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Gynaecology Flashcards

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1
Q

How common are pelvic floor disorders?

A

20% adult women experience regular incontinence
10% will have surgery for prolapse
< 10% anal incontinence
Increase with age, parity, obesity, smoking

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2
Q

What should you also consider with pelvic floor disorders?

A

Sexual dysfunction linked to lower urinary tract, vaginal and bowel
Can’t be considered in isolation

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3
Q

What is incontinence?

A

Involuntary leakage of urine
Social or hygiene problems
Can be objectively demonstrable

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4
Q

What happens with an overactive bladder/detrusor overactivity?

A

Involuntary bladder contractions

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5
Q

What are the symptoms of overactive bladder?

A

Urgency and urgency incontinence
Frequency
Nocturia
Nocturnal enuresis
‘Key in door’
Sound of running water
Intercourse

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6
Q

What happens with stress urinary incontinence?

A

Sphincter weakness

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7
Q

What are the symptoms of stress incontinence?

A

Involuntary leaking due to anything that increases intraabdominal pressure as sphincter not working properly
Cough
Laugh
Lifting
Exercise
Movement
Walking/running downhill
Intercourse
Stumble/choking/vomiting

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8
Q

Name 3 different types of incontience

A

Sphincter weakness - stress incontinence
Detrusor overactivity - overactive bladder
Mixed
Fistula
Neurological and functional eg dementia - can cause reflux into kidneys as bladder pressure so high
Overflow and retention

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9
Q

What assessments can you do for incontinence?

A

Urinalysis - MSU
Frequency and volume chart
Residual urine measurement
Questionnaire - ePAQ

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10
Q

What is recorded on a frequency volume chart?

A

Bladder diary
- Voided volume
- Frequency of urination
- Quantity and frequency of leakage
- Fluid intake
Diurnal variation
Initial assessment and clinical diagnosis
Planning treatment
Adjunct to cystometry

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11
Q

How is residual urine measurement done?

A

In and out catheter - CISC
- Post-surgical voiding dysfunction
- Post-natal retention
- Neuropath
Indwelling - suprapubic/urethral
USS

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12
Q

What are the different sections of the ePAQ questionnaire?

A

Urinary
- Pain
- Voiding
- Overactive bladder
- Stress incontinence
- QoL
Vaginal
- Pain
- Capacity
- Prolapse
- QoL
Bowel
- IBS
- Constipation
- Evacuation
- Continence
- QoL
Sexual
- Urinary
- Bowel
- Dyspareunia
- Overall sex life

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13
Q

What lifestyle adaptations can help with incontinence?

A

Weight loss including bariatric surgery
Smoking cessation - smoking damages collagens of pelvic organs, chronic cough
Reduced caffeine intake - stimulant
Avoidance of straining and constipation

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14
Q

How can you manage incontinence via containment?

A

Bladder bypass (catheters) - indwelling, clean intermittent self-catheterisation (CISC)
Leakage barriers (pads/pants)
Vaginal support (pessaries)
Skin care (barrier creams) to protect skin
HRT (vaginal oestrogen)
- Oestrogen and progesterone receptors - bladder dome, trigone, urethra, bladder neck, vagina, vesico-vaginal fascia
- Local vaginal oestrogen less frequency, urgency and incontinence
- Very little gets absorbed into system, fewer s/e
- Topical oestrogen
Lifestyle adaptation

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15
Q

How can you manage incontinence with treatment?

A

Overactive bladder
- Bladder drill
- Drugs (anti-cholinergic)
- Botox
- Augment
- Bypass
Stress incontinence
- Conservative (physio and lifestyle adaptation)
- Surgery (sling, suspension)
Reassurance, support, lifestyle adaptation, containment

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16
Q

What is the detrusor muscle?

A

Smooth muscle, transitional epithelium, normally contracts only during micturition

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17
Q

What innervates the detrusor muscle?

A

Sacral parasympathetic (S2-4) - reflex
Neurotransmitter - Ach
Receptors - muscarinic M2 and 3
T11 and 12 maintain relaxation of bladder for urine storage, reflex bladder contractions suppressed, brain will remove inhibition when goes to toilet

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18
Q

Name an Ach antagonist

A

Atropine

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19
Q

What are the S/E of atropine?

