pelvic pain, normal and abnormal uterine bleeding

UTI: antimicrobial therapy

a high serum level of antibiotics is undesirable in the treatment of acute cystitis because it tends to alter normal bacterial flora= Nitrofurantoin (Macrodantin). single dose therapy is effective alternative to 3-7 day course, esp. in patients with acute uncomplicated cystitis. for pyelonephritis use antibiotics that will attain significant serum level because based infected renal tissue is poorly perfused.

DUB: hysterectomy, CHM, nonemergency AUB d/t anovulation managed --? chronic anovulatory AUB managed with?

Hysterectomy: last resort for menorrhagia not resolved with other treatments. Chinese herbal medicine (CHM): may be effective-more research needed. Nonemergent AUB due to anovulation managed by administration of COCs. Chronic anovulatory AUB managed with cyclic progestin and estrogen added in the latter 10-15 days of the 25 days estrogen cycle. Cycle progestins alone may be used for younger patients who have enough endogenous estrogens to prime the endometrial progesterone receipts. For older adults endometrial ablation, vaginal hysterectomy.

AUB & DUB: irregular menstrual cycles common when? ovulatory AUB occurs in -- years and during -- years. can be sign of -- disease. 3 types of irregular menses. systemic causes?

Irregular menstrual cycles: menarche and perimenopause. Ovulatory AUB occurs in post adolescent (11-14) years and during premenopausal years (45-50) AUB can be sign of systemic disease. Amenorrhea, oligomenorrhea, menorrhagia. Renal (hyperprolactinemia), liver (impaired metabolism of estrogens), thyroid diseases; coagulopathies; thrombocytopenia; von Willebrand's disease (VWD); coagulation factor deficiencies.

AUB and DUB: many -- predispose women to AUB. - and - risk for oligomenorrhea and amenorrhea. drugs? postmenopausal women who are --?

Many medications predispose women to AUB (exogenous estrogen-oral contraceptives, aspirin, heparin, Coumadin, tamoxifen, IUD). Athletic women and those with eating disorders at risk for oligomenorrhea and amenorrhea. Illicit drugs inhibit ovulation. Postmenopausal women who are alcohol dependent can have hyperprolactinemia, increased MCV or both

Amenorrhea: primary vs secondary

No menses by age 14; absence of growth or development of secondary sexual characteristics. No menses by age 16; regardless of presence of normal growth and development of secondary sexual characteristics. Women who have menstruated previously; no menses for interval of time equivalent to total of at least three previous cycles, or 6 months.

DUB: nsaids, tranexamic acid, D&C, endometrial ablation, uterine artery embolization

Nonsteroidal anti-inflammatory drugs (NSAIDs): ovulatory-idiopathic menorrhagia. Tranexamic acid (antifibrinolytic agent): reduces menstrual bleeding. D & C: quickest way to stop acute bleeding. Endometrial ablation: less invasive procedure. Uterine artery embolization: safe and effective option; retain fertility.

AUB (abnormal) & DUB: normal menses. causes of abnormal bleeding? anovulatory DUB diagnosis? hormonal imbalances?

Normal menses: hypothalamic-pituitary-ovarian axis; hormonal events that lead to ovulation. Causes of abnormal bleeding: physiologic, pathologic, pharmacologic. Anovulatory uterine bleeding (DUB): after excluding all other causes of abnormal bleeding. Hormonal imbalances: estrogen withdrawal, estrogen breakthrough, progestogen breakthrough

amenorrhea assessment: most common cause? most reliable measure?

Ovarian function abnormalities most common cause of amenorrhea Estrogen production most reliable measure of ovarian function Random serum estradiol >40-functioning ovaries, if low may be due to ovarian failure or hypothalamic amenorrhea Progestogen challenge test-withdrawal bleeding=functioning ovaries

genirourinary dysfunction: pelvic organ prolapse? types 3?

