John Ellwood

• Professor Emeritus

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For example pain treatment sickle cell buy genuine aspirin line, a poor seal between the cystoscope and distd urethral mucosa may lead to inadequate sac d pain relief treatment center llc cheap aspirin 100 pills without a prescription. Also treatment for lingering shingles pain purchase aspirin online now, nattow or stcnotic diverticular ostia may not communicate with the urethral lumen and can be missed treatment for shingles pain mayo clinic generic aspirin 100 pills visa. Although cystourethroscopy is minimally invasive wrist pain yoga treatment cheap aspirin master card, patient pain and risk of postprocedural ~tion are additional considerations heel pain treatment yahoo buy aspirin canada. Genitourinary Fistula and Urethral Diverticulum 11 thick: exudate or debris prevents adequate filling with contrast mediwn or if the diverticular ostium is stenotic. Although the endowethral technique appears to have excellent specificity, it is expensive and may be more invasive that the other sonographic routes (Chancellor, 1995). Advantages of sonography include patient comfon, avoidance of ionizing radiation and contrast exposure, relative low cost, and reduced invasiveness. Because corueruus is lacking on which primary modality is best, we begin with cystourethroscopic evaluation. Inuavenous contraat and an external plate are added to help improve image resolution. Coruervative management is initially recommended and includes sitz baths, oral analgesics, and a broad-spectrwn antibiotic such as a cepbalosporin or Buoroquinolone. Import2nt surgical risks include urethrovaginal fistula, worsening or de novo urinary incontip nence, alu:rcd voiding stream or pattern, and dyspareunia. For those electing observation, however, long-term data arc lacking regarding rues of subsequent symptom development, divcrticup lum enlargement, or eventual need for surgical excision. Many practitioners may deliberate as to whether an enlarged infiamed cystic connection with the urethra is tenncd an "inflamed Skene gland cyst" or a "urethral divcrticulum. Procedures include diverticulec:tomy, trarisvaginal partial ablation, and marp supialization. Of these, divtrdadecumy is the most &equcntly chosen to treat diverticula at any site along the urethra. Passage of a lacrimal duct probe demonstrates the communication between the urethral lumen and the diverticular cavity. However, disadvantages include risks for postsurgical urethral 12 Female Pelvic Medicine and Reconstructive Surgery stenosis, urethrovaginal fistula, injury to the urinary sphincter continence mechanism with subsequent incontinence, and recurrence. As noted earlier, although this practice is supported by some studies, our preference is to approach it as a staged procedure. Another surgery, partial diverticular sac ablation, may be preferred for proximal diverticula to avoid bladder entry or bladder neck injury. Instead, the preserved diverticular sac tissue is reapproximated to dose the defect (Tancer, 1983). Last and less frequently, diverticulum marsupialization, also known as the Spence procedure, has been used for distal diverticula Spence, 1970). Other procedures described in case reports include urethrosoopic transurethral dectrosurgical fulguration of the divenicular sac and transurethral incision to widen the diverticular ostia (Miskowiak, 1989; Saito, 2000; Vergunst, 1996). Chan R, Rajanahally S, Hollander A, et al: Urethral divcrticulum after midurethral sling erosion, excision, and subsequent management. Obstet Gynecol 127(2):369, 2016 Clayton M, Siami P, Guinan P: Urethral diverticular carcinoma. J Urol 166(2):626, 2001 Dakhil L: Urcthrovaginal fistula: a rare complication of transurethral catheteri. Obstet Gynccol 105:1193, 2005 Ginsburg D, Genadry R: Suburcthral diverticulum: classification and therapeutic considerations. J Obstet Gynaecol Res 35(1):160, 2009 Golomb J, Leibovicch I, Mor Y, et al: Comparison of voiding cystourcthrography and double-balloon urethrography in the diagnosis of compla female urethral divcrticula. Surg Gynecol Obstet 124:1260, 1967 Harkki-Sircn P, Sjoberg J, Tiitinen A: Urinary tract injuries after hysterectomy. Urology 61:1129, 2003 Martius H: Die operative Wiederhertellung der vollkommen fehlenden Harnrohre und des Schie. Female Pdvic Med Reconsu Surg 18(6):362, 2012 McNally A: A diverticulum of the female urethra. Int UrogynecolJ 26(3):441, 2015 Miskowiak J, Honnens de Lichtenberg M: Transurethral incision of urethral diverticulum in the female. J Obstet Gynaecol Br Commonw 80:598, 1973 Monteiro H, Nogueira R, de Carvalho H: Beh~s syndrome and ve. J Urol 164:428, 2000 Romics I, Kdemen Z, Fazakas Z: the diagnosis and management ofvesicovaginal fistulae. J Urol 170:82, 2003 Saito S: Usefulness of diagnosis by the urethroscopy under anesthesia and effect of uansurethral electrocoagulation in symptomatic female urethral diverticulL J Endourol 14:455, 2000 Scholler D, Brucker S, Reisenauer C: Management of urethral lesions and urethrovaginal fistula formation following placement of a tension-free suburethral sling: evaluation from a university continence and pdvic floor centre. Geburtshilfc Frauenheilkd 78(10):991, 2018 Shalev M, Misuy S, Kernen K, et al: Squamous cell carcinoma in a female urethral diverticulum. Obstet Gynecol 62:511, 1983 Vakili B, Wai C, Nihira M: Anterior urethral divcrticulum in the female: diagnosis and surgical approach. Obstet Gynecol 102:1179, 2003 Vargas-Serrano B, Cortina-Moreno B, Rodriguez-Romero R, et al: Transrectal uluasonography in the diagnosis of urethral diverticula in women. Am J Obstet Gynecol 188:1111, 2003 W aaldijk K: Surgical classification of obstetric furulas. Inc J Gynaecol Obstet 49:161, 1995 W aaldijk K: the immediate surgical management offresh obsteuic furulas with catheter and/or early closure. This growth pattern disparity underlies the effectiveness of chemotherapeutic agents. N amdy, a tumor mass requires progressively longer times to double in size as it enlarges. However, as a tumor enlarges, the number of its cells undergoing replication decreases due to limitations in blood supply and increasing interstitial pressure. When tumors are in the exponential phase of gompertzian growth, they should be more sensitive to chemotherapy because a larger percentage of cells are in the active phase of the cdl cycle. For this reason, metastases should be more sensitive to chemotherapy than a large primary tumor. In addition, when a tumor mass shrinks in response to treatment, the presumption is that a greater number of cells will enter the active phase of the cell cycle to accelerate growth. This larger percentage of replicating cells should also increase the sensitivity of a tumor to chemotherapy. Sdecting appropriate drugs and limiting toxicity demands an understanding of cellular kinetics and