BENIGN GYNECOLOGIC LESIONS

1. BENIGN GYNECOLOGIC LESIONS

3. 10. granular cell myoblastoma 11. von Recklinghausen 12. hematomas 13. dermatologic diseases a. pruritus & vulvodynia b. vulvar vestibulitis c. contact dermatitis d. psoriasis e. seborrheic dermatitis f. lichen planus g. hidradenitis suppurativa h. edema

4. VAGINA 1. urethral diverticulum 2. inclusion cysts 3. dysontogenic cysts 4. tampoon problems 5. local trauma

5. UTERUS I. CERVIX 1. endocervical & cervical polyps 2. nabothian cysts 3. lacerations 4. cervical myomas 5. cervical stenosis

6. UTERUS II. BODY OF THE UTERUS 1. endometrial polyps 2. hematometra 3. leiomyoma OVUDUCT/FALLOPIAN TUBES 1. leiomyomas 2. adenomatoid tumors 3. paratubal cysts 4. torsion

7. OVARY 1. functional cysts a. follicular cyst b. corpus luteum cysts c. theca lutein cysts 2. benign neoplasms of the ovary a. benign cystic teratoma( mature teratoma) b. endometriomas c. transitional cell tumor(Brenner) d. adeofibroma/cystadenofibroma e. torsion f. ovarian remnant syndrome g. fibroma

8. VULVA 1. Urethral carunle � small fleshy outgrowth of distal edge of urethra may be 1 � 2 cm diameter more in postmenopause sec. to chronic irritation or infection histologically composed of transitional and stratified squamous epithelium symptoms � dysuria, frequency,urgency point tenderness, ulcerative-hematuria approximately � 1 in 40 cases may dev malignant neoplasm

9. Urethral caruncle diagnosis � biopsy treatment � cryosurgery lasertherapy fulguration operative excision urethral prolapse � disease of premenarche : diagnosis in child treatment � hot sitz bath, antibiotics topical estrogen Diff dx � primary ca of urethra, prolapse urethral mucosa

10. VULVA Cyst most common large cyst � cystic dilatation of an obstructed Bartholin�s duct Treatment- not necessary in women less than 40 years old unless infected or enlarges to produce symptoms cyst maybe clear , yellow, blue

11. Wolffian duct cyst � found near the clitoris and lateral to the hymenal ring. They have thin walls and contain clear serous fluid. Epidermal inclusion cyst or sebaceous cyst-located beneath the epidermis, or the anterior half of the labia majora. usually multiple, movable, nontender, slow growing, firm to shotty in consistency grossly white or yellow

12. Inclusion cyst � following trauma like episiotomy site or obstetric laceration Most inclusion cyst of vagina are directly related to previous trauma while most inclusion cyst of vulva are not related to trauma. Most of these cysts need no treatment if infected � heat applied locally and incision and drainage.

13. Nevus � mole, localized nests or cluster of melanocytes vulvar nevi � asymptomatic 5 � 10 % of all malignant melanomas from vulva 50% arise from pre-existing nevi more in 50 year old woman ideally all flat nevi should be excised and examined histologically flat nevi have greater malignant potential

14. S/S A- asymmetry B- border irregularity C- color variegation D- Diameter more than 6 mm Hemangiomas � rare malformation of blood vessels Discovered initially � childhood Single, flat, soft, brown to red to purple

15. Hemangiomas most are asymptomatic may ulcerate and bleed 5 types 1. strawberry � young patients, red 2. cavernous � young patients, purple increase in size till 2 years old 3. senile � small lesions arise in labia majora, postmenopause, red brown to dark blue 4. cherry- postmenopause, red brown-blue 5. angiokeratomas � purple or dark red age � 30 � 50 years old, rapid growth bleed on strenuous exercise

16. Hemangiomas diagnosis � gross inspection of vascular lesion treatment � with bleeding cryosurgery or argon laser FIBROMA � most common solid benign tumors of the vulva More in labia majora, slow growing Low grade potential for malignancy Smooth surface and distinct contour Treatment � operative removal of fibromas if symptomatic or continue to grow

