REFERRAL RECOMMENDATIONS : PAEDIATRIC SURGERY
GYNAECOLOGY REFERRAL RECOMMENDATIONS
|Diagnosis / Symptomatology |Evaluation |Management Options |Referral Guidelines |
|Gynaecology problems are addressed under the following|A thorough history and examination is required to |Specific treatments depend on specific problems |These guidelines are provided (below) to give greater |
|headings: |determine a specific diagnosis and its degree of |identified as noted below. |clarity in situations of the primary/secondary |
| |urgency. Some appropriate investigation by the | |interface of care. Clear telephone/fax communication |
|Amenorrhoea |referrer will facilitate the referral process. |Be aware of molar pregnancies. |would enhance appropriate treatment. |
|Diseases of the vulva | | | |
|Dysmenorrhoea |Pelvic examinations – GPs, specialists. | | |
|Excessive/irregular menstrual loss | | | |
|Infertility | | | |
|Menopause/HRT | | | |
|Other bleeding problems | | | |
|Ovarian cysts | | | |
|Pelvic inflammatory disease | | | |
|Prolapse | | | |
|Urinary symptoms | | | |
|Vaginal discharge | | | |
|Diagnosis / Symptomatology |Evaluation |Management Options |Referral Guidelines |
|Amenorrhoea |
|Primary |Age > 15 years. |Counselling and support. |Where there are abnormal results or significant |
| |Weight history. | |patient stress/anxiety – refer to the appropriate |
| |Dietary history. | |specialist service – Category 4. |
| |Exercise history. | | |
| |Physical/secondary sexual development. | | |
| |Family history. | | |
| |Evidence of any congenital gynaecological abnormality/| | |
| |abdominal mass. | | |
| |Sexual history. | | |
| | | | |
| |INVESTIGATIONS: | | |
| |FSH/LH/HCG. | | |
| |Prolactin x 3*. | | |
| |Thyroid function test. | | |
| |Ultrasound. | | |
| | | | |
| |Chromosomal studies may be requested in consultation | | |
| |with the specialist service. | | |
| | | | |
| |*Note: Only one is necessary if initial test is | | |
| |normal. | | |
|Secondary (> 6 months) |All of the above plus: |Counselling and support. |Where there are abnormal results or significant |
| |Contraception history. | |patient stress/anxiety – refer to the appropriate |
|(Cross-refer to Endocrinology Referral |Drug history, eg psychotropic. | |specialist service – Category 4. |
|Recommendations.) |Galactorrhea. | | |
| |Signs of masculinisation. | |If associated with infertility. |
| |Hirsutism. | | |
| |Significant stress and anxiety. | | |
| |Environmental factors. | | |
| |Past gynaecological history/surgery. | | |
| | | | |
| |INVESTIGATIONS: | | |
| |HCG. | | |
| |FSH/LH/E2/Prolactin x 3*. | | |
| |Testosterone/SHBG/DHEA (if Hirsute). | | |
|Diagnosis / Symptomatology |Evaluation |Management Options |Referral Guidelines |
|Diseases of the vulva |
| |Symptomatology – pain, swelling, pruritus, |Antibiotic treatment of Bartholins abscess is of no |Bartholin's abscess – Category 2. |
| |dyspareunia, localised lesions (pigmented or |value. Acute referral for assessment recommended. |Bartholin's cyst – refer – Category 4. |
| |non-pigmented lesions). |Bartholins cyst, refer for specialist management. |Older woman with localised lesion – Category 2. |
| |Current treatment to date. |The older the patient and the more localised the | |
| |Systemic dermatological problems. |lesion of the vulva, the more urgent the assessment. | |
| | | | |
| |INVESTIGATIONS: | | |
| |Consider swabs/scrapings. | | |
| |Consider biopsy for a generalised skin condition. | | |
|Diagnosis / Symptomatology |Evaluation |Management Options |Referral Guidelines |
|Dysmenorrhoea | | | |
| |Examination history. |Symptomatic analgesia/NSAIDS – Preferred NSAID |Unresponsive to treatment (no improvement in 90 days) |
| |Symptomatology – pain (increasing with duration of |preparation is Mefenamic Acid 500mgs TDS. Days 1-3 of|or if symptoms severe earlier. (? Endometriosis, |
| |period – suspect endometriosis), vomiting, fever, |flow. Alternatively, Diclofenac 75-100mgs plus |sub-mucous fibroids) – Category 4. |