Pelvic Organ Prolapse-protrusion of pelvic organs into vaginal canal or beyond vaginal opening due to weakness in the endopelvic fascia and ligamentous supports Anterior vaginal prolapse-cystocele Posterior vaginal prolapse Apical vaginal and uterine prolapse Procidentia (uterine prolapse through vaginal hymen)-failure of all vaginal supports

DUB laboratory and diagnostic testing

Pregnancy test. Complete blood count. Thyroid-stimulating hormone (TSH). Prolactin level. Pap test. Nucleic acid amplification test (NAAT). Microscopic examination of vaginal secretions. Coagulation studies (PT and PTT Platelet count Serum progesterone. Serum ferritin test. Transvaginal ultrasonography (TV US) & Endometrial biopsy if normal DUB is likely. Hysteroscopy. Magnetic resonance imaging (MRI). Computerized tomography (CT) scan

diagnosis and management-prolapse

Quantify and stage: 0- no prolapse 1- most distal portion of prolapse -1cm (above level of hymen) 2- most distal portion >/= -1 but , </= +1 (</= 1cm above or below the hymen) 3- most distal part >+1 but beyond the hymen; protrudes no farther than 2cm less that the total vaginal length 4- complete eversion; most distal part >/= tvl -2 Extent of prolapse is evaluated and measured relative to the hymen Stages can be assigned according to the most severe portion of the prolapse Management- Nonsurgical-Pelvic floor muscle exercises, pessaries (requires proper fitting/size) Surgical-refer for evaluation

stress urinary incontinence: etiology, exam, diagnostics, and management

SUI is involuntary leaking or urine in response to physical exertion, sneezing, or coughing. etiologies: urethral hyper motility d/t vaginal wall relaxation, displacing the bladder neck and proximal urethra downward. intrinsic sphincter deficiency. Diagnostic: patient examined with a full bladder in the lithotomy position. patient is asked to cough (+ is short spurts of urine with each cough). Q-tip test-determines mobility and descent of the urethrovesicular junction on straining and allows differentiation from anterior vaginal laxity alone (normal change in angle is up to 30 degrees. in patients with pelvic relocation and SUI, the change ranges from 30-60 degrees. Good history and PE, cotton swab test and cough stress test is adequate. Treatment: postmenopause-estrogen (improve urethral closing pressure, vaginal epithelial thickness, and vascularity, and reflex urethral function), pelvic floor exercise (1st line for mild to moderate). surgical therapy.

amenorrhea: TV US, serum FSH, if there are normal then dx is --? other than pregnancy, most common cause? other labs and diagnostic test?

TV US: Endometrial thickness should correlate with progestogen challenge test and estradiol levels Serum FSH: low result normal functioning ovaries; elevated may indicate disease-evaluate further If these are normal then dx is chronic anovulation Other than pregnancy, most common cause thyroid disease and hyperprolactinemia Prolactin level, TSH MRI

dysmenorrhea-primary vs secondary. clinical features (initial onset, duration of pain, assoc. symptoms, pelvic exam), treatments (general, medical, other measures)

dysmenorrhea-painful menstruation Primary-no readily identifiable cause, 17-22 years Secondary-caused by organic pelvic disease; Older women Clinical features: initial onset usually within 2 years of menarche. Begins a few hours before or just after the onset of menstruation and usually lasts 48-72 hours. Pain is described as cramp-like and is usually strongest over the lower abdomen and may radiate to the back or inner thighs. assoc. symptoms: n/v, fatigue, diarrhea, lower backache, headache. pelvic exam: normal Treatments: general-reassurance and explanation. medical-NSAIDs (ibuprofen 400 every 6 hours, naproxen 250 every 6h, mefenamic acid-500 mg every 8 h), hormonal contraceptives (including hormone releasing IUD and vaginal rings-reduce menstrual flow, inhibit ovulation). progestins, tocolytics (salbutamol), analgesics. other measures: transcutaneous nerve stimulation, acupuncture, psychotherapy, and hypnotherapy.

