Urogynaecology, Breast & Misc Flashcards
Urogynaecology
Definition: Stress urinary incontinence
Involuntary leakage of urine during increased abdominal pressure in the absence of a detrusor contraction
* e.g. sneezing/coughing
Name 5 risk factors for urinary incontinence (8)
- Increased age
- Post-menopausal
- Increased BMI
- Previous pregnancy/vaginal delivery
- Pelvic organ prolapse
- Pelvic floor surgery
- Neurological conditions (e.g. MS)
- Cognitive impairment / dementia
Name 4 modifiable lifestyle factors than can contribute to incontinence symptoms
- Caffeine consumption
- Alcohol consumption
- Meds
- BMI
Name 4 investigations for urinary incontinence
- Bladder diary: track fluid intake, urination, incontinence over at least 3 days
- Urine dipstick testing: test for infection, microscopic haematuria etc
- Post-void residual bladder volume: incomplete emptying
- Urodynamic testing
Name 5 urodynamic tests
- Cystometry: measures detrusor muscle contraction & pressure
- Uroflowmetry: measures flow rate
- Leak point pressure: point at which bladder pressure results in urine leakage: assesses for stress incontinence
- Post-void residual bladder volume: incomplete emptying
- Video urodynamic testing: filling bladder with contrast & taking xray images as bladder is emptied (not routine)
What is the management of stress incontinence? (3)
excluding fluid intake/restriction and avoiding caffeine/diuretics etc.
- Pelvic floor exercises (at least 3 months before considering surgery)
- Surgery: TVT, autologous sling, colposuspension, intramural urethral bulking, artificial urinary sphincter
- Duloxetine: second line where surgery is less preferred
What is the management of urge incontinence / overactive bladder? (4)
- Bladder training (for at least 6 weeks)
- Anticholinergic meds
- Botox
- Mirabegron (alt Tx with less of an anticholinergic burden)
- Augmentation cystoplasty (making bladder bigger)
Definition: Urge incontinence (overactive bladder)
Caused by overactivity of the detrusor muscle.
- Suddenly feeling the urge to pass urine
What is the classic triad seen in overactive bladder?
- Frequency: voiding >8 times a day more than 2 hourly (affected by age and race)
- Nocturia: interruption of sleep due to micturition more than once every night
- Urgency: feeling of sudden, compelling desire to pass urine, which is difficult to defer
Name 3 anticholinergic meds used to treat urge incontinence
- Oxybutynin
- Tolterodine
- Solifenacin
When is mirabegron contraindicated?
In uncontrolled hypertension
Name 4 invasive options for treating overactive bladder
- Botulinum toxin type A injection into bladder wall
- Percutaneous sacral nerve stimulation
- Augmentation cystoplasty: using bowel tissue to enlarge bladder
- Urinary diversion: redirecting urinary flow to a urostomy on the abdomen
Definition: pelvic floor prolapse
- Descent of pelvic organs into the vagina
- Result of weakness & lengthening of ligaments/muscles surrounding the uterus,rectum & bladder
What us uterine prolapse?
Where the uterus itself descends into the vagina
What is a cystocele?
Caused by a defect in the anterior vaginal wall, allowing the bladder to prolapse backwards into the vagina
cystourethrocele: prolapse of both the bladder and the urethra
What is a rectocele?
Caused by a defect in the posterior vaginal wall, allowing the rectum to prolapse forwards into the vagina.
* Associated with constipation and faecal loading in the part of the rectum that has prolapsed
* Loading of faeces = constipation, urinary retention, palpable lump
Name 6 risk factors for pelvic organ prolapse
- Multiple vaginal deliveries
- Instrumental/prolonged/traumatic delivery
- Older & post-menopausal
- Obesity
- Chronic resp disease causing coughing
- Chronic constipation causing straining
Name 5 presenting symptoms of pelvic organ prolapse
- Feeling of ‘something coming down’ in the vagina
- Dragging/heavy sensation in the pelvis
- Urinary Sx: incontinence, urgency, frequency, weak stream, retention
- Bowel Sx: constipation, incontinence, urgency
- Sexual dysfunction: pain, altered sensation, reduced pleasure
What are the 3 options for management of a pelvic floor prolapse?
