Gynaecology Flashcards
How common are pelvic floor disorders?
20% adult women experience regular incontinence
10% will have surgery for prolapse
< 10% anal incontinence
Increase with age, parity, obesity, smoking
What should you also consider with pelvic floor disorders?
Sexual dysfunction linked to lower urinary tract, vaginal and bowel
Can’t be considered in isolation
What is incontinence?
Involuntary leakage of urine
Social or hygiene problems
Can be objectively demonstrable
What happens with an overactive bladder/detrusor overactivity?
Involuntary bladder contractions
What are the symptoms of overactive bladder?
Urgency and urgency incontinence
Frequency
Nocturia
Nocturnal enuresis
‘Key in door’
Sound of running water
Intercourse
What happens with stress urinary incontinence?
Sphincter weakness
What are the symptoms of stress incontinence?
Involuntary leaking due to anything that increases intraabdominal pressure as sphincter not working properly
Cough
Laugh
Lifting
Exercise
Movement
Walking/running downhill
Intercourse
Stumble/choking/vomiting
Name 3 different types of incontience
Sphincter weakness - stress incontinence
Detrusor overactivity - overactive bladder
Mixed
Fistula
Neurological and functional eg dementia - can cause reflux into kidneys as bladder pressure so high
Overflow and retention
What assessments can you do for incontinence?
Urinalysis - MSU
Frequency and volume chart
Residual urine measurement
Questionnaire - ePAQ
What is recorded on a frequency volume chart?
Bladder diary
- Voided volume
- Frequency of urination
- Quantity and frequency of leakage
- Fluid intake
Diurnal variation
Initial assessment and clinical diagnosis
Planning treatment
Adjunct to cystometry
How is residual urine measurement done?
In and out catheter - CISC
- Post-surgical voiding dysfunction
- Post-natal retention
- Neuropath
Indwelling - suprapubic/urethral
USS
What are the different sections of the ePAQ questionnaire?
Urinary
- Pain
- Voiding
- Overactive bladder
- Stress incontinence
- QoL
Vaginal
- Pain
- Capacity
- Prolapse
- QoL
Bowel
- IBS
- Constipation
- Evacuation
- Continence
- QoL
Sexual
- Urinary
- Bowel
- Dyspareunia
- Overall sex life
What lifestyle adaptations can help with incontinence?
Weight loss including bariatric surgery
Smoking cessation - smoking damages collagens of pelvic organs, chronic cough
Reduced caffeine intake - stimulant
Avoidance of straining and constipation
How can you manage incontinence via containment?
Bladder bypass (catheters) - indwelling, clean intermittent self-catheterisation (CISC)
Leakage barriers (pads/pants)
Vaginal support (pessaries)
Skin care (barrier creams) to protect skin
HRT (vaginal oestrogen)
- Oestrogen and progesterone receptors - bladder dome, trigone, urethra, bladder neck, vagina, vesico-vaginal fascia
- Local vaginal oestrogen less frequency, urgency and incontinence
- Very little gets absorbed into system, fewer s/e
- Topical oestrogen
Lifestyle adaptation
How can you manage incontinence with treatment?
Overactive bladder
- Bladder drill
- Drugs (anti-cholinergic)
- Botox
- Augment
- Bypass
Stress incontinence
- Conservative (physio and lifestyle adaptation)
- Surgery (sling, suspension)
Reassurance, support, lifestyle adaptation, containment
What is the detrusor muscle?
Smooth muscle, transitional epithelium, normally contracts only during micturition
What innervates the detrusor muscle?
Sacral parasympathetic (S2-4) - reflex
Neurotransmitter - Ach
Receptors - muscarinic M2 and 3
T11 and 12 maintain relaxation of bladder for urine storage, reflex bladder contractions suppressed, brain will remove inhibition when goes to toilet
Name an Ach antagonist
Atropine
What are the S/E of atropine?
CNS - cognitive impairment
Constipation
Dry mouth
Blurred vision
Tachycardia
What are anticholinergics?
Atropine like agents M2 and 3 receptor antagonists
Antimuscarinic
Name an anti-cholinergic drug and it’s dose
Oxybutynin 2.5-5mg BD-TDS
PRN as effective, less S/E
What are the S/E of oxybutynin?
Dry mouth, blurred vision, drowsiness, constipation
Can’t see, can’t pee, can’t spit, can’t shit
What is the success rate of treatment with anti-cholinergics?
7% cured in one year
Large placebo effect
Name 2 other anti-cholinergics
Tolterodine
Propiverine
Trospium - doesn’t cross BBB so lower risk for CNS s/e - consider in older patients
Solifenacin
What is mirabegron?
