Pemicu 5 Reproduksi

Rilianda L Simbolon
405140172
Abses folikel atau kelenjar sebasea
Furunkel
• =suatu keadaan dimana
terdapatnya pus / nanah pada
folikel rambut dan kelenjar
sebasea yang disebabkan oleh
proses perdangan atau inflamasi
• Bbrp penyakit yg dapat
menimbulkan abses pd foikel
rambut dan kelenjar sebasea
– Folikulitis
– furnkel
– Karbunkel
Folikulitis
– peradangan pada selubung akar
rambut atau folikel rambut, yang
umumnya di sebabkan oleh bakteri
gram positif staphylococcus
aureus.
– peradangan pada folikel rambut
dan jaringan subkutan
sekitarnyaKarbunkel
– satu kelompok beberapa folikel
rambut yang terinfeksi oleh
Staphylococcus aureus, yang
disertai oleh peradangan daerah
sekitarnya dan juga jaringan
dibawahnya termasuk lemak
bawah kulit
– Gabungan beberapa furunkel yang
dibatasi oleh trabekula fibrosa yang
berasal dari jaringan subkutan yang
padat.
Abses folikel atau kelenjar sebasea
Epid Etiologi
• Penyakit ini sangat erat • Staphylococcus aureus
hubungannya dengan
keadaan sosial-ekonomi.
• Folikulitis dan furunkel
dapat mengenai semua
umur, tetapi lebih sering di
jumpai pada anak – anak
dan juga tidak di pengaruhi
oleh jenis kelamin.
• Folkulitis lebih sering
timbul pada daerah panas
atau beriklim tropis.
Manifestasi Klinis

• Folikulitis
Timbulnya rasa gatal dan agak
nyeri, tetapi biasanya tidak terlalu
menyakitkan hanya seperti
gigitan serangga, tergores atau
akibat garukan dan trauma kulit
lainnya. Kelainan di kulitnya dapat
berupa papul atau pustul yang
erimatosa yang dan di tengahnya
terdapat rambut dan biasanya
multiple serta adanya krusta di
sekitar daerah inflamasi.
• Pemeriksaan lab
– Pewarnaan Gram
– Kultur bakteri
 Penatalaksanaan
• Folikulitis
– Umum
Cukup dengan menjaga kebersihan diri terutama kulit, menghindari
garukan dan faktor pencetus seperti gesekan pakaian atau mencukur
dan luka atau trauma.
– Khusus, terbagi 2 yaitu secara tropikal dan secara sistemik
Furunkel dan Karbunkel
– Non Farmakologis
– Farmakologis
Akne Vulgaris
– Terapi Lokal
– Terapi Sistemik
 Salfingitis 4A
• Akut
• Kronis
 TORSI DAN RUPTUR KISTA
• Torsi dan ruptur kista adalah kegawatan di bidang obstetri
dan ginekologi

• Torsi komplit menyebabkan gangguan peredaran darah 

kongesti + nekrosis, radang, pendarahan

• Torsi dan ruptur kista merupakan komplikasi dari kista

ovarium
• Menyebabkan tuba falopi berotasi, situasi ini bisa
menyebabkan nekrosis

• Kondisi ini sering menyebabkan infertilitas

• Manifestasi dari torsio kista ovarium adalah
nyeri perut unilateral yang biasanya menyebar
turun ke kaki

• Pada kondisi ini pasien harus segera di bawa

ke rumah sakit. Jika pembedahan selesai pada
6 jam pertama setelah onset krisis, intervensi
pada kista torsio bisa dilakukan
 Tanda dan Gejala
• Nyeri kuat yang berlokasi di salah satu sisi dari
abdomen, biasanya bersifat radial

• Jika torsio lebih dari 6 jam dan tuba falopi

sudah nekrosis, pasien akan kehilangan tuba
falopiinya
 Faktor Resiko Torsio
• Teratoma kistik benigna – kista dermoid
• Kistadenoma pseudomusinosum
• Kista teka lutein
 Ruptur Kista
• Pendarahan / rupturnya kista yang ditandai
dengan ascites dan sering sulit untuk
dibedakan dari kehamilan ektopik

