1

BENIGN GYNECOLOGIC LESIONS

th
Comprehensive Gynecology, 6 Edition

VULVA
DESCRIPTION CAUSE DIFFERENTIAL DIAGNOSIS SIGNS AND SYMPTOMS DIAGNOSTIC TESTS TREATMENT

URETHRAL Classified according to histologic Arise from an ectropion Urethral carcinoma- mostly Majority are Diagnosis established Initial therapy is oral or
CARUNCLE appearance: of the posterior urethral arise from distal urethra asymptomatic by biopsy topical estrogen and
1. Papillomatous wall associated with Urethra prolapse- If the patient Dysuria avoidance or irritation
2. Granulomatous retraction and atrophy of is a child (premenarcheal Frequency If the carucle does not
3. Angiomatous the postmenopausal female) Urgency regress or symptomatic
Small, fleshy outgrowth of the distal edge vagina Produces point of Cryosurgery
of the urethra Secondary chronic tenderness after contact Laser therapy
Occur most frequently in irritation or infection with undergarments or Fulguration
postmenopausal women during intercourse Operative
Submucosal layer contains large dilated Ulcerative lesions excision
veins produce spotting on
contact more commonly
than hematuria

BARTHOLINS CYST Rounded, pea-sized glands deep in the Caused by obstruction of Wolffian duct cyst Mostly are Treatment not necessary
perineum the duct secondary to Mesonephric cyst asymptomatic in women less than 40
Located at the entrance of the vagina at nonspecific inflammation Found near clitoris and unless infected or
5 oclock and 7 oclock or trauma lateral to the hymeneal ring symptomatic
Normally are not palpable Treatment of choice of
Its duct is approximately 2 cm long, symptomatic or infected
and open in a groove between the hymen cases is
and labia minora in the posterior lateral marsupialization
wall of the vagina In women older than 40,
Most common large cyst of the vulva biopsy is performed to
exclude adenocarcinoma
of Bartholins gland

SKENES DUCT Small Secondary to infection Urethral diverticula Discomfort Imaging studies Asymptomatic cyst in
CYST Physical compression of cyst should not and scarring of small premenopausal women
produce fluid from urethral meatus unlike ducts may be managed
urethral diverticula conservatively
Excision with careful
dissection to avoid
urethral injury

EPITHELIAL CYST Located beneath the epidermis

Most commonly discovered on anterior
half of labia majora
Multiple, freely movable, round, slow
growing and non tender
Firm to shotty consistency
Contents are usually under pressure
White or yellow and contents are
caseous like thick cheese
Most common small valvular cyst

GYNECOLOGY: BENIGN GYNECOLOGIC LESIONS SECTION 3-E MEDICINE 2015-2016

 2

EPIDERMAL Epithelial lining of keratinized, stratified May develop following
INCLUSION CYST squamous epithelium with center cellular trauma when an infolding
debris that grossly resembles sebaceous of squamous epithelium
material has occurred beneath the
epidermis in the site of an
episiotomy or obstetric
laceration
Fibromas Asymptomatic unless No treatment
Lipomas secondarily infected If becomes infected heat
Hidradenomas is applied locally and I &
D
If recurrently infected or
produce pain should be
excised when acute
inflammation subsided

NEVUS Commonly referred as a mole, is a These undifferentiated Hemangioma Generally asymptomatic Ideally all vulvar nevi Excision
localized nest or cluster of melanocytes cells arise from the Endometriosis Most women do not should be excised and Removal may be
Vulvar nevi are one of the most common embryonic neural crest Malignant melanoma closely inspect their examined histologically accomplished with
benign neoplasm in female and are present from birth Vullvar intraepithelial neoplasia vulvar skin and are Special emphasis local anesthesia or
Many are not recognized until they Seborrheic keratosis unaware of biologic should be directed coincidentally with
become pigmented at the time of puberty changes in gross toward flat junctional obstetric deliver or
Exhibit a wide range in depth of color, appearance of these nevus and the dysplastic gynecologic surgery
from blue to dark brown to black, and lesions. nevus for they have the Proper excisional
some may be amenalotic greatest potential for biopsy should be 3
Diameter of most nevi ranges from a few malignancy dimensional and
mm to 2 cm LIFETIME RISK FOR adequate in width and
Grossly, a benign may be flat, elevated MALIGNANCY: depth.
or pedunculated Congenital nevus >2 cm Approximately 5 to 10
Histologically, the lesions are subdivided in diameter: 10% mm of normal skin
into 3 major groups: Dysplastic nevi: 15x that surrounding the nevus
1. Junctional of general population should be included
2. Compound Dysplastic nevi is and the biopsy should
3. Intradermal nevi described as more than include the underlying
5-10% of all malignant melanoma in 5mm in diameter, with dermis as well.
women arise from the vulvar area. irregular borders and Nevi that are raised or
Speculation includes that junctional patches of variegated contain hair rarely
activity is common in vulvar nevi and the pigment undergo malignant
many irritants to which the skin is Recent changes in change
exposed may lead to malignancy growth or color, However, if they are
ulceration, bleeding, frequently irritated or
The majority of women who develop
pain or the development bleed spontaneously,
melanomas are in their 50s
of satellite lesions they should be
Family history of melanoma is one of the
mandate biopsy removed
strongest risk factors for the disease
The characteristic
clinical features of an
early malignant
melanoma may be
remembered by thinking
ABCD: asymmetry,
border irregularity, color
variegation and a
diameter usually greater
than 6 mm

GYNECOLOGY: BENIGN GYNECOLOGIC LESIONS SECTION 3-E MEDICINE 2015-2016

 3

HEMANGIOMA Vulvar hemangioma frequently are Rare malformations of Angiokeratorma ddx: Kaposis Diagnosis is usually -asymptomatic
discovered initially during childhood. blood vessels rather than sarcoma and angiosarcom established by gross hemangiomas and
Usually single, 1 to 2 cm in diameter, flat, true neoplasms Pyogenic granuloma ddx: inspection of the hemangiomas in children
soft and they range in color from brown malignant melanoma, basal cell vascular lesion. rarely require therapy.
to red or purple. carcinomas, vulvar condylomas When the differential -in adults, initial treatment of
Histologically, the multiple channels of or nevi diagnosis is large symptomatic
hemangiomas are predominantly thin- questionable, excisional hemangiomas that are
walled capillaries arranged randomly and biopsy should be bleeding or infected may
separated by thin connective tissue performed require subtotal resection.
septa. Venous malformation: -a hemangioma that is
These tumors change in size with venography and Doppler associated with troublesome
compression and are not encapsulated ultrasound bleeding may be destroyed
5 different types of vulvar Hemangiomas. by cryosurgery or use of an
1. Strawberry Hemangioma- usually argon laser.
bright red to dark red, elevated and -cryosurgical treatment
rarely increases in size after age 2 involves a single freeze/
2. Cavernous Hemangiomas- usually thaw cycle repeated 3 times
purple in color and vary in size, with at monthly intervals.
the larger lesions extending deeply into -obviously, if the histologic
the subcutaneous tissue diagnosis is questionable,
These hemangiomas initially any bleeding vulvar mass
appear during the first few should be treated by
months of life and may increase excisional biopsy so that the
in size until age 2 definitive diagnosis can be
Cavernous and strawberry established.
hemangiomas are congenital -surgical removal of a large,
defects discovered in young cavernous hemangioma
children may be technically quite
Spontaneous resolution difficult.
generally occurs before age 6
3. Senile or cherry angiomas: common Venous malformation:
small lesions that arise on the labia sclerotherapy
majora, usually in postmenopausal
women. They are most often less than
3 mm in diameter, multiple, and red-
brown to dark blue.
4. Angiokeratomas: approximately twice
the size of cherry angiomas, are purple
or dark red, and occur in women
between the ages of 30 and 50. They
are noted for their rapid growth and
tendency to bleed during strenuous
exercise.
5. Pyogenic granulomas are an
overgrowth of inflamed granulation
tissue. These lesion grow under the
hormonal influence of pregnancy.
approximately 1 cm in diameter
Another rare malformation is the vulvar
venous malformation
Become symptomatic at any age
and are relatively prone to
thrombosis
Different from vulvar varicosities,
which are exacerbated with
pregnancy and tend to regress
postpartum

GYNECOLOGY: BENIGN GYNECOLOGIC LESIONS SECTION 3-E MEDICINE 2015-2016

 4

FIBROMA Most common benign solid tumor of Treatment is operative

the vulva, commonly found in the labia removal
majora
Slow growing but may attain gigantic
proportion
Have a low-grade potential for becoming
malignant

