gynaecology Flashcards
what are the risk factors for urinary incontinence?
advancing age previous pregnancy and childbirth high BMI hysterectomy family history
what are the different types of urinary incontinence?
overactive bladder (urge incontinence: due to detrusor over activity
stress incontinence: leaking small amounts when coughing or laughing
mixed incontinence - both urge and stress
overflow incontinence - due to bladder outlet obstruction e.g. prostate enlargement
what investigations would you perform for urinary incontinence?
bladder diaries should be completed for a minimum of three days
empty supine stress test urinalysis post-void residual measurement cough stress test urodynamic testing vaginal exam to exclude organ prolapse
how is urge incontinence managed?
1st line is behavioural approach plus lifestyle changes (bladder training and pelvic floor exercises, plus weigh loss, caffeine reduction, fluid management, smoking cessation)
2nd line -antimuscarinincs oxybutynin (immediate release), tolterodine (immediate release). oxybutynin should be avoided in frail old women.
mirabegron may be useful in frail older patients
how is stress incontinence managed?
1st line - pelvic floor exercises, vaginal device, lifestyle changes - weight loss, caffine reduction, fluid management
if there is urethral sphincter insufficiency - pseudoephdrine or duloxetine
surgical procedures may be required
retropubic suspension
retropubic colposuspension (burch colposuspension)
mid-urethral sling
What are the types of urogenital prolapse?
cystocele, cystourethrocele
rectocele
uterine prolapse
what are the risk factors for urogenital prolapse?
increasing age multiparity vaginal deliveries obesity spina bifida
how do prolapses present?
sensation of pressure, heaviness, bearing down
urinary sypmtoms - incontinence, frequency, urgency
consipation
sexual dysfunction
lower back pain
how are prolapses managed?
if asymptomatic
observation and pelvic floor exercises and weight loss
the use of a pessary
vaginal wall repair
what are the different types of pessaries used for prolapse?
Ring - usually first line, but requires intact perineal body for retention
shelf - used when ring pessary not retained
What are uterine fibroids?
they are also known as leiomyomata
Fibroids are benign smooth muscle tumours of the uterus,
smooth muscle and fibrous elements are present
*the growth is oestrogen and progesterone dependant
what are the different types of uterine fibroids?
intramural (confined to the myometrium)
subserosal (located just under the uterine serosal (outer surface) and can distort the outer surface of the uterus)
pedunculated (on a stalk)
submucosal (develops immediately underneath the endometrium and protrudes into the uterine cavity
what are the risk factors for fibroids?
obestiy early menarche increasing age fam history ethnicity
what are the symptoms of fibroids?
many patients will be asymptomatic
symptoms are more related to the site rather than the size
submucosal will cause abnormal menstrual bleeding whereas subserosal is more likely to be asymptomatic
The main presentation is menorrhagia Pain - dysmenorrhoea there may be pressure symptoms - urinary frequency and retention Fertility can be impaired a solid pelvic mass may be palpable
what are the problems of fibroids with pregnancy?
premature labour malpresentation transverse lie obstructed labour postpartum haemorrhage
what investigations would you perform for fibroids?
USS - transvaginal
endometrial biopsy
you could also consider:
MRI
hysteroscopy
laparoscopy
how would you manage fibroids?
levonorgestrel-releasing intrauterine system
other options:
OCP
tranexamic acid
GnRH agonist - may reduce the size of fibroid - good for short term management
OR
myomectomy
If fertility preservation is not required…
uterine artery embolisation
hysterectomy
What are the different types of functional ovarian cysts?
Follicular cysts (most common, due to non-rupture of the dominant follicle, they commonly regress after several menstrual cycles). Usually not bigger than 3cm
Corpus luteum cyst - occurs when the corpus luteum does not break down in the absence of pregnancy. Usually less than 5cm
Theca-lutein cysts - in response to hCG - only occur during pregnancy.
what are benign germ cell tumours?
dermoid cysts
also called mature cystic teratomas
they are usually line with epithelial tissue and hence may contain skin appendages, hair and teeth
torsion is more common than with other types of tumour?
what are the classifications of cysts?
