GU + Sexual health Flashcards
Bacterial vaginosis
The overgrowth of ANAEROBIC bacteria in the vagina, caused by the LOSS of LACTOBACILLI.
NOT AN STI but is a RFx for STIs - can occur alongside other infections
Role of lactobacilli in healthy vagina
Produce LACTIC ACID - keeps vagina ACIDIC (<4.5)
When reduced numbers of lactobacilli - becomes ALKALINE allowing ANAEROBIC bacteria to multiply
Examples of anaerobic bacteria associated with bacterial vaginosis
- Gardnerella vaginalis (most common)
- Mycoplasma hominis
- Prevotella species
RFx for bacterial vaginosis
- Multiple sexual partners
- Excessive cleaning of vagina
- Recent antibiotics
- Copper coil
- SMOKING
Less common if on combined pill/using condoms
Sx of bacterial vaginosis
Strong fishy odour of watery grey/white discharge
- the discharge is homogenous + coating the walls of vagina + vestibule
(50% asymp; itching/irritatiion or pain = suggests other cause)
Bacterial vaginosis investigations
- speculum examination to check discharge (not always required if v typical/low risk of STI)
- VAGINAL SWAB:
- pH paper shows >4.5
- CHARCOAL SWAB for MICROSCOPY
- CLUE CELLS on microscopy (epithelial cells so covered in bacteria their edges are grainy)
Bacterial vaginosis management
Asymp = none; generally can self resolve
-
METRONIDAZOLE (only works on ANAEROBIC) - ORAL or VAGINAL GEL
- 2nd: Clindamyicin
- Swab for STIs + assess risk of other pelvic infection
- Give advice/info
- Don’t drink while on metranidazole
Can prevent with ACIDIFIED VAGINAL GEL
Complications of Bacterial vaginosis
- Risk of catching STIs
- Miscarriage
- Preterm delivery
- Premature rupture of membranes
- Chorioamnionitis
- Low birth weight
- Postpartum endometritis
Balanitis
Inflammation of the glans penis
Balanitis Sx
- Inflamed (red, swollen, itchy, sore)
- Dysuria
- Discharge from under foreskin/bleeding
- Difficulty pulling back foreskin (may be normal in children)
- Odour
Investigation of balanitis
- Clinical presentation
- charcoal swab for microscopy if infection suspected (or first catch urine)
- biopsy if extensive skin change / scarring
May do blood tests if severe: Blood glucose??
Balanitis Tx
Core treatment:
- Saline washes
- Ensuring to clean properly under foreskin
- 1% hydrocortisone if more severe irritation - for a SHORT TIME
Depends on cause:
- Steroid cream
- Mild = dermatitis, circinate balanitis (reative arthritis)
- High potency = lichen sclerosus
- Antifungal cream
- topical CLOTRIMAZOLE
- Antibiotics
- oft oral FLUCLOX / clarithro (as staph and strep B are most common bacterial causes)
- Metronidazole if anaerobic bacteria
May remove foreskin if recurrent (or for lichen sclerosus)
Causes of balanitis
- not washing
- irritation from soaps/condoms
- DIABETES -> THRUSH
- STI including TRICHOMONAS VAGINALIS
Thrichomoniasis
STI caused by Trichomonas vaginalis (flagellate protozoa)
- in urethra (male/female) and vagina
Thrichomoniasis presentation
50% asymp
- Vaginal discharge (typical = frothy yellow green but can vary; may smell fishy)
- Itching
- Dysuria
- Dyspareunia (painful sex)
- Balanitis
Strawberry cervix from inflam + multiple tiny haemorrhaeges (on examinarion) AND ACIDIC pH
Trichomoniasis Dx
- CHARCOAL SWAB + MICROSCOPY
- ideally from POSTERIOR FORNIX (behind cervix) but self taken works too
- urethral swab or first-catch urine in men
Trichomoniasis Mx
- Refer to GUM
- CONTACT TRACING
- METRONIDAZOLE
Trochomoniasis complication
Increases risk of:
- Contracting HIV by damaging the vaginal mucosa
- Bacterial vaginosis
- Cervical cancer
- Pelvic inflammatory disease
- Pregnancy-related complications such as preterm delivery
Herpes simplex virus (HSV)
- HSV-1 = typically cold sores
- HSV-2 = typically genital herpes
Can also cause apthous ulcer, herpes keratitis (eye inflam), herpetic whitlow (painful lesion on fingers)
Both common in UK
Oft asymp - spread through mucous membranes/secretions
HSV goes dormant in the associated sensory nerve gangioln. Which are these usually?
