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Welcome to
Qods Polyclinic
    (SSO)
Clinical Diseases
   Qods Polyclinic (SSO)
      Arasteh Athary
B.S midwife, Homoeopathist
Vaginitis



Unfortunately, inexpensive2004)
         (Bornstein, 2001; Landers, laboratory
testing is not as accurate as a clinician
                would hope.
Herpes

From sensory nerve endings,
undergoes    retrograde axonal
transport to the DORSAL ROOT
GANGLION
Primary herpes, male
Recurrent herpes, male
Herpes, female
Primary herpes, female
Same patient, four days later
Herpes cervicitis
Three stages of lesions in HSV:

1. Vesicle with or without pustule formation,
           which last about a week

               2. Ulceration

                 3. crusting
HSV1          HSV2

Gold standard for diagnosis → tissue
               culture

                     But

 HSV1 & HSV2 antibodies testing ≥ 96 percent

                     &

PCR is 1.5 to 4 times more sensitive than
                  culture
Rx


        First clinical episode

Episodic therapy for recurrent disease

   Oral suppressive therapy option
First Clinical Episode
Acyclovir 400 mg x3 times daily for 7- 10 days

Episodic Therapy for recurrent Disease
 Acyclovir 4oo mg x3 times daily for 5 days

   Oral Suppressive Therapy Option
       Acyclovir 400 mg x2 times daily
Acyclovir
        C-group in pregnancy

  DNA polymerase inhibitor activity

After an hour 50% in CSF above the plasma
               concentration
HPV

HPV 16 → the dominant cancer− related HPV

      so interested in squamous cell

                   BUT

 HPV 18 → a dominant role in Rapid Transit
    Cervical cancer (within 1-3 years)
RX
              HPV
      HPV vaccination
a quadrivalent vaccination against
        types 6, 11, 16 & 18
                 or
   a bivalent HPV 16/18 vaccine
    routinely to girls 11-12 Y/O
                 or
       anybody in 9-26 Y/O
Granuloma inguinale
Granuloma inguinale, male
Granuloma inguinale, female
Granuloma inguinale, chronic destructive lesion
Granuloma inguinale with
both active and healed lesions
Granuloma inguinale, Donovan bodies
Wright-Giemsa staining creates a “closed safety pin”
Klebsiella


              encapsulated

             mildly contagious

       requires repeated exposures

has a long incubation period of weeks to months
RX
       Granuloma Inguinale

   Doxycycline 100 mg twice daily for a
minimum of 3 weeks and until lesions have
           completely healed

                   or

 Azithromycin 1 g orally once a week as
                 above

                    or

Ciprofloxacin 750 mg orally twice daily as
Chancroid
Chancroid ulcers
Chancroid Male - regional adenopathy
Chancroid - ruptured node
Chancroid - gram stain of H. ducreyi
Haemophilus ducreyi

    Incubation 3-10 days

requires a break in mucus or skin

  No prodromal syndrome
RX
               Chancroid


         Azithromycin 1 g orally

                    or

     Amp. Ceftriaxone 250 mg IM

                    or

Ciprofloxacin 500 mg twice daily for 3 days
Condyloma acuminata
       HPV
Condyloma acuminata, penile
Condyloma acuminata, anal
Condyloma acuminata, meatal
Condyloma acuminata, vulva
Condyloma acuminata, vaginal wall
RX
        Condyloma acuminata


electrosurgical, cryotherapy, laser ablation

                Alternatively

    5%-imiquimod cream (Aldara, 3M)

                     or

A biologically active extract of Podophyllin
      0.5% Gel or solution (Condylox)
Chlamydia
 symptoms of Chlamydia are usually mild or
  absent, serious complications that cause
irreversible damage, including infertility, can
    occur "silently" before a woman ever
            recognizes a problem.
Chlamydia   can   be   transmitted •
Chlamydia can also be passed fro
                          .
If the infection spreads from the cervix to
the fallopian tubes, some women still have
     no signs or symptoms; others have:

  lower abdominal pain, low back pain,
nausea, fever, pain during intercourse, or

  bleeding between menstrual periods.
  Chlamydial infection of the cervix can
         spread to the rectum.
nucleic acid amplification tests
              (NAATs)
as a screen test for both Chlamydia &

