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Home , Atrophic vaginitis, Cystocele, Rectocele, Urethral caruncle, Uterine prolapse

SOME GYNECOLOGICAL PROBLEMS

IN THE AGEDt

Gerald W. Korn, M.

I have selected just three topics for this dis- However, carcinoma of the and the have cussion and try to give some practical tips as to the a higher incidence in the aged. management of some of the problems that fall under Where there has been a definite blood loss, it is these headings. For the purpose of this discussion, I mandatory to perform a comprehensive examination am using the age of seventy as the lower limit of of the pelvic organs. This should include (1) a care- the aged female, although, or course, many of the ful inspection of the external genitalia (2) a speculum problems that I will mention can occur in women examination (3) a bimanual examination (4) a cer- much younger than that. However, I am trying to vical and posterior vaginal wall smear (5) a curet- avoid getting into the perimenopausal era, which has tage in almost all cases (6) a biopsy of any lesions its own particular problems. suspected as being the site of the bleeding. Postmenopausal bleeding is my first large group Even where one has found an obvious vaginal, of problems and, as you are well aware, there is a urethral or cervical lesion, a curettage should be per- long list of causes of this symptom. However, in the formed where the bleeding has been of significance. aged, the number of likely causes can be reduced to Perhaps the only exclusions should be where there a small list-others being of considerable rarity. is an obvious vulval malignancy and where the upper When dealing with women in their seventies and genital tract can be palpated and visualized and seems eighties, some of the non-malignant conditions be- to be normal. come as important numerically as the malignant. When performing the curettage, it should always Atrophic or senile , urethral caruncles, ure- be done in a fractional or differential manner with thral , ulcerations of the prolapsed , a careful exploration of, first, the endocervical canal, ulcerations of the vaginal mucosa in long-standing then, the region of the internal cervical os and finally, procidentias, ulcerations of the vaginal mucosa as a the upper cavity of the . From the point of result of prolonged and neglected wearing of pes- view of subsequent treatment, it is vital to know where saries and benign cervical polyps, are all commonly the malignant lesion, if it exists, lies. Endometrial seen causes of bleeding. Generally speaking, when cancer may spread downwards into the endocervix one has reached this age, carcinoma of the cervix before spreading outwards. Once in the cervix, the becomes a rare condition and certainly has a lower spread is along channels draining the cervix-that is, incidence than that of carcinoma of the . the spread is the same as in a primary cervical can- cer. Whereas the treatment of a carcinoma limited tPaper presented at the Annual Meeting of the College of Family Physicians of Canada, Saskatchewan Chapter, Sas- to the body of the uterus is either a preliminary katoon, 1968. intracavity and vaginal vault radiation using the Hey- man's technique, to be followed by surgical removal AUTHOR of the uterus, tubes and ovaries, the management of *Gerald W. Korn, M.D.; extension to the cervix is more complicated involving M.R.C.S.; L.R.C.P.; D.R.C. the same preliminary radiation and a subsequent O.G.; F.A.C.O.G.; Assistant Wertheim and lymphadenectomy, or Professor, Obstetrics a n d that type of major without preliminary radia- , University of tion. Saskatchewan. Chief of De- see reason partment of Obstetrics and In point of fact, I cannot really any Gynaecology, Saskatoon City why every curettage performed at any age for diag- Hospital. nostic purposes should not be of this same fractional type. In this way, the origin of an unsuspected car- 22 CANADIAN FAMILY PHYSICIAN-DECEMBER, 1968 cinoma would always be apparent when subsequently Very often there is associated with an atrophic diagnosed histologically and this would then prevent vaginitis an atrophic . There is an eversion a number of unnecessary repeat examinations. of the urethral mucosa which pouts outwards and very Turning to some of the more common causes of often gives a picture similar to the urethral caruncle. small amounts of bleeding-first of all, atrophic The urethral mucosa may easily be damaged by rub- vaginitis, sometimes called senile vaginitis, rarely bing on underclothes and a granular and occasionally causes more than a serosanguinous discharge, but ulcerative appearance is seen. The local application to the elderly woman who suddenly finds her panties of cream within the vagina and some gently soiled or notes this blood on the toilet tissue, it can rubbed into the every time the application be most distressing. Following the usual examinations is inserted, will soon improve the appearance of the and having identified the cause of the bleeding as urethra and even reverse the eversion. within the vagina, the treatment is relatively simple. The urethral