17. LIPOMA � benign, slow growing circumscribed tumors of fat cells Arising from subcutaneous tissue of the vulva it�s a mesenchymal tumor more in the labia majora Slow growing low malignant potential DIAGNOSIS - excision

18. HIDRADENOMA benign vulvar tumor from apocrine sweat glands of inner surface of labia majora and nearby perineum Age � 30 � 70 years old May be solid or cystic Tumors are well defined, sessile, pinkish gray with well defined capsules Asymptomatic TREATMENT � excisional biopsy

19. SYRINGOMA Rare, cystic,asymptomatic Small subcutaneous papules More in labia majora Pruritus TREAMENT � excisional biopsy cryosurgery

20. ENDOMETRIOSIS In the vulva is rare Firm nodule cystic or solid Subcutaneous, lesions are blue, red or purple, found in old OB lacerations Symptoms � vulva � pain, introital dyspareunia, cyclic discomfort with menstruation TREATMENT- wide excision laser vaporization

21. GRANULOSA CELL MYOBLASTOMA Rare, slow growing,solid tumor, Schwannoma ( neural sheath) Subcutaneous tissue of the vulva Commonly found in the tongue Nodules are pailess Cut surface is yellow TREATMENT � wide excision excisional biopsy

22. HEMATOMAS Secondary to blunt trauma like straddle injury from fall automobile accident, assault Management for non obstetric hematoma - conservative if meas is less than 10cm - if bleeding is venous TREATMENT- ice pack operative therapy drainage and debridement

23. DERMATOLOGIC DISEASES OF THE VULVA a. Pruritus � intense itching, desire to scratch �itch- scratch cycle� b. Vulvodynia � chronic vulvar discomfort, burning, stinging and rawness. c. Vulvar vestibulitis � unknown etiology pain and burning at introitus not an inflammation allodynia � pain related to nonpainful sti TREAMENT � topical anesthetics surgical removal of skin

24. d.Contact dermatitis � site � intertriginous areas red, edematous, inflammed skin weeping eczematoid vesicles TREATMENT � withdraw offending substance Burrows solution petroleum jelly hydrocortisone prednisone

25. e. Psoriasis - common generalized unknown etiology chronic spontaneous remission, or exacerbation genetics, multifactorial more in scalp and fingernails red to yellow papules may be 1st clin manifestation of HIV does not involve vagina DIAGNOSIS � classic silver scales and bleeding on scraping of plaques TREATMENT � hydrocortisone, chronic fissures � flourinated corticosteroids

26. f. Seborrheic dermatitis- rare etiology � unknown pale to yellow � red erythematous, edematous oily scales TREATMENT- hydrocortisone cream g. Lichen Planus � chronic eruption of shiny, violaceous papules inner aspects of the vulva etio � local autoimmune cell mediated response s/s � pruritus & pain, burning, scarring DIAGNOSIS � small punch biopsy TREATMENT � topical steroid cream

27. h.Hidradenitis suppurativa chronic, unrelenting, refractory infection of skin and subcutaneous tissue painful with foul smelling discharge more in reproductive age women DIAGNOSIS : biopsy TREATMENT- antibiotics and topical steroids options: antiandrogens, isotretinoin cyclosporin refractory cases � aggressive excision

28. VAGINA 1. Urethral diverticulum � permanent epithelialized sac- like projection from posterior urethra. suspect in chronic infection or recurrent lower urinary tract symptoms may be congenital or acquired most frequent symptoms- urgency frequency, dysuria,hematuria, 3 Ds dysuria, dribbling, dyspareunia

29. VAGINA- URETHRAL DIVERTICULUM DIAGNOSIS- foundation � physician�s awareness voiding cystourethrography cystourethroscopy others: TVS, CT scan, MRI positive pressure urethrography TREATMENT � excisional surgery most serious consequence � urinary incontinence, urethral vaginal fistula

