Case 2 Flashcards
MOA of combined oral contraceptive pill
Oestrogen - inhibits FSH, therefore stops follicle development
Progesterone - inhibits LH, therefore stops ovulation. Also prevents sperm traffic since P causes vagina to have thicker mucus and be more acidic
ADRs of combined oral contraceptive pill
Thromboembolism Stroke/MI Increased risk of breast cancer Hypertension Skin pigmentation Weight gain Nausea Irregular bleeding Mood changes
Contraindications for combined oral contraceptive pill
Hx of thrombosis,
Risk factors for thromboembolism - obese, immobile, >35yrs, smoking, family hx
Heart disease with pulmonary hypertension/embolism
Migraines
Hx or family Hx of breast cancer
Methods of emergency contraception
Levonorgestrel - Inhibits GnRH release by binding to O and P receptors. Can be used up to 70 hours after unprotected sex.
Ulipristal - Inhibits ovulation by binding to progesterone receptor. Can be used up to 120 hours after unprotected sex.
IUD - more effective than levonorgestrel (unknown comparison to ulipristal). Can be used up to 120 hours after unprotected sex.
Methods of Contraception: Cap/Diaphragm
Inserted up to 2 hrs before sex
Left in for at least 6 hours after sex.
Can be used during period.
Used with spermicide gel.
Methods of Contraception: Depo Provera
Medroxyprogesterone injection, lasting 12-14wks
ADRs
Little or no bleeding, mood problems, bone density problems, long lasting effects (can be more than one year)
Methods of Contraception: Implanon
Etonergestrol Lasts 3 yrs 15-20% risk of abnormal bleeding Regain fertility very quickly after removal **Most effective form of contraception**
Methods of Contraception: Intrauterine System
Progesterone impregnated coil.
Progesterone creates an unfavourable environment for sperm - thick mucus and acidic
Lasts 5 yrs
Sometimes causes hormonal problems and irregular bleeding
Methods of Contraception: Intrauterine Device
Copper coil (copper is spermicidal)
Lasts 10yrs
Often causes heavy bleeding
Almost 100% effective
Effects of FSH
Development of primary follicles
Effects of LH
Ovulation
Stimulates theca cells to convert cholesterol to androgens
Effects of oestrogen
Inhibits FSH
Stimulates granulosa cells to convert androgens to oestrogens
Makes cervical mucus thinner and therefore easier for sperm to swim
Stimulates proliferation of stratum basalis to form stratum functionalis (thickening of endometrium) AND elongation of endometrial glands
Increased movement in uterine tubes
Increased clotting factors and platelet adhesion
Reduced bone loss
Effects of progesterone
Thickening of endometrium
Increased viscosity and acidity of cervical mucus
Stimulates uterine glands to secrete uterine milk (high in protein and glycogen)
Suppresses maternal immune response during pregnancy
Decreased uterine contractility
Inhibits lactation
LH and FSH are released from:
Anterior pituitary
Progesterone is secreted by…
Granulosa cells
How does the secondary follicle differ from primary?
Larger
More follicular/granulosa cells
Follicular fluid spaces have formed and will coalesce to form the antrum.
Theca layer differentiates into an interna and externa
How do theca interna and externa cells differ?
Theca interna - large, steroid hormone-producing cells
Theca externa - small, compact cells, continuous with stroma
Function of thecal cells
Production of steroid
Function of granulosa cells
Converts steroids into oestrogen
Peg cell
Non ciliated epithelial cell within uterine tube. Secretes a watery solution to nourish gametes.
LH surge occurs as a result of…
High levels of oestrogen
Formation of corpus luteum
LH stimulates proteolytic activity in theca externa and tunica albuginea - therefore breakdown of collagen
Corpus luteum appears yellow due to…
Fat
Formation of corpus albicans
Progesterone secretion by corpus luteum inhibits FSH and LH
After 10 days, leutolysis of CL
Corpus albicans is formed at day 25.
It is a fibrous, ovoid structure.
Cholesterol to Oestrogen
Theca cells convert cholesterol to androgens (stimulated by LH). Androgens converted to oestrogen by granulosa cells (stimulates by FSH and oestrogen)
Epithelium found in uterine tubes
Simple cuboidal
Secretory peg cells and ciliated
Epithelium found in ectocervix
Non keratinised, stratified squamous epithelium - protection from abrasion
Epithelium found in endocervix
Simple columnar epithelium. Contains crypts which secrete mucous.
Nervous innervation of Clitoris and Vestibule (Anterior vulva)
Anterior ilioinguinal branch of genitofemoral nerve.
