Gynaecology 2 DME MULAGO for all midwifery in tertiary institutions docx

PREPARED BY WILFRED IREMBA
0774122842 / 0750441600
Irembawilfred0608@gmail.com
MSRH/BScN/PGDME/ADPCN/CCN/RN
GYNAECOLOGY 2
MULAGO SCHOOL OF NURSING AND MIDWIFERY
NOTES
Gynaecology Course Outline
  Structural abnormalities of the female genital tract
  Menstruation disorders
  Dysfunctional uterine bleeding
  Menopause
  Abortions
  Ectopic Pregnancy
  Hydatidiform mole
  Pelvic Inflammatory Diseases
  Fibroids
  Vesico-Vaginal Fistula(VVF) and Recto-Vaginal fistula
(RVF)
  Genital cancers (Cervix, Uterus, and Ovaries)
  Breast cancer
  Uterine prolapse
  Genital prolapse ( Rectocele and Cystocele)
  Infertility

CONGENITAL ABNORMALITIES OF THE REPRODUCTIVE TRACT
This term refers to a variety of structural disorders of the reproductive tract (vagina, cervix,
uterus and fallopian tubes) that occur while the child is growing in the womb. Congenital
abnormalities of the reproductive tract occur in a few percent of the female population, and may
affect:
Congenital anomalies of the uterus
• Septate uterus: A common congenital uterine abnormality, this condition occurs when a
band of muscle or tissue divides a uterus into two sections. This condition can cause
miscarriages and preterm birth.
• Bicornuate uterus: This condition deals with a heart shaped uterus with two horns. It
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could increase the risk of pre-term labor.
• Arcuate uterus: This condition is described as a uterine surface that has a slight
indentation. This condition isn’t highly associated with the loss of pregnancy.
• Unicornuate: A unicornuate describes a uterus that is only half developed.
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• Didelphys: This condition occurs when a woman has two uterine bodies. Each uterus has a
cervix.
Congenital malformations of the vulva
• Labial hypoplasia: Labial hypoplasia occurs when one or both of the labia do not develop
normally. The labia act as fat pads that protect from trauma. This irregularity can surface
either during childhood, or through puberty.
• Labial hypertrophy: Labial hypertrophy describes the enlargement of the labia. This can
lead to irritation, chronic infections, interference with intercourse and pain.
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Congenital anomalies of the hymen
• Imperforate hymen: A hymen is a membrane that surrounds or covers the opening of the
vagina. The hymenal tissue is a circular form of tissue, which has a hole within the center.
When there is no opening in the hymen, a membrane covers the area called an imperforate
hymen. This requires surgical correction and is usually diagnosed in newborns, or during
the first menstrual period. If it isn’t surgically corrected, you may experience irregular
menstrual periods due to a blockage. This blockage can cause back pain, abdominal pain or
difficulty with urination.
• Microperforate hymen: A microperforate hymen is similar to an imperforate hymen, but
with the presence of a very small hole within. This hole makes it difficult for blood and
mucus to come through the hymenal opening. Instead of a regular period lasting four to
seven days, you could experience longer periods due to the fact that blood cannot drain at a
normal rate. This can also make wearing tampons painful. The hymenal tissue could tear
during intercourse. A microperforate hymen could go away as you age, or it could tear
away due to tampons and intercourse. A surgical correction can be performed to remove
extra tissue and create a normal opening.
• Septate hymen: A septate hymen is when the hymenal membrane has extra tissue in the
middle, causing two small vaginal openings as opposed to one. This could interfere with
the ability to wear a tampon, or to take a tampon out after it has filled with blood. A septate
hymen doesn’t need to be surgically removed and is typically torn during sexual
intercourse. Possible side effects include pain, discomfort or bleeding. This can be
corrected via a simple surgical approach that removes the septate hymen.
Congenital anomalies of the vagina
• Transverse vaginal septum: A transverse vaginal septum is a horizontal collection of
tissue that forms in the embryo. It essentially creates a blockage of the vagina. This can
occur at different levels of the vagina. Some women have a small hole in the septum called
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a fenestration. During a menstrual period, blood could take longer to flow, causing periods
to last longer than four to seven days. If there is no hole and the septum is blocking the
upper vagina from the lower vagina, menstrual blood can pool and may cause abdominal
pain. This will most likely require surgical correction.
• Vertical or complete vaginal septum: A vertical or complete vaginal septum is a
condition where a wall of tissue runs vertically up and down the length of the vagina,
dividing it into two cavities. While this condition may cause no symptoms, you could
experience pain when removing or inserting a tampon, or pain during intercourse.
• Vaginal agenesis: Vaginal agenesis is a condition that develops before birth where the
vagina fails to fully develop. The most common form of this condition is Mayer von
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Rokitansky–Küster Hauser’s syndrome (MRKH), in which the vagina does not develop in
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the embryo. Women with MRKH have functional ovaries. There are several variations of
MRKH, such as the lack of a vagina and a uterus, or no vagina, a single midline uterus and
no cervix. Symptoms include a small pouch where the vagina should be, absence of a
menstrual cycle and lower abdominal pain. Vaginal agenesis requires surgical correction,
or having intercourse and a baby may be impossible. Some women may have kidney
abnormalities.
Congenital anomalies of the cervix
• Cervical agenesis: Cervical agenesis occurs when a woman is born without a cervix. This
means there could be the absence of a uterus and a vagina. If a uterus is present, your
doctor may suggest medications to control retrograde menstruation, the backward
movement of menstrual fluid. Your doctor may also perform a surgical procedure that
fuses the uterus to a vagina.
• Cervical duplication: Cervical duplication occurs when a woman is born with two
cervixes. Symptoms can include abnormal pain before a period, abnormal bleeding and
infertility issues.
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• Cervical incompetence: An incompetent cervix, also called a cervical insufficiency, is a
condition that occurs when weak cervical tissue contributes to premature birth or loss of an
otherwise healthy pregnancy.
NB: A developmental disorder may be obvious as soon as the child is born, or it may be
diagnosed during puberty or after menstruation has begun. For some females, a congenital
disorder of the reproductive tract is not identified until they are pregnant or trying to conceive.
Disorders of the reproductive tract may be accompanied by congenital disorders of the urinary
tract, kidneys, and spine. What are the symptoms associated with a congenital abnormality of the
reproductive tract?
Symptoms vary according to the girl’s age and condition.
Signs apparent in infancy may include:
• Abnormal vaginal opening
• Genitals that are hard to identify as a girl or boy (ambiguous genitalia)
• Labia that are stuck together or unusual in size
• No openings in the genital area or a single rectal opening  Swollen clitoris
As the female matures, symptoms may include:
• Amenorrhea by the age of 15 despite normal female development
• Monthly cramping or pain, without menstruation
• A lump in the lower abdomen, usually caused by blood or mucus that cannot drain
appropriately
• Painful menstruation that worsens with time
• Menstrual overflow with tampon use (a sign of a second vagina)
• Pain with intercourse
• Repeated miscarriages or preterm births (may be due to an abnormal uterus)
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How is a congenital abnormality of the reproductive tract diagnosed?
Our specialists in pediatric gynecology can detect some abnormalities on physical examination.
Further diagnostic tests may include:
• History taking
• Physical examination
• Karyotyping (genetic testing)
• Testing of Hormone levels
• Ultrasound or MRI of the pelvic area.
• Exam under anesthesia
• Abdominal CT scans
• Hysterosalpingogram (HSG): An HSG is an X ray procedure typically used to asses
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fertility.
• Magnetic resonance imaging (MRI)—An MRI is a diagnostic procedure that utilizes a
large magnet, radiofrequencies and a computer to reflect images of structures and organs
within your body.
Treatment
Surgery: There are certain disorders of the reproductive tract that can be corrected with surgery.
If there is a blockage of the vagina and/or uterus, surgical repair is necessary to fix this problem.
Although some surgeries for reproductive disorders may be performed on infants, most
procedures are delayed until the child is older and has started to menstruate.
Dilator: If a girl is born without a vagina, there options for creating a vagina for her once she has
gone through puberty. The simplest effective treatment is to use a dilator; this device is used to
stretch or widen the area where the vagina is supposed to be. This nonsurgical therapy takes four
to six months to create a new vagina.
Psycho-social Support: This is key for families of children diagnosed with abnormalities of the
reproductive organs. As the girls get older, we also recommend counseling and support groups
for them.
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INCOMPETENT CERVIX
Definition:
An incompetent cervix, also called a cervical insufficiency, is a condition that occurs when weak
cervical tissue contributes to premature birth or loss of an otherwise healthy pregnancy.
In general terms the cervix becomes “WEAK” so that as the pregnancy advances and pressure in
the uterus increases the cervix opens up gradually so that the membranes may bulge through the
cervix and eventually rupture thereby causing the liquor to drain out.
Alternatively the fetus in its complete sac comes out through this dilated cervix.
An incompetent cervix can be difficult to diagnose and as a result treat. If your cervix begins to
open early, your health care provider might recommend preventive medication during pregnancy,
frequent ultrasounds or a procedure that closes the cervix with strong sutures.
NB: abortions as a result of incompetent cervix always take place above 20th
week of gestation.
Causes
• Congenital weakness
• Uterine abnormalities e.g. Bicornuate uterus
• Genetic disorders affecting a fibrous type of protein that makes up your body’s connective
tissue might cause an incompetent cervix.
• Exposure to diethylstilbestrol (DES), a synthetic form of the hormone estrogen, before
birth also has been linked to cervical insufficiency.
• Cervical Trauma. If you experience a cervical tear during a previous labour and delivery
you could have an incompetent cervix.
• Dilatation and curettage (D & C):- This procedure is used to diagnose or treat various
uterine conditions such as heavy bleeding or to clear the uterine lining after a miscarriage
or abortion. On rare occasions it may cause structural damage to the cervix.
• Cone Biopsy for cancer of the cervix in early stages.
• During Merchester repair for Prolapse of the uterus in young women.
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• Amputation of the cervix for example chronic cervicitis.
Clinical presentation
Mild symptoms between 14wks to 20 weeks of gestation
• Pelvic pressure
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• Back ache
• Pre-menstrual cramping
• Vaginal discharge that increases in volume
• Vaginal discharge that changes from clear, white or light yellow to pink.
• Light vaginal bleeding
Others
• The woman will present with drainage of liquor before 4 -5 -6 months.
• A relatively painless delivery or abortion
• Usually they deliver a live fetus eventually it will pass away because it is too
small.  Alternatively the fetus may come out in its complete sac. (CA- L) 
Painless cervical dilatation, short labors.
• Cervical effacement before 24wk of pregnancy.
Diagnosis
It can only be detected during pregnancy and not on the first pregnancy. This is done
during the second Trimester.
• History: of habitual abortions while coughing.
• Exam: Before pregnancy the cervix may look completely normal. Short cervix
 Cervical tears.
• Investigations: Abdominal scan during pregnancy may reveal the incompetence.
 Hegar’s dilator size 4 enters the cervix easily.
 Ballooned folley catheter comes out easily.
 Trans-vaginal ultrasound —helps to evaluate the length of your cervix
beginning at 16 weeks to measure the length of the cervix and it is done every
2 weeks until 23 weeks and if the cervix is shorter than 25 mm it means one is
likely to have incompetent cervix.
 Pelvic exam —your health care provider will examine your cervix to see if the
amniotic sac has begun to protrude through the opening.
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 If the fetal membranes are visible and an ultrasound shows signs of
inflammation but you don’t have symptoms of an infection.
 Your health care provider might test a sample of amniotic fluid to diagnose
infection.
Treatment
• Progesterone supplementation. If you have a history of premature birth, your
health care provider might suggest weekly shots of a form of the hormone
progesterone called hydroxyprogesterone caproate (makena) during your second
Trimester. Currently progesterone treatments do not seem to be helpful for
pregnancy with twins or more so its contraindicated.
• Cervical cerclage: - If you are less than 24 wks pregnant or have a history of
early premature birth and an ultrasound shows that your cervix is opening a
surgical procedure known as cervical cerclage might help prevent premature birth.
During this procedure, the cervix is stitched closed with strong sutures. Also
prophylactic cerclage can also be done before l4wk of pregnancy. The type of
stitch used is called shirodker stitch or MacDonald’s stitch. they use spinal
anesthesia.
Dangers of the shirodker stitch
• Rupture of the uterus if the patient goes into labour when the stitch has not been
removed.
• Infection.
• Cervical tear if the patients stitch is not removed before she goes into labour.
• If the stitch is tied very tightly the distal part of the cervix may slough off because
the blood supply will be cut off.
• Puncture of the membranes.
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• Cervical dystocia —the cervix fails to dilate because the stitch has not been
removed.
When do you remove a shirodker stitch?
• When membranes have ruptured whether or not she has reached term?
• When pregnancy reaches term?
• When there is I.U.F.D?
• When patient goes into labour?
• When there is gross/severe con genital abnormalities?
Others
Health provider might also recommend the use of a device that fits inside the vagina and
is designed to hold the uterus in place (pessary). This help to lessen pressure on the
cervix.
Your health provider might recommend restricting sexual activity or limiting certain
physical activities. Bed rest may be prescribed in some cases seek regular prenatal care.
Patient information
• Seek regular prenatal care.
• Eat a healthy diet e.g. folic acid, calcium, iron, vitamin.
• Gain weight wisely
• Avoid risky substances e.g. smoking, Alcohol.
ADENOMYOSIS
This is a condition which occurs when the endometrial tissue which normally lines the
uterus exists within the myometrium.
Causes
The cause of adenomyosis remains unknown but the disease typically disappears after
menopause. However experts theories about a possible cause include.
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• Invasive Tissue growth: Some experts believe that ademyosis results from the
direct invasion of endometrial cells from the linning of the uterus into the muscle
that forms the uterine walls. Uterine incisions made during an operation such as a
cesarian section may promote the direct invasion of the endometrial cells into the
wall of the uterus.
• Developmental origins: Other experts speculate that ademyosis originates within
he uterine muscle from endometial tissue deposited there when the uterus first
formed in the fetus.
• Uterine inflammation related to child birth: Another theory suggests a link
between adenomyosis and child birth. An inflammation of the uterine linning
during the post partum period might cause a break in the normal boundary of cells
that line the uterus. surgical procedures on the uterus have a similar effect.
• Stem cell origins: A recent theory proposes that the bone marrow stem cells may
invade the uterine muscle causing ademyosis.
NOTE: regardless of how adenomyosis develops ots growth depends on the circulating
oestrogen in a woman’s body. When oestrogen production decreases at menopause,
adenomyosis eventually goes away
Signs and symptoms of adenomyosis
• Sometimes adenomosis is silent causing no signs or symptoms or only mildly
uncomfortable and in other cases, adenomyosis may cause: -
• Abdominal pressure and bloting before menstruation  Heavy or prolonged
menstrual bleeding.
• Severe cramping or sharp, knifelike pelvic pain during menstruation.
• Menstrual cramps that last throught your period and worsen as you get older.
• Pain during coitus
• Blood clots that pass during your periods.
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Diagnosis
Based on the following
• Signs and symptoms
• A pelvic exam that reveals an enlarged, masses in the uterus
• Ultra sound scan of the uterus
• Magnetic resonance imaging (MRI) of the uterus
Differential diagnosis
• Leiomyomas
• Endometriosis
• Endometrial polyps Management
Adenomyosis usually goes away after menopause so treatment may depend on how
close you are to that stage of life
Treatment
Anti-inflammatory drugs e.g. ibuprofen before periods 2 to 3 days and continue to take it
during your periods. Hysterectomy
Other treatment therapies
• Soak in the warm bath
• Use a heating pad on your abdomen
• Take an over the counter anti – inflammatory medication such as ibuprofen.
ENDOMETRIOSIS
It is often a painful disorder in which endometrial tissue that normally lies inside the
uterus grows outside the uterus.
Sites of endometriosis
• Pouch of Douglas
• Ovaries
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• Utero Vesical pouch
• Peritoneum
• Stomach
• Intestines
• Spleen
Signs and symptoms
The signs depend on the site where endometrial tissue is
Reproductive system
• Painful periods (dysmenorrhoea)
• Dsyspareunia (painful coitus)
• Excessive bleeding (menorrhagia)
• Infertility
• Lower backache
Urinary system
• Urinary tract infections
• Dysuria
• cyclical heamaturia
Gastro intestinal tract
• Painful defecation (dyschezia)
• Cyclical rectal bleeding
• Fatigue, diarrhoea, constipation, bloating or nausea especially during menstrual
periods  Lungs
• Cyclical haemoptysis
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• Haemo-pneumothorax
Incidence
• More common in Asians and whites and black women.
• Women who have never had a full term pregnancy
• 30 years and above
• Common in high social economical class
Causes
The actual cause in unknown however there are several explanations.
• Genetic: - it may run in the family
• Retrograde menstruation: - This is the most likely explanations for
endometriosis because menstrual blood containing endometrial cells flows
back through the fallopian tubes and into the pelvic cavity instead of the
uterus then out of the body. These displaced endometrial cells stick to the
pelvic walls and surface of pelvic organs, where they grow and continue to
thicken and bleed over the course of each menstrual cycle.
• Embryonic cell growth: - the cells linning the abdominal and pelvic cavities
come from embryonic cells. When one or more small areas of the abdominal
linning turn into endometrial tissue, endometriosis can develop.
• Surgical scar implantation: - After a surgery such as hysterectomy or
caesarian section endometrial cells may attach to a surgical incisions
• Endometrial cell transport: - The blood vessels or tissue fluid (lymphatic)
system may transport endometrial cells to other parts of the body
• Immune system disorder: - It’s possible that a problem with the immune
system may make the body unable to recognize and destroy endometrial
tissue that’s is growing outside the uterus. Risk factors for endometriosis
• Null para
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• One or more relatives (mother, aunt, sister) with the condition
• Any medical condition that prevents the normal passage of menstrual flow
out of the body
• History of a pelvic infection
• Uterine abnormalities that prevent the normal out flow of the menstrual
blood. Differential diagnosis
• Pid
• Irritable bowel syndrome
• Ovarian cysts Diagnosis
• Pelvic exam – doctor manually palpates the areas in your pelvis
abnormalities
• Ultra sound
• Laparascopy
Management
Treatment for endometriosis is usually with medications or surgery. Doctor
chooses treatment depending on the severity of your signs and symptoms.
