CLINICAL GYNAECOLOGY Q U I C K R E FE R E N C E G U I D E FIFTH EDITION Editors: MH Botha, T Matsaseng, TF Kruger Clinical Gynaecology: A Quick-Reference Guide Fifth edition Editors T F Kruger M H Botha T Matsaseng Disclaimer In the writing of this book, every effort has been made to present accurate and up-to-date information from the best and most reliable sources. However, the results of healthcare professionals depend on a variety of factors that are beyond the control of the authors and publishers. Therefore, neither the authors nor the publishers assume responsibility for, nor make any warranty with regards to, the outcomes achieved from the procedures described in this book. Clinical Gynaecology: A Quick-Reference Guide First edition 1993 Second edition 2001 Third edition 2007 Fourth edition 2011 Fifth edition 2016 Juta and Company (Pty) Ltd PO Box 14373, Lansdowne, 7779, Cape Town, South Africa © 2016 Juta and Company (Pty) Ltd ISBN 978 1 4851 1 545 8 All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage or retrieval system, without prior permission in writing from the publisher. Subject to any applicable licensing terms and conditions in the case of electronically supplied publications, a person may engage in fair dealing with a copy of this publication for his or her personal or private use, or his or her research or private study. See Section 12(1)(a) of the Copyright Act 98 of 1978. Project manager: Seshni Kazadi Editor: Sarah O’Neill Typesetter: AN dtp Services Typeset in 8.5pt on 9pt Minion Printed in South Africa by The author and the publisher believe on the strength of due diligence exercised that this work does not contain any material that is the subject of copyright held by another person. In the alternative, they believe that any protected pre-existing material that may be comprised in it has been used with appropriate authority or has been used in circumstances that make such use permissible under the law. CONTENTS SECTION 1 ONCOLOGY (BENIGN AND MALIGNANT DISEASES) 1. Diseases of the vagina .......................................................................3 2. Diseases of the vulva .........................................................................5 3. Vulvodynia ........................................................................................7 4. Carcinoma of the cervix....................................................................9 5. Malignancies of the uterine corpus ................................................11 6. Postmenopausal bleeding (PMB) ...................................................14 7. Ovarian tumours .............................................................................16 SECTION 2 GENERAL GYNAECOLOGY 8. Pelvic inflammatory disease .........................................................21 9. Ectopic pregnancy. ........................................................................24 10. Miscarriage ....................................................................................27 11. Leiomyomata ................................................................................31 12. Dysmenorrhoea .............................................................................35 13. Pelvic pain .....................................................................................38 14. Abnormal uterine bleeding ...........................................................40 15. Antibiotic therapy in gynaecology ................................................42 16. Premenstrual tension ....................................................................47 SECTION 3 GYNAECOLOGY, ENDOCRINOLOGY AND INFERTILITY 17. Amenorrhoea, oligomenorrhoea, galactorrhoea ..........................53 18. An alternative approach to make a diagnosis in patients with amenorrhoea .................................................................................56 19. Hyperandrogenism .......................................................................57 20. Paediatric gynaecology. .................................................................60 21. Infertility .......................................................................................64 22. Polycystic ovary syndrome ............................................................69 23. Endometriosis and adenomyosis ..................................................72 24. Contraception ...............................................................................75 SECTION 4 UROGYNAECOLOGY 25. Disorders of the lower urinary tract .............................................81 26. Pelvic organ prolapse ....................................................................84 27. Gynaecological fistulae ..................................................................88 28. Puberty ..........................................................................................91 ONCOLOGY (BENIGN AND 1 SECTION MALIGNANT DISEASES) 1 1 Diseases of the vagina B G Lindeque (See Chapter 7 of Clinical Gynaecology, 5th edition for more detailed information.) CLASSIFICATION There are several diseases that can occur in the vagina, either as de novo conditions or as part of disorders affecting other parts of the genital tract. Table 1.1 Diseases of the vagina Vaginitis Postmenopausal atrophic vaginitis Emphysematous vaginitis Toxic shock syndrome Cystic lesions Epidermal cysts Congenital cysts Endometriosis Solid tumours Condylomata acuminata Polyps Leiomyomata Vaginal adenosis Premalignant VAIN I, II and III lesions Invasive squamous carcinoma Malignant lesions Adenocarcinoma Melanoma Sarcoma DES-related malignancies Secondary malignancies MALIGNANT LESIONS Primary vaginal malignancies are rare and constitute 1 percent of gynaecological cancers. As a general rule, a vaginal malignancy should be regarded as a metastasis until proven otherwise. Table 1.2 FIGO staging of vaginal carcinoma 2 Stage I Carcinoma limited to the vaginal wall. Stage II Involvement of subvaginal tissues, not reaching the pelvic wall. Stage III Extension to the pelvic wall. Stage IV Extension beyond the true pelvis; involvement of the mucosa of the bladder or rectum. 4  Clinical Gynaecology: A Quick-Reference Guide 2 Diseases of the vulva T Smith (See Chapter 8 of Clinical Gynaecology, 5th edition for more detailed information.) DERMATOLOGICAL CONDITIONS  Dermatitis may be caused by contact with an irritant, such as laundry detergents, toilet paper, deodorants, dusting powders, lubricants and spermicides  Lichen planus may cause redness, soreness and burning associated with raw areas of skin  Psoriasis can affect the vulva alone. INFECTIONS  Candidiasis is caused by an overgrowth of yeast-like fungi called Candida albicans and may be treated with local or systemic imidazole derivatives  Herpes simplex causes painful shallow vesicles that may become secondarily infected and antiviral medications can help reduce the duration and severity of an outbreak  Condylomata acuminata (genital warts) are commonly associated with human papillomavirus types 6 and 11. A vaccine may be important in decreasing the incidence of warts in the female population  Syphilis is caused by the spirochaete Treponema pallidum. Recommended treatment is with benzathine penicillin G, 2.4 million units intramuscularly, or erythromycin 500 mg, qid for three weeks if the patient is allergic  Lymphogranuloma venereum is caused by Chlamydia trachomatis. Doxycycline or erythromycin should be given orally for at least three weeks  Molluscum contagiosum appear as dome-shaped lumps, 1–2 mm in diameter with tiny dimples in their centre, and contain a cheese-like substance. BENIGN LESIONS Bartholin’s cysts occur when ducts of the Bartholin’s glands are obstructed at their vestibular orifice and the obstruction results in subsequent cystic dilatation of the duct. A Bartholin’s abscess is an acute process often associated with Neisseria gonorrhoeae infection, although it may be related to staphylococci or anaerobic organisms. The affected Bartholin’s gland should be marsupialised.