management for CPP

multidisciplinary. relaxation, cognitive, and behavioral therapy. medical and surgical: initial- a trial of ovulation with or without menstrual suppression with CHC, high dose or IUDs or gonadotropin releasing hormone agonist. Also NSAIDs. Anesthesia: acupuncture, nerve blocks, and trigger point injections of local anesthetics. Many have abdominal wall trigger points or nerve entrapments that response to biweekly injections

common abnormal bleeding patterns

polymenorrhea: abnormally frequent menses at intervals <24 days. menorrhagia: excessive and/or prolonged menses (>80ml and >7 days) occurring at normal intervals. metrorrhagia: irregular episodes of uterine bleeding. menometrorrhagia: heavy and irregular uterine bleeding. inter menstrual bleeding: scant bleeding at occupation for 1 or 2 days.

early ectopic pregnancy diagnosis is facilitate by - & -?

quantitative hCG testing and TV US discriminatory zone: weeks from LMP 5-6, hcg 1500-2000

common treatment for uncomplicated bacterial cystitis

single dose: ampicillin 2g, amoxicillin 3 g, nitrofurantoin 200 mg. 3 day course: ampicillin 250 QID. amoxicillin 500 TID. trimethoprim 100 BID. 7-10 course: nitrofurantoin 100 mg at bedtime.

Management: surgical and medical, other

surgical: laparotomy if hemodynamically stable. salpingectomy if significant damage to tube. partial salpingectomy: generally is implanted in the mid-ampullary portion. salpingostomy (incision left open), compared to salpingotomy results in better long term tubal function. there is a 10-20% risk for residual trophoblastic tissue whenever the products on contraception are dissecting from the tube. if repeat hCG titers fail to decline, methotrexate can be started. Ambulatory diagnosis and management of women with early, enraptured ectopic= MTX. if the patient becomes more symptomatic or if hCG titters increase during therapy, surgical intervention is required. other: if diagnosed at time of laparoscopy MTX, prostaglandins, or hyperosmolar glucose may be injected into the amniotic sac by salpingocentesis expectant management: reserved for reliable, relatively asymptomatic patients in whom the hCG titers are low enough to make rupture very likely (<200 and declining).

endometriosis surgical treatments (most definitive)

total abdominal hysterectomy, bilateral sapling oophorectomy (TAH-BSO). nearly 25% of kidneys are lost when endometriosis blocks the uterus. fertility preserving: laparoscopic or open surgery with destruction and removal of all adhesions.large endometriomas (>3cm) are amenable only to surgical resection. prep treatment with GnRH against for 3-6 months improves success. there is a risk of recurrence throughout life.

Endometriosis management

treatment is indicated for endometriosis assoc. pelvic pain, dysmenorrhea, dyspareunia, abnormal bleeding, ovarian cycles, and infertility d/t gross distortion of tubal and ovarian anatomy. no evidence treatment significantly improves fertility in women with mild endometriosis.

UTI: uncomplicated, complicated, pylenephritis. risk factors for UTI-premenopausal vs postmenopausal

uncomplicated= non pregnant, first episode or far removed from previous episode. complicated= pregnancy, neurologic or obstructive abnormalities or in those with underlying parenchymal disease. risk factors premenopausal: history of UTIs, frequent or recent sexual activity, diaphragm, spermicidal agents, increase parity, DM, obesity, sickle cell, urinary tract calculi. post: vaginal atrophy, incomplete bladder emptying, poor perineal hygiene, rectocele, cystocele, urethrcele, uterovaginal prolapse, type I DM

Over active bladder: etiology, exam, diagnostics, and management

urgency, with or without urge incontinence, usually with frequency and nocturia. etiology mostly unknown. management starts with behavioral modifications (reducing fluids, avoid fluids during the evening, increasing intervals between voiding, kegal exercises) and physical intervention such was electrical stimulation. identify triggers. self-reported bladder diary. pharm: antimuscarinics, or anticholinergics. mainstays are oxybutynin (ditropan) and detrol.