Doctor recommend trying conservative treatment approaches first before opting for
surgery.
• Pain medication e.g. Nsaids these help ease painful menstrual cramos.
• Hormonal therapy e.g. Po, depo-provera, danazol gn – r4 agonists and
antagonists.
• Conservative surgery either by laparascopic surgery or tradition abdominal
sugery.
• Assisted reproductive technologies e.g. In vitro fertilization
• Hysterectomy most preferably total hsterectomy

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Other treatments
• Warm bath
• A heating pad can help to relax pelvic muscle tus reducing cramping and
pain
• NSAIDS
• Getting regular exercise may help improve symptoms
• Acupunctuetreatment
• Joining a support group for women with endometriosis.
ENDOMETRITIS
It is the inflammatory condition of the linning of the uterus and usually due to an
infection.
It is usually not life threatening but it’s important to get treated with antibiotics and
goes away.
Causes
• It is generally caused by infections e.g. sexually transmitted infections such
as chlamydia and gonorrhea and Tuberculosis.
• Infections resulting from the mix of normal vaginal bacteria.
• After medical procedure that involves entering the uterus through the cervix.
e.g. hysteroscopy, placement of an intra-uterine device, dilatation and
curettage (uterine scrapping) After an abortion.
• Following a long labour or a caesarian section
Symptoms of Endometritis
• Abdominal swelling
• Abnormal vaginal bleeding
• Constipation
• Discomfort when having a bowel movement
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• Fever
• Genera; feeling of sickness
• Pain in the pelvis, lower abdominal area and rectal area
Diagnosis
Conducting a physical exam and pelvic exam on the abdomen, uterus, cervix for
signs of tenderness and discharge.
The following tests may also help diagnose the condition:-
• Taking samples or cultures from the cervix to test for bacteria that can cause
an infection such as chlamydia and gonococcus
• Removing a small amount of tissue from the linning of the uterus to test
which is called endometrial biopsy.
• A laparoscopy procedure that allows your doctor to look more closely at the
insides of your abdomen
• Looking at the discharge under a microscope
• Blood test can also be done to measure your white blood cells and
erythrocyte sedimentation rate
Treatment
Endometritis is treated with antibiotics.
Sexual partners may also need to be treated if a doctor finds out that you have an
STI serious or complex cases may need intravenous fluids and rest in hospital
especially if the condition follows child birth.
Complications
• Infertility
• Pelvic peritonitis which is general pelvic infection.
• Collections of pus or abcesses in the pelvic or uterus

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• Septicaemia which is bacteria in the blood
• Septic shock which is an overwhelming blood infection that leads to very
low blood pressure
Prevention
• Using sterile equipment and techniques during delivery or surgery
• Precaution of abc during c/s or before surgery begins
• Practicing safe sex e.g. Using condoms
• Getting routine screening and early diagnosis of suspected stis in both your
self and your partner
• Finishing all treatment prescribed for an STIs
UTERINE FIBROIDS
These are non-cancerous growths of the uterus that often appear during a woman’s
child bearing years.
• They are also referred to as fibromyomas, leiomyomas or myomas.
• They grow within the smooth muscle of the uterus (myometrium) with a
variable amount of fibrous tissue.
• When cut across they show a wholed appearance which is onion like.
Incidence
• Develop in women between 25 – 50 years
• May spontaneously regress after menopause
Risk factors associated with fibroids
• Can be hereditary
• Increased intake of oestrogen and progesterone stimulate the development of
the uterine lining in preparation for pregnancy and appears to promote the
growth of fibroids
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• Race: - more common in blacks than in whites
• Age rare before the age of 20years
Obesity

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• Infertility or low infertility
• Women who have never given birth
• Vitamin D deficiency
• Alcohol
• Low vegetable diet and high red meat diet
• Early onset of menstruation Types of uterine fibroids
These are according to the location
• Sub mucous fibroids: - these grow in the endometrium or hanging into the
cavity incase they form a polyp along a long pedicle (hence called
pediculated sub mucosal fibroids)
• Sub serosal fibroids: - these lie below the perimetrium. they project outside
of the uterus commonly causing pressure symptoms on the bladder, rectum
or spinal nerves (backache)
Interstitial fibroids (intra mural): - are within the myometrium layer
• Cervical fibroids: - is within the cervix
• Broad ligament fibroids: - as serous fibroids arising from either of the body
of the uterus or cervix and lying between the two folds of the broad
ligaments.

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Clinical presentation
Small fibroids do not cause symptoms especially if the patient is obese. However
the nearer the fibroid is to the endometrium the more symptoms it is likely to cause
the following
• Palpable mass firm, rubbery in consistency with abdominal swelling
• Menorrhagia and anaemia especially in sub mucosal fibroids due to over
bleeding.
• Pressure symptoms on pelvic organs leads to
 Frequency micturition in-case it is on the urinary bladder
 Constipation and hemorrhoids in-case it is near the rectum
 Backache and leg pain and spinal nerves
 Pelvic pain and pressure
• Infertility may be a presenting symptom
• Dyspareunia
• Severe pain in-case of torsion of the pedicle of the sub mucosal fibroid

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NB: Malignant change is rare but can give to sarcoma of the uterus in less than
0.5%
Pregnancy (because of periods of amenorrhoea/missed period)
• Ovarian cysts /tumors
• Adenomyosis
• Endometriosis
• Ectopic pelvic kidney
Management
This will depend on
• Age of the client
• Parity
• Size of the tumor
• Symptoms caused by the tumor
Investigations done
• Radiography
• Abdominal ultra-scan confirm diagnosis
• Trans-vaginal ultra sound scan
• Hysteroscopy: - sterile injected into the uterine cavity and x- ray pictures are
then taken.
• HSG – a dye is injected in the uterine cavity through to the tubes and X-ray
pictures taken.
• Blood: Hb estimation to rule anaemia
• Grouping and x- match incase transfusion becomes necessary to know the
blood group A,B,AB and O
• FBC, ESR, WBC to rule out infections
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• Prothrombin time to rule out bleeding disorder s (bleeding and clotting
time) Hormonal assay to rule hormonal imbalance.
• Routine urinalysis to rule infection, sugar levels, proteins.
Others
• History taking
• Abdominal examination Medical treatment
• Progesterone and NSAIDs drugs can be used to control menstrual loss but
have no effect on the size of the fibroid.
• Gonadotrophin releasing hormone (GnRH) analogues can be used to reduced
to reduce the size of the fibroids can be used to reduce the size of the fibroid.
However if used for long time, reduce bone density and usually the fibroids
return to the original size once treatment is stopped. Its most useful prior to
myomectomy.
• Uterine artery embolism: are catheterized via the femoral artery and
polyvinyl particles injected to reduce blood supply to the uterus. The fibroid
shrinks due to ischemia
Surgical treatment
• The treatment may be the removal of the tumor by a surgery called
myomectomyand it is for women who want or expect more babies.
• Fibroid polypectomy: this is a surgical removal of a fibroid polyp while
twisting it off the pedicle.
• Total hysterectomy: - in women who are elderly or not expecting any more
change.  Neglect them in-case of women nearing menopause.
Assignment
• Draw and name the uterus and indicate various sites of fibroids

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• Explain pre-operative and post-operative nursing care of a patient of
myomectomy.
Complications of fibroids
Haemorrhage: fibroids hardly have any blood vessels in their substance
instead they got their blood vessels in pseudo capsule and if they rupture the
woman may bleed heavily in the peritoneal cavity which may be confused
with ruptured spleen or ruptured ectopic pregnancy.
Infection: Common in-cases of;-
 Submucosal fibroids prolapsed into the cervix
 Cut off the blood supply to the large fibroid
 Ulcerated or traumatised fibroid
Signs and symptoms
 Offensive vaginal discharge which may be blood stained
 Common in puerperium
Treatment
Refer to hospital as fibroid may be removed vaginally especially if
there is PPH
 Torsion: a sub serous (pediculated) fibroid may undergo rotation as veins
within the walls occlude, arteries remain open causing engorgement
Signs and symptoms
 Severe abdominal pain (acute)
 Vomiting
 Vaginal bleeding
 May be in shock
Treatment: refer urgently to the hospital for surgery
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Others
• Compression of the fallopian tube may cause partia; blockage leading to
ectopic pregnancy
• Abortion
• Obstructed labour
• Placenta previa
• Pre-mature labour
• Anaemia from menorrhagia
• Malpresentations
• Malignant change (uncommon) i.e. It will become a sarcome
• Infertilty as a result of compression of the tube incase fibroids are near the
tube  Poor implatation sites
Complaints related to pregnancy and fibroids
Amenorrhoea: fibroids never cause amenorrhoea unless
• There is pregnancy
• The woman has reached menopause
• Cryptomenorrhoea (hidden masses) due to fibroid embeddance at cervical os
and obstructing the menstrual flow.
Infertility
• Blockage of the fallopian tubes
• Interference with transport of the sperms from the cervix of the fallopian
tubes
• Sub seroal fibroids can interfere with the implantation and growth of an
embryo
Abortions
• Due to poor implantation sites

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• Uterus doesnot expand to accommodate the growing fetus
Others
• Premature labour
• Intra uterine fetal growth retardation
• Malpresentation: any presentation other than the vertex.  Retained
placenta leading to haemorrhage  Post partum haemorrhage.
Changes that can take place in the fibroid
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Red degeneration: occurs during pregnancy due to the interference with blood
supply, the fibroid becomes necrosed and reddish (beefy red soft) and becomes
soft.
Signs and symptoms
• There is acute abdominal pain
• Area is tender and tense
• Vomiting
• Slight pyrexia
• Shock
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Treatment
• Bed rest
• Analgesics
• Antibiotics
• Patients settles down within 5 – 7 days NB: the fibroid is not removed.
Degeneratic changes
• Atrophy may occur after menopause
• Hyaline degeneration: the fibroid becomes soft and the muscle fibers are
replaced by homogenous structureless material
• Parasitic fibroid: is a fibroid where blood supply has been cut off by torsion of
its pedicle and gets a new blood supply from the surrounding e.g.
Cystic change: following hyaline degeneration of the new almost rotten material is
turned into fluid so that the whole fibroid becomes cystic almost like an ovarian cyst
Fatty change: The muscle fibers are replaced by fat
Calcification: Calcium salts are deposited in the fibroid so that instead is now
hardened like a stone.
Egg shell fibroid (calcification): the calcium salts are deposited on the outside of the
fibroid so at the inside of it remains with its usual consistency.
Womb stone: the whole of the fibroid is deposited with calcium salts so that the
fibroid is hardened like a stone
HYSTERECTOMY
It is a surgical removal of the uterus.
The uterus can be removed either through the abdomen as is called abdominal
hysterectomy or through the vagina which is called vaginal hysterectomy.
Total hysterectomy
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The whole uterus is removed including the cervix
Sub-total hysterectomy
The body of uterus is removed leaving behind the whole cervix or part of the cervix.
Others
Hysterectomy + surgical of the ovaries is termed as hysterectomy + oophorectomy or
hysterectomy + bilateral oophorectomy.
Hysterectomy + removal of the fallopian tubes is hysterectomy + Bi-lateral
salpingectomy
Hysterectomy + removal of ovaries + removal of fallopian tubes is hysterectomy + bi-
lateral salpingo – oophorectomy
Indications for Hysterectomy
• Ruptured uterus
• Uterine fibroid
• Cancer of the body of the uterus (endometrial carcinoma)
• Uncontrolled post-partum haemorrhage
• Cancer of the cervix
• Prolapse of the uterus
• Placenta acreta
• Ovarian cysts in post-menopausal women
• Ovarian cancer
• Chronic pelvic inflammatory diseases with inflammatory masses not responding
to medical therapies
• Trophoblastic diseases (molar pregnancy) in old women 40yrs and above
• Invasive or perforated hydatid form mole perforating the uterus
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Preparation of a patient undergoing hysterectomy, oophorectomy, myomectomy
It can be a planned surgery or an emergency incase of torsion of the
pediculated fibroids Admission of the patient on the gnaecological
ward History taking: personal, medical, social, gyanaecological.
Physical examination
• Vital observations; temperature, respirations, blood pressure and pulse 
Head to toe examination: to rule out anaemia, dehydration, jaudice Vaginal
examination: to rule out abnormalities.
• General assement by the gynaecologist.
Investigations
• Urinalysis
• HB, Blood grouping and cross match
• Abdominal ultra sound scan
• Urea and electrolytes
Patient education: about the surgery i.e. its purpose, complications and side effects of
anaethesia.
Re-assuring the patient
Obtaining of the informed consent form
Feeding: No feeds or drinks on the day of the operation
Rest and sleep: ensuring enough rest and sleep i.e. minizing noise, reducing
bright light Morning at the day of the operations
• IV line is put up
• Booking for blood in the laboratory
• Catheterisation of the patient
• Administration of pre-medications
• Helping the patient to change into hospital gown
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• Removal of all ornaments from the patint and keep them prperly.
• Continouesconselling to relieve anxienty
• Preparation of patients medical document
• Taking the patien to the theater and handing him over to the theater.
Post operative management
Post operative bed is made
When the operation is finished, the information from the theater will be sent to the
ward and 2 nurses will go and collected the patient
Reports are received from the surgeon, recovery room nurses and
anaethestists Then the patient is wheeld to the ward.
Patient is received in a warm bed, flat position and turned to one side. As soon as she
gains consciuosness put in a supine if it abdominal surgery and comfortable position if
through vaginal surgery.
Observation
These are taken ¼ hrly on the 1st
hour, ½ hrly for the next 1hr until discharge.
Observe temperature, pulse and respiration and Blood pressure
Observe for bleeding of the site and oedema
Observe IV if running well and blood transfusion line
On gaining consciuosness
Welcome patient from the patient from theater and explain what was done and pope up
in the bed and sponge the face
Give a mouth wash and change the gown
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Repeat observations
Medical treatment
Analgesics
Pethidine 100mg 8hrly for 3 doses on change to panadol to complete 5 days
Antibiotics: ampicillin or gentamycin as ordered
Supportives: vitamins like vitamin c, Iron, folic acid, diazepam
Care of the wounds incase of the abdominal
surgery Leave the wounds untouched: if
bleeding, re – bodage.
Inspect for tension on the wound i.e. oedema.
Observe for slouging.
If grafting was done/ leave of wound untouched for 48hrs. care for donor site and
drains is done. Stitches are removed on the 8th
– 10th
day
Nursing care
Hygiene; assist the patient with bed bath oral care is done until the patient is able
to do it yourself. Diet: allow as soon as she is able, give plenty of fluids and assist
until patient is able to feed herself Elimination: encourage regular emptying of the
bowel and bladder offer assistance util she is able.
Exercise: begin chest and leg exercise as soon as conscious.
Begin with fingers, then wrist after 48hrs. this is to avoid swelling and bleeding in the
wound.
Increase to shoulder then the whole arm.
This is to prevent deformity and contractures.
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By the 1th day patient should be able to touch the back and her head or 2 comb her
hair. Psychotherapy: reassure the patient and consel on the use of artificial breast.
Advice on discharge
Regular checkups
OVARIAN CYSTS
This is the tumor of the ovary containing fluid.
Classification of ovarian cysts according to the location
 Physiological
(functional) cysts  New
growths
PHYSIOLOGICAL (FUNCTIONAL) CYSTS
Follicular cysts
• This occurs when the ovary does not release the ovum and distension of Graafian
follicle occurs in which the oocyte has degenerated the granulosa cell continue
secreting liquor folliculi which distend the Graafian follicle (sac)
• They rarely grow beyond 3 – 5 cm they are usually asymptomatic usually
detected on routine scanning of the abdomen usually disappear within 60 days
• Occasionally they may cause delay in the coming of menstruation which may
later be followed by heavy bleeding in which the patient may interpret to mean
ABORTION.
• Pain and aching in your lower belly usually when you are in the middle of your
menstrual cycle  Vaginal bleeding when one is not in periods.
Luteal Cysts
• These arise from the corpus luteum where there is accumulation of blood called
corpus luteum haemorrhagica and other type’s fluid.
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• The natural history of a normal corpus luteum is to regress by the end of the 1st
trimester of pregnancy has occurred. If a corpus luteum fails to regress and
instead enlarges with or without haemorrhage, a corpus luteum cyst is formed.
• When associated with pregnancy, most corpus luteal cysts spontaneous involute
at the end of the 2nd
trimester.
• Commonest in early pregnancy and tend to disappear as pregnancy advances and
note that sometimes it persists throughout pregnancy as a LUTEOMA.
General characteristics include
• Diffusely thick wall
• Peripheral vascularity <3cm in diameter
• Possible crenulated contour
 Irregular shaped cyst
It is can be difficult to differentiate from a tubal ring in an ectopic pregnancy in some
situations, and correct clinical interpretation is often required.
NB: some functional cysts can twist or break opens (rupture) and bleed. Causing severe
pain often with nausea and vomiting, Dyspareunia, post coital pain,
NEW GROWTHS
Exact cause is not known
Woman who ovulates regularly but has a few children or no children at all has a high
risk of getting ovarian cysts
A woman who is using COCS has a less risk of getting ovarian cysts
Young girls who develop ovarian cysts must be treated seriously because in such
children there are usually not physiological cysts because they do not ovulate
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Similarly ovarian cysts in post-menopausal women must be treated seriously because
such cysts cannot be physiological.
Types of new growths
Benign
These are not malignant from the word go but they may become malignant later.
Serous: - usually contain serous or clear fluid and have a high risk of becoming
malignant serous cytademona–usually means a non-malignant cyst containing serous
(clear fluid)
Mucinous: These contain mucus like fluid and if they are benign one is called Mucous
cytadenoma
Malignant (cancerous): These may be cancerous from the beginning or they may
behave become malignant from the benign type. Serous cytadenoma carcinoma
/Mucinous cytadenoma carcinoma.
Teratoma (Dermoid Cysts)
These contains hairs, teeth, bones, ovarian tissue and they are called Struma ovari
Clinical features of new growth ovarian cysts
• Ovarian cysts do not cause menstrual disturbances unless they are producing
hormones e.g. granula cell tumor.
• May produce heaviness in the lower abdomen plus discomfort.
• They are usually painless unless complications have set in.
