Reproductive Flashcards
Who does torsion affect?
Teen or young adult males
Where does torsion occur most frequently? Types?
Left side more than right
- Intravaginal = bell-clapper deformity (tunica vaginalis joins high on spermatic cord –> testis free to rotate)
- Extravaginal = neonates
Bell-clapper can be fixed during emergency op to prevent reoccurrence in other testicle.
Presentation of torsion?
Symptoms
- Lower abdominal pain, swollen/painful testes, nausea, vomiting
Signs
- ↑HR
- High riding/horizontal riding testes, thickened spermatic cord (early sign)
- -ve Prehn’s sign (elevating testes does not relieve pain; if +ve more suggestive of epididymitis)
- Absent cremasteric reflex
Management of torsion?
Senior Review Immediately
Testicular tissue will become necrotic in hours – requires emergency surgical exploration.
- NBM
- IV access
- Fluids
- Analgesia (morphine 5mg IV PRN – titrate to pain) with cyclizine 50mg/8h IV)
- Book emergency theatre
When should you consider ectopic?
CONSIDER IN EVERY WOMAN OF CHILD-BEARING AGE PRESENTING WITH COLLAPSE, ACUTE ABDO PAIN +/- PV BLEEDING
Risk factors for ectopic?
- ↑Maternal age
- Previous ectopic
- Tubal surgery
- Previous STIs/PID
- IUCD
- Assisted conception techniques
- Smoking
Presentation of ectopic?
Symptoms
- Usually presents at 6-9wk gestation.
- Abdominal pain, shoulder tip/back pain, PV bleeding, recent amenorrhoea, dizziness
Signs
- Abdo - unilateral iliac fossa pain +/- mass; if rupture, guarding. ↑HR, ↓BP.
- PV - bleeding, extreme cervical pain.
- Ruptured ectopic = collapse, shock, peritonism.
Investigations in ectopic?
Urine – do a PT
Bloods - Β-hCG (serum and urine), FBC, G+S/X-match
USS – foetal sac/pole in the adnexae, free fluid (may be transvaginal USS)
Management of ectopic?
RUPTURE
- A to E. IV access (14-16G), IV fluids and urgent referral to gynae
Medical
- Methotrexate used for small ectopic in stable patients
Surgical
- Laparoscopic/open salpingectomy/salpingostomy/ oophorectomy
Virus that causes genital warts? How is it transmitted? When do the warts present? When do they resolve?
HPV 6, 11
Skin to skin contact through micro-abrasions during close sexual contact
Present within 3 weeks to 2 years
Most resolve within 2-3 months (usually shed within 2-3 years)
Treatment of warts in pregnancy?
Has to be cryotherapy (creams are teratogenic)
Hard to get rid of them during pregnancy because of lowered immune system
Tests for ALL POSSIBLE STIs?
VVS/first pass urine for chlamydia/gonorrhoea
Blood test for syphilis and HIV
Swab any lesions for viral PCR
Options for treating genital warts?
- Imiquidmod (aldara) 5% cream)
- Apply 3 times a week, low reccurance rate
- Requires 2-3 months of treatment, may come back
- Cyrotherapy
- Surgical
- Cutterage, excision
What causes genital herpes? What is its cycle of infectivity?
HSV 1 - skin to skin contact
Latent virus lays dormant in local sensory ganglia
- Reactivation
- Symptomatic recurrence or outbreak
- Asymptomatic episode (viral shedding)
- Patient is at their most infectious, may pass it on
Symptoms of genital herpes? Potential problem?
Clusters of shallow, painful, ulcerated lesions
Sore genital area, general malaise
PREGNANCY
- if in late stages, may need long term therapy.
Management of genital herpes?
General
- Explanation
- Infection likely to return - prodrome of tingling bits, take aciclovir as soon as this happens
- Infective when symptoms present - wait 2 weeks until lesions have cleared.
- Partner notification!
- Condoms reduce risk of transmission
Medical
- Oral aciclovir – 400mg TDS for five days (can give supply for recurrence)
- Analgesia – paracetamol/ibuprofen, EMLA cream to reduce pain on urination, salt water bathing good for pain
Definition of HIV?
