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Pelvic > Final > Flashcards

Final Flashcards

1
Q

Is prostate intra or retro?

A

retro

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2
Q

what are the 2 regions of the prostate?

A
  • fibromuscular region/stroma

- glandular region (posterior)

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3
Q

which reigion has less clincal significance?

A

fibromuscular region/stroma

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4
Q

what are the 4 zones of the prostate?

A
  • peripheral
  • central
  • transitional
  • periurethral glandular tissue/zone
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5
Q

how much of the prostate does the peripheral zone take up?

A

70%

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6
Q

how often (percent) are cancers found in the peripheral zone?

A

70%

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7
Q

which zone is considered the “eggcup” holding the egg of the central gland

A

peripheral zone

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8
Q

how much of the prostate does the central zone take up?

A

25%

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9
Q

how often (percent) is cancer in the central zone?

A

5%

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10
Q

what is located in the central zone?

A

vas deferns

seminal vesicles

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11
Q

what makes up the transitional zone?

A

lateral aspects of the proximal prostatic urethra

5% of glandular tissue

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12
Q

how often (percent) is cancer found in the transitional zone?

A

20%

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13
Q

periurethral glandular zone

A

tissue that lines the proximal prostatic urethra

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14
Q

what is the prostatic urethra divided by (proximal and distal)?

A

verumontanum

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15
Q

what does the “surgical capsule” seperate?

A

inner and outer gland

NOT A TRUE CAPSULE

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16
Q

What is transabdominal good for looking at?

A

gross porastate

bladder evaulation

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17
Q

transabdominal sonographic appearance of the prostate

A
  • heterogenous
  • should be symmetrical
  • limited resolution
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18
Q

what is the approx size and weight of the prostate?

A

weight-20 grams

measurement-4cmx3cmx3.8cm

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19
Q

what zones have similar echotexture?

A

central and transition

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20
Q

are you able to distinguish the 4 zones of the prostate with TRUS?

A

nope

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21
Q

what do we divide the prostate into?

A
  • central or inner gland

- peripheral or outer gland

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22
Q

transrectal probe frequency

A

7-11 MHz

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23
Q

what are some sonographic applications expanded with TRUS?

A
  • size and echotexture
  • evaluation of BPH
  • Prostatis
  • detection of masses
  • sonographic correlation of findings from DRE
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24
Q

TRUS to a lesser degree

A

male infertitiy

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25
Q

sonographic appearance of peripheral or outer gland

A
  • uniform, homogenous texture

- slighty more echogenic than inner gland

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26
Q

sonographic appearance of central or inner gland

A
  • more hypoechoic

- heterogenous

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27
Q

what are some benign conditions of the prostate?

A
  • normal varients
  • BPH
  • prostate cysts
  • prostatitis
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28
Q

benign ductal ectasia (normal varient)

A
  • older
  • atrophy and dilation of prostatic ducts
  • single or grouped
  • tubular structures in the peripheral zone
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29
Q

prostatic calcifications (normal variants)

A
  • normal finding
  • more common in elderly
  • bright echogenic foci clumps in prostate
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30
Q

corpora amylacea (normal varient)

A
  • proteinaceous debris
  • sound attenuation
  • create twinkle artifact
  • no clincal sigificance
  • along surgical capsule
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31
Q

what does BPH stand for?

A

benign prostatic hypertrophy or hyperplasia

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32
Q

what is BPH?

A
  • enlarged prostate (greater than 40 grams)
  • not serious
  • usually happens with all men as age
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33
Q

what is the etiology for BPH?

A

unclear

maybe due to hormones

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34
Q

what part of the gland is affected in BPH?

A

all components
(fibrous, muscular, and glandular elements)
PRIMARILY AFFECTS TRANSITIN AND PERIURETHRAL ZONES

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35
Q

What are symptoms of BPH?

A 
-asymtomatic
lower urinary tract symtoms:
-Frequency
-nocturia
-weka stream
-trouble starting or stopping
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36
Q

BPH has a small risk for complete blockage, why may this happen?

A

result in urinary retention

  • bladder stones
  • bladder infection
  • kidney damage
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37
Q

what may BPH to do the bladder?

A

may push prostate into bladder

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38
Q

what is the typical sonographic appearance of BPH?

A

enlargement of the inner gland

  • nodules with distinct margins
  • calcifications
  • parenchymal degenerative cysts
  • retention cysts
  • may buldge into bladder
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39
Q

what is considered the standard treatment for BPH?

A

TURP

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40
Q

what are some other treatments for BPH?

