Vaginal Cancer: Causes, Risks, Symptoms, Treatments

DEFINITION

Vaginal malignancy is an abnormal proliferation of vaginal epithelium demonstrating malignant cells below the basement membrane.

PHYSICAL FINDINGS & CLINICAL

PRESENTATION

  • Majority of cases are asymptomatic
  • Postmenopausal vaginal bleeding and/or vaginal discharge are the most common symptoms
  • May also present as pelvic pain or pressure, dyspareunia, dysuria, malodor, or postcoital bleeding
  • May present as a vaginal lesion or abnormal Pap smear

ETIOLOGY

  • The exact etiology is unknown.
  • Vaginal intraepithelial neoplasia is believed to be a precursor for squamous cell carcinoma of the vagina.
  • Long-term pessary use has been associated with vaginal malignancy.
  • Prior pelvic radiation may be a risk factor.
  • Clear-cell adenocarcinoma is related to in utero diethylstilbestrol exposure.

DIAGNOSIS

DIFFERENTIAL DIAGNOSIS

  • Extension from other primary carcinoma more common than primary vaginal cancer
  • Vaginitis

WORKUP

  • Diagnosis is made histologically by biopsy.
  • Colposcopy and biopsy should follow suspicious Pap smear.
  • Cystoscopy, proctosigmoidoscopy, chest radiography, IV urography, and barium enema may be used for clinical staging.
  • CT scan , FDG, PET scan, and MRI are used to evaluate spread.
  • Staging I to IV


IMAGING STUDIES

  • Chest radiography, IV urography, and barium enema are used for staging.
  • CT scan and MRI are good for assessing tumor spread.

TREATMENT

NONPHARMACOLOGIC THERAPY

  • Radiation therapy is the mainstay of treatment.
  • Stage I tumors that are small and confined to the posterior, upper third of the vagina may be treated with radical surgery.
  • Other stages require a whole-pelvis, interstitial, and/or intracavitary radiation therapy.
  • Chemotherapy is used in conjunction with radiotherapy in rare select cases.

Urinary Incontinence: Management Guideline

DEFINITION

Incontinence is the involuntary loss of urine.

TREATMENT 

Transient incontinence: treatment of under lying medical conditions and behavioral therapy to include habit training and timed voiding

    • Urge incontinence: anticholinergic antimuscarinic agents (tolterodine, oxybutynin, trospium chloride, fesoterodine, darifenacin, solifenacin). Anticholinergics bind to muscarinic receptors in the bladder and relax detrusor smooth muscle but can cause dry mouth, constipation, confusion, and cognition abnormalities in the elderly. Other treatment modalities include biofeedback, Kegel exercises, and surgical removal of obstructing or other pathologic lesions. A recent trial comparing oral anticholinergic therapy and onabotulinum toxin A by injection shows similar reductions in the frequency of daily episodes of urgency urinary incontinence. The group receiving onabotulinum toxin A was less likely to have dry mouth and more likely to have complete resolution of urgency urinary incontinence but higher rates of transient urinary retention and urinary tract infections. Mirabegron is a beta-3 adrenergic agonist recently FDA approved for overactive bladder. It is better tolerated than anticholinergic agents but has significant drug interactions and can cause urinary retention.

  • Stress incontinence: pelvic floor muscle training (PFMT), Kegel exercises. Duloxetine improves incontinence rates and quality of life but does not cure incontinence. It can be tried if PFMT has been unsuccessful. PFMT is considered first-line therapy for stress incontinence and is also beneficial in mixed urge and stress incontinence.

