Obs and Gynae Flashcards
What is cystocele?
defect in the anterior vaginal wall, allowing the bladder to prolapse backwards into the vagina
what is a grade 1 cystocele?
mild - the bladder droops only a short way into the vagina
what is grade 2 cystocele?
medium - bladder sunk to reach opening of vagina
what is grade 3 cystocele?
advances - bladder bulges out through opening of vagina
what are 7 risk factors for pelvic organ prolapse?
advanced age and post menopause low oestrogen
overweight
childbirth - vaginal delivery
constipation and straining
heavy lifting
chronic cough
previous pelvic surgery
What are 6 symptoms of cystocele?
pelvic heaviness/fullness
bluge in vagina
aching/pressure in lower belly/pelvis/back that get worse with standing/lifting/coughing
frequent UTIs and LUTS
pain during sex
constipation
What are 6 symptoms of pelvic organ prolapse?
pelvic heaviness/fullness
bluge in vagina
urinary incontinance
constipation
pelvic/back/abdo pain
sexual dysfunction
What is the conservative management for pelvic organ prolapse?
physio - pelvic floor exercise
weight loss
lifestyle changes
symptom treatement
vaginal oestrogen cream
what are the 5 different types of pessaries that can be used for vaginal prolapse?
Ring
shelf/gellhorn - flat disc with stem
Cube
Donut
Hodge - rectangularish
what should be given with pessaries to protect from vaginal irritation?
oestrogen cream
what is the difinitive treatment for pelvic organ prolapse?
surgery
What is rectocele?
defect in the posterior vaginal wall, allowing the rectum to prolapse forwards into the vagina.
particularly associated with constipation
can develop faecal loading and urinary retention
what is uterovaginal prolapse?
where the uterus +/- the vagina itself descends out of the vagina
what is urge incontinence?
caused by overactivity of detrusor muscle meaning people feel the sudden need to pass urine
what is stress incontinance?
due to weakness of the pelvic floor and sphincter muscles urine to leaks at times of increased pressure on the bladder like laughing , coughing or surprise
what is overflow incontinence?
occurs with chronic urinary retention (more common in men) and without the urge to pass urine can be due to anticholinergic meds, fibroids, pelvic tumours and neuro conditions
what are 6 risk factors for urinary incontinance in women?
increased age
pregnancy
obesity
pelvic organ prolapse
Neurological disorder
FHx
what are 4 investigations for urinary incontinance in women?
urinalysis
urodynamic tests
bladder diary
post void residual bladder volume
what is the gold standard investigation of urinary incontinence?
urodynamic testing
what are 3 differential of urinary incontinance?
UTI
pregnancy
urogenital fistula
what are 4 lifestyle managements of stress incontinance
avoid caffine
avoid smoking
weight loss
reduce fluid intake
What is the first line medication to manage stress incontinance?
Duloxetine
What are 3 contra-indications to duloxetine?
hepatic impairment
severe renal impairement (<30 creatinine clearance)
Uncontrolled hypertension
what are 4 surgeries for stress incontinance?
tension-free vaginal tape
autologous sling
colosuspension
intramural urethral bulking
what is the management of urge incontinance?
bladder retraining
anticholinergic medication
what are 3 examples of anticholinergic medications for urge incontinance?
Oxybutynin
tolterodine
darifenacin
what are 4 anticholinergic side effects?
dry mouth and eyes
constipation
urinary retention
cognitive decline
what are 4 invasive options for urge incontinance?
Botulinum toxin type A - botox - injection in bladder wall
percutaneous sacral nerve stimulation
augmentation cystoplasty
urinary diversion
what is one non-anticholinergic that can be used to treat urge incontinance?
Mirabegron
CAN CAUSE HYPERTENSIVE CRISIS!!
Where do renal stones commonly get stuck?
vesico-uteric junction
what are 2 key complications of kidney stones?
obstruction => AKI
infection
what is the most common composition of kidney stones?
calcium oxalate
what are th 2 types of clacium renal stones?
calcium oxalate
calcium phosphate
what are 3 non-calcium kidney stones?
struvate - related to UTI
uric acid - fluid loss related
cystine - due to autosomal recessive cystinuria
what type of renal stones aren’t visible on x-ray?
uric acid stones are radiolucent
what are 4 risk factors for renal stones?
dehydration
FHx
obesity and diet
UTIs
what are 5 symptoms of renal stones?
acute severe ‘loin to groin’ pain
nausea/vomiting
urinary frequency/urgency
haematuria
testicular pain
what is the gold standard investigation of renal stones?
