Gynaecology Flashcards
(142 cards)
1
Q
When to consider OP follow up with endometriosis?
A
- Deep endometriosis, involving bowel, bladder or ureter
- Endometrioma >3cm
2
Q
When to refer to gynaecology and when to refer to specialist endo service
A
Gyane
- Initial treatment, not effective/tolerated/CI
- Symptoms having detrimental impact
- Persistent/recurrent symptoms.
- Pelvic signs, but deep Endo NOT suspected
Endo service
– endometrioma
– deep endo
– outside pelvis
3
Q
Deep infiltrating endometriosis definition
A
> 5mm below peritoneal/serosal surface
4
Q
GnRH use for endometriosis
A
2nd line treatment
Side effects and loss BMD
Required addback HRT
May worse sx initially
Triptorelin
Goserelin
Leuprorelin
5
Q
Danazol
A
Licenced for endometriosis but not used often
Synthetics steroid = hypoestrogenic and hyperandrogenic
Side effects
- deep voice
- Liver dysfunction
- hirsuitism, male pattern balding
- teratogenic
6
Q
Which surgical measures for endometriosis can Improve fertility outcomes?
A
Excision/ablation + adhesiolysis not involving bowel/bladder/ureters
Ovarian cystectomy + excision cyst wall/drainage (NB ovarian reserve)
7
Q
Hysterectomy for endometriosis
A
May be indicated with adenomyosis/HMB not responding to other tx
Excise visible deposits
+/- BSO (if >45)
8
Q
IOTA descriptors
A
- Cysts type: Unilocular, unilocular, solid, multilocular, multilocular, solid, solid
- Cyst contents: anechoic (black) = clear fluid, low-level, groundglass, haemorrhagic, mixed
- Solid materials/papillary structures (3 mm) or wall irregularities (3 mm)
- vascularity (1 - 4, 1=none, 4=strongly)
- shadow
- ascites
9
Q
Benign Ovarian cysts (6)
A
- Functional (follicular, CL, theca lutein, haemorrhagic)
- Endometrioma
- Mature cystic teratoma/dermoid
- Cystadenoma (serious/mucinous)
- Fibroma
- Thecoma
10
Q
Follicular cyst
A
- Dominant Follicle fails to erupt
- most common
- 3 to 5 cm
- Can secrete oestrogen (precocious puberty)
US: thinwall, unilocular, anechoic fluid
Sx: nil/pelvic pain if rupture
Mx: resolve 6 - 8 weeks
11
Q
Corpus luteum cyst
A
- Persistence of CL
- 3 - 5 cm
US: thick-wall, ring of Fire
Sx: nil/pain if rupture
Mx: usually resolve
12
Q
Theca lutein cyst
A
- Excessive hCG (molar, multiple preg, OHSS)
- > 8cm
- abdo pain/distension
Mx: treat underlying cause
13
Q
Haemorrhagic cyst
A
- bleeding into a functional cyst
- variable size
US: internal echo, fishnet pattern clot
Sx: acute pain if rupture
Mx: conservative, surgical and washout if needed
14
Q
Endometrioma
A
- chocolate cyst
US: Unilocular/multilocular, groundglass, no vascularity.
Sx: endometriosis, chronic pelvic pain
Mx: conservative, cystectomy, medical mx endo
15
Q
Dermoid cyst (mature cystic teratoma)
A
- Most common benign, ovarian neoplasm in young women.
- Contains all 3 germ-cell layers (ectoderm, mesoderm, endoderm
- fat, hair, teeth, cartilage
US: mixed echo, hypoechoic, shadowing, Rockatansky nodule, no int vascularity
Mx: conserv, >5cm risk of torsion
16
Q
Cystadenoma (serous / mucinous)
A
Serous
- ciliated columnar epithelium (Fallopain tube)
- fluid: clear/anechoic
- <10 cm
- thin wall, unilocular
- rarely —> serous cystadenocarcinoma/borlerline
Mucinous
- mucin producing columnar epithelium
- contents: thick/gelatinous
- >10 cm
- thin/thick walled, multiloc
- rarely —> mucinous cystadenocarcinoma/borderline
Both can = nil/pain/torsion
Management conserv/cystectomy
17
Q
Fibroma
A
Sex chord stromal tumour
Meig’s syndrome (Fibroma, ascites, pleural effusion)
DO NOT SECRETE HORMONE
Hyperechoic, well defined mass, posterior acoustic shadow
Mx depends on size
18
Q
Thecoma
A
- Rare sex cord stromal tumour
- From ovarian thecal cells —> oestrogen
- Can cause abnormal PV bleeding, PMB, endometrial hyperplasia
- Solid, well circumscribed, hypoechoic mass
Mx: surgery due to effects of oestrogen
19
Q
Serous carcinoma high grade
A
Most common Ovarian cancer (70%)
Arise from fallopian tube.