 Gonorrhea enzyme immunoassays
             (EIAs)

     direct fluorescent antibody
                 (DFA)
RX
               Chlamydia

      Azithromycin 1 g orally once

                    or

Doxycycline 100 mg twice daily orally daily
               for 7 days
Gonorrhea
Gonococcal urethritis
Gonococcal cervicitis
Gonorrhea - gram stain of urethral discharge
Bartholin’s abscess
Bartholin’s abscess
Gonococcal ophthalmia
Disseminated gonorrhea - skin lesion
Disseminated gonorrhea - skin lesion
Gonorrhea
    This sexually transmitted disease (STD) is often
 asymptomatic, but if left untreated, it can lead to long-
term health consequences, including chronic pelvic
    pain, ectopic pregnancy, and infertility.
Gonorrhea can also increase the risk of contracting
               and transmitting HIV.
Any genital symptoms such as


 An unusual sore, discharge with odor,
  burning during urination, or bleeding
between menstrual cycles could mean an
             STD infection
RX
               Gonorrhea



     Ceftriaxone 250 mg as a single dose

                     +

    Azithromycin 1 gram as a single dose



                    or
Doxycycline 100 mg twice daily for
For patients sensitive to cftriaxone or when
             it is not available

Cefexim 400 mg orally + Azithromycin 1gr. Orally

                      or

    Doxycycline 100mg twice daily for 7 days
Lymphogranuloma
   venereum
     LGV
LGV has three stages:

      Stage 1- small vesicle or papule
Stage 2- inguinal or femoral lymphadenopathy
     Stage 3- angenitorectal syndrome
LGV primary lesion
Chronic lymphogranuloma venereum in female. Genital
                   elephantiasis
LGV lymphadenopathy
RX
   Lymphogranuloma Venereum

Cap. Doxycycline 100 mg for 21 days

             Alternatively

Cap. Erythromycin 500 mg four times
      daily the same duration
Azithromycin
           B-group in pregnancy
         Form of drug: Cap. 250 mg

            Bacteriostatic & Bactericide
      Effect on Aerobic & anaerobic Bacteria
                      Gram +, -
          Trachoma, Pneumonia, Borrelia
              It can not reach to CNS.
                    Indications:
       Urethritis (Gonorrhea & ungonorrhic),
                Chlamydia Cervicitis,
Side effects: Vomit, Diarrhea, Abdominal pain, ↑Cr.,
                      AST, ALT
Doxycycline
              D-group in pregnancy
           Form of drug: Cap. 100 mg.
                  Bacteriostatic

                Indications;
Acute Gonorrhea, Primary & Secondary Syphilis

Side effects: GI tract effects, Loss or reduction of
               smelling, Esophagit
Metronidazol
               B-group in pregnancy
   Form of Drug: Infu. 500 mg, Tab. 250mg,Vag.
                    Bactericide
                   Indications:
Anaerobic infections in abdomen, Liver, Peritonitis,
Side effects: Vomit, Metal taste, Psuedomembrane
                Colitis, Neuropathy
Ceftriaxone Sodium
         B-group in pregnancy
              Bactericide

             Indications:
    Gonorrhea, Cervicitis, Septicemia

        Mode of administration:
Single dose 125mg up to 250 mg IM

 Side effect: PT↑, CBC abnormalities……
Squamous metaplasia is a normal
process and occurs most actively
immediately to the original SCJ,
creating a zone (TZ), between the
original SCJ and the columnar
epithelium.
Theoretically, cervical cells
         undergoing




metaplasia are particularly
vulnerable to the oncogenic
effects of   HPV and co-
carcinogens.
Metaplasia is most active during
 adolescence and pregnancy.



