Ebook Williams gynecology (Second edition): Part 2

Continued part 1, part 2 of ebook Williams gynecology (Second edition) provide readers with content about: female pelvic medicine and reconstructive surgery; gynecologic oncology; aspects of gynecologic surgery; atlas of gynecologic surgery; surgeries for benign gynecologic conditions; minimally invasive surgery; surgeries for pelvic floor disorders;... Please refer to the ebook for details!

SECTION FEMALE PELVIC MEDICINE AND RECONSTRUCTIVE SURGERY MCGH222-Ch23_605-632.indd 605 05/01/12 1:51 PM 606 CHAPTER 23 Urinary Incontinence DEFINITIONS EPIDEMIOLOGY RISKS FOR URINARY INCONTINENCE 607 609 609 BLADDER EMPTYING CONTINENCE THEORIES 611 615 616 616 DIAGNOSIS HISTORY 607 PATHOPHYSIOLOGY BLADDER FILLING 606 PHYSICAL EXAMINATION 618 618 624 DIAGNOSTIC TESTING TREATMENT CONSERVATIVE/NONSURGICAL TREATMENT OF STRESS URINARY INCONTINENCE 625 628 630 TREATMENT OF URGE URINARY INCONTINENCE REFERENCES 624 DEFINITIONS Urinary incontinence is defined as any involuntary leakage of urine In addition to the urethra, urine may also leak from extraurethral sources, such as fistulas or congenital malformations of the lower urinary tract Although incontinence is categorized into a number of forms, this chapter will focus on the evaluation and management of stress and urge urinary incontinence Stress urinary incontinence (SUI) is the involuntary leakage of urine with exertion or with sneezing or coughing Urge urinary or “urge”—incontinence is the involuntary leakage accompanied or immediately preceded by a perceived strong imminent need to void A related condition, overactive bladder, describes urinary urgency with or without incontinence and usually with increased daytime urinary frequency and nocturia (Abrams, 2009) According to International Continence Society guidelines, urinary incontinence is a symptom, a sign, and a condition (Abrams, 2002) For example, with SUI, a patient may complain of involuntary urine leakage with exercise or laughing Concurrent with these symptoms, involuntary leakage from the urethra synchronous with cough or Valsalva may be observed during examination by a provider And as a condition, SUI is objectively demonstrated during urodynamic testing if involuntary leakage of urine is seen with increased abdominal pressure and absence of detrusor muscle contraction Under these circumstances, when the symptom or sign of SUI is confirmed with objective testing, the term urodynamic stress incontinence (USI), formerly known as genuine stress incontinence, is used With urge urinary incontinence, women have difficulty postponing urination urges and generally must promptly empty their bladder on cue and without delay If urge urinary incontinence is objectively demonstrated during urodynamic testing with cystometric evaluation, the condition is termed detrusor overactivity (DO), formerly known as detrusor instability When both stress and urgency components are present, it is called mixed urinary incontinence Functional incontinence occurs in situations in which a woman cannot reach a toilet in time because of physical, psychological, or mentation limitations Often, this group would be continent if these issues were absent Urinary Incontinence EPIDEMIOLOGY RISKS FOR URINARY INCONTINENCE ■ Age The prevalence of incontinence appears to increase gradually during young adult life (Fig 23-1) A broad peak is noted at middle age and then steadily increases after age 65 (Hannestad, 2000) Similarly, data from the 2005-2006 NHANES demonstrate a steady increase in incontinence prevalence with age: percent in those aged 20 to 40 years, 17 percent for ages 40 to 60, 23 percent for ages 60 to 80, and 32 percent for those older than 80 (Nygaard, 2008) Incontinence should not be viewed as a normal consequence of aging However, several physiologic age-related changes in the lower urinary tract may predispose to incontinence, overactive bladder, or other voiding difficulties First, the prevalence of involuntary detrusor contractions increases with age, and detrusor overactivity is found in 21 percent of healthy, 40 35 Percentage (%) 30 25 20 15 10 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75–79 80–84 85+ Unknown 0.3 0.6 1.1 1.6 2.4 3.1 3.6 4.8 4.2 5.2 5.7 Slight 6.3 10.7 11.5 11.6 13.7 12.3 9.3 7.8 5.6 5.7 5.9 2.6 Moderate 2.5 4.5 4.9 7.5 8.3 8.8 8.4 7.6 8.3 8.1 8.1 8.1 8.2 Severe 1.3 1.6 1.6 2.6 3.3 4.1 6.1 6.8 7.2 8.7 12.1 14.6 16.1 19.3 Age (years) FIGURE 23-1 Prevalence of incontinence by age group (n ϭ 8002) (Adapted from Hannestad, 2000, with permission.) CHAPTER 23 In Western societies, epidemiologic studies indicate a prevalence of urinary incontinence of 15 to 55 percent This wide range is attributed to variations in research methodologies, population characteristics, and definitions of incontinence As part of the 2005-2006 National Health and Nutrition Examination Survey (NHANES), a cross-sectional group of 1961 nonpregnant, noninstitutionalized women in the United States were questioned about pelvic floor disorders Urinary incontinence that was characterized by participants as moderate to severe leakage was identified in 15.7 percent (Nygaard, 2008) However, current available data are limited by the fact that most women not seek medical attention for this condition (Hunskaar, 2000) It is estimated that only one in four women will seek medical advice for incontinence due to embarrassment, limited access to health care, or poor screening by health care providers (Hagstad, 1985) Among ambulatory women with urinary incontinence, the most common condition is SUI, which represents 29 to 75 percent of cases Urge urinary incontinence accounts for up to 33 percent of incontinence cases, whereas the remainder is attributable to mixed forms (Hunskaar, 2000) In a review of overactive bladder, 15 percent of 64,528 women met criteria for overactive bladder with or without incontinence, and 11 percent had urge urinary incontinence (Hartmann, 2009) Urinary incontinence can significantly impair a woman’s quality of life, leading to disrupted social relationships, psychological distress from embarrassment and frustration, hospitalizations due to skin breakdown and urinary tract infection, and nursing home admission An incontinent elderly woman is 2.5 times more likely to be admitted to a nursing home than a continent one (Langa, 2002) Likewise, the monetary ramifications of incontinence are considerable An estimated $32 billion is spent annually in the United States caring for community-dwelling and institutionalized patients with urinary incontinence (Hu, 2004) Moreover, population projections from the U.S Census Bureau forecast that the number of American women with urinary incontinence will increase 55 percent from 18.3 million to 28.4 million between 2010 and 2050 (Wu, 2009) 607 608 Female Pelvic Medicine and Reconstructive Surgery SECTION continent community-dwelling elderly (Resnick, 1995) Total bladder capacity and the ability to postpone voiding decreases, and these declines may lead to urinary frequency In addition, urinary flow rates are reduced in both older men and women and likely due to an age-associated decrease in detrusor contractility (Resnick, 1984) In women, postmenopausal decreases in estrogen levels result in atrophy of the urethral mucosal seal, loss of compliance, and bladder irritation, which may predispose to both stress and urge urinary incontinence Finally, there are age-related changes in renal filtration rate and alterations in diurnal levels of antidiuretic hormone and atrial natriuretic factor These changes shift the diurnal-predominant pattern of fluid excretion toward one with greater urine excretion later in the day (Kirkland, 1983) ■ Race Traditionally, white women are believed to have higher rates of stress urinary incontinence than women of other races In contrast, urge urinary incontinence is believed to be more prevalent among African-American women Most reports are not population based and thus are not the best estimate of true racial differences In addition, existing data on racial differences are largely based on small sample sizes (Bump, 1993) However, data from the Nurse’s Health Study cohorts, which included more than 76,000 women, did support these racial differences Investigators found the highest 4-year incidence rates in white participants compared with that in Asian and black women (Townsend, 2010) It is not yet clear whether these differences are biologic, related to health care access, or affected by cultural expectations and symptom tolerance thresholds ■ Obesity Several epidemiologic studies have shown that an increased body mass index (BMI) is a significant and independent risk factor for urinary incontinence of all types (Table 23-1) Moreover, the prevalence of both urge urinary and stress incontinence increases proportionally with BMI (Hannestad, 2003) Theoretically, the increase in intraabdominal pressure that coincides with an TABLE 23-1 Risk Factors for Urinary Incontinence Age Pregnancy Childbirth Menopause Hysterectomy Obesity Urinary symptoms Functional impairment Cognitive impairment Chronically increased abdominal pressure Chronic cough Constipation Occupational risk Smoking increased BMI results in a higher intravesical pressure This higher pressure overcomes urethral closing pressure and leads to incontinence (Bai, 2002) Accordingly, as a greater portion of our population becomes overweight and obese, we can expect to see an increase in the prevalence of urinary incontinence in the United States (Flegal, 2002) Encouragingly, weight loss for many can be an effective treatment In overweight or obese women, the prevalence of urinary incontinence significantly declines following weight loss achieved by behavior modification or with bariatric surgery (Burgio, 2007; Deitel, 1988; Subak, 2009) ■ Menopause Studies have inconsistently demonstrated an increase in urinary dysfunction after a woman enters her postmenopausal years (Bump, 1998) In those with symptoms, separating hypoestrogenism effects from the effects of aging is difficult High-affinity estrogen receptors have been identified in the urethra, pubococcygeal muscle, and bladder trigone but are infrequently found elsewhere in the bladder (Iosif, 1981) Hypoestrogenic-related collagen changes and reductions in urethral vascularity and skeletal muscle volume are factors They are thought to collectively contribute to impaired urethral function via a decreased resting urethral pressure (Carlile, 1988) Moreover, estrogen deficiency with resulting urogenital atrophy is believed to be responsible in part for urinary sensory symptoms following menopause (Raz, 1993) Despite this current evidence that estrogen plays a role in normal urinary function, it is less clear whether estrogen therapy is useful in the treatment or prevention of incontinence (Cody, 2009; Fantl, 1994, 1996) ■ Childbirth and Pregnancy Many studies reveal the prevalence of urinary incontinence to be higher in parous women compared with nulliparas The effects of childbirth on incontinence may result from direct injury to pelvic muscles and connective tissue attachments In addition, nerve damage from trauma or stretch injury may result in pelvic muscle dysfunction Specifically, rates of prolonged pudendal nerve latency after delivery are higher in women with incontinence compared with asymptomatic puerperal women (Snooks, 1986) One large epidemiologic study identified vaginal delivery parameters that may affect the risk of urinary incontinence later in life First, fetal birthweight Ն4000 g increased the risk of all urinary incontinence types (Rortveit, 2003b) Secondly, cesarean delivery may have a short-term protective effect for preventing urinary incontinence In this study, the adjusted odds ratio for any incontinence associated with vaginal delivery compared with that with cesarean delivery was 1.7 (Rortveit, 2003a) However, the protective effect of cesarean delivery on incontinence may dissipate after additional deliveries, decreases with age, and is not present in older women (Nygaard, 2006) ■ Family History Evidence suggests that the risk of urinary incontinence may be increased in the daughters and sisters of incontinent women In one large survey, daughters of incontinent women had an increased relative risk of 1.3 and absolute risk of 23 percent Urinary Incontinence of having urinary incontinence Younger sisters of incontinent women also had