GU Flashcards
Duplicated collecting system - what inserts where?
What’s the problem with the upper pole ureter?
What’s the problem with the lower pole ureter?
Upper pole inserts inferomedially and ectopically. Obstructs, usually ureterocele.
Lower pole refluxes, inserts normally.
Differences among sepate, arcuate, bicornuate, didelphys
Septate- normal fundal contour, muscular and/or fibrous septum (needs to be removed)
Arcuate-normal outer contour, slight dip in myometrium, no consequence (fairly normal, actually)
bicornuate- separated horns/dip in contour
didelphys- separate uterus including cervix
Ddx for cortical nephrocalcinosis
*chronic glomerulonephritis
*acute cortical necrosis
*rejected renal transplant
*Alport syndrome
*oxalosis
putty kidney from TB
renal infarction / ischaemia
sepsis
drugs
hemolytic uraemic syndrome (HUS)
Ddx for medullary nephrocalcinosis
*hyperparathyroidism
*medullary sponge kidney
*renal tubular acidosis
hypervitaminosis D
milk-alkali syndrome
sarcoid
other pathological hypercalcemic or hypercalciuric states
What’s medullary sponge kidney?
The medullary and papillary portions of the collecting ducts are dysplastic and dilated and in most cases develop medullary nephrocalcinosis.
Ddx renal hemosiderosis
sickle cell
thalassemia
*Paroxysmal nocturnal hemoglobinuria
mechanical valves causing chronic hemolysis
Ddx striated nephrogram (unilateral)
Pyelonephritis
obstruction
renal vein thrombosis
(contusion, radiation)
Ddx striated nephrogram (bilateral)
acute pyelonephritis acute tubular necrosis (e.g. from contrast) hypotension infarcts/PAN SLE lymphoma
What stage is an RCC with IVC extension below the diaphragm? Above?
T3b
T3c for above
Ddx retroperitoneal adenopathy
lymphoma
mets from testicular, prostate, endometrial, cervical
infection: TB, HIV
On what side should scrotal varicoceles raise concern?
the right side is abnormal and raises concern for an RP mass
80% of varicoceles are left-sided
large mass ~upper pole kidney
RCC, adrenal cortical carcinoma, pheo, mets, retroperitoneal sarcoma, malignant fibrous histiocytoma
hysterosalpingogram - diverticula off tube
Salpingitis isthmica nodosa (asociated with PID, infertility, ectopic pregnancy)
Tubal TB
tubal endometriosis
when you see a large adnexal nonvascular (noncystic) mass, what should you include?
ovarian torsion
Parts of the male urethra, bladder out:
Where is the verumontanum? Where are posterior urethral valves?
prostatic, membranous
bulbar (turns and becomes horizontal), penile
verumontanum is posterior of prostatic portion, posterior urethral valves begin here and go to distal prostatic urethra
Ddx for male urethral stricture
Carcinoma (TCC in prostatic, adeno (at Cowper’s glands just below prostate), squamous cell (from prior stricture of anterior urethra)
Post-infectious stricture
post-catheter stricture (penoscrotal jctn or membranous)
Ddx for fat-containing mass in region of adrenal gland
myelolipoma of adrenal gland
AML of kidney
liposarcoma
HCC/adeno of liver
ddx for renal papillary necrosis (sloughing of papilla)
P : pyelonephritis O : obstruction S : sickle cell disease T : tuberculosis C : cirrhosis A : *analgesic abuse* - NSAIDS R : renal vein thrombosis D : *diabetes mellitus* S : systemic vasculitis/des
ddx of omental caking
mets (ovarian, GI, pancreas, GB)
TB
Lymphoma
Mesothelioma
Pt with rcc and multiple renal cysts might have?
What other features of this diz?
think vHL
also have pheos, pancreatic islet cell tumors and panc cysts
cerebellar and retinal hemangioblastomas
numerous cysts in atropied kidneys
acquired renal cystic disease of dialysis
increased risk of RCC
What’s adenomyosis? What dx criteria?
the presence of ectopic endometrial tissue within the myometrium
junctional zone greater than 12mm
Bosniak renal cyst classification system:
1-simple
2-single thin septation or thin calc or high attenuation non-enhancing
2F-thicker septations or thicker calc
3-more complex
4-obviously malignant, a lot of solid parts
1 & 2 - no follow-up, never malignant
2F-4 - follow-up
renal mass with multiple cysts, herniates into renal pelvis - what is it? Who gets it?
Multilocular cystic nephroma
males under 5
women in their 40s
Hysterosalpingogram - intrauterine senechiae
Asherman’s syndrome, usually 2/2 D&C, IUD, severe endometritis
causes of RP fibrosis
idiopathic, meds, blood (rp bleed), radiation, peri-aneurysmal, malignancy
Ureters pushed away from spine vs pulled medially - what does that distinguish?
