GROSS B Can also cause accumulation of fluid in

o
Correlative Anatomy: the scrotal sac
Male and Female Reproductive System There are also PARASITES that can cause
Dr. Capulong accumulation of fluid in the scrotum(RARE)

STAGES
MALE ACUTE
o There is initial secretion of fluid within the
HYDROCELE scrotal sac and usually takes around a
few days to a week
Accumulation of o Gradually, if this is secondary to infection,
fluid within the this will subside especially with antibiotic
scrotal sac treatment.
Collection of fluid o But because this is a non-communicating
within the tunica type, this can linger and be the chronic
albuginea or type
persistent processus CHRONIC
vaginalis o More common and usually the etiology is
unknown
PROCESSUS VAGINALIS
connection with the anterior abdominal wall TYPES
usually follows the descend of the testis
COMMUNICATING NON-COMMUNICATING
Before 36 weeks (age of gestation), the testicles will
gradually go down and during BIRTH, it is expected that
the testes is already in the scrotal sac. Along with the
descent, there is an infolding of the peritoneal lining (+) connection no connection
which is called processus vaginalis. As the testis resides between the between the
within the scrotal sac, usually, the processus vaginalis abdominal cavity abdominal cavity
CLOSES so that there will be no communication between
the abdominal cavity and the testicles.
infants adults
ETIOLOGY
DEVELOPMENTAL
o COMMUNICATING HYDROCELE Fluid is around the testis; in between the skin and the
There are newborns born with fluid investing fascia of scrotum and testicle. The cord
already in the scrotal sac because of the structures will go through the inguinal canal. During
failure or non-closure of the processus development, the area by which the testicles are going
vaginalis and there is a communication down is the INGUINAL CANAL. So if the processus
between the abdominal cavity and the vaginalis did not close, then there is communication and
scrotal area and this is called that will be the source of the HYDROCELE.
COMMUNICATING HYDROCELE.
INFECTION INCIDENCE
o Orchitis Infants and children communicating type
o Epidydimitis Adult (40 y/o & older) non-communicating type
**Communicating hydrocele is usually related to the inguinal
INFECTION hernia.

CLINICAL MANIFESTATIONS
Inflammatory reactions
PAINLESS CYSTIC MASS IN SCROTUM
edema Initially starting very small and if the child is lying
down, it is not well-appreciated. But when
standing up, because of gravity, fluid will go
secretion of fluids down to the most dependent portion. There will
be appreciation of the enlargement of the
scrotal sac.
cause of hydrocele
CYSTIC MASS THAT IS SOFT IN THE MORNING,
NON-COMMUNICATING TYPE TENSE IN THE AFTERNOON (COMMUNICATING)
This is also due to gravity. The more time that you
TRAUMA spend upright, more fluid will go down the scrotal
sac.
1 Bernabe, Maria Katrina (2013)
DIAGNOSIS
TRANSILLUMINATION TEST (+)
o Put the penlight on the scrotal sac
o See if there would be transillumination
o Light will pass through the fluid
Normally if there is no fluid there, it will
not transilluminate because light will not
pass though the testis.
TREATMENT
OBSERVATION
o Done if child is less than 1 year because
we give time for the processus vaginalis
to close. (Maybe there is only delay of
closure of processus vaginalis)
SURGERY
o Done if the hydrocele persists for more
than 1 year and there is increase in size.
o if associated with hernia; Ligation
o Same ligation for hernia and hydrocele
o HIGH LIGATION
obliterate the connection of the
abdominal cavity to the scrotum
TIE/LIGATE processus vaginalis
Ligate just as it comes out of the
external inguinal ring
ETIOLOGY
Hereditary
Drugs: estrogen and progestin
o Exogenous sources
o If the mother had exposure to
exogenous hormones during the start of
pregnancy.
o Since there is an abnormal increase in
estrogen and progestin, there will be
feminization or abnormal (incomplete)
development of the male reproductive
tract.
o Presence of hypospadia is an evidence
of feminization especially pernoscrotal or
perineal type thus indicating possible
intersex problem
o More evident in PENOSCROTAL and
PERINEAL type
If you have these types of
hypospadias, you should
investigate further regarding the
sexual orientation of the patient
because the usual types are
SHAFT or CORONAL.
Very short urethra (The urethra
follows the penile shaft.)

