Pathology Flashcards
(189 cards)
1
Q
Which phase of the menstrual cycle can vary in length
A
Proliferative phase
This is why women have different cycle lengths
2
Q
Which hormones maintain the endometrium during pregnancy
A
Progesterone
HCG
3
Q
Which cells within the ovary secrete hormones
A
The granulosa cells which surround the oocyte
4
Q
Presence of what on histology suggest the endometrium is in the proliferative phase
A
Mitotic figures
5
Q
Presence of what on histology suggest the endometrium is in the secretory phase
A
Glands become more complex
More tortuous/wiggly and later fill with secretions
6
Q
How does obesity increase your risk of endometrial cancer
A
Higher levels of circulating oestrogen
Fat cells can produce it
7
Q
List some indications for endometrial sampling
A
Abnormal bleeding Infertility Abortion - spontaneous and therapeutic Endometrial ablation Endometrial cancer screening
8
Q
What is considered post-menopausal bleeding
A
if there has been no bleeding for a year and then it starts up again
9
Q
What are the common causes of abnormal uterine bleeding
A
DUB due to anovulatory cycles Pregnancy and miscarriage Endometritis– inflammation of the endometrium Bleeding disorders Cancer
10
Q
What is adenomyosis
A
Where you get glands and stroma in the muscular wall of the uterus which will cycle as normal
Leads to menorrhagia and dysmenorrhoea
Very painful condition and sometimes the only way to manage is hysterectomy
11
Q
What is a leiomyoma
A
A very common smooth muscle tumour which can occur anywhere
Often called a fibroid
12
Q
Which drugs can lead to abnormal uterine bleeding
A
Anything with exogenous hormones
HRT and tamoxifen
13
Q
What endometrial thickness would be considered abnormal in post-menopausal women
A
Greater than 4mm
This is an indication for biopsy
14
Q
How can you sample the endometrium
A
Endometrial pipelle - limited sample but easier/safer
Dilatation and curretage
15
Q
Which phase in the menstrual cycle is worst for taking an endometrial sample
A
During menstruation
The architecture is hard to analyse as it is in the process of breaking down
Can exclude malignancy but nothing else
16
Q
What is dysfunctional uterine bleeding
A
Irregular uterine bleeding that reflects a disruption in the normal cyclic pattern of ovulatory hormonal stimulation to the endometrial lining
No organic cause for bleeding
17
Q
When is DUB most common
A
Either end of reproductive life
18
Q
How can you recognise anovulation on histology
A
Gland will be disordered
Will have just kept proliferating
19
Q
What is the function of the cervical mucous plug
A
Protects the endometrium from ascending infection
Changes with the cycle - easy for sperm to enter when fertile, harder when not
20
Q
What is endometritis
A
Inflammation of the endometrium
21
Q
Which microorganisms can cause endometritis
A
Neisseria Chlamydia TB - uncommon in UK CMV HSV
22
Q
What are some non-microbiological of endometritis
A
IUD - copper
Post-partum or post-abortal
Leiomyomas or polyps
Granulomas - sarcoid
23
Q
If you can see plasma cells in the endometrium what is the diagnosis
A
Chronic plasmacytic endometritis
Shouldn’t have plasma cells in the endometrium
Caused by an infection unless proven otherwise - associated with PID
24
Q
How do endometrial polyps present
A
Usually asymptomatic but may present with bleeding or discharge
Common around or after the menopause
25
What might be seen in a sample from a miscarriage
Foetal RBC
Chorionic villi
Need to take a sample to exclude molar pregnancy
26
What is a molar pregnancy
When a non-viable fertilised egg implants in the uterus or tube
27
What is a complete mole
When one or two sperm combine with an egg which has lost its DNA
Only has the father's DNA
Will form placenta and some structure but never a foetus
28
What is a partial mole
An egg fertilised by 2 sperm or a 1 sperm which reduplicates itself
It will have 2 copies of dad and one of mum
Leads to a crazy placenta and some foetal parts
29
What is the risk of leaving a complete mole behind
High risk of it developing into a choriocarcinoma
30
How can leiomyomas of the uterus present
Menorrhagia
Infertility
Mass effect
Pain
31
What drives the growth of leiomyomas
Oestrogen
32
How is CT used in gynae patients
Can be used to assess post-surgical complications
Staging of gynaecological malignancy, especially ovarian and endometrial
Assessing response to treatment in patients after chemotherapy +/- radiotherapy
33
How are MRI scans used in gynae patients
Cancer staging – especially cervical cancer
Further evaluation and characterisation of adnexal and uterine masses
Evaluation of patients with sub-fertility - looks for anatomical issues
Scan pituitary in suspected prolactinoma
34
What makes up a dermoid cyst
They contain tissue derived from ectoderm, mesoderm and endoderm
Therefore have a mixture of many types of tissue, particularly fat
Often lined with epithelial tissue and hence may contain hair, teeth.