- Conservative: physio, wt loss, lifestyle changes, vaginal oestrogen cream, treating Sx
- Vaginal pessary: inserted to provide extra support
- Surgery
What is a vaginal fistula
A tunnel-like opening that develops in the wall of the vagina
What is a genitourinary vaginal fistula?
Form between vagina/uterus and organs in the urinary system
What is the most common type of genitourinary vaginal fistula?
Vesicovaginal fistula: opening between vagina and bladder
Others: ureterovaginal (vagina & ureter), urethrovaginal (vagina & urethra)
What are other types of vaginal fistulas (not genitourinary)?
- Rectovaginal fistula: between vagina & rectum
- Colovaginal fistula: between vagina & large intestine
- Enterovaginal fistula: between vagina & small intestine
Name 7 causes of vaginal fistulas
- Prolonged labour
- Vaginal tears during childbirth
- Abdo/pelvic surgery, inc C-sections / hysterectomies
- Cervical / Colorectal cancer
- IDB (Crohn’s / UC)
- Diverticulitis
- Radiation therapy to pelvic region
What is the pathophysiology of vaginal fistulas?
- Lack of blood supply to vaginal tissue = tissue dies
- Hole/fistula forms in tissue
Name 5 symptoms of genitourinary vaginal fistulas
- Urinary incontinence
- Chronic urine odour
- Skin irritation in vagina/vulva/perineum
- Painful intercourse
- Recurrent UTIs, kidney infections, vaginitis
Name 5 symptoms of vaginal fistulas between the vagina and organs in the digestive system (8)
- Abdo pain
- Foul smelling vaginal discharge
- Gas/pus/stool leaking from vagina (faecal incontinence
- N+V / diarrhoea
- Painful intercourse
- Recurrent UTIs / kidney infections
- Rectal / vaginal bleeding
- Unexplained wt loss
What investigations are used to diagnose vaginal fistulas?
- Physical exam
- FBC & urinalysis: infections
- Dye test: insert dye into rectum & check for leakage from vagina
- Fistulogram X-ray
- CT / MRI / Cystoscopy / Flexible sigmoidoscopy / Colonoscopy
What is the management of vaginal fistulas?
- Antibiotics: infections
- Meds for IBD
- Temporary self-catheterisation: drain bladder whilst vesicovaginal fistula heals
- Ureteral stents: keep ureters open
- Surgery: close opening
What is the most common form of cancer in the UK?
Breast cancer
What are the risk factors for breast cancer?
- Female (99% of cases)
- Increased oestrogen exposure (early onset period / late menopause)
- Denser breast tissue - more glandular tissue
- POST MENOPAUSAL Obesity
- Smoking
- alcohol
- Family Hx (first-degree)
- Combined contraceptive pill - small increased risk but returns to normal 10 years after stopping
- HRT (particularly combined HRT - both oestrogen and progesterone)
What gene mutation is responsible for breast cancer?
BRCA gene = tumour suppressor gene
What chromosomes are BRCA1 and BRCA2 genes found on? And what are the chances of developing cancer due to mutations in these genes?
BRCA1: chromosome 17
* ~70% will develop BC by 80 yrs old
* ~50% will develop ovarian cancer
* increased risk of bowel & prostate cancer
BRCA2: chromosome 13
* ~60% will develop BC by 80 yrs old
* ~20% will develop ovarian cancer
Name the types of breast cancer
Pre-invasive:
* Ductal Carcinoma In Situ (DCIS)
* Lobular Carcinoma In Situ (LCIS)
Invasive:
* Invasive ductal carcinoma (NST)
* Invasive lobular carcinoma (ILC)
Others:
* Inflammatory Breast Cancer
* Paget’s Disease of the Nipple
Rarer types:
* Medullary
* Mucinous
* Tubular
What is ductal carcinoma in situ?