• Situasi ini juga perlu pembedahan darurat

 Gejala
• Nyeri kuat yang berlokasi di salah satu sisi dari
abdomen (pada ovarium yang mengandung
kista).
• Ruptur kista ovarium juga mengakibatkan
anemia
• Kadang asimptomatik
• Tanda pertama yang bisa terjadi adalah terasa
nyeri di abdomen bagian bawah, mual,
muntah dan demam
 Faktor Resiko Ruptur
• Korpus luteum
• Kista folikel
• Endometrioma
• Kista teka – lutein
• Teratoma kistik benigna – kista dermoid
• Kisadenokarsinoma
 Infertilitas
• Primer Faktor Risiko
– kegagalan suatu pasangan • Gaya hidup
untuk mendapatkan – Konsumsi alkohol
kehamilan
sekurangkurangnya dalam 12 – Merokok
bulan berhubungan seksual – Olahraga
secara teratur tanpa • Obat-obatan
kontrasepsi
– Spironolakton
• Sekunder – Antibiotik
– ketidakmampuan seseorang (tetrasiklin,neomisin,
memiliki anak atau gentamisin, eritromisin,
mempertahankan nitrofurantoin) pd dosis tinggi
kehamilannya – Simetidin, siklosporin
– Herbal
• Pekerjaan
 Penyebab Infertilitas pada Wanita
• Gangguan ovulasi
– SOPK, insufisiensi ovarium
primer
• Gangguan tuba dan pelvis
– Infeksi (chlamydia,
gonorrhea, TBC)
– endometriosis
• Gangguan uterus
– Mioma submukosum
– Polip endometrium
– Leimyomas
– Sindrom asherman
Faktor yang Mempengaruhi Kehamilan
• Usia
• Frekuensi senggama
• Pola hidup (alkohol, merokok, BB)
• Masalah pada vagina
• Masalah pada uterus
• Masalah pada tuba
• Masalah pada ovarium
• Masalah pada peritoneum
 Pemeriksaan dasar
• Anamnesis
• Pemeriksaan fisik
• Pemeriksaan penunjang (progesteron, TSH, LH
dan FSH)
• Pemeriksaan analisis sperma
 Pemeriksaan analisis sperma
• Abstinensia 2-3 hari
• Keluarkan sperma dengan cara mastrubasi
• Hindari penggunaan pelumas
• Hindari kondom untuk menampung sperma
• Gunakan tabung dengan mulut yang lebar untuk
penampungan sperma
• Tabung sperma dilengkapi nama, tanggal, waktu
pengumpulan, metode pengeluaran sperma
• Kirimkan sampel secepat mungkin ke lab sperma
• Hindari paparan tempertatur yang terlalu tinggi atau
rendah
 Nilai normal analisis sperma
Kriteria Nilai rujukan normal
Volume 2 ml atau lebih
Waktu likuefaksi Dalam 60 menit
pH 7,2 atau lebih
Konsentrasi sperma 20 juta/ml atau lebih
Jumlah sperma total 40 juta per ejakulat atau lebih
Lurus cepat 25 % atau lebih
Jumlah antara lurus cepat dan lurus 50% atau lebih
lambat
Morfologi normal 30% atau lebih
Vitalitas 75% atau lebih yang hidup
Leukosit Kurag dari 1 juta per mililiter
 Terminologi dan definisi analisis
sperma berdasarkan kualitas sperma
Terminologi Definisi
Normozoospermia Ejakulasi normal sesuai nilai rujukan
WHO (normal : 20 juta/ml atau >)
Oligozoospermia Konsentrasi sperma <
Astenospermia Konsentrasi sperma dengan motilitas <
Teratozospermia Konsentrasi sperma dengan motilitas
rendah
Azoospermia Tidak didapatkan sel sperma dalam
ejakulat
Aspermia Tidak terdapat ejakulat
Kristospermia Jumlah sperma sangat sedikit.
Didapatkan setelah sentrifugasi
 Indikator rujukan
Jenis kelamin Indikator rujukan
Usia > 35 tahun
Riwayat KET
Riwayat kelainan tuba
Riwayat pembedahan tuba
Perempuan Menderita endometriosis
Gangguan haid seperti oligomenorea
atau amenorea
Hirsutisme atau galaktorea

Kemoterapi
Andesensus testis, varikokel
Laki - laki Kemoterapi, riwayat pembedahan
urogenital dan PMS
 Servisitis
• Peradangan beerat mukosa dan submukosa
serviks.
• Infiltrasi sel-sel radang akut dan nekrosis
• C.trachomatis dan N.gonorrhoeae
 Cervical polyp
• Most originate from the endocervix; a few arise from
the portio
• relatively common in multigravidas over 20 years of
age.
• rare before menarche,
• an occasional polyp may develop after menopause.
• Asymptomatic polyps often are discovered on routine
pelvic examination.
• Most are benign,
– but all should be removed and submitted for pathologic
examination because malignant change may occur
• Etiology:
– chronic inflammation,
– an abnormal local responsiveness to hormonal
stimulation,
– a localized vascular congestion of cervical blood
vessels
– often found in association with endometrial
hyperplasia, suggesting that hyperestrogenism
plays a significant etiologic role
• Classification:
– Endocervical polyps
• usually are red, flame-shaped, fragile growths.
• Vary; from a few millimeters in length and diameter to
larger tumors 2–3 cm or several centimeters long.
• usually are attached to the endocervical mucosa
• microscopic : the stroma of a polyp is composed of
fibrous connective tissue containing numerous small
vessels in the center
• Classification:
– Ectocervical polyps
• are pale, flesh-colored, smooth, and rounded or
elongated, often with a broad pedicle.
• arise from the portio
• less likely to bleed than are endocervical polyps
• Microscopically:
– more fibrous than endocervical polyps, with few or no mucus
glands.
– covered by stratified squamous epithelium.
• Symptoms and Signs:
– Abnormal vaginal bleeding is often reported.
• Intermenstrual or postcoital bleeding (most common
symptom)
• Postmenopausal bleeding
– Leukorrhea and hypermenorrhea have also been
associated with cervical polyps.
– Infertility may be traceable to cervical polyps and
cervicitis.
– Cervical polyps appear as smooth, red, fingerlike
projections from the cervical canal.
• usually are approximately 1–2 cm in length
• 0.5–1 cm in diameter.
• Generally they are too soft to be felt by the examiner's
finger.
• Diagnosed:
– Hysterosalpingogram (HSG)
– Lab
• Vaginal cytology
– signs of infection and often mildly atypical cells
• Blood and urine studies are not helpful
– hysteroscopy
 Kista dan abses kel.bartholini
• Obstruction o this gland’s duct is
common and may follow
infection, trauma, mucus
changes, or congenitally
narrowed ducts.
• The underlying cause is often
unclear.
• In some cases, cyst contents may
become infected and lead to
abscess formation.
• A wide spectrum o organisms has
been cultured. Escherichia coli is
the most common isolate, but
various other gram-positive and
gram-negative aerobes and
anaerobes are found
• In requently, Neisseria
gonorrhoeae or Chlamydia
trachomatis is identifed.
 Diagnosis and Treatment
• Most Bartholin gland cysts are small and asymptomatic except for minor
discomfort during sexual contact
• Larger or infected cystssevere vulvar pain that precludes walking, sitting, or
sexual activity .
• PEcysts typically are unilateral, round or ovoid, and tense. If infected, they
display surrounding erythema and are tender.
• The mass is usually located in the inferior labia majora or lower vestibule.
• Whereas most cysts and abscesses lead to labial asymmetry, smaller cysts may be
detected only by palpation.
• Bartholin abscesses on the verge of spontaneous decompression will exhibit an
area of softening, where rupture will most likely occur.
• Small, asymptomatic Bartholin gland duct cysts require no intervention except
exclusion of neoplasia in women older than 40 years.
• However, a symptomatic cyst may be managed with one of several techniques.
These include incision and drainage (I&D), marsupialization, and Bartholin gland
excision.
• Abscesses are treated with I&D or marsupialization.
 Corpus alineum vaginae

