pediagenosis: Reproductive
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Showing posts with label Reproductive. Show all posts
Showing posts with label Reproductive. Show all posts

Monday, February 15, 2021

SUPPORT OF PELVIC VISCERA

SUPPORT OF PELVIC VISCERA

SUPPORT OF PELVIC VISCERA

To clarify the relationships of muscles and fasciae in supporting the pelvis, with particular reference to the vagina and internal female genitalia, the uterus, in the accompanying picture, has been elevated upward and backward.  The plane chosen for the section (small upper diagram) runs from a point anterior to the body of the uterus down through the anterior vaginal fornix and along the longitudinal axis of the vagina to the perineum. At this level, the large iliac vessels run close to the superior pubic rami which form the lateral pelvic walls. These pubic rami are connected to the ischiopubic rami across the obturator foramen by the obturator membrane, the obturator internus muscle, and the obturator fascia. The broad ligaments begin at the lateral pelvic walls as double reflections of the parietal peritoneum, forming large wings, which divide to include the uterus and separate the pelvic cavity into anterior and posterior compartments. They are continuous with the peritoneum of the bladder anteriorly and the rectosigmoid posteriorly. The broad ligaments contain fatty areolar tissue, blood vessels, and nerves, and at their apices invest the round ligaments, which are condensations of smooth muscle and fibrous tissue holding the uterus forward and inserting below and anterior to the fallopian tubes. The left ovary has been lifted up to demonstrate the uteroovarian and infundibulopelvic ligaments, the latter containing the ovarian blood supply. The bladder peritoneal reflection has been detached from the uterus, revealing the endopelvic or uterovaginal fascia, which runs laterally to the pelvic wall as the cardinal ligament, and with the associated blood vessels, nerves, and fat forms the parametrium. The uterine arteries and veins extend medially from their origins in the hypogastric vessels to the lateral vaginal fornices. The ureters (cross-sectioned) at this point pass beneath the uterine vessels and then continue in the uterovaginal fascia medially and anteriorly across the upper vagina into the bladder. The close proximity of the ureters to the uterine blood supply and vagina explains why they may easily be injured during hysterectomy and in operations to repair lacerations of the endopelvic fascia.

PELVIC DIAPHRAGM II—FROM ABOVE

PELVIC DIAPHRAGM II—FROM ABOVE

PELVIC DIAPHRAGM II—FROM ABOVE

The pelvic diaphragm forms a musculotendinous, funnel-shaped partition between the pelvic cavity and the perineum and serves as one of the principal supports of the urethra, vagina, rectum, and pelvic viscera. It is composed of the levator ani and coccygeus muscles, sheathed in a superior and inferior layer of fascia. The muscles of the pelvic diaphragm extend from the lateral pelvic walls downward and medially to fuse with each other and are inserted into the terminal portions of the urethra, vagina, and anus. Anteriorly, they fail to meet in the midline just behind the pubic symphysis, exposing a gap in the pelvic floor, which is completed by the urogenital diaphragm. This gap is partially filled by the subpubic ligament that is pierced by the dorsal vein of the clitoris. In this area, the inferior fascia of the pelvic diaphragm fuses with the superior fascia of the urogenital diaphragm.

PELVIC DIAPHRAGM I—FROM BELOW

PELVIC DIAPHRAGM I—FROM BELOW

PELVIC DIAPHRAGM I—FROM BELOW

Removing the superficial muscles and fasciae of the pelvic floor, the pelvic diaphragm, viewed from below, forms a hammock of muscle from the pelvic brim, investing the urethra, vagina, and rectum and attaching posteriorly to the sacrum and coccyx. The principal muscles of this group are the levatores ani, consisting of both medial and lateral components on each side and supplied by the pudendal nerve. The larger medial component, the pubococcygeus, arises from the posterior surface of the superior ramus of the pubis adjacent to the symphysis, whence the fibers pass downward and backward around the lateral walls of the vagina, with some fibers reaching the coccyx, some terminating in the fascia forming the central tendinous point of the perineum, and others blending with the longitudinal muscle coats of the rectum. The pubococcygei are separated medially by the interlevator cleft through which pass the dorsal vein of the clitoris, the urethra, vagina, and rectum. These organs are supported by musculofascial extensions from the pubococcygei, their inferior fascia being continuous with the superior fascia of the urogenital diaphragm.

