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Gynaecology Flashcards

1
Q

28 years old girl complaining of severe abdominal pain during her periods for the last 6 months.

What are the differential diagnosis?

A
  1. Endometriosis
  2. PID
  3. Fibroids
  4. IUCD
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2
Q

28 years old girl complaining of severe abdominal pain during periods.

What is the diagnosis?

A

Condition: Endometriosis

Cause: Unknown

Commonality: very common 1 in 100 women have it.
Most common site of endometriosis- walls of the uterus, ovaries, fallopian tubes, uterine ligaments, and other pelvic organs.

Clinical features:
1. Dysmenorrhea
2. Dyspareunia
3. Dyschazia
4. Menorrhagia
Signs: in DRE - nodularity and tenderness in the pouch of Douglas and uterosacral ligament

Complications:
1. Menorrhagia
2. Infertility

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3
Q

28 years old girl complaining of severe abdominal pain during periods.

Investigations and Management

A

Investigations:
1. FBE with ESR and CRP
2. UEC
3. Coagulation profiles
4. USG of the lower tummy - to rule out fibroids
5. Transvaginal USG and laparoscopy (CONFIRMATORY)

Treatment
1. Panadol for the pain
2. Refer to specialist

Medical treatment:
1. OCP - taken for 6 months
2. Progestens like Depoprovera and Mirena
3. GnRh analagues -intra-nasally or injections 3 or 6 monthly
- cannot be taken for more than six months
- induce severe postmenopausal symptoms like hot flushes, heavy, sweatings mood, swings, joint pain, muscle, pain, and osteoporosis 

  1. Danazol - for 3-6 months
    - cannot be taken more than six months
    - mail characteristics like voice change, increased hair growth

Surgical:
-If medical management fails
- infertility
- severe symptoms
1. Laparoscopy cutting away of the deposits
2. Endometrial ablation by laser or electrocautery

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4
Q

17 year old Maya has not started her periods yet.

What can be the probable causes?

A

Hypothalamic causes:
1. Eating disorders
2. Exercise related
3. Stress related
4. Chronic illnesses - long term renal or liver problems, DIABETES, severe depression)
5. Kalman’s Syndrome

Pituitary causes:
1. Hyperprolactinoma

Ovarian causes:
1. PCOS
2. POF
3. Turners syndrome
4. Chemotherapy or radiotherapy to the ovaries

Uterine causes:
1. Pregnancy
2. Mullerian Agenesis
3. Androgen Insensitivity Syndrome

Vaginal causes:
1. Imperforate hymen
2. Transverse vaginal septum

Other hormonal causes:
1. Hyper/Hypothyroidism
2. Cushing syndrome

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5
Q

17 years old Maya has not started her periods yet.

What investigations will you do?

A

Blood :
FBE with ESR and CRP
S. UEC
LFT
TFT
S. Prolactin level
LH, FSH
Oestrogen and Progesterone level

Urine: UPT

Imaging: Pelvic USG

Karyotyping : Turners and Kallman’s Syndrome

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6
Q

20 years old Maria presents to the GP with absence of periods for the last 6 months.

What can be the causes?

A

Causes of secondary amenorrhea:

  1. Pregnancy
  2. Post-pill amenorrhea
  3. PCOS
  4. POF
  5. HyperProlactinaemia
  6. Asherman syndrome
  7. Thyroid disorders
  8. Eating disorders
    **9. Exercise induced amenorrhea
  9. Stress related
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7
Q

A ballat dancer has not had her periods for 6 months .

What is the condition and what is its management?

A

Condition: Exercise Induced Amenorrhea

Cause: HPO axis dysfunction

Complications:
1. Infertility
2. Decrease in bone density, bones become brittle and break easily
3. Increased cholesterol levels
4. Premature aging

Investigations:
1. FBE
2. UEC
3. LFT
4. TFT
5. Serum prolactin
6. Vitamin D and calcium levels
7. Hormones: GnRh, LH, FSH, oestrogen and progesterone
8. Pelvic USG

Management:
1. Refer to specialist
2. Adopt healthy lifestyle:
- put on 2-3kg weight
- limit exercise to 8 hours/week
3. Refer to dietician for dietary advice
4. Prescribe, vitamin D and calcium supplements

If these are not working in six months, we can put you on OCP.

