Gynecology

Question 1

What is the UVJ?

Answer 1

Urethrovesical junction

– where the Bladder meets the Urethra (NOT the ureters!)

Question 2

The balance of what 2 pressures are the cause of urinary continence vs. incontinence?

Answer 2

Intra-urethral pressure must exceed intra-vesical pressure for urinary continence at rest.

Question 3

What are Estrogen’s effects on urinary continence?

Answer 3

Estrogen increases intra-urethral pressure.

Lack of estrogen, decreases intra-urethral pressure, causing INcontinence at rest.

Question 4

Internal vs. External urethral sphincter: which is continuously contracted, maintaining continence?

Answer 4

Internal urethral sphinctor is continously contracted & maintains intra-vesical pressure.

The External provides about 50% of urethral resistance & is second line of defense against incontinence

Question 5

4 major types of incontinence

Answer 5

1. Stress: urine loss w/ exertion/straining such as laughing, coughing, exercising. Ass’d w/ pelvic relaxation & displacement of urethrovesical junction.
2. Urge: leakage due to involuntary & uninhibited bladder contractions; detrusor instability.
3. Total: continuous leakage due to urinary fistula resulting from pelvic surgery or pelvic radiation.
4. Overflow: poor/absent bladder contractions leading to urine retention & overdistension of bladder

Question 6

Cotton swab test

Answer 6

Hypermobility = Stress incontinence
A swab is placed in the urethra to the bladder neck. Movement of the UVJ w/ Valsalva (straining) should be less than 30 degrees.
When pelvic relaxation results in hyper mobility of the bladder neck, there is a large change of UVJ w/ Valsalva

Question 7

Cystometrogram – what is it & what’s it’s use?

Answer 7

Pressure sensors used to determine bladder & sphincter tone as bladder is filled w/ fluid.
Used to distinguish between genuine stress incontinence & detrusor instability.

Question 8

Risk factors for stress incontinence?

Answer 8

Cause Pelvic Relaxation:
Childbirth, Aging, Genetics

Cause Chronic Increases in Intra-Abdominal Pressure:
- Constipation, chronic coughing (lung disease, smoking), chronic heavy lifting, obesity (worsens incontinence, doesn’t cause it)

Cause Weakening of Urethral Closing Mechanism:
- Estrogen deficiency (menopause), scarring, denervation, meds

Question 9

Stress Incontinence diagnostic findings?

Answer 9

• Poor anatomic support w/ Cotton swab test, X-ray, or Urethroscopy
• Demonstratable leakage w/ stress (stress test or pad test)
• Normal urinalysis, Neuro exam, Cystometrogram or Urethrocystometry
• Negative Urine Culture

Question 10

Common cause of stress incontinence?

Answer 10

Usually due to pelvic relaxation (i.e. w/ aging or childbirth) that results in a hyper mobile bladder neck or from intrinsic sphincter deficiency

Question 11

Detrusor instability, o/w known as ____ incontinence.

Answer 11

Urge

– results from involuntary & uninhibited bladder contractions

Question 12

Causes of urge incontinence?

Answer 12

• Idiopathic (most common)
• UTIs
• Bladder stones
• Cancer
• Diverticula
• Neurologic disordes (stroke, MS, Alzheimer’s, cerebrovascular accident)

Question 13

Urge incontinence symptoms?

Answer 13

Urinary urge

• Frequency
• Nocturia

Question 14

Meds that treat urge incontinence?

Answer 14

Anticholinergics (Imipramine, Tolterodine, Oxybutynin)

• can also use bladder training
• if neuro cause present, treat neurologic disorder

Question 15

Total incontinence causes?

Answer 15

Usually Fistulas:
Vesicovaginal, Urethrovaginal, or Ureterovaginal

• • caused by pelvic radiation & pelvic surgery in >95% of cases in U.S.
• • in developing countries, usually attributable to obstetric trauma, leading to urinary fistula

Question 16

Total incontinence Tx?

Answer 16

Surgical repair of fistula

Question 17

Overflow incontinence causes?

Answer 17

Most commonly Detrusor insufficiency caused by meds or neurologic disease
– obstruction & post-operative distension occur less frequently in women

Question 18

Overflow incontinence Tx?

