Gynaecology: Pelvic floor ovary and vulva

🩺 Pelvic floor, ovarian and vulval problems -prolapse and urinary incontinence affect many women after childbirth and the menopause, yet are often hidden through embarrassment; simple pelvic floor exercises help most. Ovarian cysts are common and usually benign, but ovarian torsion is a surgical emergency, and any pelvic mass in an older woman needs assessment for cancer. Vulval itching in an older woman is often lichen sclerosus, which needs treatment and follow-up.
Your four questions for every patient: Could she be pregnant (pelvic pain)? Is this an emergency (torsion, bleeding, sepsis)? Is there a risk of cancer (pelvic mass, CA125, vulval lesion)? How much is this affecting her life -and what does she want to do about it?

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Pelvic Organ Prolapse

• What it is: One or more pelvic organs bulge down into or out of the vagina because of weak support (pelvic floor muscles and ligaments).
• Types:
  • Anterior wall -cystocele (bladder); urethrocele.
  • Posterior wall -rectocele (rectum); enterocele (small bowel, upper posterior wall).
  • Apical -uterine prolapse; vault prolapse (after hysterectomy).
  • Procidentia -the whole womb outside the vagina.
• Risk factors:
  • Vaginal childbirth (especially large babies, forceps, long second stage).
  • Age and menopause (low oestrogen).
  • Obesity; chronic cough; constipation and straining; heavy lifting.
  • Previous hysterectomy; connective tissue disorders (Ehlers–Danlos).
• Symptoms:
  • A feeling of a lump or something "coming down"; dragging; worse at the end of the day or after standing.
  • Bladder -frequency, urgency, incomplete emptying, slow stream, needing to push the bulge back to void, recurrent UTIs.
  • Bowel -incomplete emptying, needing to press on the perineum or vagina to open the bowels (rectocele).
  • Sexual problems; ulceration and bleeding (procidentia).
• Examination -Sims' speculum in the left lateral position; ask her to bear down; grade the prolapse (e.g. POP-Q stages 0–4). Check for incontinence (cough test), and examine the abdomen for a mass (rare -a pelvic mass can push organs down).

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Treating Prolapse

• No symptoms -no treatment needed; advise on risk factors.
• Conservative (NICE NG123):
  • Lifestyle -weight loss, treat constipation and cough, avoid heavy lifting.
  • Supervised pelvic floor muscle training for at least 16 weeks -helps mild to moderate prolapse.
  • Vaginal oestrogen -if vaginal atrophy, especially with a pessary.
• Vaginal pessaries:
  • Ring (most common), shelf, Gellhorn, cube.
  • Good for women who don't want or are unfit for surgery, or are planning more children.
  • Changed or cleaned every 6–12 months (or self-managed).
  • Complications -discharge, bleeding, ulceration, rarely fistula or impaction (neglected pessary).
• Surgery:
  • Anterior or posterior repair (colporrhaphy).
  • Vaginal hysterectomy with repair (uterine prolapse); uterus-sparing procedures (sacrohysteropexy).
  • Vault prolapse -sacrocolpopexy, sacrospinous fixation.
  • Colpocleisis -closing the vagina (for frail women who are not sexually active).
  • Mesh -transvaginal mesh for prolapse is no longer used in the NHS (high-vigilance restrictions since 2018 because of serious complications -pain, erosion). Mesh is still used in some abdominal procedures with strict governance.

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Urinary Incontinence -Assessment

Type	Features
Stress incontinence	Leaking with coughing, sneezing, laughing, exercise -weak pelvic floor or urethral sphincter
Urge incontinence (overactive bladder)	Sudden strong urge to pass urine with leaking before reaching the toilet; frequency, nocturia -overactive detrusor muscle
Mixed incontinence	Both -treat the main symptom first
Overflow incontinence	Dribbling from a full bladder that doesn't empty -obstruction or an underactive bladder (diabetes, neurological disease, drugs)
Functional incontinence	Normal bladder but can't get to the toilet in time -mobility, dementia
Fistula	Continuous leaking (vesicovaginal fistula -after surgery, radiotherapy or obstructed labour)

