Vulvovaginal Disorders

Question 1

What is stress incontinence?

Answer 1

Leakage of urine when there is increased intra-abdominal pressure, with the absence of detrusor muscle contraction

Question 2

What are the features of stress incontinence?

Answer 2

Common after childbirth, pelvic surgery and oestrogen deficiency
Triggers: coughing, sneezing, exercise
Small volume of leakage

Question 3

Which investigations should be done for stress incontinence?

Answer 3

Exclude UTI
Frequency/volume charts –> normal frequency and bladder capacity
Urodynamic studies

Question 4

What are the management options for stress incontinence?

Answer 4

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)

Question 5

What is the medical option for management of stress incontinence, and what are the side effects?

Answer 5

Duloxetine:

• difficulty sleeping
• headaches
• dizziness
• blurred vision
• change in bowel habit
• N & V
• dry mouth
• sweating
• reduced appetite and weight loss
• decreased libido

Question 6

What is urge incontinence?

Answer 6

Increased urgency and frequency

Question 7

What are the features of urge incontinence?

Answer 7

Triggers: hearing running water, cold weather
Nocturia
Larger volumes of leakage
Urgency + frequency

Question 8

What are the causes of urge incontinence?

Answer 8

Idiopathic
Pelvic surgery
MS
Spina bifida

Question 9

How is urge incontinence diagnosed?

Answer 9

Frequency/volume charts –> increased frequency

Urodynamic testing –> overactivity of detrusor muscle

Question 10

What are the management options for urge incontinence?

Answer 10

Lifestyle:
- decrease fluid intake
- minimise caffeine and diuretics (alcohol)
Blader retraining with incontinence team
Medical
Surgery

Question 11

What are the medical management options for urge incontinence?

Answer 11

Anticholinergics:
- tolterodine, solifenacin
- oxybutynin (risk of cognitive impairment in elderly)
Mirabegron
Intravaginal oestrogens (if vaginal atrophy)
Desmopressin in nocturia

Question 12

What are the surgical options for urge incontinence?

Answer 12

Botox
Percutaneous sacral nerve stimulation
Augmentation cystoplasty

Question 13

What is overflow incontinence?

Answer 13

Leakage of urine from a full bladder, often with the absence of an urge to urinate

Question 14

What are the causes of overflow incontinence?

Answer 14

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

Question 15

How is overflow incontinence diagnosed?

Answer 15

Urodynamic testing shows inactivity of detrusor muscle

Question 16

How is overflow incontinence managed?

Answer 16

Treat the cause

Question 17

What are the different types of vaginal prolapse?

Answer 17

Bladder (cystocele)
Uterus
Vagina
Rectum (rectocele)

Question 18

How is severity of prolapse graded?

Answer 18

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)

Question 19

What are the risk factors for prolapse?

Answer 19

Increasing age
Multiparity, vaginal deliveries
Obesity
Spina bifida

Question 20

What are the clinical features of a prolapse?

Answer 20

Sensation of pressure, heaviness, bearing down

Urinary incontinence, frequency, urgency

Question 21

What are the management options for prolapse?

Answer 21

If mostly asymptomatic, no treatment required
Lifestyle:
- weight loss, avoid constipation, smoking cessation, avoid heavy lifting, caffeine reduction
Pelvic floor training
Ring pessary
Surgery

Question 22

What is the surgical management of a cystocele/cystourethrocele?

Answer 22

Anterior colporrhaphy

Question 23

What are the surgical options for management of a uterine prolapse?

Answer 23

Hysterectomy
Sacrohysteropexy
Sacrospinous fixation

Question 24

What is the surgical management of a rectocele?

Answer 24

Posterior colporrhaphy

Question 25

What is the management of UTI in pregnancy?

Answer 25

Urine culture
Nitrofurantoin –> 1st + 2nd trimester
Trimethoprim –> 3rd trimester

Question 26

What is a Bartholin’s cyst/abscess?

Answer 26

Fluid filled sac within one of the Bartholin’s glands of the vagina –> can become infected (abscess)

Question 27

What are the clinical features of a Bartholin’s cyst?

Answer 27

Asymptomatic if small
If large;
- vulvar pain
- superficial dyspareunia
- spontaneous rupture --> sudden relief of pain

Question 28

What are the clinical features of a Bartholin’s abscess?

Answer 28

Acute pain and/or difficulty passing urine
Unilateral labial mass arising from posterior aspect of labia majora
Tense mass with surrounding cellulitis

Question 29

What is the management for a Bartholin’s cyst?

Answer 29

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

Question 30

What is lichen sclerosis?

Answer 30

Chronic inflammatory skin disease of the anogenital region in women

Question 31

What are the clinical features of lichen sclerosis?

Answer 31

White atrophic patches on the skin of anogenital region
Itching is most common
Skin might fissure or erode —> pain
Dyspareunia

Question 32

What might be seen on examination in lichen sclerosis?

Answer 32

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

Question 33

How is lichen sclerosis treated?

Answer 33

Immunosuppression

–> topical steroids e.g. clobetasol propionate

Question 34

Why should patients with lichen sclerosis be followed up?

Answer 34

Risk of developing squamous cell carcinoma

Question 35

What are the risk factors for vulval intraepithelial neoplasia?

Answer 35

HPV - young women

Chronic lichen simplex chronicus or lichen sclerosis - older women

Question 36

What are the features of vulvar invasive carcinoma?

Answer 36

Squamous carcinoma
- ulcer or exophytic mass
- itching, burning, bleeding
Spreads to inguinal nodes

Question 37

What is the management of vulvar cancer?

Answer 37

Excision
- wide local excision to radical vulvectomy
+ Inguinal lymphadenectomy