General gynaecology Flashcards
Heavy menstrual bleeding
History and examination
History:
Periods - frequency, length, regularity, IMB, pain, heaviness, symptoms of anaemia and impact on life
Discharge, bladder or bowel dysfunction
Other bleeding symptoms
G and P
Contraception, smears, previous STIs
Medical, surgical and psychiatric history
Family history
Medications and allergies
Social history - home, relationship, FV screen, occupation, substance use
Examination:
Obs
BMI
Conjunctivae, pallor
Abdomen - soft, pain, massess
Speculum - vulva, vagina, cervix, discharge, bleeding
Bimanual - uterine size, version, mobility, descent and suitability for TVH, massess, tender
Heavy menstrual bleeding
Differential diagnosis and
investigations
Differential diagnosis:
* Polyps
* Adenomyosis
* Leimyomata
* Malignancy/hyperplasia
* Coagulopathy - vWD, TTP
* Ovulatory dysfunction - PCOS, obesity, hypothryoidism
* Endometrial - infection
* Iatrogenic - CuICD, anticoagulation
* Not otherwise specified
Investigations:
- Hb
- Ferritin
- Coagulation screen, vWF if risks
- TFTs
- BhCG
- Vaginal swabs
- Cervical smear if due/cervix abnormal
- USS pelvis
- Pipelle biopsy
Heavy menstrual bleeding management
Fe replacement
Reverse cause if known and applicable
Give written information
NSAIDs
Mirena
COCP or progesterone - provera, norethisterone
TXA
NSAIDs
Endometrial ablation
Myomectomy
Uterine artery embolisation
Hysterectomy - TLH, TVH, TAH. Conserve ovaries
Von Willebrand‘s disease
- types
- diagnosis
- treatment
Three types:
1 - less of vWF (AD)
2 - present but not functioning (AD)
3 - severe reduction/absent (AR)
Diagnosis:
- Prolonged APTT
- Low vWF
- Low Factor VIII
- PFA-100 (screening tool)
Treatment:
- Haematology referral
- dDAVP
- Replacement from human derived factor VIII, cryo
- TXA
- Avoid aspirin and NSAIDs
- Hormonal control
- Topical - surigcel/gelfoam soaked in thrombin
- Factor VIIa - bypasses need for factor VIII
- Consider pregnancy implications
Mirena
- indications
- contraindications
- method of action
- risks
Indications:
- Contraception
- HMB
- Endometriosis
- Dysmenorrhoea
- Hyperplasia without atypia
- Stage 1A endometrial cancer and uterine preservation desired or poor surgical candidate
Contraindications
- Active infection
- Distorted uterine cavity
- Breast cancer (PR+)
Method of action:
Local release of 52mg levonorgrestrel over 5years, causes endometrial atrophy. Weak effect on ovarian function.
Risks:
Insertion - pain, bleeding, infection, perforation
Malposition/expulsion
Failure
Abnormal bleeding
Management of uterine fibroids
Assess:
* Number, location, size
* Type
Counsel:
* Bleeding, pressure symptoms, degeneration
* Pregnancy - may impact fertility (SM), malpresentation, IUGR, difficulty palping fundal height, abruption, needs for CS, PPH, red degeneration, torsion
Management:
* Medical - OCP, Mirena (not if cavity distorting), TXA, NSAIDs
* GnRH analogue - usually only pre-operative
* Hysteroscopic resection if submucosal
* Myomectomy - uterine preserving
* Uterine artery embolisation - Placement of an angiographic catheter into uterine arteries via common femoral artery injection of embolic particles until the flow becomes sluggish in both uterine arteries. Aims to reduce uterine blood flow by producing ischaemic injury causing necrosis and shrinking. 65% of women avoid hysterectomy. Possible complications: groin haematoma, arterial thrombosis. Vaginal discharge, infection, expulsion of necrotic fibroid and VTE. Embolisation syndrome - fever nausea pain and malaise.
* Hysterectomy
* MRI guided focused USS ablation - High frequency USS waves produce heat to denature proteins leading to cell death and shrinkage of fibroids. Quick recovery and very low morbidity.
