WH: Vaginal + Vulval Disorders Flashcards
What is urinary incontinence ?
It is the involuntary loss of control of urination
what are the main 2 types of urinary incontinence ?
- Stress
- Urgency
(mixed)
What is urge incontinence ? also known as ?
urge incontinence (overactive bladder)
- overactivity of detrusor muscle of bladder
what will patients with urge incontinence often complain of ?
sudden feeling to urine + rush to the toilet
(when they gotta go, they gotta go)
what is stress incontinence ? due to?
due to weakness of the pelvic floor + sphincter muscles => allows mine to lead when increased pressure on bladder (increased intraabdominal pressure)
what will patients with stress incontinence complain of?
leakage of urine when laughing, coughing or surprised
What is mixed incontinence ?
symptoms of both stress + urge incontinence
What is overflow incontinence ?
obstruction to outflow of urine => chronic urinary retention => overflow + leakage of urine
What is overflow incontinence caused by ? (4)
- Anticholinergic meds
- Fibroids
- Pelvic tumours
- Neurological disorders (MS, Diabetic neuropathy)
- posterior POP (+faecal loading)
RF for urinary incontinence ? (6)
- Increasing age
- Post-menopausal
- increased BMI
- prev pregnancy + vaginal deliveries
- POP
- neurological disorders
What investigations are done for urinary incontinence ?
- Bladder diary
- Urine dipstick (to exclude infection)
- Post-void residual bladder vol
- urodynamic testing
what info is there in a bladder diary ?
- fluid intake
- urination vol
- incontinence vol
Management of stress incontinence ?
- Lifestyle: avoid caffeine, alcohol, smoking, dietetics + overfilling bladder
- Weight loss
- Supervised pelvic floor exercises
Urge incontinence management ?
- Bladder retraining
- Anticholinergic meds (oxybutymin)
- Incasive procedures
what does bladder retraining involve ?
gradually increase the time between voiding
SE of anticholinergic medications? (3) give example of this type of drug
oxybutymin
SE:
- dry mouth
- dry eyes
- urinary retention
What is pelvic organ prolapse ?
Descent of pelvic organs into the vagina
POP pathophysiology ?
as a result of lengthening + weakness of muscles + ligaments surround the uterus, rectum + bladder
name the pelvic organs from anterior to posterior
ant
- bladder
- vagina
- rectum
post
what is an anterior compartment prolapse ?
weakenes anterior vaginal wall
- cystolcele
- urethrocele
what is a cystolcele ?
bladder prolapse into vagina
what is a urethrocele + cystocele called ?
cystourethrocele
what is a middle compartment prolapse ? (2)
- uterine prolapse
- Vault prolapse (post hysterectomy)
what is a posterior compartment POP ? (3)
involvement of posterior vaginal wall
- Enterocele
- Rectocele
-
What is enterocoele? be specific
(posteirorcompartment)
small bowel prolapse
- usually pouch of Douglas
what is rectocele and what can its cause?
rectum prolapse
- causes constipation + faecal loading => urinary retention (due to urethral compression)
POP RF? (6)
things that weaken + stretch ligaments
- Postmenopausal
- Multiple vaginal deliveries (increasing parity)
- Instrumental/prolonger/traumatic deliveries
- Obesity
- Hypertension
- DM
POP presentation ? (3)
- feeling of something coming down/dragging heavy sensation
- Urinary symptoms (incontinence, urgency, frequency, weak stream, retention)
- Sexual dysfunction: pain, altered sensation, reduced enjoyment
what would you do for POP examination ?
sims speculum
(support anterior wall to see rectocele (vice versa)
how many grades of uterine prolapse are there ? which is worse ?
grade 0 - 4
- grade 0: normal
- grade 4: full descent with eversion of the vagina
what are the 3 general categories for POP management ?
- Conservative
- Pessaries
- Surgery
what is involved in conservative POP management ?
- Physiotherapy
- Weight loss
- Lifestyle changes (reduce caffeine)
Conservative management of POP is not proving effective. what next ? explain
Vaginal pessaries: provide extra support to pelvic organs
what might be needed in combo with vaginal pessaries ?
oestrogen cream helps protect vaginal walls from potential irritation
surgical POP management complications ?
- Pain, bleeding, infection, DVT
- Damage to bladder or bowel
- Recurrence of prolapse
- Altered experience of sex
what are other names for renal stones ?
- renal calculi
- Urolithiases
- Nephrolithiasis
what are renal calculi ?
(kidney stones)
- hard stones that form in the renal pelvis
what is the renal pelvis ?
where urien collects before travelling down ureters
key complications of kidney stones ?
- Obstruction (=> AKI)
- Infection (=> obstructive pyelonephritis)
What can hypercalcaemia cause ?