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8
Q

A 30 years old woman, having OCP did not have her periods follow the last two courses of pills.

  1. What is the diagnosis?
  2. Management of this condition.
  3. Key point in this case
A

Diagnosis: Post-pill amenorrhea

Management:
1. Do a UPT to rule out pregnancy
2. Periods will become normal once you discontinue the pill.
3. Prescribe another pill with a higher dose of oestrogen
OR, 4. Prescribe a triphasic pill
OR, 5. Stop OCP and try other methods of contraception

Key point and critical error:
Must do a Urine Pregnancy Test

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9
Q

38 years old Susan is complaining of heavy menstrual bleeding for the last 4 months.

What are the possible causes?

A
  1. Endometriosis
  2. Fibroids
  3. PID
  4. Ovarian tumours/cysts
  5. Thyroid disorders (hyperthyroidism)
  6. Bleeding disorders
  7. Blood thinners
    **8. DUB
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10
Q

38 years old Susan is complaining of heavy menstrual bleeding for the last 4 months.

What investigations will you do?

A
  1. FBE : to see Hb and Platelet count
  2. If Hb is low: Iron profile
  3. Blood grouping and cross matching
  4. Coagulation profiles
  5. LFT
  6. TFT
  7. UEC
  8. Pelvic USG
  9. Endometrial sampling (must in women >35years to rule out malignant changes)
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11
Q

Management of DUB

A
  1. Refer to the specialist
    Give iron tablets
  2. Conservative - for 6 months
    •Non Hormonal management:
    1. Tranexamic acid
    2. Mefenamic acid
      • Hormonal management:
             1. OCP
             2. Mirena
             3. IUCD
             4. GnRh analogue, Danazol
  3. Surgical:
    1. Endometrial ablation
    2. Hysterectomy (if family complete)
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12
Q

13 years old Maria has been brought by her mother due to heavy bleeding during her first period.

What can be the possible causes?

A
  1. Pubertal Menorrhagia
  2. Pregnancy
  3. Thyroid disorders
  4. Bleeding disorders
  5. Blood thinners
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13
Q

25 year old Isa presented with lower abdominal pain for the past one hour.

What can be the causes?

A
  1. Mittleschmerz
  2. Ectopic pregnancy
  3. PID
  4. Ovarian cyst
  5. Acute appendicitis
  6. Bowel obstruction
  7. Acute pyelonephritis
  8. Renal stones
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14
Q

Contraindications of combined OCP

A

Absolute contradictions:
1. DVT
2. Breast cancer
3. Active liver disease or previous cholestatic jaundice
4. Unexplained vaginal bleeding
5. Migraine

Relative contraindications:
1. HTN
2. DM
3. Severe depression
4. Very irregular periods and oligomenorrhoea

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15
Q

Mechanism of action of OCP

A

Contains two female hormones: Oestrogen and Progesterone
(That are normally present in the body and which regulate our menstrual cycle)

Mechanism of action:
1. Preventing ovulation/stopping the release of eggs from the ovaries
2. Make the cervical secretions thick so that sperm cannot enter
3. Thinning of the endometrium which prevents fertilisation

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16
Q

Side effects of OCP

A
  1. Nausea/vomiting and diarrhoea
  2. Abdominal distension or bloating
  3. Breast soreness - in just the first 1-2cycles
  4. Breakthrough bleeding/Bleeding in between periods - usually settles in 3-4 months

Major side effects (rare with low dose pills)
1. Stroke
2. DVT
3. MI

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17
Q

Advantages of OCP

A
  1. Periods become more regular, lighter and shorter
  2. Less pain during periods
  3. Decreased incidence of :
    benign breast lumps
    PID
    Thyroid disorders
    Endometrial and ovarian cancers
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18
Q

Which OCP to start with and How to take it

A

Start with low dose oestrogen pill
- less breakthrough bleeding
- low failure rate

Better to choose a triphasic pill
- less post-pill amenorrhoea

How to take:
From a 28pack pill
21 pills - hormonal
7 pills - sugar coated or dummy

• Start from the first day of your next period,
• 1 tablet each day and at the same time every day.
• then take the 7 sugar pills and you will get your periods