a greater likelihood of having any urinary incontinence (Hannestad, 2004) In women older than 60 years with chronic obstructive pulmonary disease, a significantly increased risk of urinary incontinence is found (Brown, 1996; Diokno, 1990) Similarly, cigarette smoking is identified as an independent risk factor for urinary incontinence in several studies Both current and former smokers were noted to have a two- to threefold risk of incontinence compared with nonsmokers (Brown, 1996; Bump, 1992; Diokno, 1990) In another study, investigators also identified an association between current and former smoking and incontinence, but only for those who smoked more than 20 cigarettes daily Severe incontinence was weakly associated with smoking regardless of cigarette number (Hannestad, 2003) Theoretically, persistently increased intraabdominal pressures are generated from a smoker’s chronic cough, and collagen synthesis is diminished by smoking’s antiestrogenic effects ■ Hysterectomy Studies have inconsistently shown that hysterectomy is a risk factor for developing urinary incontinence Those that show an association are retrospective, lack appropriate control groups, and are often based solely on subjective data (Bump, 1998) In contrast, studies that include pre- and postoperative urodynamic testing reveal clinically insignificant changes in bladder function Moreover, evidence does not support avoidance of clinically indicated hysterectomy or the selection of supracervical hysterectomy as measures to prevent urinary incontinence (Vervest, 1989; Wake, 1980) PATHOPHYSIOLOGY ■ Continence The bladder is a urine storage organ with the capacity to accommodate large increases in volume with minimal or no increases in intravesical pressure The ability to store urine coupled with convenient and socially acceptable voluntary emptying is continence Continence requires the complex coordination of multiple components that include: muscle contraction and relaxation, appropriate connective tissue support, and integrated innervation and communication between these structures Simplistically, during filling, urethral contraction is coordinated with bladder relaxation and urine is stored During voiding, the urethra relaxes and the bladder contracts These mechanisms can be challenged by uninhibited detrusor contractions, marked increases in intraabdominal pressure, and changes to the various anatomic components of the continence mechanism ■ Bladder Filling Bladder Anatomy The bladder wall is multilayered and contains mucosal, submucosal, muscular, and adventitial layers (Fig 23-2) The bladder Innervation Overview Normal function of the lower urinary tract requires integration of peripheral and central nervous systems The peripheral nervous system contains somatic and autonomic divisions (Fig 23-3) Of these, the somatic component innervates striated muscle, whereas the autonomic division innervates smooth muscle The autonomic nervous system controls involuntary motion and is categorized into sympathetic and parasympathetic divisions The sympathetic system mediates its end-organ effects through epinephrine or norepinephrine acting on ␣- or ␤-adrenergic receptors (Fig 23-4) The parasympathetic division acts through acetylcholine binding to muscarinic or nicotinic receptors In the pelvis, autonomic fibers that supply the pelvic viscera course in the superior and inferior hypogastric plexi (Fig 23-5) The somatic nervous system controls voluntary movement, and the portion of this system that is most relevant to lower urinary tract function originates from Onuf somatic nucleus (p 613) This nucleus is located in the ventral horn gray matter of spinal levels S2–S4 and contains the neurons that innervate the striated urogenital sphincter complex, described next Nerves involved with that connection include branches of the pudendal and pelvic nerves Urogenital Sphincter As the bladder fills, synchronized contraction of the urogenital sphincter is integral to continence Composed of striated muscle, this sphincter complex includes: (1) the sphincter urethrae, (2) the urethrovaginal sphincter, and (3) the compressor urethrae The sphincter urethrae wraps circumferentially around the urethra In comparison, the urethrovaginal sphincter and the compressor urethrae arch ventrally over the urethra and insert into the fibromuscular tissue of the anterior vaginal wall (Fig 23-6) These three muscles function as a single unit and contract to close the urethra Contraction of these muscles circumferentially constricts the cephalad two thirds of the urethra and laterally compresses the distal one third The sphincter urethrae is predominantly composed of slow-twitch fibers and remains tonically contracted, contributing substantially to continence at rest In contrast, the urethrovaginal sphincter and the compressor CHAPTER 23 ■ Smoking and Chronic Lung Disease mucosa is comprised of a transitional cell epithelium, supported by a lamina propria With small bladder volumes, the mucosa is thrown into convoluted folds However, with bladder filling, it is stretched and thinned The bladder epithelium, termed uroepithelium, is comprised of distinct cell layers The most superficial is the umbrella cell layer, and its impermeability is thought to provide the primary urine-plasma barrier Covering the uroepithelium is a glycosaminoglycan (GAG) layer This GAG layer may prohibit bacterial adherence and prevents urothelial damage by acting as a protective barrier Specifically, theories suggest that this carbohydrate polymer layer may be defective in patients with interstitial cystitis (Chap 11, p 320) The muscular layer, termed the detrusor muscle, is composed of three smooth-muscle layers arranged in a plexiform fashion This unique arrangement allows for rapid multidimensional expansion during bladder filling and is a key component to the bladder’s ability to accommodate large volumes 609 610 Female Pelvic Medicine and Reconstructive Surgery Median umbilical ligament SECTION Ureter Peritoneum Detrusor muscle Ureteral openings Trigone Neck of urinary bladder Transitional epithelium Mucosa Lamina propria Submucosa Internal urethral sphincter Detrusor muscle Urogenital sphincter in the perineal membrane Adventitia A Transitional epithelium Lamina propria LM 78x Transitional epithelium Lamina propria Submucosa Detrusor muscle of muscularis LM 18x B urethrae are comprised of fast-twitch muscle fibers, which allow brisk contraction and urethra lumen closure when continence is challenged by sudden increases in intraabdominal pressure Innervation Important to Storage The urogenital sphincter receives somatic motor innervation through the pudendal and pelvic nerves (see Figs 23-5 and 23-7) FIGURE 23-2 Bladder anatomy A Anteroposterior view of bladder anatomy Inset: The bladder wall contains mucosal, submucosal, muscular, and adventitial layers B Photomicrograph of the bladder wall The mucosa of an empty bladder is thrown into convoluted folds or rugae The plexiform arrangement of muscle fibers of the detrusor muscle cause difficulty in defining its three distinct layers (From McKinley, 2006, with permission.) Thus, pudendal neuropathy, which may follow obstetric injury, can affect normal sphincter functioning Additionally, prior pelvic surgery or pelvic radiation therapy may damage nerves, vasculature, and soft tissue Such injury can lead to ineffective urogenital sphincter action and contribute to incontinence Sympathetic fibers are carried through the superior hypogastric nerve plexus and communicate with ␣- and ␤-adrenergic Urinary Incontinence Central nervous system Peripheral nervous system Somatic nervous system Smooth muscle Striated muscle Sympathetic division Parasympathetic division α-adrenergic receptors β-adrenergic receptors Muscarinic receptors Nicotinic receptors FIGURE 23-3 Divisions of the human nervous system The peripheral nervous system includes: (1) the somatic nervous system, which mediates voluntary movements through its actions on striated muscle, and (2) the autonomic nervous system, which controls involuntary motion through its actions on smooth muscle The autonomic nervous system is further divided into the sympathetic division, which acts through epinephrine and norepinephrine binding to adrenergic receptors, and the parasympathetic division, which acts through acetylcholine binding to muscarinic or nicotinic receptors receptors within the bladder and urethra ␤-Adrenergic receptor stimulation in the bladder dome results in smooth-muscle relaxation and assists with urine storage (Fig 23-8) In contrast, ␣-adrenergic receptors predominate in the bladder base and urethra These receptors are stimulated by norepinephrine, which initiates a cascade of events that preferentially leads to urethral contraction and aids urine storage and continence These effects of ␣-stimulation underlie the treatment of SUI with imipramine, a tricyclic antidepressant with adrenergic agonist properties Urethral Coaptation One key to maintaining continence is adequate urethral mucosal coaptation The uroepithelium is supported by a connective tissue layer, which is thrown into deep folds, also known as plications A rich capillary network runs within its subepithelial layer This vascular network aids in urethral mucosal approximation, also termed coaptation, by acting like an “inflatable cushion” (Fig 23-9) In women who are hypoestrogenic, this submucosal vasculature plexus is less prominent In part, hormone replacement targets this diminished vascularity and enhances coaptation to improve continence ■ Bladder Emptying Innervation Related to Voiding When an appropriate time for bladder emptying arises, sympathetic stimulation is reduced and parasympathetic stimulation is triggered Specifically, neural impulses carried in the pelvic nerves stimulate acetylcholine release and lead to detrusor muscle contraction (Fig 23-10) Concurrent with detrusor stimulation, acetylcholine also stimulates muscarinic receptors in the urethra and leads to outlet relaxation for voiding Within the parasympathetic division, acetylcholine receptors are broadly defined as muscarinic and nicotinic The bladder is densely supplied with muscarinic receptors, which FIGURE 23-4 The bladder dome is rich in parasympathetic muscarinic receptors (M) and sympathetic ␤-adrenergic receptors (␤) The bladder neck contains a greater density of sympathetic ␣-adrenergic receptors (␣) CHAPTER 23 Autonomic nervous system (ANS) 611 612 Female Pelvic Medicine and Reconstructive Surgery SECTION FIGURE 23-5 The inferior hypogastric plexus, also known as the pelvic plexus, is formed by visceral efferents from S2 to S4, which provide the parasympathetic component by way of the pelvic nerves The superior hypogastric plexus primarily contains sympathetic fibers from the T10 to L2 cord segments and terminates by dividing into right and left hypogastric nerves The hypogastric nerves and rami from the sacral portion of the sympathetic chain contribute the sympathetic component to the pelvic plexus The pelvic plexus divides into three portions according to the course and distribution of its fibers: the middle rectal plexus, uterovaginal plexus, and vesical plexus Muscular Activity with Voiding is ideally suited for rapid concentric contraction during bladder emptying During voiding, all components of the striated urogenital sphincter relax Importantly, bladder contraction and sphincter relaxation must be coordinated for effective voiding Occasionally, in a condition known as detrusor sphincter dyssynergia, the urethral sphincter fails to relax during contraction of the detrusor, and retention ensues Women with this condition may be treated with pharmacologic agents such as muscle relaxants These drugs purportedly relax the urethral sphincter and levator ani muscles to improve coordinated voiding Smooth muscle cells within the detrusor fuse with one another so that low-resistance electrical pathways extend from one muscle cell to the next Thus, action potentials can spread quickly throughout the detrusor muscle to cause rapid contraction of the entire bladder In addition, the plexiform arrangement of bladder detrusor fibers allows multidirectional contraction and Theories on continence abound and vary in their supporting scientific evidence Most theories can ultimately be distilled down to those that involve the concepts of anatomic stress incontinence and decreased urethral integrity (sphincteric