• Assessment (NICE NG123):
  • History -type, triggers, fluid intake (especially caffeine and alcohol), drugs (diuretics), bowel function, effect on life.
  • Bladder diary for at least 3 days (frequency, volumes, leaks, drinks).
  • Urine dipstick -infection, blood, glucose; culture if symptoms of infection.
  • Post-void residual (bladder scan) -if voiding symptoms or suspected retention.
  • Examination -abdominal (bladder), vaginal (prolapse, atrophy, pelvic floor strength), neurological if indicated.
  • Urodynamics -before surgery for stress incontinence if the type is unclear, or after failed treatment.
• Red flags (refer) -visible haematuria, recurrent UTIs with haematuria in older women, pelvic mass, suspected fistula, palpable bladder after voiding, neurological symptoms (cauda equina -urgent), previous pelvic cancer surgery or radiotherapy.

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Stress Incontinence

• Risk factors -pregnancy and vaginal birth, menopause, obesity, chronic cough, constipation, prolapse, previous pelvic surgery.
• Treatment:
  • Lifestyle -weight loss (BMI over 30), reduce caffeine, avoid too much or too little fluid, stop smoking.
  • Supervised pelvic floor muscle training for at least 3 months -at least 8 contractions three times a day (first line; helps most). Biofeedback or electrical stimulation if she can't contract the muscles.
  • Vaginal oestrogen for atrophy (doesn't treat stress incontinence on its own).
  • Duloxetine -second line if surgery isn't wanted or suitable (nausea common).
  • Vaginal devices (continence pessaries) for exercise.
  • Surgery (if conservative measures fail):
    • Colposuspension (open or laparoscopic).
    • Autologous rectus fascial sling.
    • Urethral bulking agents -less invasive, less durable.
    • Mid-urethral mesh tapes (TVT, TOT) -under strict restrictions since 2018 in the UK (pain and erosion concerns); used only with full informed consent in specialist centres.

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Overactive Bladder and Urge Incontinence

• Overactive bladder -urgency, with or without urge incontinence, usually with frequency and nocturia, without infection or other disease.
• Causes and triggers -idiopathic (most); caffeine, alcohol, fizzy drinks; UTI (exclude); bladder stones or cancer (haematuria); neurological disease (MS, Parkinson's, stroke, spinal injury); drugs (diuretics); atrophy; constipation.
• Treatment (step up):
  • Lifestyle -reduce caffeine and fizzy drinks; fluid intake about 1.5–2 L a day; weight loss; treat constipation.
  • Bladder training for at least 6 weeks -gradually increasing the time between voids.
  • Vaginal oestrogen if postmenopausal with atrophy.
  • Antimuscarinic drugs -e.g. solifenacin, tolterodine, fesoterodine, trospium:
    • Side effects -dry mouth, constipation, blurred vision, urinary retention, confusion.
    • Anticholinergic burden -linked to falls and cognitive decline and dementia in older people. Avoid oxybutynin (immediate release) in frail older women; consider the total burden.
    • Contraindicated in angle-closure glaucoma, myasthenia, urinary retention.
  • Mirabegron (beta-3 agonist) -if antimuscarinics are contraindicated, not tolerated, or not effective; or preferred in older people. Check BP (avoid in severe uncontrolled hypertension). Vibegron is another option.
  • Review drug treatment at 4 weeks.
  • Specialist -urodynamics; botulinum toxin A injections into the bladder (may need self-catheterisation); percutaneous tibial nerve stimulation; sacral nerve stimulation; augmentation cystoplasty (rarely).
• Nocturia -also consider heart failure, diabetes, sleep apnoea, evening fluids, and nocturnal polyuria (desmopressin with sodium monitoring in some).

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Other Bladder Problems

• Voiding dysfunction and retention in women -after childbirth or surgery, epidural, drugs (anticholinergics, opioids), prolapse, neurological disease, constipation, pelvic mass. Catheterise if residual over 500 mL; intermittent self-catheterisation for chronic retention.
• Bladder pain syndrome (interstitial cystitis) -pain related to bladder filling, frequency, urgency, normal cultures; cystoscopy; bladder instillations, amitriptyline, pentosan polysulfate (eye toxicity -screening), specialist care.
• Recurrent UTIs -see the Tubular, Inherited and Stones chapter.
• Fistulas -vesicovaginal (continuous leaking) after hysterectomy, radiotherapy, cancer, obstructed labour; surgical repair.
• Urethral diverticulum -dribbling after voiding, painful sex, a tender anterior vaginal lump.
• Containment products and continence services for those who can't be cured.