This may explain why early age of sexual
activity and first pregnancy are known risk
factors for cervical cancers.
Genital HPV is the most common sexually
transmitted infection.




    The Centers for Disease Control and
Prevention (2002) estimates that the risk of a
 woman acquiring genital HPV by age 50 is
         greater than 80 percent.
–
AnyAA women with       unexplained
postcoital bleeding should undergo
colposcopic examination if no
other obvious source of bleeding is
identified.
Dysfunctional Uterine Bleeding


     80% to 90% because of dysfunction of
      hypothalamic-pituitary-ovarian axis


10% to 20% of women with DUB, ovulation occurs
                  cyclically
Differences between:

                  Anovulatory DUB

NO Progesterone, Persistent proliferative endometrium


                     Ovulatory DUB
Alterations in vascular architecture, Predominantly from
                 vascular dilatation alone
Medical treatment

tranexamic acid (antifibrinolytic agent)

               NSAID
               COCs
             Progestins
             Androgens
            GnRH agonists
Management of acutely menorrhagia
           by COCs

4 Pills → every 6 hours for at least 24 hours
     reduce it to 3 pills up to next 3 days
     reduce it to 2 pills up to next 3 days
                       then
   fix it to 1 pills daily up to next 21 days!
The American College of OB & GYN:

  Endometrial assessment in any woman
older than 35 years with abnormal bleeding
                and ………
Hyperplasia

        >5 mm endometrial thickness
                       ↓
     SIS, hysteroscopy, endometrial biopsy

≤4 mm for exclusion of endometrial cancer
        (Its sensitivities up to 95%-97%)
When there is a heterogeneous endometrial
     echogenicity or fluid collection




endometrial biopsy or hysteroscopy should
              be performed
DUB due to systemic causes

        Renal disease
        Liver disease
       Thyroid disease
CoagulopathyThrombocytopenia
    Von Willebrand disease
RX of Von Willebrand disease
Desmopressin ( a vasopressin analog promotes release of vWF from
     storage sites in patients with the common type 1 vWD)




  It is available in an IV infusion & a concentrated intranasal form)
Lichen Sclerosus

Chronic inflammatory skin conditions
   that predominantly affects the
           anogenital skin
Pathophysiology of Lichen Sclerosus

Unknown, may be genetic, infection, hormonal &
          autoimmune etiologies


                 Hallmark of it:
Vulvar pruritus which results from inflammation
           local terminal nerve fibers
RX

                  Patient education

               Topical Corticosteroids
   ( the best of them Clobetasol ointment 0.05% )

                   Topical estrogen

                       Retinoids
    (improves dysplastic changes, stimulates collagen &
glycosaminoglcan synthesis and induces local angiogensis)

                        Surgery
Intertrigo (friction between moist opposed skin surfaces)

           Atopic Eczema (in the first 5 years of life)

Psoriasis ( T- cell-mediated inflammatory reactions are linked with
                keratinocyte hyperproliferation)
Lichen Planus
T-cell-related autoimmunity to basal keratinocytes

             Vulvar Lichen Planus:
                  Erosive……
             Papulosquamous…….
               Hypertrophic……
RX

Ultrapotent topical corticosteroids x2 times daily up
                     to 3 months
Vulvodynia

“Vulvar discomfort, burning pain, NO visible
      finding or neurologic disorder”
Neuropathies changes

   Serotonin-containing neuroendocrine cells in
               female genital tract

                        &

Substance P axons in the ducts of vestibular glands
RX

        Lidocaine 5% ointment

Topical or intrvaginal estrogen therapy

          Antidepressants

                  &

           Anticonvulsants
IUDs
     Copper T, Mirena, LNG-IUS

Failure rate respectively: 0.8% & 0.1%
  Advantages of Mirena: ↓ PID, for
women with contraindications to COCs
Disadvantages of IUDs

    Silent perforation, Cramping & Bleeding,
Menorrhage, Infection, Pregnancy with retained IUD
ParaGard T 380A contraindications:
        Any Copper allergy