MANIFESTATIONS
HYPOSPADIA Difficulty directing urine during voiding
Clinical condition where the external urethral
meatus opens at the VENTRAL side CHORDEE
Abnormal location of the urethral opening o Bowing or dropping of
the penis is secondary to
CLASSIFICATION the chordee
o There is an abnormal
tissue that pulls down the
penis
o If the penis is bowing
there will be difficulty
during sexual intercourse
and difficult for the
female to get pregnant

Failure to obtain satisfactory erection

NORMAL ERECT SIZE OF THE PENIS

(Varies from one continent to the other)
Blacks 7-8 inches (longest)
Caucasians 4-5 inches
Asians 3 inches

GLANDULAR proximal to the glans Stenosis or narrowing of urethral meatus

o Reason why children with hypospadias
CORONAL at coronal sulcus will have difficulty in urination
body of penis o More often than not, Hypospadias will be
PENILE SHAFT accompanied by other infections (UTI)
Proximal/mid./distal
because of incomplete release of urine
PENOSCROTAL just before scrotal area due to stenosis
Associated with undescended testis
PERINEAL lowest opening Ambiguity of genitalia
o Warrants further investigation of genetic
sex
2 Bernabe, Maria Katrina (2013)
DIAGNOSIS
Physical examination
Buccal smear and karyotyping
o Karyotyping: especially to identify
gender of the patient
Excretory urography
o to assess upper urinary tract for other
anomalies
o if the very short urethras will be
corrected, then you will dissect the
urethra and create a new canal or
opening (new urethral meatus), that is
why you have to identify if there are
other anomalies in the urinary tract
TREATMENT
Determine genetic sex of individual
Repair should be done before school age usually
done about 2 years old and up
Reconstructing the urethral using the prepuce
can be done in a 1-stage or 2-stage procedure
1-STAGE Coronal/Glandular type
2-STAGE Penoscrotal/Perineal type
Because you want to have an elongation of
the newly created urethral canal
Before circumcision, identify first if the child will
have normal meatus (location wise; no
hypospadias)
o If unchecked and proceeded to
circumcision, repair of the hypospadias
will not be possible because of the
removal of the prepuce
Release of chordee (fibrotic tissue or band that
holds the shaft of the penis) to obtain erection
and be able to void adequately in standing
position
EPISPADIA
Urethral opening is displaced dorsally
CLASSIFICATION
GLANDULAR Dorsum of glans
PENILE Within the shaft
Urethral meatus is broad, gaping and
located between pubis and coronal sulcus
PENOPUBIC Located peno-pubic junction with distal
dorsal groove extending up to the glans
penis
MANIFESTATION
Urinary incontinence
o Due to maldevelopment of urethral
sphincter
Dorsal chordee (resulting to pataas ang ihi)
Pubic bones are separated
Epispadia may signify a mild form of bladder
dystrophy
3 Bernabe, Maria Katrina (2013)
TREATMENT
Correction wise, it is the same with hypospadias.
You need to create a new urethral canal. And if
it is in the glans or the penile type, it is much
easier to trim.
o Use the prepuce to create a new
urethral canal
o Trim the prepuce put a catheter
catheter will stay for several weeks (for
granulation of tissues) new urethral
canal
The earlier the hypospadias and epispadias are
corrected, the better. The older you do the correction, it
will be much harder because the penis is very sensitive.
When the penis becomes erect and you have a new
canal, the canal will be ruined.
VARICOCELE
Abnormal dilatation of the pampiniform plexus of
vein above the testis
When the pampiniform plexus is engorged, the
