Deck 12 Flashcards
Phimosis presentation and management
Can’t retract foreskin
May have weak stream, dribbling, haematuria, painful erections, recurrent UTIs
Management with hygiene, steroid cream, circumcision
Paraphimosis presentation and management
Swelling, painful erection, necrosis
Can use analgesia, compression, osmotic reduction (50% dextrose), puncture, cicumcision
Paraphimosis RF
Foreskin scaring, vigorous sexual activity, chronic valanitis, urinary catheterisation
Priapism
RF
Types
Erection >4h, despite ejaculation
Affects cavernosum
RF: sickle cell, sildenafil, antidepressants, cannibis, cocaine, leukaemia, pelvic tumour
Can be low flow or high flow
Low flow priapism
Blood doesn’t drain, intermittent but has risk of scarring if >4h. Can lead to impotence and fibrosis
High flow priopism
Rarer than low flow, less painful, often due to trauma/spinal cord injury
Tx may be cold pack and compression
Penis carcinoma
RF
Presentation
Mets
SCC of gland/prepuce
RF: phimosis, HPB 16 and 18,
Presents as burning itch, mass, ulceration
Can spread to liver/lung
Urethral stricture presentation
weak urinary stream, dyuria, incomplete voiding, may have retention
Urethral stricture causes and diagnosis
Narrowing. Can be injury, urethral instrumentation, infection, inflammatory conditions (e.g. lichen sclerosis)
Can be congenital or malignancy related
Diagnosed by cystoscopy
Painful testicular lumps
Generally strangulated inguinal hernias, testicular torsion or epididymo-orchitis
Painless scrotal lump
Often testicular tumour, haematocoele, epididymal cyst, varicocoele, hydrocoele
Varicocoele
Bag of worms, lump, dragging sensation, painless or dull ache
Disappears lying down, reappears on standing/valsalva
Needs investigating for malignancy obstructing left renal vein, so much do abdo exam
May have subfertility
Can manage with embolisation/ligation but ONLY if painful, infertility or occurance in children
Hydrocoele
Can be congenital, may be unilateral/bilateral
Peritoneal fluid collects between parietal and visceral tunica vaginalis (can be patent processus vaginalis (congenital or in raised intra abdo pressure such as fluid overload or dialysis) but can be imbalance of fluid secretion/reabsorption in older patients)
Can also occur in minor trauma, torsion or epididymitis
Aspiration possible but can reoccur inless roort cause resolves
Epididymal cyst/spermatocoele
Common, esp in middle age.
No increased malignancy risk.
Painless, smooth, well defined, fluctuant lumo, transilluminates. Separate to testes, chronic onset. Often superior and posterior
Epididymo-orchitis
Inflammation of epididimus/testicle, due to infection
In <35, often STI (Chlamydia/gonorrhoea), in >35 then more likely UTI (E/coli/pseudomonas)
Tender, oedema. Dysuria, fever, urethral discharge. Positive Phren sign (relief on testicular elevation)
Mumps can also cause orchitis so need to palpate parotid if fever prodrome
Bilateral mumps associated with infretility
If no STI/UTI symptoms then ? torsion instead
Orchitis causes
Can be extrapulmonary TB (also has thickened spermatic cord), or mumps (palpate parotid if fever prodrome)
Torsion of testicular appendage
Less painful than testicular torsion. Get small, blue nodule visible under the scrotum
No testicular elevation
Classically occurs at start of puberty
DDx for testicular torsion
Torsion of testicular appendage, epididymitis, indirect, inguinal strangulated hernia
RF for testicular cancer
RF: white, FHx testicular ca, undescended testes, infertility, infant hernia, klinefelters, hypospadia
Typical testicular cancer mets
Typically spread it to para-aortic lymph nodes, and to liver and lungs.
Semimona
50% of testicular cancer. From seminiferous tubules.
Peak age is 35
Malignant
Teratoma testicular cancer
Germ layer mix. Peak age 25
Can be embryonal, yolk sac(often benign but aggressive if malignant), choriocarcinoma (early lung mets, poor prognosis)
Non germ cell testicular cancers
Can be lymphoma, leydig tumour (respongs to LH, makes Testosterone or oestrogen), sertoli cells (can secrete oestrogen or teststerone)
Choriocarcinoma
Malignant trophoblast teratoma germ cell tumour. Poor prognosis. Early lung mets
Leydig tumour
Responds to LH, makes testosterone or oestrogen. Non germ cell
Sertoli cell tumour
Can secrete oestrogen or testosterone. Non germ cell tumour
Germ cell tumours
Seminomas or teratomas
Testicular cancer presentation
painless, fixed, film, irregular mass that does not transilluminate. May cause a secondary hydrocoele. May present with haematospermia. Can present with hormone secretion or mets (gynaecomastia, weight loss, back pain, dysponoea, SOB)
Investigation of testicular tumours
tumour markers (alpha fetoprotein in yolk sac tumour, b-hCG in teratomas and seminomas), USS, excision biopsy, staging (CT CAP). Royal marsden system for staging (1 is no mets, 2 is abdo node mets, 3 is supradiaphragmatic node mets and 4 is extra lymphatic mets)
Alpha fetoprotein for testicular cancer marker
Yolk sac teratoma (often benign but aggressive if malignant. Germ cell. Peak age is 25
b-hcG in testicular cancer
teratoma and seminoma investigation
milk production
15 lobules with milk glands empty into lactiferous duct
Breast lymph drainage
75% to ipsilateral axilla, 25% to internal mammary lymph gland (runs alongside internal mammary artery - crosses midline and allows spread)
benign breast lumps
tend to be smooth (examples are fibroadenoma, fibrocystic disease, breast cysts, breast abscesses, fat necrosis)
malignant breast lumps
Tend to be craggy, irregular, fixed
USS imaging in breast pathology
Generally under 35, if over this then mammorgram better.