Non-contrast CT kidneys ureters and bladder (within 24 hours!)
what are 4 investigations for renal stones?
Urinalysis - ?haematuria
bloods - ?infection ?hypercalcaemia ?kidney function
abdo X-ray - shows calcium based stones
ultrasound KUB
What are the symptoms of hypercalcaemia?
Renal Stones
Painful Bones
Abdominal Groans
Psychic Moans
What is the management of renal stones?
NSAIDs - ibruprofen/diclofenac
Antiemetics - metoclopramide
antibiotics - if infective
watchful waiting
tamsulosin - alpha blocker - can aid passage
surgery
what size of renal stones require surgery?
> 10mm
what 4 types of surgical intervention are there for renal stones?
extracorporeal shock wave lithotripsy
uteroscopy laser lithtripsy
percutaneous nepholithotomy
open surgery - rare
what are 4 lifestyle changes to prevent further renal stones?
increase fluid intake
add lemon juice to water
reduce salt intake
avoid carbonated drinks
what are 2 medications that increase risk of renal stones?
potassium citrate
thiazide diuretics
what are 6 risk factors for vaginal fistula?
childbirth
injury
surgery
infection
radiation
IBD
what is a vesicovaginal fistula?
urinary bladder and vagina fistula
what is an enterovaginal fistula?
opening between small intestine and vagina
what are 4 investigations of vaginal fistulae?
Dye test - into bladder and rectum to check for leakage
Imaging - USS, CT, MRI
conoloscopy
cystourethroscopy
What is tripple assessment of breat lumps?
clinical assessment - Hx and exam
imaging - USS, mamography
histology - fine needle/core biopsy
each scored 1-5 from normal to malignant
what is fibroadenoma?
most common cause of breast mass
normally more likely in early reproductive years
painless, smooth, round, firm, well defined, mobile, usually <3cm
what is phyllodes tumour?
can be benign or malignant breast lumps
rapidly growning painless breast lumps
what are 8 clinical features of breast cancer?
hard, irregular, painless, fixed lumps
lumps tethered to skin or chest wall
nipple retraction
skin dimpling - peau d’orange
nipple discharge
rash, crusting or scaling around nipple
change in shape/size of breast
auxillary lymphadenopathy
what is a fibrocystic breast ?
usually in pre/perimenopausal women
mobile with dystinct borders - lumpy breasts
sometimes tender
fluctuate with mentruation
what do breast fat necrosis lumps present with?
hard, fixed masses
very like malignancy and require biopsy
what is breast papilloma?
breast lump usually in ducts
usually benign but can be associated with cancer
bloody nipple discharge is typical
what are breast abscesses?
breast lump typical in breastfeeding
ruptured sub-areolar ducts leak into periductal space
must be differentiated from inflammatory breast cancer
what is breast lipoma?
benign tumours of adipose tissue
soft, painless, mobile, no skin changes
what is galactocele?
occur in lactating women often after stopping
breast milk filled cysts due to lactiferous ducts being blocked
firm mobile, painless lump beneath areola
what is the most common type of breast cancer?
invasive ductal carcinoma
what is the most common causative pathogen of infective mastitis?
staphylococcus aureus
what is mastitis?
inflammation of breat with or without infection
common with breast feeding
what are breast absecesses?
a localised area of infection with a walled off collection of puss - with or without mastitis
what are 5 symptoms of mastitis?
fever
decreased milk outflow
breast warmth, tenderness, swelling, redness
breast pain
flu like symptoms
what are 3 investigations for breast abscess?
breast ultrasound
needle aspiration drainage
cystology of nipple discharge/aspiration
what are 3 investigations for mastitis?
milk/aspirate/discharge/biopsy culture and sensitivity
histopathological exam of biopsy
pregnancy test
what lifestyle treatment is there for breastfeeding mastitis?
continue breastfeeding/expressing milk
heat packs
warm showers
simple analgesia
what is the treatment of suspected infective mastitis?
