1. Geriatric Gynecology

2. 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

3. 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

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

5. Lichen Planus

6. 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

7. 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

8. 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

9. Atrophic Vaginitis

10. 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.

11. Differential
UTI
Pelvic Floor dysfunction

12. 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

13. 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.

14. 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)    Accessed March 1, 2010, with additional information from references 1 and 13.

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