Genitourinary Flashcards
What are the causes of papillary necrosis?
Diabetes (most common)
Pyelonephritis
TB
Sickle cell
Analgesics
Cirrhosis
What are the causes of medullary nephrocalcinosis?
Da: hyper vitamin D
C: calcaemic/calciuric state
RA: renal tubular acidosis (type 1)
M: medullary sponge kidney (usually unilateral)
P: hyperparathyroidism
S: sarcoid
T: hyper/hypothyroid
What are the causes of pyramidal nephrocalcinosis?
Da: drugs (furosemide)
H: hyperuricaemia
I: infection (TB)
P: papillary necrosis
S: sickle cell disease
What are the causes of cortical nephrocalcinosis?
P: chronic pyelonephritis
R: reflux
A: Alport syndrome
N: necrosis (renal cortical)
H: hypercalcaemia/hyperoxaluria
A: autosomal recessive polycystic kidney disease
What are the causes of cortical necrosis?
P: pregnancy
I: infarct
T: transplant rejection
H: Haemolytic uraemic syndrome (HUS)
E: Extracorporeal shock wave lithotripsy (ESWL)
A: arsenic
D: drugs
S: sepsis, snake bites
Patients had previous renal biopsy.
US shows tissue vibration artefact, high arterial velocity and pulsatile flow in the vein.
Diagnosis?
Arteriovenous fistula (AVF)
Patient who had renal transplant 2 weeks previously has an ultrasound.
The kidney appears swollen and there is reversal of diastolic flow in the renal artery.
What is the diagnosis?
Renal vein thrombosis
Reversal of diastolic flow = “reverse M sign”
What disorder is associated with medullary RCC?
Sickle cell trait
What syndrome is associated with chromophobe RCC?
Birt Hogg Dube
What disorder is associated with clear cell RCC?
von Hippel Lindau
What is the differential for a T2 dark renal cyst?
Lipid poor AML
Haemorrhagic cyst
Papillary subtype RCC
What are the only renal calculi not seen on CT and which group of patients get them?
Indinavir calculi
(Seen in HIV patients on indinavir)
Renal lesion with fat and no calcification.
Angiomyolipoma
What are some causes of a calcaemic/calciuric state?
Cushing’s
Bartters
Multiple myeloma
Bony metastases
What 3 conditions are associated with medullary sponge kidney?
Ehlers-Danlos syndrome
Carolis syndrome
Beckwith-Weidman syndrome
What are the causes of a delayed nephrogram?
i.e. failure of normal temporal progression of nephrographic contrast.
Obstructive uropathy (most common)
Renal vein thrombosis
Renal artery stenosis
Extrinsic compression (Page kidney)
What are the causes of a persistent nephrogram?
Hypotension/Shock
Acute tubular necrosis
Bilateral renal vein thrombosis
Bilateral renal artery stenosis
Bilateral obstructive uropathy
What is a normal resistive index in a transplant kidney?
Less than 0.7
What are the causes of post renal transplant fluid collections?
Haematoma (immediate)
Encapsulated urine collection: urinoma (1-2 weeks)
Abscess (3-4 weeks)
Lymphocele (2 months)
What percentage of the population have an early branching renal artery?
(Branches before the renal hilum)
10%
What percentage of the population have an accessory renal artery and which side is more common?
30%
left accessory renal artery is more common
Patient who had renal transplant 2 weeks previously, presents with decreases urine output. Ultrasound shows anechoic well defined perirenal mass with no septations.
What is the most likely diagnosis?
Urinoma
How would you distinguish acute tubular necrosis from acute rejection of renal transplant?
MAG3: ATN has normal perfusion and rejection does not. Both have delayed excretion.
What are the criteria for renal artery stenosis in transplants?
Peak systolic velocity >200cm/s
2:1 PSV ratio between stenotic and pre-stenotic artery
Turbulent flow (spectral broadening)
Tardus-parvus waveform (measured at main renal artery hilum)
What are the two main causes of ureteral wall calcifications?
TB
Schistosomiasis
Numerous tiny subepithelial fluid-filled cysts with the wall of ureter which is typically seen in diabetics with recurrent UTI. What is the likely diagnosis?
Ureteritis cystica
Multiple small outpouchings of upper ⅔ of the ureter associated with chronic inflammation and an association with TCC. What is the likely diagnosis?