Beta-3 adrenergic receptor agonist
Relaxes smooth muscle detrusor
Increased bladder capacity
How is stress incontinence treated?
Emphasis on conservative treatment before surgery
Self-help and lifestyle adaptation
- Weight, smoking, oestrogen
Physio, pelvic floor exercises, biofeedback, electrical stimulation, vaginal cones
Surgery
- Colposuspension, sling
- May be unsuitable due to medical conditions, mild/intermittent symptoms, personal circumstances
What are the principles of surgery for stress incontinence?
Restore pressure transmission to urethra
Support/elevate urethra
Increase urethral resistance
What history might you get for someone with uretero-vaginal prolapse?
Something coming down lump, discomfort, pelvic floor and sexual dysfunction
How would you examine someone with suspected uretero-vaginal prolapse?
Bimanual and sims speculum
What investigations should you do for uretero-vaginal prolapse?
Usually none
What is the treatment for uretero-vaginal prolapse?
Reassurance and advice, treat pelvic floor symptoms, pessary (holds vagina in place, can insert themselves), surgery
When do you repair a uretero-vaginal prolapse?
Symptomatic - dyspareunia, discomfort, obstruction, bothersome
Severe - outside vagina, ulcerated, failed conservative measures
How does an ovarian cyst present?
Presents with pain in the quadrant that the cyst is
What investigations should you do when someone presents with pain that could be an ovarian cyst?
Pregnancy test
Bloods
If in L lower quadrant then USS for appendicitis
Why do ovarian cysts cause pain?
○ Haemorrhage into cyst with sudden increase in size and/or rupture into peritoneal cavity with spillage of blood
If twists blood supply reduced, can be intermittent initially as it untwists, can stop hurting if necrotic
What are the treatment options for ovarian cysts?
Remove ovary - reduced fertility, may subsequently have cyst on other ovary
Remove cyst - spillage of dermoid contents may cause chemical peritonitis or at least untwist it with view to later surgery
Do nothing for now - pain unresolved, risk of torted ovary becoming necrotic and dying
What surgery can be done for ovarian cysts?
Laparotomy - cystectomy most easily achieved successfully, more pain, prolonged hospital stay, longer recovery, more wound infections, greater risk of thrombosis
Laparoscopy - less painful, shorter hospital stay, more difficult to shell out cyst and conserve ovarian tissue, longer procedure, increased risk of damage to major blood vessels and bowel
How common are miscarriages?
Occurs in 20% pregnancies
When is a miscarriage inevitable?
Once cervical os open enough to admit a finger
How can you diagnose a delayed miscarriage?
Ultrasound scan, empty gestation sac seen or foetal pole with no heart beat
How many early pregnancies complicated by vaginal bleeding will remain viable?
Approximately 60%
What management should you do when miscarriage incomplete and not associated with heavy bleeding or at early gestation < 8 weeks?
Expectant management
What is surgical treatment of miscarriage associated risks?
Uterine perforation
How quickly can medical management of delayed miscarriage be complete?
24 hours
Depends upon size on scan if > 12 weeks size
How common are ectopic pregnancies?
Approx 1% pregnancies
What is the most common site of an ectopic pregnancy?
Fallopian tube most common site (85-90%) of which cornual (interstitial) are 10% then ovary, cervix, and abdomen
When should you consider an ectopic pregnancy?
When empty uterus found on USS in patient with positive pregnancy test
What is the risk of a ruptured ectopic pregnancy?
Death
What is the maternal mortality rate with ectopic pregnancies?
Maternal mortality rate 10.12 per 100,000
How can ectopic pregnancies be treated?
Fallopian tube doesn’t need to be removed to remove ectopic pregnancy - salpingotomy - open fallopian tube and remove ectopic pregnancy, risk of incomplete removal so monitor hCG levels
Can treat medically using methotrexate
- Beta hCG level criteria (< 3000)
- Satisfactory LFTs and U&Es
- Needs to attend hospital for regular monitoring in pregnancy resolved
How common is vomiting in early pregnancy?
80%
What is hyperemesis gravidarum?
Excessive vomiting associated with dehydration and ketosis
In whom is hyperemesis gravidarum most common in?
Women with high beta hCG levels - such as twin pregnancies
How is hyperemesis gravidarum treated?
Rehydrate IV fluids
Vitamin supplements
NBM until oral fluids tolerated
Small, frequent meals recommended once easting recommenced
Anti-emetics
What is the menopause?
Cessation of menstruation
Average age 51
Diagnosed at 12 month of amenorrhoea
Onset of symptoms if hysterectomy