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Phase 3a - Arun&Erin > Urogynaecology, Breast & Misc > Flashcards

Urogynaecology, Breast & Misc Flashcards

1
Q

Urogynaecology

Definition: Stress urinary incontinence

A

Involuntary leakage of urine during increased abdominal pressure in the absence of a detrusor contraction
* e.g. sneezing/coughing

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2
Q

Name 5 risk factors for urinary incontinence (8)

A
  • Increased age
  • Post-menopausal
  • Increased BMI
  • Previous pregnancy/vaginal delivery
  • Pelvic organ prolapse
  • Pelvic floor surgery
  • Neurological conditions (e.g. MS)
  • Cognitive impairment / dementia
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3
Q

Name 4 modifiable lifestyle factors than can contribute to incontinence symptoms

A
  • Caffeine consumption
  • Alcohol consumption
  • Meds
  • BMI
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4
Q

Name 4 investigations for urinary incontinence

A
  • 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
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5
Q

Name 5 urodynamic tests

A
  • 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)
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6
Q

What is the management of stress incontinence? (3)

excluding fluid intake/restriction and avoiding caffeine/diuretics etc.

A
  • 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
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7
Q

What is the management of urge incontinence / overactive bladder? (4)

A
  • Bladder training (for at least 6 weeks)
  • Anticholinergic meds
  • Botox
  • Mirabegron (alt Tx with less of an anticholinergic burden)
  • Augmentation cystoplasty (making bladder bigger)
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8
Q

Definition: Urge incontinence (overactive bladder)

A

Caused by overactivity of the detrusor muscle.

  • Suddenly feeling the urge to pass urine
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9
Q

What is the classic triad seen in overactive bladder?

A
  • 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
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10
Q

Name 3 anticholinergic meds used to treat urge incontinence

A
  • Oxybutynin
  • Tolterodine
  • Solifenacin
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11
Q

When is mirabegron contraindicated?

A

In uncontrolled hypertension

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12
Q

Name 4 invasive options for treating overactive bladder

A
  • 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
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13
Q

Definition: pelvic floor prolapse

A
  • Descent of pelvic organs into the vagina
  • Result of weakness & lengthening of ligaments/muscles surrounding the uterus,rectum & bladder
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14
Q

What us uterine prolapse?

A

Where the uterus itself descends into the vagina

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15
Q

What is a cystocele?

A

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

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16
Q

What is a rectocele?

A

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

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17
Q

Name 6 risk factors for pelvic organ prolapse

A
  • Multiple vaginal deliveries
  • Instrumental/prolonged/traumatic delivery
  • Older & post-menopausal
  • Obesity
  • Chronic resp disease causing coughing
  • Chronic constipation causing straining
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18
Q

Name 5 presenting symptoms of pelvic organ prolapse

A
  • 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
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19
Q

What are the 3 options for management of a pelvic floor prolapse?

A
  • Conservative: physio, wt loss, lifestyle changes, vaginal oestrogen cream, treating Sx
  • Vaginal pessary: inserted to provide extra support
  • Surgery
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20
Q

What is a vaginal fistula

A

A tunnel-like opening that develops in the wall of the vagina

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21
Q

What is a genitourinary vaginal fistula?

A

Form between vagina/uterus and organs in the urinary system

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22
Q

What is the most common type of genitourinary vaginal fistula?

A

Vesicovaginal fistula: opening between vagina and bladder

Others: ureterovaginal (vagina & ureter), urethrovaginal (vagina & urethra)

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23
Q

What are other types of vaginal fistulas (not genitourinary)?

A
  • Rectovaginal fistula: between vagina & rectum
  • Colovaginal fistula: between vagina & large intestine
  • Enterovaginal fistula: between vagina & small intestine
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24
Q

Name 7 causes of vaginal fistulas

A
  • 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
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25
Q

What is the pathophysiology of vaginal fistulas?

