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Definitions > Gynae > Flashcards

Gynae Flashcards

1
Q

two processes that ensure only one sperm fertilizes eggs

A

zonal inhibiting proteins

membrane depolarisation

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2
Q

Zonal inhibiting proteins

A

cause the release of any other attached sperm and destroy the oocyte’s sperm receptors, thus preventing any more sperm from binding

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3
Q

Functionsoftheplacenta

A

protection, echanger, endocrine fx

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4
Q

hcg function during the beginning of pregnancy

A

promotes the maintenance of the corpus luteum

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5
Q

epoophoron

A

remnant of the mesonephric tubules that can be found next to the ovary and fallopian tube

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6
Q

paroophoron

A

remnant of the lower part of the mesonephros in the broad ligament between the epoophoron and the uterus

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7
Q

Gartner’s duct cyst

A

a benign vaginal cyst that originates from the Gartner’s duct, which is a vestigial remnant of the mesonephric duct (wolffian duct) in females

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8
Q

H-Y antigen

A

a male histocompatibility antigen that causes females to reject male skin grafts

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9
Q

Primary amenorrhea

A

the failure of menses to occur by age 16 years, in the presence of normal growth and secondary sexual characteristics

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10
Q

Secondary amenorrhea

A

defined as the cessation of menses sometime after menarche has occurred

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11
Q

Müllerian agenesis

A

a congenital malformation characterized by a failure of the Müllerian duct to develop

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12
Q

other names for Müllerian agenesis

A

Mayer–Rokitansky–Küster–Hauser syndrome (MRKH)

vaginal agenesis

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13
Q

menopause sx

A 
Vaginal dryness
Hot flashes
Weight gain and slowed metabolism
Thinning hair and dry skin
Sleep problems
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14
Q

Asherman’s syndrome

A

an acquired uterine condition that occurs when scar tissue (adhesions) form inside the uterus and/or the cervix

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15
Q

what does oxytocin and prostaglandins do during parturition

A

cause uterine contractions

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16
Q

lung changes in pregnancy

A

decr: expiratory reserve volume
residual volume
functional residual capacity
total lung capacity

same: vital capacity
insp reserve volum

incr: tidal volume
insp capacity
dead volume

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17
Q

Polar bodies fx

A

to eliminate one half of the diploid chromosome set produced by meiotic division in the egg, leaving behind a haploid cell

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18
Q

sinual tubercle gives rise to (M & F)

A

M: seminal colliculus.
F: vaginal plate and hymen

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19
Q

granulosa cells

A

production of steroids and LH receptors

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20
Q

thecal cells

A

produce androgens

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21
Q

what are oestrogens are bound to

A

albumin and sex hormone-binding globulin

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22
Q

what are progesterones are bound to

A

albumin & transcortin

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23
Q

oestrogen fx

A

Stimulate proliferation of epithelial cells of uterine tubes, uterus & vagina
Reduce membrane potential of myometrial muscle fibres
Stimulate duct growth in mammary glands

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24
Q

progesterone fx

A

incr membrane potential of myometrial muscle fibres
Stimulates alveolar formation in breasts
Antagonises action of aldosterone on kidney

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25
Q

Sertoli cell fx

A

Secrete H-Y antigen
Synthesise oestradiol from androgens
Secrete ABP

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26
Q

Seminal vesicle

A 
Secretions are neutral/alkaline 
constitiutes 60% of semen
Nutrition to sperms
clotting of sperms
enhances fertilization of ovum
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27
Q

prostate

A 
Secretion is a thin, milky alkaline fluid 
constitutes 30% of semen 
a role in the activation of sperm
Maintenace of sperm motility
Clotting of semen
Lysis of seminal coagulum
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28
Q

Bulbourethral Gland

A

Produce thick, clear mucus prior to ejaculation that neutralizes traces of acidic urine in the urethra

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29
Q

Theca externa

A

PGF2α induces the contraction of the smooth muscle cells of the theca externa, increasing intrafollicular pressure. This aids in rupture of the mature oocyte

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30
Q

Theca interna

A

receptors for LH to produce androstenedione

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31
Q

Barr body

A

inactive X chromosome in a female somatic cell, rendered inactive in a process called lyonization

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32
Q

effects of 5-alpha reductase mutation

A

hypospadias
female external genitalia
lack of prostate growth

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33
Q

Bicornuate uterus facts

A 
No fertility issues		
Recurrent miscarriages	
Fetal malpresentation
Prematur labour		
Rx with metroplasty
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34
Q

Unicornuate uterus facts

A

Second trimester miscarriage
endometriosis is common when underdeveloped horn has cavity
Associated with renal anomalies

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35
Q

Cervical cerclage

A

procedure used to reinforce cervix that shortens too quickly

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36
Q

activin

A

incr FSH binding and aromatization

incr action of LH

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37
Q

Hypothalamic–pituitary–adrenal axis fx

A

regulates many body processes, including digestion, the immune system, mood and emotions, sexuality, and energy storage and expenditure

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38
Q

Hypothalamic–pituitary–gonadal axis

A

controls development, reproduction, and aging in animals

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39
Q

Hypothalamic–pituitary–thyroid axis

A

regulation of metabolism, thyroid levels and also responds to stress

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40
Q

Primary Ovarian Insufficiency

A

Intermittent ovarian function
HRT, Weight-bearing exercise and calcium essential
Barrier contraception

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41
Q

Oxytocin and arginine vasopressin (AVP) are neuropeptides synthesized in which nuclei of the hypothalamus

A

paraventricular

supraoptic

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42
Q

Mayer-Rokitansky-Kuster-Hauser Syndrome (utero-vaginal agenesis)

A

Normal secondary development, external female genitalia & ovaries
Absent uterus and upper vagina
Ass w/ renal, skeletal and middle ear anomalies

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43
Q

Androgen Insensitivity

A

Normal looking female external genitalia breasts &
No sexual hair
Absent uterus and upper vagina

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44
Q

Gestational trophoblastic disease facts

A

Spectrum of diseases arising from fetal chorionic tissue.
All the neoplasms have cytotrophoblasts and syncytiotrophoblasts
Secreting B-HCG

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45
Q

cytotrophoblast fx

A

secretes proteolytic enzymes to break down the extracellular matrix between the endometrial cells to allow finger-like projections of trophoblast to penetrate through the myometrium

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46
Q

Syncytiotrophoblast fx

A

actively invades the uterine wall to facilitating passive exchange of material between the mother and the embryo

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47
Q

Complete hydatidiform mole facts

A

No foetal embryonic tissue develops
Hydropic swelling villi and trophoblastic hyperplasia
Chromosomes of the sperm duplicate

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48
Q

list 3 types of Gestational trophoblastic disease (GTD)

A

Complete Hydatidiform Mole (CHM)
Choriocarcinoma (Cca)
Placental site trophoblastic tumour

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49
Q

Invasive mole usually develops from

A

partial or complete mole

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50
Q

cause of a Partial hydatidiform mole

A

2 Sperm cells fertilize normal egg

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51
Q

Placental site trophoblastic tumour facts

A

Do not have villi
BHCG levels low
Epitheloid trophoblastic tumour (ETT) is a rare variant of PSTT (Placental site trophoblastic tumour)

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52
Q

Risk factors of GTD

A

Poor social economic conditions
Lack of carotene
< 20 years / > 40 years

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53
Q

list 2 s/s and 3 Symptoms of GTN

A

Uterus larger than expected
BHCG higher than gestational age

Vaginal bleeding during pregnancy
Passage of grapelike villi from uterus
Hyperemesis Gravidarum

