Gynae 2 Flashcards
hydrocoele
Defined as a collection of fluid within the tunica vaginalis (between the visceral and parietal layers) of the testis
congenital hydrocele
Communicating (“vogbreuk”) Infantile/fluid hernia
Interstitial
Cord
acquired primary hydrocele
Idiopathic (aetiology not known)
Imbalance between the fluid secretion and absorption (decreased) of the tunica vaginalis
acquired secondary hydrocele
Infection Trauma Tumor Torsion Abnormalities in inguinal lymph nodes
hydrocele Rx
Communicating- May close spontaneously
Tying off the patent processus vaginalis
Primary- Hydrocelectomy
Aspiration + injection of sclerosing agent
Secondary- Treat underlying pathology
differentiating btwn hydrocele and inguinal hernia
hydrocele- palpable cord above mass, transclucent, fluctuate, fluid thrill
inguinal hernia- testis palpable, cough impulse, reducible, bowel sounds
colour of fluid of supratesticular cystic masses
Cord hydrocele- Straw color
Spermatocele- Milky or Grey opaque (barleywater) Epididymis cyst- Clear
varicocele
Defined as an abnormal dilatation of the veins of the pampiniform plexus of the spermatic cord
varicocele aetiology
Abnormality/absence of the venous valves
Left spermatic vein joining the left renal vein directly at a 90° angle
Longer left spermatic vein with increased hydrostatic pressure
Pressure of superior mesenteric artery on the left renal vein (Nutcracker phenomenon)
varicocele sx and s/s
Complaints of a scrotal mass (“Bag of worms”)
Complaints of scrotal discomfort
Fertility problems
Smaller left testis (atrophy
varicocele classification
Primary- Abnormality of valves in the spermatic vein
Secondary- Tumor of the left kidney (Tumor thrombus from renal cell CA)
Retro-peritoneal masses
Trauma
varicocele Rx
Spermatic venography plus embolisation with heated contrast/resin/coils (Antegrade or retrograde procedure)
Surgery- Open (Ivanissevitch, Paloma)
Laparoscopic
risk factors of penis cancer
Smoking
UV radiation
Foreskin (Phimosis, poor hygiene, smegma)
HPV infection 16 & 18
penis cancer presentation
A sore that fails to heal
Induration
Phimosis – obscures it and grows undetected
Rarely – mass, ulceration , suppuration or haemorrhage from inguinal mets
Usual delay in presentation due to Embarrassment, fear
Natural history of penis cancer
Begins as small lesion, papillary & exophytic or flat & ulcerative
Pattern in lymphatic spread
Metastatic nodes cause erosion into vessels, skin necrosis, chronic infection
Distant metastasis uncommon
Death within 2 years for untreated patients
Condyloma Acuminatum facts
Genital warts related to HPV (16 & 18)
Associated with SCC
Soft, multiple lesion on glans, prepuce & shaft
Dx: Biopsy
Treatment: Podophyllin, fulgaration, cryotherapy
Erythroplasia of Queyrat – non keratinising
Occur on glans
Red velvety circumscribed painless lesion
May ulcerate and painful – 10X more likely to progress than Bowen’s disease
Treatment- Penile preserving – topical 5-FU or imiquimod
Laser
Mohs surgery
Balanitis Xerotica Obliterans
Lichen sclerosis et atrophicus
>10% - penile cancer
White patch on glans and prepuce. Also meatus Aetiology – chronic infection, phimosis
Treatment – Steroid cream, Surgical
Bowenoid papulosis
Resembles carcinoma in situ Multiple papules or flat glanular lesion Dx – biopsy sx- pruritis, burning, dysuria Treatment - electrodesiccation, cryotherapy, laser, topical 5-fluorouracil cream, excision with skin grafting
Giant condyloma acuminata – BuscheLowenstein tumour
Displaces, invades ad destroys adjacent structures
No metastasis
Treat wide excision
other penile CA condition
Cutaneous horn – extreme hyperkeratosis
Psuedo-epitheliomatous micaceous & keratotic balanitis
Leukoplakia – whitish lanular plaque invove meatus
renal tumours presentation
Classic triad- hematuria, pain and a flank mass
Para-neoplastic syndrome
Varicocele
renal tumours Rx
Surgery
Renal tumors are notoriously radio-resistant
Novel therapies are at present only investigational- Cryotherapy, Radiofrequency ablation, HIFU
testicular CA
35 years old male
hemoptysis, abdominal discomfort
no child
Big R testis , normal Left testis
testicular CA Risk Factors
Previous history of testicular tumour UDT Infertility Atrophic testis CIS (carcinoma in situ)
testicular CA aetiology
Gonadal dysgenesis Environmental factors Chemical carcinogens Infections 7-10% in undescended testis- dysgenesis, high temperature, abnormal blood supply, endocrine dysfunction
testicular CA classification
Germ cell- Seminoma -Non seminoma: Teratocarcinoma, Yolk sac tumour, Choriocarcinoma, Embryonal, Mixed variant