Dysmenorrhoea/pelvic pain management
MDT - pain specialist, physio, psychologist, dietician, social worker
Written information
Lifestyle modification - diet, exercise, sleep hygiene, reduce psychosocial stressors
Mindfulness, restorative yoga
NSAIDs
Hormonal suppression - OCP, Depo, Mirena
Neuropathic agents - gabapentin, nortriptyline, amitriptylline
(Laparoscopy for endometriosis)
You are performing a laparoscopy for a 14year old for pelvic pain. You note extensive superficial endometriosis on uterosacrals and posterior broad ligment. Outline your management steps
Document - photographs, descriptions
Escalate to suitably qualified/skilled senior/surgeon
Biopsy
Resection - now, planned later or later only if symptoms/fertility concern
Now - Butterfly peritoneal resection
Later - planned procedure with advanced laparoscopic surgeon, colorectal, ureteric stents
Mirena or other hormonal suppression
Follow up, MDT, pain team
Counsel re central sensitisation and fertility impacts
DES exposure
Risks, management
Women: 30% increase in breast cancer -> mammograms
Female fetus:
Breast cancer - mammorgams, breast exams
Clear cell ca of vagina and cervix
Cervical/vaginal dysplasia (large ectropions and large area of metaplasia) -> annual gynaecology review: general exam, colposcopy, HPV and smear co-test, bimanual. Experienced colposcopist.
Uterine malformations: Endometrial adhesions, hypoplastic uterus and cervix, preterm birth, miscarriage, ectopic.
Male fetus:
Testicular abnormality: epididymal cyst, hypogonadism, undescended testis. NOT cancer or infertility.
Secondary ammenorrhoea
Differential diagnosis, investigations
Differentials:
- Pregnancy
- Lactation
- Menopause
- POI
- Ashermann’s
- Hypothalamic (intensive exercise, weightloss)
- PCOS
- Sheehan’s syndrome
- Infection
- Drugs
Investigations:
- BhCG
- FSH, LH, oestradiol
- PRL
- Pelvic USS
- Hysterosalpingogram
- Hysteroscopy
Ashermann’s syndrome management
Hysterosopic resection
- Scissors
- May do concurrent laparoscopy to reduce perforation risk
Measure to prevent reformation
- Intrauterine balloon 7-10days
- IUCD
- Oestrogen to promote rapid re-epithelialisation
Counsel post op about recurrence, pregnancy complications incl accreta spectrum, PTB, PPH
Rudimentary uterine horn
Complications, management
Communicating or non-communicating
Complications:
Dysmenorrhoea
Endometriosis
Cornual ectopic pregnancy - rupture
Pregnancy: miscarriage, PTB, IUGR, malpresentation, CS birth
Management:
Surgical excision (laparoscopic hemi hysterectomy) +/- treatment of endeemtriosis
Consider endometrial ablaton, hysteroscopic resection (still risk of ectopic)
Scan for renal and skeletal anomalies - renal USS and XRs
Differentiation between PCOS, CAH, Androgen tumors of ovaries and adrenals
Testosterone, DHEAS, cortisol, 17-OHP
PCOS: Testosterone increased, DHEAS normal, Cortisol normal, 17-OH-progesterone normal
Congenital Adrenal hyperplasia: Testosterone increased or normal, DHEAS increased, Cortisol normal or decreased, 17-OH-progesterone increased.
Androgen producing tumour – adrenal: Testosterone increased, DHEAS increased, Cortisol increased, 17-OH-progesterone normal
Androgen producing tumour – ovarian: Testosterone increased, DHEAS normal, Cortisol normal, 17-OH-progesterone normal
Secondary amenorrhoea
Differential diagnosis and investigations
Pregnancy - BhCG
PCOS - USS, free androgens, SHBG, LH, FSH, mid luteal progesterone
Obesity
Hypothalamic or functional e.g. stress, excessive exercise, eatig disorder - history may suggest
Hyperprolactinaemia - PRL
Thyroid dysfunction - TSH
Sheehan’s syndrome - ask for PPH history
Medications
Chronic disease
Ashermann’s - USS, hysteroscopy, history may suggest
Cervical stenosis - suspect on history
POI - karyotype, autoantibody, FMR1 screen
Late onset CAH - 17OHP
Androgen tumor - ovarian or adrenal - DHEAS
Exogenous androgen
You suspect a patient has PCOS; what investigations would you perform to rule out other causes?
- BhCG
- FSH, LH, oestradiol, mid-luteal phase progesterone
- Testosterone, FAIS, SHBG +/- DHEAS
- Serum PRL, TFTs
- Pelvic USS
- 17-OH progesterone level (CAH)
- (Progestin withdrawal test if no other cause found ?intrauterine cause)
Outline the main risks and management options for women with PCOS
General:
* Weight loss: dietician, exercise, green prescription, Orlistat(?)
