Jasmin Jaber\'s Gynaecology Notes PDF

Preview

Summary

Jasmin Jaber 2015 1. Gynecological History and Examination History Consultation should be held in a closed room Establish initial rapport with the patient and help them feel at ease Patient may bring someone with them to the consultation, but a part of it should be with patient alone Show respect to...

Description

Jasmin Jaber 2015

1. Gynecological History and Examination History - Consultation should be held in a closed room - Establish initial rapport with the patient and help them feel at ease - Patient may bring someone with them to the consultation, but a part of it should be with patient alone - Show respect to religious/cultural views - Use a set template to help direct consultation Examination 1. Abdominal - Patient should empty bladder - Inspection  Abdominal contour  Surgical scars  Dilated veins  Striae gravidarum (stretch marks)  Check for laparoscopy or Pfannenstiel scars  Check for hernias - Palpation  If there is pain, examine that area last  Start at left lower quadrant  right lower quadrant  Check for masses, liver, spleen, kidneys  You cannot palpate below pelvic masses (abdominal/pelvic differentiation) - Percussion  If suspecting free fluid  If recumbent – flank dullness  If lying on side – dullness with shift to lowermost side + fluid thrill - Auscultation 2. Pelvic - Inspection  External genitalia and surrounding skin  Patient should strain down and cough to check for signs of prolapse - Speculum  Bi-valve/Cusco’s  Holds back the anterior and posterior walls of the vagina  Allows visualization of cervix  Sim’s  Used in left lateral position  Allows inspection of the vaginal walls (useful for examining of prolapse) - Bimanual examination  Assess the pelvic organs  1 or 2 fingers are inserted into the vagina, passed upwards and backwards to reach the cervix  Palpate for any irregularity, hardness, tenderness  Press down from outside to palpate the fundus of the uterus and adnexae 3. Rectal - Useful to differentiate between an eneterocele and a rectocele - Palpating uterosacral ligaments - Lesion in the rectovaginal septum

Jasmin Jaber 2015

2. Development of the Genital Organs, Anatomy of the External Genitalia Embryology 1. Development of the blastocyst - Beginning of 4th week after the last menstrual period, composed of the trophoblastic ring, extra-embryonic mesoderm, and amniotic cavity and primary yolk sac (separated by bilaminar embryonic disk) - 12 days after ovulation, extra-embryonic mesoderm contains isolated spaces that form the extra-embryonic coelom - Secondary yolk sac develops from cells in the embryonic disk in primary yolk sac 2. Formation of the placenta - 13-15 days after ovulation, primary chorionic villi develop, along with blood vessels in the extra-embryonic yolk sac - Primary villi are made up of cytotrophoblasts surrounded by syncytiotrophoblasts - Acquire a central mesenchymal core from the extra-embryonic mesoderm  secondary villi - Embryonic blood vessels in mesenchymal core  tertiary villi - Villi of decidua capsularis degenerate  chorion leve; villi of decidua basalis proliferate  chorion frondosum 3. Normal placentation - Blastocyst hatches, trophoectoderm layer attaches to the cell surface of endometrium, early trophoblastic penetration within the endometrial stroma - Entire blastocyst eventually sinks into the maternal decidua, with trophoblastic cells reaching the deciduo-myometrial junction between 8 and 12 weeks of gestation 4. Ovary - At 4-5 weeks of embryonic life, genital ridges form overlying the embryonic kidney (still identical in both sexes) - Primitive gonad formed between 5 and 7 weeks of gestation (becomes an ovary if there are no male determinants) - Granulosa cells from the coelomic epithelium surround germ cells and form primordial follicles, each consisting of an oocyte in a single layer of granulosa cells - Theca cells developing from coelomic epithelium are separated from granulosa cells by a basal lamina - Oocyte development is arrested at the prophase of its first meiotic division and remains so until it regresses or enters the meiotic process before ovulation 5. Uterus and vagina - At the 5th week of embryonic life, the nephrogenic duct develops from the mesoderm and forms the urogenital ridge and mesonephric duct - Mesonephric (Wolffian) duct develops under testosterone influence into the vas deferens, epididymis, and seminal vesicle, but regresses in the female fetus - Female reproductive tracts develop from the paramesonephric (Mullerian) ducts; they distally fuse in the midline to form the uterus, cervix, and proximal 2 3 of the vagina and the unfused ends form the Fallopian tubes. The sinovaginal bulbs in the upper portion of the urogenital sinus form the distal vagina 6. External genitalia - Between 5th and 7th weeks of life, the cloacal folds fuse anteriorly to form the genital tubercle (becomes the clitoris) - Perineum develops and divides the cloacal membrane into a urogenital membrane (anterior) and anal membrane (posterior) - Anterior cloacal folds form the labia minora; the labioscrotal folds within the cloacal membrane form the labia majora - Urogenital sinus  vestibule of vagina 7. Ultrasound imaging - First sonographic evidence of pregnancy is the gestational sac (deciduo-placental interface and chorionic cavity); visualized at around 32-34 days after the onset of the last menstruation