A

CNS - cognitive impairment
Constipation
Dry mouth
Blurred vision
Tachycardia

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20
Q

What are anticholinergics?

A

Atropine like agents M2 and 3 receptor antagonists
Antimuscarinic

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21
Q

Name an anti-cholinergic drug and it’s dose

A

Oxybutynin 2.5-5mg BD-TDS
PRN as effective, less S/E

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22
Q

What are the S/E of oxybutynin?

A

Dry mouth, blurred vision, drowsiness, constipation
Can’t see, can’t pee, can’t spit, can’t shit

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23
Q

What is the success rate of treatment with anti-cholinergics?

A

7% cured in one year
Large placebo effect

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24
Q

Name 2 other anti-cholinergics

A

Tolterodine
Propiverine
Trospium - doesn’t cross BBB so lower risk for CNS s/e - consider in older patients
Solifenacin

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25
What is mirabegron?
Beta-3 adrenergic receptor agonist Relaxes smooth muscle detrusor Increased bladder capacity
26
How is stress incontinence treated?
Emphasis on conservative treatment before surgery Self-help and lifestyle adaptation - Weight, smoking, oestrogen Physio, pelvic floor exercises, biofeedback, electrical stimulation, vaginal cones Surgery - Colposuspension, sling - May be unsuitable due to medical conditions, mild/intermittent symptoms, personal circumstances
27
What are the principles of surgery for stress incontinence?
Restore pressure transmission to urethra Support/elevate urethra Increase urethral resistance
28
What history might you get for someone with uretero-vaginal prolapse?
Something coming down lump, discomfort, pelvic floor and sexual dysfunction
29
How would you examine someone with suspected uretero-vaginal prolapse?
Bimanual and sims speculum
30
What investigations should you do for uretero-vaginal prolapse?
Usually none
31
What is the treatment for uretero-vaginal prolapse?
Reassurance and advice, treat pelvic floor symptoms, pessary (holds vagina in place, can insert themselves), surgery
32
When do you repair a uretero-vaginal prolapse?
Symptomatic - dyspareunia, discomfort, obstruction, bothersome Severe - outside vagina, ulcerated, failed conservative measures
33
How does an ovarian cyst present?
Presents with pain in the quadrant that the cyst is
34
What investigations should you do when someone presents with pain that could be an ovarian cyst?
Pregnancy test Bloods If in L lower quadrant then USS for appendicitis
35
Why do ovarian cysts cause pain?
○ Haemorrhage into cyst with sudden increase in size and/or rupture into peritoneal cavity with spillage of blood If twists blood supply reduced, can be intermittent initially as it untwists, can stop hurting if necrotic
36
What are the treatment options for ovarian cysts?
Remove ovary - reduced fertility, may subsequently have cyst on other ovary Remove cyst - spillage of dermoid contents may cause chemical peritonitis or at least untwist it with view to later surgery Do nothing for now - pain unresolved, risk of torted ovary becoming necrotic and dying
37
What surgery can be done for ovarian cysts?
Laparotomy - cystectomy most easily achieved successfully, more pain, prolonged hospital stay, longer recovery, more wound infections, greater risk of thrombosis Laparoscopy - less painful, shorter hospital stay, more difficult to shell out cyst and conserve ovarian tissue, longer procedure, increased risk of damage to major blood vessels and bowel
38
How common are miscarriages?
Occurs in 20% pregnancies
39
When is a miscarriage inevitable?
Once cervical os open enough to admit a finger
40
How can you diagnose a delayed miscarriage?
Ultrasound scan, empty gestation sac seen or foetal pole with no heart beat
41
How many early pregnancies complicated by vaginal bleeding will remain viable?
Approximately 60%
42
What management should you do when miscarriage incomplete and not associated with heavy bleeding or at early gestation < 8 weeks?