Anovulation and hyperplasia:
* COCP, Mirena, cyclical progesterone 12 days/month.
* Pipelle if thick ET and RFs.
CVD and diabetes:
* Regular screening: weight, BMI, abdo circumference, BP, lipids, HbA1c
Infertility:
* Weight loss
* Ovulation induction letrozole +/- metformin, gonadotrophin therapy
* Laparoscopic ovarian drilling
Hirsuitism and acne:
* COCP, Ginet (cyproterone acetate)
* Spironolactone, finasteride (MUST have contraception)
* Cosmetic hair removal - shaving, waxing, laser, electrolysis, creams
* Dermatologist
NB expect to take 6months
Mental health:
* screen for mood disorders and treat
OSA:
* screening for snoring and day time somnolence
* refer to respiratory
Pregnancy: miscarriage, GDM, PET, PTB, CS.
* Dating scan if unsure dates
* Aspirin, calcium
* Early OGTT
* PET screening
* Growth USS if high BMI
PCOS
Patient explanation
An endocrine disorder involving abnormal ovarian androgen production, increased insulin resistance and impaired oestrogen feedback – you meet the criteria for diagnosis with irregular menstruation, biochemical and clinical hyperandrogenism, and polycystic ovaries on your ultrasound.
Short term implications include difficult weight management, infertility, acne/hirsutism, and depression
Long term implications include CVD, diabetes, obstetric complications and malignancy/hyperplasia involving the endometrium
Endometriosis
Explanation, management
An inflammatory disease characterised by lesions of endometrial tissue outside of uterus. May cause dysmenorrhea, dyspareunia, dyschaezia and infertility.
MDT - pain specialist, pelvic floor physio, psychologist, dietician, social worker
Written information - pelvic pain foundation
Lifestyle modification - diet, exercise, sleep hygiene, reduce psychosocial stressors
Mindfulness, restorative yoga
Medical management:
* NSAIDs
* Neuromodulators e.g. Amitriptyline or Gabapentin
* Ovulation suppression - Depo-provera, COCP levlen or Yasmin or Mirena
Surgical management consider if:
- Symptoms not responding to medical treatment
- Sure diagnosis of complex cysts
- Significant pain and infertility
Surgery has been shown to reduce pain but laparoscopy and medical therapy for at least 18-24 months is superior prolonging times between surgery and improving fertility long term.
Recurrence 20% at 2 years and 40% at 5 years
Vulval itch - history, exam and differentials
Differentials
* Lichen simplex chronicus
* Lichen sclerosus
* Lichen planus
* Fungal infection
* Psoraisis
* Atrophy
* HPV papilloma
* VIN
* Malignancy
* Paget’s disease
* Systemic illness e.g. renal or hepatic failure
Lichen sclerosus - management
- Counsel with written information - lifelong disease causing anatomical distortion, may flare from time to time. Must treat lifelong and compliance important. 5% risk of progression to dVIN and malignancy.
- Vulval cares - avoid perfumed creams and soaps. Avoid pads and liners. Use cotton underwear. Break itch/scratch cycle. Address continence issues.
- Ultrapotent topical steroid ointment e.g. Clobetasol proprionate 0.05% - daily with a flare then maintenance twice weekly ongoing
- Emollients/barrier creams
- Vaginal oestrogen if atrophy
- Treat secondary bacterial/fungal infection
- Sexual health - vaginal dilators, generous amounts of lubricant
- Annual reviews, earlier if lump, bleeding, ulceration - biopsy if areas of concern
- Screen for thyroid disease
Lichen sclerosus histology
Epidermal atrophy
Hyperkeratosis with sub-epidermal hyalinization of collagen
Lichenoid infiltrate of mononuclear cells in the dermis
How do you manage a 53yo woman who presents with hot flushes?
Assess:
* Onset of menopause
* PMHx - in particular risk factors and contraindications for MHT, whether has a uterus
* Impact of symptoms on day to day life
Manage:
* Well woman check - cervical smear, mammogram, BP, HbA1c, lipids, DEXA scan
* Address modifiable risk factors
* Lifestyle adjustments - stress reduction, limit alcohol and caffeine, dress in layers, avoid hot drinks, using a fan
* Non-hormonal pharmacot therapy options - SNRI, SSRI, gabapentin, clonidine, tibolone
* Non-pharmacotherapy - Relaxation technique, CBT, Stellate ganglion blockade if severe resistant
* Urogenital symptoms - vaginal oestrogen
* Sexual health - vaginal moisturises, lubricants
* Contraception if <12m of final period
MHT
* Counsel
* Benefits = for vasomotor symptoms, BMD, CVD, and dementia protection, mood and psychosexual improvement
* Risks = VTE, breast cancer (additional 8:1000 over 10years), stroke, CVD only if outside of window of opportunity, endometrial hyperplasia or cancer if unopposed oestrogen. Aim for lowest effective dose
* Oestrogen: transdermal patch (lowest VTE risk), oral tablet
* Progesterone if uterus: Mirena, oral micronised progesterone, oral progesterone.