    +  Cystourethropexy : Marshall-Marchetti-Krantz procedure, Burch procedure, Raz procedure, Stamey-Raz procedure, Gittes procedure, in situ  transvaginal sling, pubovaginal sling with autologous or cadaver graft, laparoscopic Burch procedure, laparoscopic sling, tension-free vaginal tape

    +  For intrinsic sphincter deficiency: bulking agents (e.g., collagen), sling, and artificial  sphincter

      • Overflow incontinence: surgical removal of any obstructing lesions, clean intermittent catheterization, indwelling catheter
      • Functional incontinence: behavioral training to include habit training and timed voiding, incontinence undergarments and pads, external collecting devices, environmental manipulation

    • Mixed urgency and stress incontinence: PFMT and use of measures recommended in the management of stress and urge incontinence
    • Sensory urgency: bladder relaxants (e.g., anticholinergics, muscle relaxants, and tricyclic antidepressants), behavior therapy to include habit training and timed voiding, cystoscopy and hydrodilation
    • Sphincteric deficiency: urethral bulking agents, sling procedure, artificial sphincter, mechanical clamp, external collection devices
    • Botox (onabotulinum toxin A injection; Allergan) has been approved for the treatment of urinary incontinence in patients with neurologic conditions (e.g., spinal cord injury) and those with multiple sclerosis who have overactive bladder.

What is Cervicitis?

DEFINITION

Cervicitis is an infection of the cervix. It may result from direct infection of the cervix, or it may be secondary to uterine or vaginal infection.

SYNONYMS

  • Endocervicitis
  • Ectocervicitis
  • Mucopurulent cervicitis

PHYSICAL FINDINGS & CLINICAL

PRESENTATION

Cervicitis is usually asymptomatic or associated with mild symptoms. Copious purulent or mucopurulent vaginal discharge , pelvic pain, and dyspareunia may be present if cervicitis is severe. The cervix can be erythematous and tender on palpation during bimanual examination. The cervix may also bleed easily when obtaining cultures or a Pap smear. Patients may have postcoital bleeding.

ETIOLOGY

  • Chlamydia trachomatis
  • Trichomonas
  • Neisseria gonorrhoeae
  • Herpes simplex
  • Trichomonas vaginalis
  • Human papillomavirus


DIAGNOSIS

DIFFERENTIAL DIAGNOSIS

  • Carcinoma of the cervix
  • Cervical erosion
  • Cervical metaplasia

WORKUP

The patient usually presents with a vaginal discharge or history of postcoital bleeding. Otherwise the patient is asymptomatic and diagnosed during routine examination. On examination there is gross visualization of yellow, mucopurulent material on the cotton swab.

LABORATORY TESTS

A finding of leukorrhea (.10 WBC per highpower field on microscopic examination of vaginal fluid) has been associated with chlamydial and gonococcal infection of the cervix. Positive Gram stain is found. Nucleic acid amplification tests (NAAT) should be used for diagnosing C. trachomatis and N. gonorrhoeae in women with cervicitis; this testing can be performed in either vaginal, cervical, or uterine samples. Use a wet mount to look for trichomonads, but because the sensitivity of microscopy to detect T. vaginalis is relatively low (~50%), symptomatic women with cervicitis and negative microscopy for trichomonads should receive further testing with culture. Obtain a Pap smear. HIV testing is recommended in all patients with supposed cervicitis. Although HSV-2 infection has been associated with cervicitis, the utility of specific testing (i.e., culture or serologic testing) for HSV-2 in this setting is unknown.

TREATMENT

NONPHARMACOLOGIC THERAPY

  • Cervicitis is treated in an outpatient setting. Safe sex should be practiced with the use of condoms.
  • Partners should be treated in all cases of infection proven by culture.

ACUTE GENERAL Rx

  • Because Chlamydia and gonorrhoeae cause 50% of cases of infectious cervicitis, if it is suspected treat without waiting for test results.
  • Administer ceftriaxone 125-mg IM single dose followed by azithromycin 1-g single dose or doxycycline 100 mg PO bid for 7 days. If the patient is pregnant, treat with azithromycin 1-g single dose instead of using doxycycline, which is contraindicated in pregnant or nursing mothers.
  • If Trichomonas is the etiologic agent, treat with metronidazole 2-g single dose. For herpes, treat with acyclovir 200 mg PO five times daily for 7 days.

Candida Albicans Infection

Infection caused by the species of the genus Candida, mainly Candida albicans. Candida species are ubiquitous. They are the most common fungal pathogens affecting mankind. Cutaneous candidiasis comprises superficial Candida infections of the skin and mucosal membranes.

ETIOLOGY

The most common cause of cutaneous candidiasis is Candida albicans.

