Men and Womens Health Flashcards
Symptoms and signs suggestive of gynae cancer
- Abnormal cervix appearance
- Blood glucose level high + visible haematuria in women over 55 and +
- Hb low + visible haematuria in women 55 and +
- Post menopausal bleeding in all women
- Thrombocytosis + visible haematuria or vaginal discharge in 55 and +
- Appetite loss/early satiety in 50 and +
- Unexplained vaginal discharge
- Abdominal distension (esp in 50 and
- Ascites
- IBS 50 and +
- Abdo/pelvic mass
- Change in bowel habit
- Fatigue
- Urinary urgency/frequency, persistent esp women 50 and +
- Weight loss
- CA125
- Vulval lump/bleeding
Causes of post coital bleeding
- Infection
- Cervical ectropion - esp in COCP users
- Cervical/endometrial polyps
- Vaginal cancer
- Cervical cancer
- Trauma/sexual abuse
- Vaginal atrophic change
Causes of intermenstrual bleeding
- Pregnancy - inc ectopic and gestational trophoblastic disease
- Physiological
- Vaginal - adenosis, vaginitis, tumours
- Cervical - cancer, polyps, infection (C&G), ectropion,
- Uterine - fibroids, polyps, cancer, adenomyosis, endometritis
- Oestrogen secreting ovarian cancers
- Iatrogenic - tamoxifen, smear/cervix treatment, missed OCP, drugs affecting clotting, St Johns wort + COCP
Management of menorrhagia
- 1st line is Levonogestrel IUS
- Can use tranexamic acid and NSAID such as mefanamic acid
- May need USS for fibroids if suspected
When is primary dysmenorrhoea likely?
- Menstrual pain begins 6-12 months after menarche - cycles are then regulary
- Pain cramping, lower abdo, may radiate to back or thighs
- Starts shortly before menses and lasts up tp 72hrs improving as menses progressses
- Other symptoms eg N+V, emotional, bloating, headache are present
- Other gynae symptoms not present
- Pelvic exam normal
When is secondary dysmenorrhoea likely?
- Pain starts after years of painless periods
- Pain may persist after menstruation ends or throughout cycle but worse when menstruates
- Other gynae symptoms eg dysparaunia, vaginal discharge, menorrhagia IMB, PCB
- Non-gynae eg rectal pain and bleeding can be present
- Pelvic exam abnormal (although normal cannot exclude this diagnosis)
Secondary causes of dysmenorrhoea
- Endometriosis
- Adenomyosis
- Fibroids
- PID
- Ectopic pregnancy
- Ovarian/cervical cancer
- IUD insertion
Cause menorrhagia
- No cause - dysfunctional uterine bleeding
- Uterine fibroids
- Polyps
- Adenomyosis
- IUD
Management primary dysmenorrhoea
- Offer NSAID
- If NSAID contraindicated/not tolerated - paracetamol
- If not wish to conceive - hormonal contraceptive trial for 3-6months eg COCP, Depot, implant or IUS
- Can combine this with NSAID or para
- Non-pharm - heat eg hot water bottle, transcutaenous electrical nerve stimulation
- Refer if no improvement 3-6 months
Management secondary dysmenorrhoea - red flags
- Refer urgently if
- Positive pregnancy test with pelvic pain and vaginal bleeding
- Ascites +/- abdominal mass
- Abnormal cervix
- Persistent IMB/PCB with features of PID
What is primary amenorrhoea?
- No menses have commenced at the age of 14 if no secondary sexual characteristics (but 16 if development is normal)
What is secondary amenorrhoea?