• Retention of the urine is usually due to a cyst trapped in the pouch of Douglas
thereby causing compression of urethra.
• Swelling in the abdomen reported by the patient or found on routine examination
of the abdomen.
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On examination
• Cystic mass which may be mobile or fixed.
• It is usually found centrally in the abdomen through sometimes they may be
lying more to one side than the other.
• It is usually separate from the uterus of it may be attached to the uterus.
• Ectopic pregnancy
• Uterine fibroids
• Pregnancy
• Ascites
• Appendicular abscess
• Ectopic kidney
• Full bladder
• Splenomegally
• Full rectum
• Intestinal tumors
• Ovarian abscess
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Investigations
• Abdominal ultra sound scan
• X-ray abdomen – useful in dermoids cysts which will show teeth, bones in
the cysts
Risk factors of ovarian cysts
• Infertility treatment: Patients being treated for infertility by ovulation
induction with gonadotropins or other agents, such as clomiphene citrate or
letrozole, may develop cysts as part of ovarian hyper-stimulation syndrome.
• Pregnancy .In pregnant women, ovarian cysts may form in the second
trimester, when HCG levels peak.
• Drugs e.g. Tamoxifen can cause benign functional ovarian cysts that usually
resolve following discontinuation of treatment.
• Hypothyrodism: Because of similarities between the alpha subunit of
thryroid stimulating hormone (TSH) and HCG, hypothyroidism may
stimulate ovarian and cyst growth.
• Maternal gonadotropins: The transplacental effects of maternal
gonadotropins may lead to the development of neonatal and fetal ovarian
cyst.
• Cigarrete smoking: The risk of functional ovarian cysts is increased with
smoking . Risk with smoking is possibly increased further with a decreased
body mass index.
• Tubal ligation .functional cysts have been associated with tubal ligation
sterilization.
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General clinical manifestation of ovarian cysts
Often times, ovarian cysts do not cause any symptoms. However, symptoms can
appear as the cyst grows. Symptoms include;
• Abdominal bloating.
• Painful bowel movements.
• Pelvic pain before or during the menstrual cycle.
• Painful intercourse.
• Pain in the lower back or thighs.
• Breast tenderness.
• Nausea and vomiting.
• Micturition may occur frequently and is due to pressure on the bladder.
Diagnosig an ovarian cyst
In determining a diagnosis of ovarian cysts, clinicians are interested in
knowing the following;  The shape of the cyst.
• The size of the cyst.
• The composition of the cyst- is it filled with solid, fluid or both ? In most
cases fluid- filled cysts are not cancerous.
• History collection.
• Physical examination: A large cyst may be palpable during the abdominal
examination. Gross ascites may interfere with palpation of an intra-
abdominal mass. Advanced malignant disease may be associated with
cachexia and weight loss, lymphadenopathy in the neck ( for malignant
ovarian cystic tumours )
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• Imaging studies like ultrasonography, CT scan and MRI. Ultrasonography is
the primary imaging tool for a patient considered to have an ovarian cyst.
Findings can help define morphologic characteristics of ovarian cysts. It is
preferred imaging modality given its low cost, availability and sensitivity.
• Blood test. I.e. CA-125 to screen for ovarian cancer.
 High CA 125 levels could mean that the patient has ovarian cancer.
 Cancer antigen 125 (CA125) is a protein expressed on the cell
membrane of normal ovarian tissue and ovarian carcinomas.
 A serum level of less than 35 U/mL is considered normal
• Pregnancy test. A positive pregnancy test result may suggest the patient has
a corpus luteum cyst.
• Laparoscopy: A thin, lighted instrument (laparascope) is inserted into the
patient’s abdomen through a small incision (skin cut).
If the doctor spots an ovarian cyst he/she may also remove it there and then.
Management of ovarian cysts
Several factors are taken into account when deciding on the type of treatment for
ovarian cysts. The main factors are;
• The patient’s age.
• Whether the patient is pre –or post-menopausal.
• The appearance of the cyst.
• The size of the cyst.
• Whether there are associated symptoms or not.
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Conservative treatment
• Watchful waiting (observation)- An ultrasound scan will be carried out about
a month or later to check it, and to see whether it has gone.
• Hormonal birth control pills; prevents the development of new cysts in those
who frequently get them.
• Analgesic (pain relievers) Such as NSAIDS and opioid analgesics .
NB. Many patients with simple ovarian cysts based on ultrasonography findings do
not require treatment.
• Follow up a patient in case of functional ovarian cyst such as follicular cysts
or corpus luteum cysts usually disappear after 6 weeks
• Cysts during early pregnancy especially the corpus luteum cysts tend to
disappear as pregnancy progresses.
• Ovarian cysts diagnosed during late pregnancy and they are not likely to
cause obstructed labour and managed after the patient has delivered
normally then laparatomy is later on performed.
Surgery
Persistent simple ovarian cyst larger than 10cm and complex ovarian cysts should
be removed surgically Laparoscopy ( key hole surgery): A thin , lighted
instrument (laparascope) is inserted into the patient’s abdomen through a small
incision (skin cut). With very small tools a surgeon is able to remove the cyst
through the small incisions. Some-times a sample (biopsy) of the cyst is taken to
determine what type it is.
Laparotomy: This is a more serious operation and may be recommended if the cyst
is cancerous. A longer cut is made across the top of pubic hairline, giving a
surgeon better access to the cyst . The cyst is removed and sent to the lab.
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Ovarian cystectomy: - a cyst is dissected out of the normal ovarian tissue which is
the repaired so that the ovary is left behind. Treatment of choice for benign ovarian
cyst in young girls so that the ovaries are spared.
Ovariotomy/ovariectomy: - implies that its removal of the ovarian tissue together
with whatever ovarian tissue left.
Total abdominal Hysterectomy salpingo-oophorectomy: - In old post menopausal
women, ovarian carcinoma and a woman with bi-lateral ovarian cyst in the old
women.
Complications of
ovarian cysts In
pregnancy
• Abortion i.e. If the corpus luteum cyst is removed before the placenta is fully
developed abortion may occur
• Malpresentations
• Obstructed labor
• Infection
Other complications
• Acute onset of severe abdominal pain caused by peritoneal irritation of the
contents of the cyst after it ruptures.
• Infection is likely to occur during puerperium if woman has been pregnant
the cyst may become malignant
• Haemorrahge as a result of rupture of the cyst’s blood vessels on it.
• Intestinal obstruction as a result of adherence of the intestines on the cysts
especially the malignant one.
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Prevention of ovarian cysts
• Current use of oral contraceptive pills protects against the development of
functional ovarian cysts.
• All women should undergo an annual gynaecologic examination. No
generalized screening test is available for ovarian cystadenocarcinoma, but
women at high risk based on family history or previous history of breast
cancer should undergo an annual ultrasonographic examination and CA125
test.
• Women at high risk for ovarian cystadenocarcinoma may be offered
prophylactic oophorectomy, which will prevent the development of ovarian
cancer.
PELVIC ORGAN PROLAPSE
Definition
It refers to the descending or drooping of any pelvic floor organs.
Organs include the following
• Bladder
• Uterus  Vagina
• Small bowel
• Rectum
Types of pelvic organ prolapse
Pelvic organ prolapse is divided into the following
• Anterior vaginal wall prolapse
• Apical prolapse
• Posterior vaginal wall prolapse
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Anterior Vaginal Wall Prolapse
Cystocele: A prolapse of the bladder into the vagina, the most common condition
A cystocele, also called a prolapsed or dropped bladder, is the bulging or dropping
of the bladder into the vagina.
A cystocele receives one of three grades depending on how far a woman’s bladder
has dropped into her vagina:
• Grade 1—mild, when the bladder drops only a short way into the vagina.
• Grade 2—moderate, when the bladder drops far enough to reach the opening
of the vagina
• Grade 3—most advanced, when the bladder bulges out through the opening
of the vagina Urethrocele: A prolapse of the urethra (the tube that carries urine)
Apical Prolapse
“Apical” means near the apex, or top. There are three kinds of apical prolapse:
Enterocele: Small bowel prolapse. i.e. it means the small intestine has dropped
down and is bulging into the upper part of the back wall of the vagina. This can
also happen at the top of the vagina, where the intestine sits on top and sinks down
into it.
Uterine prolapse: Prolapse of the uterus
Uterine prolapse is a condition characterised by protrusion of the uterus out of/into
the vagina due to weak pelvic floor muscles and ligaments stretch and weaken,
providing inadequate support for the uterus resulting into it slipping down into or
protrudes out of the vagina.
The degree of uterine prolapse/descent is determined according to the
Pelvic Organ Prolapse Quantification System (POP- Q) as:
• Stage 0 – No prolapse
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• Stage 1 – descent of the cervix. Cervix more than 1 cm above the hymen.
• Stage 2 – descent within 1 cm above or below the hymen.
• Stage 3 – descent more than 1 cm past the hymen.
• Stage 4 – complete vault eversion- also called procidentia.
Prolapsed uterus can be described in the following stages:
• First degree: The cervix descends downward into the vagina.
• Second degree: The cervix comes down to the opening of the vagina.
• Third degree: The cervix is outside the vagina.
• Fourth degree: The entire uterus is outside the vagina. This condition is also
called procidentia. This is caused by weakness in all of the supporting
ligaments.
Vaginal vault prolapse: prolapse of the vagina
It occurs when the upper portion of the vagina loses its normal shape and sags or
drops down into the vaginal canal or outside the vagina.
Posterior Wall Prolapse
“Posterior” means back. These prolapses happen when the tissue between the
vagina and rectum (the end of your large bowel) stretches or separates from the
bones in the pelvis. There are two kinds of posterior wall prolapse:
Rectocele: A rectocele/rectal wall prolapse is a bulging of the front wall of the
rectum into the back wall of the vagina.
Rectal prolapse: This is different than a rectocele or rectal wall prolapse. With a
rectal prolapse, part of the rectum turns inside out and pokes out through your
anus. Mostly mistakenly called a hemorrhoids.
Incidence
44

It is estimated that about 50 % of women over 50 experience some degree of
prolapse.
Aetielogy and Pathogenesis of pelvic organ prolapse
The aetiology of POP is multifactorial and only a few items on the aetiological
shopping list are relevant:
• Congenital: there are genetic factors related to connective tissue quality,
which predispose to the development of a POP.
• Pregnancy, labor and childbirth: The excessive stretching of the
ligaments, fascia and other connective tissue during childbirth results in
collagen breakdown, with the new collagen being less resilient. The more
deliveries, the bigger the babies, the longer the second stage of labour, and
the greater the potential damage to the tissues.
• Denegenerative: With advancing age, skeletal muscle tone and volume are
reduced. This can contribute to the development of POP.
• Obesity: Which can become more common with advancing age is also a
contributory factor.
• Endocrine: the ligamentous structures, pelvic muscles and fascia all contain
oestrogen receptors, and lack of oestrogen after the menopause has some
effect on POP. Progesterone receptors are fewer, and lack of progesterone is
less significant.
• Latrogenic: Complicated operative deliveries and previous pelvic floor
repair operations may be a contributory factor i.e. hysterectomy.
• Pelvic organ cancers e.g. cervical cancer e.t.c
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 Chronic respiratory conditions e.g. chronic pulmonary disease 
Constipation
• Traumatic: incases of accidents affecting the pelvic floor muscles
• Heavy lifting: It weakens the pelvic floor muscles
Clinical manifestations of POP
The manifestation depends greatly on the prolapsed organ
Uterine prolapse
Uterine prolapse varies in severity. You may have mild uterine prolapse and
experience no signs or symptoms. However moderate to severe uterine prolapse,
one may experience:
• Pelvic heaviness or pulling
• Vaginal bleeding or an increase in vaginal discharge
• Difficulties with sexual intercourse
• Urinary leakage, retention or bladder infections
• Bowel movement difficulties, such as constipation
• Lower back pain
• Uterine protrusion from the vaginal opening
• Sensations of sitting on a ball or that something is falling out of the vagina 
Weak vaginal tissue
In mild cases, there may be no symptoms. Symptoms that appear only sometimes
often become worse toward the end of the day.
Rectocele
Rectal Symptoms
• Difficulty having a complete bowel movement
• Stool getting stuck in the bulge of the rectum
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• The need to press against the vagina and/or space between the rectum and
the vagina to have a bowel movement
• Straining with bowel movements
• The urge to have multiple bowel movements throughout the day
• Constipation
• Rectal pain
Vaginal Symptoms
• Pain with sexual intercourse (dyspareunia)
• Vaginal bleeding
• A sense of fullness in the vagina
Cystocele
• Pelvic fullness
• A vaginal bulge
• The feeling that something is falling out of the vagina
• The sensation of pelvic heaviness or fullness
• Difficulty starting a urine stream
• A feeling that you haven't completely emptied your bladder after urinating
• Frequent or urgent urination
• Increased discomfort when you strain, cough, bear down or lift
• Repeated bladder infections
• Pain or urinary leakage during sexual intercourse
In severe cases, a bulge of tissue that protrudes through your vaginal opening and
may feel like sitting on an egg
Clinical Assessment History
The principal symptom experienced is the sensation of “something coming down”.
Discomfort is sometimes reported as a “dragging feeling”.
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Whether there are associated urinary or bowel symptoms depends on the type of
prolapse. A rectocoele may be associated with difficulty with defaecation.
Examination
Abdominal Examination: Should always precede vaginal examination to exclude
an abdominal or pelvic mass pushing the pelvic organs down.
Speculum Examination: This is usually carried out in the dorsal position,
although using a Sim’s speculum, in the left lateral position, may have a place. The
vagina is inspected for anterior or posterior bulges. It is often not possible to
diagnose whether an enterocoele (the bulge contains small bowel) is present until
the time of surgery.
The presence of stress incontinence can be diagnosed by asking the patient with a
full bladder to cough – a swab in a sponge holder should be held at the ready near
the urethra to catch any urine before spraying the examiner.
Bimanual Examination: A routine bimanual examination should be undertaken,
assessing the size of the uterus, its mobility, and the presence of any pelvic lesions,
e.g. ovarian cysts.
Diagnostic investigations
• Urinary tract X-ray (intravenous pyelography)
• CT scan of the pelvis
• Ultrasound of the pelvis
• MRI scan of the pelvis
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Other specific investigations
Rectocele
Defecography: A special X-ray test that shows the rectum and anal canal as they
change during defecation. This study is very specific and can pinpoint the size of
the rectocele and the degree to which the rectum is emptied
Treatment
Conservative Management
Conservative management of POP should be considered prior to surgical
intervention.
• In women who are overweight, weight loss should be recommended as a first
line treatment.
• Behavioral treatments like Pelvic floor exercises – “Kegel’s” exercises, are
recommended several times a day. In order to do these exercises, women
need to identify the appropriate muscles by stopping the flow of urine mid-
stream. They should then learn to contract these muscles for 10s, relax for 10
s and repeat ten sets at least three times daily.
• Directed pelvic floor physiotherapy is highly recommended. Pelvic floor
exercises have a positive effect on prolapse symptoms and severity, as
reported in a Cochrane analysis.
• Mechanical treatments: such as inserting a small plastic device called a
pessary into the vagina to provide support for the drooping organs. There are
many different types of pessaries available made of either silicone or inert
plastic. Ring pessaries are the first line option as they are easy to insert and
remove. More advanced stage prolapse may require the use of a space
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occupying pessary. These pessaries are not suitable for women who are
sexually active.
Hormonal
• Local oestrogen (delivered directly to the vagina) is a useful treatment for
women with atrophic vaginitis. It may also be helpful for women suffering
from incontinence. This treatment is suitable for all women.
• There are a variety of different ways of delivering this form of therapy
including creams, tablets and via a vaginal ring impregnated with a low dose
of oestradiol which is released at a steady rate over a period of 3 months.
Surgical
Surgical management of prolapse is determined by the compartment affected, the
size of the prolapse and most importantly by informed patient choice.
This involves the removal of the prolapsed organ.
MENOPAUSE
Definitions
Menopause is the cessation of ovarian function due to decline in the production
and function of the reproductive hormones.
A woman is “post-menopausal” 12 months after her last menstrual period. Ovarian
function declines in the 5 years running up to menopause, and this is known as the
“peri-menopause” or the “menopause transition”. “ Premature menopause”, now
known as “premature ovarian insufficiency” (POI), occurs when a woman’s
ovaries cease functioning under the age of 40.
Incidence
Menopause affects 100 % of women, usually between the ages of 45–55.
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Aetielogy and Pathogenesis
During reproductive life, in regularly ovulating women, the menstrual cycle occurs
repeatedly every 4 weeks. The cycle commences with a batch of follicles starting
to develop, and during the follicular phase, oestrogen is secreted, resulting in
endometrial proliferation. One follicle becomes the leading follicle, and in an
ovulatory cycle, ovulates and then becomes the corpus luteum (CL), which
produces progesterone as well as oestrogen. The Corpus Luteum has an inherent
life span of about 2 weeks, when, in the absence of a pregnancy it succumbs,
resulting in a drop in oestrogen and progesterone levels, which causes in the
endometrium to slough (menstrual period). During the menopause transition, a
woman has cycles where she makes follicles, but does not ovulate; the follicle still
secretes oestrogen which causes endometrial proliferation, and when the follicle
undergoes atresia, then oestrogen secretion ceases, and the endometrium is lost –
still resulting in menstruation (although in an anovulatory cycle). Once ovarian
function totally ceases, there is no folliculogenesis, no oestrogen secreted, no
endometrial proliferation or shedding, and amenorrhoea results.
Clinical Assessment/Manifestations History
The symptoms of the menopause/peri-menopause can be divided into those due to
hormonal fluctuation and those resulting due to the long term consequences of
oestrogen deficiency. As these symptoms and signs are usually reported as a
continuum, they are considered together, and classified into five types:
1. Vasomotor: this includes “hot flushes”, palpitations, nights sweats, an
altered sleep pattern and fatigue.
51

2. Neuromuscular and degenarative: this includes headaches, joint and muscle
pain, hair and skin changes
3. Psychogenic: this includes poor concentration, forgetfulness, depression,
anxiety, claustrophobia, agoraphobia, irritability, difficulty coping,
tearfulness and lack of drive including sex drive.
