Medical Instructor, Michigan State University College of Osteopathic Medicine
Many experts now believe the primary de ect leading to prolapse is loss o support at the vaginal apex treatment naive definition purchase generic topamax. This allows the apical portions o the anterior and posterior vaginal walls to descend pretreatment purchase topamax online from canada. As such medicine over the counter cheap topamax 100mg on-line, resuspension o the vaginal apex will restore support to both the anterior and posterior walls treatment esophageal cancer buy generic topamax on-line. The adventitia, which is typically seen deep to muscularis, is not shown in this section. Additionally, abnormal synthesis or degradation o vaginal wall collagen and elastin bers appears to contribute to prolapse. The Defect T eory of Pelvic Organ Prolapse this theory states that tears in di erent sites o the "endopelvic ascia" surrounding the vaginal wall allow herniation o the pelvic organs. Speci cally, attenuation o the vaginal wall without loss o ascial attachments is called a distention cystocele or rectocele. With distention-type prolapse, the vaginal wall appears smooth and without rugae, due to abdominal contents pressed against the vagina rom within. In contrast, anterior and posterior wall de ects due to loss o the connective tissue the vagina is a bromuscular, attened, cylindrical tube with three levels o support, as described by DeLancey (1992). De ects in each level o support result in identi able vaginal wall prolapse: apical, anterior, and posterior. Level I support consists o the cardinal and uterosacral ligaments attachment to the cervix and upper vagina. The cardinal ligaments an out laterally and attach to the parietal ascia o the obturator internus and piri ormis muscles, the anterior border o the greater sciatic oramen, and the ischial spines. The uterosacral ligaments are posterior bers that attach to the presacral region at the level o S2 through S4. It allows the vagina to be supported by the levator plate and positions the cervix just superior to the level o the ischial spines. This is requently associated with small bowel herniation into the vaginal wall, that is, enterocele. Rugae are present, which indicates that loss of support is lateral rather than central. Pelvic Organ Prolapse lateral vagina anteriorly to the arcus tendineus ascia pelvis and posteriorly to the arcus tendineus rectovaginalis. Detachment o this connective tissue rom the arcus tendineus ascia pelvis leads to lateral or paravaginal anterior vaginal wall prolapse. The perineal body is essential or distal vaginal support and proper unction o the anal canal. Prolapse rarely creates severe morbidity or mortality, however, it can greatly diminish quality o li. T us, initial evaluation must include a care ul assessment o prolapserelated symptoms and their e ect on activities o daily living. Symptoms Associated with Pelvic Organ Prolapse Symptoms Bulge symptoms Sensation of vaginal bulging or protrusion Seeing or feeling a vaginal or perineal bulge Pelvic or vaginal pressure Heaviness in pelvis or vagina Urinary symptoms Urinary incontinence Urinary frequency Urinary urgency Weak or prolonged urinary stream Hesitancy Feeling of incomplete emptying Manual reduction of prolapse to start or complete voiding Position change to start or complete voiding Bowel symptoms Incontinence of flatus or liquid/solid stool Feeling of incomplete emptying Hard straining to defecate Urgency to defecate Digital evacuation to complete defecation Splinting vagina or perineum to start or complete defecation Feeling of blockage or obstruction during defecation Sexual symptoms Dyspareunia Decreased lubrication Decreased sensation Decreased arousal or orgasm Pain Pain in vagina, bladder, or rectum Pelvic pain Low back pain Other Possible Causes Rectal prolapse V ulvar or vaginal cyst/mass Pelvic mass Hernia (inguinal or femoral) Urethral sphincter incompetence Detrusor overactivity Hypoactive detrusor function Bladder outlet obstruction. Symptoms are care ully reviewed to determine i they are caused by the prolapse or by other etiologies. Other symptoms, such as back pain, constipation, and abdominal discom ort, may coexist with prolapse but not result rom it. These are typi ed by eeling or seeing