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54
Q

GTN metastases sites

A

lung
liver
brain

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55
Q

Low risk disease management of GTN

A

Methotrexate or Actinomycin-D

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56
Q

High-risk GTN Mx- 1st line

A

EMA-CO

Etoposide, methotrexate, actinomycin-D, Cyclophosphamide, Vincristine (Oncovin)

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57
Q

what is done to remove the oocytes from the ovary for IVF

A

transvaginal oocyte aspiration (TVOA)

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58
Q

Areas identified within the IVF environment that may pose a threat to ART

A 
infx
power failure
equipment
natural disasters eg floods
type/quality of medium
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59
Q

embryo transfer facts

A
  • The embryo can be transferred into the uterus of the patient on day 2, 3 or 5 of culture
  • The patient is required to have a full bladder for easier visualization and position of the uterus
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60
Q

what are DHEA and DHEAS tests used for

A

to determine andrenal contribution to disease of androgen excess

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61
Q

triad of presesnting sx of ectopic

A

vaginal bleeding
amenorrhea
abd pain

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62
Q

Reasons for decline in fertility

A

Women delaying pregnancy for careers
Increasing use of contraception
Unfavourable economic conditions- rising cost of living

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63
Q

Subfertility

A

patients have a successful pregnancies after fertility Rx

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64
Q

Fecundity

A

the probability to achieve pregnancy in 1 menstrual cycle

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65
Q

Male infertility cx

A

primary pathologies of male reproductive system
environmental lifestyle factors
systemic dz

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66
Q

Ovarian hyperstimulation syndrome (OHSS)

A

is an excessive response to taking the fertility medication to stimulate egg growth. When OHSS is severe enough you can get blood clots, shortness of breath, abdominal pain

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67
Q

Antral follicle count

A

a transvaginal ultrasound study, performed in the early phase of your menstrual cycle, in which your physician visually counts the number of egg-containing follicles that are developing on both of your ovaries

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68
Q

how many follicles in an Antral follicle count indicate a poor ovarian reserve

A

less than 5

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69
Q

3 Basic test for infertile couple

A

Semen analysis
Tests for ovulation
Tests for tubal patency

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70
Q

in semen analysis what will we test for

A

Sperm count
Motility
morphology

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71
Q

we can test for ovulation using

A

endometrial biopsy
Progesterone on day 21
Tests for ovarian reserve

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72
Q

give eg for Tests for ovarian reserve

A

Day 2/3 serum FSH,LH and estradiol levels
Antral Follicle Count
Anti-mullerian hormon

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73
Q

in Tests for tubal patency what are our first and second line options

A

1st line: Hysterosalpingography (HSG)
Hysterosalpingo-contrast sonography

2nd line: (invasive)Laparoscopy
chromopertubation

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74
Q

chromopertubation

A

a method for the study of patency of fallopian tube

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75
Q

prolactin facts

A

produced from lactotrophs & decidual cells
Stimulated by TRH and VIP (vasoactive intestinal peptide)
short half life
cleared by the liver and kidneys
suppress the secretion of GnRH from the hypothalamus

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76
Q

Physiological causes of hyperprolactinemia

A

Pain
Vaginal examination
Sleep

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77
Q

Pathological causes of hyperprolactinemia

A

Hypothalamic: craniopharyngioma
Thyroid: Hypothyroidism
Chronic renal disease

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78
Q

Drug induced causes of hyperprolactinemia

A

Dopamine antagonist - Sulpiride
Dopamine depleting agents - aldomet
Narcotics - Codeine

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79
Q

idiopathic causes of hyperprolactinemia

A

Ovulatory dysfunction
Osteoporosis
Visual field defects

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80
Q

how does prolactin cause amenorrhea

A

by suppress the secretion of GnRH from the hypothalamus

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81
Q

galactorrhea Rx

A

Bromocriptine 2,5 – 10 mg dly
Lisuride 0.1-0.2 mg dly
Carbergoline 0.25- 1 mg weekly

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82
Q

lung changes in pregnancy DECREASE

A

decr: expiratory reserve volume
residual volume
functional residual capacity
total lung capacity

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83
Q

lung changes in pregnancy SAME

A

same: vital capacity

insp reserve volum

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84
Q

lung changes in pregnancy INCREASE

A

incr: tidal volume
insp capacity
dead volume

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85
Q

what does accumulation of mineralocorticoid precursors in 11 hydroxylase deficiency result in

A

hypernatremia
hypokalemia
HT
excess andrgens

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86
Q

what dose HAIR-AN syndrome consist of

A 
hyperandrogenism (HA)
insulin resistance (IR)
acanthosis nigricans (AN)
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87
Q

High-risk GTN Mx- 2nd line

A

EMA-EP

Etoposide, Methotrexate, Actinomycin D, Etoposide, Cisplatin

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88
Q

Hyperandrogenism in females

A

amenorrhea
Hyperlipidemia
virilization

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89
Q

Hyperandrogenism in males

A

Dehydration and shock due to decr Na & incr K
Phallic enlargement without testicular enlargement
Inhibition of GNRH secretion testis atrophy leading to:
-low testosterone levels
-low sperm count

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90
Q

what are the common effects of Hyperandrogenism in both sexes

A

Rapid skeletal maturation

Premature epiphyseal fusion

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91
Q

Non-tumour related causes of hyperandrogenism

Adrenal causes

A

CAH - 21 hydroxylase deficiency
- 11 hydroxylase deficiency
Cushing syndrome

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92
Q

Non-tumour related causes

ovarian causes

A

PCOS
Hyperthecosis
HAIR-AN syndrome

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93
Q

Medications that cause hyperandrogenism

A

Danazol- androgen
Metoclopramide- stomach medication
Resepine- HT medication

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94
Q

Tumour related causes of hyperandrogenism

Adrenal tumours

A

Adrenocortical tumour
Adrenal adenoma
Adrenal carcinoma

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95
Q

Tumour related causes of hyperandrogenism

Ovarian tumours

A

Arrhenoblastoma
Hilar cell ovarian tumour
Krukenberg tumour

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96
Q

non classical CAH

A

Milder enzyme deficiency

No genital ambiguity

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97
Q

classic CAH Rx

A

hydrocortisone
prednisone
dexamethasone

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98
Q

Gestational hyperandrogenism presesnts with

A 
Luteoma
theca lutean cysts
Ovarian tumour
Exogenous androgens/progestogens
Placental	aromatase deficiency
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99
Q

hirsutism Mx

A

COC
Inhibit LH stimulate SHBG production
Cosmetic therapy

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100
Q

what can you do if you find a child with Ambiguous genitalia

A

Physical exam
Ultrasonography
Karyotype

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101
Q

classic CAH facts

A

low aldosterone and cortisol
high ACTH & 17-OH progestonolone
can prenatal Dx using Amniocentesis and chorionic villi sampling

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102
Q

Pre-testicular cx of male infertility

A

General factors - Viral illness
Endocrine - Hypothalamic (Kallman’s syndrome)
Drugs - H2 receptor antagonists

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103
Q

testicular cx of male infertility

A

Varicocele
Previous testicular torsion/ trauma
Mumps orchitis

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104
Q

post-testicular cx of male infertility

A

Congenital bilateral absence of the vas deferens
Retrograde ejaculation
Sexual problems- erectile dysfunction

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105
Q

Semen analysis can be informative about

A

Sperm production
Sperm transport and maturation
Sperm transfer and function in the female tract