- Trigeminal nerve ganglion - HSV1
- Sacral nerve ganglion - HSV2
Genital herpes Sx
Typically ~2weeks after contracting + lasting 3 weeks (most intense) - any proceeding reactivation usually milder/shorter
- Ulcers/blisters
- Neuropathic pain
- FLU-LIKE (fatigue, headache)
- DYSURIA
- INGUINAL LYMPHADENOPATHY
Genital herpes Dx
Contact trace (including ask about cold sores)
Clinical diagnosis
- Confirm with VIRAL PCR
Genital herpes Tx
- Refer to GUM
ACICLOVIR (regeime depends)
Additional measures, including to manage the symptoms include:
- Paracetamol
- Topical lidocaine 2% gel (e.g. Instillagel)
- Cleaning with warm salt water
- Topical vaseline
- Additional oral fluids
- Wear loose clothing
- Avoid intercourse with symptoms
Genital herpes complication
Vertical transmission via lesions during delivery of baby
- low risk if recurrent
- if primary give prophylactic ACICLOVIR even after initial course finished
- if contracted before 28 wks - might still consider vaginal delivery if asymp; after 28 wks do C-section
Chancroid
STI caused by FASTIDIOUS, GRAM -VE COCCOBACBILLI, Haemophilus ducreyi
Typically in resource-poor countries
OFT CO-FACTOR IN HIV transmission
Chancroid RFx
- Multiple sexual partners/contacts with sex workers
- Unprotected sex
- SUBSTANCE ABUSE (HIGH RISK BEHAVIOUR esp for things like crack cocaine)
- MALES
- Lack of circumcision
- Poor hygine
Chancroid Sx
- GENITAL PAPULES ( Early stage)
- GENITAL ULCERS (later)
- sharply defined, undermined, irregular border
- Lymphadenitis/buboes - usually UNILATERL (+ painful)
Typical STI Sx: discharge, pain
Sometimes rectal pain/bleeding +/- rectovaginal fistula
Chancroid Dx
- Clinical + charcoal swab -> MS+C
- Bloods - serology +/- antigen testing if available
- Ulcer biopsy
Rule out other STIs + TEST FOR HIV (serum ELISA)
Chancroid Tx
ANTIBIOTICS:
- Azithromycin or Ceftriaxone
- CIPROFLOXACIN or ERYTHROMYCIN if HIV +ve
- Don’t give Ciprofloxacin if PREG
Lymph node aspiration +/- incision + drainage (as needed)
Genital warts
Common STI caused by HPV (usually 6 + 11)
- Esp in 16 - 25 y/o
Genital warts RFx
- Intercourse from earlier age + more lifetime partner
- Immunocompromise
Genital warts Sx
Oft asymp
Usual stuff: itching, pain, bleeding
Can get haematuria/abnormal stream if inside urethra
Genital warts Dx
Clinical
Can biopsy if severe/not responding to treatment - check for dysplasia
ano/urethroscopy as required
Genital warts Tx
- Topical posophyllotoxin (SE: irritant) - not recommended if preg
- Cryotherapy, surgical excision, Tricholoro/bichloroacetic acid (high recurrance)
National Chlamydia Screening Programme
Tests every sexually active person under 25 y/o annually over with every new sexual partner
Re-test 3 months after treatment (if +ve) to ensure no re-infection
What is commonly tested at an STI screening
- Chlamydia + Gonorrhoea (NAAT (swab, urine or urethral) + charcoal for both)
- Syphilis (blood test)
- HIV (blood test)
- swabs from any ulcers
What types of tests are used for STI testing
- Charcoal swabs (in Amies transport medium) -> MS+C
- Nucleic Acid Amplification Test (NAAT)
- specifically for Chlamydia + Gonorrhoea (+ mycoplasma genitalium)
- endocervical swab is gold but can self-swab/first catch urine
Can also be an pharyngeal or rectal swab
Chlamydia Sx
Oft Asymp
Consider if sexually active +:
Female:
- Abnormal vaginal discharge
- Pelvic pain
- Abnormal vaginal bleeding (intermenstrual or postcoital)
- Painful sex (dyspareunia)
- Painful urination (dysuria)
Male:
- Urethral discharge or discomfort
- Painful urination (dysuria)
- Epididymo-orchitis
- Reactive arthritis
