Acute gynaecology and vulval conditions

Question 1

What is an ectopic pregnancy?

Answer 1

A pregnancy outwith the endometrial cavity

Question 2

Name symptoms of ectopic pregnancy

Answer 2

• shoulder tip pain
• bleeding
• LMP
• dyschezia
• vomiting and diarrhoea

Question 3

Name risk factors for ectopic pregnancy

Answer 3

• previous ectopic
• tubal damage; infection, endometriosis, surgery
• intrauterine contraceptive devices
• smoking
• infertility
• infertility treatment
• extremes of reproductive age

Question 4

Describe the management of ectopic pregnancy

Answer 4

• resuscitation
• ABCDE
• laparoscopy
• laparotomy
• salphingectomy or salphingotomy
• anti D

Question 5

What are the clinical signs of pregnancy of unknown location and what is the management?

Answer 5

• static HCG (HCG should double every 24 hours
• clinically well
• expectant management
• medical management; methotrexate

Question 6

Describe the management of ovarian torsion?

Answer 6

• resuscitation
• laparoscopy
• laparotomy
• detorsion
• cystectomy
• oophorectomy

Question 7

Describe the management of cyst rupture

Answer 7

• conservative
• resuscitation
• laparoscopy
• lavage
• stop bleeding
• ?oophorectomy

Question 8

Name causes of pelvic inflammatory disease

Answer 8

• ascending infection from endocervix
• endometritis, salphingitis, tubo-ovarian abscess
• chlamydia
• gonorrhoea
• gardenella
• anaerobes

Question 9

Describe management of acute bleeding?

Answer 9

• resuscitation
• tranexamic acid
• mefenamic acid
• norethisterone
• IUS
• COCP
• GnRH analogues

Question 10

Name symptoms of HSV infection

Answer 10

• pain
• ulceration
• discharge
• dysuria
• urinary retention
• inguinal lymphadenopathy

Question 11

Describe management of HSV infection

Answer 11

• aciclovir
• bladder catheter
• local anaesthetic gel

Question 12

Describe management of bartholins abscess

Answer 12

• conservative
• antibiotics; broad spectrum
• incision and drainage
• word catheter
• marsupialisation

Question 13

Name differentials of vulval itch

Answer 13

• candidiasis; albicans, non-albicans
• trichomoniasis
• pubic lice
• scabies
• vulval intra-epithelial neoplasia
• atrophic vulvovaginitis
• dermatitis; atopic, irritant, allergic
• psoriasis
• lichen sclerosis
• lichen planus
• lichen simplex chronicus

Question 14

What is lichen sclerosus?

Answer 14

Inflammatory, scarring dermatosis of ano-genital skin

Question 15

What can typically be seen on examination in lichen sclerosus?

Answer 15

• white papules and plaques (vulval and perineal skin, figure of 8 pattern, vagina not involved)
• ecchymosis, erosions and fissures
• architectural change
• extragenital skin involvement (10% of women with vulval disease)

Question 16

Describe the management of lichen sclerosus

Answer 16

• genital skin care; wash gently once a day with soap substitute, avoid irritants, try to avoid tight clothing rubbing scratching etc, apply emollients to relieve dryness and itching
• potent topical steroid (clobetasol propionate 0.05% AKA dermovate); 1/2 finger tip unit, 12 week regimen then PRN

Question 17

Name differentials of vulval pain

Answer 17

Acute; 
- genital ulceration; primary herpes, recurrent herpes, apthous ulcers, varicella zoster 
- traumatic 
- bartholins cyst / abscess 
- dermatitis 
Chronic 
- vulvudynia; generalised /localised, provoked / unprovoked 
- female genital mutilation 
- pudendal nerve dysfunction 
- lichen sclerosis 
- lichen planus 
- vulval intra-epithelial neoplasia / cancer

Question 18

What can be seen on examination for vulvodynia?

Answer 18

• high tone at introitus
• v tender on advancing small speculum; unable to tolerate
• mucosae unremarkable
• point tenderness 4-7 o clock with cotton swab

Question 19

What is vulvodynia?

Answer 19

• vulval discomfort, most often described as burning pain, occuring in the absence of relevant visible findings or a specific, clinically identifiable, neurological disorder
• generalised or localised
• provoked, unprovoked or mixed

Question 20

Describe the management of vulvodynia

Answer 20

• information
• genital skin care advice and emollients
• localised provoked pain; lidocaine 5% ointment, vaginal trainers, physiotherapy
• unprovoked pain; tricyclics, gabapentin / pregabalin
• psychosexual interventions

Question 21

What is the WHO classification of FGM?

Answer 21

• type 1; partial or total removal of the clitoris and or the prepuce (clitoridectomy)
• type 2; partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision)
• type 3; narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and or the labia majora, with or without excision of the clitoris (infibulation)
• type 4; all other harmful procedures to the female genitalia for non-medical purposes for example; pricking, piercing, incising, scraping and cauterisation

Question 22

What are the short term complications of FGM?

Answer 22

• haemorrhage
• urinary retention
• genital swelling
• infection and sepsis

Question 23

What are the long term complications of FGM?

Answer 23

• urinary tract infections; type 2 and type 3
• urinary stricture or fistulae
• dyspareunia, apareunia and impaired sexual function
• PTSD
• haematocolpos
• HIV and hep B
• obstetric complications; obstructed labour, postpartum haemorrhage, perineal trauma and sphincter injury

Question 24

What is the most common form of vulval cancer?

Answer 24

Squamous cell carcinoma

Question 25

Name risk factors for prolpase

Answer 25

- women - pregnancy, childbirth, menopause - increasing age - obesity - smoking - heavy lifting - constipation - COPD - prior pelvic surgery

Question 26

Name signs and symptoms of prolapse

Answer 26

- sensation of heaviness or pulling in your pelvis - tissue protruding from your vagina - urinary problems, such as urine leakage (incontinence) or urine retention - trouble having a bowel movement - feeling as if you're sitting on a small ball or as if something is falling out of your vagina - sexual concerns

Question 27

Describe the degrees of uterine descent of uterovaginal prolapse

Answer 27

- 1st degree; in vagina - 2nd degree; at interoitus - 3rd degree; outside vagina - 4th degree; entirely outside vagina

Question 28

Describe symptoms of cystocele (anterior)

Answer 28

- bulging - pressure - mass - difficulty voiding - incomplete emptying - splinting vaginal wall - difficulty inserting tampon - pain with intercourse

Question 29

Describe symptoms of rectocele (posterior)

Answer 29

- bulging - pressure - mass - difficulty in defecation - incomplete defecation - splinting vaginal wall or perineum - difficulty inserting tampon

Question 30

Describe the pelvic organ prolapse quantification system (POP-Q)

Answer 30

- patient straining 6 specific sites are evaluated and 3 at rest - measure each site (cm) in relation to the hymenal ring, which is fixed - the hymenal ring is the zero point of reference - if a site is above the hymen, assigned a negative number - if site prolapses below the hymen, the measurement is positive