- cyclical of menses stopped <12m ago
Follow-up
* 3months - consdier up titration if not effective yet
* Annual reviews - ensure benefit >risk
* Return advice if bleeding
* Reassess after 5 years
*
A patient who has a history of breast cancer presents with vasomotor symptoms after a risk reducing BSO. How do you manage?
- Review post op recovery
- Check PMHx for RFs modifiable and non-modifiable
- Ensure up to date with breast ca follow up
- Perform well woman check - BP, lipids, HbA1c, DEXA scan
- Screen for symptoms of peritoneal disease (depending on time post op)
- Lifestyle adjustments - dress in layers, avoid hot drinks, using a fan
- MHT contra-indicated
- Non-hormonal pharmacotherapy options - SNRI, SSRI (paroxetine contraindicated if on tamoxifen) gabapentin, clonidine
- Non-pharmacotherapy - Relaxation technique, CBT, Stellate ganglion blockade if severe resistant
- No good evidence for alternative therapies
- Use ovestin in consultation with oncology for urogenital symptoms
Factors to assess for any women who is >50 or postmenopausal
WELL WOMAN CHECK
* BMI, BP, lipids, HbA1c - cardiovascular disease risk assessment
* Adjust modifiable RFs
* Mammogram
* Cervical smear
* DEXA scan, prevention of osteoporosis
* MHT if symptomatic vasomotor and no contraindications (breast ca, uncontrolled HTN, current VTE, cardiovascular disease, untreated endometrial hyperplasia, unexplained vaginal bleeding,
* Urogenital symtpoms - ovestin
* Contraception if <12m post menopause
* Sexual function - utilise lubricant
* Mood and wellbeing check
After arranging a DEXA scan as part of your well woman check, you see a patient back to discuss her results. How do you proceed?
- Assess for RFs - FHx, low BMI, previous fragility fracture, menopausal, late menarche/early menopause, vitamin D and calcium deficiency, heavy soft drink intake, low physical activity/sedentary lifestyle, longterm corticosteroids
- Use T-score to calculate FRAX score - T </= 2.5 = 3% risk of hip fracture over 10years -> TREAT
- Lifestyle modifications - stop smoking, optimise weight BMI 20-25, regular weightbearing exercises
- Supplement Ca and vitamin D
- Bisphosphonates - IV or PO. These should reduce the risk of fracture by 20%.
- Monoclonal antibody (Denosumab)
- MHT if vasomotor symptoms or other treatment inappropriate
What is your approach to a patient who is a Jehova’s Witness and will not consent to blood products?
Assess:
* Competency
* Ensure has a good understanding of reasons for a blood transfusion and consequence of not
* Ensure no coercion - preferably discuss alone
Manage:
* MDT (depending on context) - obs/gynae team, anaesthetics, haematology, JW liaison, legal team
* Clear advanced directive - signed in front of notes for accept/decline
- RBCs
- Plts
- Albumin
- Fractionated blood products
- Immunoglobulins
- Recombinant factor VIII
- Autologous blood (stored prior or cell saver)
- Cardiac bypass
- ECMO
- Fe
- TXA
* Focus on respecting autonomy - follow advanced care directive unless changes mind. May have NO BLOOD wristband on
* Optimise Hb prior - Fe, EPO
* Reduce blood loss - most experienced person present do procedure, minimally invasive, meticulous haemostasis, TXA, keep warm, avoid HTN and venous congestion, pre-op adjuncts e.g. Zoladex
* Hypervolaemic haemodilution
* Measure blood loss throughout
* Utilise cell saver where able
* Lower recourse to hysterectomy if bleeding
* Limit blood collection afterwards
Outline options for management of PMS and PMDD
Assess:
* Symptom diary - must be worse pre period and settle within few days of menses
* Severity/impact on life
* Screen for mental health aspect ?PMDD
* Zoladex for 3m - if resolves can confirm if uncertain
Manage:
Conservative:
- Exercise
- Diet
- CBT
Medical:
- Complementary: evening primrose oil, calcium supplement
- Vitamin B6
- COCP (drosperinone containing, take continuous)
- SSRI if symptoms mostly emotional
- HRT (estradiol patch + utrogestan or Mirena)
- GnRH analogue + add-back HRT
- Bone density and CVD precautions/advice/tx
- Spironolactone for fluid retention
Surgical:
- Hysterectomy, BSO + HRT (give zoladex +HRT first to ensure can tolerate) - ovarian conservation not recommended and drivers of symptoms. BSO alone not recommended as need HRT and progesterone for endometrial protection may worsen
Differential diagnosis for hirsuitism
- PCOS
- CAH
- Adrenal tumor
- Ovarian tumor - Sertoli Leydig
- External steroid use
Vulval ulcer - history, examination, differentials
History:
* Assoc pain, bleeding
* Other ulcerations prev or atm incl in mouth
* Meds
* Contact with anyone
Exam:
* Ulceration - appearance, location, pain
* Vaginal mucosa, cervix and vulva
* Lymphadenopathy
* Mouth
Differentials and investigations:
* HSV - swab, viral PCR. Serology.