biochemistry. The speed with which tumors grow and double in size is largely regulated by the number of cdls that are actively dividing-known as the growth fraction. Typically, only a small percentage of the tumor will have cells that are rapidly proliferating. In general, tumors that are cured by chemotherapy are those with a high growth fraction, such as gestational trophoblastic neoplasia. When tumor volume is reduced by surgery or chemotherapy, the remaining tumor cdls are theoretically propdled from the G 0 phase into the more vulnerable phases of the cell cycle, rendering them susceptible to chemotherapy. When this is prolonged, the cell is considered to be in the G 0 phase, that is, the resting phase. G 1 cdls may either terminally differentiate into the G 0 phase or reenter the cdl cycle after a period of quiescence. Agents are organized according to the cell cycle stage in which they are most effective for tumor control. By combining ~ that act in different phascoi ofthe cdl cycle, the overall cd1 kill should be enhanced. Atijuvant chemotherapy is given to destroy remaining microscopic cells that may be present after the primary tumor is removed by surgery. Neoadjuvant chemotherapy refers to drug treatment directed at an advanced cancer to decrease preoperativcly the extent or morbidity of a subsequent surgical resection. Consolid4tion (or maintmanc~) chemotherapy apy and aims to prolong the duration ofcllnical rem. Therapy applied to recurrent disease or to a tumor that is refractory to initial treatment is termed salva~ (or paJ. Emphasis is placed on maintaining curative dosages and adhering closely to the trcaoncnt schedule. This may lead to significant toxicity and require growth-&ctor support to counter ancmia or neutropenia. However, for the possibility of achieving cure, these side effects arc typically deemed acceptable. Rather than a defined number of treatment courses, a clinician mwt frequently revisit treatment efficacy and alter the dosage and timing ofchemotherapy administrarlon aa:ordingly. However, using two or more 590 Gynecologic Oncology drugs simultaneously may greatly exacerbate toxicity. Moreover, the use of multiple drugs with differing mechanisms tends to minimiu the emergence of drug resistance. Dose reductions initiated soldy to allow the addition of other agents are counterproductive because most drugs must be used near their maximum tolerated dose to ensure efficacy. The goal of chemoradiation is to achieve local control by chemically rendering the tumor more sensitive to radiation. For example, care of locally advanced cervical cancer was transformed by adding weekly cisplatin to standard radiotherapy. However, patients recently treated with radiation therapy may have bone marrow, skin, or other body systems that are more susceptible to chemotherapy toxicity. She may then receive pelvic radiation preceded or followed by combination chemotherapy. Patient examination and review of blood work results, in the context of the tumor response and overall treatment goals, will help determine whether drugs are changed or their dosages revised. Over time, the treatment strategy is continually reassessed as circumstances change. Although height is a fixed variable, patient weights are obtained prior to every therapy course, as they may fluctuate significantly. Rarely, tissue edema or ascites must be factored, since doses should be based on weight without this coexisting fluid. For example, bevacizumab is a monoclonal antibody metabolized and eliminated via the reticuloendothelial system. For renally excreted drugs, such as carboplatin, dosing may be based on an estimate of the glomerular filtration rate (Calven formula). Its primary importance is in highly responsive tumors, in which cure can be achieved with chemotherapy. Ali the intended therapy is finalized, extensive information regarding anticipated side effects and clarification of all potential logistical challenges. Prior to drug infusion, a complete medical history and comprehensive physical examination are mandatory. Blood work, including a complete blood count, comprehensive metabolic panel, and tumor markers as indicated, is performed and reviewed before orders to begin infusion are signed. The setting for drug administration must provide staff that are immediately available should the need arise. Extravasation of these into the subcutaneous tissue can result in severe pain and necrosis. Regional chemotherapy delivers drugs directly into the cavity in which the tumor is located. However, penetration into peritoneal tumor nodules by passive diffusion can be limited by intraabdominal adhesions, poor fluid circulation, fibrotic tumor encapsulation, and coexisting ascites. As a variation, heated chemotherapy may further improve absorption by tumors and destroy microscopic cancer cells. Drug inactivation, elimination, or excretion dramatically influences activity and toxicity. As a result, drug activity may be diminished and toxicity exacerbated when normal hepatic or renal function is impaired. In addition, drug toxicity is often more pronounced in the elderly or malnourished. Ifa carboplatin dose is calculated using this falsely low value, the amount may be excessive and result in considerable morbidity. Accordingly, a trained nursing staff and resources to manage these sudden, but common, issues are required. Prior to drug administration, the patient is instructed to repon symptoms that may herald an anaphylactic reaction such as flushing, pruritus, dyspnea, tachycardia, hoarseness, or lightheadedness. Emergency equipment that includes supplemental oxygen, ventilatory face mask and bag, or intubation equipment must be immediately available. However, for a generalized hypersensitivity or anaphylactic response, chemotherapy should be stopped immediatdy, the emergency team notified, and emergency drugs administered, such as epinephrine (1 to S mL of a 0. Intrinsic drug resistance is seen if tumors are first exposed to an agent and fail to respond. In contrast, with acquired drug resistance, turners no longer respond to drugs to which they were initially sensitive. Most patients will initially achieve remission with platinum-based chemotherapy, but 80 percent will ultimately relapse and die from tumors that have become resistant to all cytotoxic therapy. Moreover, women also often receive analgesics, antiemetics, and antibiotics during chemotherapy. Most drug interactions are of little consequence, but some may lead to substantially altered drug toxicity. Ultimately, women who have any possibility of cure are those who first achieve a complete response. However, if chemotherapy results in a partial response, many women still view this as advantageous compared with supportive care, even if a survival benefit is unproven. However, at high doses, although used infrequently, this agent can lead to fatal bone marrow toxicity.