Abx - flucloxacillin or erythromyacin (in allergy) for 10 days if still symptomatic 12-24 hours after 1st presentation with lifestyle management
what is the treatment of breast abscess?
surgical drainage
What are 6 risk factors for breast cancer?
Female
increased oestrogen exposure - OCP and HRT
more dense breast tissue
obestiy
smoking
FHx
What chromosome is BRACA1 on?
chromosome 17
what cancers does BRACA1 increase risk of?
breast - 70% BY 80yo
ovarian - 50%
prostate and bowel
what chromosome is BRACA2 on?
chromosome 13
what is ductal carcinoma in situ?
pre-cancerous or cancerous epithelial cells of breast ducts
localised
good prognosis
what is lobular carcinoma in situ?
precancerous
usually asymptomatic and undetectable on mammogram
increased risk of invasive breast cancer in future
often managed with close managing
what is invasive ductal carcinoma?
originates in cells of breast ducts
80% of invasive breast cancers
seen on mamograms
what is invasive lobular carcinoma?
10% of invasive breast cancers
from breast lobules
not always visible on mammograms
what is inflammatory breast cancer?
1-3% of breast cancer
similar to breast abscess or mastitis
swollen, warm, tender breat with peau d’orange
doesnt respond to antibiotics
worse prognosis
what is pagets disease of the nipple?
loosk like eczema of nipple
erythematous, scaly rash
indicates breast cancer of niple
may be DCIS or invasive breast cancer
requires biopsy, staging and treatment
when is breast cancer screening offered?
aged 50-70 every 3 years mammogram
what medications can be used as chemoprevention of breast cancer in those with high risk?
tamoxifen - premenopause
anastrozole - postmenopausal
what are 4 investigations for breast cancer?
mammogram
biopsy and histology
breast MRI
breast ultrasound
what are 2 investigations needed of confirmed breast cancer?
hormone receptor testing - oestrogen and progesterone receptor status
HER2 testing
what medication can be used in HER2 positive breast cancer?
trastuzamab (herceptin)
what is the usual management for breast cacinoma in situ?
lumpectomy + radiotherapy
tamoxifen/aromatase inhibitors can be used in high risk patients
what is pagets disease of the breast?
eczema like changes to skin of nipple and areola - sign of breast cancer
dark scaly rash - often sore and inflamed
what is ductal ectasia?
benign condition of milk duct due to walls thickening and getting blocked
more common in women approaching menopause
often asymptomatic but can cause discharge from breast, lumps under nipple or rarely breast pain
can be surgically treated
What causes peau d’orange?
blocked lymphatic drainage causes superficial oedema with sweat ducts making small dimples
What is the name of the extention of breast tissue to the axilla?
tail of spence
what is the name of a breast milk filled cyst caused by lactiferous duct blockage?
galactocele
what chemical has a inhibitory effect on prolactin?
Dopamine
what enzyme in adipose tissue converts androgens to oestrogen?
aromatase
what type of tumour can cause gynacomastia due to oestrogen secretion?
leydig cell tumour - testicular cancer
which common heart meds can cause gynaecomastia?
digoxin and spiro
what is intraductal papilloma?
a benign wart like lump that develops in one or more of the milk ducts in the breast
can cause a lump, nipple discharge and pain or discomfort
what is bacterial vaginosis?
overgrowth of anaerobic bacteria in vagina that causes unusual fishy smelling, grey-ish white thin discharge
what percentage of women with BV have no symptoms?
50%
What symtoms are not related to BV?
Soreness or itching
What are 4 risk factors for BV?
multiple sexual partners
recent Abx
IUD - copper coil
excessive vaginal cleaning
what are 2 complications of BV?
small chance of premature birth/miscarriage
Inceased risk of STI
What is the first line antibiotic for BV?
Metronidazole 400mg BD 5-7days
intravaginal gel 0.75% OD 5 days
Clindamycin gel 2% OD 7 days 2nd choice
SAFE FOR PREGGOS!
What is the healthhy bacteria in the vagina?
lactobilli - produce lactic acid and reduce pH of vagina (<4.5)
What is the most common cause of BV?
