Pathology Flashcards
Which phase of the menstrual cycle can vary in length
Proliferative phase
This is why women have different cycle lengths
Which hormones maintain the endometrium during pregnancy
Progesterone
HCG
Which cells within the ovary secrete hormones
The granulosa cells which surround the oocyte
Presence of what on histology suggest the endometrium is in the proliferative phase
Mitotic figures
Presence of what on histology suggest the endometrium is in the secretory phase
Glands become more complex
More tortuous/wiggly and later fill with secretions
How does obesity increase your risk of endometrial cancer
Higher levels of circulating oestrogen
Fat cells can produce it
List some indications for endometrial sampling
Abnormal bleeding Infertility Abortion - spontaneous and therapeutic Endometrial ablation Endometrial cancer screening
What is considered post-menopausal bleeding
if there has been no bleeding for a year and then it starts up again
What are the common causes of abnormal uterine bleeding
DUB due to anovulatory cycles Pregnancy and miscarriage Endometritis– inflammation of the endometrium Bleeding disorders Cancer
What is adenomyosis
Where you get glands and stroma in the muscular wall of the uterus which will cycle as normal
Leads to menorrhagia and dysmenorrhoea
Very painful condition and sometimes the only way to manage is hysterectomy
What is a leiomyoma
A very common smooth muscle tumour which can occur anywhere
Often called a fibroid
Which drugs can lead to abnormal uterine bleeding
Anything with exogenous hormones
HRT and tamoxifen
What endometrial thickness would be considered abnormal in post-menopausal women
Greater than 4mm
This is an indication for biopsy
How can you sample the endometrium
Endometrial pipelle - limited sample but easier/safer
Dilatation and curretage
Which phase in the menstrual cycle is worst for taking an endometrial sample
During menstruation
The architecture is hard to analyse as it is in the process of breaking down
Can exclude malignancy but nothing else
What is dysfunctional uterine bleeding
Irregular uterine bleeding that reflects a disruption in the normal cyclic pattern of ovulatory hormonal stimulation to the endometrial lining
No organic cause for bleeding
When is DUB most common
Either end of reproductive life
How can you recognise anovulation on histology
Gland will be disordered
Will have just kept proliferating
What is the function of the cervical mucous plug
Protects the endometrium from ascending infection
Changes with the cycle - easy for sperm to enter when fertile, harder when not
What is endometritis
Inflammation of the endometrium
Which microorganisms can cause endometritis
Neisseria Chlamydia TB - uncommon in UK CMV HSV
What are some non-microbiological of endometritis
IUD - copper
Post-partum or post-abortal
Leiomyomas or polyps
Granulomas - sarcoid
If you can see plasma cells in the endometrium what is the diagnosis
Chronic plasmacytic endometritis
Shouldn’t have plasma cells in the endometrium
Caused by an infection unless proven otherwise - associated with PID
How do endometrial polyps present
Usually asymptomatic but may present with bleeding or discharge
Common around or after the menopause
What might be seen in a sample from a miscarriage
Foetal RBC
Chorionic villi
Need to take a sample to exclude molar pregnancy
What is a molar pregnancy
When a non-viable fertilised egg implants in the uterus or tube
What is a complete mole
When one or two sperm combine with an egg which has lost its DNA
Only has the father’s DNA
Will form placenta and some structure but never a foetus
What is a partial mole
An egg fertilised by 2 sperm or a 1 sperm which reduplicates itself
It will have 2 copies of dad and one of mum
Leads to a crazy placenta and some foetal parts
What is the risk of leaving a complete mole behind
High risk of it developing into a choriocarcinoma
How can leiomyomas of the uterus present
Menorrhagia
Infertility
Mass effect
Pain
What drives the growth of leiomyomas
Oestrogen
How is CT used in gynae patients
Can be used to assess post-surgical complications
Staging of gynaecological malignancy, especially ovarian and endometrial
Assessing response to treatment in patients after chemotherapy +/- radiotherapy
How are MRI scans used in gynae patients
Cancer staging – especially cervical cancer
Further evaluation and characterisation of adnexal and uterine masses
Evaluation of patients with sub-fertility - looks for anatomical issues
Scan pituitary in suspected prolactinoma
What makes up a dermoid cyst
They contain tissue derived from ectoderm, mesoderm and endoderm
Therefore have a mixture of many types of tissue, particularly fat
Often lined with epithelial tissue and hence may contain hair, teeth.
