Clin Med GUT Women's health Anat/Radiology Part 2

Question 1

Anatomy of the KUB:

-Note location of the Kidneys, ureters and bladder

Answer 1

Slide 2 image

Question 2

Hysterosalpingogram=

Answer 2

an X-ray procedure that is used to view the inside of the uterus and fallopian tubes. It often is used to see if the fallopian tubes are partly or fully blocked.

-synechiae-adhesions

Question 3

Does VUR cause Renal Damage?

Answer 3

VUR= vesicoureteral reflux

answer: not necessarily!

Question 4

VUR:

-genetic disposition? Primary vs Secondary

Answer 4

• Primary= (genetic predisposition to short ureteral tunnel through bladder) – small chance of renal damage from VUR
• Secondary (to bladder and/or urethral dysfunction, ie neurogenic bladder or posterior urethral valves)

Question 5

VUR:

Primary or secondary cases have more problems?

Answer 5

Secondary cases have the most problems and have increased chance of renal damage from VUR

Question 6

Vesicoureteral Reflux (VUR):

• Predisposition to UTIs (yes or no?)
• demographic?

Answer 6

• VUR does NOT predispose to UTIs if there is no stasis of urine in the GUT
• A Hydronephrosis found on prenatal US requires a followup eval after birth to determine etiology.
• **30-40% of children <5 yrs with UTIs have VUR

Question 7

Febrile UTIs, or VUR plus UTIs have increased chance of ____

Answer 7

**renal scarring

Question 8

Surgery to reimplant ureters and/or prophylactic antibiotics do not necessarily prevent:

Answer 8

UTIs and/or renal damage

Question 9

VUR:

-Greater grade of reflux associated with increased chance of ______

Answer 9

**renal damage

Question 10

Bottom line: for VUR and UTIs

Answer 10

**both require individual evaluation and treatment as these are complex entities with still evolving knowledge of their associations

Question 11

VUR grading

Answer 11

Grade I-V (Grade 4-5 =SEVERE)

Question 12

VUR work-up should include:

Answer 12

**VCUG (=voiding cystourethrography) or Isotope Cystogram and a Radionuclide DMSA Renogram

-You are evaluating renal parenchyma and presence of reflux.

Question 13

VUR:
Reflux is of 2 types:
Type 1 is due to–>

Answer 13

**1) Due to immaturity with a short ureteral tunnel in the bladder. If reflux is present with a UTI, pyelonephritis and renal damage can result. Immature short tunnel usually resolves with age.

Question 14

VUR:
Reflux is of 2 types:
Type 2 is due to–>

Answer 14

2) Due to a congenital anomaly at the UV junction, ie no tunnel, adjacent bladder diverticulum, or displaced orifice. If reflux is present with a UTI, pyelonephritis and renal damage can result.

Question 15

VUR:

With Posterior Urethral Valves OR a Neurogenic Dysfunctional Bladder, reflux:

Answer 15

**does not necessarily occur if the ureteral tunnel is normal. If the tunnel is abnormal, reflux occurs.

Question 16

When prenatal fetal hydronephosis occurs OR the patient has documented pyelonephritis, What must be done?

Answer 16

*a work up – VCUG or Radionuclide Cystogram – is indicated to determine if underlying anatomic or functional abnormalities are present. If so, depending on findings, treat.

Question 17

Hydronephrosis can occur 2/2 _____

Answer 17

ureteral obstruction

Question 18

Pyelosinus backflow of urine usually occurs through infractions of the calyceal fornices from ______

Answer 18

obstruction

1 case that witwer mentioned regarding pyelosinus backflow 2/2 pressure:
=> ruptured renal collecting system w/ pyelosinus backflow

Question 19

Bilateral collecting system=

• how are most diagnosed?
• associated w/ ?

Answer 19

= an unusual renal tract abnormality

• most are incidentally seen
• associated w/ GU abnormalities

Question 20

Cystitis=

Answer 20

=inflammation of the urinary bladder, often caused by infection and is usually accompanied by frequent painful urination (dysuria)

Question 21

16 YO patient with recurrent UTIs. Thickened bladder wall and
tubular structure that turned out to be a blind ureter, on
Retrograde Pyelography–> dx?

Answer 21

think Cystitis**

Question 22

Polycystic Ovary Disease (PCOD)=

Answer 22

**Enlarged ovaries with thick sclerotic capsules and an abnormally high number of follicles

on imaging: Increased central stroma with multiple small subcapsular follicles

Question 23

Stein-Leventhal Syndrome= (what Sx are assoc. with this syndrome**)

Answer 23

**amenorrhea, infertility, hirsutism and enlarged polycystic ovaries

Question 24

Imaging findings revealed:

• Large ovary with large follicles
• Large ovary without demonstrable Doppler flow

Most likely dx= ?

Answer 24

*ovarian torsion

Question 25

Ectopic Pregnancy:
-If the Pt’s beta-HCG level is >_____ IU/mL (2IS Standard) OR >_____ IU/mL (IRP standard), an intrauterine gestational sac SHOULD be identifiable on a transvaginal sonogram

Answer 25

> 1000 IU/mL (2IS Standard) or >2000 IU/mL (IRP Standard)

Question 26

An intrauterine gestational sac should be present by __ weeks and also show embryonic cardiac activity by ___ weeks on a Transvaginal Sonogram when the sac is at least 16mm long or embryonic crown rump length is at least 5mm.