Ureteral pseudodiverticulosis.
In the renal tract, schistosomiasis predisposes to which cancer?
Squamous cell carcinoma.
Smooth oblong, mobile defect in the proximal ureter on urography.
Fibroepithelial polyp.
What are the causes of lateral deviation of the ureters?
Retroperitoneal adenopathy
Aortic aneurysm
Psoas hypertrophy (proximal ureter)
What are the causes of medial deviation of the ureters?
Retroperitoneal fibrosis
Retrocaval ureter (right side)
Pelvic lipomatosis
Psoas hypertrophy (distal ureter)
A urachal remnant may transform into what malignancy?
Adenocarcinoma
What is the most common bladder cancer in children <10 years?
Rhabdomyosarcoma
What is the site of injury in a bicycle crossbar injury of the urethra in a male?
Bulbous urethra
What is the difference in the urethral stricture caused by straddle injury vs gonococcal infection?
Straddle injury : short segment
Gonococcal : long irregular stricture
Both are bulbous urethra
What part of the prostate is commonly involved in BPH?
Transitional zone
What conditions are associated with a prostatic utricle cyst?
Hypospadias (most common)
Cryptorchidism
Unilateral renal agenesis
- Prune belly syndrome*
- Imperforate anus*
- Down’s*
Which malignancy is associated with leukoplakia?
Squamous cell carcinoma
Conditions associated with a congenital seminal vesicle cyst?
Agenesis (renal/vas deferens)
Polycystic kidney disease
Ectopic ureter insertion
What are some of the common features of Turner syndrome?
(excluding MSK manifestations)
Coarctation of the aorta
Bicuspid aortic valve
Horseshoe kidney
Streaky ovaries/uterus
Pyloric stenosis
What are the common MSK manifestations of Turner syndrome?
Scoliosis
Short 4th metacarpal
Madelung deformity
Narrow scapholunate angle (+ve carpal sign)
Short stature
MEN type 2a is characterised by what?
Phaeochromocytomas
Parathyroid hyperplasia
Medullary thyroid cancer
MEN type 2b is characterised by what?
Phaeochromocytoma
Medullary thyroid cancer
Mucosal neuroma/ganglioneuromas
Marfanoid body habitus
MEN type 1 is an autosomal dominant syndrome characterised by what?
Pi: pituitary adenoma
Par: parathyroid proliferative disease
Panc: pancreatic endocrine tumours
1 month old with failure to thrive, diarrhoea and vomiting. CT shows hepatosplenomegaly and bilateral enlarged, calcified adrenal glands. What is the diagnosis?
Wolman disease
What is the Carney triad?
Extra-adrenal paraganglioma
GIST
Pulmonary chondroma (hamartoma)
What is the Carney complex?
Cardiac myxoma
Extra-cardiac myxoma
Skin pigmentation (blue naevia)
Testicular tumours (Sertoli most common)
What is Waterhouse-Friderichsen syndrome?
Adrenal haemorrhage in the setting of fulminant meningitis
(from Neisseria Meningitidis)
Which conditions are associated with phaeochromocytoma?
Multiple endocrine neoplasia (MEN II)
von-Hippel-Lindau
Neurofibromatosis type 1
What is the main cause of congenital adrenal hypertrophy?
21-hydroxylase deficiency (90%)
11-beta-hydroxylase deficiency
A child presents with genital ambiguity, electrolyte imbalance and dehydration.
How can you differentiate normal neonatal adrenals from congenital adrenal hyperplasia?
Congenital adrenal hyperplasia will have:
Cerebriform pattern (characteristic)
Bilateral enlarged adrenal glands (limb width > 4mm, length > 20mm)
Patient presents with hypertension, persistent hypokalaemia and increased serum/urinary aldosterone. What are the most common causes of this syndrome?
Syndrome = Conn syndrome
Benign hyperfunctioning adrenal cortical adenoma 80%
Adrenal hyperplasia 20%
What are the causes of Cushing syndrome?
Adrenal hyperplasia - 70%
(90% pituitary microadenoma and 10% ectopic ACTH usually Ca)
Benign adrenal adenomas - 20%
Adrenal carcinoma - 10%
What is the absolute percentage washout of a benign adrenal nodule?
>60% at 15 minutes
What is the relative percentage washout of a benign adrenal nodule?