deficiency) when stimulated lead to detrusor contraction Of the muscarinic receptors, five glycoproteins designated M1–M5 have been identified M2 and M3 receptor subtypes have been identified as the ones predominantly responsible for detrusor smooth muscle contraction Thus, treatment with muscarinic antagonist medication blunts detrusor contraction to improve continence Specifically, continence drugs that target only the M3 receptor maximize drug efficacy yet minimize activation of other muscarinic receptors and drug side effects ■ Continence Theories FIGURE 23-6 Striated urogenital sphincter anatomy The perineal membrane is removed to show the three component muscles of the striated urogenital sphincter This sphincter receives most of its somatic innervation through the pudendal nerve FIGURE 23-7 Onuf nucleus is found in the ventral horn gray matter of S2 through S4 This nucleus contains the neurons whose fibers supply the striated urogenital sphincter The urethrovaginal sphincter and compressor urethrae are innervated by the perineal branch of the pudendal nerve The sphincter urethrae is variably innervated by somatic efferents that travel in the pelvic nerves 614 Female Pelvic Medicine and Reconstructive Surgery SECTION FIGURE 23-8 Physiology of urine storage Bladder distension from filling leads to: (1) ␣-adrenergic contraction of the urethral smooth muscle and increased tone at the vesical neck (via the T11-L2 spinal sympathetic reflex); (2) activation of urethral motor neurons in Onuf nucleus with contraction of striated urogenital sphincter muscles (via the pudendal nerve); and (3) inhibited parasympathetic transmission with decreased detrusor pressure ␣ ϭ alpha adrenergic receptors; ␤ ϭ beta adrenergic; M ϭ muscarinic (cholinergic) A B FIGURE 23-9 Drawing of urethral anatomy A Urethral anatomy in cross section Urethral coaptation results in part from filling of the rich subepithelial vascular plexus The urethra contains circular and longitudinal smooth muscle layers B Vesical neck and urethral anatomy The striated urogenital sphincter lies external to the urethral smooth muscle layers Index Baden-Walker Halfway system for evaluation of, 636, 638t classification, 636–637 defect theory of, 639–640 and dyspareunia, 319 epidemiology of, 633 evaluation for, in urinary incontinence, 618 evaluation of patient with, 641–647 magnetic resonance imaging of, 57 nonsurgical treatment for, 648–650, 651t pelvic floor muscle exercise, 649–650 pessaries, use of, 648–649, 651t pathophysiology of, 637–640 connective tissue role in, 639 levator ani muscle role in, 637–639 levels of vaginal support in, 640 vaginal wall in, 639 Pelvic Organ Prolapse Quantification staging system of, 636, 636f, 637f perineal examination in, 644–645, 644f physical examination in, 644–647 risk factors for, 633–635, 634t age, 634 connective tissue disorders, 634 elective cesarean delivery, 634 elevated intraabdominal pressure, 635 obstetric-related, 634 race, 635 vaginal childbirth, 634 signs and symptoms of, 633 surgical treatment for, 651–656 anterior compartment, 652 hysterectomy for, 653 and incontinence surgery, 655–656 laparoscopic and robotic approach for, 652 obliterative procedures, 651 perineum, 654 plan for, 652 posterior compartment, 653–654 reconstructive procedures, 651–652 success of, 656 use of mesh and materials in, 654–655, 655t vaginal apex, 652–653 symptoms associated with, 641–644, 641t bulge symptoms, 643 gastrointestinal symptoms, 643 pelvic and back pain, 643–644 sexual dysfunction, 643 urinary symptoms, 643 vaginal examination in, 645–647, 645f–647f visual descriptors for, 635, 635f Pelvic Organ Prolapse Quantification staging system of pelvic organ prolapse, 636, 636f, 637f Pelvic Organ Support Study (POSST), 634 Pelvic pain in abnormal uterine bleeding, 223 acute, 306–309, 306t chronic, 310–318 adhesions and, 311, 316–317 analgesics for, 314 anticonvulsants for, 316 antidepressants for, 315–316, 315t combination drugs for, 316 computed tomography in, 313 cystoscopy in, 313 definition of, 310 depression in, 311 dyspareunia and, 319 endometriosis and, 310, 314 endoscopy in, 313–314 etiology of, 310 in gastrointestinal disease, 321–323 hernias and, 312 history-taking in, 310–311, 310t hormonal suppression for, 314–315 imaging in, 313–314 laparoscopy in, 313 lithotomy-position examination for, 313 mobility testing in, 312–313, 312f musculoskeletal origins of, 311t, 323–326 neurologic etiologies of, 326–328 and obstetric history, 310–311 ovarian remnant syndrome and, 317 in ovarian retention syndrome, 317 in pelvic congestion syndrome, 317–318 physical examination for, 311–313 and psychosocial history, 311 questions relevant to, 310t sitting posture evaluation in, 313 sonography in, 313 and stance and gait, 311–312, 311t, 312f supine evaluation in, 312–313 surgery for, 316 and surgical history, 311 treatment of, 314–316 interstitial cystitis and, 320 in leiomyomas, 251 Pelvic pain questionnaire, 310 Pelvic plexus, 612f, 928 Pelvic resection, en bloc, 1309–1312, 1309f–1312f Pelvic surgery, and vesicovaginal fistulas, 679 Pelvic ureter, 938 Pelvic wall muscles, in myofascial pain syndrome, 326, 326f Pelvis anatomy of, 922–940 evaluation of, 516–520, 517t blood supply to, 927–928, 927f, 928t bony pelvis and pelvic joints, 922–923 connective tissue of, 639, 927 and surgical spaces of, 934f examination of in menopausal patient, 575 innervation, 928, 929f muscles in, 326 pelvic floor, 925–927 retroperitoneal surgical spaces, 937–940 viscera, 928–937 walls of muscles and fascia of, 923–925, 924f openings in, 922, 923f retroperitoneal space of, 937–938, 938f Penicillamine, hypertrichosis caused by, 464t Penicillin G, 68t Penicillin(s), 67 for Actinomyces israelii infections, 67 adverse effects and side effects of, 67, 70t allergy to, 67 desensitization for, 67 classification of, 68t–69t clinical applications of, 67 and hormonal contraceptive efficacy, 155t plus β-lactamase inhibitor, 67 plus clavulanic acid, 67, 68t plus sulbactam, 67 structure of, 67, 67f Penicillin V (Pen VK), 68t Penile urethra, examination of, 511 Pentosan polysulfate sodium in interstitial cystitis, 321 Pepcid See Famotidine Pergonal, for ovulation induction, 534t Perinatal loss, 368–369 Perineal body, 945 Perineal membrane, 943–944 Perineal sonography, for pelvic floor, 38 Perineoplasty, 1070, 1070f Perineorrhaphy, 654, 1223–1224, 1223f, 1224f Perineum, 941f, 942–945 anal triangle, 944–945 anatomy of, 942–945 blood supply to, 945 defects of, 491 innervation, 946 inspection of, lymphatics of, 945–946 muscles, in myofascial pain syndrome perineal body, 945 urogenital triangle, 942–944 Periodontal disease, and miscarriage risk, 172 Peripartum pelvic pain syndrome, 326 Peripheral nerves, compression of, 327 Peripheral sensitization, 306 Peritoneal disease, and infertility, 542–543 Peritoneal incision, 1021, 1021f, 1023, 1023f Permethrin cream, for scabies, 90 Persistent pulmonary hypertension in the newborn (PPHN), 367–368 Personal Health Questionnaire-2 (PHQ2), 27 1387 1388 Index Pessaries complications with use of, 649, 652f incontinence, 625 indications for use of, 648 patient evaluation and placement, 648–649, 650f, 651t in pelvic organ prolapse, 648–649, 651t space-filling, 648 support, 648, 649f types of, 648, 648f ulcers, 649 PET See Positron emission tomography (PET) Petrolatum (Vaseline) for pediculosis, 91 Peutz-Jeghers syndrome (PJS), 347t, 887, 892 Pfannenstiel incision, 1022–1023, 1022f, 1023f p53 gene, mutation in, 860 Phallus, 486 Phenazopyridine, for cystitis, 93 Phenazopyridine hydrochloride, 680–681 Phenergan See Promethazine Phenobarbital, and hormonal contraceptive efficacy, 155t Phenothiazines and galactorrhea, 341t hirsutism caused by, 464t for nausea and vomiting, 963t Phenylpropanolamine, for stress urinary incontinence, 625 Phenytoin for chronic pain syndromes, 315t and hormonal contraceptive efficacy, 155t hypertrichosis caused by, 464t Pheochromocytoma, paraovarian, 273 Pheromones, 415 Phosphorus-32, 714t Photodynamic therapy (PDT) for vulvar intraepithelial neoplasia, 760 Photoelectric effect, 715, 715f Phthirus pubis, 91f Physical examination in menopausal patient, 575 Physical therapy, for dysmenorrhea, 319 Physiologic discharge, in newborn, 388 Phytoestrogens, for vasomotor symptoms, 589–590 Phytoprogestins, for vasomotor symptoms, 590 Pictorial blood assessment chart (PBAC), 220, 221f PID See Pelvic inflammatory disease (PID) Pimecrolimus, for lichen sclerosus, 116 p16INK4A, 347t, 747 Pinopods, 434 Pioglitazone, 474 and urinary incontinence, 619t Pipelle device, endometrial sampling with, 226–227, 226f Piperacillin, 69t for postoperative infections, 103t Piperacillin-tazobactam, 69t for postoperative infections, 103t Pipracil See Piperacillin Piriformis muscle, 923 stretch injury to, 925 Piriformis syndrome, 328 Pitressin (8-arginine vasopressin), 1040 Pituitary adenomas amenorrhea caused by, 450 classification of, 418, 419t, 420f clinical features of, 419t monohormonal, 418 multihormonal, 418 and pregnancy, 420 reproductive effects of, 420 treatment of, 420–423 Pituitary adenylate cyclase-activating peptide (PACAP), 413 Pituitary apoplexy, 420, 450 Pituitary disease, amenorrhea caused by, 441t, 450 Pituitary gland anterior, 450 acquired abnormalities, amenorrhea caused by, 450 disorders, amenorrhea caused by, 450 hormones, 413–414 inherited abnormalities, amenorrhea caused by, 450 posterior, 416–417 Pituitary tumor(s), amenorrhea caused by, 441t, 450 PJS See Peutz-Jeghers syndrome (PJS) p57KIP2 protein, immunostaining of, 902–903, 903f PKS PlasmaSORD Bipolar Morcellator, 1104 Placental protein 14 (PP14), serum in endometriosis, 290 Placental steroids, 435 Plan B, 163t Plan B One-Step, 163t Planned Parenthood v Casey, 188 Plasmakinetic (PK) Gyrus, 1105 Platelet-derived growth factor (PDGF) in endometrium, 434t Platelet dysfunction, and abnormal bleeding, 235 Platinum compounds, and radiation therapy, combined, 724 Plexus of Santorini, 939 Plicae transversales recti, 937, 937f Ploidy, determination of, 902 Pneumococcal Polysaccharide vaccine (PPSV), 8t Pneumonia, hospital-acquired, 967–968, 967f Pneumoperitoneum, creation of, during laparoscopy, 1095 Podofilox, for external genital warts, 88, 89t Podophyllin, for external genital warts, 88, 89t POF See Premature ovarian failure (POF) Poly (ADP) ribose polymerase (PARP) inhibitors, 707 Polycystic ovarian syndrome (PCOS), 460 amenorrhea caused by, 451 frequency of, 441t androgen excess in, 460 consequences of, 463t CYP11a gene dysregulation in, 461 definitions of, 460–461, 461t diagnosis of, 469–473 cortisol levels and, 471–472 DHEAS levels in, 471 17-hydroxyprogesterone levels in, 471 prolactin level in, 469–470 testosterone levels in, 470–471 thyroid-stimulating hormone level in, 469 etiology of, 461 genetics of, 461 HAIRAN syndrome, 461 incidence of, 460 obesity and, 530 ovarian hyperthecosis, 461 pathophysiology of, 461–463 androgen level in, elevated, 462–463 anovulation in, 463 gonadotropins in, 461, 462f insulin resistance in, 461–462 SHBG levels in, low, 463 and recurrent miscarriage, 186 signs and symptoms of, 463–469 acanthosis nigricans, 466–467, 467f acne, 465f, 465–466 alopecia, 466 amenorrhea, 463 cardiovascular disease, 468 dyslipidemia, 467 endometrial cancer, 468 hirsutism, 463–464 hyperandrogenism, 463–466 impaired glucose tolerance, 467 infertility, 468 insulin resistance, 466–467, 466f menstrual dysfunction, 463 metabolic syndrome, 467–468, 468f obesity, 467, 467f obstructive sleep apnea, 467 oligomenorrhea, 463 pregnancy and neonatal complications, 469 pregnancy loss, 468 psychosocial problems, 469 type diabetes mellitus, 467 sonographic findings in, 472–473, 473f treatment for, 473–477 dietary, 473 exercise in, 473–474 by observation, 473 surgical weight loss in, 473 weight loss in, 473 Polyembryoma, 884 Polyethylene glycol 3350, for IBS, 323t Index Polymerase chain reaction (PCR) testing for herpes simplex infection diagnosis, 77 Polypectomy, hysteroscopic, 1164–1165, 1164f Polypharmacy, for chronic pelvic pain, 316 Polythelia, 391 PONV See Postoperative nausea and vomiting (PONV) POP See Pelvic organ prolapse (POP) Portia, 150t Positive pressure urethrography (PPUG), 49–50 for urethral diverticulum evaluation, 687, 687f Positron emission tomography (PET), 52, 53f for cervical cancer, 778–780 for uterine sarcoma evaluation, 841 Postcoital bleeding, 223 Postcoital test, 520–521, 521f Postembolization