Obs + Gynae - Urogynaecology + GUM Flashcards
Match the definition to the type of urinary incontinence:
a. ) unable to reach the toilet in time, for such reasons as poor mobility or unfamiliar surroundings
b. ) involuntary leakage of urine on effort or exertion, or on sneezing or coughing due to incompetent sphincter
c. ) involuntary urine leakage accompanied by, or immediately preceded by, urgency of micturition
d. ) involuntary leakage of urine associated with both urgency and exertion, effort, sneezing or coughing
e. ) urgency that occurs with or without urge incontinence and usually with frequency and nocturia
f. ) usually due to chronic bladder outflow obstruction. It is often due to prostatic disease in men
g. ) may be due to a fistulous track between the vagina and the ureter, or bladder, or urethra. There is continuous leakage of urine
- ) Urge incontinence
- ) Mixed incontinence
- ) Overactive Bladder syndrome
- ) True incontinence
- ) Overflow incontinence
- ) Functional Incontinence
- ) Stress incontinence
a.) 6 b.) 7 c.) 1 d.) 2 e.) 3 f.) 5 g.) 4
Management of urge incontinence
- bladder retraining (lasts for a minimum of 6 weeks - gradually increase the intervals between voiding)
- bladder stabilising drugs: antimuscarinics are first-line. (Oxybutynin, Tolterodine (immediate release) or darifenacin (once daily preparation)) Immediate release oxybutynin should be avoided in ‘frail older women’!)
- mirabegron (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patients
Management of stress incontinence
- pelvic floor muscle training: at least 8 contractions performed 3 times per day for a minimum of 3 months
- surgical procedures: e.g. retropubic mid-urethral tape procedures
- duloxetine (noradrenaline and serotonin reuptake inhibitor) may be offered to women if they decline surgical procedure
(mechanism of action: increased synaptic concentration of noradrenaline and serotonin within the pudendal nerve → increased stimulation of urethral striated muscles within the sphincter → enhanced contraction)
Initial investigation of urinary incontinence
- bladder diaries should be completed for a minimum of 3 days
- vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles (‘Kegel’ exercises)
- urine dipstick and culture
- urodynamic studies
What muscle is responsible for urge incontinence?
Detrusor overactivity
Risk factors for urinary incontinence
- advancing age
- previous pregnancy and childbirth
- high body mass index
- hysterectomy
- family history
What is a rectocele?
Rectoceles are caused by a defect in the posterior vaginal wall, allowing the rectum to prolapse forwards into the vagina
What is the most common symptom in patients with a rectocele?
Constipation (faecal loading)
Risk factors for pelvic organ prolapse
- Multiple vaginal deliveries
- Instrumental, prolonged or traumatic delivery
- Advanced age and postmenopause status
- Obesity
- Chronic respiratory disease causing coughing
- Chronic constipation causing straining
Features of pelvic organ prolapse
- A feeling of “something coming down” in the vagina
- A dragging or heavy sensation in the pelvis
- Urinary symptoms, such as incontinence, urgency, frequency, weak stream and retention
- Bowel symptoms, such as constipation, incontinence and urgency
- Sexual dysfunction, such as pain, altered sensation and reduced enjoyment
What are the main three management options for pelvic organ prolapse?
- Conservative management
Physiotherapy (pelvic floor exercises) / Weight loss / Lifestyle changes (reduced caffeine intake and incontinence pads) / Treatment of symptoms, such as treating stress incontinence with anticholinergic mediations) / Vaginal oestrogen cream - Vaginal pessary
Ring pessaries sit around the cervix holding the uterus up
Shelf and Gellhorn pessaries sit below the uterus with the stem pointing downwards
Cube pessaries
Donut pessaries consist of a thick ring
Hodge pessaries are almost rectangular. One side is hooked around the posterior aspect of the cervix and the other extends into the vagina. - Surgery
What are some possible complications of pelvic organ prolapse surgery?
- Pain, bleeding, infection, DVT and risk of anaesthetic
- Damage to the bladder or bowel
- Recurrence of the prolapse
- Altered experience of sex
What is thrush also called
Vaginal candidiasis
Risk factors for thrush
- Increased oestrogen (higher in pregnancy, lower pre-puberty and post-menopause)
- Poorly controlled diabetes
- Immunosuppression (e.g. using corticosteroids)
- Broad-spectrum antibiotics
Thrush features
- Thick, white discharge that does not typically smell
- Vulval and vaginal itching, irritation or discomfort
More severe infection can lead to:
- Erythema
- Fissures
- Oedema
- Pain during sex (dyspareunia)
- Dysuria
- Excoriation
Investigation of thrush
- Test vaginal pH using a swab
pH paper can be helpful in differentiating between bacterial vaginosis and trichomonas (pH > 4.5) and candidiasis (pH < 4.5)
A charcoal swab with microscopy can confirm the diagnosis.