>40% at 15 minutes
How do you calculate the relative percentage washout of an adrenal nodule?
Portal venous - delayed x 100
Portal venous
How do you calculate absolute percentage washout of an adrenal nodule?
Portal venous - delayed x 100
Portal venous - unenhanced
Congenital bilateral absence of the vas deferens is seen in what condition?
Cystic fibrosis
Name 4 syndromes associated with male infertility.
Pituitary adenoma (makes prolactin)
Kallmans syndrome (can’t smell + infertile)
Klinefelters syndrome (tall, gynaecomastia and infertile)
Zinner syndrome (renal agenesis + ipsilateral seminal vesicle cyst)
What are the non-obstructive causes of male infertility?
Varicocele
Cryptorchidism
Anabolic steroid use
Erectile dysfunction
Cowden syndrome increases your risk of which cancers?
Breast cancer
Endometrial cancer
Follicular thyroid cancer
Lhermitte-Duclos (brain hamartoma)
What are the MRI characteristics of a fibroadenoma?
T2 bright with non-enhancing septa and type 1 curve
What is the MRI characteristics of extracapsular silicon?
T1 dark, T2 bright
What is the imaging modality of choice to look for saline implant rupture?
Plain mammogram
What type of breast implant rupture is associated with the “step ladder” appearance on US and “linguine sign” on MRI?
Intracapsular rupture of a silicone implant
(saline has no capsule so cannot have intracapsular rupture)
What are the risk factors for male breast cancer?
BRCA mutation (normally BRCA 2)
Klinefelter syndrome
Cirrhosis
Chronic alcoholism
When would you do a LMO view on a mammogram?
Kyphosis
Pectus excavatum
Avoid medial pacemaker/central line
What are the causes of granulomatous prostatitis?
Intra-vesical BCG
Sarcoidosis
Tuberculous prostatitis
Patient with hyperthyroidism has an MRI pelvis. This reveals a multilocular cystic mass with intensely enhancing solid component. Cystic component is very low signal on T2.
What is the diagnosis?
Struma ovarii
(ovarian teratoma)
Triad of ascites, pleural effusion and benign ovarian tumour (most commonly fibroma) is referred to as what syndrome?
Meigs syndrome
Rarely a dermoid can undergo malignant transformation. What cancer does it tend to transform into?
Squamous cell cancer
An endometrioma can rarely undergo malignant degeneration to what?
Clear cell carcinoma
What are the imaging features of polycystic ovarian syndrome (PCOS)?
≥ 10 peripheral simple cysts
“string of pearls” appearance
Enlarged ovaries ≥ 10 ml
How do you differentiate an endometrioma from haemorrhagic cyst?
Follow up US in 6-12 weeks
Haemorrhagic cyst will resolve
What are the classical MRI appearances of an endometrioma?
T1 bright (blood)
No fat suppression
T2 dark with “shading”
What is the classic ultrasound appearance of an endometrioma?
Rounded mass with homogeneous low level internal echoes and increased through transmission (posterior acoustic enhancement)
What are the radiological features of ovarian hyperstimulation syndrome?
Enlarged ovaries with theca lutein cysts
Ascites
Pleural effusions
May have pericardial effusion
Patient has an ultrasound which shows multilocular cystic ovary with “spokewheel” appearance.
It is diagnosed as theca lutein cyst.
What are the associations with this?
Gestational trophoblastic disease
Multifetal pregnancy
Ovarian hyperstimulation syndrome
PCOS
Diabetes
Clomiphene
What is normal endometrial thickness for post-menopausal woman on tamoxifen and not on tamoxifen?
No tamoxifen ≤ 4 mm
Tamoxifen ≤ 8 mm
Hereditary non-polyposis colon cancer (HNPCC) is associated with which gynaecological malignancy?
Endometrial cancer
What is the differential for endometrial thickening?
Pregnancy (early/ectopic/retained products)
Endometrial cancer
Endometrial hyperplasia
Endometritis
HRT/taxoxifen
Oestrogen secreting ovarian tumours (granulosa cell, endometroid carcinoma)
Patient with post-menopausal bleeding and endometrium > 5 mm.
What is the next step?
Biopsy
What is the MR appearance of hyaline degeneration of leiomyomas?
T2 dark. Does not enhance.