feeling would be having a bag of worms
(typical presentation of varicocele)
ETIOLOGY
Incompetent valves more on the LEFT side
o Because of inadequate drainage
Renal tumor (very rare)
MANIFESTATION
Dilated veins (bag of worms) in scrotum above
testis extending up the spermatic cord
Infertility
o Sperm motility and concentration is
significantly decreased
Recently, more and more males are afflicted with
varicocele, because of incompetent valves (no. 1 cause)
but most of them will not undergo operation. But the
drawback here is since you have engorgement of the
pampiniform plexus, the pooling of blood will change the
temp. in the testis. The testis maintains a certain temp. in
order for the sperm cells to replicate and live.
MORE KILLS
MALE
VARICOCELE TEMPERATURE SPERM
INFERTILITY
PRESENT CELLS
 Testicular atrophy Undescended testicles
Occurs when one or both the testicles fail to
IMPROPER CIRCULATION OF BLOOD
move down into the scrotal sac
During development just prior to delivery, the
POOLING OF VENOUS DRAINAGE OF THE TESTIS testicles from its intraabdominal location, will
settle down in the scrotal area and this will follow
the area of the inguinal canal until its final resting
INADEQUATE BLOOD FLOW place in the scrotum. Any deviation can cause
undescend of the testis:
o Blockage
TESTICULAR ATROPHY
o Infant is delivered prematurely
incomplete descent of testis
TREATMENT o Hereditary
Varicocelectomy Most common location: INGUINAL CANAL
o Ether TESTICULAR (easiest way) or
INGUNAL approach ETIOLOGY
o Can be done on an out-patient basis Hormonal factors (testosterone deficiency)
Ligation of the internal spermatic veins at or o Making the reproductive tract
above the internal inguinal ring development incomplete
Prenatal exposure to diethylstilbesterol
(exogenous hormone; secondary to intake of the
PENILE FRACTURE mother)
Due to the tearing or Prematurity
rupture of the tunica o Premature neonates are most commonly
albuginea covering affected because testes normally
the corpora descend into scrotum around 28 weeks
cavernosa (usually gestation
filled up with blood Mechanical interference with the passage of the
during erection) testes into the scrotum
Happens when penis is erect o Mass/tissue blocking inguinal canal
Secondary to vigorous or acrobatic sexual Deficiency of gonadotropin
intercourse
o It is as if the glans penis is hitting the DIAGNOSIS
sacral bone. The force of trauma of
hitting the bone can readily rupture the Differentiate from retractile testis
tunica albunginea
Aggressive masturbation
CRYPTORCHIDISM RETRACTILE TESTIS
SURGICAL EMERGENCY
o because of uncontrollable bleeding due undescended testis testis goes down and up
to the fracture; all the blood from the testis is completely secondary to hyperfunctioning
columns, corpora cavernosa, will come absent in scrotum of cremaster muscle (pulls the
testis up and down)
out
during cold temperatures, testis
o it can also be a cause of death because is not present in scrotum
of necrosis, ischemia and bleeding but during warm temperatures,
In the elderly, it may be secondary to PRIAPISM testis is present
especially those taking anti-erectile dysfunction
medications (Viagra)
How to test:
1. Insert fingers into scrotal area
CRYPTORCHIDISM 2. Palpate in the inguinal canal. If you palpate a
round structure in the inguinal canal, probably
thats the testis.
3. Instruct the patient to bear down so that the
testis will go down OR ask patient to stand up.
4. If you cannot still identify, you can do other tests
o ULTRASOUND
Abdominal cavity and inguinal
area to check for the location of
the testis
o CT SCAN