• Contraceptive efficacy comes after 7 pills.
So use condoms until that time

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19
Q

Must remember about OCPs

A
  1. Contraceptive efficacy takes around 7 pills to become satisfactory. So use condoms as well till then.
  2. OCPs do not give protection against STI. Use condoms if STI is a concern.
  3. If diarrhoea or vomiting occurs within 2 hours of taking the pill, then take a pill again and keep going with the rest.
    Use condoms until diarrhoea and vomiting lasts.
  4. If you go to a doctor or pharmacist for any condition, let them know that you are taking OCP because there are many medicines that interfere with it
  5. Follow up in 3 months to check your
    -BP
    - pills are working properly or not
    - any problems due to which the pills need to be changed
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20
Q

25 year old Maria has given birth 2 weeks ago and is exclusively breastfeeding her child. She wants to know the contraceptive options available for her.

A
  1. Barrier methods : Condoms and Vaginal rings or diaphragms
  2. Progesterone only pills
  3. Depo-Provera or medroxyprogesterone acetate
  4. Implanon
  5. IUCD

Contraindicated in breast feeding mothers:
1. Combined OCPs
2. Lactational amenorrhoea - not much safe or reliable

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21
Q

Progesterone only pills
C A C A S A D

A

Contains - Progesterone only

Action - Thickening of the cervical secretion so sperm cannot enter
- Thinning of the endometrium (lesser extent)

Contraindications-
1. DVT
2. Breast cancer
3. Active liver disease
4. Unexplained vaginal bleeding
5. Previous history of ectopic pregnancy
6. Patient on antiepileptic drugs

Administration - 28 pills pack, all hormonal
- taken 1 tab each day
When - 3 weeks post partum
Contraceptive efficacy achieved after 3 pills

Side effects -
1. Irregular vaginal bleeding
2. Breast soreness
3. Weight gain

Disadvantages: No protection against STI

22
Q

Depoprovera/Medroxyprogesterone Acetate

C A C A S A D

A

Contains - Progestogen: Medroxyprogesterone Acetate

Action - 1. Prevents ovulation
2. Thickens cervical secretions
3. Thinning of endometrium

Contraindications-
1. Breast cancer
2. Unexplained vaginal bleeding
3. Bleeding disorders
4. Cardiac illness
5. If she wants to be pregnant again in 1 year

Administration-
IM injections every 12 weeks.
Contraception lasts for 12 weeks
When - 6 weeks post partum (can travel through breast milk and baby cannot handle depo)

Side effects-
1. Breast soreness
2. Amenorrhoea
3. Weight gain
4. Delay in the return of ovulation and fertility (6months to 1 year after stopping)
5. Osteoporosis/ Thinning of bones (advice calcium rich diet)

Advantages-
1. High efficacy and compliance
2. Does not interfere with oral medications

Disadvantages - No protection against STI

23
Q

Implanon

C A C A S A D

A

Contains - Progestogens

Action - 1. Prevents ovulation
2. Thickening of cervical secretions
3. Thinning of endometrium

Contraindications:
1. Active liver disease
2. Breast cancer
3. Bleeding disorders
4. Enzyme

Administration:
A 4cm rod containing the hormone is inserted into the inner aspect of the upper part of your non-dominant arm
under local anaesthesia
When - 3 weeks postpartum
Gives contraception for 3 years

Side effects:
1. Irregular vaginal bleeding
2. Amenorrhoea
3. Breast soreness
4. Weight gain
5. Acne
6. Headache
7. Mood swings

Advantages:
1. High efficacy and compliance
2. Does not interfere with oral medications
3. Rapid return of ovulation/fertility

Disadvantages: No protection against STI

24
Q

54 years old Michelle has come to the GP because of severe itching in the vulva.

What are the possible causes?

A
  1. Atrophic Vaginitis
  2. Lichen Sclerosis
  3. Candidiasis
  4. Skin conditions - Dermatitis
    - Psoriasis
    - Eczema
    - Allergies to newly used vaginal creams, douches or pessaries
  5. Diabetes
  6. Steroids
25
Q

54 years old Michelle has come to the GP with severe itching in her vulva.

What is the diagnosis?