Parasympathetic innervation from cavernous nerves of uterovaginal plexus
Nervous innervation of Posterior vulva
Posterior pudendal nerve and cutaneous nerve of thigh
Lymphatic drainage of vulva
Superficial inguinal lymph nodes
Venous drainage of vulva
Pudendal vein
Arterial supply of vulva
Pudendal artery
Epithelium found in vagina
Stratified squamous - protection, lubrication, stimulated by oestrogen to secrete glycogen
Arterial supply of vagina
Uterine and vaginal arteries branching from internal iliac vein
Venous drainage of vagina
Vaginal venous plexus, drains into internal iliac vein
Lymphatic drainage of vagina
Iliac and superficial inguinal lymph nodes
Nervous innervation of vagina
Superior portion - inferior uterovaginal plexus
Inferior portion - deep perineal branch of pudendal nerve
Tissues of the penis
Corpus cavernosum (x2) Corpus spongiosum (x1) contains urethra
Muscles involved in maintaining an erection
Ischiocavernosus - surrounds crura, contracts to push blood into corpus cavernosum.
Bulbospongiosus - associated with bulb of penis, contracts to empty urethra of residual semen and urine
Arterial supply of penis
Internal pudendal (branch of internal iliac)
Venous drainage of penis
Deep dorsal vein of penis - drains cavernous spaces into prostatic venous plexus
Superficial dorsal veins - drain superficial structures such as skin and cutaneous tissues
Sensory and sympathetic innervation of penis
Dorsal nerve (branch of pudendal nerve)
Parasympathetic innervation of penis
Cavernous nerves from prostatic plexus
Tunica Albuginea of testis
Divides testi into lobules
Nervous innervation of testis and epididymis
Testicular plexus - derived from renal and aortic plexus)
Arterial supply of testis and epididymis
Testicular arteries - branch from aorta
Venous drainage of testis and epididymis
Pampiniform plexus forms testicular veins
Layers of spermatic cord
Skin Dartos External spermatic fascia Cremaster muscle Internal spermatic fascia Tunica vaginalis - parietal and Visceral Testis
Some Damned Englishman Called It The Testis
Contents of spermatic cord
3x Arteries: Testicular, Cremasteric and artery to vas deferens
Pampiniform plexus and cremasteric vein
Lymph vessels (drain into paraaortic nodes (lumbar)
Vas deferens
Genital branch of genitofemoral nerve
Arterial supply of scrotum
Posterior scrotal artery (branch of internal pudendal artery)
Anterior scrotal artery (branch of external pudendal artery)
Venous drainage of scrotum
Scrotal vein - into external pudendal
Seminal Vesicles
Secrete 70% of semen
Alkaline fluid - neutralises vagina
Fructose - nourishment of sperm
Prostaglandins - suppress female immune response to foreign bodies
Clotting factors - keeps semen in female reproductive tract
Bulbourethral glands
Produce an alkaline lubricant to carry sperm
Prostate cancer
Peripheral zone (adjacent to rectum) - most common site of prostate cancer (carcinoma) Transitional zone - most common site of benign prostatic hyperplasia
Nervous innervation of prostate
Inferior hypogastric plexus
Venous drainage of prostate
Prostatic venous plexus
Arterial supply of prostate
Prostatic arteries
Function of dartos muscle
Temperature regulation - contracts to decrease surface area of scrotum, therefore reducing heat loss
Nervous innervation of anterolateral scrotum
Genital branch of genitofemoral nerve
Nervous innervation of anterior and posterior scrotum
Scrotal nerve
Nervous innervation of inferior scrotum
Perineal branches of posterior femoral cutaneous nerve (from sacral plexus)
Sertolli Cells
Tall, simple columnar epithelial cells
Provide nutrients to sperm
Phagocytose excess spermatoid cytoplasm
Have tight junctions between them, forming the blood-testis barrier
Leydig Cells
Intersitial cells, lying between tubules in the testis.
Have an eosinophilic, cholesterol containing cytoplasm
Secrete testosterone in response to LH
Direct inguinal hernia
Medial to epigastric vessels
Weakness in posterior wall of inguinal canal - inguinal contents emerges medial to deep ring
Seen in elderly with chronic conditions
Indirect inguinal hernia
Lateral to epigastric vessels
Inguinal contents pass through inguinal canal and exit through superficial inguinal ring
Seen in children and young people
Can descend into scrotum
Deep inguinal ring is located…
At the midpoint between ASIS and pubic tubercle
Symptoms of lower UTI
Dysuria (pain on urination) and nocturia
Smelly, cloudy, foul-smelling urine
Urgency
Frequency
(Suprapubic tenderness and haematuria in cystitis)
Symptoms of upper UTI
Loin pain Chills Fever Dysuria (pain on urination) Smelly, cloudy urine Urgency Frequency
Management of UTI
Encourage fluids inc. Cranberry Juice
Uncomplicated - Trimethoprim
Complicated - Amoxycillin +/- gentamycin
Complicated UTI?