30. VAGINA 2. Inclusion cyst � common located inposterior or lateral walls of the lower third of vagina more in parous women secondary to birth trauma asymptomatic TREATMENT � excisional biopsy

31. VAGINA 3. Dysontogenic cysts � thin walled soft cyst of embryonic origin Gartner duct cyst � anterior lateral wall of vagina. Mullerian cyst � upper half of the vagina, multip[le Vestibular cyst - urogenital sinus cyst asymptomatic TREATMENT � if with symptom operative excision

32. VAGINA 4. Tampoon problems � foreign body �toxic shock syndrome� staph aureus foul vaginal discharge TREATMENT - antibiotics for 7 days vaginal cream for 7 days

33. VAGINA 5. Local trauma � common due to coitus factors : virginity, postpartum and postmenopausal vaginal epithelialization pregnancy, intercourse after prolonged abstinence, hysterectomy usually � transverse tear in posterior fornix, presents with profuse or prolong vaginal bleeding MANAGEMENT � suturing under anesthesia

34. UTERUS CERVIX 1. Endocervical /cervical polyps most common multiparous � 40-50 years old maybe single or multiple bleed when touched, friable endocervix polyp- long pedicle, and narrow more in reproductive years intermenstrual bleeding

35. CERVIX ectocervix polyp � short base, postmenopause women histologically � columnar or squamous 6 different types 1. adenomatous 2. cystic 3. fibrous 4. vascular 5. inflammatory 6. fibromyomatous MANAGEMENT � grasping polyp with clamp, chemical cautery, electrocautery cryocautery

36. CERVIX 2. Nabothian cyst retension cyst of endocervical columnar cells multiple cyst, translucent or opaque yellow secondary to spontaneous healing of cx asymptomatic NO TREATMENT

37. CERVIX 3. Lacerations � in deliveries located at 3 and 9 oclock lacerations may extend to the broad ligament MANAGEMENT � suturing 4. Cervical myomas smooth, firm mass, solitary arise in isthmus of uterus small and asymptomatic dyspareunia, dysuria,urgency,ureteral and cervical obstruction

38. DIAGNOSIS � CERVICAL MYOMA inspection and palpation TREATMENT- ASYMPTOMATIC observe persistence of symptoms � GnRH myomectomy/hysterectomy radiologic catheter embolization

39. CERVIX 5. Cervical stenosis � internal os acquired or congenital if acquired sec to operative procedure infection, neoplasia,atrophic changes operative proc like cone biopsy, cautery of cervix common symptom in premenopause dysmenorrhea, pelvic pain, abn bleed amenorrhea, infertility

40. Cervical stenosis postmenopause � asymptomatic then slowly they develop hematometra hydrometra, pyometra DIAGNOSIS - inability to introduce a 1-2mm cervical dilator in uterine cavity MANAGEMENT � dilation of cx with Dilators under USG guidance, monthly Laminaria tents, leave a T tube or latex nasopharyngeal airway as a stent in cx canal for few days to maintain patency

41. BODY OF THE UTERUS 1. Endometrial polyps- localized overgrowth of endometrial glands and stroma that projects beyond surface of endometrium soft, pliable, single or multiple broad base � sessile Pedunculated- slender pedicle Etiology � unknown associated with endometrial hyperplasia

42. BODY OF UTERUS endometrial polyp majority are asymptomatic if with s/s � menorrhagia,premenstrual and postmenopausal staining and scanty postmenstrual spotting color � gray or tan occasionally red or brown age � peak � 40 � 49y/o

43. BODY OF UTERUS components of endometrial polyp 1. endometrial glands 2. endometrial stroma 3. central vascular channel malignant transformation 0.5% DIAGNOSIS � hysterectomy vaginal hydrosonography hysteroscopy,hysterosalphingography MANAGEMENT-curettage with removal of polyp hysteroscopy