What is the most classic features of adenomyosis?
Thickening of the junctional zone to > 12 mm (normal is < 5 mm)
What is the classic MR appearance in red (carneous) degeneration of a leiomyoma?
Peripheral rim of T1 high signal
What are the contraindications to a hysterosalpingogram?
Infection (PID)
Active bleeding
Pregnancy
Contrast allergy
Which uterine abnormality results in infertility issues and why?
Septate uterus
Fibrous or muscular septum has poor blood supply so implantation on the septum fails
When are hysterosalpingograms performed?
Day 7-10 menstural cycle
What is uterine didelphys?
Complete uterine duplication with two cervices, two uteri and two upper ⅓ vagina with a transverse vaginal septum 75% of the time (associated with hydrometrocolpos)
Name 2 associations with Mullerian agenesis
Renal anomalies 30-40%
Vertebral anomalies 10%
Mayer-Rokitansky-Kuster-Hauser syndrome (Mullerian agenesis) has what three features?
Vaginal atresia
Absent or rudimentary uterus
Normal ovaries
(Atypical form can have associated ovarian abnormalities)
What are the features of a Bosniak type II cyst?
Thin curvilinear calcification
Hyperdense cyst < 3cm
What are the features of a Bosniak type IIF cyst?
Thin septa
Mural or septal enhancement (visible but not measurable)
Nodular calcification
Hyperdense cyst > 3cm
What are the features of a Bosniak type III cyst?
Thick septa
Mural enhancement (measurable)
Coarse calcification
Irregular margin
Smooth mural thickening
What are the features of a Bosniak type IV cyst?
Large cystic/ necrotic area
Irregular mural thickening
Solid enhancing structures
What percentage of Bosniak I and II cysts are malignant?
0%
Which percentage of Bosniak type IIF cysts are malignant?
5%
Which percentage of Bosniak type III cysts are malignant?
50%
Which percentage of Bosniak type IV cysts are malignant?
>90%
“Shrinking breast” can be used to describe which cancer?
Invasive lobular breast cancer
Where would you find a Rotter node?
between pectoralis major and minor
Describe the location of level 1 axillary nodes.
lateral to pectoralis minor
Describe the location of level 2 axillary nodes.
deep to pectoralis minor
Describe the location of level 3 axillary nodes.
medial to pectoralis minor
What are the causes of increased breast density?
Pregnancy
Hormone replacement therapy
Pituitary prolactinoma
Medication (anti-psychotics)
Malignancy
Sub-areolar lesion with a fat-fluid level following cessation of lactation. Diagnosis?
Galactocele
True lateral view on mammogram is useful for localising things seen on only one view. If the abnormality is only in the CC view when would you do ML lateral over LM lateral?
if the abnormality is lateral an ML lateral should be performed (if medial, LM lateral)
If an abnormality is only seen in the MLO view (not the CC). What view would you do next?
true lateral view ML
(most cancers are lateral)
A lesion that is medial on the CC film will move in which direction on the MLO?
Will become more superior (and more superior on the ML)
Lead sinks, muffins rise
A lesion that is lateral on the CC film will move in which direction on the MLO?
inferior
“lead sinks, muffins rise”
If a breast lesion is only seen on the CC view, how do we know if it is superior or inferior in the breast?
If you roll the breast medial a superior tumour will move medial, a inferior lesion will move lateral
Milk of calcium/ tea-cupping is seen in what?
fibrocystic change
What is the name for a thrombosed vein in the breast with that presents as a tender palpable cord?
Mondor disease
(treatment is warm compress and NSAIDS)
Which benign lesion of the breast is described as a “breast within a breast”?
Hamartoma
Malignant phyllodes tumours can metastasise to where?
lungs and bone
Rapidly growing mass in a middle aged lady which looks like a fibroadenoma. Diagnosis?
Phyllodes
What are the imaging features of a fibroadenoma?
Oval circumscribed mass
homogenous hypoechoic echotexture with a central hyperechoic band
Popcorn calcifications in older patients
T2 bright with progressive (type 1) enhancement
What is the most common invasive breast cancer?
invasive ductal carcinoma
Which subtype of invasive ductal carcinoma is associated with a radial scar?
Tubular
What is the difference between multifocal and multicentric breast cancer?
multifocal = same quadrant
multicentric = different quadrants
What is the most common cause of bloody nipple discharge?
