Shaw's Textbook of Gynaecology

597 Pages·2015·50.95 MB·English

Howkins & Bourne

Shaw’s Textbook of

Gynaecology

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Howkins & Bourne

Shaw’s Textbook of

Gynaecology

VG Padubidri, ms, frcog (lond)
Formerly Director, Professor and Head, Department of Obstetrics and Gynaecology
Lady Hardinge Medical College, and Smt. Sucheta Kriplani Hospital, New Delhi

Shirish N Daftary, md, dgo, fics, fic, ficog
Professor Emeritus and Former Medical Advisor, Nowrosjee Wadia Maternity Hospital, Mumbai
Formerly Dean, Nowrosjee Wadia Maternity Hospital
Past President, Bombay Obstetrics and Gynaecological Society
Past President, Federation of Obstetrics and Gynaecological Societies of India
Former Jt. Associate Editor, Journal of Obstetrics and Gynaecology of India
Past President, Indian College of Obstetrics and Gynaecology
Past Chairman, MTP Committee of FOGSI
Vice President, Indian Academy of Juvenile and Adolescent Gynaecology and Obstetrics
Chairman, Indian College of Maternal and Child Health

16TH EDITION

ELSEVIER
A division of
Reed Elsevier India Private Limited

Edited by

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Shaw’s Textbook of Gynaecology, 16/e
Padubidri and Daftary

© 2015 Reed Reed Elsevier India Private Limited

Previous editions, 1936, 1938, 1941, 1945, 1948, 1952, 1956, 1962, 1971, 1989, 1994, 1999, 2004,
2008, 2011

All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any
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This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).

ISBN: 978-81-312-3672-7
e-book ISBN: 978-81-312-3872-1

Notices

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Dedicated to

the medical students

who have always been the source of inspiration

and the patients

who have provided valuable clinical knowledge

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to the 16th edition
Preface

We, the editors of Howkins and Bourne Shaw’s Textbook of
Gynaecology, are pleased to acknowledge that this book has
continued to provide basic foundation of this speciality
since 1936. Keeping in view of the popularity of the book,
the first Indian edition (10th edition) was published in
1989. Since then, the book has been updated from time to
time in the light of the advances made in this speciality. The
15th edition was revised in 2010. Our commitment to the
students to improve and update the quality of the book, and
provide them with the advanced knowledge prompted us to
bring out the 16th edition.

In this edition, not only we have added the latest knowl-

edge on the subject, but also inserted more illustrations,
flowcharts and tables to make the reading easier and under-
standable. We have added more MRI, CT, and many other
illustrations wherever required.

Considering the high associated morbidity and mortality

of gynaecological malignancies, we have approached
the topic of genital tract cancers more exhaustively in
this edition. Emphasis has also been laid on the gynaeco-
logical problems amongst adolescents and menopausal
women. Minimal invasive surgery for the benign condi-
tions is now being replaced by non-surgical therapy
such as MRI-guided ablative therapy without the need for

hospitalization. Hopefully these procedures will turn safe
and effective in near future.

A website of the book has been created for more informa-

tion on the subject in the form of video clips, online testing
and MCQs for entrance tests and the latest updates on the
subject.

We owe our special thanks to the entire staff of Elsevier

for their wholehearted support and encouragement. We
will fail in our duty if we did not make a special reference to
Shabina Nasim with whom we interact on a daily basis and
also Renu Rawat. We appreciate their professional attitude
and their knowledge towards the project, their efficiency
and enormous patience to bring out the best for this project.

Our very special thanks and gratitude go to Mr YR

Chadha, Publishing Consultant, BI Churchill Livingstone,
New Delhi, who initiated and guided us in the First Indian
Edition in 1989, without whose persuasion and encourage-
ment this book would not have seen the day. There are many
others who have worked behind the scene, we acknowledge
our thanks to them.

Last, but not the least, we thank our readers and the

student community for their unstinted support over the last
25 years.

VG Padubidri

Shirish N Daftary

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to the 10th edition
Preface

Ever since Shaw’s Textbook of Gynaecology appeared in the
United Kingdom in 1936, it has maintained its popularity
with teachers, examiners and the student community. It
has gone through several editions. The ninth edition, edited
by Dr John Howkins and Dr Gordon Bourne, was brought
out in 1971, and its popularity in India has remained undi-
minished. It is therefore timely and opportune that this
standard textbook should be revised by Indian teachers of
gynaecology to meet the requirements of our undergradu-
ate students. We consider ourselves fortunate for having
been assigned this challenging task by the publishers.