Highly aggressive, late presentation.
Histology = psammoma bodies, papillary, solid growth, marked nuclear atypia.
BRCA 1/2 mutation
MX debulking surgery and platinum based chemo
20
Q
Serous carcinoma low grade
A
Slow growing
Histo: mild nuclear atypia
Mx: surgery, Less responsive to chemo
21
Q
Endometrioid carcinoma
A
2nd most common
Associated with endometriosis in 15-20% cases
Ca125 raised
Sx: abnormal bleeding, pain.
Mx: surgery, platinum chemo
22
Q
Mucinous carcinoma
A
Rare
Often a 1’ GI tumours (Krukenberg) than ovarian 1’ and usually bilateral
Unilateral if 1’
Surgery and platinum chemo
23
Q
Clear cell carcinoma
A
5-10%
Highly aggressive
Associated w endometriosis 50%
Large clear calls with hobnail nuclei
24
Q
Brenner tumour
A
<1%
Rare and aggressive
From transitional epithelium
Nests of urothelial cells
25
Granulosa cell tumour
Most common stromal tumour
Adult (95%) or juvenile (5%)
Histo: call-exner body pattern
Secrete oestrogen - PMB, IMB, precocious puberty, breast tenderness
26
Sertoli-Leydig cell tumour
Androgen producing, high testosterone --> vitalisation
Histo: sertoli and Leydig cells
27
Dysgerminoma
Most common germ cell tumour
Histo: larger uniform cells
Raised LDH +/- hCG
28
Yolk sac tumour
2nd most common
Histo: Schiller-Duval bodies
Raised AFP
29
Immature teratoma
Malignant version dermoid
Large pelvic mass, risk of torsion
30
Embryonal carcinoma
Rare and aggressive
Can secrete oestrogen (AUB, amenorrhoea)
Histo: large sheets primitive cells
31
Choriocarcinoma
Raised hCG - amenorrhoea, +ve PT
Histo: trophoblastic + syncytiotrophblasts
Meta lung, liver, brain
32
IOTA simple rules
**Benign rules**
Unilocular
Largest Solid component < 7 mm
Acoustic shadows
Smooth, multilocular <10 cm
No blood flow
**Malignant Rules**
Irregular solid tumour
4+ papillary structures
Ascites
Irregular multilocular solid tumour >10 cm
Prominent blood flow
95% sensitivity, 91% specificity
33
RMI
RMI = U x M x Ca123
Ultrasound features, point for each: Multilocular, solid, metastases, ascites, bilateral lesions
U = 0 (US = 0)
U = 1 (US = 1)
U = 3 (US = 2+)
Menopause status:
1 = premenopausal
3 = postmenopausal
CA125
34
Definition of endometrial hyperplasia?
Irregular proliferation with increase in gland to stroma ratio (3:1) when compared with proliferative endometrium
35
Referral criteria to suspected cancer for PMB (not on HRT)?
1. >55 + PMB = 2WW
2. <55 + PMB consider referral
36
Endometrial cancer: Direct access referral for TVUSS for patients over 55?
