Urogynaecology, Breast & Misc Flashcards
(87 cards)
1
Q
Urogynaecology
Definition: Stress urinary incontinence
A
Involuntary leakage of urine during increased abdominal pressure in the absence of a detrusor contraction
* e.g. sneezing/coughing
2
Q
Name 5 risk factors for urinary incontinence (8)
A
- Increased age
- Post-menopausal
- Increased BMI
- Previous pregnancy/vaginal delivery
- Pelvic organ prolapse
- Pelvic floor surgery
- Neurological conditions (e.g. MS)
- Cognitive impairment / dementia
3
Q
Name 4 modifiable lifestyle factors than can contribute to incontinence symptoms
A
- Caffeine consumption
- Alcohol consumption
- Meds
- BMI
4
Q
Name 4 investigations for urinary incontinence
A
- Bladder diary: track fluid intake, urination, incontinence over at least 3 days
- Urine dipstick testing: test for infection, microscopic haematuria etc
- Post-void residual bladder volume: incomplete emptying
- Urodynamic testing
5
Q
Name 5 urodynamic tests
A
- Cystometry: measures detrusor muscle contraction & pressure
- Uroflowmetry: measures flow rate
- Leak point pressure: point at which bladder pressure results in urine leakage: assesses for stress incontinence
- Post-void residual bladder volume: incomplete emptying
- Video urodynamic testing: filling bladder with contrast & taking xray images as bladder is emptied (not routine)
6
Q
What is the management of stress incontinence? (3)
excluding fluid intake/restriction and avoiding caffeine/diuretics etc.
A
- Pelvic floor exercises (at least 3 months before considering surgery)
- Surgery: TVT, autologous sling, colposuspension, intramural urethral bulking, artificial urinary sphincter
- Duloxetine: second line where surgery is less preferred
7
Q
What is the management of urge incontinence / overactive bladder? (4)
A
- Bladder training (for at least 6 weeks)
- Anticholinergic meds
- Botox
- Mirabegron (alt Tx with less of an anticholinergic burden)
- Augmentation cystoplasty (making bladder bigger)
8
Q
Definition: Urge incontinence (overactive bladder)
A
Caused by overactivity of the detrusor muscle.
- Suddenly feeling the urge to pass urine
9
Q
What is the classic triad seen in overactive bladder?
A
- Frequency: voiding >8 times a day more than 2 hourly (affected by age and race)
- Nocturia: interruption of sleep due to micturition more than once every night
- Urgency: feeling of sudden, compelling desire to pass urine, which is difficult to defer
10
Q
Name 3 anticholinergic meds used to treat urge incontinence
A
- Oxybutynin
- Tolterodine
- Solifenacin
11
Q
When is mirabegron contraindicated?
A
In uncontrolled hypertension
12
Q
Name 4 invasive options for treating overactive bladder
A
- Botulinum toxin type A injection into bladder wall
- Percutaneous sacral nerve stimulation
- Augmentation cystoplasty: using bowel tissue to enlarge bladder
- Urinary diversion: redirecting urinary flow to a urostomy on the abdomen
13
Q
Definition: pelvic floor prolapse
A
- Descent of pelvic organs into the vagina
- Result of weakness & lengthening of ligaments/muscles surrounding the uterus,rectum & bladder
14
Q
What us uterine prolapse?
A
Where the uterus itself descends into the vagina
15
Q
What is a cystocele?
A
Caused by a defect in the anterior vaginal wall, allowing the bladder to prolapse backwards into the vagina
cystourethrocele: prolapse of both the bladder and the urethra
16
Q
What is a rectocele?
A
Caused by a defect in the posterior vaginal wall, allowing the rectum to prolapse forwards into the vagina.
* Associated with constipation and faecal loading in the part of the rectum that has prolapsed
* Loading of faeces = constipation, urinary retention, palpable lump
17
Q
Name 6 risk factors for pelvic organ prolapse
A
- Multiple vaginal deliveries
- Instrumental/prolonged/traumatic delivery
- Older & post-menopausal
- Obesity
- Chronic resp disease causing coughing
- Chronic constipation causing straining
18
Q
Name 5 presenting symptoms of pelvic organ prolapse
A
- Feeling of ‘something coming down’ in the vagina
- Dragging/heavy sensation in the pelvis
- Urinary Sx: incontinence, urgency, frequency, weak stream, retention
- Bowel Sx: constipation, incontinence, urgency
- Sexual dysfunction: pain, altered sensation, reduced pleasure
19
Q
What are the 3 options for management of a pelvic floor prolapse?