- Menses commenced but have no stopped
- For at least 6 months when menses were regular (longer if infrequent)
Cause of primary amenorrhoea if secondary sexual characteristics are present
- Constitutional delay
- GU malformation - imperforate hymen, transverse vaginal septum, absence of uterus/vagina
- Androgen resistance syndrome (testicular feminisation) - XY
- Hyperprolactinaemia
- Pregnancy
Causes of primary amenorrhoea if no secondary sexual characteristics
- Ovarian failure - chemo, radiation, chromosomal gonad abnormality
- Hypothalamic failure - anorexia nervosa, stress, excessive exercise, chronic illness, obesity
- CAH - causes precocious puberty
Cause of secondary amenorrhoea - no signs androgen excess
- Pregnancy, lactation, menopause
- Premature ovarian failure
- Depot/impant
- Weight loss
- Hyperprolactinaemia
- Hypothalamic dysfunction
- Thyroid disease
- Post pill amenorrhoea - should resolve within 3 months
Causes of secondary amenorrhoea with signs of andorgen excess
- PCOS
- Cushing syndrome
- Late onset CAH
- Adrenal or ovarian carcinoma - these can produce androgens
Investigations for amenorrhoea
- Pregnancy test
- Gonadotrophins eg FSH, LH
- Prolactin
- Total testosterone and sex hormone binding globulin, oestradiol
- TFTs
- Pelvic USS
Managing amenorrhoea
- May need referral to fertility clinic in future
- Contraception if do not wish for pregnancy
- TREAT UNDERLYING CAUSE EG:
- HRT for premature ovarian failure (under 40, have until 50)
- Monitor Vit D and calcium for bone protection
Investigations for dysmenorrhoea
- Abdominal exam
- Pelvic exam
Consider:
* USS - fibroids
* High vaginal and endocervical swabs if risk STI
* Pregnancy test - exclude ectopic
Investigations menorrhagia
- FBC for all
- Pelvic USS for larger fibroids
- Routine Transvaginal US for suspected adenomyosis OR if gynae symptoms
- Consider referal hysteroscopy if history suggests fibroids, polyps or endometrial pathology
- Endometrial biopsy may be done at this time
Symptoms at menopause/perimenopause period
- Change to menstrual pattern
- Hot flushes/night sweats
- Cognitive impairemnt and mood disorders
- Urogenital symptoms - vulvovaginal irritation, dysparaunia etc
- Altered sexual function
- Sleep disturbance
- Other - joint.muscle pain, headache, fatigue
When to consider FSH for menopause diagnosis (not usually used)
As long as they are not on COCP or high dose progesterone and:
* Patients over 45 with atypical symptoms
* Patients from 40-45 with menopause symptoms inc change to cycle
* Patients younger than 40 whom premature menopause is suspected
What do flow volume charts or bladder diarys detect?
- Frequency - within 24hrs should be around 5-8x
- Polyuria - up to 3L in 24hrs is normal
- Nocturia
- Nocturnal polyuria - passing more than 35% of total urine output in 24hrs at night
How are LUTS dividided?
- Storage
- Voiding
- Post micturition
Causes of LUTS
- UTI
- Menopause
- Urge/stress/functional incontinence
- Diabetes
- Bladder stones
- Bladder cancer
- Neurological causes eg MS
- Medication - eg antidepressants, diuretics, lithium
Common tests performed when LUTS present
- Urine dip
- Send urine off to hopsital to confirm dipstick findings
- HbA1C for diabetes
May have USS or urodynamic testing if needed
Managing LUTS
- Decrease fluid intake if high intake - but avoid drinking too little
- Reduce caffeine
- Lose weight if overweight
- Stop smoking
- Try bladder training for urge incont
- Pelvic floor exercises for stress incont
- Continence clinics
Medication for LUTS
- Urge - oxybutynin, solifenacin and tolterodine (antimuscarinics)
- HRT if menopausal symptoms
- Surgery
Options for stress incont
- Pelvic floor muscle training - at least 3 months of supervised
- If conservative management fails - can have surgery eg colposuspension, autologous rectus fascial sling, retropubic mid urethral mesh sling, intramural urethral bulking agents
- If not suitable for surgery or opts not to, offer Duloxetine
Managing urge incontinence specifically
- Bladder training for at least 6 weeks
- Offer antimuscarinic if persists (eg oxybutynin, tolterodine)
- Explain side effects (eg dry mouth, constipation) and may take while to take effect (at least 4 weeks)
- review in 4 weeks time (earlier if not tolerating)
When to refer LUTS on 2WW?
