Vulvovaginal Disorders Flashcards
What is stress incontinence?
Leakage of urine when there is increased intra-abdominal pressure, with the absence of detrusor muscle contraction
What are the features of stress incontinence?
Common after childbirth, pelvic surgery and oestrogen deficiency
Triggers: coughing, sneezing, exercise
Small volume of leakage
Which investigations should be done for stress incontinence?
Exclude UTI
Frequency/volume charts –> normal frequency and bladder capacity
Urodynamic studies
What are the management options for stress incontinence?
Lifestyle: - weight loss - smoking cessation - avoid constipation - caffeine reduction Conservative: - pelvic floor exercises for 3 months - use of pads Surgical: - e.g. tension free vaginal tape Medical (only if conservative/surgical not suitable)
What is the medical option for management of stress incontinence, and what are the side effects?
Duloxetine:
- difficulty sleeping
- headaches
- dizziness
- blurred vision
- change in bowel habit
- N & V
- dry mouth
- sweating
- reduced appetite and weight loss
- decreased libido
What is urge incontinence?
Increased urgency and frequency
What are the features of urge incontinence?
Triggers: hearing running water, cold weather
Nocturia
Larger volumes of leakage
Urgency + frequency
What are the causes of urge incontinence?
Idiopathic
Pelvic surgery
MS
Spina bifida
How is urge incontinence diagnosed?
Frequency/volume charts –> increased frequency
Urodynamic testing –> overactivity of detrusor muscle
What are the management options for urge incontinence?
Lifestyle: - decrease fluid intake - minimise caffeine and diuretics (alcohol) Blader retraining with incontinence team Medical Surgery
What are the medical management options for urge incontinence?
Anticholinergics:
- tolterodine, solifenacin
- oxybutynin (risk of cognitive impairment in elderly)
Mirabegron
Intravaginal oestrogens (if vaginal atrophy)
Desmopressin in nocturia
What are the surgical options for urge incontinence?
Botox
Percutaneous sacral nerve stimulation
Augmentation cystoplasty
What is overflow incontinence?
Leakage of urine from a full bladder, often with the absence of an urge to urinate
What are the causes of overflow incontinence?
Inactive detrusor muscle –> no urge to urinate
- neuro conditions e.g. MS
Involuntary bladder spasms
- CV disease and diabetes
Cystocele or uterine prolapse can block exit if severe
Prostate problems
How is overflow incontinence diagnosed?
Urodynamic testing shows inactivity of detrusor muscle
How is overflow incontinence managed?
Treat the cause
What are the different types of vaginal prolapse?
Bladder (cystocele)
Uterus
Vagina
Rectum (rectocele)
How is severity of prolapse graded?
1st degree: mild protrusion, -1cm of introitus
2nd degree: present at introitus (between -1cm and +1cm)
3rd degree: beyond +1cm of introitus
4th degree: procidentia (complete prolapse)
What are the risk factors for prolapse?
Increasing age
Multiparity, vaginal deliveries
Obesity
Spina bifida
What are the clinical features of a prolapse?
Sensation of pressure, heaviness, bearing down
Urinary incontinence, frequency, urgency
What are the management options for prolapse?
If mostly asymptomatic, no treatment required
Lifestyle:
- weight loss, avoid constipation, smoking cessation, avoid heavy lifting, caffeine reduction
Pelvic floor training
Ring pessary
Surgery
What is the surgical management of a cystocele/cystourethrocele?
Anterior colporrhaphy
What are the surgical options for management of a uterine prolapse?
Hysterectomy
Sacrohysteropexy
Sacrospinous fixation
What is the surgical management of a rectocele?
Posterior colporrhaphy
What is the management of UTI in pregnancy?
Urine culture
Nitrofurantoin –> 1st + 2nd trimester
Trimethoprim –> 3rd trimester
What is a Bartholin’s cyst/abscess?
Fluid filled sac within one of the Bartholin’s glands of the vagina –> can become infected (abscess)
What are the clinical features of a Bartholin’s cyst?
Asymptomatic if small If large; - vulvar pain - superficial dyspareunia - spontaneous rupture --> sudden relief of pain
What are the clinical features of a Bartholin’s abscess?
Acute pain and/or difficulty passing urine
Unilateral labial mass arising from posterior aspect of labia majora
Tense mass with surrounding cellulitis
What is the management for a Bartholin’s cyst?
Word Catheter
- incision made and catheter inserted
- left in place for 4-6 weeks to form tract so that it doesn’t recur
OR Marsupialisation
What is lichen sclerosis?
Chronic inflammatory skin disease of the anogenital region in women
What are the clinical features of lichen sclerosis?
White atrophic patches on the skin of anogenital region
Itching is most common
Skin might fissure or erode —> pain
Dyspareunia
What might be seen on examination in lichen sclerosis?
Well defined white lesions Evidence of adhesion and/or scarring: - clitoral hood fusion - fusion of labia minora to labia majora - posterior fusion --> loss of vaginal opening
How is lichen sclerosis treated?
Immunosuppression
–> topical steroids e.g. clobetasol propionate
Why should patients with lichen sclerosis be followed up?
Risk of developing squamous cell carcinoma
What are the risk factors for vulval intraepithelial neoplasia?
HPV - young women
Chronic lichen simplex chronicus or lichen sclerosis - older women
What are the features of vulvar invasive carcinoma?
Squamous carcinoma
- ulcer or exophytic mass
- itching, burning, bleeding
Spreads to inguinal nodes
What is the management of vulvar cancer?
Excision
- wide local excision to radical vulvectomy
+ Inguinal lymphadenectomy