4. Urogenital: symptoms of vaginal dryness, uterovaginal prolapse and urinary
symptoms including urgency and urge incontinence/ overactive bladder.
Although stress incontinence is more common in post-menopausal women,
the aetiology of this is probably not due to oestrogen deficiency.
5. Osteoporosis can result in fractures.
Examination
A general examination including blood pressure, breast examination and bimanual
examination including a cervical smear (if indicated) should be undertaken.
Clinical signs are unlikely to be found, although signs of vaginal atrophy due to
lack of oestrogen may be detected.
Investigations
Hormone Tests
These offer little benefit and can be confusing.
• FSH: FSH >30 MiU/ml suggests menopause. However, during the
menopause transition the level of FSH can oscillate significantly. Therefore,
one cannot diagnose a woman as “postmenopausal” on a single FSH level.
• Anti Mullerian Hormone (AMH) – There is no place for measuring this in
a woman who is thought to be menopausal. Its value is in predicting ovarian
52

reserve in younger woman, but once in the peri-menopause, AMH will
always be low, and knowing its value does not change patient management.
53


Oestrogen: Measuring oestrogen in a peri-menopausal/ post-menopausal
woman is of little benefit. The level of oestrogen does not reflect the degree
of symptoms, nor does it help with assessing the effect of hormone
replacement therapy (HRT).
• Thyroid Function Tests (TFTs) or fasting glucose or HbA1c should only
be measured if medically indicated.
• Bone mineral density: Once a woman becomes Post-menopausal, she loses
about 1 % of her bone mass per year. As osteoporosis is a signify cant
problem in postmenopausal women, prevention is important. Knowing the
baseline bone mineral density is useful.
Treatment
Medical
Hormonal
Menopausal women are oestrogen deficient.
Hormonal treatment necessitates replacement of oestrogen. This can be oral,
transdermal, vaginal or by subcutaneous implant.
Women who have a uterus need endometrial protection. This is provided by using
a progestin which can be oral, transdermal or intrauterine (Mirena ®). Progestin
therapy can be provided either sequentially or continuously. Other Medical
Some women do not want to take oestrogen, whilst for others, oestrogen
replacement is contraindicated. For these women it is possible to provide
symptomatic treatment with various degrees of success. These treatments include
the use of antidepressants in the SSRI group, gabapentin and clonidine.
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Complications
These are either the consequences of oestrogen deficiency if HRT is not taken, or
the complications of HRT- abnormal bleeding, hormonal side effects, venous
thromboembolism, and possibly a small increase in the risk of some cancers (such
as breast).
INFERTILITY
Infertility is the inability of a couple to conceive a child after 12 months of
unprotected regular sexual intercourse and without birth control measures.
Man is responsible for about 30% of cases of fertility, woman is responsible for
about 40% and man + woman are responsible for 30%.
Types of infertility
Male infertility
Female infertility
Male infertility
Up to 15 percent of couples are infertile. This means they aren't able to conceive a
child even though they've had frequent, unprotected sexual intercourse for a year
or longer. Not being able to conceive a child can be stressful and frustrating, but a
number of male infertility treatments are available.
Elements needed to achieve conceptions
• Production of healthy sperms:Initially, this involves the growth and
formation of the male reproductive organs during puberty. At least one of
testicles must be functioning correctly, and the body must produce
testosterone and other hormones to trigger and maintain sperm production.
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Sperm have to be carried into the semen: Once sperm are produced in the
testicles, delicate tubes transport them until they mix with semen and are
ejaculated out of the penis.
• There needs to be enough sperm in the semen: If the number of sperm in
semen (sperm count) is low, it decreases the odds that one of the sperm will
fertilize the partner's egg. A low sperm count is fewer than 15 million sperm
per milliliter of semen or fewer than 39 million per ejaculate.
• Sperm must be functional and able to move: If the movement (motility) or
function of the sperm is abnormal, the sperm may not be able to reach or
penetrate the partner's egg.
Aetiology and pathogenesis
Medical causes
Problems with male fertility can be caused by a number of health issues and
medical treatments. Some of these include
• Ejaculation problems: Retrograde ejaculation occurs when semen enters the
bladder during orgasm instead of emerging out the tip of the penis. Various
health conditions can cause retrograde ejaculation, including diabetes, spinal
injuries, medications, and surgery of the bladder, prostate or urethra.
• Auto-immunity: Anti-sperm antibodies are immune system cells that
mistakenly identify sperm as harmful invaders and attempt to eliminate
them.
• Infection: Some infections can interfere with sperm production or sperm
health or can cause scarring that blocks the passage of sperm. These include
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
inflammation of the epididymis (epididymitis) or testicles (orchitis) and
some sexually transmitted infections, including gonorrhea or HIV. Although
some infections can result in permanent testicular damage, most often sperm
can still be retrieved.
• Undescended testicles: In some males, during fetal development one or both
testicles fail to descend from the abdomen into the sac that normally contains
the testicles (scrotum). Decreased fertility is more likely in men who have
had this condition.
• Defects of tubules that transport sperm: Many different tubes carry sperm.
They can be blocked due to various causes, including inadvertent injury
from surgery, prior infections, trauma or abnormal development, such as
with cystic fibrosis or similar inherited conditions. Blockage can occur at
any level, including within the testicle, in the tubes that drain the testicle, in
the epididymis, in the vas deferens, near the ejaculatory ducts or in the
urethra.
• Tumors: Cancers and nonmalignanttumors can affect the male reproductive
organs directly, through the glands that release hormones related to
reproduction, such as the pituitary gland, hypothalamus or through unknown
causes. In some cases, surgery, radiation or chemotherapy to treat tumors
can affect male fertility.
• Varicocele: A varicocele is a swelling of the veins that drain the testicle. It's
the most common reversible cause of male infertility. Although the exact
reason that varicoceles cause infertility is unknown, it may be related to
abnormal testicular temperature regulation. Varicoceles result in reduced
quality of the sperm. Treating the varicocele can improve sperm numbers
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
and function, and may potentially improve outcomes when using assisted
reproductive techniques such as in vitro fertilization.
• Hormone imbalances: Infertility can result from disorders of the testicles
themselves or an abnormality affecting other hormonal systems including the
hypothalamus, pituitary, thyroid and adrenal glands. Low testosterone (male
hypogonadism) and other hormonal problems have a number of possible
underlying causes.
Chromosome defects: Inherited disorders such as Klinefelter's syndrome —
in which a male is born with two X chromosomes and one Y chromosome
(instead of one X and one Y) — cause abnormal development of the male
reproductive organs. Other genetic syndromes associated with infertility
include cystic fibrosis, Kallmann's syndrome and Kartagener's syndrome.
• Problems with sexual intercourse: These can include trouble keeping or
maintaining an erection sufficient for sex (erectile dysfunction), premature
ejaculation, painful intercourse, anatomical abnormalities such as having a
urethral opening beneath the penis (hypospadias), or psychological or
relationship problems that interfere with sex.
• Celiac disease: A digestive disorder caused by sensitivity to gluten, celiac
disease can cause male infertility. Fertility may improve after adopting a
gluten-free diet.
• Certain medications: Testosterone replacement therapy, long-term anabolic
steroid use, cancer medications (chemotherapy), certain antifungal
medications, some ulcer drugs and certain other medications can impair
sperm production and decrease male fertility.
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• Prior surgeries: Certain surgeries may prevent you from having sperm in
your ejaculate, including vasectomy, inguinal hernia repairs, scrotal or
testicular surgeries, prostate surgeries, and large abdominal surgeries
performed for testicular and rectal cancers, among others. In most cases,
surgery can be performed to either reverse these blockage or to retrieve
sperm directly from the epididymis and testicles.
Environmental causes
Over exposure to certain environmental elements such as heat, toxins and
chemicals can reduce sperm production or sperm function. Specific causes include:
• Industrial chemicals: Extended exposure to benzenes, toluene, xylene,
pesticides, herbicides, organic solvents, painting materials and lead may
contribute to low sperm counts.
• Heavy metal exposure: Exposure to lead or other heavy metals also may
cause infertility.
• Radiation or X-rays: Exposure to radiation can reduce sperm production,
though it will often eventually return to normal. With high doses of
radiation, sperm production can be permanently reduced.
• Overheating the testicles: Elevated temperatures impair sperm production
and function. Although studies are limited and are inconclusive, frequent use
of saunas or hot tubs may temporarily impair your sperm count.
• Sitting for long periods, wearing tight clothing or working on a laptop
computer for long stretches of time also may increase the temperature in
your scrotum and may slightly reduce sperm production.
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Health, lifestyle and other causes
• Illicit drug use: Anabolic steroids taken to stimulate muscle strength and
growth can cause the testicles to shrink and sperm production to decrease.
Use of cocaine or marijuana may temporarily reduce the number and quality
of your sperm as well.
• Alcohol use: Drinking alcohol can lower testosterone levels, cause erectile
dysfunction and decrease sperm production. Liver disease caused by
excessive drinking also may lead to fertility problems.
• Tobacco smoking: Men who smoke may have a lower sperm count than do
those who don't smoke. Secondhand smoke also may affect male fertility.
• Emotional stress: Stress can interfere with certain hormones needed to
produce sperm. Severe or prolonged emotional stress, including problems
with fertility, can affect your sperm count.
Weight: Obesity can impair fertility in several ways, including directly
impacting sperm themselves as well as by causing hormone changes that
reduce male fertility.
Risk factors linked to male infertility include:
Certain occupations including welding or those involving prolonged sitting, such
as truck driving, may be associated with a risk of infertility. However, the research
to support these links is mixed.
• Smoking tobacco
• Using alcohol
• Using certain illicit drugs
• Being overweight
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• Having certain past or present infections
• Being exposed to toxins
• Overheating the testicles
• Having experienced trauma to the testicles
• Having a prior vasectomy or major abdominal or pelvic surgery
• Having a history of Undescended testicles
• Being born with a fertility disorder or having a blood relative with a fertility
disorder
• Having certain medical conditions, including tumors and chronic illnesses,
such as sickle cell disease
• Taking certain medications or undergoing medical treatments, such as
surgery or radiation used for treating cancer
Diagnostic measures of male fertility
• General physical examination
• Medical history
• Semen analysis
• Scrotal ultrasound
• Hormone testing
• Post-ejaculation urinalysis
• Genetic tests
• Testicular biopsy
• Specialized sperm function tests
• Transrectal scan
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Treatments for male infertility include:
• Surgery: For example, a varicocele can often be surgically corrected or an
obstructed vas deferens repaired. Prior vasectomies can be reversed. In cases
where no sperm are present in the ejaculate, sperm can often be retrieved
directly from the testicles or epididymis using sperm retrieval techniques.
• Treating infections: Antibiotic treatment might cure an infection of the
reproductive tract, but doesn't always restore fertility.
• Treatments for sexual intercourse problems: Medication or counseling
can help improve fertility in conditions such as erectile dysfunction or
premature ejaculation.
• Hormone treatments and medications: The doctor might recommend
hormone replacement or medications in cases where infertility is caused by
high or low levels of certain hormones or problems with the way the body
uses hormones.
Assisted reproductive technology (ART): ART treatments involve
obtaining sperm through normal ejaculation, surgical extraction or from
donor individuals, depending on your specific case and wishes. The sperm
are then inserted into the female genital tract, or used to perform in vitro
fertilization or intracytoplasmic sperm injection.
Home activities to increase your chances of achieving pregnancy:
• Increase frequency of sex. Having sexual intercourse every day or every
other day beginning at least 4 days before ovulation increases your chances
of getting your partner pregnant.
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• Have sex when fertilization is possible. A woman is likely to become
pregnant during ovulation — which occurs in the middle of the menstrual
cycle, between periods. This will ensure that sperm, which can live several
days, are present when conception is possible.
• Advise the patient to avoid the use of lubricants. Products such as
Astroglide or K-Y jelly, lotions, and saliva might impair sperm movement
and function. Supplements with studies showing potential benefits on
improving sperm count or quality include:
• Herbal supplements
 Chewing dry coffee
 Eating plenty of ground nuts
 Chewing roots of herbal plants e.g. Mulondo
FEMALE INFERTILITY
The main symptom of infertility is the inability to get pregnant. A menstrual cycle
that's too long (35 days or more), too short (less than 21 days), irregular or absent
can mean that one is not ovulating.
There may be no other outward signs or symptoms.
Women who have repeated abortions are also said to be infertile.
Types of female infertility
• Primary infertility
• Secondary infertility
Primary infertility: is one which the woman has never been pregnant.
Secondary infertility: is one in which there has been a previous pregnancy is
successful or unsuccessful.
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NOTE: it takes a man and a woman to make a baby therefore when a woman
presents with this problem the other party has to be investigated as well.
• Age of the couple is important in fertility especially that of the woman.
• Frequency of coitus is also important regularly 4 – 5 times a week.
• Age 24years for a woman is the most ideal fertility decreases between 25 –
30 decreases further after 35years.
• It does not necessary mean that if a woman exposes herself to pregnancy
even at a time of ovulation she will automatically conceive.
Sterility
This word should only be used when there is no remedy to help this woman to
become pregnant e.g. if she does not have ovaries or uterus.
Factors essential to become pregnant:
• Ovulation is required. To get pregnant, the ovaries must produce and
release an egg, a process known as ovulation. Your doctor can help evaluate
the menstrual cycles and confirm ovulation.
The partner needs sperm: For most couples, this isn't a problem unless
your partner has a history of illness or surgery. The doctor can run some
simple tests to evaluate the health of her partner's sperm.
• Having regular intercourse: The client needs to have regular sexual
intercourse during her fertile time.
• A need to have open fallopian tubes and a normal uterus: The egg and
sperm meet in the fallopian tubes, and the embryo needs a healthy uterus in
which to grow.
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
CAUSES OF FERTILITY
Ovulation disorders
• Ovulation disorders, means that one ovulates infrequently or not at all,
account for infertility in about 1 in 4 infertile couples. Problems with the
regulation of reproductive hormones by the hypothalamus or the pituitary
gland, or problems in the ovary, can cause ovulation disorders.
• Polycystic ovary syndrome (PCOS); PCOS causes a hormone imbalance,
which affects ovulation. PCOS is associated with insulin resistance and
obesity, abnormal hair growth on the face or body, and acne. It's the most
common cause of female infertility.
• Hypothalamic dysfunction: Two hormones produced by the pituitary gland
are responsible for stimulating ovulation each month — (FSH) and
luteinizing hormone (LH). Excess physical or emotional stress, a very high
or very low body weight, or a recent substantial weight gain or loss can
disrupt production of these hormones and affect ovulation. Irregular or
absent periods are the most common signs.
• Premature ovarian failure: Also called primary ovarian insufficiency, this
disorder is usually caused by an autoimmune response or by premature loss
of eggs from your ovary (possibly from genetics or chemotherapy). The
ovary no longer produces eggs, and it lowers estrogen production in women
under the age of 40.
• Too much prolactin: The pituitary gland may cause excess production of
prolactin (hyperprolactinemia), which reduces estrogen production and may
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cause infertility. Usually related to a pituitary gland problem, this can also be
caused by medications you're taking for another disease.
Damage to fallopian tubes (tubal infertility)
• Damaged or blocked fallopian tubes keep sperm from getting to the egg or
block the passage of the fertilized egg into the uterus. Causes of fallopian
tube damage or blockage can include:
• Pelvic inflammatory disease, an infection of the uterus and fallopian tubes
due to chlamydia, gonorrhea or other sexually transmitted infections
• Previous surgery in the abdomen or pelvis, including surgery for ectopic
pregnancy, in which a fertilized egg implants and develops in a fallopian
tube instead of the uterus
• Pelvic tuberculosis, a major cause of tubal infertility worldwide, although
uncommon in the United States
• Endometriosis: Endometriosis occurs when tissue that normally grows in the
uterus implants and grows in other locations. This extra tissue growth — and
the surgical removal of it — can cause scarring, which may block fallopian
tubes and keep an egg and sperm from uniting. Endometriosis can also affect
the lining of the uterus, disrupting implantation of the fertilized egg. The
condition also seems to affect fertility in less-direct ways, such as damage to
the sperm or egg.
Uterine or cervical causes
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Several uterine or cervical causes can impact fertility by interfering with
implantation or increasing the likelihood of a miscarriage:
• Benign polyps or tumors (fibroids or myomas) are common in the uterus.
Some can block fallopian tubes or interfere with implantation, affecting
fertility. However, many women who have fibroids or polyps do become
pregnant.
• Endometriosis scarring or inflammation within the uterus can disrupt
implantation.
• Uterine abnormalities present from birth, such as an abnormally shaped
uterus, can cause problems becoming or remaining pregnant.
• Cervical stenosis, a narrowing of the cervix, can be caused by an inherited
malformation or damage to the cervix.
• Sometimes the cervix can't produce the best type of mucus to allow the
sperm to travel through the cervix into the uterus. Unexplained infertility
Sometimes, the cause of infertility is never found. A combination of several minor
factors in both partners could cause unexplained fertility problems. Although it's
frustrating to get no specific answer, this problem may correct itself with time.
Risk factors
Certain factors may put you at higher risk of infertility, including:
• Age: The quality and quantity of a woman's eggs begin to decline with
increasing age. In the mid-30s, the rate of follicle loss speeds, resulting in
fewer and poorer quality eggs. This makes conception more difficult, and
increases the risk of miscarriage.
• Smoking: Besides damaging your cervix and fallopian tubes, smoking
increases your risk of miscarriage and ectopic pregnancy. It's also thought to
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age your ovaries and deplete your eggs prematurely. Stopping smoking
before beginning fertility treatment should advise to the patient.
• Weight:Being overweight or significantly underweight may affect normal
ovulation. Getting to a healthy body mass index (BMI) may increase the
frequency of ovulation and likelihood of pregnancy.
• Sexual history: Sexually transmitted infections such as Chlamydia and
gonorrhea can damage the fallopian tubes. Having unprotected intercourse
with multiple partners increases your risk of a sexually transmitted infection
that may cause fertility problems later.
• Alcohol: Stick to moderate alcohol consumption of no more than one
alcoholic drink per day.