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Benign Ovarian Cysts

Type	Features
Functional cysts (follicular, corpus luteum)	The commonest in premenopausal women; simple, thin-walled, usually under 5 cm; resolve within 2–3 cycles. Corpus luteum cysts can bleed or rupture.
Mature cystic teratoma (dermoid cyst)	The commonest benign tumour in young women; contains fat, hair, teeth; often bilateral; high torsion risk; rarely malignant change.
Endometrioma ("chocolate cyst")	Endometriosis; old blood ("ground glass" on ultrasound); painful periods, dyspareunia, subfertility.
Serous cystadenoma	Common benign epithelial tumour; may be bilateral.
Mucinous cystadenoma	Can become very large; rupture can cause pseudomyxoma peritonei (mucinous ascites).
Fibroma	Solid; Meigs' syndrome -ovarian fibroma, ascites and right pleural effusion (resolves after removal).
Theca lutein cysts	With very high hCG (molar pregnancy, multiple pregnancy, IVF).
Polycystic ovaries	Many small follicles -not true cysts; part of PCOS.

• Symptoms -often none (found on scans); pelvic pain or pressure, bloating, urinary frequency, dyspareunia; acute pain with torsion, rupture or bleeding.
• Management of simple cysts in premenopausal women (RCOG):
  • Under 5 cm -usually functional; no follow-up needed.
  • 5–7 cm -repeat ultrasound yearly (refer to gynaecology).
  • Over 7 cm -further imaging (MRI) or surgery (laparoscopic cystectomy -keeps the ovary).
• Postmenopausal women -any cyst needs CA125 and ultrasound; small simple cysts (under 5 cm) with normal CA125 can be monitored.

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Assessing an Adnexal Mass

• Premenopausal women:
  • Pregnancy test (ectopic).
  • Transvaginal ultrasound.
  • CA125 is not needed for simple cysts on ultrasound (raised in endometriosis, fibroids, PID, pregnancy, menstruation).
  • Tumour markers (LDH, AFP, hCG) in women under 40 with a complex mass -germ cell tumours.
• Postmenopausal women and any suspicion of cancer:
  • CA125 and transvaginal ultrasound.
  • Risk of Malignancy Index (RMI) = ultrasound score (U) × menopausal status (M) × CA125:
    • U -0, 1 or 3 based on features: multilocular, solid areas, bilateral, ascites, metastases.
    • M -1 (premenopausal) or 3 (postmenopausal).
    • RMI 200 or more (or 250 in some protocols) -refer to the gynaecological oncology MDT.
  • Newer tools -IOTA simple rules, ADNEX model, O-RADS.
  • Worrying ultrasound features -solid areas, thick septations, papillary projections, increased blood flow, ascites, bilateral masses.
• Ovarian cancer symptoms in primary care (NICE NG12) -persistent bloating, early satiety, pelvic or abdominal pain, urinary urgency or frequency, especially in women over 50: check CA125 (35 IU/mL or more → ultrasound). Ascites or a pelvic mass (not obviously fibroids) → suspected cancer pathway.
• See the Breast and Gynaecological Cancers chapter.

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Ovarian Torsion

• What it is: The ovary (often with the tube) twists on its blood supply, causing ischaemia. A surgical emergency -delay risks losing the ovary.
• Risk factors -an enlarged ovary: cysts (especially dermoid), tumours, ovarian stimulation (IVF, OHSS), pregnancy. Can happen in children and teenagers with normal ovaries.
• Features:
  • Sudden, severe, one-sided lower abdominal pain, often colicky or intermittent (twisting and untwisting).
  • Nausea and vomiting (common).
  • Sometimes after exercise or a sudden movement.
  • Tender adnexal mass; low-grade fever.
• Diagnosis -mainly clinical.
  • Pregnancy test (exclude ectopic).
  • Ultrasound -enlarged, oedematous ovary, free fluid, "whirlpool sign" (twisted pedicle). Normal Doppler flow does not exclude torsion.
• Management -urgent laparoscopy to untwist (detort) the ovary -even a dark, ischaemic-looking ovary often recovers, so conserve it (especially in young women); cystectomy if a cyst is present; oophorectomy only if necrotic. Analgesia and fluids before surgery.