A
  • Lack of blood supply to vaginal tissue = tissue dies
  • Hole/fistula forms in tissue
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26
Q

Name 5 symptoms of genitourinary vaginal fistulas

A
  • Urinary incontinence
  • Chronic urine odour
  • Skin irritation in vagina/vulva/perineum
  • Painful intercourse
  • Recurrent UTIs, kidney infections, vaginitis
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27
Q

Name 5 symptoms of vaginal fistulas between the vagina and organs in the digestive system (8)

A
  • 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
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28
Q

What investigations are used to diagnose vaginal fistulas?

A
  • 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
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29
Q

What is the management of vaginal fistulas?

A
  • Antibiotics: infections
  • Meds for IBD
  • Temporary self-catheterisation: drain bladder whilst vesicovaginal fistula heals
  • Ureteral stents: keep ureters open
  • Surgery: close opening
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30
Q

What is the most common form of cancer in the UK?

A

Breast cancer

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31
Q

What are the risk factors for breast cancer?

A
  • 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)
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32
Q

What gene mutation is responsible for breast cancer?

A

BRCA gene = tumour suppressor gene

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33
Q

What chromosomes are BRCA1 and BRCA2 genes found on? And what are the chances of developing cancer due to mutations in these genes?

A

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

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34
Q

Name the types of breast cancer

A

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

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35
Q

What is ductal carcinoma in situ?

A

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

36
Q

What is lobular carcinoma in situ?

A

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%)

37
Q

What is invasive ductal carcinoma of no specific type (NST)?

A
  • Originates in cells from breast ducts
  • 80% of invasive BC
  • Can be seen on mammogram
38
Q

What is invasive lobular carcinoma?

A
  • Originates in breast lobule cells
  • ~10% of invasive BC
  • Not always visible on mammograms
39
Q

How does inflammatory breast cancer present?

A
  • 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
40
Q

What is Paget’s disease of the nipple?

A
  • Looks like eczema of the nipple
  • Erythematous, scaly rash
  • Indicates BC involving the nipple
  • May represent DCIS or invasive BC
  • Requires biopsy, staging & Tx
41
Q

Who is breast cancer screening offered to? And how often?

A
  • Women aged 50 - 70 yrs
  • Mammogram every 3 years
42
Q

What are 4 downsides to screening?

A
  • Anxiety & stress
  • Radiation exposure - small risk of causing BC
  • Missing cancer –> false reassurance
  • Unnecessary further tests/Tx
43
Q

What are the clinical features of breast cancer?

A
  • 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
44
Q

What is the referral criteria for breast cancer?

A

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

45
Q

What is included in a triple diagnostic assessment for breast cancer? (4)

A
  • 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

46
Q

What imaging is done for breast cancer?

A
  • 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
47
Q

What is included in a lymph node assessment?

A
  • USS of axilla
  • Ultrasound-guided biopsy of any abnormal nodes
  • Sentinel lymph node biopsy
48
Q

What are the 3 types of breast cancer receptors?

A
  • Oestrogen receptors (ER)
  • Progesterone receptors (PR)
  • Human epidermal growth factor (HER2)
49
Q

What is triple negative breast cancer?

A

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

50
Q

What are the 4 notable locations that breast cancer metastasis occur?

A
  • Lungs
  • Liver
  • Bones
  • Brain
51
Q

What system is used to stage breast cancer?

A

TNM
* Tumour
* Nodes
* Metastasis

52
Q

What are the management options for breast cancer?

A
  • Surgery
  • Radiotherapy
  • Chemotherapy
  • Hormone therapy
  • Targeted treatments
53
Q

What surgery is available to treat breast cancer?

A
  • 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)
54
Q

What is chronic lymphoedema?

A

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)

55
Q

How do you manage chronic lymphoedema?

A
  • Manual lymphatic drainage
  • Compression bandages
  • Weight loss
56
Q

How is radiotherapy used?

A

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

57
Q

What are common side effects of radiotherapy?

A
  • General fatigue from radiation
  • Local skin & tissue irritation/swelling
  • Fibrosis of breast tissue
  • Shrinking of breast tissue
  • Long term skin colour changes
58
Q

What 3 scenarios is chemotherapy used in?