LIPOMA Second most frequent benign vulvar Tumors of fat cells arising Fibroma Unless extremely large, Excision is usually Small lipomas are just
mesenchymal tumor from the subcutaneous Lipomas are softer and lipomas do not produce performed to establish the followed conservatively
Slow-growing, with very low malignant tissue of the vulva larger than fibromas symptoms diagnosis
potential Histologically, lipomas are
Majority in the vulvar area (superficial usually more homogeneous
labia majora) because of fat distribution than fibromas
Usually <3cm

HIDRADENOMA Location: inner surface of the labia Lesions from apocrine Pyogenic granuloma Generally asymptomatic Histopathology Excisional biopsy is the
majora and nearby perineum sweat glands Adenocarcinoma because of its Pruritus or bleeding if the treatment of choice
Discovered exclusively in white women Some originate from hyperplastic adenomatous tumor undergoes necrosis
(30-70y/o); most commonly in the fourth eccrine sweat glands pattern, a hidradenoma may be
decade of life mistaken at first glance for an
Well defined and usually sessile, pinkish adenocarcinoma
gray nodules not larger than 2 cm in
diameter
Usually surface epithelium is white, but
occasionally necrosis of a central
indented area occurs, with a protrusion of
reddish-brown granulation tissue
Review by Woodworth and colleagues
55% cystic; may also be solid
38% labia majora
26% labia minora
50% are <1cm

SYRINGOMA Very rare, cystic, benign tumor Adenoma of the eccrine Most common ddx is Fox Asymptomatic Treated by excisional
Small subcutaneous papules sweat glands Fordyce disease, a condition of biopsy or cryosurgery
< 5 mm in diameter; skin colored or multiple retention cysts of
yellow and that may coalesce apocrine glands accompanied
Usually located in the labia majora by inflammation of the skin; very
pruritic and is treated by oral or
topical estrogens and topical
retinoic acid

ENDOMETRIOSIS Firm, small nodule or nodules may be May be secondary to Vulvar adenosis may appear Symptoms do not appear Wide excision or laser
cystic or solid and vary from a few metaplasia, retrograde similar to endometriosis that for many months following vaporization depending
millimeters to several centimeters in lymphatic spread, or occurs after laser therapy of implantation on the size of the mass
diameter potential implantation of condylomata acuminata The most common Recurrences are
The subcutaneous lesions are blue, red, endometrial tissue during symptoms of common following
or purple, depending on their size, operation; associated with endometriosis of the vulva inadequate operative
activity, and closeness to the surface of prophylactic postpartum are pain and introital removal of all the
the skin curettage of the uterus to dyspareunia involved area
The gross and microscopic pathologic prevent postpartum The classic history is cyclic
picture of vulvar endometriosis is similar bleeding discomfort and an
to endometriosis of the pelvis enlargement of the mass
Endometriosis of the vulva is usually associated with menstrual
found at the site of an old, healed periods
obstetric laceration, episiotomy site, an
area of operative removal of a Bartholins
duct cyst, or along the canal of Nuck

GYNECOLOGY: BENIGN GYNECOLOGIC LESIONS SECTION 3-E MEDICINE 2015-2016

 5

GRANULAR Rare, slow-growing, solid vulvar tumor
MYELO- These tumors are found in connective
BLASTOMA tissues throughout the body, most
commonly in the tongue, and occur in any
age group
Usually located in the labia majora but
occasionally involve the clitoris.
The tumor originates from The tumor nodules are
neural sheath (Schwann) painless. These tumors
cells and sometimes called are subcutaneous
a schwannoma nodules, usually 1 to 5 cm
in diameter
They are benign but
characteristically infiltrate
the surrounding local
tissue
The tumors are slow
growing, but as they grow,
they may cause
ulcerations in the skin
The overlying skin often
has hyperplastic changes
that may look similar to
invasive squamous cell
carcinoma
Grossly, these tumors are
not encapsulated
The cut surface of the
tumor is yellow
Histologically,there are
irregularly arranged
bundles of large, round
cells with indistinct borders
and pink-staining
cytoplasm
Wide excision to remove
the filamentous projections
into the surrounding tissue
If the initial excisional
biopsy is not adequate and
aggressive enough, these
benign tumors tend to
recur
Recurrence occurs in
approximately one in five
of these vulvar tumors
The appropriate therapy is
a second operation with
wider margins, as these
tumors are not
radiosensitive.

HEMATOMA Usually venous in origin Secondary to blunt trauma Endoscopy to rule out Conservative unless
Small hematomaas regress in time such as straddle injury from urinary bladder and hematoma > 10cm or
fall, automobile accident or rectosigmoid rapidly expanding
physical assult Compression
Spontaneous hematoma- Ice pack
rare; rupture of varicose Surgery- ligate damaged
vein during pregnancy or vessel
postpartum period Chronic expanding
Repetitive episodes of hematoma- drainage and
bleeding from capillaries in debridement
the granulation tissue of the
hematoma resulting to
chronic, slowly epanding
valvular mass

DERMATOLOGIC
DESCRIPTION CAUSE DIFFERENTIAL DIAGNOSIS SIGNS AND SYMPTOMS DIAGNOSTIC TESTS TREATMENT

PRURITUS Single most common gynecologic Skin infections Intense itching with an Treating offending cause
problem STD associated desire to Improving hygiene
Itch scratch cycle must be interrupted Specifiic dermatoses scratch and rub the area
before the condition becomes chronic Valvular dystrophies Secondary valvular pain
resulting to lichenification of the skin Lichen sclerosus Repetitive itch scratch
(lichen simplex chronicus) Premalignat and malignant cycle- producing
Latter process the skin becomes white, disease excoriation and healing
thickened and leathery Contact dermatitis
Dry, scaly skin frequently cracks, forms Atrophy
fissures and becomes secondarily Diabetes
infected Drug allergies
Vitamin deficiencies
Peidulosis
Scabies
Psychological causes
Leukemia
Uremia

GYNECOLOGY: BENIGN GYNECOLOGIC LESIONS SECTION 3-E MEDICINE 2015-2016


VULVAR PAIN One of the most common gynecologic
SYNDROME problem
Women having had chronic severe pain
during their lifetimes
Chronic pain may be designated as
vulvodynia once the diagnosis of
infection, invasive disease or
inflammation have been excluded
Vulvar pain syndrome is further
subdivided into two categories:
1. Vestibulodynia
2. Dysesthetic vulvodynia.
GYNECOLOGY: BENIGN GYNECOLOGIC LESIONS
Wide spectrum of
symptomatology as well as
causes
6
Neurologic diseases Triad of severe pain to Examination of vulva for Similar to other chronic
Herpes simplex infection touch, localized to the abnormal redness, pain syndromes, tricyclic
Chronic infection vaginal vestibule and erosions, crusting, antidepressants or
Abuse pain syndrome dyspareunia; pain and ulceration, gabapentin have found to
Neoplasia tenderness localized only hypopigmentation be successful.
Contact dermatitis to the vestibule; and mild Cotton swab test to Doses of Gabapentin: 300
Psychogenic causes to moderate erythema identify areas of pain on to 600 mg, given with
Vestibulodynia involves pressure (e.g., vestibule) increasing doses every
the symptom of allodynia, Sensory neurologic week
which is hyperesthesia, a examination for allodynia Biofeedback and behavior
pain that is related to and symmetrical sensation modification therapy
nonpainful stimuli Examination for vaginal For women with
The pain is not present redness, erosions, pallor, vestibulodynia
without stimulation dryness unresponsive to other
Diagnostic maneuver to o Biopsy of specific skin therapies, surgery is
establish the allodynia is to findings for evaluation usually recommended
lightly touch the vulvar by dermatopathologist Vestibulectomy and
vestibule with a cotton- Microscopic evaluation of modified vestibulectomy
tipped applicator. If this vaginal secretions for
produces pain, it is yeast, pH, increased white
consistent with allodynia blood cells
Erythema is not always Culture for candida
present, but when present, (exclusive of C.albicans)
is confined to the vulvar and bacteria (especially
vestibule group B Streptococcus)
Patients with o Evaluation for
vestibulodynia experience depression and
intolerance to pressure in impact on quality of
the vulvar region life
Intolerance to pressure Classification of vulvar
may be caused by tampon vestibulitis syndrome or
use, sexual activity, or tight dysesthetic vulvodynia
clothing
Pain is described as raw
and burning. It is not a
spontaneous pain; it is
invoked. However, it is
severe in nature.
Symptoms may appear
around the time of first
inter-course, or within the
next 5 to 15 years
Vulvar dysesthesia/
vulvodynia is a non
localized pain that is
constant (not provoked by
touch), mimicking a
neuralgia
Women with vulvodynia
are more often
perimenopausal or
postmenopausal
Dyspareunia is currently
present, but has usually
not been present prior to
the development of
dysesthesia
SECTION 3-E MEDICINE 2015-2016
 7