Pre-cancerous/cancerous epithelial cells of breast ducts localised to a single area
* Has potential to spread locally or become invasive
* Often picked up by mammogram screening
* Good prognosis
What is lobular carcinoma in situ?
Pre-cancerous, opccurs typically in pre-menopausal women
* Usually asymptomatic & undetectable on mammogram (diagnosed incidentally on breast biopsy)
* Increased risk of invasive BC in the future (~30%)
What is invasive ductal carcinoma of no specific type (NST)?
- Originates in cells from breast ducts
- 80% of invasive BC
- Can be seen on mammogram
What is invasive lobular carcinoma?
- Originates in breast lobule cells
- ~10% of invasive BC
- Not always visible on mammograms
How does inflammatory breast cancer present?
- 1-3% of breast cancers
- Presents similarly to breast abscess / mastitis
- Swollen, warm, tender breast with pitting skin (peau d’orange) + nipple retraction
- Doesn’t respond to ABx
- Worse prognosis than other BC
What is Paget’s disease of the nipple?
- Looks like eczema of the nipple
- Erythematous, scaly rash
- Indicates BC involving the nipple
- May represent DCIS or invasive BC
- Requires biopsy, staging & Tx
Who is breast cancer screening offered to? And how often?
- Women aged 50 - 70 yrs
- Mammogram every 3 years
What are 4 downsides to screening?
- Anxiety & stress
- Radiation exposure - small risk of causing BC
- Missing cancer –> false reassurance
- Unnecessary further tests/Tx
What are the clinical features of breast cancer?
- Lumps that are hard, irregular, painless or fixed in place
- Nipple retraction
- Skin dimpling/oedema (peau d’orange)
- Lymphadenopathy - axilla
- bloody nipple discharge
- sx of hypercalcemia due to bone resorption of calcium into the blood
What is the referral criteria for breast cancer?
2 week wait referral for suspected BC for:
* unexplained lump in breast or axilla in pts 30 yrs or above
* unilateral nipple changes in pts 50 yrs or above
* skin changes suggestive of BC
What is included in a triple diagnostic assessment for breast cancer? (4)
- Clinical assessment 1-5 score
- Imaging (USS / mammography) 1-5 score
- Biopsy (fine needle aspiration / core biopsy) 1-5 score
- ** followed by MDT concordance review**
1= normal
5= malignant
What imaging is done for breast cancer?
- USS - younger women, distinguish solid lumps from cystic
- Mammogram - older women, pick up calcifications
- MRI - screen higher risk women, further assess size/features of a tumour
What is included in a lymph node assessment?
- USS of axilla
- Ultrasound-guided biopsy of any abnormal nodes
- Sentinel lymph node biopsy
What are the 3 types of breast cancer receptors?
- Oestrogen receptors (ER)
- Progesterone receptors (PR)
- Human epidermal growth factor (HER2)
What is triple negative breast cancer?
Where breast cancer cells don’t express any of the 3 receptors.
* Worse prognosis as it limits the Tx options for targeting the cancer
Tx is CHEMOTHERAPY
What are the 4 notable locations that breast cancer metastasis occur?
- Lungs
- Liver
- Bones
- Brain
What system is used to stage breast cancer?
TNM
* Tumour
* Nodes
* Metastasis
What are the management options for breast cancer?
- Surgery
- Radiotherapy
- Chemotherapy
- Hormone therapy
- Targeted treatments
What surgery is available to treat breast cancer?
- Breast-conserving surgery -wide local excision, usually coupled with radiotherapy
- Mastectomy - removal of whole breast
- Axillary clearance - removal of axillary lymph nodes (increased risk of chronic lymphoedema though)
What is chronic lymphoedema?
Chronic condition caused by impaired lymphatic drainage of an area.