• Adalah terdapatnya benda asing yang tertinggal

di dalam vagina akibat memasukkan benda asing
ke dalam vagina, biasanya oleh penderita
psikopatiaseksualis dan kasus perkosaan.
• Benda asing ini bisa tetap tinggal di dalam vagina
karena lupa atau karena penderita sendiri tidak
ingin mengeluarkannya
https://www.scribd.com/doc/243976383/Corpus-Alienum-Vagina
 Diagnosis
Anamnesis:
• Keluhan pasien (leukorea, nyeri, perasaan tidak
nyaman)
• Riwayat memasukkan benda asing ke dalam vagina
Diagnosis ditegakkan dengan menemukan corpus
alineum di dalam vagina pada pemeriksaan
ginekologis:
• Pengaruh corpus alineum dalam vagina tergantung
dari bentuk dan jenis benda tersebut
 Penanganan

• Mengambil benda asing

• Melakukan pemulihan bentuk anatomik vagina
dengan cara menghindari berhubungan seksual
hingga iritasi sudah sembuh

Pencegahan
• Tidak memasukkan benda asing ke dalam vagina.
 Schorge JO, Schaffer JI, Halvorson LM,
Hoffman BL, Bradshaw KD, Cunningham FG,
editors. Williams gynecology. New York:
 Abses tubo ovarium

• Adalah Radang bernanah yang terjadi pada ovarium dan

atau tuba fallopii pada satu sisiataukedua sisi adneksa
• Salah satu komplikasi akhir penyakit radang panggul (PID)

Epidemiologi
• Sering terjadi pada wanita fase seksual aktif yakni antara
usia20-40tahun
 Etiologi

• Etiologi Paling sering disebabkan oleh gonococcus, staphylococus

dan streptococ.
• Infeksi dapat terjadi sebagai berikut :
- Menjalar dari alat yang berdekatan seperti dari ovarium yang
meradang
-Naik dari cavum uteri.
F.risiko
 Gejala

• Demam tinggi dengan menggigil. ·

• Nyeri kiri dan kanan di perut bagian bawah terutama kalau ditekan.
• Mual dan muntah, jadi ada gejala abdomen akut karena terjadi
perangsang peritoneum
• Leukosit meningkat
• Toucher :
- Nyeri kalau portio digoyangkan.
- Nyeri kiri dan kanan dari uterus.
- Kadang-kadang ada penebalan dari tuba. Tuba yang sehat tak teraba.
-Nyeri pada ovarium karena meradang.
 Pemeriksaan dan diagnosa

• Ultrasonografi, bisa dipakai pada kecurigaan

adanya ATO atau adanya masa diadneksa
melihat ada tidaknya pembentukan kantung-
kantung pus, dapat untuk evaluasi kemajuan
terapi.
 Penatalaksanaan

- Doksiklin 2x / 100 mg / hari selama 1 minggu atau

ampisilin 4 x 500 mg / hari, selama 1 minggu.
- Pengawasan lanjut, bila masa tak mengecil dalam 14
hari atau mungkin membesar adalah indikasi untuk
penanganan lebih lanjut dengan kemungkinan untuk
laparatomi
 Kista Nabothi
• Penutupan muara sekret kelenjar endoserviks
-> tertahan -> kista
• Inspekulo : penonjolan kistik di daerah
endoserviks
• P.D menjadi lebih jelas + dasar yang berwarna
putih kekuningan _> metaplsa skuamosa
• Mucus-secreting columnar cells line the
endocervical canal.
• During squamous metaplasia, squamous
epithelium may cover functional glandular
cells and secretions may accumulate.
• As this benign process continues, smooth,
clear, white or yellow, rounded elevations
may form and are visible during routine
examination.
• They also are requently seen as well-
defined anechoic sonolucency along the
endocervical canal
• Nabothian cysts typically do not warrant
therapy. However, if they grow large
enough to make Pap testing or cervical
examination difficult or cause symptoms,
they can be opened with a biopsy forceps
and drained.
• Moreover, if the diagnosis of a cervical
mass is uncertain, biopsy or histologic
confirmation is obtained.
Vesicovaginal Fistula 2
• Increased incidence of cephalopelvic disproportion.
• Pelvic bone immaturity.
– Reduced birth canal size before age 18.
– Reduced inlet, midplane, outlet dimensions.
– Late onset of puberty.
– Malnutrition.
• Net = “Low” gynecological age.
– Chronological age – age at menarche.
• Younger age at marriage.

46
 Gynaecological causes
• Operative Injury – Ant. Colporraphy ,
Abdominal hysterectomy
• Traumatic - ant. Vaginal wall & bladder may
be injured following fall on a pointed objects,
by a stick used for criminal abortion
• Malignancy – by direct spread in cases of
Advanced ca of cervix, vagina or bladder
• Radiation - Due to radiation effect ishemic
necrosis may occur
 Types
• Simple - Healthy tissues with good acces
• Complicated – Tissue loss,scarring, difficult access
associated with RVF
Depanding upon SITE of the Fistula –
Juxtracervical :( close to cx) –communication
between supratrigonal region of bladder and
vagina
Midvaginal : communication between
base(Trigone) of bladder and vagina
Juxtraurethral: communication between neck of
bladder and vagina
 Rectovaginal Fistula

