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Obs & Gynae > Pelvic Pain and Genital Infection > Flashcards

Pelvic Pain and Genital Infection Flashcards

1
Q

Lymph drainage of the vulva:

relevant for metastatic spread of vulval carcinoma

A

-most into inguinal nodes –> femoral nodes —> external iliac nodes of pelvis

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2
Q

Pruritis Vulvae:
Give 2 infective causes
2 Dermatological causes
and 1 neoplasia cause

A
  • infection: candidiasis (+vaginal discharge), vulval warts, pubic lice, scabies
  • derm: eczema, psoriasis, lichen simplex, lichen sclerosus, lichen planus, contact dermatitis
  • neoplasia: carcinoma of vulva, vulval intraepithelial neoplasia (VIN-premalignant)
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3
Q 
Lichen simplex (aka chronic vulval dermatitis) is a chromic inflammatory condition that particularly affects women with what predisposing factors?
How does it present?
A
  • women with: sensitive skin, dermatitis, eczema
  • presents with: severe intractable pruritis esp. at night, affected labia majora is inflamed, thickened +/- change in pigmentation
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4
Q

What should be avoided in lichen simplex vs. what can help?

A
  • avoid irritants like soap (can exacerbate chemical/contact dermatitis)
  • use emollients, mod strength steroid creams, +antihistamines to break itch-scratch cycle
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5
Q

Lichen planus can affect anywhere but especially mucosal surfaces such as ___ and ___.

  • presents with what type of lesion,
  • cause is unkown
  • how is it treated?
A
  • mouth and genital regions
  • flat, papular, purple-ish lesions, that are painful and can be erosive
  • treat with high-potency steroid creams
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6
Q

Lichen sclerosus refers to what change to the vulval epithelium due to loss of c_____.

  • 40% with this go on to develop what another ______ ____
  • describe the appearance of lesions in this condition (can affect younger women, but most = postmenopausal)
A
  • thin epithelium, loss of collagen
  • another autoimmune condition (e.g. thyroid disease, vitiligo often co-exist)
  • pink-white papules, coalesce –> parchment like skin with fissures
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7
Q

Lichen Sclerosus (thin parchment like skin w fissures from loss of collagen) can cause severe pruritis especially at night can -> scratching
-what are the consequences of this severe scratching, suggest 3
-if inflammatory adhesions form, what can happen to the labia and introitus?
NB: treat w ultra-potent topical steroids

A
  • scratch: trauma, bleeding, skin splitting, sx of discomfort, pain + dyspareunia
  • fusion of labia, narrowing of introitus
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8
Q

Is there a link between lichen sclerosus and vulval carcinoma?
If so, what is a necessary investigation?

A
  • yes, carcinoma can develop in 5% of cases

- do biopsy to exclude this, and confirm the diagnosis

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9
Q

Vulvular Dysaesthesia/Vulvodynia are dx of exclusion

  • whats the difference between generalised, how does it often present?
  • and vulval -and what is the typical presentation here?
    clue: : consider age, localisation and type of pain
A

-generalised: burning pain more in older women
-vulval: superficial dyspareunia or pain using tampons in younger women
(must rule out introital damage)

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10
Q

Name 3 RFs for candidiasis of the vulva:

treat with topical/oral antifungal therapy

A
  • prolonged exposure to moisture
  • diabetics
  • obese
  • pregnancy
  • when abx has been used/immunity is compromised
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11
Q

Bartholin’s glands if blocked can -> cyst formation

  • if infected can –> abscess, suggest a common causative organism of this?
  • how would an abscess present?
  • treat with incision and drainage
A
  • E coli

- presents acutely painful, large red swelling

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12
Q

Vaginal adenosis is when what epithelium is found in the normal _____ epithelium
what is the usual disease course? (therefore annual colposcopy offered)
-most often in women whose mothers received DES in pregnancy

A
  • when columnar epi is found (normally = squamous)
  • usually spontaneously resolves but small risk of malignant transformation
  • women with DiEthylStilboestrol exposure in utrero screened annually
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13
Q

Vulval Intraepithelial Neoplasia (VIN) is divided into usual type and differentiated type, give a feature or association of each:

A
  • usual type: can be warty, basaloid/mixed, common in 35-55yr ages, associated w HPV (16), CIN, smoking and chronic immunosupression
  • differentiated: rare, may be associated with lichen sclerosis, in older women, usually unifocal ulcer/plaque lesion, higher risk of progression to cancer
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14
Q

VIN can cause pruritis and pain, what treatment can help and what is the gold standard rx (to relieve sx, confirm dx and exclude invasive disease)

A
  • emollients/mild topical steroid can help

- gold standard - local surgical excision

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15
Q

Vulval carcinoma accounts for 5% genital tract cancers

  • what age does it most commonly affect?
  • 95% are _____ ____ carcinomas
  • often arises de novo, other associations include…
A
  • affects 60yrs+ mostly
  • squamous cell carcinoma
  • or arises from VIN, associated with: lichen sclerosus, immunosupression, smoking and paget’s disease of vulva
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16
Q

How does carcinoma of vulva look on exam?