Consider if >55 with:
1. Unexplained PV discharge, thrombocytopenia or haematuria
2. Visible haematuria with low Hb, thrombocytopenia or high blood glucose
37
Classification of endometrial cancer
Type 1 common
Estrogen dependent
Low-grade, min invasive
E.g. low-grade endometrioid cancer
Type 2 rare
Non estrogen dependent
High grade, myometrial invasion
Aggressive plus maths
E.g. serous carcinoma/clear cell carcinoma
Mixed type 1+2
Mixed/undifferentiated
38
20 year risk of progression to cancer: endometrial hyperplasia without atypia and for atypical endometrial hyperplasia
Without atypia: <5%
Atypical: 25%
39
Factors for endometrial hyperplasia pleasures (5)
1. Raised BMI (excessive peripheral conversion androgens to estrogen)
2. Anovulation (menopause, PCOS)
3. Oestrogen secreting tumours (granulosa cell)
4. HRT (unopposed estrogen)
5. Tamoxifen long-term
40
Management of hyperplasia without atypia
- majority regress spontaneously
- manage RF: BMI, HRT, tamoxifen
- conservative or progesterone
- if conservative mx fails for progesterone
- TVUSS if not already done
**Treatment**
1st line IUS
2nd line MPA 10-20mg/day, NET 10-15mg/day for 6/12
Review + biopsy at 6/12
X2 6/12 reviews with normal biopsy —> discharge or
If high risk (BMI or on PO progesterone) then annual review
If hyperplasia persists 12 months = increased risk of ca and reduced chance of regression -> hysterectomy ( + BSO if PM)
41
Management of atypical hyperplasia
- total hysterectomy (+BSO if PM)
- preserve fertility/surgery CI
Rule our endo/ovarian ca
IUS (PO prpgesteone 2nd line)
- r/v 3/12, once 2 normal samples can go to 6-12 monthly f/u
42
Gynaecology cancers HRT CI
Low
43
Primary amenorrhoea
No periods by 15 in presence of normal secondary sexual characteristics
Or 13 in absence of any secondary sexual characteristics
No periods within 3 years of thelarche and 5 years (if breast budding before 10)
44
Secondary amenorrhoea
No periods 6/12 after prev regular periods
Or 12 months if oligomenorrhoea (<6/52 bleeds)
45
Stages of puberty
1. Adrenarche androgens from adrenals = acne, body odour (independent HPG)
2. Thelarche breast budding from rose in oestrogen (aged 10)
3. Pubarche pubic and axillary hair
Adrenal androgens, Independent HPO
4. Menarche endometrium responded to oestrogen (12-13 years)
46
Precocious puberty
Onset of secondary sexual characteristics <8 in girls <9 in boys
47
Delayed puberty definition
No beast development by 13 or no period by 15 in presence of normal pubertal signs
48
Central causes precocious puberty?
Gonadtrophin dependent
Premature activation HPG axis
74% idiopathic
CNS pathology - tumours, congenital, acquired
GnRH simulation test = increased LH:FSH ratio in CPP
A normal result in pre-puberty = FSH predominates
LH predominates because the body is entering puberty early — and the HPG axis behaves like it would during normal puberty, with a characteristic LH-dominant response to GnRH stimulation.
49
Peripheral causes of precocious puberty?
**Ovarian**: oestrogen (granulos, functional cysts) or androgen secreting (sertoli-leydig cell tumour)
**Adrenal**: CAH, cushionings, adrenal tumours
**McCune-Albright syndrome**: cafe-au-lait spots, fibrous dysplasia bone,endocrine hyperfunction
**Severe hypothyroid**: high TSH can cross react with FSH receptors = androgen secretion
50
Delayed puberty causes
Constitutional delay
Hypogonadotrophic hypogonadism
Low FSH/LH
- functional: stress, low weight
- endocrine: hyperprolactinaemia, hypothyroidism
- structural/congenital: kallman syndrome, pituitary damage
Hypergonadoteophic hypogonadism
High FSH/LH
- turners
- Gonadol dysgenesis
51
XY embryology
Y = SRY gene (triggers testes development)
Sertoli cells -> AMH (regression Müllerian ducts)
Leydig cells -> testosterone -> Wolffian duct maturation
52
XX embryology
No SRY gene, AMH or testosterone
Müllerian ducts persist
Wollfian regress
No DHT
External genitalia develop
53
Mullerian agenesis or MKAH (Mayer-Rokitansky-Küster-Hauser) syndrome
46XX ovaries present
Autosomal dominant
Absent of uterus and upper vagina
May have rudimentary uterine tissue
Absent or short vagina
Normal 2’ sexual characteristics
Vaginal dilators
54
Cause of unicornuate uterus?