Retrovirus that replicates in CD4 T cells and macrophages
Progressive immune dysfunction, opportunistic infection and malignancy (AIDS)
How is HIV transmitted?
Blood, sexual fluids and breast milk
Presentation of HIV?
Early Infection
- Seronegative conversion - 2-4 weeks post infection. Flu-like symptoms and rash. Test here!
- Persistent generalised lymphadenoapthy - 2+ non-contagious sites from >3 months. Exclude TB, infection, malignancy.
Latent Phase
- Asymptomatic until complications
Where is HIV testing important?
- Sexual health clinics
- Antenatal services
- Drug dependency programmes
- Patients with TB, hep B, hep C, lymphoma.
3 types of HIV complication?
- Opportunistic infection
- Malignancy
- Co-morbidity
Opportunistic infections in HIV?
- Pneumocystic jivovecii: progressive SOBOE, cough, malaise. No significant chest findings. Perihilar infiltrates/normal CXR. Rx IV co-trimoxazole 21days.
- Candidiasis: oral or oesophageal, treat with systemic antifungals
- Toxoplasma gondii: intracranial mass ‘ring enhancing’ lesions on MRI when CD4 <200.
- CMV: retinitis, encephalitis, GI disease. Owl’s eye inclusions on GI biopsy. Rx with ganciclovir.
- Cryptococcus Neoformans: systemic fungal infection: meningitis, fever, headaches w/ assoc. skin (molloscum like) and lung disease. Treat with amphotericin B.
- Cryptosporidium: chronic non-bloody watery diarrhoea with cholangitis and pancreatitis. Supportive rx and ART
What’s this?
MRI of toxopalsma gondii infection
- Ring enhancing lesions
- Carried by cute little kitty cats (trainspotting)
What’s this?
Owl’s eye inclusions on GI biopsy - CMV
Other symptoms = retinitis, encephalitis, GI disease
Treat with ganciclovir
What’s this?
CXR of pneumocystic jiroveci
- Perihilar infiltrates/normal CXR
- No significant chest findings
- Rx IV co-trimoxazole 21 days
Malignant complications of HIV?
-
Kaposi Sarcoma
- Most common tumour in HIV, AIDS defining. Cutaneous or mucosal lesions, patch/plaque or nodular.
-
Lymphoma
- Increased risk non-Hodkin’s lymphoma including large B cell lymphoma, burkitt’s lymphoma, primary CNS lymphoma.
- Lymphadenopathy, cytopenia, CNS symptoms. Rx with ART and chemo
Co-morbidity complications of HIV?
- Increased risk of CVD, acceleration of atherosclerotic process and hyperlipidaemia from ART.
- Low bone mineral density and fragility # (increased RF e.g. smoking, alcohol)
- TB/Hep B/Hep C (assess all with these conditions for HIV)
Investigations in HIV?
-
ELISA
- HIV antibody and antigen p24. Assay test. Reduces window period to 10 days.
-
Point of Care
- Immunoassay from finger prick or mouth swab. Serology to confirm.
-
Viral Load
- Quantification of HIV RNA. Use to monitor response to ART. Not diagnostic.
-
Nucleic acid testing/viral PCR
- Qualitative test for presence of viral RNA in neonates (maternal antibodies present in ELISA test until 18 months)
Management of HIV?
Investigations
- Baseline tests CD4, viral load, FBC, LFTs, electrolytes, UEs, pregnancy type
- Screen for infection and malignancy
Conservative
- Counselling: treatment, SE, sexual health, adherence, partner testing
- Review other medications for possible interactions
Medical
- Offer co-trimoxazole if CD4 <200.
- Start ART within 2 weeks of abx initiation for opportunistic infection
Prevention of HIV?
Condom use
PEP
- Short term ART after potential exposure (sexual or occupational). <72hrs post exposure. Test for HIV 2-3M post exposure
PrEP
- Use of ART in high risk community e.g. partner with HIV/ MSM. 86% reduction in HIV incidence in initial trials
Vertical
- Testing of pregnant women, begin ART by 24 weeks. C section if viral load >50. 4 weeks neonatal PEP and bottle feed
Bacteria causing gon, chlam and syphilis?