Investigations
• History taking
• Urinalysis
• Full Blood Count
• Pelvic ultra sound scan
• hysterosonography is used to see details inside the uterus that can’t be seen
on a regular ultrasound
• Laparascopy
• cervical mucus
• Endometrial biopsy
• For testing for tubal patency Tubal insuflation/Rubin test:
Hysterosalpingography
• Ovarian reserve testing
• Post coital test (Sims huhner test
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Treatment
Infertility can be treated with medicine, surgery, artificial insemination or assisted
reproductive technology.
Infertility treatment depends on the cause, your age, how long you've been infertile
and personal preferences. Because infertility is a complex disorder, treatment
involves significant financial, physical, psychological and time commitments.
Although some women need just one or two therapies to restore fertility, it's
possible that several different types of treatment may be needed.
Treatments can either attempt to restore fertility through medication or surgery, or
help one to get pregnant with sophisticated techniques.
Fertility restoration: Stimulating ovulation with fertility drugs
Fertility drugs regulate or stimulate ovulation. Fertility drugs are the main
treatment for women who are infertile due to ovulation disorders.
Fertility drugs generally work like the natural hormones — follicle-stimulating
hormone (FSH) and luteinizing hormone (LH) — to trigger ovulation. They're also
used in women who ovulate to try to stimulate a better egg or an extra egg or eggs.
Fertility drugs may include:
• Clomiphene citrate: Clomiphene is taken by mouth and stimulates
ovulation by causing the pituitary gland to release more FSH and LH, which
stimulate the growth of an ovarian follicle containing an egg.
• Gonadotropins: Instead of stimulating the pituitary gland to release more
hormones, these injected treatments stimulate the ovary directly to produce
multiple eggs. Gonadotropin medications include human menopausal
gonadotropin or hMG and FSH. Another gonadotropin, human chorionic
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gonadotropin is used to mature the eggs and trigger their release at the time
of ovulation. Concerns exist that there's a higher risk of conceiving multiples
and having a premature delivery with gonadotropin use.
• Metformin: Metformin is used when insulin resistance is a known or
suspected cause of infertility, usually in women with a diagnosis of PCOS.
Metformin helps improve insulin resistance, which can improve the
likelihood of ovulation.
• Letrozole: Letrozole belongs to a class of drugs known as aromatase
inhibitors and works in a similar fashion to clomiphene. Letrozole may
induce ovulation. However, the effect this medication has on early
pregnancy isn't yet known, so it isn't used for ovulation induction as
frequently as others.
• Bromocriptine: Bromocriptine, a dopamine agonist, may be used when
ovulation problems are caused by excess production of prolactin
(hyperprolactinemia) by the pituitary gland.
Risks of fertility drugs
Using fertility drugs carries some risks, such as:
Pregnancy with multiple fetuses.
Ovarian hyper-stimulation syndrome (OHSS):Injecting fertility drugs to induce
ovulation can cause OHSS, which causes swollen and painful ovaries. Signs and
symptoms usually go away without treatment, and include mild abdominal pain,
bloating, nausea, vomiting and diarrhea. If ones become pregnant, however, the
symptoms might last several weeks. Rarely, it's possible to develop a moresevere
form of OHSS that can also cause rapid weight gain, enlarged painful ovaries, fluid
in the abdomen and shortness of breath.
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Long-term risks of ovarian tumors: Most studies of women using fertility drugs
suggest that there are few if any long-term risks. However, a few studies suggest
that women taking fertility drugs for 12 or more months without a successful
pregnancy may be at increased risk of borderline ovarian tumors later in life.
Fertility restoration: Surgery
Several surgical procedures can correct problems or otherwise improve female
fertility. However, surgical treatments for fertility are rare these days due to the
success of other treatments. They include:
• Laparoscopic or hysteroscopic surgery: These surgeries can remove or
correct abnormalities to help improve your chances of getting pregnant.
Surgery might involve correcting an abnormal uterine shape, removing
endometrial polyps and some types of fibroids that misshape the uterine
cavity, or removing pelvic or uterine adhesions.
• Tubal surgeries: If your fallopian tubes are blocked or filled with fluid
(hydrosalpinx), the doctor may recommend laparoscopic surgery to remove
adhesions, dilate a tube or create a new tubal opening. This surgery is rare,
as pregnancy rates are usually better with IVF. For hydrosalpinx, removal of
your tubes (salpingectomy) or blocking the tubes close to the uterus can
improve your chances of pregnancy with IVF.
Reproductive assistance
The most commonly used methods of reproductive assistance include:
• Intrauterine insemination (IUI). During IUI, millions of healthy sperm are
placed inside the uterus close to the time of ovulation.
• Assisted reproductive technology. This involves retrieving mature eggs
from a woman, fertilizing them with a man's sperm in a dish in a lab, then
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transferring the embryos into the uterus after fertilization. IVF is the most
effective assisted reproductive technology. An IVF cycle takes several
weeks and requires frequent blood tests and daily hormone injections.
Ways to battle infertility
• Counseling is very important
• Regular exercises
• Avoid alcohol, tobacco and narcortics
• Limit caffeine intake
• Limit medication
• Eat a well balanced
• Coping with infertility
• Consider other options e.g. Adoption, donor sperm or egg.
• Talk about your feeling : - to each other Or support groups, counseling
services.
OBSTETRIC/VAGINAL FISTULAE
This is an abnormal communication (opening) of the vagina and the neighboring -
pelvic organs as a result of obstetrical causes e.g. delivery.
A fistula is an abnormal communication between two or more epithelial surfaces.
Types of vaginal/obstetric fistulae
A fistula that has formed in the wall of the vaginais called a vaginal fistula.
A vaginal fistula that opens into the urinary tract is called a vesicovaginal fistula.
A vaginal fistula that opens into the rectum is called a rectovaginal fistula.
A vaginal fistula that opens into the colonis called a colovaginal fistula.
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A vaginal fistula that opens into the small bowel is called a enterovaginal fistula.
VESICO-VAGINAL FISTULA
Vesicovaginal fistula or VVF is an abnormal fistulous tract extending between the
bladder (vesico) and the vagina that allows the continuous involuntary discharge of
urine into the vaginal vault. OR: It is the abnormal opening of the vagina and the
urinary bladder
Introduction
Vesico-vaginal fistula is classified under a large group called the
URINARYFISTULAS
A urinary fistulais a pathological connection between the urinary tract and an
adjacent structure through which urine escapes.
Sites of the urinary fistula
• Vesco-vaginal (the commonest).
• Urethro-vaginal.
• Vesco cervical vaginal.
• Utero vesico vaginal.
• Urethro vesical vaginal.
• Vesical intestinal.
Pathology of a urinary fistula
• If the cause is a tear, urine escapes at once but the wound may not become
infected immediately and primary union can occur in one week or two
provided the urinary stream is diverted.
• If the cause is pressure necrosis, the affected area will form a slough which
eventually drops out leaving a fistula.
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• If the fistula is large (over 2cm diameter) spontaneous healing is unlikely
and scar tissue gradually forms a dense white ring round the edge of the
fistula even fixing it to the pubic ramus.
• Urinary fistula has a natural tendency to close by granulation, fibrosis and
contraction.
Incidence
• Vesicovaginal fistula (VVF) is still a major cause for concern in many
developing countries. It represents a significant morbidity in female urology.
Continual wetness, odor, and discomfort cause serious social problems
• Although the incidence of VVFs has become rare in the industrialized world,
they still commonly occur in developing countries.
• Estimates suggest that at least three million women in poor countries have
unrepaired VVFs, and that 30,000–130,000 new cases develop each year in
Africa alone.
Types of VVF
• Simple fistula: Only about 20% of obstetric fistulas can be defined as
simple. Simple fistulas are less than 3 cm in diameter with no or only mild
scarring and do not involve the urethra.
• Complex fistula: A complex obstetric fistula can be described being larger
than 3 cm, involving the urethra and associated with reduced vaginal
capacity from significant scarring and/or a reduced bladder volume.
Sometimes the defect may be urethrovaginal, but more commonly both the
urethra and bladder are involved and therefore the fistula is called an
urethrovesicovaginal.
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Causes of Vesico – vaginal fistula
They are divided into two
• Gynecological causes
• Obstetrical cause
Obstetrical causes
Obstructed labour
Normally during labor the urinary bladder is displaced into the abdomen.
Now if there is unrelieved labor obstruction and the fetal part will compress the
urinary bladder against the posterior border of the symphysis pubis and pubic
bones. Blood supply to that part of the bladder is cut off and the tissue of will
sooner later die off and they undergo necrosis and thereby creating the abnormal
opening between the bladder and the vagina During caesarian section
 Bladder is cut
 Bladder wall can be sutured when closing the uterus.
 In a woman who has had a previous c/s scar and the bladder is stuck on to
the scar. It may be torn as the bladder is pushed down from the uterus up tearing
the urethra and bladder During forceps delivery
• During ruptured uterus
 The rupture of the uterus may involve the bladder especially in a patient
who has a previous scar and the bladder is stuck on the scar
 Bladder may be cut or sutured either when the uterus is being repaired or
during hysterectomy
• Craniotomy: - during the procedure pieces of the bone may also pierce the
bladder as a fetal head is being delivered.
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• Symphysiotomy: - during the procedure, the urethra and the bladder are not
displaced away from the midline and can easily be damaged
• Ruptured uterus: - in the process, repair of the uterine rupture may also
involve the bladder more especially in previous scar when the bladder is
adherent to the scar.
Gynaecology causes
• During insertion of the shirodikar stitch.
• During hysterectomy (as done before 28 weeks)
• During dilatation and curettage especially during termination of pregnancy
 Cancer of the cervix stage 4 that extends to the bladder.
• During radiotherapy: where radiations burn the urinary bladder tissues and
the near by organs
• Infections like schistosomiasis, lymphogranuloma venerium
• Anterior corrporaphy (repair of the cystoce)
• Manchester operation: - for repair of the prolapse of the uterus.
Risk factors
• Poverty
• Malnutrition
• Lack of education
• Early child birth
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Lack of healthcare
• Status of women
Pathology of a vesico-vaginal fistula
A vaginal fistula starts with some kind of tissue damage. After days to years of
tissue breakdown, a fistula opens up.
A vaginal fistula sometimes happens after:
• Surgery of the back wall of the vagina, the perineum, anus, or rectum. Open
hysterectomyis linked to most vesicovaginal tract fistulas.
• Radiationtreatment for pelvic cancer.
• A period of inflammatory bowel disease(including Crohn's diseaseand
ulcerative colitis) or diverticulitis.
• A deep tear in the perineumor an infected episiotomyafter childbirth.
In areas where women have no health carenearby, vaginal fistulas are much more
common. After days of pushing a baby that does not fit through the birth canal,
very young mothers can have severe vaginal, bladder, or rectal damage, sometimes
causing fistulas.
Clinical manifestations
• Mother gives history of prolonged and obstructed labor
• On abdominal palpation no bladder is felt since all urine escapes as soon as
it reaches the bladder.
• Mother smells of urine and will report leakage of urine.  Signs of
UTI infections and low grade fever
• Repeated vaginal or urinary tract infections.
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• Irritation or pain in the vagina or surrounding areas.
• Constant leakage of urine.
• Foul-smelling vaginal discharge.
• Pain during sexual activity.
• On vulva inspection, urine is seen dribbling from the vagina
• On speculum examination a defect is seen with urine
• If methylene blue is injected into the urinary catheter, the dye will be seen
escaping through the vagina
• Soft tissue x-ray shows a defect
• Cystography shows injury in the bladder.
Diagnostic measures
Diagnosis is based on symptoms. The evaluation of size, number, and exact
location of fistula is important before curative surgery is undertaken. Better pre-
operative diagnosis allows better surgical planning.
• Physical examination is of vital importance. The site of the fistula and its
surroundings must be thoroughly observed.
• Methylene blue or geritah violet is injected via catheter into the bladder and
can be seen passing through the vagina
• In a patient with urinary incontinence, the tampon test, where a tampon is
inserted into the vagina after filling the bladder with the solution and the
patient is ambulated, can lead to the confirmation of diagnosis.
• Cystoscopy is also of particular help and can clarify the exact anatomic
origin
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For small fistulas, it may be helpful to attempt to pass a small ureteric
catheter through the suspected fistula tract to determine if it enters the
vagina.
• Soft tissue x-ray
• Speculum examination
• Digital examination
• Urinalysisto check for infection.
• Bloodtest (complete blood count) to check for signs of infection in your
body.
• Further diagnostic procedures should include retrograde and voiding the
cysto-urethrography. A high creatinine level of the discharge can confirm the
urinary leakage.
• The advanced but more invasive and/or costlier techniques include combined
vaginoscopy– cystoscopy, subtraction magnetic resonance fistulography and
endocavitary ultrasound through transrectal or more properly through
transvaginal route with or without Doppler or contrast agents.
• Transvaginal sonographic evaluation can clearly visualize the exact site,
size, and course of the fistula.
• Finally, if there is a suspicion of malignancy, a biopsy must be taken for
histologic examination.
Management
• Treatment of patients with VVF must embrace their immediate and in most
cases subsequent surgical management. It is vital to consider the nutritional
and rehabilitative needs of patients. When a delayed approach to surgery is
intended, it is essential to take care of the sanitary protection and the skin
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• In 10 % of the cases, the fistula closes spontaneously after 0.5–2 months of
urethral catheterization and anticholinergic medication, especially if the
fistula is of small diameter, is detected early or there is no epithelization of
the fistula.
• If the diagnosis is established late and the fistula has epithelized,
electrocoagulation of the mucosal layer and 2–4 weeks of catheterization
may lead to closure.
• However, in patients with a thin vesico vaginal septum, large VVF or those
with significant inflammation around the fistula tract, risks of failure and the
possibility of enlarging the size of the fistula and devitalizing adjacent
tissues.
• Fibrin sealant has been used as an adjunctive measure to treat VVF. This
material may be injected directly into the fistula tract following electro
coagulation. The bladder is then drained for several weeks.
• The therapeutic result of this approach is a result of the gel-like nature of the
fibrin sealant that plugs the hole until tissue in growth occurs from the edges
of the fistula.
• Fibrin sealant has also been successfully used in combination with collagen
as an additional “plug”. Unfortunately in most cases these conservative
methods fail and the performance of surgery is needed.
• Surgery should be postponed if devitalized tissues, cystitis or encrustation is
present.
• The classical strategy is a delayed repair undertaken after 3–6 months to
allow healing of any inflammation and edema.
• Even a delay of 1–2 years is reasonable after radiation damage.
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• Regular examination is fundamental to selecting the earliest date for surgery.
• The first step before repair is to treat any acute infection with antibiotics
while encrusted deposits must be removed both from the bladder and the
vagina.
simple fistulas are treated using simple vaginal approaches, while complex
fistulas are commonly treated either vaginally using a myocutaneous flap or
through an abdominal approach
• Most gynecologic surgeons favor the vaginal approach. This approach
minimizes the operative complications, hospital stay, blood loss and pain
following the procedure and still achieves success rates when compared with
the abdominal approach
• The advantage of having the fistula well repaired from first time is crucial
because success rate decreases with more attempts of repair: First repair
success rate: 70-90%
 2nd repair success rate: 50-60%
 > than 2 procedures: <40%
In the health center
Mother is encouraged on personal hygiene and reffered to the hospital
In Hospital
• Mother is admitted in a gynecological ward
• Doctor is informed who will carryout gynecological examination:- genital
examination with fingers, no instruments are used for fear of enlarging the
opening.
• He may carry out speculum examination
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• A self retaining catheter is passed and the mother is kept on continuous
bladder drainage as dripping of urine prevents healing.
• Give a balanced diet including iron, vitamin supplements and if necessary
blood transfusion to restore her general health.
• Most fistulas will close spontaneously within 6 weeks as long as there is
continuous bladder drainage, good health and control of infections.
• Use of antiseptic vaginal douches to clear any smell
• At the end of puerperium a patient is assessed by means of speculum
examination.
• Previously enough time was to be given to allow the tissue to heal and
strengthen up sufficiently
• Thereafter a mother would be asked to go home and return for surgery after
3 months. Through today it can be repaired as soon as it is diagnosed
• During the resting and waiting time for the surgery allowing are necessary
 Encouragement
 Plenty of rest
 Good diet with high protein and vitamin for quick healing
 Hygiene/ vulva toilet
 Wearing pads of all times and frequent changing.
 Use of a barrier cream to prevent excoriation of the skin e.g. Zinc and
Custer oil
 Mother is put on continuous bladder drainage and this can
Actual treatment
Repair the fistulae as soon as the patient is first seen repair the examination needed
under anaethesia to establish where urine is coming from and the appropriate
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position for repair. This can be done together with injection of the dye through a
catheter into the urinary bladder to observe where the opening is as a dye will be
seen coming out of it . Then the fistulae can be repaired surgically.
Care after repair
• Like for any mother after operation or obstructed labour
• Mother is nursed in a spine position to prevent excessive pressure on the
suture site.
Continuous bladder drainage so at the bladder is rested to allow proper
healing.
• Plenty of fluids to flash the bladder and prevent pressure on the wound. Any
blood clot or debris is washed out. This helps to prevent urine stasis which
prevents urinary tract infections.
• Maintain fluid balance chart.
• Observe the amount of urine passed and its colour especially blood clots
which may block the catheter.
• Bed is observed daily for wetness
• Remove catheter after 2 weeks if the bed is dry. Or else if most of the
catheter is insitu because it might prevent a small area which is not healed or
closed yet and with time it might close.
• Continuous bladder drainage for preventing the bladder from over distending
so that there is proper healing. Catheter is kept in or at least 2 weeks or until
there is no more leakage of urine.
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• If all the time urine is leaking on the bed and very little or no urine is
draining into the bag chances are that the bladder repair has almost
completely broken down and a repeat repair is needed.
• Inspect the bed to see that it is dry.
• Make sure there’s no blood clots/debris blocking the catheter make sure
there is free drainage of urine
• Plenty of fluids to prevent formation of debris which will block the catheter
• Bladder training release urine at increasing intervals to allow bladder to
regain its capacity and muscles to regain their tone.
• If after 2 weeks all the urine is draining into the catheter, bed is dry, bladder
training is done.
This helps to allow the bladder regain its capacity and strength after a
longtime of disuse it had.  At about 10 – 14 on there after bladder training for
5 days.
