Gynaecology Flashcards

Question

What are the risk factors for stress incontinence?

Answer 1

``` Pregnancy Vaginal delivery DM Oral oestrogen therapy High BMI Vaginal hysterectomy Perimenopause Parity ```

Answer 2

Leakage of urine on sneezing, coughing, exercise, rising from sitting or lifting.

Answer 3

Possible vaginal atrophy

Answer 4

``` Bladder chart for 3 days In history ask about sexual dysfunction and quality of life, assess functional status, bowel habit MSU & urinalysis Urodynamic Urinary flow rates Assessment of residual urine ```

Answer 5

Pelvic floor exercises (3 month trial) Drug treatment e.g. duloxetine Surgical treatment e.g. retropubic mid-urethral tape, open colposuspension, autologous rectal fascial sling Temporary containment products to achieve social continence should be offered until there is a specific diagnosis and management plan

Answer 6

It is the second most common cause of female urinary incontinence. Prevalence increases with age. It may be associated with Parkinson's disease, spinal cord injury, MS, dementia, stroke or diabetic neuropathy

Answer 7

Sudden urge to urinate that is difficult to delay and may be associated with leakage, frequency in micturition, nocturia, abdominal discomfort and urge incontinence.

Answer 8

``` Stress incontinence Functional incontinence Overflow incontinence Urinary fistula Enuresis UTI DM Bladder cancer Bladder stones ```

Answer 9

MSU & urinalysis Blood for renal function, U&Es, Ca2+ and fasting glucose Urodynamic studies

Answer 10

Lifestyle changes: reduce caffeine, modification of fluid intake, weight loss if BMI >30 Bladder training: first line for 6 weeks, pelvic muscle training, scheduled voiding intervals with stepped increases and suppression of urge with distraction/relaxation techniques Drug treatment: anticholinergics, intravaginal oestrogens, mirabegron Botox into the bladder wall Sacral nerve stimulation Surgery: only indicated for intractable and severe idiopathic OAB. Augmentation cystoplasty

Answer 11

``` Increased age Vaginal delivery Increased parity Obesity Previous hysterectomy Possible: obstetric factors, family history of prolapse, constipation, connective tissue disorders, occupations involving heavy lifting ```

Answer 12

Anterior compartment: urethrocele, cystocele, cystourethrocele Middle compartment: uterine prolapse, vaginal vault prolapse, enterocele Posterior compartment: rectocele

Answer 13

May be asymptomatic and an incidental finding. Vaginal symptoms: sensation of pressure, fullness or heaviness, sensation of bulge/protrusion/something coming down, seeing/feeling a bulge/protrusion, spotting, difficulty retaining tampons Urinary symptoms: incontinence, frequency, urgency, weak/prolonged urinary stream, incomplete bladder emptying Coital difficulty: dyspareunia, loss of vaginal sensation, vaginal flatus, loss of arousal Bowel symptoms: constipation/straining, urgency of stool, faecal incontinence

Answer 14

Examination. If patient has urinary symptoms then MSU, post-void residual urine, urea and creatinine levels. Renal USS. Occasionally USS and MRI

Answer 15

Conservative: watchful waiting, lifestyle changes, pelvic floor muscle exercises, vaginal oestrogen creams. Vaginal pessary insertion Surgery

Answer 16

Prepubertal girls | Postmenopausal women

Answer 17

Itch - can disturb sleep, usually worse at night Pain - dyspareunia Perianal lesions - constipation Can be asymptomatic

Answer 18

White lesions, may progress to crinkled white patches. Active lesions may have areas of ecchymosis, hyperkeratosis or bullae. Destructive scarring may cause shrinkage of the labia, narrowing of the introitus or the clitoris. Perianal lesions occur in approx 30% of cases

Answer 19

Biopsy Swabs to rule out infection Bloods including autoimmune screen and TFTs

Answer 20

``` In children, signs may mimic those of child sexual abuse. Vitiligo Localised Scleroderma Lichen planus Leukoplakia Vulval intraepithelial neoplasia Bowen's disease ```

Answer 21

A reducing course of clobetosol propionate is the usual treatment. Wash with bland emollients Scarring may require surgery

Answer 22

3rd most commonly diagnosed cancer worldwide | More common in those aged 25-34

Answer 23

70% are squamous carcinomas 15% are a mixed pattern 15% are adenocarcinomas All 3 cause pre-invasive and invasive disease

Answer 24

Many cases are detected by screening. First symptoms: vaginal discharge, bleeding (can be spontaneous but can occur after sex, micturition or defecation), vaginal discomfort/urinary symptoms. Late symptoms: painless haematuria, chronic urinary frequency, painless fresh rectal bleeding, altered bowel habit, leg oedema, pain, hydronephrosis

Answer 25

White or red patches on the cervix | DRE may reveal a mass or bleeding due to erosion

Answer 26