Physiological: occur as an exaggerated response to normal physiological processed; follicular, endometriotic, corpus luteum and theca lutein cysts
Infectious: and abscess or cystic collection of cellular debris
Benign neoplastic: excessive growth of normal ovarian tissue types without dysplasia - serous cystadenoma, mucinous cystadenoma, adenofibroma, fibroma, dermoid cyst and brenner’s tumour.
Malignant neoplastic: serous cystadenocarcinoma, endometrioid carcinoma and immature teratoma
Metastatic: invasion and growth of neoplastic tissue from another malignant source, most commonly ovarian, endometrial, colonic or gastric cancers.
what is an endometrioma?
a pathological cyst - also called chocolate cysts and are present in the ovaries of people with endometriosis.
There is bleeding into the cyst which gives the appearance
what is the presentation of ovarian cysts?
chronic pain
pressure symptoms (bowel/bladder frequency and constipation)
acute pain - rupture or bleeding into a cyst
bloating and early satiety
Ovarian cancer presentation is vague and delayed
what are the complications of ovarian cysts?
rupture into the peritoneal cavity causes intense pain particularly with and endometrioma or a dermoid
Haemorrhage into a cyst or peritoneal cavity causes pain
peritoneal cavity haemorrhage is occasionally severe enough to cause hypovolaemic shock
torsion of the pedicle causes infarction of the ovary and tube and causes severe pain
what investigations would you perform for ovarian cysts ?
transvaginal USS
CA125
how are ovarian cysts managed?
if the patient is acutely ill - laparoscopy or laparotomy
what is an enterocele?
prolapse of the upper posterior wall of the vagina. The resulting puch usually contains a loop of small bowel
what are the different degrees of prolapse?
first degree - the lowest part of the prolapse descends half way down the vaginal axis to the introitus
second degree - the lowest part of the prolapse extends to the level of the hyman and through the hyman on straining
third degree - the lowest part of the prolapse extends through the hymen and lie outside the vagina
fourth degree - complete prolapse - no support visible
what are the surgical options for prolapse?
uterine prolapse - vaginal hysterectomy, hysteropexy
vaginal vault prolapse - sacrocolpopexy, sacrospinous fixation
vaginal wall prolapse - anterior and posterior repairs
what is ovarian torsion?
A twisting of the ovary and/or fallopian tube on its vascular and ligamentous supports, blocking adequate blood flow to the ovary
what can cause ovarian torsion?
underlying anatomical abnormalities
cysts and neoplasms account for 90% of all cases and . the rest occur in normal appearing ovaries
the larger the ovary the more chance there is of torsion
also long fallopian tubes
sudden increase in abdominal pressure
what are the signs of ovarian torsion
usually sudden onset of deep colicky abdominal pain associated with vomiting and distress
abdominal and pelvic tenderness
palpable adnexal mass
what investigations would you perform for ovarian torsion?
FBC - leukocytosis may increase the suspicion of torsion however it is not always seen
pregnancy test
transvaginal USS - enlarged ovary; soli, cystic or complex adnexal mass; diminished or absent blood flow to the ovary
abdominal USS
urinalysis
surgical visualization - confirms diagnosis
what are the differentials for ovarian torsion?
ectopic pregnancy PID appendicitis endometriosis UTI ovarian cyst
how is ovarian torsion managed?
1st line - surgical detorsion
2nd line - salpingo-oophorectomy
what are the different types of germ cell tumours?
teratoma
dysgerminoma
yolk sac tumour
choriocarcinoma
what are the different types of sex cord-stomal tumours?
granulose cell tumour (malignant - produces oestrogen leading to precocious puberty in children or endometrial hyperplasia in adults)
Sertoli-leydig cell tumour (benign, produces androgens - masculinising effects
Fibroma (benign) tyically occurs around the menopause - classically causing a pulling sensation
what is a kurkenberg tumour?
