Causes of Urinary Incontinence
Reversible causes of Urinary Incontinence (DIAPPERS)
- 1. Medications
- 2. Excess urine output (eg. congestive heart failure, diabetes mellitus)
- 3. Alcohol
- 4. Delirium due to any cause.
- 5. Restricted mobility and stool Impaction
Medications that commonly cause Urinary Incontinence
- • Alpha-adrenergic antagonists (urethral relaxation)
- • Antichollnergics, opiates, calcium channel blockers (urinary retention/overflow)
- • Diuretics (excess urine production)
Evaluation of Urinary Incontinence in Elderly
- As older adults often lack typical signs or symptoms of UTI, urinalysis with culture should be obtained routinely.
- Once infection is excluded, additional testing is based on clinical findings that suggest other etiologies (eg, focal neurologic deficits, cognitive Impairment, systemic symptoms)
It is an anticholinergic agent, is indicated for urge incontinence or overactive bladder symptoms.
Indications of endometrial Biopsy
Abnormal uterine bleeding (AUB)
- It is any menstrual bleeding that is heavy, lasts more than 7 days, or occurs more often than every 21 days or less frequently than every 35 days.
- Other than pregnancy, AUB may be due to structural causes (eg, fibrolds, adenomyosis, endometrial polyps, endometrial hyperplasia/malignancy) or nonstructural conditions (eg, coagulopathy, ovulatory dysfunction).
Work up Of Abnormal Uterine Bleeding
- Once pregnancy is ruled out, the initial workup for AUB includes a complete blood count along with pelvic ultrasound to evaluate for structural abnormalities.
- In a patient age less than 45 with AUB and risk factors for endometrial hyperplasia (eg, obesity, oligomenorrhea), endometrial biopsy is also indicated.
- Prolonged periods of oligomenorrhea (eg, menses less than every 35 days for 5 years) is evidence of chronic anovulation and increased risk of abnormal endometrial proliferation.
- Evaluation for endometrial hyperplasia or malignancy is also necessary in all patients age more than 45 with AUB.
Causes of abdominal pain in a sexually active female
- 1. Gastrointestinal (GI) : peptic ulcer disease, appendicitis, bowel obstruction or perforation.
- 2. Genitourinary: kidney stone
- 3. Ectopic pregnancy, ovarian torsion, pelvic inflammatory disease)
- 4. Vascular (eg, bowel ischemia), and
- 5. Musculoskeletal
Evaluation of Abdominal pain in a young female
- A pregnancy test should be performed first as early pregnancy can present with Gl symptoms including nausea, vomiting, abdominal bloating, and constipation.
- In addition, pregnancy should be excluded before exposing this patient to any tests involving radiation (eg, x-ray, CT scan).
Radiation Exposure in a Embryo
- An embryo exposed to ionizing radiation during the first 14 days after conception may survive undamaged, but is often severely injured and subsequently resorbed.
- Further, exposure after the first 14 days frequently leads to developmental defects.
Causes of abnormal menstrual bleeding
- It is a benign condition characterized by the presence of endometrial glands in the uterine muscle. These glands invade the uterine musculature and cause blood deposits inside the myometrium as the endometrium cycles.
- The disruption of the arrangement of the smooth muscle fibers interferes with normal uterine contraction and causes dysmenorrhea and heavy menstrual bleeding.
Clinical Features and Treatment of Adenomyosis
- The typical presentation is a patient age more than 40 with new-onset dysmenorrhea that can progress to chronic pelvic pain.
- The uterus gradually increases in size due to accumulation of blood within the myometrium but remains smaller than 12 weeks, located below the pubic symphysis.
- On examination, the symmetrically enlarged uterus may feel boggy, globular and tender.
- Definitive diagnosis is made with surgical pathology after hysterectomy.
Work Up of a case of Adenomyosis
- The initial diagnostic workup of suspected adenomyosis consists of pelvic ultrasonography and/or MRI.
- The gold standard for definitive diagnosis is histopathologic examination of a hysterectomy specimen.
- Hysterectomy is the definitive treatment if hormonal methods (oral contraceptives, levonorgestrel intrauterine device) are unsuccessful.
Risk Factors for Ovarian Cancer
- 1. Age
- 2. Use of fertility drugs,
- 3. Uninterrupted ovulation (eg, nulligravidity), and
- 4. BRCA mutation
Work up of Ovarian mass in Post menopausal women
- CA-125 levels are measured in conjunction with pelvic ultrasonography findings to categorize an ovarian mass as likely malignant or benign.
- If there are suspicious features on ultrasound (eg, large mass, solid components, septations) and/or if the CA-125 level is elevated, the patient should undergo further imaging (eg, MRI, CT scan) to assess the extent of disease.
- It is the result of high levels of prolactin, which has an inhibitory effect on the production of the hypothalamic gonadotropin-releasing hormone (GnRH).
