Geriatric Gynecology

Mrs. Jones 82 year old female who presents with a chief complaint of blood on the tissue when she wiped yesterday. ROS: + dysuria, vaginal itching Back pain, frequency, discharge Not sexually active UA: +blood, +LE, - nitrites, Mod squams, rare bacteria

Differential Dx UTI Atrophic Vaginitis Lichen Sclerosus Lichen Planus Lichen Simplex Chronicus Paget’s Disease Vulvar Cancer VIN Psoariasis Seborrheic Dermatitis Contract Dermatitis Misc: phemphagoid, Becets

Lichen sclerosis Left: “cigarette paper” skin, excoriation Right: advanced with loss of archetecture of labia, decreased introitus size, clitoris

Lichen Planus

differences Lichen Sclerosis Lichen Planus Vulvar and peri-anal locations Doesn’t involve vagina Biopsy thickened areas- concern for progression to CA Increased risk of autoimmune disorders Chronic Progressive Inflammatory Can be vulvar, vaginal or peri-anal 3 types erosive, papulosquamous, hypertrophic Less concern for cancer Chronic Autoimmune Inflammatory

similarities Treatment: STEROIDS, STEROIDS, STEROIDS- high potency applied 1-2 times a day ( second line treatment is intra-lesional steroid in Sclerosis and PO steroid in Planus) Both are chronic and often require maintenance steroid therapy Tacrolemus (protopic) and Pimicrolemus (elidel) can also be tried, though it is an off label use

Lichen Simplex Chronicus Lichenification of skin due to itch/scratch cycle Skin becomes thick and leathery Excoriations can occur but not erosive like Planus Treat the itch po meds and topical steroids

Atrophic Vaginitis

Mrs. doubtfire 72 year old female who presents with complaints if difficulty urinating and pelvic pain/pressure. She reports she has to go to the bathroom frequently and sometimes struggles to get the urine out, when she thinks she is done and stands up she will leak more urine.

Differential UTI Pelvic Floor dysfunction

Terminology Cystocele, Rectocele no longer utilized Anterior Compartment Prolapse Posterior Compartment Prolapse Apical Compartment Prolapse- descent of the apex of the vagina into the lower vagina to the level of the hymen or lower Uterine Procidentia- hernia of all three compartments through the vaginal introitus Enterocele- hernia of intestines to/through the vaginal wall

Examination Head of the bed at 45 degrees Use speculum to identify cervix or vaginal cuff, remove speculum while patient performs a valsalva and see how much of the pelvic organs/tissue follow the speculum down in the vault Disassemble speculum and use lower blade to examine vaginal compartments separately If no prolapse identified but patient reports a bulge examine patient in standing position.

Staging BADEN-WALKER SYSTEM PELVIC ORGAN PROLAPSE–QUANTIFICATION SYSTEM GRADE DESCRIPTION STAGE Normal position for each respective site, no prolapse No prolapse 1 Descent halfway to the hymen I > 1 cm above the hymen 2 Descent to the hymen II ≤ 1 cm proximal or distal to the plane of the hymen 3 Descent halfway past the hymen III > 1 cm below the plane of the hymen, but protrudes no farther than 2 cm less than the total vaginal length 4 Maximal possible descent for each site IV Eversion of the lower genital tract is complete Adapted with permission from Onwude JL. Genital prolapse in women. Clin Evid (Online) . 2007. http://clinicalevidence.bmj.com/ceweb/conditions/who/0817/0817_T1.jsp. Accessed March 1, 2010, with additional information from references 1 and 13.

Treatment Pelvic Floor Retraining- send to Urology they do amazing work! Pessary- Surgery-