⚠️ Safety Pearl: A normal Doppler doesn't rule out ovarian torsion. If the story fits -sudden one-sided pain, vomiting, and an ovarian cyst -arrange urgent laparoscopy.

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Cyst Rupture and Haemorrhage

• Ruptured or haemorrhagic cyst (usually a corpus luteum cyst in the second half of the cycle):
  • Sudden one-sided pain, often after sex or exercise; may be peritonism.
  • Free fluid on ultrasound.
  • Most settle with analgesia and observation.
  • Significant haemoperitoneum (falling Hb, shock -especially on anticoagulants) -laparoscopy.
• Dermoid rupture -chemical peritonitis; surgery.
• Endometrioma rupture -peritonitis-like pain.

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Acute Pelvic Pain -Approach

• Always start with a pregnancy test.
• Gynaecological causes:
  • Ectopic pregnancy; miscarriage.
  • Ovarian torsion; cyst rupture or haemorrhage.
  • Pelvic inflammatory disease and tubo-ovarian abscess (see the Sexual Health chapter).
  • Endometriosis; fibroid degeneration; mittelschmerz (mid-cycle, mild, self-limiting).
  • OHSS after IVF.
• Non-gynaecological causes:
  • Appendicitis.
  • UTI, pyelonephritis, kidney stones.
  • Diverticulitis (older women), IBD, IBS, constipation, bowel obstruction.
  • Hernias.
• Tests -pregnancy test, urine dipstick, FBC, CRP, STI swabs (NAAT), group and save; transvaginal ultrasound; CT if non-gynae cause suspected.
• Diagnostic laparoscopy if the cause is unclear and pain or peritonism continues.

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Bartholin's Cyst and Abscess

• Bartholin's glands -two pea-sized glands at the back of the vaginal opening (at 4 and 8 o'clock) that make lubricating mucus.
• Bartholin's cyst -the duct blocks: a painless swelling on one side of the vulva. Small cysts need no treatment (warm baths).
• Bartholin's abscess -infected cyst: a very painful, hot, red swelling; difficulty walking and sitting.
  • Organisms -skin and gut bacteria; sometimes gonorrhoea or chlamydia (test).
  • Treatment -analgesia; antibiotics if cellulitis (e.g. co-amoxiclav); drainage -Word catheter insertion (left for 4 weeks), or marsupialisation (stitching the cyst open) to reduce recurrence.
• Over 40 -a new Bartholin's swelling or a solid mass should be biopsied (rare Bartholin's gland cancer).

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Lichen Sclerosus

• What it is: A chronic inflammatory skin condition, usually of the vulva and around the anus; probably autoimmune. Most common in postmenopausal women (also prepubertal girls and men -foreskin).
• Features:
  • Intense itching (often worse at night), soreness, painful sex, splitting.
  • White, shiny, thin ("cigarette paper") patches; can affect the vulva and perianal skin in a figure-of-eight.
  • Purpura, fissures; scarring -loss of the labia minora, fusion over the clitoris, narrowing of the vaginal opening.
  • Doesn't affect the vagina itself.
• Diagnosis -clinical; biopsy if atypical, not responding, or suspicion of cancer.
• Treatment:
  • Potent topical steroid -clobetasol propionate 0.05% ointment: once daily for 4 weeks, alternate days for 4 weeks, twice weekly for 4 weeks, then as needed for maintenance (e.g. 1–2 times a week).
  • Emollients and soap substitutes; avoid irritants.
  • Surgery for severe scarring (narrowed introitus).
• Cancer risk -about 2–5% lifetime risk of vulval squamous cell carcinoma; good control with steroids reduces this. Long-term follow-up; teach self-examination; biopsy any persistent ulcer, lump or thickened area.
• Associated with other autoimmune diseases (thyroid, vitiligo).