Expectant management
43
What is surgical treatment of miscarriage associated risks?
Uterine perforation
44
How quickly can medical management of delayed miscarriage be complete?
24 hours Depends upon size on scan if > 12 weeks size
45
How common are ectopic pregnancies?
Approx 1% pregnancies
46
What is the most common site of an ectopic pregnancy?
Fallopian tube most common site (85-90%) of which cornual (interstitial) are 10% then ovary, cervix, and abdomen
47
When should you consider an ectopic pregnancy?
When empty uterus found on USS in patient with positive pregnancy test
48
What is the risk of a ruptured ectopic pregnancy?
Death
49
What is the maternal mortality rate with ectopic pregnancies?
Maternal mortality rate 10.12 per 100,000
50
How can ectopic pregnancies be treated?
Fallopian tube doesn't need to be removed to remove ectopic pregnancy - salpingotomy - open fallopian tube and remove ectopic pregnancy, risk of incomplete removal so monitor hCG levels Can treat medically using methotrexate - Beta hCG level criteria (< 3000) - Satisfactory LFTs and U&Es - Needs to attend hospital for regular monitoring in pregnancy resolved
51
How common is vomiting in early pregnancy?
80%
52
What is hyperemesis gravidarum?
Excessive vomiting associated with dehydration and ketosis
53
In whom is hyperemesis gravidarum most common in?
Women with high beta hCG levels - such as twin pregnancies
54
How is hyperemesis gravidarum treated?
Rehydrate IV fluids Vitamin supplements NBM until oral fluids tolerated Small, frequent meals recommended once easting recommenced Anti-emetics
55
What is the menopause?
Cessation of menstruation Average age 51 Diagnosed at 12 month of amenorrhoea Onset of symptoms if hysterectomy
56
What is the perimenopause?
Period leading up to menopause Characterised by irregular periods and symptoms eg hot flushes, mood swings, urogenital atrophy Decreased oestrogen levels
57
What are the central effects of decreased oestrogen during the perimenopause?
Vasomotor symptoms - hot flushes, sweats MSK symptoms - joint and muscle pain Low mood and sexual difficulties - low sexual desire
58
What are the local effects of decreased oestrogen during the perimenopause?
Urogenital symptoms - vaginal dryness due to vaginal atrophy
59
What are the short term impacts of the menopause?
Vasomotor symptoms - Experienced by 60-80% women - Last on average 2-7 years - Impact on sleep, mood, and QoL General symptoms - Mood change/irritability - Loss of memory/concentration - Headaches, dry and itchy skin, joint pains - Loss of confidence, lack of energy
60
What are the medium term impacts of the menopause?
Urogenital atrophy - Dypareunia - Recurrent UTIs - PMB - Peak incidence of urinary incontinence and prolapse in 55-65
61
What are the long term impacts of the menopause?
Osteoporosis Cardiovascular disease- adverse changes in lipid Dementia - increased prevalence with early menopause Risk reduction strategies start at time of menopause
62
How can you manage menopausal symptoms?
Holistic approach Lifestyle advice Reduce modifiable risk factors Inform about options - Hormonal - HRT, vaginal oestrogens - Non-hormonal eg clonidine Non-pharmaceutical eg CBT
63
What are the benefits of HRT?
Relief of menopause symptoms Bone mineral density protection Possibly prevent long term morbidity
64
What are the risks of HRT?
Breast cancer VTE CVS disease Stroke
65
What is the breast cancer risk with HRT?
HRT with oestrogen alone - little or no change in risk HRT with oestrogen + progesterone - increased risk Increased risk related to treatment duration and reduces after stopping HRT
66
What is the risk of VTE with HRT?
Risk increased by oral HRT Oral > transdermal Transdermal = baseline population Transdermal - BMI > 30 or increased risk of VTE High risk women eg strong FH or thrombophilia refer to haematology for assessment before starting HRT
67
What is the risk of CVD with HRT?
HRT doesn't increased CVS risk when started in women < 60 Baseline risk of CVD varies according to existing risk factors Presence of CVS risk factors not CI to HRT as long as optimally managed