generally rule for UTI

bacteriuria should be treated, and not pyuria.

diagnosis of endometriosis

definitive diagnosis is generally made by the gross and histologic findings obtains at laparoscopy or laparotomy. BUT should be suspected in afebrile patient with the characteristic triad of pelvic pain, a firm, fixed, tender adnexal mass, and tender modularity in the cul de sac and uterosacral ligaments

endometriosis medical treatment

1. NSAIDs, low dose oral contraceptives, and progestins (medroxyprogesterone). Give first line 3-6 months. 2. GnRH agonist (temporary medical castration), higher dose progestins, or danazol ("pseduomenopause").

DDs for endometriosis

1. chronic PID or recurrent acute salpingitis 2. hemorrhagic corpus lute 3. benign or malignant ovarian neoplasm 4. ectopic pregnancy

AUB and DUB: all women who present with AUB considered --? reproductive tract malignancies? postmenopausal uterine bleeding? infections? other causes?

All women who present with AUB considered pregnant until proven otherwise. Reproductive tract malignancies (endometrial and cervical cancer). Postmenopausal uterine bleeding-ALWAYS abnormal and endometrial cancer needs to be ruled out! Infections may cause irregular spotting. Fibroids, adenomyosis, cervical polyps. Trauma to reproductive tract. Anatomic abnormalities of outflow tract can interfere with normal menstrual flow.

Chronic Pelvic Pain: diagnosed? DD's and management

Chronic Pelvic Pain (CPP)-> 6 months and significant effect on daily function and QOL

ectopic pregnancy: symptoms and clinical diagnosis-classic triad of symptoms? medical emergency? probable ectopic pregnancy? possible ectopic pregnancy?

Classic triad of symptoms: prior missed menses, vaginal bleeding, and lower abdominal pain Acutely ruptured ectopic pregnancy-medical emergency Abdominal pain, dizziness, may have signs of hemodynamic instability Probable ectopic pregnancy-lower pelvic pain, vaginal spotting, bleeding (with or without amenorrhea); abdominal tenderness, CMT Possible ectopic pregnancy-most common presentation-mild and nonspecific symptoms Mild lower abdominal discomfort, amenorrhea (or abnormal LMP), abnormal vaginal bleeding (may be confused as menses

Assessment for DUB

Detailed menstrual and contraception history. Age; age at menarche and menopause; cycle length, duration, estimated amount of flow; when menstrual pattern changed. Contraceptive: type, length of use, side effects. Complete medication history. Physical and pelvic examination (verify the source of bleeding is uterine and not the result of cervical, rectal, vaginal, vulvar, or urethral lesions) Speculum and bimanual examination

Endometriosis: what is it? risk factors? most common occurs in -- areas. symptoms? DD and management

Endometriosis: benign condition in which endometrial glands and stroma are present outside the uterine cavity and walls. 30's, nulliparous, infertile (not all women with endometriosis fit this description) Most commonly occurs in dependent portions of the pelvis, 2/3 of ovarian involvement. Symptoms: triad of dysmenorrhea, dyspareunia (assoc. with deep thrust penetration), and dyschezia (experienced with uterosacral, cul-de-sac and rectosigmoid colon involvement). Also premenstrual and post menstrual spotting.

ectopic pregnancy: estimated to occur in 1 of every --? risk factors? key to successful management?

Estimated to occur in 1 of every 80 spontaneously conceived pregnancies-gestation that implants outside endometrial cavity Risk factors: history of tubal infection, cig smoking, prior ectopic, history of tubal sterilization within the past 1-2 years/higher with cauterization, pregnancy with IUD/depot/or EC, infertility d/t tubal factors, use of assisted reproductive factors. Key to successful management-EARLY DIAGNOSIS

Adenomyosis: what is it? symptoms? pelvic exam? conservative management?