     Mirena contraindications:

Hypersensitivity to any component of
            this product
Known or suspected carcinoma of the
               breast
    Acute liver disease or tumor
Procedures of Insertion

  FDA requirement: the woman must be given
detailed brochure about side effects & apparent risks
                    from its use


     Postpartum insertion?..........?
Cystic Ovarian Mass

         Symptoms

          Diagnosis

       Management:
Observation, Surgical Excision
Premenopausal women (<50 years):
               CA 125 >200 U/ml
                     Ascites
  Evidence of abdominal or distant metastasis
      Positive of breast or ovarian cancer

Postmenopausal Women(≥50 years)
               CA 125 > 35 U/ml
                     Ascites
         Nodule or fixed pelvic mass
  Evidence of abdominal or distant metastasis
      Positive of breast or ovarian cancer
Serum alpha-fetoprotein (AFP)


  Endodermal sinus tumor or Embryonal cell
                carcinoma

                  ß-hCG



a mixed germ cell or Embryonal cell carcinoma

                 CA (19-9)



    Mucinous epithelial ovarian carcinoma
Management of ovarian mass found
            with imaging

                Premenopausal
-Simple cyst ( hemorrhagic or unhemorrhagic)

      ≤3 cm diameter & >3 cm diameter

          Postmenopausal woman
       ≤5 cm diameter & >5 cm diameter

              -Complex mass

-Solid or predominantly solid-appearing mass
Expectant management

1. Sonographic evidence of a thin-walled,
   unilocular cyst

2. Cyst diameter less than 5 cm

3. No cyst enlargement during surveillance

4. Normal serum CA125 levels
Overactive Bladder (OAB)

 Urgency: a sudden, compelling desire
to pass urine, which is difficult to defer
Other OAB-related symptoms

Frequency, Nocturia, Urge Urinary incontinence
The normal urge to void:
It appears to be mediated by heterogeneous
         activity in muscle bundles



    The presence of urgency in the absence of
 increased intravesical pressure may result from
enhanced coupling between bundles, resulting in a
     wave of diffuse activity and producing an
         involuntary bladder contraction
Detrusor overactivity (DO)

Stress & Urge       mixed urinary incontinence
RX

                      Imipramine,
(a tricyclic antidepressant with adrenergic properties)

                     Coaptation
In bladder emptying:

           Sympathetic stimulation ↓
              Parasympathetic ↑

                       &

   Acetylcholine release → detrusor activity

Usually RX with muscarinic antagonist medications
            blunt detrusor contraction
Psychological effects of OAB

 Disturbed sleep, impaired mobility &
   work productivity, depression &
impaired domestic and sexual function
Thank you for
your attention

