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4th year passmedicine by topic > Vulval/Vaginal/Urogenital > Flashcards

Vulval/Vaginal/Urogenital Flashcards

1
Q

Around 80% of vulval cancers are

A

squamous cell carcinomas

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2
Q

Vulval carcinoma cases occur in women over the age

A

65 years

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3
Q

Vulval cancer is relatively rare with only around 1,200 cases diagnosed in the UK each year.

A

true

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4
Q

Vulval carcinoma - Other than age, risk factors include:

A

Human papilloma virus (HPV) infection
Vulval intraepithelial neoplasia (VIN)
Immunosuppression
Lichen sclerosus

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5
Q

Vulval carcinoma Features

A

lump or ulcer on the labia majora

may be associated with itching, irritation

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6
Q

Vaginal candidiasis (‘thrush’) is an extremely common condition which many women diagnose and treat themselves. Around 80% of cases of ?, with the remaining 20% being caused by other candida species.

A

Candida albicans

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7
Q

The majority of women will have no predisposing factors. However, certain factors may make vaginal candidiasis more likely to develop:

A

diabetes mellitus
drugs: antibiotics, steroids
pregnancy
immunosuppression: HIV

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8
Q

Vaginal candidiasis Features

A

‘cottage cheese’, non-offensive discharge
vulvitis: superficial dyspareunia, dysuria
itch
vulval erythema, fissuring, satellite lesions may be seen

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9
Q

Vaginal candidiasis ix

A

a high vaginal swab is not routinely indicated if the clinical features are consistent with candidiasis

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10
Q

Vaginal candidiasis mx

A

options include local or oral treatment
local treatments include clotrimazole pessary (e.g. clotrimazole 500mg PV stat)
oral treatments include itraconazole 200mg PO bd for 1 day or fluconazole 150mg PO stat
if pregnant then only local treatments (e.g. cream or pessaries) may be used - oral treatments are contraindicated

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11
Q

BASHH define recurrent vaginal candidiasis

A

4 or more episodes per year

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12
Q

recurrent vaginal candidiasis ix

A

compliance with previous treatment should be checked
confirm the diagnosis of candidiasis
high vaginal swab for microscopy and culture
consider a blood glucose test to exclude diabetes
exclude differential diagnoses such as lichen sclerosus

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13
Q

recurrent vaginal candidiasis mx

A

consider the use of an induction-maintenance regime

induction: oral fluconazole every 3 days for 3 doses
maintenance: oral fluconazole weekly for 6 months

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14
Q

Trichomonas vaginalis

A

Offensive, yellow/green, frothy discharge
Vulvovaginitis
Strawberry cervix

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15
Q

Urogenital prolapse Types

A

cystocele, cystourethrocele
rectocele
uterine prolapse
less common: urethrocele, enterocele (herniation of the pouch of Douglas, including small intestine, into the vagina)

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16
Q

Urogenital prolapse Risk factors

A

increasing age
multiparity, vaginal deliveries
obesity
spina bifida

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17
Q

Urogenital prolapse Presentation + Management

A

Presentation
sensation of pressure, heaviness, ‘bearing-down’
urinary symptoms: incontinence, frequency, urgency

Management
if asymptomatic and mild prolapse then no treatment needed
conservative: weight loss, pelvic floor muscle exercises
ring pessary
surgery

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18
Q

Urogenital prolapse Surgical options

A

cystocele/cystourethrocele: anterior colporrhaphy, colposuspension
uterine prolapse: hysterectomy, sacrohysteropexy
rectocele: posterior colporrhaphy

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19
Q

Urinary incontinence (UI) is a common problem, affecting around 4-5% of the population. It is more common in elderly females.