What is hysterosalpingography
X-ray procedure where cervix is cannulated and radiopaque contrast instilled to fill the uterine cavity
For assessment of tubal patency in patients with infertility
How does endometriosis present on MRI
Endometriosis deposits contain altered blood and haemoglobin degradation products
These have characteristic MR signals - high on T1 (looks white)
How does ovarian cancer spread
Disseminates by peritoneal spread
Ascites, omental and peritoneal nodules are common. Sub-diaphragmatic deposits and deposits on the surface of the liver are also seen
How do you diagnose ovarian cancer
US usually makes the initial diagnosis - ovarian mass
CT is used for staging
How do you diagnose endometrial cancer
TV US - looks for abnormally thickened endometrium
MRI used to assess myometrial invasion
CT used to look for mets
What are the two types of US used in gynae
Transabdominal
Transvaginal
Which type of US scan needs a full bladder
Transabdominal -distended bladder displaces gas-filled bowel loops out of the pelvis
Transvaginal needs an empty bladder
How is a transabdominal US carried out
The pelvic organs are scanned through the anterior abdominal wall
What is the benefit of transvaginal; US
ultrasound probe is as close as possible to the pelvic organs
Gives better spatial resolution
What is female genital mutilation
All procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons
FGM is recognised internationally as a violation of the human rights of girls and women
What are the impacts of obesity in O andG
Increased infertility
Decreased effectiveness of IVF
Increased risk of miscarriage
Increased risk of pregnancy complications
What are the risks of smoking in pregnancy
Risk of stillbirth, premature birth, sudden infant death syndrome
Describe a follicular ovarian cyst
Very common
Thin-walled, lined by granulosa cells
Follicle grows into a cyst - can be several cm
Usually resolve over a few months
What are the different types of ovarian cyst
Follicular e.g. polycystic ovaries) Luteal - benign and form from the CL Theca luteal Endometriotic - filled with blood Epithelial - can be benign or malignant Mesothelial
What features of a cyst would make you consider malignancy
If has a solid component with a high CA125
What is endometriosis
Endometrial glands and stroma outside the uterine body - in the wrong place
Causes inflammation in the area leading to pain and infertility
What are the signs/symptoms of endometriosis
Pain is the significant symptom - severe and chronic pelvic pain
Heavy and painful periods
Painful sex - often deep
Infertility
Fatigue
Cyclical bowel issues
Adhesions or scarring in the reproductive tract
Which sites are commonly affected by endometriosis
Ovary (‘chocolate’ cyst) Pouch of Douglas Peritoneal surfaces, including uterus Cervix, vulva, vagina Bladder, bowel etc
What are the signs of endometriosis in the ovaries
Metaplasia of mesothelium
Adhesions on the ovary (from inflammation)
Chocolate cysts
Haemorrhage, inflammation, fibrosis
What are the complications of endometriosis
Pain Cyst formation Adhesions Infertility Ectopic pregnancy Malignancy (endometrioid carcinoma)
What is salpingitis
Inflammation of the fallopian tubes
Often due to infections
What is an ectopic pregnancy
Implantation of a conceptus outside the endometrial cavity
Often ruptures
May cause fatal haemorrhage
Where can an ectopic pregnancy occur
Commonest site is Fallopian tube
May occur in ovary or peritoneum
What are the differentials for a pelvic mass
Constipation! Caecal carcinoma Appendix abscess Diverticular abscess Urinary retention Pregnancy Uterine mass - benign or malignant Adnexal mass - benign or malignant
What family history is significant in a pelvic mass
Lynch Syndrome
BRCA (ovarian breast and prostate cancer)
HLRCC (renal cancer with fibroids)
Which blood tests should you do in a pelvic mass case
Young women: LDH, AFP, HCG
Older: Ca125
How do you assess pelvic malignancy risk
Risk of Malignancy Index (RMI)
Involves menopausal status, US features, Serum CA125
If someone has a high risk of pelvic cancer, what further investigations would you do
CT - check surrounding organs for involvement
MRI - Better view of the lesion itself
Hysteroscopy
Diagnostic laparoscopy
What are the most common benign ovarian tumours
Functional cysts
Epithelial tumours - serous, clear cell etc
Teratoma - germ cell tumour
Stromal tumours
What are functional cysts
Ovarian cysts that are related to ovarian cycle
Can be follicular or luteal
Usually resolve spontaneously after a few cycles and are asymptomatic
May bleed or rupture and cause pain