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Other Vulval Skin Conditions

• Vulval itch -causes:
  • Candida (thrush) -the commonest; recurrent in diabetes, antibiotics, pregnancy.
  • Irritant or allergic contact dermatitis -soaps, bubble baths, wipes, pads, topical creams, urine.
  • Lichen sclerosus; lichen simplex chronicus (thickened skin from scratching).
  • Lichen planus -erosive, can affect the vagina and mouth (vulvovaginal–gingival syndrome); scarring.
  • Psoriasis (shiny red, no scale in skin folds); eczema.
  • Atrophy after the menopause.
  • Infections -trichomonas, scabies, pubic lice.
  • VIN and vulval cancer (persistent itch with a lesion).
• General advice -avoid soaps and irritants; use emollients as soap substitutes; cotton underwear; avoid tight clothing.
• Vulval lumps -Bartholin's cyst, sebaceous cysts, genital warts, molluscum, hidradenitis suppurativa (recurrent painful nodules and sinuses in groins), varicosities, skin tags; vulval cancer (ulcer or lump in an older woman -refer).
• Vulval ulcers -herpes simplex, syphilis, Behçet's disease, Crohn's, aphthous, erosive lichen planus, cancer.

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Vulvodynia and Painful Sex

• Dyspareunia -painful sex:
  • Superficial (at the entrance) -infection (thrush, herpes), vulvodynia, vaginismus, atrophy, lichen sclerosus, scarring after childbirth (episiotomy), FGM, lack of lubrication.
  • Deep -endometriosis, PID, adhesions, ovarian cysts, fibroids, adenomyosis, pelvic congestion.
• Vulvodynia -chronic vulval pain (burning, stinging) for 3 months or more without a visible cause:
  • Provoked (vestibulodynia -pain on touch, tampons, sex) or unprovoked (constant).
  • Cotton bud test reproduces pain at the vestibule.
  • Treatment -explanation; avoid irritants; topical lidocaine before sex; neuropathic agents (amitriptyline, gabapentin); pelvic floor physiotherapy; psychosexual therapy and CBT.
• Vaginismus -involuntary spasm of the pelvic floor muscles making penetration difficult or impossible; psychosexual therapy, graded dilators, physiotherapy.
• Sexual dysfunction -low desire, arousal or orgasm problems; consider relationship issues, depression, drugs (SSRIs), menopause, past trauma.

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Vulval Intraepithelial Neoplasia

• What it is: Pre-cancerous changes of the vulval skin.
• Types:
  • HSIL (usual-type VIN) -HPV-related; younger women; smokers; often with cervical or anal HPV disease.
  • Differentiated VIN -not HPV-related; older women with lichen sclerosus or lichen planus; higher risk of progression to cancer.
• Features -itch, soreness, raised or thickened patches (white, red or brown); may be found during colposcopy.
• Diagnosis -biopsy.
• Treatment -surgical excision; laser ablation; topical imiquimod (HPV-related); stop smoking; long-term follow-up.
• Vulval cancer -see the Breast and Gynaecological Cancers chapter.

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Female Genital Mutilation

• What it is: Any procedure that intentionally alters or injures the female genitals for non-medical reasons. Illegal in the UK (including taking a girl abroad for it). Usually done to girls before puberty.
• WHO types:
  • Type 1 -removal of the clitoral glans and/or hood.
  • Type 2 -removal of the clitoris and labia minora (± labia majora).
  • Type 3 -infibulation: narrowing the vaginal opening by cutting and sealing the labia.
  • Type 4 -other harmful procedures (pricking, piercing, cauterising).
• Complications:
  • Immediate -pain, bleeding, infection, urinary retention, death.
  • Long term -recurrent UTIs, painful periods (haematocolpos), cysts, painful sex, psychological trauma (PTSD), subfertility.
  • Obstetric -obstructed labour, perineal tears, PPH.
• Legal duties:
  • Mandatory reporting -health professionals in England and Wales must report to the police (call 101) if a girl under 18 tells them she has had FGM, or they see signs of it -within 1 month.
  • Record FGM in the notes (enhanced dataset) for women of any age.
  • Safeguarding referral if any girl (including daughters of a woman with FGM) is at risk.
  • Re-infibulation after birth is illegal.
• Care:
  • Sensitive, non-judgemental; use a professional interpreter (not family).
  • Deinfibulation (opening type 3 FGM) -ideally before pregnancy or in the second trimester, or in labour.
  • Specialist FGM clinics; psychological support.