Papilloma
(most common intraductal mass lesion)
What are the contraindications to galactography?
active infection
inability to express discharge
contrast allergy
prior surgery to the nipple areola complex
Can you see intracapsular rupture of a silicone implant on mammogram?
Yes
What are the MRI features of fat necrosis?
T1/ T2 bright with fat saturation
What are the mammographic appearances post radiotherapy?
skin thickening
trabecular thickening
should improve on subsequent mammograms
What is the most common primary to metastasise to the breast?
melanoma
What are the criteria for a T4 breast lesion?
chest wall fixation
skin involvement
inflammatory breast cancer
When should you do a breast MRI?
day 7-14 of menstrual cycle
Which breast cancers can be bright on T2?
colloid cancer
mucinous cancer
What is the single most predictive feature of breast malignancy?
spiculated margins
What are the MRI features of an ovarian fibroma?
Low on T1/ T2
Does not enhance/ heterogenous enhancement (unlike fibroids)
What are the typical MRI features of prostate cancer?
Low on T1 and T2
Type 3 contrast curve (early enhancement, early washout)
Where is the most common location for a prostate tumour?
Peripheral zone (70%)
What cysts are found on the cervix as a result of plugging of the mucous glands?
Nabothian cysts
Where is the classic location of a Gartner duct cyst?
Anterior lateral wall of the upper vagina
Where is the classic location of a Bartholin cyst?
Posterolateral inferior third of the vagina
Below the pubic symphysis
What cyst is found laterally to the external urethral meatus and inferior to the pubic symphysis?
Skene gland cyst
(paraurethral cyst)
What is the likely diagnosis for a midline, infra-umbilical soft tissue mass with calcification?
Urachal adenocarcinoma
Which uterine anomaly has two uterine canals separated by a deep myometrial cleft?
Bicornuate uterus
(can be differentiated from septate by the presence of a fundal cleft)
What are the associations with testicular microlithiasis?
Cryptorchidism
Infertility
Klinefelters
Downs syndrome
Alveolar microlithiasis
Testicular carcinoma
What are the diagnostic criteria for contrast induced nephropathy?
Exposure to a contrast agent
Increased serum creatinine of 0.5mg/dL OR 25% increase from baseline
Increase in serum creatinine 48-72 hours after administration of contrast which persists 2-5 days
Alternate injuries rules out
What are the features of a prostatic utricle cyst?
Occur in the 1st and 2nd decades of life
Arise in the midline at the level of the verumontanum
Communicate with the urethra
Do not extend above the prostate gland
What are the features of a mullerian duct cyst?
Occur in the 3rd and 4th decades of life
Anywhere along the path of mullerian duct regression from scrotum to prostatic utricle
Do not communicate with the urethra
Often extend superior to the prostate
In regards to bladder cancer, what are T1 and T2 sequences used for?
T1: assess peri-vesicle extension
T2: assess muscle invasion
Squamous metaplasia secondary to chronic irritations. Imaging shows mural filling defects in the bladder and ureter. What is the most likely diagnosis?
Leukoplakia
What is malacoplakia?
Chronic granulomatous disease in immunocompromised females secondary to recurrent UTIs (E.coli) in which you get mucosal mass involving the bladder
What is the histological finding in malacoplakia?
Von Hansemann cells which contain calcific Michaelis-Gutmann bodies
What is the cause of primary congenital bladder diverticula?
Hutch diverticula
Occurs at the UVJ and is associated with ipsilateral reflux
What are the secondary causes of bladder diverticula?
Ehlers Danlos
Chronic outlet obstruction
Menkes (kinky hair syndrome)
Prune belly syndrome
Williams syndrome
What are the 5 types of urethral injury?
Type 1: stretched (has peri-urethral haematoma)
Type 2: rupture above urogenital diaphragm (extraperitoneal contrast)
Type 3: rupture below the urogenital diaphragm (extraperitonal and perineal contrast)
Type 4: Injury involves the bladder extending to the urethra
Type 5: Injury to the anterior urethra
Clear cell carcinoma of the vagina is associated with what?
DES (synthetic estrogen)
Think about this if patient also described as having “T-shaped” uterus
What ovarian lesion has intense peripheral blood flow?
Corpus luteum