A
  • watchful waiting
  • medical therapy
  • open surgery
  • laser therapy
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41
Q

do we treat an asymptomatic patient with BPH?

A

no

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42
Q

what do we need to exclude before TURP?

A
  • neurologic disorders
  • diabetes
  • local urinary conditions
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43
Q

whta are some prostate cysts?

A
  • parenchymal
  • retention
  • congenital
  • ejaculatory duct
  • cystic tumors
  • abscesses
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44
Q

where are most cysts?

A

midline

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45
Q

what is associated wirth BPH?

A

parenchymal Degenerative and retention with BPH

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46
Q

appearance of congenital cysts?

A
  • sonographically the same

- tear dropped shaped

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47
Q

what is utrical cysts associated with?

A

unilateral renal agenesis

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48
Q

what is ejaculatry cysts associtaed with?

A

infertility

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49
Q

what cyst os most common associated with BPH?

A

parenchymal degenerative cysts

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50
Q

where are parenchymal degenerative cysts located?

A

transition zone

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51
Q

what can happen if parenchymal degenerative cysts are large?

A

contribute to urinary or ejaculatory obstruction

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52
Q

what do parenchymal degenerative cysts look like sonographically?

A

unilocular or thinly septated multilocular cyst in a BPH nodule in the transitional zone

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53
Q

where are retention cysts located?

A

focal cysts on the surface of the prostate

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54
Q

why do retention cysts occur?

A

duct obstruction

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55
Q

appearances of retention cysts?

A

-small

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56
Q

where are congenital cysts located?

A

in or close to midline

-Wolffian or pronephric ducts or mullerian ducts

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57
Q

congenital cysts are usually asymtomatic, when do they become symptomatic?

A

if infected
(Prostatic utricle cysts
Mullerian duct cysts)

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58
Q

what are utrical cysts (congenital cysts) caused by?

A

dilation of prostatic utricle

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59
Q

what are utrical cysts (congenital cysts) associated with?

A

unilateral renal agenesis

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60
Q

where are uitrical cysts (congenital cysts) located?

A

always midline

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61
Q

Where are mullerian duct cysts (congenital cysts)

A

mainly midline

no associations

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62
Q

what is the sonographic appearance of mullerian and utricle cysts?

A
  • same sonographically
  • tear dropped shaped pointy end to vermontanum
  • thick walled
  • cause obstruction of ejaculatory ducts is large
  • develop calcifications
  • both can become symptomatic, painful or infected, rarely becomes tumors
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63
Q

ejaculatory duct cysts appearance

A
  • usually small
  • fusiform in shape
  • typically pointed at both ends
  • infertility
  • can cause perineal pain
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64
Q

what may a ejaculatory duct cyst also be seen as?

A
  • cystic dilation of ejaculatory duct

- diverticula of duct

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65
Q

cystic neoplasms (tumors)

A
  • rare

- cystadenoma and cystadenocarcinoma have been seen

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66
Q

what is the most common etiology of prostate abscesses?

A

coliform organisms such as E.Coli

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67
Q

what does a prostatic abscess look like sonographically?

A
  • thick
  • irregular walls
  • debris within fluid
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68
Q

what is a treatment for prostatic abscess?

A

transrectal aspiration or TURP drainage and antimicrobia therapy

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69
Q

cysts caused by parasites are rare in _________

A

western countries

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70
Q

ALL BENIGN CYSTS important points:

A
  • have potential to cause ejaculatory obstructions if become large
  • have potential to become infected leading to symtoms
  • if buldge capsule can mimic solid nodule on DRE
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71
Q

are cystic tumors rare or common?

A

RARELY DEVELOP

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72
Q

What are areas for classification for prosatitis?

A
  • acute bacterial prostatitis
  • chronic bacterial prostatitis
  • chronic prostatitis/chronic pelvic pain symdrome
  • asymptomatcic inflammatory prostatitis
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73
Q

which prostitis characterizaton is most common?

A

Chronic prostatitis/chronic pelvic pain syndrome

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74
Q

what are some subtypes of Chronic prostatitis/chronic pelvic pain syndrome?

A
  • inflammatory

- non inflammatory

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75
Q

which prostatitis is not apart of the 4 classifications of prosatitis?

A

granulomatous

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76
Q

sonogrpahic appearance of prostatitis?

A
  • can appear normal on TRUS
  • non specifiic US findings associated with most types
  • some can cause elevation of PSA or hard lump
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77
Q

when may we see elevation of PSA or hard lump

A
  • asymtomatic inflammatory

- granulomatous

78
Q

what does prostatitis refer too?