A

Condition: Lichen Sclerosis - Chronic inflammatory skin condition

Cause: Autoimmune disease

Commonality: Not so uncommon

Clinical Features-
1. Intense itching in the vulvar area
2. White shiny wrinkled plaques in the vulvar area

Course: It is lifelong condition and there is no definite treatment because it is a autoimmune condition. But we can keep it under control

Complications:
1. Scar formation
2. Adhesions with the skin in the surrounding genital area
3. Labial fusion
4. 4% can turn pre-cancerous

26
Q

54 years old Michelle has come to the GP with severe itching in her vulva.

What investigations and management will you do for this condition?

A

Investigations:
1. FBE
2. UEC
3. TFT (to rule out autoimmune thyroiditis)
4. Multiple punch biopsy of the lesion to rule out any nasty/pre-cancerous changes
[KEY POINT]

Management:
1. Steriod creams
- twice daily for the first one month
- then once daily for the second month
- then decrease the amount and number of applications depending on your response
- BUT KEY POINT: She needs life long maintenance therapy, i.e 1-2 applications per week for the rest of her life

  1. If not responding to steriods - retinoids or UV therapy
  2. Refer to the specialist for multiple punch biopsy
  3. Good genital hygiene
  4. Lifelong surveillance for any malignant changes- first 6 monthly intervals and then annually
  5. Keep upto date with your CST and Mammogram
  6. Surgery required if any of the above stated complications occur.
27
Q

60 year old Mary presents to the GP with complaints of spotting since the last two months.

What are the Differential Diagnosis?

A
  1. Atrophic Vaginitis
  2. Endometrial hyperplasia
  3. Endometrial polyps
  4. Endometrial cancer
  5. Cervical polyps
  6. Cervical ectropion
  7. Cervical cancer
28
Q

60 years old Mary presents to the GP with spotting for the last two months.

What investigations will you do?

A
  1. FBE
  2. UEC
  3. Transvaginal USG
    - any abnormal growths
    - any polyps in the endometrium or cervix
    - endometrial thickness (normal thickness in post menopausal women = 5mm)
29
Q

Management of Atrophic Vaginitis

A

Condition: Atrophic vaginitis

Cause: lack of oestrogen after menopause causes dryness and thinning of the vaginal wall

Clinical features:
1. Dysparuenia
2. Post coital bleeding

Commonality: Very common

Course and Complications: Nil

Investigations:
1. FBE
2. UEC
3. Transvaginal USG

Treatment:
1. Vaginal oestrogen cream or tablets for 8 weeks
2. Vaginal Lubricants during intercourse
3. Atrophic vaginitis alone is not an indication of HRT. If you start showing post menopausal symptoms then consider HRT.

Red flags
Review in 2 days

30
Q

Management of Endometrial hyperplasia

A

Condition: Endometrial hyperplasia/ Thickness of the inner lining of the womb increased

Cause: Due to unopposed action of oestrogen from the peripheral fat tissue conversion, without being counteracted by Progesterone

Clinical features: Bleeding

Complications:
7% of cases turn to endometrial cancer

Management:
1. Refer to specialist for hysteroscopy and biopsy
2. Put her on Progestogens - orally (POP) or IUD (Mirena)
3. If biopsy shows atypical changes - removal of the uterus/hysterectomy

31
Q

25 year old Melinda comes to the GP with a lump in her vulva which is so severely uncomfortable that she cannot even sit or walk.

Tell the differential diagnosis

A
  1. Bartholin’s cyst
  2. Bartholinitist
  3. Bartholin’s abscess
32
Q

25 years old Melinda has come to the GP because a lump in her vulva which is severely uncomfortable to sit or walk.

What is the diagnosis and management

A

Management of Bartholin’s gland abscess:

  1. Give painkillers now
  2. Refer to the specialist in the hospital
  3. If it’s a small abscess, make an incision over the gland, drain the pus and send it for culture and sensitivity.
  4. If it’s a large gland, Marsupilization:
    - make an incision, drain the pus and send it for culture and sensitivity
    - the cut margins will be everted and stitched to the surrounding skin folds, so the gland will remain open.
    - This will prevent further collection and thus recurrences, and promote healing.
  5. Antibiotics
  6. Hot saline bath
    - to promote healing
  7. Good genital hygiene
  8. Advise regarding STI and practicing safe sex
33
Q

Management of Bartholin’s cyst and Bartholinitis

A

Management of Bartholin’s cyst:
1. Painkillers
2. Hot saline bath
3. If very very uncomfortable, do an aspiration of the cyst
4. Red flags

Management of Bartholinitis:
1. Painkillers
2. Antibiotics
3. Review in a week
4. Red flags

34
Q

30 years old Lisa presents to the GP with complaints of itching and burning sensation in her vagina, with discharge. This is the 4th time she is having such symptoms and was treated with Nystatin before without any improvement.