a vaginal or perineal protrusion, and the sensation o pelvic pressure. Women may comment on eeling a ball in the vagina, sitting on a weight, or noting a bulge rubbing against their clothes. Speci cally, women with prolapse beyond the hymen are more likely to report a vaginal bulge and have more symptoms than those with prolapse that stops above the hymen (Bradley, 2005; an, 2005; Weber, 2001a). I bulge symptoms are the primary complaint, successul replacement o the prolapse with nonsurgical or surgical therapy will usually provide adequate symptom relie. For example, irritative bladder symptoms (requency, urgency, and urgency urinary incontinence) may not improve with prolapse replacement. In contrast, urinary retention has been ound to improve with prolapse treatment i the symptom is due to an obstructed urethra (FitzGerald, 2000). For these reasons, urodynamic testing is a valuable adjunct in women with urinary symptoms who are undergoing treatment o prolapse (Chap. Additionally, consideration may also be given to temporarily placing a pessary prior to surgery to determine i urinary symptoms improve. T us, surgical repair or treatment with a pessary will not usually cure constipation and may actually worsen it. In one study o de ect-directed posterior repair, constipation resolved postoperatively in only 43 percent o patients (Kenton, 1999). Constipation should be viewed as a problem distinct rom prolapse and evaluated separately. Digital decompression o the posterior vaginal wall, the perineal body, or the distal rectum to evacuate the rectum is the most common de ecatory symptom associated with posterior vaginal wall prolapse (Burrows, 2004; Ellerkmann, 2001). Surgical approaches to this problem provide variable success, and symptom resolution rates range rom 36 to 70 percent (Cundi, 2004; Kenton, 1999). On occasion, prolapse may lead to stool trapping in the distal rectum with subsequent leakage o liquid stool around retained eces. Do you usually feel you have not completely emptied your bowels at the end of bowel movement 3. Do you usually experience a strong sense of urgency and have to rush to the bathroom to have a bowel movement 8.
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The typical "mature woman" is aged 40 years or older and has completed childbearing symptoms vomiting diarrhea discount topamax 200 mg on line. Detailed in Chapter 21 treatment zoster ophthalmicus buy topamax 200mg without a prescription, this period o physiologic change due to ovarian senescence and estrogen decline is usually completed between ages 51 and 56 medicine keppra buy generic topamax canada. Menopause marks a de ning point in this transition and is de ned as the point in time o permanent menstruation cessation due to loss o ovarian unction mueller sports medicine purchase genuine topamax online. Clinically, the menopause re ers to a point in time that ollows 1 year a ter cessation o menstruation. Some lead to physical symptoms, such as vasomotor symptoms and vaginal dryness, whereas others are metabolic and structural changes. These include bone loss, skin thinning, atty replacement o the breast, lipoprotein changes, and genitourinary atrophy. As a result, postmenopausal women have unique issues associated with aging and estrogen loss that may negatively a ect their individual health. For many years, menopause was seen as a "de ciency disease" o estrogen, progesterone, and testosterone. For this reason, hormone replacement therapy has been used in one orm or another or more than 100 years. The history surrounding this treatment is discussed here, as are current recommendations or the treatment o menopausal symptoms. Current thinking is that that these early nonrandomized, unblinded, observational studies included samples o women who were not necessarily representative o the entire postmenopausal population. These hormone users tended to have superior access to care and to be thinner, wealthier, and healthier (Grodstein, 2003; Prentice, 2006). An additional source o con ounding and possible selection bias is suggested to be the timing o H initiation relative to the underlying state o the vasculature. Some investigators suggest that estrogen may delay the onset o the earliest stages o atherosclerosis, which are more likely to