Maria Eva Trent, M.D., M.P.H.

https://www.hopkinsmedicine.org/profiles/results/directory/profile/0016881/maria-trent

Examination reveals normal appearing external female genitalia prostate cancer hospitals buy alfuzosin pills in toronto, blind vagina prostate cancer books buy discount alfuzosin 10 mg online, and absence or sparsity of pubic and axillary hair mens health 6 pack abs buy alfuzosin cheap. Breast development is normal prostate cancer 2 causes alfuzosin 10 mg discount, as the androgens produced by the testes are aromatized to estrogens leading to breast development prostate optimizer order cheap alfuzosin line. The presentation can also be during childhood with testes present within inguinal hernias. The diagnosis should be considered in any young female presenting with inguinal hernia or labial mass. Some are advocating leaving the gonads in place and monitoring for development of gonadoblastoma, but this is not standard. Dosage is higher than for a postmenopausal woman to promote bone growth and secondary sexual characteristics. Fertility treatment is not possible as there are no oocytes, nor a uterus to carry a pregnancy. The female phenotype is similar to the patient with complete androgen insensitivity, but generally exhibits differing degrees of ambiguous genitalia axillary/ pubic hair at puberty. The male phenotype, exhibited in Reifenstein syndrome, is infertile and typically includes hypospadias and bifid scrotum. There is also a range of external genitalia from microphallus with a normal urethra, to the creation of a pseudovagina and lack of scrotal fusion. These males typically have gynecomastia and normal pubic and axillary hair but no chest or facial hair. However, some surgical procedure is often performed to modify the ambiguous genitalia to facilitate gender assignment. In the presence of this defective gene, gonads do not differentiate in to testes, and no testosterone or antimüllerian hormone is produced. Clinical manifestations include an externally female appearance, with nonfunctioning gonads. Therefore, girls often present with delayed puberty, both lack of menstruation and failure of secondary sex characteristics development, such as breast development. Diagnosis can be suspected in the setting of delayed puberty, with elevation in measured gonadotropins. This suggests that the pituitary is functioning normally, but the gonads are not responding. Hormonal supplementation for initiation of puberty with estrogen alone, followed by addition of progesterone to facilitate regular menstruation as uterus is present. Presentation is in adolescence or adulthood with hirsutism, irregular menstruation, or infertility. Diagnosis is made by measuring 17-hydroxyprogesterone which will be elevated due to the 21-hydroxylase deficiency. Neonates with ambiguous genitália must have serum electrolytes monitored for evidence of salt wasting, which can be life-threatening, and a karyotype. E 5-Alpha reductase deficiency is a disease in which the 5-alpha reductase enzyme is not present, and testosterone is not converted to dihydrotestosterone in peripheral tissues. Dihydrotestosterone is required in utero for normal development of male external genitalia. There is normal production of antimüllerian hormone, and therefore no development of müllerian duct structures occurs. Clinical manifestations range from the appearance of normal male external genitalia, normal female genitalia, or ambiguous genitalia. These infants are born with testes and wolffian duct structures, but can have the appearance of female primary sex characteristics. At puberty, these individuals can present with primary amenorrhea and may also have increased virilization, with testicular descent, and normal male-pattern hirsutism. Diagnosis is considered with the presentation of the above-mentioned constellation of clinical manifestations. There is usually a low or low-normal testosterone level, decreased levels of dihydrotestosterone, and a higher testosterone/dihydrotestosterone ratio. Those assigned to the male gender can be given exogenous dihydrotestosterone before puberty to increase the size of the penis. Psychological support is also important given the difficulties that can occur with specific gender identity. Estrogen replacement to promote puberty and breast development with subsequent addition of progestin to regulate menstruation. Estrogen dosing should be higher than postmenopausal woman to promote bone growth and secondary sexual characteristics. Pregnancy can be achieved with assisted reproductive technology and donor oocytes. There is typically a unilateral intra-abdominal testis, a streak gonad on the opposite side, and presence of müllerian structures. There is also a high risk of developing a gonadoblastoma, and as a result, removal of the gonads is recommended. Müllerian Anomalies and Disorders of Sexual Development 247 Study Questions for Chapter 21 Directions: Each of the numbered items or incomplete statements in this section is followed by answers or by completions of the statement. A Elevated serum testosterone B Vaginal agenesis, absent uterus C Scant/absent pubic hair, normal axillary hair D Gonads should be removed E Pregnancy possible with gestational carrier 2. A 15-year-old female is referred to you because of worsening dysmenorrhea, associated with nausea and vomiting. She has had such severe vomiting that she has not been able to go to school for the past 6 months and has forced out of the cheerleading squad because of her frequent absences. The rest of her medical history is notable for asthma, irritable bowel, and renal agenesis diagnosed during her fetal ultrasound. Her pediatrician has given her a diagnosis of "cyclic vomiting syndrome" and is treating her with antinausea medication and antidepressants and has referred her to a psychiatrist. Estrogen replacement needed to induce puberty, gonads do not need to be removed 5. Estrogen therapy needed to induce puberty, gonads need to be removed at diagnosis 6. Associated with blue bulging introitus with valsalva due to obstruction 248 Chapter 21-Answers and Explanations Answers and Explanations 1. The vagina and uterus are underdeveloped or absent, but the ovaries are not affected and are normal. Both the axillary and pubic hair are normal for a female as the androgen receptors are intact. Pregnancy is possible with a gestational carrier as the oocytes are normal and can be fertilized and transplanted in to a surrogate uterus. The gonads are testes and should be removed after puberty due to the increased risk of malignant transformation. There is no vagina or uterus because the testes did produce antimüllerian hormone during embryonic development. Pregnancy with gestational carrier is not possible as the testes do not function normally and do not produce sperm or contain oocytes. This young woman has increasingly severe dysmenorrhea, associated with nausea and vomiting and has a history of congenital renal agenesis. Uterus didelphys with obstructed hemivagina is less likely as she has not masses appreciated on abdominal examination. A karyotype is also not necessary as she has normal external genitalia and normal menstruation. Uterus didelphys is usually associated with a longitudinal vaginal septum and two vaginal canals. With tampon insertion in to one hemivagina, the other hemivagina is patent and therefore not occluded. Breast development will need to be induced with estrogen, but the ovaries do not need to be removed. Since malignant transformation can occur at any time, gonadectomy should be performed at time of diagnosis. To carry a pregnancy using donor oocytes, a uterus is necessary and nonfunctioning gonads would be present. Uterus didelphys with obstructed hemivagina is associated with right renal agenesis much more frequently than left. Transverse vaginal septum that is low needs to be distinguished from imperforate hymen as the surgical approach is different. Imperforate hymen just involves resection of hymenal tissue while transverse vaginal septum required resection of the septum with anastomosis of upper and lower vaginal canals. Cervical agenesis needs to be differentiated from high transverse vaginal septum as surgical resection of high vaginal septum is not associated with risk of infection as the cervix serves as a barrier to infection. With anastomosis of the vagina to the uterus, the protective barrier, the cervix, is not present and ascending infection from the vagina to the uterus and peritoneal cavity with subsequent death has been reported. Imperforate hymen is associated with primary amenorrhea with cyclic or chronic pelvic pain often associated with a mass. If there is a large hematocolpos present that extends down to the introitus, then a blue hue bulge of the distended