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Gynaecology > Pelvic Pain and vaginal discharge > Flashcards

Pelvic Pain and vaginal discharge Flashcards

1
Q

PALM COIEN For DDX of AUB

A 
Structural 
- Polpys
- Adeniomyosis
- Leiomyoma - Submucosa or other
- Malignancy
Not structural
- Coagulopathy - VWF
- Ovarian - PCOS
- Endometriosis
- Iatrogenic
- Not otherwise specified
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2
Q

Tx of Heavy periods that are regular

A

Transexamic acid for first 3 to 5 days of menses. (50%)
Mefenamic acid (NSAID) if pain.
COCP only if excluded RF - Smoking, ^BMI, diabetes, ^BP
Levonorgestrel intrauterine system
Progestogens at high doses throughout cycle.

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3
Q

Tx of irregular heavy period

A

?

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4
Q

Tx for Chylamdia

A 
Azithromycin single dose
also treat gonorrhoea as they often co exist.
Reportable disease
treat partners
Test of cure required if pregnant
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5
Q

Tx of gonrrhoea

A

Ceftriaxone IM single dose
Treat chlamydia as well
treat partners
reportable disease

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6
Q

Tx of syphillis

A

Benzylpencillin 1g
if greater then 1 year then repeat weekly for 3 weeks
Neurosyphilis = IV penicillin QDS for 10days

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7
Q

What is normal vaginal discharge

A

Clear, white, flocculent, odourless
pH 3.8-4.2
Smear contains epithelial cells and Lactobacilli
Increase with oestrogen e.g. pregnancy, OCP, mid cycle, PCOS, premenarchal

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8
Q

Tx of vulvovaginitis

A

Hygiene and local measure e.g. white cotton, no tight clothes, avoid bubble baths, stop fabric softener, use ild detergent.
Vitamin A and D ointment
IF infectious Abx.

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9
Q

DDX of vulvovaginitis in prepubertal girls

A 
Infections
Foreign body e.g. toilet paper
Candida if on diapers
Pinworms
Polyps, tumor
Skin disease e.g. lichen sclerosis, condyloma acuminata 
Contact dermatitis
Trauma
endocrine (bleeding)
Blood dyscrasia (bleeding)
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10
Q

Atrophic vaginitis

A

visual diagnosis: thinning of tissues, erythema, petechiae, bleeding points, dryness on speculum exam.
Rule out Malignancy especially endometrial cancer
Tx: Local oestrogen replacement or oral or transdermal hormone replacement therapy
Good hygiene

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11
Q

Presentation of Candidiasis

A

Predisposing factors: immunosuppressed, recent antibiotic use, increase oestrogen levels e.g. pregnancy, OCP
Discharge: whitish cottage cheese minimal.
20% asymptomatic
Intense itch
swollen inflamed genitals
vulvar burning dysuria and dyspareunia
Not sexually transmitted disease

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12
Q

Ix of candidiasis

A

pH less than 4.5

KOH wet mount reveals hyphae and spores

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13
Q

Tx of Candidiasis

A

Clotrimazole creams for vaping amount of days

Fluconazole - not in pregnancy

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14
Q

Presentation of bacterial vaginosis

A

Discharge: Gray, thin, diffuse, fishy odour after coitus
50-75% asymptomatic
absence of vulvar/vaginal irritation
Not sexually transmitted

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15
Q

Ix of Bacterial Vaginosis

A

pH greater then 4.5

Clue cells coccobacili organisms

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16
Q

Tx of bacterial vaginosis

A

if pregnant or asymptomatic no tx
Oral or topical metronidazole 7days
warm them not to drink alcohol
Clindamycin in pregnancy

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17
Q

risk of bacterial vaginosis in pregnancy

A

Associated with recurrent preterm labor

preterm birth and postpartum endometritis

18
Q

Presentation of trichomoniasis infections

A 
Sexual transmission
Yellow green, alodorous, diffuse, frothy
25% asymptomatic
Petechiae on vagina and cervix
Occasionally irritated tender vulva
Dysuria, frequency
19
Q

Ix for trichomoniasis

A

greater then 4.5 pH
motile flagellated organisms
Many WBC
Inflammatory cells

20
Q

Tx of trichomoniasis

A

Tx even if symptomatic
Metronidazole 2g oral once.
Treat partners
Pregnant: treat once with 2g metronidazole

21
Q

Notifiable diseases for STI

A 
Chancroid
Chlamydia
Gonorrhea
Hepatitis A,B,C
HIV
Syphilis
22
Q

Presentation of chlamydia

A

asymptomatic in 80%
Muco-purulent endocervical discharge
Urethral syndrome: dysuria, frequency, pyuria, no bacteria on culture
Pelvic pain
postcoital bleeding or inter menstrual bleeding
symptomatic sexual partner

23
Q

Ix for chlamydia

A

cervical culture or PCR

first catch urine PCR

24
Q

When to screen for chlamydia

A

High risk groups
15 to 30 yr old
pregnancy

25
Q

Complications of Chlamydia

A

Acute salpingitis, PID
Fitx-hugh-curtis syndrome - liver capsule inflammation
Reactive arthritis (male predominance, HLA-B27 associated),
Conjunctivitis
Urethritis
Infertility from tubal obstruction from low grade salpingitis
ectopic pregnancy
chronic pelvic pain
Perinatal infection: conductivity or pneumonia