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106
Q

Standard instructions for semen collection

A

defined abstinence 3 days

evaluated within one hour of collection

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107
Q

Macroscopic evaluation of Semen analysis

A 
Colour - greyish - white
Viscosity - smooth and watery
Liquefaction time- 15-60 mins
Volume - 2-6ml
pH - 7.2 or more
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108
Q

Microscopic evaluation of Semen analysis

A 
Motility 
Vitality- measurement of all living sperm-whether they're moving or not
Count 
Morphology 
MAR (antisperm antibodies)
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109
Q

cx of No ejaculate

A

Ductal obstruction
Retrograde ejaculation
Hypogonadism

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110
Q

cx of Low volume ejaculate

A

ductal Obstruction
Absence of vas deferens or seminal vesicles
Infectio

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111
Q

Asthenozoospermia cx

A 
Immunological factors (ASABs)  
Defect in sperm structure  
Poor liquefaction
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112
Q

Azoospermia cx

A

Klinefelter’s syndrome
Sertoli only syndrome
Hypogonadotrophic hypogonadism

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113
Q

oligospermia cx

A

Genetic disorder
Endocrinopathies
Varicocele

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114
Q

Teratozoospermia cx

A

Varicocele
Stress
Infection

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115
Q

teratozoospermic index (TZI)

A

Ratio of the number of abnormalities/abnormal sperm

should be between 1 and 3

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116
Q

Aetiology of recurrent pregnancy loss

A

Unknown
toxins
immunologic
anatomic

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117
Q

Contraindications to medical or expectant management of pregnancy losses

A

Haemodynamically or medically unstable patient
Signs of pelvic infection/sepsis
History of coagulopathy

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118
Q

Misoprostol Side effects include

A

diarrhoea
N+V
fever/rigors

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119
Q

Mifepristone

A

antiprogestin that result in weakening of the uterine attachment of a pregnancy. This results in capillary breakdown and synthesis of prostaglandins

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120
Q

antiphospholid syndrome pregnancy complications

A

fetal death
pre eclampsia
thrombocytopenia

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121
Q

Screening tests for recurrent pregnancy loss

A 
Lupus	anticoagulant
anticardiolipid	antibodies
anti-ß2	glycoprotein1	antibodies
diabetic screening - glucose	tolerance	test
prolactin
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122
Q

Cervical insufficiency facts

A

Second trimester miscarriage losses
Screening with transvaginal ultrasound cervical length from 16 weeks to <24wks
If cervical length < 25mm then cerclage
Vaginal Progesterone (200mg) at night

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123
Q

Cervical insufficiency Hx

A

painless dilatation of the cervix in the second trimester
delivery of a live fetus
Spontaneous rupture of membranes

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124
Q

Antiphospholipid syndrome Mx

A

Low dose Aspirin (75 -100mg) daily once fetal heart seen

can be combined with Unfractionated Heparin or LMWH until 36 wks

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125
Q

advantages of LMWH over heparin

A

less osteoporosis, haemorrhage and thrombocytopenia
reduced protein binding
longer half life

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126
Q

Complications of termination of pregnancy

A

Incomplete miscarriage
Heamorrhage
Infection

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127
Q

Rotterdam Criteria

A

irregular or absent ovulation, elevated levels of androgenic hormones, and/or enlarged ovaries containing at least 12 follicles each

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128
Q

PCOS presents clinically by

A 
menstrual irregularity
androgen excess (hirsutism)
acne
androgen-dependent alopecia 
infertility- anovulation
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129
Q

4 danger signs of cancer

A

Abnormal bleeding
Abnormal masses
Unexplained fever
Weight loss

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130
Q

another 4 danger signs of cancer

A

Pain
Pale
Change in personality, gait, balance
Red eye or absent red reflex

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131
Q

methods of epigenetic change

A

Changes in DNA methylation
Histone modification
Polycomb group proteins

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132
Q

Un-methylated gene promotor sections allow

A

transcription of genes

expression of protein product

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133
Q

Over- or undermethylation patterns allow

A

activation of usually silence genes

silencing of important genes

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134
Q

MicroRNA or miRNA

A

Very important during embryogenesis and early development
Interacts by being incorporated into the RNA protein complex
Degrades and/or block mRNA before transcription

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135
Q

epigenetic drugs

A

Demethylation agents or DNMT-I

Histone deacetylases H-DACS

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136
Q

Characteristic signs of hereditary breast/ovarian cancer syndrome

A

Early or pre-menopausal breast cancer
Bilateral breast cancer
Any single individual with both diseases

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137
Q

aetiology of intersex disorders

A

Due to excessive androgens
Arising in fetus → CAH
Arising in mother – androgens secreting tumor.
Ingested by mother, eg. Danazol

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138
Q

21 hydroxylase deficiency presentation:

A

Enlarged clitoris
fused labioscratal folds and urogenital sinus.
Internal genitalia development normal

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139
Q

eg of ovarian androgen secreting tumours

A

Luteoma
Arrehenoblastooma
Kruken berg tumors

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140
Q

True gonadal dysgenesis features

A

Streak gonads
normal mullerian structures
Normal external female genitalia

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141
Q

Urinary incontinence

A

involuntary loss of urine

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142
Q

Continent

A

ability to retain urine between voluntary episodes of micturition

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143
Q

Urge incontinence

A

a sudden and strong need to urinate

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144
Q

Urinary Incontinence s/x

A

Frequency
Urgency
Nocturia

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145
Q

Stress urinary incontinence

A

involuntary loss of urine on effort or physical exertion or on sneezing or coughing due to sudden pressure on the bladder and urethra

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146
Q

Overactive bladder

A

group of urinary symptoms such as
urinary urgency, usually accompanied by frequency and nocturia, with or without urgency urinary incontinence, in the absence of UTI or other obvious pathology

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147
Q

Mixed urinary incontinence

A

involuntary leakage associated with Stress Urinary Incontinence and Urge Urinary Incontinence

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148
Q

diabetes sx

A 
polyuria and polydipsia
blurry vision (retinopathy)
weight loss (type 1) or weight gain (type 2)
neuropathy
fatigue
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149
Q

Stress Urinary incontinence Rx

A

Conservative- Vaginal pessaries
mild-Pelvic floor exercises with electrical stimulation
moderate to severe- BURCH or Slings surgery

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150
Q

Overactive bladder Rx

A 
Lifestyle modification
Behavioural  modification
Pelvic Floor Muscle Training
Anticholinergics  
Neuromodulation
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151
Q

eg of drugs to control urination

A 
trospium
oxybutynin
propiverene
darifenacin
fesoterodine
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152
Q

Urinary Incontinence & Pelvic organ prolapse risk factors

A

Vaginal childbirth
Connective tissue disorders
Menopause

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153
Q

anti cholinergic S/E

A

Dry mouth
Blurred vision
Constipation

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154
Q

Artifactual asthenozoospermia

A

Abstinence period too long, too short
Lubricants
Incomplete ejaculate

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155
Q

Transdermal patch

A

avoids the first pass metabolism through the liver
fewer oestrogen-related side effects
Applied weekly

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156
Q

vaginal ring

A

in the vagina for 3 weeks followed by ring-free week Avoids 1st pass metabolism
fewer oestrogen-related side effects

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157
Q

Oestrogen excess side effects

A

Bloating
migraine headache
breakthrough bleeding- refers to vaginal bleeding or spotting that occurs between menstrual periods or while pregnant