hymenal tissue can be seen with valsalva. If not such blue bulging tissue is seen, then imperforate hymen may not be the diagnosis. Primary amenorrhea is the absence of menses by the age of 13 years in girls who do not show signs of developing secondary sexual characteristics, or by the age of 15 years in girls with normal development of secondary sexual characteristics. The age of work-up has decreased slightly over the past years due to a secular trend of earlier onset of menarche. Secondary amenorrhea is the cessation of menses for a period of 6 months or a three-cycle interval in women who have been menstruating regularly. B Normal menstrual cycle physiology requires interaction between the hypothalamus, pituitary gland, ovaries, and uterus. Granulosa cells produce progesterone during the luteal phase, resulting in luteinization of endometrial glands to their secretory form in preparation for a pregnancy. If pregnancy is not established, the corpus luteum regresses, progesterone support is withdrawn and menses ensues. It is defined as secondary amenorrhea with ovarian failure before 40 years of age. Fragile X premutation is associated with premature ovarian insufficiency and is caused by an increased number (55 to 200) of trinucleotide repeats on the X chromosome (2) Autoimmune disease: Typically autoimmune ovarian insufficiency is highly correlated with and can follow autoimmune adrenal insufficiency. The most common autoimmune disease seen with premature ovarian insufficiency is thyroid disease as it is the most common autoimmune disease. Other autoimmune diseases seen with autoimmune premature ovarian insufficiency include hyperparathyroidism, pernicious anemia, myasthenia gravis, and diabetes. The accumulated galactose metabolites is toxic to the ovary, and decreases the number of oogonia (5) Iatrogenic: Chemotherapy (especially alkylating agents) or pelvic radiation 2. This typically results from a chromosomal anomaly, the most common of which is 45,X. Patients with Y-bearing cell lines should undergo a gonadectomy as they are at increased risk of a germ cell malignancy. Turner syndrome (1) the most common genotype is 45,X, which is accompanied by nonfunctional streak ovaries and primary amenorrhea. Amenorrhea 251 (3) Phenotypic characteristics include short stature, webbed neck, shield chest, and increased carrying angle at the elbow. It is essential to rule out cardiovascular and renal anomalies in suspected cases. Rare disorder, due to defective gonadotropin receptors or a postreceptor signaling defect. On histology the ovaries are found to have follicles, but these follicles do not respond to gonadotropin stimulation. As a result there is little or no hormone production from the ovaries, although the ovaries are normal and capable of producing hormones. Bulimia (binging and purging with vomiting, laxatives, or diuretics) may be seen in 50% of patients. This syndrome is defined as disordered eating, amenorrhea, and osteopenia or osteoporosis. This condition is usually associated with sports favoring a lean body type such as running, figure skating, gymnastics, and ballet. Although this is thought of as a disorder seen in elite athletes, high school and college athletes are also at risk. Sporadic and genetic cases exist; inheritance can be X-linked, autosomal dominant, or autosomal recessive. Signs and symptoms include primary amenorrhea, normal karyotype, infantile sexual development, and the inability to perceive odors (anosmia or hyposmia). Possible coexisting features include bone and renal anomalies, cleft lip and palate, color blindness, or hearing deficit. Masses of the pituitary gland itself, or the surrounding structures, can effect hormone secretion. These tumors can be associated with visual changes, galactorrhea, and other hormone deficiencies, including hypothyroidism, amenorrhea, and adrenal insufficiency. Pituitary adenomas (1) Microadenomas are less than 10 mm in size, macroadenomas are greater than or equal to 10 mm. Infarction of the pituitary gland, which typically occurs due to a postpartum hemorrhage. Hemochromatosis, histiocytosis, or other infiltrative processes can involve the hypothalamus and pituitary and result in amenorrhea. Less common in girls than boys; there is often a family history of delayed puberty. Adrenarche and gonadarche are both delayed; normal pubertal development occurs, just at a later age.

However prostate cancer 2 stages 10 mg alfuzosin purchase overnight delivery, other treatment regimens have not been tested adequately for patients with neurosyphilis prostate cancer 045 discount alfuzosin 10 mg online. These patients should undergo skin testing followed by penicillin desensitization for two reasons: tetracycline and doxycycline are contraindicated in pregnancy prostate 180 purchase 10 mg alfuzosin mastercard, and only penicillin has been proven to prevent fetal infection prostate cancer 4049 10 mg alfuzosin with visa. Congenital syphilis (1) Treatment is recommended for infants who are strongly suspected of being born with syphilis because of specific abnormalities on physical examination mens health 5k training discount alfuzosin 10 mg without a prescription, serum nontreponemal serologic titer four times greater than the maternal titer, positive darkfield examination of infant body fluid, or history of inadequately treated maternal syphilis. Alternatively, procaine penicillin G 50,000 units/kg/dose, intramuscularly once daily, can be given for the first 10 days of life. Patients with early syphilis should have a fourfold decline in titer by 3 months posttreatment. Retreatment should be considered for a fourfold increase in titer, for failure of an initial titer greater than 1:32 to decrease fourfold 12 to 14 months after treatment, or if symptoms or signs of disease occur after treatment. Close serologic follow-up is warranted in patients treated with alternative regimens. Exhaustive epidemiologic studies have demonstrated that male homosexuals and bisexuals, intravenous drug users, female heterosexual consorts of infected men, recipients of tainted blood or concentrated blood products, and neonates born to infected women are the predominant populations at risk. Recent studies show that currently more than 80% of infections are transmitted through sexual contact. Sexually Transmitted Infections 381 (1) the usual incubation period is 2 to 4 weeks. A thorough history and physical examination, including gynecologic examination and Pap smear b. Identification of patients in need of immediate medical care and antiretroviral therapy or prophylaxis for opportunistic infections d. Administration of recommended vaccines (1) Pneumococcal (2) Influenza (3) Hepatitis B if susceptible (4) Measles if needed (5) Haemophilus influenzae B f. Psychosocial and behavioral evaluation and counseling, including counseling about high-risk behaviors as well as identification of sexual partners for testing g. Viral expression, symptoms, persistence and oncogenicity on both viral type and the immune response of an infected individual. In women whose sexual partners have obvious genital warts, the risk of contracting warts is 60% to 85%. Transmission to the fetus may occur, occasionally causing neonatal and juvenile respiratory papillomatosis. Genital warts can sometimes grow extensively during pregnancy and may need removal because of their size and friability. Also, cesarean section may be necessary if wart proliferation obstructs the vagina or makes the vaginal surface extremely friable. Exuberant exacerbation of genital warts during pregnancy generally regresses without treatment after delivery. Types 16 and 18 are the most commonly associated with cervical or anal squamous cell carcinoma. Lesions include overt anogenital warts (condyloma acuminatum) and dysplastic lesions. Visual inspection of overt warty disease of the lower genital tract detects obvious lesions, which are often multifocal in distribution. Approximately 2% to 4% of Pap smears demonstrate the pathognomonic cell-the koilocyte (or halo cell). This exfoliated squamous cell has a wrinkled, somewhat pyknotic nucleus surrounded by a perinuclear clear zone or halo. Pap smears with this change are designated as low-grade squamous intraepithelial lesions. The lesions are flat, small, and acetowhite, with vascular punctuation or mosaicism. Histologically, these lesions reveal koilocytosis, acanthosis, and variable nuclear atypia. Treatment of anogenital external warts: Even without treatment, many warts resolve. Patient-applied methods (1) Podophylotoxin solution or gel causes arrest of mitosis by binding to microtubules. Patients apply this medication to warts twice daily for 3 days followed by 4 days off for up to four cycles. Up to 94% of genital warts have been shown