68
What is the risk of stroke with HRT?
Baseline population risk of stroke 11.3 per 1000 over 7.5 years Oral (not transdermal) increases this risk slightly
69
What dose of oestrogen should you give for HRT?
Aim for lowest effective dose
70
Who should have transdermal HRT?
Gastric upset eg Crohn's Need for steady absorption eg migraine/epilepsy Percieved increased risk of VTE Older women - higher risk of HRT Medical conditions eg hypertension Patient choice
71
What is premature ovarian insufficiency?
Menopause < 40 years
72
What can cause premature ovarian insufficiency?
Majority of causes - idiopathic Natural causes - Chromosome abnormalities - FSH receptor gene polymorphisms - Inhibin B mutations - Enzyme deficiencies - Autoimmune disease Iatrogenic - Surgery - Chemotherapy - Radiotherapy
73
How is premature ovarian insufficiency diagnosed?
FSH > 25 - 2 samples > 4 weeks apart + 4 months amenorrhoea
74
How is premature ovarian insufficiency treated?
Encouraged to use HRT at least until average age of menopause
75
What happens with conception and the menopause?
Fertile for 2 years if menopause < 50 Fertile for 1 year if menopause > 50
76
How do you assess someone's need for HRT?
Assess severity of symptoms Risk factors for osteoporosis
77
What are the CI to starting HRT?
Undiagnosed abnormal PV bleeding, breast lump, active liver disease
78
What are the cautions with HRT treatment?
Fibroids, uncontrolled BP, migraine, epilepsy, endometriosis, VTE family history Caution in starting HRT in over 60s
79
What are the most common gynaecological cancers?
Uterus and ovary
80
How common is endometrial cancer?
Incidence - 9000 cased UK/year and rising
81
What can increase your risk of endometrial cancer?
Obesity T2DM Nulliparity Late menopause Ovarian tumours Oestrogen only HRT Pelvis irradiation Tamoxifen PCOS
82
What signs might you get of endometrial cancer?
Post-menopausal bleeding
83
What investigations can you do for endometrial cancer?
Transvaginal USS Endometrial biopsy Hysteroscopy
84
What type of cancer is endometrial cancer?
Adenocarcinoma
85
What is the staging for endometrial cancer?
FIGO I/II/III/IV
86
What is the treatment for endometrial cancer?
Surgery - hysterectomy, bilateral salpingo-oophorectomy +/- pelvic lymph nodes Radiotherapy Progesterones
87
What is the prognosis of stage 1 endometrial cancer?
5 year survival for stage 1 disease > 90%
88
What can cause endometrial cancer?
HPV
89
How common is HPV?
75% population affected by HPV at some point if life pre-vaccination
90
Why does HPV cause endometrial cancer?
Regions E6 and 7 of HPV genome cause growth stimulation Persistent HPV infection associated with increased risk of high grade cervical intraepithelial neoplasia
91
How common is cervical cancer?
Incidence highest in 30-34 years Highest rates in areas of high deprivation Majority diagnosed at stage 1
92
What cell type is cervical cancer?
Squamous (90%)/adenocarcinoma
93
What is the cervical cancer staging?
FIGO I/II/III/IV
94
What is the prognosis for stage 1 cervical cancer?
Stage I > 90% 5 year survival
95
How is cervical cancer treated?
Stage 1 treatment - surgery Stages 2+ treatment - Radiotherapy - Chemotherapy - Palliative care
96
How common is vulval cancer?
Uncommon, 20th most common cancer in women
97
What can cause vulval cancer?
HPV/lichen sclerosis
98
What cell type is vulval cancer?
Squamous (90%)
99
What are the symptoms of vulval cancer?
Vulval itching Vulval soreness Persistent lump Bleeding Pain on passing urine Past history of VIN/lichen sclerosis
100
What are the stages of vulval cancer?
I < 2cm (79% 5 yr survival) II > 2cm (59% 5 yr survival) III adjacent organs/unilateral nodes (43% 5 yr survival) IV bilateral nodes/distant mets (13% 5 yr survival)
101
What is the treatment for vulval cancer?
Surgery - conservative Surgery - radical Radiotherapy +/- chemo
102
How does ovarian cancer present?
Bloating/IBS like symptoms Abdominal pain/discomfort Change in bowel habit Urinary frequency Bowel obstruction No symptoms at all