* Syphilis - swab (dark ground microscopy), serology
* LGV
* Donavanosis
* Lipschutz
* Behcet’s
* VIN - biopsy
* Vulval cancer - biopsy
* Drug reaction e.g. Stephen Johnson - drug Hx
* Crohn’s disease - biopsy, Hx of IBD
PID management
Assess:
* Sexual history, substance use, social situation
* FBC, CRP, renal, LFTs, Hep B and C serology, HIV, syphilis
* HVS - MC&S, NAAT
* Endocervical for gonoccocal culture and sensitivities
* USS pelvis ?TOA
Counsel:
* Important to treat to limit progression
* Risks of pain, sepsis, TOA, LFT derangement
* Long term risk of pain, adhesions, infertility, ectopic
Manage:
* Admit if more than mild
* Triple ABx - ceftriaxone 1g IM (gonorrohoea), doxycycline 100mg PO BD 14days (chlamydia), metronidazole 400mg PO BD 14days (trichomonas/BV)
* Analgesia
* Contact trace - test and treat
* Barrier contracpetion for 2weeks after treated
* Keep IUD in situ unless not improving after 48hours
* Re-test 3months as high risk re-infection
* Contraception
* Referral for social supports if needed
How do you manage a TOA (in addition to standard PID treatment)?
- Conservative - IVABx, time
- IR (CT or USS) drainage - TV or TA
- Laparoscopy + washout + drainage
What needs to be taken into account when a patient reports a sexual assault?
- Ensure safety, support, confidentiality
- Event timing, place, circumstances. Which orifices entered. Whether a condom was used.
- Perpetrator - known to victim, any ongoing threat to victim or others
- Any associated toxins - alcohol, cannabis, other
- Survey for any injuries - sexual and otherwise
- Assess and manage any instability first
- Ascertain if want to provde police statement
- Ascertain if would like forensic exam - do not shower. Refer to DSAC
- Check for pregnancy, emergency contraception, follow up pregnancy test in 2weeks
- Check for STIs (swabs, serology), STI prophylaxis, re-test in 4-6weeks (serology in 3-6months). Consider hepatitis B vaccine. Consider HIV PEP
- Psychological counselling - ACC sensitive claim
- Victim support, sleeping aides
- Follow up
Vaginismus management
Assess:
* Pain, discharge, bleeding
* When pain happens - intercourse, tampons, speculums
* Psychosocialsexual screen - any exacerbating factors, relationship difficulties, history of assault or trauma, MH screen
* Obstetric and gynae history
* Screen for persistent pain
* Exam - cotton tip test, hymenal narrowing at all
* STI swabs
Manage:
* MDT (and involve partner) - gynae, physio, therapist
* Physiotherapy - exercises, dilators
* Psychologist - CBT, sex therapy
* Topical (or oral) neuropathic agents
* Lubricant, LA gel for intercourse
* Clear documentation in notes, make a plan for speculum, vaginal exams
* Consideration given in trying to concieve
Management of a prolapse
Conservative
* Supervised PFM exercises for at least 12weeks - improves symtpoms, may not cure more advanced prolapse, may assist with recurrence reduction
* Lifestyle modification - weightloss, constipation management, optimising chronic cough, avoiding heavy lifting
* Ovestin - adjunct to all, very few contraindications but does need to self insert
Pessary
* Benefits - avoids surgical risks, easy to fit same day, can self manage
* Risks - may interfere with intercourse, need to insert ovestin, discharge, erosion, need for long term reviews and changes
Surgical
Anterior/posterior repair
* Benefits - 85% success
* Risks - pain, bleeding, infection, injury to bladder/bowel, VTE, anaesthetic risks, impact on sexual function, unmasking stress urinary incontinence, recurrence, need to focus on recovery
Hysterectomy
* Benefits - success, reduces risk of endometrial/cervical pathology, short recovery time if done vaginally
* Risks - pain, bleeding, infection, injury to internal organs, VTE, anaesthetic risks, vault dehiscence, fistula
Sacrospinous fixation
* Benefits - success for central compartment/vault prolapse, vaginal access, quicker recovery