``` Cervicitis Dysfunctional uterine bleeding Ectropion PID Endometrial cancer ```

Answer 27

``` Chlamydia test Colposcopy Cone biopsy FBC, renal function and LFTs CT chest, abdo and pelvis PET scan ```

Answer 28

Surgery - extent of which is dictated by tumour stage, age of patient and co-morbidites. Patients fertility options/wishes should be taken into account. Radiotherapy Chemotherapy

Answer 29

``` Prolonged periods of unopposed oestrogen Being nulliparous Menopause past the age of 52 Obesity Endometrial hyperplasia HNPCC PCOS DM Tamoxifen ```

Answer 30

Post-menopausal bleeding Irregularities of the menstrual cycle Unlikely to be any physical abnormality unless the disease is well advanced

Answer 31

Transvaginal USS Endometrial biopsy e.g. pipelle Hysteroscopy and biopsy Many women also have a CXR and bloods (FBC, LFTs)

Answer 32

Surgery - TAH and BSO, use of progesterone to protect fertility Radiotherapy Chemotherapy

Answer 33

90% are squamous cell carcinoma, others are basal cell carcinomas, adenocarcinomas, sarcomas and melanomas

Answer 34

VIN Lichen sclerosus HPV Paget's disease of the vulva

Answer 35

Vulval lump Vulval bleeding due to ulceration, pruritus or pain 75% of all growths are primarily on the labia; there should be a high index of suspicion for abnormal lesions in the vulva including "warts" in the post-menopausal woman.

Answer 36

Examination and biopsy Cystoscopy Proctoscopy CXR and MRI for staging

Answer 37

``` Lichen planus Ulcers Dermatitis Fungal infection Other causes of swellings of the vulva e.g. boils, Bartholin's cyst ```

Answer 38

Surgery Radiotherapy Chemotherapy

Answer 39

Usually squamous cell carcinoma involving the posterior wall of the upper 1/3 of the vagina. Lesions ay be ulcerative or exophytic 85% of cases are SCC, 10% are adenocarcinoma (peak incidence 17-21), rarely melanoma and sarcomas are primary vaginal cancers

Answer 40

Vaginal bleeding or bloody discharge may be seen. | Advanced tumours may affect the rectum or bladder or extend to the pelvic wall causing pain or leg oedema

Answer 41

``` Colposcopy Biopsy Cervical cytology Endometrial biopsy CT scan FDG-PET CXR Cystoscopy Sigmoidscopy ```

Answer 42

Treatment options depend on tumour stage. Surgery and radiotherapy are very effective in early stage disease. Radiotherapy is the primary treatment for more advanced stages. Chemotherapy has not yet show to be curative. Surgery: radical TAH with removal of upper vagina

Answer 43

Premalignant: hydatidiform mole - complete or partial Malignant: GTN - invasive mole, choriocarcinoma, placental site trophoblastic tumour, epithelioid trophoblastic tumour

Answer 44

More common in women >45 and < 16 years old | Increased risk with multiple pregnancy and previous molar pregnancy

Answer 45

Vaginal bleeding in the 1st trimester and uterine evacuation at approx 10 weeks. All products of conception from a non-viable pregnancy should undergo histological examination. Women with persistent abnormal vaginal bleeding after a non-pregnancy should have bhGC done to exclude GTN

Answer 46

Urine and blood levels of hCG Histology of products of conception USS Staging investigations where metastatic disease is suspected

Answer 47

Registration Suction curettage for complete and partial molar pregnancies and surveillance after hydatidiform mole Chemotherapy

Answer 48

Estimated to affect 10-15% of women of reproductive age. | Endometriosis has a higher prevalence in infertile women, estimated 25-40%

Answer 49

``` Early menarche Late menopause Delayed childbearing Short menstrual cycles Long menstrual flow Obstruction to vaginal outflow Family history ```

Answer 50