103
How common is ovarian cancer?
> 7000 cases UK/year Highest in 75-79 years > 6/10 women present with advanced disease
104
What can cause ovarian cancer?
Ovulation - menarche, menopause, parity, breast feeding, OCP, hysterectomy, ovulation induction Gene mutation - BRCA1/2
105
What is the prognosis of stage 3 ovarian cancer?
Stage 3 disease up to 40% 5 yr survival
106
What cell type is ovarian cancer?
Epithelial 85% - includes fallopian tube and primary peritoneal cancers
107
What investigations should you do for ovarian cancer?
Symptoms and age CA125 USS CT Image guided biopsy
108
What is the management for ovarian cancer?
Surgery Chemotherapy
109
What is endometriosis?
Presence of endometrial tissue outside the endometrial cavity Chronic condition High risk of recurrence Impact on fertility Impact on quality of life
110
What are the symptoms of endometriosis?
Cyclic pain Dysmenorrhoea Dyspareunia Young Low parity
111
How can you treat endometriosis?
Abolish cyclicity - OCP - GnRH agonists Glandular atrophy - Oral progestagens - Depot provera - Mirena
112
How do GnRH agonists work?
Inhibit stimulation of pituitary release of gonadotrophins - increased FSH and LH Followed by down regulation - decreased FSH and LH
113
What are the risks of GnRH agonists?
Prolonged treatment may be necessary HRT - add back therapy
114
How can you treat endometriosis with surgery?
Ablation - maintains fertility Excision - maintains fertility Oophorectomy - if fertility no longer desired Pelvic clearance - if fertility no longer desired
115
How can endometriosis cause infertility?
Immune factors Oocyte toxicity Adhesion Tubal dysfunction Ovarian dysfunction
116
How common are endometrial polyps?
15% malignant in post-menopausal women
117
What are raised nitrites in an MSU an indication of?
Infection
118
What are raised leukocyte esterases in an MSU an indication of?
Infection
119
What is microscopic haematuria in an MSU an indication of?
Glomerulonephritis Nephropathy Neoplasia Calculus Infection
120
What is proteinuria in an MSU an indication of?
Renal disease Cardiac disease
121
What is glucosuria in an MSU an indication of?
Diabetes IGT Nephropathy Reduced renal threshold
122
What can a frequency volume chart also be used for?
Bladder drill/bladder training
123
What is the lower end of normal for the amount of voided urine?
400ml
124
What is urodynamics and what is it used for?
Measuring intravesical (bladder) and intraabdominal pressures Helps to determine type of incontinence Can work out detrusor pressure
125
What determines bladder pressure?
Detrusor pressure and abdominal pressure
126
What is a cystogram?
Visualising continence Helps diagnose stress incontinence
127
Why can spinal cord damage cause incontinence?
T11 and 12 control over bladder reflex lost
128
How does botox treat incontinence?
Over active bladder Neurotoxin Blocks acetylcholine release - prevents muscle contraction
129
Where is the uterus in a 1st degree prolapse?
Uterus in upper half of vagina
130
Where is the uterus in a 2nd degree prolapse?
Uterus nearly descended into opening of vagina
131
Where is the uterus in a 3rd degree prolapse?
Uterus prolapsed out of vagina
132
Where is the uterus in a 4th degree prolapse?
Completely out of vagina
133
What are the 2 layers of the pelvic floor?
Levator ani - anterior muscles Coccygeus - posterior muscles
134
What are the 3 levator ani muscles?
Pubococcygeus Iliococcygeus Puborectalis - forms a sling around rectum
135
What is the nerve innervation of coccygeus?
S2-3
136
What is the role of coccygeus?
Resists intraabdominal pressure
137
Name 4 risk factors for getting a pelvic prolapse
Obesity Previous pelvic surgery Chronic constipation Vaginal or instrumental births Multiple pregnancies Larger babies Post-menopausal Hysterectomy Genetics - weak connective tissues
138
What is a threatened miscarriage?
Associated with vaginal bleeding with/without abdo pain

Women's health (9 decks)

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