A
- Conservative: physio, wt loss, lifestyle changes, vaginal oestrogen cream, treating Sx
- Vaginal pessary: inserted to provide extra support
- Surgery
20
Q
What is a vaginal fistula
A
A tunnel-like opening that develops in the wall of the vagina
21
Q
What is a genitourinary vaginal fistula?
A
Form between vagina/uterus and organs in the urinary system
22
Q
What is the most common type of genitourinary vaginal fistula?
A
Vesicovaginal fistula: opening between vagina and bladder
Others: ureterovaginal (vagina & ureter), urethrovaginal (vagina & urethra)
23
Q
What are other types of vaginal fistulas (not genitourinary)?
A
- Rectovaginal fistula: between vagina & rectum
- Colovaginal fistula: between vagina & large intestine
- Enterovaginal fistula: between vagina & small intestine
24
Q
Name 7 causes of vaginal fistulas
A
- Prolonged labour
- Vaginal tears during childbirth
- Abdo/pelvic surgery, inc C-sections / hysterectomies
- Cervical / Colorectal cancer
- IDB (Crohn’s / UC)
- Diverticulitis
- Radiation therapy to pelvic region
25
What is the pathophysiology of vaginal fistulas?
* Lack of blood supply to vaginal tissue = **tissue dies**
* Hole/fistula forms in tissue
26
Name 5 symptoms of genitourinary vaginal fistulas
* Urinary **incontinence**
* Chronic urine **odour**
* **Skin irritation** in vagina/vulva/perineum
* **Painful intercourse**
* Recurrent **UTIs**, **kidney infections**, **vaginitis**
27
Name 5 symptoms of vaginal fistulas between the vagina and organs in the digestive system (8)
* **Abdo pain**
* Foul smelling vaginal **discharge**
* Gas/pus/stool leaking from vagina (**faecal incontinence**
* **N+V** / **diarrhoea**
* Painful intercourse
* Recurrent UTIs / kidney infections
* **Rectal** / **vaginal bleeding**
* Unexplained **wt loss**
28
What investigations are used to diagnose vaginal fistulas?
* **Physical** exam
* **FBC** & **urinalysis**: infections
* **Dye test**: insert dye into rectum & check for leakage from vagina
* **Fistulogram X-ray**
* CT / MRI / Cystoscopy / Flexible sigmoidoscopy / Colonoscopy
29
What is the management of vaginal fistulas?
* **Antibiotics**: infections
* Meds for IBD
* Temporary **self-catheterisation**: drain bladder whilst vesicovaginal fistula heals
* **Ureteral stents**: keep ureters open
* **Surgery**: close opening
30
What is the most common form of cancer in the UK?
Breast cancer
31
What are the risk factors for breast cancer?
* **Female** (99% of cases)
* Increased **oestrogen** exposure (early onset period / late menopause)
* **Denser breast tissue** - more glandular tissue
* **POST MENOPAUSAL Obesity**
* **Smoking**
* **alcohol**
* **Family Hx** (first-degree)
* **Combined contraceptive pill** - small increased risk but returns to normal 10 years after stopping
* **HRT** (particularly combined HRT - both oestrogen and progesterone)
32
What gene mutation is responsible for breast cancer?
**BRCA gene** = **tumour suppressor gene**
33
What chromosomes are BRCA1 and BRCA2 genes found on? And what are the chances of developing cancer due to mutations in these genes?
BRCA1: **chromosome 17**
* ~70% will develop BC by 80 yrs old
* ~50% will develop ovarian cancer
* increased risk of bowel & prostate cancer
BRCA2: **chromosome 13**
* ~60% will develop BC by 80 yrs old
* ~20% will develop ovarian cancer
34
Name the types of breast cancer
Pre-invasive:
* **Ductal Carcinoma In Situ** (DCIS)
* **Lobular Carcinoma In Situ** (LCIS)
Invasive:
* **Invasive ductal carcinoma** (NST)
* **Invasive lobular carcinoma** (ILC)
Others:
* Inflammatory Breast Cancer
* Paget's Disease of the Nipple
Rarer types:
* Medullary
* Mucinous
* Tubular
35
What is ductal carcinoma in situ?
