Gynaecology Flashcards
Androgen insensitivity syndrome
X-linked recessive condition caused by a mutation in the androgen receptor gene which results in cells being unable to respond to androgen hormones due to lack of androgen receptors. Extra androgens are converted to oestrogen giving female sexual characteristics. Patients are genetically male. Patients have testes in the abdomen but female external genitalia.
Presentation of androgen insensitivity syndrome
Presents in infancy with inguinal hernias containing testis.
In puberty presents with primary amenorrhoea
Hormone test results for patients with androgen insensitivity syndrome
Raised LH
Normal or raised FSH
Normal or raised testosterone (for a male)
Raised oestrogen levels for a male
Management of androgen insensitivity syndrome
Bilateral orchidectomy
Oestrogen therapy
Vaginal dilators or vaginal surgery
Support and counselling
Typical complications of bicornate uterus
Miscarriage
Premature birth
Malpresentation
Imperforate hymen - what is it? how does it present and diagnosed? how is it treated? complications?
Imperforate hymen is where the hymen at the entrance of the vagina is fully formed without an opening.
Presents with cyclical pain and cramping that would ordinarily be associated with menstruation but without ny vaginal bleeding
Diagnosed on clinical examination
Surgically managed by creating an opening in the hymen.
Complications: can lead to endometriosis
Transverse vaginal septae - what is it? what types are there? how would they present? how is it treated? complications?
Caused by an error in development where a septum forms transversely across the vagina. Septum can be either imperforate or perforate.
If perforate, then girls will still menstruate but can have difficulty with intercourse or tampon use.
If imperforate, it will present similarly to an imperforate hymen with cyclical pain and cramping without menstruation.
Diagnosis is by examination, USS or MRI.
Treatment is surgical.
Complications: vaginal stenosis and recurrence of the septa
Immediate complications of female genital mutilation
Pain
Bleeding
Infection
Swelling
Urinary retention
Urethral damage and incontinence
Long term complications of FGM
Vaginal infections
Pelvic infections
UTIs
Dysmenorrhoea
Sexual dysfunction and dyspareunia
Infertility and pregnancy-related complications
Significant psychological issues and depression
Management of FGM
Report all cases of FGM and refer to FGM specialist.
What is Lichen Sclerosis?
Chronic inflammatory autoimmune skin condition which presents with patches of shiny white skin.
What areas does lichen sclerosis affect?
Labia, perineum and perianal skin in women.
In men, foreskin and glans of penis
How does lichen sclerosis present?
Itching
Soreness and pain - possibly worse at night
Skin tightness
Painful sex
Erosions
Fissures
How would lichen sclerosis appear on the skin?
Porceline-white in colour
Shiny
Tight
Thin
Slightly raised
Management of lichen sclerosis
No cure. Followed up every 3-6 months
Topical steroids are main treatment - OD for 4 weeks.
Emollients as well used regularly
Complications of lichen sclerosis
Squamous cell carcinoma of vulva
Pain and discomfort
Sexual dysfunction
Bleeding
Narrowing of the vaginal or urethral openings
Bartholin’s Cyst/abscess
Blockage of the bartholin’s glands which are located on either side of the vaginal opening. Ducts can become blocked and cause the glands to swell forming a cyst. Cysts can become infected and form an abscess.
Management of bartholin’s cyst/abscess
Cysts usually resolve
Biopsy may be required to exclude vulval malignancy in women over 40.
Abscess will require antibiotics - swab of pus or fluid can be taken for culture and sensitivity.
Most common cause of bartholin abscess (organism)
E.coli
What is urge incontinence?
Overactivity of the detrusor muscle.
What is stress incontinence?
Due to weakness of the pelvic floor and sphincter muscles which allows urine to lead at times of increased pressure on the bladder.
What is mixed incontinence?
Combination of urge and stress incontinence
What is overflow incontinence?
Occurs when there is chronic urinary retention due to an obstruction to the outflow of urine.