Most common type of ovarian cyst
What type of ovarian cysts can be caused by endometriosis
Endometriotic cysts - also called chocolate cysts
Blood filled cysts
Typically tender mass with ‘nodularity’ and tenderness
What cell types can be found in a dermoid cyst
It has totipotential
Commonly hair, teeth, sebaceous material and thyroid tissue
May present with thyrotoxicosis
What are the signs of ovarian torsion
Acute colicky pain associated with nausea, vomiting and distress
Can occur as a result of a benign cyst
How can you manage fibroids
CONSERVATIVE
MEDICAL – Mirena (1st line), GnRH analogues, Progestins
SURGICAL – Laparoscopic/Laparotomy
Myomectomy (Hysteroscopic or abdominal)
Subtotal Hysterectomy
Total hysterectomy
How does position of the transformation zone change throughout life
It has a physiological response to:-
menarche
pregnancy
menopause
what is the transformation zone of the cervix
Squamo-columnar junction between ectocervical (squamous) and endocervical (columnar) epithelia
What is cervical erosion
When exposure of delicate endocervical epithelium to acid environment of vagina leads to physiological squamous metaplasia
What inflammatory conditions can affect the cervix
Cervicitis – Often asymptomatic but can lead to infertility
Non-specific acute/chronic inflammation.
Follicular cervicitis
Chlamydia Trachomatis
Herpes Simplex Viral Infection
How does vulvar Paget’s disease present
Crusting rash.
Tumour cells in epidermis, contain mucin.
What is Paget’s disease of the vulva
A tumour which arises from sweat gland in skin.
usually no underlying cancer
What is the definition of primary amenorrhea
Failure of menstruation to start by the age of 16
What are the 3 major features of PCOS
Amenorrhea or oligomenorrhea
Multicystic large volume ovaries on US
Androgenic feature - acne, hirsutism
Need 2 out of 3 for diagnosis
What is Sheehan’s syndrome
A condition that affects women who either lose a life-threatening amount of blood in childbirth or have severe low blood pressure during or after childbirth, which can deprive the body of oxygen
This lack of oxygen that causes damage to the pituitary gland
Can cause amenorrhea, hypothyroidism, difficulty breastfeeding
How would you treat hyperprolactinemia
Prescribe a dopamine agonist as this will inhibit the release of prolactin and reduce levels
Often very quickly - restores fertility fast
How would you treat premature ovarian failure
Prevent osteoporosis - bisphosphonate and vit D
Prescribe HRT or COCP to preserve secondary sexual characteristics and reduce menopause symptoms
Which other condition is seen in those with premature ovarian failure
Osteoporosis
They lose the protective effect of oestrogen
Seen after around 6 months of POF
Patients with which ovarian condition are at high risk of endometrial hyperplasia/cancer
PCOS
Which drugs are used to induce ovulation in PCOS
clomiphene, letrazole or gonodatropins
What are the fertility options for those with POF
Fertility treatment is unlikely to work on them - unlikely to produce own eggs anymore Discuss the low chance of spontaneous pregnancy
Discuss use of donated eggs or adoption
Those with PCOS are at high risk of which other medical condition
T2DM
Should be offered a random blood glucose followed by oral GTT
How is PCOS treated
Lifestyle advice -weight loss, exercise etc.
Start on cyclical progestogen to induce withdrawal bleed then assess endometrial thickness. If normal there are a variety of contraceptive options for her depending on her wishes.
Combined pill would help hirsutism (option is BMI dependent)
Also offer advice on hair removal – electrolysis, androgen creams and traditional cosmetic procedures
Weight loss is incredibly effective in the treatment of PCOS - true or false
True
In some cases it can cure it
Also, those with PCOS are at high risk of hypertension, heart disease and heart disease so weight loss is very important
How do you prevent endometrial hyperplasia/cancer in those with PCOS
Progesterone treatment such as Mirena coil or cyclical oral progestogen
What is the first line investigation for those with chronic pelvic pain
Diagnostic laparoscopy
List some of the pathologies associated with chronic pelvic pain
Endometriosis Adhesions PID Ovarian cysts Pelvic congestion syndrome Nerve entrapment or other MSK cause IBS Interstitial cysts 30-50% have no obvious cause
How is endometriosis diagnosed
Clinical suspicion from history
Laparoscopic investigation
Histological samples
How does ovarian endometriosis present on US
May see fluid filled cyst of ground glass echogenicity.
