Genitourogynaecology

Question 1

What are the clinical features of bacterial vaginosis?

Answer 1

Grey discharge with fishy smell
Predisposed by high vaginal pH from excess douching

Investigation:
Assess vaginal pH
Vaginal swab for microscopy and staining

Management:
Only treat if symptomatic or pregnant
Metronidazole for 5 days

Question 2

What are the clinical features of vulvovaginal candidiasis?

Answer 2

Thick white discharge
Itchiness
Erythema of vulva/vagina

More likely to be symptomatic if: Diabetes, Pregnant or immunocompromised

Investigation:
Swab - Microscopy and culture

Management:
Intravaginal antifungal cream/pessary (Clotrimazole, econazole) or oral antifungal (fluconazole)

Question 3

What are the clinical features of trichomoniasis (Trichomonas vaginalis)?

Answer 3

Yellow-Green frothy discharge
Strawberry cervix
Increased vaginal pH
Symptoms of vaginitis (Itching, dysuria, inflammation)
Dyspareunia

Investigation:
High vaginal swab - NAAT

Management:
Metronidazole

Question 4

What are the clinical features of gonorrhoea?

Answer 4

Typically asymptomatic
May present with discharge
Symptoms of cervicitis (Intermentrual/Post-coital bleeding)
Dysuria
Dyspareunia

Investigation:
Swab - NAAT

Management:
Ceftriaxone IM

Question 5

What are the clinical features of chlamydia?

Answer 5

Typically asymptomatic
May present with discharge
Symptoms of cervicitis (Intermentrual/Post-coital bleeding)
Dysuria
Dyspareunia

Investigation:
Swab - NAAT

Management:
7 days PO Doxycycline or 1g stat Azithromycin
If pregnant, Azithromycin

Question 6

What are the clinical features of pelvic inflammatory disease?

Answer 6

Fever
Lower abdominal pain
Deep dyspareunia
Dysuria
Cervical excitation
Vaginal discharge
Post-coital bleeding/Intermenstrual bleeding

Question 7

What are the investigations for PID?

Answer 7

Pregnancy test to rule out ectopic pregnancy
STD tests
High vaginal swabs

Question 8

What is the management of PID?

Answer 8

Doxycycline/Azithromycin + Metronidazole + Ceftriaxone

Question 9

What are the complications of PID?

Answer 9

Ectopic pregnancy
Subfertility due to inflammation of fallopian tubes or endometrium
Chronic pelvic pain
Fitz-Hugh Curtis syndrome - RUQ pain due to perihepatitis

Question 10

What are the clinical features of genital herpes?

Answer 10

Multiple superficial tender ulcers with regional lymphadenopathy
Genital pain
Dysuria

Investigation:
Swab + PCR

Management:
Aciclovir

Question 11

What are the clinical features of genital warts?

Answer 11

Typically caused by HPV 6 & 11 (Whereas cancer is normally by 16 & 18)

Management:
Cryotherapy (Optional as wart is benign)
Medical = Imiquimod

Question 12

What are the clinical features of syphilis?

Answer 12

Caused by treponema pallidum

Single genital lesion at sight of infection (chancre)
Lesion is painless, but may exudate serous fluid
Regional lymphadenopathy

Secondary syphillis:
Widespread erythematous rash on palms and soles
Raised lesions in anogenital region known as condylomata lata

Management:
Penicilin

Question 13

What investigations are conducted for patients presenting with urinary symptoms?

Answer 13

Urine dipstick:
	• Glucose = Diabetes
	• Nitrites = Infection (UTI)
	• Protein = Renal disease
	• Blood = Bladder carcinoma or calculi

Urinary diary - Time/Volume of fluid intake & micturition

Post-micturition ultrasound/catheterisation - Exclude chronic urine retention

Urodynamic studies, cystometry - Useful for diagnosing stress/urge incontinence

Question 14

What is the mechanism of stress incontinence?

Answer 14

When stress (e.g. sneeze) causes increased intraabdominal pressure, the bladder pressure also increases due to compression. The bladder neck should equally be compressed to maintain pressure, however if it slips below the pelvic floor (because of weak supports for example) it does not get compressed. This pressure difference, if uncompensated by the rest of the urethra, results in incontinence.

Question 15

What are the clinical features of stress incontinence?