Gonorrhoea
- Neisseria gonorrhoea (gram -ve diplococcus)
Chlamydia
- Chlamydia trachomatis (gram -ve)
Syphilis
- Treponema pallidum (spirochete)
Presentation and complications of gonorrhoea?
- May be asymptomatic
- Purulent yellow/green discharge
- Dysuria
- Intermenstrual bleeding/Post coital bleeding
Complications
PID (10%), bartholin’s abcess or tubal infertility and increased risk of ectopic, proctitis, epidydimo-orchitis, prostatitis
Treatment of gonorrhoea?
Investigations
- Teat for alllll the STIs
General
- Safe sex precautions
- Treat partners and contact trace
Medical
- Ceftriaxone 500mg IM stat + azithromycin 1g PO
Presentation and complications of chlamydia?
Signs
- Cervicitis: red, inflamed, discharge
Symptoms
- Vaginal discharge, post-coital bleeding, IMB, pelvic pain, dysuria
Complications
- PID, tubal infertility, ectopic pregnancy
- Perihepatitis (Fitz Hugh Curtis)
- Reiter’s syndrome (urethritis, conjunctivitis, arthritis – males
Pregnancy complications of gonorrhoea, chlamydia and syphilis?
Gon and Chlam
- PROM, prem delivery, chorioamnionitis, neonatal pneumonitis, opthalmia neonatorum
Syphilis
- Saddle nose, limb abnormalities, prem birth/still birth
Management of chlamydia?
Investigations
- Test for alllll the STIs
General
- Partner notification
- National screening programme
Medical
- Azithromycin 1g stat or doxycyclin 100mg BD 7 days
- No sex until both partners have completed course
General presentation of syphilis?
Single non-tender ulcer
Non-tender enlarged lymph nodes
3 phases of syphilis?
- Early - infectious
- Latent - asymptomatic
- Late (20-40 years post infection)
Early syphilis?
Primary (3-8 weeks)
- Chancre at site of inoculation
Secondary (>3m)
- Systemic infection
- Mucocutaneous rash on palms and soles
- Buccal snail track ulcers
- Hepatitis
- Condylomata (horrible pale genital ulceration)
Latent (secondary) syphilis>
- Early, no signs, positive syphilis test with negative result in previous 2 years. Can treat with 1 injection
- Late, no signs but positive test with no negative test in previous 2 years. Must be treated with 3 injections
Late (tertiary) syphilis?
20-40 years post infection
- Aortic root involvement
- Gummatous nodules (granulomas - liver) and necrotic facial lesions
- Neurological involvement: meningovascular, tabes dorsalis (dorsal column loss), paraesis
Management of syphilis?
Bezathine penicillin 2.4mg IM stat
Partner notification - regular partner needs treatment before +ve result
What are repeat window period bloods?
- Time between exposure and showing up on test
- 3 months for syphilis and HIV
Causes and risk factors for erectile dysfunction?
Causes
- Vascular, neurological (central and peripheral), hormonal, anatomical, medications, psychogenic.
Risk factors
- CVD disease: lack of exercise, obesity, smoking, high ch, high BP, diabetes.
Management of erectile dysfunction?
Investigations
- Look for cause
- HBA1c and lipid profile
General
- Advice on lifestyle and risk factors - smoking, obesity, exercise, alcohol
Medical
- Sildenafil - 50mg starting dose. Contraindicated with nitrates.
- Vacuum devices
What is phimosis? Types of phimosis?
Difficulty retracting foreskin - can occur at any age.
Physiological Phimosis
- Before age of 2 years, normal to have non-retractile foreskin with spontaneous resolvement. Not a problem unless obstruction, haematuria or pain.
Pathological Phimosis
- Usually secondary to infection of foreskin.
Presentation of phimosis? Complications?
Symptoms
- Painful erections, haematuria, recurrent UTI, preputial pain, weak steam.