4 Bernabe, Maria Katrina (2013)

COMPLICATIONS
TESTICULAR CANCER
o 7 years old and up: you have to correct
it already
o 20 y/o with undescended testis: chances
of acquiring testicular cancer is higher
MALE INFERTILITY
o Adequate temp. for spermatogenesis is
not maintained
TESTOSTERONE LEVEL IS LOW
TREATMENT
ORCHIDOPEXY: permanently putting the testis in
the scrotum
1. Identify first the location of testis
2. If testis is in the ingunal canal, extract the
testis, pull it down
3. if testicles are short, dissect it
4. Free the vas deferens so it can go down
5. Once the testis is in the scrotum, suture the
testis
The concern for surgery is the TESTICULAR
CANCER and not the infertility
PHIMOSIS
Inability of the foreskin to be
retracted due to a very small
opening of the foreskin
Usually cause frequent UTI in
children
TREATMENT: circumcision
This is the only indication for
circumcision of newborns
and children
If there is no phimosis and no UTI, the
recommendation would be circumcision at an
age wherein the child is desirous of having
circumcision and the foreskin is completely
retracted beyond the glans penis.
o If these conditions are not present,
usually we can delay the circumcision.
o Circumcision should be a decision from
the child and not the parents.
Coronal Circumcision
Removal of the foreskin
Not done anymore because when you remove
the foreskin, you expose the penis to stimulation.
Excessive stimulation can cause premature
ejaculation
There is a higher incidence of premature
ejaculation to males circumcised coronally rather
than those who underwent DORSAL SLIT because
the foreskin will protect the penis from excessive
stimulation
German cut
5 Bernabe, Maria Katrina (2013)
PARA PHIMOSIS
When the foreskin is
retracted beyond the glans and
inability of the foreskin to return
back to the tip of the penis
When a child out of
curiosity is retracting the foreskin
wherein the opening is still small.
When the foreskin is forcefully
pulled down and unable to return
back.
Can cause ischemia of the glands
Emergency surgical circumcision to release
foreskin and correct the ischemia
PROSTATE DISEASES
PROSTATITIS
infection of the prostate
treated with antibiotics and correct the problem
more common to those who lack sexual activity
BPH (BENIGN PROSTATIC HYPERTROPHY)
medial lobe is the most common affected
Usual manifestation is difficulty in urination (due
to hypertrophy compression of urethra)
Treatment with medications, TURP
PROSTATE CANCER
posterior lobe most common lobe affected
Diagnosis:
o Digital Rectal Examination (DRE)
Gold standard for checking the
prostate gland
By doing this, you can feel for
the posterior lobe of the prostate
(+) CA: Stony hard prostate
(-) CA: rubbery, well-
circumscribed feeling of a
benign prostate
o Transrectal Ultrasound followed by
biopsy
o Prostate Specific Antigen (PSA)
Usually for 50y/o and up
Screening
Non specific (can also be
elevated in even in prostatitis)
o Elevated PSA + (+) DRE can detect
early prostate cancer
o Must correlate it with physical
examination
Example:
Patient with stony hard prostate + elevated PSA
What is the next step to do?
Order for a Transrectal Ultrasound (probe is
put on the rectum so it can readily identify
the enlargement in the prostate) followed by
a biopsy (insertion of a needle; getting a
sample of the prostate gland).
 INCARCERATION: the incomplete indirect hernia
INGUINAL HERNIA becomes complete and the
Most common location: INGUINAL AREA scrotum cannot reduce its size
Most common type of hernias are groin or because the intraabdominal
inguinal types (75%) contents are now located in the
scrotum.
INGUNAL HERNIA
STRANGULATION: there is vascular compromise.
Indirect type (There are times that it can be
patent processus vaginalis (PPV) incarcerated but not
young patients compromised.)
same cause as hydrocele This is an emergency. If
scrotum becomes enlarged uncorrected, it will cause
ischemia.
Direct type
weakness in the abdominal wall musculature
(floor) FEMORAL HERNIA
older patients hernia protrudes through femoral canal
bulge is within the inguinal canal and does not manifestation would be below inguinal ligament
go down in the scrotum Females > Males

SLIDING HERNIA (PANTALOONS HERNIA)

DIRECT INDIRECT Part of the processus vaginalis is accompanied
Post. wall Deep ring by an organ
Less common 70% part of sac: viscera
Older Congetinal LEFT SIDE: sigmoid colon or bladder
Smaller Scrotal RIGHT SIDE: cecum or bladder
Hesselbach's Triangle Deep ring RICHTERS HERNIA: involves the bladder only
Medial to inferior Lateral to inferior
epigastric vessels
Lower risk
epigastric vessels
Incarceration,
VASECTOMY
Strangulation surgical sterilization that involves ligation and
resection of part of vas deferens
bilateral cutting of the continuation of the vas
The defect for direct type would be on the deferens
posterior wall because of the weakness of the muscle. In can be done on an out-patient basis
the indirect type, the defect is in the deep inguinal ring 1. Make a small incision on the scrotum
where the processus vaginalis will come out. 2. Feel for the vas deferens
3. Cut
70% would be of the indirect type; and the direct only done if patient is 100% sure that he decides
type is less common and is usually seen in older patients. not to bear a child anymore
Usually, the indirect type is congenital and it has a scrotal there would be degeneration of sperm cells
component (scrotum also becomes big especially if this is
a complete type of indirect inguinal hernia). In direct,
there is no enlargement of the scrotum.