syndrome, 256 Posterior colporrhaphy, 1219 procedure for, 1219–1222, 1219f–1222f Posterior superior iliac spine (PSIS), 311 Postmenopausal Estrogen/Progestin Interventions (PEPI) trial, 571, 582 Postmenopausal Evaluation and RiskReduction with Lasofoxifene (PEARL) study, 597 Postmenopause, 554 Postoperative ileus (POI), 969–970 Postoperative nausea and vomiting (PONV), 962 prevention of, 962, 963t Postoperative orders, 962, 964t Postpartum Support International, 368 Postvoid residual (PVR), measurement of postoperative, 620–621 for urinary incontinence evaluation, 620, 620f Power Doppler imaging, 35 PPA See Phenylpropanolamine PPUG See Positive pressure urethrography (PPUG) Pravastatin, for lowering lipids level, 24t Prazosin, and urinary incontinence, 619t Precocious puberty, 393–394 central, 393 definition of, 393 etiologies of, 394t evaluation of, 394t heterosexual, 394 peripheral, 393–394 Preconceptional counseling, topics for, 12t–13t Pregabalin, for chronic pain syndromes, 315t Pregnancy after myomectomy, 1042, 1144 and breast cancer risk, 346 cervical, 213–214, 214f cesarean scar, 214, 215f complications of, in polycystic ovarian syndrome, 469 endocrinology of, 434–435 heterotopic, 214 interstitial, 212–213, 213f laparoscopy in, 1096 ovarian, 212 prevention of, after sexual assault, 371, 372t psychiatric disorders during, 367–369 puerperal mastitis in, 340 and sexuality, 376–377 spontaneous nipple discharge during, 339 unplanned, 132 and urinary incontinence, 608 Pregnancy loss in polycystic ovarian syndrome, 468 with unicornuate uterus, 498 Pregnancy of unknown location (PUL), 204 Prehypertension, 19, 19t, 20t See also Hypertension Preimplantation genetic diagnosis (PGD), 181, 548–549 Prelief See Calcium glycerophosphate Premarin, 597t See also Conjugated equine estrogens (CEE) for dysfunctional uterine bleeding, 238 for menopausal vasomotor symptoms, 587t for menorrhagia, 237t Premature adrenarche, 395 Premature menarche, 395 Premature ovarian failure, 554 evaluation of, 456 Premature ovarian failure (POF) autoimmune disorders and, 446 chromosomal defects and chromosomal mosaicism, 445–446 Turner syndrome, 445, 445f definition of, 444 gene mutations and, 446 incidence of, 444 medical treatments and, 446–447 Premature thelarche, 394 Premenstrual disorders, 364–367 diagnosis of, 365–366 drug therapy for, 366–367, 366t pathophysiology of, 364 central nervous system interaction, 364 renin-angiotensin-aldosterone system, 364 serotonin, 364 sex steroids, 364 signs and symptoms of treatment of, 366–367 Premenstrual dysphoria (PMD), 364 Premenstrual syndrome (PMS), 364–367 Premphase and galactorrhea, 341t for menopausal vasomotor symptoms, 587t Prempro, for menopausal vasomotor symptoms, 587t Preoperative patient evaluation, 948–958 cardiac evaluation in, 951–952 diagnostic testing in, guidelines for, 958 endocrine evaluation in, 956–958 functions of, 948 hematologic evaluation in, 954–956 hepatic evaluation in, 952–953 medical consultation in, 948–949 pulmonary evaluation in, 949–951 renal evaluation in, 953 Preoperative testing, guidelines for, 958 Presacral nerve, 928, 929f Presacral neurectomy (PSN) for chronic pain treatment, 316 for dysmenorrhea, 319 for endometriosis-related pain, 297 Presacral space, 938–939, 939f Pressure flowmetry, 623 Pressure lavage under ultrasound guidance (PLUG), 41 Prevent Recurrence of Osteoporotic Fractures (PROOF) study, 595 Prevesical space, 939–940, 940f Previfem, 150t Primary peritoneal carcinomas, 866, 866t Primaxin See Imipenem-cilastatin Primidone, and hormonal contraceptive efficacy, 155t Principen See Ampicillin Pristiq See Desvenlafaxine PRL See Prolactin Prochieve 4%, for menopausal vasomotor symptoms, 587t Prochlorperazine and galactorrhea, 341t for nausea and vomiting, 963t Procollagen I carboxy terminal propeptide, as marker of bone formation, 577, 577t Procrit See Epoetin alfa Proctalgia fugax, 672 Progesterone, 411t action of, in pregnancy, 441 chemical structure of, 410f serum in ectopic pregnancy, 203 in ovulation tests, 513 serum, reference ranges for, 409t Progesterone antagonists (PAs), for endometriosis, 294 Progesterone receptor, 406 Progesterone withdrawal test, 454 Progestin-only contraceptives, 157–159 injectable progestins, 158–159 progestin-only pills (mini-pills), 157–158 Progestin(s), 410 for adenomyosis, 261 for dysmenorrhea, 319 for endometriosis-related pain, 292–294 and functional ovarian cysts development, 265 hirsutism caused by, 464t implants, 143, 145f 1389 1390 Index Progestin(s) (continued) injectable, 158–159 for leiomyomas, 254 oral for dysfunctional uterine bleeding, 237–238 Progestogens, 410 natural, 410 receptors binding affinities to, 411t synthetic, 410 Prolactin, 532 elevated levels of, 532 increased, amenorrhea caused by, frequency of, 441t, 450 Prolactin inhibitory factor (PIF), 416 Prolactinomas, 417 Prolactin test, in amenorrhea, 455 Prolapse of pedunculated submucosal leiomyoma, 1043 vaginal myomectomy for, 1043–1044, 1043f, 1044f Prolapse ulcers, 649 Prolia See Denosumab Promethazine, for nausea and vomiting, 963t Prometrium See also Micronized progesterone for menopausal vasomotor symptoms, 587t Pronto, 91 Proopiomelanocortin, 413 Propoxyphene, for chronic pelvic pain, 314 Propulsid See Cisapride Prostaglandin E2 (PGE2), role in endometriosis, 282, 283f Prostaglandins, 431 Prostaphlin See Oxacillin sodium Prostate, Lung, Colorectal and Ovarian (PLCO) Trial, 856 Protein C deficiency, 961 Protein S deficiency, 961 Prothrombin G20210A mutation, 961 Prothrombin time (PT), 953 Protopic See Tacrolimus Provera See Medroxyprogesterone acetate (MPA) Proximal fallopian tube cannulation, hysteroscopic, 1176–1177, 1176f Proximal tubal obstruction, 540, 1176 treatment of, 540–541, 541f tubal cannulation for, 1176 (See also Proximal fallopian tube cannulation, hysteroscopic) Prozac See Fluoxetine Pruritus nocturnal, 388 pathogens causing, 89–91 vulvar, in pediatric patient, 387 Pseudocyesis, 449 Pseudogestational sac, 204, 205f Pseudohermaphroditism female, 488–489 male, 489 Pseudo-Meigs syndrome, 252 Pseudomyxoma peritonei, 865, 1333 PSN See Presacral neurectomy (PSN) Psoralens, hypertrichosis caused by, 464t Psoriasis, 117, 117f Psychiatric assessment, of women, 356, 358t Psychiatric disorders, 356–357 in late life, 369–370 during menopausal transition, 369 in menopausal transition, 572 during pregnancy, 367–369 Psychotherapy, for depression in pregnancy, 368 Psyllium, for fecal incontinence, 669t Psyllium husk, for IBS, 323t PTEN gene, role in endometriosis, 284 Pubarche, 383, 395 Puberty delayed, 395, 395t amenorrhea caused by, frequency of, 441t normal, variations of, 394–395 physiologic changes with, 383 Tanner stages of, 383, 384f Pubic hair, development of, 383, 384f Pubis, 922, 922f Puborectalis muscle, 944–945 Pubourethral ligament, 943 Pubovaginal slings, 1196–1197, 1196f, 1197f for SUI, 626t, 627 Pudendal canal, 944, 944f Pudendal nerve terminal motor latency (PNTML), 668–669, 668f Pudendal neuralgia, 327–328 Pudendal thigh fasciocutaneous flaps, 1292 Pulmonary complications postoperative, 966–969 atelectasis, 966–967 pneumonia, 967–968 risk factors for, 966 prevention of, 950–951 risk factors for, 949–950 patient-related, 949–950 surgical (procedure-related), 949 Pulmonary evaluation diagnostic testing in, 950 history-taking in, 950 physical examination in, 950 preoperative, 949–950 Pulmonary function testing, preoperative, 950 Pulmonary toxicity, from bleomycin, 701 Puncture injury, laparoscopy and, 1097 PVDR See Paravaginal defect repair (PVDR) Pyelonephritis, acute uncomplicated, 93 Pyridinoline, urinary, as marker of bone resorption, 577, 577t Pyridium See Phenazopyridine; Phenazopyridine hydrochloride Pyridoxine, in premenstrual syndrome, 367 Pyrogens, 971 Q QCT See Quantitative computed tomography (QCT) Q-tip test, 619, 620f Quantitative computed tomography (QCT), 50, 51 Quantitative real-time polymerase chain reaction (qPCR), 548 Quantitative sonography (QUS), 51 Quasense, 151t Quazepam, for insomnia, 29t Quick Inventory of Depressive Symptomatology-Self Report (QIDS-SR), 357, 360t–361t Quinolones See also Fluoroquinolones prophylactic, perioperative, 959t Quinupristin/dalfopristin for complicated MRSA infections, 105 R Race and pelvic organ prolapse, 635 and urinary incontinence, 608 Radiation biology, 716–719 alpha/beta ratio, 719 cell death, 717–718 cell repair, 718 potentially lethal damage repair, 718 sublethal damage repair, 718 cell survival curve, 719, 719f direct and indirect actions of radiation, 716–717, 717f DNA molecule, breaking of, 716 five R’s of, 718–719 oxygen enhancing ratio, 717, 717f Radiation physics, 712–716 depth-dose curve, 716 electromagnetic radiation, 712–713, 712f, 713f and energy transfer, 715, 715f linear energy transfer, 715–716 particle radiation, 713–714 radiation equipment cobalt machine, 714 linear accelerator (linac), 714 radiation unit, 716 radionuclides, 714, 714t Radiation therapy, 712–727 bioreductive agents with, 723 and blood transfusion, 723 brachytherapy, 712, 721–722 equipment for, 721–722 high dose-rate, 722 interstitial, 721 intracavitary, 721 low dose-rate, 722 manual afterloading approach, 722 permanent, 721 remote afterloading approach, 722 temporary, 721 carcinogenesis caused by, 727, 727t and chemotherapy, combined, 723–724 conformal, 720 Index delivery of, 712 effects of on bladder, 726 on epithelium and parenchyma, 725 on kidneys, 726–727 on ovarian function, 726 on pregnancy outcomes, 726 on rectosigmoid, 726 on skin, 725 on small bowel, 726 on vagina, 725–726 external beam therapy, 712, 720–721 fractionated, 720 altered fractionation, 720 standard fractionation, 719–720 and genitourinary fistulas, 679 hyperbaric oxygen and, 723 image-guided, 721 intensity-modulated, 720, 721f intraoperative, 725 for ovarian germ cell tumors, 886 patient evaluation for, 719 postoperative, 725 preoperative, 724–725 radiation biology and, 716–719 radiation physics and, 712–716 and recombinant human erythropoietin, 723 role of, 713t stereotactic body, 721 and surgery, combined, 724–725 tissue response to, 725–727 tumor control by, probability of, 722–723, 722t intrinsic radiosensitivity in, 722, 722t treatment time in, 722–723 tumor hypoxia and, 723 for vaginal intraepithelial neoplasia, 756 Radical complete vulvectomy, 1340–1342, 1340f–1342f Radical partial vulvectomy, 1337–1339, 1337f–1339f Radiography, 48–49 for ovarian cancer, 861 Radionuclides, 714, 714t Radiotherapy, miscarriage risk from, 173 Raloxifene for breast cancer, 351 chemical structure of, 410f estrogenic agonist/antagonist effects of, 411t for leiomyomas, 255 for lobular carcinoma in situ, 343 for osteoporosis, 592–593, 592t Ramelteon, 366t for insomnia, 29t Raniclor See Cefaclor Ranitidine, and galactorrhea, 341t RANTES, endometriosis and, 283 Rape See Sexual assault Rape trauma syndrome, 372 Raphe, labial, 386 Rapid plasma reagin (RPR) test for syphilis, 79 R&C, 91 Receptor activator of nuclear factor kappa-B (RANK) ligand pathway, 564, 565t Receptor tyrosine kinases (RTKs), 706f, 707 Reclipsen, 150t Recombinant parathyroid hormone for osteoporosis, 595 Rectal examination, in chronic pelvic pain, 313 Rectal pillars, 934 Rectoanal inhibitory reflex (RAIR), 661 Rectocele, 635, 635f abdominal sacrocolpopexy for, 1225–1229, 1226f–1228f repair of, 653 Rectosigmoid resection, 1327–1330, 1328f–1330f Rectouterine pouch, 937 Rectovaginal examination, 6, 6f Rectovaginal fistulas, 1255 repair of, 1255–1256, 1255f, 1256f Rectovaginal fistulas (RVFs), 673–675, 673f classification of, 673 definition of, 673 diagnosis of, 673–674 diagnostic testing for, 674 high, 673 history examination in, 673 low, 673 midlevel, 673 physical examination in, 673–674 risk factors for, 674t treatment of, 674–675 Rectovaginal palpation, in chronic pelvic pain, 313 Rectovaginal space, 934–935 Rectum, 937 accommodation, 661–662 compliance, 662 embryology of, 482, 483f Rectus abdominis myocutaneous (RAM) flaps, 1292, 1294, 1294f, 1295 Rectus sheath, anterior abdominal wall, 918–920, 919f Red clover and galactorrhea, 341t for vasomotor symptoms, 590 Red man syndrome, 74–75, 75t Red raspberry, and galactorrhea, 341t Referral zone, 325 Reglan See Metoclopramide Reid Colposcopic Index, 748, 749t Relative biologic effectiveness (RBE), 716, 716f Remeron See Mirtazapine Remnant cysts, in vagina, 495 Renal disease, and abnormal uterine bleeding, 234 Renal evaluation, preoperative, 953 Replens, for vaginal