with myomas, the UT is _____. There will be profused or prolonged ______ and pain.
What are the four uterine locations of Leiomyomas? describe each.
Submucosal- disruption (may erode) into endometrial cavity; causes heavy and irregular bleeding (leading to anemia); infertility
Intramural- within myometrium, may enlarge & cause pressure on adjacent organs, infertility, and reoccurring pregnancy loss.
Subserosal- arise from myometrium and project exophytically; enlarge & cause pressure on adjacent organs.
Pedunculated- appear as extrauterine masses
Myomas are ______ dependent. They may _____ in size during pregnancy.
About ______ of all myomas show little change during pregnancy.
Leiomyomas rarely develop in _______ women; most _____ or ______ in size following menopause because of lack of ______ stimulation.
However, myomas may _____ in size in postmenopausal patients undergoing HRT. Rapid increase in myoma size, especially in _______ women, is suspicious for _______.
postmenopausal; stabilize or decrease; estrogen
increase; postmenopausal; neoplasm (leiomyosarcoma)
In case of infertility and submucosal myoma, surgery by _________ is often the treatment of choice when it comes to Myomas.
How is menorrhagia treated? (4)
Hormonal supression- to stop bleeding (least invasive); Endometrial Ablation; Uterine artery embolization (UAE); High intensity focused ultrasound (HIFU)
What is the most common cause of UT calcifications?
Less common cause?
arcuate artery calcification in periphery of UT
Uterine calcifications are thought to occur as consequence of _____________ within these vessels. UT calcs can indicate ___________, such as diabetes mellitus, hypertension, or chronic renal failure.
Such calcs have been termed "__________" and appear in arteries throughout the body.
calcific sclerosis; underlying disease