Gynaecology Flashcards
What is amenorrhoea
Absence of menstrual periods
What are the 2 types of amenorrhoea
Primary
Secondary
What is primary amenorrhoea
Failure to start having periods
- In presence of secondary sexual characteristics by 16+
- In absence of secondary sexual characteristics at 14-16
What is secondary amenorrhoea
Cessation of periods for over 6 months
After pregnancy has been excluded
What is oligomenorrhoea
Irregular periods
Menstrual cycle >35 days
<9 periods per year
What are the 4 groups of hypothalamic causes for amenorrhoea
- Reduced secretion of GnRH
- Functional disorders
- Severe chronic conditions
- Kallmann syndrome
Why is reduced secretion of GnRH a hypothalamic cause of amenorrhoea
Decreased pulsatile release of LH and FSH from anterior pituitary
Causes anovulation
What are the functional disorders that are hypothalamic causes of amenorrhoea
High levels of exercise
Eating disorders
Suppression of GnRH (due to ghrelin and leptin levels)
What are the severe chronic conditions that are hypothalamic causes of amenorrhoea
Psychiatric disorders
Thyroid disease
Sarcoidosis
What is Kallmann syndrome and how is it a hypothalamic cause of amenorrhoea
X-linked recessive disorder
Failure of migration of GnRH cells
What are the 5 pituitary causes of amenorrhoea
- Prolactinomas
- Other pituitary disorders
- Sheehan’s syndrome
- Destruction of pituitary gland
- Post-contraception amenorrhoea
What is a prolactinoma and how is it a pituitary cause of amenorrhoea
Pituitary tumour
Secretes high levels of prolactin (suppressing GnRH release)
Causes anovulation, amenorrhoea, and galactorrhoea
How do non-prolactinoma tumours of the pituitary cause amenorrhoea
Get gonadotropin deficiency from mass effect of tumour
What is Sheehan’s syndrome and how is it a pituitary cause of amenorrhoea
Post-partum pituitary necrosis
Due to massive obstetric haemorrhage
Get varying degrees of anterior pituitary hormone deficiency
What are the causes of pituitary gland destruction that can cause amenorrhoea
Radiation
Autoimmune disease
What is post-contraception amenorrhoea and how is it a pituitary cause of amenorrhoea
Due to prolonged use of contraceptives
Get downregulation of pituitary gland
Mostly seen in depo-provera (can take 18 months for periods to return)
What are the 3 ovarian causes of amenorrhoea
PCOS
Turner’s syndrome
Premature ovarian failure
How is PCOS an ovarian cause of amenorrhoea
Usually more associated with oligomenorrhoea
High androgen levels
Also get hirsutism, acne, and weight gain
What is Turner’s syndrome and how is it an ovarian cause of amenorrhoea
45 XO
Get amenorrhoea, but have secondary sexual characteristics
Almost universal infertility
Associated with short stature, webbed neck, aortic coarctation
What is primary ovarian failure and how is it a cause of amenorrhoea
Premature ovarian insufficiency before age 40
Get menopause symptoms
Have low oestrogen, high FSH
What is the adrenal gland cause of amenorrhoea
Late onset/mild congenital adrenal hyperplasia
What is late onset/mild congenital adrenal hyperplasia and how is it a cause of amenorrhoea
Partial deficiency of 21 hydroxylase (needed for cortisol and aldosterone production)
Presentation: early development of pubic hair, irregular/absent periods, hirsutism, acne
Have high levels of 17-hydroxyprogesterone in blood
What are the genital tract abnormalities that can cause amenorrhoea
Ashermann’s syndrome
Imperforate hymen/transverse vaginal septum
Mayer-Rokitansky-Kuster-Hauser syndrome
What is Ashermann’s syndrome and how is it a genital tract abnormality cause of amenorrhoea
Secondary to uterus instrumentation
Usually after surgical management of miscarriage
Have damage to basal layer of endometrium
Get intrauterine adhesions
Get failure to respond to oestrogen stimulus
How are imperforate hymen and transverse vaginal septum genital tract abnormality causes of amenorrhoea
Have a mechanical obstruction
What is Mayer-Rokitansky-Kuster-Hauser syndrome and how is it a genital tract abnormality cause of amenorrhoea
Agenesis of Mullerian duct
Congenital absence of uterus and upper 2/3 of vagina
What are the common causes of oligomenorrhoea
PCOS
Contraceptive/hormonal treatment
Perimenopause
Thyroid disease
Diabetes
Eating disorder/excessive exercise
Medications (antipsychotics, antiepileptics)