``` Dysmenorrhoea Dyspareunia Cyclic or chronic pelvic pain Subfertility Bloating Lethargy Constipation Low back pain ```

Answer 51

Examination is often normal but can have posterior fornix or adnexal tenderness Palpable nodules in the posterior fornix or adnexal masses Bluish haemorrhagic nodules visible in the posterior fornix

Answer 52

``` PID Ectopic pregnancy Torsion of ovarian cyst Appendicitis Primary dysmenorrhoea IBS Uterine fibroids UTI ```

Answer 53

``` Transvaginal USS and pelvic USS Diagnosis laparoscopy - GOLD STANDARD MRI FBC Urinalysis and MC&S Cervical swabs bhCG ```

Answer 54

Medical: COCP, mednoxyprogesterone acetate and GnRH agonists, Mirena IUS Surgery: remove severe and deep infiltrating lesions, ovarian cystectomy, adhesiolysis, TAH & BSO Pain management specialists and clinical psychologists

Answer 55

The presence of functioning endometrial tissue which has penetrated the myometrium by direct spread from the uterine lining

Answer 56

1/3 of patients are asymptomatic Progressively increasing pain usually associated with menstruation Menstrual irregularities e.g. premenstrual staining and spotting, increased flow or more frequent periods

Answer 57

Enlarged and tender uterus

Answer 58

Transvaginal USS Pelvic USS MRI of the uterus

Answer 59

Anti-inflammatories during the period, hormonal treatments e.g. COCP, progesterone-only pill/injection mirena IUS, GnRH analogues, endometrial ablation, uterine artery embolisation, TAH If the patient is asymptomatic then treatment may not be necessary

Answer 60

Being in 40s or 50s before menopause Having children Previous uterine surgery e.g. LSCS

Answer 61

Primary - occurs in young females with no pelvic pathology | Secondary - occurs in association with some form of pelvic pathology

Answer 62

``` Endometriosis Adenomyosis PID Fibroids Adhesions Developmental abnormalities Copper IUD ```

Answer 63

Adenomyosis - uterus may be enlarged and tender with a "boggy" feel Endometriosis - generalised tenderness in the pelvic area Partially imperforate hymen Vaginal septum

Answer 64

``` Vaginal swabs Cervical smear Pelvic USS Transvaginal USS MRI scan Laparoscopy +/- biopsy ```

Answer 65

Lifestyle changes e.g. smoking cessation, self-help techniques NSAIDs Hormonal treatment

Answer 66

It is very common in post-menopausal women due to the falling levels of oestrogen. Natural menopause Oopherectomy Anti-oestrogenic treatments, radiotherapy or chemotherapy Post-partum or with breastfeeding

Answer 67

``` Asymptomatic Vaginal dryness Burning or itching of the vagina or vulva Dyspareunia Vaginal discharge Vaginal bleeding Post-coital bleeding Urinary symptoms ```

Answer 68

``` External genitalia may show reduced pubic hair Reduced turgor/elasticity Narrow introitus Thin mucosa with erythema Occasional petechiae or ecchymoses s Dryness Lack of vaginal folds ```

Answer 69

Genital infections e.g. BV, trichomonas, candidiasis, endometritis Local irritation due to soap, panty liners etc

Answer 70

Investigation may not be necessary but is useful to exclude other potential diagnosis. Vaginal pH testing Vaginal cytology

Answer 71

Vaginal lubricants and moisturisers Vaginal oestrogen Hormone replacement therapy

Answer 72

Excess androgens are produced by the theca cells of the ovaries (either due to hyperinsulinaemia or increased LH), insulin resistance, increased LH and increased oestrogen in some women

Answer 73

``` Oligomenorrhoea (<9 periods/year) Infertility or subfertility Acne Hirsutism Alopecia Obesity or difficulty losing weight Psychological symptoms - mood swings, depression, anxiety, low self-esteem Sleep apnoea ```

Answer 74

``` Hirsutism Male pattern balding/alopecia Obesity Acanthosis nigrans Occasionally clitoromegaly Increased muscle mass Deep voice ```

Answer 75

ROTTERDAM CRITERIA: 2 of the 3 following: Polycystic ovaries (>/= 12 peripheral follicles or increased ovarian volume >10cm3) Oligo-ovulation or anovulation Clinical and/or biochemical signs of hyperandrogenism