Non Germ cell- Leydig cell, Sertoli cell, Sarcoma, Leukaemia, Lymphoma, Metastasis
Non-seminoma tumour facts
Choriocarcinoma- Can present with extensive metastasiss with paradoxically small primary
Teratoma- mature and immature elements
Yolk sac tumour- In infants and young children
Frequency of testicular CA types
Seminoma, Embryonal Carcinoma, Teratocarcinoma Teratoma, Mixed, Choriocarcinoma
secondary tumours
Lymphoma
Leukaemic infiltration
Metastasis- prostate, breast, kidney
testicular CA presentation
50% have metastasis at diagnosis- Neck mass, respiratory, GIT, bone pain, neurological, lower extremities
Heavy feeling or painless swelling around testicular region
acute testicular pain
Gynaecomastia
Metastasis of testicular CA primary “landing zone”
left-sided tumours: para-aortic, left renal hilar lymph nodes
right-sided: inter-aortocaval and paracaval nodes
testicular CA Treatment
Multimodal- Radical orchidectomy Radiotherapy Chemotherapy Retroperitoneal lymph node dissection Follow up (surgical approach is inguinal)
Risk of incontinence
Abdominoperineal resection Polio (almost always recovers) Diabetic neuropathy Lumbar disc disease Stroke Meningomyelocele
risk factors of bladder tumours
Smoking Chemical exposure – exposure to carcinogen – Dye, rubber, aluminium, leather Radiation - pelvic Chemotherapy cyclophosphamide Bladder.Parisitic infection
Clinical presentation of bladder & upper tract tumours
Haematuria – painless
LUTS – Dysuria, urgency, Frequency
Pelvic pain – advanced disease
urothelial tumours mx
Superficial low grade disease – Resection or fulgeration
Superficial high grade disease – Resection or fulgeration – Intravesical immune therapy: BCG installations
– Intravesical chemotherapy: Mitomycin C Installations
Management - TCC
Muscle invasive disease
– Clinically resectable: pelvic lymph adenectomy + radical cystectomy + urinary diversion, Partial cystectomy
– Clinically unresectable: Radiation therapy, Chemotherapy + re-assessment regarding salvage surgery
Metastatic disease – Chemotherapy: Methotrexate,vinblastine,doxorubicin,cisplatin
Newer agents = Taxoids,gemcitabine
Management - SquamousCa of bladder
Resectable – Pelvic lymphadenectomy + radical cystectomy + urinary diversion
Unresectable – Radiation
upper tract tumours presentation and mx
Haematuria, Flank pain, Colic pain, Flank mass, Weight loss
Mx- Gold standard: Nephro-ureteroctomy and cuff of bladder
CausesofabnormalSHBGinmales&females
decr- obesity, hypothyroidism, PCOS, high doses of glucocorticoids, androgens
icr- anorexia nervosa, hyperthyroidism, liver dz, anit convulsants, oestrogens
Symptomsandsignsofmalehypogonadism
physical- gynocomastia, decr muscle mass aand/or BMD
psychological- depression, lack of energy
sexual- erectile dysfunction, decr libido
countries with highest rates of femicide
hondura jamaica lesotho RSA guinea bissau
Intimate Partner Violence
IPV includes physical violence, sexual violence, stalking and psychological
aggression by a current or former intimate partner (spouse,
boyfriend/girlfriend, dating partner or ongoing sexual partner)
risk factors for IPV
Individual risk factors- younger age, intellectual disability
Relationship risk factors- separated relationship status, marital disagreements
Community risk factors- high levels of crime, poverty and unemploymen
Social risk factors- gender inequality, devaluation of women
protocol for IPV assessment
Screen in a safe setting with the woman alon
Use professional language interpreters
Incorporate screening for IPV into routine medical history
Keep printed take home resources such as hotline numbers
Documentation
encounters may become forensic evidence of the abuse
Direct quotations and photos should be included after informed consent is given by patient
Complete documentation should include the history, timeline, examination, symptoms, witnesses and results of imaging and laboratory studies as well as referrals and law enforcement notification
Belmont report 3 core principles
respect for persons
Beneficence
Justice
virtue
A dispositional trait of character that is socially valuable and reliably
present in a person, and a moral virtue is a dispositional trait of
character that is morally valuable and reliably present
The cardinal virtues
courage, prudence, temperance, and justice
B&C five virtues
applicable to the medical practitioner:
trustworthiness, integrity, discernment, compassion, and
conscientiousness
Conservative management of female sexual dysfunction
Lifestyle changes such as weight loss, decreasing
fatigue, stress management, and smoking/alcohol
cessation
Manage contributary co morbidities.