35
What is hysterosalpingography
X-ray procedure where cervix is cannulated and radiopaque contrast instilled to fill the uterine cavity
For assessment of tubal patency in patients with infertility
36
How does endometriosis present on MRI
Endometriosis deposits contain altered blood and haemoglobin degradation products
These have characteristic MR signals - high on T1 (looks white)
37
How does ovarian cancer spread
Disseminates by peritoneal spread
Ascites, omental and peritoneal nodules are common. Sub-diaphragmatic deposits and deposits on the surface of the liver are also seen
38
How do you diagnose ovarian cancer
US usually makes the initial diagnosis - ovarian mass
| CT is used for staging
39
How do you diagnose endometrial cancer
TV US - looks for abnormally thickened endometrium
MRI used to assess myometrial invasion
CT used to look for mets
40
What are the two types of US used in gynae
Transabdominal
| Transvaginal
41
Which type of US scan needs a full bladder
Transabdominal -distended bladder displaces gas-filled bowel loops out of the pelvis
Transvaginal needs an empty bladder
42
How is a transabdominal US carried out
The pelvic organs are scanned through the anterior abdominal wall
43
What is the benefit of transvaginal; US
ultrasound probe is as close as possible to the pelvic organs
Gives better spatial resolution
44
What is female genital mutilation
All procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons
FGM is recognised internationally as a violation of the human rights of girls and women
45
What are the impacts of obesity in O andG
Increased infertility
Decreased effectiveness of IVF
Increased risk of miscarriage
Increased risk of pregnancy complications
46
What are the risks of smoking in pregnancy
Risk of stillbirth, premature birth, sudden infant death syndrome
47
Describe a follicular ovarian cyst
Very common
Thin-walled, lined by granulosa cells
Follicle grows into a cyst - can be several cm
Usually resolve over a few months
48
What are the different types of ovarian cyst
```
Follicular e.g. polycystic ovaries)
Luteal - benign and form from the CL
Theca luteal
Endometriotic - filled with blood
Epithelial - can be benign or malignant
Mesothelial
```
49
What features of a cyst would make you consider malignancy
If has a solid component with a high CA125
50
What is endometriosis
Endometrial glands and stroma outside the uterine body - in the wrong place
Causes inflammation in the area leading to pain and infertility
51
What are the signs/symptoms of endometriosis
Pain is the significant symptom - severe and chronic pelvic pain
Heavy and painful periods
Painful sex - often deep
Infertility
Fatigue
Cyclical bowel issues
Adhesions or scarring in the reproductive tract
52
Which sites are commonly affected by endometriosis
```
Ovary (‘chocolate’ cyst)
Pouch of Douglas
Peritoneal surfaces, including uterus
Cervix, vulva, vagina
Bladder, bowel etc
```
53
What are the signs of endometriosis in the ovaries
Metaplasia of mesothelium
Adhesions on the ovary (from inflammation)
Chocolate cysts
Haemorrhage, inflammation, fibrosis
54
What are the complications of endometriosis
```
Pain
Cyst formation
Adhesions
Infertility
Ectopic pregnancy
Malignancy (endometrioid carcinoma)
```
55
What is salpingitis
Inflammation of the fallopian tubes
| Often due to infections
56
What is an ectopic pregnancy
Implantation of a conceptus outside the endometrial cavity
Often ruptures
May cause fatal haemorrhage
57
Where can an ectopic pregnancy occur
Commonest site is Fallopian tube
| May occur in ovary or peritoneum
58
What are the differentials for a pelvic mass
```
Constipation!