* Tissues in areas affected become swollen with excess, protein-rich fluid (lymphoedema)
* Areas of lymphoedema are also prone to infection (lymphatic system plays role in immune system)
How do you manage chronic lymphoedema?
- Manual lymphatic drainage
- Compression bandages
- Weight loss
How is radiotherapy used?
Used in patients with breast-conserving surgery to reduce risk of recurrence (usually sessions daily for 3 weeks)
* High dose radiation is delivered from multiple angles to concentrate radiation on a targeted area
What are common side effects of radiotherapy?
- General fatigue from radiation
- Local skin & tissue irritation/swelling
- Fibrosis of breast tissue
- Shrinking of breast tissue
- Long term skin colour changes
What 3 scenarios is chemotherapy used in?
- Neoadjuvant therapy - shrink tumour before surgery
- Adjuvant chemotherapy - after surgery to reduce recurrence
- Treatment of metastatic / recurrent BC
- Ki67 +ve cancers
- high grade tumours
What 2 main first-line treatments are given to patients with oestrogen-receptor positive breast cancer?
- Tamoxifen for pre-menopausal women
- Aromatase inhibitors for post-menopausal women (e.g. letrozole, anastrozole, exemestane)
Given for 5-10 years
What is tamoxifen?
Selective oestrogen receptor modulator (SERM)
* blocks oestrogen receptors in breast tissue
* stimulates oestrogen receptors in uterus & bones (helps prevent osteoporosis, but increases risk of endometrial cancer)
What is aromatase?
Enzyme found in fat tissue that converts androgens to oestrogen
* Aromatase inhibitors block the creation of oestrogen in fat tissue
What treatments may be given to patients with HER2 positive breast cancer?
- Trastuzumab (Herceptin) - targets HER2 receptor. Can affect heart function so monitoring is required
- Pertuzumab (Perjeta) - also targets HER2 receptor, used in combination with trastuzumab
- Neratinib (Nerlynx) - tyrosine kinase inhibitor, reduces growth of breast cancers
- give chemotherapy also
What are the options for reconstructive breast surgery?
- Immediate or delayed
- Partial reconstruction - using a flap/fat tissue to fill gap
- Reduction & reshaping - removing tissue & reshaping both breasts to match
- After mastectomy - breast implants or flap reconstruction (using tissue from another part of body)
Pros and cons of breast implants?
Pros
* Relatively simple procedure compared to flap
* Minimal scarring
* Acceptable appearance
Cons
* Feels less natural (cold, less mobile, static size & shape)
* Long term problems - hardening, leakage, shape change
What are the types of flap reconstructions?
- Latissimus dorsi flap: either pedicled (with blood supply) or free flap
- TRAM flap (transverse rectus abdominis - poses risk of abdominal hernia due to weakened abdo wall): either pedicled or free flap
- DIEP flap (deep inferior epigastric perforator): free flap.
- Deep inferior epigastric artery w/ associated fat, skin and veins is transplanted from abdo to breast - vessels attached to branches of internal mammary artery & vein (less risk of abdo hernia as abdo wall left in tact)
What is a fibroadenoma?
“breast mouse”
- Common benign tumour of stromal/epithelial breast duct tissue
- Typically small & mobile
- More common in younger women (20 - 40 yrs)
- Respond to female hormones (oes & prog), often regress after menopause
How do fibroadenomas present on examination?
- Painless
- Smooth
- Round
- Well-defined borders
- Firm
- Mobile
- Up to 3cm diameter
What are breast cysts?
- Benign, individual, fluid-filled lumps
- Most common between 30-50 yrs
- Can be painful and may fluctuate in size over menstrual cycle
- Require further assessment to exclude cancer w/ imaging & aspiration/excisio
- Having breast cyst may slightly increase risk of breast cancer
How do breast cysts present on examination?
- Smooth
- Well-defined borders
- Mobile
- Possible fluctuant
What is a breast abscess?
