Bacterial vaginosis

Disease class: Bacterial infections

This refers to a disturbance of the natural microbiome in the vagina.

 

Symptoms and signs

• Foul vaginal smell

 

Pathophysiology

• Loss of natural lactobacillus bacteria.
• Overgrowth of other bacterial species. 

 

Aetiology

• Usually caused by douching and other excessive hygiene routines. 
• One contributing factor is sexual transmission of micro-organisms. There is a positive correlation with the number of sexual partners and sexual activity.

 

Associated microorganisms / Pathogens

• Gardnerella vaginalis

Vulvitis

Disease class: Vulvar diseases

This refers to inflammation of the vulvae (the external female genitalia). 

The vulva includes the mons pubis, labia majora, labia minora, clitoris, vestibular bulbs, vulval vestibule, urinary meatus, the vaginal opening, and Bartholin's and Skene's vestibular glands.

Vaginitis

Disease class: Vaginal diseases

This refers to inflammation of the vagina.

Uterine cervicitis

Disease class: Uterine cervical diseases

 

Parametritis

Disease class: Pelvic Inflammatory Disease

Oophoritis

Disease class: Ovarian diseases
Disease class: Pelvic Inflammatory Disease

This refers to inflammation of the ovaries.

Endometritis

Disease class: Pelvic Inflammatory Disease

Disease class: Uterine diseases

This refers to inflammation of the uterus.

[Obstetrics and gynaecology] Introduction

Gynaecologists specialise in disease of the female genitourinary system. This includes the vagina, cervix, uterus, fallopian tubes, and ovaries.

Obstetricians specialise in diseases of pregnancy.

There is great overlap between obstetrics and gynaecology, and they are impossible to separate in early training. Many senior physicians are able to eventually subspecialise.

There is significant overlap with urology, and genitourinary medicine.

 

Etymology

Latin obstētrīx, obstētrīcis = midwife

Ancient Greek γυνή (gunḗ) = woman
Ancient Greek λογία (logia) = study

 

History taking 

• Obstetrics 
• Gynaecology 

 

Physical examination

• Pelvic examination
• Speculum examination
• Bimanual vaginal examination
• Obstetric examination

 

Procedures

 

Common presentations

• Reduced fetal movements (RFM)
• Suspected miscarriage 
• Labour complications 
• Referral from midwife or GP 

• Menorrhagia 
• Dysmenorrhoea 
• Amenorrhoea
• Dysuria
• Urinary incontinence
• Dyspareunia 
• Dysorgasmia
• Infertility 

 

Female urogenital diseases and Pregnancy complications

 

Conditions 

• Gestational diabetes
• Pre-eclampsia 
• Eclampsia
• Polyhydramnios
• Oligohydramnios
• Hyperemesis gravidarum
• Placenta praevia
• Placental abruption 
• Postpartum bleeding
• Intrahepatic cholestasis of pregnancy
• Postpartum depression
• Postpartum psychosis
• Molar pregnancy 
• Ectopic pregnancy 
• Ruptured ectopic pregnancy 
• Rhesus disease
• Sheehan's syndrome
• Pelvic inflammatory disease
• Salpingitis
• Tubo-ovarian abscess 
• Pelvic organ prolapse  
• Ovarian cyst 
• Ruptured ovarian cyst   
• Polycystic ovarian syndrome (PCOS)  
• Premature ovarian failure  
• Uterine cancer 
• Ovarian cancer
• Turner syndrome 

Frasier syndrome

Disease class: Chronic kidney failure

Ambiguous genitalia

Disease class: Disorders of sex development

Hypochromic anaemia

Disease class: Anaemia

Types

• anaemia, Iron-Deficiency

Disorders of sex development

Disease class: Gonadal disorders

 

Hypogonadism

Disease class: Gonadal disorders

Types

• Eunuchism
• Kallmann syndrome
• Klinefelter syndrome
• Sexual infantilism

Postmenopausal bleeding

Disease class: Metrorrhagia 

Postmenopausal bleeding is defined as vaginal bleeding occurring after twelve months of amenorrhoea, in women at the age where the menopause can be expected. It can, however, occur in younger women who have experienced premature ovarian failure or premature menopause. Postmenopausal bleeding is usually benign, however, endometrial malignancy should be ruled out with urgency.

Causes

• The most common cause of postmenopausal bleeding is vaginal atrophy: The thinning, drying, and inflammation of the walls of the vagina due to a reduction in oestrogen following the menopause can result in vaginal bleeding
• HRT (hormone replacement therapy) is also a common cause of postmenopausal bleeding: Periods or spotting can continue in some women taking HRT for many months with no pathological cause, or endometrial hyperplasia due to long-term oestrogen therapy may occur, which can also cause bleeding
• Endometrial hyperplasia, an abnormal thickening of the endometrium and a precursor for endometrial carcinoma: Risk factors include obesity, unopposed oestrogen use, tamoxifen use, polycystic ovary syndrome and diabetes
• Endometrial cancer: Although 10% of patients with postmenopausal bleeding have endometrial cancer, up to 90% of patients with endometrial cancer present with postmenopausal bleeding, meaning it must be ruled out urgently
• Cervical cancer: It is important to obtain a full record of prior cervical screening programme attendance
• Ovarian cancer: Can present with postmenopausal bleeding, especially oestrogen-secreting (theca cell) tumours
• Vaginal cancer: Uncommon but can present with postmenopausal bleeding
• Other uncommon causes include trauma, vulval cancer and bleeding disorders