dryness, 597 Reproductive endocrinology, 400 See also Hormone(s) Reproductive Risks for Incontinence Study at Kaiser (RRISK) study, 634 Repronex, for ovulation induction, 534t Reserpine and galactorrhea, 341t hirsutism caused by, 464t Resistant ovary syndrome, 446 Respiratory physiotherapy, 951 Rete ovarii, 484 Retinoids, topical for acne, 476, 477f Retropubic space See Prevesical space Retropubic urethropexy, 1189–1190 for SUI, 626–627, 626t Revised Cardiac Risk Index (RCRI), 952 Rhomboid flaps, 1292, 1347, 1347f Rid, 91 Rifampin, and hormonal contraceptive efficacy, 155t Rimantadine, and galactorrhea, 341t Ring of fire, 43, 205, 205f, 266 Ring pessaries, 648, 649 Risedronate, for osteoporosis, 592t, 594 Risk of Ovarian Cancer Algorithm (ROCA), 856 Robot-assisted laparoscopic staging, of endometrial cancer, 831 Robotic radical hysterectomy, 1272–1275, 1273f, 1274f Robotic surgery, 1107–1108 DaVinci surgical system, 1107–1108, 1107f patient selection for, 1108 port placement for, 1108, 1108f Robotic surgical staging, for gynecologic malignancies, 1306–1308, 1307f Rocephin See Ceftriaxone Roe v Wade, 188 Rokitansky protuberance, in mature cystic teratoma, 269 Rome III criteria, of functional gastrointestinal disorders, 672, 672t Rosiglitazone, 474 for endometriosis, 296 and urinary incontinence, 619t Rosuvastatin, for lowering lipids level, 24t Rotational flaps, 1292 Rotterdam criteria, for PCOS definition, 460, 461t Round ligaments, of uterus, 930–931, 930f Roux-en-Y gastric bypass, 16 Roxicet See Oxycodone IR RVFs See Rectovaginal fistulas (RVFs) S Sacral nerve stimulation (SNS) for fecal incontinence, 672 for intractable constipation, 673 1391 1392 Index Sacral neuromodulation, 1212–1213, 1212f, 1213f foramen needle insertion, 1212f implantable pulse generator placement, 1213f pulse generator incision and lead passage, 1213f Sacral venous plexus, 939 Sacrocolpoperineopexy, 654 Sacrocolpopexy abdominal, 1225–1229, 1226f–1228f minimally invasive technique, 1230–1233, 1230f–1232f Sacroiliac joint, 922 Sacrospinous ligament, 922, 923 Sacrospinous ligament fixation (SSLF), 653, 1238–1241, 1238f–1240f Sacrotuberous ligament, 922 Sacrum, 922 Safyral, 150t Saline infusion sonography endometrial sampling (SISES), 40, 41f Saline infusion sonography (SIS), 35–36, 35f, 36f, 558 in abnormal uterine bleeding, 228–229, 228f catheter for, 35, 36f complications of, 36 contraindications to, 36 distending solutions for, 35 for endometrial abnormalities, 40–41, 40f in evaluation of pelvic anatomy, 518–519 for lost IUD location, 41 of normal endometrial cavity, 35, 35f in premenopausal woman, 36 submucous leiomyoma, 253f tamoxifen therapy and, 41 for uterine cavity defects, 45, 45f Saline, use of, in colposcopy, 748 Salmon calcitonin, for osteoporosis, 592t Salpingectomy, 1033 in ectopic pregnancy, 211 interval partial indications for, 1030 Irving method, 1032, 1032f modified Pomeroy method, 1031, 1031f Parkland method, 1030–1031, 1030f, 1031f Pomeroy method, 1031, 1031f procedure for, 1030–1032, 1030f–1032f Uchida method, 1031, 1032f laparoscopic, 1129–1130, 1129f, 1130f ectopic pregnancy following, 1130 endoscopic loop ligation, 1130f fallopian tube desiccation, 1129f looped portion of tube excised, 1130f mesosalpinx incision, 1129f procedure for, 1033–1034, 1033f Salpingitis, acute, 93 See also Pelvic inflammatory disease (PID) Salpingitis isthmica nodosa, 515 Salpingostomy, 1033, 1034 in ectopic pregnancy, 211 Sampling, 661 Sanctura, for urge urinary incontinence, 628t Sanctura XR, for urge urinary incontinence, 628t Sandostatin See Octreotide Santura See Trospium chloride Saracatinib, 593 Sarafem See Fluoxetine Sarcoidosis, amenorrhea caused by, 450 Sarcoma botryoides, 813–814, 814f Sarcomas paraovarian, 273 of vulva, 804, 804f Sarcoptes scabiei, scabies by, 89 Sargis uterine manipulator, 1102 Scabies diagnosis of, 89–90 etiology of, 89 treatment of, 90 Scarpa fascia, 918, 919f Schiller-Duval bodies, 883, 883f Sciatic hernia, 312 Sclerosing stromal tumors, 891 Scopolamine for nausea and vomiting, 963t and urinary incontinence, 619t Scotch-tape test, 388 Scrotum, 486 SCSTs See Sex cord-stromal tumors (SCSTs) Seasonalef, 151t Seasonique, 151t Seborrheic keratosis, vulvar, 121 Seizure disorders, oral contraceptives and, 156 Selective androgen-receptor modulators (SARMs), 411 Selective estrogen-receptor modulators (SERMs), 410–411 for leiomyomas, 255 for osteoporosis, 591–593 for vaginal atrophy, 597 Selective muscarinic-receptor antagonists for urge urinary incontinence, 629 Selective photothermolysis, 475 Selective progesterone-receptor modulators (SPRMs), 164, 411 for endometriosis, 294 for leiomyomas, 255–256 Selective salpingography, 50 Selective serotonin-reuptake inhibitors (SSRIs) for chronic pain syndromes, 315t and galactorrhea, 341t for IBS, 323t indications for, 366t side effects of, 366t use in pregnancy, risks of, 367–368 Selective steroid-receptor modulators, 410–411, 411t Self breast examination (SBE), 3, Semen analysis for male fertility evaluation, 522 reference values for, 522t Semen volume, 522 Seminiferous tubule(s), 509f, 521 embryology of, 483 Senile dementia of the Alzheimer type (SDAT), 599 Sentinel lymph node mapping, 1343 Sentinel-node biopsy, and vulvar cancer, 800–801, 801f Separation pain, 210 Septate uterus, 45f, 500–501, 501f Septo-optic dysplasia, 450 Septoplasty, 1174 Septra DS See Trimethoprimsulfamethoxazole DS Septum resection, 1174 SERMs See Selective estrogen-receptor modulators (SERMs) Serotonin and hot flashes, 561 and PMS pathophysiology, 364 role in IBS, 322 5-HT3 Serotonin antagonists, for nausea and vomiting, 963t Serotonin noradrenergic reuptake inhibitors (SNRIs) indications for, 366t side effects of, 366t Serotonin syndrome, 367 Serous borderline tumor, 858f Serous carcinoma, 774, 863, 864f Serous cystadenoma, 266, 268f Serous cystadenomafibroma, 266 Serpasil See Reserpine Serrated graspers, 1101f, 1102 Sertoli cells, 483, 485t, 521 Sertoli cell tumors, 891 Sertoli-Leydig cell tumors, 891–892 Sertraline, 366t and galactorrhea, 341t Sex cord-stromal tumors (SCSTs) ovarian, 887–894 chemotherapy for, 893–894 classification of, 888, 889t clinical presentation of, 887 computed tomography for, 888 diagnosis of, 887–888 role of generalist in, 888 diagnostic procedures for, 888 epidemiology of, 887 FOXL2 gene mutation and, 887 histologic grading, 888 imaging of, 888 laboratory testing for, 887–888 natural history of, 888 origin of, 880f, 887 Index pathology of, 888–892 patterns of growth and spread, 888 physical findings in, 887 postoperative treatment of, 893f in pregnancy, 894 prognosis for, 887 radiation therapy for, 894 recurrent, 894 stage and survival of, 890t staging of, 893f surgery for, 892 surveillance, 893 treatment of, 892–894 tumor markers for, 888t unclassified, 892 WHO classification of, 889t Sex cord tumors with annular tubules, 892 Sex, determination of, 482, 483 Sex-determining region of the Y (SRY ), 483 Sex hormone-binding globulin (SHBG), 405, 522 and gestational diabetes mellitus, 463 in menopausal transition, 557–558 in polycystic ovarian syndrome, 463 Sex of rearing, 395–396 Sexual abuse, 372 See also Child sexual abuse and chronic pelvic pain, 311 and primary dyspareunia, 319 Sexual arousal, 376 disorders of, 378t Sexual assault, 370–372 definition of, 370 documentation of evidence gathering after, 371 follow-up care after, 372 physical examination and evidence collection after, 370–371, 371t physical findings in, 370 pregnancy prevention after, 371, 372t psychological response to, 372 psychological sequelae, 370 sexually transmitted disease prevention after, 371–372, 372t treatment after, 371–372 Sexual aversion disorder, 378t Sexual desire, 376 hypoactive, 378t Sexual development disorders, investigation of, algorithm for, 492f Sexual dysfunction, 377–378, 378t evaluation of, 377–378 incidence of, 377 in menopausal patient, 573–574 risk factors for, 377 treatment of, 378 Sexual infantilism, 446 Sexuality, 375–377 in late life, 377 in menopausal transition, 377 pregnancy and, 376–377 Sexually transmitted disease (STD) See also Chlamydia trachomatis; Gonorrhea; Trichomoniasis prevention of, after sexual assault, 371–372, 372t screening for, 7, 11t Sexual response cycle, 375–376, 375f arousal, 376 drive/desire, 376 release, 376 resolution, 376 A-200 shampoos, 91 SHBG See Sex hormone-binding globulin (SHBG) Sheehan syndrome amenorrhea caused by, frequency of, 441t, 450 Shigella spp., prepubertal vulvovaginitis caused by, 389 Shock index, ruptured ectopic pregnancy and, 202 Sibutramine, 16 Sigmoid conduits, 1284 Sildenafil citrate, 544 Silver nitrate, for wound care, 974t Sims-Huhner test, 520–521, 521f Simvastatin, 24t for endometriosis, 296 for lowering lipids level, 24t Sinecatechin ointment for external genital warts, 88, 89t Single-incision laparoscopic surgery (SILS) See Single-incision surgery Single-incision surgery, 1115, 1115f Single-port access (SPA), 1115 Sino-implant II, 143 SIS See Saline infusion sonography (SIS) Sitz baths, 387 Skeletal muscle relaxants and urinary incontinence, 619t Skene gland(s), 123, 941 abscess, 123 cysts, 123 embryology of, 482 Skin aging, treatment of, 598 cancer screening for, 11 menopausal transition and, 571 Ski needle, 1117–1118, 1118f Skinning vulvectomy, 1335–1336, 1335f, 1336f Sleep disordered breathing (SDB), 572 Sleep dysfunction, in menopausal transition, 561, 563t, 571–572 Sleep medication, for vasomotor symptoms, 589 Slippery Stuff, 597 Small bowel resection, 1325–1326, 1325f, 1326f Small bowel obstruction (SBO), 970 treatment of, 970 Small cell carcinoma ovarian, 866 hypercalcemic type, 866 pulmonary type, 866 Small intestines, obstruction of, 970 Smoking, 27, 29 and cervical cancer, 739, 770 cessation of, drugs for, 28t and ectopic pregnancy risk, 201 effect on fertility, 508t and endometrial cancer, 819 and infertility, 530 and pelvic organ prolapse, 635 pharmacotherapy for, 28t, 29 and pulmonary complications risk, 949 and urinary incontinence, 609 SNS See Sacral nerve stimulation (SNS) Solia, 150t Solid tumor(s), paraovarian, 272–273 Solifenacin, for urge urinary incontinence, 628t, 629 Somatoform disorders, 370 Sonography, 33–48 in abnormal uterine bleeding, 227–229 for abnormal uterine bleeding evaluation, 558 for adenomyosis, 39, 39f of adnexal torsion, 271, 271f beads on a string sign in, 43f for breast mass, 336 in young female, 392 in chronic pelvic pain, 313 clinical applications of, 38–46 compression, 48 Doppler technology, 35 double decidual sign on, 43, 44f in ectopic pregnancy, 43, 44f, 204–205, 204f, 205f of endometrial abnormalities, 39–41 for endometriosis, 46 examination techniques, 34–36 focused ultrasound therapy, 34–35 free fluid detection by, 43–44 for functional ovarian cysts, 265–266, 265f, 266f in gestational trophoblastic disease, 44 harmonic imaging in, 34 of hematometra, 259f for hydrosalpinx, 273, 273f hysterosalpingo-contrast, 46 in infertility, 44–46 in intraabdominal fluid, 43–44 for leiomyomas, 38–39, 39f, 253, 253f of mature cystic teratoma, 269, 269f for monitoring folliculogenesis, 46 normal findings on, 36–38 endometrium, 37–38, 37f pelvic floor, 38 reproductive tract organs, 36–37, 36f, 37f for ovarian cancer, 861, 862f for ovarian cyst, 263 of ovarian germ cell tumors, 880 of ovarian masses, 41–42, 42f in ovulation evaluation, 514 in pelvic inflammatory disease, 42–43, 43f 1393 1394 Index Sonography (continued) physics of, 33–34 in polycystic ovarian syndrome, 472–473, 473f quantitative, 51 saline-infusion, 35–36, 35f, 36f in evaluation of pelvic anatomy, 518–519 screening, 348 three-dimensional, 46–48 transabdominal, 34 transrectal, 34 transvaginal, 34 in evaluation of pelvic anatomy, 518, 519f for molar pregnancy, 902, 902f of ovarian teratoma, 34f of premenopausal ovary, 34f of tuboovarian abscess, 274 for urethral diverticulum evaluation, 687–688, 688f for uterus didelphys, 45, 45f Sonohysterography See also Saline infusion sonography (SIS) in abnormal uterine bleeding, 228–229, 228f Sonosalpingography See Hysterosalpingocontrast sonography (HyCoSy) Sonovaginography, 35 Sorafenib, 724 Sorbitol (70%), for IBS, 323t Soy products, for vasomotor symptoms, 589 Space of Retzius See Prevesical space Spectracef See Cefditoren Speculum examination, 4–5, 5f Spence procedure, 689 Spermatogenesis, 510f, 511, 521–522 Sperm Chromatin Structure Assay (SCSA), 524 Sperm count, 522 Sperm DNA testing, 181 Sperm function, assays of, 