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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3230_Библиотеки_им_академика_М_И_Перельмана
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CHAPTER 15 GU signs
372
Ulcers and lumps of the vulva
Some differential diagnoses and typical outline evidence
Vulval warts
(condylomata
acuminata) due
to human
papilloma virus
Suggested by: warts on vulva, perineum, anus, vagina, or
cervix. Florid in pregnancy or if immunosuppressed
Confirmed by: above clinical appearance. Managed
initially by annual cervical smears and observation of
the vulva and anus
Urethral
caruncle caused
by meatal
prolapse
Suggested by: small, red swelling at the urethral orifice.
Tender and pain on micturition
Confirmed by: above clinical appearance
Bartholin’s cyst
and abscess
caused by
blocked duct
Suggested by: extreme pain (cannot sit) and a very
swollen, hot, red labium
Confirmed by: above clinical appearance
Herpes simplex
(herpes type II)
Suggested by: vulva ulcerated and exquisitely painful.
Urinary retention may occur.
Confirmed by: above clinical appearance
Other causes of vulval lumps: local varicose veins; boils; sebaceous cysts;
keratoacanthomata, condylomata, latent syphilis; primary chancre; mol-
luscum contagiosum; abscess; uterine prolapse or polyp; inguinal hernia;
varicocele; carcinoma
Other causes of vulval ulcers: syphilis, herpes simplex, chancroid;
lymphogranuloma venereum; granuloma inguinale; TB, Behçet’s syndrome;
aphthous ulcers; Crohn’s disease
LUMPS IN THE VAGINA1
373
Lumps in the vagina
Some differential diagnoses and typical outline evidence
Cystocele Suggested by: frequency and dysuria. Bulging upper
front wall of the vagina
Confirmed by: cystogram showing residual urine within
the cystocele
Urethrocele Suggested by: stress incontinence (leaks with laughing,
exertion). Bulging of the lower anterior vaginal wall
Confirmed by: micturating cystogram showing displaced
urethra and impaired sphincter mechanisms
Rectocele Suggested by: patient may have to reduce herniation
prior to defecation by putting a finger in the vagina.
Bulging middle posterior wall
Confirmed by: barium enema or MRI scan showing
rectum bulging through weak levator ani
Enterocele Suggested by: bulging of the upper posterior vaginal wall
Confirmed by: barium enema or MRI scan showing
loops of intestine in the pouch of Douglas
Uterine
prolapse
Suggested by: “dragging” or “something coming down,”
is worse by day. Cystitis, frequency, stress
incontinence, and difficulty in defecation
Confirmed by: seeing the cervix well down in the vagina
(first-degree prolapse) or cervix protruding from the
introitus when standing or straining (second degree),
or the uterus lying outside the vagina, which is kerati-
nized, and the cervix ulcerated (third-degree prolapse
or procidentia)
Vaginal
carcinoma
Suggested by: vaginal bleeding. Tumor in the upper
third of the vagina
Confirmed by: squamous cell carcinoma on biopsy
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
CHAPTER 15 GU signs
374
Ulcers and lumps in the cervix
Some differential diagnoses and typical outline evidence
Cervical
ectropion
(“erosion”
innocuous)
Suggested by: red ring of soft glandular tissue around
cervical opening, often found with puberty, combined
contraceptive pill, during pregnancy. May be bleeding,
producing excess mucus or infected
Confirmed by: (in cases of doubt) histology showing
columnar epithelium
Nabothian
cysts
Suggested by: smooth spherical (mucus retention)
Confirmed by: above clinical appearance
Cervical
polyps
Suggested by: increased mucus discharge or postcoital
bleeding. Pedunculated polyp arising from mouth of
cervix
Confirmed by: histology showing pedunculated benign
tumor arising from endocervical junction
Cervicitis
Suggested by: increased mucus discharge or postcoital
bleeding. Very red, swollen cervix with overlying
mucous and blood
Confirmed by: histology being follicular or mucopurulent.
Vesicles in herpes. Culture may produce chlamydia,
gonococci, etc.
Cervical
intraepithelial
neoplasia (CIN)
Suggested by: overlying cervicitis, older age,
smokers, lower socioeconomic background, prolonged
contraceptive pill use, high parity, history of many
sexual partners or a partner having many other partners,
early first coitus, sexually transmitted diseases
Confirmed by: Papanicolaou smear showing degree of
dyskaryosis but no malignancy on cervical biopsy
Cervical
carcinoma
Suggested by: intermenstrual or postcoital bleeding.
Firm or friable mass that bleeds on contact
Confirmed by: Papanicolaou smear showing severe
dyskaryosis and malignancy on cervical biopsy
This page intentionally left blank
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
CHAPTER 15 GU signs
376
Tender or bulky mass (uterus, fallopian
tubes, or ovary) on pelvic examination
Some differential diagnoses and typical outline evidence
Pregnancy Suggested by: amenorrhea in sexually active woman.
Uterus at 6 weeks of pregnancy is like an egg, at 8
weeks like a peach, at 10 weeks it is like a grapefruit,
and at 14 weeks it fills the pelvis
Confirmed by: pregnancy test positive, pregnancy sac
seen on abdominal or transvaginal ultrasound
Ovarian tumor,
benign
functional cysts,
theca-lutein
cysts, epithelial
cell tumors
(serous and
mucinous),
cystadenomas,
mature terato-
mas, fibromas
malignant
cystadenomas,
germ cell or
sex cord
malignancies,
secondaries
from the uterus
or stomach,
Krukenberg
tumors
spreading via
the peritoneum
Suggested by: painless pelvic mass often to one side.