Gardnerella vaginalis
what are 3 common pathogenic causes of BV?
gardnerella vaginalis (most common)
Mycoplasma hominis
prevotella species
ALL ANAEROBIC
What is normal vaginal pH?
3.5-4.5
What is the is the gold standard investigation for BV?
high or low vaginal swab
should also swab for STIs
What cells are found under a microscope in BV?
clue cells
Which antibiotic shoudl you avoid alcohol whilst on?
Metronidazole - causes nausea, vomiting, flushing and sometimes shock
what is the most common cause of vaginal thrush?
Candida albicans
What are 4 risk factors for thrush?
increased oestrogen (pregnancy)
poorly controlled diabetes
immunosuppresion
Broad spectrum ABx
what are the symptoms of vaginal thrush?
thick white discharge
vulva and vaginal itching and irritation
What are 6 complications of vaginal thrush?
erythema
fissures
oedema
pain during sex (dyspareunia)
dysuria
excoriation
what is one test that can be used to distiguish between trush and BV/trichomonas?
vaginal pH swab
>4.5 in BV and Trichomonas
<4.5 in candidiasis
what swab is used for vaginal MCS?
charcoal swab - for BV, candidiasis, gonorrhoea, trichomonas, other bacteria
What is the management for thrush?
antifungal cream - clotrimazole 5g 10% single dose
antifungal pessary - clotrimazole 500mg single dose
Oral antifungal - fluconazole 150mg single dose
what should you tell patients using antifungal creams?
can degrade latex condoms and prevent spermacides from working => use other forms of birth control for at least 5 days
how is trichomonas spread?
sexual activity
what does trichomonas infection increase risk of?
HIV contraction (due to vaginal mucosa damage)
BV
cevical cancer
PID
pregnancy complications
What does the discharge look like in trichomonasis?
frothy, yellow-green fishy smelling discharge
on pelvic examination what can be found in someone with trichomoniasis?
strawberry cervix (colpitis macularis) caused by inflammation causing tiny haemorrhages on cerviix surface
how is trichomoniasis diagnosed?
charcoal microscopy swab from posterior fornix of vagina
vaginal pH >4.5
Urethral or first catch urine in men
What is the treatment for trichomoniasis?
refer to GUM for contact tracing
metronidazole 2g single dose (NOT IN PREGGOS)
OR
400-500mg TD 5-7days
what are 4 causes of balantitis?
exzema/dermatitis, allergy, psoriasis etc
gonorrhoea
candidosis
penile neoplasm
what are 4 risk factors for balantitis
poor hygiene
over washing
HPV
uncircumsised
what are 2 investigations for balantitis?
swab for microbiology and PCR
viral swab
What bacteria causes chancroid?
coccobacillus haemophilus ducreyi
What STI is an important cofactor in HIV transmision?
Chancroid
what are 2 symptoms of chancroid?
genital papules/ulcers
lymphadenitis and buboes
what STI causes genital ulcers?
chancroid
What is the treatment for chancroid?
azithromycin 1g one off dose
What bacteria causes chalmydia?
Gram negative chlamydia trachomatis
what is the most common STI in the UK?
Chlamydia
what percentage f menand women are asymptomatic with chlamydia?
men - 50%
women - 75%
what is nucleic acid amplification test swabbing used for?
chlamydia and gonorrhoea
what are 5 chlamydia symptoms in women?
Abnormal vaginal discharge
pelvic pain
abnormal vaginal bleeding
painful sex
dysuria
what are 4 symptoms of chlamydia in men?
urethral discharge/discomfort
painful urination
epididymo-orchitis
reactive arthritis
what is the 1st line treatment for chlamydia?
Doxycycline 100mg BD 7 days
NOT IN PREGGOS
what are 8 complications of chlamydia?
PID
chronic pelvic pain
infertility
ectopic pregnancy
epididymo-orchitis
conjunctivitis
lymphogranuloma venereum
reactive arthritis
chorioamnionitis
what are 5 complication of chlamydia in pregnancy?
preterm deliivery
premature rupture of membranes
low birthweight
post partum endometritis
neonatal infection - conjunctivitis and pneumonia
what are the stages of lymphogranuloma venereum?
primary - painless ulcer on genitals
secondary - lymphadenitis
tertiary - inflamation of rectum leading to anal pain, change in bowel, tenesmus and discharge
what is the treatment of lymphogranuloma venereum?