44. BODY OF UTERUS 2. Hematometra uterus is distended with blood sec to partial or complete obstruction of lower genital tract obstruction of isthmus of uterus, cervix, or vagina may be congenital or acquired

45. BODY OF THE UTERUS Acquired obstruction senile atrophy, scarring by synecchia cervical stenosis sec to surgery, radiation, cryocautery, electrocautery malignant dse of endocervical canal suction curettage Symptoms- depends on age infection cyclic lower abdominal pain primary amenorrhea, tender uterus

46. DIAGNOSIS HEMATOMETRA history taking TREATMENT dependent on operative relief 3. Leiomyoma- also called myoma benign of muscle origin may also called fibroma or fibromyomas most frequent pelvic tumors may be single or multiple s/s pain sec large myoma /pressure abn bleeding, dysmenorrhea most � are asymptomatic

47. Leiomyoma 3 most common types 1. intramural 2. subserous- may become parasitic 3. submucous- most troublesome special nomenclature � broad lig myoma parasitic myoma Grossly � solid pearly, white mass histo- whorled configuaration of cells with pseudocapsule

48. Leiomyomas growth dependent on estrogen/progesterone tends to enlarge during pregnancy tends to decrease in size on menopause Myoma may degenerate into 1. hyaline 2. myxomatous 3. calcific 5. fatty 4. cystic 6. red degeneration

49. Leiomyoma mildest degeneration � hyaline acute degeneration � red & carneous carneous � occurs during pregnancy DIAGNOSIS- pelvic exam ,USG,CT scan MRI MANAGEMENT - small/asymptomatic observe Myomectomy & or hysterectomy

50. Leiomyoma Classic indications for myomectomy 1. rapidly expanding pelvic mass 2. persistent abnormal vaginal bleeding 3. pain or pressure 4. enlargement of asymptomatic myoma To more than 8 cm in a woman who has not completed childbearing

51. Leiomyoma contraindications to myomectomy 1. pregnancy 2. advanced adnexal dse 3. malignancy 4. situation in which enucleation of myoma may result in severe reduction of endometrial surface � uterus not functional

52. Leiomyoma Hysterectomy done with completed family size size 14 to 16 weeks gestation rapid growth of myoma after menopause Medical management Danazol, medroxyprogesterone acetate antiprogesterone RU 486

53. OVIDUCT/FALLOPIAN TUBES 1. Leiomyoma tubal may be single or multiple usually in interstitial portion usually coexist with uterine myoma smooth, firm mobile, nontender maybe subserosal interstitial, submucosal majority are asymptomatic

54. OVIDUCT 2. Adenomatoid tumors most prevalent benign tumors of FT small, gray white, circumscribed nodules, 1-2 cm diameter usually unilateral do ot become malig TREATMENT- EXCISION

55. OVIDUCT 3. Paratubal cyst- are incidental discoveries Small, asymptomatic, slow growing 40-50 years old When they are near the fimbrial end they are called Hydatid cyst of Morgagni Generally they produce a dull pain During pregnancy grow rapidly TREATMENT � SIMPLE EXCISION

56. OVIDUCT 4. Torsion acute torsion is a rare event predisposing factor � pregnancy usually accompanies torsion of ovary right tube is frequently involved MANAGEMENT � explore lap

57. OVARY 1. Functional cyst a. Follicular cyst � most frequent multiple from few mm to 15 cm physiologic, not neoplastic translucent, thin walled, filled with watery, clear to straw color fluid majority are asymptomatic Initial MGT. � observe persistent ovarian mass � excision cystectomy

58. OVARY 2. Corpus luteum cyst less common clinically more important all corpora lutea are cystic with gradual reabsorption of a limited amt of hemorrhage which may form a cavity clinically they a re not term corpus luteum cyst unless they are of 3 cm dia corpus luteum assoc with normal endocrine function or prolong sec of progesterone