Chlamydia potential examination findings
- Pelvic or abdominal tenderness
- Cervical motion tenderness (cervical excitation)
- Inflamed cervix (cervicitis)
- Purulent discharge
Chlamydia Tx
Check local guidelines but:
doxycycline 100mg twice a day for 7 days - 1st
- DON’T USE IF PREG
Preg alts:
Azithromycin 1g stat then 500mg once a day for 2 days
Erythromycin 500mg four times daily for 7 days
Erythromycin 500mg twice daily for 14 days
Amoxicillin 500mg three times daily for 7 days
No sex; Contact tracing; STI screening; advice + safeguarding
Chlamydia complications:
Pelvic inflammatory disease
Chronic pelvic pain
Infertility
Ectopic pregnancy
Epididymo-orchitis
Conjunctivitis
Lymphogranuloma venereum
Reactive arthritis
In preg:
Preterm delivery
Premature rupture of membranes
Low birth weight
Postpartum endometritis
Neonatal infection (conjunctivitis and pneumonia)
Lymphogranuloma Venereum (LGV)
Affects lymphoid tissue around site of chlamydia infection - more common in MSM
Stages of Lymphogranuloma venereum (LGV)
- Primary: Painless ulcer (penis, vagina or rectum)
- Secondary: Lymphadenitis
- Tertiary: Proctitis. Proctocolitis -> Pain, chnage in bowel, tenesmus, discharge.
LGV Tx
Doxycycline 100mg twice daily for 21 days (1st)
Erythromycin, azithromycin and ofloxacin are alternatives
Order of swabbing for STIs
- NAAT first
- Charcoal swab
Double vs triple swabs for STI screening
- Double swabs: a NAAT swab (endocervical or vulvovaginal) and a high vaginal charcoal media swab.
- Triple swabs: a NAAT swab (endocervical or vulvovaginal), a high-vaginal charcoal media swab and an endocervical charcoal media swab.
Which group has highest incidence of STIs
MSM
Gonorrhoea pathophys
- Gram -VE Nisseria gonorrhoeae DIPLOCOCCI (2nd mc in UK)
- Transmitted VIA MUCOUS SECRETIONS - oft through unprotected sex OR vertically during birth
- Frequently found in throat
- doesn’t necessarily have to be through direct innoculation - Strong affinity for mucous membranes
- uterus, urethra, cervix, fallopian tubes, ovaries, testicles, rectum, throat, sometimes eyes
STI RFx
- Aged <25 YEARS
- MSM
- Living in high density urban areas
- MULTIPLE SEXUAL PARTNERS
- Previous/current STI
Gonorrhoea Px
More likely to have Sx than chlamydia - more so in MEN:
- Odourless, purulent discharge - possibly green or yellow, oft thin + watery
- occasionally easily induced cervical bleeding e.g. post-coital - Dysuria; Dyspareunia
- Pelvic pain (Female)
- Testicular pain / swelling (epididymo-orchitis)
Congunctivitis -> ERYTHEMA + purulent discharge
REctal infection + Pharyneal infection oft asymp
- rectal discomfort + discharge
- sore throat
- Sometimes prostatitis
Gonorrhoea Ix
- Nucleic Acid Amplification Test (NAAT)
- Endocervical/Vaginal
- First pass urine - Charcoal bacterial swab -> MS+C
- Endocervical / urethral
- Urethral/meatal swab
Gonorrhoea Mx
-
IM CEFTRIAXONE 1g - if sensitivites not known
- 500mg ORAL CIPRO - if sensitivites known - Screening
- CONTACT TRACING
- Encourage safe sex + abstain from sex
- Finish antibiotics - Advice
- Safeguarding in young people
Complications of gonorrhoea
- PELVIC INFLAM DISEASE
- chronic pain, INFERTILITY + ectopic preg - Epididymo-orchitis / Prostatitis (rarely causes infertility)
- CONJUNCTIVITIS
- esp in vertical transmission to baby -> Associated with SEPSIS - Urethral strictures
- DISSEMINATED GONOCOCCAL INFECTION (septic)
- Skin lesions
- SEPTIC ARTHRITIS
- Endocarditis
- Fitz-Hugh-Curtis syndrome
Disseminated Gonococcal Infection
- Non-specific SKIN LESIONS
- PolyARTHRALGIA / Migratory Polyarthritis
- Tenosynovitis
