Health Awareness blog

I am sure some of us may have heard about this term. Uterine fibroid is one of the common benign smooth muscle tumors. It is also known as “leiomyomata”. The occurrence of fibroids is more than 20% among Caucasian women. Peak age is more than 30 years. Classifications:

1.       Subserous – this is when the fibroid project from peritoneal surface of the uterus

2.       Intramural – it means that the fibroid lie within the uterine wall

3.       Submucous – the fibroid intrude on the uterine cavity

4.       Pedunculated – this means that the fibroid arise from either the subserous layer or the submucous layer

Pathophysiology of fibroid is simple. Fibroids arise from smooth muscle cells during reproductive life. It basically increases in size in response to oestrogen. Fibroids usually slightly decrease in size during postmenaupausal stage.

As common as it is, it may remain silent. Majority of women with fibroids are asymptomatic. Sometimes they may only been found by accidental finding, for example on abdominal ultrasound scan during antenatal check up. Symptoms of fibroids are abdominal distension, menorrhagia (heavy menses) and pressure symptoms. Pressure symptoms include urinary frequency and incomplete voidance. Some patients may present with anemia due to severe menorrhagia and may need blood transfusion. Most of them do not complaint of abdominal pain unless the fibroid is too big and compress other structures or there is red degeneration or torsion of pedunculated fibroid. Occasionally, patient may present to clinic with infertility. On abdominal examination, we may reveal a palpable mass rising from the pelvis. We can confirm this finding by doing pelvic examination. The outline of the mass may appear irregular.

There are few investigations that can be offered to the patient. Most of the time blood investigations are not needed unless there is suspicion of malignant tumor. In this case, tumor markers and other baseline blood investigations will be sent. During some circumstances, blood investigations will be ordered by your doctor base on the symptoms that you have present. For example, if you present with menorrhagia, your doctor will send for full blood count to look for hemoglobin level. They will send for coagulation profile to rule out any bleeding disorder. If you present with urinary symptoms they may send for urine FEME to rule out ant urinary tract infection. The investigation that really been use for diagnosis is ultrasonography or ultrasound scan. Exploration under anesthesia or hysteroscopy plus endometrial biopsy will confirm the diagnosis. Usually, the gynaecologists only offer this to you if you have abnormal per vaginal bleeding or if there is any suspicion of malignant tumor.

The treatment is usually not needed hence we can divide the management into 2 either by conservative management or surgical. If the patient is asymptomatic, no treatment is offer to the patient however your gynaecologist will monitor your disease and will discuss about the further step should the fibroid getting bigger or cause problem. Surgical management will be offer if the fibroid is too big, causing pain or abnormal bleeding. The surgical management is either by myomectomy (removal of the fibroid only) or hysterectomy, if the fibroid is too big and you have completed your family.

There are some complications of fibroids include the poor vascularity of the fibroids that encourage degeneration (hyaline, cystic, red, sarcomatous) of the disease. Sometimes the fibroids will become calcified and necrosis. It also may become tort and infected. Rarely, it will become malignant and metastasize.

Related:

• Uterine inversion

Reference:

1.       Gynaecology in focus. Churchill Livingstone. Janice Rymer et al. 2005.

Inguinal hernia is a protrusion of abdominal cavity into the inguinal canal. It has a very close relation with premature infants and affecting up to 25% of male infants. Overall incidence is more common in male rather than female gender. Previous study showed that the testicles only descent into the scrotum after 32 completed week gestation follows by the contraction of the processus vaginalis at the inguinal canal. As addition, studies revealed that premature infants having IH were more likely to have had lower gestational age, lower birth weight and required prolonged ventilator assistance.

There are 2 types of inguinal hernia; first is indirect inguinal hernia and second is direct inguinal hernia. Indirect inguinal hernias are congenital hernias. It is more common in males due to the way they develop in the womb. In male fetus, the spermatic cord and both testicles usually descend from intra abdominal cavity into the scrotum through inguinal canal. The entrance of the inguinal canal at the inguinal ring should close just after birth. However, it may not happen sometimes, particularly in premature infant. This will lead to abdominal weakness and allow fat or part of the small intestine slides through into the inguinal canal causing a hernia. The different in females is the indirect inguinal hernia is caused by the female organs or the small intestine sliding into the groin through a weakness in the abdominal wall. There is no canal involve.

Meanwhile, direct inguinal hernia is caused by connective tissue degeneration of the abdominal muscles which weaken during adulthood. It develops gradually because of the continuous stress of the muscles. Direct inguinal hernias can only occur in males. These hernias usually slide back and forth spontaneously and can often be reduced back into the abdomen with gentle massage.

The symptoms of inguinal hernia include a small bulge in one or both sides of the groin that may increase in size and disappear when lying down. Males can present as a swollen or enlarged scrotum. There is often associated with discomfort or sharp pain especially during straining, lifting, or exercising that usually improves when resting. In premature infant, it is mainly the clinical examination as the baby cannot obviously complain any pain. Excessive cry may suggest pain. The hernia may become incarcerated or strangulated. Incarcerated means the hernia cannot be reduce back to abdominal cavity and may later lead to strangulated hernia that require emergency operation. If surgery is not performed right away, the condition can become life threatening. The affected intestine may die and need resection. These two complications are rarely seen in infants.

In term of treatment, inguinal hernia is usually surgically managed. The operation mainly divided by two; open surgery or laparascopy. For adult, the surgeon will do herniorraphy or hernioplasty while in infancy they will do herniotomy. Traditionally in herniorraphy, the weak spot in the muscle wall will be repaired by sewing the edges of the healthy muscle tissue together. Today, a mesh patch (or patches) of synthetic material are now widely use. It will be sewn over the weakened area in the abdominal wall after the hernia is reduced back in the abdominal cavity, hence we get the term ‘hernioplasty’. In herniotomy, the patient processus vaginalis will be excised and ligated. Generally, it will be unnecessary to perform formal repair of the abdominal wall.

References:

1. Newell, SJ. and Darling, JC. Lecture notes paediatrics. Eight edition. Singapore: Blackwell Publishing; 2008.

2. Brooker, RW. and Keenan, WJ. Inguinal hernia: relationship to respiratory disease in prematurity. Journal of Pediatric Surgery. 2006 November. 41 (11): 1818-1821.

3. Kumar, VH.S. , Clive, J. and Rosenkratz, TS, Bourque, MD and Hussain, N.. Inguinal hernia in preterm infants, Pediatrics Surg Int, 2002: 147-152.

4. Yeo, CL. and Gray, PH. Inguinal hernia in extremely preterm infants. Journal Paediatrics Child Health, 1994. 30 : 412-413.

5. Simon, C., Everitt, H. and Kendrick, T. Oxford Handbook of General Practice, Second edition, Oxford: Oxford University Press; 2005.