Female Urology and Reproductive Flashcards
1
Q
Menstrual Cycle - Mencarche - Normal
A
11 to 15 years
2
Q
Menstrual Cycle - Length of cycle - Normal
A
20-45 days (avg 28 days)
3
Q
Menstrual Cycle - Ovulation - Normal
A
14 days
4
Q
Menstrual Cycle - Menstruation - Normal
A
5 days
5
Q
Menstrual Cycle - Menstrual pain
A
Cramping before bleeding begins
Peaks 24 hrs
Decreases gradually
Does not limit function
6
Q
Menstrual Cycle - Length of cycle? - Abnormal
A
Infrequent menstruation - more than 31-35 days apart
OR
Frequent menstruation - less than 2 weeks apart
7
Q
Menstrual Cycle - Bleeding - Abnormal
A
Lasts more than 7 days
8
Q
Menstrual Cycle - Menstrual pain - Abnormal
A
Severe abdominal cramping that limits function
Occurs days before bleeding
Lasts more than 3 days
Pain inc as bleeding dec
9
Q
Age related changes - Perimenopause/Menopause transition
A
Usually occurs between 45-50 years old
Time leading up to complete menopause is usually 3-4 years
Hormonal levels decline and irregular cycle occurs
10
Q
Age related changes - menopause
A
End of reproductive potential with permanent cessation of ovarian function
11
Q
Age related changes - postmenopause
A
Live 1/3 of life cycle in this stage with increased life expectancy
Estrogen plays protective role - so keep that in mind with post menopausal patients
12
Q
Menopause - clinical implications
A
1 Increased urinary incontinence
2 Increased risk of pelvic organ prolapse
3 Increased risk of dyspareunia/pain
13
Q
Menopause - clinical implications - Inc in urinary incontinence includes what
A
Inc post void residual
Dec power of detrusor mm
Dec pelvic floor mm and collagen support
14
Q
Menopause - clinical implications - Inc risk of pelvic organ prolapse includes what
A
Dec estrogen is associated with collagen changes and dec vascularity of supporting tissue
So CT not holding things up
15
Q
Menopause - clinical implications - Inc risk of dyspareunia/pain includes what
A
Dryness of vagina
Dec vascularization of the urethra with dec blood flow and blood volume
Genital atrophy from dec hormones
16
Q
Menopause - clinical implications - impacts what
A
ALL SYSTEMS!
17
Q
Menopause - clinical implications - GI system
A
Bloating
Abdominal pain
Irritable bowel
18
Q
Menopause - clinical implications - Integumentary
A
More thinning
Bruise easier
19
Q
Menopause - clinical implications - Endocrine
A
Mostly estrogen is declining
Can lead to decrease in metabolism
20
Q
Menopause - clinical implications - Cardiovascular
A
Inc in truncal obesity can inc risk of CV complications
After menopause - women become higher risk
21
Q
Menopause - clinical implications - Musculoskeletal
A
OP
Fractures
Postural changes
22
Q
Menopause - clinical implications - Nervous
A
More impairments in cognitive function
Sleep disturbances
23
Q
Pelvic floor mm - description
A
Skeletal muscle sling from pubic bone to coccyx - surrounds the urethra, vagina, and rectum
24
Q
Purpose of the pelvic floor mm
A
Support internal pelvic organs
Closes off urethra for continence
Closes off rectum for continence
Participate in sexual arousal and orgasm
25
Puborectalis
Most medial
Pubic bone - wraps around urethra, vaginal opening, and rectum
Like a lasso around the openings
26
Micturation - phases
Storage/Filling phase
| Emptying phase
27
Micturation - Storage/Filling phase
Parasympathetic receptors are inhibited
Sympathetic receptors are stimulated
Sympathetic will keep detrusor relaxed and keep bladder neck contracted
28
Micturation - Emptying phase
Sympathetic receptors are inhibited - relaxation of bladder neck, cessation of stretch receptors
Parasympathetic receptors are stimulation - detrusor contraction is strengthened
29
Micturation - Sympathetic =
Storage
30
Micturation - Parasympathetic =
Emptying phase
31
Micturation - bladder fills at what rate
Constant rate!