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Std

  • 2. Clinical Diseases Qods Polyclinic (SSO) Arasteh Athary B.S midwife, Homoeopathist
  • 3. Vaginitis Unfortunately, inexpensive2004) (Bornstein, 2001; Landers, laboratory testing is not as accurate as a clinician would hope.
  • 4. Herpes From sensory nerve endings, undergoes retrograde axonal transport to the DORSAL ROOT GANGLION
  • 9. Same patient, four days later
  • 11. Three stages of lesions in HSV: 1. Vesicle with or without pustule formation, which last about a week 2. Ulceration 3. crusting
  • 12. HSV1 HSV2 Gold standard for diagnosis → tissue culture But HSV1 & HSV2 antibodies testing ≥ 96 percent & PCR is 1.5 to 4 times more sensitive than culture
  • 13. Rx First clinical episode Episodic therapy for recurrent disease Oral suppressive therapy option
  • 14. First Clinical Episode Acyclovir 400 mg x3 times daily for 7- 10 days Episodic Therapy for recurrent Disease Acyclovir 4oo mg x3 times daily for 5 days Oral Suppressive Therapy Option Acyclovir 400 mg x2 times daily
  • 15. Acyclovir C-group in pregnancy DNA polymerase inhibitor activity After an hour 50% in CSF above the plasma concentration
  • 16. HPV HPV 16 → the dominant cancer− related HPV so interested in squamous cell BUT HPV 18 → a dominant role in Rapid Transit Cervical cancer (within 1-3 years)
  • 17. RX HPV HPV vaccination a quadrivalent vaccination against types 6, 11, 16 & 18 or a bivalent HPV 16/18 vaccine routinely to girls 11-12 Y/O or anybody in 9-26 Y/O
  • 21. Granuloma inguinale, chronic destructive lesion
  • 22. Granuloma inguinale with both active and healed lesions
  • 23. Granuloma inguinale, Donovan bodies Wright-Giemsa staining creates a “closed safety pin”
  • 24. Klebsiella encapsulated mildly contagious requires repeated exposures has a long incubation period of weeks to months
  • 25. RX Granuloma Inguinale Doxycycline 100 mg twice daily for a minimum of 3 weeks and until lesions have completely healed or Azithromycin 1 g orally once a week as above or Ciprofloxacin 750 mg orally twice daily as
  • 28. Chancroid Male - regional adenopathy
  • 30. Chancroid - gram stain of H. ducreyi
  • 31. Haemophilus ducreyi Incubation 3-10 days requires a break in mucus or skin No prodromal syndrome
  • 32. RX Chancroid Azithromycin 1 g orally or Amp. Ceftriaxone 250 mg IM or Ciprofloxacin 500 mg twice daily for 3 days
  • 39. RX Condyloma acuminata electrosurgical, cryotherapy, laser ablation Alternatively 5%-imiquimod cream (Aldara, 3M) or A biologically active extract of Podophyllin 0.5% Gel or solution (Condylox)
  • 40. Chlamydia symptoms of Chlamydia are usually mild or absent, serious complications that cause irreversible damage, including infertility, can occur "silently" before a woman ever recognizes a problem.
  • 41. Chlamydia can be transmitted • Chlamydia can also be passed fro .
  • 42. If the infection spreads from the cervix to the fallopian tubes, some women still have no signs or symptoms; others have: lower abdominal pain, low back pain, nausea, fever, pain during intercourse, or bleeding between menstrual periods. Chlamydial infection of the cervix can spread to the rectum.
  • 43. nucleic acid amplification tests (NAATs) as a screen test for both Chlamydia & Gonorrhea enzyme immunoassays (EIAs) direct fluorescent antibody (DFA)
  • 44. RX Chlamydia Azithromycin 1 g orally once or Doxycycline 100 mg twice daily orally daily for 7 days
  • 48. Gonorrhea - gram stain of urethral discharge
  • 54. Gonorrhea This sexually transmitted disease (STD) is often asymptomatic, but if left untreated, it can lead to long- term health consequences, including chronic pelvic pain, ectopic pregnancy, and infertility. Gonorrhea can also increase the risk of contracting and transmitting HIV.
  • 55. Any genital symptoms such as An unusual sore, discharge with odor, burning during urination, or bleeding between menstrual cycles could mean an STD infection
