Some other gynaecological problems

Here are a few more problems; some, such as congenital abnormalities and injuries, occur anywhere. Others are specifically tropical.

Fig. 20-23 HAEMATOCOLPOS. A, the bulging membrane retaining a girl's first menstrual discharges. B, a cross-section shows that there is also some degree of haematometra. After Young, James, ''A Textbook of Gynaecology', (5th edn. 1939). A and C Black, permission requested.

OTHER GYNAECOLOGICAL PROBLEMS CONGENITAL ABNORMALITIES [s7]OF THE GENITAL TRACT If A GIRL FROM 14 TO 16 HAS LOW ABDOMINAL PAIN AND AN ABDOMINAL MASS (not uncommon), examine her vagina and vulva. If you find a bulging membrane, her vagina and perhaps her uterus are distended with her first menstrual discharges[md]haematocolpos, perhaps with haematometra, as in Fig. 20-23. Make the diagnosis by inspecting her introitus and by a finger in her rectum. If the membrane feels thin, incise it with a cross-shaped incision. If it is not thin, refer her. Don't do anything more than make a cruciate incision in a thin membrane. Don't insert a drain; you risk introducing infection. If the gap between her upper and lower vagina is more than a thin membrane, the operation to establish patency is not easy, and restenosis is common. The problem is not urgent.

If a girl 6 months to 2 years after puberty has a LOWER ABDOMINAL MASS, one of the possibilities is a haematometra in the horn of a uterus didelphus (double uterus with two cervices, rare) with one cervix stenosed so that a haematometra develops. You can usually manage her by repeatedly dilating her stenosed cervix.

If she complains of a SWELLING IN HER ANTERIOR VAGINAL WALL behind her urethra, especially before the reproductive years, consider the possibility of a URETHRAL DIVERTICULUM (not uncommon in some tropical communities), and don't confuse it with a cystocele or a urethrocele. If you can squeeze its contents into her urethra, the diagnosis is confirmed. If necessary, do a urethrogram as in Section 34.5. If you cannot refer her, consider excising the diverticulum, which is usually not difficult. Operate with a urethral catheter in place. Repair the small defect in her urethra which was the neck of the diverticulum.

INJURIES [s7]OF THE GENITAL TRACT If an irritant has been placed in her vagina so as to cause a CHEMICAL VAGINITIS, this may be so severe as to involve the whole thickness of her vaginal wall, and be followed by stenosis. Irritants include caustic soda and rock salt and are sometimes used to procure abortions.

If you see her in the acute phase, admit her and remove all traces of the chemical, under anaesthesia if necessary. Douche the lesion with a mild antiseptic, and give her an antibiotic to limit the infection. Continue with salt baths until her wound is clean.

If the whole thickness of her vaginal skin has sloughed, severe fibrosis and a VAGINAL STRICTURE are likely. If you cannot refer her, consider inserting a skin graft (57.2) on a large mould, as soon as her vaginal cavity is clean. A dentist may have suitable material for the mould. Make it round a Hegar dilator, and then withdraw this, so as to make a passage for her menstrual fluid to escape. Stick a split skin graft to the outside of the mould with Compound Paint of Mastic BPC, or Compound Tincture of Benzoin BPC. Hold the mould in place with sutures. Remove these 21 days later, and immediately regraft any raw areas.

If PART OF HER URETHRA HAS BEEN DESTROYED, she might have lost the proximal part during labour (18.18) or the distal part from lymphogranuloma venereum (see below). Provided the proximal quarter is intact, the loss of the distal three-quarters usually causes no symptoms. An operation for repair of the proximal quarter is difficult, so refer her for this.

CHRONIC INFECTIONS AND PARASITOSES [s7]OF THE GENITAL TRACT If she presents with NODULES OR PAPILLOMAS of her lower genital tract, and you are in an endemic area for S. haematobium or S. mansoni, consider the possibility of SCHISTOSOMAL GRANULOMAS. These take various forms: (1) Frond-like (fern-like) lesions with a narrow base or plaques developing on the vulva, usually before puberty from the age of 6 to 15 years. These are often single, cause no problems, seldom bleed, and can be removed easily. (2) Multiple granulomata of the vagina and cervix in the reproductive years and after them. These also seldom bleed, but they may be so extensive that they distort the bladder/urethral angle and cause incontinence. (3) Ulceration or papillomas of the cervix, closely resembling carcinoma. Look for ova in her urine, stool, vaginal discharge, and tissue scrapings or biopsies. Venereal warts (condyloma acuminatum) are the major differential diagnosis. Give her the appropriate chemotherapy.

