7 - Vaginal and Vulval Disorders inc Urinary Incontinence Flashcards
What are some risk factors for stress and urge incontinence?
Stress: childbirth causing denervation of pelvic floor, obesity, oestrogen deficiency/menopause , pelvic surgery, irradiation, pelvic organ prolapse
Urge (OAB): idiopathic, MS, spina bifida, pelvic surgery
What are some other causes of urinary incontinence apart from urge and stress?
- Retention with overflow
- Bladder fistulae
- Urethral diverticulum
- Ectopic ureter
- Functional
- Temporary due to reversible factors e.g UTI
What features may be found in the history and examination with stress and urge incontinence?
Stress
Hx: leaking on sneezing, coughing exercise
Exam: may be prolapse, ask woman to cough and will demonstrate
Urge:
Hx: urgency, frequency, nocturia with triggers e.g cold weather, running water. Larger volumes of incontinence than stress
Exam: coughing/sneezing may cause bladder contractions so falsely looks like stress
What investigations need to be done with incontinence?
ALWAYS EXCLUDE INFECTION!!
- Urine dipstick +/- MS
- Vagine Stress test
- Post void bladder scan
- QoL assessment!!!!!
- Frequency/Volume charts (at least 3/7)
- Urodynamic studies (look at detrusor activity for OAB and surgery prep for stress)
How can stress incontinence be managed?
Conservative
- Pelvic floor muscle training for at least 3.12
- Weight loss and smoking cessation
- Treatment of risk factors e.g chronic cough
Medical (LAST RESORT)
- Duloxetine (if surgery not worked or not appropriate)
Surgical
- Colposuspension (open or laparoscopic)
- Autologous Rectal Fascial Sling
- Tension Free Vaginal Tape
- Periurethral injections
- Transobturator mid urethral slings
How can urge incontinence be managed?
Conservative
- Avoid caffeine, diuretics, alcohol
- Bladder training for at lead 6/52 increasing interval between voids
- Catheterisation
Medical
- Anticholinergics: Oxubutynin, Solifenacin, Tolterodine
- Mirabegron
- Vaginal oestrogen if atrophy
- Botulinum Toxin A
- Sacral nerve neuromodulation and stimulation
Surgical
- Detrusor myomectomy and augmentation cystoplasty (only if debilitating symptoms)
What are some contraindications and side effects of anticholinergics for OAB?
SE: dry mouth, dry eyes, constipation, blurred vision, arrhythmias, confusion
CI: acute angle closure glaucoma, MG, GI obstruction, elderly
What are some causes of overflow incontinence in women?
- Bladder outlet obstruction: prolapse, fibroids or following pelvic surgery.
- Detrusor underactivity: impaired contraction of detrusor muscle can lead to retention and overflow leakage. Advancing age, peripheral neuropathy, MS and secondary to medications (e.g. antimuscarinics)
What are some side effects of duloxetine?
SNRI
- dry mouth
- headache
- dizziness
- nausea
- sexual dysfunction
- increased risk of suicide.
In mixed urinary incontinence which should you treat?
One with predominant symptoms
When should you offer pads for incontinence?
NEVER EVER AS LONG TERM MANAGEMENT ALONE!!!
Review this yearly if being done
Offer only if all other treatments explored, as an adjunct or to help cope with symptoms e.g leakage exercise
What is a genital/pelvic organ prolapse and the different types of these?
Descent of pelvic structure from their normal anatomical location toward or through the vaginal opening.
Anterior vaginal wall:
- Cystocele (may lead to stress incontinence)
- Urethrocele
- Cystourethrocele
Posterior vaginal wall:
- Enterocele (small intestine) or rectocele
Apical vaginal wall/Central Prolapse
- Uterine prolapse or Vaginal vault prolapse (roof of vagina, common after hysterectomy)
What are some risk factors of pelvic organ prolapse?
- Age
- Menopause
- Parity
- Connective tissue disease
- Obesity
- Smoking
- Hysterectomy
- Chronic constipation
What are some symptoms of a pelvic organ prolapse?
- “something coming down”
- back or abdominal pain
- urinary or faecal incontinence
- dysparaunea
- issues with defecation or micturition
What investigations and examinations should you do for a woman present with symptoms of a POP?