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158
Q

progestational side effects

A

Headaches
breast tenderness
mood changes

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159
Q

Major Side Effects of contraception

A

Thromboembolism
Cardiovascular Risk
Cancer Risk

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160
Q

vaginal fistula causes

A

Abdominal surgery (hysterectomy or C-section)
Pelvic, cervical, or colon cancer
Bowel disease like Crohn’s or diverticulitis

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161
Q

urinary fistula cx

A

Hysterectomy
congenital
Radiation treatment

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162
Q

what does Oral estrogen increase

A

MMP and CRP levels

Macrophages release Matrix Metalloproteinase (MMP) that digest collagen

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163
Q

menopausal hormone therapy risks

A 
thromboembolism
gallbladder disease
stroke
myocardial infarction
breast cancer
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164
Q

When to prescribe tibolone (Progestin)

A

Any symptomatic post menopausal woman
an increase in breast pain despite HRT dose adjustment
low libido

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165
Q

endometriosis theories

A

Retrograde menstruation (Sampson’s Theory)
Lymphatic spread
Coelomic metaplasia/induction theory

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166
Q

endometriosis Common sites

A

Kidney, lung, liver, diaphragm
Ovaries
Anterior and posterior cul-de-sac

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167
Q

endometriosis Clinical presentation

A

Dysmenorrhoea
Subfertility
Chronic pelvic pain

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168
Q

Mechanism of subfertility in endometriosis

A

Mechanical interference- adhesions
Ovulatory dysfunction
Peritoneal fluid- has macrophages which are spermicidal

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169
Q

Adenomyosis def and s/x

A

Presence of endometrial glands and stroma in the myometrium

Uterus is enlarged and globular
Menorrhagia – 50%
Dysmenorrhoea – 30%

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170
Q

Adenomyosis dx and Rx

A

TVS- Resembles myoma
MRI- Cystic spaces give a “honey-comb” appearance

Laparoscopic resection
L/S electrocoagulation
Hysterectomy

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171
Q

Primary dysmenorrhea

A

common menstrual cramps that are recurrent and are not due to other diseases

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172
Q

Secondary dysmenorrhea

A

pain that is caused by a disorder in the woman’s reproductive organs

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173
Q

Pharmacological dysmenorrhea Mx

A

NSAIDS
Pharmacological dysmenorrhea Mx
COC

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174
Q

non Pharmacological dysmenorrhea Mx

A

Transcutaneous Electrical Nerve Stimulation.
Acupuncture
heat Therapy

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175
Q

surgical dysmenorrhea Mx

A

Laparoscopic Uterosacral Nerve Ablation

Laparoscopic Presacral Neurectomy

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176
Q

gynaecological cx of Secondary dysmenorrhea

A

Extrauterine- Pelvic congestion syndrome
Intramural- fibroids
intrauterine- IUCD

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177
Q

non gynaecological cx of Secondary dysmenorrhea

A

GUT- Interstitial cystitis
GIT- Irritable bowel syndrome
Orthopaedic- Spondylosis

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178
Q

physical sx of PMS

A

abd bloating
extreme fatigur
breast tenderness

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179
Q

behavioural sx of PMS

A

Labile Mood
Irritability
Tensions

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180
Q

Phamarcological treatment of PMS

A

Hormonal- COC’s eg. Yasmin
Antidepressants- Fluoxetinine 20mg daily
Analgesia- NSAIDs

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181
Q

non Phamarcological treatment of PMS

A

Cognitive therapy
Calcium 1200mg/day
exercise

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182
Q

Premenstrual syndrome types

A

Premenstrual Molimina- No interference with everyday
functioning
Premenstrual syndrome- With some functional impairment
Premenstrual dysphoric disorder (PMDD)- Mimic psychiatric disorders

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183
Q

Lichen sclerosus et atrophicus

A

a chronic skin disease characterized by white, flat papules with an erythematous halo and black, hard follicular plug

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184
Q

what kind of trauma is most seen in pre-adolescent girls

A

tears
abrarasion
ecchymosis
haematomas

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185
Q

Labial agglutination

A

occurs when the labia minora become fused together

and can lead to UTIs or vulvulovaginitis

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186
Q

4 phenotypes of PCOS

A

Type A: hyperandrogenism, chronic anovulation and polycystic ovaries(O+H+P)
Type B: hyperandrogenism and chronic anovulation (O+H)
Type C: hyperandrogenism and polycystic ovaries (H+P)
Type D: chronic anovulationand polycystic ovaries.(O+P)

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187
Q

possible diff dx when considering Hyperandrogenism

A 
Cushing’s syndrome
Thyroid dysfunction
Hyperprolactinaemia
Congenital Adrenal Hyperplasia
Androgen secreting neoplasm
HAIR-AN Syndrome
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188
Q

“SOCIETAL EFFECTS” of fertility control

A

Reduces teenage, unwanted and unplanned pregnancy
Reduction in poverty
Increase in female education and employment, income

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189
Q

“MEDICAL EFFECTS” of contraception

A

Prevents pregnancy related complications and deaths eg. miscarriage
Direct benefits of barrier methods eg decr STI’s
Direct benefits of hormonal methods- Reduces ovarian and endometrial cancer

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190
Q

Non infective cx of Vaginal discharges and Infections

A

Foreign body/non specific infection
Fistulae
malignancy

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191
Q

Normal physiological discharge clinical hallmarks

A

Non offensive
noncopious
no associated symptoms

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192
Q

Candida on vagina presents with

A

Itching and burning
Copious white – varying consistency (cottage cheese discharge)
Vulvar erythema ± perianal

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193
Q

Trichomonas presentation

A

Profuse frothy yellow green discharge. Strong odour Vulvar erythema and oedema
Classic ‘strawberry’ cervix

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194
Q

Gonococcal infection Presentation

A

Typically invades the cervix resulting in pus like discharge/offensive/abdominal cramping/bleeding and painful urination
Complications – PID/Bartholins gland abscess/disseminated gonococcal infections
Rx cefixime 400mg PO or Ceftiaxone 125mg IM

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195
Q

Chlamydia infx presentation

A

Can cause bartholins gland abscess, vaginitis, cervicitis,acute salpingitis and PID
Symptoms include mucopurulent discharge, abdominal pain,dysuria
Treatment – azithromycin or doxycyline

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196
Q

Syphilitic lesions of the vagina Presentation

A

chancre
Associated lypmphadenopathy
If left untreated secondary syphilitic lesions – chondylomata lata, snail track ulcers and mucous paches

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197
Q

Genital Tuberculosis Presentation

A 
Ages 20-40yrs old 
Pelvic pain (chronic) 
Inflammatory pelvic mass
Menstrual irregularities and infertility 
amenorrhoea
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198
Q

INH

A

5mg/kg.max 300mg
Hepatotoxicity
N +V
Peripheral neuropathy

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199
Q

Rifampicin

A

10mg/kg max 600mg
Hepatotoxic
fever
rash

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200
Q

Ethambutol dosage and s/e

A

15mg/kg max 800-1000mg
Optic neuritis
hypersensitivity reaction
fever and lymphadenopathy

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201
Q

pyrizinamide

A

15-30mg/kg max1.5-2g
Hepatitis
Hyperuricemia
rash

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202
Q

Differential Diagnosis when you suspect PID

A 
Appendicitis
Ectopic pregnancy
Endometritis
Ovarian cyst
Ovarian torsion
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203
Q

Indication for surgery in PID

A

Ruptured TOA or generalized peritonitis
Septic Shock or multiorgan dysfunction
TOA or pelvic abscess not responding to treatment