What are the investigations used for amenorrhoea
Pregnancy test
Bloods (TFTs, prolactin, FSH, LH, oestradiol, progesterone, testosterone)
Karyotyping
Ultrasound
Progesterone challenge
What is the progesterone challenge used to look for causes of oligo/amenorrhoea
Give progesterone
- If able to elicit a withdrawal bleed, means that levels of oestrogen are high enough but still not getting ovulation
- If get no withdrawal bleed, means that there is low oestrogen or an outflow obstruction
What are the broad categories of management of oligo/amenorrhoea
Regulation of periods
Hormone replacement
Symptom control
Lifestyle advice
Treat underlying cause
Improve fertility
Surgery
How is regulation of periods achieved in the management of oligo/amenorrhoea
COCP/POP - keep endometrial lining thin
IUS - reduces flow/stops periods
How is hormone replacement therapy used in the management of oligo/amenorrhoea
For patients with premature ovarian failure/insufficiency
Cyclical oestrogen (+/- progesterone)
Treats symptoms of menopause
Advantages: decreases cardiovascular risk, maintains bone density prevents osteoporosis
What are the methods of symptom control used in oligo/amenorrhoea
Manage excessive hair growth with COCPs
Acne treatment (antibiotics, benzoyl peroxide, retinoids)
What are the methods of improving fertility that are used in the management of oligo/amenorrhoea
Clomifene - stimulates ovulation
Metformin - induces ovulation in PCOS
IVF
How is surgery used in the management of oligo/amenorrhoea
Remove tumours
Correct genital tract abnormalities
What is heavy menstrual bleeding
Excessive menstrual loss that interferes with the patient’s quality of life
Abnormal uterine bleeding
What are the causes of heavy menstrual bleeding
PALM-COEIN
Structural causes
- Polyp
- Adenomyosis
- Leiomyoma (fibroids)
- Malignancy and hyperplasia
Non-structural causes
- Coagulopathy
- Ovulatory dysfunction
- Endometrial
- Iatrogenic
- Not yet classified
What are the risk factors for heavy menstrual bleeding
Age (around menarche and menopause)
Obesity
How may a woman with heavy menstrual bleeding present
Excessive bleeding (for patient)
Fatigue
Shortness of breath
What would you look for on examination of a woman with heavy menstrual bleeding
Pallor
Palpable uterus or pelvic mass
Tender uterus/cervix (specific to adenomyosis and endometriosis)
Cervical changes (inflammation, polyps, tumour)
Vaginal tumour
What are the differential diagnoses for heavy menstrual bleeding
Pregnancy
Endometrial/cervical polyps
Adenomyosis
Fibroids
Endometrial malignancy or hyperplasia
Coagulopathies (usually Von Willebrand’s disease)
Ovarian dysfunction
Iatrogenic
Endometriosis
What investigations would you use for heavy menstrual bleeding
Pregnancy test
Bloods (FBC, TFTs, coagulation studies…)
USS (transvaginal/pelvic)
Cervical smear (if not up to date)
Pipelle endometrial biopsy
Hysteroscopy and endometrial biopsy
What is a pipelle biopsy and what are the indications for its use
Endometrial biopsy for heavy menstrual bleeding
Indications
- Persistent intermenstrual bleeding
- Age >45
- Failure of pharmacological treatment
What is the pharmacological management for heavy menstrual bleeding
Levonorgestrel-releasing IUS (LNG-IUS)
- Also contraceptive, thins endometrium, can shrink fibroids
Tranexamic acid
- Only during menses (reduces bleeding)
Mefenamic acid
- NSAID
COCP/POP
What is the surgical management for heavy menstrual bleeding
Endometrial ablation (not able to get pregnancy after this)
Hysterectomy (definitive management)
What is dysmenorrhoea
Painful periods
What is the difference between primary and secondary dysmenorrhoea
Primary
- Menstrual pain with no underlying pathology
Secondary
- Menstrual pain associated with pelvic pathology
What is the pathophysiology of dysmenorrhoea
Regression of corpus luteum if no fertilisation
Get a drop in oestrogen and progesterone
Endometrial cells sensitive to drop in progesterone
Endometrial cells release prostaglandins
Prostaglandins cause spiral artery vasospasm and increase myometrial contraction
Primary dysmenorrhoea is due to excessive prostaglandin release
What are the risk factors for dysmenorrhoea
Early menarche
Long menstrual phase
Heavy periods
Smoking
Nulliparity
How may a woman with dysmenorrhoea present?