Diagn lnterv Imaging 94(1):3 chronic pain treatment options buy generic aspirin 100pills, 2013 Liang E pain evaluation and treatment center tulsa ok purchase discount aspirin on line, Brown B a better life pain treatment center generic 100pills aspirin with amex, Racbiruky M: A clinical audit on the efficacy and safety of uterine artery embolisation for symptomatic adenomyosis: resulu in 117 women pain medication for dogs over the counter cheap aspirin 100 pills with visa. ObstetGynecol 116(4):865 treatment for shingles pain and itching buy aspirin 100 pills free shipping,2010 Ma G treatment for nerve pain after shingles cheap aspirin 100pills with mastercard, Miao Q, Liu X, et al: Different surgical strategies of patients with intravenous leiomyomatosis. Hum Reprod 27(12):3425, 2012 Maheshwari A, Gurunath S, Fatima F, et al: Adenomyosis and subfertility: a systematic review of prevalence, diagnosis, ueatment and fertility outcomes. Hum Reprod Update 18(4):374, 2012 Miliriinen L, Ylilmrkala 0: Primary and myoma-associated menorrhagia: role ofprostaglandins and effects of ibuprofen. Cardiovasc Intervene Radial 35(3):530, 2012 Mara M, Kubinova K, Maskova J, et al: Uterine artery embolization versus laparoscopic uterine artery occlusion: the outcomes of a prospective, nonrandomized clinical trial. Obstet Gynecol 90(6):967, 1997 Mazzon I, Favilli A, Grasso M, et al: Predicting success of single step hysteroscopic myomectomr. J Minim Invasive Gynecol 22(2):239, 2015 Miettinen M, Fdisiak-Golabek A, Wasag B, et al: Fumarase-deficient uterine leiomyomas: an immunohistochemical, molecular genetic, and clinicopathologic study of86 cases. A prospective study of prevalence using uansvaginal uluasound in a gynaecology clinic. Hum Reprod 27(12):343, 2012 Olufowobi 0, Sharif K, Papaionnou S, et al: Are the anticipated benefits of myomectomy achieved in women of reproductive age Case Rep Obstet Gynecol 2014:602139, 2014 Osuga Y, Enya K, Kudou K, et al: Oral gonadotropin-releas. Obstet Gynecol 133(3):423, 2019 Osuga Y, Fujimoto-Okabe H, Hagino A: Evaluation of the efficacy and safety of dienogest in the treatment of painful symptoms in patients with adenomyosis: a randomized, double-blind, multicenter, placebo-controlled study. Fertil Steril 70(1):111, 1998 Palomba S, Orio F Jr, Russo T, et al: Gonadotropin-releasing hormone agonise with or without raloodfene: effects on cognition, mood, and quality of life. Fertil Steril 82(2):480, 2004 Palomba S, Zupi E, Russo T, et al: A multicenter randomized, conuolled study comparing laparoscopic versus minilaparotornic myomectomr. Neonatal Med 21:1, 2018 Popovic M, Puchner S, Berzaczy D, et al: Uterine artery embolization for the treatment of adenomyosis: a review. J Vase lnterv Radiol 22(7):901, 2011 Preutthipan S, Herabutya Y: Hysteroscopic rollerball endometrial ablation as an alternative treatment for adenomyosis with menorrhagia and/or dysmenorrhea. One Health Tecbnol &sess Ser 15(4):1, 2015 Qin J, Yang T, Kong F, et al: Oral conuaceptive use and uterine leiomyoma risk: a m=-analysis based on cohort and case-conuol studies. Radiology 199(1):151, 1996 Rossetti A, Sizzi 0, Soranna L, et al: Long-term results of laparoscopic myomectomy: recurrence nte in comparison with abdominal myomectomy. Uterine system and a low-dose combined oral contraceptive fur fibroid-related menorrhagia. Fertil Steril 74(3):540, 2000 Setubal A, Alves J, Os6rio F, et al: Treatment for uterine i. Tohoku J Exp Med 224(2):87, 2011 Socolov D, Blidaru I, Tamba B, et al: Lcvonorgesud rdeasing-inuauterine system for the treatment of menorrhagia and/or frequent irregular uterine bleeding associated with uterine leiomyoma. Fertil Steril 83(5):1473, 2005 Tahara M, Shimizu T, Shimoura H: Prdiminary report of treatment with oral contraceptive pills fur intermenstrual vaginal bleeding secondary to a cesarean section scar. Steril 86(2):477, 2006 Takeuchi H, Kinoshita K: Evaluation of adhesion formation after laparoscopic myomectomy by systematic second-look microlaparoscopy. Clin Exp Obstet Gynecol 44(1):61, 2017 Tulandi T, Leung A, Jan N: Nonmalignant sequdae of unconfined morcellation at laparoscopic hysterectomy or myomectomy. Obstet Gynecol 124(5):904, 2014 Yamamoto T, Noguchi T, Tamura T, et al: Evidence fur estrogen synthesis in adenomyotic tissues. Am J Obstet Gynecol 169(3):734, 1993 Yan L, Ding L, Li C, et al: Effect of fibroids not distorting the endomeuial cavity on the outcome of in vitro fert. Fertil Steril 101(3):716, 2014 Yang C, Fang H, Yang Y, et al: Diagnosis and surgical management of inferior vena cava leiomyomatosis. X, Yang M, Wang Q, et al: Prospective evaluation of five methods used to ueat cesarean scar defects. Im J Gynaecol Obstet 134(3):336, 2016a Zhang Y: A comparative study of uansvaginal repair and laparoscopic repair in the management of patients with previous cesarean scar defect. Histologkally, ovarian cysta are often divided into those derived from neoplastic growth, (lt)ttrian cyrtic neoplmms, and those created by disruption of nonnal ovulation, foncti01llll ovarian cysts. Differentiation of these is not always clinically apparent using either imaging or twnor markers. Thus, ovarian cysts are often man~ as a single composite clinical entity, and the next sections describe this general approach. Angiogenesis is an essential component of both the follicular and luteal phases of the ovarian cycle. Management goals include identifying malignancy and treating symptoms while preserving ovarian function when possible and minimizing overtreatment. However, despite continuous improvement in diagnostic methods, it is often impossible to clinically differentiate between benign and malignant conditions. Thus, management mwt balance the surgical morbidity from excision of an innocent lesion with the. In ovarian malignancies, diagnosis depends on providers having a high index ofsuspicion in symptomatic women (Scborge, 2010). For example, exceS& estrogen production from granulosa cell stimulation may disrupt normal menmuation or initiate bleeding even in prepubertal or postmenopauaal patient&. The flmbrlated end of the fallopian tube Is seen below the ovary, and the uterus lies at the lower right (Reproduced with permission from Dr. Other tumor markers are typically proteins produced by cancer cells or by the body in response to tumor cells. Levels may also rise in women with nonmalignant disease such as leiomyomas, endometriosis, adenomyosis, and salpingitis. This algorithm helps predict the likelihood of finding malignancy at surgery in women with known adnexal masses to aid presurgical triage. This last element is derived from ovarian appearance, and presence of ascites or intraabdominal metastases Qacobs, 1990; Karlsen, 2012). They are reserved for those with a known surgical mass to guide specialty referral. Transabdominal scanning is performed first to avoid missing a large cyst that lies outside the pelvis. Characteristic findings for specific types of ovarian cysts have been defined to help discriminate malignant from benign lesions (Table 10-2). Specifically, thick septa