| 15 drops/minute
32
Micturation - sensations and capacity
First sensation to void = 40% capacity (about 150 mL)
First desire to void is about 60% capacity
Strong desire to void is at more than 90% capacity (about 400-500 mL)
33
Micturation - patient education
Nerve signals from bladder go to brain sacral micturation center
Brain tells bladder that it cannot contract
Signals to bladder neck/outlet to contract more so can continue filling
(outlet pressure more than bladder pressure)
34
Pelvic floor mm dysfunction - classified by
symptoms, signs, and conditions
35
Pelvic floor mm dysfunction - 5 symptoms/5 types of dysfunction
```
1 Lower UT symptoms
2 Bowel symptoms
3 Vaginal symptoms
4 Sexual function
5 Pain
```
36
Pelvic floor mm dysfunction - 5 symptoms/5 types of dysfunction - Lower UT symptoms
Urinary incontinence
Urgency
Frequency
37
Pelvic floor mm dysfunction - 5 symptoms/5 types of dysfunction - Bowel symptoms
Obstructed defecation
Functional constipation
Fecal incontinence
Rectal/Anal prolapse
38
Pelvic floor mm dysfunction - 5 symptoms/5 types of dysfunction - Vaginal symptoms
Pelvic organ prolapse
39
Pelvic floor mm dysfunction - 5 symptoms/5 types of dysfunction - Sexual function
Orgasmic dysfunction
Dyspareunia in women
Erectile and ejaculatory dysfunction in men
40
Pelvic floor mm dysfunction - 5 symptoms/5 types of dysfunction - Pain
Chronic pelvic pain
| Pelvic pain syndrome
41
Pelvic floor dysfunction - underactive PFM
1 Dec strength and endurance
2 Poor coordination of PFM with changes in intraabdominal pressure (cough, sneeze, laugh)
3 Urinary or fecal incontinence, prolapse
42
Pelvic floor dysfunction - underactive PFM - Causes
```
PFM avulsion (maybe childbirth)
Age
High BMI
Type 2 D
Heavy lifting
Constipation
Overstretching of the PFM and CT Pudendal nerve damage
Birth trauma
Dec mobility
```
43
Pelvic floor dysfunction - overactive PFM
1 Inc in PFM tension, active spasm
2 Incoordination of PFM causing dysfunction of urogenital or colorectal systems
3 Musculoskeletal pain from hypertonicity
44
PFM Dysfunction Diagnosis - Underactive
1 Urinary incontinence
2 Prolapse
3 Fecal incontinence
45
PFM Dysfunction Diagnosis - Overactive
```
1 Levator ani syndrome
2 Chronic pelvic pain
3 Vaginismus
4 Tension myalgia
5 Coccygodynia
6 Interstitial cystitis/painful bladder
```
46
Pelvic floor dysfunction - overactive PFM - Causes
```
Multifactorial
Symptom of other pathology
Job stress, menstrual cycle, constipation
Hx of abuse
Habitual postures
Orthopedic malalignment
```
47
Urinary incontinence - is what
symptom of ANY involuntary leaking of urine
48
Urinary incontinence - prevalence
35-38% in women
| often is underreported though
49
Stress urinary incontinence is what
Involuntary leakage with activities, sneezing, or coughing
| Anything that causes inc abdominal pressure
50
Stress urinary incontinence is due to
Due to increased abdominal pressure relative to urethral closure pressure
51
Urge urinary incontinence is what
Sudden, unexpected urge with uncontrolled loss of urine
52
Mixed urinary incontinence is what
Combination of both stress and urge
| Is the most common
53
Less common types of urinary incontinence - Insensible UI
Loss of urine where the person has no idea how it occurred
54
Less common types of urinary incontinence - Continuous UI
Complaints of continuous leakage
55
Less common types of urinary incontinence - Postural UI
Leakage with changes in position - most common is leaning over and then when they come back up
Or also from sit to stand (this is huge with males post prostectomy)
56
Less common types of urinary incontinence - Nocturnal enuresis
Leakage of urine while sleeping
57
Less common types of urinary incontinence - Coital UI
Leakage while involved in intercourse
58
UI epidemiology - any urine leakage during physical or non physical activity, or before reaching toilet
51. 1 % women
| 15. 1 % men
59
UI risk factors
```
1 PFM damage
2 Pelvic organ prolapse
3 Sphincter mm weakness or damage
4 Pudendal nerve damage
5 Neurological disorder
6 Psychogenic
7 Constipation
8 Medications
9 Inc age or dec cog function
10 Impaired mobility
11 Pregnancy or Obesity
```
60
Neurogenic Bladder Disorders are what
Voiding dysfunction from neurologic conditions caused by an interruption of the nerve supply to the bladder
Can be UMN or LMN lesion
61
Neurogenic Bladder Disorders - Clinical presentation
Smaller urine volume on voiding
Incontinence
Urgency and frequency
Higher rates of UTIs
62
Bladder Storage Symptoms
```
Inc daytime urinary freq
Nocturia