be present in younger women. However, estrogen may be ine ective or even trigger events in advanced lesions that are ound in older women (Mendelsohn, 2005). This potential "window o opportunity" is supported by animal and laboratory studies (Grodstein, 2003). In sum, these study biases may have contributed to avorable outcomes attributed to estrogen in observational trials. These women received estrogen as secondary prevention or urther cardiac disease progression. This major study was to evaluate the putative protective e ects o H on common chronic diseases o aging. This design dictated that i the incidence o an end point was exceeded within a given period, the study would be terminated. Moreover, combined end points were weighted into a "global index," which i exceeded, would result in study termination. This preceded journal publication o the data and timely education o health care providers. Chaos ensued while physicians and patients evaluated research acts and be ore recommendations could be made. This translated into 188 actual cases in the hormone group and 147 in the placebo group (Anderson, 2004). However, there were no signi cant di erences in coronary revascularization, hospitalization or angina, con rmed angina, acute coronary syndrome, or congestive heart ailure. Primary outcomes studied in the 875 women evaluated during 3 years included measurement o systolic blood pressure and o serum lipid, insulin, and brinogen levels. Fibrinogen levels were increased in the placebo group compared with groups given hormones. However, no di erences were identi ed in systolic blood pressure or glucose-challenged insulin levels. In evaluating data by age, lower risk was ound or young women and higher risk or older patients. Although this was the principal analysis conclusion, the results led providers and patients to limited H use, even or healthy women with bothersome vasomotor symptoms during menopausal transition. Analyzing data collected rom this study, Vickers and coworkers (2007) ound that H increases cardiovascular and thromboembolic risk when started many years a ter the menopause. With this background in mind, data rom no single trial can be extrapolated to all women. A metaanalysis by Salpeter and associates (2004) pooled data rom 26,708 participants to reveal that the mortality rate associated with H was 0. O note, H reduced mortality rates in women younger than 60 years but not in women older than 60. Moreover, the incidence o cardiovascular events can potentially increase in older groups due to an increased risk or blood clots. Similarly, Rossouw and colleagues (2007) showed a nonsigni cant tendency or the e ects o H on mortality rates to be more avorable in younger than older women. Current guidelines recommend reevaluation o the need or H at 6- to 12-month intervals. Accordingly, bone-speci c agents would likely be more appropriate in women requiring long-term osteoporosis prevention or treatment. For women with a uterus, a progestin is combined with an estrogen to lower risks o endometrial cancer.
Vague pelvic symptoms are common during adolescence due to initiation o ovulation and menstrual cramping treatment pink eye order 200mg topamax free shipping. Moreover symptoms ulcerative colitis purchase generic topamax online, girls may be silent about changes to their normal pattern symptoms xanax addiction buy line topamax, ear ul o their signi cance symptoms 2 days after ovulation purchase topamax 100mg mastercard. Most young women with these tumors are nulligravidas with normal periods, but as discussed later, dysgenetic gonads is a known risk actor or development o these tumors (Brown, 2014b). There ore, adolescents who present with pelvic masses and delayed menarche should be evaluated or gonadal dysgenesis (Chap. The mature cystic teratoma, also called dermoid cyst, is by ar the most common subtype. This accounts or 95 percent o all germ cell tumors, is clinically benign, and discussed in Chapter 9 (p. In contrast, malignant germ cell tumors compose 2 to 3 percent o malignant ovarian cancers in Western countries and include dysgerminoma, yolk sac tumor, immature teratoma, and other less common types. T ree eatures distinguish malignant germ cell tumors rom epithelial ovarian cancers. First, individuals typically present