Vaginal and Vulval Disorders Flashcards
What is urinary incontinence?
- Involuntary leakage of urine, several triggers, types and causes - most cases occurring in elderly, postmenopausal, parous women.
What is stress incontinence?
Stress incontinence - defined as the involuntary leakage of urine during increased intra-abdominal pressure (in the absence of detrusor contraction), typically seen after childbirth- the most common causative factor - resulted in denervation of the pelvic floor. Other risk factors: oestrogen deficient states, pelvic surgery and irradiation.
What is urge incontinence?
Urge incontinence (overactive bladder syndrome) in the presence of urgency, usually with frequency and nocturne, in the absence of urinary tract infection or any other pathology. Urodynamic testing shows over-activity of the detrusor muscle - type of incontinence seen in neurological conditions like MS and spina bifida - most cases are idiopathic and some caused by pelvic/incontinence surgery itself.
Other causes of incontinence?
1) Overflow incontinence (overfill urinary bladder - in the absence of any urge to urinate)
2) Bladder fistulae (opening between the bladder and another organ (vagina/rectum))
3) Urethral diverticulum (out-pocketing of urethra into the anterior vaginal wall)
4) Congenital anomalies (ectopic ureter)
5) Functional incontinence (physical/mental barriers preventing patient reaching toilet - dementia/immobility)
6) Temporary incontinence (due to reversible factors - constipation and UTI)
Clinical features of incontinence?
Stress incontinence - involuntary leakage on exertion.
- When intra-abdominal pressure rises and this is communicated through to bladder .
- Leakage on coughing, sneezing, exercise.
O/E - prolapse of urethra and anterior vaginal wall may be present - ask woman to cough with semi full bladder.
Urge incontinence - overactivity of bladder.
- Urgency (sudden and compelling desire to pass urine - difficult to defer)
- Larger volumes of leakage compared to stress.
- Nocturia - Having to wake up 1 or more times during night to pass urine.
- Day time frequency- perception of voiding urine too often during the day.
Investigations of incontinence?
1) EXCLUDE INFECTION
2) Frequency/volume charts: Stress - normal frequency and bladder capacity. Urge - Increased frequency.
3) Urodynamic studies - performed in stress urinary incontinence when considering surgery to confirm diagnosis and rule out detrusor overactivity.
Management of Stress Incontinence?
Conservative, medical and surgical therapies.
- Conservative:
1) Lifestyle changes
2) Treatment of risk factors (that raise intra-abdominal pressure such as chronic cough)
3) Pelvic floor muscle training - 3 months at least - Surgical:
1) Burch colposuspension - rarely performed due to introduction of vaginal tapes - inserting sutures between paravaginal fascia and cooper’s ligament.
2) Laparoscopic colposuspension - similar to above but laparoscopic.
3) Peri-urethral injection - older patients and those unfit for surgical options, low morbidity and involves injecting bulking agents periurethrally under local.
4) Tension free vaginal tape (TVT) - MOST COMMON - high objective cure rate. Tape placed under mid urethra via a small vaginal incision (recent complaints of erosions in vagina, urethra and bladder - Medical:
1) Duloexetine
Management of Urinary Incontinence?
Conservative:
1) Lifestyle changes - advice on fluid intake and avoid caffeine and diuretics (including alcohol).
2) Bladder retraining
Medical:
1) Anticholinergic medication - oxybutynin, solifenacin, tolterodine
2) Intravaginal oestrogens - may alleviate symptoms for those with vaginal atrophy
3) Botulinum toxin A
4) Neuromodulation and sacral nerve stimulation
Surgical:
- Detrusor myomectomy and augmentation cystoplasty.
What is a Bartholin’s cyst?
A bartholin’s cyst is a fluid-filled sac within one of the Bartholin’s glands of the vagina.
- Bartholin’s glands (greater vestibular) are located deep to the posterior aspect of the labia major.
- They secrete mucus to lubricate vagina.
- Build up of mucus secretions can cause duct to become blocked from which cyst develops.
- Cyst can become infected and if untreated - develop into an abscess - usually aerobic: E.coli, MRSA and STIs the most common.
Risk factors of Bartholin’s cysts?
Occur in NULLIPAROUS WOMEN of CHILD-BEARING AGE.
1) PH of Bartholin’s cyst
2) Sexually active (STIs can cause Bartholin’s cyst or abcess)
3) History of vulval surgery.
Clinical features of Bartholin’s cysts?
- Often asymptomatic
1) Vulval pain when walking and sitting
2) Superficial dyspareunia
3) Cyst can undergo spontaneous rupture - sudden relief of pain
4) Bartholin’s abscesses typically present with acute onset of pain/difficulty passing urine
On examination:
1) Unilateral labial mass observed - arising from posterior aspect of labia major (large cyst or abscess can expand anteriorly)
Cyst - typically soft, fluctuant and non-tender
Abscess - typically tense and hard, with surrounding cellulitis.
Ddx of Bartholin’s cyst?
1) Bartholin’s gland carcinoma/benign tumour
2) Other types of cyst
3) FIbroma, lipoma, leiomyoma
Investigations for Bartholin’s cyst?
CLINICAL DIAGNOSIS
- IF women over 40 years - biopsy of cyst should be considered (if solid components to swelling) to exclude vulval carcinoma.
- Any indication of STI - endocervical and high vaginal swabs.
Management of Bartholin’s cyst?
If small and asymptomatic no treatment required - warm. baths can help the cyst spontaneously rupture.
1) WORD CATHETER - incision into cyst/abcess and catheter inserted - tip inflated with saline and left in place for 4-6 weeks to allow epithelisation of the surgically created tract. NOT SUITABLE FOR DEEP CYSTS/ABCESSES. Under local anaesthetic.
(infection, dyspareunia, recurrence, scarring)
2) MARSUPIALISATION - vertical incision made into cyst behind hymenal ring - spontaneous drainage of the cavity - cyst wall everted and approximated to the end of the vaginal mucoa by sutures. (General anaesthetic needed t achieve good marsupialisation. (bleeding/haematoma, dyspareunia and infection).
Complete excision of the gland only in suspected malignancy.
What is Lischen Sclerosis?
- Chronic inflammatory skin disease of the anogenital region in women.
- Peaks in prepubescent girls and post-menopausal women - uncommon but can be debilitating - potential to progress to squamous cell carcinoma.
- Unknown cause - Its have high titre of antibodies to extracellular matrix protein 1 - autoimmune possibly.
RF: Genetics (FH) or other autoimmune disorders such as thyroid, T1DM, alopecia aerata.
Microscopy: Lischen sclerosis causes atrophy - thin stratified squamous epithelium, band-like infiltrate of chronic inflammatory cells can be observed beneath this layer.