Answer 26

**5 weeks

5+ weeks

Question 27

IF none of the above are evident (ie no intrauterine gestational sac present at 5 weeks, or embryonic cardiac activity by 5 weeks OR beta-HCG levels >1000 or >2000 and no identifiable gestational sac) –> strongly suspect ectopic pregnancy.

-Additional criteria for ectopic pregnancy are:

Answer 27

• If no intrauterine gestational sac is seen at all
• If a live, extrauterine embryo is identified
• There is free fluid in the pelvis or peritoneum
• There is an adnexal mass
• There is a hematosalpinx

(MEMORIZE)

Question 28

PID is associated with ____ abscess

Answer 28

**tuboovarian

Question 29

Dermoid Cyst of the Ovary:

-contains ______

Answer 29

skin tissue, and hair, fat tissue, can have mandibles (ie can have teeth in it)–> diagnosis made by removing it and send to pathologist

Question 30

Serous Cystadenoma of the Ovary:

-size?

Answer 30

often very large

Question 31

Endometrioma=

Answer 31

a type of cyst formed when endometrial tissue (the mucous membrane that makes up the inner layer of the uterine wall) grows in the ovaries

(Endometrioma contains blood tissue (endometrial tissue aka it’s very vascularized)
–the blood will be brown because it’s old= termed a “chocolate” cyst )

Question 32

Endometriosis=

Answer 32

presence of endometrial glands and tissue OUTSIDE of the uterus.
-Women with endometriosis may have problems with fertility

(remember: endometrial tissue is sensitive to the hormonal environment) this is common and can be VERY painful

Question 33

Uterine Leiomyomata/Fibroids:

Answer 33

-very common
=noncancerous growths of the uterus that often appear during childbearing years. Also called leiomyomas, uterine fibroids aren’t associated with an increased risk of uterine cancer and almost never develop into cancer

Question 34

Uterine Adenomyosis= occurs when ______

Answer 34

the tissue that normally lines the uterus (endometrial tissue) grows into the muscular wall of the uterus

(on imaging: Note Thickened Myometrium )
.

Question 35

**Echogenic mass within the Uterine Cavity replacing the endometrial stripe=

Answer 35

**endometrial carcinoma

Question 36

Post menopausal woman with vaginal bleeding. What MUST you R/O?

Answer 36

**r/o endometrial carcinoma (cancer)

Question 37

Supporting and Stabilizing Structures of the uterus – (Experts differ):
-structures associated with the Pelvic Diaphragm (=pelvic floor)=

-Others?

Answer 37

• Pelvic Diaphragm (Pelvic Floor): (consists of)
• -Levator Ani
• -Coccygeus Muscle
• -And associated fascia
• Urogenital Diaphragm/Perineal membrane
• Perineal Body

Question 38

T/F: the Broad Ligament, Round Ligament, suspensory ligament of the ovary, and peritoneal folds associated with the uterus are not considered to be true uterine support stuctures

Answer 38

true

Question 39

“Ligamentous Supporting” Structures of the Uterus

-List the 3 Supporting/Stabilizing Structures aka Major Ligaments of the uterus:

Answer 39

• Cardinal (Transverse cervical, Mackenrodt)= fibromuscular fascia from either side of cervix to the pelvic walls
• Uterosacral ligaments=>from posterior cervix to the sacrum–comprised of the Recto-uterine folds – comprised of fibrous tissue and muscular fibers attached to front of sacrum
• Anterior Pubocervical ligament => from the uterus to the pubic symphysis
• MEMORIZE*

Question 40

Cardinal ligament= aka ______ ______ ligament

Answer 40

*transverse cervical

Question 41

Condensations of _____ form Ligaments

Answer 41

fascia

Question 42

Peritoneal folds associated with the Uterus:

List:

Answer 42

**Broad Ligament, Mesovarium, Mesosalpinx, & Round Ligament

Question 43

Folds of Peritoneum form Pouches:

-list ex’s

Answer 43

• Note the Urachus and Umbilical folds
• Note Vesicouterine pouch
• Note Rectouterine Pouch (Douglas)

Question 44

Pouch of Douglas =

–this is a deep pouch, located ______

Answer 44

• *Rectouterine or Rectovaginal Pouch or Space

- **This is a deep pouch posterior to the uterus and anterior to the rectum

Question 45

Mesovarium= a fold of peritoneum off of the _____

Answer 45

** Broad Ligament

Question 46

Suspensory Ligament of Ovary= a fold of peritoneum from _______

Answer 46

**superiolateral pelvic wall and contains arteries, veins, lymphatics

Question 47

Ligament of the Ovary is continuous with the ______. Attached to ______

Answer 47

• *Round Ligament of Uterus.

- lower pole of ovary to Uterus

Question 48

Describe how a cystocele occurs

Answer 48

-**The Pubocervical Fascia
supports the bladder

-When the Pubocervical
Fascia weakens, often
2/2 child birth,
then the support of the 
Bladder weakens and 
Cystocele (Prolapse) 
occurs

Question 49

Urachus=

Answer 49

a hollow canal connecting the fetal urinary bladder to the umbilical cord**

Question 50

Normally the urachus is obliterated during ______ to become _______

Answer 50

**development to become the Median Umbilical Ligament or Fold

Question 51

The **Medial Umbilical Ligament is different, this is the obliterated ________

Answer 51

**Umbilical Artery that during fetal development connected to the Internal Iliac Artery

Question 52

IF the lumen remains open (ie patent urachus (aka urachus stays open) a communication can occur between the urinary bladder and _______, OR a _____ can form

Answer 52

**If the lumen remains open, a communication can occur between the Urinary Bladder and Umbilicus or a Urachal Cyst can form.