RISK FACTORS
Risk factors that allow Candida infection include:
• Age >65 yr
• Females in the third trimester
• Defects in the mucocutaneous barrier (e.g., wounds, burns, ulcerations)
• Decreased/defective granulocytes/monocytes
• Diseases of white blood cells (e.g., chronic granulomatous disease)
• Complement deficiency
• Certain diseases associated with cell-mediated immunity (e.g., HIV, DM)
• Use of certain medications (e.g., broadspectrum antibiotics, high doses of steroids)
• Increased skin pH due to panty liners and occlusive attires
Anatomical sites predisposed to Candida infection include:
• Axilla
• Beneath the breast, abdominal fold, intertriginous areas
• Periungual creases
• Inguinal creases
• Back and buttocks of bedridden persons

PHYSICAL FINDINGS & CLINICAL PRESENTATION
There are several clinical presentations of cutaneous candidiasis. A few are presented here.
A. Cutaneous candidiasis
1. Presents as erythematous, sometimes shiny with flakes and fluid lesions at the edge of the redness (satellite pustules). It is itchy and the skin becomes inflamed. Pustules may be present in candidiasis of the scrotal and perineal skin.
B. Gastrointestinal tract candidiasis
1. Oropharyngeal candidiasis
• Usually seen in diabetics, after exposure to inhaled steroids or broad-spectrum antibiotics and in immunosuppressed individuals (e.g., patients with a history of HIV infection). Symptoms include:
– White thick patches on the oral mucosa
– Dysphagia, mouth soreness, and pain
– Tongue burning
• Physical examination shows:
– Erythema of the buccal mucosa
– White patches on buccal cavity surfaces
– Transverse fissuring
2. Esophageal candidiasis:
• History of oropharyngeal candidiasis
• Symptoms include:
– Dysphagia
– Odynophagia
– Epigastric pain
– Retrosternal pain
• Physical examination shows:
– Affects of mainly the distal one third of the esophagus
– Endoscopy shows areas of the erythema and edema; scattered white patches or ulcers.
3. Perianal candidiasis
• Skin maceration
• Itching

Chlamydia Trachomatis

The second most common sexually transmitted disease (STD) and most common bacterial STD is infection caused by Chlamydia trachomatis. More common than Neisseria gonorrhoeae by 3-fold, infections with C. trachomatis can be the source of significant complications and infertility.

Predominant Age: 15 to 30 years (85%), peak age 15 to 19 years. The Centers for Disease Control and Prevention recommend screening all sexually active women younger than age 26 years.

PATHOGENESIS

Infection by the obligate intracellular organism C. trachomatis. Chlamydia has a long incubation period (average, 10 days) and may persist in the cervix as a carrier state for many years.

RISK FACTOR

The risk of contracting chlamydial infection is five times greater with three or more sexual partners and four times higher for patients using no contraception or nonbarrier methods of birth control. Other factors are age younger than 26 years, new partner within the preceding 3 months, other sexually transmitted diseases, vaginal douching.

SIGNS & SYMPTOMS

  • Frequently asymptomatic
  • Cervicitis; pelvic inflammatory disease (PID); or, much less common, lymphogranuloma venereum
  • Less common: nongonococcal urethritis and inclusion conjunctivitis
  • Eversion of the cervix with mucopurulent cervicitis supports the diagnosis but not pathognomic

DIFFERENTIAL DIAGNOSIS

  • Gonorrhea
  • Pelvic Inflammatory Disease (PID)
  • Septic abortion
  • Appendicitis
  • Gastroenteritis

LABORATORY

Cultures on cycloheximide-treated McCoy cells are specifi c and may be used to confirm the diagnosis, but these cultures are expensive, difficult to perform, and often not available. Two clinical screening tests are an enzyme-linked immunoassay (enzyme-linked immunosorbent assay) performed on cervical secretions and a monoclonal antibody test carried out on dried smears.

MANAGEMENT

_ Aggressive antibiotic therapy should be instituted in those suspected of infection. Approximately 45% of patients with chlamydial infection have coexisting gonorrhea; the therapy chosen should consider this.

