Vulval/Vaginal/Urogenital Flashcards
Around 80% of vulval cancers are
squamous cell carcinomas
Vulval carcinoma cases occur in women over the age
65 years
Vulval cancer is relatively rare with only around 1,200 cases diagnosed in the UK each year.
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Vulval carcinoma - Other than age, risk factors include:
Human papilloma virus (HPV) infection
Vulval intraepithelial neoplasia (VIN)
Immunosuppression
Lichen sclerosus
Vulval carcinoma Features
lump or ulcer on the labia majora
may be associated with itching, irritation
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.
Candida albicans
The majority of women will have no predisposing factors. However, certain factors may make vaginal candidiasis more likely to develop:
diabetes mellitus
drugs: antibiotics, steroids
pregnancy
immunosuppression: HIV
Vaginal candidiasis Features
‘cottage cheese’, non-offensive discharge
vulvitis: superficial dyspareunia, dysuria
itch
vulval erythema, fissuring, satellite lesions may be seen
Vaginal candidiasis ix
a high vaginal swab is not routinely indicated if the clinical features are consistent with candidiasis
Vaginal candidiasis mx
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
BASHH define recurrent vaginal candidiasis
4 or more episodes per year
recurrent vaginal candidiasis ix
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
recurrent vaginal candidiasis mx
consider the use of an induction-maintenance regime
induction: oral fluconazole every 3 days for 3 doses
maintenance: oral fluconazole weekly for 6 months
Trichomonas vaginalis
Offensive, yellow/green, frothy discharge
Vulvovaginitis
Strawberry cervix
Urogenital prolapse Types
cystocele, cystourethrocele
rectocele
uterine prolapse
less common: urethrocele, enterocele (herniation of the pouch of Douglas, including small intestine, into the vagina)
Urogenital prolapse Risk factors
increasing age
multiparity, vaginal deliveries
obesity
spina bifida
Urogenital prolapse Presentation + Management
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
Urogenital prolapse Surgical options
cystocele/cystourethrocele: anterior colporrhaphy, colposuspension
uterine prolapse: hysterectomy, sacrohysteropexy
rectocele: posterior colporrhaphy
Urinary incontinence (UI) is a common problem, affecting around 4-5% of the population. It is more common in elderly females.
Risk factors
advancing age previous pregnancy and childbirth high body mass index hysterectomy family history
Urinary incontinence Classification
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
Urinary incontinence ix
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
Urinary incontinence
Management depends on whether urge or stress UI is the predominant picture. If urge incontinence is predominant:
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
Urinary incontinence If stress incontinence is predominant: mx
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
What is duloxetine
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
WHO FGM Classification:
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.
Ovulation disorders are the cause of infertility in approximately
one-quarter of couples who have difficulty conceiving naturally, and whilst ovulation may occur sometimes, natural spontaneous conception is usually unlikely
Normal ovulation The early follicular phase
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.
Normal ovulation In the mid-follicular phase,
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.
Normal ovulation In the luteal phase,
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.
Categories of ovulatory disorders
Class 1 (hypogonadotropic hypogonadal anovulation) Class 2 (normogonadotropic normoestrogenic anovulation) - polycystic ovary syndrome Class 3 (hypergonadotropic hypoestrogenic anovulation)
Categories of ovulatory disorders epidiomology
Class 1 5-10% of women
Class 2 80% of cases
Class 3 5-10% of cases
Class 3 (hypergonadotropic hypoestrogenic anovulation) how successful is ovulation induction
In this class, any attempts at ovulation induction are typically unsuccessful and therefore usually require in-vitro fertilisation (IVF) with donor oocytes to conceive
Goals of ovulation induction
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
Forms of ovulation induction
Exercise and weight loss
Letrozole
Clomiphene citrate
Gonadotropin therapy
polycystic ovarian syndrome, as ovulation can spontaneously return with even a modest ?% weight loss
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
Letrozole mechanism
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
Letrozole side effects
fatigue (20%), dizziness (10%)
first-line medical therapy Ovulation induction
why is this first line?
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
clomiphene treatment highest rate live births
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
clomiphene Mechanism of action:
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
clomiphene Side effects
hot flushes (30%), abdominal distention and pain (5%), nausea and vomiting (2%)
Gonadotropin therapy
This tends to be the treatment used mostly for women with
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
Mechanism of action: pulsatile GnRH
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
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
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In OHSS what happens
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
OHSS mx
Depending on the severity, the management includes:
Fluid and electrolyte replacement
Anti-coagulation therapy
Abdominal ascitic paracentesis
Pregnancy termination to prevent further hormonal imbalances
Ovarian hyperstimulation syndrome pathophysiology
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
Up to one third of women who are having IVF may experience a mild form of OHSS
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The RCOG uses the following classification of OHSS
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