THE VAGINA

THE VAGINA

THE VAGINA

The vagina (from Latin, literally “sheath” or “scabbard”) serves as the portal to the internal female reproductive tract and a route of egress for the fetus during delivery. The viscera contained within the female pelvis minor include the pelvic colon, urinary bladder and urethra, uterus, uterine tubes, ovaries, and vagina. These structures surround the vagina and interact with it in the clinical setting. Therefore, the vagina also provides a convenient portal to understanding the female pelvic viscera.

FEMALE CIRCUMCISION

FEMALE CIRCUMCISION

FEMALE CIRCUMCISION

Female circumcision is a culturally determined practice of ritually cutting a female’s external genitals that results in removal of part or all of the external genitalia including the labia majora, labia minora, and/or the clitoris. This activity is illegal in many locations. Female circumcision (female genital mutilation, infibulation) is generally performed as a ritual process, often without benefit of anesthesia and frequently under unsterile conditions, generally near the time of puberty or soon after. The resulting scarring may preclude intromission or normal vaginal delivery should pregnancy be achieved. In rare cases, scarring and deformity may be sufficient to result in amenorrhea or dysmenorrhea. The ritual is often performed to reinforce a woman’s place in her society, to establish eligibility for marriage and entry into womanhood. It is sometimes also performed to safeguard virginity or to paradoxically improve fertility. Although the ritual can have devastating effects on the woman’s sexual pleasure, it is some- times performed to enhance the husband’s pleasure.

Sunday, February 14, 2021

MALIGNANT TUMORS

MALIGNANT TUMORS

MALIGNANT TUMORS

About 5% of the malignant tumors of the female genital organs originate on the vulva. (The incidence of vulvar cancer rose by approximately 20% between 1973 and 2000, likely related to increased exposure to human papillomavirus [HPV].) Primary carcinoma is almost always seen in elderly women with an average age for in situ tumors being 40 to 49 years, and 65 to 70 for invasive lesions. The vast majority of these tumors are of the squamous cell variety. Histologic types include squamous cell (90%), melanoma (5%), basaloid, warty, verrucous, giant cell, spindle cell, acantholytic squamous cell (adenoid squamous), lymphoepithelioma-like, basal cell, and Merkel cell. Sarcoma accounts for approximately 2% of vulvar cancers. Metastatic tumors from other sources are rare but do occur.

BENIGN TUMORS

BENIGN TUMORS

BENIGN TUMORS

Benign tumors of the vulva include the fibroma, fibromyoma, lipoma, papilloma, condyloma acuminatum, urethral caruncle, hidradenoma, angioma, myxoma, neuroma, and rarely endometrioid growths.

Monday, February 8, 2021

CIRCULATION IN PLACENTA

CIRCULATION IN PLACENTA

CIRCULATION IN PLACENTA

During the third week of gestation, the villi at the base of the placenta become firmly anchored to the decidua basalis. In later weeks the zone of anchoring villi and decidua becomes honeycombed with maternal vessels that communicate with the intervillous space. The spiral arteries in the decidua become less convoluted and their diameter is increased. This increases maternal blood flow to the placenta and decreases resistance. In response to the presence of the trophoblasts, the vascular endothelium is replaced by the trophoblast, and both the trophoblast and an amorphous matrix of fibrin and other constituents replace the internal elastic lamina and smooth muscle of the media. These changes are most marked in the decidual portion of the spiral arteries but extend into the myometrium as the pregnancy advances. The basal arteries are not affected.