- SYSTEMIC - Fever, fatigue etc (septic)
Fitz-Hugh-Curtis syndrome
Complication of PID
- Inflam + infection of LIVER CAPSULE
-> ADHESIONS between liver + peritoneum
-> RUQ pain (referred to shoulder)
-> Tx with laproscopy + adhesiolysis
Bacteria can spread from pelvis via peritoneal cavity, lymph or blood
Syphilis pathophys
Transmitted by SPIROCHETE, Gram -VE Treponema pallidum subspecias pallidum
- it is MOTILE + can enter through broken skin / intact mucus membrane
- Bacteria divide + Chancre (hard ulcer) forms at site after 2-3 wks (incubation period)
- Primary syphilis
- Can progress into oblitering arteritis (endothelial proliferation -> lumen narrowing) -> multi-system ischaemia + Sx
Via blood, bodily fluids + vertically (through placenta)
Syphilis RFx
- Unprotected sex
- Multiple sexual partners
- MSM
- HIV infection
Stages of Syphilis
- Primary (on average within 21 days of infection: 9-90 days)
- CHANCRE - Secondary syphilis (Usually after 3 months /4-10 wks)
- After 3-12 weeks of 2ndry -> LATENT SYPHILIS
- After ~2 years = LATE LATENT
- TERTIARY (no longer infectious - many years later)
- Gummatous syphilis
- Neurosyphilis
- Cardiosyphilis
Secondary Syphilis Px
- Non-painful/-itchy SKIN RASH
- Typically on hands + feet
- FEVER, MALAISE, Arthralgia, HEadaches
- Weight loss; Painless LYMPHADENOPATHY
- CONDYLOMATA LATA (plaque-like warts in moist areas e.g. axilla, inner thighs, anogenital)
- Silvery grey lesions on mucosa
- Can start getting neuro, eye + liver Sx (or really any type infection)
- Alopecia (moth eaten appearance)
Basically just systemic infection
Gummatous syphilis
Granulomas in BONE, SKIN, MUCOSA of URT, mouth + viscera / connective tissue
Neurosyphilis
- Tabes dorsalis
– ataxia, numb legs, absence of deep tendon reflexes, lightning pains, loss of pain and temperature sensation, skin and joint damage. - Dementia
– PROGRESSIVE cognitive impairment, mood alterations, psychosis. - Meningovascular complications
– cranial nerve palsies, stroke, cerebral gummas. - Argyll Robertson pupil
– constricted and unreactive to light, but reacts to accommodation
Syphilis Examination
- Genitals
- Skin + mucosa
- Neuro
- MSK (esp in congenital)
- Cardio (for signs of AORTIC REGURG)
- Neuro
Syphilis Ix
- Treponema pallidum PCR
- Syphilis point of care test
- DARK FILED/GROUND MICROSCOPY of chancre fluid (move v quick)
- Serology:
- Treponemal tests (tho might not be indicative of syphilis)
- Treponemal ELISA (IgG/IgM - always +ve after infection)
- TPPA (+ve for life)
- Non-treponemal (non-specific; in titres)
- detect autoantibodies -> RPR / VDRL
- high in early disease, falls = Tx success OR progression to LATE
- False +ve in inflam / preg - Lumbar puncture in neurosyphilis
Syphilis Mx
BENZATHINE PENICILLIN 2.4 MU IM - in buttocks
- Early = 1 INJECTION
- Late infection = 3 INJECTIONS (once weekly)
Alt = DOXYCYCLINE 100mg Bidaily (can’t use in preg)
- Early = 14 days
- Late = 28 DAYS
Ceftriaxone can also work
Need more later on to cover slow growing, late latent treponema
+ just general STI stuff e.g. contact tracing, screening, follow-up, education
Jarisch Herxheimer reaction
Inflam response 2ndry to DEATH OF TREPONEMES
- Flu like illness WITHIN 24hrs of Tx
- Only supportive UNLESS cardio / neurosyphilis -> give ORAL STEROIDS before Abx
When is syphilis followed up
RPR/VDRL bloods at 3, 6 + 12 months
Signs of congenital syphilis
Early:
- ## haemorrhagic rhinitis
Late (at least 2 yrs after birth):
- Interstitial keratitis
- Cluttons joint
- Hutchinson’s incisors
- Mulberry molars
- High arched palat
- Rhagades (peri-oral fissures)
- Sensorineural deafness