Signs
- Swelling/redness and tenderness with purulent discharge
- Adhesions between inner surfaces of prepuce and glans
- May be visible scarring of meatus - fibrous white marks
Complications
- Risk factor for penile carcinoma.
- Balanitis xerotica obliterans may require circumcision and dilatation of the urethral meatus.
Management of phimosis?
Conservative
- Cleaning under a retractable foreskin, and always reduce to cover glans
- Topical steroid application
Surgical
- Plastic surgery including release of adhesions, dorsal incision: allows preservation of the foreskin
- Circumcision: removal of the foreskin.
What is paraphimosis?
This occurs when a tight prepuce is retracted and then unable to be replaced as the glans swells.
This is a urological emergency.
Risk factors for paraphimosis? Presentation?
- Failing to replace foreskin after catheterisation or cleaning
- Scarring of prepuce after forcible retraction
- Vigorous sexual activity
- Chronic balanoposthitis: in diabetics
- Penile piercing
Signs
- Oedema around constricting band.
- Check no encircling foreign body such as ring, rubber band.
- Later stage: blue or black colour due to necrosis
Symptoms
- Pain on erection, irritation
Management of paraphimosis?
- Gentle compression with saline soaked swab followed by reduction of prepuce over glans.
- Manual compression of 30 mins with 50% dextrose to reduce swelling
If this does not work, refer urgently to urology. Dorsal incision occasional required.
What is balanitis?
Acute inflammation of the foreskin and glans
Causes of balanitis? Risk factors?
Infective
- Strep/Staph
- Candida (20%)
Dermatological
- Drug eruption, circinate balanitis, balanitis xerotica obliterans/lichen sclerosis.
- Lichen planus, leukoplakia, psoriasis
Risk Factors
- Diabetes mellitus
- Oral abx, poor hygiene, immunosuppression
Presentation of balanitis?
Signs
- Non-retractile foreskin (phimosis). Ulceration, plaques, satellite lesions, discharge. Regional lymphadenopathy.
Symptoms
- Sore inflamed and swollen glans, dysuria, impotence or pain during coitus
Complications
- Difficult retracting foreskin, can lead to paraphimosis. More likely if chronic infection.
Investigations and management of balanitis?
Investigations
- Check for diabetes - urine dip/HbA1c
- Swab for MC+S
- STI –> GUM
Conservative
- Clean daily with warm water/saline bath
- Screen partners if STI suspected
Medical
- Dermatitis: topical rx with hydrocortisone 1%
- Candida: Clotrimazole cream 1% BD until settled symptoms.
- Bacterial: swab for MC&S, commonly flucloxicillin or erythromycin
Surgical
- If recurrent or pathological phimosis present
What is epididymo-orchitis?
Causes?
Acute spread of infection from the GU tract to the testes
- Usually secondary to STI - chlamydia, gonorrhoea
- May spread from UTI/cystitis
Presentation and complications of epididymo-orchitis?
Signs
- Tenderness on affected side, palpable swelling of epididymis.
- Urethral discharge, secondary hydrocele, erythema, oedema, pyrexia
Symptoms
- Pain and tenderness in testes. Inflammation and swelling, usually on one side
Complications
- Hydrocele, abscess
Things to rule out in epididymo-orchitis? Investigations?
TORSION
Mumps/TB in high risk groups (traveller, unvaccinated)
- NAAT - chlam and gon
- Bloods - HIV/syphilis
- Urinalysis - UTI
Management of epididymo-orchitis?
Treat to cover most common cause - chlamydia. Dual treament if evidence of gonorrhoea present.
Azithromycin 1mg stat
+
Ceftriaxone 500mg IM
Partner notificaiton
Types of testicular cancer?
Risk factors?
- Seminoma 55% (30-65yrs)
- Non-seminoma germ cell 33% (20-30 yrs)
- Mixed germ cell 12%
- Lymphoma
RFs
- Undescended testes, infant hernias, infertility
Presentation of testicular cancer?
Complications?
Usually solid painless lump, not separate from the testes.
Pain, dyspnoea (lung mets), abdominal mass (enlarged nodes) or effects of secreted hormones
Complications
- 25% seminoma on presentation
- 50% non-seminomatous
- Abdominal lymph nodes, lung, liver, bones, brain
Investigations and staging in testicular cancer?