Extension of endometrial glands and stroma into the uterine musculature more than 2.5 mm beneath the basalis layer (may be associated with endometriosis) Many are asymptomatic May have severe secondary dysmenorrhea and menorrhagia Pelvic Exam: symmetrically enlarged, somewhat boggy uterus, may be slightly tender if premenstrual Conservative management: NSAIDs and hormonal control of endometrium. hysterectomy and endometrial ablation to control bleeding is another option.

Ectopic pregnancy diagnostics: fertilized egg rapidly divides and produces --. majority of normal pregnancies show -- of hcg levels every -- hours in the first few weeks of pregnancy. if hcg < --%, the DDs should include - or -. TV ultrasound. discriminatory zone? diagnostic of ectopic pregnancy? if hCG below DZ? serum progesterone?

Fertilized egg rapidly divides and produces hCG Majority of normal pregnancies show doubling of hCG levels every 48 hours in the first few weeks of pregnancy If hCG levels rise less than 53%, the DDs should include an abnormal IUP or an ectopic pregnancy TV US helpful in dx; no IUP identified with adequately high hCG levels-IUP should be visualized by the time the hCG levels reach the 'discriminatory zone' (DZ) DZ: the titer of hCG which an intrauterine sac should reliably be seen with TV US in a normal pregnancy *Abnormally rising hCG level above 2000 with no gestational sac seen on US is diagnostic of ectopic pregnancy However, if hCG is below DZ, an endometrial aspiration with a manual vacuum extractor can be performed. If hCG levels are not changing appropriately and no products of contraception are found on "state" histologic study of the aspirate, the diagnosis of ectopic pregnancy is secure. Serum progesterone levels >25 can reliable indicate a normal IUP

UTI management

UA (a negative gram stain virtually eliminates significant bacteriuria, pyuria->5 WBCs, without significant bacteria may indicate nonbacterial inflammation or urinary tract foreign body or tumor, classic finding in urinary TB, casts indicate renal parenchymal disease), C&S if indicated (E.Coli is predominant organism, three techniques midstream clean catch, urethral cath, suprapubic aspiration) Rest, hydration (dilution of bacterial counts, frequent bladder emptying, reduction of medially osmolality) Acidification of urine (ascorbic acid-500 mg BID, ammonium chloride-12g/day in divided doses, apricot, plum, prune, or cranberry juices. avoid grapefruit and carbonated voices d/t turning urine alkaline Urinary analgesics (Azo, pyridium 100 mg daily for 2-3days)

abnormal and dysfunctional uterine bleeding: amenorrhea, menorrhagia. diagnosis? may or may not be r/t to --? can signal --?

Abnormal uterine bleeding (AUB) common reason women seek health care. Amenorrhea (no menses); menorrhagia (abnormally long or heavy menses). Diagnosis: irregular in amount, frequency, duration, timing. May or may not be related to menstrual cycle. Can signal pathologic, life-threatening conditions (etopic pregnancy or endometrial cancer).

functional hypothalamicamenorrhea: absense of menses d/t --? typical patient? treatment?

Absence of menses due to suppression of HPOA in which no anatomic organic disease is identified. Typical patient Adolescent Underweight Overexercises Experiencing great deal of stress Treatment Weight gain Exercise reduction Stress reduction/counseling may be helpful Offset bone loss

DD's for ectopic pregnancy: gyn vs non-gyn

GYN- Threatened abortion Ruptured corpus luteum cyst Acute PID Degenerating leiomyoma (especially in pregnancy) Non-GYN Acute appendicitis Pyelonephritis Pancreatitis

Goals for treating AUB 4, acute hemorrhage, estrogen therapy

Goals for Treating AUB Normalize bleeding. Correct any anemia. Prevent cancer. Restore quality of life. Concomitant therapy may be necessary. Acute hemorrhage: physician referral; medical management in hospital. Estrogen therapy: stimulates endometrial proliferation; resolves bleeding.