USS used for lymph nodes.
Imaging in recurrent breast cancer
MRI
Imaging in lobular cancer
MRI
Core needle biopsy
USS or MRI guided.
Fibroadenoma
Most common benign. Stromal tissue. Common in young females
Painless, rubbery, firm, well demarcated. Highly mobile. No lymphadenopathy. Can be multiple, bilateral.
No treatment as 1/3 involute. if >4cm then patient may want removal
Fibrocystic disease
Very common. General lumpiness (rope like texture). See cysts, fibrosis, hyperplasia of duct epithelium. Can get cysts.
May be cyclical
Presents: lumpy breast, swelling, generalised pain, tenderness, armpit pain, green/dark brown nipple discharge (no blood)
Triple assessment, then management conservatively (supportive bra, COC, evening primrose oil)
Breast cyst
Benign, fluid filled cyst. Common in 30-50
Sudden onset swelling,symmetrical smooth, fluctuating with menstruation. Often solitary.
FNA under USS to diagnose. Straw coloured but if blood stain the ?cancer. Check breast as can co-exist with cancer
Fat necrosis
RF are BMI>30 and Hx of breast trauma
Firm, painless lump (may be tenderness surrounding it), irregular outline, thick/retracted skin, red/bruising
Needs triple assessment. Analgeia as Tx as reabsorbs over time
Phylloides tumour
Rapidly growing benign stromal tumour
Lactational breast abscess
S aureus from baby’s nose.
Hot, red, swollen, lumo. May have pus, pyrexia, sepsis.
USS guided aspiration. Rest breast of breastfeeding. fluclox
Non-puerperal breast abscess
RF are diabetes and smoker.
Gram negative bacteria (metronidazole)
See hot, red, swollen lump. May have pus dicharge. Can have pyrexia/sepsis.
USS guided aspiration
Most common breast cancer type
Invasive ductal (75-85%)
Less common breast cancer types
Invasive lobular
Breast cancer met sites
bone, lung, liver and brain
Lobular breast cancer diagnosis
More difficult due to stromal thickening (best seen on MRI) rather than lump
Breast cancer RF
female, FHx of breast ca, post menopausal, obesity, high alcohol consumption, BRCA1, BRCA2, lifetime oestrogen exposure (nulliparity, OCP, early menarchy, late menopause, HRT)
Breast cancer presentations
thickened areas, dimpling, nipple crush, bump, growing vein, sunken nipple, new shape/size/asymmetry, red/hot, discharge, skin sore, peau d’orange, hard lump, axillary lump (axillary lump is breast ca until proven otherwise).
Paget’s disease of the nipple
rare skin condition associated with 1-4% of breast cancers - can mimic eczema. Intra ductal.
Presents as rough, reddened, ulceration of nipple, flaking skin and itching.
Skin biopsy and triple assessment required.
Breast caricnoma in situ
pre-cancerous lesion (yet to breach basement membrane). Normally ductal carcinoma in situ (DCiS) but can be lobular - seen as microcalcifications on mammogram. Needs triple assessment.
BRCA1
autosomal dominant, tumour suppressor gene on chromosome 17. Increased risk of breast cancer and ovarian cancer, as well as prostate and colon cancer
BRA2
autosomal dominant on chrom 13, increased risk of breast and ovarian cancer and also MALE breast cancer
Who should be offered genetic testing for breast cancer
Young females with breast cancer
Relative may get prophylactic surgery if appropriate
Reducible hernia
Can be manipulated back via wall defect into original position
Irreducible hernia
Can’t be manipulated back into position without surgery
Incarcarated hernia
Irreducible with contents trapped due to adhesions. Firm, tender, red
Strangulated ihernia
ischaemic hernia (necrosis and sepsis). Severely painful
Obstructed hernia
Bowel lumen obstructed. Abdo pain, distension, absolute constipation and N&V occur
RF for hernia
weak abdo wall, increased abdominal pressure, abdominal surgery, male (central obesity), lifting, protein deficiency (less collagen for gut lining), increasing age (less collagen)
Inguinal hernia
Can present with pain (Esp on coughing or stooping), altered bowel habit, constipation, burning sensation in groin, scrotal swelling
Contents of inguinal canal in males and females
Males have spermatic cord with nerves
Females have round ligament with nerves
Borders of the inguinal canal : Roof
Transversalis fascia, internal oblique, transversus abdominus
Posterior wall of inguinal canal
transversalis fascia (only 1 wall so weakest side)
Floor of inguinal canal
inguinal ligament, lacunalr ligament
Anterior wall of inguinal canal
Aponeurosis of external oblique and internal oblique
Deep ring location
Midpoint of inguinal ligament (lateral to epigastric vessels).