Investigations
- CXR, CT, excision biopsy
- AFP and b-hCG to monitor treatment response
Staging - Royal Marsden Staging
- No evidence of mets
- Para-aortic nodes BELOW diaphragm
- Para-aortic nodes ABOVE diaphragm
- Lung involvement
Things to consider when examining a testicular lump?
Can you get above it? Is it separate from the testes? Cystic or solid/does it transilluminate?
- Cannot get above: inguinoscrotal hernia/proximal hydrocele
- Separate and cystic: epididymal cyst
- Separate and solid: epididymitis/varicocele
- Testicular and cystic: hydrocele
Management of testicular cancer?
Radical orchidectomy = 1st line
Stage 1 Seminoma
- Orchidectomy + radiotherapy cures 95%
Non-Seminoma
- Cure can be achieved even with metastases present
- 3x bleomycin, etopside and cisplatin (BEP)
- Be aware of fibrosis side effect of bleomycin
Follow up to detect relapse
REGULAR SELF-EXAMINATION
What is prostatitis? Causes and risk factors?
Inflammation of prostate tissue, may be acute or chronic.
<35 years = bacterial prostatisis
- Acute: Gram –ve: S.faecalis/ E.coli / chlamydia/gonorrhoea (previously TB)
- Chronic: untreated bacterial or non-bacterial: elevated prostatic pressures
Risk Factors:
- STIs, UTIs, catheter, increasing age, following manipulation of gland e.g. biopsy
Presentation and complications of prostatitis?
Symptoms
- Frequent UTI, retention, pain, haematospermia
- Fever, malaise, lower back/abdo pain, pain on ejaculation
- Chronic = same Sx for >3 months
Signs
- Swollen, boggy prostate on DRE
Complications
- Chronic inflammation, pain, sepsis
Management of prostatitis?
Investigations
- If septic - FBC, U+E, blood cultrues
- Dip urine for leukocytes/nitrites, MC+S of urine
Medical
- Analgesia + cather if in retention
- Levofloxacin 500mg OD PO 28 days
- Avoid recurrent DRE to prevent spread of infection
- Chronic non-bacterial will not respond to abx
- Anti-inflammatories
Later
- Refer to urology if required
- Alpha blockers
- Prostatic massage
- Alpha blockers
What is a fibroadenoma?
Who gets them?
Benign overgrowth of collagenous mesenchyme of one breast lobule
Usually <30 years but can present up to menopause
How do fibroadenomas present?
What is their course?
- Firm, smooth, mobile lump.
- Non-tender, may be multiple.
1/3 regress
1/3 stay the same
1/3 get bigger
Management of fibroadenoma?
Investigations
- USS
- FNA and biopsy (if unsure and want to exclude cancer)
Management
- Observation and reassurance
- Surgical excision if large
Types of breast cancer?
Pre-Invasive
- Non-invasive ductal carcinoma in situ - pre-malignant
- Non-invasive lobular carcinoma - rarer and multifocal
Invasive
- Ductal carcinoma (70%)
- Lobular carcinoma (10-15%)
- Medullary (5%), younger patients
- Colloid/mucoid (2%) elderly.
60% are oestrogen recepter +ve (better prognosis)
30% over express HER2 = aggressive disease and poorer prognosis
Risk factors for breast cancer?
Family history, age
Uninterrupted oestrogen exposure
- Nulliparity
- 1st pregnancy >30 years
- Early menarche
- Late menopause
- HRT
- Obesity
- BRCA genes
- Not breastfeeding
- Past breast cancer
Presentation of breast cancer?
Signs
- Fixed, irregular, hard lump.
- Dimpling of the skin (peu d’orange)
- Swelling/lump in axilla
Symptoms
- New lump or area of thickened tissue in breast.
- Change in size or shape.
- Blood stained discharge, dimpling of skin, rash on or around nipple, inversion of nipple.
Complications
- Metastases: lymph nodes, liver, lungs, bone and brain.