Crampy lower abdominal pain
May have radiation to back/anterior thigh
Lasts 48-72 hours
Non-specific symptoms: malaise, nausea, vomiting, diarrhoea, dizziness
What are the differential diagnoses for dysmenorrhoea
Primary dysmenorrhoea
- Diagnosis of exclusion
Secondary dysmenorrhoea
- Endometriosis, adenomyosis, PID, adhesions
Non-gynaecological
- IBD, IBS
What are the investigations to use in dysmenorrhoea
Focussed on ruling out pathology
High risk of STIs
- High vaginal and endocervical swabs
Pelvic mass palpated
- Transvaginal USS
What is the pharmacological management for dysmenorrhoea
Analgesia
- Paracetamol, NSAIDs
Hormonal contraceptives
- 3-6 month trial
- Monophasic COCP or IUS
What is the non-pharmacological management for dysmenorrhoea
Smoking cessation
Local heat application
TENS machine
What is adenomyosis
Endometrial tissue in myometrium of uterus
Variant of endometriosis
Main symptoms: menorrhagia, dysmenorrhoea
Often found alongside fibroids
What is the aetiology and pathophysiology of adenomyosis
Endometrial stroma communicates with myometrium after uterine damage
Associated with: pregnancy and childbirth, C-section, uterine surgery, termination of pregnancy
Mostly in posterior wall
What are the risk factors for adenomyosis
High parity
Uterine surgery
Previous C-section
Hereditary
How may a woman with adenomyosis present
Menorrhagia
Dysmenorrhoea
Deep dyspareunia
Irregular bleeding
What would you find on examination of a woman with adenomyosis
Symmetrically enlarged, tender uterus
What are the differential diagnoses for adenomyosis
Endometriosis
Fibroids
Endometrial hyperplasia/carcinoma
Endometrial polyps
PID
Hyperthyroidism
Coagulation disorders
What are the investigations for adenomyosis
Definitive diagnosis
- Histology after hysterectomy
Transvaginal USS
- Globular uterus
- Poor definition of endometrial-myometrial interface
- Intramyometrial cyst
MRI
- Endo-myometrial junction zone thickening
What is the management of adenomyosis
Curative therapy: hysterectomy
Simple analgesia
Hormonal
- Reduce proliferation of ectopic endometrial cells
- COCP, POP, IUS, GnRH agonist, aromatase inhibitor
Non-hormonal
- Uterine artery embolisation (if wanting to preserve fertility), endometrial ablation, tissue resection, laparoscopic excision
How common is endometrial cancer and when is the peak age of diagnosis
4th most common cancer of women in the UK
Peak age 65-75
What is the most common form of endometrial cancer, what is the pathophysiology
Adenocarcinoma
Due to stimulation of endometrium by unopposed oestrogen
What are the risk factors for endometrial cancer
Anovulation
- Early menarche/late menopause, low parity, PCOS, HRT, tamoxifen
Age
- Peak at 65-75, low risk in <45
Obesity
- More peripheral fat, faster peripheral aromatisation of androgens and oestrogen
Hereditary
How may a woman with endometrial cancer present
Post-menopausal bleeding
Clear/white vaginal discharge
Abnormal cervical smear
In advanced disease: abdominal pain, weight loss
What might you find on examination of a woman with endometrial cancer
Abdominal/pelvic mass
Vaginal/vulval atrophy
Cervical lesions
What are the differential diagnoses for endometrial cancer
Vulval causes
- Atrophy, malignant/pre-malignant conditions
Cervical causes
- Polyps, cancer
Endometrial causes
- Hyperplasia without malignancy, benign polyps, atrophy
What are the investigations for endometrial cancer
Transvaginal ultrasound (first line)
Endometrial biopsy (if >4mm on ultrasound)
Hysteroscopy with biopsy
Staging CT/MRI
What is the FIGO staging for endometrial cancer
Stage 1
- Carcinoma confined to uterine body
Stage 2
- Carcinoma extends to cervix, but not beyond uterus
Stage 3
- Carcinoma goes beyond uterus, but confined to pelvis
Stage 4
- Carcinoma involves bladder/bowel, or has metastasised to distal sites
What is the management of endometrial hyperplasia