with increased vascularity, papillary intracystic growths, and solid elements within the cyst raise concern. This can add information regarding lesion structure, malignant potential, and possible torsion. Sonographic color Doppler and spectral analysis of flow signals are combined with tumor size and morphology in several scoring systems to help differentiate malignant and benign masses (Chap. At our institution, we use the Ovarian Tumor Index developed by Twickler and colleagues (1999). From American College of Obstetricians and Gynecologists, 2016; Atri, 2019; Levine, 2010. However, in most clinical settings, sonography alone is suitable (Atri, 2019; Outwater, 1996). For postmenopausal women with a simple ovarian cyst, expectant management also may be reasonable if several criteria are met. Moreover, the American College of Obstetricians and Gynecologists (2016) notes that simple cysts up to 10 cm in diameter by sonographic evaluation may safely be followed even in postmenopausal women. Some experts recommend 1 year of surveillance for patients with stable adnexal masses without solid components and 2 years for those with stable masses with solid components (Suh-Bergmann, 2014, 2015). With any surveillance plan, the risks of potentially serious pathology and patient anxiety are weighed against surgical morbidity. For diagnosis, ovarian cyst aspiration usually is avoided because of possible intraperitoneal seeding by earlystage ovarian cancer. Moreover, false-positive and false-negative results are common (Martinez-Onsurbe, 2001; Moran, 1993). Accordingly, for many cases, cyst excision serves as the definitive diagnostic tool. With suspected ovarian cancers, optimal surgical resection and proper staging by a gynecologic oncologist during the primary operation are major factors in long-term patient survival. Thus, women with pdvic masses and preoperative findings suspicious for malignancy are generally referred. The American College of 0 bstetricians and Gynecologists (2017) and Society of Gynecologic Oncologists have jointly presented guiddines regarding clinical criteria that should prompt preoperative referral to a gynecologic oncologist (see Table 10-2). For the generalist, cysts presumed to be benign may be excised or the whole ovary may be removed. Of these, cystectomy offers the advantage of ovarian preservation hut risks cyst rupture and content spill. With ovarian cancer, such spill and subsequent malignant seeding can worsen patient prognosis. Thus, the decision for one surgical technique in preference over the other is influenced by lesion size, patient age, and intraoperative findings. For example, in premenopausal women, smaller lesions generally require only cystectomy with preservation of reproductive function. Larger lesions may prompt oophorectomy because of their greater risk for rupture during enucleation, difficulty in reconstructing ovarian anatomy following large cyst removal, and the increased risk of malignancy in these bigger cysts. However, in postmenopausal women, oophorectomy is preferred because the risk for cancer is higher. The ovaries in these women are also no longer providing sufficient estrogen production or fertility potential (Okugawa, 2001). Laparoscopy and minilaparotomy are the more common approaches to a benign adnexal mass. Advantages of these minimally invasive techniques compared with laparotomy include reduced pain, length of stay, incidences of postoperative fever, and complication rates (Medeiros, 2009). However, during laparoscopic cystectomy or oophorectomy, cyst size must allow suitable optics. Moreover, laparoscopic instruments must have sufficient room to interact effectivdy and to create tissue tension. Contained cyst removal without morcellating the ovarian cortex also is desirable in cases with an intermediate risk of malignancy. For larger cysts, primary decompression through the incision can then permit excision and extraction of the entire specimen. Last, women with large cysts or other factors indicating a higher malignancy risk often are managed by laparotomy. With a greater potential for malignancy, a midline vertical incision provides a surgical fidd large enough for oophorectomy or cyst enucleation without tumor rupture and for surgical staging if malignancy is found. Clinical findings of an unexpected malignancy at the time of surgery will dictate further actions. Multiple small lesions studding the peritoneal surface, ascites, and exophytic growths extending from the ovarian capsule should prompt collection of peritoneal fluid for cytologic study and intraoperative frozen section analysis. If cancer is found, a gynecologic oncologist is ideally consulted intraoperativdy. They are subcategorized as either follicular cysts or corpus /uttum cysts based on both their pathogenesis and histologic qualities. They are not neoplasms and derive mass from accumulation of intrafollicular fluids rather than cellular proliferation. With follicular cyst formation, hormonal dysfunction prior to ovulation results in expansion of the follicular antrum with serous fluid. In contrast, excessive hemorrhage from the vascular corpus luteum following ovulation may fill its center to create a corpus luteum cyst. Thus, follicular and corpus luteum cysts differ in their genesis, but symptoms and management are similar. However, in subsequent studies Benign Adnexal Mass with low-dose pills, which contain 35 pg of eth. By contrast, the incidence of follicular cysts is increased with many progestin-only conttaceptives. Recall that continuous, low-dose progestins do not completdy suppress ovarian function. Clinically, follicular cygts are found with greater frequency in thooe using the levonorgesttel-rdeasing intrauterine system (I. Both pre- and postmenopawal women treated with tamoxifen for breast cancer have a higher risk for benign ovarian cygt formation (Chalas, 2005; Simpk:im 2005). Premenopausal women and women with greater body mass index are disparatdy a1fected. If clinical signs of malignancy are present, surgical exploration is indicated, and tamoxifen is discontinued. Several epidemiologic studies have linked smoking with functional cyst devdopment (Holt, 2005; Wyshak, 1988). Although the exact mechanism(s) is unknown, changes in gonadotropin secretion and ovarian function are suspected (Michnovia, 1986). Surgical excision may be reasonable for large persistent cysts, usually those > 10 cm, or for smaller ones producing persistently bothersome symptoms. With a corpus luteum, transvaginal sonography and applied color Doppler typically display a brightly colored ring because of enhanced vascularity surrounding the cyst. Bilateral, multiple smooth-walled cysts form and range in size from 1 to 4 cm in diameter. These cysu typically resolve spontaneously following removal of the stimulating hormone source. In categorizing tumors within the epithelial family, benign turners are designated as adenomas; malignant tumors, as carcinomar, and those with exuberant cellular proliferation without invasive behavior as low malignant potential (Chen, 2003).