Essentials of post-operative Catheter care
• Catheter must drain freely at all times if it becomes blocked the operation
may fail
• Catheter strapped on the mothers thighs
• Patients must not lie on the catheter
• Catheter or tubing must not be twisted
• Drainage or tubing must go into a basin or bucket at the side of the bed.
Urine must be draining at all the time.
• Patient must drink all kinds fluids freely as soon as she has recovered from
the anaesthetic.
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• Urine should be very pale almost like H20 if not patient should drink more.
• If catheter stops draining or patient complains of the full bladder
immediately catheter must be removed
• It must be irrigated to unblock it
• If it fails the catheter must be changed or once by the doctor
• Apply Vaseline around the thighs
Advice on discharge
• No coitus for atleast 3 – 6 months
• Rest and take drugs
• Vulva hygiene to be maintained
• Come back for review
• Continue feeding well
• Mode of delivery next time is ELECTIVE C/S  Pelvic floor exercises.
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Factors affecting natural
closure 
Continued flow of
urine.
• Sepsis.
• Persistence of causative factor e.g. malginancy or radiation necrosis
Complications
• Recurrent fistula (persistent incontinence): Fistulas can be closed
successfully in 72% to 92% of cases. The definition of success, however, is
often different when the perspectives of the patient and the surgeon are
compared. “Success” to a fistula patient means complete restoration of
urinary continence and control, whereas many surgeons define “success” as
simply closing the fistula.
• Sociocultural stigmatization for various reasons.
• Psychological trauma
• Desertion by the husband leading to breakage of marriage
• It may be permanent despite of expert surgery
• Necrosis of the skin around the thighs and here a mother is advised to apply
Vaseline on the skin between thighs to prevent dermatitis.
Prevention of VVF a)Community
• Health education of the cause e.g. Obstructed labor, small pelvis,
young age
• Avoid early sex
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• ANC – emphasize regular attendance herbs (native medicine)
• Training of traditional birth attendants
• Mothers at risk seen during ANC if a maternity center, carryout timely
referral. b)Health workers
• Sensitization regarding VVF problem in the country
• Health education
• Proper screening and early referral e.g. In the antenatal clinic and
early detection of obstructed labor
• Referral to higher centers
• Attitude of health workers towards the community
• Proper management of labor on a partograph
• Catheterization of patients going for C/S
c)Government
• It facilitates nearer to community
• Transport and communication
• Recruitment of more health workers
• Equip health centers adequate equipment
• Motivation of health workers
• Proper security of health units
RECTO-VAGINAL FISTULA
Recto vagina fistula is the connection between a woman’s rectum and vagina. The
opening allows stool and gas to leak from the bowel into the vagina.
Causes
• Complications during childbirth: During difficult delivery, the perineum can
tear, or when performing episiotomy to deliver the baby.
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• Inflammatory bowel disease (IBD), Crohn’s disease and ulcerative colitis.
They cause inflammation in the digestive tract. In rare cases, these
conditions can increase the risk of developing a fistula.
• Cancer or radiation to the pelvis: Cancer in the vagina, cervix, rectum,
uterus, or anus can cause a recto vaginal fistula. Radiation to treat these
cancers can also create a fistula.
• Surgery: Surgery on the vagina, rectum, perineum, or anus can cause an
injury or infection that leads to an abnormal opening
 Fecal impaction (stool stuck in the rectum) Infections
due to HIV.
 Sexual assault.
Signs and symptoms
Recto-vaginal fistulas can cause a variety of symptoms:
• Passing stool or gas from the vagina
• Trouble controlling bowel movements  Smelly discharge from
the vagina.
• Repeated vaginal infections.
• Pain in the vagina or the area between the vagina and anus
(perineuum Dyspareunia.
Risk factors
• Mother with Prolonged labor.
• Mother with Obstructed labor.
• Episiotomy during labor.
• Women with infections such as an abscess or diverticulitis.
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• Women having cancer of the vagina, cervix, rectum, uterus, or anus, or
radiation to treat these cancers
• Women who have under gone hysterectomy or other surgeries to the pelvic
area.
Diagnosis
• History taking.
• The doctor will ask about the symptoms and perform a physical
examination.
• With a gloved hand, the doctor will check the vagina, anus, and
perineum.
• A speculum may be inserted into the vagina to open it up so the doctor
can see the area more clearly.
• A proctoscopecan help the doctor see into the anus and rectum.
• Tests that may be done to help diagnose rectovaginal fistula include:
• Anorectal or transvaginal ultrasound. During this test, a wand-like
instrument is inserted into the anus and rectum, or into the vagina. An
ultrasound uses sound waves to create a picture from inside the pelvis.
• Methylene enema. A tampon is inserted into the vagina. Then, a blue
dye is injected into the rectum. After 15 to 20 minutes, if the tampon
turns blue, one has a fistula.
• Barium enema. A contrast dye that helps a doctor to see the fistula on
an X-ray.
• Computerized tomography (CT) scan. This test uses powerful X-rays
to make detailed pictures inside the pelvis.
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• Magnetic resonance imaging (MRI). This test uses strong magnets and
radio waves to make pictures from inside the pelvis. It can show a fistula
or other problems with the organs, such as a tumor.
Management
• The main treatment for a fistula is surgery to close the abnormal opening.
However, you can’t have surgery if you have an infection or inflammation.
The tissues around the fistula need to heal first.
• The doctor might decide to wait for three to six months for an infection to
heal, and to see if the fistula closes on its own. Antibiotics given to treat an
infection or infliximab (Remicade) to bring down inflammation if the patient
has Crohn’s disease.
• While waiting to have surgery:
• Take the antibiotics and analgesics.
• Keep the area clean. Wash the vagina gently with warm water if you pass
stool or a foul-smelling discharge. Use only gentle, unscented soap. Pat the
area dry.
• Unscented wipes are used instead of toilet paper after visiting the bathroom.
• Apply talcum powder or a moisture-barrier cream to prevent irritation in the
vagina and rectum.
• Wear loose, breathable clothing made from cotton or other natural fabrics.
• If leaking stool, wear disposable underwear or an adult diaper to keep the
feaces away from the skin.
• Rectovaginal fistula surgery can be done through the abdomen, vagina, or
perineum.
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 Vaginal repair: Is usually done when the fistula is in the lower half of
the vagina or near the perineum.
 Abdominal repair: This approach is used by general surgeon when
repairing, a retro vaginal fistula arising in the vault after hysterectomy or
radiotherapy.
 During the surgery, the doctor will take a piece of tissue from somewhere
else in the body and make a flap or plug to close the opening.
 The surgeon will also fix the anal sphincter muscles if they’re damaged.
 Some women will need a colostomy if a fistula is large and if a continuing
malignant tissue were suspected.
Complications
• Rectovaginal fistula can affect your sex life.
• Trouble controlling the passage of stool (feacal incontinence)  Repeated
urinary tract or vaginal infections.
• Inflammation of the vagina or perineum.
• Abscess in the fistula
• Another fistula after the first one is treated
Prevention
• Health Education to women on regular ANC services
• Early detection of associated risks and appropriate referral should be made.
• Proper monitoring of labor using the pantograph  Skilled attendance at all
births
GYNAECOLOGICAL CANCERS
These are the cancers that affect the reproductive system organs.
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These include the following
• Cervical cancer
• Endometrial cancer
• Ovarian cancer
• Breast cancer
• Vulva cancer
CERVICAL CANCER
Definition
It is the malignant growth of the cervix or cervical epithelium.
Dysplasia
In the cervix it means that are zones or areas in the cervical epithelium in which
normal cervical epithelium cells are replaced by abnormal cells. Depending on the
degree of the abnormal growth or development, dysplasia is graded as follows
• Mild
• Moderate
• Severe
Cervical intra epithelial neoplasia: it is of alternative name to pre-invasive
cancer of the cervix. It means carcinoma insitu.
It is graded into 3
CIN 1:- Mild dysplasia
CIN 2:-Moderate dysplasia
CIN 3:-Severe dysplasia
It usually starts at squamous columnar junction which is the point where cancer
cervix starts.
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Squamous metaplasia
Carcinoma insitu: This is when cancer cells have not invaded the basement
membrane.
Micro-invasive carcinoma: when cancer cells have invaded the basement
membrane to the depth of 1 – 2mm below the basement membrane.
Types of cervical cancers
1. Squamous carcinoma 80-90%
• Originate in squamocolumnar junction
• Often associated with pre-invasive disease
2. Adenocarcinoma
• Increasing incidence
• Occur in younger women
• Endocervical mucous-producing gland cells
3. Adenosquamous
 more aggressive clear cell, sarcoma, small cell
Incidence
Cervical cancer is most common in women aged 30–34.
Approximately 90 % of cervical cancers are squamous in origin (arising from the
stratified squamous epithelium of the cervix). The remaining 10 % are
adenocarcinomas (arising from the endo-cervical columnar cells).
Types of cervical cancers
Squamous carcinoma 80-90%
• Originate in squamocolumnar junction
• Often associated with pre-invasive disease
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Adenocarcinoma
• Increasing incidence
• Occur in younger women
• Endocervical mucous-producing gland cells
Adenosquamous –more aggressive Clear cell, sarcoma, small cell
Epidemiology
Cancer of the cervix has long been known to be related to sexual activity. Early age
at coitarche and multiple sexual partners are known risk factors. In addition,
women who are partners with males who had a previous partner with cervical
cancer are at higher risk themselves for this disease.
The causative agent of the vast majority of cervical precancerous and cancerous
lesions is the human papilloma virus (HPV). Certain high-risk genotypes of HPV,
most commonly types 16 and 18, are more frequently associated with cancer of the
cervix, while other types, such as types 6 and 11, are usually associated with
condyloma and non-progressive mild dysplasia. Cigarette smoking is also
associated with an increased risk of cervical cancer, although the exact causal
factor is still unknown.
Aetiology and Pathogenesis
Squamous cell carcinoma is caused by oncogenic subtypes of Human Papilloma
Virus (HR-HPV), the commonest of which are type 16 and 18.
98% percent of infections will resolve spontaneously due to the immune system.
When the immune system is unable to prevent viral replication, precancerous
changes develop, which may lead to cervical cancer. This is more likely to occur in
the presence of co-factors such as cigarette smoking.
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It has also been recognised for many years that cervical dysplasia develops over a
number of years, long before a woman develops cancer. Recognisable graded
abnormalities may be detected on cervical cytology during this time and these
abnormalities are known as dyskaryosis (graded as mild, moderate and severe).
Cervical cytology, first described by Papanicolaou in 1943 is used to detect these
precancerous changes, and has reduced mortality.
Adenocarcinoma arises in the glands of the cervical canal. It is becoming more
common in association with HPV type 18.
Risk factors of cervical cancer
• Large number of children
• Poor hygiene
• Multiple sexual partners
• Early coitus less than 17 years
• Coitus during menstruation
• Prolonged use of COCs
• Smoking
• Penile carcinoma in the sexual partner
• Low social class
• Alcoholism
• 1st
pregnancy at early age
Clinical Assessment/manifestation
Early stage
In early stages cervical cancer is asymptomatic however these can appear
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Vaginal discharge, sometimes foul smelling
Irregular vaginal bleeding
Post-coital bleeding in women of any age
Post-menopausal bleeding (especially if not responding to appropriate
treatment)
Late stage
• Urinary frequency and urgency
• Backache, lower abdominal pain
• Dyspareunia
• A speculum examination may detect a cervical lesion (squamous cell) or
abnormal tissue arising from the endo cervix (adenocarcinoma).
Very late stage
• Severe back pain
• Weight loss
• Oliguria (due to ureteric obstruction or renal failure)
• Urinary/ faecal incontinence
• Oedema of lower limbs
• Dyspnoea (due to anaemia, metastasis or pleural effusion)
• Frequency in micturition
• Dysuria
• Anorexia
• Weight loss
• General body weakness
• Cough and chest pain
• Hydronephrosis and renal failure
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Investigations
• For invasive cancer, consider stages of cancer
• Speculum examination: Cervical lesion that easily bleeds on contact
• PAP smear
• Visual Inspection with Acetic acid (VIA)
• Visual Inspection with Lugols Iodine (VILI)
• Human Papilloma Virus/DNA testing
• Colposcopy
• Biopsy
• Erythrocyte Sedimentation Rate
• Reneral function
• Intravenous pyelography
• X-rays: Chest X-Rays, skeletal X-rays, CT-scan
• Magnetic Resonance Imaging of lymphatic metastasis
Staging of cervical cancer
• Stage 0: Carcinoma in situ
• Stage 1: cancer is confined within the cervix
 Stage 1 a: cancer is in the micro-invasive stage
 Stage 1 a 1: Stromal invasion <3 mm (micro-invasive)
 Stage 1 a 2: stromal invasion 3-5 mm
 Stage 1 b: cancer cells only confined in the body of the cervix
 Stage 1 b 1: Stromal invasion >5 mm, or gross cervical lesion
<4cm
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 Stage 1 b 2: gross cervical lesion > 4 cm
• Stage 2: cancer has spread beyond the cervix
 Stage 2 a: extending to upper 2/3 vagina
 Stage 2 b: cancer has invaded the parametrium but has not reached the
pelvic wall.
• Stage 3a: Extending to lower 1/3 vagina
• Stage 3b: Extending into parametrium to pelvic sidewall or hydronephrosis
• Stage 4a: extending to bladder/ bowel mucosa
• Stage 4b: distant metastasis
Management
Principle of treatment
• Provide general supportive care, e.g., correction of anemia
• Undertake examination under anesthesia for staging, biopsy
• Provide supportive treatment, surgery, and or radio therapy according to
staging
General measures
• It is important to clinically assess the extent of disease prior to the onset of
treatment.
• Surgery can be utilized in early stage- disease Ia1-IIa.
• Radiotherapy+/- chemotherapy can be utilized in all stages I-IV. Surgery
Depends on the stage
 Stage 0
Cone biopsy: If she is young and wants to give birth
Total Hysterectomy: it she is a grown up and doesn’t want to have children
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
• Stage Ia1: Cold knife cone or LEEP cone in young patients, in old women
hysterectomy.
• Stage Ib1, Ib2, IIa: radical hysterectomy with bilateral pelvic
lymphadenectomy (Para aortic nodes optional) combined with radiotherapy
• Stage III and IV: Inoperable (radiotherapy) and palliative care
Recommendations
• HPV vaccine is more important for the prevention of cancer cervix
• Cervical cancer screening (HPV, pap smear, VIA, VILI, Coloposcopy,
biopsy)
• Treatment of pre-cancerous lesion (cryotherapy, LEEP, Cervical conisation)
• Treatment of invasive cancer (radiotherapy, surgery, chemotherapy)
• Psychologic and financial support in advanced stage of cervical cancer
Complications
• Anaemia due blood loss
• Sepsis
• Vesico vaginal fistula
• Rectal vaginal fistula
• Chronic & ill health
• Weight loss
• Renal failure
• Cachexia
Pain
Hematuria and dysuria
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Ureteral obstruction and renal failure
Oedema of legs
• Bowel invasion: Diarrhea, Tenesmus,rectal bleeding
• Metastasis
NB: May occur due to local invasion of tissues – bladder, obstruction of the ureters
and/or infiltration of the rectum, or distal metastases e.g. lung, liver, or distant
lymph nodes.
Prognosis
The 5 year survival rate depends on the stage of the disease when it is
diagnosed. It ranges from 93 % with low grade cancers, to 35 % for advanced
cervical cancer.
ENDOMETRIAL CANCER
This is usually adenocarcinoma.
Endometrium cancer is a growth of abnormal cells in the endometrial lining of the
uterus.
Incidence
It usually occurs in post-menopausal women (age peak: 40 to 55 years). The
lifetime risk of developing the cancer is 1.1%, while the lifetime of dying is 0.4%,
reflecting the good prognosis with early diagnosis it is more common in women
who have not had children, who are obese, who have polycystic ovarian syndrome,
hypertension and diabetes.
In contrast to cervical cancer, the incidence of endometrial cancer is increasing in
line with the obesity epidemic.
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Endometrial cancer is thought to be caused by unopposed/excessive oestrogen
exposure. The combined administration of oestrogen along with a progestogen as
with combined oral contraception (COC) has a protective effect on the
endometrium.
Risk factors
• Post menopause
• Atypical hyperplasia of endometrium
• Excessive endogenous oestrogens (nullipartiy, obesity, early puberty, late
menopause)
• Treatment with unopposed oestrogen
• Treatment with tamoxifen
• Family history of endometrium cancer
• Obesity
• Hypertension
• Diabetes
Stages of endometrial cancer
• Stage 1: Disease confined to the body of uterus
 Stage 1a: Carcinoma confined to the endometrium
 Stage 1b: Myometrial invasion less than 50%
 Stage 1c: Myometrial invasion more than 50%
• Stage 2: Cervix involved
 Stage 2a: Endocervical gland involvement only
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 Stage 2b: Cervical stromal invasion but does not extend beyond the
uterus
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Stage 3: Spread to serosa of uterus, peritoneal cavity, or lymph nodes
 Stage 3a: Carcinoma involving seros of the uterus or adnexae, positive
ascites, or positive peritoneal washings
 Stage 3b: Vaginal involvement either direct or metastatic
 Stage 3c: Para-aortic or pelvic node involvement
• Stage 4: Local or distant metastases
 Stage 4a: Carcinoma involving the mucosa of the bladder or rectum
 Stage 4b: Distant metastases or involvement of other abdominal or
unguinal lymph nodes
Clinical Assessment/manifestations History
The commonest presenting symptom is heavy menstrual bleeding (HMB) for
women who are premenopausal, or post-menopausal bleeding (PMB) in women
who are menopausal.
• Peri or post-menopausal vaginal bleeding
• Postmenopausal vaginal discharge (pyometra)
• Symptoms of metastasis
NB: A speculum examination is usually normal, as is a bimanual examination.