CONTACT Vulvar skin especially the intertriginous
DERMATITIS areas, is a frequent site of contact
dermatitis
Two basic pathophysiologic processes:
1. Primary irritant
(nonimmunologic)- irritants
produce immediate symptoms
such as a stinging and burning
sensation when applied to the
vulvar skin, disappears within
12 hours of discontinuing the
offending substance
2. Definite allergic
(immunologic) origin- allergic
contact dermatitis requires 36 to
48 hours to manifest its
symptoms, and persists for
several days despite removal of
the allerge
History of atopy or eczema are more
prone to contact dermatitis and tend to be
more sensitive to skin irritations
Urine and feces Red, edematous,
Rarely, some will be inflamed skin, weeping
allergic to latex or semen and eczematoid
Cosmetic or therapeutic Most severe skin
agents reactions are from
Most severe cases involve vesicles, may become
lesions of the vulvar skin secondarily infected
secondary to poison ivy or Common symptoms of
poison oak contact dermatitis:
superficial vulvar
tenderness, burning, and
pruritus
Chronic untreated
contact dermatitis can
evolve into a syndrome of
lichenification. Skin
develops a leathery
appearance and texture,
lichen simplex chronicus
Withdraw the offending
substance
Vulvar skin should be kept
clean and dry
Initial treatment of severe
lesions: wet compresses
of Burows solution
(diluted 1 to 20) for 30
minutes several times a
day
o Use of
lubricating agent
such as
petroleum jelly or
Eucerin cream to
reduce the
pruritus by
rehydrating the
skin
Cotton undergarments
that allow the vulvar skin
to aerate should be worn
Avoid constrictive,
occlusive, or tight-fitting
clothing such as
pantyhose
Treatment of poison ivy
and poison oak: Synthetic
systemic corticosteroids
(prednisone, starting with
50 mg/day for 7 to 10
days in a decreasing
dose)
Antipruritic medications,
such as antihistamines,
are not of great
therapeutic benefit except
as soporific agents

PSORIASIS Vulvar psoriasis usually affects 25% of affected women Candidiasis Persistent itchy redness For mild disease: 1%
intertriginous areas have family history of the Seborrheic dermatitis on the vulva hydrocortisone cream
Manifested by red to red-yellow disease Eczema Soreness of the lesions if For pain secondary to
papules that tend to enlarge and become How to differentiate: margins of scratched or rubbed chronic fissures/moderate
well-circumscribed, dull-red plaques psoriasis are more well-defined against friction disease: 4 week course of
Generally developed during teenage and do not involve the vagina, fluorinated corticosteroid
years only the vulva cream
3% of adult women affected If this treatment is not
20% with involvement of vulvar skin successful, a
Chronic and relapsing disease dermatologist should be
May be the first clinical manifestation of consulted
HIV infection Systemic steroids: often
produce a rebound flare-
up of the disease

GYNECOLOGY: BENIGN GYNECOLOGIC LESIONS SECTION 3-E MEDICINE 2015-2016

 8

SEBORRHEIC Common chronic skin disease of Yeast: Pityrosporum ovale Psoriasis Mild to severe pruritus Hydrocortisone cream:
DERMATITIS unknown origin Attacks precipitated by Cutaneous candidiasis most effective medication
Classically affects the face, scalp, excessive sweating and Contact dermatitis Topical ketoconazole
sternum, and the area behind the ears emotional tension cream: sometimes used
Rarely, affects the mons pubis and vulvar for refractory cases
areas
Vulvar lesions are pale to yellow-red,
erythematous and edematous, and
covered by a fine, non-adherent scale
that is usually oily
2-4% of women have some of the
disease

LICHEN PLANUS Uncommon vulvovaginal dermatosis Autoimmune phenomenon Lichen sclerosis: because of the Pruritus Local lesions: topical
Unique, chronic eruption of shiny, caused by drugs (B- same presentation of a Severe form: pain, steroids (e.g. Clobetasol)
violaceous papules blockers, ACEis, etc.) hypertrophic, coalesced plaque burning, scarring, and Intensely symptomatic:
Tiny flat papules appear on flexor Initial onset usually follows To differentiate: Lichen sclerosis eventually vaginal oral steroids
surfaces, mucous membranes, and a time of intense emotional does not involve the vagina stenosis with loss of Chronic resistant cases:
vulvar skin stress Lichen planus may present as a normal architecture Dapsone
Occur in women >30 years old severe and deforming erosive Women should be
Most are located on the inner aspects of vaginitis that may be mistaken monitored at periodic
the vulva, especially the labia minor and as atrophic vaginitis intervals because of an
vestibule associated risk of
developing vulvar
carcinoma.

BEHCET Women with eastern Mediterranean and Presents as recurrent,
SYNDROME Middle Eastern ancestry are the most painful ulcers and
susceptible to this autoimmune papules on the vulva and
disease oral mucosa, without
other significant
syndromes of
inflammation
The symptoms respond to
topical anesthetics
Severe disease may
require antineoplastic
therapy including
methotrexate, steroids, or
other medications

HIDRADENITIS Chronic, unrelenting, refractory infection Cause of this condition Simple folliculitis As the infection
SUPPURATIVA of skin and subcutaneous tissue that favor an inflammation Crohns disease of the vulva progresses over time,
contains apocrine glands beginning in the hair Pilonidal cysts deep scars and pits are
The disease is rare before puberty; 98% follicles Granulomatous sexually formed
of cases are found in reproductive-age transmitted diseases The patient undergoes
women, and most all disease regresses The differentiation from Crohns great emotional distress
after menopause disease is usually made by as this condition is both
The term sometimes used synonymously history with an absence of painful and is associated
is acne inversa. The lesions involve the gastrointestinal involvement with a foul-smelling
mons pubis, the genitocrural folds, and discharge
the buttocks. The early phase of the
disease involves
infection of the
follicular epithelium,
with what first appears
as a boil
Erythema, involvement of
multiple follicles, chronic
infections that burrow
and form cysts that break
open and track through
subcutaneous tissue
creating odiferous and
painful sinuses and
fistula in the vulva
The chronic
scarring,fibrosis,
hyperpigmentation with
With early disease during
which there are small
furuncles and folliculitis,
topical and oral
clindamycin is effective in
the short term; 3-month
courses of antibiotics
should be given
Patients may relapse
If treatment is
unsuccessful with long-
term antibiotic therapy and
topical steroids, other
medical therapies have
included antiandrogens,
isotretinoin, and
cyclosporine
The treatment of
refractory cases is
aggressive, wide
Operative excision of the
infected skin

GYNECOLOGY: BENIGN GYNECOLOGIC LESIONS SECTION 3-E MEDICINE 2015-2016

 9

foul smelling discharge

and soiling of
underclothes leads to a
socially debilitating
condition

EDEMA Edema of the vulva may be a symptom of Two of the most common Infectious diseases that are
either local or generalized disease causes of edema of the associated with vulvar edema
Vulvar edema is often recognized before vulva are secondary include
edema in other areas of the female body reactions to inflammation Necrotizing fasciitis
is noted or to lymphatic blockage. Tuberculosis
The loose connective tissue of the vulva Systemic causes of vulvar Syphilis
and its dependent position predispose to edema include circulatory Filariasis
early development of pitting edema and renal failure, ascites, Lymphogranuloma
and cirrhosis venereum
Vulvar edema also may
occur after intraperitoneal
fluid is instilled to prevent
adhesions or for dialysis
Local causes of vulvar
edema include allergy,
neurodermatitis,
inflammation, trauma, and
lymphatic obstruction
caused by carcinoma or
infection