Jasmin Jaber 2015

-

First embryonic structure visible in the chorionic cavity is the secondary yolk sac (excludes possibility of pseudosac or ectopic pregnancy) 8. Symptomatology - Classical triad of pregnancy disorder: amenorrhea, pelvic/low abdominal pain, vaginal bleeding - hCG detection in the urine Anatomy - External genitalia (vulva)  Includes mons pubis, labia majora and minora, vaginal vestibule, clitoris, and greater vestibular glands  The labia majora contain sebaceous and sweat glands, and specialized apocrine glands; internally each labium contains fatty tissue continuous with the inguinal canal (where the fibers of the round ligament terminate)  The labia minora divide anteriorly to form the prepuce and frenulum of the clitoris, and posteriorly to form the fourchette (fold of skin at the back of the vaginal opening)  The clitoris is an erectile structure (0.5-3.5 cm in length); the body is made of paired columns of erectile and vascular tissue (corpora cavernosa)  The vestibule (containing the urethra, Bartholin’s glands, and the vagina) is the cleft between the labia minora  The hymen is a thin mucous membrane covering the entrance to the vagina; usually perforated to allow menstruation, ruptured during intercourse (remaining tags are called ‘carunculae myrtiformes’)

Jasmin Jaber 2015

3. Anatomy of the Internal Reproductive Organs and the Female Pelvis Vagina: - Fibromuscular canal lined with stratified squamous epithelium leading from the uterus to the vulva - Posterior wall (9 cm) is longer than the anterior wall (7 cm) - The vault of the vagina is divided into: anterior, posterior, and 2 lateral fornices - No glands; kept moist by secretions from the uterine and cervical glands and transduation from the epithelial lining - Epithelium is rich in glycogen (not before menopause or after puberty); glycogen is degraded to lactic acid by Doderlein’s bacillus  produces pH of 4.5 - The upper posterior wall forms the anterior peritoneal reflection of the pouch of douglas - Anteriorly, the vagina is in direct contact with the base of the bladder, and the urethra runs down the lower half in the midline and opens into the vestibule - Laterally, the vagina is related to the cardinal ligaments, with the levator ani muscles and ischiorectal fossae below Uterus

-

Situated entirely in the pelvis in the non-pregnant state External dimensions: 7.5 cm long, 5 cm wide, and 3 cm thick; weighs 70 g The upper part is termed ‘corpus’; the area of insertion of the Fallopian tubes is the ‘cornu’; the part of the body above the cornu is the ‘fundus’; the uterus tapers into the isthmus, below which is the cervix Consists of 3 layers: the serous layer (peritoneum), the muscular layer (myometrium), and the mucous layer (endometrium) The endometrial layer has tubular glands that dip into the myometrium and is covered by a single layer of columnar epithelium; varies in thickness between 1 and 5 mm (cyclical)

Cervix

-

Narrower than the body of the uterus; about 2.5 cm in length Upper part is mostly made of involuntary muscles, and the lower part is made of fibrous connective tissue The endocervix has anterior and posterior columns with folds radiating out (arbor vitae); has deep glandular follicles that secrete alkaline mucous Epithelium is columnar and ciliated in the upper 23 , which changes to stratified squamous epithelium at the external os (at the squamocolumnar junction) Approximately 90% of cervical cancers arise at the squamocolumnar junction

Fallopian Tubes - Extend from the uterine cornu to the ovary; opens into the peritoneal cavity at the abdominal ostium - Each tube is about 10 cm long and is made of four parts:  Interstitial portion – within the uterine wall  Isthmus – narrow portion passing into the ampulla  Ampulla – the widest part  Infundibulum or fimbrial portion – covered by ciliated epithelium, one fimbria is longer and extends to the ovary Ovaries - Increase to adult size during puberty, measuring about 3 cm long, 1.5 cm wide, and 1 cm thick - The only intra-abdominal structure not covered by peritoneum - Each ovary is attached to the cornu of uterus by the ovarian ligament and at the hilum to the broad ligament by the mesovarium - Surface of the ovaries is covered by a single layer of cuboidal cells (germinal epithelium)