A
  • ulcer/mass commonly on labia majora or clitoris

- inguinal LNs may be enlarged, hard and immobile

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17
Q

Treatment of stage 1a vs all other stages of vulval carcinoma:

A
  • 1a: wide local excision
  • all others: sentinel LN biopsy (SLNB) determining if +: WLE and groin lymphadenectomy, if - complete inguinofemoral lymphadenectomy
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18
Q

What is more common 1 or 2ndry carcinoma of the vagina?

how is primary vaginal cancer treated?

A
  • secondary is much more common (from local infiltration or metastatic spread)
  • primary rx: intravag. radiotherapy or radical surgery
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19
Q

Clear cell adenocarcinoma is a rare complication affecting daughters of women prescribed what during pregnancy to prevent miscarriage in 60s? NB: survival rates post radical surgery are good

A

DES (DiEthylStilboestrol)

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20
Q

Endometriosis is the presence and growth of what?

-accumulated altered blood is dark brown and can form what in the ovaries?

A
  • tissue similar to endometrium (responds to E2) outside the uterus
  • can form a ‘chocolate cyst’ or endometrioma in the ovaries
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21
Q

Suggest 2 symptoms/features of the sx of endometriosis

A

-chronic pelvic pain
-cyclical pain
dysmenorrhoea before menstruation onset
-deep dsyspareunia
-subfertility
-pain on passing stool ‘dyschezia’ during menses

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22
Q

Bimanual exam findings of endometriosis, suggest 2

NB: in mild disease, the pelvis can appear normal

A
  • tenderness
  • thickening behind the uterus/in adnexa
  • may be a rectovaginal nodule of endometriosis, can be visible on speculum
  • (if advanced, uterus may be retroverted and immobile due to adhesions)
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23
Q

How is definitive diagnosis of endometriosis made? How do active vs. older areas appear?
NB: ovarian endometriomas and extensive adhesions indicate severe disease

A
  • visualisation with biopsy at laparoscopy
  • active: red vesicles/punctate marks
  • older: white scars or brown spots ‘powder burn’
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24
Q

(other than laparoscopy) How can ovarian endometrioma ‘chocolate cyst’ be excluded in the investigation of endometriosis?

A

-TVUS

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25
Q

If clinical evidence suggests ureteric/bladder/bowel involvement of deep infiltrating endometriosis, how should this be investigated?

A

-MRI and intravenous pyelogram (IVP) and barium studies

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26
Q

give 3 ddx of endometriosis:

A
  • adenomyosis
  • chronic PID
  • chronic pelvic pain
  • irritable bowel syndrome
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27
Q

Suggest how endometriosis can be medically managed?

A
  • trial of COCP or IUS to supress ovarian activity
  • progestogens
  • GnRH analougues (to induce ‘menopause-like state’) +/- HRT
  • NSAIDs / paracetamol
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28
Q

Suggest 2 surgical approaches that may be taken to treat endometriosis:

A
  • scissors/laser/bipolar diathermy
  • dissection of adhesions
  • removal of ovarian endometriomas (open and drain then remove or ablate cyst wall)
  • hysterectomy with bilateral salpingo-oophorectomy (last resort)
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29
Q

Does endometriosis affect fertility?

A
  • yes
  • 25% of laparoscopies for subfertility find endometriosis
  • the more severe the greater chance of subfertility
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30
Q

What is the definition of chronic pelvic pain?

A
  • intermittent/constant pain in lower abdo/pelvis for at least 6months
  • not occurring exclusively with menstruation or intercourse
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31
Q

Suggest 4 causes of chronic pelvic pain (CPP)

A
  • hormonally driven e.g. endometriosis, adenomyosis (supress ovarian activity to treat)
  • gynae or pelvic adhesions, ovarian tissue can be trapped in adhesions –> cyclical pain
  • IBS
  • interstitial cystitis
  • pyschological factors: depression, sleep disorders, childhood/ongoing abuse
  • pelvic congestion syndrome from venous congestion
  • myofascial syndrome: pain originates in muscle trigger points/trapped nerves
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32
Q

If CPP sx suggest irritable bowel syndrome what medication should be trialled along side dietary change?