VAGINA
DESCRIPTION CAUSE DIFFERENTIAL DIAGNOSIS SIGNS AND SYMPTOMS DIAGNOSTIC TESTS TREATMENT

URETHRAL Permanent, epithelialized, saclike Result from repetitive or Gartners duct cyst Often they present as a Clinical suspicion in Excisional surgery if not
DIVERTICULUM projection that arises from the posterior chronic infections of the Ectopic ureter that empties into mass of the anterior patients with chronic acutely infected
urethra periurethral glands the urethra vaginal wall symptoms of lower urinary Operative techniques:
Small, from 3 mm to 3 cm in diameter Skenes glands cysts Majority of urethral tract infection transurethral and
May be congenital or acquired diverticula open into the Two most common transvaginal approach
Majority of cases are initially diagnosed in midportion of the urethra methods of diagnosing (most preferred)
reproductive-age females Symptoms are extremely urethral diverticulum Simple marsupialization
The peak incidence in the fourth decade chronic in nature and 1. Voiding diverticula of the distal one
of life they have not resolved cystourethrography third
with multiple courses of o 70% of urethral Urinary incontinence and
oral antibiotic therapy diverticula will be filled urethrovaginal fistula
Symptoms of a urethral by contrast material most serious
diverticulum are on a postvoiding consequences of surgical
nonspecific and are radiograph with a repair
identical to the symptoms lateral view Postoperative incontinence
of a lower urinary tract 2. Cystourethroscopy may be secondary to
infection o Demonstrate the damage to urethral
Most common symptoms urethral opening of sphincter following repair
associated with urethral the urethral of large diverticula
diverticula are urinary diverticulum in 6/10
urgency, frequency, cases
and dysuria Other diagnostic tests:
Symptoms also include Urethral pressure
the three Ds: dysuria, profile recordings
dyspareunia, dribbling of Transvaginal
urine ultrasound
Suburethral Diverticulum CT scans
Classic sign: MRI
expression of Positive-pressure
purulent material urethrography

GYNECOLOGY: BENIGN GYNECOLOGIC LESIONS SECTION 3-E MEDICINE 2015-2016

 10

from the urethra o Done with a

after compressing special double-
the suburethral balloon urethral
area during a catheter (Davis
pelvic examination catheter)
specific but with No imaging modality has
poor sensitivity been shown to be superior
to any other
If a woman has a urethral
diverticulum and urinary
incontinence, performing a
stress urethral pressure
profile will help to
differentiate the etiology

INCLUSION CYST Most common cystic structure of the Birth trauma Inclusion cyst of the vagina Majority are aymptomatic Excisional biopsy if it
vagina Gynecologic surgery Sebaceous cyst produces dyspareunia or
Usually discovered at the: Small tag of vaginal pain
o Posterior or lateral walls of the lower epithelium buried beneath
third of the vagina the surface following a
o Site of previous episiotomy or; Gyne or OB procedure
o Apex of the vagina following Misplaced island of
Hysterectomy embryonic remnant that
Vary from 1mm to 3 cm in diameter was destined to form
More common in parous women epithelium
Lined by stratified squamous epithelium
containing a thick, pale yellow substance
that is oily and formed by degenerating
epithelial cells

DYSONTOGENIC Thin-walled, soft cysts of embryonic If a segment of an A large cyst presenting at the Most are asymptomatic, Operative excision for
CYST origin embryonic structure fails introitus may be mistaken for a sausage-shaped tumors chronic symptoms
May arise from the ff: to regress, and the cystocele, anterior enterocele that are discovered Marsupialization in the
o Mesonephros (Gartners Duct Cyst) obrtsucted vestigial or obstructed aberrant ureter incidentally acute phase
Cuboidal, non-ciliated epithelium remnant becomes cystic In a study, dyspareunia,
Anterior lateral wall vaginal pain, urinary
Lower one third of the vagina if symptoms and a palpable
distal portion of the mesonephric mass
duct
o Paramesonephricum (Mullerian
Cyst) - columnar, endocervical-like
epithelium
o Urogneital Sinus (Vestibular Cyst)
Most commonly single, but may be
mutiple that may present like a string of
large, soft beads
1 to 5 cm in diameter

TAMPON Rare associated risks with tampon usage: Pathophysiology of the No clinical symptoms Persistent ulcer should Management is
PROBLEMS Vaginal ulcers ulcer: secondary to drying were associated with be biopsied to establish conservative
The forgotten tampon and pressure necrosis these microscopic the cause Ulcers heal spontaneously
Toxic shock syndrome - toxins induced by the tampon change when the foreign object is
elaborated by Staphylococcus lost or forgotten removed
aureus tampon: foul vaginal Treatment of lost or
Wearing tampons for a few days has discharge and forgotten tampon:
been associated with microscopic occasionally spotting antibiotic vaginal cream
epithelial changes for 5 to 7 days
Majority develop epithelial dehydration
and epithelial layering
Some develop microscopic ulcers
Between 48 hours and 7 days to heal
Microulcerations - a potential portal of

GYNECOLOGY: BENIGN GYNECOLOGIC LESIONS SECTION 3-E MEDICINE 2015-2016

 11

entry for the HIV virus

Large macroscopic ulcers of the vaginal
fornix occur in tampon abusers.
Wearing vaginal tampons for prolonged
lengths of time for persistent vaginal
discharge or spotting
A base of clean granulation tissue with
smooth, rolled edges
Foreign body fragments in biopsy
specimens (fibers from tampons)

LOCAL TRAUMA Predisposing factors: MC cause of trauma to the Secondary injury to the urinary Most prominent History taking Prompt suturing under
Virginity lower genital tract of adult and gastrointestinal tracts symptom: profuse or Often the history of the adequate anesthesia
State of the postpartum and females is coitus should be ruled out prolonged vaginal coital injury is not
postmenopausal vaginal epithelium 80% of vaginal lacerations - bleeding obtained or woman may
Pregnancy secondary to sexual Sharp pain during even give misleading
Intercourse after a prolonged period intercourse intercourse information
of abstinence Other causes: Persistent abdominal Coital injury to the vagina
Hysterectomy Straddle injuries pain should be considered in
Inebriation Penetration injuries by The most troublesome any woman with profuse
MC injury is a transverse tear of the foreign objects complication: vaginal or prolonged abnormal
posterior fornix Sexual assault evisceration vaginal bleeding
Similar linear lacerations often occur in Vaginismus Sensitive but thorough
the right or left vaginal fornices Waterskiing accidents history regarding abuse is
The location of the coital injury is believed always appropriate
to be related to the poor support of the
upper vagina, which is supported only by
a thin layer of connective tissue

CERVIX
DESCRIPTION CAUSE DIFFERENTIAL DIAGNOSIS SIGNS AND SYMPTOMS DIAGNOSTIC TESTS TREATMENT

ENDOCERVICAL & MC benign neoplastic growths of Secondary to inflammation Endometrial polyps, small Classic symptom of Polypectomy
CERVICAL POLYP cervix or abnormal focal prolapsed myomas, retained intermenstrual bleeding If base is broad/bleeding
6 histologic types: responsiveness to products of conception, especially following coitus is present, may do
1. Adenomatous (80%) hormonal stimulation ---> squamous papilloma, sarcoma, or pelvic exam chemical cautery,
2. Cystic focal hyperplasia and and cervical malignancy electrocautery or
3. Fibrous proliferation cryocautery after
4. Vascular Color depends on origin removing the polyps
5. Inflammatory
6. Fibromyomatous
Endocervical: more common
o Base is narrow, long pedicle,
cherry red
o Occur during reproductive years
esp. multiparous women of ages
40-50
Cervical (Ectocervical):
o Base is broad, short pedicle,
grayish white
o Occur in postmenopausal
women, usually as single polyp

NABOTHIAN CYST Retention cysts of endocervical columnar
cells
Grossly transluscent/opaque, whitish or
yellow, usually multiple micro-macro size
3mm-3cm
Occurring where a tunnel or Very common, considered as a Asymptomatic No treatment is necessary
cleft has been covered by normal feature of adult cervix
squamous metaplasia
(transformation zone)

GYNECOLOGY: BENIGN GYNECOLOGIC LESIONS SECTION 3-E MEDICINE 2015-2016

 12

LACERATIONS Obstetric lacerations vary from minor Frequently occur with both
superficial tears to extensive full normal and abnormal
thickness lacerations at 3 and 9 oclock, deliveries
respectively, which may extend into the May occur in nonpregnant
broad ligament Women with mechanical
Extensive cervical lacerations, especially dilation of the cervix
those involving the endocervical stroma, Atrophic cervix of the
may lead to incompetence of the cervix postmenopausal woman
during a subsequent pregnancy predisposes to the
complication of cervical
laceration when the cervix
is mechanically dilated for a
diagnostic D&C
Lacerations that are not Practice of routine
repaired may give the
external os of
Cervix a fish-mouthed
appearance; however,
they are usually
asymptomatic
Acute cervical lacerations
inspection of the cervix,
stabilized with one or
more ring forceps,
following every second-
or third-trimester delivery
Lacerations should be
palpated to determine the
extent of cephalad
extension of the tear
bleed and should be
sutured
The use of laminaria tents
to slowly soften and dilate
the cervix before
mechanical
instrumentation of the
endometrial cavity has
reduced the magnitude of
iatrogenic cervical
lacerations