| |fainting, associated discharge, deep dyspareunia. |Paracetamol 1gm rectally 12 hourly may be helpful. | |
| |Time off activities of daily living. |Response to NSAID can be idiosyncratic. | |
| | |OCPs. Consider continuous (bleed free) regimen | |
| |INVESTIGATIONS: | | |
| |If PID suspected (see below). |Note: If no clinical abnormality demonstrable: treat | |
| | |pre-menstrual discomfort (relieved by flow) | |
| | |symptomatically whenever possible. This is rarely | |
| | |amenable to surgical correction. | |
|Diagnosis / Symptomatology |Evaluation |Management Options |Referral Guidelines |
|Excessive/Irregular menstrual loss |
|(Minimum of 3 months unless bleeding continues.) |Drug history (contraception, HRT). |Hormonal control, eg oral contraceptive/HRT. |Refer Category 3 for any of the following: |
| |Symptomatology, eg pain, fatigue. |Non-steroidals, eg Mefenamic Acid 500mgs TDS. |Anaemia Hb 52 years. |HRT after six months – Category 4. |
| |Fasting lipid profile. | | |
| |FBC. |Tertiary Menopause Clinic (KEMH) for complex | |
| |TFT. |menopausal problems eg patients with a history of | |
| |Mammogram. |oestrogen sensitive tumours or venous thrombosis | |
| |Consider bone density – (c.f. National Health | | |
| |Committee’s guidelines for HRT). before treatment is | | |
| |commenced. | | |
|Diagnosis / Symptomatology |Evaluation |Management Options |Referral Guidelines |
|Other abnormal bleeding |
|Post-menopausal. |Drug history (contraception, HRT particularly |Note: Cervical polyps associated with post-menopausal|Refer to specialist service – Category 2. |
|(Twelve months from last menstrual period.) |oestrogen only regimens). |bleeding should be referred as frequently associated | |
| |Evidence of any genital tract abnormalities, eg |with sinister pathology. | |
| |cervical polyps/ atrophic change or abdominal mass. | | |
| |Sexual/PID history. | | |
| |INVESTIGATIONS: | | |
| |Smear. | | |
| |HVS. | | |
| |+/– Pipelle. | | |
| |Pelvic ultrasound | | |
| |Preferably Transvaginal by specialist with expertise | | |
| |in Gynaecological Ultrasound | | |
| |Pregnancy test (unnecessary > 55 years). | | |
|Post-coital bleeding. |Examine. |Support and counselling. |Recurrent, troublesome or embarrassing – refer to |
| |Smear. |Report further episodes. |specialist service – Category 2. |
| |HVS. |Encourage return if symptoms recur/change. | |
|Postpartum bleeding (within six weeks). |Drug history, including contraception. |Treat with Augmentin 500mg TDS 5-7 days. |No response to treatment – refer – Category 2. |
| |Delivery history. |Consult with specialist service and refer. | |
| |Symptomatology – pain, fever, uterine size, | | |
| |tenderness. | | |
| |INVESTIGATIONS: | | |
| |Endocervical swab. | | |
| |Chlamydia test. | | |
| |Consider scan for retained products. | | |
| |Hb. | | |
|Diagnosis / Symptomatology |Evaluation |Management Options |Referral Guidelines |
|Ovarian Cyst |
| |HISTORY: | | |
| |Asymptomatic? | |Refer as soon as possible – Category 2 / 3. |
| |Incidental clinical or ultrasound finding. | | |
| | | | |
| |Symptomatic? | |Refer urgently if persistent or colicky pain, weight |
| |Cyclical symptoms. |If 5 cm ( size. Repeat scan after menstrual period |loss, anaemia, any suspicion of ascites or irregularly|
| |Pain. |when applicable (can exclude such as corpus luteal |contoured mass on abdominal or pelvic examination – |
| |Dyspareunia. |cysts). |Category 2. |
| |Irregular cycle. | | |
| |Gastrointestinal. | | |
| | | | |
| |(Note: Ovarian pathology (eg torsion and not least | | |
| |carcinoma) may present with gastrointestinal symptoms.| | |
| |Risk of malignancy greater pre-pubertally and with | | |
| |increasing age to 70(.) | | |
| | | | |
| |INVESTIGATIONS: | | |
| |Examination. | | |
| |Size. | | |
| |Consistency. | | |
| |Contour. | | |
| |Ultrasound scan. (specialist experienced in | | |