Pushed away - lymphoma
Pulled medially - RP fibrosis
Ddx of multiple filling defects of ureter
spreading or multifocal TCC vascular indentations multiple ureteral stones (steinstrasse) blood clots ureteritis cystica Stevens-Johnson syndrome Malakoplakia (benign, related to chronic infection)
What’s ureteritis/pyeloureteritis cystica?
benign supepithelial cysts, likely 2/2 chronic UTIs
Where does prostate cancer usually originate?
Peripheral zone (thus easy to feel on rectal exam)
what are you looking for on prostate US or MRI?
hypointensity of peripheral zone, extracapsular spread, invasion of neurovascular bundle or seminal vessicles, lymph nodes, bone mets
What does a goblet sign on retrograde ureterography mean?
slow-growing TCC (not a stone) - results from peristalsis
Ddx for single ureteral filling defect
tumor, stone, clot, sloughed papilla, fungus ball, air bubble
Air in scrotal wall or perineum = worry about
Fournier gangrene (necrotizing fasciitis)
Ddx perirenal stuff/soft tissue
lymphoma blood urine (infiltrative TCC or RCC) extramedullary hematopoesis Erdheim-Chester dz lymphangiomatosis
urachal diverticulum - what kind of cancer?
adenoca
cyst adjacent to urethra
urethral diverticulum
Gartner duct cyst - high, anterolat wall of vagina
Bartholin gland cyst - low, posterolateral
what’s nutcracker syndrome?
compression of left renal vein between aorta and SMA
pt gets hematuria
Rx stent
adrenal masses
hemorrhage, cortical carcinoma, adenoma (fat or >50% washout), myelolipoma, pheo
focal calcium in renal cortex
calyceal diverticulum with stone
at risk for infection and neoplasm
ddx cause of colovesicle fistula
diverticulitis, cancer, crohn’s
“teardrop” shaped bladder - what caused it?
trauma with hematoma, pelvic lipomatosis, lymphadenopathy
rx of intraperitoneal versus extraperitoneal
intra - Surgery, top of bladder - direct trauma
extra - just decompress, pelvic fracture
childhood renal tumors - names and ages:
Mesoblastic nephroma: under 1 year
ossyfying renal tumor of infancy: under 1 year
Nephroblastoma/tosis: 1 year, can be any age
Multilocular cystic nephroma: boys under 5 (and middle-aged women)
Wilms: peak at 3-4 (rarely up to 15)
RCC (in vHL): teens
renal tumor in pts with sickle trait or SC disease:
renal medullary carcinoma
Ddx bilateral enlarged ureters
Congenital (eg post urethral valves Reflux Bilat UVJ obstruction bilat stones RP fibrosis bladder neoplasm
Complications of urethral diverticulum
Stones, infection, squamous cell ca
Hepatic mass in infant, elevated AFP:
hepatoblastoma
Ddx bladder calcification
Schistosomiasis, TB (thimble bladder), cancer, radiation
others are less common
Who gets renal medullary carcinoma?
Young patients
Sickle trait or SC (NOT sickle cell dz)
What is nephroblastomatosis, what age, and what’s the concern?
Multiple/diffuse nephrogenic rests (foci of metanephric blastema that persist beyond 36 weeks gestation), they have the potential for malignant transformation into Wilms tumour.
Age newborn-7y
What’s the risk with schistosomiasis of the bladder?
Increased risk of squamous cell cancer of bladder (Schisto is Squamous)
What’s the treatment for gonadal vein thrombosis?
Anticoagulation and Abx
Ddx multiple renal aneurysms. What do the aneurysms cause?
PolyArteritis Nodosa, speed kidney (amphetamine abuse).
The aneurysms thrombosis and cause infarcts.
Multiple ureteral wall outpouchings
Ureteral pseudodiverticulosis.
Increased risk of infection and of malignancy.
Dilated rete testis is called:
Tubular ectasia of the rete testis (benign)
Causes of hematometrocolpos
Imperforate hymen, cervical stenosis, vaginal atresia
Dx for rapidly enlarging uterine mass
leiomyosarcoma (needs surgery)
Solid ovarian neoplasms ddx:
Brenner tumor, stromal (fibroma, fibrothecoma, etc.), germ cell (non-cystic teratoma, dysgerminoma), met (Krukenberg), lymphoma
What’s the problem with a cancer within a bladder diverticulum?
It’s a pseudodiverticulum and there’s no containment - tumor just spreads
How do you distinguish a Gartner’s duct cyst from a Bartolin’s gland cyst?
Gartner’s duct - above inferior part of the pubic symphysis, anterolateral
Bartolin’s gland cyst is inferior, posterolateral, near labia
Tubular ureteral filling defect
ureteral fibroepithelial polyp (removed because they cause intermittent obstruction)
sites of botryoid rhabdomyosarcoma:
What does it look like?