CERVICAL MYOMA Smooth, firm masses that are similar to Majority of myomas that Most cervical myomas Diagnosis of a cervical Asymptomatic, small
myomas of the fundus appear to be cervical are small and myoma is by inspection myomas may be
Is usually a solitary growth in contrast to actually arise from the asymptomatic and palpation observed for rate of
uterine myomas, which in general, are isthmus of the uterus When symptoms do Grossly and growth
multiple occur, they are histologically, cervical Occurrence and
dependent on the myomas are identical to persistence of
direction in which the and indistinguishable symptoms from a cervical
enlarging myoma from myomas of the myoma are an indication
expands corpus of the uterus for medical therapy:
Cervical myomas may Vascular leiomyoma- GnRH agonists or
produce dysuria, subtype of cervical myomectomy or
urgency, urethral or myoma that will hysterectomy, depending
ureteral obstruction, demonstrate many on the patients age and
dyspareunia, or hyalinized, thick-walled future reproductive plans
obstruction of the cervix blood vessels that are May be treated by
Occasionally may postulated to be the radiologic catheter
become pedunculated source of the neoplastic embolization
and protrude through the smooth muscle tumor
external os of the cervix-
ulcerated and infected
A very large cervical
myoma may produce
distortion of the cervical
canal and upper vagina
Rarely, a cervical myoma
causes dystocia during
childbirth

CERVICAL Most often occurs in the region of the Causes of acquired cervical
STENOSIS internal os stenosis are operative,
May be divided into congenital or radiation, infection,
acquired types neoplasia, or atrophic
changes
Cone biopsy and cautery of
the cervix, either
electrocautery or
cryocoagulation, are the
operations that most
commonly cause cervical
stenosis
Symptoms depend on Diagnosis is established
whether the patient is
premenopausal or
postmenopausal and
whether the obstruction is
complete or partial
Common symptoms in
premenopausal women
include dysmenorrhea,
pelvic pain, abnormal
bleeding, amenorrhea,
and infertility
Postmenopausal women
are usually asymptomatic
for a long time
Slowly they develop a
hematometra (blood),
hydrometra (clear fluid),
or pyometra (exudate)
Management of cervical
by inability to introduce a
1- to
2-mm dilator into the
uterine cavity
stenosis is dilation of the
cervix with dilators under
ultrasound guidance
Prevention: Peri- and
postoperative treatment
with vaginal or systemic
estrogen
Stenosis recurs: monthly
laminaria tents may be
used
After cervical dilation, it is
often useful to leave a T
tube or latex
nasopharyngeal airway as
a stent in the cervical
canal for a few days to
maintain patency

GYNECOLOGY: BENIGN GYNECOLOGIC LESIONS SECTION 3-E MEDICINE 2015-2016

 13

UTERUS
DESCRIPTION CAUSE DIFFERENTIAL DIAGNOSIS SIGNS AND SYMPTOMS DIAGNOSTIC TESTS TREATMENT

ENDOMETRIAL Localized overgrowths of endometrial Cause is unknown Submucous leiomyoma Majority are Diagnosis is not usually Optimal management of
POLYP gland and stroma projecting beyond the Because polyps are often Adenomyoma asymptomatic established until the endometrial polyp is
endometrial surface of the endometrium associated with Retained products of Those that are uterus is open following removal by
Peak incidence between age 40-49 endometrial hyperplasia, contraception symptomatic are hysterectomy for other HYSTEROSCOPY with
They may be soft, pliable, and may be unopposed estrogen may Endometrial hyperplasia associated with abnormal reasons D&C
single or multiple be one cause Endometrial carcinoma bleeding patterns Endometrial polyps may
They may have broad base (sessile) or Uterine sarcoma Sometimes large be discovered by vaginal
be attached by a slender pedicle endometrial polyp may ultrasound
(pedunculated) contribute to infertility
Mostly arise from the fundus of the
uterus
Polyploidy hyperplasia- is a benign
condition in which numerous small polyps
are discovered throughout the
endometrial cavity
Three histological components:
1. Endometrial glands
2. Endometrial stroma
3. Central vascular channels
Malignant transformation is estimated at
0.5%

HEMATOMETRA Uterus distended with blood secondary to 2 most common congenital Primary or secondary Generally suspected by Depends on operative
gynatresia (partial or complete causes: amenorrhea the history of amenorrhea relief of lower tract
obstruction of any portion of the Lower 1. Imperforate hymen Possible cyclic lower and cyclic abdominal pain obstruction
Genital Tract) 2. Transverse vaginal abdominal pain Confirmed by: Vaginal
septum Possibility of of ultrasound or probing the
Acquired Causes: secondary infection cervix with a narrow
1. Senile atrophy of producing pyometra. metal dilator with release
cervical canal & o Pelvic Exam: Mildly of dark brownish black
endometrium tender, globular blood from the
2. Scarring of the isthmus uterus is usually endocervical canal
by synechiae palpated Foul odor
3. Cervical stenosis
associated with
surgery, radiation
therapy, cryocautery,
electrocautery,
endometrial ablation &
malignant disease of
the endocervical gland

LEIOMYOMA Also called myomas, are benign tumors Origin of uterine Pregnancy Acute muscular infarction Confirmed by physical Judicious observation for
of muscle cell origin leiomyomas is incompletely Adenomyosis causes severe pain and examination small, asymptomatic
Often referred to by their popular names, understood, but cytogenetic Ovarian neoplasm localized peritoneal Ultrasound is diagnostic myomas
fibroids or fibromyomas analysis has demonstrated irritation Submucosal myomas Majority of women will not
Contain varying amounts of fibrous tissue that myomas have multiple Most common symptoms may be diagnosed by need an operation
Most frequent pelvic tumors and the most chromosomal abnormalities related to myomas are vaginal ultrasound, Myomectomy and
common tumor in women Theory: neoplastic pressure from an hysteroscopy or hysterectomy is usually
Occurring during the fifth decade transformation is the result enlarging pelvic mass, occasionally as a filling determined by the
More common in African-american and of a somatic mutation in the pain including defect on patients age, parity, and
white women single progenitor cell dysmenorrhea, and hysterosalpingography most im- portant, future
30% to 50% of perimenopausal women causing atrophy and abnormal uterine Abdominopelvic reproductive plans
More prone to grow and become fibrosis secondary to bleeding (most common radiograph will note (hysterectomy has higher
symptomatic in nulliparous women degeneration of some of symptom is menorrhagia) concentric calcifications satisfaction rate but more
Majority are found in the corpus of the the smooth muscle cells Severity of symptoms is CT and MRI can urinary tract injuries
Risk factors associated with usually related to the distinguish between Indications for a