| |Gynaecological Ultrasound) | | |
| |Tumour Markers (OMMA +/- AFP, CEA, HcG) |Was the ultrasound both transvaginal & abdominal | |
| | |Ultrasound should comment as to whether the cyst has | |
| | |any malignant features, such as: Septae, solid areas, | |
| | |papillary projections, ascites or abnormal blood flow.| |
| | | | |
|Diagnosis / Symptomatology |Evaluation |Management Options |Referral Guidelines |
|Pelvic Inflammatory Disease |
|Acute |Symptomatology – pain, discharge, pyrexia. |Antibiotics for PIDs. Triple therapy: |Acutely unwell, pelvic mass, unresponsive to treatment|
| |Out of phase bleeding. |– Augmentin 500mgs TDS 10 days. |(12-16 hours). Refer for admission – Category 1. |
|(c.f. Sexual Health Referral Recommendations.) |? Presence of IUCD. |– Flagyl 400mgs TDS 7 days. |Positive pregnancy test with pelvic pain + - fever |
| | |– Doxycycline 100mgs BID minimum 14 days. |(consider septic abortion). Refer for admission – |
| |INVESTIGATIONS: | |Category 1. |
| |FBC/ESR. |Link and liaise with STD clinic as appropriate. | |
| |HVS/chlamydia smear/swabs. | | |
| |Urine specimen - Chlamydia |(Note: Erythromycin may be used as an alternative to | |
| |Endocx/urethral/rectal swab. |Augmentin in cases of penicillin allergy.) | |
| |HCG. | | |
| |? Smear. | | |
|Chronic |Symptomatology – chronic pain, discharge, erratic |1. Symptomatic after treatment – refer. |Unresponsive to treatment – Refer Category 2. |
| |bleeding, recurrent episodes of acute PID, | | |
| |dyspareunia. | | |
| | | | |
| |INVESTIGATIONS: | | |
| |See acute. | | |
| |Ultrasound scan. | | |
|Diagnosis / Symptomatology |Evaluation |Management Options |Referral Guidelines |
|Prolapse |
|Pelvic anatomical relaxation. |Symptomatology – lump, difficulty with |Symptoms of prolapse without signs may resolve on |Symptomatic prolapse – Category 4. |
| |defaecation/micturition, dyspareunia. |treatment with local oestrogen, which is worth a try | |
| | |before referral (ie, 3 months). | |
| |INVESTIGATIONS: |Consider ring pessary. | |
| |MSU. | | |
| |Consider: | | |
| |FBC. | | |
| |Renal biochemistry. | | |
|Diagnosis / Symptomatology |Evaluation |Management Options |Referral Guidelines |
|Urinary symptoms |
| |Stress incontinence + - prolapse. |Refer to specialist physiotherapy/ continence nurse. |Where indicated, refer for urodynamic assessment. |
| |Hesitancy associated with prolapse. |HRT/local oestrogens if post-menopausal. | |
| |Other associated pressure symptoms, eg on bladder, on | |Refer to Gynaecology or Urological Service as |
| |bowel, pelvic pain. |Note: |appropriate – Category 4. |
| |Urge incontinence. |Pelvic floor exercises by trained continence therapist| |
| |Frequency. |if available (and local oestrogens if post-menopausal)| |
| |Previous gynae, surgery/obstet history. |should be tried for three months before referral in | |
| | |any event. | |
| |INVESTIGATIONS: |If stress incontinence associated with urgency, | |
| |MSU. |frequency, nocturia etc (ie, a mixed picture) | |
| |FBC. |persists, then primary referral to the Urology Service| |
| |Renal function biochemistry/blood sugar. |is recommended. | |
| |Imaging if warranted. | | |
| |Pregnancy test. | | |
|Diagnosis / Symptomatology |Evaluation |Management Options |Referral Guidelines |
|Vaginal Discharge |
|(c.f. Sexual Health Referral Recommendations.) |Sexual and PID history. |STDs – treat patient and partner. Referral to STD |STD Services. |
| | |clinic for contact tracing and counselling. | |
| | |Thrush (incl recurrent), local treatments – cyclical | |
| |Characteristics – odour, quantity, irritation, |local treatments, oral therapy. | |
| |bloodstaining. |Physiological – counselling and education. |Recurrent, failed treatment – refer to specialist |
| | | |services – Category 4. |
| |INVESTIGATIONS: | | |
| |Smear. | | |
| |Swab, HVS, chlamydia, viral. | | |
| |Blood glucose. | | |
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