Investigations
• Transvaginal Ultrasound
• Hysteroscopy
• Endometrial biopsy
• CT-scan
• Investigations for metastasis
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Management
Surgery
• Total abdominal hysterectomy and bilateral salpingo- oophorectomy (TAH-
BSO): stage I
• Radical hysterectomy: stage II
• Radical surgery with maximal debulk followed by radiotherapy: stage III
• Radical radiotherapy + or not hormonal and or Chemotherapy: stage IV
Radiotherapy
• Most patient with early disease receive a combination of surgery and
radiotherapy after histopathology findings
• Patients treated with surgery alone are limited to those where the carcinoma
is endometrioid type confined to less than 50% of the mymetrial thickness
Hormonal therapy
• Progestogens are the most common used form of hormonal therapy in
endometrial cancer Chemotherapy
The use of chemetharapy is uncommon but should be considered in fit patient with
systemic disease Medicines used in chemotherapy are:
Doxorubicin (anthracycline) and Cyplatin
OR
Carboplatin (platinum medicines) daily use limited by patient advanced age
and poor performance status. Cisplatinum 50mg/m2 IV, Adriamycin
45mg /m2 IV D1 followed by Paclitaxel 160mg/m2 repeat every 21 days OR
Carboplatin and Paclitaxel as for ovarian cancer
Recommendations
• Patient education e.g. familial endometrial cancer
Address if post-menopausal bleeding
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
Early reproductive period parity
Avoid obesity
Address if hypertensive and/or diabetic
• Consult before taking unopposed oestrogens and tamoxifen
Complications
Endometrial cancer can spread locally to bladder or bowel, and can obstruct the
ureters. Distal metastases can also occur to lymph nodes, lung, liver, bones, brain
and vagina.
Prognosis
Again, this depends on the stage of the cancer.
Five year survival rates can be as high as 90 % for early cancers, to as low as 15 %
for more advanced stage cancer.
OVARIAN CANCER
It is the malignant growth within the ovarian tissue
Incidence
It is the most common gynecological cancer.
Most of the ovarian cancers (90 %) arise from the epithelial layer on the outside of
the ovary, and are epithelial cancers. The other types of ovarian cancer arise from
the germ cells or from the sex cord stromal cells.
Ovarian cancer is most common in postmenopausal women, with 75 % of women
being diagnosed over the age of 55.
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There appears to be a link between ovulation and epithelial ovarian cancer. Using
combined hormonal contraception reduces the risk of ovarian cancer by
approximately 50 %. Having a first degree relative with ovarian cancer is a risk
factor.
Taking COC, having children, breast feeding and having the tubes ligated have all
been suggested to be protective against ovarian cancer.
Risk Factors
• Post-menopausal women but the cancer is considered in Women above 40
years old
• Family history of 2 or more affected first degree relatives (mother and sister)
• Abnormal ovarian development as in Turner’s syndrome
• Nulli parity
• Being a carrier of BRCA 1 and 2 genes
• Smoking and alcoholism
• Ovulatory stimulant drugs
• High fat diet
• Use fertility drugs
• Hormonal replacement therapy
• Increased number of ovulatory cycles i.e. early menarch, late menopause
Stages of ovarian cancer
Stage 1: Disease confined to the ovaries (25% of presentations)
 Stage 1a: Involving only one ovary
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 Stage 1b: Involving both ovaries
 Stage 1c: Positive cytology or ascites or breaching the capsule of
either ovary
• Stage 2: Confined to pelvis (5-10% presentations)
• Stage 2: Confined to peritoneal cavity (45% presentations)
 Stage 3a: Micronodular disease outside the pelvis
 Stage 3b: Macroscopictumor deposits <2 cm
 Stage 3c: Tumor>2 cm or retroperitoneal node involvement
• Stage IV: Distant metastases (20% of presentations)
Clinical Manifestations
Unfortunately ovarian cancer does not have any early symptoms. When the disease
spreads it may cause the following signs and symptoms
• Pain
• Feeling of bloating or fullness
• Abdominal distention
• Lower abdominal pain
• Pelvic mass
• Menstrual disturbances (e.g. menorrhagia)
• Gastro intestinal signs
• Pressure symptoms (Dyspareunia, urinary frequency, constipation)
• Ascites and any other signs related to metastasis
• Symptoms of metastasis, including nausea, tiredness, or shortness of breath.
NB: 70 -80 % are diagnosed at an advanced stage
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Investigations
• Abdominal ultrasound
• Intravenous urogram
• Ascitic tap for cytology
• Laparotomy/laparoscopy for biopsy and histology
• CT-scan and/or MRI
• CA-125
• Chest x-ray, FBC, liver function, renal function
Management
Surgery is the principal treatment
• Laparatomy with large debulking if possible
• Washings from peritoneal cavity or any ascitis for cytology
• Where possible, a total abdominal hysterectomy, bilateral salpingo-
oophorectomy and infracolic omentectomy. The retroperitoneal lymph nodes
are biopsied in women with clinically less than stage 3c.
Chemotherapy
It is given to all patients after surgery; the overall response rate is 70-80%
• Carboplatin AUC 5-7 IV and Paclitaxel 175mg /m2 iv 21 day cycles for
3 -6 cycles or,
• Cisplatin 75mg/m2 iv and Paclitaxel 135 mg/m2 iv infusion over 24hrs
(neurotoxic) or,  Carboplatin and Cyclophosphamide 750mg /m2 IV
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Hormonal
Tamoxifen may be used where other treatment is deemed inappropriate.
Radiotherapy
It is not usually used for treating ovarian cancer. It may be used in early stage
cancer post-operatively, or in advanced cancer as “palliative radiotherapy”.
Recommendations
• Manage pelvic pain and/or abdomno-pelvic mass especially associated with
vaginal bleeding
• Perform annual pelvic examination and pelvic ultrasound in reproductive
and advanced age
• Encourage oral contraceptive for high risk women of cancer of the ovary
• Consider prophylactic bilateral laparoscopic oophorectomy in women that
don’t desire fertility with a risk of cancer of the ovary.
• CA 125 is good test for follow up of patients with cancer of ovary but it’s
not good for screening
Complications
As ovarian cancer is often not diagnosed until it is advanced, it may only come to
light when it causes a complication. This could include
• Ascites
• Bowel obstruction/ Intestinal occlusion
• Bladder infiltration causing haematuria, or as a result of secondary deposits
in liver or lung.  Severe loss of weight
• Ascites
• Spread of the cancer to other organs (metastases)
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• Death
Prognosis
The prognosis depends on the cancer type and the stage of the disease at the time
of diagnosis. For epithelial tumours, 5 year survival is as high as 90 % for early
disease, but as low as 17 % for advanced disease. For ovarian stromal tumours, the
range is 95–35 %, and germ cell tumours, 98–69 %.
BREAST CANCER
This is a malignant growth that begins in the tissue of the breast in which abnormal
cells grow in an uncontrolled way. Incidence
This is the most common and the second killer in women after cervical cancer in
the world, but can also appear in men.
Causes/Risk factors
• Early onset menarche
• Late menopause
• Delayed first pregnancy (after 30 years of age)
• Null parity
• Family history (maternal or paternal) BRCA1 and BRCA2 genes
• History of breast biopsy
• Excessive alcohol consumption
• Use of Hormonal therapy for more than 4 years
• Smoking
Obesity
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Protective factors
• Breastfeeding for 12 months
• Multi-parity
• Regular physical exercise
Clinical
manifestations

Asymptomatic
• Lump in the breast
• Unilateral nipple discharge
• Change in breast size
• Nipple or skin retraction
• Local lymphadenopathy
• Skin changes-orange like appearance (pend’s orange)
• Nipple or skin ulceration  Breast pain
• Symptoms of metastasis
Investigations
• Self-examination or examination by a practitioner
• Bilateral Mammography and /or ultrasound
• Renal and Hepatic profile
• Chest X- Ray
• Biopsy (Preferably Fine niddle aspiration)
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TNM Staging of breast cancer TNM staging system
Doctors use the results from diagnostic tests and scans to answer these questions:
• Tumor (T): How large is the primary tumor? Where is it located?
• Node (N): Has the tumor spread to the lymph nodes? If so, where and how
many?
• Metastasis(M): Has the cancer spread to other parts of the body? If so,
where and how much?
Specific tumor stage information in listed below.
Tumor (T):
TX: The primary tumor cannot be evaluated.
T0 (T plus zero): There is no evidence of cancer in the breast.
Tis: Refers to carcinoma in situ. The cancer is confined within the ducts of the
breast tissue and has not spread into the surrounding tissue of the breast. There are
2 types of breast carcinoma in situ:
Tis (DCIS): DCIS is a noninvasive cancer, but if not removed it may develop into
an invasive breast cancer later. DCIS means that cancer cells have been found in
breast ducts and have not spread past the layer of tissue where they began.
Tis (Paget’s): Paget’s disease of the nipple is a rare form of early, noninvasive
cancer that is only in the skin cells of the nipple. Sometimes Paget’s disease is
associated with another, invasive breast cancer. If there is another invasive breast
cancer, it is classified according to the stage of the invasive tumor.
T1: The tumor in the breast is 20 millimeters (mm) or smaller in size at its widest
area.
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This is a little less than an inch. This stage is then broken into 4 substages
depending on the size of the tumor:
T1mi is a tumor that is 1 mm or smaller
T1a is a tumor that is larger than 1 mm but 5 mm or smaller
T1b is a tumor that is larger than 5 mm but 10 mm
or smaller T1c is a tumor that is larger than 10 mm
but 20 mm or smaller T2: The tumor is larger than
20 mm but not larger than 50 mm.
T3: The tumor is larger than 50 mm.
T4: The tumor falls into 1 of the following groups:
T4a means the tumor has grown into the chest wall.
T4b is when the tumor has grown into the skin.
T4c is cancer that has grown into the chest wall and the skin.
T4d is inflammatory breast cancer
Node (N)
The “N” in the TNM staging system stands for lymph nodes. Regional lymph
nodes include:
Lymph nodes located under the arm, called the axillary lymph nodes
Above and below the collarbone
Under the breastbone, called the internal mammary
lymph nodes  NX: The lymph nodes were not
evaluated.
• N0: Either of the following:
• No cancer was found in the lymph nodes.
• Only areas of cancer smaller than 0.2 mm are in the lymph nodes.
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• N1: The cancer has spread to 1 to 3 axillary lymph nodes and/or the internal
mammary lymph nodes. If the cancer in the lymph node is larger than 0.2
mm but 2 mm or smaller, is it called "micro-metastatic" (N1mi).
• N2: The cancer has spread to 4 to 9 axillary lymph nodes. Or it has spread to
the internal mammary lymph nodes, but not the axillary lymph nodes.
• N3: The cancer has spread to 10 or more axillary lymph nodes. Or it has
spread to the lymph nodes located under the clavicle, or collarbone. It may
have also spread to the internal mammary lymph nodes. Cancer that has
spread to the lymph nodes above the clavicle, called the supraclavicular
lymph nodes, is also described as N3.
Metastasis (M)
The “M” in the TNM system describes whether the cancer has spread to other parts
of the body, called distant metastasis. This is no longer considered early-stage or
locally advanced cancer. For more information on metastatic breast cancer, see the
Guide to MX: Distant spread cannot be evaluated.
• M0: The disease has not metastasized.
• M0 (i+): There is no clinical or radiographic evidence of distant metastases.
Microscopic evidence of tumor cells is found in the blood, bone marrow, or
other lymph nodes that are no larger than 0.2 mm.
• M1: There is evidence of metastasis to another part of the body, meaning
there are breast cancer cells growing in other organs.
Stage grouping
• Stage 0: Tis, NO, MO
Stage 1: T1, NO, MO
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• Stage 2a:
 T0, N1, MO
 T1, N1, M0
 T2, N0, M0  Stage 2b:
 T2, N1, M0 T3, N0, MO  Stage 3a:
 T0, N2, M0
 T1, 1,N2, MO
 T2, N2, MO
 T3, N1, M0
 T3, N2, M0  Stage 3b:
 T4, N0, MO
 T4, N1, MO
 T4, N2, MO  Stage 3c:
 Any T, N3  Stage IV:
 Any T, any N, M1
Staging of breast cancer
• Stage 1: Cancer involves only the breast tissue but the lump is still small
2.5cm in diameter.
• Stage 2: cancer has spread and now involves the axillary node
• Stage 3: the skin is now involved with the tumor which is fixed on he
underlying musclesand lump is still less than 10cm.
• Stage 4: disseminated spread to other areas of the body,
Management
Depend on the stage of the
diseases Stage 0 (Cancer in situ):
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• Young women: conservative surgery only (lumpectomy)
• Advanced age: Mastectomy only
Early stage: stage I and II
• Surgery: Modified radical mastectomy and lymphadenectomy (advanced
age) and Simple mastectomy or wide local lumbectomy (Young age)
• Hormonal therapy: Tamoxifen 20mg orally daily for 5 years: may cause
retinal damage
• Chemotherapy
 Cyclophosphamide 30mg/kg IV single dose
 Fluoruracil 300-1000mg /m2 IV, this may be given every 4 weeks
depending on the response of the patient
 Paclitaxel 6mg /ml in combination with Cisplatin 1mg /ml
Late cancer: stage III and IV: wide spread distance (metastasis)
 Hormonal therapy: Tamoxifen 20mg orally daily for 5 years: may
cause retinal damage  Chemotherapy:
 Cyclophosphamide 30mg/kg IV single dose
 Fluoruracil 300-1000mg /m2 IV, this may be given every 4 weeks
depending on the response of the patient
 Paclitaxel 6mg /ml in combination with Cisplatin 1mg /ml
Recommendation
• Auto palpation once per month to exclude any breast mass
• Regular clinical checkup and mammography at least every 2 years
MASTECTOMY
This is a planned operation which is described as the surgical removal of the breast
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Types of mastectomy
• Partial mastectomy: removal of lumps with the surrounding wedge of normal
tissue 2 – 3cm
• Simple mastectomy: breast tissue is removed and biopsy of nodes is done
• Extended simple mastectomy: removal breast tissue, axillary tail and nodes
removed  Total mastectomy: whole breast is removed, pectoralis muscle
is left  Radical mastectomy: breast, skin, muscle, nodes are removed.
• Modified radical mastectomy: breast, skin, muscles, nodes removed and skin
grafting is done
Pre-operative care of mastectomy
Admission
Patient is admitted in a surgical ward. It possible this should be near a patient
recovering from the same operation
The patient is re assured and made to feel comfortable
Crete a good NPR and maintain confidentiality
Counseling on about the use of an artificial breast
History taking
Patient particulars are taken i.e. medical, surgical, Gynaecology histories are taken
and recorded General examination to exclude out dehydration, jaundice,
anemiae.t.c
Observations
• Vital observations i.e. TPR/BP
• Specific e.g. ulcer on the breast, enlargement,
• General observations e.g. anxiety, pain, restlessness or depression
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The doctor is informed and will carry out examination and order investigations.
Investigations
• Urinalysis
• HB, Blood grouping and cross match
• Urea and electrolytes
• Stool for ova and cysts
• Random blood glucose tests
Patient education: about the surgery i.e. its purpose, complications and side effects
of anaethesia.
Re-assuring the patient
Obtaining of the informed consent form
Feeding: No feeds or drinks on the day of the operation
Rest and sleep: ensuring enough rest and sleep i.e. minizing noise, reducing
bright light Morning at the day of the operations
• IV line is put up
• Booking for blood in the laboratory
Catheterisation of the patient
• Administration of pre-medications
• Helping the patient to change into hospital gown
• Removal of all ornaments from the patint and keep them prperly.
• Continouesconselling to relieve anxienty
• Preparation of patients medical document
• Taking the patien to the theater and handing him over to the theater.
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General preparation
Nursing care
General nursing care is given to the patient including diet, exercise, hygiene, rest
and sleep, care of the mind.
Care of the breast
Dress ulcer if
present.
Use a breast sling to reduce Oedema and to relieve
Exercise
Teach the mother breathing exercises and arm exercises
Psychotherapy
Counsel mother on the use of the artificial breast and allay anxiety.
Anesthetist will review of the patient and access if the condition can allow her to
undergo general anaesthesia Consent
An informed consent is obtained from the patient after explaining clearly what is
going to take place.
Local preparation
• Clean the axilla for application of the bandage post operatively
• Chest arm up the wrist, umbilicus, midline of the back
• Prepare the donor site if skin grafting is to be done
• The breast is marked
• Premedication is given
• Patient is starved from midnight  Check if booked blood is ready.
• IV line is started in the morning
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Post operative management of mastectomy
Post operative bed is made
When the operation is finished, the information from the theater will be sent to the
ward and 2 nurses will go and collected the patient
Reports are received from the surgeon, recovery room nurses and
anaethestists Then the patient is wheeld to the ward.
Patient is received in a warm bed, flat position and turned to one side. As soon as
she gains consciuosness sit her in the bed leaning on the affected side to aid
drainage.
Care of the arm
This depends on the surgeon’s orders
Elevate one pillow with elbow at the right angle
Elevate the lie on the drip stand
On gaining consciousness, put the arm sling.
Observation
These are taken ¼ hrly on the 1st
hour, ½ hrly for the next 1hr until discharge.
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Observe temperature, pulse and respiration and Blood pressure
Observe for bleeding of the site and oedema
Observe IV if running well and blood transfusion line
On gaining consciuosness
Welcome patient from the patient from theater and explain what was done and
pope up in the bed and sponge the face
Give a mouth wash and change the gown
Repeat observations
Medical treatment
Analgesics
Pethidine 100mg 8hrly for 3 doses on change to panadol to complete 5 days
Antibiotics: ampicillin or gentamycin as ordered
Supportives: vitamins like vitamin c, Iron, folic acid, diazepam
Care of the wounds
Leave the wounds untouched: if bleeding, re – bodage.
Inspect for tension on the wound i.e. oedema.
Observe for slouging.
If grafting was done/ leave of wound untouched for 48hrs. care for donor site and
drains is done. Stitches are removed on the 8th
– 10th
day
Care drainage
There are 2 main drains, one in the wound and one in the axilla.
First dressing is done 48hrs – 72hrs
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Dress the axilla wound separately using normal salaine to remove serum
Remove drainage if there is nothing coming out. Axilla drain is removed 3 – 4days
after the operation.
Nursing care
Hygiene; assist the patient with bed bath oral care is done until the patient is
able to do it yourself. Diet: allow as soon as she is able, give plenty of fluids
and assist until patient is able to feed herself Elimination: encourage regular
emptying of the bowel and bladder offer assistance util she is able.
Exercise: begin chest and leg exercise as soon as conscious.
Begin with fingers, then wrist after 48hrs. this is to avoid swelling and bleeding in
the wound.