What is the cause of her recurrence?

A
  1. Pregnancy
  2. Immune deficiency sates
  3. Medications - Steroids
    - Antibiotics
  4. OCP
  5. Diabetes
  6. Vaginal creams or douches
  7. Tight clothing or pantyhose
35
Q

Investigations and Management for Recurrent Candidiasis

A

Investigations:
1. FBE with ESR and CRP
2. UEC
3. LFT (must check liver before prescribing antifungals)
4. TFT
5. Two vaginal swabs for microscopic culture and sensitivity

Management:
According to the RACGP guidelines
1. Induce symptom remission by using oral antifungal agents like:
- Fluconazole 50mg once daily
- Itraconazole 100mg once daily
For 2 weeks to 6 months as long as it takes for the symptoms to subside

  1. Maintaining the remission by:
    - Fluconazole or Itraconazole weekly for 6 months
  2. Stop taking OCP and discuss other methods of contraception
  3. Refrain from sexual intercourse until the symptoms subside (although this isn’t a STI)
  4. Don’t wear tight jeans or pantyhose.
    If you go swimming, change the wet clothes immediately after
36
Q

Investigations and Management of Bacterial Vaginosis

A

Investigations:
1. High vaginal swab - for microscopy and gram staining
2. Amine whiff test - in potassium hydroxide solution it gives out a pungent fishy smell
3. pH of the vaginal fluid - >4.5 in Bacterial Vaginosis

Treatment:
1. Metronidazole 400mg twice daily with food for 7 days
If pregnant- Clindamycin 300mg twice daily for 7 days

  1. Avoid vaginal douching or creams - they can alter the normal bacteria in your vagina
  2. If concerned about STI - offer STI screening
  3. Partner does not require treatment at the moment but practice safe sex
  4. It can recur in 6-12 months even after the treatment and be associated with STI
37
Q

Investigations and Management of Trichomoniasis

A

Investigations:
1. High vaginal swab - for microscopy

Treatment:
1. Notify the DHS
2. Metronidazole 500mg twice daily with food for 7 days
3. Treat the partner as well
4. Offer STI screening

38
Q

34 year old Venessa has come to the ED due to severe abdominal pain. She has not passed urine since last night.

What can be causing her urinary retention?

A
  1. Fibriods
  2. HSV infection
  3. UTI
  4. Utero vaginal prolapse
  5. Ovarian tumours
39
Q

Initial management of any patient coming with urinary retention

A
  1. Inspection:
    Of the abdomen- any masses or distended bladder
    Any rashes or vesicles around the vulva vagina
  2. Palpation:
    Of the lower abdomen to see :
    - tenderness
    - bladder is palpable or not
  3. Percussion:
    - the bladder is dull on percussion or not
  4. USG scan of the bladder to confirm Urinary retention

After confirming:
- with all aseptic precautions, insert a sterile Foley’s catheter to empty the bladder
- measure the amount of urine collected and send it for Culture and sensitivity
- keep the catheter in situ until the patient is seen and evaluated by a specialist

40
Q

34 year old Venessa has come to the ED due to severe abdominal pain. She has not passed urine since last night and has painful vesicles around her private parts.

What is the diagnosis and management of this condition?

A

Condition: HSV infection

Cause: Viral infection caused by Herpes Simplex Virus, and sexually transmitted.
The virus stays dormant in the nerve cells and gets reactivated when the body is going through a immune deficiency state:
- pregnancy
- infection
- steroids
- uncontrolled DM

Commonality: Common

Clinical features: Painful rash, ulcers or vesicles around the private parts
- Urinary retention due to pain or UTI

Investigations:
1. To confirm - Take a swab a send it for
PCR
2. STI screening of her and her partner (with the patient’s consent)

Treatment:
1. Acyclovir 800mg for 5-7 days
2. Strong painkillers
3. Can use ice packs over the lesions to bring down the pain and dry the area afterwards. Do not try to manually rupture the vesicles
4. If you have difficulty passing urine again, try it under a warm salt bath (salt bath will decrease the pain and warmth will stimulate the bladder)
5. Good genital hygiene and keep the area clean and dry
6. Don’t wear any tights jeans or pantyhose

  1. Partner needs to be checked and treated.
  2. Refrain from sexual intercourse until lesions subside
41
Q

What are the causes of utero vaginal prolapse?