to be eradicated with application of podophylotoxin. Patients apply this medication to warts three times a week at bedtime and wash it off after 6 to 10 hours. This cream can be used for up to 16 weeks and produces a 72% to 84% clearance rate with a 5% to 19% recurrence rate. Provider-applied methods (1) Cryotherapy with liquid nitrogen or a cryoprobe produces a 63% to 72% clearance rate. Care must be used in application to avoid damage to surrounding normal tissue since this agent is very caustic. It is injected in to lesions with a high effectiveness rate after multiple injections. Treatment of cervical disease is reserved for high grade and persistent low grade change. Treatment methods rely on removal or destruction of lesions defined on colposcopy as well as the cervical transformation zone. Methods for excision/destruction for treatment of cervical dysplasia include: (1) Loop electrode excision of the transformation zone (2) Laser vaporization (3) Cryotherapy (4) Cone biopsy of the cervix d. More recently, another bivalent vaccine, Cervarix (Glaxo-Smith Kline) was approved for use in females aged 10 to 25 years. Immunization is intended to decrease infection and subsequent development of cervical intraepithelial neoplasia. Both these viruses have an affinity for infecting mucocutaneous tissues of the lower genital tract and are maintained in pelvic ganglia as a latent reservoir for recurrent herpetic genital infection. The incubation time from exposure to symptoms for genital herpes is between 3 and 7 days. Frequency of recurrence is influenced by severity and duration of the primary episode as well the serotype of the infection virus and the host immune response. Primary genital herpetic infections may also be accompanied by systemic viral symptoms such as fever, myalgias, headache, and general malaise. Primary lesions start as small vesicles and then become shallow, coalescent, painful ulcers in a few days and may last for 2 to 3 weeks. These lesions may be accompanied by severe dysuria with urinary retention, mucopurulent vaginal discharge, painful inguinal adenopathy, generalized myalgias, headaches, and fever. Recurrent lesions are similar but less severe in intensity, duration, and systemic side effects. Infants who come in to contact with maternal active infection at birth are at risk for potentially fatal systemic infections. This situation is most likely to occur in infants born to mothers who are having their initial outbreak. When maternal active herpes infection is suspected at term or at the time of labor, cesarean section is generally the recommended route for delivery. Herpes cultures obtained from the vesicular fluid or the edge of the ulcerative lesion give the best results. Cytologic demonstration of multinucleated epithelial cells with intranuclear inclusions is helpful in the diagnosis. Initiation of one of the following regimens as soon as diagnosis is suspected is appropriate to decrease severity and duration of primary infection: (1) Acyclovir 400 mg orally three times daily for 7 to 10 days or 200 mg orally five times daily for 7 to 10 days (2) Famciclovir 250 mg orally three times daily for 7 to 10 days (3) Valacyclovir 1 g orally twice daily for 7 to 10 days b. Prompt treatment with one of the regimens below decreases duration and severity of symptoms. Initiation of treatment should be done as soon as possible since treatment is more effective when initiated within 24 hours of symptom occurrence. Suppressive therapy can be utilized by patients who either have frequent and/or severe recurrence. Asymptomatic shedding and infection of noninfected sexual partners may also be decreased by continuous regimens. Because risk of recurrence varies over time even without suppressive treatment, suppressive treatment should be periodically reevaluated. The benefits and risks of suppressive therapy for longer than 6 years have not yet been studied. Condom use to decrease transmission should also be encouraged in discordant couples. One of the following regimens is appropriate for suppressive treatment: Sexually Transmitted Infections 385 (1) Acyclovir 400 mg orally twice daily (2) Famciclovir 250 mg orally twice daily (3) Valacyclovir 500 mg orally once daily or 1. This virus creates small (1 to 5 mm), umbilicated papules in the cutaneous genital region of sexually active individuals. The lesion itself is pathognomonic, but the diagnosis can be confirmed on histologic demonstration of a papule with a hyperkeratotic plug arising from an acanthotic epidermis. The disease is usually self-limited, with spontaneous resolution in 6 to 9 months. Local excision, cryotherapy, electrocautery, and laser vaporization are suitable treatment modalities to decrease the duration of symptoms. There were approximately 60,000 new infections in the United States in 2004, check stats down from an average of 260,000 in the 1980s. Fifteen to twenty-five percent of those with chronic infection die of liver disease. Only 2% to 6% of infected adults become chronically infected, but 90% of congenitally infected infants develop chronic infection. Interferon-alfa and lamivudine have been used in attempts to treat chronic hepatitis B. Hepatitis C infection is the most common blood-borne infection in the United Stated and evidence of hepatitis C infection has been found in approximately 2% of the adult population of the United States. The main mode of transmission is through exposure to infected blood products or contaminated needles. When symptoms occur they are vague and nonspecific such as malaise, nausea, fatigue, myalgias and generalized weakness. The goal of treatment is to prevent cirrhosis and subsequent sequelae of chronic liver disease. While infection can be asymptomatic, trichomoniasis can cause acute vulvovaginitis in women and urethritis in men. Trichomonas is diagnosed in up to 35% of women presenting with vulvovaginitis complaints. Vaginal erythema and occasional intense erythematous mottling of the cervix (strawberry cervix) 4. In both sexes carriers may be asymptomatic for long periods of time C Diagnosis 1. Inflammatory response and motile, flagellated trichomonads on wet mount preparations, best appreciated when wet mount is promptly viewed. Cultures for Trichomonas are available but are usually reserved for resistant cases in which antimicrobial testing can be used 4. Newer immunochromatic and nucleic probe tests with 83% sensitivity and 97% specificity are available. Positive results on these tests should be interpreted with caution in low prevalence populations D Treatment Therapy using metronidazole in either of the following regimens produces cure rates of greater than 95%. Patients should be counseled to avoid alcohol during treatment with metronidazole and tinidazole because of a possible Antabuse reaction. A Pediculosis pubis (Phthirus pubis) the crab louse is a slow-moving insect approximately 1 mm long. After 7 days, nymphs arise from the nits and progress to the adult stage in 2 to 3 weeks. The crab louse can be transmitted through direct sexual contact or through fomites, such as blankets and sheets. Hard, smooth surfaces such as toilet seats are not suitable fomites for the transmission of the crab louse. Intense vulvar pruritus secondary to an allergic sensitization is the presenting symptom. Identification of the crab louse or nits can be made with a hand lens inspection of the hair-bearing pubic region. When eyelashes are infected, treatment involves application of an occlusive ophthalmic ointment to eyelids two times daily for 10 days. Resistance to treatment a and b below is widespread and retreatment with different agents may be necessary. Permethrin cream, 1%, rinse applied to affected areas and rinsed after 10 minutes. Pyrethrins with piperonyl butoxide applied to the affected area and washed off after 10 minutes. Duration of treatment and odor of medication limits use to treatment failures with the above. Lindane is contraindicated in pregnancy and lactation and in children less than 2 years of age. Lindane is not recommended for first-line therapy since toxicity includes seizures and aplastic anemia and has been reported when exposure exceeded 4 minutes. Use of lindane should be limited to a 4-minute exposure in nonpregnant or lactating adults weighing more than 100 lb and should be reserved for treatment failures with other medications. Infected individuals should be re-evaluated 1 week after treatment for nits or lice. Unlike the crab louse, it can be found anywhere on the skin, where it burrows a 5-mm-long tunnel to lay its eggs. Scabies can be transmitted by close sexual contact but also by nonsexual contact, such as sharing clothing or bedding. With initial infection, sensitization to scabies must occur before pruritus begins.