Answer 18

Self-catheterization

Meds:

• • Cholinergic agents (increase contractility)
• • α-adrenergics (lower urethral resistance)

Question 19

HPV types ass’d w/ cancer & hyperplasia?

Answer 19

16, 18, 31, & 45

Question 20

Management of high risk Pap smears?

Answer 20

Colposcopy & directed biopsy

includes:
- - ASC-H, LSIL, HSIL,
- - ASC-US w/ high risk type of HPV

Question 21

CIN I management?

Answer 21

Followed w/ repeat pap smears q 6 months x 1 year

Question 22

CIN II management?

Answer 22

CIN II or III should be treated w/ surgical excision (LEEP/loop/Lletz)

Question 23

CIN II or III confined to ectocervix management?

Answer 23

Destruction of lesion w/ LEEP, laser therapy, or cryotherapy

Question 24

CIN II or III confined to endocervix management?

Answer 24

2-stage LEEP or cold knife conization (CKC)

Question 25

Chemotherapy agent used in cervical cancer?

Answer 25

Cisplatin (combined w/ radiation Tx)

Question 26

What is Condyloma Accuminata?

Answer 26

Genital Warts

• • they are caused by HPV
• • appear as clusters of pink or skin-colored lesions w/ a smooth, teardrop appearance

Question 27

Condyloma Accuminata (genital warts) – Tx?

Answer 27

Smaller lesions = Trichloroacetic Acid or Podophyllin

Larger lesions = Excision or Fulguration (electrical current)

Question 28

What is Condyloma Lata?

Answer 28

• • Flat, velvety lesions
• • Caused by secondary Syphillis
• • Respond to Penicillin

Question 29

Lichen Sclerosus presentation?

Answer 29

PE:

• • Thin, white, wrinkled skin over the labia in a postmenopausal female
• • porcelain-white, polygonal macules & patches w/ an atrophic “cigarette-paper” quality

Sx:
– Anogenital discomfort, such as pruritus, dyspareunia, dysuria, & painful defecation

– Chronic, inflammatory condition over anogenital region

Question 30

Vulvar Lochen Planus presentation?

Answer 30

• • Typically middle-aged women
• • Lesions are hyperkeratotic, erosive, or papulosquamous in appearance
• • Pruritus, soreness, or vaginal discharge are common

Question 31

Mgmt when suspected Lichen Sclerosus et Atrophicus?

Answer 31

Punch-biopsy to rule out SCC
(since LS&A is a premalignant lesion)

– Tx w/ Corticosteroids

Question 32

Menopause-related atrophic vaginitis – Tx?

Answer 32

Estrogen cream

could initially present w/ dyspareunia & vaginal pruritus

Question 33

Primary Syphilis presentation?

Answer 33

• • Painless (genital) papule @ site of inoculation ~2-3wks after infection
• • papule ulcerates, forming a chancre w/ a punched-out base & raised, indurated margins
• • Painless inguinal lymphadenopathy

**spontaneously heals in 1-3 months if left untreated

Question 34

Dx testing for Primary Syphilis

Answer 34

Dark Field Microscopy w/ spirochete identification

– RPR not sensitive during primary syphilis b/c body has not yet built up antibodies. This is used instead for screening.

Question 35

Ovarian Torsion presentation

Answer 35

Sudden unilateral, sharp lower abdominal pain with nausea & vomiting.
PE may show palpable, tender adnexal mass.
– commonly in women of reproductive age
– more common on Right side b/c utero-ovarian ligament is longer

• • Fever & leukocytosis indicate adnexal necrosis
• • Abnormal vaginal bleeding is less common

Question 36

Dx test for suspected Ovarian Torsion?

Answer 36

Abdominal & Transvaginal Ultrasound w/ color Doppler

– reveals enlarged, edematous ovary w/ localized tenderness & signs of impaired ovarian bloodflow

Question 37

Risk Factors for Ovarian Torsion?

Answer 37

• • Pregnancy
• • Ovulation induction (infertility tx)
• • Ovarian masses (esp >5cm)