caruncle, which is either a granu- I use Dienestrol Cream and I prescribe initially two lomatous or angiomatous lesion, is a polypoidal tubes with instructions to use one applicatorful each cherry-red lesion of the posterior wall of the urethra night until both tubes have been emptied. If the wom- and is usually very tender when touched. It usually an is frail and apparently unable to introduce the bleeds very easily too. If there is some doubt about medication herself, a relative, companion, V.O.N. the between it and a urethral nurse or nurse in the Home Care Programme, should eversion with granulation, I use Dienestrol Cream do it for her. I like to re-examine the vagina at the for about ten days first of all and then, if the lesion end of the treatment and if, as one would expect, persists, I cauterize this in the office. If it is too tender the vagina is well estrogenized-it being pink and to cauterize, one or two cc's of 1 % Xylocaine can be rugose once more, I ask the woman to return in three introduced by a 22 gauge needle below it and it can months time for further examination, or make arrange- then be cauterized. Large caruncles usually need to ments to examine her elsewhere. In many cases, the be excised and after this is done a few fine stitches effect of the treatment will have worn off by then of 000 plain catgut on an atraumatic needle are in- and a further tube of cream will be required. I usually serted to control the bleeding from the base of the find that the use of one tube every three months is lesion. satisfactory treatment and will keep the atrophic Turning now to bleeding ulcerative lesions of the changes at bay and certainly will prevent bleeding vagina, one must suspect the existence of a carcinoma and vaginal soreness. Some people prefer the intro- of the vagina until proven otherwise where one is duction of two applicatorsful every week. as opposed faced with an ulcer of any size which bleeds to touch. to the ten or so applications every three months, and The edges of an ulcer can be biopsied using either a I would have no quarrel with that method of treat- punch biopsy or a knife biopsy, again under the same ment. I think you will all agree that it is imperative type of local anaesthetic and as an out-patient pro- that the patient be followed at regular intervals to cedure. If the ulcer is large and there is a major make sure that she is neither getting an insufficient degree of prolapse, replacement of the prolapse and amount nor an unnecessarily excessive amount of local applications of Dienestrol Cream do wonders. therapy. The patient should be given regular appoint- The healing is very rapid. Unfortunately, this may ments for follow-ups, or, if one is dealing with a mean keeping the patient in bed for long periods of Nursing Home or a bedridden patient, regular visits time with all its attending problems. When one is should be made to the patient. Sidetracking for just dealing with a severe degree of prolapse, however, one moment, may produce a num- there is no real alternative. The advantage of replacing ber of different symptoms other than bleeding. Vagi- the prolapse and hence improving the lymphatic and nal soreness and irritation, a purulent discharge, re- venous drainage and the rapid healing therefrom, prob- current attacks of urinary frequency, urgency and ably outweighs the dangers of bed confinement. and , in those still full of the joys of spring, may all occur and all will benefit from the This leads me to my second topic-that of pro- use of the local cream. When the are lapse. Major degrees of prolapse, for instance the symptoms third with present, I prefer local application of the estrogen degree , , or, worse still, the complete proci- rather than the systemic use of estrogen, as some of dentia, may make the later years of life one of re- the side effects such as nausea, breast soreness and lative misery. I have already mentioned the problems lower abdominal cramps, may become apparent with that ulceration may bring, with its attendant discharge oral or injectable materials but rarely do so with the of pus or pus and blood mixed. The existence of a local applications. large lump which hangs between the legs or has to CANADIAN FAMILY PHYSICIAN-DECEMBER, 1968 23 SOME GYNECOLOGICAL PROBLEMS ... be manipulated in order to empty the bladder or than the other standard forms of repair and takes at rectum, is often very distressing. A large cystocele may least as long to perform. prevent efficient emptying of the bladder and the Rarely these days is therapy advised. attendant stasis may lead to chronic urinary . However, if the patient really is too ill for any form A big enterocele and rectocele may be associated with of surgery or, alternatively, refuses to have any sur- chronic and impaction of faeces needing gical procedure, then a plastic ring can be inserted manual removal is also seen from time to time. The and this may help. I rarely use the rubber-covered very existence of the lump, even without bowel and watchspring pessary these days. Sometimes the nylon bladder problems, may severely reduce normal mo- doughnut-type