A

-antispasmodics and analgesia

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33
Q

CPP hollistic management approach may include what?

A
  • therapeutic trial with COCP if cyclical pain
  • counselling, psychotherapy
  • pain management programs: relaxation techniques, sex therapy, diet and exercise
  • attempt to rx pain with management plan in partnership w woman even if no cause found
  • Amitriptyline or gabapentin can be used
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34
Q

Fibroids are more common in certain patient groups, suggest 3
(NB: they are less common in parous women, those who’ve taken the COCP/injectable progestogens)

A
  • older women
  • reproductive age
  • black and asian women
  • obese women
  • those with an early menarche (before 11)
  • women w an affect 1st-degree relative
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35
Q

Give 3 locations uterine fibroids can exist in:

A
  • intramural
  • subserosal
  • submucosal (occasionally these form intracavity polyps)
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36
Q

50% fibroids are asymptomatic, sx depend mainly on site.

-suggest 2 sx of fibroids

A
  • heavy menstrual bleeding e.g. from submucoasal or polypoid fibroid
  • dysmenorrhoea
  • if large and pressing on bladder can -> frequency or rarely urinary retention
  • if pressing on ureters can -> hydronephrosis
  • subfertility can result if tubal ostia are blocked/submucous fibroids prevent implantation
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37
Q

Suggest 2 things that may be palpable on examination in a women with either a fibroid or multiple

A
  • solid mass on pelvic exam
  • will arise from pelvis and be continuous with uterus
  • multiple cause “knobbly” enlargement of uterus
38
Q

What is ‘red degeneration’ of a fibroid?

A
  • result of inadequate blood supply

- pain and uterine tenderness due to haemorrhage and necrosis

39
Q

0.1% fibroids are leiomyosarcomata (malignant), in what pt’s/presentations may you suspect this (need to biopsy to diagnose)

A

consider if:

  • there is rapidly enlarging fibroids
  • fibroid growth in post-menopausal women
  • sudden onset of pain
40
Q

Which type of fibroid (think shape) have the possibility of undergoing torsion? (NB: torsion - v painful)

A

-pedunculated fibroids

41
Q

Suggest 4 complications that can arise due to fibroids in pregnancy?

A
  • premature labour
  • malpresentations
  • transverse lie
  • obstructed labour
  • post partum haemorrhage
  • red degeneration
42
Q

Why should fibroids not be removed at C-section?

A

-can cause heavy bleeding

43
Q

What effect can HRT have on fibroids?

A
  • can cause continued fibroid growth post-menopause

- NB: rx is same as for pre-menopausal women or withdraw HRT

44
Q
  • Initial screening ix for fibroids is …

- if diagnostic uncertainty/need greater accuracy what ix is done? differentiates which ddx?

A
  • US initial screen

- MRI more detail. Differentiates from Adenomyosis

45
Q

Interestingly, Hb in women with fibroids can be low or high, explain why?

A
  • low as result of vaginal heavy bleeding

- high as fibroids can secrete erythropoietin

46
Q

When do fibroids need treatment?

A

-when they cause symptoms (affect QoL or fertility)

47
Q

Give 3 types of medical treatment that may be utilised in the rx of fibroids?
NB: while the IUD is good for HMB usually, it’s efficacy is poorer in women w fibroids

A
  • transexamic acid
  • NSAIDs
  • progestogens
  • GnRH agnoists
  • SPRMS (selective progesterone receptor modulators) e.g. ulipristal acetate
48
Q

GnRH agonists cause temporary _______ and fibroid ______ by inducing a temporary ________ state.
Due to what SE is their use limited to 6 months (in this time makes surgery easier and safer by also thinning endometrium and reducing vascularity)?

A
  • amenorrhoea
  • fibroid shrinkage
  • menopausal
  • bone density loss
49
Q

Bone density loss and SEs mean GnRH agonists for fibroids’ use limited to 6 months (in this time makes surgery easier and safer), how can we prevent such SEs without causing enlargement so we can use for longer periods of time?

A

-concomitant use of ‘add-back’ HRT

50
Q

In what patient group with fibroids would GnRH agonists be inappropriate treatment?