Placenta Praevia androgen hormone for women 10 mg alfuzosin with visa, Placenta Praevia Accreta and Vasa Preavia: Diagnosis and Management androgen hormone quizzes alfuzosin 10 mg order without a prescription, 2011 prostate oncology specialists in illinois order genuine alfuzosin on-line. If a cervical smear is overdue prostate health foods buy generic alfuzosin 10 mg on-line, the woman with Antepartum Haemorrhage 215 Placenta Praevia at a Glance Definition Placenta implanted in uterine lower segment prostate cancer diagnosis discount 10 mg alfuzosin visa. Furthermore, there is growing evidence that in utero health and growth influences health, particularly car diac disease, in later life. Care of the fetus in pregnancy must be directed towards the causes of these: the prin cipal causes of death and cerebral palsy are outlined in the boxes below. Identification and management of the compromised fetus is difficult, not least be cause of the difficulty in identifying the pregnancy at risk, limited resources and the potential for over medicalization of pregnancy. Traditionally, small size was felt to reflect chronic compromise due to pla cental dysfunction. If a fetus was genetically deter mined to be 4 kg at term and delivers at term weighing 3 kg, its growth has been restricted, and it may have placental dysfunction. Similarly, an ill, malnourished, tall adult may weigh more than a healthy shorter one. Fetal distress this refers to an acute situation, such as hypoxia, that may result in fetal damage or death if it is not reversed, or if the fetus delivered urgently. Nevertheless, most babies that subsequently develop cerebral palsy were not born hypoxic. Fetal compromise this describes a chronic situation and should be defined as when conditions for the normal growth and neuro logical development are not optimal. The methods used will vary according to pregnancy risk and events during the pregnancy. Problems with fetal surveillance All methods of surveillance have a false positive rate. Whilst they may identify problems, they do not necessarily solve them and prevent adverse outcomes. Uterine artery Doppler can also be performed in the first trimester but is less sensitive than at 23 weeks. In this way, factors in the history and investigations can be used to identify more highrisk women (with a lower false positive rate). This is currently under evaluation but is likely to enable more appropriate targeting of hospital based and highrisk antenatal care. Methods of fetal surveillance Routine pregnancy care the tests outlined below are not routine in low risk pregnancy. Ultrasound assessment of fetal growth What it is: Ultrasound scan is used to measure fetal size after the first trimester, particularly the abdominal and head circumferences. Benefits: Serial ultrasound is safe and useful in confirm ing consistent growth in highrisk and multiple preg nancies, and is essential to the management of such pregnancies. Doppler umbilical artery waveforms What it is: Doppler is used to measure velocity wave forms in the umbilical arteries. Benefits: Umbilical artery waveforms help identify which small fetuses are actually growth restricted and therefore compromised. Its usage improves perinatal outcome in highrisk pregnancy whilst reducing inter vention in those not compromised. Limitations: Doppler is not a useful screening tool in lowrisk pregnancies and is less effective at identifying the normalweight but compromised fetus. With fetal compromise, the middle cerebral artery often develops a low resistance pattern in comparison to the thoracic aorta or renal vessels. Benefits: the use of these is restricted to highrisk preg nancy and specific situations. Fetal Growth, Compromise and Surveillance 221 Maximum systolic frequency Minimum enddiastolic frequency (a) Waveform in systole Waveform in diastole (reversed) (b). Reduced liquor (oli gohydramnios) is a nonspecific finding that is more common in compromised fetuses. Cardiotocography or non-stress test What it is: the fetal heart is recorded electronically for up to an hour (this can be combined with ultrasound as a biophysical profile). Benefits: Antenatal abnormalities represent a late stage in fetal compromise and delivery is indicated. Fetal Growth, Compromise and Surveillance 223 Kick chart What it is: the mother records the number of indi vidual movements that she experiences every day. Benefits: Most compromised fetuses have reduced movements in the days or hours before demise. Routine counting is of very limited benefit in reducing perinatal mortality, may lead to unnecessary intervention and increases maternal anxiety. Maternal risks are greater because preeclampsia may coexist and because Caesarean delivery is often used. These centiles are used for the whole population, and therefore do not take account of genetic and ethnic differences. Aetiology Fetal size and health is determined by a combination of genetic and acquired factors. Low maternal height and weight, nulliparity, Asian (as opposed to Caucasian or AfroCaribbean) ethnic group and female fetal gender are all associated with smaller babies. In addition, maternal obesity and diabetes, and male gender, are associated with an increased risk of adverse outcomes. The small but consistently growing fetus with normal umbilical artery Doppler values does not need intervention. Bedrest does not increase fetal growth, but admission or even delivery may be needed for other indications, particularly severe preeclampsia. However, prolonged pregnancy increases the chances of fetal distress when labour does start: this also leads to an increased chance of a Caesarean section. The aim is to balance the risks of obstetric intervention against those of prolonged pregnancy. Induction before 41 weeks does not have this effect, and is associated with increased intervention. However, the risk of perinatal mortality and morbidity starts increasing between 41 and 42 weeks. The aetiology of prolonged pregnancy is not understood, but it is more common if previous pregnancies have been pro longed and in nulliparous women, and is rarer in South Asian and black women. Elective induction for pregnancies at or beyond 41 weeks of gestation and its impact on stillbirths: a systematic review with metaanalysis. Neonatal illness and encephalopathy, meconium passage and a clinical diagnosis of fetal dis tress are more common. Abnormal