Abnormal
communication
between the
rectum
andvagina with
involuntry
escape of flatus
and or feces into
vagina is called
RVF
 Causes
1-Acquired
2- Congenital
Acquired –
Obstatrical causes –
• Incomplete healing or unrepaired recent
complete perineal tear is commonest
• Obstructed labour- During obstructed labour
the compression effect produces necrosis
→infection→ sloughing→ fistule
• Instrumental injury inflicted during destructive
operation
Gynaecological –
• Following incomplete healing of repaired CPT
• Trauma during operative procedure
• Malignancy of vagina, cervix or bowel
• Radiation
• Fall on sharp object
 Diagnosis
• Involuntry escape of flatus & or feces into
vagina
• Rectovaginal examination – size &shape of
fistula
• Confirmation done by probe passing through
vagina into rectum
 Investigation
• Barium enema
• Barium meal &follow trough to confirm
intestinal fistula
• Sigmoidoscopy & proctoscopy
 Taratoma ovarium (kista dermoid)
• These belong to the germ cell family of ovarian neoplasms.
Teratomas arise from a single germ cell, and therefore may
contain any of the three germ layers—ectoderm, mesoderm,
or endoderm. These layers are typically disorganized
• Teratomas are classifed as: Immature teratoma (malignant)
Immature tissues from one, two, or all three germ cell layers
are found and often coexist with mature elements.; Mature
teratoma(benign) tumor contains mature forms of the
three germ cell layers:
– Mature cystic teratoma develops into a cyst, is common, and is
also called benign cystic teratoma or dermoid cyst.
– Mature solid teratoma has elements formed into a solid mass.
– Fetiform teratoma or homunculus forms a doll-shape, as the germ
cell layers display considerable normal spatial differentiation.
• Microscopically, endodermal or
mesodermal derivatives may be
found, but ectodermal elements
usually predominate.
• The cyst is typically lined with
keratinized squamous epithelium
and contains abundant sebaceous
and sweat glands. Hair and fatty
secretions are often found within.
At times, bone and teeth are also
identified.
• The Rokitansky protuberance is
usually the site where the most
varied tissue types are found and is
also a common location of
malignant transformation.
• Malignant transformation develops
in 0.06 to 2 percent o cases and
typically in older women.
• Most malignant cases are squamous
cell carcinoma.
• The diverse tissues found within
teratomas are thought to develop
from genetic material contained
within a single oocyte by asexual
parthenogenesis. As a result,
almost all mature cystic teratomas
have a 46,XX karyotype.
• Mature cystic teratomas can often
undergo torsion, but cyst rupture
is rare. Presumably, their thick cyst
wall resists rupture compared with
other ovarian neoplasms. If cysts
do spill, acute peritonitis is
common.
• The benefits of intraoperative
lavage to prevent peritonitis and
adhesion formation.
• Chronic leakage of teratoma
contents is rare but can lead to
granulomatous peritonitis.
• Symptoms from these teratomas • Sonographymain imaging tool,
are similar to those of other
ovarian cysts. However, ovarian
teratomas can rarely cause
immune-mediated encephalitis.
• Neurologic symptoms stem from
antibodies to N-methyl-d-
aspartate receptors (NMDARs),
which have critical roles in
synaptic transmission.
• The teratomas contain primitive
neural tissue, which presumably
provides the antigen that prompts
NMDAR antibody formation.
• Teratoma resection is essential to
resolution, which can often be
dramatic. Resection may be
combined with immunotherapy.
mature cystic teratomas display several
characteristic features:
– First, fat- fluid or hair- fluid levels are
seen as a distinct linear demarcation
where serous fluid interfaces with
sebum, which is liquid at body
temperature. When floating, hair forms
accentuated lines and dots that
represent hair in longitudinal and
transverse planes.
– The Rokitansky protuberance is a
rounded mural nodule that measures 1
to 4 cm, is predominantly hyperechoic,
and creates an acute angle with the
cyst wall.
– Last, the “tip o the iceberg” sign is
created by amorphous echogenic
interfaces of fat, hair, and tissues in the
foreground that shadow and thus
obscure structures behind it. These
findings are not exclusive to mature
cystic teratomas
 Kista ovarium
• Functional ovarian cysts make up a
• Histologically, ovarian cysts are large portion.
often divided into those derived
rom neoplastic growth, ovarian • Neoplasms constitute most of the
cystic neoplasms, and those remainder, and these predominantly
created by disruption of normal are benign
ovulation, functional ovarian cysts
• Differentiation of these is not
always clinically apparent using
either imaging tools or tumor
markers.
• The exact mechanisms leading to
cyst formation are unclear.
• Angiogenesis is a component of
various pathologic ovarian
processes, including follicular cyst
formation, PCOS, ovarian
hyperstimulation syndrome, and
benign and malignant ovarian
neoplasms
 Symptoms
• Most women with ovarian cysts are asymptomatic.
• If symptoms develop, pain is common.
• Dysmenorrhea may indicate endometriosis with an associated endometrioma.
• Intermittent or acute severe pain with vomiting often accompanies torsion.
• Other causes of acute pain include cyst rupture or tuboovarian abscess.
• In contrast, pressure or ache may be the sole symptom and can result rom ovarian
capsule stretching.
• In advanced ovarian malignancies, women may note increased abdominal girth and
early satiety from ascites or from an enlarged ovary.
• In some women, evidence of hormonal disruption can be found. For example,
excess estrogen production from granulosa cell stimulation may disrupt normal
menstruation or initiate bleeding in prepubertal or postmenopausal patients.
• Increased androgens produced by theca cell stimulation can virilize women.