Physical therapy and pelvic floor rehabilitation
Psychological intervention: Couples and individual
counselling, sex therapy, psychiatry
medical management of female sexual dysfunction
Hormone therapy Serotinergic/dopaminergic agents Apomorphine Bremelanotide Phosphodiesterase inhibitors
medical management of female sexual dysfunction GPPD
Topical anaesthetics, hormones Ospemifine Antidepressants Oral neuropathic pain meds i.e Gabapentin Botox Injectable steroids Vaginal laser therapy Vestibulectomy
acute pelvic pain Also seen with disorders of
gastrointestinal
Urinary
Musculoskeletal systems
most probable causes of acute pelvic pain 0-21yrs
dysmenorrhea PID ovarian cysts rupture haemorrage
most probable causes of acute pelvic pain 21-35yrs
ovarian cystes endometriosis pregnancy spontaneous abortion ectopic pregnancy
most probable causes of acute pelvic pain 35yrs to menopause
uterine fibroids endometriosis ovarian cancer/tumour pregnancy abortion
progesterone in leiomyomas
Results in increased cell proliferation and survival and enhancement of extracellular matrix formation
Renal colic
- Acute flank pain
- On and off character (traditional definition)
- Loin to groin radiation
- Associated n+v
referred pain of renal colic
gastric liver and biliary colonic ureteral and kidney diaphragmatic irritation
renal colic causes
Renal • Benign -infective- pyelonephritis perinephric abscess • Malignant -renal cell carcinoma
Non-renal • Bowel related- -appendicitis (rt sided pain) -diverticulitis Gynae related- -p.i.d -ectopic pregnancy
renal colic mx
• Conservative management Medical Expulsive Therapy (MET) • Intervention - Minimally invasive- ESWL - Endoscopic- stenting- retrograde stent insertion - Ureterorenoscopy + lithotripsy
Indications for surgical intervention in renal colic
- Obstructive calculus with Infection
- Solitary kidney with calculus
- Bilateral ureteric calculus obstruction
- Renal insufficiency with calculi
- Intractable pain
- Failed conservative management
Relative indications for surgical intervention in renal colic
• Occupational- high risk duty like pilots
• Abberant anatomy- ureterocele, ectopic
kidneys, post-reimplantation ureters.
what composition of stones is suited to which procedure
- ESWL- wedelite- CaOx Dihydrate
- URS- brushite (colorless to pale yellow monoclinic prismatic crystals), cysteine, whewelite -hydrated calcium oxalate
most common renal stones formed
calcium
struvite
uric acid
cysteine
ureterorenoscopic complications
Early: mucosal injury
• ureteral perforation
• bleeding
• avulsion
Late: stricturing sepsis
• reflux hematuria
• persistence of colic
Renal colic in pregnancy
- Be as conservative as possible
- Severe colic: u/s
- if fails,
- limited Intravenous pyelogram (control,x2films)
- Mx- URS (ESWL is c/i)
- holmium YAG preferable (smaller penetr)
Renal colic in children
• Amenable to ESWL, URS
• Small calibre ureter, urethra, ESWL bias
Stone types- ?cysteine; ?brushite
calcium oxalate stones and calcium phosphate stones, are the most common types of kidney stones in children
viral STI
Common – HIV-1 & 2 – HSV 1 & 2* – HPV* – HBV
• Less common
– HCV
– Molluscum contagiosum*
– CMV (in immunosuppressed individuals)*
HIV TRANSMISSION (through genital mucosa)
direct penetration
transcytosis
infx of Langerhans cells
Factors influencing sexual transmission of HIV
- High HIV viral load
- Other STIs - ↑ CD4 lymphocytes, genital ulcers
- Female gender – at ↑ risk than males
- Circumcision status - ↑ risk in uncircumcised men
- Vaginal tears – during sexual intercourse
HIV transmission routes high to low
blood products IV drugs penile anal needle stick penile vaginal
genital herpes Complications
– recurrency – aseptic meningitis – meningo-encephalitis – urinary retention – transmission to the foetus/neonate
HSV Treatment & prophylaxis
• Acyclovir, Valacyclovir*, Famcyclovir for 7 days
– Early antiviral treatment alleviates symptoms &
prevents serious complications
• Resistant infections: Foscarnet, Cidofovir
pathophysiology of stricture
Noxious stimulus (bacterial, chemical, physical) Denuded epithelium Squamous metaplasia Fissures develop in epithelium Urine extravasation Fibrosis develops in the corpus spongiosum Fibrotic plaques coalesce Stricture
Aetiology of strictures
Congenital
Acquired
• Infections
• Trauma
Clinical presentation of strictures