Collection of pus in breast, usually caused by bacterial infection
2 types:
* Lactational abscess (associated w/ breastfeeding)
* Non-lactational abscess (unrelated to breastfeeding)
What is mastitis?
Inflammation of breast tissue, often related to breastfeeding, but can be caused by infection
* mastitis caused by infection may precede development of an abscess
What are 4 risk factors for infective mastitis and breast abscesses?
- Smoking
- Damage to nipple (e.g. eczema, candidal infection, piercings - provide bacteria entry)
- Underlying breast disease (e.g. cancer) can affect drainage of breast - predisposing to infection
- immunocompromised
What are the most common causative bacteria for breast abscesses?
- Staph aureus - MC
- Streptococcal species
- Enterococcal species
- Anaerobic bacteria
How does a breast abscess present?
- Fluctuant lump - able to **move fluid around within lump **using pressure during palpation
- Nipple changes
- Purulent nipple discharge
- Localised pain
- Tenderness
- Warmth
- Erythema (red)
- Hardening of skin/breast tissue
- Swelling
- Generalised infection Sx - aches, fatigue, fever, sepsis signs
What is the management of mastitis?
Lactational mastitis
* conservative Tx
* continue breastfeeding
* heat packs & warm showers
* simple analgesia, then antibiotics where infection is suspected
Non-lactational mastitis
* Analgesia
* ABx - broad spectrum (co-amoxiclav, erythromycin/clarithromycin PLUS metronidazole)
* treat underlying cause (e.g. eczema or candidal infection)
What is the management of a breast abscess?
- Referral to on-call surgical team
- ABx
- USS (confirm Dx)
- Drainage (needle aspiration / surgical incision & drainage)
- MC+S of fluid
Describe the hypothalamic-pituitary-gonadal axis
- Hypothalamus releases gonadotrophin-releasing hormone (GnRH)
- GnRH stimulates anterior pituitary to produce luteinising hormone (LH) & follicle-stimulating hormone (FSH)
- LH & FSH stimulate development of follicles in the ovaries
- Theca granulosa cells around follicles secrete oestrogen
- Oestrogen has a negative feedback effect on the hypothalamus and anterior pituitary to suppress the release of GnRH, LH & FSH
What is oestrogen? And what does it do?
- Steroid sex hormone produced by ovaries in response to LH & FSH
- Acts on tissues with oestrogen receptors to promote female secondary sexual characteristics
- Stimulates: breast tissue development, growth/development of female sex organs at puberty, blood vessel development in uterus, development of endometrium
What is the most prevalent and active version of oestrogen?
17-beta oestradiol
What is progesterone? And what does it do?
- Steroid sex hormone produced by corpus luteum after ovulation
- When pregnant, progesterone is mainly produced by placenta from 10 weeks gestation
- Acts on tissues that have previously been stimulated by oestrogen
- Acts to: thicken & maintain endometrium, thicken cervical mucus, increase body temp
Reason why mammograms only offered from 50-70 (3)
-rare to get breast cancer before 50
-glandular breast tissue (white) will obscure the potential cancer (white) older women have more fatty tissue (black) so easier to see
-not cost effective to screen everyone
How are women with BRCA mutations screened
-From 30 years
-MRI
-every year
Mammogram findings of DCIS
Branching micro calcification following ducts
Lobular cancer growth pattern
They form thickenings/sheets grow outwards unlike DCIS which is hard lump
Reasons for doing mastectomy (4)
-high chance of reoccurrence - e.g BRCA mutation gene carrier
-people who cant have radiotherapy (as radiotherapy has to happen after breast conserving surgery)
-patient preference
-big breast cancer and small breasts
What occurs in a Sentinel node biopsy
-Radioactive dye injected near site of cancer
-to see how it drains
-if lymph nodes have absorbed it they are removed and analysed for cancer
Tx for inflammatory breast cancer
-Mastectomy and anxillary node clearance
-adjuvant radiotherapy