Failure of formation of one of the Müllerian ducts
Hemi -uterus
May have contralateral uterine horn, which may contain endometrial tissue and may or may not be connected
55
Failure of fusion of Müllerian ducts can lead to:
- uterus didelphys (2 uteri, often 2 cervices)
- bicornuate uterus (partial fusion with two horns)
- longitudinal vaginal septum (incomplete fusion of vaginal canal)
56
Failure of reabsorption of wall between ducts can lead to?
- Septate uterus (internal wall remains dividing uterus)
- Transverse septum between vaginal plate and Müllerian structures
57
Kallmann’s syndrome
Hypogonadotrophic hypogonadism
Congenital absence GnRH neurons
Anosmia
Colour blind
58
PALM COEIN
Polyp
Adenomysosi
Leiomyoma
Malignancy/hyperplasia
Coagulopathy
Ovulation dysfunction
Endometrial
Iatrogenic
Not yet classified
59
Kallmann syndrome
1:50,000
Failure of migration of olfactory and GnRH neurons
Hypogonadotrophic hypogonadism
Delayed puberty
Amenorrhoea
Anosmia
Unilateral renal agenesis
Abnormal bones in fingers
Colour blind
Infertility
60
Turner syndrome 45XO
High FSH and LH
hypergonadotropism hypergonadism
Short
Streak like gonads
Wide nipples
Short webbed neck
Rotation/horseshoe kidney
Coarction of aorta
61
Androgen insensitivity syndrome
46XY
Defective androgen receptors (can’t sense testosterone)
Feminised genitalia, short vagina
Female phenotype (due to aromatisation of testosterone to oestrogen)
1’ amenorrhoea, talk stature, sparse public hair
Testes fail to make sperm but maintain testosterone and AMH leads to regression of internal Müllerian structures
Removal gonads post puberty due to risk of malignancy
62
Management of prolactinomas
Cabergoline (more effective than bromocriptine and has less SE)
Medical unless surgery indicated
(Fail med mx, expanding with progressive neuro deficits)
63
PCOS
Raised LH:FSH ratio due to anovulation and no progesterone, which increases GnRH pulses, impaired folliculogenesis
Normal levels oestrogen (which is unopposed due to anovulatory cycles)
Insulin resistance = low SHBG = high androgens
Hyperinsulinaemia = Thea cells —> ovarian androgens
Rotterdam criteria
1. Oligo/amenorrhoea
2. Clinical/biochem hyperandrogenism
3. PCO >20 follicles/ovary or >10ml
64
PCOS management
COC
Weight loss/healthy
Reduce risk of T2DN and CVD
Check for OSA
If oligo/amenorrhoea
- if <1 period per 3 months, abnormal bleeding or excessive weight…cyclical progestogens e.g. MPA 10mg for 14 days to induce withdrawal bleed every 1-3 months
? Metformin also
- check endo thickness
If >10 for biopsy
If normal then cyclical progestogens every 3/12, low dose COC or IUS
- fertility: clomifine, gonadotrophins, IVF (increased risk OHSS) 
65
Causes of hyperandrogenism
PCOS
CAH
Cushing’s syndrome
Androgen secreting tumours (adrenal/ovarian origin)
Exogenous androgen
66
PMS/PMDD
Repetitive cyclical cycles in luteal phase
PMDD more severe, at least 1 affective symptom e.g. anger/ ability
Symptoms must remit post menses.
High risk in menopause
**Diagnosis:**
Symptom diary for 2 cycles
GnRH analogues for 3/13 to confirm
**Management**
1st line
- exercise, CBT
- DRSP COC cont or cyclical (Yaz)
- low dose SSRI (luteal or cont)
E.g. 10 mg citalopram
2nd line
- TD estradiol + micronised progesterone day 17-28 or IUS
- higher dose SSRI
3rd line
- GnRH analogues + add back ccHRT or tibolone
- surgical hysterectomy + BSO
67
Embryology week 1
Fertilisation (usually in ampulla)
Cleavage
Compaction
Morula
Blastocyst (inner cell mass -> embryonic tissue, outer trophectoderm -> placenta)
Implantation
68
Gastrulation day 14-16
Formation of 3 germ cell layers:
1. Ectoderm (skin, CNS, pituitary)
2.Mesoderm (MSK, CVS, reproductive system)
3. Endoderm (epithelial layers, lungs, GI, bladder, thyroid)
69
Neural tube closure
Day 25-28
70
What HCG level is pregnancy visible on USS?