A

chronic pain syndrome

79
Q

prostatitis for men under 50

A

leading cause of visits to urologist

80
Q

prostatitis for men over 50

A

3rd most common cause, after BPH and cancer

81
Q

what is the least common type of prostatitis?

A

acute bacterial

82
Q

what is the sonographic appearance of acute bacterial prostatitis?

A

findings only seen in 1/2 of men

  • edema
  • enlargment
  • increased blood flow
  • venous engorgement
  • hypoechoic peripheral halo
  • patchy echo changes
83
Q

what is the treatment for acute bacterial prostatitis?

A

antibiotics

abscess can occur in 0.5-2.5% of patients

84
Q

which type of prostatitis have no US findings?

A

chronic bacterial prostatitis

85
Q

what are the symoptoms of chronic bacterial prostatitis?

A

recurrent episodes of bacterial UTI-like symptoms

86
Q

what is the treatment for chronic bacterial prostatitis?

A

6-12 weeks of antimicrobial therapy

87
Q

what is the most common form of prostatic inflammation?

A

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPP)

90% cases

88
Q

which type of prostatitis is difficult to understand and treat?

A

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPP)

89
Q

what is the etiology of Chronic prostatitis/chronic pelvic pain syndrome (CP/CPP)?

A

unknown

90
Q

prostatitis inflammartory type A

A

Diagnosed by leukocytes in prostate secretions, urine or semen

91
Q

prostatitis non inflammartory type B

A

No evidence of inflammation also called “prostatodynia”

92
Q

what is the treattment to Chronic prostatitis/chronic pelvic pain syndrome (CP/CPP)?

A

may respond to

  • antibiotics
  • alpha blockers
  • nonsterodial anti-inflammatory drugs
  • analgesics
93
Q

what does Chronic prostatitis/chronic pelvic pain syndrome (CP/CPP) look like sonographically?

A 
usually appears normal
Or nonspecific findings
-Peripheral hypoechoic areas
-Calcifications
-Venous congestion
-Increased arterial flow
-Bladder neck thickening
-Hypoechoic prostatic rim
-Periurethral hypogenicity
94
Q

Asymptomatic inflammatory prostatitis

A

-No hx of genitourinary pain complaints but inflammatory changes histologically
-Usually chronically elevated or fluctuating PSA
>10ng/mL

95
Q

what does Asymptomatic inflammatory prostatitis look like sonographically?

A
  • Multiple inflammatory areas
  • Mimics cancer
  • Biopsy needed to exclude cancer
96
Q

Granulomatous prostatitis Etiology

A
  • usually idiopathic

- can follow prior instrumentation maybe caused by bacteria, fungi, and parasites

97
Q

what is Granulomatous prostatitis commonly caused by in north america?

A

BCG-bacille Calmette-Guerin

98
Q

BCG

A

-instilled into bladder to treat TCC
-leaks into prostate
(can cause Granulomatous prostatitis)

99
Q

Granulomatous prostatitis

A
  • Can mimic cancer on DRE & TRUS
  • Elevates PSA
  • Biopsy needed
100
Q

TRUS and Prostatitis

A

-Limited to acute prostatitis
-Problem
too painful
-U/S can mimic cancer
Hypoechoic
Hypervascular

101
Q

who does prostate cancer usually occur in?

A

men over 50

102
Q

what is 95% of prostate cancers?

A

adenocarcinomas

103
Q

what is 5% of prosate cancer?

A

many different types that do not elevate PSA

104
Q

prostate cancer is the _____ leading cause of cancer deaths

A

2nd

1st is lung

105
Q

prostate cancer is the ____ most common male malignancy worldwide

A

4th

106
Q

what are standard tests for prostate cancer screening?

A

PSA

DRE

107
Q

PSA density

A
  • ratio of PSA to prostate volume

- Assumes cancer increase PSA more than benign conditions

108
Q

PSA velocity

A
  • not used as much

- role in active survelliance

109
Q

Free/Total PSA ratio

A

cancer total PSA increases so ratio would increase

110
Q

what are some indications for an inital biopsy?

A
  • abnormal DRE
  • abnormal TRUS
  • unexplained elevation of PSA
  • Excessive PSA velocity
  • positive chips at TURP
  • metastatic adenocarcinoma when primary not evident
111
Q

what could appear on US that would indicate an initial biopsy?

A

suspicuous hypoechoic or vascular areas sampled by 10-12-core pattern

112
Q

what are some indicatons for a repeat biopsy?

