Final Exam Study Guide 6550

Genitourinary, gynecologic, renal and acid/base conditions o Carcinoma of the Cervix Increased risk in women who smoke and those with HIV or high-risk HPV types. Considered a sexually transmitted disease as both squamous cell and adenocarcinoma of the cervix are secondary to infection with HPV; squamous cell accounts for 80 percent of cervical cancers, 15 % adenocarcinoma, and 3-5 % neuroendocrine. Prevention through vaccination- recombinant 4 or 9-valent HPV vaccination which target HPV types that pose the greatest risk. Prognosis- overall 5- year relative survival rate is 68 % for white women and 55 % in black women- survival rates are inversely proportionate to the stage of cancer. Signs/Symptoms- Metrorrhagia, postcoital spoting, and cervical ulceration. Gross edema of the legs may be indicative of vacular and lymphatic stasis due to tumor. Pain in the back (lumbosacral plexus region) indicates neurologic involvement. Bladder and rectal dysfunction or fistulas are severe late symptoms. Two to 10 years are required for carcinomas to penetrate the basement layer of the membrane and become invasive- screening has decreased mortality. Diagnostic Tools- Cervical Biopsy- After a positive papnicolaou smear biopsy or endocervical curettage is necessary to determine the extent and depth of the cancer cells. Surgery and radiation should be delayed until biopsy results. Imaging- CT, MRI, lymphangiography, fine-needle aspiration, ultrasound, and laparoscopy are utilized for staging of invasive cancer. Allows for more specific treatment planning. Complications- Metastases to regional lymph nodes occurs with increasing frequency from Stage I to Stage IV. Extension occurs in all directions from the cervix. Hydronephrosis (urine-filled dilation of the renal pelvis due to obstruction) and hydroureters (dilation of the ureter), is a result of the ureters becoming obstructed lateral to the cervix which can lead to impaired kidney function. Treatment/Management- Refer all patients to Gynecologic Oncologist Carcinoma in situ (Stage 0)- women whom child-bearing is not a consideration, total hysterectomy is definitive treatment. Retain uterus- cryosurgery, laser surgery, LEEP, or cervical conizations are options. Close follow-up with pap smears every 3 months for 1 year and every 6 months for another year after cryo/laser surgery. Invasive Carcinoma- treated with hysterectomy. Stage IA1, IBI, and IIA hysterectomy and concomitant radiation and chemotherapy or with radiation and chemo alone; Stages IB2, IIB, III, and IV cancers treated with radiation therapy plus concurrent chemotherapy. Emergency presentation- vaginal hemorrhage- due to gross ulceration and cavitation of cervix- late stage- packing, cautery, tranexamic acid to stop bleeding temporarily. Ligation and suturing not an option due to diffused ulceration. o Fibroid Tumor Uterine leiomyomas are the most common neoplasm in the female genital tract- it is a round, firm, often multiple uterine tumor composed of smooth muscle and connective tissue. Classification by anatomical location- 1. Intramural, 2. Submucous, 3. subserious, 4. Intraliagmentous, 5. Parasitic (blood supply from an organ to which its attached) 6. cervical In non-pregnant women, myomas are frequently asymptomatic- symptoms which prompt for treatment include AUB and pelvic pain or pressure. Complications of fibroids include miscarriage if they block the uterine cavity or preterm delivery and malpresentation. Diagnostic- Patients may present with iron deficiency anemia (blood loss). Imaging to include a pelvic ultrasound and monitor growth. MRI can be delineate intramural and submucous myomas and is required prior to uterine artery embolization to assess the blow flow to the fibroid. R/O: subserous myomas from oviarian tumors Treatment/Management Small asymptomatic myomas can be evaluated annually- Patients who defer surgery, non- hormonal therapies (NSAIDs and tranexamic acid) have been show to decrease menstrual blood loss. Hormonal therapies- GnRH agonists and SPRMs, shown to reduce myoma volume, uterine size, and menstrual blood loss. Surgical intervention should be based on patient’s symptoms and desire for future fertility- uterine size is not an indication alone for surgery- cervical myomas 3-4 cm in diameter that protrude through cervix, can cause infection, bleeding, pain, or urinary retention, which require removal. ................................CONTINUED....................................