Children under 5 Pregnant women Men Patient who is immunocompromised Patient with renal impairment or renal tract abnormality Pyelonephritis Recurrent or relapsed UTI
MOA of beta lactam antibiotics
Inhibit cell wall synthesis
Beta Lactam Antibiotics examples
Penicillins - amoxycillin, flucloxacillin
Cephalosporins - cefalexin
MOA of aminoglycoside antibiotics
Binds to 30s of ribosome, causing mRNA to be read incorrectly. Inhibitor of protein synthesis
Aminoglycoside Antibiotic examples
Gentamycin
Steptomycin
Kanamycin
MOA of glycopeptide antibiotics
Inhibit cell wall synthesis
Glycopeptide antibiotic examples
Vancomycin
MOA of Quinolone antibiotics
Interfere with DNA replication and transcription
Quinolone antibiotic examples
Ciprofloxacin
Levofloxacin
MOA of Oxazolidinones
Inhibit protein synthesis
Oxazolidinone antibiotic examples
Linezoid
Posizoid
Cycloserin
ADRs of beta lactam penicillins
GI disturbance
Type I and IV hypersensitivity reactions
Cholestatic jaundice (with co-amoxiclav)
Indication for beta lactam antibiotics
Gram positive and negative organisms
Amoxicillin is indicated for…
Oral infections: Lyme Disease, Anthrax, H-Pylori
ADRs of Quinolones
Tendon rupture (elderly) Decreased seizure threshold Peripheral neuropathy Hypoglycaemia High C. Diff risk
Co amoxiclav is indicated for…
Animal bites
GU infection
Joint/bone infection
Indication for Quinolones (Ciprofloxacin)
Gram +ve and -ve bacteria
Pseudomonas, chlamydia, gonorrhoea and typhoid
MOA of Macrolides
Bind to 50s of ribosome, inhibiting binding of tRNA.
Protein synthesis inhibition.
Example of macrolide antibiotic
Clarithromycin
Indication for Cephalosporins (Beta Lactam)
Septicaemia Pneumonia Biliary tract infection Meningitis Epiglottitis Gonorrhoea
Indication for clarithromycin
Atypical pneumonias
Campylobacter
ADRs of macrolides
QT Prolongation
SJS/TENS (potentially fatal skin reaction)
ADRs of Aminoglycosides/Gentamyci
Nephrotoxicity
Irreversible ototoxicity
MOA of nitrofurantoin
Acetyl CoA inhibitor. Interferes with CHO metabolism
Indication for nitrofurantoin
UTIs
ADRs of nitrofurantoin
Pulmonary fibrosis
Retroperitoneal fibrosis
Peripheral neuropathy
MOA of Trimethoprim
Inhibits dihydrofolate reductase.
Therefore, reduced folate metabolism.
Indication for trimethoprim
UTI
Bronchitis
Pneumocystic Pneumonia
ADRs of Trimethoprim
Hyperkalaemia
Indication for glycopeptides/vancomycin
Gram positive cocci
C.Diff
ADRs for glycopeptides/vancomycin
Nephrotoxicity
Ototoxic
MOA of metronidazole
Disrupts DNA structure and inhibits nucleic acid synthesis
Indication for metronidazole
Anaerobic infection
Protozoal infection
H. Pylori
Crohn’s
ADRs of metronidazole
Disulfram reaction with alcohol
Acute pyelonephritis
Inflammation of kidney tissue
Pain in loins, fever, shivering, fits, N+V, Malaise
Perinephrosis
Obstruction and infection of the kidney - usually caused by a kidney stone.
Leading to pus formation
Signs/Symptoms: Loin pain/swelling Weight loss Night sweats and rigor Scoliosis
Staghorn calculus
Branched kidney stone forms a cast of collecting system of kidney. Fills calyx and pelvis.
Can cause perinephric abscess or pyonephrosis.
Vesico-ureteric reflux
On contraction of the bladder, valve between ureter and bladder is not closed off (due to damage or congenital abnormality). Back flow of urine into ureter, where it sits as a stagnant pool - infected urine can reach the kidneys.