Diagnosis
• Findings vary, but typically
masses are mobile, cystic, non
tender, and found lateral to the • Increased serum levels o β-hCG
uterus.
• Serum β-hCG testing is
invaluable in the evaluation of
adnexal pathology. Less
commonly, β-hCG can also
serve as a tumor marker in
defining germ cell neoplasms.
• CA125 serum levels are often
elevated in women with
epithelial ovarian cancer. serum
CA125 determinations may be
helpful and are often obtained
if ovarian cysts are large or have
sonographically worrisome
signs.
• serum alpha- etoprotein (AFP)
levels can be elevated in those
rare patients with an
endodermal sinus tumor or
embryonal carcinoma.
may indicate an ovarian
choriocarcinoma, a mixed germ
cell tumor, or embryonal
carcinoma.
• Inhibin A and B are markers for
granulosa cell tumors.
• lactate dehydrogenase (LDH)
levels may be increased in those
with dysgerminoma, whereas
elevated carcinoembryonic
antigen (CEA) and cancer antigen
19–9 (CA19–9) levels arise rom
secretions of mucinous epithelial
ovarian carcinomas.
 Penyakit radang panggul
• Infeksi pada alat genital atas
• Endometrium, tuba fallopi, ovarium,
miometrium, parametrium, peritoneum panggul
• Setelah tindakan (biopsi, kuretase, histeroskopi,
dan insersi AKDR)
• Infeksi melaluui serviks
• Poli mikrobial, infeksi C.trchomatis -> rusak
jaringan -> akses organisme lain dari vagina atau
serviks ke atas
 Penyakit radang panggul
• Banyak pasangan seks
• Infeksi oleh organisme menular seksual
• Pemakaian AKDR (terutama setelah 3 minggu)
• Nyeri abdominopelvik,keluar cairan
vagina/pendarahan, demam dan menggigil,
mual dan disuria
• Kriteria utama: Nyeri gerak serviks, nyeri tekan
uterus, nyeri tekan adneksa
 Penyakit radang panggul
• Biopsi endometrium +histopatologis endometritis
• USG transvaginal -> tuba penuh berisi cairan,
• Terapi parenteral A :sefotetan sefoksitin
• Terapi oral A: Levofloksasin 500 mg
• Infertilitas, kehamilan ektopik
• Sindrom Fitz-Hugh-Curtis -> perlengketan fibrosa
perihepatik -> nyeri tekan kuadran kanan atas
 Source: http://www.glowm.com
Rectocele
• Cystocele occurs when support
between vagina & bladder is
weakened.
• Rectocele results from weakening
between vagina & rectum.
• Etiology:
 Affect multiparous women, resulting
from obstetric damage or ↑ tissue
laxity w/ aging & menopausal
atrophy.
 Most common: obstetric events
(trauma → part descends quickly 2nd
stage of labour → predispose
rectocele formation)
 Low rectocele: isolated defect
suprasphincteric portion of
retrovaginal fascia. (E/: trauma →
disrupts attachements of levator ani
fascia & bulbocavernous muscles).
 Mid / high rectocele: alter vaginal axis
(women w/ android pelvic: risk cause labor
forces directed toward posterior vaginal
wall & perineum → leaving anterior vaginal
wall)
 Midvaginal rectocele: trauma (not involve
levator ani); rectovaginal fascia damaged
by stretching & laceration of tissue,
thinning of fascia, leading subsequent
adhesion formation.
 High rectocele: pathologic overstretching
of pudendal nerves during descent fetal
head cause atrophy & denervation of pelvic
floor muscles.
 Defecation disorder → cause rectocele.
 Congenital absence of perineum → mimic
a rectocele.
 Differences in connective tissue strength
between races. (Hispanic, Filipino &
Chinese ↑ risk of laxity tissue. Black ↓.)
 Source: http://www.glowm.com
Rectocele
• Clinical Presentation:
 Bowel dysfunction
(asymptomatic → severe)
1. Common: constipation (75%)
2. Incomplete rectal emptying
3. Sense of rectal pressure
4. Vaginal bulge
5. Vaginal digitation / perineal
support → defecation
 Non-specific symptoms: rectal
pain, bleeding, fecal / gas
incontinence, LBP worsens
throughout day but relieved by
lying down, dyspareunia.
 Usually: asymptompatic (80%)
• Physical Examination:
 1st: dorsal supine position (lead to underscoring
rectocele) for gynaecologist & left lateral
decubitus position (closely matched finding
defecography) for colorectal surgeon.
 After external genitalia inspected → strength,
integrity & prolapse perineum tested; patient
asked to strain down / cough forcefully (allows
pelvic organs descend to determine extent of
prolapse).
 Digital support of perineum opens genital hiatus
→ allow visualization anatomy; posterior vaginal
wall prolapsed cause by rectocele enterocele
assessed by rectal finger evaluate anterior
displacement of rectovaginal septum & perineal
body.
 Rectocele can differentiated from enterocele by
noting bowel in retrovaginal space
 Retrovaginal examination → reveal small bowel
herniating into this space when enterocele
present.
 Rectoceles → can be diagnosed w/ PE.
 Source: http://www.glowm.com

• Diagnostic Studies:
Rectocele
• Surgery Repair:
1. Defecography
1. Defect-Specific Rectocele Repair
2. Ultrasound
2. Traditional Transvaginal Repair
3. Anal Mammometry
3. Transrectal Approach
4. Electromyography & NCS (Nerve
4. Transabdominal Repair
Conduction Studies)
5. Mesh/Graft Augmentation
5. Colonic Transit Studies

• Complication:
• Management:
1. Clinical diagnosis made, confirmed Bleeding Difficulty w/ bowel
emptying
by ancillary studies.
Constipation Fecal incontinence
2. Non-surgical treatment: proper
bowel training, active lifestyle & Dyspareunia Proctotomy
eating dietary fiber. (important: Pelvic pain/pressure Rectovaginal fistula
constipation, prolapse symptoms)
3. Surgery: severe symptoms
(anatomic defect)
 Endometritis
• Bakteri patogen yang naik dari serviks ke
endometrium
• C.trachomatis, N.gonorhoeae, staphylococcus
dan streptococcus
• Salah satu penyebab penyakit radang panggul,
tahapan antara dalam penyebaran infeksi ke
tuba fallopi
 Endometritis kronik
• Asimptomatik, klasik : pendarah vaginal
intermenstrual, pendarahan pascasanggama dan
menoragia.
• Nyeri tumpul di perut bagian bawah terus menerus

Endometritis akut
• Bersamaan dengan pid biasa terjadi nyeri tekan
uterus
• Doksisiklin 100 mg per oral 2x
 ENDOMETRIAL CANCER