How is endomtriosis treated
Hormonal suppression with a contraceptive
Choice depends on the patient
Symptoms will recur when stopped
Painkillers such as NSAIDs
Laparoscopic surgery - ablation or excision
Hysterectomy if patient has completed their family and isn’t responding to more conservative methods
What is chronic pelvic pain syndrome
An intermittent or constant pain in the lower abdomen or pelvis of a woman of at least 6 months in duration, not occurring exclusively with menstruation or intercourse and not associated with pregnancy
List the different types in FGM
Type 1 - Removal of all or part of the clitoris and clitoral hood
Type 2 - Removal of all or part of the clitoris and inner labia
? Removal of all or part of the inner and outer labia
Type 3 - Closure of the vagina (also known as infibulation)
Type 4 includes All other harmful procedures to the female genitalia for non-medical purposes, for example pricking, piercing, incising, scraping and cauterising the genital area
In which countries is FGM typically practiced
The majority of women are from Africa - 29 specific countries
Also seen in the middle east and south/southeast asia
List some of the short term consequences of FGM
Haemorrhage Severe pain Wound infection - sepsis Urinary retention Tetanus and gangrene Damage to adjacent organs Fractures (because of being forcibly held down) Infections - HIV, Hep Death
List some of the long term consequences of FGM
Recurrent UTI Painful menstruation Psychological issues Sexual difficulties Recurrent pelvic and urinary infections Keloid scarring and cysts Complications in pregnancy and delivery - for both mum and baby Infertility Post-traumatic stress disorder (PTSD) Psychosexual problems
Is FGM illegal in the UK
Yes
It is considered child abuse
It is also illegal to arrange FGM overseas for a UK resident
What do you do if you identify a child under 18 who has had FGM
Mandatory reporting to the police - 101
Should also refer to children’s social care
May require an examination -preferably with an experienced pediatrician
Which girls are considered to be at risk of FGM
Those born to a mother with FGM
Those with a sibling or family member who has undergone FGM
Those who state that they are being taken abroad - perhaps for a ceremony
Girl who is withdrawn from PSHE lessons or from learning about FGM
Which subtype of FGM is most likely to cause issues with childbirth
Type 3 - infibulation
Inability to complete vaginal exams, take sample from baby, deal with complications such as prolapse and prolonged labour due to total/partial occlusion
If a pregnant woman has had FGM when is deinfibulation usually performed
Between 20-32 weeks
This allows time for the new scar to heal
What conservative treatment is available for urge incontinence
Lifestyle changes: reduce weight, fluid intake, alcohol and caffeine
If your patient drinks a lot of tea/coffee encourage them to cut down or switch to decaf
Use pads
Bladder retraining = don’t go just because there is a toilet, let the bladder fill
What surgical treatment is available for urge incontinence
Botox is commonly used
All other surgical treatment is very much last line
How is urge incontinence treated
Conservative and medical treatment
Surgery is very much last line
What medical treatment is available for urge incontinence
Vaginal oestrogen
Anti-cholinergics - tolterodine (1st line) then soliphenacin
May consider a transdermal preparation if they cannot tolerate oral
Beta-3-adrenoceptor agonist - mirabegron (alternative to anti-cholinergic, good in elderly)
If none work individually you can consider dual therapy
Desmopressin can be used to treat nycturia
List some of the anti-cholinergic side effects of the drugs used in the treatment of urge incontinence
Dry mouth
Constipation
Around 50% of patients will not tolerate the anti-cholinergic side effects
How does urge incontinence present on detrusor tracing
You will see the detrusor contracting in large peaks when the bladder isn’t quite full
Detrusor over activity
Frequency/volume charts will show increased frequency
How is stress incontinence treated
Conservative then surgical treatment
What is bladder pain syndrome
Functional disorder
Cannot find a physical problem but patient presents with pain, incontinence, painful sex
How do you diagnose bladder pain syndrome
Examination, US and cystoscopy (to exclude more serious causes)
How do you manage
bladder pain syndrome
Lifestyle changes - weight loss, reduced caffeine
List some conservative options for prolapse treatment
Lifestyle advice - weight loss, avoid constipation, smoking cessation, avoid heavy lifting