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Another obstetric classification ranks urinary fistulas based on their needed surgical repairs (Waaldijk wrist pain treatment yahoo cheap aspirin master card, 1995) active pain treatment knoxville buy aspirin 100pills low price. To aid objective comparison ofsurgical outcomes treatment guidelines for chronic pain cheap 100 pills aspirin amex, a more comprehensive classification system has been developed (Table 26-3) shingles and treatment for pain order aspirin on line. It integrates fistula distance from the external urethral meatus pain treatment center purchase generic aspirin line, fistula size pain management for shingles pain buy aspirin online, degree of surrounding tissue fibrosis, and extent of vaginal length reduction (Goh, 2004). This system has good interand intraobserver reproducibility and has demonstrated efficacy in predicting which patients are at risk of postfistula urinary incontinence and of failed closure (Bengtson, 2016; Goh, 2008, 2009). None or only mild fibrosis around fistula and/or vagina) and/or vaginal length >6 cm, normal capacity ii. Moderate or severe fibrosis (around fistula and/or vagina) and/or reduced vaginal length and/or capacity iii. Thus, most vesicovaginal fistulas are acquired and typically result from either obstetric trauma or pelvic surgery. For example, both childbearing at a young age, before the pelvis has completdy developed, and female genital mutilation may significantly narrow the vaginal introitus and obstruct labor. In contrast, in most developed countries, fistulas uncommonly follow obstetric procedures or deliveries. Rardy, cesarean deliveries, usually those accompanied by obstetric complications, have led to complex: urinary fistula (Billmeyer, 2001). Iffound, they are commonly associated with other renal or urogenital abnormalities. The remaining fistulas result &om procedures performed by urologists and by colorectal, vascular, and general surgeons. In industrialized countries, hysterectomy is the most common surgical precursor to vesicovaginal fistula, accounting for approximately 75 percent of fistula cases (Symmonds, 1984). When all hysterectomy types are considered, vesicovaginal fistula is estimated to complicate 0. In their review of more than 62,000 hysterectomy cases, laparoscopic hysterectomies were associated with the greatest incidence (2 per 1000), followed by abdominal (1 per 1000), vaginal (0. With hysterectomy for benign disease, bladder wall laceration extending into the bladder neck or ureteral orifice (trigone) significantly raised the risk of subsequent vesicovaginal fistula Duong, 2009). Thus, intraoperative cystoscopy can be a useful adjunct, particularly in cases posing greater risk for ureteral or bladder injury. Also, during sling surgeries, excess sling tension may increase tissue stress and necrosis. Thus, initial material selection and patient evaluation for poor wound healing risk factors are important prevention steps (Giles, 2005). Other rare causes of fistula formation include infections such as lymphogranuloma venereum, urinary tuberculosis, pelvic inflammation, and syphilis; inflammatory bowel disease; and autoimmune disease (Ba-Thike, 1992; Monteiro, 1995). Additionally, poor wound healing is often linked to poorly controlled diabetes mellitus, smoking, peripheral vascular disease, and chronic corticosteroid therapy. Other less specific symptoms of genitourinary fistula include fever, pain, ileus, and bladder irritability. This modality is a frequent cause, and some series have reported that up to 6 percent of genitourinary fistulas can result from radiation (Lee, 1988). Although most damage following this therapy develops within weeks and months, associated fistulas may present up to 20 years after the original insult (Graham, 1967; Zouhek, 1989). Thus, tissue biopsy is routinely considered during diagnostic evaluation of women with a fistula and history of malignancy. Given that transurethral catheter placement has been linked to urethrovaginal fistula, this commonly used device should be placed, maintained, and removed with care (Dakhil, 2014). A meticulous assessment for other fistulous tracts is performed, and their location and size are noted. Visual assistance with an endoscopic lens and translucent vaginal speculum can sometimes help identify a vaginal-apex fistula, which can be more difficult to detect. Occasionally, the vaginal fluid source is unclear, and a small amount of urine can easily be mistaken for vaginal discharge. Both arrows show anomalous tracking of contrast the lower arrow denotes a fistulous tract to the upper vagina. The urethra Is seen between the forceps arms, and urine streams from a vesicovaginal fistula. If the presence of a urinary fistula is Wlcertain or its vaginal location is not identi1i. A diluted solution of methylene blue is instilled into the bladder using a transurethral catheter. After 15 to 30 minutes of routine activity, the gauze is removed serially from the vagina, and each is inspected for dye. The specific gauze colored with dye suggests the futula location-a proximal or high location in the vagina for the innermost gauze and a low or distal fistula for the outermost. If the distally placed sponge is stained with dye, urine leaking out through the urethra. It permits futula localization, determination of its proximity to the ureteral orifices, inspection for multiple fistula sites, and assessment of surrounding bladder mucosa viability. In addition, cystourethroscopy and vaginoscopy used sequentially at the same visit has been described to identify vesicovaginal fistula (Andreoni, 2003). Concomitant ureteral involvement is estimated to complicate 10 to 15 percent of vesicovaginal fistula cases and is sought during diagnostic evaluation (Goodwin, 1980). Often carried out in conjunction with cystoscopy, it is performed by placing a small catheter into the distal ureter. With some advanced planning, phenazopyridine hydrochloride (Pyridium) can be used in conjunction with the three-swab test to determine ureteral involvement, as a very rudimentary alternative to the aforementioned more sophisticated imaging. In this case, if the most proximal (innermost) gauze is colored with orange dye, ureteral involvement is suspected. If both orange and blue dyes are seen, then involvement of both the bladder and ureter(s) is suspected. Fluoroscopic images of the lower urinary tract are then obtained during patient micturition. However, without color Doppler, sonography failed to identify 29 percent of vesicovaginal fistula cases in one study (Adetiloye, 2000). This may be secondary to epithelialization of the fistulous tract (Davits, 1991; Tancer, 1992). Moreover, continued urinary drainage may lead to further bladder inflammation and irritation (Zimmern, 1991). Importantly, if attempting conservative treatment of a vesicovaginal fistula with catheter insertion and chronic drainage, urinary drainage ideally begins shortly after the inciting event. Fibrin sealant (Tisseel, Evicel), also colloquially called fibrin glue, is formed from concentrated fibrinogen combined with thrombin to simulate the final clotting cascade stages. Although fibrin sealant has been described for vesicovaginal