Risk factors

A 
advancing age
previous pregnancy and childbirth
high body mass index
hysterectomy
family history
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20
Q

Urinary incontinence Classification

A

overactive bladder (OAB)/urge incontinence: due to detrusor overactivity
stress incontinence: leaking small amounts when coughing or laughing
mixed incontinence: both urge and stress
overflow incontinence: due to bladder outlet obstruction, e.g. due to prostate enlargement

21
Q

Urinary incontinence ix

A

bladder diaries should be completed for a minimum of 3 days
vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles (‘Kegel’ exercises)
urine dipstick and culture
urodynamic studies

22
Q

Urinary incontinence

Management depends on whether urge or stress UI is the predominant picture. If urge incontinence is predominant:

A 
bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding)
bladder stabilising drugs: antimuscarinics are first-line. NICE recommend oxybutynin (immediate release), tolterodine (immediate release) or darifenacin (once daily preparation). Immediate release oxybutynin should, however, be avoided in 'frail older women'
mirabegron (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patients
23
Q

Urinary incontinence If stress incontinence is predominant: mx

A

pelvic floor muscle training: NICE recommend at least 8 contractions performed 3 times per day for a minimum of 3 months
surgical procedures: e.g. retropubic mid-urethral tape procedures
duloxetine may be offered to women if they decline surgical procedures

24
Q

What is duloxetine

A

a combined noradrenaline and serotonin reuptake inhibitor
mechanism of action: increased synaptic concentration of noradrenaline and serotonin within the pudendal nerve → increased stimulation of urethral striated muscles within the sphincter → enhanced
contraction

25
Q

WHO FGM Classification:

A

Type 1 Partial or total removal of the clitoris and/or the prepuce (clitoridectomy).
Type 2 Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision).
Type 3 Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation).
Type 4 All other harmful procedures to the female genitalia for non-medical purposes, for example: pricking, piercing, incising, scraping and cauterization.

26
Q

Ovulation disorders are the cause of infertility in approximately

A

one-quarter of couples who have difficulty conceiving naturally, and whilst ovulation may occur sometimes, natural spontaneous conception is usually unlikely

27
Q

Normal ovulation The early follicular phase

A

requires an increase in gonadotropin-releasing hormone (GnRH) pulse frequency which increases the release of follicle-stimulating hormone (FSH) and luteinising hormone (LH), to allow for stimulation and development of multiple ovarian follicles, and usually only one of which will become the dominant ovulatory follicle in that menstrual cycle.

28
Q

Normal ovulation In the mid-follicular phase,

A

FSH gradually stimulates estradiol production, following which estradiol itself produces a negative feedback loop on the hypothalamus and pituitary gland to suppress FSH and LH concentrations.

29
Q

Normal ovulation In the luteal phase,

A

there is a unique switch from negative to positive feedback of estradiol, resulting in a surge of LH secretion and this leads to subsequent follicular rupture and ovulation.

30
Q

Categories of ovulatory disorders

A 
Class 1 (hypogonadotropic hypogonadal anovulation) 
Class 2 (normogonadotropic normoestrogenic anovulation) - polycystic ovary syndrome
Class 3 (hypergonadotropic hypoestrogenic anovulation)
31
Q

Categories of ovulatory disorders epidiomology

A

Class 1 5-10% of women
Class 2 80% of cases
Class 3 5-10% of cases

32
Q

Class 3 (hypergonadotropic hypoestrogenic anovulation) how successful is ovulation induction

A

In this class, any attempts at ovulation induction are typically unsuccessful and therefore usually require in-vitro fertilisation (IVF) with donor oocytes to conceive

33
Q

Goals of ovulation induction

A

It is ideal to start with the least invasive and simplest management option first, and work the way up to more complicated and intensive treatment
For most women, it is the goal to induce mono-follicular development and subsequent ovulation as opposed to multi-follicular development, and this is to ultimately lead to a singleton pregnancy, which tends to be far lower risk and therefore preferable

34
Q

Forms of ovulation induction

A

Exercise and weight loss
Letrozole
Clomiphene citrate
Gonadotropin therapy

35
Q

polycystic ovarian syndrome, as ovulation can spontaneously return with even a modest ?% weight loss