26
Q

Presentation of Gonorrhea

A

Same as chlamydia

27
Q

Ix for Gonorrhea

A

Gram -ve intracellular diplococci

Cervical rectal, and throat culutre

28
Q

Genital warts

A

HPV 6, 11
Clinical features
- Latent infection: asymptomatic, only detected by DNA hybridisation
- Subclinical infection: visible lesion found during colposcopy
- Clinical infection: visible wart-like lesion without magnification, vulvar edema
Ix - cytology: koilocytosis, Biopsy
Tx- Cryotherapy, Topical imiquimod
Prevention: Gardasil or Cervarix

29
Q

Presentation of Herpes simplex

A

Asymptomatic
Initially: present 2-21 days following contact
Prodrome: tingling, burning, pruritus
Multiple painful, shallow ulceration with small vesicles appear 7-10 days after initial infection
Lesions are infectious
Inguinal lymphadenopathy, malaise, and fever with 1st infection
Urinary symptoms if in UTi

30
Q

Ix for herpes

A

viral culture of lesions
Cytologic smear - Tzanck smear: giant cells and acidophilic intranuclear inclusion bodies
Serologic
HSV DNA PCR

31
Q

Tx of herpes

A

1st episode: acyclovir or famciclovir or valacyclovir
Daily suppressive therapy: if recurrent more then 6 times per year.
Severe : IV acyclovir
education regarding transmission
Avoid contact from onset of prodrome until lesions have cleared
use barrier contraception.

32
Q

Concerns with herpes in pregnancy

A

treat from 36 weeks gestation onward
should have C-section if active at time of delivery
Tx: acyclovir

33
Q

Classifications of syphilis

A

Primary syphilis: 3-4 wk, painless chancre and inguinal lymphadenopathy, serology is usually negative

Secondary syphilis: 2-6m,

  • nonspecific symptoms: malaise, anorexia, headache, diffuse lymphadenopathy
  • generalised maculopapular rash: palms, soles, trunk, limbs
  • Condylomata lata: anogenital, broad-based fleshy grey lesions.
  • Serology tests usually positive

Latent syphilis: no signs, only serology

Tertiary syphilis: any organ

  • Neuro: tabes dorsalis, general paresis
  • CVS: aortic aneurysm, dilated aortic root
  • Vulvar gumma:nodules that enlarge, ulcerate and become necrotic

Congenital syphilis: fetal anomalies, still births, and neonatal death. Hutchining teeth.

34
Q

Ix for syphilis

A

Aspiration of ulcer
Darkfield microscopy for spirochetes
Non-treponemal screening test e.g. VDRL, RPR - non reactive after tx, can be positive in other conditions
Specific antitreponemal antibody e.g. FTA-ABS, MHA-TP, TP-PA) remains reactive for life

35
Q

Bartholin gland abscess

A

Organisms: anaerobic or polymicrobial e.g. gonorrhoea, chlamdyia, E.Coli, Stretp or staph
Feature: unilateral swelling and pain in inferior lateral opening of vagina, Sitting and walking may become difficult or painful
Tx: sitz bath, warm compresses, Antibiotic e.g. cephalexin, incision and drainage, marsupialisation

36
Q

PID causes

A

Inflammation of upper genital tract including endometrium, fallopian tubes, ovaries, pelvic, peritoneum, and contiguous structure
C. Trachomatic
N. Gonorrhoeae
Endogenous flora e.g. e.coli, staph, strep, enterococcus, bacteroids, peptostrptococcus, H, Influenzae,

37
Q

RF for PID

A 
age less then 30
RF as for chlamydia or gonorrhea
vaginal bouching
IUD in the first 10 days
invasive gynecologic procedures
38
Q

Presentation of PID

A

2/3 asymptomatic
Commonly:
- fever greater then 38.3, lower abdo pain and tenderness, abnormal discharge
Uncommonly:
- N/V, dysuria, AUB
Chronic disease (often due to chlamdyia)
- Constant pelvic pain, dyspareunia, palpable mass, very difficult to treat, may require surgery

39
Q

Ix for PID

A

B HCG
FBC
BC
Urine MCS
speculum and bimanual, swab- vaginal for gram neg, cervical for Chlamdyia and gonorrhoea
USS: free fluid in cul-de-sac, abscess, hydrosalpinx
Laparoscopy if gold standard

40
Q

Cx of PID

A 
I FACE PID
Infertility
Fitx-Hugh-Curtis syndrome
Abscess
Chronic pelvic pain
Ectopic pregnancy
Peritonitis
Intestinal obstruction
Disseminated infection e.g. sepsis, endocarditis, arthritis, meningitis
41
Q

Tx for PID

A

Abx - ceftriaxone and doxycycline +/-metronidazole
Inpatient or outpatient
If outpatient follow up within 48hrs

42
Q

Toxic shock syndrome

A

multiple orang system failure due to S.aureaus exotoxin
presents: sudden high fever, sore throat, headache, diarrhoea, erythroderma, signs of multi system organ failure, refractory hypotension, exfoliate of palmer and plantar surfaces of hands and feet 1-2 wk after onset of illness
Tx - remove source of infection, decried necrotic tissues, hydration, ABx, +/-steroids

Gynaecology (15 decks)

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