at a younger age, usually in their teens or early 20s. T ird, prognosis is excellent- even or those with advanced disease-due to exquisite tumor chemosensitivity. Fertility-sparing surgery is the primary treatment or women seeking uture pregnancy, although most will require postoperative chemotherapy. Imaging Early symptoms can be misinterpreted as those o pregnancy, and acute pain may be con used with appendicitis. In most cases, sonography can adequately display those qualities that typically characterize benign and malignant ovarian masses (Chap. Once these hypoechoic smooth-walled cysts are identi ed by sonography, they may be observed. Mature cystic teratomas (dermoid cysts) usually display characteristic eatures when imaged with sonography or computed tomography (C) (Chap. In contrast, the appearance o malignant germ cell tumors dif ers, and a multilobulated complex ovarian mass is typical. Moreover, prominent blood ow in the brovascular septa may be seen using color ow Doppler sonography and suggests the likelihood o malignancy (Kim, 1995). Chest radiography is warranted upon diagnosis to search or tumor metastases in the lungs or mediastinum. Distinguishing physical ndings are typically lacking in individuals with malignant germ cell tumors. In children and adolescents, however, completing a comprehensive pelvic or transvaginal sonographic examination can be di cult and can lead to diagnostic delay. Accordingly, premenarchal patients may require examination under anesthesia to adequately assess a suspected adnexal tumor. The remainder o the physical examination searches or signs o ascites, pleural ef usion, and organomegaly. Alternatively, the appropriate tumor markers may be ordered in the operating room i the diagnosis was not previously suspected (Table 36-1). The surgeon should request a rozen section analysis to con rm the diagnosis, but discrepancies between rozen section interpretations and the nal para n histology are commonplace (Kusamura, 2000). In addition, speci c immunostaining is o ten required to resolve equivocal cases (Cheng, 2004; Ramalingam, 2004; Ulbright, 2005). In contrast, a sonographically or C -guided percutaneous biopsy has a very limited role in the management o select patients with an ovarian mass suspicious or malignancy. Role of the Generalist Most patients will initially be seen by a generalist gynecologist. Initial symptoms may point to the more common unctional 6 3 R E T P A H C 762 Gynecologic Oncology ovarian cyst. Persistent symptoms or an enlarging pelvic mass, however, should prompt sonographic evaluation. I a specialist is unavailable or the diagnosis is not anticipated be orehand, intraoperative decision making is crucial to adequately treat the patient without compromising uture ertility. Peritoneal washings are obtained and set aside be ore proceeding with dissection o any suspicious adnexal mass. Initially, the decision to per orm cystectomy or oophorectomy depends on the clinical circumstances (Chap. In general, the entire adnexa should be removed once a malignant ovarian germ cell tumor is diagnosed. A generalist gynecologist should request intraoperative assistance with staging rom a gynecologic oncologist or re er the patient postoperatively i a specialist is not immediately available. Palpation o the omentum and upper abdomen and inspection o the pelvis-especially the contralateral ovary-is easy to per orm and document. Histogenesis Primitive germ cells migrate rom the wall o the yolk sac to the gonadal ridge. Rarely, these tumors may develop primarily in extragonadal sites such as the central nervous system, mediastinum, or retroperitoneum (Hsu, 2002). Dysgerminomas are primitive neoplasms that do not have the potential or urther dif erentiation. Embryonal carcinomas are composed o multipotential cells that are capable o urther dif erentiation. This lesion is the precursor o several other types o extraembryonic (yolk sac tumor, choriocarcinoma) or embryonic (teratoma) germ cell tumors. The process o dif erentiation is dynamic, and the resulting neoplasms may be composed o dif erent elements that show various stages o development (eilum, 1965). These tumors are composed o several histologically dif erent tumor types derived rom primordial germ cells o the embryonic gonad.