Caecal carcinoma
Appendix abscess
Diverticular abscess
Urinary retention
Pregnancy
Uterine mass - benign or malignant
Adnexal mass - benign or malignant
```
59
What family history is significant in a pelvic mass
Lynch Syndrome
BRCA (ovarian breast and prostate cancer)
HLRCC (renal cancer with fibroids)
60
Which blood tests should you do in a pelvic mass case
Young women: LDH, AFP, HCG
| Older: Ca125
61
How do you assess pelvic malignancy risk
Risk of Malignancy Index (RMI)
| Involves menopausal status, US features, Serum CA125
62
If someone has a high risk of pelvic cancer, what further investigations would you do
CT - check surrounding organs for involvement
MRI - Better view of the lesion itself
Hysteroscopy
Diagnostic laparoscopy
63
What are the most common benign ovarian tumours
Functional cysts
Epithelial tumours - serous, clear cell etc
Teratoma - germ cell tumour
Stromal tumours
64
What are functional cysts
Ovarian cysts that are related to ovarian cycle
Can be follicular or luteal
Usually resolve spontaneously after a few cycles and are asymptomatic
May bleed or rupture and cause pain
Most common type of ovarian cyst
65
What type of ovarian cysts can be caused by endometriosis
Endometriotic cysts - also called chocolate cysts
Blood filled cysts
Typically tender mass with ‘nodularity’ and tenderness
66
What cell types can be found in a dermoid cyst
It has totipotential
Commonly hair, teeth, sebaceous material and thyroid tissue
May present with thyrotoxicosis
67
What are the signs of ovarian torsion
Acute colicky pain associated with nausea, vomiting and distress
Can occur as a result of a benign cyst
68
How can you manage fibroids
CONSERVATIVE
MEDICAL – Mirena (1st line), GnRH analogues, Progestins
SURGICAL – Laparoscopic/Laparotomy
Myomectomy (Hysteroscopic or abdominal)
Subtotal Hysterectomy
Total hysterectomy
69
How does position of the transformation zone change throughout life
It has a physiological response to:-
menarche
pregnancy
menopause
70
what is the transformation zone of the cervix
Squamo-columnar junction between ectocervical (squamous) and endocervical (columnar) epithelia
71
What is cervical erosion
When exposure of delicate endocervical epithelium to acid environment of vagina leads to physiological squamous metaplasia
72
What inflammatory conditions can affect the cervix
Cervicitis – Often asymptomatic but can lead to infertility
Non-specific acute/chronic inflammation.
Follicular cervicitis
Chlamydia Trachomatis
Herpes Simplex Viral Infection
73
How does vulvar Paget's disease present
Crusting rash.
| Tumour cells in epidermis, contain mucin.
74
What is Paget's disease of the vulva
A tumour which arises from sweat gland in skin.