A
  • initial biopsy is negative, strong clinical suspicion
  • PSA over 10 or rising
  • initial suspicious histology (atypical cells, microcancer)
  • follow up of men under surveillance
113
Q

do initial or repeated biopsies have a more extensive sampling pattern?

A

repeat biopsy

114
Q

core pattern for repeat bipsy?

A

13-15 core patten

115
Q

sameples of repeat biopsies areas?

A
  • lateral periperal zone (2)
  • medial peripheral zone (3)
  • transition zone (1)
  • midline (1)
  • base (1)
116
Q

where are only a few cancers found?

A

midline

transition

117
Q

what is the equipment for a biopsy?

A

TRUS

Biopsy gun

118
Q

what is the preparation for a TRUS biopsy?

A
  • consent
  • cleansing enema
  • broad-spectrum antobiotics
  • STOP anticoagulating agents several days prior (aspirin, warfarin)
119
Q

what kind of biopsy gun is used?

A

18 gauge

doctor controls the gun and probe

120
Q

how does an automatic biopsy gun work?

A
  • collecting core samples of the prostate
  • sample suspocious nodules first
  • systemic samples taken after
121
Q

what are minor side effects of biopsy?

A
  • blood in urine, stool, sperm
  • last few days to weeks
  • ejaculate can be discoloured for months
122
Q

what are some significant complications of biopsy? (1-2%)

A
  • sepsis
  • large hematoma
  • urinary retention
  • significant rectal bleeding
123
Q

what are some significant complications of biopsy? (1-6%)

A
  • hypotensive vasovagal-like reaction
  • 30-60 minutes after
  • sweating, nausea, vomiting, bradycardia
124
Q

where is most of prostate cancer found?

A

periphral zone (70%)

125
Q

where is prostate cancer easy to detect?

A

peripheral becasuse homogenous texture and the cancer stands out

126
Q

where is 20% of prostate cancer found?

A

transition zone

127
Q

where is cancer difficult to detect?

A

transition zone becuase its heterogenous and area of BPH nodules

128
Q

what are clues for detecting cancer in the transition zone?

A

poorly marginated hypoechoic area and focal loss of surgical capsule

129
Q

abterior midline tumor

A
  • very difficult to detect
  • far from probe and obtructed from urethra
  • become very large before detection
130
Q

what is the classic sonographic appearance of prostate cancer?

A

hypoechoic nodule in the peripheral zone (along capsule)

131
Q

what modality is not good at detecting prostate cancer?

A

CT

132
Q

what modalities have sensitivity similar?

A

DRE
PSA
MRI

133
Q

______ of prostate cancer is not detectable

A

30-50%

134
Q

_____ of prostate cancer is isoechoic?

A

30%

135
Q

how else may the prostate appear with cancer?

A

hypoechoic, hyperechoic, calcifications

136
Q

what appearance switches with prostate cancer?

A

replace entire peripheral zone more hypoechoic peripheral versus more hyperechoic inner gland

137
Q

what other function helps determine cancer?

A

power doppler

138
Q

what is staging and histologic grading?

A

determine treatment, options and prognosis

139
Q

what does staging and histologic grading integrate?

A

clinical
imaging
pathologic staging info

140
Q

what is staging?

A
  • extent of the disease
  • broken down into clinical pathological staging
  • imaging can be used to help
141
Q

what is used to estimate extent of prostate cancer?

A

DRE
PSA
imaging

142
Q

cTX

A

primary tumor canot be assessed

143
Q

cT0

A

no evidence of primary tumor

144
Q

stage cT1 (a,b,c)

A

not palpable and not visable on imaging

145
Q

stage cT2 (a,b,c)

A

palpable on DRE, confined to prostate

146
Q

stage cT3

  • cT3a
  • cT3b
A

extends through prostate capsule
cT3a-periprostatic soft tissue
cT3b-seminal vesicles

147
Q

stage T4

A
  • tumor is fixed or invades adjacent structures other than SV
  • bladder neck, external sphincter, rectum, levator mucles, pelvic wall
148
Q

which staging is considered more accurate for prognosis of prostate cancer?

A

pathological staging

149
Q

what does pathological staging require?

A

histologic evaluation of prostate, SV, lymph nodes

150
Q

pT2

A

organ confined

151
Q

pT3

A

extraprostatic extension

152
Q

pT4

A

invasion of rectum, levator muscles and pelvic wall

153
Q

histologic grading system

A

gleason scoring system

-microscopic pathological spectrum

154
Q

how is histologic grading determined?

A

glandular differentiation and histologic aggressiveness

155
Q

what is the score for histologc grading?