CAUTION ! (1) In a schistosomal area don't consider all suspicious vulval or cervical lesions as carcinoma. (2) She may have carcinoma and something else. (3) Don't excise large vulval lesions without doing a biopsy first.

If she presents with CHRONIC ULCERATION OF HER VULVA, the differential diagnosis includes: (1) Small and usually ulcerated granulomata arising in a perineum that is permanently wet from a VVF (salt baths will improve her temporarily). (2) Furunculosis; she may be diabetic, test her urine for glucose. (3) Secondary syphilis; painless, moist, flat-topped swellings. (4) Chancroid; painful shallow ulcers. (5) Tuberculosis (29.1). (6) Amoebiasis (rare); painless ulcers which may mimic carcinoma and usually respond dramatically to metronidazole (31.2). (7) Schistosomiasis (see above). (8) Carcinoma (32.35a). (9) Donovanosis (granuloma inguinale); red, angry, destructive lesions with a raised edge. (10) Lymphogranuloma venereum (see below, 22.10). Distinguishing between these last two can be difficult, and she may have both. Donovanosis can cause a pseudoepitheliomatous hyperplasia, which may be mistaken histologically for carcinoma. Fortunately, they both respond to tetracycline given for 3 weeks. You can also give chloramphenicol.

If she has LYMPHOEDEMA OF HER VULVA, consider the possibility of tuberculous glands of her groin (29.1), bancroftian or Malayan filariasis, lymphogranuloma venereum, secondary or tertiary syphilis, and donovanosis, etc. Massive elephantiasis of the vulva is usually caused by donovanosis or filariasis (31.4). Vulval oedema can sometimes be so gross as to mimic elephantiasis of the scrotum.

Suggesting lymphogranuloma: a fistulated inguinal adenitis with a sour smell, a concealed indolent sore of her vaginal vault, vesicovaginal or rectovaginal sinuses and rectal strictures; painlessness. Histology is often non-specific.

Treat any local sepsis. If elephantiasis has produced a large tumour of her vulva, you may have to excise it, but excision, particularly of enlarged labia majora, is likely to be disappointing. Excise a wide area of skin, so that the incision goes through healthy skin; this will assist healing, and make recurrence less likely. Insert an indwelling catheter to make nursing easier during the first week. Apply a well-padded dressing of vaseline gauze.

CAUTION ! (1) Operate under antibiotic cover. (2) Don't excise her lymph nodes, this will only make the condition worse, since all lymph from the involved areas has to drain through them.

OTHER [s7]GYNAECOLOGICAL PROBLEMS If she complains of a PROFUSE VAGINAL DISCHARGE OR POST-COITAL BLEEDING, one cause is CERVICAL EVERSION (also called a cervical erosion); other more common ones are described elsewhere (M 29.6). The normal columnar endothelium of her cervix bulges out, and you can see it when you do a speculum examination. Cervical eversion usually causes no symptoms. If necessary, cauterize her cervix with a hot cautery or a stick of silver nitrate.

If you use a cautery, make 6[nd]8 radial burns from her external os to the junction of the glandular eversion (the erosion) with her normal squamous epithelium. You will need a cervical block or general anaesthesia.

If you use a stick of silver nitrate, just touch all the glandular epithelium. Warn her that her discharge will get worse for a week before it improves. No anaesthesia is necessary.

If she complains of a small round red LUMP ON THE POSTERIOR MARGIN OF HER URETHRAL ORIFICE, it is probably a URETHRAL CARUNCLE. Usually, it needs no treatment; if it is pedunculated and bleeding, excise it. See also prolapse of the urethra 20.5.

If an OLD WOMAN COMPLAINS OF SUDDEN SEVERE VAGINAL BLEEDING, suspect a vaginal tear (not uncommon), usually in her posterior fornix as the result of sex, especially after a period of abstinence. You will see the tear on speculum examination: (1) If she has stopped bleeding, do nothing. (2) If she continues to bleed, insert one or two mattress sutures. (3) If the tear has gone through her posterior fornix (rare), replace her gut and repair it.

Fig. 20-24 URETHRAL CARUNCLE. This usually needs no treatment (A); if it is pedunculated (B), excise it. After Young, James, ''A Textbook of Gynaecology', A and C Black, permission requested. 21 The breast and the thyroid