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
What is the perimenopause?
Period leading up to menopause
Characterised by irregular periods and symptoms eg hot flushes, mood swings, urogenital atrophy
Decreased oestrogen levels
What are the central effects of decreased oestrogen during the perimenopause?
Vasomotor symptoms - hot flushes, sweats
MSK symptoms - joint and muscle pain
Low mood and sexual difficulties - low sexual desire
What are the local effects of decreased oestrogen during the perimenopause?
Urogenital symptoms - vaginal dryness due to vaginal atrophy
What are the short term impacts of the menopause?
Vasomotor symptoms
- Experienced by 60-80% women
- Last on average 2-7 years
- Impact on sleep, mood, and QoL
General symptoms
- Mood change/irritability
- Loss of memory/concentration
- Headaches, dry and itchy skin, joint pains
- Loss of confidence, lack of energy
What are the medium term impacts of the menopause?
Urogenital atrophy
- Dypareunia
- Recurrent UTIs
- PMB
- Peak incidence of urinary incontinence and prolapse in 55-65
What are the long term impacts of the menopause?
Osteoporosis
Cardiovascular disease- adverse changes in lipid
Dementia - increased prevalence with early menopause
Risk reduction strategies start at time of menopause
How can you manage menopausal symptoms?
Holistic approach
Lifestyle advice
Reduce modifiable risk factors
Inform about options
- Hormonal - HRT, vaginal oestrogens
- Non-hormonal eg clonidine
Non-pharmaceutical eg CBT
What are the benefits of HRT?
Relief of menopause symptoms
Bone mineral density protection
Possibly prevent long term morbidity
What are the risks of HRT?
Breast cancer
VTE
CVS disease
Stroke
What is the breast cancer risk with HRT?
HRT with oestrogen alone - little or no change in risk
HRT with oestrogen + progesterone - increased risk
Increased risk related to treatment duration and reduces after stopping HRT
What is the risk of VTE with HRT?
Risk increased by oral HRT
Oral > transdermal
Transdermal = baseline population
Transdermal - BMI > 30 or increased risk of VTE
High risk women eg strong FH or thrombophilia refer to haematology for assessment before starting HRT
What is the risk of CVD with HRT?
HRT doesn’t increased CVS risk when started in women < 60
Baseline risk of CVD varies according to existing risk factors
Presence of CVS risk factors not CI to HRT as long as optimally managed
What is the risk of stroke with HRT?
Baseline population risk of stroke 11.3 per 1000 over 7.5 years
Oral (not transdermal) increases this risk slightly
What dose of oestrogen should you give for HRT?
Aim for lowest effective dose
Who should have transdermal HRT?
Gastric upset eg Crohn’s
Need for steady absorption eg migraine/epilepsy
Percieved increased risk of VTE
Older women - higher risk of HRT
Medical conditions eg hypertension
Patient choice
What is premature ovarian insufficiency?
Menopause < 40 years
What can cause premature ovarian insufficiency?
Majority of causes - idiopathic
Natural causes
- Chromosome abnormalities
- FSH receptor gene polymorphisms
- Inhibin B mutations
- Enzyme deficiencies
- Autoimmune disease
Iatrogenic
- Surgery
- Chemotherapy
- Radiotherapy
How is premature ovarian insufficiency diagnosed?
FSH > 25 - 2 samples > 4 weeks apart + 4 months amenorrhoea
How is premature ovarian insufficiency treated?
Encouraged to use HRT at least until average age of menopause
What happens with conception and the menopause?
Fertile for 2 years if menopause < 50
Fertile for 1 year if menopause > 50
How do you assess someone’s need for HRT?
Assess severity of symptoms
Risk factors for osteoporosis
What are the CI to starting HRT?
Undiagnosed abnormal PV bleeding, breast lump, active liver disease
What are the cautions with HRT treatment?
Fibroids, uncontrolled BP, migraine, epilepsy, endometriosis, VTE family history
Caution in starting HRT in over 60s
What are the most common gynaecological cancers?
Uterus and ovary
How common is endometrial cancer?
Incidence - 9000 cased UK/year and rising
What can increase your risk of endometrial cancer?
Obesity
T2DM
Nulliparity
Late menopause
Ovarian tumours
Oestrogen only HRT
Pelvis irradiation
Tamoxifen
PCOS
What signs might you get of endometrial cancer?
Post-menopausal bleeding
What investigations can you do for endometrial cancer?
Transvaginal USS
Endometrial biopsy
Hysteroscopy
What type of cancer is endometrial cancer?
Adenocarcinoma
What is the staging for endometrial cancer?
FIGO I/II/III/IV
What is the treatment for endometrial cancer?
Surgery - hysterectomy, bilateral salpingo-oophorectomy +/- pelvic lymph nodes
Radiotherapy
Progesterones
What is the prognosis of stage 1 endometrial cancer?
5 year survival for stage 1 disease > 90%
What can cause endometrial cancer?
HPV
How common is HPV?
75% population affected by HPV at some point if life pre-vaccination
Why does HPV cause endometrial cancer?
Regions E6 and 7 of HPV genome cause growth stimulation
Persistent HPV infection associated with increased risk of high grade cervical intraepithelial neoplasia
How common is cervical cancer?