DEVELOPMENTAL EVENTS OF THE SECOND TRIMESTER

DEVELOPMENTAL EVENTS OF THE SECOND TRIMESTER

DEVELOPMENTAL EVENTS OF THE SECOND TRIMESTER

The second trimester (14 to 28 weeks) is a time of growth and refinement of function; all major structures including hands, feet, head, brain, and other organs are present, and they continue to grow and develop. During this trimester, the risk of pregnancy loss dramatically lessens and levels of human chorionic gonadotropin plateau and often decline, easing many of the early adverse symptoms of pregnancy such as breast tenderness and morning sickness, though the enlarging uterus may now precipitate heartburn and constipation. (When a second-trimester pregnancy loss occurs, it is strongly associated with placental inflammation, often related to ascending infection and/or acute chorioamnionitis, though it may also occur because of aneuploidy, by thrombophilias, by cervical insufficiency, and others.) Any weight loss experienced in the first weeks of gestation is regained and further weight is gained to provide stores needed to provide nutrition for the growing fetus. Despite the relative lack of complications during the second trimester, early signs of later problems may first appear during this phase of pregnancy.

DEVELOPMENTAL EVENTS OF THE THIRD TRIMESTER

DEVELOPMENTAL EVENTS OF THE THIRD TRIMESTER

DEVELOPMENTAL EVENTS OF THE THIRD TRIMESTER

During the third trimester (27 to 40+ weeks) the fetus continues to grow and develop, and maternal physiology changes in preparation for childbirth. It is most often during this phase of pregnancy that complications such as preeclampsia, bleeding, complications of diabetes or hypertension, abnormalities of growth or amniotic fluid, and preterm labor may emerge.

DEVELOPMENTAL EVENTS OF THE FIRST TRIMESTER

DEVELOPMENTAL EVENTS OF THE FIRST TRIMESTER

DEVELOPMENTAL EVENTS OF THE FIRST TRIMESTER

The first weeks following fertilization represent the most critical period for the success of a pregnancy. A high percentage (as high as 50% to 60%) of fertilized oocytes do not result in pregnancies completing the first trimester of gestation. Despite the dramatic changes that the conceptus undergoes in the first 14 weeks of gestation, many patients are unaware of their pregnancy or delay seeking prenatal care. Emerging evidence suggests that during this period the foundations of a successful pregnancy and even the future health of the adult individual are set.

IMPLANTATION AND EARLY DEVELOPMENT OF OVUM

IMPLANTATION AND EARLY DEVELOPMENT OF OVUM

IMPLANTATION AND EARLY DEVELOPMENT OF OVUM

Fertilization of the human ovum usually occurs in the ampullary portion of the oviduct, although in rare instances it may take place elsewhere in the genital tract or even in the ovary. Soon after the spermatozoon enters the ovum, the male and female pronuclei fuse to form the segmentation nucleus, which rapidly divides and redivides. Segmentation, thus initiated, continues until the original fertilized ovum is transformed into a mass of cells called the morula.

Tuesday, January 26, 2021

CYSTS

CYSTS

CYSTS

A Bartholin cyst results from the occlusion of the excretory duct or one of its subdivisions. Etiologic factors include specific or nonspecific infections and accidental or operative trauma. Most often an infection in one or both Bartholin glands results in swelling and/or abscess formation. Usually the acute process is unilateral and marked by pain and swelling. Systemic symptoms are minimal except in advanced cases. Once the acute infection has passed, stenosis and scarring of the duct may result in the formation of a chronic cyst.

CHANCROID AND OTHER INFECTIONS

CHANCROID AND OTHER INFECTIONS

CHANCROID AND OTHER INFECTIONS

Infection by Haemophilus ducreyi results in chancroid, one of a group of infrequently encountered sexually transmitted infections. Chancroid is more common than syphilis in some areas of Africa and Southeast Asia but uncommon in the United States. After incubation of 3 to 10 days, a papule or pustule, surrounded by a vivid areola of inflammation, may be noted within the vestibule, at the fourchette or on the labia minora. This develops into one or more typical “soft chancres.” The chancroid appears as a pinkish-red, granular ulcer with punched-out, uneven, undermined edges and a necrotic, purulent floor. The ulceration is painful and destructive and lacks the characteristic induration seen in the primary chancre of syphilis. Suppurative inguinal nodes or “buboes” are common. The combination of a painful ulcer and tender inguinal adenopathy suggests chancroid; when accompanied by suppurative inguinal adenopathy, they are almost pathognomonic. A definitive diagnosis of chancroid requires identification of H. ducreyi on special culture media that are not widely available; even using these media, sensitivity is 80% or less. Gram stain of material from open ulcers can also be confirmatory.

