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General Practice YR3 > Men and Womens Health > Flashcards

Men and Womens Health Flashcards

1
Q

Symptoms and signs suggestive of gynae cancer

A
  • Abnormal cervix appearance
  • Blood glucose level high + visible haematuria in women over 55 and +
  • Hb low + visible haematuria in women 55 and +
  • Post menopausal bleeding in all women
  • Thrombocytosis + visible haematuria or vaginal discharge in 55 and +
  • Appetite loss/early satiety in 50 and +
  • Unexplained vaginal discharge
  • Abdominal distension (esp in 50 and
  • Ascites
  • IBS 50 and +
  • Abdo/pelvic mass
  • Change in bowel habit
  • Fatigue
  • Urinary urgency/frequency, persistent esp women 50 and +
  • Weight loss
  • CA125
  • Vulval lump/bleeding
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2
Q

Causes of post coital bleeding

A
  • Infection
  • Cervical ectropion - esp in COCP users
  • Cervical/endometrial polyps
  • Vaginal cancer
  • Cervical cancer
  • Trauma/sexual abuse
  • Vaginal atrophic change
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3
Q

Causes of intermenstrual bleeding

A
  • Pregnancy - inc ectopic and gestational trophoblastic disease
  • Physiological
  • Vaginal - adenosis, vaginitis, tumours
  • Cervical - cancer, polyps, infection (C&G), ectropion,
  • Uterine - fibroids, polyps, cancer, adenomyosis, endometritis
  • Oestrogen secreting ovarian cancers
  • Iatrogenic - tamoxifen, smear/cervix treatment, missed OCP, drugs affecting clotting, St Johns wort + COCP
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4
Q

Management of menorrhagia

A
  • 1st line is Levonogestrel IUS
  • Can use tranexamic acid and NSAID such as mefanamic acid
  • May need USS for fibroids if suspected
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5
Q

When is primary dysmenorrhoea likely?

A
  • Menstrual pain begins 6-12 months after menarche - cycles are then regulary
  • Pain cramping, lower abdo, may radiate to back or thighs
  • Starts shortly before menses and lasts up tp 72hrs improving as menses progressses
  • Other symptoms eg N+V, emotional, bloating, headache are present
  • Other gynae symptoms not present
  • Pelvic exam normal
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6
Q

When is secondary dysmenorrhoea likely?

A
  • Pain starts after years of painless periods
  • Pain may persist after menstruation ends or throughout cycle but worse when menstruates
  • Other gynae symptoms eg dysparaunia, vaginal discharge, menorrhagia IMB, PCB
  • Non-gynae eg rectal pain and bleeding can be present
  • Pelvic exam abnormal (although normal cannot exclude this diagnosis)
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7
Q

Secondary causes of dysmenorrhoea

A
  • Endometriosis
  • Adenomyosis
  • Fibroids
  • PID
  • Ectopic pregnancy
  • Ovarian/cervical cancer
  • IUD insertion
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8
Q

Cause menorrhagia

A
  • No cause - dysfunctional uterine bleeding
  • Uterine fibroids
  • Polyps
  • Adenomyosis
  • IUD
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9
Q

Management primary dysmenorrhoea

A
  • Offer NSAID
  • If NSAID contraindicated/not tolerated - paracetamol
  • If not wish to conceive - hormonal contraceptive trial for 3-6months eg COCP, Depot, implant or IUS
  • Can combine this with NSAID or para
  • Non-pharm - heat eg hot water bottle, transcutaenous electrical nerve stimulation
  • Refer if no improvement 3-6 months
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10
Q

Management secondary dysmenorrhoea - red flags

A
  • Refer urgently if
  • Positive pregnancy test with pelvic pain and vaginal bleeding
  • Ascites +/- abdominal mass
  • Abnormal cervix
  • Persistent IMB/PCB with features of PID
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11
Q

What is primary amenorrhoea?

A
  • No menses have commenced at the age of 14 if no secondary sexual characteristics (but 16 if development is normal)
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12
Q

What is secondary amenorrhoea?