CPP DDs

Gyn causes: endometriosis (size and location does not appear to correlate to pain), PID, uterine myomas (usually do not cause pain unless degenerating, torsion, compression nerves), ovarian pain (retroperitoneal secondary to inflammation or previous surgery and cyst formation), pelvic congestion syndrome (pelvic vein varicosities and congested pelvic organs, menorrhagia and urinary frequency), cyclic pain, myxomata uteri, adenomyosis, adhesion. Genitourinary pelvic pain (urinary retention, urethreal syndrome, trigonitis and interstitial cystitis) GI (penetrating neoplasms, IBS, partial bowel obstruction, diverticulitis, and hernia formation), Neuromuscular pain (chronic low back pain without lower abdominal pain is seldom gyn. etiology) Psychological factors

DUB management: heavy bleeding resulting in --? progestogens? levonoregestrel? gonadotropic releasing hormone agonist?

Heavy bleeding resulting in hemodynamic instability requires hospitalization. Progestogens: treat chronic heavy bleeding due to anovulation. Levonorgestrel-releasing intrauterine system (LNG-IUS): effective therapy for menorrhagia caused by fibroids. Gonadotropin-releasing hormone agonists (GnRHa): not recommended for long-term use.

evidence for practice/special consideration: treatment choice for AUB? special considerations

Treatment of choice for AUB: pharmacologic treatment with combined contraceptives. Special Considerations Adolescents Women with Disabilities Perimenopause Older Women Cultural Factors

criteria for medical management of ectopic pregnancy with methotrexate-absolute, relative, contraindications

absolute: hemodynamic stable without active bleeding. nonlaparoscopic diagnosis, patient desires future fertility, general anesthesia poses significant risk, able to return for follow up, no CI to methotrexate. relative: unruptured mass <3.5 cm, no fetal cardiac motion detected, patient who's hCG does not exceed 6000-15,000. ABSOLUTE: breastfeeding, overt or laboratory evidence of immunodef., alcoholism, alcoholic liver disease, chronic liver disease. pre-existing blood dycrasias, active pulmonary disease, PUD, hepatic, renal, or hematologic dysfunction. Relative CI: gestational sac >3.5, embryonic cardiac motion

UTI terminology: bacteriuria, asymptomatic bacteria, pyelonephritis, chronic pyelonephritis, cystitis, persistence of bacteriuria, superinfection, relapse, reinfection, recurrent UTI is diagnosed when

bacteriuria: presence of bacteria in the urine (significant bacteriuria is generally acceptation as a bacterial colony count of 10^5 or more per milliliter or urine in a clean catch specimen in asymptomatic patient. lower colony counts accepted in symptomatic patients). asymptomatic bacteria: significant bacteriuria with or without pyuria in a patient without symptoms of UTI pyelonephritis: bacterial infection of the renal parenchyma (acute-chills, fever, flank pain, CVT, frequency, urgency, dysuria and chronic- histologic changes) chronic pyelonephritis: not synonymous with chronic UTI cystitis: inflammation of urinary bladder, usually have symptoms of lower UTI, dysuria, urgency, frequency persistence of bacteriuria: presence of microorganisms that were isolated at the start of treatment and continue to be isolated while patient is receiving therapy superinfection: different organisms while the patient is still receiving therapy. the new organism may be a different strain or different serologic type relapse: occurs with the recurrence of significant bacteria with the same species and serologic strain go organism, usually appears within 2-3 weeks of completion of therapy, reinfection: infection occurring after cessation of therapy with different strain, occurs 2-12 weeks after previous episode and indicated recurrent bladder bacteriuria recurrent UTI is diagnosed when two UTIs occur within 6 months or three or more during a single year. women of blood group B or AB have an increased risk for recurrent UTIs

recurrent urinary tract infection

benefit of long term administration (6-18 months) of antimicrobials in women with recurrent UTs. prophylactic therapy should be initiated when the patient has had 2 infection within 6 months because she faces 65% change of another infection within the next 6months. for women who are able to relate the frequently recurring infection to sexual activity, a single dose of an antimicrobial drug immediately after coitus has been shown to prevent bacteriuria and symptomatic infection