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Common Gynaecological Operations

• Hysteroscopy -a camera into the womb (outpatient or under anaesthetic): biopsy, polyp or fibroid removal, IUD retrieval. Risks -pain, infection, perforation (rare).
• Laparoscopy -keyhole surgery: diagnosis, ectopic, cysts, endometriosis, sterilisation. Risks -bowel, bladder or vessel injury (about 1 in 1,000), conversion to open surgery, port-site hernia, shoulder tip pain (gas).
• Hysterectomy:
  • Routes -vaginal, laparoscopic, abdominal (open).
  • Total (womb and cervix) or subtotal (cervix kept -still needs cervical screening).
  • With or without removal of tubes (salpingectomy reduces ovarian cancer risk) and ovaries (oophorectomy -causes surgical menopause if premenopausal).
  • Risks -bleeding, infection, VTE, ureteric injury, bladder or bowel injury, vault prolapse later, early menopause.
• Endometrial ablation -destroys the lining (heavy periods; family complete; contraception still needed).
• LLETZ (large loop excision of the transformation zone) -treats cervical pre-cancer (CIN); slight increase in preterm birth risk.
• After gynaecological surgery -watch for ureteric injury (loin pain, fever, leaking urine), bladder injury, bowel injury (pain and sepsis days later), VTE.

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Drug Reference Table

Drug	Key points
Solifenacin / tolterodine / fesoterodine	Antimuscarinics for overactive bladder; dry mouth, constipation; anticholinergic burden in older people.
Oxybutynin (immediate release)	Avoid in frail older women (confusion, falls, dementia risk).
Mirabegron	Beta-3 agonist for OAB; check BP; avoid in severe uncontrolled hypertension.
Botulinum toxin A (intravesical)	Refractory OAB; risk of retention and need for self-catheterisation; UTIs.
Duloxetine	Second line for stress incontinence; nausea.
Vaginal oestrogen	Atrophy with prolapse, OAB or recurrent UTIs; pessary users.
Clobetasol propionate 0.05% ointment	Lichen sclerosus -reducing regimen then maintenance.
Emollients (soap substitutes)	All vulval skin conditions.
Lidocaine 5% ointment	Provoked vulvodynia before sex.
Amitriptyline / gabapentin	Vulvodynia, bladder pain syndrome, neuropathic pelvic pain.
Co-amoxiclav	Bartholin's abscess with cellulitis.

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Spot the Diagnosis

Clue	Diagnosis
Dragging feeling and a lump at the vulva, has to push the lump up to pass urine	Cystocele
Needs to press on the back wall of the vagina to open her bowels	Rectocele
Leaks when she coughs or runs	Stress incontinence -pelvic floor exercises
Sudden urge and leaks before reaching the toilet; drinks 8 coffees a day	Overactive bladder -reduce caffeine, bladder training
Constant leaking after a hysterectomy	Vesicovaginal fistula
Confusion after starting oxybutynin in an 84-year-old	Anticholinergic side effect
Fat, hair and teeth in an ovarian cyst on imaging	Mature cystic teratoma (dermoid)
Ovarian fibroma with ascites and right pleural effusion	Meigs' syndrome
Sudden severe left iliac fossa pain and vomiting with a known 6 cm dermoid	Ovarian torsion
Sudden pain after sex on day 24 of cycle, free fluid, negative pregnancy test	Ruptured corpus luteum cyst
Postmenopausal woman, complex cyst, CA125 220	High RMI -gynae-oncology referral
Hot, very painful swelling at the posterior vaginal opening	Bartholin's abscess
Itchy, white, shiny figure-of-eight skin around vulva and anus at 68	Lichen sclerosus
Persistent ulcer on a background of lichen sclerosus	Possible vulval SCC -biopsy
Burning pain on tampon insertion with a normal-looking vulva	Provoked vulvodynia
15-year-old says she was "cut" as a child	FGM -mandatory report to police

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Exam-style Scenarios

1. A 58-year-old with three vaginal births has a "bulge" in the vagina, worse at the end of the day, and a slow urine stream. Examination shows a grade 2 cystocele.
Answer: Symptomatic anterior wall prolapse.