Typical
- Mirena coil, surveillance biopsies
Atypical
- Total abdominal hysterectomy and bilateral salpingo-oophorectomy
What is the management of endometrial cancer
Stage 1
- Total abdominal hysterectomy and bilateral salpingo-oophorectomy
Stage 2
- Radical hysterectomy (also remove supporting tissue of uterus and vaginal tissue around cervix)
Stage 3
- Maximal de-bulking surgery
- Chemoradiotherapy
Stage 4
- Maximal de-bulking surgery
- Usually need palliative approach
What are the common sites of endometrial tissue in endometriosis
Ovaries
Pouch of Douglas
Uterosacral ligaments
Pelvic peritoneum
Bladder
Umbilicus
Lungs
At what age is endometriosis most commonly diagnosed
25-40
What are the risk factors for endometriosis
Early menarche
Family history
Short menstrual cycle
Long duration of menstrual bleeding
Heavy menstrual bleeding
Defects in uterus/fallopian tube
How may a woman with endometriosis present
Cyclical pelvic pain (can be constant with adhesions)
Dysmenorrhoea
Dyspareunia
Dyschezia (painful defecation)
Subfertility
Signs related to ectopic sites
- Haemothorax…
What would you find on bimanual examination of a woman with endometriosis
Fixed, retroverted uterus
Uterosacral ligament nodules
Genital tenderness
What are the differential diagnoses for endometriosis
Pelvic inflammatory disease
Ectopic pregnancy
Fibroids
IBS
What are the investigations for endometriosis
Laparoscopic visualisation
- Gold standard
- Chocolate cysts, adhesions, peritoneal deposits
Pelvic ultrasound
- To determine severity
- May see ‘kissing ovaries’ (bilateral endometrioma adhered together)
What is the management for endometriosis
No treatment for asymptomatic patients
Analgesia
Suppress ovulation
- For 6-12 months
- Get atrophy of endometrial tissue
- Low dose COCP, norethisterone, injections, coils
Surgery
- Excision, ablation
- Definitive management: hysterectomy and bilateral oophorectomy
What are fibroids
Aka leiomyomas
Benign smooth muscle tumours of uterus
How are uterine fibroids classified
Based on position on uterine wall
Intramural
- Most common, confined to myometrium
Submucosal
- Immediately beneath endometrium, protrude into uterine cavity
Subserosal
- Protrude into serosal surface, may be pedunculated
What stimulates the growth of fibroids
Oestrogen
What are the risk factors for developing fibroids
Obesity
Early menarche
Increasing age
Family history
Ethnicity (African-American)
How may a woman with uterine fibroids present
Pressure symptoms (urinary frequency/retention)
Abdominal distention
Heavy menstrual bleeding
Subfertility (obstructive effect)
Acute pelvic pain (only if torsion of pedunculated fibroid)
What would you find on examination of a woman with fibroids
Solid mass
Non-tender uterus
What are the differential diagnoses for fibroids
Endometrial polyps
Ovarian tumours
Leiomyosarcoma (malignancy of myometrium)
Adenomyosis
What investigations are used in fibroids
Pelvic USS
Consider MRI if suspecting sarcoma
What is the medical management for fibroids
Tranexamic/mefanamic acid
Hormonal contraceptives
GnRH analogues (Zolidex)
- Suppresses ovulation, get temporary menopausal state
- Pre-op, to reduce size of fibroid
- Maximum use 6 months
Selective progesterone receptor modulators (ulipristal)
- Reduces size of fibroids
- Severe risk of liver injury
What is the surgical management for fibroids
Hysteroscopy and transcervical resection (TCRF)
Myomectomy (if want to preserve uterus)
Uterine artery embolisation
Hysterectomy
What are cervical polyps
Benign growths protruding from inner surface of cervix
Usually asymptomatic
Can undergo malignant changes
What are the causes of cervical polyps
Chronic inflammation
Abnormal response to oestrogen
Localised congestion of cervical vasculature
How might a woman with cervical polyps present
Abnormal vaginal bleeding (menorrhagia, intermenstrual, post-coital, post-menopausal)