In the indirect type, the hernia comes from the

deep ring; whereas, the direct type, it is from the
Hesselbachs triangle.

In the indirect type, the hernia will be lateral to

the inferior epigastric vessels; whereas, the direct type will
be medial to the inferior epigastric vessels.

The indirect type has a higher incidence of

incarceration and strangulation; whereas, the direct type
has a lower incidence.

6 Bernabe, Maria Katrina (2013)

 FEMALE
may end in:

BARTHOLINS CYST

1: very seldom; 2 and 3: more common

Bartholins glands homologue is the Cowpers Gland.
The bartholins gland usually secrete a fluid or mucoid Medical emergency if it is ruptured because of
discharge to lubricate the vaginal opening. At times, this the uncontrollable bleeding
can be blocked and the problem would be the o Patients can go into hypotension
abnormal accumulation of the fluid within the gland itself. because of hemoperitoneum
This will present as a swelling in between the labia majora
and minora. DIAGNOSIS
(+) pregnancy test
blockage of the Bartholins glands causing fluid ULTRASOUND: very sensitive for this; shows the site
accumulation of the ectopic pregnancy
may be secondary to infection (or inadvertent High HCG, sonography and endometrial biopsy
pulling of hair in the area of the labia) showing decidual reaction but no chorionic villi
Treatment:
o Antibiotics
o Draining (if unresponsive to antibiotics) CLASSIFICATION
o MARSUPIALIZATION
Procedure of choice for these
kind of cysts
opening up of the cyst
draining the content suture
around the edges
for delaying the closure of the
wound to promote adequate
drainage
If only incision and drainage is used,
after a few hours, it is already closed
and the cycle will repeat itself.

Tubal most common

ECTOPIC PREGNANCY
happens if you have fertilization and the mature
ova is implanted in another location other than
the uterine cavity
disorders of early pregnancy
Most common site: FALLOPIAN TUBE (>90%)
rarely in the ovary or abdominal cavity
associated with PID (pelvic inflammatory
diseases) and endometriosis
o increases the risk of ectopic pregnancy
o causes scarring and blockage of the
tube difficulty in migration of the
fertilized ova
o it stops or hinder the normal migration of
the fertilized ova
but 50% occur with no known cause
7 Bernabe, Maria Katrina (2013)
Ovarian
Cervical
Abdominal
o NOT compatible to life
o will present as a normal pregnancy
o mother doesnt have any abdominal
signs and symptoms because there will
be no obstruction of the tube
o ONLY clinical manifestation is when
ultrasound is done, THE uterine cavity is
EMPTY despite the positivity of the
pregnancy test initially
o When you scan the abdominal cavity, it
may be lodged/implanted in the
mesentery
o The implant must be surgically removed
Interstitial pregnancy in the intramural part
INTERSTITIAL TUBAL ECTOPIC PELVIC SUPPORT PROBLEMS
2.5% of all tubal pregnancy There can be organs accompanying the uterus as it slides
Early rupture doesnt occur because of the down.
bigger space where the fetus can develop CYSTOCELE
However, because of the blood supply (coming o Posterior portion of the bladder slides
from the ovarian and uterine arteries) rupture of together with the uterus
this type of ectopic is most likely fatal
Often diagnosis is late RECTOCELE
o Anterior portion of the rectum slides
TREATMENT down
Surgical removal ENTEROCELE
o Portions of the small bowel goes down
SALPHINGOSTOMY: and slide together with the uterine
1. Initially, you can do a small incision within the prolapse
fallopian tube (if located in the f.tube)
2. Remove the product of conception STAGES OF UTERINE PROLAPSE
3. Leave it as is because it usually seals off.
CERVIX DROOPS TO THE
1ST DEGREE
VAGINA
Minimal handling of the tube: Better.
This is to avoid any scarring. CERVIX STICKS TO
OPENING OF VAGINA
BUT if there would be repeated incidence of 2ND DEGREE FISH-MOUTH APPEARANCE
tubal pregnancy especially on the same side: OF CERVIX between the
SALPHINGECTOMY (removal of fallopian tube). folds of labia minora
CERVIX IS OUTSIDE OF
3RD DEGREE
VAGINA
UTERINE PROLAPSE
ENTIRE CERVIX & UTERUS
4TH DEGREE
COMES OUT OF VAGINA