1000-1500 IU/L
71
Miscarriage diagnosis using CRL
CRL <7mm + no FH, repeat scan in 7 days
CRL >7mm + no FH, seek 2nd opinion/repeat in 7 days
On TA scan: if CRL >7mm + no FH, re scan in 14 days
72
Miscarriage diagnosis using MSD
TV:
MSD >25mm + no fetal pole, confirm with 2nd opinion or rescan in 7 day
TA:
MSD >25mm + no fetal pole, re scan in 14 days to confirm
If MSD <25mm re scan in 7 days, if no growth then can confirm diagnosis
73
When to offer progesterone in threatened miscarriage?
PV bleeding with normally sited IUP confirmed on US and previous hx of miscarriage
400mg micronised progesterone PV BD
Continue till 16 weeks gestation
74
Miscarriage management 1st line
1st line: expectant 7-14 days then review, if hx suggested of passing, then PT in 3 weeks and return if +ve
Exclusion:
- Increased risk bleeding (late 1st trimester) if medically vulnerable to haemorrhage
- prev adverse experience/not acceptable
- infection
75
Miscarriage - medical management of miscarriage and incomplete miscarriage
Medical mx if conservative failed or not acceptable
Mifepristone 200mg PO
48’ later misoprostol 800mg PV/PO/buccal
Incomplete miscarriage = 600-800mg misoprostol only
PT at 3 weeks old
76
Surgical management miscarriage
MVA with LA if:
<12 weeks
No signs infection
Cervix accessible
No CI to LA
ERPC
- increased bleeding risk
- structural abnormalities
- difficult cervix access
- later gestations
250 IU Anti D only for Rh -ve and surgical management a
77
Recurrent miscarriage investigations
3+ 1st trimester miscarriages
Acquired thrombophilia, lupus anticoagulant and anticardiolipin antibodies
Cytogenetic analysis of POC
Parental blood karyotyping
Congenital uterine anomalies
TFT
Thyroid peroxidase antibodies
Life style advice
BMI
Smoking/alcohol
Caffeine <200 mg/day
78
Ectopic pregnancy management, when can expectant be used
**Expectant if:**
- Stable and pain free
- <35mm and no FH
- HCG failing <1500
- able to return for f/u
HCG on days 2, 4 and 7:
If drops by >15% repeat weekly till <20 IU/L
If not or increasing, then review
79
PUL management
48’ HCG (don’t use progesterone
>50% drop - prob miscarriage, PT 2 weeks after 2nd HCG (if +ve return within 24’)
<50% drop - < 63% rise ? Ectopic, review within 24’
>63% rise - probably IUP, repeat TVUS in 7-14 days (consider sooner if HCG >1500)
80
Ectopic pregnancy medical management
**Offer methotrexate F:**
- No significant pain
- No evidence of rupture
- <35mm and no FH
- HCG <1500
- No IUP
- Able to return for F/U
If HCG 1500-5000 can have medical or surgical but increased risk of rupture with medical
81
Methotrexate
- Competitive inhibitor of dihydrofolate reductions
- Dose 50 mg/m² use patient’s body surface area.