• Cancer of the uterine endometrial lining

• Most common female reproductive cancer
– 40,000 new cases/year
– 7,000 deaths/year
• Most of these malignancies are
adenocarcinoma
 RISK FACTORS FOR ENDOMETRIAL
CANCER
• Early menarche
(<age 12)
• Late menopause
(>age 52)
• Infertility or nulliparous
• Obesity
• Treatment with tamoxifen
for breast cancer
• Estrogen replacement
therapy (ERT) after
menopause
• Diet high in animal fat
• Diabetes
• Age greater than 40
• Caucasian women
• Family history of
endometrial cancer or
hereditary nonpolyposis
colon cancer (HNPCC)
• Personal history of breast
or ovarian cancer
• Prior radiation therapy for
pelvic cancer
 Endometrial Carcinoma
Etiology
• Unnoposed estrogen
hypothesis: exposure to
unopposed estrogens
Pathology
• Spreads through uterus,
fallopian tubes, ovaries and
out into peritoneal cavity
– Metastasizes via blood and
lymphatic system
 SYMPTOMS OF
ENDOMETRIAL CANCER
• Symptoms
– Non-menstrual bleeding or discharge
• Especially post-menopausal bleeding
– Heavy bleeding
– Dysuria
– Pain during intercourse
– Pain and/or mass in pelvic area
– Weight loss
– Back pain
 Sumber: Buku Saku Pelayanan Kesehatan Ibu Di Fasilitas Dasar Dan Rujukan. Bagian 5. Hal. 212.
Kista Ovarium (Tumor Adneksa)
• Definisi:
 Tumor kistik pd ovarium.
 Nyeri perut akut e/ ruptur
terutama kehamilan trimester 1.
• Diagnosis:
 Nyeri perut.
 Teraba massa pd pemeriksaan
dalam.
 Ditegakkan dgn USG.
• Tatalaksana:
a. Tatalaksana Umum:
 Curiga tumor adneksa → hrs
rujuk ke RS.
b. Tatalaksana Khusus:
 Hamil: neoplasma uk > telur angsa → hrs
dikeluarkan.
 Tumor diketahui ganas / disertai gejala akut
→ ps rujuk segera u/ angkat tumor (≠
menghiraukan usia kehamilan).
 Tumor halangi jalan lahir → lakukan SC +
angkat tumor.
 Tumor ≠ ganas (usia kehamilan muda) →
angkat tumor ditunda sampai hamil usia 16
minggu. Pengangkatan sebaiknya dilakukan
di usia kehamilan antara 16- 20 minggu. Bila
pengangkatan terpaksa dilakukan sblm16
minggu → stlh angkat → suntikan progestin
s/d usia kehamilan melewati 16 minggu.
 Tumor (usia kehamilan tua & ≠ penyulit
obstetri / ≠ curiga keganasan) → kehamilan
dibiarkan s/d partus spontan. Angkat: masa
nifas.
 Sumber: Buku Saku Pelayanan Kesehatan Ibu Di Fasilitas Dasar Dan Rujukan. Bagian 5. Hal. 212.

Kista Ovarium (Tumor Adneksa)

Ruptur
• Kista ovarium ruptur: b. Tatalaksana Khusus:
 Kista ovarium ruptur + nyeri
 Tjd trimester 1 perut → laparotomi.
kehamilan.  Kista ovarium asimptomatik:
 Masa nyeri tekan i. Kista uk >10 cm →
abdomen bawah. laparotomi trimester 2
kehamilan.
 Asimptomatik. ii. Kista uk <5 cm → ≠ operasi.
iii. Kista uk 5-10 cm →
• Tatalaksana: observasi: menetap /
membesar → laparotomi
a. Tatalaksana Umum: trimester 2 kehamilan.
 Segera rujuk ke RS.  Curiga ganas → rujuk RS lbh
lengkap.
 Karsinoma Ovarium
• 5 – 15% kasus per 100.000 wanita setiap
tahun
Faktror resiko:
• Lingkungan
• Reproduksi
• Genetik / keturunan
 Karsinoma Ovarium
• Sebagian besar → asimptomatik
• Perut membesar / ada perasaan tekanan,
dispareunia, berat badan meningkat
• Penanda tumor Ca-125

Medical Mini Notes. Gynecologic. Medical

Mini Notes Production; 2014.
 MIOMA UTERI
• =Leiomyoma
• Tumor jinak dengan struktur utama otot polos
uterus

Medical Mini Notes. Gynecologic. Medical

Mini Notes Production; 2014.
 INSIDENS MIOMA UTERI
• Terjadi pada 20 – 25% wanita usia produktif
• 3 – 9x lebih banyak pada ras kulit berwarna
(African-American women) dibandingkan ras
kulit putih (Caucasian-Asian women)

Medical Mini Notes. Gynecologic. Medical

Mini Notes Production; 2014.
 Schorge JO, Schaffer JI, Halvorson LM,
Hoffman BL, Bradshaw KD, Cunningham FG,
editors. Williams gynecology. New York:
 KLASIFIKASI MIOMA UTERI
• Mioma subserosa
– Tumbuh di bawah lapisan serosa uterus, tumbuh
ke arah luar
• Mioma submukosa
– Tumbuh di lapisan bawah endometrium, tumbuh
ke arah dalam (cavum uteri)
• Mioma intramural
– Tumbuh dan berkembang di dalam miometrium
• Pedunculated → jika terdapat tangkai
Medical Mini Notes. Gynecologic. Medical
Mini Notes Production; 2014.
 GEJALA MIOMA UTERI
• Pada 35 – 50% penderita :
– Perdarahan abnormal uterus
– Rasa nyeri → dismenore, dispareunia, nyeri
pinggang
– Efek penekanan → ureter, VU, rektum
– Infertilitas
• Semakin besar → gejala klinis semakin terlihat

Medical Mini Notes. Gynecologic. Medical

Mini Notes Production; 2014.
 Diagnosis of adenomiosis
• Approximately 1/3 of women
with adenomyosis have
symptoms, and HMB and
dysmenorrhea are common.
Perhaps 10 % complain of
dyspareunia. Symptom
severity correlates with
increasing number of ectopic
foci and extent of invasion .
• The pathogenesis of these
symptoms is unknown,
although myometrial
contractility and markers of
inflammation are implicated.
• Any link with subfertility is
unclear
• For many years, the diagnosis
of adenomyosis in most cases
has been made retrospectively
following hysterectomy and
histologic examination.
• Serum measurement of cancer
antigen 125 (CA125), one
tumor marker, is unhelpful.
• Although CA125 levels are
typically elevated in women
with adenomyosis, they may
also be elevated in those with
leiomyomas, endometriosis,
pelvic infection, and pelvic
malignancies.
 Source: Williams Gynecology 3rd Ed. New York: Mc-Graw-Hill, 2016. Sc 2. Ch 17. Pg 386-400.