2WW cancer pathway if:
Aged 45 and over with:
* Unexplained visible haemtauria without UTI
* OR visible haematuria persistent or recurrent after UTI successful treatment
* OR over 60 with unexplained non-visible haematuria and dysuria or raised WCC on blood test
What to refer LUTS routinely?
- Palpable bladder
- Voiding difficulty
- Pelvic mass clinically benign
- Associated faecal incontinence
- Suspected neurological disease
- History previous incontinence surgery, pelvic cancer surgery or raditation therapy
- Recurrent UTI
- Suspected urogenital fistulae
Investigations for males with LUTS
- Frequency volume chart
- International Prostate Symptom score (IPSS)
- Dipstick urine
- PSA if indicated (+DRE) - cautious with interpreting
- eGFR if indicated
Red flags associated with male LUTS
- Urological cancer - Prostate hard and irregular, bone pain, lower back pain, unexplained haematuria, weight loss.
- Urological infection - loin pain, pain on urination, fever, abnormal dipstick findings
- Sciatica - weakness/numbness/tingling down leg and can cause or aggrevate LUTS
Managing male patients with voiding symptoms - first line
- Active surveillance
Conservative: - pelvic floor muscle training
- bladder training
- Normal fluid intake
- Avoid constipation
- Healthy lifestyle - weight, exercise, diet, smoking, alcohol
- Use of containment products (pads, waterproof pants, externla sheath)
Managing voiding symptoms men - second line if conservative not suitable/not worked
- Alpha blocker if IPSS of 8 or more
- Review 4-6 weeks then every 6-12 months
- Offer 5 alpha reductase inhibitor if at high risk of progression eg Finasteride
- Consider combo if severe
Management voiding and storage symptoms male
- Consider adding antimuscarinic eg oxybutynin/tolterodine to alpha blocker
Secondary care options male voiding management if primary care fails
- Urethral catheterisation
- Prostate surgery - TURP
Managing OAB in males
- Conservative
- Containment products
- Supervised bladder training
- If persist offer antimuscarinic
- Offer mirabegron if animuscarinic not tolerated
- Secondary care options inc injection botulinum into bladder wall, implanted sacral nerve stimulation and cystoplasty
Additonal services for OAB
- Bladder and bowel have helpline
- Just can’t wait toiletcard when out in public
Causes of erectile dysfunction - organic
- Vascular - eg CVD, HTN, PAD
- Neurological (central) - MS, stroke, CNS tumour
- Neurological (peripheral) - T1/2DM, CKD
- Anatomical/structural - prostate cancer, congenital curvature of penis
- Endocrine - DM, hyperprolactinaemia, hypogonadism
Causes of erectile dysfunction - psychogenic
- Generalised
- Situational - partner, performance related issues, relationship problems
Drugs that can cause ED
- Antihypertensives
- Diuretics
- Antidepressants
- Antiarrhythmic
Lots of drugs common to those with diabetes and vascular problems
How to determine cause of ED?
- Psychosexual factors (eg orientation, past or current relationships)
- Progressive symptoms (suggests organic cause, sudden suggests psychological)
- Cardiac RF
- Surgery RF
- LUTS?
- Check external genitalia and DRE
- HbA1C and QRISK score and fasting serum testosterone (between 9-11am)
Can do additonal tests such ast TFTs, PSA, LFTs, U&Es depending on clinical judgement
Cardiac risk stratification and ED
- Men can be divided into low, intermediate and high risk depending on cardiac history as to CV disease being cause for ED
Management ED - support
- NHS information on ED
- British association of urological surgeons website on ED
- Sexual advice association
Management ED - lifestyle
- Weight loss if overweight
- Smoking cessation
- Exercise
- Alcohol intake to recommended levels
- If high cardiac risk, stop sexual activity until cardiologist review
- Stopping cycling for a trial period (if more than 3hrs a week)
Management ED - medication
If not high cardiac risk:
* Consider Phosphodiesterase 5 inhibitors eg sildenafil
* 50mg can be OTC purchased and do not need script
* Can only be prescribed if meets certain criteria