Investigation of breast cancer?
All breast lumps should undergo triple assessment.
- Clinical examination
- Radiology: USS <35, mammography and USS for >35 years
- Histology/cytology (FNA/core biopsy: USS guided core biopsy)
If cystic lump, aspirate:
- Residual mass: core biopsy
- Bloody fluid: cytology
- Clear fluid: reassure, if no fam history and –ve biopsy
If solid lump, core biopsy:
- Malignant, plan Rx
- Clear fluid, discard and reassure
Staging of breast cancer?
- Confined to breast, mobile
- Growth confined to breast, mobile, lymph nodes in same axilla.
- Tumour fixed to muscle, lymph nodes fixed, skin involvement larger than Ca
- Complete fixation of tumour to chest wall, distant mets
Management of breast cancer? (Stage 1-2)
Surgical = WLE or mastectomy/reconstruction/node removal for biopsy (sentinel node)
Radiotherapy = all patients with invasive Ca after WLE, decreases recurrence.
Chemotherapy = adjuvant chemo, lowers recurrence
Endocrine Agents
- Used in oestrogen/progesterone receptor +ve disease
- ER blocker Tamoxifen e.g. 20mg/day PO for 5 yrs. (risk of endometrial Ca)
- Anastrazole (aromatase inhibitors) if post menoposal
- Pre-menopausal: ovarian oblation or GnRH analogues (goserulin)
What does aromatase do?
Synthesises oestrogen from androgens in post-menopausal women
How do GnRH analogues work?
Downregulate gonadotrophin release after initial ‘flare’.
Breast cancer is stimulated by oestrogen!
Investigations and management in distant breast cancer disease?
Bloods = LFTs, Ca2+
Imaging = CXR, bone scan, liver USS, CT/MRI or PET/CT
Management = palliation
- Radiotherapy and phosphonates for bony lesions to reduce pain and # risk
How often do women get mammograms and at what ages?
2 view mammogram every 3 years for women age 47-73 years
What is a breast abscess?
Causes and risk factors?
Infection of mammary duct often associated with lactation. Collection of pus causing pain and swelling
Causes
- Usually staph aureus, may be secondary to generalised mastitis.
- Nipple piercing, smoking, diabetes
Complications of breast abscess?
If untreated, may form fistula.
Nipple inversion.
Recurrence of infection
Management of breast abscess?
Investigations
- Breast examination to examine lump
- USS to confirm abscess
- Culture of fluid from asbcess to guide abx choice
Surgical
- Drainage of abscess - USS guided needle aspiration/surgical
Medical
- Abx for S.aureus
General
- Encourage breast feeding (including from affected breast)
Causes and RF for PID?
Causes
- STIs
- Hysteroscopy/IUD insertion
- TOP
- Postpartum
RFs
- <35, previous hx or multiple sexual partners
Presentation and complications of PID?
Symptoms
- Lower abdo pain, constant or intermittent. Deep dyspareunia, discharge, IMB/PCB.
Signs
- Cervical motion/adnexal tenderness.
Complications
- Abscess, Fitz-Hugh-Curtis, recurrent PID, tubal infertility, ectopic, adhesions
Management of PID?
Investigations
- VVS for NAAT and bloods for HIV/syphilis
- MC&S
- Bloods and cultures (sepsis)
General
- Contact tracing and partner notification
Medical
- Ceftriaxone 500mg IM
- Azithromycin 1g (or doxy 100mg BD 14 days)
- Metronidazole 400mg BD 14 days
What is endometriosis?
Causes?
Presence of endometriotic tissue outside the uterus, driven by oestrogen
Causes
- Unknown ? retrograde menstruation.
- 10% of population thought to be affected, 40-60% of those with dysmenorrhoea
Presentation and complications of endometriosis?
Symptoms
- Pain: cyclical or constant if adhesions
- Dysmenorrhoea, dyspareunia, dysuria
- Pain on opening bowels
- Subfertility, asymptomatic
Signs
- Fixed, retroverted uterus
Complications
- Subfertility, chronic pelvic pain
Investigations and management of endometriosis?