Polycystic Ovarian Syndrome (PCOS)

• Definition: Common
endocrinopathy typified
by oligoovulation or
anovulation, signs o
androgen excess, and
multiple small ovarian
cysts.
• Sign & symptoms: vary
widely between women
& within individuals
over time, have higher
rates of dyslipidemia &
insulin resistance.
 Source: Williams Gynecology 3rd Ed. New York: Mc-Graw-Hill, 2016. Sc 2. Ch 17. Pg 386-400.
Polycystic Ovarian Syndrome (PCOS)
• Incidence:
 4-12% general population
studies.
 An affected individuals & their
sisters (32-66%) & (24-52%)
mothers.
 Genome-wide association
studies in Chinese women have
identified variants in 11
genomic regions as potential
PCOS risk factors.
 Epigenetic modification of
genetic susceptibility within the
maternal-fetal environment
may influence adult PCOS
development.
• Etiology:
 Underlying cause: unknown.
 Genetic basis: multi-factorial
& polygenic is suspected,
well-documented aggregation
of syndrome within families.
 Twin also suggest prominent
heritable influence.
 Some suggested an
autosomal dominant
inheritance w/ expression in
females & males. (higher
rates of DHEAS level, early
balding & insulin resistance
compare w/ male controls)
 Teratoma Ovarium
• Teratomas constitute 15% to 20% of ovarian
tumors
• Predilection to arise in the first 2 decades of
life
• the younger the person, the greater the
likelihood of malignancy
• Def: a special type of mixed tumor that
contains recognizable mature or immature
cells or tissues representative of more than
one germ cell layer and sometimes all three.
• Sign&symptom:
– Asymptomatic
• Mature cystic teratomas of the ovary are often
discovered as incidental findings on physical
examination, during radiographic studies, or during
abdominal surgery performed for other indications
– abdominal pain
• Usually: constant and ranges from slight to moderate in
intensity
– mass or swelling
– abnormal uterine bleeding
– Bladder symptoms, gastrointestinal disturbances,
and back pain are less frequent
• Diagnosed: CT ; MRI
• Classification:
– Benign (Mature) Cystic Teratomas
– Immature Malignant Teratomas
– Specialized Teratomas
 Benign (Mature) Cystic
Teratomas
• = dermoid cyst
• Almost all: marked by the presence of mature
tissues derived from all three germ cell layers:
ectoderm, endoderm, and mesoderm
– Ectoderm (skin derivatives and neural tissue)
– Mesoderm (fat, bone, cartilage, muscle)
– endoderm (eg, gastrointestinal and bronchial
epithelium, thyroid tissue)
• Most are discovered in young women as ovarian
masses or are found incidentally on abdominal
radiographs or scans
• About 90% are unilateral,
– the right side more commonly affected.
• Rarely do these cystic masses exceed 10 cm in
diameter
– grow slowly at an average rate of 1.8 mm each year
• Diagnosed: CT ; MRI
• Complication:
– For unknown reasons, these neoplasms sometimes
produce (in 10% to 15% of cases)
 Immature Malignant Teratomas
• Malignant (immature) teratomas are found early
in life
– The mean age at clinical detection being 18 years.
• They differ strikingly from benign mature
teratomas :
– Bulky; typically larger (14–25 cm) than mature cystic
teratomas
– predominantly solid on cut section, and punctuated
by areas of necrosis
– microscopic examination, the distinguishing feature is
presence of immature elements or minimally
differentiated cartilage, bone, muscle, nerve, or other
tissues
 Corpus alineum vaginae

• Adalah terdapatnya benda asing yang tertinggal di dalam vagina

akibat memasukkan benda asing ke dalam vagina, biasanya oleh
penderita psikopatiaseksualis dan kasus perkosaan.
• Benda asing ini bisa tetap tinggal di dalam vagina karena lupa atau
karena penderita sendiri tidak ingin mengeluarkannya

https://www.scribd.com/doc/243976383/Corpus-Alienum-Vagina
 Diagnosis
Anamnesis:
• Keluhan pasien (leukorea, nyeri, perasaan tidak nyaman)
• Riwayat memasukkan benda asing ke dalam vagina
Diagnosis ditegakkan dengan menemukan corpus alineum di dalam
vagina pada pemeriksaan ginekologis:
• Pengaruh corpus alineum dalam vagina tergantung dari bentuk
dan jenis benda tersebut
• Benda terbuat dari kain dengan cepat menimbulkan infeksi
disertai leukorea yang berbau
• Pesarium yang dipasang untuk prolapsus uteri dapat pula
menimbulkan iritasi dan perlukaan apabila tidak dikeluarkan
dan dibersihkan secara berkala
• Pesarium yang terlalu lama di vagina dapat terbenam
sebagian dalam dinding vagina
• Perlukaan pada vagina bisa juga terjadi apabila digunakan
benda untuk melakukan abortus provocatus criminalis
• Karena benda tsb tidak steril, timbul bahaya perdarahan,
tetanus / sepsis dengan segala akibatnya
 Penanganan

• Mengambil benda asing

• Melakukan pemulihan bentuk anatomik vagina dengan cara
menghindari berhubungan seksual hingga iritasi sudah sembuh