Answer 76

``` Thyroid disorder Hyperprolactinaemia Cushing's syndrome Acromegaly Side effects from medication Late-onset congenital adrenal hyperplasia Androgen-secreting ovarian or adrenal tumours Ovarian hyperthecosis ```

Answer 77

Pelvic USS | Total testosterone, free testosterone, LH, TFTs, fasting glucose and lipids, sex hormone-binding globulin

Answer 78

Counselling on long-term effects Weight control and exercise Low GI diet If not wanting to conceive: COCP, co-cyprindrol, metformin, eflornithine, orlistat If wishing to conceive: clomifene, metformin, laparoscopic ovarian drilling

Answer 79

A rare, acquired condition of the uterus resulting in intrauterine adhesions

Answer 80

``` Myomectomy LSCS Infections Age Genital TB Repeated D&C or over-vigorous D&C Obesity ```

Answer 81

Decrease in flow and duration of bleeding Oligomenorrhoea Pain during menstruation and ovulation Infertility

Answer 82

Hysteroscopy HSG Sonohysterography - USS pelvis when uterus is filled with sterile fluid

Answer 83

Adhesiolysis and follow up tests to ensure adhesions haven't returned

Answer 84

Extent of adhesion formation is critical | Mild-moderate adhesions can usually be treated with success

Answer 85

Benign, prolactin-producing tumours of the pituitary gland. Microadenomas are the most common (90%) Macroadenomas are rare (>10 mm in size) approx 10% Can also have giant pituitary adenomas (>40mm) and malignant prolactinomas (vary rare)

Answer 86

``` Amenorrhoea Oligomenorrhoea Anovulatory cycles Galactorrhoea Infertility Hirsutism Reduced libido ```

Answer 87

Bitemporal hemianopia as a result of compression of the optic chiasm Cranial nerve palsies

Answer 88

TFTs, bhCG, basal serum prolactin Visual field testing Pituitary imaging preferably MRI Assessment of pituitary function

Answer 89

Treat with dopamine agonists: cabergoline, bromocriptine, quinagolide Surgery Radiotherapy - rarely used

Answer 90

Osteoporosis, reduced fertility (erectile dysfunction and infertility in men)

Answer 91

Often polymicrobial, can be caused by genital mycoplasmas, endogenous vaginal flora, aerobic streptococci, mycobacterium tuberculosis and STIs e.g. Chlamydia trachomatis and Neisseria gonorrhoeae

Answer 92

Risk factors for acquiring STIs Having had an IUCD fitted in the last 20 days Termination of pregnancy

Answer 93

Bilateral lower abdominal pain Deep dyspareunia Abnormal vaginal bleeding Vaginal or cervical purulent discharge

Answer 94

Lower abdominal tenderness Mucopurulent discharge and cervicitis on speculum Cervical motion tenderness and adnexal tenderness on bimanual examination Fever >38C

Answer 95

``` bhCG Cervical and endocervical swabs ESR or CRP Endometrial biopsy USS Diagnostic laparoscopy Urinalysis and urine culture ```

Answer 96

Mild-moderate disease: primary care/outpatients Severe disease: inpatient for IVABx Moxifloxacin is 1st line Doxycycline as an empirical treatment for male partners Refer to GUM clinic for full work up

Answer 97

``` Infertility Ectopic pregnancy Perihepatitis Tubo-ovarian abscess Reactive arthritis ```

Answer 98

Amenorrhoea in a patient who has never had a period. Investigate in 14 year old girls with no breast development or 15 year old girls with breast development. The most common cause is late puberty. Consider genetic karyotyping for Turner's syndrome or testicular feminisation. True primary amenorrhoea is caused by congenital absence/undeveloped uterus or ovaries

Answer 99

Amenorrhoea in patients who previously had periods.

Answer 100

``` Emotional distress Weight loss Low BMI Excessive exercise Systemic disease Hyperthyroidism Drug-induced (contraceptives, antipsychotics, long term opiates) Early menopause PCOS Pituitary tumour Pituitary necrosis ```

Answer 101

``` FSH (increased in premature menopause) Testosterone (increased in PCOS) LH (increased in PCOS) TFTs bhCG (could be pregnant!) USS Prolactin ```

Answer 102

Treatment depends on the cause