Supervised pelvic floor exercises
Vaginal oestrogen
Pessaries
List some surgical options for prolapse treatment
Anterior (bladder prolapse) or posterior repair (rectal prolapse)
This is where stitch the fascia to hold organs up
Sacrospinous repair - strong ligament so you fix the cervix or top of vagina to it to hold it up
May combine the above surgery depending on where the prolapse is
Laparoscopic sacrohysteropexy/ colpopexy - suspension (old mesh)
Colpocleisis - sew vaginal walls together
Used women who are no longer sexually active
May do a hysterectomy
List some of the differentials for a pelvic mass
Pregnancy Full bladder - should only be felt when completely full Fibroids PID - abscesses Benign ovarian disease Malignant ovarian disease
Why might a patient not realise/feel that their bladder is full
Peripheral neuropathy (e.g. in diabetes) Spinal injury, cauda equina, paraplegia Also after prolonged labour anaesthesia
What test is always carried out first in a patient with a pelvic mass
a pregnancy test
What is the nerve supply to the pelvic organs
S2, 3, 4
What is the blood supply to the ovary
Ovarian artery supplies the ovary and is a branch of the aorta
Veins drain to the IVC (right) or the renal vein (left)
Which genetic mutations come with an increased risk of ovarian cancer
BRCA 1 and 2
HNPCC
Which subtype of fibroids are most likely to cause worst symptoms
Submucosal
Infertility and heavy bleeding
How can you treat symptomatic fibroids
Treat with IUS
Also can use tranexamic acid or norethisterone to reduce bleeding
If family is complete you can offer myomectomy or hysterectomy
What is the most common type of uterine fibroid
Intramural
Define stress incontinence
Complaint of involuntary
loss of urine on effort or physical exertion including
sporting activities, or on sneezing or coughing (increased intra-abdominal pressure)
All in abscence of detrusor muscle contraction
Define an overactive bladder or urge incontinence
Urinary urgency, usually
accompanied by increased daytime frequency and/or
nocturia
Individual often says “If I have to go, I have to go immediately”
With urinary incontinence (OAB-wet) or
without (OAB-dry), in the absence of urinary tract
infection or other detectable disease.
What is mixed urinary incontinence
Complaints of both stress
and urgency urinary incontinence, i.e. involuntary loss
of urine associated with urgency and also with effort or
physical exertion including sporting activities or on
sneezing or coughing.
List some of the main causes of urinary incontinence
Age High parity Obesity Pregnancy Menopause and oestrogen deficiency Hysterectomy UTIs Smoking Family History
What conservative treatment is available for stress incontinence
Lifestyle - weight loss, stop smoking, avoid constipation, avoid heavy lifting, reduce caffeine
Pelvic floor training - often with physio
Use pads
Incontinence ring
What medical treatment is available for stress incontinence
Vaginal oestrogen
Duloxetine - last line as lots of side effects
What surgical treatment is available for stress incontinence
Bulking agents
Fascial slings
Colposuspension - lap or open
Artificial urinary sphincters (In severe cases where previous surgery has failed)
List the urinary symptoms relating to storage
Frequency Nocturia (>1) Urgency Incontinence Constant leakage (secondary to fistula
List the urinary symptoms relating to voiding
Hesitancy
Straining
Poor flow
List common post micturition symptoms
Incontinence
Sensation of
incomplete emptying
Which examinations should you perform on a patient presenting with incontinence
BMI
Abdominal exam
Vaginal exam
Neuro (emphasis on sacral roots S2-4)
Which investigations should you perform on a patient presenting with incontinence
Urinalysis
Post-void residual volume
Cystoscopy
Urodynamics
List the different types of pelvic organ prolapse
Cystocele - anterior wall Rectocele - posterior wall Uterine prolapse Vaginal vault prolapse - top of the vagina following hysterectomy
List some of the causes of pelvic organ prolapse
Age
High parity - vaginal deliveries
Post menopausal (oestrogen deficiency affecting periurethral collagen metabolism)
Obesity and chronic increase in intra abdominal
pressure (chronic cough, heavy lifting, constipation)
Neurological conditions eg spina bifida and muscular
dystrophy
Genetic connective tissue disorders eg Marfans and
Ehlers-Danlos
List the common symptoms of prolapse
Heaviness or dragging in the vagina Urinary symptoms - urgency, frequency, hesitancy, incomplete emptying, manual reduction of prolapse or position change to accomplish voiding Faecal incontinence Excessive straining Sexual dysfunction.