524 Spermicide-microbicide agents, 162 Spermicides, 161–162 Spermiogenesis, 510f Sperm morphology, 523 abnormal, 523, 523t Sperm motility, 523 Sperm penetration assay, 524 Sphincteroplasty, 1252–1254, 1252f, 1253f end-to-end, 1252, 1253f overlapping, 1252, 1253f Sphincter urethrae, 936, 936f Spiegelian hernia, 920 Spinnbarkeit, 520 Spiral CT, 51 Spironolactone for hirsutism, 475 and urinary incontinence, 619t Splenectomy, 1315–1316, 1315f, 1316f Split-thickness skin grafts (STSG), 1292, 1293, 1293f, 1295, 1346, 1347f Sprintec, 150t SPRMs See Selective progesterone-receptor modulators (SPRMs) Squamocolumnar junction (SCJ), 128, 930 Squamous cell carcinoma of cervix, 771, 773–774, 774f (See also Cervical cancer) of endometrium, 827 ovarian, 865 Squeeze pressure, 661 Sronyx, 150t SSLF See Sacrospinous ligament fixation (SSLF) SSRIs See Selective serotonin-reuptake inhibitors (SSRIs) Stages of Reproductive Aging workshop (STRAW) report on female reproductive aging nomenclature, 554–555, 555f Staphylococcus aureus prepubertal vulvovaginitis caused by, 389 toxic shock syndrome by, 105t Staplers, use of, 1119 Statins, 24t Sterilization, 145–148 See also Tubal sterilization female, 145–147 indications for, 145 patient regrets about, 145 hysterectomy for, 146 laparoscopic, 1123–1128 bipolar electrosurgical coagulation, 1124–1125, 1125f clip application around fallopian tube, 1124, 1124f closed clip around tube, 1125f Falope ring and ring stretched around applicator, 1125f Falope ring applicator placement, 1126f Falope ring in place, 1127f Filshie clip placement, 1124, 1124f Hulka clip application, 1127, 1127f Hulka clip closure, 1127, 1127f Hulka spring secured, 1128f pap smear screening before, 1123 pregnancy evaluation before, 1123 risks from, 1123 tube drawn into inner sheath, 1126f male, 147–148 reversibility of, 540–541 transcervical, 146–147, 1172–1173, 1172f, 1173f Steroid-cell tumors, 892 Steroid-cell tumors not otherwise specified (NOS), 892 Steroid hormone contraception, and dysmenorrhea, 318–319 Steroidogenesis, 403, 403f and clinical disorders congenital adrenal hyperplasia, 405 ovarian, 425 in childhood, 427 postmenopause, 428 at puberty, 427–428, 427f two-cell theory of, 425, 427f Steroidogenic enzyme, 403, 403t Steroid receptor superfamily classification of, 406 modular structure of, 406, 407f Steroid(s) adrenal, in menopausal transition, 556–557 gonadal, 440 gonadal, release of, in gestation, 382 placental, 435 reference ranges for, 409t Stimulation tests, 408 St Marks (Vaizey) Incontinence Score, 663–664, 663t Stool DNA (sDNA) test, 11 for colorectal cancer detection, 15t Stool guaiac testing, in pelvic pain, 307 STOP-Bang survey, 949 Storz Rotocut, 1103–1104 Straddle injury in pediatric patient, 390f Straight leg test, 313 Strassman metroplasty, for bicornuate uterus repair, 500, 500f Streak gonads, 445, 445f, 446, 489 Streptococcus pneumoniae prepubertal vulvovaginitis caused by, 389 Streptomycin, hypertrichosis caused by, 464t Stress amenorrhea caused by, 448–449 frequency of, 441t management of, and fertility, 531–532 Stress urinary incontinence (SUI), 606 See also Urinary incontinence Striated urogenital sphincter complex, 936, 936f Stroke, 24, 25t Stromal cells, 425 Stromal luteomas, 892 Strontium-89, 714t Struma ovarii, 267 STSG See Split-thickness skin grafts (STSG) Subareolar duct excision, for pathologic nipple discharge, 340 Subseptate, 45f Substance abuse, 29–30, 357 diagnostic criteria for, 363t Substance dependence, diagnostic criteria for, 363t Sumatriptan, and galactorrhea, 341t Sunitinib, 706f, 707 Superficial circumflex iliac artrey, 920f, 921 Superficial epigastric vessels, 920f, 921 Superior hypogastric plexus See Presacral nerve Superior rectal artery, 928 Suppression tests, 408 Suppressive therapy, for herpes simplex virus infection, 78, 78t Index Suprapubic teloscopy, 1187, 1188f Suprax See Cefixime Surgery for bicornuate uterus, 500, 500f for breast cancer, 350 for chronic pelvic pain, 316 diaphragmatic, 1317–1318, 1317f for dysmenorrhea, 319 for gynecologic malignancies, 1259–1348 informed consent for, 958 for lichen sclerosus, 116 for LMP tumors, 858 for longitudinal vaginal septum, 494–495 postoperative orders for, 962, 964t prophylactic antibiotics for, 958, 959t for septate uterus, 501 for transverse vaginal septum, 493–494 for vulvodynia, 127 Surgical site infection, interventions for prevention of, 973t Suspensory ligament, of ovary, 933 Sutent See Sunitinib Suture loops, 1119, 1119f Suturing, 1116–1119 Swyer syndrome, 446 Symphysis pubis, 922 Synarel See Nafarelin Synechiae, 516, 542, 1178, 1178f Synercid See Quinupristin/dalfopristin Syphilis, 78–80 CNS complications of, 79 diagnosis of, 79–80 latent, 79 early, 79 late, 79 pathophysiology of, 78 primary, 78, 79f secondary, 78–79, 79f serofast, 79 tertiary, 79 treatment of, 80, 80t by Treponema pallidum, 78, 78f Syringoma, 122 vulvar, 122, 122f Systemic lupus erythematosus, oral contraceptives and, 156 T Tacrolimus, for lichen sclerosus, 116 Tagamet See Cimetidine Tamoxifen, 705–706 and abnormal uterine bleeding, 233 adenomyosis and, 260 for breast cancer, 350, 351 chemical structure of, 410f for ductal carcinoma in situ, 345 and endometrial cancer, 818 estrogenic agonist/antagonist effects of, 411t and functional ovarian cysts development, 265 for lobular carcinoma in situ, 343 for mastalgia, 342 mechanism of action of, 705–706 for ovulation induction, 533 toxicity of, 706 Tampon test, 680 Tanner stages, 383, 384f TAS See Transabdominal sonography (TAS) Taxanes for breast cancer chemotherapy, 350 for cancer, 702–703, 702f, 703t and radiation therapy, combined, 724 Taxol See Paclitaxel Taxotere See Docetaxel Tazarotene, for acne, 476, 477f Tazicef See Ceftazidime TCAs See Tricyclic antidepressants (TCAs) Tdap (Tetanus, diphtheria, pertussis) vaccine, 9t Td (Tetanus, diphtheria) vaccine, 9t Tegaserod, for IBS, 322 Tegress, for urethral bulking, 1198 Tegretol See Carbamazepine Tegrin LF, 91 Telavancin, for complicated MRSA infections, 105 Temazepam efficacy, hormonal contraceptives and, 154t for insomnia, 29t Temovate, for lichen sclerosus, 114, 115t Temsirolimus (CCI-779), 707 Tenormin See Atenolol Tension-free vaginal tape (TVT), 626t, 627, 1191 procedure for, 1191–1193, 1192f, 1193f Teratoma(s), 266–269 fetiform, 267 immature, 267 mature cystic, 267–269, 268f, 269f (See also Mature cystic teratoma) mature solid, 267 monodermal, 267 tissues in, 267 Teratospermia, 523, 523t Teratozoospermia, 545 Terazosin, and urinary incontinence, 619t Terconazole for candidiasis, 85t for vulvovaginal candidiasis, 85t Teriparatide, for osteoporosis, 592t, 595 Terminal deoxynucleotidyl transferasemediated dUTP nick-end labeling (TUNEL) assay, 524 Testes, 509f embryology of, 483–484, 485f functions of, 521 Testicular biopsy, 525 Testicular sperm extraction (TESE), 545 Testosterone chemical structure of, 410f elevated levels of in polycystic ovarian syndrome, 463 free, measurement of, 405 hirsutism caused by, 464t levels, measurement of, 455 maternal exposure to, and ambiguous genitalia, 488 role in male phenotype development, 483–484 serum, reference ranges for, 409t 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) role in endometriosis, 284 Tetracyclic antidepressants indications for, 366t side effects of, 366t Tetracyclines, 75–76 adverse reactions from, 76 and hormonal contraceptive efficacy, 155t spectrum of action of, 75–76 Theca cells, 425 Theca-lutein cysts, 44, 266 Thecomas, 890 Thelarche, 383, 390, 391 premature, 391, 391f Theophylline, efficacy, hormonal contraceptives and, 154t Thermablate Endometrial Ablation System, 1170 ThermaChoice III Uterine Balloon Therapy System, 1170, 1171f Thermal balloon ablation systems, 1170 Thermal injury, laparoscopy and, 1098 Thermoregulation, in menopausal transition, 560–563, 562f Thiazolidinediones, 474 and urinary incontinence, 619t ThinPrep, 741 Thioridazine, and urinary incontinence, 619t Thorazine See Chlorpromazine Threading, 475 3-dimensional conformal radiation therapy (3D-CRT), 720 Three-dimensional sonography, 46–48 for congenital müllerian anomalies, 47–48 for IUD positioning, 47, 48f for pelvic floor anatomy, 38 of septate uterus, 45, 45f for transcervical sterilization confirmation, 47, 48f of unicornuate uterus, 45, 46f 3-D sonography with power Doppler angiography (3D-PDA), 47 Three-swab test See Tampon test Thromboembolism, venous acute, anticoagulation for, 954, 955f prevention of, 954–956, 955f recurrent, anticoagulation for, 954–956, 955f Thrombophilias, and miscarriage risk, 174 Through-transmission, 34, 34f 1395 1396 Index Thyroid disease, 25 and abnormal uterine bleeding, 234 amenorrhea caused by, frequency of, 441t, 451 early pregnancy loss from, 173 Thyroid-stimulating hormone (TSH), 401, 416 in amenorrhea, 455 Thyrotropin-releasing hormone (TRH), 413–414, 416 Tibolone, for leiomyomas, 255 Ticarcillin, 68t Ticarcillin-clavulanate, 68t for postoperative infections, 103t Tigan See Trimethobenzamide Tigecycline, for complicated MRSA infections, 105 5-mm Ti-KNOT instrument, 1119 Tilia Fe, 151t Timentin See Ticarcillin-clavulanate Tindamax See Tinidazole Tinidazole, 75 for bacterial vaginosis, 67t for trichomoniasis, 86, 86t Tinzaparin, 969t Tioconazole for candidiasis, 85t for vulvovaginal candidiasis, 85t Tischler cervical biopsy instrument, for vulvar sampling, 112–113 Tissue culture, for herpes simplex infection diagnosis, 77 Tissue plasminogen activator (TPA), 433 Tissue-selective estrogen complexes (TSEC), 593 TMP-SMZ See Trimethoprimsulfamethoxazole (TMP-SMZ) Tobacco use, and cervical cancer, 739 Today brand vaginal sponge, 162, 162f Tofranil See also Imipramine for urge urinary incontinence, 628t Toki-shakuyaku-san, for dysmenorrhea, 319 Tolterodine, for urge urinary incontinence, 628–629, 628t Tomosynthesis, breast, 348 Toothed graspers, 1101 Topical antibiotics, for acne, 476 Topiramate, and hormonal contraceptive efficacy, 155t Topoisomerase inhibitors, for cancer, 704 Topotecan, 703t, 704 administration of, 704 and extravasation injury, 696t mechanism of action of, 704 toxicity of, 704 Toremifene, for mastalgia, 342 Total laparoscopic hysterectomy (TLH), 1152–1156, 1153f–1156f Toviaz, for urge urinary incontinence, 628t Toxic shock syndrome, 105, 105t Trachelectomy, 1055–1056 extraperitoneal dissection, 1055, 1055f stump excision, 1056, 1056f uterosacral and cardinal ligament transection, 1055–1056, 1055f Tramadol hydrochloride, 314 Tranexamic acid for dysfunctional uterine bleeding, 239 for menorrhagia, 237t Tranquilizers, efficacy, hormonal contraceptives and, 154t Transabdominal pelvic sonography for ovarian tumors in prepubertal child, 390 Transabdominal sonography (TAS), 34 for ovarian cyst, 263 Transanal sonography, 666–667, 667f Transcervical sterilization, 1172–1173, 1172f, 1173f Transcutaneous electrical nerve stimulation (TENS), for dysmenorrhea, 319 Transderm Scop See Scopolamine Transforming growth factor-β (TGF-β) family in endometrium, 434t Transitional cell carcinoma, ovarian, 865 Transobturator tape (TOT), 626t, 627–628 sling, 1194–1195, 1195f Transrectal sonography, 34 for anal sphincter morphology after childbirth, 38 Transvaginal approach, to genitourinary fistula repair, 682 classical technique in, 682 Latzko technique in, 682 Transvaginal color Doppler sonography (TV-CDS) in abnormal uterine bleeding, 229, 229f of adnexal torsion, 271 for ovarian cyst, 263 Transvaginal sonography (TVS), 34, 38 in abnormal uterine bleeding, 227–228, 227f of adenomyosis, 39, 39f for endometrial abnormalities, 39–40 of leiomyomas, 38–39, 39f for molar pregnancy, 902, 902f for ovarian cyst, 263 for paraovarian cyst, 272 Transversalis fascia, anterior abdominal wall, 919f, 920 Transverse abdominal incision(s), 1022– 1023, 1022f, 1023f, 1024, 1024f, 1025, 1025f Transverse cervical ligaments, 930 Transverse colon conduit, 1284, 1287, 1287f Transverse vaginal septum, 493–494, 494f Trastuzumab, for breast cancer, 349, 350 Trauma, genital, in pediatric patient, 389 Trazodone, 366t for vasomotor symptoms, 588t Trelstar See Triptorelin Trendelenburg test, 312 Treponema pallidum risk factors for, 11t screening for, 11t syphilis by, 78, 78f Treponema pallidum particle agglutination (TP-PA), 79 Tretinoin, for acne, 476, 477f Triazolam, for insomnia, 29t Trichloroacetic acid, for external genital warts, 88, 89t Trichomonas vaginalis in sexually abused child, 389 trichomoniasis by, 84–86, 86f Trichomoniasis co-infections