Table II-3-1. Management of Vulvar Carcinoma
| Radical vulvectomy | Removes entire vulva | Sexual dysfunction |
| (subcutaneous and fatty tissue, | ||
| labia minora and majora, | ||
| perineal skin, clitoris) | ||
| Modified radical | Wide local excision | Less sexual morbidity |
| vulvectomy | (for unilateral labial lesions | |
| that do not cross the midline) | ||
| Lymphadenectomy | Inguinal node dissection | Lower-extremity edema |
| (bilateral if midline lesions | ||
| >1 mm invasion; unilateral | ||
| selectively) | ||
Benign Vulvar Lesions
• Mulluscom contagiosum. A common benign, viral skin infection. Most commonlyseen in children, sexually active adults, and immunodeficient patients. The mollusci-pox virus causes spontaneously regressing, umbilicated tumors of the skin rather than poxlike vesicular lesions. Mulluscom contagiosum is transmitted primarily through direct skin contact with an infected individual. Management includes observation, curettage, and cryotherapy.
• Condylomata acuminata. These are benign cauliflower like vulvar lesions due to HPVtypes 6 & 11. They have no malignant predisposition. Condylomata are discussed in detail in chapter 7. Management is to treat clinical lesions only.
• Bartholin cyst. Obstruction of the Bartholins gland duct may occur due to infection(GC). After immune defenses overcome the infection the duct remains obstructed resulting in cystic dilation of the gland. Aspiration of the cyst yields sterile fluid. Management is conservative unless pressure symptoms due to size. Bartholin cyst isdiscussed in chapter 7.
166
| S2 OB-GYN.indb 166 | 7/8/13 6:35 PM | |||
GI
| Disorders of | 4 | ||
| the Cervix and Uterus | |||
CERVICAL LESIONS
Cervical Polyps
Description. Cervical polyps are fingerlike growths that start on the surface of the cervix orendocervical canal. These small, fragile growths hang from a stalk and push through the cervi-cal opening.
|
|
|
• The cause of cervical polyps is not completely understood. They may be associated with chronic inflammation, an abnormal response to increased levels of estrogen, or thrombosed cervical blood vessels.
• Cervical polyps are relatively common, especially in older multiparous women. Only a single polyp is present in most cases, but sometimes two or three are found.
Findings
• The history is usually positive for vaginal bleeding, often after intercourse. This bleeding occurs between normal menstrual periods.
• Speculum examination reveals smooth, red or purple, fingerlike projections from the cervical canal.
• A cervical biopsy typically reveals mildly atypical cells and signs of infection.
Small cervical polyp Large and small cervical polyps
Cervical origin of a polyp
Figure II-4-1. Cervical Polyps
167
USMLE Step 2 l Gynecology
Management
• Polyps can be removed by gentle twisting or by tying a surgical string around the base and cutting it off. Removal of the polyp’s base is done by electrocautery or with a laser.
• Because many polyps are infected, an antibiotic may be given after the removal even if there are no or few signs of infection. Although most cervical polyps are benign, the removed tissue should be sent to pathology. Regrowth of polyps is uncommon.
Nabothian Cysts
A nabothian cyst is a mucus-filled cyst on the surface of the uterine cervix. The cervical canal is lined by glandular cells that normally secrete mucus. These endocervical glands can become covered by squamous epithelium through metaplasia.
This is a benign condition. Rarely, cysts may become so numerous or enlarged that the cervix becomes clinically enlarged.
• These nests of glandular cells (nabothian glands) on the cervix may become filled with secretions. As secretions accumulate, a smooth, rounded lump may form just under the surface of the cervix and become large enough to be seen or felt upon examination.
|
|
|
• Each cyst appears as a small, white, pimple-like elevation. The cysts can occur singly or in groups, and they are not a threat to health. The cysts are more common in women of reproductive age, especially women who have already had children. There are no observable symptoms.
Findings. Pelvic examination reveals a small, smooth, rounded lump (or collection of lumps)on the surface of the cervix. Rarely, a colposcopic exam is necessary to distinguish nabothian cysts from other types of cervical lesions.
Management. No treatment is necessary. However, nabothian cysts do not clear spontaneously.They can be easily cured through electrocautery or cryotherapy. Both procedures can be done in the doctor’s office.
Cervicitis
Symptoms. Often, there are no symptoms, except vaginal discharge.
Examination. The most common finding is mucopurulent cervical discharge and a friablecervix. This diagnostic finding is confirmed by endocervical bleeding easily induced by passage of a cotton swab through the cervical os. No pelvic tenderness is noted. Patient is afebrile.
Investigative Findings. Routine cervical cultures are positive for chlamydia or gonorrhea. WBCand ESR are normal.
Management. Oral azithromycin in a single dose or oral doxycycline BID for 7 days.
168
S2 OB-GYN.indb 168
GI
7/8/13 6:35 PM
GI
Chapter 4 l Disorders of the Cervix and Uterus
CERVICAL NEOPLASIA
Abnormal Pap Smear
A 23-year-old woman is referred because of a Pap smear showing HSIL (high-grade squamous intraepithelial lesion). The patient states that her Pap smear 2 years ago was negative. She has been on combination steroid vaginal ring contraception for the past 4 years. Her cervix appears unremarkable on gross visual inspection.
Presentation. Premalignant lesions of the cervix are usually asymptomatic. The progression frompremalignant to invasive cancer has been reported to be approximately 8–10 years. Most lesions will spontaneously regress; others remain static, with only a minority progressing to cancer.
|
|
|
Etiology. The most common etiology of cervical cancer is the human papilloma virus (HPV).Over 75 subtypes of HPV have been identified. HPV 16, 18, 31, 33, and 35 are the most com-mon HPV types associated with premalignant and cancerous lesions of the cervix. HPV 6 and 11 are the most common HPV types associated with benign condyloma acuminata.
| 65% | 20% | 15% | |||
| Regress | Same | ||||
| Progress | |||||
HPV types 6, 11
HPV types 16, 18, 30s
Figure II-4-2. Natural History of Cervical Dysplasia: Response to HPV types
Risk Factors. These include early age of intercourse, multiple sexual partners, cigarette smok-ing, and immunosuppression. The mediating factor for all these conditions is probably HPV.
Дата добавления: 2018-11-24; просмотров: 278; Мы поможем в написании вашей работы! |
Мы поможем в написании ваших работ!