Pre-cancerous/cancerous **epithelial cells** of **breast ducts** localised to a **single area**
* Has potential to spread locally or become invasive
* Often picked up by mammogram screening
* Good prognosis
36
What is lobular carcinoma in situ?
Pre-cancerous, opccurs typically in **pre-menopausal** women
* Usually asymptomatic & undetectable on mammogram (diagnosed incidentally on breast biopsy)
* Increased risk of invasive BC in the future (~30%)
37
What is invasive ductal carcinoma of no specific type (NST)?
* Originates in cells from breast ducts
* 80% of invasive BC
* Can be seen on mammogram
38
What is invasive lobular carcinoma?
* Originates in breast lobule cells
* ~10% of invasive BC
* Not always visible on mammograms
39
How does inflammatory breast cancer present?
* 1-3% of breast cancers
* Presents similarly to **breast abscess** / **mastitis**
* **Swollen**, **warm**, **tender** breast with **pitting skin** (peau d'orange) + **nipple retraction**
* Doesn't respond to ABx
* Worse prognosis than other BC
40
What is Paget's disease of the nipple?
* Looks like **eczema** of the nipple
* **Erythematous**, **scaly rash**
* Indicates BC involving the nipple
* May represent DCIS or invasive BC
* Requires **biopsy**, staging & Tx
41
Who is breast cancer screening offered to? And how often?
* Women aged **50 - 70 yrs**
* Mammogram every **3 years**
42
What are 4 downsides to screening?
* Anxiety & stress
* Radiation exposure - small risk of causing BC
* Missing cancer --> false reassurance
* Unnecessary further tests/Tx
43
What are the clinical features of breast cancer?
* **Lumps** that are **hard**, **irregular**, **painless** or **fixed in place**
* **Nipple retraction**
* Skin **dimpling**/**oedema** (peau d'orange)
* **Lymphadenopathy** - axilla
* **bloody nipple discharge**
* **sx of hypercalcemia due to bone resorption of calcium into the blood**
44
What is the referral criteria for breast cancer?
**2 week wait referral** for suspected BC for:
* unexplained lump in breast or axilla in pts 30 yrs or above
* unilateral nipple changes in pts 50 yrs or above
* skin changes suggestive of BC
45
What is included in a triple diagnostic assessment for breast cancer? (4)
* **Clinical assessment** 1-5 score
* **Imaging** (USS / mammography) 1-5 score
* **Biopsy** (fine needle aspiration / core biopsy) 1-5 score
* ** followed by MDT concordance review**
1= normal
5= malignant
46
What imaging is done for breast cancer?
* **USS** - younger women, distinguish **solid** lumps from **cystic**
* **Mammogram** - older women, pick up **calcifications**
* **MRI** - screen higher risk women, further assess size/features of a tumour
47
What is included in a lymph node assessment?
* USS of axilla
* Ultrasound-guided biopsy of any abnormal nodes
* Sentinel lymph node biopsy
48
What are the 3 types of breast cancer receptors?
* **Oestrogen** receptors (ER)
* **Progesterone** receptors (PR)
* **Human epidermal growth factor** (HER2)
49
What is triple negative breast cancer?
Where breast cancer cells don't express any of the 3 receptors.
* Worse prognosis as it limits the Tx options for targeting the cancer
**Tx is CHEMOTHERAPY**
50
What are the 4 notable locations that breast cancer metastasis occur?
* **L**ungs
* **L**iver
* **B**ones
* **B**rain
51
What system is used to stage breast cancer?
**TNM**
* Tumour
* Nodes
* Metastasis
52
What are the management options for breast cancer?
* **Surgery**
* **Radiotherapy**
* **Chemotherapy**
* **Hormone therapy**
* Targeted treatments
53
What surgery is available to treat breast cancer?
* **Breast-conserving surgery** -wide local excision, usually coupled with radiotherapy
* **Mastectomy** - removal of whole breast
* **Axillary clearance** - removal of axillary lymph nodes (increased risk of chronic lymphoedema though)
54
What is chronic lymphoedema?