* Risks - pain, buttock pain, bleeding, infection, injury to internal organs or pudenal neurovascular bundle, VTE, anaesthetic risks, impact on sexual function as changes vaginal axis
Sacrocolpo(hystero)pexy
* Benefits - gold standard success for central compartment/vault prolapse, able to retain uterus if hysteropexy, less impact on sexual function, can be done open or laparoscopic
* Risks - pain, bleeding, infection and osteomyelitis, injury to internal organs, VTE, mesh erosion, fistula, recurrence, hernia formation, anaesthetic risks, longer recovery time
Colpocleisis
* Benefits - complete closure of vagina, often seen as last resort and very effective
* Risks - pain, bleeding, infection, injury to adjacent organs, VTE, recurrence, if retained uterus inability to sample cervix or uterus
Counsel regarding a pessary
A pessary is a soft, flexible silicone device that is placed in the vagina to help support the bladder, vagina, uterus, and/or rectum.
It may be the only management a woman needs for prolpase management, it also may be used whilst awaiting a surgical procedure.
Women who have gone through menopause, are recommended to use vaginal estrogen to prevent injury to the vaginal tissue.
The estrogen cream makes the lining of the vagina thicker and healthier this is used at night, twice a week
Side effects of a pessary can be vaginal discharge, irritation and discomfort, trouble passing urine or your bowels, and scarring over or around the pessary
You can be taught how to insert and remove your pessary.
If you are able to care for your pessary at home, we typically recommend that you take it out and clean it daily. You should use a mild soap with water, rinse and dry it completely, and reinsert it into the vagina the next morning. It is OK to keep it in for a longer period of time but never more than 3 months at a time.
Sexual activity is possible with a ring pessary insitu. if there is difficult with sexual activity you can remove and replace it
If you are unable to remove and reinsert your own pessary, we will want to see you in the office for cleaning and examination every three months.
We can check your ability to do so in the clinic and ensure you may empty your bladder prior to leaving.
We will provide you with written information about pessary management and a number to contact if there are any issues when you are at home.
Post operative vesicovaginal fistula - how do you diagnose and manage?
History
* constant vaginal leakage, smells like urine
Exam
* Fistula seen
* Methylene blue tampon test
Investigations
* Cystoscopy
* EUA
* MRI
* Intravenous pyelogram or cystourethrogram
Management
* If small may manage conservatively - IDUC, anticholinergics,
* Surgical repair timing depends on tissue integrity - ASAP if obstetric, 6weeks delayed if gynaecological.
* Catheterise defect, excise surrounding epithelium. Close defect with a Martius vaginal flap, suture in layers
Management options for stress urinary incontinence
Pelvic floor exercises
Ovestin
Pessary with continence knob
* Benefits - can fit in clinic, avoids surgical risks, les invasive, reversible
* Risks - dislodgement, discomfort, ulceration, need for ovestin cream, serial reviews,
Retropubic vaginal sling - mesh or autologous from rectus sheath or tensor fascia lata
* Benefits - 80% success, autologous avoids mesh erosion
* Risks - pain, bleeding, infection, bladder injury 10%, VTE, recurrence, urinary retention, de novo urgency, mesh erosion
TOT
Burch colposuspension
Periurethral bulking
* Benefits - few surgical risks, may be done in clinic setting
* Risks - Lasts ~ 6months , infection, urinary retention
Articifical urinary sphincter
Management options for detrusor overactivity
Bladder retraining
Ovestin
Anticholinergics - oxybutynin, solifenacin, mirabegron
Bladder botox
Posterior tibial nerve stimulation