| usually no underlying cancer
75
What is the definition of primary amenorrhea
Failure of menstruation to start by the age of 16
76
What are the 3 major features of PCOS
Amenorrhea or oligomenorrhea
Multicystic large volume ovaries on US
Androgenic feature - acne, hirsutism
Need 2 out of 3 for diagnosis
77
What is Sheehan's syndrome
A condition that affects women who either lose a life-threatening amount of blood in childbirth or have severe low blood pressure during or after childbirth, which can deprive the body of oxygen
This lack of oxygen that causes damage to the pituitary gland
Can cause amenorrhea, hypothyroidism, difficulty breastfeeding
78
How would you treat hyperprolactinemia
Prescribe a dopamine agonist as this will inhibit the release of prolactin and reduce levels
Often very quickly - restores fertility fast
79
How would you treat premature ovarian failure
Prevent osteoporosis - bisphosphonate and vit D
Prescribe HRT or COCP to preserve secondary sexual characteristics and reduce menopause symptoms
80
Which other condition is seen in those with premature ovarian failure
Osteoporosis
They lose the protective effect of oestrogen
Seen after around 6 months of POF
81
Patients with which ovarian condition are at high risk of endometrial hyperplasia/cancer
PCOS
82
Which drugs are used to induce ovulation in PCOS
clomiphene, letrazole or gonodatropins
83
What are the fertility options for those with POF
Fertility treatment is unlikely to work on them - unlikely to produce own eggs anymore Discuss the low chance of spontaneous pregnancy
Discuss use of donated eggs or adoption
84
Those with PCOS are at high risk of which other medical condition
T2DM
| Should be offered a random blood glucose followed by oral GTT
85
How is PCOS treated
Lifestyle advice -weight loss, exercise etc.
Start on cyclical progestogen to induce withdrawal bleed then assess endometrial thickness. If normal there are a variety of contraceptive options for her depending on her wishes.
Combined pill would help hirsutism (option is BMI dependent)
Also offer advice on hair removal – electrolysis, androgen creams and traditional cosmetic procedures
86
Weight loss is incredibly effective in the treatment of PCOS - true or false
True
In some cases it can cure it
Also, those with PCOS are at high risk of hypertension, heart disease and heart disease so weight loss is very important
87
How do you prevent endometrial hyperplasia/cancer in those with PCOS
Progesterone treatment such as Mirena coil or cyclical oral progestogen
88
What is the first line investigation for those with chronic pelvic pain
Diagnostic laparoscopy
89
List some of the pathologies associated with chronic pelvic pain
```
Endometriosis
Adhesions
PID
Ovarian cysts
Pelvic congestion syndrome
Nerve entrapment or other MSK cause
IBS
Interstitial cysts
30-50% have no obvious cause
```
90
How is endometriosis diagnosed
Clinical suspicion from history
Laparoscopic investigation
Histological samples
91
How does ovarian endometriosis present on US
May see fluid filled cyst of ground glass echogenicity.
92
How is endomtriosis treated
Hormonal suppression with a contraceptive
Choice depends on the patient
Symptoms will recur when stopped
Painkillers such as NSAIDs
Laparoscopic surgery - ablation or excision
Hysterectomy if patient has completed their family and isn't responding to more conservative methods
93
What is chronic pelvic pain syndrome
An intermittent or constant pain in the lower abdomen or pelvis of a woman of at least 6 months in duration, not occurring exclusively with menstruation or intercourse and not associated with pregnancy
94
List the different types in FGM
Type 1 - Removal of all or part of the clitoris and clitoral hood
Type 2 - Removal of all or part of the clitoris and inner labia
? Removal of all or part of the inner and outer labia
Type 3 - Closure of the vagina (also known as infibulation)
Type 4 includes All other harmful procedures to the female genitalia for non-medical purposes, for example pricking, piercing, incising, scraping and cauterising the genital area
95
In which countries is FGM typically practiced
The majority of women are from Africa - 29 specific countries
Also seen in the middle east and south/southeast asia
96
List some of the short term consequences of FGM
```
Haemorrhage
Severe pain
Wound infection - sepsis
Urinary retention
Tetanus and gangrene
Damage to adjacent organs
Fractures (because of being forcibly held down)
Infections - HIV, Hep
Death
```
97
List some of the long term consequences of FGM
```
Recurrent UTI
Painful menstruation
Psychological issues
Sexual difficulties
Recurrent pelvic and urinary infections
Keloid scarring and cysts
Complications in pregnancy and delivery - for both mum and baby
Infertility
Post-traumatic stress disorder (PTSD)
Psychosexual problems
```
98
Is FGM illegal in the UK
Yes
It is considered child abuse
It is also illegal to arrange FGM overseas for a UK resident
99
What do you do if you identify a child under 18 who has had FGM
Mandatory reporting to the police - 101