Chronic condition caused by **impaired lymphatic drainage** of an area.
* Tissues in areas affected become **swollen** with excess, protein-rich fluid (lymphoedema)
* Areas of lymphoedema are also **prone to infection** (lymphatic system plays role in immune system)
55
How do you manage chronic lymphoedema?
* **Manual lymphatic drainage**
* Compression bandages
* Weight loss
56
How is radiotherapy used?
Used in patients with breast-conserving surgery to **reduce risk of recurrence** (usually sessions daily for 3 weeks)
* High dose radiation is delivered from multiple angles to concentrate radiation on a targeted area
57
What are common side effects of radiotherapy?
* General fatigue from radiation
* Local skin & tissue irritation/swelling
* Fibrosis of breast tissue
* Shrinking of breast tissue
* Long term skin colour changes
58
What 3 scenarios is chemotherapy used in?
* **Neoadjuvant therapy** - shrink tumour before surgery
* **Adjuvant chemotherapy** - after surgery to reduce recurrence
* Treatment of **metastatic** / **recurrent** BC
* Ki67 +ve cancers
* high grade tumours
59
What 2 main first-line treatments are given to patients with **oestrogen-receptor positive** breast cancer?
* **Tamoxifen** for pre-menopausal women
* **Aromatase inhibitors** for post-menopausal women (e.g. letrozole, anastrozole, exemestane)
## Footnote
Given for **5-10** years
60
What is tamoxifen?
**Selective oestrogen receptor modulator** (SERM)
* blocks oestrogen receptors in breast tissue
* stimulates oestrogen receptors in uterus & bones (helps prevent osteoporosis, but increases risk of endometrial cancer)
61
What is aromatase?
**Enzyme** found in **fat tissue** that converts **androgens** to **oestrogen**
* Aromatase inhibitors block the creation of oestrogen in fat tissue
62
What treatments may be given to patients with **HER2 positive** breast cancer?
* **Trastuzumab** (Herceptin) - targets HER2 receptor. Can affect heart function so monitoring is required
* **Pertuzumab** (Perjeta) - also targets HER2 receptor, used in combination with trastuzumab
* **Neratinib** (Nerlynx) - tyrosine kinase inhibitor, reduces growth of breast cancers
* give chemotherapy also
63
What are the options for reconstructive breast surgery?
* **Immediate** or **delayed**
* **Partial reconstruction** - using a flap/fat tissue to fill gap
* **Reduction & reshaping** - removing tissue & reshaping both breasts to match
* After mastectomy - **breast implants** or **flap reconstruction** (using tissue from another part of body)
64
Pros and cons of breast implants?
Pros
* Relatively simple procedure compared to flap
* Minimal scarring
* Acceptable appearance
Cons
* Feels less natural (cold, less mobile, static size & shape)
* Long term problems - hardening, leakage, shape change
65
What are the types of flap reconstructions?
* **Latissimus dorsi flap**: either **pedicled** (with blood supply) or **free** flap
* **TRAM flap** (transverse rectus abdominis - poses risk of abdominal hernia due to weakened abdo wall): either pedicled or free flap
* **DIEP flap** (deep inferior epigastric perforator): free flap.
* Deep inferior epigastric artery w/ associated fat, skin and veins is transplanted from abdo to breast - vessels attached to branches of internal mammary artery & vein (less risk of abdo hernia as abdo wall left in tact)
66
What is a fibroadenoma?
## Footnote
"breast mouse"
* Common benign tumour of stromal/epithelial **breast duct tissue**
* Typically **small** & **mobile**
* More common in younger women (**20 - 40 yrs**)
* Respond to female hormones (oes & prog), often regress after menopause
67
How do fibroadenomas present on examination?
* Painless
* Smooth
* Round
* Well-defined borders
* Firm
* Mobile
* Up to 3cm diameter
68
What are breast cysts?
* Benign, individual, **fluid-filled** lumps
* Most common between **30-50 yrs**
* Can be painful and may fluctuate in size over menstrual cycle
* Require further assessment to exclude cancer w/ imaging & aspiration/excisio
* Having breast cyst may slightly increase risk of breast cancer
69
How do breast cysts present on examination?
* Smooth
* Well-defined borders
* Mobile
* Possible fluctuant
70
What is a breast abscess?