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204
Q

Chronic pelvic infection facts

A

Due to acute PID, recurrent lowgrade pyogenic infection or TB
Occlusion of ostia – hydro/pyo salpinx
Prone to secondary bacterial infection or simply persistent low grade infection

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205
Q

Chronic pelvic infection Symptoms and Mx

A

chronic pelvic pain
Dyspareunia
Menorrhagia

Medication- Analgesia & Antibiotics
Surgery- total abd hysterectomy

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206
Q

organs affected by Genital Tuberculosis

A

fallopian tube
endometrium
ovaries

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207
Q

Treatment methods for cervical neoplasia

A

Local destruction: cryotherapy, laser
Local excision: LLETZ, cone biopsy
Surgical options: hysterectomy

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208
Q

cervical CA s/s and s/x

A

intermenstrual bleeding
dysparenia
Pain is a LATE complaint

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209
Q

Treatment options in cervical CA

A

Stage IA: LLETZ or cone is sufficient
Stage IB: RHLND: radical hysterectomy and pelvic node dissection
Stage II, III: Radical radiotherapy to pelvis with added chemotherapy
Stage IV: Chemotherapy plus pelvic irradiation

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210
Q

Postmenopausal atrophic vaginitis facts

A

Burning, itching, dyspareunia, bloodstained discharge
Vaginal epithelium shiny, thin and transparent
Vaginal moisturisers and lubrication 1st line (topical vaginal estrogen)

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211
Q

Emphysematous vaginitis

A

Gas-filled blisters in vagina
PV discharge / “popping sound”
Associated with bacterial or trichomonal vaginitis

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212
Q

Toxic shock syndrome of vagina

A

Symptoms may include fever, rash, skin peeling, and hypotension
Risk factors: very absorbent tampons, and skin lesions in young children

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213
Q

Benign conditions of the vagina

A

Vaginitis
Cystic swellings
Solid tumors
Vaginal adenosis

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214
Q

Epidermal inclusion cysts

A

Women of childbearing age
Following obstetric or other trauma of vagina
Posterior and lateral vaginal wall

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215
Q

Congenital cysts of vagina

A

Mesonephric system (Wolffian duct)
Gartner duct cysts
Anterolateral aspect of vaginal wall

Paramesonephric system (Müllerian duct) 
Rare &amp; occur on Lower 3rd of vagina near hymen
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216
Q

Polyps in vagina of vagina

A

proliferation of vaginal lamina propria
Usually asymptomatic / incidental finding
Differentiate from sarcoma botryoides (esp. children) and pyogenic granulomas (after surgery)

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217
Q

Vaginal adenosis

A

benign, Abnormal presence of columnar epithelium in vagina

Mucoid discharge, postcoital bleeding, dyspareunia DES syndrome

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218
Q

most vaginal cancers are metastatic what are the sites

A

cervix or endometrium

Vulva • Ovaries • Choriocarcinoma

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219
Q

If vaginal biopsy shows adenocarcinoma where do you look for other primary lesion

A

Endometrial cancer • Colon • Rectum

Breast • Ovary

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220
Q

Melanoma of vagina

A

Malignant melanoma of the vagina is rare
Present as pigmented masses, plaques or ulcerative lesions
Most frequently on the distal one-third of the anterior vaginal wall

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221
Q

Sarcomas of vagina

A

Most common sarcoma botryoides
Highly malignant tumor that occurs in the vagina during infancy and early childhood (mean age 3 years)
Gross appearance of grape-like masses that are exophytic

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222
Q

Diseases caused by HPV besides cerrvicalCA include

A

Head and neck cancers
Anogenital warts
Recurrent respiratory papillomatosis

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223
Q

Pre-operative factors associated with post-operative cardiac complication

A

Jugular vein distention or S3 gallop
Myocardial infarct within 6 months
Arrhythmia

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224
Q

Pre-op risk factors for post-op pulmonary complications

A

Pre-op history of COPD
Purulent productive cough
Anesthesia time greater than 3 hours

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225
Q

Preventing prolonged post-operative ileus

A

Reducing use of opioids in favor of NSAIDs

Using stimulant laxatives (Dulcolax) in addition to stool softeners

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226
Q

Postoperative care procedures

A

Early removal of the foley catheter in uncomplicated patients prevents UTIs
Early ambulation Reduces incidence of VTE
Early feeding facilitating early discharge and reducing length of hospital stay

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227
Q

Wound Complications

A

Dehiscence- Separation of facial layers, Serosanguinous drainage, Evisceration
Seroma- Benign, No erythema or tenderness Collection of liquefied fat, serum and lymphatic fluid under the incision
Hematoma- Abnormal collection of blood that causes discoloration of the wound edges
Infection
Incisional Herni

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228
Q

Factors influencing post-op infection

A 
Definite decrease in host resistance 
increasing age 
obesity/malnutrition 
diabetic ketoacidosis 
acute/chronic steroid use

possible decrease in host resistance
some forms of cancer
radiation therapy
adrenocortical insufficiency

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229
Q

Wound Infection

A

Necrotizing fasciitis - Bacterial infection of underlying fascia
Clostridial Myositis - Clostridial muscle infection

230
Q

Hypothermia

A

Drop in body temperature of 2 degrees C
halts coagulation cascade thus bleeding cont
Platelet dysfunction

Mild - 32 – 35C
Mod – 28 – 32C
Severe – 25 – 28C

231
Q

Malignant Hyperthermia

A

Rare; autosomal dominant
Fever, tachycardia, rigidity, cyanosis
First sign is increased end tidal CO2 (Often within 30 minutes)
Rx: Dantrolene, correct electrolytes, cooling blanket

232
Q

Postoperative fever

The Six W’s

A 
Wind: pneumonia 
Wound: infections 
Water: UTI 
Walking: DVT (possible PE) 
Waste: abscess 
Wonder Drug: medication
233
Q

Postoperative fever facts

A

Noninfectious- Within the first 48-72 hours
Infectious- Fevers on post op days 3-8

dx: Fever within 24 hours – atelectasis
fever on 5th to 10th day – wound infection

Rx: acetaminophen or ibuprofen

234
Q

Pulmonary Complications of surgery

A

Atelectasis
Aspiration Pneumonitis
Pulmonary edema

235
Q

Cardiac complications of surgery

A

Hypertension
Ischemia/Infarction
arrhythmias

236
Q

Renal Complications of surgery

A

Urinary retention

Acute Renal Failure

237
Q

Gastrointestinal Complications of surgery

A

Postoperative ileus
GI Bleeding
Pseudomembranous colitis

238
Q

Neurologic Complications of surgery

A

Delirium, Dementia and Psychosis
Seizure Disorders
Stroke and Transient Ischemic Attacks

239
Q

Contributing factors to paeds vulvovaginitis

A

Suboptimal handwashing
Tight, non-absorbent or wet clothing
Topical irritants- bubble baths, detergents

240
Q

Non-Specific Vulvovaginitis

A

No infectious etiology found

Clinically, less discharge and erythema than in cases with infectious etiology

241
Q

Non-Specific Vulvovaginitis Rx

A

Remove tight-fitting clothes and wet bathing suits immediately after use
Avoid bubble baths and strong detergents
Cotton underwear
Desotin, A&D ointment, other emollients (preparation that softens the skin)
Short course of a mild topical steroid to reduce itching

