Vulva & Genitourinary Flashcards
Stress incontinence
Triggered by increased pressure on sphincter/ bladder
Urge incontinence
Overwhelming sensation to urinate due to overactivity of the detrusor muscles
Causes of overflow incontinence
Medication
- Anticholinergics
Anatomical obstruction
- Fibroids
- Pelvic tumours
Neurological
- MS
- Spinal cord injury
- Diabetic neuropathy
Risk factors for incontinence in women
Pregnancy related
- Previous vaginal delivery
- Gravida
Surgery
- Pelvic floor surgery
Demographic
- Increased age
- High BMI
- Post-menopausal
Neurological
- MS, spinal cord lesion
- Cognitive impairment.
Oxford grading system for pelvic floor muscle
Used to grade the strength of contraction of pelvic floor muscles during bimanual exam
<2 = weak, very weak or no contraction
3= moderate
4,5= good, strong
What things should be assessed for in incontinence?
- Pelvic organ prolapse
- Atrophic vaginitis
- Pelvic masses
- Urethral diverticulum
Initial investigations in incontinence
Bladder diary
- Minimum 3 days
Urine dipstick
- Rule out infection, kidney damage
- Mid-stream MCS if positive for nitrites and leucocytes
Urodynamic tests for urinary incontinence
Investigation that compares the pressure in rectum compared to bladder
2-week wait indications in incontinence
45+ and
- Unexplained frank haematuria without UTI
- Frank haematuria after UTI treatment
60+ with Unexplained non-visible haematuria AND
- Dysuria or
- Raised WCC on blood test
Lifestyle management for stress incontinence
- Avoid caffeine
- Sensible fluid intake/ overfilling bladder
- Weight loss if BMI > 30
- Smoking cessation
Non-pharmacological treatments for stress incontinence
At least 3 months of supervised pelvic floor muscle training
- At least 8 pelvic floor contractions 3x daily
Secondary care treatment of stress urinary incontinence
Surgery
- Tension-free vaginal tape
- Colposuspension
- Autologous rectus fascial sling
- Retropubic mid-urethral mesh sling
- intramural urethral bulking agents.
Medication (if surgery not suitable or preferred)
- Duloxetine
Initial management of overactive bladder
Bladder training
- Via continence physiotherapist/ continence nurse
- At least 6 weeks
- 8 PFM contractions at least 3x day
Second line treatment for urge incontinence + side effects
Antimuscurinic medications
- Oxybutynin immediate release
- Tolterodine immediate release
- Darifenancin
Side effects
- Dry mouth
- Constipation
- Drowsiness
3rd line management for urge incontinence (if bladder training and anti-muscarinics fail)
Mirabegron
- Beta-3 agonist
Contraindications of mirabegron
Uncontrolled hypertension
Medication to manage nocturia
Desmopressin
Contraindications of desmopression
> 65
Uncontrolled hypertension
CVD
Last line management of urge incontinence
Botulinum toxin type A injections
Surgery
Cystometry and Uroflowmetry
Urodynamic test that measures the detrusor muscle contraction and pressure
Uroflowmetry measures the flow rate
Leak point pressure
Urodynamic test that measures pressure required to cause leakage of urine
- Assess stress incontinence
Colposuspension
Surgery that involves stitches connecting the anterior vaginal wall and the pubic symphysis.
The stitches go around the urethra, and pulls the vaginal wall forwards and adding support to the urethra
Vulva carcinomas typically spread lymphatically to _______
Inguinal and femoral nodes
Most common type of vulva cancer is _______
Squamous cell carcinoma
Features of vulva carcinoma
Firm, asymmetrical lump
Itching/ mild pain
Bleeding- if ulcerated
Risk factors for vulva carcinoma
HPV infection
Vulva intraepithelial neoplasm (VIN)
Immunosuppression
Lichen planus
Bartholin’s cysts
- Presentation
Unilateral swelling near vaginal opening
- Pain when walking
- Dyspareunia
Typically, in women of child-bearing age
Presentation of an infected Bartholin’s cyst
Infection
- Acutely painful
- Erythema
- Fever
- Inguinal lymphadenopathy
First line treatment for bartholin’s cyst
Marsupialisation
- Inversion of skin after incision and drainage
First line treatment for Bartholin’s cyst abscess
Expidite marsupialisation
Antibiotics if systemically unwell.
Law regarding FGM
Illegal and any cases <18 but be reported to the police.
Type 1 FGM involves removal of ____
Part/ all of the clitoris
Type 2 FGM involves removal of ____
Part/ all of clitoris and labia minora
Type 3 FGM involves ____
Infibulation
- Narrowing/ closing of the vaginal orifice
Which country has the highest rate of FGM?
Somalia
Vault prolapse is when…
Top of vaginal prolapses into the vaginal
Rectocele describes when…
Rectum prolapses into vaginal due to weakness in posterior vaginal wall
Cystocele describes when…
Bladder prolapses into vaginal due to defect in anterior vaginal wall
_______ is the grading system for pelvic organ prolapse
Pelvic organ prolapse quantification (POP-Q)
- Grades 0-4.
First line management of Pelvic organ prolapse (POP-Q grade 1-2)
Pelvic floor muscle exercises
- 16 weeks
- Led by OT/ physio
Lifestyle
- Weight loss if BMI >30
Second line management of Pelvic organ prolapse (POP-Q grade 1-2)
Vaginal pessary ring
- Provides support for pelvic organs
Complications of vaginal pessary ring
Bleeding
Abnormal discharge
Expulsion
Vaginal pessary ring must be removed every…
6 months
_______ is the definitive treatment for pelvic organ prolapse
Surgery
________ is the uterus preserving surgery indicated for uterine prolapse
Vaginal sacrospinus hysteropexy/ Manchester repair.
________ is a non-uterus preserving surgery indicated for uterine prolapse
Hysterectomy +/- vaginal sacrospinus fixation
________ is the surgery indicated for vault prolapse
Vaginal sacrospinus fixation w/ suturs
Sacrocolpopexy
Medications that exacerbate urge incontinence
ACEi
Diuretics
Antidepressants
HRT
Sedatives