Which is acidic / alkaline on a pH swab? (vaginosis and Trichomonas vs candidiasis)
bacterial vaginosis and trichomonas (pH > 4.5) and candidiasis (pH < 4.5)
Thrush management
Treatment of candidiasis is with antifungal medications
- Antifungal cream (i.e. clotrimazole) inserted into the vagina with an applicator
- Antifungal pessary (i.e. clotrimazole)
- Oral antifungal tablets (i.e. fluconazole)
(Canesten Duo is a standard over-the-counter treatment worth knowing - It contains a single fluconazole tablet and clotrimazole cream to use externally for vulval symptoms)
Recurrent infections (more than 4 in a year) can be treated with a regime over six months with oral or vaginal antifungal medications
Warn women that antifungal creams and pessaries can damage latex condoms and prevent spermicides from working, so alternative contraceptive is required for at least five days after use.
Public Health England has set out a National Chlamydia Screening Programme (NCSP)
How often and for who?
This program aims to screen every sexually active person under 25 years of age for chlamydia annually or when they change their sexual partner. Everyone that tests positive should have a re-test three months after treatment
What are the two types of swabs used in sexual health screening?
- Charcoal swabs
- Nucleic acid amplification test (NAAT) swabs
Charcoal swabs allow for microscopy (looking at the sample under the microscope), culture (growing the organism) and sensitivities (testing which antibiotics are effective against the bacteria). Charcoal swabs look like a long cotton bud that goes into a tube with a black transport medium at the end. The transport medium is called Amies transport medium, and contains a chemical solution for keeping microorganisms alive during transport.
What swab is used to test for Chlamydia vs Gonorrhoea?
Charcoal - Gonorhhoea
NAAT - Chlamydia
Features of Chlamydia in women vs men
The majority of cases of chlamydia in women are asymptomatic. Consider chlamydia in women that are sexually active and present with:
- Abnormal vaginal discharge
- Pelvic pain
- Abnormal vaginal bleeding (intermenstrual or postcoital)
- Painful sex (dyspareunia)
- Painful urination (dysuria)
(Chlamydial conjunctivitis?)
Consider chlamydia in men that are sexually active and present with:
- Urethral discharge or discomfort
- Painful urination (dysuria)
- Epididymo-orchitis
- Reactive arthritis
(Lymphogranuloma Venereum in me who have sex with. men = painless ulcer > lymphadenitis > proctitis)
What is first-line treatment for uncomplicated chlamydia infection?
(Other measures for patient to consider?)
doxycycline 100mg twice a day for 7 days.
(alternative - Azithromycin / Erythromycin)
- Abstain from sex for seven days of treatment of all partners to reduce the risk of re-infection
- Refer all patients to genitourinary medicine (GUM) for contact tracing and notification of sexual partners
- Test for and treat any other sexually transmitted infections
- Provide advice about ways to prevent future infection
- Consider safeguarding issues and sexual abuse in children and young people
Most common complication of Chlamydia?
+ any others?
PID
Also:
- Chronic pelvic pain
- Infertility
- Ectopic pregnancy
- Epididymo-orchitis
- Conjunctivitis
- Lymphogranuloma venereum
- Reactive arthritis
Pregnancy-related complications of Chlamydia?
- Preterm delivery
- Premature rupture of membranes
- Low birth weight
- Postpartum endometritis
- Neonatal infection (conjunctivitis and pneumonia)
What are the friendly bacteria in the vagina called?
+ what condition is caused by a lack of these?
lactobacilli (produce lactic acid that keeps the vaginal pH low)
(+ Bacterial vaginosis)
What are some anaerobic bateria associated with bacterial vaginosis?
- Gardnerella vaginalis (most common)
- Mycoplasma hominis
- Prevotella species
What is the standard presenting feature of Bacterial Vaginosis?
fishy-smelling watery grey or white vaginal discharge. (Half of women with BV are asymptomatic)
(Itching, irritation and pain are not typically associated with BV)