Nighttime freq
Urgency
Overactive bladder symptoms
```
63
Normal bladder habits - how many times a day/night
4-8 times a day
| At night shoulder be 0-1 if under 65, 1-2 if over
64
Normal bladder habits - time between urination
Generally urinate every 2-5 hours
65
Normal bladder habits - Length of urination
8-10 sec
66
Normal bladder habits - Urine color
light yellow
67
Dietary recommendations - aim for how much fluid/day
48-64 ounces of water
Concentrated urine will irritate bladder
If over 80-100 oz is associated with inc incontinence
68
Dietary recommendations - Bladder irritants
Coffee, tea, soda, medications, caffeine, chocolate, alcohol, nicotine, carbonation, high acid, artificial sweeteners
69
Behavior Training - Forms of behavioral treatment for urinary incontinence
```
Bladder training
Use bladder diary/voiding log
Urge suppression techniques
Dietary modifications
Appropriate fluid intake
Weight loss
Pelvic floor exercises
```
70
Bladder training - Bladder diary includes what
```
How often
How many leaks
Size of leak
Activity during leak
Amount and type of fluid consumed
Amount and fluid voided
Number of pads used per day
Amount voided
```
71
Bladder training - Bladder diary - how often is most effective
Have them do it for 3 days - gives you enough info and inc compliance/honesty
72
Bladder training - Bladder diary - defining the size of the leak
Drops to a teaspoon = small
Tablespoon = moderate
1/4 of a cup = significant lea (will go through clothes)
73
Bladder training - urgency control
1 Sit - perineal pressure inhibits bladder - sitting on the perineum can inhibit it
2 Relax
3 Distract
4 do NOT rush
5 When urge dissipates, wait until rx time or 5-15 min and then walk to toilet
74
Bladder training - what else besides bladder control techniques
Scheduled voiding
Avoid just in case urinating
Prompted training for cognitive impaired or SNF/LTC
75
Purpose of bladder training
```
Improve bladder control by changing bx
Break cycle of urgency/frequency
Dissociate functional bladder capacity
Inc functional bladder capacity
Inc self confidence
Correct improper voiding habits
```
76
Dysfunctional bladder habits
Delaying bladder too long
Hoovering over toilet
Bearing down to initiate or complete urination
Not allowing full time for bladder to empty
Voiding just in case
Failing to wipe front to back
Urinary frequency over 10x/day
77
Treatment of underactive PFM
```
Bx training
Postural education
Coordination of breath and PFM
Strengthening PFM, abs, back
Inc PFM coordination, endurance, and force by skilled PT with training for internal eval
```
78
Treatment of overactive PFM
Bladder retraining
Schedule interval is critical
Urgency control
Avoid just in case voiding
79
Treatment of overactive PFM - Schedule interval
Short mandatory voiding interval for mod-severe urgency
| No sooner than __ hours for mild symptoms
80
Treatment of overactive PFM - Urgency control
Sit - perineal pressure to inhibit bladder
Relax
Distract with pos thoughts of being in control
Do NOT rush
When urge dissipates, wait until rx time or 5-15 min and walk to toilet
81
Measurement of PFM dysfunction - ICS definition
```
Pathophysiology = cause
Impairment = non functioning PFM (over or under)
Disability = leakage
```
82
Pelvic organ prolapse is what
Descent of one or more of the pelvic organs into the vagina due to the loss of fibromuscular support
83
Pelvic organ prolapse is described by
the compartment of the vagina in which it occurs
84
Pelvic organ prolapse - Cystocele
Anterior vaginal wall prolapse
Most common
Bladder falling forward
85
Pelvic organ prolapse - Retocele
Posterior vaginal wall prolapse
| Rectum coming forward
86
Pelvic organ prolapse - Apical
the loss of support of the uterus
vaginal vault
Uterus coming down and vaginal vault coming down
Common after hysterectomy
87
Pelvic organ prolapse - epidemiology of ages 18-82 years
Stage 1 = 43.3 %
| Stage 2 = 47.7%
88
Pelvic organ prolapse - etiology
```
Pelvic mm weakness, ligamentous lax
Multiple preg and deliveries
Obestiy
Traumatic
Prolonged labor/delivery
Excessive and rep. straining with bowel mvmnts
Aging and DM inc risk
Neuro conditions
Posture and IAP management
```
89
Prolapse risk factors
```
1 Multiple preg and deliveries
2 Prolonged labor
3 Improper bearing down with delivery
4 Nerve damage with delivery
5 Obesity
6 Aging
7 Chronic constipation
8 Chronic heavy lifting
9 Chronic cough
```
90
Prolapse symptoms
Urinary
Bowel
Sexual
General
91
Prolapse symptoms - urinary symptoms
Incontinence, freq, urgency, hesitancy