SYPHILIS

SYPHILIS

SYPHILIS

Syphilis presents with an easily overlooked first stage and, if left untreated, can slowly progress to a disabling disease noted for central nervous system, cardiac, and musculoskeletal involvement. The primary lesion of syphilis, though readily noted by the male, is not infrequently overlooked by the female. It appears most commonly on the labia majora, mons veneris, clitoris, fourchette, and vaginal mucosa but can also be seen on the anus, rectum, pharynx, tongue, lips, fingers, or the skin of almost any part of the body. The initial lesions first appear 10 to 60 days (average, 21 days) after infection as a fissure, abrasion, or nodule with slight erosion and may then develop the characteristics of a hunterian chancre; an orange-red, granular ulcer, round or oval in shape, 1 or 2 cm in diameter, with sharp margins, and an indurated base. Multiple chancres are sometimes seen, particularly within the labial folds.

VULVAR VESTIBULITIS

VULVAR VESTIBULITIS

VULVAR VESTIBULITIS

Vulvar vestibulitis is an uncommon syndrome of intense sensitivity of the skin of the posterior vaginal introitus and vulvar vestibule, characterized by progressive worsening, which leads to dyspareunia, vulvodynia, and loss of sexual function. Some estimates place its prevalence at 15% of all women, but significant, disabling symptoms are much less common. Although the median age of occurrence is 36 years, it can occur at any time after the late teenage years. New onset of symptoms is uncommon after menopause.

DIABETES, TRICHOMONIASIS, MONILIASIS

DIABETES, TRICHOMONIASIS, MONILIASIS

DIABETES, TRICHOMONIASIS, MONILIASIS

Vulvovaginal infections are a common occurrence and frequent cause for clinical evaluation. Although most frequently these are not associated with any underlying risk factor, women who are immunocompromised or have diabetes mellitus are at increased risk for opportunistic infections such as yeast infections.

GONORRHEA

GONORRHEA

GONORRHEA

The symptoms of acute gonorrhea of the vulva may appear from 1 day to several days after contact, are often mild or transitory, and may be overlooked. The patient may experience burning on urination, urinary frequency, leukorrhea, and itching in the vestibule. Occasionally, however, the first suggestive manifestation of disease is not apparent until the following menses or shortly thereafter, when the ascending infection has resulted in an acute salpingitis. Examination of the external genitalia may reveal a congested vestibule bathed in pus and an inflammation of the urethra and Skene and Bartholin ducts. The acute infection ascends via the mucosa and epithelium of the urogenital tract and may give rise to an endometritis, peritonitis (pelvic inflammatory disease), and tuboovarian abscess. By lymphatic absorption and hematogenous spread, it may result in septicemia, endocarditis, arthritis and tenosynovitis. Although if untreated, gonorrheal infection may, at times, be uncomplicated and self-limited, the tendency for establishment of deep-seated chronic foci is strong. These occur particularly within compound tubular glands and structures lined by columnar epithelium, such as the periurethral and Bartholin glands and the endocervix.

Wednesday, January 6, 2021

CIRCULATORY AND OTHER DISTURBANCES

CIRCULATORY AND OTHER DISTURBANCES

CIRCULATORY AND OTHER DISTURBANCES

Varices of the vulva occur most often during pregnancy or as an aftermath of repeated pregnancies or processes that increase intraabdominal pressure. They are usually associated with varicose veins of the lower extremities. A primary factor in their development is the presence of retarded venous flow caused by increased intrapelvic or intraabdominal pressure. The veins of the labia and prepuce are most commonly involved, either unilaterally or bilaterally. They may form subcutaneous convolutions, which sometimes reach the size of a fist. Subjectively, there may be an annoying “dragging” or heavy sensation. The varices become prominent when the patient is standing and tend to disappear when she is in the supine position. Those that occur during pregnancy are apt to subside, to a great extent, after delivery. A varix may rupture as a result of direct trauma, injury during labor, excessive coughing or other straining. Rarely, a venous thrombosis may ensue. When the patient is symptomatic, resection, fulguration, sclerosis, or embolization therapies may be required.

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