242
Q

Specific Vulvovaginitis

Infectious Etiologies

A 
Respiratory Pathogens
Enteric Bacteria
STD’s
Candida
Pinworms
243
Q

sx of some infx and non infx cx of Vulvovaginitis

A

strep pyogenes: Dysuria, vulvar pain, pruriitis or burning

candida: Pruritis, thick white d/c (Discharge
pinworm: intense vulvar or perianal pruritis, esp at night

non infx foreign body: Purulent, foul smelling, often brown/bloody vaginal discharge

244
Q

Specific Vulvovaginitis

NON Infectious Etiologies

A 
Foreign Body
Systemic Illness
Miscarriage
Vulvar Skin Disease
Trauma
245
Q

Risk factors of vulvar cancer

A

HPV
Lichen sclerosis
Long history of puritis

246
Q

Vulvar Intraepithelial Neoplasms s/s and sx

A

asymptomatic
itching
hyperpigmentation
rough raisesd lesion

247
Q

Melanoma of vulva

A

Usually arises from nevi
Blue/black
Ulcerated

RX: wide excision with 2 cm free border

248
Q

Pagets Disease of the Vulva

A

Hyperemic tissue
Cake icing effect (red, velvety area with white islands of tissue on the vulva)
Rx: wide local excision

30% will develop adenocarcinoma of the breast, colon, and rectum

249
Q

treatments for infx cx of Vulvovaginitis

A

oral penicillin
cephalosporin
erythromycin
amoxicillin

250
Q

Sexuality

A

sexual orientation, sexual activity and the capacity for sexual feelings

251
Q

Sexual response cycle phases

A

excitement
plateau
orgasm
resolution

252
Q

Types of Paraphilic disorders

A 
Paedophilia
Voyeurism
Sadism
Frotteurism 
Transvestism
253
Q

viagra side effects

A

headaches
indigestion
vision problems for people with retinal eye conditions

254
Q

eg of biological solutions in sexual problems

A

viagra
transurethral alprostadil
injectable phentolamine

255
Q

mx of abn uterine bleeding

A 
COC 
Tranexamic acid 
Mirena 
Hysterectomy
endometrial ablation
256
Q

non structural cx of abn uterine bleeding

A 
Coagulopathy 
Ovulatory 
Endometrial 
Iatrogenic 
Not yet classified
257
Q

structural cx of abn uterine bleeding

A

Polyps
Adenomyosis
Leiomyoma
Malignancy

258
Q

fibroids presentation

A 
Asymptomatic 
Presence of a pelvic mass 
Abnormal uterine bleeding
infertility
Pain: Backache, dysmenorrhoea, dyspareunia
259
Q

Complications of fibroids

A

Torsion of pedunculated myoma
Bleeding and anaemia
Degeneration: Red, Hyaline, Mucoid, Cystic, Fat

260
Q

cx of sexual dysfunction

A

Psychiatric disorders – Depression
Pharmacological Agents – Antidepressants;
Medical conditions – Endocrine disorders
Surgical procedures – Radiation therapy

261
Q

Biological approach to sexual dysfunction is Contraindicated in people who

A

use nitrates
have heart problems
hypo/hypertensio

262
Q

what are X-rays in gynae used for

A

hystero-salpingram and for diagnosis of perforations

263
Q

endometrium and myometrium echogenicity

A

Early menstrual phase- anechoic- blood , Very thin 1-4 mm
Proliferative; 4-8 mm, isoechoic or slightly hyperechoic relative to the outer
Late proliferative (periovulatory)- A multilayered endometrium
Secretory phase- echogenic, 8-16 mm

Homogenous Low-medium echogenicity

264
Q

echogenicity of gynae conditions

A

Ectopic pregnancy- Consist of central hypoechoic area surrounded by echogenic rim of trophoblastic tissue
Molar pregnancy- Echogenic intrauterine tissue with cystic appearance
Incomplete Miscarriage- thickened irregular endometrium with hyper and hypoechoic echoes

265
Q

Rape trauma syndrome short and long term effects

A

Short term- Humiliation
Helplessness
Anxiety

long term- Sexual dysfunction
Increased number of gynaecological problems
Frequent users of medical services

266
Q

mx of rape/sexual abuse

A

Informed consent
Thorough History & Examination
complete necessary forms and collect evidence

Pregnancy, RPR & HIV test.
Emergency contraception

Doxycycline 100mg bd PO x10d.
Metronidazole 2g PO STAT. OR Zithromax 1g stat.
PEP - AZT & 3TC anti-retroviral
counsel and follow up

267
Q

Functional benign cysts

A

Follicular cyst- Usually less than 5 cm
Corpus luteal- Haemorrhagic corpus luteum
Granulosa-theca lutein cyst- In molar pregnancy or part of ovarian hyperstimulation syndrome

268
Q

non Functional benign cysts

A

Endometrioma- Filled with dark haemolysed blood

PCOS- Anovulation, Hyperandrogenism

269
Q

Primary ovarian tumours

A

Benign- Epithelial

Malignant- Germ cells tumours, Sex cord

270
Q

Epithelial tumours types

A 
Serous- malignant type is the commonest of ALL ovarian cancer 
Mucinous- If ruptured  pseudomyxoma peritonei 
Endometrioid- occurs primarily in women who are between 50 and 70 years of age 
Clear cell (mesonephroid)- Polypoid masses that protrude into the cyst
Brenner- Usually benign, occur in reproductive life
271
Q

Germ cell tumours

A

Dermoid cyst ( benign cystic teratoma) - Contain tissue derived from 2 or more germ cell layers
Non- gestational choriocarcinoma- Secrete HCG.
Malignant Germ cell tumour- Dysgerminoma which is highly malignant

272
Q

Sex cord tumours

A

Granulosa cell tumour
Fibromas
Thecomas

273
Q

complication of ovarian tumours

A

Torsion
Haemorrhage
Rupture

274
Q

malignant vs benign

A 
Benign- Thin cyst walls
Smooth cyst walls
Size less than 8 cm in diameter
Unilaterality
No ascitic fluid or blood flow
malignant- Thick cyst walls
Papillary growths on inner or outer surfaces
Bilaterality
Ascitic fluid present
Very strong blood flow
275
Q

Post Menopausal Bleeding

A

Uterine bleeding more than one year after last menstruation

Vaginal bleeding in the presence of raised FSH and LH values in perimenopausal age group

276
Q

levonorgestrel additional benefits

A

Thickens cervical mucus
Decidualizes endometrium
Leads to glandular atrophy that further prevents implantatio

277
Q

Disadvantages of IUCD

A

Cu IUCD’s can increase volume of blood loss during menses
Only LNG IUCD protects against PID
Can increase dysmenorrhea

278
Q

advantages of IUCD

A

Doesnt require adherence
fewer side effects
Reduced risk of cervical and ovarian cancer

279
Q

Contraindications of IUCD

A

Distortion of uterine cavity – congenital, fibroids
Unexplained uterine bleeding
Breast cancer – only for LNG IUCD
Wilson’s disease for Cu IUCD

280
Q

Tubal occlusion methods

A 
Partial salpingectomy
Salpingectomy
Fimbriectomy 
Bipolar cauterization – not a good method 
Clips 
Ring
281
Q

Leiomyosarcomas facts

A

Rare Aggressive tumours
Usually large (> 10 cm) soft tumours in the myometrium of the uterus
Leiomyomas NOT precursor to leiomyosarcomas
variants Epithelioid & Myxoid

282
Q

Leiomyosarcomas Clinical presentation

A 
Asymptomatic
Pre or Postmenopausal bleeding or both 
Abdominal pain 
Abdominal distension 
Urinary symptoms
283
Q