Doxycycline 100mg BD 21 days
What bacteria causes syphilis?
Treponema pallidum
spirochete
what is the incubation period for syphilis?
9-90 days
average 21 days
what are the 5 stages of syphilis?
primary
secondary
latent
tertiary
neurosyphilis
what are 2 symptoms of primary syphilis?
painless genital ulcer (chancre)
local lymphadenopathy
tends to resolve in 3-8 weeks
what are 6 symptoms of secondary syphilis?
maculopapular rash - trunks, palms, soles
condylomata lata - grey warts around genitals and anus
low grade fever and lymphadenopathy
oral lesions - snail trail ulcers
alopecia
3-12 weeks long
what are 3 symptoms of tertiary syphilis?
gummatous lesions - granulomatous lesions on skin, organs and bone
aortic aneurysms
neurosyphilis
Argyll-Robertson pupil - accommodates but does not react
what are 8 symptoms of neurosyphilis?
headache
altered behaviour
tabes dorsalis - demyelination of posterior columns of spinal cord
ocular syphilis
paralysis
sensory impairment
Argyll-robertson pupil (prostitutes pupil - accommodates but does not react)
How do you diagnoses syphilis?
antibody testing for T.pallidum antibodies
dark field microscopy
PCR
rapid plasma reagin - non-specific but sensitive
veneral disease research laboratory test - non-specific but sensitive
What is the 1st line treatment for syphilis?
Deep IM benzathine benzylpenicillin 1.8g single dose
SAFE IN PREGGOS
What can trichomoniasis in pregnancy cause?
premature birth
low birthweight
what can syphilis in pregnancy cause?
congenital syphilis
miscarriage
still birth
early death
What is the treatment for chlamydia in preggos?
Azithromycin 1g once then 500mg OD for 2 days
Erythromycin 500mg QD for 7 days
Amoxicillin 500mg TD 7 days
what are the complications of chlamydia during pregnancy?
pre-term labour
bleeding in pregnancy
PID + fertility problems
ectopic pregnancy
congenital chlamydia - eye or chest infection
what is a complication of spriocete (syphilis) infection after antibiotic treatment that can can cause premature labour?
Jarisch-herxheimer reaction - fever, headach, myalgia, fetal distress
also lymes + other spirocete
Which ganglia is genital herpes usually latent in?
sacral nerve ganglia
Which ganglia is genital herpes usually latent in?
sacral nerve ganglia
what are 5 manifestations of HSV?
Cold sores
Genital herpes
aphthous ulcers (in mouth)
herpetic whitlow (painful skin lesions on fingers)
herpes keratitis - inflammation of cornea
what are 5 presentations of herpes?
ulcers
neuropathy
flu like symptoms
dysuria
inguinal lymphadenopathy
what pathogen causes genital warts ?
Human papillomavirus
HPV6 and 11 most commonly
what is the treatment for genital warts?
imiquimod
podephylltoxin
cryotherapy
What bacteria causes gonorrhoea?
Neisseria gonorrhoeae
Gram -ve diplococci
what are 4 symptoms of gonorrhoea?
odourless purulent discharge (can be green/yellow)
Dysuria
pelvic pain
testicular pain
How do you diagnose gonorrhoea?
Nucleic Acid Amplification Test
What is the treatment for gonorrhoea?
IM ceftriaxone 1g (also in preggos)
Oral Ciprofloxacin 500mg
Single dose
What are 5 complications of gonorrhoea?
PID
Infertility
Prostatitis
Septic arthritis
Conjunctivitis
What is the first line medication for oestrogen receptor +ve breast cancer if premenopausal women?
tamoxifen - 5 years
What is the first line medication for oestrogen receptor +ve breast cancer in post-menopausal women?
Aromatase inhibitors
e.g. anastrozole
What medication is used in HEr2 +ve breast cancer?
Trastuzamab
3 weekly injections for a year after surgery
what are 9 risk factors for ectopic pregnancy?