GYNECOLOGY: BENIGN GYNECOLOGIC LESIONS SECTION 3-E MEDICINE 2015-2016

 14

uterus the development of number, location, and benign and malignant myomectomy include
May be single but most often are multiple myomata include size of the myomas myomas persistent abnormal
Vary in size from microscopic to increasing age, early Over two thirds of women Serial ultrasound bleeding, pain or
multinodular uterine tumors that may menarche, low parity, with uterine myomas are examinations have been pressure, or enlargement
weigh more than 50 pounds tamoxifen use, obesity, and asymptomatic used to evaluate of an asymptomatic
Initially most myomas develop from the in some studies a high-fat One of three women with progression in size of myoma to more than 8 cm
myometrium, beginning as intramural diet (Women who smoke myomas experiences myomas or response to in a woman who has not
myomas, grows and attached in a pedicle cigarettes and are thus pelvic pain or pressure. therapy completed childbearing
Forms a pseudocapsule, no true capsule relatively estrogen-deficient May produce urinary Contraindications to a
Three most common types of myomas have a lower incidence) frequency and urgency myomectomy include
and parasitic myoma Increase in estrogen and May produce a unilateral pregnancy, advanced
1. Intramural- progesterone enlarges or bilateral hydroureter adnexal disease,
2. Subserous- just beneath the myomas malignancy, and the
serosa, give the uterus its knobby situation in which
contour, become a parasitic enucleation of the myoma
myoma not possible
3. Submucosal- with special Indications for
nomenclature for broad ligament, hysterectomy for myomas
located just below the are similar to indications
endometrium, usually are the for myomectomy plus
most troublesome clinically; when the uterus has
associated with abnormal vaginal reached the size of a 14-
bleeding or distortion of the to 16-week gestation and
uterine cavity that may produce rapid growth of a myoma
infertility or abortion; Rarely, after the menopause
enlarges and becomes Medically by reducing the
pedunculated. circulating level of
Large, broad ligament myomas may estrogen and
produce a hydroureter progesterone. GnRH
Both estrogen and progesterone agonists,
receptors are found in higher medroxyprogesterone
concentrations acetate (Depo-Provera),
Often enlarge during pregnancy and danazol, aroma- tase
OCP, reduced in menopause inhibitors, and the
Grossly, a myoma has a lighter color than antiprogesterone RU 486
the normal myometrium, the tumor has a have undergone clinical
glistening pearl-white appearance with trials
the smooth muscle arranged in a Uterine myomas may also
trabeculated or whorled configuration be treated with uterine
when cut artery embolization (UAE)
Histologically, proliferation of mature Acute muscular infarction:
smooth muscle cells. The nonstriated best treated with
muscle fibers are arranged in interlacing nonsteroidal anti-
bundles inflammatory agents for
Cellular leiomyomata - exhibit 72 hours, as long as the
hypercellularity woman is less than 32
More collagen, described as a stiffer weeks gestation
cytoskeleton During pregnancy this
Fate of some myomas is determined by complication should be
their relatively poor vascular supply treated medically
Severity of the discrepancy between the If the patient is not
myomas growth and its blood supply pregnant, acute
determines the extent of de generation: degeneration is not a
hyaline, myxomatous, calcific, cystic, contraindication to
fatty, or red degeneration and necrosis myomectomy
Mildest form of degeneration of a myoma If menopausal, total
is hyaline degeneration abdominal hysterectomy
Most acute form of degeneration is red,
or carneous, infarction

GYNECOLOGY: BENIGN GYNECOLOGIC LESIONS SECTION 3-E MEDICINE 2015-2016

 15

ADENOMYOSIS Often referred as endometriosis interna Pathogenesis: Unknown Uterine myoma Over 50% are Pelvic exam: uterus is NO satisfactory medical
Presence of endometrial glands and Theories: Uterine leiomyoma asymptomatic diffusely enlarged, management
stroma within the myometrium more than 1. Disruption of the of the Symptomatic cases are globular, usually 2-3 x o GnRH agonist
one low power field (2.5 mm) from the barrier between the between the ages of 35 normal size o Cyclic hormones
basalis layer endometrium endometrium and and 50 o Diagnosis is o Prostaglandin
Derived from the aberrant glands of the myometrium Classic Symptoms: confirmed following synthetase
basalis layer of the endometrium 2.Trauma to the Secondary histologic Hysterectomy is the
endometrial-myometrial dysmenorrhea examination of definitive treatment
interface Menorrhagia hysterectomy o Factors to consider:
specimen o Age
Ultrasonography o Parity
o Sensitivity: 53-89% o Reproductive plans
o Specificity: 50-89% o Uterine size
MRI o Presence of
o Sensitivity:88-93% associated pelvic
o Specificity: 66-91% pathology

OVIDUCT
DESCRIPTION CAUSE DIFFERENTIAL DIAGNOSIS SIGNS AND SYMPTOMS DIAGNOSTIC TESTS TREATMENT

LEIOMYOMA Usually discovered in the interstitial Asymptomatic Bimanual palpation - Excision if symptomatic
portion of the tubes Rarely, undergo acute smooth, firm, mobile,
Usually coexist with uterine leiomyomas degeneration or usually non -tender
May be subserosal, interstitial, or associated with unilateral masses
submucosal tubal obstruction or Laproscopy - spherical
torsion mass that protrudes from
beneath the peritoneal
surface

ADENOMATOID Angiomyoma Asymptomatic Frozen section often

TUMOR Most prevalent benign tumor of the mistaken for a low-grade
oviduct; do not become malignant neoplasm
Usually unilateral and present as small Histology - small tubules
nodules just under the tubal serosa lined by a low cuboidal or
flat epithelium; thin-
walled channels that
comprise these tumors
are of mesothelial origin

PARATUBAL CYST Frequently incidental From the mesonephric Hydatid cysts of Morgagni Asymptomatic, if not they Pelvic examination - Simple excision
Small, slow growing and discovered duct, with the cysts arising called such if pedunculated and generally produce a dull difficult to distinguish a Aspiration - limited to
during the third and fourth decades of life from the main duct or near the fimbrial end of the pain from an ovarian mass cysts that are completely
May grow rapidly during pregnancy can accessory tubules oviduct simple and associated
lead to torsion with normal cancer
antigen-125 (CA-125)
levels

GYNECOLOGY: BENIGN GYNECOLOGIC LESIONS SECTION 3-E MEDICINE 2015-2016

 16

TORSION Right tube is involved more frequently Secondary to an ovarian Appendicitis Acute lower abdominal Vaginal ultrasound Excise- if gangrenous
Can occur from preadolescence to mass Ectopic pregnancy and pelvic pain (usually Exploratory operation- Manual untwisting
women of reproductive age Intrinsic - congenital PID at the iliac fossa radiating determines the extent of Suture into a secure
abnormalities such as Rupture of torsion of an ovarian to the right and flank) hypoxia and the choice of position to prevent
increased tortuosity cyst May be acute or gradual operative techniques recurrence
caused by excessive Duration <48 hours
length of the tube and
pathologic processes such
as hydrosalpinx,
hematosalpinx, tubal
neoplasms, and previous
operation, especially tubal
ligation
Extrinsic - ovarian and
peritubal tumors,
adhesions, trauma, and
pregnancy

OVARY
DESCRIPTION CAUSE DIFFERENTIAL DIAGNOSIS SIGNS AND SYMPTOMS DIAGNOSTIC TESTS TREATMENT

FOLLICULAR CYST Most frequent cystic structures in normal Arise from dominant ovarian neoplasm Most are asymptomatic Discovered during Observation- initial
ovaries of young menstruating woman mature follicles failure to May experience ultrasound imaging of management
Translucent, thin-walled filled with watery, rupture (persistent follicle) tenesmus, trainsent pelvic the pelvis or a routine Complex cysts or
clear to straw-colored fluid. and immature follicles tenderness, deep pelvic examination persistent simple cysts
Found as early as 20 weeks gestation in failure to undergo atresia dyspareunia, no pain Endovaginal ultrasound larger than 10 cm should
female fetuses and throughout a Significant intraperioneal o Helpful in be evaluated
womans reproductive life bleeding (rare) differentiating Majority disappear
Frequently multiple and varies a few mm Large cysts- vague, full simple from spontaneously in 4-8
to 15 cm in diameter sensation or heaviness in complex cysts and weeks:
Minimum diameter to be considered a the pelvis is also helpful o Reabsorption of cyst
cyst = 2.5-3.0cm during conservative fluid
Not neoplastic,dependent on management by o Silent rupture
gonadotropins for growth providing OCPs -prescribed for 4-6
Situated in the ovarian cortex, and dimensions to wks for young women w/
sometimes they appear as translucent determine if the adnexal masses
domes on the surface of the ovary. cyst is increasing in Cystectomy- for persistent
Usually composed of a closely packed size ovarian masse
layer of round, plump granulosa cells, Characteristics of Strict preoperative criteria
with the spindle-shaped cells of the theca ovarian masses should be fulfilled before
interna deeper in the stroma correlate with laparoscopy:
Occasionally, follicular cysts are better malignancy: o Womans age
termed follicular hematomas, because o Septations o Size of the mass
blood from the vascular theca zone fills o Thickness of o Ultrasound
the cavity of the cyst septations characteristics, such
o Internal papillations as nonadherent,
(echogenic smooth, and thin-
structures walled cysts, with- out
protruding into the papillae or internal
mass) echoes (simple)
o Loculations Cyst should be removed if
o Solid lesions there is any suspicion of