• Obstructive /Irritative LUTS • Urinary tract infections • Acute urinary retention • Overflow incontinence • Renal failure • Haematuria Asymptomatic
Non invasive tests for stricture
Uroflow
SONAR- Useful for bulbar
strictures? limited
invasive tests for stricture
Catheterisation • Radiology – Contrast studies- retrograde urethrogram, voiding cystogram. • VCUG • Urethrocystoscopy – urethral – suprapubic – Does not show length
Rx of stricutures
• Optical urethrotomy • Dilatation • Laser urethrotomy (holmium:YAG laser) • Urethroplasty – One stage – Two stage
complications of penile fracture
Sepsis/ abscess Urine leak Venogenic e.d Acquired lateral curvature Recurrence of fracture
Rx of penile fracture
Optimize the surgical exposure. Evacuate the hematom Identify the site of injury. Correct the defect in the tunica albuginea. Repair the urethral injury
Mx- penile amputation
Sterile saline-soaked gauze Salvage 18 hours Microvascular repair- artery, nerve Tunical repair- interrupted sutures Urethra, if involved: 2 layer repair over catheter
Botched circumcision
Penile stumps
Perineal urethrostomies
Psychological morbidity, body-image issues among previously fit young men
Technicalities of transplant
1,5mm cavernosal artery reanastomosis
Full sensation not yet achieved (may take up to 2yrs)
Indefinite immunosuppressive medication
Ethical, social concerns
Testicular and scrotal injuries
Blunt (85%)
Penetrating (10-15%; gsw and stabs)
Avulsion (work-related)
Causes: sport-related
self-mutilation
animal-bites
mx of bites to testicules
Mx- dog bites- irrigate, debride primary closure a/b- prev- Pen V + cephalexin ATT antirabies vaccine Human bites- n.b- do not close primarily
Scrotal trauma
<50% surface area- primary closure
If extensive- delay closure- thigh pouch
Reconstruction – local skin flaps- medial thigh
rectus
Mechanisms of injury in urter
• Traumatic- blunt vs penetrating
• Iatrogenic- more common cause of injury- gynaecologic
urologic- endoscopic, open
general surg
radiation related
imaging in ureteral injuries
- non-invasive
IVP- ? obsolete
CT ivp – gold standard - Invasive
Retrograde pyelogram
Antegrade pyelogram (where nephrostomy present)
Management of ureteric injury
- Stent insertion
- Primary Anastomosis- ureteroureterostomy
- Transureteroureterostomy
- Ureteric reimplantation
- Urinary diversion; percutaneous or ureterostomy
Jj stent insertion
• Incomplete/partial ureteric stenosis
• Post ureteric repair- ureteroneocystostomy
uretero-ureterostomy
complications of transureteroureterostomy/ Ileal interposition
• Early: Urinomas Retroperitoneal abscesses • Late: Ureteric strictures - renal damage fistulae
Mechanisms of injury to bladder
• Traumatic - blunt; *MVA most common cause- pelvic fracture blow/kick to full bladder fall from height - Penetrating; GSW stab - Iatrogenic; gynae- hysterectomy, c/s uro- open endoscopic- e.g turbt laparoscopic
Principles of intraperitoneal repair
- Avoid pelvic hematoma; stay midline
- Visualise u.o’s
- Post-op drainage
- Catheter 7 to 10 days; then cystogram
Indications for open repair
- Intraperitoneal rupture
- Laparatomy for other reasons- ortho- open pelvic # needing orif
- Penetrating injury
- Bladder neck injury
- Rectal or vaginal injury
- Spicules in bladder
- Relative- unresolving gross hematuria
Surgical options for urethral stricture
disease
• Urethral dilation
• Internal urethrotomy- cold knife, laser
• Permanent urethral stents
• Open reconstruction- primary repair
tissue transfer repair technics- buccal, preputial, bladder, t.vaginalis
Surgical options for delayed repair
• Endoscopic-
‘cutting to the light’
• Open- perineal approach
• transpubic approach
Risk Factorsfor POP
Aging
Menopause
Pregnancy & parity ( esp. associated prolonged labour, instrumental
delivery, big baby, episiotomy)
Obesity
Chronic constipation
Genetic factors ( connective tissue disorders; Ehlers Danlos, Marfan)
metabolic acidosis causes
Diarrhea (loss of HCO3)
– Diabetic ketoacidosis
– Renal failure
High anion gap metabolic acidosis
- M = methanol
- U = uraemia
- D = diabetic ketoacidosis
- P = propylene glycol (in diazepam inj)
- I = isoniazid
- L = lactic acidosis
- E = ethylene glycol / ethonol
- S = salicylates
• CUTE DIMPLES (includes cyanide & Touline)
Imaging modalities for the urinary tract
• Radiography • Ultrasound • Computed Tomography (CT) • Magnetic Resonance Imaging (MRI) • Angiography/Intervention • Nuclear Medicine