Investigations
- Gold standard: laparoscopy for biopsy: chocolate cysts
Medical
- COCP, oral progesterone, depo or Mirena coil
- GnRH (goserulin) used for <6m in subfertility patient’s pre-IVF
Surgical
- If medical fails
- Laparoscopic excision, ablation
- Hysterectomy last resort
What is ovarian torsion? Where does it happen?
Twisting of the ovary, leading to reduced venous return ischaemia and pain. Emergency.
- Uncommon. Unilateral.
- More common in pregnancy.
- Large ovarian mass <6cm (60% cases)
Presentation of ovarian torsion?
Severe lower abdominal pain and vomiting. Pain may reduce after 24hrs when ovary begins to die.
Cyst rupture = similar presentation but + haemorrhagic shock/peritonitis
Investigations
- PT
- USS with doppler anaylsis (imapired blood flow)
Management
- Fluid assessment, analgesia and NBM for surgery
- Referral to gynae for laparoscopy and surgical management
Presentation of trichomonas?
Symptoms
- Yellow, frothy, smelling discharge.
- Soreness, itching, dysuria
- Lower Abdominal pain
Signs
- Speculum - Strawberry cervix
Presentation and management of candida albicans?
Cottage cheese discharge,
Itching
Yeast infection, can be detected via microscope
Management
- Clotrimazole (pessary or tablet)
Presentation of BV?
White/grey discharge, fishy smell.
Could be asymptomatic
- Overgrowth of gram –ve bacteria due to douching, soaps, hormonal change.
- Investigation: HVS
- Microscope shows reduced normal lactobacilli
Cervical causes of abnormal vaginal bleeding?
- Polyp
- Cervicitis - Cherry red cervix, usually chlamydia or gonorrhoea. Treat underlying infection.
- Ectropion - Fragile overgrowth of columnar epithelium into the outer cervix. Common with the COCP. Normal variant.
- Cancer - Craggy, irregular, hard, bleeding mass. URGENT colposcopy referral
Endometrial causes of abnormal vaginal bleeding?
Polyp
- May prolapse through os into vagina
Endometrial Hyperplasia
- Usually presents with PMB - pre-cursor to endometrial Ca (10%).
- RF = unopposed oestrogen (HRT, early menarche, late menopause)
Fibroids
- RFs = near menopause, afro-caribbean, FH, obesity
- Menorrhagia, dysmenorrhoea, infertility, pressure effects
Investigations in IMB/PMB?
Speculum, abdominal and bimanual examination
- Smear, swabs for MC+S, NAAT if suspect STI
Cervical abnormality
- Colposcopy +/- biopsy
PMB
- Urgent USS, if >5mm –> hysteroscopy and biopsy.
Management of fibroids, cervical ectropion and endometrial hyperplasia?
Fibroids
- Asymptomatic = no treatment
- Medical: Tranexamic acid, NSAISDS, progesterones, GnRH (3M before surgery to shrink)
- Surgical: Hysteroscopic if small, radical myomectomy, embolization.
Ectropion
- Silver nitrate
Endometrial Hyperplasia
- Atypical cells – immediate hysterectomy
- No atypical cells: high dose progesterones (oral and/or mirena)
- Ca = refer 2 week wait to gynae
What is a hypospadia?
Affects 1 in 350 male births. Abnormal position of external urethral meatus of the ventral penis
Difficulty urinating while standing and cosmetic appearance. Avoid circumcision, use foreskin for pre-school surgical repair
How common is undescended testes? Types?
2-3% neonates, 15-30% prem babies
- Truly undescended = complete absence of testis from scrotum
- Retractile - normally developed but exaggerated cremasteric reflex. Examine in warm bath and reassure.
- Mal-descended = found anywhere along normal path of descent from abdomen to groin
Surgery at 12 months to prevent infertility and reduce risk of testicular cancer (x5 risk if untreated, as Ca not detected)
What is fibrocystic disease?
Nodular or glandular breast tissue. Very common and not pathological.
- No increased risk of breast cancer.
- Areas of lumps or thickening +/- tenderness, size changes, nipple discharge. Usually symmetrical change.