of pessary can be used, but I think bility. By way of illustration, I would like to cite the more rigid clear plastic is probably the best of a case that I had some years ago. An elderly woman all. Occasionally, one is faced with a complete who had a complete procidentia, fell and fractured procidentia or at least a third-degree uterine pro- her hip. This was pinned satisfactorily but rehabilita- lapse, where a ring fails to hold the prolapse up. Here tion was being made difficult by the protruding one may be forced into using a rather antiquated but procidentia. I repaired the prolapse by performing still useful appliance, the Napier cup and stem. a vaginal hysterectomy and the patient became so mobile again that she fell and broke her other hip! My final topic is that of vulval and vaginal irrita- However, I still think that the principle of repair was tion. The list of possible causes of this distressing a good one. symptom is a long one, and whilst a number of causes are common and easy to recognize, one is occasionally In my view, there are very few elderly women left with a very difficult diagnostic problem. Jeffcoate whose last years cannot be made more comfortable by says that not less than 10% of women attending a good repair operations. The pre-operative and post- gynaecologist complain of pruritis vulvae as their pre- operative care of the tissues is of greatest importance senting symptom. "Pruritis" means a sense of itching once one has made the decision to operate. The re- and a desire to scratch and should be differentiated placement of the prolapse and adequate estrogeniza- from "irritation", which often means to the patient, tion of the tissues is essential to obtain a good result soreness or tenderness or even actual . Com- and after surgery the use of for all time is monly, pruritis is associated with a essential. Here again, one would use Dienestrol Cream, but there are really only two types of discharges that inserting one applicatorful each day until one tube has actually are associated with itching and these are due been used, approximately every three months. Ignoring to either the trichomonas vaginalis organism or the the post-operative period and allowing the atrophic Monilial group. If there is no apparent external lesion changes to return, may render one's operation value- when one is faced with this problem, but a profuse less in many cases. discharge, one can usually differentiate the two fairly Having adequately prepared the vagina, the sur- simply. The clinical picture of the thin, yellowy, some- gery is performed either under a general anaesthetic, what frothy discharge associated with a generalized or, if the patient is considered unfit for general reddening of the vagina with spotted areas on the anaesthetic, a spinal anaesthetic can be given. In vaginal wall and cervix, are almost always diagnostic arteriosclerotic and hypertensive patients, it is par- of the trichomonas vaginalis infection. A drop of the ticularly important to maintain adequate levels of discharge mixed with one drop of saline and looked blood pressure during the surgery. at under the microscope, will soon reveal the swarm- The type of the operation depends upon the pro- ing trichomonads. When in doubt, a swab of the dis- lapse. In the worst cases, a vaginal hysterectomy and charge immersed in 1/½% saline in a tube is sent to the Lab. The treatment is I repair is the best procedure and where one is deal- today usually simple. prescribe Flagyl in doses of one tablet twice a day ing with a very small uterus this is usually not too for ten days. If there is a male sexual partner, he difficult. As one is only likely to be operating in ma- should be treated in the same way too. jor degrees of prolapse in aged patients, this type of The Monilial also fea- is the one that one would most discharge possesses typical procedure probably tures. It is usually a thicker, yellowy-white discharge, commonly adopt. Sometimes, however, a cystocele, often attached to the vagina in plaques. A swab of enterocele or rectocele are the only areas requiring the discharge can be plated out on Nickerson's repair and here the appropriate surgery is performed. Medium and this grows the typical brown spots within The Le Forte operation is, in my view, a bad opera- forty-eight hours. I usually keep a supply of Nicker- tion, being no more than a skin-to-skin repair, and I son's Media in my office. These are supplied by the cannot recommend it. It is certainly no easier to do Ortho Company and can easily be smeared in a sec- 24 CANADIAN FAMILY PHYSICIAN-DECEMBER, 1968 ond. I also take a portion of the discharge, add one chromic and macrocytic anemias may give quite a lot drop of 10% Potassium Hydroxide on a slide and put of vulval irritation and other such deficiency states a cover slip on it, and look for the typical mycelia. such as chronic diarrhoea, malabsorption syndromes My treatment of a Monilial vaginal infection is the use and achlorhydria, especially in the post-gastrectomy of Mycostatin inserts and I usually find that these syndrome, have also been cited as a cause of vulval