  • 56. RX Gonorrhea Ceftriaxone 250 mg as a single dose + Azithromycin 1 gram as a single dose or Doxycycline 100 mg twice daily for
  • 57. For patients sensitive to cftriaxone or when it is not available Cefexim 400 mg orally + Azithromycin 1gr. Orally or Doxycycline 100mg twice daily for 7 days
  • 58. Lymphogranuloma venereum LGV
  • 59. LGV has three stages: Stage 1- small vesicle or papule Stage 2- inguinal or femoral lymphadenopathy Stage 3- angenitorectal syndrome
  • 61. Chronic lymphogranuloma venereum in female. Genital elephantiasis
  • 63. RX Lymphogranuloma Venereum Cap. Doxycycline 100 mg for 21 days Alternatively Cap. Erythromycin 500 mg four times daily the same duration
  • 64. Azithromycin B-group in pregnancy Form of drug: Cap. 250 mg Bacteriostatic & Bactericide Effect on Aerobic & anaerobic Bacteria Gram +, - Trachoma, Pneumonia, Borrelia It can not reach to CNS. Indications: Urethritis (Gonorrhea & ungonorrhic), Chlamydia Cervicitis, Side effects: Vomit, Diarrhea, Abdominal pain, ↑Cr., AST, ALT
  • 65. Doxycycline D-group in pregnancy Form of drug: Cap. 100 mg. Bacteriostatic Indications; Acute Gonorrhea, Primary & Secondary Syphilis Side effects: GI tract effects, Loss or reduction of smelling, Esophagit
  • 66. Metronidazol B-group in pregnancy Form of Drug: Infu. 500 mg, Tab. 250mg,Vag. Bactericide Indications: Anaerobic infections in abdomen, Liver, Peritonitis, Side effects: Vomit, Metal taste, Psuedomembrane Colitis, Neuropathy
  • 67. Ceftriaxone Sodium B-group in pregnancy Bactericide Indications: Gonorrhea, Cervicitis, Septicemia Mode of administration: Single dose 125mg up to 250 mg IM Side effect: PT↑, CBC abnormalities……
  • 68. Squamous metaplasia is a normal process and occurs most actively immediately to the original SCJ, creating a zone (TZ), between the original SCJ and the columnar epithelium.
  • 69. Theoretically, cervical cells undergoing metaplasia are particularly vulnerable to the oncogenic effects of HPV and co- carcinogens.
  • 70. Metaplasia is most active during adolescence and pregnancy. This may explain why early age of sexual activity and first pregnancy are known risk factors for cervical cancers.
  • 71. Genital HPV is the most common sexually transmitted infection. The Centers for Disease Control and Prevention (2002) estimates that the risk of a woman acquiring genital HPV by age 50 is greater than 80 percent.
  • 72. – AnyAA women with unexplained postcoital bleeding should undergo colposcopic examination if no other obvious source of bleeding is identified.
  • 73. Dysfunctional Uterine Bleeding 80% to 90% because of dysfunction of hypothalamic-pituitary-ovarian axis 10% to 20% of women with DUB, ovulation occurs cyclically
  • 74. Differences between: Anovulatory DUB NO Progesterone, Persistent proliferative endometrium Ovulatory DUB Alterations in vascular architecture, Predominantly from vascular dilatation alone
  • 75. Medical treatment tranexamic acid (antifibrinolytic agent) NSAID COCs Progestins Androgens GnRH agonists
  • 76. Management of acutely menorrhagia by COCs 4 Pills → every 6 hours for at least 24 hours reduce it to 3 pills up to next 3 days reduce it to 2 pills up to next 3 days then fix it to 1 pills daily up to next 21 days!
  • 77. The American College of OB & GYN: Endometrial assessment in any woman older than 35 years with abnormal bleeding and ………
  • 78. Hyperplasia >5 mm endometrial thickness ↓ SIS, hysteroscopy, endometrial biopsy ≤4 mm for exclusion of endometrial cancer (Its sensitivities up to 95%-97%)
  • 79. When there is a heterogeneous endometrial echogenicity or fluid collection endometrial biopsy or hysteroscopy should be performed
  • 80. DUB due to systemic causes Renal disease Liver disease Thyroid disease CoagulopathyThrombocytopenia Von Willebrand disease
  • 81. RX of Von Willebrand disease Desmopressin ( a vasopressin analog promotes release of vWF from storage sites in patients with the common type 1 vWD) It is available in an IV infusion & a concentrated intranasal form)