Investigations

• NICE guidelines state that women over the age of 55 with postmenopausal bleeding should be investigated within two weeks by ultrasound for endometrial cancer¹
• A thorough history is necessary: Enquire about timing, consistency and quantity of the bleeding, as well as a full gynaecological and obstetric history. It is especially important to ask about risk factors for endometrial cancer and to establish a menstrual timeline from menarche to menopause. A full drug history including HRT use should be sought. Red flag symptoms for gynaecological cancer should be enquired about¹
• A vaginal and a full abdominal examination should be performed: Looking for any masses or abnormalities within the abdomen or felt from within the vagina, as well as a speculum visualisation of the walls of the vagina and cervix. Blood or discharge may be seen
• Immediate testing could include a urine dipstick to look for haematuria or infection, a full blood count to look for anaemia or a bleeding disorder, as well as CA-125 levels
• For those referred on a cancer pathway within two weeks, a transvaginal ultrasound is the investigation of choice: The endometrial lining thickness is assessed, for post-menopausal women with bleeding, an acceptable depth is <5mm. However, it may miss some pathology and if clinical suspicion is high, further testing is required
• A definitive diagnosis of endometrial cancer can be achieved by an endometrial biopsy: This can either be taken during hysteroscopy or by an aspiration (pipelle) biopsy, where a thin flexible tube is inserted into the uterus via a speculum to remove cells for testing
• Imaging in secondary care could include a CT or MRI of the uterus, pelvis and abdomen
• Women on HRT with postmenopausal bleeding still need to be investigated to rule out endometrial cancer

Management

• Once a more serious diagnosis has been ruled out, the following can be used to treat the more common causes of postmenopausal bleeding
• Vaginal atrophy: Topical oestrogens and lifestyle changes such as lubrication can help reduce the symptoms of vaginal atrophy, HRT can also be used
• If a bleed is due to the type of HRT that the patient is on, different HRT preparations can be used to try to reduce this
• In the case of endometrial hyperplasia, usually dilatation and curettage is performed to remove the excess endometrial tissue

Herpes genitalis

Disease class: Herpes simplex 
Disease class: Male genital diseases

Pathogen: Herpes simplex virus

Metrorrhagia

Disease class: Uterine haemorrhage

 
This term describes vaginal bleeding outside the menstruation phase of the menstrual cycle. 

Subtypes

• Intermenstrual bleeding
• Postmenopausal bleeding 

Menorrhagia

Disease class: Uterine haemorrhage

This describes excessive volumes of blood lost through the vagina during menstruation. Generally the definition of excessive bleeding is "an amount which the woman considers unusual for her". 

Osteoporosis

Disease class: bone diseases, Metabolic

[Urology] Procedures

General urinary tract investigations

• Radiograph: Kidneys, Ureters, and Bladder (KUB)
• Intravenous pyelogram
• CT urography

Bladder

• Cystoscopy
• Suprapubic cystostomy

Prostate

• Transurethral resection of the prostate
• Prostate biopsy 

Vas deferens

• Vasectomy 
• Vasovasostomy (vas deferens to vas deferens) 
• Vasoepididymostomy (epididymis to vas deferens connection)

Urethra

• Urinary catheterisation
• Retrograde urethrogram
• Urethrotomy
• Urethroplasty
• Urethral bulking injections (gynaecology)

Penis

• Penile plethysmography (PPG)
• Penile prosthesis
• Penectomy

Foreskin and frenulum

• Preputioplasty
• Superincision
• Circumcision
• Frenuloplasty of prepuce of penis

Testicles 

• Orchiopexy
• Orchidectomy (Gonadectomy)

[Obstetrics and gynaecology] Procedures

Introduction to obstetrics and gynaecology

Procedures

 

Gynaecology

Contraception

• IUD insertion
• Tubal ligation

Cervical dysplasia

• Papanicolaou smear collection
• Colposcopy
• Cervical conisation
• Loop electrical excision procedure

 Haemorrhagia 

• Endometrial ablation
• Uterine artery embolisation 

Miscarriage / abortion

• Vacuum aspiration

 Infertility

• Hysterosalpingogram (HSG)

Investigations

• Hysteroscopy
• Falloposcopy
• Endometrial biopsy

Removal of growths or entire organs

• Cervicectomy
• Salpingectomy
• Oophorectomy 
• Salpingoophorectomy 
• Uterine myomectomy
• Hysterectomy 
• Pelvic exenteration 

 

Obstetrics

Prenatal diagnostics

• Cardiotocography
• Chorionic villus sampling
• Amniocentesis 

Prenatal intervention

• External cephalic version 
• Fetal surgery

Perinatal intervention

• Induction
• Amniotomy (artificial rupture of membranes)
• Episiotomy (perineotomy) 
• Symphysiotomy
• Vacuum extraction
• Forceps extraction 
• Dystocia management
• C-section (Caesarean section) 

Postnatal intervention

• Manual placenta removal  
• B-Lynch suture