- Renal stones
- Painful bones
- Abdo groans
- Psychiatric moans
causes of hypercalcaemia ? (3)
- Calcium supplementation
- Hyperparathyroidism
- Cancer (myeloma, breast, lung)
where do urolithiasis often get stuck ?
usually at veseco-uteric junction
What types of kidney stones are there ? (made of) most common ?
- Calcium based: Calcium oxalate (most common)
- Other: uric acid
RF for calcium based kidney stones ?
- Hypercalcaemia
- low urine output
Renal stones presentation ?
- Asymptomattic
- renal cold (unilateral loin to groin pain - excruciating)
- haematuria
- Nausea + vomiting
- low urine output
- Symptoms of sepsis
what investigations for renal stones ? gold standard ?
- Urine dipstick (Haematuria)
- abdo x ray: will show calcium based stones
- CT KUB: (gold standard)
Kidney stones management ?
- Analgesia: NSAIDs (IM diclofenac)
- Antiemetics
depends on size
- <5mm: watchful waiting: pass without intervention
- >5mm surgical intervention.
what surgical intervention for renal stones ?
- Extracorporeal shock wave lithotripsy (ESWL): shock waves break stone into smaller parts
- Percutaneous nephrolithotomy (PCNL)
what can you do to reduce risk of recurrent stones ?
- increase oral fluid intake (add fresh lemon)
- reduce dietary salt
What is Atrophic vaginitis ? related to lack of what ?
dryness + atrophy of vaginal mucosa related to lack of oestrogen
(occur in women from menopause onwards)
describe he relationship between oestrogen and Atrophic vaginitis ?
low oestrogen => thinking + reduced elasticity + drying of epithelial lining in vagina + urinary tract => prone to inflammationphic
atrophic vaginits presentation ? (4)
post menopausal
- itching
- dryness
- dyspareunia
- bleeding
what might be seen OE in atrophic vaginitis ? (3)
- pale mucosa
- thin skin
- dryness
atrophic vaginits Mx ?
vaginal lubricants 9cream, pessary, tablet)
What is lichen sclerosis ?
Chronic inflam skin condition affecting labia, perineum, perianal (anogenital region)
how is lichen sclerosis diagnosed ? (2)
usually made clinically
- vulval biopsy can confirm
lichen sclerosis presentation ? age?
45-60 woman with vulval itching + skin changes
lichen sclerosis Mx ?
cannot be cured
- potent topical steroids
what is the main concerning complication associated with lichen sclerosis ?
5% risk of developing squamous cell carcinoma of the vulva
Where are bartholins glands located ?
located deep to posterior aspect of labia major (4 + 8 o’clock)
what causes bartholins cyst ?
build up of mucuc secretions in duct => gland blocked => cyst development
what causes bartholins abscess ?
bartholins cyst 9small + tender) get infected => bartholins abscess (hot, tender, red, potentially daring pus)
what is the most likely infective organism in bartholins abscess ?
E.Coli
bartholins abscess RF?
Hx of prev cyst
sexually active
bartholins cyst clinical features ?
often asympotmattic
- if large: valvular pain, superficial dyspareunia
- abscess: acute onset of pain, difficulty passing uric
how is botholins cyst diagnosed ?
made clinically based on H + E
- consider cyst biopsy to exclude vuval carcinoma
bartholins cyst Mx? abscess ?
small or asymptomatic: no Tx
- resolve with good hygiene, analgesia
- abscess: Abx, swab pus/fluid, STI check, surgical drainage
what is FGM ?
surgically chaining genital of a female for no-medical reasons
what do you do if there is patient with FGM ?
it is illegal (FGM act 2003): so legal require for healthcare professional to report it to the police
(report all <18 cases, risk assess for >18)
where is FGM common ? highest rates ?
highest rates in Somalia, Ethiopia, Sudan
what are the different types of FGM ? (4)
1) removal of part/all of clitoris
2) removal of part/all of clitoris + labia minor
3) narrowing of closing of the vaginal orrifice (infibulation)
4) all other
complications of FGM ? immediate and long term ?
immediate: pain, bleeding, infection, swelling, incontinence, retention
long term: infection, PID, UTI, dysmenorrhoea, sexual dysfunction, dysparaenia, infertility , psychological
What is most common type of vulval cancer ? cell type ?
90% are squamous cell carcinomas
vulval cancer RF ?
- advancing age (>75)
- Immunosuppression
- HPV infection
- Lichen sclerosis
what is vulval intraepithelial neoplasia ? can lead to what ?
premalignant condition of squamous epithelium fo the skin
- can precede vulval cancer
Mx of vulval intraepithelial neoplasia ?
specialist
- watch + wait
- wide local excision
- laser ablation
vuval cancer presentation ?
(>75)
- vulval lump
- ulceration
- bleeding
- pain
- itching
- groin lymphadenopathy
vulval cancer Mx ?
- biopsy, sentinel node biopsy, further imaging
- wide local excision, chemo, radiotherapy