Half way between ASIS and PT
Mid inguinal point
Half way between ASIS and PS
Superficial ring
Superior to pubic tubercle
Direct inguinal hernia
20% of inguinal hernias. Defect in posterior wall (Hesselbach’s triangle). Tend to reduce easily and not strangulate
Indirect inguinal hernia
80% of hernias. Most common hernia in women.
Goes through both deep and superficial ring (incomplete processus vaginalis). More likely to strangulate as superficial ring is not dilated. More likely to enter scrotum
Most common hernia
indirect inguinal
Differentiating between indirect and direct inguinal hernias
Direct reappears on coughing once pressure applied over inguinal ligament midpoint.
On surgical exploration, indirect as lateral to inferoir epigastric vessels. Direct are medial to inferior epigastric vessels
Hernia lateral to inferior epigastric vessels
indirect
Hernia medial to inferior epigastric vessels
Direct hernia
Femoral hernias
5% of hernias
Viscera or omentum pass through femoral ring into potential space
Femoral hernia RF
female (wider pelvis), pregnancy (esp multiparous), raised intraabdominal pressure)
Femoral canal
Medial to femoral vein, gives space for vein to expand
Femoral triangle
Inguinal ligaement superiorly, medial border of sartorius laterally, lateral border of adductor longus medially
Femoral hernia investigation and management
Can present as painless groin lump, but can progress quickly so needs urgent evaluation.
High strangulation risk (due to narrow femoral canal.
Differentiating inguinal from femoral hernia
Inguinal tend to be superiomedial to pubic tubrecle, femoral hernias tend to be inferiolateral
Richter’s hernia
Femoral hernia with only sidewall of bowel and not lumen - can give stranglation and perforation without obstruction
Umbilical hernia
defect in transversalis fascia (umbilical ring site)- more common in children, but also in pregnancy and gross ascites. Low strangulation risk. Generally not operated on until over 2 years
Paraumbilical hernia
adjacent to unbilicus (superior or inferior) due to linea alba weakness. More common in women 35-50 (often obesity or gross ascites) and have high risk of strangulation
Epigastric hernia
Hernia from fat overlying bowel through linea alba ABOVE umbilicus (often slightly off midline), 1cm or less in diameter. More common in young males.
Can cause discomfort on eating/exercise with nausea and bloating. Relieved by reclining.
Incisional hernia
Risk from any abdo surgery. Mesh repair possible.
Needs mentioning as part of consent.
RF: poor surgical technique, emergency surgery, midline incisions, wound infection, reduced healing capacity (diabetes, smoking, vascular disease, immunosuppression, pre op chemo), absorbable stiches
Divarication of recti
Not really a hernia. Separation of rectus abdominus due to linea alba laxity. More common in truncal obesity in men and pregnancy in women, but also repeated midline ops and chronically raised intra-abdominal pressure.
Diagnosed by USS and by prominent midline bulge when patient head is raised.
Conservative hernia management
Weight loss and smoking cessation
Hernia ddx
Lipoma, femoral artery aneurysm (pulsatile), saphenous ovarix (dilatation of saphenous vein in groin, lymph node
Catheter indications
urinary retention, output monitoring (critical illness/perioperative patients), incontinence, aid in surgery
Contraindications for catheter
urethral injury (e.g. pelvic fracture) or acute prostatitis (use suprapubic instead - bladder must be full for this).
Sizing for catheter
12 for female, 14 for male
Catheter maintenance
Tube and site of entry should be cleaned twice daily, bag changed at least weekly. Empty bag when 2/3 full.
Proper care reduces change of stricture formation and infection.
Catheter complications
Infection, paraphimosis, creation of false passages, urethral strictures, urethral perforation, bleeding.
Urine sample from catheter?
Never from bag, only from port in tubing or aseptic aspiration of tubing
RF for post surgical infection
Age, malnutrition, cancer, immunosuppresion, obesity, hypoxia, anaemia, type of surgery, length of procedure, foreign body insertion, ischaemia, lack of abx prophylaxis, virulence of organism
Wound healing
Haemostasis Inflammation (oedema, infiltration) Proliferation (fibroblasts give collagen, myofibroblasts secrete actin products. Angiogenesis and granulation) Epithelialisation Remodelling