fistula treatment, it is often selected as a surgical adjunct rather than primary surgical treatment (Evans, 2003). Data regarding fibrin sealant effectiveness are sparse, and well-designed trials are lacking. In sum, a trial of conservative therapy is usually warranted and reasonable, especially if instituted shortly after the inciting event and if the fistula is small. These include accurate fistula delineation; adequate assessment of surrounding tissue vascularity; timely repair; multilayer, tension-free, and watertight defect closure; and postoperative bladder drainage. Primary surgical repair of genitourinary fistula is associated with high cure rates (75 to 100 percent) (Rovner, 2012b). Factors that support this rate include adequate vascularity of the surrounding tissue, brief fistulous tract duration, no prior radiation therapy, meticulous surgical technique, and surgeon experience. Of these, 81 percent are corrected with the first attempt, and 65 percent with the second (Elkins, 1994; Hilton, 1998). Approximately 12 percent of women treated by sustained catheterization alone had fistulas that healed spontaneously (Oakley, 2014; Waaldijk, 1994). Another series reported fistulas up to 2 cm in diameter spontaneously healed in 50 to 60 percent of patients treated with an indwelling catheter (Waaldijk, 1989). Many studies are vague regarding how fistula size is measured, and each series has potential for considerable Timing of Repair One principle of fistula repair dictates that a repair be performed in noninfected and noninflamed tissues. Early surgical intervention of uncomplicated fistulas within the first 24 to 48 hours following the inciting surgery is possible, as it avoids Genitourinary Fistula and Urethral Diverticulum 579 the brisk postoperative inflammatory response. In instances of extensive and severe inflammation, we recommend delaying operative repair for 6 weeks until inflammation subsides. During this time, a trial of catheter drainage, while the surrounding tissue has an opportunity to heal, is reasonable. However, data that support an optimal route are limited, and the lack of consensus may reflect variances in surgeon experience and preference. The transvaginal route also allows easy access for ancillary equipment, such as ureteral scents. One transvaginal approach used most commonly by gynecologists, the Latzko technique, is illustrated in Chapter 45 (p. In this technique, likened to a partial colpocleisis, the most proximal portions of the anterior and posterior vaginal walls are surgically apposed to close the defect, without completely removing the fistulous tract. Because of the potential for vaginal shortening, this technique may not be appropriate if vaginal depth has already been compromised or if sexual dysfunction preexists. If use of the Latzko technique is anticipated, patient counseling should specifically addresses these issues and potential sequelae. After tract resection, the bladder mucosa is first closed, and a watertight repair is confirmed. Of the two approaches, some favor incomplete fistulous tract excision (Latzko repair) to avoid weakening the surrounding tissue, enlarging the defect, and thereby potentially compromising the repair. With this route, the fistula is accessed and excised through an intentional cystotomy on the preperitoneal side of the bladder as shown in Chapter 45 (p. This approach is used for situations in which the fistula: (1) is located proximally in a narrow vagina, (2) lies close to the ureteral orifices, (3) is complicated by a concomitant ureteric fistula, (4) persists after prior repair attempts, (5) is large or complex in configuration, or (7) requires an abdominal interposition graft, described in the next section. Evidence-based support for laparoscopic genitourinary fistula repair is limited to case series (Miklos, 2015). Surrounding tissue vascularity is essential for successful genitourinary fistula repair healing. Sections 45-2 and 45-11 of the atlas illustrate the omental J-flap, which is an abdominal option, whereas a Martius bulbospongiosus fat pad Hap is used during vaginal procedures (p. Although interposition flaps are useful in situations where tissue viability is in question, their utility in uncomplicated cases ofvesicovaginal fistula is unclear. Urethrovaginal fistulas commonly result from surgery involving the anterior vaginal wall, in particular anterior colporrhaphy and urethral diverticulectomy (Blaivas, 1989; Scholler, 2018). In developing countries, as with vesicovaginal fistula, obstetric trauma remains the most common cause of urethrovaginal fistulas. Frequently, patients present with continuous urinary drainage into the vagina or with stress urinary incontinence. The principles of repair are similar, namely, layered closure, tension-free repair, and postoperative bladder drainage. This outpouching is commonly asymptomatic but may require surgical excision for symptoms. Urethral diveniculum is reported to develop in 1 to 6 percent of the general female population. With greater awareness and radiologic advances, diagnosis rates are increasing (Rovner, 2012a). However, the true incidence may be underestimated because diverticula are frequently asymptomatic and thus underreponed. In women with lower urinary tract symptoms, the incidence dramatically rises and may reach 40 percent (Stewart, 1981). Urethral diverticulum is diagnosed most often in the third to sixth decades of life and more commonly in females than in 580 Female Pelvic Medicine and Reconstructive Surgery Paraurelt11al glands and ducts Proximal urettira,~. In some studies, but not all, a greater predominance of urethral divcrticula is noted in Attican-Americans compared with whites (Davis, 1970; Leach, 1987; Bwrows, 2005). Congenital causes include persistence of embryologic remnants, defective closure of the ventral portion of the urethra. In the vagina, miillerian mucinous columnar epithelium is replaced by squamous epithelium of the urogenital sinus. Of these glands, the bilateral Skene glands arc the most distal and typically the largest. The arborizing pattern in portions of this network helps to aplain the complexity ofsome urethral diverticula (Vakili, 2003). If these do not spontancowly resolve or infection is not treated promptly, an abscess can form. Subsequent abscess expansion and continued inflammation may rupture the gland inm the wethra. As infection clears, the dilated divcrticular sac and its new communicating ostium into the urethra persist. More often than not, urethral cultures from women with diverticula arc unrevealing. Urethtal trauma may stem from childbinh, urethtal instrumentation, female genital mutilation. Ginsbwg and Genadry (1983) aeated a preoperative classification system based on urethral location. In this system, the diveniculwn characteristics are described according to its location (L). Location describes lesions as being distal, mid-, or proximal urethral and as extending or not extending beneath the bladder neck. Logieal1y, this distribution reflects the predominance of parawethral glands along the middle third of the urethra. Ascertainment of the number ofdiverticula is important to prevent incomplete excision of multiple lesions and thus symptom persistence.