Recurrent UTI
Different organism causing UTI each time
Relapse UTI
Same organism causing another UTI within 2 weeks
Treatment of non pregnant, adult female with symptoms of lower UTI
Trimethprim or nitrofurantoin
Treatment of non pregnant, adult female with symptoms of upper UTI
Ciprofloxacin or co-amoxiclav
Treatment of adult male with symptoms suggestive of prostatitis
Ciprofloxacin (Quinolones)
Treatment of UTI in pregnant woman
Nitrofurantoin
Amoxicillin
UTI antibiotics contraindicated in pregnancy
Trimethoprim - Folate antagonist
Ciprofloxacin - causes bone development problems
Why does pregnancy increase risk of UTI?
Reduced hygiene
Compression of bladder by uterus - incomplete voiding
Increased GFR - glc filtered out more rapidly, more glc in urine attracting bacteria
Function of internal urethral sphincter
Only found in males
Contracts during ejaculation to prevent seminal regurgitation
In response to sympathetic innervation
Mechanisms of prevention of UTI by the body:
Complete urinary voiding (vesicoureteric junction)
Bactericidal secretions
Low pH of urine
High [urea] in urine
Clinical measure of GFR
Creatinine
Arterial supply of ureters
Abdominal region - renal and testicular/ovarian arteries
Pelvic region - vesical arteries
Venous drainage of ureters
Abdominal region - renal and testicular/ovarian veins
Pelvic region - vesical veins
Nerve supply of ureters
T11-L2
Renal, testicular/ovarian hypogastric plexuses
Epithelium found in bladder
Transitional - able to stretch in response to increasing volume of bladder
Looks like stratified squamous epithelium
Detrusor Muscle
Smooth muscle found in walls of bladder.
Contracts during voiding
Trigone
Smooth, triangular area of the bladder, marking the internal urethral orifice
Borders: 2 ureteric openings and 1 urethral opening.
Nervous innervation of bladder
Sympathetic (retention) - hypogastric nerve T12-L2
Parasympathetic (micturition) - Pelvic nerve S2-S4
Somatic - Pudendal nerve S2-S4
Function of external urethral orifice
Skeletal muscle involved in micturition (in both sexes)
Bartholin’s Glands
Posterior and to the left and right of the vaginal opening.
Secrete mucus to lubricate the vagina.
Homologous to bulbourethral glands in males.
Epithelium found in proximal convoluted tubule
Simple, tall cuboidal
Convoluted surface, increases surface area for reabsorption
Function of PCT
Responsible for 2/3s of reabsorption of H2O, Na+, K+, Cl- and HCO3-
Glucose transporters found in PCT
Proximal 2/3: GLUT2 and SGLT2 (low affinity, act when [Glc] is high)
Distal 1/3: GLUT1 and SGLT1 (high affinity)
SGLT
Sodium Glucose Transport Proteins. Reabsorption of Glc in PCT coupled with movement of Na+ down its concentration gradient.
AQP1
Aquaporin. Allows reabsorption of water from descending loop of Henle
How does epithelium in DCT differ from that of the PCT?
DCT also has cuboidal epithelium
But has fewer villi (since it is less important for absorption)
Calcium reabsorption in kidney nephrons
TRPV5 and TRPV6 (increased expression in response to PTH, in order to increase plasma Ca2+)
70% occurs in PCT and ascending loop
How does ADH/vasopressin bring about increased water reabsorption?
Released from posterior pituitary.
Binds to GPCRs on basolateral membrane.
Activation of AC, increased cAMP and activation of PKA.
PKA initiates fusion of vesicles containing water channels - Aquaporins 2 and 3
Progression of acquired syphilis
Painless but highly infectious rash for 2-6wks
Followed by sore throat, fever and skin rash.