- Hx: prolapse symptoms, urinary symptoms, bowel symptoms, sexual symptoms
- Assess presence and degree of prolapse of the anterior, central and posterior vaginal compartments of the pelvic floor, using the POP‑Q (Pelvic Organ Prolapse Quantification) system
- Assess pelvic floor muscles
- Assess for vaginal atrophy
- Rule out a pelvic mass or other pathology e.g ovarian cancer
What are the non-surgical treatment options for a pelvic organ prolapse?
- Lifestyle: lose weight if BMI<30, avoid heavy lifting, prevent/treat constipation
- Vaginal oestrogen pessaries or rings: if vaginal atrophy
- Pelvic floor muscle training for at least 16 weeks if stage 1 or 2 on POP-Q
- Pessaries
What needs to be discussed with a woman before giving a pessary?
CONSIDER FOLLOW UP IN 6 MONTHS IF PT AT RISK OF COMPLICATIONS E.G COGNITIVE DECLINE THAT COULD MAKE THEM FORGET TO TAKE PESSARY OUT
- consider treating vaginal atrophy with topical oestrogen
- explain that more than 1 pessary fitting may be needed to find a suitable pessary
- discuss the effect of different types of pessary on sexual intercourse
- describe complications including vaginal discharge, bleeding, difficulty removing pessary and pessary expulsion
- explain that the pessary should be removed at least once every 6 months to prevent serious pessary complications and look for ulceration
What are the surgical management options for a uterine POP?
Some evidence of benefit, but limited evidence on long-term effectiveness and adverse effects. USE A DECISION AID
No preference to preserve uterus
- Vaginal hysterectomy, with or without vaginal sacrospinous fixation with sutures
- Vaginal sacrospinous hysteropexy with sutures
- Manchester repair
- Sacro-hysteropexy with mesh
Preserve uterus
- Vaginal sacrospinous hysteropexy with sutures
- Manchester repair, unless the woman may wish to have children in the future
If a women is having surgery for an apical or anterior POP, what do you need to warn them about?
If they have no incontinence, this surgery could cause them to have postoperative urinary incontinence
What is a Manchester repair?
Shortening of the cervix to treat uterine prolapse
What are the surgical management options for a vault POP?
- Vaginal sacrospinous fixation with sutures or
- Sacrocolpopexy (abdominal or laparoscopic) with mesh
Colpocleisis is closure of the vagina
What surgery can be offered to women with anterior and posterior POP?
Anterior: anterior repair without mesh
Posterior: posterior vaginal repair without mesh
Serious but well-recognised safety concerns with use of mesh and unknown long term outcomes so do not use
How should a woman following prolapse surgery be followed up and what are the issues with using mesh?
- Review 6 months after surgery
- Vaginal examination and, if mesh was used, check for mesh exposure
What do you need to warn a woman who is having a surgical procedure for both urinary incontinence and POP at the same time?
- That there is uncertainty about whether combined procedure is effective for treating stress urinary incontinence beyond 1 year, and that stress urinary incontinence might persist despite surgery
What are some investigations you may do if you suspect mesh-related complications?
- US
- CT
- Laparoscopy
- MRI (if think infection)
- Cystography or Bowel Enema (if think fistula)
- Urinary flow studies
- NCS (if think nerve injury)
What are the treatment options for mesh sling exposure?
- Removal of mesh but could make worse and other complications
- Vaginal oestrogen cream if area <1cm3
What is the mechanism of action of the following drugs used for urinary incontinence:
- Duloxetine
- Mirabegron
- Oxybutynin
- SNRI: increases striated muscle sphincter activity
- B3 agonist: detrusor relaxation
- Anticholinergic M3: relaxes detrusor
How do you take a history from a woman about urinary symptoms of incontinence?
- Presenting symptoms: stress or urge mainly?
- Severity: amount, pad use (size and amount), QoL
- Fluid Intake
- Associated symptoms: prolapse? faecal incontinence? constipation?
- Obstetric History: how many, birth weight, any tears, any forceps?
- Surgical History: hysterectomy, pelvic surgery
- PMHx and FHx: lung disease (cough) diabetes, connective tissue disease, HTN (diuretics)
What is a pad test?
Objective measure of amount of leakage
24 hours at home
Cystoscopy is not often used to investigate urinary incontinence. What are some situations where it would be used?
What are the three stages of uterine prolapse?
Stage 1 - Descent into vagina
Stage 2 - Uterus reaches vaginal opening
Stage 3 - Uterus completely outside vagina
What are the principles of surgery for a prolapse?
What are some complications with prolapse surgery?
- Recurrence
- Persistent pain
- Stress incontinence
- Pain on sex
- Infections
- Problems emptying bladder fully
- Urge incontinence
Avoid Manchester repair if wanting to be pregnant later
What are the 4 stages of POP-Q?