- Saddle nose
- Cranial frontal bossing
Other forms of Treponemal infections
- Yaws (bones + joint)
- PInata (skin)
- Bejel (chronic skin + tissue)
Commonly seen in older people with dementia: Trep Ab +ve, RPR negative
- (symptomatic tertiary syphilis usually RPR +ve)
Tx to cover late latent syphilis just incase
HSV transmission
- Direct via mucosa / skin breaks
- Higher risk of transmission if visible lesions
- 80% UNAWARE
- Asymp viral shedding MORE FREQUENT (more common in genital HSV-2 + esp in first 12 months + in peri-flare periods)
More common in younger people due to not having had previous exposure
Sx can RECCUR
HSV stages / natural progression
- 1st infection then LETENT in ANTERIOR HORN CELL in local sensory ganglion
- REactivation: can be symp lesions or asymp but INFECTIOUS + shedding
- After 1st Sx episode usually get it ~4 times in a year but the longer you have -> fewer recurrences
HSV Px
- Painful ulcer
- Dysuria
- Vaginal/urethral discharge
- Systemic Sx (fever, myalgia)
- Blistering
- Tender lymphadenopathy
HSV Dx
- NAAT HSV DNA (high specific + sensitive)
- can differentiate HSV-1 and HSV-2 - Viral culture (specific but sensitivity declines as lesions heal)
- Type-specific SEROLOGY
- useful in preg: can check if they have Ab in blood = she was already infected so she will pass immunity to child so don’t have to do c-section - Antigen detection (to check response to antiviral)
- Cytological examination
HSV Tx
General:
- Saline bathing
- Analgesia
- Topical anaesthetic
Antiviral:
- Aciclovir (44mg TDS or 200mg 5 daily)
- Valaciclovie
Genital HSV complications
- Hospitalisation for URINARY RETENTION
- Consider SUPRAPUBIC if catheterisation but avoid altogether if possible - ASEPTIC MENINGISM
- Severe constitutional Sx
- Super-infection
- Autoinoculation
- Neonatal HSV if during 3rd trimester
HSV prevention
- Safe sex
- Anti-viral prophylaxis SOMETIMES (can still pass on to other even with this)
- given for preg, frequent shedders etc - SCREEN for STIs
RFx for developing thrush/candidiasis
- Increased oestrogen (e.g. in preg)
- Poorly controlled diabetes
- Immunosuppression
- Broad-spec Abx
The candida (usually albiacans) can already be colonising vagina and just not presenting
Candidiasis Px
- Thick, white discharge that does not typically smell
- Vulval and vaginal ITCHING, Irritation or discomfort
More severe:
- Erythema
- Fissures
- Oedema
- Dyspareunia
- Dysuria
- Excoriation (skin wears off)
Candidiasis Ix
- Vaginal pH (swab + pH paper) to differentiate
- bacterial vaginosis + trichomoniasis = pH >4.5
- Candidiasis = pH <4.5 - CHARCOAL swab + Microscopy (confirms)
Start giving Tx based on clinical Px tho
Candidiasis Tx
- Intravaginal antifungal cream - CLOTRIMAZOLE
- Single dose of 5g of 10% cream at night - Antifungal pessary - CLOTRIMAZOLE
- can do 500mg for 1 night OR 200mg each for 3 nights - Oral antifungal - FLUCONAZOLE
- typically only need 1 dose of 150mg
Options include Canesten Duo - OVER-THE-COUNTER
- includes 1 fluconazole tablet + clotrimazole cream for external vulva Sx
If recurrent (>4 / year) -> treat with induction + mainteneance over 6 months (oral or vaginal)
What is one side effect of antifungal creams/pessaries
Can damage latex + prevent spermicides from working so need alt contreception
HIV epid
- HIV-1 most common
- HIV-2 more common in WEST AFRICA
Seroconversion meaning
The transition from the point of viral infection to when the antibodies are made
- e.g. this the time period when the initial HIV infection presents with flu-like Sx
Transmission of HIV
- Unprotected sex (more likely to infect in MSM?)