Should also refer to children's social care
May require an examination -preferably with an experienced pediatrician
100
Which girls are considered to be at risk of FGM
Those born to a mother with FGM
Those with a sibling or family member who has undergone FGM
Those who state that they are being taken abroad - perhaps for a ceremony
Girl who is withdrawn from PSHE lessons or from learning about FGM
101
Which subtype of FGM is most likely to cause issues with childbirth
Type 3 - infibulation
Inability to complete vaginal exams, take sample from baby, deal with complications such as prolapse and prolonged labour due to total/partial occlusion
102
If a pregnant woman has had FGM when is deinfibulation usually performed
Between 20-32 weeks
| This allows time for the new scar to heal
103
What conservative treatment is available for urge incontinence
Lifestyle changes: reduce weight, fluid intake, alcohol and caffeine
If your patient drinks a lot of tea/coffee encourage them to cut down or switch to decaf
Use pads
Bladder retraining = don't go just because there is a toilet, let the bladder fill
104
What surgical treatment is available for urge incontinence
Botox is commonly used
| All other surgical treatment is very much last line
105
How is urge incontinence treated
Conservative and medical treatment
| Surgery is very much last line
106
What medical treatment is available for urge incontinence
Vaginal oestrogen
Anti-cholinergics - tolterodine (1st line) then soliphenacin
May consider a transdermal preparation if they cannot tolerate oral
Beta-3-adrenoceptor agonist - mirabegron (alternative to anti-cholinergic, good in elderly)
If none work individually you can consider dual therapy
Desmopressin can be used to treat nycturia
107
List some of the anti-cholinergic side effects of the drugs used in the treatment of urge incontinence
Dry mouth
Constipation
Around 50% of patients will not tolerate the anti-cholinergic side effects
108
How does urge incontinence present on detrusor tracing
You will see the detrusor contracting in large peaks when the bladder isn't quite full
Detrusor over activity
Frequency/volume charts will show increased frequency
109
How is stress incontinence treated
Conservative then surgical treatment
110
What is bladder pain syndrome
Functional disorder
| Cannot find a physical problem but patient presents with pain, incontinence, painful sex
111
How do you diagnose bladder pain syndrome
Examination, US and cystoscopy (to exclude more serious causes)
112
How do you manage
| bladder pain syndrome
Lifestyle changes - weight loss, reduced caffeine
113
List some conservative options for prolapse treatment
Lifestyle advice - weight loss, avoid constipation, smoking cessation, avoid heavy lifting
Supervised pelvic floor exercises
Vaginal oestrogen
Pessaries
114
List some surgical options for prolapse treatment
Anterior (bladder prolapse) or posterior repair (rectal prolapse)
This is where stitch the fascia to hold organs up
Sacrospinous repair - strong ligament so you fix the cervix or top of vagina to it to hold it up
May combine the above surgery depending on where the prolapse is
Laparoscopic sacrohysteropexy/ colpopexy - suspension (old mesh)
Colpocleisis - sew vaginal walls together
Used women who are no longer sexually active
May do a hysterectomy
115
List some of the differentials for a pelvic mass
```
Pregnancy
Full bladder - should only be felt when completely full
Fibroids
PID - abscesses
Benign ovarian disease
Malignant ovarian disease
```
116
Why might a patient not realise/feel that their bladder is full
```
Peripheral neuropathy (e.g. in diabetes)
Spinal injury, cauda equina, paraplegia
Also after prolonged labour anaesthesia
```
117
What test is always carried out first in a patient with a pelvic mass
a pregnancy test
118
What is the nerve supply to the pelvic organs
S2, 3, 4
119
What is the blood supply to the ovary
Ovarian artery supplies the ovary and is a branch of the aorta
Veins drain to the IVC (right) or the renal vein (left)
120
Which genetic mutations come with an increased risk of ovarian cancer
BRCA 1 and 2
| HNPCC
121
Which subtype of fibroids are most likely to cause worst symptoms
Submucosal
| Infertility and heavy bleeding
122
How can you treat symptomatic fibroids
Treat with IUS
Also can use tranexamic acid or norethisterone to reduce bleeding
If family is complete you can offer myomectomy or hysterectomy
123
What is the most common type of uterine fibroid
Intramural
124
Define stress incontinence
Complaint of involuntary
loss of urine on effort or physical exertion including
sporting activities, or on sneezing or coughing (increased intra-abdominal pressure)
All in abscence of detrusor muscle contraction
125
Define an overactive bladder or urge incontinence
Urinary urgency, usually
accompanied by increased daytime frequency and/or
nocturia
Individual often says “If I have to go, I have to go immediately”
With urinary incontinence (OAB-wet) or
without (OAB-dry), in the absence of urinary tract
infection or other detectable disease.