Metastases from a gastrointestinal tumour resulting in a mucin-secreting signet-ring cell adenocarcinoma
what is Lichen sclerosus?
an chronic inflammatory skin disease of the anogenital area in women - usually in the elderly
the vulval epithelium is thin with a loss of collagen
what are the clinical features of lichen sclerosus?
white atrophic patches on the skin, usually within the anogenital region
most common symptom is itching and the skin may undergo fissuring or erosions which causes pain
sexually active women often experience dyspareunia
some patients are asymptomatic
inflammatory adhesions can form and potentially cause fusion of the labia
vulval carcinoma can develop in 5% of cases. 1
how is lichen sclerosus managed?
first line - topical steroids e.g. clobetasol
if severe - immunosuppression
when may patients with lichen sclerosus need a biopsy?
if there is a suspicion of neoplastic change
if disease fails to respond to adequate treatment
if there is extragenital LS, with features suggesting an overlap with morphoea
if there are pigmented areas, in order to exclude an abnormal melanocytic proliferation
what is the most common type of ovarian cancer?
epithelial carcinoma - 95%
if a women under the age of 30 is affected by ovarian cancer what is the likely type of cancer?
germ cell tumour
what are some risk factors for ovarian cancer?
family history of the BRCA1 or BRCA 2 gene
many ovulations: early menarche, late menopause, null parity
**pregnancy, lactation and the use of OCP are protective
what are the clinical features of ovarian cancer?
** silent nature means it presents v late on
70% of patients present with stage 3-4
persistent abdominal distension and bloating, feeling full, LOA, pelvic/abdo pain, urinary symptoms (urgency and frequency)
symptoms similar to IBS
there may be a palpable abdominal mass
is there screening for ovarian cancer?
no screening for the general population only for high risk patients (fam history of ovarian and/or breast cancer)
what is the staging of ovarian cancer?
stage 1 - disease macroscopically confined to ovaries
1a - one ovary affected - capsule intact
1b - both ovaries affected- capsule intact
1c - 1a or 1b with tumour on the surface, ruptured capsule, cytologically positive ascites, or positive peritoneal washings
stage 2 - disease extends to the pelvis - e.g. uterus, fallopian tubes or other pelvic tissue
stage 3 - abdominal disease and/or effected lymph nodes
stage 4 - disease beyond the abdomen
the degree of differentiation or grade is also reported
what investigations would you perform for ovarian cancer?
CA125 should be measured in woman over 50 with any abdominal symptoms
If CA125 is raised above 35 IU/mL then urgent USS of abdo and pelvis should be ordered.
USS
in women under 40 AFP and hCG should be measured as these are indicative of germ cell tumours
how is ovarian cancer managed?
usually surgery and platinum based chemo (carboplatin)
what are the different types of cervical cancer?
70-80% are squamous cell carcinomas
15% adenocarcinoma (worse prognosis)
15% mixed in type
what happens before cervical cancer develops?
cervical cancer usually develops as a progression from cervical intraepithelial neoplasia which occurs over the course of 10-20 years - sometimes this does regress and does not form cancer
what are some risk factors for cervical cancer?
HPV infection smoking STIs >8 years of OCP use immunodeficiency e.g. HIV early onset of sexual activity multiple sexual partners
what are the features of cervical cancer?
may be asymptomatic abnormal vaginal bleeding (post coital, intermenstrual or post-menopausal) vaginal discharge (blood stained or foul smelling) many cases detected through routine screening
what is the most important causative factor for the development of cervical cancer?
Human papillomavirus HPV
what stereotypes of the HPV are the most important in the development of cervical cancer?
16
18
33
what forms of HPV are responsible for genital warts?
6
11
what can endocervical cells infected with HPV develop into?
Koilocytes
what are the characteristics of koilocytes?
enlarged nucleus
irregular nuclear membrane contour
the nucleus stains darker than normal (hyperchromasia)
a perinuclear halo may be seen
who is screened for cervical cancer and how often?
25-49 - 3 yearly screening
50-64 - 5 yearly screening
how is the cervical cancer screened?
Papanicolaou (Pap) smears
or liquid based cytology
what investigations would you perform for cervical cancer?
vaginal or speculum examination
colposcopy
biopsy
HPV testing
what are the different abnormal cervical smear results?
Borderline or Mild dyskaryosis - The original sample is tested for HPV*
if negative the patient goes back to routine recall
if positive the patient is referred for colposcopy
Moderate dyskaryosis - consistent with cervical intraepithelial neoplasia (CIN) 2, Severe dyskaryosis - consistent with CIN 3, suspected invasive cancer: refer for urgent colposcopy