What are some important questions to ask in the history if a woman has prolapse symptoms?
NB - include in OSCE book
- PC: urinary incontinence, constipation, sexual dysfunction
- FHx: Prolapse, Connective tissue disorders
- Obstetric Hx: number of deliveries, method, future plans
- Gynae Hx
- SHx: ?smoker, ?occupation with heavy lifting
What are some complications of the surgeries used to treat stress incontinence? (colposuspension, rectus fascia sling and retropubic mesh sling)
- Damage to bladder or bowel
- Nerve damage so loss of sensation or persistent pain
- Issues emptying bladder fully
- Urge incontinence
- Infections
- Persistent pain or pain during sex
- Prolapse
- Mesh complications
What is the pathophysiology of a Bartholin’s cyst?
Bartholin Gland lie deep to labia majora and openings are at 4 and 8 o clock next to vaginal opening. Secrete mucus to lubricate vagina
Build up of mucus can cause gland to become blocked and form a cyst. If this cyst becomes infected it can form an abscess
Organisms: E.Coli, MRSA, STIs
What are some risk factors for a Bartholin’s cyst?
Usually in nulliparous women of child bearing age
- Personal history of Bartholin’s cyst
- Sexually active (STIs)
- History of vulval surgery
What are the clinical features of a Bartholin’s cyst?
- Asymptomatic if small
- Vulval pain
- Superficial dyspareunia
- If abscess then acute onset pain and/or difficulty passing urine
What are some differential diagnoses for a labial mass?
- Bartholin’s gland carcinoma
- Bartholin’s benign tumour
- Bartholin’s cyst
- Other types of cyst – sebaceous, Skene’s duct, mucous
- Other solid masses – e.g. fibroma, lipoma, leiomyoma
What investigations should you do for a Bartholin’s cyst?
- If >40 and hard areas do biopsy for vulval cancer
- Endocervical and High vaginal swabs if risk of STIs
How is a Bartholin’s cyst managed?
Asymptomatic: no treatment, warm baths for spontaneous rupture
Symptomatic
Cannot just do I+D as likely to be recurrent
- Word Catheter
- Marsupialisation
- Silver nitrate cautery
- NO ABX UNLESS SYSTEMICALLY UNWELL
What is a Word Catheter and Marsupialisation and what are the complications of these?
Word Catheter (Local Anaesthetic)
Incision made into cyst or abscess, and catheter inserted, with 2-3ml of saline in tip.
Left in place for 4-6 weeks to allow epithelisation of the surgically created tract.
Not suitable for deep cysts or abscesses
Complications: infection, recurrence, dyspareunia, scarring
Marsupialisation (General Anaesthetic)
Vertical incision made into the cyst, behind hymenal ring, allowing for spontaneous drainage of the cavity. Cyst wall everted and approximated to the end of the vaginal mucosa by sutures
Complications: bleeding/haematoma, dyspareunia and infection.
What is Lichen Sclerosus?
Chronic inflammatory skin disease of anogenital region in women
Usually bimodal in prepubescent girls then post-menopausal women
Risk of progression to squamous cell carcinoma
What is the aetiology and risk factors for lichen sclerosus?
Aetiology:?Autoimmune as higher titre of antibodies to extracellular matrix protein 1.
Atrophy microscopically
Risk Factors: family history, other autoimmune conditions e.g thyroid
What are the clinical features of lichen sclerosus?
- SEE IMAGE
- White atrophic patches on skin
- Itching
- Dyspareunia
- Can be asymptomatic
What are some differential diagnoses for lichen sclerosus?
- Lichen simplex
- Vitiligo
- Vulvae cancer or intraepithelial neoplasia
- Candidiasis
- Post-inflammatory hypopigmentation
What investigations and management are done for lichen sclerosus?
Ix
- Often clinical
- Can do punch biopsy especially if treatment failure to look for malignancy
What is the management for lichen sclerosus?
Conservative
- Annual checks for malignancy (2-5% risk of SCC)
- Good hygiene with non-soap cleaners
- Wear loose clothing
- Avoid itching
Medical
- 1st line: Topical steroids (once daily at night for 4 weeks, then on alternate nights for 4 weeks, and then twice weekly for a further 4 weeks)
- 2nd line: Topical calcineurin inhibitors
- Emollients
- Vaginal oestrogen if atrophic vaginitis
- Oral/topical retinoids and UVA1 phototherapy
What is the prognosis with lichen sclerosus?