in, 84 diagnosis of, 84–85 epidemiology of, 84 treatment of, 85–86, 86t Tricyclic antidepressants (TCAs) for chronic pain syndromes, 315t and galactorrhea, 341t for IBS, 323, 323t indications for, 366t side effects of, 366t and urinary incontinence, 619t for vulvodynia, 127 Trigger point(s), 324 inactivation of, 326 in myofascial pain syndrome, 324–326 palpation of, 325, 325f Triglycerides, serum, 23t Trihexyphenidyl, and urinary incontinence, 619t Tri-Legest, 151t Tri-Levlen, 151t, 163t Tri Lo Sprintec, 150t Trimethobenzamide, for nausea and vomiting, 963t Trimethoprim-sulfamethoxazole DS for granuloma inguinale, 81t Trimethoprim-sulfamethoxazole (TMP-SMZ) for mastitis in pregnancy, 340 for uncomplicated MRSA infections, 105 for vulvar abscess, 106 for vulvovaginitis in children, 389 Trimethoprim-sulfaoxazole DS (Bactrim DS, Septra DS), 72t Trimo-San gel, 649 Trimox See Amoxicillin Trinessa, 151t Tri-Norinyl, 151t Triphasil, 151t, 163t Triple test, concordant, 337 Triploidy, 172 Tri-Previfem, 151t Triptorelin for endometriosis, 295 for leiomyomas, 255 Tri-Sprintec, 151t Trivalent inactivated influenza vaccine (TIV), 8t Trivora, 151t, 163t Trocars, 1112, 1112f Index Trocar-site cancer metastasis, laparoscopy and, 1099 Troglitazone, and urinary incontinence, 619t Troleandomycin, efficacy, hormonal contraceptives and, 154t Trophectoderm biopsy, 549f Trospium chloride, for urge urinary incontinence, 628t, 629 TSH See Thyroid-stimulating hormone (TSH) Tubal abortion, 207 Tubal embryo transfer (TET), 548 Tubal ligation, and ovarian cancer, 854 Tubal occlusion chemical methods of, 147 mechanical methods of, 146–147 Tubal Ring, for tubal occlusion, 145 Tubal rupture in ectopic pregnancy, 199–200 and intraabdominal hemorrhage, 207 Tubal sterilization, 145 counseling for, 145 and ectopic pregnancy risk, 201 failure rate, 145–146, 146f and functional ovarian cysts, 146 and menstrual irregularities, 146 methods for tubal interruption, 145 nonpuerperal (interval), 145 psychological sequelae of, 146 puerperal, 145 reversal, 146 and risk of ectopic pregnancy, 146 surgical approach for, 145 Tuberculosis, amenorrhea caused by, 450 Tuberculous endometritis, Asherman syndrome by, 444 Tuboovarian abscess, 43, 43f, 96–97, 97f, 274 and PID, 97 signs of, 97 treatment of, 97 Tuboovarian complex, 43, 97, 274 Tumor markers, for ovarian malignancies, 262 Tumor necrosis factor-β (TNF-β) in endometrium, 434t Tumor(s) amenorrhea caused by, 449–450 solid, paraovarian, 272–273 Turner syndrome, 171, 445, 445t, 489, 490f TV-CDS See Transvaginal color Doppler sonography (TV-CDS) TVS See Transvaginal sonography (TVS) TVT See Tension-free vaginal tape (TVT) TVT-Secur, 628 Twin-twin transfusion syndrome (TTTS ), 538 Tygacil See Tigecycline Typical pelvic pain posture (TPPP), 311, 312f Tyrer-Cuzick model, for breast cancer risk calculation, 346 Tyrer-Cuzick program, 854 U UAE See Uterine artery embolization (UAE) Ulceration, definition of, 76 Ulcers, genital, infection, 76–82 Ulipristal acetate, 164 Ulipristal (CDB-2914), 256 Ultrasonic scalpel, 1105–1106, 1105f Ultravate, for lichen sclerosus, 114, 115t Umbilical ligaments, 920–921, 920f Unasyn See Ampicillin-sulbactam Undernutrition and amenorrhea, 531, 532t and infertility, 531 Unicornuate uterus, 45, 46f, 497–499, 498f Unipen See Nafcillin sodium United States Medical Eligibility Criteria (US MEC), for contraceptive use, 133–134 Urachus, 920 Ureteric bud, 482 Ureter(s), embryology of, 482, 483f Urethra anatomy of, 614f, 936–937, 936f blood supply to, 937 diverticulum repair, 1203–1205, 1203f, 1204f embryology of, 482, 483f innervation, 937 phallic, 491 Urethral bulking agents, injection of, 625, 626t Urethral bulking injections, 1198–1199, 1199f Urethral coaptation, 611 Urethral diverticulum, 123, 683–689 classification of, 685–686, 685f cystourethroscopy for, 686, 687f description of, 683 diagnosis of, 686–688 etiology/pathophysiology of, 683–685 acquired diverticulum, 683–685 cancer, 685 congenital diverticulum, 683 infection, 684 stones, 685 urethral trauma, 684 incidence of, 683 magnetic resonance imaging for, 688 mechanism of development of, 684, 684f physical examination in, 686 positive pressure urethrography for, 687 signs and symptoms of, 686 sonography for, 687–688, 688f treatment of, 688–689 voiding cystourethrography for, 687 Urethral gland(s), embryology of, 482 embryology of, 482 Urethral insert for stress urinary incontinence, 625 Urethral integrity factors affecting, 616 restoration of, 616 Urethral pressure profile, 623 Urethrolysis, 1200–1201, 1200f, 1201f Urethroscopy diagnostic and operative, techniques for, 1185–1188, 1186f, 1187f Urethrovaginal fistulas, 683 Urinalysis, for urinary incontinence evaluation, 620 Urinary bladder, 482 Urinary conduit(s) continent, 1284, 1288–1291, 1288f–1290f incontinent, 1284–1287, 1285f–1287f Urinary continence physiology of, 609 pressure transmission theory, 615–616, 615f theories of, 612, 615–616 Urinary incontinence, 606–630 conservative treatment for, 624–625 biofeedback therapy, 624 diet, 624 electrical stimulation, 624 estrogen replacement, 625 pelvic floor muscle training, 624 pelvic floor strengthening exercises, 624 scheduled voiding, 624–625 definition of, 606 diagnosis of, 616–623 bimanual and rectovaginal examination in, 619 neurologic evaluation in, 618 past medical history in, 618, 619t patient questionnaire for, 616–617, 616t pelvic support assessment in, 618 physical examination in, 618–619 symptom clustering in, 616–617, 617t tests for, 620–623 urinary symptoms in, 617–618 voiding diary in, 617 epidemiology of, 607 functional, 606 mixed, 606 pathophysiology of, 609–616 prevalence of, by age group, 607f risk factors for, 607–609, 608t age, 607–608, 607f childbirth and pregnancy, 608 family history, 608–609 hysterectomy, 609 menopause, 608 obesity, 608 race, 608 smoking and chronic lung disease, 609 stress, 606 treatment of, 625–628 treatment of, 624–630 urge, 606 Urinary retention, 630 postoperative, 966 Urinary system, embryology of, 481–487 1397 1398 Index Urinary tract infections (UTIs), 91–93 See also Cystitis pathogenesis of, 91 treatment of, 94t Urinary tract injury, laparoscopy and, 1098 Urine, storage of, 614f Urine culture, for urinary incontinence evaluation, 620 Urine evacuation, physiology of, 615f Urine LH surge assays, 513 Urodynamic stress incontinence (USI), 606 cystometrography for, 621–623, 622f Urodynamic studies (UDS), 621 Uroepithelium, 609 Uroflowmetry, 621 Urogenital atrophy, in menopausal transition, 573 Urogenital hiatus, 923, 924f Urogenital ridge, 481, 482f Urogenital sinus, 482, 483f Urogenital sphincter, 609–610, 613f Urogenital tract, embryology of, 481–487 Urogenital triangle, 794, 942–944 deep perineal space, 943, 943f perineal membrane, 943–944 superficial space, 942–943 Urogynecology, magnetic resonance imaging in, 57–58 Urokinase, 433 Urorectal septum, 482, 483f USI See Urodynamic stress incontinence (USI) U.S Preventive Services Task Force (USPSTF), 2, 7, 742 breast cancer screening guidelines by, 14t Ustekinumab, for psoriasis, 117 Uterine artery, 931, 931f Uterine artery embolization (UAE), 38, 51, 256, 256f, 257f for adenomyosis, 261 for dysfunctional uterine bleeding, 239 for leiomyomas, 256–257, 257t preoperative, for myomectomy, 1039 Uterine bleeding, abnormal and myomectomy, 1039 preoperative control of, 1039 Uterine didelphys, 499, 499f magnetic resonance imaging and, 56, 56f Uterine diverticula, 261 Uterine isthmus, 929 Uterine leiomyomas, and recurrent miscarriage, 181 Uterine manipulators, 1102–1103, 1102f Uterine papillary serous carcinoma (UPSC), 826 management of, 832–834 Uterine procidentia, 635 Uterine prolapse, 635 Uterine receptivity, 434 Uterine sarcoma, 839–850 adenosarcoma, 845–846, 846f advanced/recurrent, treatment of, 849– 550 carcinosarcomas, 845, 845f, 846f, 848, 850 diagnosis of, 840–841 and role of generalist, 841 early-stage, treatment of, 848–849 adjuvant chemotherapy, 849 adjuvant radiation, 849 and fertility-sparing management, 849 surgery, 848–849 surveillance, 849 endometrial sampling for, 840 endometrial stromal nodule, 843 endometrial stromal sarcoma, 843, 844f endometrial stromal tumors, 843, 848, 850 epidemiology of, 839 high-grade undifferentiated sarcoma, 843, 844f, 845 imaging studies for, 841 laboratory test for, 841 leiomyosarcomas, 842–843, 842f, 843t, 848–850 mixed, 841 overall survival of, 850 pathogenesis of, 839–840 pathology of, 841–846 patterns of spread of, 846–847 prognosis for, 850 pure, 841 risk factors for, 839 signs and symptoms of, 840, 840f smooth muscle tumor of uncertain malignant potential, 843 staging for, 847, 847t, 848f Uterine septum, 1174, 1174f Uteroovarian ligament, 932 Uterosacral ligaments, 639, 930 Uterosacral ligament suspension abdominal, procedure for, 1234–1235, 1234f, 1235f vaginal, procedure for, 1236–1237, 1237f Uterovaginal canal, 484 Uterus, 483f anatomy of, 928–929, 930f anomalies and infertility, 516 arcuate, 46, 47f, 501, 501f bicornuate, 499–500, 500f diagnosis of, 499–400 hysterosalpingography of, 499 and infertility, 516 magnetic resonance imaging for, 499–500 sonography for, 499 blood supply of, 222, 222f, 931, 931f broad ligaments of, 931 in childhood, 383, 384f didelphic, 499, 499f evaluation of, in chronic pelvic pain, 313 innervation, 932 lymphatic drainage of, 932, 932f magnetic resonance imaging of, 54, 54f measurement of, 36 neonatal, 383, 384f pathophysiology of, 499 reproductive outcomes with, 499 round ligaments of, 930–931, 930f septate, 500–501, 501f diagnosis of, 501 and infertility, 516 pathophysiology of, 500 reproductive outcomes with, 500–501 spontaneous abortion rate for, 500–501 treatment of, 501 sonography for evalution of, 38–41 treatment of, 500, 500f unicornuate, 497–499, 498f diagnosis of, 498 and infertility, 516 management of, 498–499 and pregnancy loss, 498 and rudimentary development of uterine horn, 498 Uterus didelphys and infertility, 516 sonography for, 45, 45f UTIs See Urinary tract infections (UTIs) V Vaccination, 7, 8t–10t Vaccines cancer, 707 for prevention of HPV infection, 737 Vagifem, 596 Vagina adenosis in, 813 anatomy of, 933–935, 933f blood supply to, 935 cysts, 495 embryology of, 482, 483f, 485, 486f examination of in menopausal patient, 575 functional, creation of, 497, 1075 (See also McIndoe procedure) innervation, 935 lesions of, 128 longitudinal septum, 494–495 obstructive variety of, 494, 495f lymphatic drainage of, 935 on magnetic resonance imaging, 54 pH of, 65 in bacterial vaginosis, 66 reconstruction, 1292–1295 septate, amenorrhea caused by, frequency of, 441t support of, 935 level III support, 640, 935 level II support, 640, 935 level I support, 640, 935 transverse septum, 493–494, 494f amenorrhea caused by, 443 diagnosis of, 493 excision, 1073–1074, 1073f, 1074f Garcia’s procedure for, 494 incidence of, 493 Index in neonates and infants, 493 non-obstructive, 493 obstructive, 493 pathogenesis of, 493 sites of, 493 thickness of, 493 treatment of, 493–494 walls of, 639, 639f, 934 abnormalities in, and POP, 639 transverse defects, 646, 646f Vaginal adenosis, 128, 813 Vaginal apex prolapse abdominal sacrocolpopexy for, 653, 1225–1229, 1226f–1228f abdominal uterosacral ligament suspension for, 1234–1235, 1234f, 1235f sacrospinous ligament fixation for, 653, 1238–1241, 1238f–1240f uterosacral ligament vaginal vault suspension for, 653 vaginal uterosacral ligament suspension for, 1236–1237, 1237f Vaginal atresia, 495–496, 497f Vaginal bleeding, in prepubertal girls, 393, 393t Vaginal cancer, 808–815 adenocarcinoma, 813 carcinosarcoma, 815 clear cell adenocarcinoma, 813 computed tomography of, 810, 810f diagnosis of, 809–810, 810t embryonal rhabdomyosarcoma, 813–814, 814f FIGO staging of, 810, 811f leiomyosarcoma, 814–815 melanoma, 815 recurrence of, 812 and related anatomy, 808 vaginal epithelium, 808 vascular and lymphatic supply, 808 squamous cell carcinoma, 809f in pregnancy, 812–813 prognosis of, 810–811 risk factors for, 809 treatment of, 811–812 chemoradiation for, 812 chemotherapy for, 812 radiation therapy for, 812 stage I, 811 stage II, 811 stage III and IVA, 811 stage IVB, 811 and surveillance, 812 verrucous carcinoma, 813 yolk sac tumor, 814 Vaginal cuff cellulitis, 100f, 102 Vaginal discharge, 82 physiologic, in newborn, 388 Vaginal flora alterations in, 65 normal, 64, 65t Vaginal hysterectomy, 1045, 1051–1054 See also Hysterectomy Vaginal intraepithelial neoplasia (VaIN), 754–756 