A
  • Menses commenced but have no stopped
  • For at least 6 months when menses were regular (longer if infrequent)
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13
Q

Cause of primary amenorrhoea if secondary sexual characteristics are present

A
  • Constitutional delay
  • GU malformation - imperforate hymen, transverse vaginal septum, absence of uterus/vagina
  • Androgen resistance syndrome (testicular feminisation) - XY
  • Hyperprolactinaemia
  • Pregnancy
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14
Q

Causes of primary amenorrhoea if no secondary sexual characteristics

A
  • Ovarian failure - chemo, radiation, chromosomal gonad abnormality
  • Hypothalamic failure - anorexia nervosa, stress, excessive exercise, chronic illness, obesity
  • CAH - causes precocious puberty
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15
Q

Cause of secondary amenorrhoea - no signs androgen excess

A
  • Pregnancy, lactation, menopause
  • Premature ovarian failure
  • Depot/impant
  • Weight loss
  • Hyperprolactinaemia
  • Hypothalamic dysfunction
  • Thyroid disease
  • Post pill amenorrhoea - should resolve within 3 months
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16
Q

Causes of secondary amenorrhoea with signs of andorgen excess

A
  • PCOS
  • Cushing syndrome
  • Late onset CAH
  • Adrenal or ovarian carcinoma - these can produce androgens
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17
Q

Investigations for amenorrhoea

A
  • Pregnancy test
  • Gonadotrophins eg FSH, LH
  • Prolactin
  • Total testosterone and sex hormone binding globulin, oestradiol
  • TFTs
  • Pelvic USS
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18
Q

Managing amenorrhoea

A
  • May need referral to fertility clinic in future
  • Contraception if do not wish for pregnancy
  • TREAT UNDERLYING CAUSE EG:
  • HRT for premature ovarian failure (under 40, have until 50)
  • Monitor Vit D and calcium for bone protection
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19
Q

Investigations for dysmenorrhoea

A
  • Abdominal exam
  • Pelvic exam

Consider:
* USS - fibroids
* High vaginal and endocervical swabs if risk STI
* Pregnancy test - exclude ectopic

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20
Q

Investigations menorrhagia

A
  • FBC for all
  • Pelvic USS for larger fibroids
  • Routine Transvaginal US for suspected adenomyosis OR if gynae symptoms
  • Consider referal hysteroscopy if history suggests fibroids, polyps or endometrial pathology
  • Endometrial biopsy may be done at this time
21
Q

Symptoms at menopause/perimenopause period

A
  • Change to menstrual pattern
  • Hot flushes/night sweats
  • Cognitive impairemnt and mood disorders
  • Urogenital symptoms - vulvovaginal irritation, dysparaunia etc
  • Altered sexual function
  • Sleep disturbance
  • Other - joint.muscle pain, headache, fatigue
22
Q

When to consider FSH for menopause diagnosis (not usually used)

A

As long as they are not on COCP or high dose progesterone and:
* Patients over 45 with atypical symptoms
* Patients from 40-45 with menopause symptoms inc change to cycle
* Patients younger than 40 whom premature menopause is suspected

23
Q

What do flow volume charts or bladder diarys detect?

A
  • Frequency - within 24hrs should be around 5-8x
  • Polyuria - up to 3L in 24hrs is normal
  • Nocturia
  • Nocturnal polyuria - passing more than 35% of total urine output in 24hrs at night
24
Q

How are LUTS dividided?

A
  • Storage
  • Voiding
  • Post micturition
25
Q

Causes of LUTS

A
  • UTI
  • Menopause
  • Urge/stress/functional incontinence
  • Diabetes
  • Bladder stones
  • Bladder cancer
  • Neurological causes eg MS
  • Medication - eg antidepressants, diuretics, lithium
26
Q

Common tests performed when LUTS present

A
  • Urine dip
  • Send urine off to hopsital to confirm dipstick findings
  • HbA1C for diabetes

May have USS or urodynamic testing if needed

27
Q

Managing LUTS

A
  • Decrease fluid intake if high intake - but avoid drinking too little
  • Reduce caffeine
  • Lose weight if overweight
  • Stop smoking
  • Try bladder training for urge incont
  • Pelvic floor exercises for stress incont
  • Continence clinics
28
Q

Medication for LUTS

A
  • Urge - oxybutynin, solifenacin and tolterodine (antimuscarinics)
  • HRT if menopausal symptoms
  • Surgery
29
Q

Options for stress incont

A
  • Pelvic floor muscle training - at least 3 months of supervised
  • If conservative management fails - can have surgery eg colposuspension, autologous rectus fascial sling, retropubic mid urethral mesh sling, intramural urethral bulking agents
  • If not suitable for surgery or opts not to, offer Duloxetine
30
Q

Managing urge incontinence specifically

A
  • Bladder training for at least 6 weeks
  • Offer antimuscarinic if persists (eg oxybutynin, tolterodine)
  • Explain side effects (eg dry mouth, constipation) and may take while to take effect (at least 4 weeks)
  • review in 4 weeks time (earlier if not tolerating)
31
Q

When to refer LUTS on 2WW?