Increased vaginal discharge
Infertility (may block cervical canal)
What would you see on speculum examination of a woman with cervical polyps
Polypoid growths
Projections through external os
What are the differential diagnoses for cervical polyps
Cervical cancer
STIs
Fibroids
Endometritis
Pregnancy-related
Endometrial carcinoma
Endometrial polyps
What are the investigations for cervical polyps
Definitive diagnosis: histological examination of polyp after removal
Triple swab (rule out infection)
Cervical smear (rule out cervical intraepithelial neoplasia)
What is the management for cervical polyps
Remove, to prevent malignant transformation
Small polyps
- Remove in primary care (polypectomy forceps, twist off)
Large polyps
- Colposcopy clinic (diathermy loop excision)
Send polyps for histology
What is cervical ectropion
Cervical erosion
Evasion of endocervix, exposing columnar cells to vagina
Benign condition
What is the pathophysiology of cervical ectropion
Stratified squamous cells undergo metaplastic change to become simple columnar
Induced by high oestrogen levels
What are the risk factors for cervical ectropion
Use of COCP
Pregnancy
Adolescence
Childbearing age
How might a woman with cervical ectropion present
Mostly asymptomatic
Post-coital bleeding
Intermenstrual bleeding
Excessive discharge
What would you find on speculum examination of a woman with cervical extropian
Everted columnar epithelium
Reddish appearance
- A ring around the external os
What are the differential diagnoses for cervical ectropion
Cervical cancer
Cervical intraepithelial neoplasia
Cervicitis
Pregnancy
What investigations would you use for cervical ectropion
Rule out other potential causes
- Pregnancy test
- Triple swab
- Cervical smear
What is the management of cervical ectropion
No treatment for asymptomatic
Stop oestrogen-containing medications (COCP)
Columnar epithelium ablation
Boric acid pessaries (acidify vaginal pH)
Who is cervical cancer most commonly diagnosed in
Half before age 47
Peak age 25-29
How long does it usually take cervical intraepithelial neoplasia to progress to cervical cancer
10-20 years
What are the risk factors for cervical cancer
HPV infection
Smoking
Other STIs
Long term COCP use (>8 years)
Immunodeficiency
How may a woman with cervical cancer present
Abnormal vaginal bleeding
Blood-stained/foul smelling discharge
Dyspareunia
Pelvic pain
Advanced disease: weight loss, oedema, loin pain, rectal bleeding, radiculopathy, haematuria
What would you find on examination of a woman with cervical cancer
Speculum
- Evidence of bleeding, discharge, ulceration
Bimanual
- Pelvic mass
GI
- Rectal bleeding, mass on PR
What are the differential diagnoses for cervical cancer
STI
Cervical ectropion
Polyps
Fibroids
Pregnancy-related bleeding
Endometrial cancer
What are the investigations for cervical cancer
Pre-menopausal
- Check for chlamydia. If negative, colposcopy and biopsy
Post-menopausal
- Urgent colposcopy and biopsy
If cancer confirmed, staging CT
What are the stages of cervical cancer
Stage 0
- Carcinoma in-situ
Stage 1
- Confined to cervix
Stage 2
- Beyond cervix, but not pelvic sidewall. Involves upper 2/3 of vagina
Stage 3
- Extends to pelvic sidewalls, involves whole vagina
Stage 4
- Extends to bladder/rectum, metastases
What is the surgical management of cervical cancer
Stage 1
- Radical trachelectomy (remove cervix and upper vagina)
Stage 2
- Radical hysterectomy
Stage 4
- Total removal, including parts of bladder and rectum
What is the non-surgical management for cervical cancer
Radiotherapy
Chemotherapy
Follow-up
- Every 4 months for 2 years after treatment
- Every 6-12 months for 3 years
How is PCOS characterised
Excess androgen production
Multiple immature follicles (cysts) in ovaries
What are the common hormonal abnormalities found in PCOS
Excessive LH
- Stimulates ovaries to produce androgens