How do you stage a prolapse
The hymen is defined as 0 and the distance to 6
anatomical points is measured in cm above the hymen (negative
number) or below the hymen (positive number)
Stage 0 -no prolapse demonstrated
Stage 1 - the leading edge is -1cm or above
Stage 2 - the leading edge is between -1cm and +1cm
Stage 3 - the leading edge is +1cm or below but
without complete eversion
Stage 4 - complete vaginal eversion
What is procedentia
Complete vaginal eversion
List some of the complications of pessary use
Vaginal discharge Ulceration - may lead to vesicovaginal or rectovaginal fistulae Formation of fibrous bands attaching the pessary to the vagina
How often should pessaries be changed
Every 6 months
This is to avoid complications
How can you prevent some of the complications of pessary use
Change it every 6 months
Topical oestrogen creams
List some of the types of pessary
Ring
Cube
Shelf
Gelhorn - looks like a dummy
Why might a prolapse patient have abnormal renal function
If they have chronic urinary retention
Should catheterize them
What is the gold standard for diagnosis of endometriosis
Diagnostic laparoscopy
It allows visualisation of implants and allows for biopsy
Why do you give GnRH analogues prior to fibroid removal surgery/hysterectomy
nRH analogue prior to surgery will cause medical menopause and also may reduce the size of the fibroids helping with the surgery
Given for 3 months before
What should you look for when inspecting the cervix
Type of cervical os – small round dimple (nulliparous) or shape of a smile (multiparous)
Colour – normally pink, bright red in cervicitis, redder area around os called ectropion
Secretions and discharge – note colour and odour
Growth/ Malignancy – cauliflower like and friable and bleeds on touch is usually associated with malignancy
Ulcerations, scars and retention cysts (Benign nabothian cysts)
If a woman has had a baby her cervical os will be smile shaped rather than round - true or false
True
The cervix is normally soft - true or false
False
It is normal for it to be firm
Hard suggests fibrosis or cancer
Soft is felt in pregnancy
When is the cervix tender
Also called cervical excitation tenderness - hurts when moved/touched
Seen in PID or ectopic pregnancy
List causes of vulval pruritus
Other skin conditions – eczema, atopic dermatitis, psoriasis
Lichen sclerosus
Lichen planus
Infection e.g. candidiasis, trichomonas vaginalis.
Extramammary Paget’s disease of the vulva
What is lichen sclerosis
A chronic inflammatory condition of unknown aetiology affecting the skin
Characterised by areas of atrophy and systematic destruction to the skin cells include melanocytes and hair follicles
Most commonly affects the genitals - most often labia majora, extending to minora and anus
How does lichen sclerosis present
Pruritus and skin irritation on the vulva
Skin is hypopigmented and atrophied giving it a shiny appearance
May be hair loss in the affected areas.
Affected areas may also bleed easily and pinpoint vessels may be seen
White polygonal papules coalesce to form plaques
In late stage you get scar formation so some present with atrophy and fusion of the labia, stenosis of the introitus or difficulties in defecation
Without treatment, lichen sclerosis can progress to what
vulvar intraepithelial neoplasia
Especially in older women
How do you treat lichen sclerosis
Treatment includes topical high-dose steroids and emollients
NICE guidelines suggest a 3month trial of topical steroids
2nd line topical calcineurin inhibitors
In cases where the lesion is treatment resistant, a biopsy is needed to confirm diagnosis and rule out malignancy
What must you do if you find Paget’s disease of the vulva
It is often a sign of other malignancy in the body therefore a full body work-up is indicated in patients presenting with this condition.
How does Paget’s disease of the vulva present
May extend towards the anus and presents as an erythematous, eczematous area with a crusting rash
List risk factors for pelvic infection
Age <25years Multiple sex partners Unprotected sexual intercourse Recent insertion of IUD Recent change in sexual partner.