Jasmin Jaber 2015

-

Beneath that is the tunica albuginea – increases in density with age

Bladder, Urethra, and Ureter - Bladder wall is made of involuntary muscle arranged in an inner longitudinal layer, middle circular layer, and an outer longitudinal later; it is lined by transitional epithelium and has an average capacity of 400 mL - Ureters open into the base of the bladder - Urethra leaves the bladder in front of the ureteric orifices - Trigone is between the ureteric orifices and internal meatus of the ureter - The female urethra is about 3.5 cm long and lined by transitional epithelium; lined by an outer longitudinal layer and inner circular layer - The urethra is separated from the symphysis in the upper 23 by loose connective tissue (mobile), and attached in the lower third to the pubic ramus by ‘pubourethral tissue’ (fixed) - The ureter is in front of the bifurcation of the common iliac artery, and supplied by branches of the ovarian, uterine, and vesical arteries. - The ureter can be damaged in hysterectomy by being cut or tied, and may undergo necrosis if the blood supply is compromised The Pelvic muscles, Ligaments, and Fascia - The pelvic diaphragm is formed by two levator ani muscles, which arise from the lower part of the body of the os pubis, the internal surface of the parietal pelvic fascia, and the pelvic surface of the ischial spine - The muscles insert into: the preanal raphe and central point of the perineum, the wall of the anal canal, the postanal/anococcygeal raphe, and the lower part of the coccyx - There are 2 parts to the muscle – the pubococcygeus (arising from the pubic bone) and iliococcygeus (arising from the ischial spine and tendinous arch) - Supplied by nerves from the 3rd and 4th sacral nerves - The urogenital diaphragm (triangular ligament) is composed of 2 layers of pelvic fascia; the deep transverse perineal muscles lie between the 2 layers and the diaphragm is pierced by the urethra and vagina The Perineal Body - A mass of muscular tissue lying between the anal canal and lower third of the vagina - The point of insertion of the superficial perineal muscles; bound above by the levator ani muscles - The apex is at the lower end of the rectovaginal septum and the base is covered with skin and extends from the fourchette to the anus The Pelvic Peritoneum - Reflected from the lateral borders of the uterus to form the broad ligament (Fallopian tube runs in the upper edge of the broad ligament) - The portion of the broad ligament above the ovary is the mesosalpinx, and below the ovary the base widens out to contain loose connective tisse (called the parametrium) - The ovary is attached to the posterior layer of the broad ligament by the mesovarium (contains the ovarian vessels and nerves) The Ovarian Ligament and Round Ligament - The ovarian ligament is beneath the posterior layer of the broad ligament, passing from the ovary to the uterus below the point of entry of the Fallopian tube - The round ligament is its continuation, running under the anterior leaf of peritoneum to enter the inguinal canal and ending in the subcutaneous tissue of the labium majore The Pelvic Fascia and Pelvic Cellular Tissue - Most of the spaces between pelvic organs are filled by loose and dense connective tissue; the pelvic arteries, veins, lymphatics, nerves, and ureters run through it.

Jasmin Jaber 2015

-

Above, the tissue is continuous with the extraperitoneal tissue of the abdominal wall, but below it’s cut off from the ischiorectal fossa by the pelvic fascia and levator ani muscles The parietal pelvic fascia lines the wall of the pelvic cavity covering the obturator and pyrmidalis muscles; where it encounters bone, it blends with the periosteum; it also forms the upper part of the urogenital diaphragm (triangular ligament) All viscera have a fascial sheath – it’s dense in the case of the vagina and cervix, but thinner over the body of the uterus and dome of the bladder The cardinal (transverse cervical) ligaments provide the essential support of the uterus and vaginal vault; these are fan-shaped bands passing from the cervix and vaginal vault to the side walls of the pelvis The uterosacral ligaments run from the cervix and vaginal vault to the sacrum; they support the cervix The bladder is supported by condensation of the vesical pelvic fascia laterally, and a sheet of pubocervical fascia lying beneath it anteriorly

Blood Supply - Pelvic organs:  The ovarian artery arises from the aorta; it supplies the ovary and tube, then anastomoses with terminal branches of the uterine artery

-

Internal iliac (hypogastric) artery:  About 4 cm long, begins at the bifurcation of the common iliac artery and divides in to an anterior and posterior branch  The uterine artery provides the main supply to the uterus, a branch to the ureter, and another branch to the cervix and upper vagina  The vaginal artery supplies the vagina; the vesical arteries supply the bladder and terminal ureter – the middle rectal artery usually arises with the lower vesical artery  The pudendal artery gives off the inferior rectal artery, terminating in branches supplying the perineal and vulval arteries

-

Superior rectal artery:  Continuation of the inferior mesenteric artery; divides into 2 branches running on either side of the rectum