A
  1. Bad obstetric history
  2. Menopause
  3. Chronic cough
  4. Constipation
  5. Obesity
42
Q

53 years old Tracey has come to the GP to discuss about HRT.

What history will you take/History structure

A
  1. What do you know about HRT?
    And any particular reason why you want to start it?
  2. Indications of HRT/Post menopausal symptoms
  3. Contraindications of HRT
  4. 5P
  5. Well person questions
  6. SADMA COT FP
43
Q

20 year old Amanda presents to the GP clinic with a history of irregular periods for the past 1 year and no periods at all for the past 3 months.

What is the condition?

A

Condition: PCOS
- complex condition
• Ovaries - become large
- develop multiple immature follicles, none of which develops to release an egg
- ovulation doesn’t take place
- periods become scanty and ultimately stops

 • Body becomes more resistant to insulin leading to Diabetes 

• Ovaries secrete testerone leading to weight gain, acne and hirsutism

Cause : Unknown but found to run in families

Complications :
1. High blood pressure
2. High blood sugar
3. High cholesterol levels
4. Infertility
5. Depression

44
Q

20 year old Amanda presents to the GP clinic with a history of irregular periods for the past 1 year and no periods at all for the past 3 months.

Investigations and Management of this condition

A

Investigations:

Blood - FBE with ESR and CRP
- UEC
- LFT
- TFT
- Lipid profile
- S. Prolactin levels
- BSL
- Hormones - GnRh, LH, FSH, Oestrogen and Progesterone levels

Imaging - Pelvic USG (to confirm)
>10 follicles <10mm in size

Management:
1. Refer to specialist

  1. Lifestyle modifications:
    - SNAP
    - loose weight be cause even 10% reduction in weight can lead to the
    • hormones getting back to normal
    • body becoming more sensitive to insulin
    • testerone levels decrease
    • refer to dietitian for that
  2. Medications:
    • OCP
    - period becomes regular
    - decrease acne and hirsutism
    - decrease the lipids and insulin resistance to an extent• Metformin
    - decreases the LH levels
    - periods become regular
    - decreases testosterone levels• GnRh analogue (if above doesn’t work)
    - suppresses the HPO axis
    - periods become regular
  3. Surgical (if medical management doesn’t work)
    • Laparoscopic ovarian drilling
    - keyhole surgery under GA to destroy small portions of the ovaries and bring down the testosterone portions and etc etc
  4. For hirsutism immediate treatment:
    - Laser therapy
  5. For infertility:
    - Lifestyle modifications for the first 6 months
    - Medical: Clomiphene citrate + Metformin
    - Surgical: Laparoscopic ovarian drilling
45
Q

68 years old lady presents to the GP clinic with complaints of inability to hold urine for 6 months. She’s very worried about it.

Take further relevant history

A
  1. About the leaking of the urine- SOCRATES
  2. About Stress incontinence
  3. About urge incontinence
  4. Water works and bowel habits
  5. Risk factors like chronic cough, constipation
  6. 5P :
    - Menopause questions
    - Pregnancy questions for
    • how many children
    • what’s the time gap between each of the children
    • any bad obstretic history like obstructed labour, prolonged labour, big baby, instrumental delivery
  7. HEADSS and support
  8. SADMA COT FP
46
Q

68 years old lady presents to the GP clinic with complaints of inability to hold urine for 6 months. She’s very worried about it.

List the investigations

A

Investigations:
1. Urine for UDT and MCS

  1. Blood for FBE with ESR and CRP, UEC, LFT, BSL
  2. Refer to specialist for Urodynamic studies
    1. Urethrocystoscopy
    2. Uroflowmetry
    3. Cystometry
    4. Post voidal residual volume (MOST IMPORTANT)
47
Q

68 years old lady presents to the GP clinic with complaints of inability to hold urine for 6 months. She’s very worried about it.