• Lifestyle (weight, constipation); supervised pelvic floor training for 16 weeks; vaginal oestrogen if atrophy.
• Pessary (ring) if she prefers or exercises fail.
• Surgery (anterior repair) if she wants definitive treatment; check post-void residual.

2. An 80-year-old with mild cognitive impairment has urgency and urge incontinence. Urine dip is negative. Bladder training hasn't helped.
Answer: Overactive bladder in a frail older woman.

• Avoid oxybutynin; consider mirabegron (check BP) rather than antimuscarinics.
• Review fluids and caffeine; vaginal oestrogen if atrophy; check post-void residual.
• Review at 4 weeks.

3. A 22-year-old has sudden severe right iliac fossa pain with vomiting for 3 hours. Pregnancy test negative. Ultrasound: 7 cm right ovarian cyst, Doppler flow present.
Answer: Suspected ovarian torsion (Doppler doesn't exclude it).

• Analgesia, fluids, nil by mouth.
• Urgent laparoscopy -detort and conserve the ovary; cystectomy.

4. A 64-year-old has bloating and early satiety for 3 months. CA125 is 310 IU/mL. Ultrasound: bilateral complex ovarian masses with ascites.
Answer: Suspected ovarian cancer (high RMI).

• Suspected cancer pathway; CT chest, abdomen and pelvis.
• Gynaecological oncology MDT.

5. A 70-year-old has vulval itching for a year. There are white, thin, shiny plaques around the vulva and anus with loss of the labia minora.
Answer: Lichen sclerosus.

• Clobetasol propionate 0.05% ointment (reducing regimen), emollients, soap avoidance.
• Biopsy if atypical or not responding; long-term follow-up; report any lump or ulcer (SCC risk).

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Key Points

• Prolapse: pelvic floor training first; pessaries or surgery; transvaginal mesh is no longer used for prolapse.
• Incontinence: bladder diary for 3 days, urine dip, post-void residual; refer red flags (haematuria, mass, fistula).
• Stress incontinence: pelvic floor training 3 months (8 contractions three times daily); duloxetine or surgery second line.
• Overactive bladder: reduce caffeine, bladder training 6 weeks, then antimuscarinics or mirabegron; avoid oxybutynin in frail older women.
• Simple premenopausal cysts under 5 cm need no follow-up; 5–7 cm yearly scan; over 7 cm MRI or surgery.
• Postmenopausal cyst or suspicion of cancer: CA125 and ultrasound; RMI 200 or more -gynae-oncology.
• Torsion: sudden one-sided pain and vomiting with a cyst -urgent laparoscopy; normal Doppler doesn't exclude it.
• Always do a pregnancy test in acute pelvic pain.
• Bartholin's abscess: drainage (Word catheter or marsupialisation); biopsy new masses over 40.
• Lichen sclerosus: clobetasol ointment; 2–5% lifetime SCC risk -long-term follow-up and biopsy any persistent lesion.
• FGM in a girl under 18 (told or seen): mandatory report to the police; safeguarding for daughters at risk.

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Guidelines and Further Reading

• NICE NG123: Urinary incontinence and pelvic organ prolapse in women -management
• RCOG Green-top Guidelines 62 and 34: Ovarian masses in premenopausal and postmenopausal women
• NICE NG12: Suspected cancer -recognition and referral (ovarian cancer)
• BASHH and British Association of Dermatologists: guideline on vulval lichen sclerosus
• RCOG Green-top Guideline 53: Female genital mutilation and its management; Home Office FGM mandatory reporting guidance
• NHS England: guidance on vaginal mesh (high vigilance restriction)
• BNF -for current doses

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