126
What is mixed urinary incontinence
Complaints of both stress
and urgency urinary incontinence, i.e. involuntary loss
of urine associated with urgency and also with effort or
physical exertion including sporting activities or on
sneezing or coughing.
127
List some of the main causes of urinary incontinence
```
Age
High parity
Obesity
Pregnancy
Menopause and oestrogen deficiency
Hysterectomy
UTIs
Smoking
Family History
```
128
What conservative treatment is available for stress incontinence
Lifestyle - weight loss, stop smoking, avoid constipation, avoid heavy lifting, reduce caffeine
Pelvic floor training - often with physio
Use pads
Incontinence ring
129
What medical treatment is available for stress incontinence
Vaginal oestrogen
| Duloxetine - last line as lots of side effects
130
What surgical treatment is available for stress incontinence
Bulking agents
Fascial slings
Colposuspension - lap or open
Artificial urinary sphincters (In severe cases where previous surgery has failed)
131
List the urinary symptoms relating to storage
```
Frequency
Nocturia (>1)
Urgency
Incontinence
Constant leakage (secondary
to fistula
```
132
List the urinary symptoms relating to voiding
Hesitancy
Straining
Poor flow
133
List common post micturition symptoms
Incontinence
Sensation of
incomplete emptying
134
Which examinations should you perform on a patient presenting with incontinence
BMI
Abdominal exam
Vaginal exam
Neuro (emphasis on sacral roots S2-4)
135
Which investigations should you perform on a patient presenting with incontinence
Urinalysis
Post-void residual volume
Cystoscopy
Urodynamics
136
List the different types of pelvic organ prolapse
```
Cystocele - anterior wall
Rectocele - posterior wall
Uterine prolapse
Vaginal vault prolapse - top of the vagina following
hysterectomy
```
137
List some of the causes of pelvic organ prolapse
Age
High parity - vaginal deliveries
```
Post menopausal (oestrogen deficiency affecting
periurethral collagen metabolism)
```
Obesity and chronic increase in intra abdominal
pressure (chronic cough, heavy lifting, constipation)
Neurological conditions eg spina bifida and muscular
dystrophy
Genetic connective tissue disorders eg Marfans and
Ehlers-Danlos
138
List the common symptoms of prolapse
```
Heaviness or dragging in the vagina
Urinary
symptoms - urgency, frequency, hesitancy, incomplete
emptying, manual reduction of prolapse or position
change to accomplish voiding
Faecal incontinence
Excessive straining
Sexual dysfunction.