A
  • Neoadjuvant therapy - shrink tumour before surgery
  • Adjuvant chemotherapy - after surgery to reduce recurrence
  • Treatment of metastatic / recurrent BC
  • Ki67 +ve cancers
  • high grade tumours
59
Q

What 2 main first-line treatments are given to patients with oestrogen-receptor positive breast cancer?

A
  • Tamoxifen for pre-menopausal women
  • Aromatase inhibitors for post-menopausal women (e.g. letrozole, anastrozole, exemestane)

Given for 5-10 years

60
Q

What is tamoxifen?

A

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)

61
Q

What is aromatase?

A

Enzyme found in fat tissue that converts androgens to oestrogen
* Aromatase inhibitors block the creation of oestrogen in fat tissue

62
Q

What treatments may be given to patients with HER2 positive breast cancer?

A
  • 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
63
Q

What are the options for reconstructive breast surgery?

A
  • 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)
64
Q

Pros and cons of breast implants?

A

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

65
Q

What are the types of flap reconstructions?

A
  • 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)
66
Q

What is a fibroadenoma?

“breast mouse”

A
  • 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
67
Q

How do fibroadenomas present on examination?

A
  • Painless
  • Smooth
  • Round
  • Well-defined borders
  • Firm
  • Mobile
  • Up to 3cm diameter
68
Q

What are breast cysts?

A
  • 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
69
Q

How do breast cysts present on examination?

A
  • Smooth
  • Well-defined borders
  • Mobile
  • Possible fluctuant
70
Q

What is a breast abscess?

A

Collection of pus in breast, usually caused by bacterial infection
2 types:
* Lactational abscess (associated w/ breastfeeding)
* Non-lactational abscess (unrelated to breastfeeding)

71
Q

What is mastitis?

A

Inflammation of breast tissue, often related to breastfeeding, but can be caused by infection
* mastitis caused by infection may precede development of an abscess

72
Q

What are 4 risk factors for infective mastitis and breast abscesses?

A
  • 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
73
Q

What are the most common causative bacteria for breast abscesses?

A
  • Staph aureus - MC
  • Streptococcal species
  • Enterococcal species
  • Anaerobic bacteria
74
Q

How does a breast abscess present?

A
  • 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
75
Q

What is the management of mastitis?

A

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)

76
Q

What is the management of a breast abscess?

A
  • Referral to on-call surgical team
  • ABx
  • USS (confirm Dx)
  • Drainage (needle aspiration / surgical incision & drainage)
  • MC+S of fluid
77
Q

Describe the hypothalamic-pituitary-gonadal axis

A
  1. Hypothalamus releases gonadotrophin-releasing hormone (GnRH)
  2. GnRH stimulates anterior pituitary to produce luteinising hormone (LH) & follicle-stimulating hormone (FSH)
  3. LH & FSH stimulate development of follicles in the ovaries
  4. Theca granulosa cells around follicles secrete oestrogen
  5. Oestrogen has a negative feedback effect on the hypothalamus and anterior pituitary to suppress the release of GnRH, LH & FSH
78
Q

What is oestrogen? And what does it do?

A
  • 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
79
Q

What is the most prevalent and active version of oestrogen?

A

17-beta oestradiol

80
Q

What is progesterone? And what does it do?

A
  • 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
81
Q

Reason why mammograms only offered from 50-70 (3)

A

-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

82
Q

How are women with BRCA mutations screened

A

-From 30 years
-MRI
-every year

83
Q

Mammogram findings of DCIS

A

Branching micro calcification following ducts

84
Q

Lobular cancer growth pattern

A

They form thickenings/sheets grow outwards unlike DCIS which is hard lump

85
Q

Reasons for doing mastectomy (4)

A

-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

86
Q

What occurs in a Sentinel node biopsy

A

-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

87
Q

Tx for inflammatory breast cancer

A

-Mastectomy and anxillary node clearance
-adjuvant radiotherapy

Phase 3a - Arun&Erin (15 decks)

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