A

2WW cancer pathway if:
Aged 45 and over with:
* Unexplained visible haemtauria without UTI
* OR visible haematuria persistent or recurrent after UTI successful treatment
* OR over 60 with unexplained non-visible haematuria and dysuria or raised WCC on blood test

32
Q

What to refer LUTS routinely?

A
  • Palpable bladder
  • Voiding difficulty
  • Pelvic mass clinically benign
  • Associated faecal incontinence
  • Suspected neurological disease
  • History previous incontinence surgery, pelvic cancer surgery or raditation therapy
  • Recurrent UTI
  • Suspected urogenital fistulae
33
Q

Investigations for males with LUTS

A
  • Frequency volume chart
  • International Prostate Symptom score (IPSS)
  • Dipstick urine
  • PSA if indicated (+DRE) - cautious with interpreting
  • eGFR if indicated
34
Q

Red flags associated with male LUTS

A
  • Urological cancer - Prostate hard and irregular, bone pain, lower back pain, unexplained haematuria, weight loss.
  • Urological infection - loin pain, pain on urination, fever, abnormal dipstick findings
  • Sciatica - weakness/numbness/tingling down leg and can cause or aggrevate LUTS
35
Q

Managing male patients with voiding symptoms - first line

A
  • Active surveillance
    Conservative:
  • pelvic floor muscle training
  • bladder training
  • Normal fluid intake
  • Avoid constipation
  • Healthy lifestyle - weight, exercise, diet, smoking, alcohol
  • Use of containment products (pads, waterproof pants, externla sheath)
36
Q

Managing voiding symptoms men - second line if conservative not suitable/not worked

A
  • Alpha blocker if IPSS of 8 or more
  • Review 4-6 weeks then every 6-12 months
  • Offer 5 alpha reductase inhibitor if at high risk of progression eg Finasteride
  • Consider combo if severe
37
Q

Management voiding and storage symptoms male

A
  • Consider adding antimuscarinic eg oxybutynin/tolterodine to alpha blocker
38
Q

Secondary care options male voiding management if primary care fails

A
  • Urethral catheterisation
  • Prostate surgery - TURP
39
Q

Managing OAB in males

A
  • Conservative
  • Containment products
  • Supervised bladder training
  • If persist offer antimuscarinic
  • Offer mirabegron if animuscarinic not tolerated
  • Secondary care options inc injection botulinum into bladder wall, implanted sacral nerve stimulation and cystoplasty
40
Q

Additonal services for OAB

A
  • Bladder and bowel have helpline
  • Just can’t wait toiletcard when out in public
41
Q

Causes of erectile dysfunction - organic

A
  • Vascular - eg CVD, HTN, PAD
  • Neurological (central) - MS, stroke, CNS tumour
  • Neurological (peripheral) - T1/2DM, CKD
  • Anatomical/structural - prostate cancer, congenital curvature of penis
  • Endocrine - DM, hyperprolactinaemia, hypogonadism
42
Q

Causes of erectile dysfunction - psychogenic

A
  • Generalised
  • Situational - partner, performance related issues, relationship problems
43
Q

Drugs that can cause ED

A
  • Antihypertensives
  • Diuretics
  • Antidepressants
  • Antiarrhythmic

Lots of drugs common to those with diabetes and vascular problems

44
Q

How to determine cause of ED?

A
  • Psychosexual factors (eg orientation, past or current relationships)
  • Progressive symptoms (suggests organic cause, sudden suggests psychological)
  • Cardiac RF
  • Surgery RF
  • LUTS?
  • Check external genitalia and DRE
  • HbA1C and QRISK score and fasting serum testosterone (between 9-11am)

Can do additonal tests such ast TFTs, PSA, LFTs, U&Es depending on clinical judgement

45
Q

Cardiac risk stratification and ED

A
  • Men can be divided into low, intermediate and high risk depending on cardiac history as to CV disease being cause for ED
46
Q

Management ED - support

A
  • NHS information on ED
  • British association of urological surgeons website on ED
  • Sexual advice association
47
Q

Management ED - lifestyle

A
  • Weight loss if overweight
  • Smoking cessation
  • Exercise
  • Alcohol intake to recommended levels
  • If high cardiac risk, stop sexual activity until cardiologist review
  • Stopping cycling for a trial period (if more than 3hrs a week)
48
Q

Management ED - medication

A

If not high cardiac risk:
* Consider Phosphodiesterase 5 inhibitors eg sildenafil
* 50mg can be OTC purchased and do not need script
* Can only be prescribed if meets certain criteria

49
Q
A

General Practice YR3 (31 decks)

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