Answer 15

Frequency
Urgency
Urge incontinence
Leakage of urine on coughing

Sims’ speculum may reveal a cystocoele or urethrocoele (potential causes of slipped bladder neck)

Question 16

What is the mechanism of urge incontinence?

Answer 16

Idiopathic detrusor overactivity resulting in increased bladder pressure that may overcome urethral pressure, resulting in incontinence

Question 17

What are the clinical features of urge incontinence?

Answer 17

Frequency
Urgency
Urge incontinence
Stress incontinence
Nocturesis

Question 18

What investigations help diagnose incontinence?

Answer 18

Urinary diary shows frequent passage of small volumes of urine in urge incontinence, particularly at night. Not useful in diagnosing stress incontinence.

Cystometry:
• In stress incontinence, when there is an increase intra-abdominal/bladder pressure due to coughing, urine flow is also seen.
• In urge incontinence, coughing has no impact on urine flow, however you may see random increases in detrusor pressure (which normally does not change at all), which causes a large increase in bladder pressure, resulting in urine flow.

Question 19

What is the management of stress incontinence?

Answer 19

If obese, encouraged to lose weight
Address causes of chronic cough (e.g. smoking)
Reduce excess fluid intake

Conservative - Pelvic floor muscle training
• For at least 3 months
• 8 contractions, 3 times per day
• May also consider vaginal cones/sponges

Surgery - Tension-free vaginal tape (TVT) or Transobturator tape (TOT)
• Used when conservative management fails and quality of life is compromised
• Tape is placed in a U-shape under the mid-urethra, tension adjusted to prevent leakage as woman coughs

NOTE: (Additional option, not commonly used)
Medical - Duloxetine (Enhances urethral sphincter activity)

Question 20

What is the management of urge incontinence?

Answer 20

Conservative:
• Simple advice - Reduce fluid intake, avoid caffeine
• Bladder training - Education, systematic delay of voiding, positive reinforcement. Avoid the urge to void, void according to timetable. Do for 6 weeks. Often combined with anticholinergic.

Medical:
• Anticholinergics/Antimuscarinics (Oxybutynin) - Suppresses detrusor overactivity
• Sympathomimetics (Mirabegron) - Used if you want to avoid anticholinergic side effects. Bladder antispasmodic.
• Botulinum toxin if nothing else works

Question 21

What are the types of prolapse?

Answer 21

Urethrocoele - Prolapse of the lower anterior vaginal wall, involves urethra

Cystocoele - Prolapse of the upper anterior vaginal wall, involving the bladder, often associated with prolapse of the urethra (cystourethrocoele)

Enterocoele - Prolapse of the upper posterior vaginal wall, resulting in descent of small bowel into pouch

Rectocoele - Prolapse of the lower posterior vaginal wall, involving the anterior wall of rectum

Vaginal vault prolapse - Prolapse of the top of the vagina, following hysterectomy

Question 22

What are the risk factors for prolapse?

Answer 22

• Pregnancy is associated with the greatest risk of future prolapse
  
  • Ehlers-Danlos syndrome
  • Menopause (incidence rises with age)
  • Obesity
  • Chronic cough
  • Constipation
  • Heavy lifting

Question 23

What are the clinical features of prolapse?

Answer 23

• Sensation of vaginal heaviness, dragging sensation. Worse at end of day
  
  • Interferes with intercourse, may ulcerate and cause bleeding
  • If cystourethrocoele, may suffer from frequency and stress incontinence
  • If rectocoele, may suffer from difficulty in defecating
  • Large prolapses are normally visible from the outside, smaller prolapses require speculum examination
  • A finger in the rectum will be seen to bulge in the posterior vaginal wall in a rectocoele but not an enterocoele (helpful to aid differentiation)

Question 24

What is the management of vaginal prolapse?

Answer 24

Conservative:
• Weight reduction. Smoking cessation.
• Pelvic floor exercises (Kegel)

Pessaries:
• Used when women are unwilling/unfit for surgery
• Placed behind the pubic symphysis
• Ring pessary most common
• Shelf pessary used for more severe prolapses

Surgical:
	• Hysteropexy/Colporrhaphy or hysterectomy
	• Anterior wall for cystourethrocoele 
	• Posterior wall for recto/enterocoele 
	• Sacrocolpopexy for vault prolapse