GYNECOLOGY: BENIGN GYNECOLOGIC LESIONS SECTION 3-E MEDICINE 2015-2016

 17

o Cystic lesions with malignancy:

solid components o Family history
o Smaller cysts o Patient age
adjacent to or part o Other non-gynecologic
of the wall of the signs and symptoms
larger cyst Pregnant women- if the
daughter cysts cyst is simple with a normal
o Bilaterality CA-125, conservative
o Free fluid in the cul management is acceptable
de sac (CA-125 is generally not
o When the diameter obtained in pregnant
of the cyst remains women with cysts less than
stable for >10 5 cm if they are simple)
weeks or enlarges, Perimenopausal or
a neoplasia should postmenopausal woman-
be ruled out removed if it is anything
CA-125 other than a simple cyst, if
o Large solitary the CA- 125 is abnormal
follicular cysts in (>35), or if the cyst is
which the lining is persistent or large (>10
luteinized are cm)
occasionally A small simple cyst in a
discovered during perimenopausal or
pregnancy and the postmenpausal woman (<5
puerperium cm) with a normal CA-125
o Used to evaluate may be observed with
such cysts in regular reevaluation
pregnancy including ultrasound
o CA-125 should be
within the normal
range past 12
weeks gestation
o Helpful in
evaluating the
adenexal mass in
postmenopausal
women
o In premenopausal
women, rarely
helpful unless the
mass is extremely
suggestive of
malignancy.
Color flow Doppler
o Measurement of
diastolic and
systolic velocities
provide indirect
indices of vascular
resistance
o Muscular arteries
have high
resistance
o Newly developed
vessels, such as
those arising in
malignancies, have
little vascular wall
musculature and
thus have low
resistance
o Usually displays
shades of red and
blue delineating

GYNECOLOGY: BENIGN GYNECOLOGIC LESIONS SECTION 3-E MEDICINE 2015-2016

 18

blood flow within a

neoplasm
o Benign ovarian
lesions have little
color flow
o Low resistance is
associated with
malignancy, and
high resistance
usually is asso-
ciated with normal
tissue or benign
disease.
Cytologic examination of
cyst fluid has poor
predictive value and
poor sensitivity in
differentiating benign
from malignant cysts

CORPUS LUTEUM Corpora lutea that is atleast 3 cm in Ectopic Pregnancy Vary from asymptomatic Cystectomy
CYST diameter Adnexal torsion masses to causing
Corporea lutea develop from graafian Ruptured endometrioma catastrophic and massive
follicles intraperitoneal bleeding

THECA LUTEIN Least common of the three types of Prolonged or excessive Corpus luteum cysts Smaller cyst: mostly Presence of theca- CONSERVATIVE, often
CYST physiologic ovarian cysts. ovarian stimualtion of asymptomatic lutein cysts is regress gradually
Almost always bilateral exogenous or Larger cyst: produce established by
Produces moderate to massively endogenous or increased vague symptoms such as palpation and often
enlargement of the ovaries. ovarian sensitivity to pelvic pressure, ascites, confirmed by
HYPERREACTIO LUTEINALIS- ovarian GONADOTROPIN increasing abdominal ultrasound
enlargement secondary to the girth examination.
development of multiple follicular cysts Complication includes
intraperitoneal bleeding
or torsion

BENIGN CYSTIC Cystic structures that contain elements
TERATOMA from all three germ cell layers
Teratomas may be benign
(dermoid/mature) or malignant
(immature)
Dermoid pertains to the preponderance
of ectodermal derivatives
Benign teratomas may have a malignant
component
90% of GCT of the ovary
Believed to arise from a Any gross ovarian mass can be
single germ cell after
meiosis I
Neoplastic sequelae of a
transformed germ cell
Alternatively believed to
have arisen from second
polar body fusion
50-60% are asymptomatic
a differential of benign cystic Pain, sensation of pelvic
teratomas pressure
Peritonitis if teratoma is Complications include:
perforated torsion, rupture, infection,
hemorrhage and
malignant degeneration
Associated diseases
include thyrotoxicosis,
carcinoid syndrome and
struma ovarii
Found incidentally at Cystectomy
laparotomy as a Laparoscopic cystectomy
semisolid mass In pregnancy, masses <10
palpated anterior to the cm are treated
broad ligament conservatively
Pelvic calcifications may Adequate irrigation is
be visible on X ray needed in cases of rupture
UTZ

ENDOMETRIOMAS Areas of ovarian endometriosis that Approximately two out of Most authors do not classify
become cystic are termed three women with
endometriomas endometriosis have
ovarian involvement.
Interestingly, only 5% of
these women have
enlargement of the
ovaries that is detectable
by pelvic examination
However, because of the
prevalence of the disease,
endometriosis is one of
Although most women
endometriosis as a neoplastic
disease, the diagnosis of
endometriosis may not be
given due consideration in the
differential diagnosis of an
adnexal mass. Ovarian
endometriosis is similar to
endometriosis elsewhere
On pelvic examination,
with endometriomas are
asymptomatic, the most
common symptoms
associated with ovarian
endometriosis are pelvic
pain, dyspareunia, and
infertility
The choice between medical
the ovaries are often
tender and immobile,
secondary to associated
inflammation and
adhesions
Endometrial glands,
endometrial stroma, and
large phagocytic cells
containing hemosiderin
may be identified
histologically
and operative management
depends on several factors:
Patients age
Future reproductive plans
Severity of symptoms
Medical therapy is rarely
successful in treating ovarian
endometriosis if the disease
has produced ovarian
enlargement. Often surgical

GYNECOLOGY: BENIGN GYNECOLOGIC LESIONS SECTION 3-E MEDICINE 2015-2016

 19

the most common causes It is important to therapy is complicated by

of enlargement of the distinguish formation of de novo and
ovary endometriosis from recurrent adhesions
benign endometrial
tumors, which are
usually adenofibromas
The latter tumor is a true
neoplasm, and there is
a malignant counterpart.
Ultrasound
characteristics include a
thick-walled cyst with a
relatively homogeneous
echo pattern that is
somewhat echolucent.

FIBROMA Fibromas are the most common benign, The average age of a Many ovarian fibromas are Pressure and abdominal Grossly, fibromas are The management of
solid neoplasms of the ovary woman with an ovarian misdiagnosed and are believed enlargement, which may heavy, solid, well fibromas is straightforward
Fibromas vary in size from small nodules fibroma is 48 to be leiomyomas prior to be secondary to both the encapsulated, and because any woman with a
to huge pelvic tumors weighing 50 Often presents in operation. size of the tumor and grayish white solid ovarian neoplasm
pounds. One of the predominant postmenopausal women Histologically the pathologist ascites The cut surface usually should have an exploratory
characteristics of fibromas is that they are The tumor arises from the must differentiate fibromas from Smaller tumors are demonstrates a operation
extremely slow-growing tumors undifferentiated fibrous stromal hyperplasia, asymptomatic because homogeneous white or Simple excision of the tumor
The diameter (Average size: 6cm) of a stroma of the ovary fibrosarcomas, and also look for these tumors do not yellowish white solid is all that is necessary
fibroma is important clinically, because epithelial elements of an elaborate hormones. tissue with a Following excision of the
the incidence of associated ascites is associated Brenner tumor Thus, there is no change trabeculated or whorled tumor, there is resolution of
directly proportional to the size of the in the pattern of menstrual appearance similar to all symptoms, including
tumor. flow that of myomas. ascites
Meigs syndrome is the association of an Fibromas may be The majority of fibromas These tumors are frequently
ovarian fibroma, ascites, and hydrothorax pedunculated and are grossly edematous discovered in
therefore easily palpable Histologically, fibromas postmenopausal women,
are composed of often a bilateral salpingo-
connective tissue, oophorectomy and total
stromal cells, and abdominal hysterectomy are
varying amounts of performed
collagen interposed Conversely, it is important to
between the cells. note that most women who
The connective tissue preoperatively have the
cells are spindle- combination of a solid
shaped, mature ovarian tumor and ascites
fibroblasts. are found to have ovarian
carcinoma