In revising the book we have endeavoured to update the

contents to include new methods of investigations and
treatment. In particular, recent advances in the physiology
of menstruation and its hormonal control, carcinoma of
the cervix and related preventive measures, endometriosis,
and the management of tuberculosis of the genital tract

have been incorporated. In addition, the latest methods of
birth control and a separate chapter on Medical Termina-
tion of Pregnancy have been added to equip our students
with the knowledge required to promote India’s family
welfare programme.

We have also tried to make the text more concise by delet-

ing information that we felt was unnecessary for the Indian
undergraduate student, without substantially changing the
original style.

We are indebted to Mr YR Chadha, Publishing Director

of BI Churchill Livingstone, New Delhi for his constant
encouragement and invaluable suggestions in the prepara-
tion of this edition. Sincere thanks are extended to Churchill
Livingstone, Edinburgh, for their assistance in making this
edition possible.

VG Padubidri

Shirish N Daftary

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Contents

Preface to the 16th Edition
vii

Preface to the 10th Edition
ix

1. Anatomy
1

2. Normal Histology
25

3. Physiology
37

4. Puberty, Paediatric and Adolescent

Gynaecology
51

5. Perimenopause, Menopause,

Premature Menopause and
Postmenopausal Bleeding
65

6. Gynaecological Diagnosis
79

7. Endoscopy in Gynaecology
93

8. Imaging Modalities in Gynaecology
111

9. Malformations of the Female

Generative Organs
123

10. Sexual Development and

Development Disorders
139

11. Sexually Transmitted Diseases
155

12. Inflammation of the Cervix

and Uterus
171

13. Pelvic Inflammatory Disease
177

14. Tuberculosis of the Genital Tract
187

15. Injuries of the Female Genital Tract
197

16. Injuries to the Intestinal Tract
205

17. Diseases of the Urinary System
211

18. Genital Fistulae and Urinary

Incontinence
219

19. Infertility and Sterility
237

20. Birth Control and Medical

Termination of Pregnancy
263

21. Ectopic Gestation
293

22. Gestational Trophoblastic Diseases 311
23. Disorders of Menstruation—

Amenorrhoea
321

24. Menorrhagia
335

25. Genital Prolapse
349

26. Displacements
365

27. Diseases of the Vulva
371

28. Diseases of the Vagina
379

29. Benign Diseases of the Uterus
391

30. Endometriosis and Adenomyosis
409

31. Disorders of the Broad Ligament,

Fallopian Tubes and Parametrium
425

32. Disorders of the Ovary
429

33. Ovarian Tumours
435

34. Breast
455

35. Acute and Chronic Pelvic Pain
463

36. Dysmenorrhoea, Premenstrual

Syndrome
471

37. Vulval and Vaginal Cancer
475

38. Cervical Intraepithelial Neoplasia,

Carcinoma of Cervix
485

39. Cancers of Endometrium,

Uterus and Fallopian Tube
507

40. Ovarian Cancer
521

41. Radiation Therapy and

Chemotherapy for Gynaecologic
Cancer
531

42. Obesity
543

43. Hormonal Therapy in Gynaecology
547

44. Pelvic Adhesions and Their

Prevention
561

45. Preoperative and Postoperative

Care, and Surgical Procedures
565

Index
573

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The Vulva 1
Labia Majora 1
Bartholin’s Gland 1
Labia Minora 2
The Vagina 3
Relations of Vagina 5
The Uterus 6
Perimetrium 6
Myometrium 7
Endometrium 7
The Uterine Appendages 8
Fallopian Tubes 10
The Ovaries 11
The Urethra 12
Relations 12
The Bladder 12
Nerve Supply 13
The Ureter 13

The Rectum and Anal Canal 14
The Lymphatics 14
Breasts 14
The Pelvic Musculature 14
Pelvic Diaphragm 15
Urogenital Diaphragm 15
The Pelvic Cellular Tissue 16
The Pelvic Blood Vessels 18
The Vaginal Arteries 19
The Arteries of the Vulva and Perineum 20
The Pelvic Veins 20
The Lymphatic System 20
The Lymphatic Glands or Nodes 20
The Nerve Supply 21
Applied Anatomy and its Clinical Signific
cance 22
Key Points 24
SelfcAssessment 24

CHAPTER OUTLINE

Chapter

1
Anatomy

The anatomical knowledge of the female genital organs
(Figure 1.1) and their relation to the neighbouring struc-
tures help in the diagnosis of various gynaecological diseases
and in interpreting the findings of ultrasound, computed to-
mography (CT) and magnetic resonance imaging (MRI)
scanning. During gynaecological surgery, distortions of the
pelvic organs are better appreciated and dealt with and a
grave injury to the structures such as bladder, ureter and
rectum is avoided. The understanding of the lymphatic
drainage of the pelvic organs is necessary in staging various
genital tract malignancies and in their surgical dissection.