CI: infection, ascites, immuno deficiency, plural effusion
Avoid pregnancy for 3 months
82
Ectopic pregnancy conservative management
Offer if:
- stable and pain free
- ectopic <35mm and no FH
- hCG <1000 and falling
- able to return for f/u
Repeat hCG day 2, 4 and 7
If dropping by >15% then repeat weekly till <20
Can consider if hCG 1000-1509
83
Ectopic pregnancy medical management
Methotrexate if:
- no significant pain
- no evidence of rupture
- mass <35mn and no FH
- HCG <1500
- no evidence of IUP
- able to return f/u
If hCG 1500-5000
Can consider MTX but increase risk of rupture
AntiD for all Rh-ve h
Check hCG day 4 and 7, then weekly till negative
84
Ectopic pregnancy surgical management
Indicated:
- signif pain
- mass >35
- FH present
- hCG >5000
Salpingectomy unless RF for infertility (contralateral tube damage, PID, prev ectopic) when salpingotomy can be offered
Salpingotomy: 1/5 risk need further tx. Needs hCG at 7 days, weekly till negative
F/u PT at 3 weeks
Anti D for all Rh-ve h
85
Methotrexate for ectopic
Competitive inhibitor of dihydrofolate reductase
50mg/m2 using pt body surface area
CI in: infection, ascites, pleural effusion, immunodeficient
Caution: bone marrow suppression, GI toxicity, photosensitive, liver toxicity
Avoid conception 3/12
86
Gestational trophoblastic disease incidence in population, <15 and >50
General 1 in 714
<15 1 in 500
>50 1 in 6
Increased incidence in Asian
87
Presentation of GTD?
USS
PV bleeding (60%)
Hyperemesis
Excessive uterine enlargement
Hypothyroidism
Early onset pre-eclampsia
Haemoptypsis/seizure (mets lung/brain)
Abdo distension from theca Lutein cysts
88
Complete molar pregnancy
- diploid and androgenic origin
- No Fetal parts
– 75 to 80% due to duplication of single sperm and empty ovum
- 20 to 25% dispermic fertilisation empty ovum
89
Partial molar pregnancy
90% triploid (69XXX/69XXY)
Dispermic fertilisation of ovum
Usually fetid/fetal blood cells
Not all triploid/tetraploid pregs are molar
Diagnosis must show histo evidence of trophoblastic hyperplasia
90
Risk of GTN after complete molar pregnancy?
20%
91
Risk of GTN after partial molar pregnancy?
1%
92
93
Which type of molar pregnancy retains p57 immunohistochemistry?
Partial
94
Histology of complete molar pregnancy?
Absent fetal tissue
Extensive hydropic change to villi
Excessive trophoblastic proliferation
95
Histology for partial molar pregnancy?
Fetal tissue
Focal hydropic change to villi
Some excessive trophoblastic proliferation
96
Is anti-D required for complete molar pregnancy?
No
But histology may take three days to return so best to give to Rh -ve
97
Follow-up for complete molar pregnancy?
Once normal HCG (after 56 days) follow-up for a further 6/12 after treatment
Otherwise for 6/12 after 1st normal HCG
98
Follow-up for partial molar pregnancy?
Concluded once times two HCG levels four weeks apart
99
Risk of repeat molar pregnancy?
1%
100
Amniocentesis
1% risk of miscarriage.
Done at 15+0
– Edward syndrome
– Downs syndrome
– Patau’s syndrome
– CF
– muscular test
– sickle cell disease
– thalassaemia
101
Chorionic villus sampling
Downs, Edwards, Pataus
1% risk of miscarriage
Done at 11+0 and 13+6
102
Zika virus
South & central America,
Caribbean,
Pacific Islands,
Africa and Asia
Female, avoid TTC for 2 months
Male avoid TTC for 3 months
103
For how long should women on anti-epileptic drugs take folic acid for?
Which other chronic conditions requires high dose for acid?
5mg till 12th week
Diabetes and IBD also till 12th week
sickle cell, thalassaemia, thalassaemia trait THROUGHOUT pregnancy
104
Which AED should be used with highly effective contraception due to risk of cleft lip and pallet?
Topiramate
Carbamazepine
105
HTN associated pregnancy risks?