  • 82. Lichen Sclerosus Chronic inflammatory skin conditions that predominantly affects the anogenital skin
  • 83. Pathophysiology of Lichen Sclerosus Unknown, may be genetic, infection, hormonal & autoimmune etiologies Hallmark of it: Vulvar pruritus which results from inflammation local terminal nerve fibers
  • 84. RX Patient education Topical Corticosteroids ( the best of them Clobetasol ointment 0.05% ) Topical estrogen Retinoids (improves dysplastic changes, stimulates collagen & glycosaminoglcan synthesis and induces local angiogensis) Surgery
  • 85. Intertrigo (friction between moist opposed skin surfaces) Atopic Eczema (in the first 5 years of life) Psoriasis ( T- cell-mediated inflammatory reactions are linked with keratinocyte hyperproliferation)
  • 86. Lichen Planus T-cell-related autoimmunity to basal keratinocytes Vulvar Lichen Planus: Erosive…… Papulosquamous……. Hypertrophic……
  • 87. RX Ultrapotent topical corticosteroids x2 times daily up to 3 months
  • 88. Vulvodynia “Vulvar discomfort, burning pain, NO visible finding or neurologic disorder”
  • 89. Neuropathies changes Serotonin-containing neuroendocrine cells in female genital tract & Substance P axons in the ducts of vestibular glands
  • 90. RX Lidocaine 5% ointment Topical or intrvaginal estrogen therapy Antidepressants & Anticonvulsants
  • 91. IUDs Copper T, Mirena, LNG-IUS Failure rate respectively: 0.8% & 0.1% Advantages of Mirena: ↓ PID, for women with contraindications to COCs
  • 92. Disadvantages of IUDs Silent perforation, Cramping & Bleeding, Menorrhage, Infection, Pregnancy with retained IUD
  • 93. ParaGard T 380A contraindications: Any Copper allergy Mirena contraindications: Hypersensitivity to any component of this product Known or suspected carcinoma of the breast Acute liver disease or tumor
  • 94. Procedures of Insertion FDA requirement: the woman must be given detailed brochure about side effects & apparent risks from its use Postpartum insertion?..........?
  • 95. Cystic Ovarian Mass Symptoms Diagnosis Management: Observation, Surgical Excision
  • 96. Premenopausal women (<50 years): CA 125 >200 U/ml Ascites Evidence of abdominal or distant metastasis Positive of breast or ovarian cancer Postmenopausal Women(≥50 years) CA 125 > 35 U/ml Ascites Nodule or fixed pelvic mass Evidence of abdominal or distant metastasis Positive of breast or ovarian cancer
  • 97. Serum alpha-fetoprotein (AFP) Endodermal sinus tumor or Embryonal cell carcinoma ß-hCG a mixed germ cell or Embryonal cell carcinoma CA (19-9) Mucinous epithelial ovarian carcinoma
  • 98. Management of ovarian mass found with imaging Premenopausal -Simple cyst ( hemorrhagic or unhemorrhagic) ≤3 cm diameter & >3 cm diameter Postmenopausal woman ≤5 cm diameter & >5 cm diameter -Complex mass -Solid or predominantly solid-appearing mass
  • 99. Expectant management 1. Sonographic evidence of a thin-walled, unilocular cyst 2. Cyst diameter less than 5 cm 3. No cyst enlargement during surveillance 4. Normal serum CA125 levels
  • 100. Overactive Bladder (OAB) Urgency: a sudden, compelling desire to pass urine, which is difficult to defer
  • 101. Other OAB-related symptoms Frequency, Nocturia, Urge Urinary incontinence
  • 102. The normal urge to void: It appears to be mediated by heterogeneous activity in muscle bundles The presence of urgency in the absence of increased intravesical pressure may result from enhanced coupling between bundles, resulting in a wave of diffuse activity and producing an involuntary bladder contraction
  • 103. Detrusor overactivity (DO) Stress & Urge mixed urinary incontinence
  • 104. RX Imipramine, (a tricyclic antidepressant with adrenergic properties) Coaptation
  • 105. In bladder emptying: Sympathetic stimulation ↓ Parasympathetic ↑ & Acetylcholine release → detrusor activity Usually RX with muscarinic antagonist medications blunt detrusor contraction
  • 106. Psychological effects of OAB Disturbed sleep, impaired mobility & work productivity, depression & impaired domestic and sexual function
  • 107. Thank you for your attention