lie occurs at 1 in 200 births, but is more common earlier in the pregnancy: before term, it is normal. Management No action is required for transverse or unstable lie before 37 weeks unless the woman is in labour. After 37 weeks, the woman is usually admitted to hospital in case the membranes rupture and an ultrasound scan performed to exclude particular identifiable causes, notably polyhydramnios and placenta praevia. If spontaneous version occurs and persists for more than 48 h the mother discharged. In the absence of pelvic obstruction, an abnormal lie will usually stabilize before 41 weeks. Aetiology Preterm labour is more commonly complicated by an abnormal lie than labour at full term. Breech presentation Definitions and epidemiology the presentation refers to the part of the fetus that occupies the lower segment of the uterus or the pelvis. Upper abdominal discomfort is common: the hard head is normally palpable and ballottable at the fundus. Management External cephalic version From 37 weeks, an attempt is made to turn the baby to a cephalic presentation. With both hands on the abdomen, the breech is disengaged from the pelvis, pushed upwards and to the side, and rotation in the form of a forward somersault is attempted. This is performed under ultrasound guidance and in hospital to allow immediate delivery if complications occur. Maternal morbidity is not increased by this policy: indeed, more than onethird of attempts at vaginal breech delivery end in emergency Caesarean section, which carries even greater maternal risks than an elective procedure. Parents should be counselled as to these findings, although the final decision rests with them. Under such circumstances, vaginal breech delivery is still appropriate, yet skills are being lost due to lack of experience. Knowledge of the technique of vaginal breech delivery remains essential and is therefore described. Vaginal breech birth delivery is often the result of injudicious traction causing extension of the head. The fetus delivers with maternal effort as far as the umbilicus, and should not be touched. This allows the anterior shoulder and then the posterior shoulder to enter the pelvis. Once the back of the neck is visible, the operator supports the entire weight of the fetus on one palm and forearm, with their finger in its mouth to guide the head over the perineum and maintain flexion. If this fails to deliver the head, an assistant holds the legs up whilst forceps are applied, and with the next contraction the head is lifted slowly out of the vagina. Under these circumstances augmentation with oxytocin is unwise and Caesarean section is performed. Planned Caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Such fetuses may be of different sex and are no more genetically similar than siblings from different pregnancies. Whether they share the same amnion or placenta depends on the time at which division in to separate zygotes occurred. Many are diagnosed only at ultrasound: as this is now performed in most pregnancies, the diagnosis is seldom missed. Antepartum complications Virtually all obstetric risks are exaggerated in multiple pregnancies. Anaemia is common, partly because of a greater increase in blood volume causing a dilutional effect and partly because more iron and folic acid are needed. Anaemia Preeclampsia Very rare Fetal Congenital anomalies Intrauterine growth restriction Polyhydramnios Malpresentation Miscarriage and preterm labour Twins have greater mortality (6-fold increase) and long-term handicap (5-fold increase). Multiple Pregnancy 233 Inter-twin membrane Shared placenta Cord Blood vessels on placental surface Cord Donor side Inter-twin membrane Direction of blood flow Direction of blood flow Recipient side Artery to artery Artery to vein. Congenital abnormalities are not more common per baby in dichorionic, but they are in monochorionic pregnancies. Complications of monochorionicity these largely result from the shared blood supply in the single placenta. It results from unequal blood distribution through vascular anastomoses of the shared placenta. Monoamniotic twins: In this rare situation, not only the placenta but also the amniotic sac is shared. Multiple Pregnancy 235 hypoxia, cord prolapse, tetanic uterine contraction or placental abruption, and may present as a breech. Multiple pregnancies increase maternal tiredness and anxiety, and may result in financial problems. Early ultrasound: Screening for chromosomal abnormalities is offered in the normal manner. Chorionicity is most accurately ascertained in the first trimester: in dichorionic twins, the dividing membrane is thicker as it meets the placentas (Lambda sign). Selective reduction to a twin pregnancy at 12 weeks should be discussed with women with triplets or higher order pregnancies. Selective reduction may also be performed if one twin has a congenital abnormality. A policy of inserting cervical sutures in all women with a short cervix is not advised but is probably appropriate if the cervix is very short, very early. Fetal abnormality Where one twin has an abnormality selective termination should be discussed. In monochorionic twins the cord must be occluded using bipolar diathermy, or its insertion ablated, because the circulation is shared. At this stage particularly, good communication with, and a comfortable position for, the mother are essential. Once the head or breech enters the pelvis, the membranes are ruptured and pushing again begins. Excessive delay is associated with increased morbidity for the second twin, but excessive haste is equally dangerous. If the head does not descend, a malpresentation (particularly a brow) is likely and Caesarean section is very occasionally required. The latter must be performed under general, epidural or spinal anaesthesia, and only by experienced personnel. It involves inserting a hand in to the uterus, grasping the feet and guiding them down. After delivery, a prophylactic oxytocin infusion is used to prevent postpartum haemorrhage. Nevertheless, vaginal delivery when the first fetus is cephalic, whatever the lie or presentation of the second, remains commonplace and is therefore discussed. Epidural analgesia is not mandatory but is helpful if difficulty is encountered with the second twin. The diagnosis is made when painful uterine contractions accompany dilatation and effacement of the cervix.