A

6-10

156
Q

higher score in histologic grading=

A

worse prognosis

157
Q

what is the therapy for prostate cancer?

A
  • radical prostatectomy
  • radiotherapy
  • focal therapy
  • watchful waiting
  • active surveillance
158
Q

what is the gold standard for therapy?

A

radical prosatectomy

-low grade cancer-90%

159
Q

focal therapy

A
  • cryotherapy
  • radiofrequency ablation therapy
  • HIFU
160
Q

active surveillance

A

-DRE and serial PSA
-Ultrasound guided bx
All to ensure cancer is maintaining low risk

161
Q

therapy effcts of sonographic appearance

A
  • therapies can alter appearance of the prostate gland
  • not able to detect recurrent cancer
  • systemic 10 core biopsy if needed
162
Q

MRI and its roles

A
  • detect cancer
  • Stage cancer
  • accuracy is improving
163
Q

how is MRI improving?

A
  • use of endorectal and pelvic coils
  • contrast agents
  • specialized sequences
164
Q

what are pitfalls of MRI?

A
  • availability
  • cost
  • time
  • intolerance of endorectal coil
165
Q

CT and its role

A
  • plays NO role in primary tumor detection or local staging
  • helps with detection of lymphadenopathy and distant Mets
  • value in radiotherapy planning and confirming seed placement with brachytherapy
166
Q

do radionuclide bone scans play a role in primary tumor detection or local staging?

A

NO

167
Q

when do we detect bone metastases in men?

A

with skeletal symtoms or PSA over 10

168
Q

what are pitfalls of TRUS?

A
  • large blood vessels in pelvis
  • pelvic kidneys can mimic mass
  • anterior meningoceles mimic masses behind rectum
169
Q

what is hematospermia?

A

macroscopic presence of blood in semen

170
Q

is hematospermia usually benign or malignant?

A

mostly benign and typically resolves

171
Q

what are the causes of hematospermia?

A
  • iatrogenic/traumatic
  • infectons or inflammatory
  • ductal obstruction, cysts, calc in seminal ducts
  • systemic factors (hypertension)
  • vascular abnormalities
  • idiopathic
172
Q

what happens within the seminal vesicles?

A

each vesicle tapers medially to from a short duct whoch joins the vas defernes to form an ejaculatory duct

173
Q

where is the seminal vesicle located?

A

situated at the base of the bladder and suprior to the prostate gland and inferior to the vas deferens and ureters

174
Q

seminal vesicles in transabdominal ultrasound

A
  • TRV left and right are seen together
  • SAG they are seen seperatley
  • should be symmetric
175
Q

axial US anatomy on TRUS of seminal vesicles

A

relatively hypoechoic

multiseptated structures

176
Q

axial US anatomy on TRUS of vas deferens

A

adjacent to SV

-uniform muscluar tubes ejaculatory ducts-2 can be followed to the verumontanum

177
Q

how can the internal sphincter appear?

A

hypoechoic

178
Q

are seminal vesicles symptomatic?

A

most are asymtomatic but can cause symptoms if large

179
Q

what are seminal vesicle cysts associated with?

A
  • Ipsilateral renal anomalies
  • Adult polycystic disease
  • Hemivertebra
  • Ipsilateral absence of testis
180
Q

what pathologies can mimic SV or prostate cyst?

A
  • ectopic ureterocele
  • cowper’s duct cyst
  • bladder diverticulum
181
Q

cowper’s duct cysts

A

urogenital diaphragm below apex of prostate

182
Q

who may calcifications be seen in?

A

calcifications in vas deferens and SV with diabetes and infection

183
Q

diabetic calcifications

A
  • involve walls

- look like train tracts on X-Ray

184
Q

infectious/inflammatory calcifications

A
  • luminal and segmental

- occasionally 1 cm eggshell calc seen in SV

185
Q

rarely SV are involved by what?

A

tumors
abscesses
amyloidosis

186
Q

when is TRUS used for infertility?

A

failure of pregnancy after 1 year unprotected intercourse

187
Q

Male factor solely responsible in ______ couples with infertility

A

20%

188
Q

where is infertility usually detected in men?

A

abnormal semen analysis

189
Q

what are male factors for infertility?

A

-pretesticular
-testicular
posttesticular

190
Q

postesticular

A
  • causes include azoospermia and oligospermia

- related to obstructive issues

191
Q

what is the role of TRUS for male infertility?

A
  • Identify anatomically correctable ejaculatory duct obstructions and anomalies
  • Using contrast agents show patency of ejaculatory ducts
  • retrieve sperm from seminal vesicles

Pelvic (5 decks)

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