- Pulsatile GnRH release from the hypothalamus is necessary for the production and release of LH and FSH by the anterior pituitary. LH and FSH stimulate the ovary to induce ovulation.
- By inhibiting GnRH, and therefore LH and FSH, prolactin prevents ovulation and menstruation.
- Because lactation suppresses ovulation, it is a natural form of contraception for the first 6 months postpartum if the mother is breastfeeding exclusively.
- After the first 6 months, more than 50% of women resume ovulation and another form of contraception should be considered.
Sheehan syndrome (postpartum hypopituitarism)
- It is characterized by absent LH and FSH production as well as low prolactin levels due to postpartum hemorrhage causing pituitary infarction.
- Clinical consequences include inability to lactate, amenorrhea and hypotension.
Amenorrhea in female Athletes
- It is thought to occur in female athletes when there is a relative caloric deficiency secondary to inadequate nutritional intake as compared to the amount of energy expended.
- Women athletes with this condition have been shown to have decreased levels of luteinizing hormone (LH) and gonadotropin-releasing hormone (GnRH), resulting in an estrogen deficiency.
- These amenorrheic women are therefore at increased risk for all conditions associated with estrogen deficiency, including infertility, vaginal atrophy, breast atrophy, and osteopenia.
Pathophysiology of functional hypothalamic amenorrhea
Functional hypothalamic amenorrhea
- It is defined as suppression of the hypothalamic-pituitary-ovarian (HPO) axis without a known anatomic (eg, uterine malformation) or metabolic (eg, hyperprolactinemia) cause.
- It may occur in women who undergo excessive physical training (with or without weight loss or caloric restriction), as well those with anorexia nervosa, marijuana use, starvation, stress, depression and chronic illness.
- Studies have suggested that fat restriction in the diet may play a role.
- Factors implicated in suppression of the HPO axis are low body fat mass and leptin, and elevated Ghrelln, neuropeptide Y, GABA, beta-endorphin, and corticotropin-releasing hormone.
- Patients are at high risk for bone loss despite physical training due to low estrogen levels offsetting the bone-building effects of exercise.
Obesity and Amenorrhea
- Obesity is a common cause of amenorrhea.
- The amenorrhea is the result of anovulation.
- The FSH and LH levels are usually normal.
- The ovaries are still producing estrogen, but progesterone is not being produced at the normal post ovulation levels. Therefore, progesterone withdrawal menses at the end of the cycle does not occur.
Treatment of Functional Hypothalamic Amenorrhea
Treatment is first behavioral (eg, increased caloric intake) but should also include estrogen repletion for those unable or unwilling to treat the underlying etiology (eg, unable to decrease stress levels, refuse to modify exercise patterns).
Side effect of a progestin-containing intrauterine device (IUD)
Disorders of sexual development
- It refers to absence of menses by age 15 in someone who has normal growth and secondary sexual characteristics.
- Most cases of primary amenorrhea are due to anatomical or genetic anomalies that affect the structures required for menstruation (ovaries, uterus, and vagina).
Androgen insensitivity syndrome (AIS)
- Diagnostic features: male karyotype, male testosterone levels, breast development, primary amenorrhea (absent ovaries, uterus, and cervix), and minimal pubic and axillary hair.
- AIS is also known as testicular feminization and results from an end-organ resistance to androgens secondary to a mutated androgen receptor. These patients have functioning testes (due to the 46,XY karyotype) that secrete anti-Millerian hormone (AMH) and testosterone.
- AMH stimulates regression of the Mullerian ducts resulting in no uterus, cervix, or upper vagina. However, masculinization does not occur due to androgen resistance in these patients, the Wolffian ducts degenerate, the fetal urogenital sinus cannot differentiate into a penis and scrotum, and male secondary sex characteristics (eg, body hair, voice deepening) are minimal or absent.
- The fetal urogenital sinus defaults into external female genitalia and testosterone is aromatized into estrogen to stimulate breast development.
- They are located bilaterally at the posterior introitus and drain through ducts into the vestibule at the 4 and 8 o'clock positions.
- These pea-sized glands provide lubrication to the vestibule and are not palpable unless ductal blockage occurs, resulting in fluid buildup and cyst formation.
Bartholin gland cyst
- It is common in women age less than 30.
- Physical examination shows a mobile, soft, nontender, well-circumscribed mass behind the labium majus, with vaginal extension.
- Small cysts may be diagnosed incidentally on routine examination, or a partner may discover it during sexual activity.
- Larger cysts may cause discomfort during sexual activity, walking, sitting, or exercise.
- Symptomatic cysts require incision and drainage, followed by Word catheter placement.
Gartner duct cyst
- It results from incomplete regression of the Wolffian duct during fetal development.
- These cysts may be single or multiple and are submucosal along the lateral (parallel) aspects of the upper anterior vagina.