UTERINE PROCIDENTIA: when there is total exit of the

uterus from the vaginal canal

CLINICAL MANIFESTATIONS
Abnormal displacement of uterus secondary to
laxity of ligaments that holds the uterus in place
(most important: UTEROSACRAL ligament; also
cardinal ligament);
another cause is relaxation of muscles because
of multiple deliveries (multiparous)
Usually passes through the vaginal canal
TREATMENT
CAUSES
Loss of muscle tone
MULTIPARITY (major factor), injury during childbirth
Other factors
o Obesity
o Chronic coughing or straining
o Constipation
intraabdominal pressure will push the uterus
down the vaginal canal
Protruding mass within the vaginal canal
Feeling of something is going to fall out
especially when in an erect position or during
walking
Varying degrees of dysuria and constipation
depending upon the combination of the
prolapsed whether cystocele or rectocele
Urinary incontinence
1ST/2ND DEGREE: anchor the uterus in its normal
place
Keep in recumbent position
Replace the uterus to its normal position and
location hold it in place
Vaginal hysterectomy (for severe cases)

This is not associated with body builders because if they

are body builders but did not experience pregnancy, the
pelvis is not tested and the ligaments were not subjected
to the strain of labor.

8 Bernabe, Maria Katrina (2013)


VAGINAL FISTULA
Abnormal connection between vaginal canal
and another organ
TYPES
RECTOVAGINAL
o abnormal communication between the
posterior vaginal wall and the anterior
rectum
o feces will be observed coming out of the
vagina
o Early sign: AIR (flatus) coming out of
vagina
o When you insert a catheter into the
vagina, it will go out of the rectum
VESICOVAGINAL
o communication between the vagina
and the bladder
o urine will be coming out of the vagina
VESICOUTERINE
URETHROVAGINAL
o Very uncommon
ETIOLOGY
Complication of difficult vaginal deliveries and
episiotomies/episiorrhapy
o When a mother deliveries a big baby
and she sustained 4th degree laceration
(worst lacearation; the laceration went
all the way into the rectum and you
have to repair the rectum);
o if the rectum is not repaired, there will an
abnormal communication between the
posterior vaginal wall and the anterior
rectum.
o Several weeks after it is healed, the feces
will be observed coming out of the
vagina (RECTOVAGINAL FISTULA)
Complications of surgeries whether normal
delivery or hysterectomy
Tumors of vagina or cervix
Following radiation for treatment of rectal cancer
o Because part of the treatment is
RADIATION and it makes tissues very
brittle and they stick together
o The moment there is adhesion of the
rectum and vagina, there can be
abnormal communications between the
two areas.
9 Bernabe, Maria Katrina (2013)
CLINICAL MANIFESTATIONS
Abnormal vaginal discharge fluid or fecaloid
o Fluid: BLADDER
o Fecaloid: RECTUM
Frequent bouts of UTI
Varying degrees of fecal incontinence
DIAGNOSIS
Physical examination: IE (internal examination)
Bi-manual Examination
1. One finger is inserted in the rectum, and the
other hand is inserted in the vagina
2. Palpate for the lines of the suture that you
made
If you can palpate the suture line in the
rectum, it means you have to correct your
repair
The repair must be SEROMUSCULAR ONLY
and it will not involve the mucosa.
Because if you suture through all the layers of
the rectum, it will involve the mucosa and
the suture can be palpated like strings of a
guitar.
Urinalysis for UTI
Contrast studies to determine the extent and
location of fistula
o X-rays and insert dyes; then follow the
tract of the dye so you can localize the
location of the fistula
Example:
both the vaginal and rectum took the
dye
TREATMENT
Best treatment is prevention
o That is why you have patients in labor to
strain properly
o Do an adequate episiotomy
Repair of defect created
Put intervening normal tissue ion between
o OMENTUM: good tissue to be used in
repairs in order to prevent adherence
and prevent formation another fistula
Be careful in doing surgeries because fistulas are
IATROGENIC (surgeon-induced if the proper technique is
not done) except for radiation treatment because it is a
complication.
 TYPES
MYOMA
INTRAMURAL
Found in the uterine wall
Surrounded by myometrium
More prone to BLEEDING