Pencegahan
• Tidak memasukkan benda asing ke dalam vagina.
Klimakterik / Perimenopausal syndrome
• Klimakterik ditandai oleh turunnya kadar estrogen dan meningkatnya
pengeluaran gonadotropin.
• Menurunnya kadar estrogen mengakibatkan gg keseimbangan hormonal
yang dapat berupa gg siklus haid, gg neurovegetatif, gg psikis, gg somatik,
dan metabolik
• Beratnya gg tsb berbeda tergantung
• Penurunan aktivitas ovarium yg mengurangi jlh hormon steroid seks
ovarium. Keadaan ini menimbulkan gejala-gejala klimakterik dini(
gejolak panas, keringat banyak, dan vaginitis atrofikans) dan gejala-
gejala lanjut akibat perubahan metabolik yang berpengaruh pada organ
sasaran (osteoporosis)
• Sosio budaya menentukan dan memberikan penampilan yang berbeda
dari keluhan klimakterik
• Psikologik yang mendasari kepribadian perempuan klimakterik itu, juga
akan memberikan penampilan yang berbeda dalam keluhan klimakterik
• Siklus yang teratur terjadi akibat keseimbangan hormon yang tepat
disertai ovulasi yang regular
• Pada perimenopause, tjd perubahan level hormon, yang
mempengaruhi ovulasi
• Jika ovulasi tidak terjadi, ovarium akan terus memproduksi
estrogen, dengan akibat penebalan endometrium
• Hal ini akan menyebabkan perdarahan ireguler ataupun spotting
• Estrogen tanpa pengaruh progesteron akan memberi gambaran
hiperplasia glandularis sistika
• Perempuan dengan kelainan siklus pada saat klimakteriu yang
berupa oligomenorea / hipomenorea tidak diperlukan terapi
• Sebaliknya perdarahan berlebih perlu mendapatkan perhatian
sepenuhnya
• Dengan kerokan perlu dipastikan perdarahan tidak berdasarkan
kelainan organik
• Gg psikis menonjol pada tahun pertama dan berakhir selama 5 tahun
• Gejalanya berupa nervous, kecemasan, irritable, depresi, dan
insomnia
• Penyebab gg psikis belum diketahui secara pasti, diperkirakan oleh
karena rendahnya kadar estrogen

Penanggulangan
• Kelainan ringan diatasi dengan konseling yang baik
• Terapi hormonal mungkin dibutuhkan terhadap hot flushes, dan
banyak berkeringat
• Dosis sekecil mungkin, dengan masa pengobatan sesingkat mungkin
• Pemberian estrogen 3 minggu, kemudian dihentikan untuk 1 minggu
dan selanjutnya cara ini diulangi, sampai terapi tidak dibutuhkan lagi
 Menopause
• Diagnosis dapat ditegakkan bila ditemukan
• Wanita usia 48-49 tahun
• Haid mulai tidak teratur
• Darah haid mulai sedikit
• Haid berhenti sama sekali
• Timbul keluhan klimakterik / tanpa
keluhan klimakterik
• Diagnosis pasti ditegakkan bila
• Usia > 40 tahun
• Tidak haid > 6 bulan
• Dengan / tanpa keluhan klimakterik
• Kadar FSH > 40mIU/ml
• E2 < 30 pg/ml
• Menopause dini : herediter, gg gizi, penyakit
menahun, penyakit/ keadaan yang merusak
kedua ovarium termasuk pengangkatan saat
operasi
• Menopause terlambat : bila masih haid diatas
usia 52 tahun, kemungkinan akibat
fibromioma uteri, tumor yang menghasilkan
estrogen, konstitusional
• Gejala perubahan pola haid : berupa polimenorea, oligomenorea, amenorea
dan metroragi ( bisa fisiologis / patologis)
• Gejala gg vasomotor : hot flushes (semburan rasa panas, mulai dari wajah,
leher dan dada sekitar 1-2 menit diiringi sakit kepala, pusing, berdebar-debar
dan mual
• Gejala kelainan metabolik
• Kelainan metabolisme lemak dan penyakit jantung koroner : produksi HDL
berkurang, LDL dan kolesterol meningkat (HDL kardioprotektif)
• Kelainan metabolisme mineral dan osteoporosis : 25% menopause
kehilangan kalsium 3% setahun (reseptor estrogen pada osteoblas, dimana
pemberian estrogen merangsang pembentukan tulang baru)
• Gejala atrofi urogenital : perubahan pada jaringan kolagen, epitel dan
berkurangnya hialuronidase yang menyebabkan cairan ekstraseluler
berkurang. Berkurangnya kolagen dan hialuronidase menyebabkan
berkurangnya aliran darah pada kulit sehingga produksi sebum dari kelenjar
akan berkurang, penampakan pada kulit berupa kasar dan keriput. Dampak
pada saluran urogenitalia al vaginitis senilis, kering pd vagina, keputihan,
perasaan perih dan terbakar pada vulva, perasaan panas / perih pada saat
miksi, dispareunia.
 Kista gartner
Gambaran umum
• Kista ini berasal dari sisa kanalis Wolfii yang berjalan sepanjang
permukaan anterior dan bagian atas vagina
• Diameter kista bergantung dari ukuran duktus dan kapasitas tamoung
cairan didalamnya sehingga bisa dalam ukuran yang relatif kecil hingga
cukup besar untuk mendorong dinding vagina ke arah tengah lumen /
dapat memenuhi lumen dan mencapai introitus vagina
Gambaran klinik
• Lokasi utama kista Gartner adalah bagian anterolateral puncak vagina
• Pada perabaan kista ini bersifat kistik, dilapisi dinding translusen tipis
yang tersusun dari epitel kuboid / kolumner, baik dengan atau tanpa
silia dan kadang2 tersusun dalam beberapa lapisan (stratified)
Terapi
• Insisi dinding anterolateral vagina dan eksisi untuk mengeluarkan kista
dari sisa kanalis Wolfii ini