59. OVARY CORPUS LUTEUM CYST assoc menstrual pattern normal, delayed, amenorrhea most are small ave dia 4 cm asymptomatic if it ruptures it may cause intraperitoneal bleeding DIAGNOSIS - USG MANAGEMENT- Cystectomy is the choice

60. OVARY 3. Theca lutein cysts least common almost always bilateral dia from 1 to 10 cm hyperreactio luteinalis � condition of ovarian enlargement sec to dev of multi luteinized follicular cysts found in 50% of molar preg 10% in chorio carcinoma

61. OVARY Theca lutein cells cyst are also found in multiple pregnancies, diabetes, Rh sensitization Grossly the total ovarian size may be 20 to 30 cm diameter Bilateral enlargement due to hundreds of thin walled locules producing honeycombed appearance. DIAGNOSIS - palpation / USG TREATMENT � CONSERVATIVE regress gradually COX- rupture

62. OVARY 4. Benign cystic teratoma (dermoids, mature teratoma) Teratoma � monstrous growth maybe benign or malignant malignant variety � immature teratoma 1-2% of dermoids most common ovarian tumors 25 � 50 years old women size from few mm to 25 cm diameter may be single or multiple, unilocular

63. OVARY BENIGN CYSTIC TERATOMA arise from single germ cell after first meiotic division Grossly cyst wall are smooth, shiny, opaque,white color Maybe composed of ectoderm, endoderm, Mesoderm materials, like hair, nails, brain Cartilage etc. DIAGNOSIS- palpation/USG MANAGEMENT � explorelap/cystectomy

64. OVARY 5. Endometriomas � separate topic 6. Fibroma of the ovary most common benign tumor of the ovary Size vary from small nodules to huge pelvic tumors weighing 50 pounds Extremely slow growing tumors Usually unilateral average age 48 years old, s/s abdominal enlargement, pressure, ascites no change in menstrual pattern Meigs syndrome � ascites hydrothorax, fibroma

65. OVARY Fibroma usually are solid, heavy,well encapsulated, grayish white On cut surface demonstrate a homogenous white or yellowish white solid tissue with a trabeculated or whorled appearace similar to myoma of the uterus Histologially � connective tissues DIAGNOSIS - palpation/ USG MANAGEMENT - explorelap

66. OVARY 7. Transitional cell tumor � Brenner tumors rare, small, smooth, solid, fibroepithelial tumors generally asymptomatic benign, low malignant potential 90% are discovered accidentally during surgery sometimes assoc with postmenopausal vaginal bleeding, endometrial hyperplsia

67. OVARY Brenner histologically it has 2 components 1. solid masses 2. nests of epithelial cells and a surrounding fibrous stroma the pale epithellial cells have a coffee bean appearing nucleus MANAGEMENT � explorelap with simple excision

68. OVARY 8. adenofibroma/cystadenofibroma closely related benign tumors, firm consists of fibrous stroma and epithelial components epithelial � serous histologically maybe mucinous, and endometroid or clear cell. small � asymptomatic large � pressure symptoms, rupture management - TAHBSO

69. OVARY 9. Torsion of the ovary or both oviduct and the ovary is uncommon cause of acute lower abdominal and pelvic pain most in reproductive years ave age mid 20s s/s acute severe, unilateral, lower abdominal and pelvic pain to an abrupt change in position, assoc with vomiting fever with necrosis of adnexal torsion DIAGNOSIS- pelvic exam/ USG Management - Explorelap

70. OVARY 10. Ovarian remnant syndrome chronic pelvic pain sec to a small area of functioning ovarian tissue following intended removal of both ovaries most women have endometriosis pain is cyclic and exacerbated following coitus masses are small 3 cm in dia located retroperitoneally near ureter

71. OVARY Ovarian remnant syndrome DIAGNOSIS PELVIC EXAM/ HISTORY/ USG MRI/ PREMENOPAUSAL FSH LEVEL to women who has had BSO MANAGEMENT � surgical removal of the ovarian remnant

75. VAGINA

79. . .