Very early: (low grade histology mens health ru order discount alfuzosin online, Stage 1a and 1b): Chemotherapy is not usually given prostate procedures for enlarged prostate alfuzosin 10 mg purchase otc. Other Stage 1 (high grade androgenic hormone baldness cheap alfuzosin 10 mg fast delivery, Stage 1c): six cycles of the platinum-agent carboplatin mens health get back in shape buy discount alfuzosin 10 mg on line, is used prostate cancer treatment drugs cheap 10 mg alfuzosin. Two-thirds of women whose tumours initially respond to first-line chemotherapy relapse within 2 years of completing treatment. Poor prognostic indicators are advanced stage, poorly differentiated tumours, clear cell tumours and slow or poor response to chemotherapy. The prognosis of ovarian cancer prognosis is improving, but largely for the minority of women with early stage disease. Support: Women must be offered support and written information, including regarding psychosocial and psychosexual issues and genetic aspects throughout the process of investigation, diagnosis and treatment. Ovarian cancer causes the most deaths, but the principles outlined are applicable to all terminal disease. Important issues include the problems of prolongation of poor-quality life, euthanasia, symptom control versus drug side effects, making the transition from curative to palliative care, and resource allocation. Organization of palliative care Three levels of care are involved, usually working together: the general practitioner, specialist practitioners such as Macmillan nurses, and specialist hospices or gynaecology units. Alternative therapies such as acupuncture or behavioural techniques may allow greater patient control. Heavy vaginal bleeding may occur with advanced cervical and endometrial carcinomas. Ascites and bowel obstruction are particular features of advanced ovarian carcinoma. If obstruction is partial, metoclopramide is used (pro-motility and antiemetic) and stool softeners, with enemas for constipation and a trial of dexamethasone to reduce tissue oedema. For complete obstruction cyclizine and ondansetron are used for nausea and vomiting, with hyoscine for spasm. Terminal distress: the last 24 h are often the memories the relatives will retain. The terminal stage should be managed sensitively with time for the patient and relatives in a quiet environment. Good symptom control with anxiolytics and analgesics without overly sedating can allow valuable time with the family. It overlaps with the vestibule, the area between the labia minora and the hymen, which surrounds the urethral and vaginal orifices. Most lymph drainage occurs via the inguinal lymph nodes, which drain to the femoral and thence to the external iliac nodes of the pelvis. Miscellaneous benign disorders of the vulva and vagina Lichen simplex (or chronic vulval dermatitis). The area, typically the labia majora, is inflamed and thickened with hyper- and hypopigmentation. The symptoms can be exacerbated by chemical or contact dermatitis and are sometimes linked to stress or low body iron stores. Symptoms can be due to local problems including infection, dermatological disease, malignant and premalignant disease, and the vulval pain syndromes. Uncontrollable scratching may cause trauma with bleeding and skin splitting and symptoms of discomfort, pain and dyspareunia. Inflammatory adhesions can form potentially causing fusion of the labia and narrowing of the introitus. Vulvar dysaesthesia (vulvodynia) or the vulval pain syndromes these are diagnoses of exclusion, with no evidence of organic vulval disease. They are divided in to provoked or spontaneous vulvar dysaesthesia and subdivided according to site: local. They are associated with many factors including a history of genital tract infections, former use of oral contraceptives and psychosexual disorders. Spontaneous generalized vulvar dysaesthesia (formerly essential vulvodynia) describes a burning pain that is more common in older patients. Vulvar dysaesthesia of the vestibule causes superficial dyspareunia or pain using tampons and is more common in younger women, in whom introital damage must be excluded. For both conditions, topical agents are seldom helpful and oral drugs such as amitriptyline or gabapentin are sometimes used. Lichen planus A common disease which may affect skin anywhere on the body, but particularly mucosal surfaces such as in the mouth and genital region. In the mouth and genital region it can be erosive and is more commonly associated with pain than with pruritis. The typical patient is postmenopausal but much younger women are occasionally affected. It causes severe pruri- Infections of the vulva and vestibule Herpes simplex, vulval warts (condylomata acuminata). Candidiasis may affect the vulva if there has been prolonged exposure to moisture. If infection occurs, commonly with Staphylococcus or Escherichia coli, an abscess forms. Treatment is with incision and drainage, and marsupialization, whereby the incision is sutured open to reduce the risk of re-formation. Spontaneous resolution is usual, but it very occasionally turns malignant (clear cell carcinoma of the vagina). Vaginal wall prolapse and vaginal discharge are discussed in Chapters 7 and 10, respectively. The lesion is usually unifocal in the form of an ulcer or plaque and is linked to keratinizing squamous cell carcinomas of the vulva. Overtightening, incorrect apposition at perineal repair or extensive scar tissue commonly present with superficial dyspareunia. They have a smooth white appearance, can be as large as a golf ball, and are often mistaken for a prolapse. Fifteen per cent of women having excision have unrecognized invasive disease, therefore, if conservative or medical treatment is used, adequate biopsies must be taken. Spread is to the superficial and then to the deep inguinal nodes, and thence to the femoral and subsequently external iliac nodes. Melanomas, basal cell carcinomas, adenocarcinomas and a variety of others, including sarcomas, account for the rest. Stage 4 Investigations Clinical features History: the patient experiences pruritus, bleeding or a discharge, or may find a mass, but malignancy often presents late as lesions go unnoticed or cause embarrassment. Examination: this will reveal an ulcer or mass, most commonly on the labia majora or clitoris. Treatment For Stage 1a disease, wide local excision is adequate, without inguinal lymphadenectomy. If the tumour does not extend to within 2 cm of the mid-line, unilateral excision and lymphadenectomy only are used. Disorders of the Vulva and Vagina 53 Malignancies of the vagina Secondary vaginal carcinoma is common and arises from local infiltration from cervix, endometrium or vulva, or from metastatic spread from cervix, endometrium or gastrointestinal tumours. Complications include wound breakdown, infection, leg lymphoedema, lymphocyst formation and sexual and body image problems. Radiotherapy may be used to shrink large tumours prior to surgery, postoperatively if groin lymph nodes are positive, or palliatively to treat severe symptoms. Behind the vaginal walls, the bladder, urethra, rectum and small bowel descend and produce a form of herniation. Prolapse is extremely common and is present to variable degrees in most older parous women. Prolapse Types of prolapse Types of uterovaginal prolapse are classified anatomically according to the site of the defect and the pelvic viscera that are involved. Urethrocoele is prolapse of the lower anterior vaginal wall, involving the urethra only. Often there is an associated prolapse of the urethra, in which case the term cystourethrocoele is used. Apical prolapse is the term used to describe prolapse of the uterus, cervix and upper vagina. If the uterus has been removed, the vault or top of the vagina, where the uterus used to be, can itself prolapse. Rectocoele is prolapse of the lower posterior wall of the vagina, involving the anterior wall of the rectum. Anatomy and physiology of the pelvic supports the pelvic floor consists of muscular and fascial structures that provide support to the pelvic viscera and the external openings of the vagina, urethra and rectum. The uterus and vagina are suspended from the pelvic sidewalls by endopelvic fascial attachments that support the vagina at three levels. Level 1: the cervix