List signs and symptoms of a pelvic infection
Lower abdominal pain Fever Abnormal vaginal bleeding (intermenstrual, menorrhea, post-coital) Offensive vaginal discharge Deep dyspareunia Dysuria or menstrual irregularities may occur Cervical motion tenderness Adnexal tenderness
What can cause tubo-ovarian abscesses
An ascending genital tract infection causes cervicitis, endometritis, salpingitis (inflammation of the cervix, endometrium, fallopian tubes)
How do ovarian cysts typically present
Presence of pelvic/abdominal mass
Pain
Incidentally on US
Pressure on the bowel or bladder depending on the size and site of the cyst
Depending on the type of cyst, disturbance in the menstrual cycle or virilisation may occur.
What are cyst accidents
When an ovarian cyst presents acutely
There may be haemorrhage within the cysts, or the cysts may rupture or twist on itself (torsion).
Functional ovarian cysts are most common in which age group
young women in their reproductive years
Benign germ cell ovarian tumours are most common in which age group
Young women
Benign epithelial ovarian tumoursare most common in which age group
Older women
Which tests should be done if an ovarian cyst has suspicious features
Tumour markers which include measuring inhibin, AFP, b-HCG, CA125
Imaging modalities such as ultrasound (transabdominal or transvaginal), CT scans or MRI
How do follicular cysts appear on US
Appear as simple, uniloculated cysts on ultrasound which measure more than 3cm
How do you treat follicular cysts
Depends on symptoms – if asymptomatic, they are observed and sequential repeat ultrasound to assess changes are recommended.
If symptomatic, laparoscopic cystectomy may be performed.
What is the most common benign ovarian tumour in women <30years
Dermoid cysts - mature cystic teratomas
Where do benign epithelial ovarian tumours arise from
Ovarian surface epithelium
Includes serous cystadenoma and mucinous cystadenoma.
What is a Bartholin cyst/abscess
Infection in the Bartholin’s glands - pair of glands located next to the entrance to the vagina
They become enlarged
How do you manage a Bartholin cyst/abscess
Sometimes these settle with antibiotics but may require a surgical procedure known as marsupialization.
Stress incontinence can be caused by what
Commonly seen after childbirth, pelvic surgery and oestrogen deficiency
Triggers: Coughing, sneezing, exercise
Prolapse may be seen alongside stress incontinence - true or false
True
Prolapse of urethra and anterior vaginal wall could be present
How do you diagnose stress incontinence
After excluding a UTI, frequency/volume charts should be done. Charts will show normal
frequency and bladder capacity.
Urodynamic studies should be done
What can cause urge incontinence
Idiopathic
Pelvic surgery
Multiple sclerosis
Spina bifida
Which type of incontinence typically has the larger volume of leakage - urge or stress
Urge
Stress is small volumes, urge is larger
What can trigger urge incontinence
Hearing running water, cold weather
What is overflow incontinence
Leakage of urine from a full urinary bladder, often with the absence of an urge to urinate
What can cause overflow incontinence
Inactive detrusor muscle: neurological conditions e.g. M.S -> no urge to urinate
Involuntary bladder spasms: can occur in cardiovascular disease and diabetes
Cystocele or uterine prolapse can block urine exit if severe
Overflow incontinence is more common in which of the sexes
Men > women due to prostate-related conditions
How do you investigate overflow incontinence
Frequency/volume charts
Urodynamic testing shows inactivity of the detrusor muscle
How do you treat overflow incontinence
Treat the cause
How does UTI present
Dysuria Increased urinary frequency Increased urinary urgency Cloudy/offensive smelling urine Lower abdominal pain Fever Malaise In elderly patients, can be a cause of delirium
How do you treat UTI in non-pregnant women
Nitrofurantoin (1st line) or Trimethoprim (2nd line) for 3 days
Urine culture should be sent if age>65 or haematuria is present
How do you treat UTI in syptomatic pregnant women
Urine culture done
Nitrofurantoin (1st and 2nd trimester), Trimethoprim 3rd trimester
How do you treat UTI in asyptomatic pregnant women
Urine culture should be done at 1st antenatal visit
High risk of progressing to acute pyelonephritis
Immediate course of Nitrofurantoin (avoid near term pregnancy), amoxicillin or cefalexin for 7
days should be started
Urine culture after treatment, for test of cure.
How do you treat UTI in cateterised patients
Only treat if symptomatic!
If definite infection treat as per complicated UTI - Amoxicillin IV 1g tds + Gentamicin IV (Total IV/PO 7 days)