- Vertical transmission (pregnancy, birth, breastfeeding)
- Mucous membrane, blood / open wound exposure to infected BLOOD / Bodily fluids
HIV screening
Routinely offered at sexual health, antenal and substance misuse services
- Need to get verbal consent to test tho
The lab test checks for HIV antibodies AND the p24 antigen
- window period of 45 days = can take up to 45 days for test to turn positive
POC test - only checks Ab
- 90 day window period
Can get home kits if think at risk
- Self-sample (lab)
- PoC test
AIDS-defining illnesses
Only occur in end-stage HIV infection when CD4 count has dropped (usually < 200)
- Kaposi’s sarcoma
- PNEUMOCYSTIS JIROVECII PENUMONIA (PCP)
- CYTOMEGALOVIRUS
- OESOPHAGEAL / BRONCHIAL Candidiasis
- Lymphomas
- TUBERCULOSIS
How is HIV monitored
- CD4 count
- norm = 500 - 1200 cells/mm3
- < 200 cells/mm3 = high risk of opportunistic infection - HIV RNA -> VIRAL LOAD
- undetectable if well treated
HIV Mx
Managed at specialist centres
Antiretroviral therapy (ART)
- can do Genotypical resistance testing to establish how resistant the HIV strain is to the diff antiretrovirals to guide Tx
Diff classes:
- Protease Inhib
- Integrase Inhib
- Nucleoside reverse transcriptase Inhib
- Non-nucleoside reverse transcriptase inhib
- Entry inhib
Usually starting regime = 2 NRTIs (e.g. Tenofovir + Emtricitabine) + a 3rd agent (e.g. Bictegravir)
- Prophylactic Co-trimoxazole if CD4 count < 200
- close CVD risk monitoring (as higher risk because of the HIV)
- YEARLY PAP smear
- Vaccinate (including PCP) but avoide live vaccines
How to prevent HIV transmission during birth
- Viral load < 50 copies/ml = normal delivery is fine
- > 50 = CONSIDER Pre-labour C-section
- > 400 = PRE- LABOUR C-SECTION
- If unknown OR >1000 = IV ZIDOVUDINE during labour
Consider prophyl for babies:
- Low risk (mum’s viral load <50) = ZIDOVUDINE for 2-4 wks
- High risk = ZIDOVUDINE, LAMIVUDINE and NEVIRAPINE for 4 WEEKS
Avoid breastfeeding afterwards!
Post-exposure prophylaxis (PEP) for HIV
- must be started within LESS thhan 72 HOURS after exposure (sooner the better)
- not 100% effective - ART combination = Emticitabine/tenofovir (Truvada) + raltegravir (for 28 DAYS)
NB can also take Emitricitabine/tenofovir before potential exposure
Risk factors for urinary incontinence
- Increasing age
- Previous preg / child birth
- High BMI
- Hysterectomy
- FHx
Classification of urinary incontinence
- Urge incontinence / overactive bladder
- caused by detrusor overactivity
- urge is quickly followed by uncontrollabe leakage
- stress incontinence
- leaking small amounts when coughing / laughing
- mixed incontinence
- overflow incontinence
- due to bledder outlet obstruction (e.g. enlarged prostate)
- Functional incontinence
- Patient can’t get to bathroom in time due to co-morbs
- e.g. dementia, sedation, injury/illness -> decreased ambulation
- Patient can’t get to bathroom in time due to co-morbs
Initial Ix for urinary incontinence
- MINIMUM 3 DAYS of bladder diary
- Vaginal exam to exclude pelvic organ prolapse + check ability to initiate colutary contraction of pelvic floor muscles
- Urine dipstick + cultures (to exclude infection)
- Urodynamic studies
Urge incontinence Mx
- Bladder retraining (for at least 6 weeks)
- Bladder stabilising drugs
- 1st line = antimuscarinics
- Oxybutynin (immediate release) (avoid immediate release in frail older women)
- Tolterodine (immediate release)
- Darifenacin (OD)
- Mirabegron (beta-3 agonist) - if worried about anti-muscarinic SE esp in frail older patients
- 1st line = antimuscarinics
- Surgical/invasive
- botulinum toxin (risk of subsequent overflow incontinence)
- Sacral nerve stimulation
Stress incontinence Mx
- PELVIC FLOOR MUSCLE TRAINING
- 8 contractions TDS, for minimum 3 months
- consider electrical stimulation
- Vaginal cones
- Duloxetine - the SNRI (can increase muscle tone of striated muscle in external urethral sphincter by increasing the synaptic concentration of noradrenaline and serotonin in the PUDENDAL NERVE)
- Surgical
- Colposuspension (lifting and fixing neck of bladder)
- Sling surgery (placed around neck of bladder) - usually autologous tissue
- Urethral bulking agenst
- Artificial urinary sphincter