and upper third of the vagina are supported by the cardinal (transverse cervical) and uterosacral ligaments. These are attached to the cervix and suspend the uterus from the pelvic sidewall and sacrum, respectively. Level 2: the mid portion of the vagina is attached by endofascial condensation (endopelvic fascia) laterally to the pelvic sidewalls. Level 3: the lower third of the vagina is supported by the levator ani muscles and the perineal body. The levator ani muscles form the floor of the pelvis from attachments on the bony pelvic walls and incorporate the perineal body in the perineum. Aetiology of prolapse Attenuation of the vaginal support mechanisms may occur as a result of: Vaginal delivery and pregnancy: Prolapse is uncommon in nulliparous women. Vaginal delivery may cause mechanical injuries and denervation of the pelvic floor, which contribute to subsequent prolapse. These risks are increased with large infants, prolonged second stage and instrumental delivery. It is thought that this is due to the deterioration of collagenous connective tissue that occurs following oestrogen withdrawal. Chronic predisposing factors: Prolapse is aggravated by any chronic increase in intra-abdominal pressure, resulting from factors such as obesity, chronic cough, constipation, heavy lifting or pelvic mass. Iatrogenic factors: Pelvic surgery may also influence the occurrence of urogenital prolapse. For example, hysterectomy is associated with subsequent vaginal vault prolapse, particularly when the initial indication was a symptom of prolapse. Causes of prolapse Vaginaldeliveryandpregnancy Congenitalfactors Menopause Chronicpredisposingfactors Iatrogenicfactors Pubic symphysis Perineal body (b) Levator Uterosacral ani ligament. Severe prolapse interferes with intercourse, may ulcerate and cause bleeding or 56 Chapter 7 Peritoneum Uterus Small bowel Large bowel Bladder Urethra Vagina (a) (b) (d) (c) Peritoneum (e) Area of prolapse. A rectocoele often causes no symptoms, but occasionally causes difficulty in defaecating. Some women have to reduce the prolapse with their fingers to enable the passing of urine or stool. Examination: Includes the abdomen followed by bimanual examination to exclude pelvic masses. An enterocoele may be mistaken for a rectocoele, but a finger in the rectum will be seen to bulge in to a rectocoele but not in to an enterocoele, which does not. Investigations To look for a cause consider a pelvic ultrasound if a pelvic mass is suspected. As repair could precipitate incontinence, concomitant surgery for stress incontinence may be required. Hysteropexy, open or laparoscopic, is an effective procedure for correcting uterine prolapse without recourse to hysterectomy. The uterus and cervix are attached to the sacrum using a bifurcated non-absorbable mesh. Vaginal vault prolapse Sacrocolpopexy, which can be laparoscopic or open, fixes the vault to the sacrum using a mesh. Sacrospinous fixation is performed vaginally and suspends the vault to the sacrospinous ligament. Management Treatment must be to alleviate symptoms and small prolapses often require no treatment. They act like an artificial pelvic floor, placed in the vagina to stay behind the symphysis pubis and in front of the sacrum. The most commonly used is the ring pessary, but the shelf pessary is more effective for severe forms of prolapse. Normal lower urinary tract function depends, during the filling phase of the cycle, upon adequate bladder capacity and a competent urethral sphincter. The voiding phase is dependent upon detrusor contractility and coordinated urethral relaxation. It is drained by the urethra, which is about 4 cm long and has a muscular wall and an external orifice in the vestibule just above the vaginal introitus. The detrusor muscle is expandable: as the bladder fills, there is no increase in pressure. Increases in abdominal pressure such as coughing will be transmitted equally to the bladder and upper urethra because both lie within the abdomen. Normally, therefore, coughing does not alter the pressure difference and does not lead to incontinence. This is achieved voluntarily by a simultaneous drop in urethral pressure (partly due to pelvic floor relaxation) and an increase in bladder pressure due to a detrusor muscle contraction. The voiding reflex consists of afferent fibres, which respond to distension of the bladder wall and pass to the spinal cord.

Endomyometritis usually occurs postpartum prostate 5lx testimonials order alfuzosin toronto, usually as a complication of cesarean section in a patient with prolonged rupture of membranes prostate cancer vs colon cancer cheap 10 mg alfuzosin with mastercard. However prostate 70 order discount alfuzosin line, if an adnexal mass is seen on ultrasound androgen hormone production alfuzosin 10 mg purchase overnight delivery, it could be either a mass (cyst or tumor) or a tubo-ovarian abscess prostate vs breast cancer generic alfuzosin 10 mg overnight delivery. Such a patient must be admitted to the hospital and placed on intravenous antibiotics. Surgical exploration should be considered if she does not respond to intravenous antibiotic therapy in 48 to 72 hours. A tubo-ovarian abscess or pelvic abscess may first be appreciated on pelvic examination and can be further evaluated with an ultrasound. The other answer choices are not criteria for hospitalization and intravenous antibiotic therapy (although some clinicians may consider her temperature as a reason to hospitalize). A broad spectrum of disorders may produce vulvovaginal symptoms, including infections, dermatologic conditions, benign and malignant neoplasms. It is made up of the mons pubis, labia majora and minora, clitoris, and the vestibule. It also contains the urinary meatus and the vaginal orifice, as well as the glands of the vulva: Bartholin glands (major vestibular glands), ducts of the Skene glands (paraurethral glands), and minor vestibular glands. Hair-bearing regions contain hair follicles, sebaceous glands, apocrine, and eccrine sweat glands. The labia minora and prepuce (the hood of the clitoris), are hairless regions which contain sebaceous glands but not hair follicles, eccrine or apocrine sweat glands. The labia majora are composed of skin enclosing a variable amount of fat and smooth muscle. The labia minora are erectile tissue, devoid of fat and composed of skin and vascular and connective tissue. The clitoris is a highly vascular and innervated, erectile organ 2 to 3 cm in length, located between the bifurcating folds of the labia minora. The vestibule is the space between the labia minora extending from the clitoris to the vaginal introitus. It contains the urethral meatus and the openings of the major and minor vestibular glands as well as the Skene glands. Ducts of the Skene glands and minor vestibular glands are paraurethral structures. The nerve supply to the vulva includes sensory nerves, special receptors, and autonomic nerves to vessels and glands. Symptoms of vulvovaginal disorders are frequently caused by irritation of the sensory nerves of the vulva. The major nerves supplying the vulva include those derived from the pudendal, ilioinguinal, genitofemoral, and posterior femoral cutaneous nerves. The pudendal nerve gives rise to the inferior hemorrhoidal nerve, the perineal nerve, and the dorsal nerve of the clitoris. The major blood vessels supplying the vulva derive from the internal pudendal artery, which arises from the internal iliac artery, and the superficial and deep external pudendal arteries, which arise from the femoral artery. The femoral and inguinal lymph nodes receive the lymphatic drainage from the vulva. Many infections or inflammatory conditions of the vulva and distal vaginal wall are accompanied by an increase in lymphatic drainage, resulting in tender lymphadenopathy at this site. It extends from the introitus to the uterus and lies dorsal to the bladder and ventral to the rectum. Estrogen stimulates the proliferation and maturation of vaginal epithelial cells, whereas progesterone is inhibitory. Endocervical and Bartholin gland secretions, with the transudation of fluid across the vaginal epithelium provide lubrication. The adventitia is a strong sheet of connective tissue, condensed anteriorly to form the pubocervical fascia, and fused to the fascial coverings of the