Collection of **pus** in breast, usually caused by **bacterial infection**
2 types:
* **Lactational abscess** (associated w/ breastfeeding)
* **Non-lactational abscess** (unrelated to breastfeeding)
71
What is mastitis?
**Inflammation** of breast tissue, often related to breastfeeding, but can be caused by infection
* mastitis caused by infection may precede development of an abscess
72
What are 4 risk factors for infective mastitis and breast abscesses?
* **Smoking**
* Damage to nipple (e.g. eczema, candidal infection, piercings - provide bacteria entry)
* Underlying breast disease (e.g. cancer) can affect **drainage** of breast - predisposing to infection
* immunocompromised
73
What are the most common causative bacteria for breast abscesses?
* **Staph aureus** - MC
* **Streptococcal** species
* **Enterococcal** species
* **Anaerobic bacteria**
74
How does a breast abscess present?
* **Fluctuant** lump - able to **move fluid around within lump **using pressure during palpation
* Nipple changes
* Purulent nipple discharge
* Localised pain
* Tenderness
* Warmth
* Erythema (red)
* Hardening of skin/breast tissue
* Swelling
* Generalised infection Sx - aches, fatigue, fever, sepsis signs
75
What is the management of mastitis?
Lactational mastitis
* **conservative** Tx
* continue breastfeeding
* heat packs & warm showers
* simple analgesia, then **antibiotics** where infection is suspected
Non-lactational mastitis
* Analgesia
* ABx - **broad spectrum** (co-amoxiclav, erythromycin/clarithromycin PLUS metronidazole)
* treat underlying cause (e.g. eczema or candidal infection)
76
What is the management of a breast abscess?
* Referral to on-call surgical team
* ABx
* USS (confirm Dx)
* Drainage (needle aspiration / surgical incision & drainage)
* MC+S of fluid
77
Describe the hypothalamic-pituitary-gonadal axis
1. Hypothalamus releases **gonadotrophin-releasing hormone** (GnRH)
2. GnRH stimulates **anterior pituitary** to produce **luteinising hormone** (LH) & **follicle-stimulating hormone** (FSH)
3. LH & FSH stimulate development of **follicles** in the **ovaries**
4. **Theca granulosa cells** around follicles secrete **oestrogen**
5. Oestrogen has a **negative feedback** effect on the **hypothalamus** and **anterior pituitary** to suppress the release of **GnRH**, **LH** & **FSH**
78
What is oestrogen? And what does it do?
* **Steroid sex hormone** produced by ovaries in response to LH & FSH
* Acts on tissues with **oestrogen receptors** to promote **female secondary sexual characteristics**
* Stimulates: breast tissue development, growth/development of female sex organs at puberty, blood vessel development in uterus, development of endometrium
79
What is the most prevalent and active version of oestrogen?
**17-beta oestradiol**
80
What is progesterone? And what does it do?
* **Steroid sex hormone** produced by **corpus luteum** after **ovulation**
* When pregnant, progesterone is mainly produced by **placenta** from 10 weeks gestation
* Acts on tissues that have previously been stimulated by **oestrogen**
* Acts to: thicken & maintain endometrium, thicken cervical mucus, increase body temp
81
Reason why mammograms only offered from 50-70 (3)
-rare to get breast cancer before 50
-glandular breast tissue (white) will obscure the potential cancer (white) older women have more fatty tissue (black) so easier to see
-not cost effective to screen everyone
82
How are women with BRCA mutations screened
-From 30 years
-MRI
-every year
83
Mammogram findings of DCIS
Branching micro calcification following ducts
84
Lobular cancer growth pattern
They form thickenings/sheets grow outwards unlike DCIS which is hard lump
85
Reasons for doing mastectomy (4)
-high chance of reoccurrence - e.g BRCA mutation gene carrier
-people who cant have radiotherapy (as radiotherapy has to happen after breast conserving surgery)
-patient preference
-big breast cancer **and** small breasts
86
What occurs in a Sentinel node biopsy
-Radioactive dye injected near site of cancer
-to see how it drains
-if lymph nodes have absorbed it they are removed and analysed for cancer
87
Tx for inflammatory breast cancer
-Mastectomy and anxillary node clearance
-adjuvant radiotherapy