inserts given morning and night until all fifteen, which irritation. are in the pack, have been used up, is sufficient treat- My object in giving you this rather extensive list ment. If the treatment fails, I use Sporostacin Cream. is to indicate the numbers of different conditions that Turning now to pruritis without vaginal discharge can actually give rise to pruritis and the need for not -it would appear that perhaps fifteen or twenty per- only local inspection but a detailed history of local cent of the cases or pruritis come under this heading applications, toilet preparations, drugs and so on, must and often provide most difficult clinical problems. be taken in case we are dealing with an allergic prob- Occasionally, a pruritis vulvae is part of a generalized lem. And, in the course of our general physical ex- pruritis, such as is seen in jaundice, uremia and other amination, a careful urine examination, blood sugars toxoc states, and it is well worth keeping in mind that and comprehensive blood work should also be done, these may exist if no local lesion is seen by the pa- together with vaginal smears and vulval scrapings. tient who complains of continuous itching. There are There are a few specific lesions of the vulva which a few skin diseases which are not specific to the vulva may cause a considerable amount of irritation. These and under this heading are psoriasis, seborrheic have been called chronic epithelial dystrophies. The dermatitis and scabies. The vulval lesion may be more principal ones are leukoplakic and lichen obvious than those elsewhere and we would have to sclerosis. The underlying cause is often obscure and look on the rest of the body for evidence of more they may present similar pictures. I have a number of widespread disease. Squamous cell carcinoma of the slides to show you the appearance of them. They vulva and carcinoma-in-situ and Paget's disease of the usually present as reddening of the vulval skin with vulva may also cause pruritis but these are rare con- shrinkage of the , localized areas of thickening of ditions and I do not wish to dwell on them at this the skin surfaces, white patches, excoriations from time. scratches and deep fissures. The two conditions are of the vulva itself may be of the tineal very difficult to tell apart. It is imporant to differenti- type, may be due to pediculosis or moniliasis. The ate them because the leukoplakic vulvitis has a some- latter produces a typical raw, beefy appearance and what more sinister connotation. Where there is marked there may be white patches on the surface of the vulva. epithelial activity, as evidence by a biopsy, then the Scraping from the vulva may identify the Monilial treatment of local vulvectomy in leukoplakic vulvitis organism or the tinea and local therapy for the tinea is the treatment of choice. However, if there is little may be given. Monilial infections of the vulva are or no epithelial activity and one is dealing with either very commonly associated with unsuspected diabetes leukoplakic vulvitis or lichen sclerosis, local applica- and it is mandatory to carry out at least a urine ex- tions of corticosteroids may be helpful. Having estab- amination for the presence of sugar on several occa- lished the diagnosis by a small biopsy, and this can sions when one is faced with a Monilial vulvitis. Even often be done in the office under general anaesthetic, if the urine is free of sugar, several spot blood sugars I usually prescribe in those non-proliferating cases, should be done as hyperglycemia can occur without an Aristoderm Foam which I advise the patient to glycosuria. Monilial vulvitis and vaginitis often occur spray on the vulva two or three times a day and together and the same general investigations should spend a few minutes in letting it dry. This I find often be done when either or both sites are infected. relieves the irritation a great deal. As irritation is often Another group of causes of pruritis are skin sen- most common at night, the patient should wear very sitivities to various chemical constituents of toilet light clothing and certainly should not wear panties tissues, particularly colored tissues, toilet soaps, bath in bed. If the corticosteroid treatment fails, a number salts and . It has also been said that contact of other preparations can be tried, e.g. local anaes- dermatitis from other cosmetics, even varnish on the thetic applications, and sometimes the multiple injec- patient's nails, is occasionally seen. Urticarial condi- tion of solutions of 95% alcohol have been found to tions of the vulva may be associated with a general be effective. If all else fails, a local vulvectomy may skin reaction and occasionally they form the pre- be performed whether there be any epithelial activity dominant manifestations of sensitivity to such things or not. If all the affected skin can be removed satis- as liver preparations and antibiotics. Deficiency states factorily beyond the edges of the affection, then the too can be a cause of pruritis and particularly hypo- results are often very satisfactory.

CANADIAN FAMILY PHYSICIAN-DECEMBER, 1968 25