Incidence highest in 30-34 years
Highest rates in areas of high deprivation
Majority diagnosed at stage 1
What cell type is cervical cancer?
Squamous (90%)/adenocarcinoma
What is the cervical cancer staging?
FIGO I/II/III/IV
What is the prognosis for stage 1 cervical cancer?
Stage I > 90% 5 year survival
How is cervical cancer treated?
Stage 1 treatment - surgery
Stages 2+ treatment
- Radiotherapy
- Chemotherapy
- Palliative care
How common is vulval cancer?
Uncommon, 20th most common cancer in women
What can cause vulval cancer?
HPV/lichen sclerosis
What cell type is vulval cancer?
Squamous (90%)
What are the symptoms of vulval cancer?
Vulval itching
Vulval soreness
Persistent lump
Bleeding
Pain on passing urine
Past history of VIN/lichen sclerosis
What are the stages of vulval cancer?
I < 2cm (79% 5 yr survival)
II > 2cm (59% 5 yr survival)
III adjacent organs/unilateral nodes (43% 5 yr survival)
IV bilateral nodes/distant mets (13% 5 yr survival)
What is the treatment for vulval cancer?
Surgery - conservative
Surgery - radical
Radiotherapy +/- chemo
How does ovarian cancer present?
Bloating/IBS like symptoms
Abdominal pain/discomfort
Change in bowel habit
Urinary frequency
Bowel obstruction
No symptoms at all
How common is ovarian cancer?
> 7000 cases UK/year
Highest in 75-79 years
6/10 women present with advanced disease
What can cause ovarian cancer?
Ovulation - menarche, menopause, parity, breast feeding, OCP, hysterectomy, ovulation induction
Gene mutation - BRCA1/2
What is the prognosis of stage 3 ovarian cancer?
Stage 3 disease up to 40% 5 yr survival
What cell type is ovarian cancer?
Epithelial 85% - includes fallopian tube and primary peritoneal cancers
What investigations should you do for ovarian cancer?
Symptoms and age
CA125
USS
CT
Image guided biopsy
What is the management for ovarian cancer?
Surgery
Chemotherapy
What is endometriosis?
Presence of endometrial tissue outside the endometrial cavity
Chronic condition
High risk of recurrence
Impact on fertility
Impact on quality of life
What are the symptoms of endometriosis?
Cyclic pain
Dysmenorrhoea
Dyspareunia
Young
Low parity
How can you treat endometriosis?
Abolish cyclicity
- OCP
- GnRH agonists
Glandular atrophy
- Oral progestagens
- Depot provera
- Mirena
How do GnRH agonists work?
Inhibit stimulation of pituitary release of gonadotrophins - increased FSH and LH
Followed by down regulation - decreased FSH and LH
What are the risks of GnRH agonists?
Prolonged treatment may be necessary
HRT - add back therapy
How can you treat endometriosis with surgery?
Ablation - maintains fertility
Excision - maintains fertility
Oophorectomy - if fertility no longer desired
Pelvic clearance - if fertility no longer desired
How can endometriosis cause infertility?
Immune factors
Oocyte toxicity
Adhesion
Tubal dysfunction
Ovarian dysfunction
How common are endometrial polyps?
15% malignant in post-menopausal women
What are raised nitrites in an MSU an indication of?
Infection
What are raised leukocyte esterases in an MSU an indication of?
Infection
What is microscopic haematuria in an MSU an indication of?
Glomerulonephritis
Nephropathy
Neoplasia
Calculus
Infection
What is proteinuria in an MSU an indication of?
Renal disease
Cardiac disease
What is glucosuria in an MSU an indication of?
Diabetes
IGT
Nephropathy
Reduced renal threshold
What can a frequency volume chart also be used for?
Bladder drill/bladder training
What is the lower end of normal for the amount of voided urine?
400ml
What is urodynamics and what is it used for?
Measuring intravesical (bladder) and intraabdominal pressures
Helps to determine type of incontinence
Can work out detrusor pressure
What determines bladder pressure?
Detrusor pressure and abdominal pressure
What is a cystogram?
Visualising continence
Helps diagnose stress incontinence
Why can spinal cord damage cause incontinence?
T11 and 12 control over bladder reflex lost
How does botox treat incontinence?
Over active bladder
Neurotoxin
Blocks acetylcholine release - prevents muscle contraction
Where is the uterus in a 1st degree prolapse?
Uterus in upper half of vagina
Where is the uterus in a 2nd degree prolapse?
Uterus nearly descended into opening of vagina
Where is the uterus in a 3rd degree prolapse?
Uterus prolapsed out of vagina
Where is the uterus in a 4th degree prolapse?
Completely out of vagina
What are the 2 layers of the pelvic floor?
Levator ani - anterior muscles
Coccygeus - posterior muscles
What are the 3 levator ani muscles?
Pubococcygeus
Iliococcygeus
Puborectalis - forms a sling around rectum
What is the nerve innervation of coccygeus?
S2-3
What is the role of coccygeus?
Resists intraabdominal pressure
Name 4 risk factors for getting a pelvic prolapse
Obesity
Previous pelvic surgery
Chronic constipation
Vaginal or instrumental births
Multiple pregnancies
Larger babies
Post-menopausal
Hysterectomy
Genetics - weak connective tissues
What is a threatened miscarriage?
Associated with vaginal bleeding with/without abdo pain