Diseases
Oculocerebral hypopigmentation syndrome type Preus
Infant respiratory distress syndrome
Laparoschisis
Ectrodactyly recessive form
ZAP70 deficiency
Mental retardation spasticity ectrodactyly
Hyperparathyroidism
Daish Hardman Lamont syndrome
T us medicine articles buy topamax 100mg free shipping, serial serum measurements can be use ul marker to monitor disease postoperatively medicine information buy topamax 100mg with amex. The microscopic appearance may be predominantly solid medications with aspirin purchase topamax online now, cystic kerafill keratin treatment purchase 100 mg topamax amex, tubular, or papillary. Endometrial clear cell adenocarcinomas are similar to those arising in the ovary, vagina, and cervix. It is these architectural forms, with the associated disappearance of intervening stroma, that distinguish well-differentiated endometrioid adenocarcinoma from complex hyperplasia. Black arrows demarcate multiple low-density areas in the liver that are consistent with metastases, and ascites (curved, white arrows) surrounding the liver. A more caudal image reveals omental caking (white arrows), surrounded by massive ascites (curved, white arrows). Psammoma bodies, which are concentrically laminated calcifications (arrow), may be present. They have high-grade nuclear features including relatively large, pleomorphic nuclei; prominent nucleoli; and frequent, abnormal mitoses. Patients are o ten diagnosed with advanced disease and have a poor prognosis (Hamilton, 2006). One to 2 percent o endometrial cancers have a mucinous appearance that orms more than hal o the tumor. However, many endometrioid adenocarcinomas will have this as a ocal component (Ross, 1983). Since endocervical epithelium merges with the lower uterine segment, the main diagnostic dilemma is 3 3 R E T P A h C 712 Gynecologic Oncology Undif erentiated carcinoma lacks architectural di erentiation and is characterized by medium-sized, monotonous epithelial cells growing in solid sheets without a pattern (Silva, 2007). Overall, the prognosis is worse than in patients with poorly di erentiated endometrioid adenocarcinomas (Altrabulsi, 2005). O rare histologic types, ewer than 100 cases o squamous cell carcinoma o the endometrium have been reported. Diagnosis requires exclusion o an adenocarcinoma component and no connection with the squamous epithelium o the cervix (Varras, 2002). Transitional cell carcinoma o the endometrium is also rare, and metastatic disease rom the bladder or ovary must be excluded during diagnosis (Ahluwalia, 2006). Cells are arranged in papillae, sheets, tubulocystic structures, or most often, some combination of these. Except or serous and clear cell histology, the combination o other types usually has no clinical signi cance. Endometrial cancers have several di erent potential ways to spread beyond the uterus (Morrow, 1991). In general, the various patterns o spread are interrelated and o ten develop simultaneously. Invasion o the endometrial stroma and exophytic expansion within the uterine cavity ollows initial growth o an early cancer. Over time, the tumor invades the myometrium and may ultimately per orate the serosa (Table 33-7). Advanced regional growth may lead to direct invasion into adjacent pelvic structures, including the bladder, large bowel, vagina, and broad ligament. Lymphatic channel invasion and metastasis to the pelvic and paraaortic nodal chains can ollow tumor penetration o the myometrium (Table 33-8). The lymphatic network draining the uterus is complex, and patients can have metastases to any single nodal group or combination o groups (Burke, 1996). Tumor cells form sheets and cribriform structures (asterisks), which in this example contain bluish mucin and numerous neutrophils. Correlation of Histologic Grade and Depth of Myometrial Invasion with Risk of Nodal Metastases Pelvic Lymph Nodes Myometrial Invasion None 50% > 50% G1 1% 2% 11% G2 7% 6% 21% G3 16% 10% 37% Paraaortic Lymph Nodes G1 < 1% < 1% 2% G2 2% 2% 6% G3 5% 4% 13% 713 G = histologic grade. Hematogenous dissemination most commonly results in metastases to the lung and less commonly to the liver, brain, bone, and other sites. Deep myometrial invasion is the strongest predictor o this pattern o spread (Mariani, 2001a). Retrograde transtubal transport o ex oliated endometrial cancer cells carries malignant cells to the peritoneal cavity. Most types o endometrial cancer cells ound in the peritoneal cavity disappear within a short time and have low malignant potential (Hirai, 2001). Alternatively, in the presence o other high-risk eatures, such as adnexal metastases or serous histology, widespread intraabdominal disease may result. Similarly, cancer dissemination ollowing specimen morcellation has been reported (Graebe, 2015). For optimal patient management, the histopathologic description o the preoperative biopsy ndings is care ully reviewed. Only a ew circumstances contraindicate primary surgery and include a desire to preserve ertility, massive obesity, high operative risk, and clinically unresectable disease. In general, an extra ascial hysterectomy, also known as type I or simple hysterectomy, is su cient. Retrieval o ascitic uid is an acceptable alternative, but ascites is in requently encountered. Next, a thorough intraabdominal and pelvic exploration is per ormed, and suspicious lesions are biopsied or excised.
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