Endometrial carcinoma Risk Factors

A 
Obesity 
Hypertension 
tamoxifen
Nulliparity
Lynch syndrome (hereditary non-polyposis colorectal cancer)
284
Q

BPH: Symptoms

A

Storage- Frequency
Urgency (Urge incontinence)
Nocturia

Voiding -Weak stream
Intermittency
Straining
Incomplete Emptying

285
Q

Later signs/symptoms of BPH

A

Abdominal/flank pain with voiding
Uremia (renal failure) →fatigue, anorexia, somnolence
UTI’s

286
Q

BPH: Clinical findings

A

Late signs of renal failure: anemia, hypertension
Abdominal exam: hydronephrosis/pyelonephritis
GU exam: hernia, stricture, phimosis
DRE in BPH: smooth, enlarged (can’t get finger above it), nodular, with a loss of distinction between the lobes

287
Q

BPH: Non-Surgical Option

A 
Herbal Phytotherapy (e.g.. Saw Palmetto)
Alpha-1-adrenergic antagonists (terazosin, doxazosin
5-Alpha-reductase inhibitors (finasteride, dutasteride)
288
Q

BPH: Surgical Option

A

TransUrethral Resection of the Prostate(TURP)
Transurethral Incision of Prostate (TUIP): less morbidity with similar efficacy indicated for smaller prostates
Open Prostatectomy

289
Q

BPH: New Modalities of Rx

A

Minimally invasive: (Prostatic Stents
Laser prostatectomy ,HoLEP) Holmium laser enucleation of the prostate
Electrovaporization (TUVP Transurethral Vaporization of Prostate

290
Q

Acute prostatitis

A

acute infectious disease
sudden onset
fever, tenderness, urinary symptoms, constitutional symptoms

291
Q

Chronic prostatitis

A

recurring infection with same organism
few prostate related symptoms
difficulty urinating, low back pain, perineal pressur

292
Q

acute bacterial Prostatitis Etiology

A

Gram-negative enteric organisms most frequent pathogens- E. col
K. pneumoniae
P. mirabilis

less frequently
P. aeruginosa
Enterobacter spp
Serratia spp

293
Q

chronic bacterial prostatitis Etiology

A

S. epidermidis
S. aureus

Other/ Unusual- CMV, TB, Candida

294
Q

prostatitis Rx

A

trimethoprim-sulfamethoxazole
fluoroquinolones (e.g., ciprofloxacin
cephalosporins

4 weeks of antibiotic therapy to reduce chronic prostatitis risk

295
Q

which antimicrobials can you use to sterilize urine prior to study in the case of significant bacteriuria

A

ampicillin, cephalexin, or nitrofurantoin for 2 to 3 days

296
Q

long-term suppressive therapy for recurrent infections

A

ciprofloxacin three times weekly
trimethoprim-sulfamethoxazole daily
nitrofurantoin 100 mg daily

297
Q

bilharzia Clinical manifestation

A

Acute: Penetration- Swimmers itch, Circulation- Katayama fever
Intestinal- Abdominal pains, Hepatomegaly
Ureter- Distal ureteric stricture, Ureteric calcifications
Bladder- Mass (inflammatory), Calcified bladder
Genitalia- Cervicitis, Epididymitis, Calcifications of genital organs

298
Q

bilharzia Rx

A

Medical- Praziquantel, 40mg/kg

Surgical- For complications

299
Q

enuresis

A

Nocturnal bedwetting in a child older than 6 years in the absence of any neurological condition

300
Q

Epidemiology: Law of 15 eg

A

1% of 15 yr. old wet
15 % of enuretics have encopresis
15% of non-enuretics have nocturnal polyuria

301
Q

enuresis Rx

A

Anticholinergics
Desmopressin
Imipramine

Limit fluid intake in the evening (from 17:00)
Child must help change sheets if wet

302
Q

Voiding Dysfunction

A

Neuropathic- Myelodysplasia (Neural Tube Defect)

Non-neuropathic- Intravaginal reflux, Hinman Syndrome, Ochoa syndrom

303
Q

Genitourinary TB Clinical manifestation

A

Kidney- Parenchymal masses, infindibular stenosis of collecting system
Ureter- Stricture, Fibrosis of Vesico-ureteric junction
Bladder- Granuloma, Contracted bladder
Prostate- Inflamed, Abscess
Epididymis- Infertility, Beaded Vas deferens
Testicle- mass, abscess

304
Q

besides RIPE what can be used to treat Genitourinary TB

A

Streptomycin
Steroids
Surgical intervention

305
Q

Erection requirements

A 
Stimulus (visual, fantasy, tactile) 
Intact nerve supply 
Normal penile vasculature
Healthy cavernous tissue 
Normal hormonal environment
306
Q

Treatment for Prostate Cancer and erectile dsyfunction

A

radical prostatectomy
External beam radiotherapy
brachytherapy
PDE5Is (Phosphodiesterase-5 inhibitors) still the first-line management for ED post-RP

307
Q

aetiology of erectile dsyfunction

A

Vasculogenic- CV disease, Lack of regular physical exercise
Central Neurogenic causes- Degenerative disorder (MS, Parkinson’s), Stroke
Peripheral Neurogenic- Polyneuropathy, Surgery (pelvic)
Structural- Phimosis, Peyronie’s disease

Hormonal- Diabetes Mellitus, Metabolic Syndrome
Drug-induced- Antihypertensives, Antidepressants
Psychogenic- Generalised (lack of arousability), Situational (partner-related)
Trauma- Penile or Pelvic fractures

308
Q

Medical management of ED

A

First-line Therapy- PDE5 inhibitors, Vacuum erection devices, Shockwave therapy (LI-SWT)
Second-line therapy- Intra-cavernous injections
Third-line therapy- Penile prostheses

309
Q

PDE5 inhibitors side effects

A 
Headache
Facial flushing
Nasal congestion
Dyspepsia
Back pain, myalgia : Tadalafil
Abnormal vision: Sildenafil/Vardenafil
310
Q

Safety issues with PDE5s

A 
Nitrates are contra-indicated
alpha Blocker interaction
Dose adjustments (CYP34A):
decr PDE5 dose- ketoconazole, ritinovir, erithromycin
incr PDE5 dose- rifampicin, phenobarbital, carbamazipine
311
Q

Other causes of anal incontinence

A

Colorectal disease: rectal prolapse/inflammatory bowel ds/fistulas
Congenital atresia
Surgical injury to the anal sphincters

312
Q

anal incontinence facts

A

Urgency of defecation- decrease in warning time indicates injury to voluntary striated ext anal sphincter or its nerve supply
Fecal incontinence with no warning- passive soiling suggests damage to the IAS
New onset symptoms- colonoscopy and barium constrast studies

313
Q

Management of Overactive bladder syndrome

A

Weight reduction
Pelvic floor muscle exercise with electrical stimulation
Anti-cholinergic medication- e.g. Oxybutynin
B3 agonists-e.g. Mirabegron
Sacral neuromodulation

314
Q

Acute urethral syndrome

A

symptoms of dysuria, frequency and/or pyuria without evidence of significant bacteriuria, often in association with vaginitis or urethritis

315
Q

Recurrent UTI

A

≥2 infections in six months or ≥3 infections in one year
Referred to as relapse when infection of the same organism occurs within 2 weeks and is usually drug-resistant
Reinfection is diagnosed when a second infection is found after effective antibiotic therapy with a subsequent negative urine culture

316
Q

Risk factors for UTIs

A

Behavioural factors- soaps
Instrumentation of the urinary tract- urethral catheterization
Voiding dysfunction
Chronic vesico-ureteric reflux