– Pre-eclampsia
– abruption
– IUGR
– PTB
– Fetal loss
ACE inhibitors and Angiotensin II receptor blockers = increased risk congenital abnormalities
As do thiazide and thiazide like diuretics
106
What should women on warfarin or oral anticoagulation do in pregnancy
Switch to LMWH asap, ideally within 2 weeks of missed period and before 6/40
107
Use of tetracycline in pregnancy
Not known to harm baby
Avoid after 13/40 as discolouration of teeth 
108
SSRIs in pregnancy
(Fluoxetine, citalopram, sertraline fluoxetine, paroxetine))
Possible increase risk of PTB, low birth weight, PPH
Hospital delivery to monitor Baby for withdrawal symptoms and persistent pulmonary hypertension of the newborn (PPHN)
Possible increased risk: autism, cognitive function and motor skills
109
Which AED generally not prescribed to women of childbearing age due to teratogenicity, requires pregnancy prevention strategy and LARC
Sodium valporate
110
LUTS storage symptoms
Frequency
Urgency
Nocturia
Stress incontinence (coughing, no urgency, small amounts)
Urge incontinence (urge, OAB)
Mixed incontinence
111
LUTS voiding symptoms
Slow
Intermittent
Hesitancy
Terminal dribble
Strain
112
LUTS post micturition symptoms
Incomplete emptying
Post micturition dribbling
113
Most common type of urinary incontinence
Stress incontinence most in common.
Followed by mixed.
Then urge incontinence
Overall prevalence UI is 13 - 35%
Prevalence of LUTS sx 39 - 67%
114
Overactive bladder syndrome
**Urgency**
+/- urge incontinence
Usually frequency & nocturia
No infection/pathology
Prevalence 13 to 16% (1/3 have leakage)
115
Stress incontinence pathophysiology
1. Loss of suburethral support (from anterior vaginal wall, damage at birth)
2. Intrinsic sphincter deficiency (denervation)
Can be combo of both
116
Urodynamic stress incontinence
Involuntary leakage
Change in bladder and abdominal pressure, but not detrusor pressure/contraction = stress incontinence
Pdet = Pves - Pabd
117
Cystometry: over activity detrusor
Peaks in bladder pressure due to peaks in detrusor pressure, no change in abdominal pressure = overactive detrusor
Diagnosis by urodynamics only
118
Desmopressin
For nocturia
Acts on renal collecting ducts and reduces UO.
Monitor you and ease at 1 week, 4 weeks and 6 months risk of low Na+
Care in elderly
119
Conservative and medical management for OAB
**conservative**
Bladder retraining
Fluid intake 1.5 to 2L / day
Avoid caffeine/alcohol
Weight loss
Review Medication
Pelvic floor and top estrogen may help
**Antimuscarinics (anticholinergics)**
Oxybutynin, solifenacin, tolterodine
Side-effects: dry mouth, blood vision, constipation, drowsiness
**Mirabegron**
Selective agonist of beta3 adrenoreveptor
**Desmopressin**
Nocturia
Monitor U&Es week 1, 4 and 6/12
Caution in elderly, monitor for low Na+
120
medical treatment for stress incontinence
Duloxetine SNRI (selective nor adrenaline re-uptake inhibitor)
Main s/e is nausea
121
Conservative treatment for POP
**Lifestyle**
– Weight loss BMI greater than 30
– minimise heavy lifting
– prevent/TX constipation
** tropical Oestrogen**
– If signs of atrophy
– consider ring if impairment makes application difficult
** pelvic floor training**
Supervised
16 weeks 
1st line is stage 1 or 2
**pessaries**
Alone or with physio
Change 6/12
Some can use with sex
122
Cancer pathway for urology
>45 visible haematuria no infection/after tx
>60 non visible haematuria + dysuria or raised WCC
123
When to use cystometry?