The Vulva

The vulva is an ill-defined area which in gynaecological
practice comprises the whole of the external genitalia
and conveniently includes the perineum. It is, therefore,
bounded anteriorly by the mons veneris (pubis), laterally by
the labia majora and posteriorly by the perineum.

Labia Majora

The labia majora pass from the mons veneris to end posteri-
orly in the skin over the perineal body. They consist of folds of
skin which enclose a variable amount of fat and are best de-
veloped in the childbearing period of life. In children before

the age of puberty and in postmenopausal women, the
amount of subcutaneous fat in the labia majora is relatively
scanty, and the cleft between the labia is therefore conspicu-
ous. At puberty, pudendal hair appear on the mons veneris,
the outer surface of the labia majora and in some cases on
the skin of the perineum as well. The inner surfaces of the
labia majora are hairless and the skin of this area is softer,
moister and pinker than over the outer surfaces (Figure 1.2).
The labia majora are covered with squamous epithelium and
contain sebaceous glands, sweat glands and hair follicles.
There are also certain specialized sweat glands called apo-
crine glands, which produce a characteristic aroma and from
which the rare tumour of hidradenoma of the vulva is de-
rived. The secretion increases during sexual excitement.

The presence of all these structures in the labia majora

renders them liable to common skin lesions such as follicu-
litis, boils and sebaceous cysts (Figure 1.3). Its masculine
counterpart is the scrotum.

Bartholin’s Gland

Bartholin’s gland lies posterolaterally in relation to the
vaginal orifice, deep to the bulbospongiosus muscle and
superficial to the outer layer of the triangular ligament. It is
embedded in the erectile tissue of the vestibular bulb at its
posterior extremity. It is normally impalpable when healthy,
but can be readily palpated between the finger and the

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Shaw’s Textbook of Gynaecology

Mons pubis
(veneris)

Clitoris
Labium majus
External urethral
orifice

Opening of
Bartholin’s duct

Hymen

Fourchette

Perineum

Anus

Prepuce
Frenum
Vestibule
Labium minus

Vaginal introitus

A

Virginal
Septate
Cribriform
Parous
B
Figure 1.2 (A) Anatomy of the vulva. (B) Variations of the hymen.

Figure 1.3 Histological section of the labium majus showing squa-
mous epithelium with hair follicle and sebaceous gland (355).

Ovary

Uterus

Figure 1.1 General view of internal genital organs showing the
normal uterus and ovaries.

thumb when enlarged by inflammation. Its vascular bed
accounts for the brisk bleeding, which always accompanies
its removal. Its duct passes forwards and inwards to open,
external to the hymen, on the inner side of the labium mi-
nus. The gland measures about 10 mm in diameter and lies
near the junction of the middle and posterior thirds of the
labium majus. The duct of the gland is about 25 mm long
and a thin mucous secretion can be expressed from it by
pressure upon the gland. Bartholin’s gland and its duct are
infected in acute gonorrhoea, when the reddened mouth of

the duct can easily be distinguished on the inner surface
of the labium minus to one side of the vaginal orifice below
the level of the hymen. Bartholin’s gland is a compound
racemose gland and its acini are lined by low columnar epi-
thelium (Figure 1.4). The epithelium of the duct is cubical
near the acini, but becomes transitional and finally squa-
mous near the mouth of the duct. The function of the gland
is to secrete lubricating mucous during coitus. The labia
majora join at the posterior commissure and merge imper-
ceptibly into the perineum.

Labia Minora

The labia minora are thin folds of skin which enclose veins
and elastic tissue and lie on the inner aspect of the labia
majora. The vascular labia minora are erectile during sex-
ual activity; they do not contain any sebaceous glands or
hair follicles (Figure 1.5). Anteriorly, they enclose the clito-
ris to form the prepuce on the upper surface and the frenu-
lum on its undersurface. Posteriorly, they join to form the
fourchette. The fourchette is a thin fold of skin, identified
when the labia are separated, and it is often torn during
parturition. The fossa navicularis is the small hollow
between the hymen and the fourchette. Labia minora is
homologous with the ventral aspect of the penis.
The clitoris is an erectile organ and consists of a glans,
covered by the frenulum and prepuce, and a body which is
subcutaneous; it corresponds to the penis and is attached to
the undersurface of the symphysis pubis by the suspensory
ligament. Normally, the clitoris is 1–1½ cm long and 5 mm