However shingles and treatment for pain safe aspirin 100pills, studies have strati6ed affected paticnu by symptoms and cytology and found no prcinvasive disease or cancer in cndocervical polyps of asymptomatic women with normal cervical cytology (long pain relief treatment center fairfax buy aspirin 100 pills, 2013; Ma(:Kcnzie pain treatment for abscess tooth order discount aspirin, 2009) marianjoy integrative pain treatment center cheap aspirin uk. For removal joint and pain treatment center santa maria ca buy discount aspirin 100 pills on-line, if the stalk is slender pain treatment center bismarck buy aspirin canada, cndoc:crvical polyps arc grasped by ring forceps. With repeated twisting, feeding vessels are strangulated, and its base will narrow and avulsc. Monscl paste (ferric subsulfatc) can be applied with direct pressure as needed to the resulting stalk stub to complete hemostasis. A thick pedicle may warrant surgical ligation and excision if heavier bleeding is anticipated. Symptoms can appear slowly or suddenly with life-threatening hcmorrhage (fimmerman, 2003). Color Doppler or power Doppler ultrasound may provide a more specific image with bright, lugc. Tranexamic acid is contraindicated due to theoretic risks of venous thromboembolism in this population. If a surgical approach is ultimately desired, endometrial ablation or hysterectomy can he considered. Anticoagulation reversal for surgery differs depending on whether surgery is urgent or elective, and both instances are described in Chapter 39. Foley balloon sizes range from the traditional 30 mL up to 80 mL, and selection can be tailored to endometrial cavity volume. For a typical uterus, intrauterine tamponade with a 30-mL balloon filled with saline is suitable. No data describe the safety or risk of short-term, high-dose estrogens or of tranexarnic acid in these cases. If persistent, intermenstrual bleeding can typically be corrected by changing to a formulation with a higher estrogen dose (Table 5-7). In contrast, users of progestin-only contraceptive methods can experience breakthrough bleeding throughout the duration of use. Although this often improves with time, chronic breakthrough bleeding with these methods can be lessened by an estrogen supplement such as an oral daily 2-mg estradiol dose or 1. With honnone replacement therapy, irregular spotting or bleeding is also a well-known early side effect. This results from either hypoestrogenism or normal estrogen levels but anovulation (Cochrane, 1997; Matuszkiewicz-Rowinska, 2004). Of these, Jeong and coworkers (2004) noted Abnormal Uterine Bleeding 15 decreased bleeding in 87 percent of 62 patients following endometrial ablation. For women with renal disease and with bleeding attributed to estrogen-deficient atrophy, shon-term estrogen use is suitable. If considered, nonoral routes bypass the liver and theoretically may minimize blood pressure elevation. Liverdysfanction, depending on its severity, can lead to menstrual abnormalities (Stdlon, 1986). Additionally, hyperestrogenism from disrupted metabolism can lead to a disordered proliferative or hyperplastic endometrium (de Costa, 1992). Moreover, thrombocytopenia is common in women with portal hypenension and splenomegaly. In those with chronic viral hepatitis and normal transaminasc levels or with mild compensated cirrhosis, hormonal contraceptive use is not restricted. Estrogen-containing products, if already in use, may be continued, whereas initiation of these is avoided. In many women, these menstrual abnormalities antedate other clinical findings of thyroid disease Qoshi, 1993). With hypenhyroidism, light or infrequent menses are more typical complaints (Krassas, 2010). This may be due to decreased coagulation factor levels, which have been identified in some hypothyroid patients. First, during initial stages of hcmostasis, platelets adhere to vessel wall breaks through binding of their receptors to exposed collagen. Once bound, platelets are activated and release a potent agonise of their aggregation, thromboxane. Second, the coagulation cascade leads to fibrin, which stabilizes aggregated platelets. For diagnosis, a history of easy bruising, bleeding complications with surgery or obstetric delivery, recurrent hemorrhagic ovarian cysts, epistaxis, and gastrointestinal bleeding or a family history of bleeding disorders raises concern for coagulopathy. However, it provides less long-term success than for those without a bleeding disorder (Rubin, 2004). For severe emergent bleeding, hormonal and antifibrinolytic options for acute hemorrhage are implemented while clotting factor deficiencies are corrected. Thus, if multiple doses or shorter dosing intervals are used, then concurrent fluid restriction and monitoring for hyponatremia is advised (Rodeghiero, 2008). Alternatively, normal platelet counts may be found, hut platelet dysfanction leads to poor aggregation. Much less often, primary genetic defects in platelet receptors, such BernardSoulier syndrome and Glanzmann thrombasthenia, lead to platelet dysfunction and abnormal bleeding. The underlying causes of anovulation are varied and fully described in Chapter 17. For chronic management, correction of the underlying cause of anovulation is primary. If this is not possible, chronic progestin therapy replaces the physiologic progesterone that is absent. In general, surgical options mirror those for abnormal bleeding associated with primary endometrial dysfunction. Each new dosing lasts 2 to 7 days depending on the level of