May or may not have amenorrhea
Confirmed by: abdominal or transvaginal ultrasound,
biopsy
Tender or bulky mass on pelvic exami
TENDER OR BULKY MASS ON PELVIC EXAMINATION1
377
Endometritis
(uterine
infection) after
abortion and
childbirth, ICU
insertion, or
surgery. May
involve fallopian
tubes and
ovaries.
Low-grade
infection is
often due to
Chlamydia
Suggested by: lower abdominal pain and fever; uterine
tenderness on bimanual palpation
Confirmed by: transvaginal ultrasound, cervical swabs
and blood cultures
Endometrial
proliferation
due to estrogen
stimulation
Suggested by: heavy menstrual bleeding and irregular
bleeding (dysfunctional uterine bleeding) and polyps
Confirmed by: cystic glandular hyperplasia in specimen
after D&C
Pyometra
(uterus
distended by
pus, associated
with salpingitis
or secondary
to outflow
blockage)
Suggested by: lower abdominal pain and fever; uterine
tenderness on bimanual palpation
Confirmed by: transvaginal ultrasound, cervical swabs
and blood cultures
Hematometra
due to imper-
forate hymen
in the young,
carcinoma,
iatrogenic
cervical stenosis
after cone
biopsy
Suggested by: lower abdominal pain and uterine
tenderness on bimanual palpation
Confirmed by: no evidence of infection. Transvaginal
ultrasound appearance
Endometrial
tuberculosis
(also affects the
Fallopian tubes
with pyosalpinx)
Suggested by: infertility, pelvic pain, amenorrhea,
oligomenorrhea
Confirmed by: transvaginal ultrasound, cervical swabs
and positive smear or cultures for AFB
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CHAPTER 15 GU signs
378
Ectopic
pregnancy
Suggested by: abdominal pain or bleeding in a sexually
active woman. Gradually increasing vaginal bleeding,
shoulder-tip pain (diaphragmatic irritation) and pain on
defecation and passing water (due to pelvic blood).
Sudden severe pain, peritonism, and shock with
rupture
Confirmed by: hCG >6000 IU/L and an intrauterine
gestational sac not seen on pelvic ultrasound or if hCG
1000–1500 IU/L and no sac is seen on transvaginal
ultrasound
Fibroids
(uterine
leiomyomata)
Suggested by: heavy and prolonged periods, infertility,
pain, abdominal swelling, urinary frequency, edema
t
ous
legs and varicose veins, or cause retention of urine
Confirmed by: normal hCG and transvaginal
ultrasound showing discrete lumps in the wall of the
uterus or bulging out to lie under the peritoneum
(subserosal) or under the endometrium (submucosal),
pedunculated
Acute salpingitis
often associated
with endometri-
tis, peritonitis,
abscess, and
chronic
infection
Suggested by: being unwell, with pain, fever, spasm of
lower-abdominal muscles (more comfortable lying on
back with legs flexed). Cervicitis with profuse, puru-
lent, or bloody vaginal discharge. Cervical excitation
and tenderness in the fornices bilaterally but worse on
one side. Symptoms vague in subacute infection
Confirmed by: laparoscopy
Chronic
salpingitis
(unresolved,
unrecognized, or
inadequately
treated acute
salpingitis)
leading to
fibrosis and
adhesions,
pyosalpinx, or
hydrosalpinx
Suggested by: pelvic pain, menorrhagia, secondary
dysmenorrhea, discharge, deep dyspareunia, depres-
sion. Palpable tubal masses, tenderness, and fixed
retroverted uterus
Confirmed by: laparoscopy to differentiate between
infection and endometriosis
This page intentionally left blank
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
CHAPTER 15 GU signs
380
Vaginal discharge
Some differential diagnoses and typical outline evidence
Excessive
normal
secretion
Suggested by: women of reproductive age, milky white
or mucoid discharge
Confirmed by: normal investigations
Bacterial
vaginosis
Suggested by: fishy odor, discharge, itching, irritation
Confirmed by: high vaginal swab, wet saline microscopy
shows presence of cells
Cervical
erosions
(ectropion)
Suggested by: no other obvious symptoms
Confirmed by: speculum examination
Endocervicitis
(gonococcus,
Chlamydia)
Suggested by: symptoms in partner of urethritis
Confirmed by: inflamed cervix on speculum
examination and endocervical swab result
Carcinoma of
cervix
Suggested by: blood-stained discharge, irregular vaginal
bleeding, obstructive uropathy and back pain in late
stage
Confirmed by: cervical smear, cytology, colposcopy with
biopsy
Foreign body Suggested by: blood-stained discharge, use of ring
pessary, IUD, tampon
Confirmed by: speculum examination or colposcopy or
hysteroscopy
Endometrial
polyp
Suggested by: blood-stained discharge, intermenstrual
spotting, postmenstrual staining
Confirmed by: hysteroscopy
VAGINAL DISCHARGE1
381
Trichomonas
vaginitis
Suggested by: profuse greenish yellow, frothy
discharge, dysuria, dyspareunia
Confirmed by: protozoa and WBC on smear
Gonococcal
cervicitis
Suggested by: purulent discharge, lower abdominal pain,
fever, cervix appears red and bleeds easily
Confirmed by: Gram stain of cervical or urethral
exudates shows intracellular gram-negative diplococci
Candida vaginitis Suggested by: purulent discharge, intense pruritus
vulvae
Confirmed by: hyphae or spores on cervical smear
Chlamydia
cervicitis
Suggested by: purulent discharge, lower-abdominal pain,
fever, cervix appears red and bleeds easily
Confirmed by: endocervical swab
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
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