```
139
How do you stage a prolapse
The hymen is defined as 0 and the distance to 6
anatomical points is measured in cm above the hymen (negative
number) or below the hymen (positive number)
Stage 0 -no prolapse demonstrated
Stage 1 - the leading edge is -1cm or above
Stage 2 - the leading edge is between -1cm and +1cm
Stage 3 - the leading edge is +1cm or below but
without complete eversion
Stage 4 - complete vaginal eversion
140
What is procedentia
Complete vaginal eversion
141
List some of the complications of pessary use
```
Vaginal
discharge
Ulceration - may lead to vesicovaginal or
rectovaginal fistulae
Formation of fibrous bands
attaching the pessary to the vagina
```
142
How often should pessaries be changed
Every 6 months
| This is to avoid complications
143
How can you prevent some of the complications of pessary use
Change it every 6 months
| Topical oestrogen creams
144
List some of the types of pessary
Ring
Cube
Shelf
Gelhorn - looks like a dummy
145
Why might a prolapse patient have abnormal renal function
If they have chronic urinary retention
| Should catheterize them
146
What is the gold standard for diagnosis of endometriosis
Diagnostic laparoscopy
| It allows visualisation of implants and allows for biopsy
147
Why do you give GnRH analogues prior to fibroid removal surgery/hysterectomy
nRH analogue prior to surgery will cause medical menopause and also may reduce the size of the fibroids helping with the surgery
Given for 3 months before
148
What should you look for when inspecting the cervix
Type of cervical os – small round dimple (nulliparous) or shape of a smile (multiparous)
Colour – normally pink, bright red in cervicitis, redder area around os called ectropion
Secretions and discharge – note colour and odour
Growth/ Malignancy – cauliflower like and friable and bleeds on touch is usually associated with malignancy
Ulcerations, scars and retention cysts (Benign nabothian cysts)
149
If a woman has had a baby her cervical os will be smile shaped rather than round - true or false
True
150
The cervix is normally soft - true or false
False
It is normal for it to be firm
Hard suggests fibrosis or cancer
Soft is felt in pregnancy
151
When is the cervix tender
Also called cervical excitation tenderness - hurts when moved/touched
Seen in PID or ectopic pregnancy
152
List causes of vulval pruritus
Other skin conditions – eczema, atopic dermatitis, psoriasis
Lichen sclerosus
Lichen planus
Infection e.g. candidiasis, trichomonas vaginalis.
Extramammary Paget’s disease of the vulva
153
What is lichen sclerosis
A chronic inflammatory condition of unknown aetiology affecting the skin
Characterised by areas of atrophy and systematic destruction to the skin cells include melanocytes and hair follicles
Most commonly affects the genitals - most often labia majora, extending to minora and anus
154
How does lichen sclerosis present
Pruritus and skin irritation on the vulva
Skin is hypopigmented and atrophied giving it a shiny appearance
May be hair loss in the affected areas.
Affected areas may also bleed easily and pinpoint vessels may be seen
White polygonal papules coalesce to form plaques
In late stage you get scar formation so some present with atrophy and fusion of the labia, stenosis of the introitus or difficulties in defecation
155
Without treatment, lichen sclerosis can progress to what
vulvar intraepithelial neoplasia
| Especially in older women
156
How do you treat lichen sclerosis
Treatment includes topical high-dose steroids and emollients
NICE guidelines suggest a 3month trial of topical steroids
2nd line topical calcineurin inhibitors
In cases where the lesion is treatment resistant, a biopsy is needed to confirm diagnosis and rule out malignancy
157
What must you do if you find Paget's disease of the vulva
It is often a sign of other malignancy in the body therefore a full body work-up is indicated in patients presenting with this condition.
158
How does Paget's disease of the vulva present
May extend towards the anus and presents as an erythematous, eczematous area with a crusting rash
159
List risk factors for pelvic infection
```
Age <25years
Multiple sex partners
Unprotected sexual intercourse
Recent insertion of IUD
Recent change in sexual partner.
```
160
List signs and symptoms of a pelvic infection
```
Lower abdominal pain
Fever
Abnormal vaginal bleeding (intermenstrual, menorrhea, post-coital)
Offensive vaginal discharge
Deep dyspareunia
Dysuria or menstrual irregularities may occur
Cervical motion tenderness
Adnexal tenderness
```
161
What can cause tubo-ovarian abscesses
An ascending genital tract infection causes cervicitis, endometritis, salpingitis (inflammation of the cervix, endometrium, fallopian tubes)
162
How do ovarian cysts typically present
Presence of pelvic/abdominal mass
Pain
Incidentally on US
Pressure on the bowel or bladder depending on the size and site of the cyst
Depending on the type of cyst, disturbance in the menstrual cycle or virilisation may occur.