SUBMUCOSAL
Located directly under the endometrium, involving
the endometrial cavity

Abnormal outgrowths of myometrial tissues
They can be located in several areas within the
uterus
Usually benign
Respond to hormonal changes
o That is why in uncomplicated myomas, it
is advised that patients wait for their
menopausal years because during
menopause, the myoma will also shrink.
However, with patients presenting with bleeding
or pain because of a very large myoma, we do
not wait for the menopause and we schedule
them for operation.
Disease characterized by fibroid (benign tumors)
in the uterus
Most common benign tumors in women
Composed of smooth cells
Become malignant in fewer than 0.1% of patients
Myomas can degenerate into sarcomas (rare)
SUBSEROSAL
Found on the outer surface (under the serosa) of the
uterus
Predisposed to TORSION (pedicle twisting) extreme
abdominal pain
WANDERING or PARASITIC
A pedunculated leiomyoma that twist on its pedicle,
breaks off, then attaches to the other tissues,
particularly the omentum
In the pelvic area, aside from the uterus and
fallopian tube, you have the mesentery of the recto-
sigmoid area and the omentum going down
Whenever you see implants that look like a part of
the endometrium or muscle looking, when you
remove it, that can be a parasitic type f myoma.
INTRALIGAMENTARY
Implants on the pelvic ligaments, may displace the
uterus or involve the ureter
myoma located within the broad ligament
CERVICAL
Occurs infrequently and may obstruct the cervical
canal
usually goes out of the cervical os

ETIOLOGY DIAGNOSIS
Growth related to estrogen stimulation because BIMANUAL EXAMINATION
the fibroids often enlarged with pregnancy and o One hand on top of abdominal cavity
shrink with menopause and the other hand doing the internal
Begins as a simple proliferation of smooth muscle examination
cells; hypertrophy hyperplasia o Push the fundus of uterus while during IE
o IE: Guide will be the FORNIX
PATHOPHYSIOLOGY 1. Touch the cervical os and check for
Fibroids vary greatly in size and usually appear smoothness and orientation
firm, surrounded by a pseudocapsule composed 2. Put your fingers on the fornix
of compressed but otherwise normal uterine 3. Touch the right and left adnexa
myometrium 4. While doing so, push the fundus of
The uterine cavity may become larger, the uterus and move it so that the
increasing the endometrial surface; this can ovaries will be pushed down to your
cause increased uterine bleeding fingers and you can palpate it
The ovary in size from very small to almost
occupying the entire uterus. ULTRASONOGRAPHY
Can simulate the age of gestation of a pregnant o For nulliparous patients with no sexual
woman that is why when you examine a patient contact yet
with myoma, you correlate the size with the age ABDOMINAL (for general
of gestation purposes) or TRANSRECTAL
(better) ULTRASOUND
o Already with sexual contact:
TRANSVAGINAL
Best
Because you can look
at the adnexa

10 Bernabe, Maria Katrina (2013)

 Endometrial biopsy
Laparascopy
Surgery depending upon the myoma
o MYOMECTOMY
Removal of myoma only
o HYSTERECTOMY
If entire uterus is involved
o OPEN LAPAROSCOPY
If subserous or intramural

COMPLICATIONS
Recurrent spontaneous abortion
o If you have a big myoma, you can have
spontaneous abortion because that will
impinge on the implantation site of the
mature ova
Preterm labor
Anemia secondary to excessive bleeding
o Especially if INTRAMURAL type
Bladder compression
o It Impinges on the bladder
Infection
Bowel obstruction

TUBAL LIGATION
Counterpart of hysterectomy of the males
Done if:
o there is desire to not have any
pregnancies anymore especially for
multiparous women
o women who have medical
complications (e.g. cardiac problems)
Surgical sterilization hat involves ligation or
resection of part of fallopian tube
Usual techniques:
o POMEROY
clamp fallopian tube then cut
problem here is there are reports
of migration and recanalization
because they are adherent to
each other
o PARKLAND
remove part of fallopian tube
then ligate
decreased incidence of
migration and recanalization

11 Bernabe, Maria Katrina (2013)