Patient Introduction and Review of Anatomy of the Female Genitourinary System

00:00 So let's move on to discuss a patient presenting with pelvic pain. This is a 64-year-old woman who is presenting to her gynecologist with vaginal pain. This has been gradually worsening over the past 2 months, and it's associated with pruritus and dyspareunia. In thinking about female genitalia, it's good to orient ourselves to basic anatomy. We have the vagina, then we have the cervix which is the canal opening into the uterus, and of course we have the fallopian tubes going out to both ovaries. We'll focus on each area as we discuss potential causes of pain in this patient starting with the external genitalia. The external genitalia or the vulvar area includes the labia minora and the labia majora in particular. It's in these sites where we may find evidence of infections most notably HSV causing genital herpes or HPV causing genital warts or condyloma acuminata. In addition, particularly in postmenopausal women you can also look for Lichen sclerosis with these white plaques in the vulvar area. Moving into the vagina itself, a common cause of certainly pruritus would be candidal species causing vulvovaginal candidiasis or if we're simply having issues with a change in vaginal discharge to a more grayish cottage cheesy discoloration we will be thinking about bacterial vaginosis, which is demonstrated here with these so-called clue cells with anaerobic bacteria adhering to vaginal epithelial cells. Moving further in into the cervix, we have cervicitis and the normal cervix is shown on the left of this image and then cervicitis on the right with erythema, some friability to the cervix, and potentially some mucopurulent discharge. All of which could be caused by Chlamydia, gonorrhea, or potentially trichomonas. And we're always of course worried about cervical cancer which is why we're going to be looking closely at the cervix and also demonstrating how to perform a Pap smear. Next up, moving in to the uterus, the things that we may pick up there when we're doing our bimanual exam may include uterine fibroids which may be palpable if they're enlarged, endometriosis or even again uterine cancer. And then moving out to the ovaries which can certainly be a common cause of low abdominal pain and pelvic pain, patients can have pelvic inflammatory disease which may be detected with cervical motion tenderness on the exam or they may simply have enlarged ovaries or ovarian cyst which can torse or rupture and cause discomfort. Patients who are sexually active we would be worried about ectopic pregnancy and as I mentioned ovarian torsion is a potential cause for an acute or subacute low abdominal pain. So returning to our patient, again, we can see that there's a lot of potential things that could be causing our 64-year-old woman to have vaginal pain.

03:00 Perhaps it's Lichen sclerosis which we'll pick up simply on our external genitalia exam. Or maybe she is having candidal infection with vulvovaginitis, bacterial vaginosis, or perhaps cervicitis. Let's do our physical exam and see what is potentially causing her pain.