diagnosis of, 755 vaginoscopy, 755, 755f high-grade, 756 incidence of, 754 low-grade, 755 pathophysiology of, 754 prognosis for, 756 risk factors for, 754–755 treatment of, 755–756 carbon dioxide laser ablation, 756 excision, 756 medical ablation, 756 radiation therapy, 756 Vaginal lubricants, 597 Vaginal moisturizers, 726 Vaginal mold, 1075 Vaginal myomectomy, for prolapsed leiomyoma, 1043–1044, 1043f, 1044f Vaginal pessaries, 128 Vaginal pH, by pH paper test strips, 82–83 Vaginal ring (Estring), 596 Vaginal specula, 5f Vaginal sponge stick, 1103 Vaginal vault prolapse, obliterative procedures for repair of, 1246 (See also LeFort partial colpocleisis) Vaginal vestibule, 941 Vaginismus, 319, 378t Vaginitis definition of, 82 infectious, 82–86 evaluation in, 82–83 fungal infection, 83–84 trichomoniasis, 84–86, 86f, 86t Vaginoscopy, 755, 755f prepubertal, 385–386, 386f VaIN See Vaginal intraepithelial neoplasia (VaIN) Valacyclovir, for herpes simplex virus infection, 78, 78t Valproic acid, and galactorrhea, 341t Valsalva maneuver, 312 Valtrex See Valacyclovir Valves of Houston, 937, 937f Valvular heart disease, and cardiac complications risk, 951 Vancocin See Vancomycin Vancomycin, 72t, 74–75 adverse effects of, 74–75, 75t for complicated MRSA infections, 105 use of, 74 Vaniqa See Eflornithine hydrochloride Vantin See Cefpodoxime Varenicline, for smoking cessation, 28t, 29, 530 Varicella vaccine, 9t Varicocele, 545 treatment for, 545 Varicoceles, 509, 511 Vascular endothelial growth factor A (VEGF-A), 707 recurrent miscarriages and, 179 Vascular endothelial growth factor (VEGF), 429, 706f in ectopic pregnancy, 206 endometriosis and, 283 function of, 434t role in angiogenesis, 262, 706 role in OHSS, 535 Vascular injury, laparoscopy and, 1097 Vascularity index, 40 Vasectomy, sterilization by, 147–148 Vasomotor symptoms, 585 CAM therapy for, 589–590 acupuncture, 589 black cohosh, 590 dong quai, 590 fat loss and aerobic exercise, 589 flaxseed, 589 phytoestrogens, 589–590 phytoprogestins, 590 red clover, 590 soy products, 589 vitamin E, 590 central nervous system agents for, 588–589 alpha-methyldopa, 589 bellergal, 589 clonidine, 588 gabapentin (neurontin), 588 selective serotonin and norepinephrinereuptake inhibitor, 588, 588t selective serotonin reuptake inhibitor, 588, 588t sleep medication, 589 environmental and lifestyle changes for, 590 hormonal therapy for, 585–588 bioidentical HT, 586, 588 estrogen, 585–586, 587t progestins, 586 in menopausal transition, 560–563, 585 risk factors for, 561, 563 and sleep dysfunction/fatigue, 561 pathophysiology of, 561 treatment of, 585–590 VCare uterine manipulator, 1103, 1103f VCUG See Voiding cystourethrography (VCUG) Vecchietti procedure, for vagina creation, 497 VEGF See Vascular endothelial growth factor (VEGF) VEGF Trap, 706f, 707 Velban See Vinblastine Velivet, 150t Venereal Disease Research Laboratory (VDRL) test for syphilis, 79 Venlafaxine for chronic pain syndromes, 315t for vasomotor symptoms, 588t 1399 1400 Index Venlafaxine XRc, 366t Venous thromboembolism (VTE) acute, anticoagulation for, 954, 955t diagnosis of, 968 oral contraceptives and, 155–156 perioperative prevention of, 960–962, 962t prevention of, 954–956, 955f recurrent, anticoagulation for, 954–956, 955f risk factors for, in surgical patients, 960t hormone discontinuation, 961 thrombophilias, 960–961, 961f treatment of, 961–962, 962t, 968–969, 969t Ventral wall hernias, 920 Verapamil, and galactorrhea, 341t Verbal Descriptor Scales (VDS), 310f Veregen See Sinecatechin ointment Veress needle, 1110–1111, 1111f Vermox See Mebendazole Verrucous carcinomas, 813 Versapoint bipolar electrosurgery system, 1161 VersaStep system, 1112–1113, 1113f Vertebral Efficacy with Risedronate Therapy (VERT) trials, 594 Very-low-density lipoprotein (VLDL), 23 Vesicant(s) definition of, 696t and extravasation injury, 696t Vesicare See also Solifenacin for urge urinary incontinence, 628t Vesicocervical space, 934, 934f Vesicovaginal fistulas, 677 classification of, 677–678, 678t, 679t repair of, 1206–1209, 1207f–1209f abdominal approach to, 1206 vaginal approach to, 1206 (See also Latzko procedure) Vesicovaginal space, 934, 934f Vestibular bulbs, 942, 942f Vestibulectomy, 1070–1071 incisions for, 1070f vaginal mucosal advancement, 1070f, 1071 Viagra See Sildenafil citrate Vibativ See Telavancin Video monitors, placement of, during laparoscopy, 1099 Villoglandular adenocarcinomas, 774 VIN See Vulvar intraepithelial neoplasia (VIN) Vinblastine, 703–704, 703t and extravasation injury, 696t Vinca alkaloids, for cancer, 702f, 703–704, 703t Vincristine, 703, 703t Vincristine, adriamycin, and cyclophosphamide (VAC) for yolk sac tumors, 814 Vinorelbine, 703t, 704 and extravasation injury, 696t Violence See also Intimate partner violence (IPV) definition of, 374 against women, 374 Virilization, clinical features of, 471t Visceral fascia, 927, 927t Viscerosomatic convergence, 305, 305f Vistaril See Hydroxyzine Visual Analog Scale (VAS), 310f Vitamin B1, for dysmenorrhea, 319 Vitamin D deficiency, 595 Vitamin D metabolism, 566f Vitamin D supplementation osteoporosis and, 595–596 Vitamin E, for dysmenorrhea, 319 Vivelle-dot, for menopausal vasomotor symptoms, 587t Viviant See Bazedoxifene Voiding cystourethrography (VCUG), 49–50, 681, 681f for urethral diverticulum evaluation, 687 Voiding trial(s), postoperative, 966 active, 966 passive, 966 VTE See Venous thromboembolism (VTE) Vulnerable Elders Survey-13 (VES-13), 26t, 27 Vulva acanthosis nigricans on, 120 anatomy of, 793–794, 940–942, 941f basal cell carcinoma of, 804 Behỗet disease, 120 biopsy, 112113, 112f blood supply to, 795, 945 cancer metastatic to, 805, 806f congenital lesions of, 127 contact dermatitis, 116, 116f, 116t Crohn disease in, 120, 120f dermatoses, 113–119 classification of, 113, 113t inflammatory, 116–119 examination of in menopausal patient, 575 external, 793–794 infectious lesions of, 127 innervation, 946 internal, 794 irritants and allergens, 111 lichen planus, 117–118 lichen sclerosus, 113–116 lichen simplex chronicus, 113 lymphatics of, 794, 945–946 melanoma of, 803–804, 803f (See also Vulvar melanomas) patient’s complaints related to approach for, 110 history taking in, 110 physical examination in, 111, 112f pigmentation, disorders of, 120–121 nevus, 120–121 vitiligo, 121, 121f sarcoma of, 804, 804f skin of, 110 traumatic injury to, 127–128 hematoma, 127 laceration, 127 sexual injury, 127–128 tumors of cystic, 123–124 solid, 121–122 Vulvar abscess, 106 incision and drainage, 1068–1069, 1068f, 1069f Vulvar cancer diagnosis of, 793, 796–797 early-stage, 800 evaluation of lesions of, 796 FIGO staging of, 797, 797t, 798f histologic subtypes of, 794t, 795 incidence of, 793 invasive, 793–806 patient evaluation in, 796, 796f in pregnancy, 802–803 prognosis of, 797 prognostic factors for, 797–799 depth of invasion, 797t lymphatic vascular space invasion, 798–799 lymph node metastasis, 797–798, 799f surgical margins, 798 tumor size, 798t recurrences distant, 802 vulvar, 802 and related anatomy, 793–795 blood supply to vulva, 795 vulva, 793–794 vulvar lymphatics, 794 risk factors for, 795–796 herpes simplex virus, 795 human papillomavirus, 795 immunosuppression, 795 lichen sclerosus, 795 vulvar intraepithelial neoplasia, 795–796 stage I, 797t, 798f stage IA, 797t, 798f, 799–800 stage IB, 797t, 798f, 800 stage II, 797t, 798f, 800 stage III, 797t, 798f, 801–802 stage IIIA, 797t, 798f stage IIIB, 797t, 798f stage IIIC, 797t, 798f stage IV, 797t, 798f stage IVA, 797t, 798f, 802 stage IVB, 797t, 798f, 802 surgical procedures for, 799, 800f radical complete vulvectomy, 799 radical partial vulvectomy, 799 skinning vulvectomy, 799 wide local excision, 799 surveillance, 802 symptoms of, 796 treatment of, 793, 799–802 Vulvar contact dermatitis, 116, 116f allergic, 116 Index irritant, 116 treatments for, 116t Vulvar intraepithelial neoplasia (VIN), 756–760 classification of, 757–758, 758t diagnosis of, 758 differentiated type, 757, 758 incidence of, 756–757 management of, 759–760 ablation, 760 excision, 760 photodynamic therapy, 760 topical therapy, 760 pathophysiology of, 757–758 prevention of, 760 prognosis for, 760 symptoms of, 758t treatment of, 1086–1089 carbon dioxide laser vaporization, 1088–1089 cavitational ultrasonic surgical aspiration, 1087–1088, 1087f wide local excision, 1086–1087 unclassified type, 757, 758 usual type, 757–758 and vulvar cancer, 795–796 vulvoscopy for, 758–759, 759f Vulvar melanomas, 803–804, 803f histologic subtypes of, 803 microstaging of, 803, 804t treatment of, 803–804 Vulvar nevi, 120–121 Vulvar Paget disease, 805, 805f Vulvar pruritus, 111 Vulvar vestibulitis, 941 Vulvar vitiligo, 121, 121f Vulvectomy partial simple, 1335 radical partial, 1337–1339, 1337f–1339f skinning, 1335–1336, 1335f, 1336f Vulvitis prepubertal, 387–388 by allergic or contact dermatitis, 387, 387f infection and, 388 by lichen sclerosus, 387–388, 388f Vulvodynia, 124–127, 1070 algorithm for diagnosis of, 125f definition of, 124 diagnosis of, 125–126, 126t etiology of, 124 history taking in, 125–126 incidence of, 124 ISSVD on, 124, 124t laboratory testing in, 126 physical examination in, 126 treatment of, 126–127 behavioral therapy, 126 biofeedback and physical therapy, 126 intralesional injections, 127 oral medications, 127 patient education, 126 surgical therapy, 127 topical medications, 126–127 vulvar care, 126 Vulvoscopy, 796 Vulvovaginitis, prepubertal, 388–389 causes of, 389t infectious, 389 nonspecific, 388–389 W Waist circumference, 13–14 measurement of, 14 Warfarin efficacy, hormonal contraceptives and, 154t therapy with, perioperative management of, 954–956, 955t Weight gain, menopausal transition and, 571 Weight loss in elderly, 25, 27 in polycystic ovarian syndrome, 473 Wellbutrin See Bupropion Well woman care, 2–30 breast examination in, 3–4, 3f, 4f history-taking in, 2–6 mental health in, 27–30 pelvic examination in, 4–6 physical examination in, 2–6 preventive care in, 7–30 Wet prep, 66 in abnormal uterine bleeding, 225 Whiff test, 66 for BV, 82 White balancing, 1107 Wide local excision, 1335 Witches’ milk, 390 Withdrawal bleeding, 219 Wolffian duct(s), 481, 482f, 483f, 484–485 remnants solid paraovarian, 272–273 Women’s Health Initiative (WHI), 570, 583 Wood lamp, 371 Word catheter, 1063, 1063f Wound care, products for, 974t classification of, 99 clean, 99 clean contaminated, 99 contaminated, 99 dirty, 99 healing, 972 postoperative, 972–975 Wound dehiscence, 972 classification of, 972 diagnosis of, 973 fascial, treatment of, 974–975 incidence of, 972 infection and, 973, 973t prevention of, 972–973 superficial, treatment of, 973–974 delayed primary closure, 974 negative-pressure wound therapy, 974 wet to dry dressing changes, 973–974 Wound vacuum-assisted closure devices (Wound VAC), 104 X Xanax See Alprazolam Xenical See Orlistat Xenografts, 655 46,XX karyotype, and true hermaphroditism, 490 46,XX/45,X, 489 47,XXY karyotype, 490–491 Y Yasmin, 150t Yaz, 150t Yersinia spp., prepubertal vulvovaginitis caused by, 389 Yolk sac tumors, 883–884 chemotherapy for, 883 stage at diagnosis, and survival, 883t tumor markers for, 881t in vagina, 814 Yuzpe method, 163 Z Zaleplon, 366t for insomnia, 29t Zantac See Ranitidine Zelnorm See Tegaserod Zenchent, 150t Zinacef See Cefuroxime; Cefuroxime axetil “Zinc fingers”, 406 Zinnati Uterine Manipulator Injector (ZUMI), 1102, 1103f Zithromax See Azithromycin Zocor See Simvastatin Zofran See Ondansetron Zoladex See Goserelin Zoledronic acid, for bone metastases, 350 Zoloft See Sertraline Zolpidem, 366t for insomnia, 29t Zolpidem extended release, for insomnia, 29t Zometa See Zoledronic acid Zoster vaccine, 9t Zosyn See Piperacillin-tazobactam Zovia 1/35, 150t Zovia 1/50, 150t Zovirax See Acyclovir Zyban See Bupropion Zyclara See Imiquimod cream Zyvox See Linezolid 1401 ... in 21 percent of healthy, 40 35 Percentage (%) 30 25 20 15 10 20 ? ?24 25 ? ?29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75–79 80–84 85+ Unknown 0.3 0.6 1.1 1.6 2. 4 3.1 3.6 4.8 4 .2 5 .2. .. 11.6 13.7 12. 3 9.3 7.8 5.6 5.7 5.9 2. 6 Moderate 2. 5 4.5 4.9 7.5 8.3 8.8 8.4 7.6 8.3 8.1 8.1 8.1 8 .2 Severe 1.3 1.6 1.6 2. 6 3.3 4.1 6.1 6.8 7 .2 8.7 12. 1 14.6 16.1 19.3 Age (years) FIGURE 23 -1 Prevalence... Neurourol Urodyn 22 :589, 20 03 Wu JM, Hundley AF, Fulton RG, et al: Forecasting the prevalence of pelvic floor disorders in U.S women 20 10 to 20 50 Obstet Gynecol 114(6): 127 8, 20 09 Zahn CM, Siddique