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The prognosis for reproductive function in early or moderately advanced endometriosis is good with conservative therapy TAH-BSO is curative for patients with severe and extensive endometriosis with pain
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Refer to a gynecologist for laparoscopic diagnosis or treatment
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Rarely necessary except for acute abdomen associated with ruptured or bleeding endometrioma
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Crosignani P et al Advances in the management of endometriosis: an update for clinicians Hum Reprod Update 2006; 12:179 89 [PMID: 16280355] Kinkel K et al Diagnosis of endometriosis with imaging: a review Eur Radiol 2006 Feb;16(2):285 98 [PMID: 16155722]
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PELVIC ORGAN PROLAPSE
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Cystocele, rectocele, and enterocele are vaginal hernias commonly seen in multiparous women Cystocele is a hernia of the bladder wall into the vagina, causing a soft anterior fullness Cystocele may be accompanied by urethrocele, which is not a hernia but a sagging of the urethra following its detachment from the pubic symphysis during childbirth Rectocele is a herniation of the terminal rectum into the posterior vagina, causing a collapsible pouch-like fullness Enterocele is a vaginal vault hernia containing small intestine, usually in the posterior vagina and resulting from a deepening of the pouch of Douglas Two or all three types of hernia may occur in combination Pelvic organ prolapse is often associated with symptoms of pelvic pressure or a dragging sensation as well as bowel or lower urinary tract dysfunction Stress urinary incontinence is a frequent symptom Supportive measures include a high-fiber diet Weight reduction in obese patients and limitation of straining and lifting are helpful Pessaries may reduce cystocele, rectocele, or enterocele temporarily and are helpful in women who do not wish surgery or are chronically ill The only cure for symptomatic cystocele, rectocele, enterocele, or stress urinary incontinence is corrective surgery
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CMDT 2008
UTERINE PROLAPSE
Uterine prolapse most commonly occurs as a delayed result of childbirth injury to the pelvic floor (particularly the transverse cervical and uterosacral ligaments) Unrepaired obstetric lacerations of the levator musculature and perineal body augment the weakness Attenuation of the pelvic structures with aging and congenital weakness can accelerate the development of prolapse A comprehensive classification system, Pelvic Organ Prolapse Quantification, has been developed to standardize the description of pelvic organ prolapse In stage I prolapse, the uterus descends only part way down the vagina; in stage II prolapse, the corpus descends to the introitus and the cervix protrudes slightly beyond; in stage III prolapse, the entire cervix and uterus protrude beyond the introitus; and in stage IV prolapse, the vagina is inverted
orrhoeae and Chlamydia trachomatis as well as endogenous organisms, including anaerobes, Haemophilus influenzae, enteric gram-negative rods, and streptococci It is most common in young, nulliparous, sexually active women with multiple partners Other risk markers include nonwhite race, douching, and smoking The use of oral contraceptives or barrier methods of contraception may provide significant protection Tuberculous salpingitis is rare in the United States but more common in developing countries; it is characterized by pelvic pain and irregular pelvic masses not responsive to antibiotic therapy It is not sexually transmitted
Clinical Findings
A Symptoms and Signs
Patients with PID may have lower abdominal pain, chills and fever, menstrual disturbances, purulent cervical discharge, and cervical and adnexal tenderness Right upper quadrant pain (Fitz-Hugh and Curtis syndrome) may indicate an associated perihepatitis However, diagnosis of PID is complicated by the fact that many women may have subtle or mild symptoms that are not readily recognized as PID
Treatment
The type of surgery depends on the extent of prolapse and the patient s age and her desire for menstruation, pregnancy, and coitus The simplest, most effective procedure is vaginal hysterectomy with appropriate repair of the cystocele and rectocele If the patient desires pregnancy, a partial resection of the cervix with plication of the cardinal ligaments can be attempted For elderly women who do not desire coitus, partial obliteration of the vagina is surgically simple and effective Uterine suspension with sacrospinous cervicocolpopexy may be an effective approach in older women who wish to avoid hysterectomy but preserve coital function A well-fitted vaginal pessary (eg, inflatable doughnut type, Gellhorn pessary) may give relief if surgery is refused or contraindicated
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