-

Pelvic veins:  Surround the bladder, uterus, vagina, and rectum and form intercommunicating plexuses  Venous drainage from the uterine, vaginal, and vesical plexus is mainly into the internal iliac veins; drainage from the rectal plexus is by the superior rectal veins to the inferior mesenteric veins; the middle and inferior rectal veins drain through the internal pudendal veins to the iliac veins  The ovarian veins begin in the pampiniform plexus between the layers of the broad ligament; they begin as 2 veins on each side, the right vein ends in the inferior vena cava and the left in the left renal vein

Pelvic Lymphatics - All lymphatic drainage is filtered through the inguinal and superficial femoral nodes, laterally forming the external iliac, common iliac, and para-aortic groups of nodes, while medially the vessels pass from the deep femoral nodes through the femoral canal to the obturator and internal iliac groups of nodes - From the internal and common iliac nodes, afferent vessels pass up the para-aortic chains to flow into the lumbar lymphatic trunks and cisterna chyli  thoracic duct - The vulva and perineum medial to the labiocrural skin folds contain superficial lymphatics which pass to the superficial and inguinal nodes. These drain into the deep femoral nodes (the largest is the node of Cloquet)

Jasmin Jaber 2015

-

Lymphatics from the lower third of the vagina follow the vulval drainage to the superficial lymph nodes, and those from the upper two-thirds join the lymphatic vessels of the cervix From the cervix, lymphatics pass either laterally in the base of the broad ligament or posteriorly along the uterosacral ligaments, mostly draining to the obturator, internal and external iliac nodes; these are joined by lymphatics from the body of the uterus The ovary and Fallopian tube have a venous plexus which drains to the para-aortic nodes The bladder and upper urethra lymphatics drain to the iliac nodes, and those of the lower urethra follow those of the vulva From the lower anal canal, lymphatics drain to the superficial inguinal nodes

Nerve Supply - Vulva and perineum  Pudendal nerve arises from 2nd, 3rd, and 4th sacral nerves, gives off inferior rectal branch, and divides into the perineal nerve and dorsal nerve of the clitoris (sensory)  The perineal nerve supplies the vulva, anterior part of the external anal canal, levator ani and the superficial perineal muscles  The posterior femoral cutaneous nerve carries sensation from the perineum to the small sciatic nerve  1st, 2nd, and 3rd sacral nerves  Levator ani muscles main nerve supply is from the 3rd and 4th sacral nerves

-

Pelvic viscera  All pelvic viscera receive dual innervations (sympathetic and parasympathetic)  Fibers from the preaortic plexus of the SNS are continuous with fibers of the superior hypogastric plexus  divides and is continuous with fibers joining the uterovaginal plexus (inferior hypogastric plexus)  Parasympathetic fibers from the 2nd, 3rd, and 4th sacral nerves join the uterovaginal plexus, as well as fibers to the uterus, bladder, vagina, and rectum  The ovaries are supplied by the ovarian plexus (joins the preaortic plexus)

Jasmin Jaber 2015

4. Sexual Differentiation, Disorders of Sexual Development Sexual Differentiation - Controlled by the sex chromosome - All fetuses shave an undifferentiated gonad as well as Mullerian and Wolffian ducts - Male:  The SRY gene causes the gonad to begin development into a testis  Sertoli cells produce AMH (Anti-Mullerian Hormone) and Leydig cells produce testosterone  Testosterone stimulates the Wolffian ducts to develop into the vas deferens, epididymis, and seminal vesicles  5-alpha-reductase converts testosterone into dihydrotestosterone which virilizes the external genitalia  Genital tubercle  penis; labioscrotal folds fuse  scrotum; urogenital folds fuse and include the urethra - Female:  Absence of AMH allows Mullerian structures to develop  Proximal 2 3 of the vagina develop from the paired Mullerian ducts, which form bilateral Fallopian tubes and fuse in the midline to produce the uterus, cervix, and upper vagina  The distal rudimentary vagina fuses with the posterior urethra to form the urogenital sinus, and the vagina develops from a combination of the Mullerian tubercles and the urogenital sinus  Cells from the upper portion of the urogenital sinus proliferate and form the sinovaginal bulbs which then fuse to form vaginal plate  canalizes from the hymen and up to the cervix  No virilization occurs, the genital tubercle becomes the clitoris, and the labioscrotal swellings form the labia Disorders of Sexual Development - Chromosomal abnormalities:  Turner syndrome  Most common female chromosomal anomaly  Complete/partial absence of one X chromosome (45XO);  Features short stature, neck webbing, wide carrying angle  Associated with coarctation of the aorta, IBD, sensorineural and conduction deafness, renal anomalies, endocrine dysfunction (i.e. AI thyroid disease)  Ovary doesn’t complete development, only the stroma is present  ‘streak gonads’ do not produce estrogen or oocytes  Diagnosed early in childhood or at birth  XY gonadal dysgenesis  XY karyotype, but gonads do not develop into a testis (ph...