Insulin resistance
- High insulin production, suppresses hepatic production of sex hormone binding globulin, get high free circulating androgens
What happens to androgen levels in PCOS, how does this affect ovulation
High circulating androgens
Suppress LH surge
- Follicles begin to develop, but then arrested, become cysts
What are the risk factors for PCOS
Diabetes
Irregular menstruation
Family history
What are the most common symptoms of PCOS
Oligomenorrhoea/amenorrhoea
Infertility
Hirsutism
Obesity
Chronic pelvic pain
Depression
What would you find on examination of a patient with PCOS
Hirsutism
Acne
Acanthosis nigrans
Male pattern hair loss
Obesity
Hypertension
What are the differential diagnoses for PCOS
Hypothyroidism
Hyperprolactinaemia
Cushing’s disease
What investigations are used for PCOS
Bloods
- High testosterone, low sex hormone binding globulin, high LH, normal FSH, low progesterone
Consider oral glucose tolerance test
Ultrasound of ovaries
What is the criteria for diagnosing PCOS
2/3 of:
- Oligo/anovulation
- Clinical/biochemical signs of hyperandrogenism
- Polycystic ovaries on imaging
What is the management for PCOS
Treat underlying condition
Oligomenorrhoea/amenorrhoea
- COCP, dydrogesterone (progesterone analogue)
Weight loss
Infertility treatment
Hirsutism treatment
How is infertility due to PCOS managed
Clomifene and metformin
- Induce ovulation
- Maximum of 6 cycles
Laparoscopic ovarian drilling
How is hirsutism in PCOS managed
Anti-androgen medication
- Eflornithine (face cream)
- Contraindicated in pregnancy (teratogenic)
What are ovarian cysts
Fluid-filled sac within ovary
Common (pre-menopausal women)
Benign
What are the risk factors for ovarian cysts and tumours
Nulliparity
Early menarche
Late menopause
Oestrogen-only HRT
Smoking
Obesity
Genetic mutations (BRCA1,2)
What are the protective factors for PCOS
Multiparity
COCP
Breastfeeding
What are the clinical features of ovarian cysts and tumours
Often asymptomatic
Chronic pain (pressure on surroundings)
Acute pain (bleeding, rupture, torsion)
Bleeding per vagina
What are the classifications of ovarian cysts
Non-neoplastic
- No malignant potential
Neoplastic
- Can become malignant
Simple
- Fluid only
Complex
- Irregular, solid material, blood, septation
What are the types of non-neoplastic ovarian cysts
Functional
- Follicular cysts, corpus luteum cysts
Pathological
- Endometrioma, polycystic ovaries, theca lutein cysts
What are the types of benign neoplastic ovarian cysts
Epithelial
- Serous cystadenoma, mucinous cystadenoma, Brenner tumour
Benign germ cell tumours
- Mature cystic teratoma (dermoid cyst)
Sex-cord stromal tumour
- Fibroma
What is the management of ovarian cysts in pre-menopausal women
No need to measure CA125
Measure lactate dehydrogenase, AFP, and BhCG
Re-scan in 6 weeks
If persistent
- USS and CA125 at 3-6 months
- Still persisting or >5cm, consider laparoscopic cystectomy and oophorectomy
What is the management of ovarian cysts in post-menopausal women
Low risk malignancy index (RMI)
- Follow up in 1 year with USS and CA125
Moderate RMI
- Bilateral oophorectomy
- If malignancy found, staging
High RMI
- Staging laparoscopy
What are the investigations for ovarian cancer
Bloods
Pelvic ultrasound
Staging CT
What is the management for ovarian cancer
Surgery
Adjuvant chemotherapy
Follow up (examination, CA125, for 5 years)
What is stress incontinence
Involuntary leakage of urine during increased intra-abdominal pressure, in absence of detrusor contraction
Usually after childbirth (denervation of pelvic floor)
What are the risk factors for stress incontinence
Childbirth
Oestrogen deficient state
Pelvic surgery
Pelvic irradiation
What is urge incontinence
Overactive bladder syndrome
Urgency, frequency, nocturia
Absence of UTI
Usually idiopathic (sometimes due to neurological conditions or pelvic surgery)