Prev ectopic
tubal surgery
Hx of STD
Smoking
IVF
IUD pregnancy
Black ethnicity
age <18 first intercourse
age >35 at time of presentation
when does ectopic pregnancy usually present?
6-8 weeks
what hCG level will mean pregnancy is visible on USS?
> 1500 IU/L
what are the 6 criteria for expectant management of ectopic pregnancies?
available for follow up
unruptured
mass <35mm
no heart beat
no significant pain
HCG <1500 IU/L
what drug is used for medical management of ectopic pregnancies?
IM methotrexate
what is the criteria for medical management of ectopic pregnancies?
HCG levels <5000 IU/L
Confirmed absence of intrauterine pregnancy on US
<35mm
minimal pain
no heart beat
What embrionic structure does the female genital system develop from?
paramesonephric (mullerian) ducts
what are 4 abnormal female organ formations?
bicornuate uterus - heart shaped
imperforate hymen
transverse vaginal septae - septum in vagina
vaginal hypoplasia and agenesis - abnormally small/absent vagina
what is androgen insensitivity syndrome?
a condition where cells are unable to respond to androgen hormones due to a lack of androgen receptors. X-linked recessive genetic condition, caused by a mutation in the androgen receptor gene on the X chromosome. Extra androgens are converted into oestrogen, resulting in female secondary sexual characteristics despite XY genetics
what are the complications of androgen insensitivity syndrome?
slightly taller than average female
no pubic or facial hair
increased risk of testicular cancer unless removed from abdomen
infertility
what is the usual presentation of androgen insensitivity syndrome?
inguinal hernias
primary amenorrhoea
What is menopause?
no periods for 12 months due to the end of menstruation
what is premature menopause?
Menopause before 40 years
What cells secrete oestrogen?
ganulosa cells
What are 8 perimenopausal symptoms?
Hot flushes
emotional lability/low mood
reduced libido
premenstrual syndrome
irregular periods
joint pain
heavier/lighter periods
vaginal dryness and atrophy
What are 4 conditions menopause increases the risk of?
CVD and stroke
osteoporosis
pelvic organ prolapse
urinary incontinance
what is the management of perimenopausal symptoms?
HRT
tibolone - synthetic steroid
clonidine - reduces hot flushes
CBT
SSRIs
testosterone gel for libido
vaginal oestrogen/moisturisers
what is adenomyosis?
Endometrial tissue inside the myometrium
More common with mutiparous
What are 5 presetations of adenomyosis?
Dysmenorrhoea
menorrhagia
dyspareunia (pain in intercourse)
Infertility
Enlarged/tender (boggy) uterus but softer than w/ fibroids
what is the 1st line investigation for adenomyosis ?
TV ultrasound
What is the gold standard investigation for adenomyosis?
histological exam after hysterectomy
what are 2 non-contraceptive treatments for mennhoragia?
Tranexamic acid - when no pain (antifibrinolytic reduces bleeding)
Mefenamic acid - with pain (NSAID - reduced bleeding and pain)
What are 3 contraceptive managements options for mennorhagia?
IUS
COCP
cyclical oral progestogens
what are 4 specialist managements of menorrhagia?
GnRH analogues to induce meno-pause like state
endometrial ablation
uterine artery embolisation
hysterectomy
what are 9 complications of adenomyosis in pregnancy?
infertility
miscarriage
preterm birth
small gestation
preterm premature rupture of membranes
malpresentation
c-section
PPH
What is asherman’s syndrome?
where adhesions form in uterus following damage
What are 3 risk factors for ashermans syndrome?
dilation and curettage (after retained products of conception)
uterine surgery
pelvic infection
what are 4 presentations of asherman’s syndrome?
secondary amenorrhoea
light periods
dysmenorrhoea
infertility
What are 4 investigations for asherman’s syndrome?
hysteroscopy
hysterosalpingography
sonohysterography
MRI
What is lichen sclerosus?
a chronic inflamatory autoimmune skin condition causing patches of shiny white skin on labia, perineum and perianal skin most commonly as well as axilla and thighs. can also affect men
what is lichen planus?
autoimmune condition causing chronic inflammation with shiny purplish flat top raised areas with white lines across surface called wickhams striae