Can lead to gummatous (15%), CVD - aortitis or aneurysm (6%) and neurological problems - dementia, psychosis, paresis (10%
Characteristics of congenital syphilis
Rash Periostitis Enlarged lymph nodes, spleen and liver Neuro and ocular movement changes Swelling of joints Tooth deformity (Hutchinson's - spikey) High palatal arch Short maxilla Saddle nose
Treatment of syphilis
Early - Penicillin for 10 days
Late - Daily penicillin, Probenecid 4x/day (increases uric acid secretion in urine, enhances action of penicillin)
Signs/Symptoms of Chlamydia
80% Asymptomatic
Urethritis
Proctitis
Epididymitis
Treatment of chlamydia
Single dose of azithromycin (protein synthesis inhibitor)
Doxycycline (protein synthesis inhibitor) BTD for 7 days
Signs/Symptoms of Gonorrhoea
10% asymptomatic Urethritis Proctitis Discharge (anal, vaginal, urethral) Pharyngitis and eye infections
Treatment of Gonorrhoea
Ceftriaxone I/M
1g Azithromycin Orally
(Single dose)
Clinical presentation of genital warts (HPV)
Painless, soft, fleshy growths around genitalia
Treatment of genital warts (HPV)
Removal (surgical, freezing, chemical)
Types of HSV
Type I - Oral cold sores
Type 2 - STI/Painful genital ulcers
Effect of compression of pudendal nerve during childbirth
Sensory loss surrounding skin of perineum
Motor loss of urethral sphincters (incontinence)
Pouch of Douglas
Rectouterine pouch
How does the female pelvis differ from the male pelvis
Female has a wider suprapubic angle and pubic inlet
Effects of relaxin hormone
Increased laxity of pubic symphysis and sacroiliac joints during pregnancy - allowing expansion during childbirth. Increased CO Induces constipation Increased renal perfusion Cervix dilatation
How do the structures palpated during a DRE differ in a male and female?
Male: seminal vesicle and prostate gland. Female: Uterus
Hypospadias
Congenital malformation causing there to be an abnormal opening to the urethral meatus
Transurethral Resection of Prostate
Removal of part of prostate through urethra using a cauterising loop.
Risk of removing part of the internal urethral sphincter - resulting in retrograde ejaculation.
‘Water under the bridge’
Ureters run underneath the uterine artery.
Important when carrying out an ovariectomy, when ovarian arteries are ligated, to avoid damage to ureters.
Pap smear
Used to detect changes to the cells (dysplasia) in and around the cervix.
Description of Pap smear showing Low grade squamous intraepithelial lesion
Mild dysplasia (CIN I) Often associated with HPV/Genital warts Normally resolved without intervention within 18-24 months
Description of Pap smear showing high grade squamous intraepithelial lesion
Severe dysplasia - shrivelled membranes, enlarged nuclei with less cytoplasm, giants cells and RBCs (CIN II and III)
Precancerous lesions
Cervical Intraepithelial Neoplasia Grade II
Moderate dysplasia
Confined to basal 2/3 of epithelium
Cervical Intraepithelial Neoplasia Grade III
Severe dysplasia
Spans more than 2/3 of epithelium (may be full thickness)
Also referred to as Carcinoma in situ
Tanner Scale
Measures male and female development (puberty)
Prader Orchometer
Measures volume of testis (4ml at the onset of puberty)
Female growth spurt occurs at age
11
Male growth spurt occurs at age
13
Effect of age on gonadal feedback
Prepuberty - gonadal steroids and gonadotrophins are LOW but feedback mechanism is very sensitive.
Puberty - gonadal steroids and gonadotrophins are HIGH but decreasing in sensitivity
Adult - maximum gonadal steroids and gonadotrophins, lowest sensitivity
Leptin deficiency in puberty
Causes biochemical Hypothalamic Hypogonadism - adult women not menstruating or are prepubertal developmentally
Effects of delayed onset puberty
Short stature Low self confidence Rejection Inadequacy Disturbed relationship with parents Attention seeking behaviour Persistence of psychological characteristics into adult life
Treatment of delayed onset puberty in males
Testosterone from 14yrs until testicular volume reaches >8mls
Pituitary-gonadal testing if no testicular enlargement occurs
Treatment of delayed onset puberty in females
Ethinyloestradiol until puberty established
Treatment of delayed onset puberty in females
Ethinyloestradiol until puberty established
Conditions associated with hypogonadotrophic hypogonadism
Kallman’s Syndrome - Mutations in KAL1 gene causing olfactory hypogenesis and failure of GnRH neuronal migration.
Prader-Willi Syndrome - impaired response to LH and FSH
Treatment of precocious puberty in females
Aromatase inhibitor - enzyme normally converts testosterone to oestrogen
Abortifacients
Mifepristone - Progesterone receptor antagonist. Causes endometrial degeneration and sensitises uterine contractions to prostaglandins
Gemeprost - Analogue of PGE2, used with mifepristone. Reduces obstetric bleeding by causing vasoconstriction.
3 forms of chlamydia
Infection of eyelids
STI
Lymphogranuloma Venereum (of lymph nodes)
Consequences of untreated chlamydia
Pelvic inflam disease Ectopic pregnancy Tubal infertility Chronic pain Increased HIV transmission Reiter's Syndrome (arthritis, conjunctivitis, urethritis) Transmission to baby during childbirth.
Antibiotics which delay metabolism in the liver
Metronidazole, Isoniazid, chloramphenicol