Aim: dx pathology and guide surgical tx
** not necessary prior to surgery for pure stress incontinence**
– Urge predominant mixed UI or unclear UI type
– Sx of voiding dysfunction
– anterior or apical prolapse
– history of previous surgery for SUI
124
Urine dip for UTI
If <65 and no RF for complicated UTI and not catheterised
**nitrites/leuk AND RBC = UTI likely**
(Only send culture if resistance/previous treatment failed)
**-ve nitrites +ve leuk = equally likely other dx**
(send culture)
**-ve for all** = UTI unlikely
(don’t send culture)
125
UTI treatment
**Standard**
Nitro 100mg BD 3/7 (if eGFR>45)
Trimeth 200mg BD 3/7
**Recurrent**
x2 in 6/12 or x3 in 12 months
Topical oestrogen
Stat dose of above if trigger identified
2nd line: amox, cefalexin
No identified triggers: nightly trimethoprim 100mg or 50mg nitro
**pregnancy**
Nitro 100mg BD 7 days (avoid at term)
2nd line: 7/7 amoxicillin 500mg TDS or cefalexin 500mg BD
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Prediction of IVF success
Maternal age
Falls with each failed cycle
Prev pregnancy/birth increases change if success
BMI 19-30 ideally before IVF
>1 unit alcohol/day
Smoking
Caffeine
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High risk HPV strains
16, 18, 31, 33, 45, 52, 58
(6 & 11 for warts)
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HPV vaccine
Guardrail 9
Children 12-13 (x1 dose)
MSM <45 (x 2 doses, 6 months - 2 years apart)
HIV and immunocompromised (3 doses 0, 1-2, 6 months)
Catch up <25s
<15 1 dose
15-25 2 doses (at least 6/12 apart)
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CIN 1-3 histology
CIN 1 changes in basal 1/3 epithelium
CIN 2 changed in basal 2/3 & marked atypia
CIN entire epithelium
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Management of CIN 1
Observe, usually abnormal regresses (90% within two years)
11% –> CIN3
1 % –> invasive cancer
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Management CIN 2/3
LLETZ/cone biopsy
TOC smear at 6/12
(if -ve retest in 3 years, if -ve then back to usual times)
(if +ve to colposcopy)
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If +ve for hrHPv but cytology normal?
Recall in 12 months
If still HPV +ve normal cytology, recall 12 months
If still +ve normal cytology then —> colposcopy
Or of inadequate samples/abnormal
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Low and high grade cytology 
Nuclear:cytoplasmic ratio
Low-grade – <50%
High grade moderate – 50 - 75%.
High grade severe – >75%
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Breast cancer screening
All of UK: Age 50-70
Every 3 years
**High risk:**
- Li-Fraumeni TP53 mutation - annual MRI from 20 (no mammogram < 30 due to radiation sensitivity)
- BRCA 1&2 annual MRI from 30 then mammogram from 40
- FHx annual from 30/40s
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Bowel cancer screening
4th most common cancer in UK
FIT kit (Fetal immunochemical test detect microscopic blood)
Every 2 years
England: 54 to 74
Wales & Scotland: 50 to 74
N Ireland: 60 to 74
Reduces risk of dying from bowel cancer by 25%.
**High risk**
**FAP** Familia adenomatous polyposis, 100% cancer risk - annual colonoscopy
**HNPCC/Lynch syndrome**: 80% lifetime risk. colonoscopy every 2 years from 25 to 75  risk of endometrial and ovarian cancers
IBD 7% risk after 30 years - colonoscopy 10 years after dx.
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Prostate screening
Ni screening program
Most common male cancer
PSA made by normal and cancerous cells, not specific
Can be raised by UTI, BPH, exercise
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Inadequate samples (HPV or cytology)
Must be repeated within 3/12
2 consecutive HPV results unavailable or inadequate cytology —> colposcopy
If normal f/u in 12 months, if normal —> routine
If inadequate, repeat screen and colp in 12 months, if normal —> routine
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Additional cervical screening for which patients?
- HIV positive (annual screening)
- End stage renal disease (at Dx)
Colonoscopy
- Renal transplant (within 1 year of transplant)
- starting cytotoxic rheum drugs (screen start of treatment)
- DES (diethylstilbestol) exposure 1938-1971
Daughters at increased risk of clear cell cancer cervix/vagina
- if stigmata (abnormal) then annual colposcopy from menarche or aged 18 cont indefinitely, otherwise usual screen
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Cervical screening
25-49 3 years
50-64 5 years
>65 if abnormal smear in last 3 years OR never had OR last one was 50 or less
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HPV +ve
Colposcopy normal
Next steps
Repeat smear in 3 years even if on 5 year recall
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Screening after LLETZ
Smear 6/12
Negative HPV - back to 3 year
Positive back to colposcopy
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Rate of SCC progression from:
Low grade SIL
High grade SIL
Differentiated VIN
SIL = squamous intraepithial lesion (prev aka VIN)
Low grade SIL —> no malignant potential
High grade SIL —> 10% (HPV related NB 16)
Differentiated VIN —> 50% (dermatoses related, not HPV)
High grade SIL mx: surgical/laser/imiquimod
High grade SIL and diff VIN f/u 6/12 for 2 years then annual