DRUGS OF CHOICE

_ Azithromycin (1 g PO, single dose) compares favorably with the standard 7-day course of doxycycline, while providing better compliance and fewer side effects. A meta-analysis of 12 randomized clinical trials of azithromycin versus doxycycline for the treatment of genital chlamydial infection demonstrated that the treatments were equally efficacious, with microbial cure rates of 97% and 98%, respectively.

_ Doxycycline (100 mg PO twice a day for 7 days) may also be used.

Ectopic Pregnancy

An ectopic pregnancy (EP) occurs when a fertilized ovum implants outside the endometrial lining of the uterus.

RISK FACTOR

_ Previous salpingitis, previous EP, previous tubal ligation, previous tuboplasty, intrauterine device use, progestin-only pill, assisted reproductive techniques.

CAUSES

_ Anatomic obstruction to zygote passage

_ Abnormalities in tubal motility

_ Transperitoneal migration of the zygote

CLINICAL

_ Abdominal tenderness

_ Adnexal tenderness

_ Peritoneal signs

_ Adnexal mass

_ Enlarged uterus

_ Shock

_ Amenorrhea or abnormal vaginal bleeding

_ Shoulder pain

_ Tissue passage

DIFFERENTIAL DIAGNOSIS

  • Corpus luteum cyst
  • Rupture or torsion of ovarian cyst
  • Threatened or incomplete abortion
  • Pelvic inflammatory disease
  • Appendicitis
  • Gastroenteritis
  • Dysfunctional uterine bleeding
  • Degenerating uterine fibroids
  • Endometriosis

WORKUP

_ The classic presentation of EP includes the triad of abnormal vaginal bleeding, pelvic pain, and an adnexal mass.

_ Transvaginal ultrasound.

_ Quantitative serum human chorionic gonadotropin level.

_ Laparoscopy in equivocal situations and possibly for treatment.

LABORATORY TESTS

  • Quantitative human chorionic gonadotropin (qhCG): If normal intrauterine pregnancy (IUP), 85% have doubling time of 2 days. If abnormal gestation, will show <>66% increase of qhCG within 2 days. However, 13% of ectopic pregnancies have a normal doubling time.
  • Progesterone: decreased production in EP; <<5 ng/ml strongly predictive of abnormal pregnancy. If >>25 ng/ml, strongly predictive of normal IUP.
  • Dropping hematocrit associated with tubal rupture, resolving EP, or abnormal intrauterine pregnancy.
  • Leukocytosis.

IMAGING

_ Ultrasound

MANAGEMENT

_ Surgery can be performed by laparoscopy if patient is stable or rarely, by laparotomy if patient is very unstable.

Vaginitis/Trichomonas

Trichomonas vulvovaginitis is the inflammation of vulva and vagina caused by Trichomonas spp. Vaginitis is very common. Most women will have some kind of vaginitis at least once in their lives. Trichomoniasis on the other hand is sexually transmitted and it will be important for sex partners to be treated so it is not passed back and forth.

PHYSICAL & CLINICAL FINDING

  • Profuse, yellow, malodorous vaginal discharge and severe vaginal itching
  • Vulvar itching
  • Dysuria
  • Dyspareunia
  • Intense erythema of the vaginal mucosa
  • Cervical petechiae (“strawberry cervix”)
  • Some infected men may have symptoms of urethritis, epididymitis or prostatitis
  • Asymptomatic in ∼50% of women and 90% of men

CAUSE

  • Single-cell protozoan Trichomonas vaginalis

RISK FACTORS

  • Multiple sexual partners
  • History of previous STDs

DIFFERENTIAL DIAGNOSIS

  • Bacterial vaginosis
  • Fungal vulvovaginitis
  • Cervicitis
  • Atrophic vulvovaginitis

WORKUP

  • Pelvic examination
  • Speculum examination
  • Mobile trichomonads seen on normal saline preparation: 70% sensitivity
  • Elevated pH (>5) of vaginal discharge
  • Culture is considered the traditional gold standard laboratory test for diagnosis of TV
  • Nucleic acid amplification tests (NAATs) have been developed that combine excellent performance characteristics with a more rapid turnaround time compared with culture.
  • APTIMA assays utilize target capture and transcription-mediated amplification (TMA) to selectively purify, amplify, and detect species- specific 16 S ribosomal RNA. APTIMA Trichomonas vaginalis transcription-mediated amplification may be a better laboratory test than culture based on sensitivity and time frame for results.