Position change or manual reduction of prolapse needed to initiate/complete voiding
Weak/prolonged stream
Incomplete emptying/actual or sensory
Leaking immediately or dribbling post void
92
Prolapse symptoms - bowel symptoms
Feelings of incomplete emptying/obstruction
Straining, digital evacuation
Splinting of vagina or perineum so that they aren't pushing more out with bowel mvmnt
93
Prolapse symptoms - Sexual symptoms
Due to changes in vagina anatomy
Dec lubrication and arousal
Dyspareunia
94
Prolapse symptoms - general symptoms
Pressure/heaviness of vagina
Bulge coming out of vagina
General pelvic pain/maybe LBP
Worse at end of day with prolonged standing/walking
Urinary, bowel, sexual symptoms may be associated
Self conscious
95
Impairments with prolapse
```
High or low tone in levator ani
Posterior pelvic tilt
Glut weakness
Poor management of abdominal pressure
Poor coordination/stabilization of core
Improper voiding techniques
```
96
Diagnosis pf pelvic organ prolapse
Pelvic exam
97
Treatment of pelvic organ prolapse
```
Rehab for underactive pelvic floor
Vaginal pessary
Corrective surgery
Weight loss if obese
Hormonal replacement therapy
Control of constipation and vasalva activities
```
98
Only ___% of patients actually seek tx for POP
10-20%
99
Considerations for udneractive PFM
```
Management of intra-abdominal pressures
Breath coordination
Posture - thoracolumbar ext, neut pelvis
Mm coordination with functional activity
Bx training - hydration, diet, urgency, freq
```
100
Pelvic pain - diagnoses consist of
```
Endometriosis
Dysmenorrhea
Hypertonus disorders
Interstitial cystitis
GI disorders
```
101
Pelvic pain - pain and hypertonus disorders may be related to
```
Delayed healing perineal lacerations
Trauma with delivery
Pelvic obliquity
Multiple gyn/visceral diagnoses
Cauda equina
Scar tissue/adhesions
Mm spasm/guarding
Abuse
```
102
Tx of overactive (hypertonic) PFM disorders
```
Posture
Joint alignment
Aerobic exercise
Pain education
Manual therapy
Stretching
Biofeedback/Relaxation training
Dilators for stretching
```
103
Painful bladder syndrome/Interstitial cystitis is what
Recurring pelvic pain, pressure, or discomfort in the bladder and pelvic region
Often associated with urinary frequency and urgency
104
Painful bladder syndrome/Interstitial cystitis - what is often a co-morbidity or the driver of the symptoms
Hypertonicity of abdominal and pelvic floor muscles
105
Painful bladder syndrome/Interstitial cystitis - exacerbated by
emotional or physical stress
106
Painful bladder syndrome/Interstitial cystitis - Flares can ocur with
Consumption of acidic food
107
Painful bladder syndrome/Interstitial cystitis - frequent comorbidities include
fibromyalgia, endometriosis, migraines, IBS, vulvodynia
108
Painful bladder syndrome/Interstitial cystitis - treatment
```
No cure
Manage s/s and treat bladder lining
Pharm - pain and bladder s/s
PT
Surgery
```
109
Painful bladder syndrome/Interstitial cystitis - - PT treatment
Overactive PFM and myofascial pain in 85%
Bx retraining and dietary modifications
Pain neuroscience education
110
Painful bladder syndrome/Interstitial cystitis - Surgery
Neuromodulation at S3 with interstim unit for treatment of urgency, frequency, retention
111
Enodmetriosis is what
A disorder that occurs when endometrial tissue grows outside of the uterus
Tissue is biochemically and endocrine active
112
Endometriosis - what does it look like
Chocolate cysts - formed by the implanted tissue as it reacts to the normal cycle
113
Endometriosis - most common sites
```
Ovaries
Fallopian tubes
Broad ligament
Pouch of douglas
Bladder
Pelvic mm
Perineum
Vulva
Vagina
Intestines
```
114
Endometriosis - Epidemiology
Affects W of all groups
2-20% of american women affected
45% of all abdominal pain
115
Enometriosis risk factors
```
Early age menarche
Short menstrual cycles
Long duration of menstrual flow
Inverse relationship to parity
Family hx
```
116
Endometriosis clinical presentation
Dysmenorrhea
Dyspareunia
Infertility
Pain - low back, pelvis, thigh, abdominals
117
Endometriosis treatment
Depends on age, reproductive desires, stage of disease and symptoms
```
None
Pharm
Surgery
PT
Alternative tx are increasing
```
118
Endometrial (uterine) cancer
Most common gynecological cancer
| 4th most common cancer for women
119
Endometrial (uterine) cancer - risk factors
Age (avg is 60, 75% in post menopausal women, 25% premenopausal, 5% in under 40)
Obesity
Nulliparity (no children)
No genetic component
120
Endometrial (uterine) cancer - Decrease risk with
Exercise!