TRANSITIONAL Rare, small, smooth, solid, fibroepithelial Result from metaplasia of Large tumors may Approximately 90% of Management of Brenner
CELL TUMOR ovarian tumors that are generally coelomic epithelium into produce unilateral pelvic these small neoplasms tumors is operative, with
asymptomatic uroepithelium. discomfort are discovered simple excision being the
The benign, proliferative (low malignant Postmenopausal bleeding incidentally during a procedure of choice
potential), and malignant forms together is sometimes associated gynecologic operation However, as with ovarian
constitute approximately 2% of ovarian with Brenner tumors, as fibromas, the patients age
tumors endometrial hyperplasia is often is the principal factor in
The majority are less than 5 cm in a coexisting abnormality in deciding the extent of the
diameter 10% to 16% of cases operation
The tumor is unilateral 85% to 95% of the
time
Grossly, Brenner tumors are smooth,
firm, gray-white, solid tumors that grossly
resemble fibromas
Histologically, Brenner tumors have two
principal components: solid masses or
nests of epithelial cells and a surrounding
fibrous stroma

GYNECOLOGY: BENIGN GYNECOLOGIC LESIONS SECTION 3-E MEDICINE 2015-2016

 20

The epithelial cells are uniform and do

not appear anaplastic
The pale epithelial cells have a coffee
beanappearing nucleus, which is also
described as a longitudinal groove in the
cells nucleus

ADENOFIBROMA Are usually small fibrous tumors that Cystadenofibroma Smaller tumor: Incidental finding: Old (post-menopausal): is
arise from the surface of the ovary asymptomatic abdominal or pelvic bilateral salpingo
Bilateral in 20% to 25% of women Large tumors: operations oophorectomy and total
Usually occur in postmenopausal women o Pressure symptoms MRI abdominal hysterectomy
1 to 15 cm in diameter o May undergo adnexal o Very low signal Young: simple excision of the
Gross: torsion intensity on T2- tumor and inspection of the
They are gray or white tumors weighted images contralateral ovary

Histology
o Small precursors of
adenofibromas are identified in
many normal ovaries
o Under the microscope, true cystic
gland spaces lined by cuboidal
epithelium are characteristic
Papillary adenofibromas
o Project from the surface of the
ovary
o May appear to be external
excrescences of a malignant
tumor

CYSTADENO- Same as that of adenofibroma, but Adenofibroma Smaller tumor: Incidental finding: Old (post-menopausal): is
FIBROMA cystadenofibromas have microscopic or asymptomatic abdominal or pelvic bilateral salpingo
occasional macroscopic areas that are Large tumors: operations oophorectomy and total
cystic. o Pressure symptoms MRI abdominal hysterectomy
o May undergo adnexal o Very low signal Young: simple excision of the
torsion intensity on T2- tumor and inspection of the
weighted images contralateral ovary

TORSION Uncommon Complication of benign Appendicitis Present with acute, Doppler flow - highly Laparoscopic surgery
Important cause of acute lower ovarian tumors in the Small intestinal obstruction severe, unilateral, lower predictive of torsion of Conservative operation is
abdominal and pelvic pain postmenopausal woman Ruptured corpus luteum or an abdominal and pelvic pain the ovary ideal [due to majority in the
Cause up to 3 percent of all acute Pregnancy adnexal abcess Relates the onset of the o False negative rate age group]
abdomens in the emergency department Enlarged secondary to severe pain to an abrupt is high 1. Untwisting of pedicle via
May occur separately from torsion of the ovulation induction during change of position Laparoscope or via
fallopian tube, but most commonly the early pregnancy Unilateral extremely laparotomy
two adnexal structures Ovarian enlargement by tender adnexal mass [90% 2. Stabilization of the ovary
Most commonly during the reproductive an 8 - 12 cm benign mass of patient] with sutures
years with the average patient being in of the ovary (most associated with nausea Unilateral salpingo-
her mid-20s common cause) and vomiting oophorectomy (if with severe
Occurs more frequently in children Inermittent previous vascular compromise)
Right ovary has a greater tendency to episodes of similar pain
twist (3 to 2) than does the left ovary for several days to several
weeks
Cyanotic, edematous
ovary which presents as
unilateral, extremely
tender adnexal mass

GYNECOLOGY: BENIGN GYNECOLOGIC LESIONS SECTION 3-E MEDICINE 2015-2016

 21

OVARIAN Chronic pelvic pain secondary to small Laparoscopic Chronic pelvic pain is Vaginal ultrasound Surgical removal of the
REMNANT area of functioning ovarian tissue oophorectomy usually cyclic and MRI ovarian remnant [most
SYNDROME following intended total removal of both exacerbated following Premenopausal levels effective treatment]
ovaries. coitus. of follicle-stimulatin Laparoscopy or laparotmy
Associated with endometriosis, chronic Masses are small (3 cm in hormone or estradiol with wide excision of the
pelvic inflammatory disease, and diameter in the [women with history of mass
extensive pelvic adhesions retroperitoneal space BSO]
adject to either urete) Challenging and
stimulating the
suspected ovarian
remnant with either
clomiphene citrate or
GnRH agonist [difficult
cases]

Coming together is a beginning. Keeping together is progress.

Working together is success.

GYNECOLOGY: BENIGN GYNECOLOGIC LESIONS SECTION 3-E MEDICINE 2015-2016

 22

DESCRIPTION CAUSE SIGNS AND SYMPTOMS DIAGNOSTIC TESTS TREATMENT

LEIOMYOMA Other types: Each tumor develops Rare before menarche, Palpation of an enlarged, Symptomatic leiomyoma- primary indication for approximately 30%
1. Intraligamentary from a single muscle diminish in size after firm, irregular uterus of all hysterectomies
2. Parasitic myomas cell a progenitor menopause Uterine artery embolization
Malignant transformation is 0.3 to 0.7%, usually myocyte Gelatin sponge (Gelfoam) silicon spheres
into a Sarcoma Cytogenetic analysis Metal coils
Rapid growth after menopause, consider demonstrated that Polyvinyl alcohol (PVA) particles
Leiomyosarcoma myomas have multiple Gelatin microspheres
Associated rare disease: chromosomal Advantages of Preoperative GnRH Agonist Treatment:
1. Intravenous leiomyomatosis abnormalities affecting Advantages Gained by Uterine-Fibroid Shrinkage
o Benign smooth muscle fibers invade regulation of growth- May allow vaginal hysterectomy
and slowly grow into the venous inducing proteins and May decrease intra-operative blood loss
channels of the pevis cytokines May allow Pfannenstiel incision
o Grossly appears like a spaghetti May facilitate endoscopic myomectomy
tumor Advantages Gained by Induction of Amenorrhea
2. Leiomyomatosis peritonealis dessiminata
May correct hypermenorrhea-menorrhagia-associated anemia
o Benign multiple small nodules over
May improve ability to donate blood
the surface of the pelvis and
abdominal peritoneum May decrease need for non-autologous blood transfusion
o Usually associated with recent May atrophy endometrium, facilitating hysteroscopic resection of
pregnancy submucosal myoma
o Management: Progestational therapy Disadvantage of Preoperative GnRH Agonist Treatment
Delay to final tissue diagnosis
Degeneration of some myomas, necessitating piecemeal
enucleation at myomectomy
Hypoestrogenic side effects.
Trabecular bone loss
Vasomotor symptoms: e.g. hot flushes
Cost
Need to self-administer or receive injections in many cases
Vaginal hemorrhage in approximately 2% of patients
Complications of Uterine Artey Embolization:
Post-embolization fever
Sepsis from infarction of the necrotic myometrium
Ovarian failure
Abdominal pain

ADENOMYOSIS Diffuse involvement of both anterior and posterior

myometrium
Focal area of involvement or adenomyoma

ADENOMATOID TUMOR Small, gray-white, circumsribed nodules 1-2 cm in

diameter

PARATUBAL CYST Vary is size from 0.5 cm to 20 cm in diameter

Majority are accessory lumina of the fallopian tubes

BENIGN CYSTIC 20-25% of all ovarian neoplasms Most common complication: Ultrasonography 95% Surgical: Oophorocystectomy
TERATOMA Most common ovarian neoplasm in prepubertal Torsion of the pedicle predictive value Laparotomy
females and also common in teenagers Associated with 3 medical Laparoscopy
Occur bilaterally 10-15% of the time condition:
Surface: Smooth, shiny, opaque white color Thyrotoxicosis
Cut-section: Thick sebaceous fluid, with tangled Autoimmune hemolytic
masses of hair and firm areas of cartilage and teeth anemia
Chromosomal make-up: 46,XX Carcinoid syndrome

ENDOMETRIOMAS Secondary to endometriosis of the ovary

Varies from small, superficial , blue-black implants
1-5 mm in diameter to large, multiloculated,
hemorrhagic cysts 5-10 in diameter

GYNECOLOGY: BENIGN GYNECOLOGIC LESIONS SECTION 3-E MEDICINE 2015-2016