- In contrast to Bartholin gland cysts, they do not involve the vulva.
Management of a Bartholin gland cyst
- An asymptomatic Bartholin cyst in a young woman does not require intervention.
- Observation is recommended as spontaneous drainage and resolution may occur.
- Symptomatic cysts are treated the same as a Bartholin abscess, with incision and drainage.
- Placement of a Word catheter after drainage reduces the risk of recurrence.
Mastitis and Breast Abscess
- Incomplete emptying of the breast (eg, poor latch, alternating breast and bottle feeds) is also a risk factor for milk stasis resulting in mastitis.
- In turn, persistent or severe mastitis can lead to focal pus collection (abscess).
- Mastitis and breast abscess are most commonly caused by Staphylococcus aureus, which enters the breast through nipple trauma (eg, nipple chafing/blisters from poor latch).
Diagnosis and Management of Breast Abscess
- Findings suggestive of an abscess include signs of mastitis - localized erythema/pain, fever, and malaise - along with a fluctuant, tender, palpable mass.
- The diagnosis is made clinically, and an ultrasound may be required to differentiate severe mastitis from an abscess if a mass is deep within the tissue.
- Needle aspiration of a breast abscess, usually under ultrasound guidance, and antibiotics (eg, dicloxaclllln, cephalexin) for the surrounding mastitis are first-line treatments.
- Continued breastfeedlng is recommended for continued milk drainage.
Selective Estrogen Receptor Modulators
Mechanism of Hot Flashes caused by Tamoxifen
- Hot flashes are the most common side effect experienced by up to 80% of patients taking tamoxifen.
- Tamoxifen is theorized to exhibit antiestrogenic activity in the central nervous system and to cause thermoregulatory dysfunction in the anterior hypothalamus via a mechanism similar to the pathophysiology of menopausal hot flashes.
- Pruritus is usually the primary symptom; dysuria and dyspareunia are also common.
- Vaginal discharge is typically thick and white "cottage cheese" appearance and adheres to the vaginal walls but may be scant in some patients.
- Risk factors include pregnancy, diabetes mellitus, Steroids and recent antibiotic use.
- Oral ( fluconazole) and intravaginal agents are equally efficacious in treating Candida vaginitis.
- Sexual partners do not require treatment.
Differential Diagnosis of vaginitis
Human Papilloma Virus
- It is the most common sexually transmitted infection and has been linked to multiple diseases, including condylomata acuminata as well as vulvar, vaginal, anal, oropharyngeal, and cervical cancer.
- Persistent HPV infection (particularly with types 16 and 18) results in cellular dysplasia as the incorporation of viral DNA creates increased pro oncogenic protein expression and inhibits normal cellular regulation.
- The HPV vaccination induces an antibody response that decreases the risk of future HPV infection and subsequent related diseases.
- Routine administration of the vaccine series begins at age 11-12, and catch-up vaccination should be offered until age 26 for patients who are either unvaccinated or did not complete the series
Pap Smear Testing
- Pap testing begins at age 21 in immunocompetent patients regardless of the age of onset of sexual activity or number of sexual partners.
- Although most young women (age <30) become Infected with HPV shortly after the onset of sexual activity, the infection is typically cleared and does not progress to cervical dysplasia or cancer.
Progression of Cervical cancer
Epithelial Ovarian Carcinoma
- The greatest risk factor for epithelial ovarian cancer is a family history of ovarian cancer at any age, even without hereditary mutations such as BRCA 1 or BRCA2.
- Additional risk factors include early menarche and late menopause, age more than 50, infertility, nulliparity, and endometriosis.
- Protective factors are combined oral contraceptive use, breastfeeding, and multiparity, as these conditions decrease the number of times that ovulation occurs.
- Anovulation decreases repeated cellular damage and repair that normally occurs on the epithelial surface of the ovary, thereby reducing the risk of oncogenic transformation.
Atypical squamous cells of undetermined significance (ASC-US)
- It refers to a Pap test with cervical cells that demonstrate reactive changes, and is the most common abnormal finding on Pap test.
- ASC-US alone does not meet cytologic criteria for premalignant disease.
- To determine if these atypical cells are indicative of an increased risk for cervical intraepithelial neoplasia (CIN), high-risk HPV co-testing is performed.
- With negative HPV co-testing, there is no increased risk for cervical cancer with an ASC-US Pap test.
CIN and Ca Cervix
- Risk Factors: Human papillomavirus infection and tobacco use
- Colposcopy is the gold standard method of diagnosing CIN.
- CIN 3 is a premalignant cervical lesion at high risk of progressing to SCC
- Cervical conization, excision of the intact transformation zone is the recommended treatment.
- Cervical conization may be performed with a scalpel (cold knife conization) or via electrocautery, also known as a loop electrosurglcal excision procedure (LEEP).