A

polycystic ovarian syndrome, as ovulation can spontaneously return with even a modest 5% weight loss
Therefore, particularly for overweight or obese women with polycystic ovarian syndrome, this should be trialled solely first, and then artificial ovulation induction be considered

36
Q

Letrozole mechanism

A

letrozole is an aromatase inhibitor, reducing the negative feedback caused by estrogens to the pituitary gland, therefore increasing the amount of follicle-stimulating hormone (FSH) production and promoting follicular development
The rate of mono-follicular development is much higher with letrozole use compared to clomiphene, which is a key goal in ovulation induction

37
Q

Letrozole side effects

A

fatigue (20%), dizziness (10%)

38
Q

first-line medical therapy Ovulation induction

why is this first line?

A

Letrozole
first-line medical therapy for patients with PCOS, due to the reduced risk of adverse effects on endometrial and cervical mucous compared to clomiphene citrate

39
Q

clomiphene treatment highest rate live births

A

most women with PCOS will respond to clomiphene treatment and ovulate (80% of women), the rates of live birth are higher with letrozole therapy, hence why it has become a first-line treatment instead

40
Q

clomiphene Mechanism of action:

A

clomiphene is a selective estrogen receptor modulator (also known as SERMs), which acts primarily at the hypothalamus, blocking the negative feedback effect of estrogens. This subsequently leads to an increase in gonadotropin-releasing hormone (GnRH) pulse frequency and therefore FSH and LH production, stimulating ovarian follicular development

41
Q

clomiphene Side effects

A

hot flushes (30%), abdominal distention and pain (5%), nausea and vomiting (2%)

42
Q

Gonadotropin therapy

This tends to be the treatment used mostly for women with

A

class 1 ovulatory dysfunction, notably women with hypogonadotropic hypogonadism

For women with PCOS, this tends to be only considered after attempt with other treatments has been unsuccessful, usually after weight loss, letrozole and clomiphene trial

This is because the risk of multi-follicular development and subsequent multiple pregnancy is much higher, as well as increased risk of ovarian hyperstimulation syndrome

43
Q

Mechanism of action: pulsatile GnRH

A

therapy involves administration of GnRH via an intravenous (or less frequently, subcutaneous) infusion pump, leading to endogenous production of FSH and LH and subsequent follicular development

44
Q

Ovarian hyperstimulation syndrome (OHSS) is one of the potential side effects of ovulation induction, and unfortunately can be life-threatening if not identified and managed promptly

A

true

45
Q

In OHSS what happens

A

ovarian enlargement with multiple cystic spaces form, and an increase in the permeability of capillaries leads to a fluid shift from the intravascular to the extra-vascular space, which has the potential to result in multiple life-threatening complications including:

Hypovolaemic shock
Acute renal failure
Venous or arterial thromboembolism

46
Q

OHSS mx

A

Depending on the severity, the management includes:
Fluid and electrolyte replacement
Anti-coagulation therapy
Abdominal ascitic paracentesis
Pregnancy termination to prevent further hormonal imbalances

47
Q

Ovarian hyperstimulation syndrome pathophysiology

A

It is postulated that the presence of multiple luteinized cysts within the ovaries results in high levels of not only oestrogens and progesterone but also vasoactive substances such as vascular endothelial growth factor (VEGF). This results in increased membrane permeability and loss of fluid from the intravascular compartment

48
Q

Up to one third of women who are having IVF may experience a mild form of OHSS

A

true

49
Q

The RCOG uses the following classification of OHSS

A 
Mild: Abdominal pain, Abdominal bloating
Moderate: As for mild
Nausea and vomiting, Ultrasound evidence of ascites	
Severe:	 As for moderate
• Clinical evidence of ascites
• Oliguria
• Haematocrit > 45%
• Hypoproteinaemia
Critical: • As for severe
• Thromboembolism
• Acute respiratory distress syndrome
• Anuria
• Tense ascites

4th year passmedicine by topic (96 decks)

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