concern for rebleeding. With any of these medication regimens, an intrauterine Foley balloon can be inflated concurrently to control brisk bleeding. As primary choices, equine estrogens can be given intravenously in 25-mg doses every 4 hours for up to three doses (DeVore, 1982). With any of these high-dose choices, an antiemetic may be needed to control estrogen-rdated nausea. If bleeding is significant, the regimen begins with one pill every 6 hours until the bleeding has markedly diminished. One proposed taper stretches dosing to every 6 hours fur 4 days, then every 8 hours for 3 days, then every 12 hours for 2 to 14 days. This binding degrades fibrin into fibrin degradation products and leads to clot lysis. Their presumed method of action is endometrial atrophy, although diminished prostaglandin synthesis and decreased endometrial fibrinolysis are other suggested actions (Irvine, 1999). Side effects include those typical for menopause, and thus associated bone loss precludes long-term use. This family of drugs, however, may be helpful for shon-term use by inducing amenorrhea and allowing women to correct their anemia. Although effective, this agent has side effects that include weight gain, oily skin, and acne. Thus, some reserve danazol as a second-line drug for short-term use prior to surgery (Bongers, 2004). The drug is used in other countries but is not approved for use in the United States. One common replacement regimen is ferrous sulfate, 325 mg tablet (contains 65 mg elemental iron) three times daily. In addition, it requires administration only during menstruation and has few minor reponed side effects. Endomarial resection or ablation attempts to permanently remove and destroy the uterine lining, using laser, radiofrequency, electrical, or thermal energies. Increasing treatment failures due to endometrial regeneration accrue with time, and by 5 years following ablation, approximately 25 percent required additional surgery, in most cases hysterectomy (Cooper, 2011). Unfortunately, prolonged use of high-dose progestins is often associated with side effects such as mood changes, weight gain, bloating, headaches, and atherogenic lipid profile changes (Lethaby, 2008). J Minim Inv:Wve Gynecol 19(1):3, 2012 American College of Obstetricians and Gynecologists: Endometrial cancer. J lhromb Hacmost 10(4):698, 2012 Baiocchi G, Manci N, Pazzaglia M, et al: Malignancy in endometrial polyps: a 12-year experience. Acta Obstet Gynecol Scand 79:317, 2000 Bar-Hava I, Orvieto R, Ferber A, et al: Asymptomatic posanenopausal intrauterine fluid accumulation: characteri. After ablation, uterine cavity anatomy is often distoned by uterine wall agglutination and intracavitary synechiae. As noted, endometrial ablation is not routindy recommended for patients at high risk for endometrial cancer. Removal of the uterus is the most effective treatment for bleeding, and overall patient satisfaction rates are high. Disadvantages to hysterectomy include more frequent and severe intraoperative and postoperative complications compared with either conservative medical or ablative surgical procedures. J Womens Health 16(9):1317, 2007 Bettocchi S, Ceci 0, Vicino M, c:t al: Diagnostic inadequacy of dilatation and curettage. Ultrasound Obstc:t Gynccol 50(1):32, 2017 Bobrowska K, Kaminski P, Cyganek A, et al: High rate of endometrial hyperplasia in renal transplanted women. Histopathology 53(3): 325,2008 Ceci 0, Bettocchi S, Pellegrino A, er al: Comparison of hysteroscopic and hysterectomy findings fur assessing the diagnostic accuracy of office hysreroscopy. Fertil Steril 78(3):628, 2002 Centers fur Disease Control and Prevt:ntion: Saually transmitted diseases treatment guiddines, 2015. Maturitas 53(4):413, 2006 Cicinelli E, De Ziegler D, Nicoletti R, et al: Chronic endometritis: correlation among hysteroscopic, histologic, and bacteriologic findings in a prospective trial with 2190 consecutive office hysteroscopies. Fertil Steril 89(3):677, 2008 Cicinelli E, Parisi C, Galantino P, et al: Rdiability, feasibility, and safety of minihysreroscopy with a vaginoscopic approach: experience with 6,000 cases. Fcrtil Stcril 80(1): 199, 2003 Cicinelli E, Resta L, Nicoletti R, et al: Endomeuial micropolyp. Hum Reprod 12:667, 1997 Cohen I: Endomeuial pathologies associated with postmenopausal tamoxifen treatment. Gynecol Oncol 94:256, 2004 Cooper K, Lee A, Chien P, et al: Outcomes following hysterectomy or endometrial ablation for heavy menstrual bleeding: retrospective analysis of hospital episode statistics in Scotland. Pharm Biol 50(4):443, 2012 Coulter A, Bradlow J, Agass M, et al: Outcomes of refurrals to gynaecology outpatient clinics fur mensuual problems: an audit of general practice records. Contraception 80(4):337, 2009 Cura M, Martinez N, Cura A, et al: Arteriovenous malfurmations of the uterus. J Reprod Med 46(5):439, 2001 Demirkiran F, Yavuz E, Erend H, et al: Which is the best technique for endometrial sampling Cancer 89(8): 1765, 2000 Dogan E, Celiloglu M, Sarihan E, et al: Anesthetic effect of intrauterine lidocaine plus naproxen sodium in endometrial biop&y. S, Hickey M, Chin J, c:t al: Levonorgestrel intrauterine system fur endomeuial protection in women with breast cancer on adjuvant tamoxifen. Ultrasound Obster Gynecol 45(6):734, 2015 Dueholm M, M01ler C, Rydbjerg S, c:t al: An ultrasound algorithm for identification ofendometrial cancer. Ultrasound Obstc:t Gynecol 43(5):557, 2014 Edlund M, Blombiick M, Fried G: Desmopress. 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