A

-in women trying to conceive due to induction of anovulation and return of fibroids on drug cessation

51
Q 
What new class of medication offers an alternative to GnRH agonists for medical rx of fibroids that reduces HMB and shrinks fibroids without causing the loss of BMD and menopausal side effects. Give 1 example of a medication of this class
-NB: used short term pre-surgery or long term to control fibroid sx
A
  • SPRMs (selective progesterone receptor modulators)

- e.g. oral Ulipristal acetate

52
Q

Hysteroscopy TCRF (transcervical resection of a fibroid) is indicated in which types/size of fibroids?

A

-fibroid polyp or small submucous fibroid (<3cm) that is causing symptoms

53
Q

Open/laporascopic myomectomy

-what is given perioperatively directly into myometrium and why?

A

-vasopressin injection, to reduce blood loss

54
Q

Adhesions can arise as a result of myomectomy for fibroids which poses what risk for future pregnancies?

A

-risk of uterine rupture during labour (so C-section may be chosen)

55
Q

What alternative to hysterectomy/myomectomy offers 80% success rate and is carried out by radiologists to reduce the volume of the fibroid?
Give 2 disadv of this rx

A
  • UAE (uterine artery embolisation)

- pain can get worse, higher rates of readmission and further surgical intervention

56
Q

Definition of adenomyosis = presence of _________ and it’s underlying stroma within the ________
NB: common around 40yrs, associated w endometriosis and fibroids

A

-presence of endometrium and it’s underlying stroma within the myometrium

57
Q

Suggest 1 sx and 1 exam finding in a patient suffering w adenomyosis:

A
  • painful, regular, heavy menstruation

- mildly enlarged, tender uterus

58
Q

What imaging modality is able to clearly diagnose Adenomyosis?

A

MRI and US have similar accuracy

59
Q

Hysterectomy for adenomyosis is often needed, however, suggest what rx may control the menoorhagia/dysmenorrhoea?

A
  • IUS
  • COCP
  • NSAIDs
60
Q

In post-menopausal women, intrauterine polyps are most commonly found in women with breast cancer on what medication?

A

-Tamoxifen

NB: it acts as an anti-oestrogen in the breast but like an oestrogen in the uterus

61
Q

Women with a congenital uterine anomaly e.g. didelphys-2cavities, 2cervices, eg. unicornuate.. etc should undergo imaging of what part of their body due to increased incidence in abnormalities of this organ?

A

-Renal tract imaging

62
Q

Suggest 2 deep and 2 superficial causes of dyspareunia:

A
  • deep: endometriosis, PID, pelvic mass, IBS, ovarian cyst

- superficial: vagina/vulva, surgery, childbirth, psychological

63
Q

Suggest an investigation for deep dyspareunia and one for superficial:
NB: remember commonest causes are endometriosis, PID, mass in deep and infection in superficial

A
  • deep: US scan, MRI or laparoscopy

- superficial: high vaginal and cervical swab

64
Q

vagina pH is what usually?

But prepubertally/post-menopausal is different how? (-> less resistant to infection)

A
  • acidic (<4.5)

- higher (6.5-7.5)

65
Q

What 3 common infections are associated w vaginal discharge?

A
  • BV: bacterial vaginosis
  • Trichomoniasis (this is an STI)
  • Candidiasis
66
Q

Bacterial vagniosis (BV) is associated w loss of lactobacilli and increase in anaerobic BV-associated bacteria that produce proteolytic enzymes causing what?

A
  • breakdown of vaginal peptides -> volatile, malodorous amines
  • causes rise in pH that facillitates the bacteria to adhere to epithelium
67
Q

Describe the discharge of BV:

What is seen on microscopy?

A

grey-white discharge with characteristic fishy odour)
NB: no vulvovaginitis
-clue cells seen (epithelial cells studded with coccobacilli)

68
Q

Treatment for symptomatic women with BV is with what creams? Suggest 1

A
  • metronidazole cream

- clindamycin cream

69
Q

What is the most common causative organism of thrush in women and give 2 RFs to it’s development:

A
  • candida albicans

- pregnancy, diabetes, use of antibiotics, immunocompromised

70
Q

Give 2 classic sx of thrush:

A
  • ‘cottage cheese’ discharge with vulval irritation and itching
  • +/-superficial dyspareunia and dysuria
  • vulva/vagina may be inflamed/red
71
Q

Thrush is diagnosed by culture, how is it treated? Give one topical (c) and 1 oral (f) suggestion

A
  • topical imidazoles e.g. clotrimazole pessary

- oral fluconazole

72
Q

What is responsible for toxic shock syndrome?