| 80% less likely compared to women that do not exercise
121
Endometrial (uterine) cancer - most common symptom
Abnormal vaginal bleeding (esp post menopausal)
122
Endometrial (uterine) cancer - diagnosis made by
tissue cytology exam
123
Endometrial (uterine) cancer - treatment
surgery and radiation
124
Endometrial (uterine) cancer - prognosis
good in early stages (90%)
| poor for late stages (10%)
125
Cervical cancer- risk factors
```
HPV (93%)
Maternal use of DES
Smoking
Hormonal contraceptive use
High parity (births)
Low SES
Ethnic background
Young age of first intercourse
Multiple sex partners (more than 5)
```
126
Cervical cancer - diagnosis
Pap screen/test can detect problems early
127
Cervical cancer - treatment
Prevention, Gardisil vaccine
| Depends on stage - hysterectomy, radiation therapy
128
Cervical cancer - prognosis
Early stages is highly curable (85%)
| Advanced (40%)
129
Ectopic pregnancy is what
Fertilization and implantation of the embryo outside of the uterine cavitiy (more than 95% are in fallopian tube)
130
Ectopic pregnancy presents with
Amenorrhea or menstrual irregularities with unilateral or bilateral abdominal and back pain
131
Ectopic pregnancy s/s of...
normal pregnancy with fatigue, nausea, breast tenderness and inc urinary freq
132
Ovarian cystic disease
Most common during reproductive years
Affects 3-7% of all women
Caused by hormonal imbalances
133
Ovarian cystic disease - presentation
```
Low back and pelvic pain
Abdominal pain and bloating
Painful urination, bowel movements and itnercourse
menstrual irregularities
large cysts can lead to infertility
```
134
Ovarian cystic disease - Diagnosis
```
US
Lab tests (CBC, CA-125 for ovarian cancer)
```
135
Ovarian cystic disease - Treatment
Depends on childbearing status
May drain spontaneously
Surgery might be necessary
Hormonal therapy restoration of progesterone
136
Polycystic ovary syndrome (PCOS) - now considered what type of disease
A systemic metabolic/hormone disorder
137
Polycystic ovary syndrome (PCOS) - epidemilogy
Affects 20% of women in US with 50% being obese
| Most common cause of infertility - 75% have some degree of it
138
Polycystic ovary syndrome (PCOS) - s/s
Impaired menstruation
glucose intolerance
Inc risk for type 2 diabetes, fibrocystic breasts, heart disease
139
Ovarian cancer - epidemiology
5th most common cancer in W
accounts for 90% of deaths related to gyn cancers
Metastatic disease in 60-70% at time of diagnosis
Peak incidence is 40-70 years (half of cases in women over 65)
140
Ovarian cancer - risk factors
```
Family hx of breast, ovarian, colon ca
Personal hx of breast or endometrial cancer
Nulliparity
Never breast fed
Presence of BRCA-1 or BRCA-2 mutation
```
141
Ovarian cancer - s/s
Early CA has no presentation and there is no screening tool
| Symptoms of metastasis = unexplained weight loss, pleurisy, ascites
142
Ovarian cancer - treatment
Surgery
Radiation
Chemotherapy
143
Ovarian cancer - prognosis
Generally poor due to metastasis at diagnosis
Early stage treatment 90% for 5 yr survival rate
Tumor recurrence within 3 yrs after treatment in most women
144
PT and gyn cancer
Medical tx is geared toward saving a life
PT is geared toward making their saved life worth living!
```
Generalized strengthening
Pelvic floor strengthening
Manual therapy for scar
Progressive dilator for stretching
Pain management
```
145
Treatment algorithm - Medical provider treatment
UTI
| Pelvic inflammatory disease
146
Treatment algorithm - PT
Pelvic pain from mm origin (lumbar/SI dysfunction)
147
Treatment algorithm - Specialized pelvic physical therapist
Pelvic floor mm dysfunction
Painful bladder syndrome
Defecation dysfunction
Dyspareuina
148
Does my patient need to see a pelvic floor specialist
```
P with sitting, can't touch it
Hx of gyn dysfunction
Hx of incontinence that isn't getting better
Pelvic pain in brim of pelvis
Suspicion that there is more to it
Tailbone pain....and more
```