Explain the condition

A

Condition- Urinary incontinence. Meaning involuntary leakage of urine.

There are two types :

  1. Stress incontinence-urine leaks while you are stressing like coughing, sneezing or laughing
    Cause is - Weakness of the spinchter muscles
  2. Urge incontinence - which occurs when you need to pee but you cannot hold it in the urine bag anymore,
  3. Mixed incontinence.

Causes - risk factors that contribute to it like:
1. Increased pressure in the abdominal wall due to
- chronic cough
- chronic constipation
2. Bad obstetric history
3. Menopause
4. UTI
5. Bladder irritants
6. Medication

Complication
1. UTI
2. Life hazards

48
Q

68 years old lady presents to the GP clinic with complaints of inability to hold urine for 6 months. She’s very worried about it.

Management of this condition

A

Management:
1. Lifestyle modifications - SNAP
Refer to a dietitian

  1. If the patient has cough or constipation
    • Treatment of the cough
    • Treatment of the constipation - stool softeners and high fibre diet
  2. Maintain a bladder diary
    • Record the time when you’re having the incontinence
    • So that we can correctly identify the type of incontinence
    • and see whether the treatment is effective or not
  3. Stress incontinence:
    By Pelvic floor muscle exercise or Kegel exercise.
    • I would refer you to a physiotherapist we can treat you this.
      • You can do this in a standing or lying position.
      • Contract your bottom muscles and count to 8 then relax them again count to 8, repeat eight times at a go three times daily.

Conservative fail I will refer you to a surgeon for different surgical options

  1. For urge incontinence:
    Pelvic or muscle exercise + Bladder retraining exercise.
    • When you feel the urge to go to the toilet, try to hold it back
    • initially for five minutes and gradually increase the span of time before you go to the toilet
    • once you start passing the urine, try to hold it back at times and then start again.
  2. Main thing I’ll do right now:
    start on some medication for one month since it is hampering your lifestyle so much
    - oxybutynin (KEY POINT)
49
Q

Causes of Breakthrough bleeding

A
  1. Not taking the pill at the same time everyday
  2. Low dose oestrogen - cannot maintain the thickness of the endometrium properly and thus it breaks down causing irregular bleeding
  3. Type of progesterone is the pill
  4. Smoking
  5. Medications- antiepileptics
  6. STI
50
Q

Management of breakthrough bleeding

A
  1. Breakthrough bleeding usually settles within 3-6 months
  2. If you are happy, you can continue the pill
  3. Take the pill everyday at the same time
  4. If bleeding continues for more than 6 months, high dose OCP with different progesterone
  5. Stop OCP at all and discuss other methods of contraceptions
51
Q

A 53 year old woman comes to the GP with feeling of something bulging down below.

Explain the condition

A

Condition- Uterovaginal prolapse
The cervix or the uterus, or both bulge into the vagina

Cause-
All the causes of uterovaginal prolapse

During pregnancy:
- due to extra weight gain and
-hormonal changes
these muscles can become weak and
At the time of labour,
- pushing or straining make these muscles become weaker
- deliver of a big baby
- prolonges labour also contribute to prolapse

After menopause, as the ovaries shut down, no oestrogen is formed. Oestrogen is necessary to maintain the strength and stability of the pelvic floor muscles.

52
Q

A 53 year old woman comes to the GP with feeling of something bulging down below.

Management of this condition

A

Management

  1. Refer to a specialist
  2. Lifestyle modification -SNAP
  3. Refer to a dietician
  4. Do regular pelvic floor muscle exercise, can be taught by a physiotherapist
    - We can do it in standing or sitting or lying position
    - Contract the bottom muscles and count till eight, then relax it and then again count till eight, do it eight times at a go three times in a day
    - It usually takes around 3 to 6 months for the pelvic exercise to work
  5. Vaginal pessary-
    it will keep the prolapse in place and prevent from getting worse,
    but it is not a definitive treatment. You need to change it every 3 to 4 months
  6. If conservative treatment fails, then surgical management:
  7. Coloporraphy: reinforcing the pelvic floor muscles by using stitches.
  8. Sacrocolpoplexy: suspending the vagina, cervix, and other pelvic organs and securing into the backbone or the sacrum
  9. Hysterectomy: Removal of the uterus

AMC (12 decks)

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