Who gets it?
polypoid or “grape like lesion” beneath the mucosa: vagina, cervix, urinary bladder, nasopharynx, biliary tract
kids - birth to 15y
Ddx for hyperenhancing lymph nodes:
castleman disease, Kaposi sarcoma, hypervascular mets (thyroid, renal)
Explain the difference between the pararenal and perirenal spaces
Perirenal is right around the kidney
Pararenal includes the fat outside the perirenal space and the space including the colon and pancreas.
Ddx midline prostate cyst
Prostatic utricle cyst, mullerian duct cyst
characteristic appearance of a urethral cyst in a woman
“biloed” or “horseshoe” cyst posterior to the urethra.
Dx with double-balloon urethrogram
list the non-CNS lesions associated with VHL
RCC, renal cysts, pancreatic cysts, pheos, liver cysts
Which Bosniak lesions are surgical?
3 and 4
What’s Hemolytic uremic syndrome? What does it look like on imaging? What causes it?
E. coli ( O157:H7), causes damage to blood vessel walls. Mostly affects children.
Echogenic kidneys on US
Acute cortical necrosis and colitis
What’s the term for blood-distended uterus? Uterus plus vagina?
Uterus: hematometros
plus vagina: hematometrocolpos
What’s a faceless kidney? Ddx for this appearance:
Effacement of renal hilar fat
TCC, lymphoma, infiltrative RCC
(mets, inflammatory pseudotumor of GU tract)
What are the complications/problems with a horseshoe kidney?
Increased risk in trauma
stones, infection
(maybe increased RCC)
What’s steinstrasse?
Complication of ECSWL
multiple tiny stones lined up in ureter, sometimes cause obstruction
Complications associated with extra-corporeal shock-wave lithotripsy
Steinstrasse, renal hematoma, hematuria
Ddx for numerous small cysts in normal-sized kidneys
Lithium nephrotoxicity
glomerulocystic disease (congenital)
medical renal disease
What disease involving kidney is associated with LAM?
TS - tuberous sclerosis
What are numerous, peripheral peribiliary lesions in the liver called?
multiple biliary hamartomas aka von Myenburg complexes
Benign
Can cause heterogeneous liver on ultrasound, tiny cyst on CT or MR
What liver masses tend to bleed?
HCC, adenoma (contraceptives or steroids)
solid ovarian lesion and ascites
Meigs syndrome - can be seen with thecoma, fibrothecoma, granulosa cell tumor
Types of urethral injury
1: Stretch, no rupture (no extrav)
2: Partial or complete rupture of the
membranous urethra above urogenital
diaphragm or perineal membrane (extrav in pelvis only)
3: Partial or complete rupture of the mem-
branous urethra with disruption of the uro-
genital diaphragm (extrav in pelvis and perineum)
4: Bladder neck injury with extension
into the urethra
5: Pure anterior urethral injury
causes of adrenal hemorrhage
Sepsis (meningococcemia is Waterhouse-Friderichsen syndrome)
DIC, thrombocytopenia, anticoag
steroids
tumor
What non-GU complication is of concern in ADPCK?
Berry aneurysms in the brain
Renal injury grades:
grade I - contusion or non enlarging subcapsular hematoma, but no laceration ;
grade II - superfical laceration < 1cm depth and does not involve the collecting system ; non expanding perirenal haematoma
grade III - laceration > 1cm, without extension into the renal pelvis or collecting system and with no evidence of urine extravasation
grade IV - laceration extends to renal pelvis or urinary extravasation.
grade V - shattered kidney ; devascularisation
What’s the concern with metformin use and CT contrast?
Increased risk of renal tubular acidosis
What organism is associated with xanthogranulomatous pyelonephritis?
Proteus (struvite stones)
Describe the infectious processes that involve the kidney and renal collecting system:
Pyelitis - inflammation of renal pelvis
Pyonephrosis - pus and obstruction (needs drainage and Abx)
Pyelonephritis - inflammation of renal parenchyma (and collecting system)
Causes of UPJ obstruction
congenital tumor stricture stone crossing vessel
ddx adrenal calcification
TB, histo, old hemorrhage, calcified mass
Ddx persistent nephrogram
ATN
renal vein thrombosis
obstruction
hypotension (including acute contrast rxn)
Hydronephrosis with debris in the collecting system
Pyonephrosis
Causes of chyluria
partial nephrectomy or RFA
childbirth
filariasis
Dilated sac beneath / ventral to anterior urethra
Cowper’s syringocele (dilitation of Cowper gland)
Risk factors for prostatitis:
Concern?
DM, immunocompromised, dialysis, repeated catheterization
Could result in abscess