163
What are cyst accidents
When an ovarian cyst presents acutely
| There may be haemorrhage within the cysts, or the cysts may rupture or twist on itself (torsion).
164
Functional ovarian cysts are most common in which age group
young women in their reproductive years
165
Benign germ cell ovarian tumours are most common in which age group
Young women
166
Benign epithelial ovarian tumoursare most common in which age group
Older women
167
Which tests should be done if an ovarian cyst has suspicious features
Tumour markers which include measuring inhibin, AFP, b-HCG, CA125
Imaging modalities such as ultrasound (transabdominal or transvaginal), CT scans or MRI
168
How do follicular cysts appear on US
Appear as simple, uniloculated cysts on ultrasound which measure more than 3cm
169
How do you treat follicular cysts
Depends on symptoms – if asymptomatic, they are observed and sequential repeat ultrasound to assess changes are recommended.
If symptomatic, laparoscopic cystectomy may be performed.
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What is the most common benign ovarian tumour in women <30years
Dermoid cysts - mature cystic teratomas
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Where do benign epithelial ovarian tumours arise from
Ovarian surface epithelium
| Includes serous cystadenoma and mucinous cystadenoma.
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What is a Bartholin cyst/abscess
Infection in the Bartholin's glands - pair of glands located next to the entrance to the vagina
They become enlarged
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How do you manage a Bartholin cyst/abscess
Sometimes these settle with antibiotics but may require a surgical procedure known as marsupialization.
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Stress incontinence can be caused by what
Commonly seen after childbirth, pelvic surgery and oestrogen deficiency
Triggers: Coughing, sneezing, exercise
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Prolapse may be seen alongside stress incontinence - true or false
True
| Prolapse of urethra and anterior vaginal wall could be present
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How do you diagnose stress incontinence
After excluding a UTI, frequency/volume charts should be done. Charts will show normal
frequency and bladder capacity.
Urodynamic studies should be done
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What can cause urge incontinence
Idiopathic
Pelvic surgery
Multiple sclerosis
Spina bifida
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Which type of incontinence typically has the larger volume of leakage - urge or stress
Urge
| Stress is small volumes, urge is larger
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What can trigger urge incontinence
Hearing running water, cold weather
180
What is overflow incontinence
Leakage of urine from a full urinary bladder, often with the absence of an urge to urinate
181
What can cause overflow incontinence
Inactive detrusor muscle: neurological conditions e.g. M.S -> no urge to urinate
Involuntary bladder spasms: can occur in cardiovascular disease and diabetes
Cystocele or uterine prolapse can block urine exit if severe
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Overflow incontinence is more common in which of the sexes
Men > women due to prostate-related conditions
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How do you investigate overflow incontinence
Frequency/volume charts
| Urodynamic testing shows inactivity of the detrusor muscle
184
How do you treat overflow incontinence
Treat the cause
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How does UTI present
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Dysuria
Increased urinary frequency
Increased urinary urgency
Cloudy/offensive smelling urine
Lower abdominal pain
Fever
Malaise
In elderly patients, can be a cause of delirium
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How do you treat UTI in non-pregnant women
Nitrofurantoin (1st line) or Trimethoprim (2nd line) for 3 days
Urine culture should be sent if age>65 or haematuria is present
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How do you treat UTI in syptomatic pregnant women
Urine culture done
| Nitrofurantoin (1st and 2nd trimester), Trimethoprim 3rd trimester
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How do you treat UTI in asyptomatic pregnant women
Urine culture should be done at 1st antenatal visit
High risk of progressing to acute pyelonephritis
Immediate course of Nitrofurantoin (avoid near term pregnancy), amoxicillin or cefalexin for 7
days should be started
Urine culture after treatment, for test of cure.
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How do you treat UTI in cateterised patients
Only treat if symptomatic!
| If definite infection treat as per complicated UTI - Amoxicillin IV 1g tds + Gentamicin IV (Total IV/PO 7 days)