pelvic and urogenital diaphragms. The pudendal nerve does not have as rich a distribution of fine sensory nerves as the nerves supplying the vulva. The major vessels supplying the vagina include the vaginal artery, arising from the internal iliac or uterine artery; the azygous artery of the vagina, arising from the cervical branch of the uterine artery; and branches of the pudendal artery. Venous drainage forms a plexus surrounding the vagina, and major vessels follow the arterial course. The lymphatic drainage of the vagina includes a complex anastomotic plexus that involves drainage to the internal iliac, pelvic, sacral, inferior gluteal, anorectal, femoral, and inguinal nodes. The vagina is usually resistant to infection for two reasons: marked acidity and a thick protective epithelium. Other host factors, such as the immune system, also play a role in vaginal defense mechanisms. A Microbiology the vaginal flora play a critical role in vaginal defenses by maintaining the normally acidic pH (3. The type and number may vary in response to normal and abnormal changes in the vaginal environment. Lactobacillus acidophilus is the dominant bacterium in a healthy vaginal ecosystem. The acidic environment of the vagina is maintained through the production of lactic acid. Lactic acid and hydrogen peroxide produced by lactobacilli are toxic to anaerobic bacteria in the vagina. Insults that affect the acidic pH and lead to a more alkaline environment result in a decrease in lactobacilli, with an overgrowth of pathogenic organisms. Normal estrogen levels are necessary for a normal vaginal environment and resistance to infection. Estrogen stimulates proliferation and maturation of the vaginal epithelium, providing a physical barrier to infection. Conditions associated with decreased estrogen levels are associated with an increase in susceptibility to vaginal infections. Mature vaginal epithelium provides glycogen, necessary for lactobacillus metabolism. Glycogen is converted to lactic acid by lactobacilli and vaginal epithelial cells. Cellular and humoral immunity play a role in the normal vaginal defense mechanisms. C Factors that alter the vaginal environment Insults that affect the vaginal microbiology, vaginal epithelium, or vaginal pH lead to an increased susceptibility to vaginal infections. Antibiotics alter the microbiology of the vagina and can increase the risk of infection. Hormonal changes may affect the vaginal epithelium and increase the risk of infection. Douching or intravaginal medications can change the vaginal pH or affect the vaginal flora, altering the resistance to infection. Intercourse affects the microenvironment of the vagina because semen has an alkaline pH. In addition, intercourse may introduce new organisms in to the vagina, thus influencing the microenvironment. Stress, poor diet, and fatigue probably play a role by affecting microbiology, pH, and the immune system. The medical history is essential in evaluating the potential causes of vulvovaginal symptoms. A History Certain conditions may predispose women to certain types of vulvovaginal infections. What is the relation of the onset of symptoms to intercourse or other sexual activity Previous treatments; use of self-prescribed medications, herbal remedies, or home remedies 11. Any other factors that may have altered the vaginal environment B Symptomatology 1. Vulvar irritation or burning is a symptom associated with a variety of disorders, including vulvovaginitis, vulvovestibulitis, and vulvodynia. Other possible causes include any skin disorder associated with pruritus, including allergic reactions. Description of the discharge is crucial to diagnosis and to the differentiation from a normal physiologic finding. Follicular-phase mucus is normally watery and abundant; postovulatory mucus can be thick and viscous. Green, yellow, or brown discharge is usually associated with an infection, a foreign body, or some other abnormality. Complaints of severe, offensive odor occur most often with retained foreign bodies, such as tampons. Inspection of the external genitalia detects gross lesions, edema (and discoloration) of the labia, inflammation, ulceration, and condylomata. The inguinal area should be palpated for the presence or absence of lymphadenopathy. B Speculum examination, using water as the only lubricant to avoid interfering with specimen collection and culturing, should reveal: 1. Evidence of trauma, congenital abnormalities, or characteristic lesions of the vaginal walls. A culture of the endocervix detects gonorrhea or chlamydial infection, and a Papanicolaou test (Pap smear) detects carcinoma or inflammation. When an infectious vaginitis is suspected, vaginal pH helps differentiate the various types of infections. Symptoms of other vulvovaginal conditions, including vulvar dystrophies, vulvar dermatitis, and other skin conditions of the vulva, may be similar to those of vaginitis. Acute herpes simplex genitalis may cause acute vulvar symptoms, necessitating prompt evaluation and treatment. Vulvovaginitis 407 A Bacterial vaginosis is the most common vaginal infection in the United States today. In the past, bacterial vaginitis was known as nonspecific vaginitis and Gardnerella vaginitis. Bacterial vaginosis is a polymicrobial clinical syndrome caused by an overgrowth of a variety of bacterial species, particularly anaerobes, often found normally in the vagina. Organisms most often involved include Bacteroides, Peptostreptococcus, Gardnerella vaginalis, and Mycoplasma hominis. The anaerobic bacteria produce enzymes that break down peptides to amino acids and amines, resulting in compounds associated with the discharge and odor characteristic of this infection. In symptomatic patients, the most common presentation is a malodorous, gray discharge. Wet mount preparations with saline reveal a "clean" background with minimal or no leukocytes, an abundance of bacteria, and the characteristic clue cells. The clue cells are squamous cells in which coccobacillary bacteria have obscured the sharp borders and cytoplasm. Therapy is based on the use of agents with anaerobic activity and involves both topical and systemic agents. Vaginal preparations (1) Intravaginal 2% clindamycin cream is used at bedtime for 7 days, or 100 mg ovules vaginally at bedtime for 3 days. Oral regimens (1) Metronidazole 500 mg twice daily for 7 days; the 2-g single dose regimen is an option, though it may be the least effective method. Routine treatment of partners has not been shown to improve cure rates or lower reinfection rates, and is therefore not recommended. Treatment during pregnancy is critical; data suggest an association of adverse maternal and fetal outcomes with bacterial vaginosis. B Candida vaginitis (candidiasis or moniliasis) is the second most common vaginal infection in the United States. Thirty percent of women may have vaginal colonization and have no symptoms of infection. There has been a recent increase in the number of infections caused by non-albicans species. Up to 20% of infections may be caused by organisms such as Candida tropicalis and Candida glabrata. Patients with monilial vaginitis characteristically complain of a thick, white discharge, vulvar burning, and extreme vulvar pruritus. Symptoms may recur and be most prominent just before menses or in association with intercourse. On examination, excoriations of the vulva may be noticeable; the vulva and vagina may be erythematous, with patches of adherent cottage cheese-like discharge. Cultures are not necessary to make the diagnosis except in some cases of recurrent infections. These drugs are available in three regimens: a single dose, 3-day course, or 7-day course. Agents include butoconazole, clotrimazole, miconazole, tioconazole, and terconazole. With recurrent candidiasis, doses of 100 mg, 150 mg, or 200 mg can be repeated orally on every third day (Days 1, 4, and 7) for a total of three doses. The dosing schedule is 200 mg twice a day for 5 days, then 100 to 200 mg daily for 6 months. Boric acid capsules intravaginally, 600 mg for 14 days, may be effective and is usually reserved for severe or nonalbicans vulvovaginitis. In most cases, no exacerbating factor can be found; however, the following possibilities should be considered: a.

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