Need long term follow up
- Malignancy risk
- Adhesions
- Scarring
What are some causes of pruritus vulvae?
- Contact dermatitis
- Psoriasis
- Lichen simplex
- Lichen sclerosus
- Candida
- BV
- Pubic lice
- Herpes
- Atrophic vaginitis
- Pregnancy
How may atrophic vaginitis present?
Inflammation of vagina often due to low oestrogen so common in menopause
- Dryness
- Itching
- Dyspareunia and post-coital bleeding due to easily damaged tissue
- Vaginal discharge
What are some differentials for atrophic vaginitis?
- STIs
- Candida
- Need to rule of endometrial cancer if post menopausal bleeding
What investigations and management are done for atrophic vaginitis?
Ix
- Vaginal exam for signs of atrophy
- Trans-vaginal US and endometrial biopsy to exclude endometrial cancer
- Infection screen if itching and discharge
Management
Hormonal treatment: HRT, Topical oestrogen
Non-hormonal treatments: lubricants for sex, regular moisturisers
What are some contraindications for topical oestrogen?
- Breast cancer
- VTE
- Angina
Need to monitor annually for endometrial hyperplasia/cancer
What is lichen planus and lichen simplex?
Lichen is a flat eruption that spreads
What potent topical steroid is used in lichen sclerosus?
Clobetasol propionate 0.05% (dermovate).
What are some complications with lichen sclerosus?
- SCC of vulva
- Pain and discomfort
- Sexual dysfunction
- Bleeding
- Narrowing of the vaginal or urethral openings
How can you test pelvic tone?
Bimanual Examination and ask woman to squeeze fingers
Modified Oxford Grading System
Before any urodynamic tests what does a patient need to do?
Stop taking any anticholinergics up to 5 days before
What are the surgical options for stress incontinence?
Always do SUPERVISED pelvic floor muscle training first (8 contractions 3 x a day)
What are the surgical options for urge incontinence?
Mirabegron can be used for urge incontinence when anticholinergics are contraindicated e.g dementia. What are some contraindications for Mirabegron?
Uncontrolled hypertension, must monitor BP whilst on this
Is a B3 agonist so can raise BP and cause hypertensive crisis that can lead to TIAs and strokes
What are the grades in the POP-Q system?
What are the different types of pessary used for a pelvic organ prolapse?
- Ring
- Shelf and Gellhorn
- Cube
- Donut
- Hodge pessaries are almost rectangular.
Pessaries should be removed and cleaned or changed periodically (e.g. every four months). They can cause vaginal irritation and erosion over time. Oestrogen cream helps protect the vaginal walls from irritation.
What are some complications for mesh repair with a pelvic organ prolapse?
What is FGM and the different types of this?
Involves surgically changing the genitals of a female for non-medical reason. Illegal under the FGM Act 2003 and need to report to police if found
- Type 1: Removal of part or all of the clitoris.
- Type 2: Removal of part or all of the clitoris and labia minora. The labia majora may also be removed.
- Type 3: Narrowing or closing the vaginal orifice (infibulation).
- Type 4: All other unnecessary procedures to the female genitalia
When do you need to be worried about the risk of FGM?
- Pregnant women with FGM with a female child
- Siblings or daughters of women affected by FGM
- Extended trips with infants or children to areas where FGM is practised
- Women that decline examination or cervical screening
- New patients from communities that practise FGM
What are some complications with FGM?
Immediate:
- Pain
- Bleeding
- Infection
- Swelling
- Urinary retention
- Urethral damage and incontinence
Long term
- Vaginal infections, such as bacterial vaginosis
- HIV Risk
- Dysmenorrhea
- Sexual dysfunction and dyspareunia
- Infertility and pregnancy-related complications
- PTSD
- Reduced engagement with healthcare and screening
Who needs to be informed of FGM once discovered?
Mandatory if under 18 to report to the police.
If >18 do risk assessment tool to decide whether to report to police e.g other female relatives at risk or if woman pregnant with baby girl
Other services should also be contacted:
- Social services and safeguarding
- Paediatrics
- Specialist gynaecology or FGM services
- Counselling
How is FGM managed?
De-infibulation (Anterior Episiotomy): done in second part of labour by specialist in order not to damage urethra. Correct the narrowing or closure of the vaginal orifice, improve symptoms and try to restore normal function
It is illegal to perform a re-infibulation after childbirth even if requested