Causes of overflow incontinence
Fibroids, pelvic tumours, neurological conditions such as MS, diabetic neuropathy and spinal cord injuries
Risk factors for urinary incontinence
Increased age
Postmenopausal status
Increased BMI
Previous pregnancies and vaginal deliveries
Pelvic organ prolapse
Pelvic floor surgery
Neurological conditions such as MS
Investigations for urinary incontinence
A bladder diary - for at least 3 days
Urine dipstick testing - assess for infection, microscopic haematuria
Post-void residual bladder volume - should be measured using a bladder scan to assess for incomplete emptying
Urodynamic testing
Describe urodynamic testing
Assesses the presence and severity of urinary symptoms.
Catheter inserted into the bladder and another into the rectum to measure the pressures in the bladder and rectum for comparison. The bladder is then filled with liquid and various measures are taken.
Management of stress incontinence
Avoid caffeine, diuretics and overfilling bladder
Weight loss
Supervised pelvic floor exercises at least 3 months before surgery
Surgery
Duloxetine (SNRI)
Management of urge incontinence
Bladder retraining (for at least 6 weeks - first line)
Anticholinergic medication - oxybutinin, tolterodine and solifenacin
Mirabegron
Invasive procedures - Botulism toxin type A, percutaneous sacral nerve stimulation, urinary diversion (involves redirecting urinary flow to a urostomy on the abdomen)
Side-effects of anticholinergics (e.g. oxybutinin, tolterodine and solifenacin)
Dry eyes, dry mouth, urinary retention, constipation and postural hypotension. Cognitive decline, memory problems and worsening dementia
What is a vault prolapse?
Occurs in women that have had a hysterectomy and no longer have a uterus. The top of the vagina descends into the vagina.
What is a rectocele? What are they associated with?
Rectoceles are caused by a defect in the posterior vaginal wall which allows the rectum to prolapse forward into the vagina. They are associated with constipation.
What is a cystocele?
Caused by a defect in the anterior vaginal wall, allowing the bladder to prolapse backwards into the vagina.
What is a prolapse of both the bladder and urethra called?
Cystourethrocele
Risk factors or pelvic organ prolapse
Multiple vaginal deliveries
Instrumental, prolonged or traumatic delivery
Advanced age and post menopause status
Obesity
Chronic respiratory disease causing coughing
Chronic constipation causing straining
How would a pelvic organ prolapse present?
Feeling something coming down the vagina
Dragging or heavy sensation in the pelvis
Urinary symptoms - incontinence, urgency, frequency, weak stream, retention
Bowel symptoms - constipation, incontinence and urgency
Sexual dysfunction - pain, altered sensation and reduced enjoyment
How would you examine someone that has a pelvic organ prolapse?
Use a sim’s speculum to support the anterior and posterior vaginal wall whilst the other vaginal walls are examined. Women can be asked to cough to assess the full descent of the prolapse.
Grading for uterine prolapses
POP-Q - pelvic organ prolapse quantification system
Grade 0 - Normal
Grade 1: The lowest part is more than 1 cm above the introitus
Grade 2: the lowest part is within 1 cm of the introitus (above or below)
Grade 3: the lowest part is more than 1 cm below the intoitus but not fully descended
Grade 4: Full descent with eversion of the vagina
Management options for vaginal prolapses
- Conservative management
- Vaginal pessary
- Surgery
How do you conservatively manage vaginal prolapses and who are they for?
For women with mild symptoms, do not tolerate pessaries or are not suitable for surgery. Conservative management includes:
- Physio
- Weight loss
- Treat related symptoms
- Vaginal oestrogen cream
Types of vaginal pessaries
Ring
Shelf
Cube
Donut
Complications of surgery for vaginal prolapse
Pain, bleeding, infection, DVT and anaesthetic risk
Damage to the bladder or bowel
Recurrence of prolapse
Altered experience of sex
What is cervical ectropion?
When the columnar epithelia of the endocervix extends out to the ectocervix
Cervical ectropion presentation?
Most are asymptomatic and found incidentally during speculum examination.
Increased vaginal discharge
Vaginal bleeding
Dyspareunia
Postcoital bleeding
Management of cervical ectropion
Asymptomatic - no treatment required
Problematic bleeding - cauterisation of the ectropion using silver nitrate or cold coagulation during colposcopy
What is Asherman’s syndrome?
It is when adhesions form within the uterus following damage. Adhesions form physical obstructions and distort the pelvic organs.