Increase to shoulder then the whole arm.
This is to prevent deformity and contractures.
By the 1th day patient should be able to touch the back and her head or 2 comb her
hair. Psychotherapy: reassure the patient and consel on the use of artificial breast.
Advice on discharge
To start radiotherapy when wound heals (6 -8wks) to last 2months.
Follow up every after 2months up to 2years
Then once 2years up to 10years
Continue with chemotherapy
Regular checkups to rule out metasis
Attend cancer institute for radiotherapy
Join mastetomy association clubs
Use of artificial breast
Regular checkups
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Complications of mastectomy
• Necrosis of the suture line
• Damage to nerves leading to paralysis of the arm
• Contractures
• Sloughing of flaps
• Infections
• Gaping of the wound
• Chronic sinus
• Oedema of arm
• Thrombosis of axillary vein
• Cosmetic defigurement
VAGINAL CANCER
Vaginal cancer is a disease in which malignant (cancer) cells form in
the vagina. Vaginal cancer is not common.
Types of vaginal cancer
There are two main types of vaginal cancer:
Squamous cell carcinoma: Cancer that forms in the thin, flat cells lining the
inside of the vagina. Squamous cell vaginal cancer spreads slowly and usually
stays near the vagina, but may spread to the lungs, liver, or bone. This is the most
common type of vaginal cancer.
Adenocarcinoma: Cancer that begins in glandular cells. Glandular cells in the
lining of the vagina make and release fluids such as mucus. Adenocarcinoma is
more likely than squamous cell cancer to spread to the lungs and lymph nodes. A
rare type of adenocarcinoma is linked to being exposed to diethylstilbestrol (DES)
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before birth. Adenocarcinomas that are not linked with being exposed to DES are
most common in women after menopause.
Risk factors to vaginal cancer
• Being aged 60 or older.
• Being exposed to DES while in the mother's womb.
• Having human papilloma virus (HPV) infection.
• Having a history of abnormal cells in the cervix or cervical cancer.
• Having a history of abnormal cells in the uterus or cancer of the uterus.
• Having had a hysterectomy for health problems that affect the uterus.
Vaginal intraepithelial neoplasia (VAIN)
These are abnormal cells are found in tissue lining the inside of the vagina.
These abnormal cells are not cancer. Vaginal intraepithelial neoplasia (VAIN) is
grouped based on how deep the abnormal cells are in the tissue lining the vagina:
• VAIN 1: Abnormal cells are found in the outermost one third of the tissue
lining the vagina.
• VAIN 2: Abnormal cells are found in the outermost two-thirds of the tissue
lining the vagina.
• VAIN 3: Abnormal cells are found in more than two-thirds of the tissue
lining the vagina. When abnormal cells are found throughout the tissue
lining, it is called carcinoma in situ.
NB: VAIN may become cancer and spread into the vaginal wall. VAIN is
sometimes called stage 0.
Stages of vaginal cancer:
Stage 1: Cancer is found in the vaginal wall only.
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Stage 2: Cancer has spread through the wall of the vagina to the tissue around the
vagina. Cancer has not spread to the wall of the pelvis.
Stage 3: Cancer has spread to the wall of the pelvis.
Stage 4: metastases
Stage 4 A: Cancer may have spread to one or more of the following areas:
• The lining of the bladder.
• The lining of the rectum.
• Beyond the area of the pelvis that has the bladder, uterus, ovaries, and
cervix.
Stage 4 B: Cancer has spread to parts of the body that are not near the vagina, such
as the lung or bone.
Signs and symptoms of vaginal cancer include pain or abnormal vaginal
bleeding.
Vaginal cancer often does not cause early signs or symptoms. It may be found
during a routine pelvic exam and Pap test.
• Bleeding or discharge not related to menstrual periods
• Pain during sexual intercourse (dyspareunia)
• Pain in the pelvic area
• A lump in the vagina
• Pain when urinating
• Constipation
Diagnostic measures
• Physical exam and history: An exam of the body to check general signs of
health, including checking for signs of disease, such as lumps or anything
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else that seems unusual. A history of the patient’s health habits and past
illnesses and treatments will also be taken.
• Pelvic exam: An exam of the vagina, cervix, uterus, fallopian tubes, ovaries,
and rectum. A speculum is inserted into the vagina and the doctor or nurse
looks at the vagina and cervix for signs of disease. A Pap test of the cervix is
usually done. The doctor or nurse also inserts one or two lubricated, gloved
fingers of one hand into the vagina and places the other hand over the lower
abdomen to feel the size, shape, and position of the uterus and ovaries. The
doctor or nurse also inserts a lubricated, gloved finger into the rectum to feel
for lumps or abnormal areas.
• Pap test: A procedure to collect cells from the surface of the cervix and
vagina. A piece of cotton, a brush, or a small wooden stick is used to gently
scrape cells from the cervix and vagina. The cells are viewed under a
microscope to find out if they are abnormal. This procedure is also called a
Pap smear.
• Colposcopy: A procedure in which a colposcope (a lighted, magnifying
instrument) is used to check the vagina and cervix for abnormal areas. Tissue
samples may be taken using a curette (spoon-shaped instrument) or a brush
and checked under a microscope for signs of disease.
• Biopsy: The removal of cells or tissues from the vagina and cervix so they
can be viewed under a microscope by a pathologist to check for signs of
cancer. If a Pap test shows abnormal cells in the vagina, a biopsy may be
done during a colposcopy.
• Chest x-ray: An x-ray of the organs and bones inside the chest. An x-ray is a
type of energy beam that can go through the body and onto film, making a
picture of areas inside the body.
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• CT scan (CAT scan): A procedure that makes a series of detailed pictures of
areas inside the body, taken from different angles. The pictures are made by
a computer linked to an x-ray machine. A dye may be injected into a vein or
swallowed to help the organs or tissues show up more clearly. This
procedure is also called computed tomography, computerized tomography,
or computerized axial tomography.
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
MRI (magnetic resonance imaging):A procedure that uses a magnet, radio
waves, and a computer to make a series of detailed pictures of areas inside
the body. This procedure is also called nuclear magnetic resonance imaging
(NMRI).
• PET scan (positron emission tomography scan): A procedure to find
malignant tumor cells in the body. A small amount of radioactive glucose
(sugar) is injected into a vein. The PET scanner rotates around the body and
makes a picture of where glucose is being used in the body. Malignant tumor
cells show up brighter in the picture because they are more active and take
up more glucose than normal cells do.
• Cystoscopy: A procedure to look inside the bladder and urethra to check for
abnormal areas. A cystoscope is inserted through the urethra into the
bladder. A cystoscope is a thin, tube-like instrument with a light and a lens
for viewing. It may also have a tool to remove tissue samples, which are
checked under a microscope for signs of cancer.
Certain factors affect prognosis (chance of recovery) and treatment options.
• The prognosis (chance of recovery) depends on the following:
• The stage of the cancer (whether it is in the vagina only or has spread to
other areas).
• The size of the tumor.
• The grade of tumor cells (how different they look from normal cells under a
microscope).
• Where the cancer is within the vagina.
• Whether there are signs or symptoms at diagnosis  The patient's age
and general health.
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
• Whether the cancer has just been diagnosed or has recurred (come back). 
When found in early stages, vaginal cancer can often be cured.
Treatment options depend on the following:
• The stage and size of the cancer.
• Whether the cancer is close to other organs that may be damaged by
treatment.
• Whether the tumor is made up of squamous cells or is an adenocarcinoma.
• Whether the patient has a uterus or has had a hysterectomy.
• Whether the patient has had past radiation treatment to the pelvis. Three
types of standard treatment are used:
• Surgery
• Radiation therapy
• Chemotherapy
Surgery
Surgery is the most common treatment of vaginal cancer. The following surgical
procedures may be used:
• Laser surgery: A surgical procedure that uses a laser beam (a narrow beam
of intense light) as a knife to make bloodless cuts in tissue or to remove a
surface lesion such as a tumor.
• Wide local excision: A surgical procedure that takes out the cancer and some
of the healthy tissue around it.
• Vaginectomy: Surgery to remove all or part of the vagina.
• Total hysterectomy: Surgery to remove the uterus, including the cervix. If
the uterus and cervix are taken out through the vagina, the operation is called
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
a vaginal hysterectomy. If the uterus and cervix are taken out through a large
incision (cut) in the abdomen, the operation is called a total abdominal
hysterectomy. If the uterus and cervix are taken out through a small incision
in the
Lymph node dissection: A surgical procedure in which lymph nodes are
removed and a sample of tissue is checked under a microscope for signs of
cancer. This procedure is also called lymphadenectomy. If the cancer is in
the upper vagina, the pelvic lymph nodes may be removed. If the cancer is in
the lower vagina, lymph nodes in the groin may be removed.
• Pelvic exenteration: Surgery to remove the lower colon, rectum, bladder,
cervix, vagina, and ovaries. Nearby lymph nodes are also removed. Artificial
openings (stoma) are made for urine and stool to flow from the body into a
collection bag.
NB: Skin grafting may follow surgery, to repair or reconstruct the vagina. Skin
grafting is a surgical procedure in which skin is moved from one part of the body
to another. A piece of healthy skin is taken from a part of the body that is usually
hidden, such as the buttock or thigh, and used to repair or rebuild the area treated
with surgery.
After the doctor removes all the cancer that can be seen at the time of the surgery,
some patients may be given radiation therapy after surgery to kill any cancer cells
that are left. Treatment given after the surgery, to lower the risk that the cancer will
come back, is called adjuvant therapy.
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
Radiation therapy
Radiation therapy is a cancer treatment that uses high-energy x-rays or other types
of radiation to kill cancer cells or keep them from growing. There are two types of
radiation therapy:
• External radiation therapy uses a machine outside the body to send radiation
toward the cancer.
• Internal radiation therapy uses a radioactive substance sealed in needles,
seeds, wires, or catheters that are placed directly into or near the cancer.
NB: The way the radiation therapy is given depends on the type and stage of the
cancer being treated. External and internal radiation therapy are used to treat
vaginal cancer, and may also be used as palliative therapy to relieve symptoms and
improve quality of life.
Chemotherapy
Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer
cells, either by killing the cells or by stopping them from dividing. When
chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter
the bloodstream and can affect cancer cells throughout the body (systemic
chemotherapy). When chemotherapy is placed directly into the cerebrospinal fluid,
an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer
cells in those areas (regional chemotherapy). The way the chemotherapy is given
depends on the type and stage of the cancer being treated.
Topical chemotherapy for squamous cell vaginal cancer may be applied to the
vagina in a cream or lotion.
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
Treatment options Stage I Vaginal Cancer
Treatment of stage I squamous cell vaginal cancer may include the following:
• Radiation (internal and external radiation)
• Wide local excision or vaginectomy with vaginal reconstruction. Radiation
therapy may be given after the surgery.
• Vaginectomy and lymph node dissection, with or without vaginal
reconstruction. Radiation therapy may be given after the surgery.
Treatment of stage I vaginal adenocarcinoma may include the following:
• Vaginectomy, hysterectomy, and lymph node dissection. This may be
followed by vaginal reconstruction and/or radiation therapy.
Radiation
• A combination of therapies that may include wide local excision with or
without lymph node dissection and internal radiation therapy.
Stage 2 Vaginal Cancer
Treatment of stage II vaginal cancer is the same for squamous cell cancer and
adenocarcinoma.
Vaginectomy or pelvic exenteration. Internal and/or external radiation therapy
may also be given.
Stage 3 Vaginal Cancer
Treatment of stage III vaginal cancer is the same for squamous cell cancer and
adenocarcinoma. Treatment may include the following:
• Radiation therapy
• Surgery (rare) followed by external radiation therapy. Internal radiation
therapy may also be given.
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
Stage 4 A Vaginal Cancer
Treatment of stage IVA vaginal cancer is the same for squamous cell cancer and
adenocarcinoma.
• Radiotherapy (External radiation therapy and/or internal radiation therapy)
• Surgery (rare) followed by external radiation therapy and/or internal
radiation therapy.
Stage 4 B Vaginal Cancer
Treatment of stage IVB vaginal cancer is the same for squamous cell cancer and
adenocarcinoma.
• Radiation therapy as palliative therapy, to relieve symptoms and improve the
quality of life.
• Chemotherapy may also be given.
VULVAR CANCER
Vulvar cancer is the malignant (cancerous) growth of cells
in the vulva. It’s rare.
Types of Vulvar Cancer
There are five main forms of this disease.
• Squamous cell carcinoma: It is the most common. It starts in the skin cells.
Some types of it are linked to HPV -- human papilloma virus. That’s an
infection you get from having sex with someone who has it. Younger women
are more likely to get vulvar cancer that’s linked to HPV. Older women
more often get forms that aren’t related to it. An extremely rare type of
squamous cell carcinoma looks like a wart. It grows slowly.
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
• Adenocarcinoma: It usually starts in cells located in the glands just inside
the opening of the vagina. It can look like a cyst, so you might not pay
attention to it at first. This type also can form in sweat glands in the skin of
the vulva.
• Melanoma: forms in cells that make pigment, or skin color. You’re more
likely to get it on skin that’s exposed to sun, but it can show up in other areas
too, like the vulva. It makes up about 6 out of every 100 vulvar cancers.
• Sarcoma: It starts in bone, muscle, or connective tissue cells. It differs from
other vulvar cancers because it can happen at any age, including childhood.
• Basal cell carcinoma: It is the most common type of skin cancer. It usually
appears on skin that’s exposed to sun. Very rarely, it occurs on the vulva.
Risk factors of Vulvar cancer
• Age: risk increases with age i.e. More than half of all cases happen in
women over age 70.  Having a history of abnormal Pap tests
• HIV
HPV infection
• Having a precancerous condition. These are changes in the cells or tissue in
the vulva that can happen sometimes years before you’re diagnosed with
cancer.
• Smoking. If you have a history of HPV and you smoke, you’re at much
greater risk for vulvar cancer.
Stages of vulvar cancer
Stage 1: The tumor is only in the vulva or the vulva and perineum. It has not
spread.
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
 Stage 1 A: The tumor is only in the vulva or the vulva and perineum, is 2 cm
or smaller, has not spread, and is no deeper than 1 mm.
 Stage 1 B: The tumor is larger than 2 cm or is deeper than 1 mm, but is only
in the vulva or the vulva and perineum.
Stage 2: The tumor is of any size and has spread to nearby structures, including the
lower part of the urethra, vagina, or anus. It has not spread to lymph nodes or other
parts of the body.
Stage 3: The cancer has spread to nearby tissue, such as the vagina, anus, or
urethra, and to the groin lymph nodes. There are no distant metastases.
 Stage 3 A: The cancer has spread to nearby tissue (the vagina, anus, or
urethra). There are 1 or 2 metastases to lymph nodes, but they are smaller
than 5 mm, or there is 1 metastasis that is 5 mm. There are no distant
metastases.
 Stage 3 B: The cancer has spread to nearby tissue (the vagina, anus, or
urethra). There are 3 or more metastases to lymph nodes, but they are
smaller than 5 mm, or there are 2 or more metastases that are 5 mm. There
are no distant metastases.
 Stage 3 C: The cancer has spread to nearby tissue (the vagina, anus, or
urethra) and to 1 or more lymph nodes and their surrounding lymph node
capsule, or covering. There are no distant metastases.
Stage 4: The cancer has spread to the upper part of the vagina or upper part of the
urethra, or it has spread to a distant part of the body.
 Stage 4 A: The tumor has spread to the upper part of the urethra, vagina, or
anus; the cancer has spread to regional lymph nodes and caused ulceration;
or it has attached the lymph node to the tissue beneath it. There are no
distant metastases.
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
 Stage 4 B: Cancer has spread to a distant part of the body.
Clinical manifestations
• Discoloration of your vulva i.e. Changes in the color and the way the vulva
looks
• Unusual growths
• Persistent and constant itching
• Abnormal vaginal bleeding i.e. Bleeding or discharge not related to
menstruation
• Vulvar tenderness
• Severe burning, itching or pain
• An open sore that lasts for more than a month
• Skin of the vulva looks white and feels rough
• Dysuria
Diagnostic measures
• Physical exam and history: An exam of the body to check general signs of
health, including checking for signs of disease, such as lumps or anything
else that seems unusual. A history of the patient’s health habits and past
illnesses and treatments will also be taken.
• Pelvic exam: An exam of the vagina, cervix, uterus, fallopian tubes, ovaries,
and rectum. A speculum is inserted into the vagina and the doctor or nurse
looks at the vagina and cervix for signs of disease. A Pap test of the cervix is
usually done. The doctor or nurse also inserts one or
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two lubricated, gloved fingers of one hand into the vagina and places the
other hand over the lower abdomen to feel the size, shape, and position of
the uterus and ovaries. The doctor or nurse also inserts a lubricated, gloved
finger into the rectum to feel for lumps or abnormal areas.
• Pap test: A procedure to collect cells from the surface of the cervix and
vagina. A piece of cotton, a brush, or a small wooden stick is used to gently
scrape cells from the cervix and vagina. The cells are viewed under a
microscope to find out if they are abnormal. This procedure is also called a
Pap smear.
• Colposcopy: A procedure in which a colposcope (a lighted, magnifying
instrument) is used to check the vagina and cervix for abnormal areas. Tissue
samples may be taken using a curette (spoon-shaped instrument) or a brush
and checked under a microscope for signs of disease.
• Biopsy: The removal of cells or tissues from the vagina and cervix so they
can be viewed under a microscope by a pathologist to check for signs of
cancer. If a Pap test shows abnormal cells in the vagina, a biopsy may be
done during a colposcopy.
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Management
Specific treatment for vulvar cancer will be determined based on:
• Your overall health and medical history
• Extent of the disease
• Your tolerance for specific medications, procedures or therapies
• Expectations for the course of the disease Treatment for cancer of the vulva
may include:Surgery:
Laser surgery: This surgery uses a powerful beam of light to destroy abnormal
cells. The beam can be directed to specific parts of the body without making a
large incision (cut). This type of therapy is only used for premalignant
(noninvasive) disease of the vulva.
Excision: The cancer cells and a margin of normal tissue around the cancer are
removed.
Vulvectomy: All tissues of the vulvar are surgically removed. The extent of the
tissue removed is based on the size and location of the lesion.
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