A

-a toxin producing staphylococcus aureus

73
Q

State 3 principles in management of STIs in a consultation:

A
  • screening for concurrent infections
  • partner notification (contact tracing)
  • confidentiality
  • education: health promotion to reduce future risk
74
Q

-chlamydia trachomatis is most prevalent in 18-24yrs. 70% females asymptomatic but what sx may be present in the remainder?

A
  • altered vaginal discharge
  • intermenstrual &/or postcoital bleeding,
  • low abdo pain and dyspareunia
75
Q

Azithromycin or doxycyline are used to treat what STI?

A

-Chlamydia

76
Q

What medication is given IM to treat gonorrhoea?

A

-Ceftriaxone

77
Q

Neisseria Gonorrhoea is a gram ____ ______

  • sx in men usually u_____
  • asymptomatic in women or may have: ….
A
  • gram negative diplococcus
  • men-> urethritis
  • women: vaginal discharge. urethritis, cervicitis..
78
Q

Diagnosis of gonorrhoea is from NAATs of what? If +, Followed by what?

A
  • of endocervical or vulvovaginal swabs

- followed by culture to check abx sensitivities

79
Q

External genital warts are most commonly caused by HPV 6 and HPV 11, what are the most oncogenic types of HPV associated with ____ intraepithelial _____?

A

-HPV 16 and HPV 18, associated with cervical intraepithelial neoplasia

80
Q

~30% of those infected with herpes have a primary infection ~1-2weeks after infection, how may this present?

A
  • feel generally unwell, flu-like sx
  • followed by stinging/itching in ano-genital area
  • small vesicles then arise, burst in a day or two and crust over and heal
81
Q

What type and name of organism causes syphilis?

A

-the spirochete, Treponema pallidum

82
Q

Syphilis in it’s primary state presents as a chancre, what is this?
Untreated weeks later, 2dry syphilis presents with rash, flu like sx and condylomata lata, what are these?
Treatment is with IM what?

A
  • chancre = solitary painless genital ulcer
  • conylomata lata = warty genital or perioral growths
  • IM penicillin
83
Q

Trichomoniasis Vaginalis (TV) is a flagellate ______, presents with what sx? (50% women asymptomatic)

  • diagnosed with NAATs, also motile trichomonads seen on wet film microscopy sometimes
  • Treatment is with systemic ________
A
  • protozoon
  • sx: green discharge, vulval irritation, dysuria and superficial dyspareunia
  • rx w Metronidazole
84
Q

Endometritis is common after misscariage/ToP esp if there are RPOC.
Can present w persistent, heavy _____ which is _____. Uterus will feel ____ and the ____ __ is commonly open
-give _____ then evacuate RPOC if sx don’t improve

A
  • vaginal bleeding which is painful
  • uterus is tender, cervical os commonly open
  • give broad spectrum antibiotics
85
Q

Although can be asymptomatic, what are the hallmark sx of pelvic inflammatory disease?

A

-bilateral lower abdo pain with deep dyspareunia +/- abnormal vaginal bleeding/discharge

86
Q

Suggest 2 findings you may elicit on examination of a patient with PID:

A
  • tachy, fever, lower abdo peritonisim in severe cases
  • bilateral adnexal tenderness
  • cervical excitation (pain on moving cervix)
  • a mass may be palpable vaginally (pelvic abcess)
87
Q

Give 2 ddx of PID that it may be confused with:

A
  • appendicitis
  • ovarian cyst accidents
  • ectopic pregnancy
88
Q

Suggest 3 ix for a pt with suspected PID:

NB: Laparoscopy with fimbrial biopsy and culture = gold standard but rarely done

A
  • endocervical swabs for chlamydia and gonorrhoea
  • blood cultures if pyrexial
  • WBC and CRP
  • Pelvic US to exclude abscess or ovarian cyst
89
Q

Treatment of PID = analgesics and IM ______ followed by d____ and m______ or o____ with m_____
NB: treat sexual partners before resuming sexual activity

A

-IM ceftriaxone followed by doxycycline+metronidazole or ofloxacin+metronidazole

90
Q

Name 2 complications of PID

A
  • formation of an abscess or pyosalphinx (rupture of which is dangerous)
  • tubal obstruction and subfertility
  • chronic pelvic infection or chronic pelvic pain
  • ectopic pregnancy x6 more likely

Obs & Gynae (9 decks)

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