What are the main causes of urinary incontinence
Stress incontinence
Urge incontinence
Overflow incontinence
Bladder fistulae
Urethral diverticulum
Congenital anomalies
Functional incontinence
What are the clinical features of stress incontinence
Leakage on coughing/sneezing/exercise
Small volumes
May have prolapse
What are the clinical features of urge incontinence
Urgency
Frequency
Nocturia
What investigations are used for urinary incontinence
Urine dip (exclude infection)
Frequency/volume chart (normal in stress, increased in urge)
Urodynamic studies (rule out detrusor overactivity in stress)
What is the non-surgical management of stress incontinence
Conservative
- Weight loss
- Smoking cessation
- Treat risk factors
- Pelvic floor muscle exercises
Medical
- Duloxetine (moderate/severe symptoms)
What is the surgical management of stress incontinence
Burch colposuspension
Laparoscopic colposuspension
Peri-urethral injection (those unfit for surgery)
Tension-free vaginal tape (tape under mid urethra)
Transobturator mid-urethral sling
What is the non-medical management for urge incontinence
Conservative
- Sensible fluid intake
- Avoid caffeine/diuretics
- Bladder retraining
Surgical
- Detrusor myomectomy and augmentation cystoplasty
What is the medical management for urge incontinence
Anticholinergics
- Oxybutynine, solifenacin, tolterodine
Intravaginal oestrogen
- If have vaginal atrophy
Botulinum toxin A
Neuromodulators and sacral nerve stimulation
What is a Bartholin’s cyst
Fluid-filled sac within a bartholin’s gland of the vagina (on either side of vaginal orifice, deep to labia majora, within vestibule)
What are the common causative organisms of Bartholin’s cysts
E.coli
MRSA
STIs
What are the risk factors for Bartholin’s cyst
Nulliparous
Childbearing age
Personal history
Sexually active
Previous vulval surgery
What are the clinical features of a Bartholin’s cyst
Often asymptomatic if small
If large: vulval pain, superficial dyspareunia
Can rupture
Bartholin’s abscess (acute onset pain, difficulty passing urine)
What would you find on examination of a Bartholin’s cyst
Unilateral labial mass
Arising from posterior labia majora
Bartholin’s cyst: soft, fluctuant, non-tender
Bartholin’s abscess: tender, hard, surrounding cellulitis
What are the differential diagnoses for Bartholin’s cysts
Bartholin’s gland carcinoma
Bartholin’s benign tumour
Other cysts: sebaceous, Skene’s, mucous
Other solid masses: fibroma, lipoma, leiomyoma
What are the investigations for Bartholin’s cyst
Clinical diagnosis
> 40s, consider biopsy
Swab if suspecting STI
What is the management for Bartholin’s cyst
Warm baths (if small)
Word catheter (in place for 4-6 weeks, not suitable for deep cysts)
Marsupialisation (incision in cyst, spontaneous drainage, cyst wall sutured to vaginal mucosa)
Silver nitrate cautery, CO2 laser, needle aspiration
What is lichen sclerosus
Chronic inflammatory skin disease of female anogenital region
Mostly in pre-pubescent girls and post-menopausal women
Can progress to squamous cell carcinoma
What are the risk factors for lichen sclerosus
Family history
Other autoimmune disorders
How might a patient with lichen sclerosus
present
White atrophic patches on skin of anogenital region
Itching
Fissuring/erosion of skin
Dyspareunia
What would you find on examination of a woman with lichen sclerosus
Clitoral hood fusion
Fusion of labia minora and labia majora
Posterior fusion (loss of vaginal opening)
Differential diagnoses for lichen sclerosus
Lichen simplex
Vitiligo
Vulvar cancer/intraepithelial neoplasia
Candidiasis
Post-inflammatory hypopigmentation
What are the investigations for lichen sclerosus
Clinical diagnosis
Biopsy (if uncertain)
What is the management of lichen sclerosus
Immunosuppression (topical steroids)
Avoid irritants to area
Follow up if chronic (risk of developing squamous cell carcinoma)