LABORATORY TESTS

  • NAAT is highly sensitive. The APTIMA T. vaginalis assay is FDA cleared for detection of T. vaginalis from vaginal, endocervical, and urine specimens from women (95%- 100% clinical sensitivity and specificity. The OSOM Trichomonas Rapid Test on vaginal secretions provides results in 10 min with sensitivity of 82% to 95% and specificity of 97% to 100%.
  • Microscopic evaluation of wet preparations of genital secretions: convenient and low cost but low sensitivity (51%-65%) in vaginal specimen with even lower sensitivity if there is a delay in evaluating slides.

TREATMENTS

NONPHARMACOLOGIC THERAPY

Condom use: best way to prevent trichomoniasis is through consistent and correct use of condoms during all penile-vaginal sexual encounters.

PHARMACOLOGIC THERAPY

  • Metronidazole 2 g PO × 1 or Tinidazole single 2-g oral dose in both sexes. Treatment of the sexual partner is essential to prevent reinfection.
  • Alternative regimen: Metronidazole 500 mg PO BID ×7 days
  • Alcohol consumption should be avoided during treatment with metronidazole (at least 24 hr after completion of therapy) and tinidazole (at least 72 hr after completion of therapy) to reduce possibility of disulfiram-like reaction.
  • Metronidazole gel: less likely to achieve therapeutic levels; therefore not recommended.
  • Metronidazole (retreat): 500 mg PO bid ×7 days.
  • Treatment of recurrences: metronidazole 2 g PO qd ×3 to 5 days.
  • Allergy, intolerance, or adverse reactions: alternatives to metronidazole are not available. Patients who are allergic to metronidazole can be managed by desensitization.
  • Pregnancy: (1). Associated with adverse outcomes (i.e., premature rupture of membranes) (2). Metronidazole 2 g PO ×1 day.

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Fibroids or Leiomyomata

Fibroids, or leiomyomata (myomas), are common noncancerous growths that usually occur in or on the muscle walls of the uterus.

CAUSES

The cause isn’t clear. Several factors probably work together to produce fibroids. These factors may be hormones such as estrogen, genetics (runs in families), and environmental. Being overweight, never having had a child, and getting periods before age 10 also may have an effect. The fibroids usually, but not always, shrink after menopause (change of life).

SYMPTOMS

Most fibroids (30% to 50%) cause no symptoms. Problems, when they occur, are related to the size and location of the fibroids. Fibroids may grow to be quite large so that a woman may look pregnant and have symptoms of pregnancy: pressure in the pelvic area (lower belly), heaviness, and need to go to the bathroom often to urinate. Fibroids in the uterine wall or in the cavity of the uterus may cause bleeding between periods or heavier and more painful periods. Constipation, backache, pain during sex, and lower belly pains may occur. Rarely, fibroids cause sudden pain or bleeding.

DIAGNOSIS

The doctor will do an examination of the pelvic area. Ultrasound or x-rays may be used but aren’t always needed for diagnosis. The doctor may do a special procedure (hysteroscopy) for women with bleeding symptoms. This simple procedure lets the doctor look into the uterus to find the cause of the bleeding or to plan or carry out therapy.

MANAGEMENT

_ Most fibroids need no treatment and only regular checks to be sure that they’re not growing too large or causing problems.
_ Medicines including hormones and drugs that act against hormones can be tried. If fibroids continue to be a problem, hysterectomy (surgery to remove the uterus) is an option.

Sometimes, fibroids alone may be surgically removed (myomectomy), which saves the uterus if children are wanted. Another newer method is uterine artery embolization.

In this method, arteries to the uterus are blocked so they don’t feed the fibroids. Myolysis (electric current destroys fibroids and shrinks blood vessels feeding them) and cryomyolysis (liquid nitrogen is used instead of electric current) are other methods. However, fibroids can return and mean more surgery later. Newer medicines may shrink fibroids, but this change is only temporary.