317
Q

Risk factors for Recurrent UTIs

A 
Lower urinary tract obstruction
Chronic retention of urine
Bladder stones
Cystocele
Vesicovaginal fistula
318
Q

Clinical symptoms of UTIs

A

Upper UTIs- Fever
Chills
Flank pain

Lower UTIs- Frequency
Urgency
Dysuria
Suprapubic pain
Haematuria-rarely
319
Q

Common Uropathogens

A 
E Coli
Proteus
Klebsiella
Enterobacter
P. aeruginosa
320
Q

UTI Rx

A

at least three-day treatment of
1st Gen Cephalosporins
Fluoroquinolones
nitrofurantoin

321
Q

UTI Rx facts

A 
Resistance rate ranges are based on patient’s age: younger women record higher rates of  resistance of E. coli toward ampicillin and trimethoprim– sulfamethoxazole than the elderly, a resistance rate higher than 15–20% requires the  choice of a different antibiotic class
Fosfomycin tromethamine can be used in a single dose, while nitrofurantoin monohydrate macrocrystals are given at seven-day treatment, twice daily
In postmenopausal women a 3-day regimen has been suggested, as well as a local hormone supplementation
322
Q

recurrent UTIs prophylaxis

A

nitrofurantoin
norfloxacin
trimethoprim–sulfamethoxazole
Cranberry and lingonberry

323
Q

postcoital prophylaxis for UTI

A

single dose of an effective antimicrobial
nitrofurantoin 50 mg
trimethoprim-sulfamethoxazole 40/200 mg
cephalexin 500 mg

324
Q

hormones kideny produces

A

renin
prostaglandins
erythropoietin

325
Q

Azotemia

A

elevation of blood urea nitrogen and creatinine levels result of a decreased glomerular filtration rate

326
Q

Uremia

A

azotemia + a constellation of clinical signs and symptoms (e.g. peripheral oedema, fatigue, restless legs)

327
Q

angiotensin II funtion

A

Stimulates sodium transport (reabsorption) at several renal tubular sites
Stimulates thirst centers within the brain
Releas ADH

328
Q

nephritic syndrome signs and sx

A 
HT
proteinuria
blurred vision
haematuria
azotaemia
oliguria
329
Q

Nephrotic syndrome

A 
characterized by very heavy proteinuria (> 3.5g/day)
hypoalbuminemia
severe oedema
hyperlipidemia
lipiduria
330
Q

Acute kidney injury

A

characterized by rapid decline in GFR (hours to days) concurrent dysregulation of fluid and electrolyte balance
retention of metabolic waste products
oliguria and anuria may develop

331
Q

Chronic kidney disease

A

diminished GFR that is persistently <60ml/minute/1.73m2 for at least 3 months and/or persistent albuminuria

332
Q

Renal tubular defects

A

dominated by polyuria, nocturia and electrolyte disorders

333
Q

nephrolithiasis

A

spasms of severe pain on flanks, back and below ribs
haematuria
pain on urination

334
Q

Acute tubular necrosis

A

Ischaemic or toxic
patients present with extreme oliguria (<100 ml of urine in 24 hours)
oliguric phase often followed by a diuretic phase
oliguric phase complicated by development of hyperkalaemia with the risk of cardiac arrhythmias

335
Q

Interstitial nephritis

A

heterogenous group of conditions which have common morphological (inflammatory reaction composed mainly of T-cells) and clinical features
Etiology- toxins, immunological, metabolic
s/s and sx- fever and/or rash, incr urine output, haematuria or dark urine

336
Q

Analgesic nephropathy

A

Results from chronic ingestion of large quantities of asprin
Asprin induces papillary ischaemia by inhibiting the synthesis of vasodilatory prostaglandins
Patients may develop transitional cell carcinoma of the renal pelvis and/or ureter

337
Q

kidney Lesions associated with metabolic disorders

A

hypokalemia- causes coarse vacuolation of the tubular epithelial cells
urate- precipitated crystals cause obstruction and tubular dilatation
hypercalcemia- stones within the pelvicalyceal system
oxalosis- tubular crystalline deposits

338
Q

kidney Lesions due to physical agents

A

Radiation nephritis- present with hypertension and renal insufficiency
Obstructive uropathy- pelvis and calyceal system become dilated due to back pressure (hydronephrosis)

339
Q

acute pyelonephritis

A

presents with malaise, fever, pain and tenderness in the loins
urine examination reveals presence of pus cells and white cell casts
abscesses and wedge-shaped foci of suppurative inflammation are seen in the renal cortex and medulla at microscopic examination

340
Q

Chronic pyelonephritis

A

develops when there is reflux of urine into the kidney during micturition raising the intrapelvic and intracalyceal pressure
deep irregular scars are seen towards the poles of the kidneys
interstitial fibrosis and tubular atrophy are seen microscopically

341
Q

Xanthoganulomatous pyelonephritis

A

develops in patients with chronic pyelonephritis
associated with Proteus and E.coli infections
presents as a renal mass mimicking a neoplasm
the kidney cut surface shows a yellow mass surrounded by distorted calyces and small abscesses

342
Q

Potter’s syndrome

A

Bilateral agenesis thus oligohydramnios thus hypoplastic lungs
presents - low set ears
receding chin
wide-set eyes
‘parrot beak’ nose
associated abnormalities: spinal cord defects

343
Q

Congenital renal diseases

A

most of the diseases are prone to infx and/or stones
Unilateral agenesis- affected children do not survive long because of associated multiple developmental abnormalities, prone to infections and trauma
Renal hypoplasia- prone to infection and stone formation
Renal dysplasia- presents as cystic kidneys

Ectopic kidneys- may be associated with intestinal malrotation
Horseshoe kidney- results from fusion of the two nephrogenic blastemas during fetal life, renal function usually normal

344
Q

MORE Congenital renal diseases

A

Cystinuria- autosomal recessive, cysteine crystals are found in the urine and calculi may develop
Renal tubular acidosis- autosomal dominant, loss of bicarbonate and failure to acidify and concentrate the urine, tendency to form stones and develop infections

345
Q

Congenital nephrotic syndrome

A

autosomal recessive
nephrotic syndrome develops due to excessive proteinuria
patients vulnerable to pneumococcal infection
the kidneys have a microcystic appearance which results from dilatation of the proximal tubules and Bowman’s capsule
high levels of alpha-fetoprotein in the amniotic fluid and maternal blood

346
Q

Alport’s disease

A

Mode of inheritance variable but is X-linked in 50% of families
triad of: nephritis, deafness and ocular lesions
presents with haematuria usually in the 1st decade of life
Renal failure in males develops in the 2nd decade
Renal function in females preserved until the 5th decade

347
Q

Simple renal cysts

A

Do not affect renal function

May present with pain if bleeding occurs

348
Q

Autosomal dominant polycystic kidney disease

A

Mutations in the ADPKD1 and ADPKD2 genes
Always bilateral
The cysts vary in size from a few millimeters to several centimeters and are separated by thin bands of renal parenchyma
Eventually results in renal failure
Patients may develop cysts in other organs including liver, pancreas and lungs and berry aneurysm

349
Q

Autosomal recessive polycystic kidney disease

A

Perinatal subgroup- affected babies are stillborn or die of renal failure and respiratory distress soon after birth

Neonatal, infantile and juvenile subgroups- characterized by less severe disease and longer survival
associated with liver abnormalities including proliferation of the bile ducts and hepatic fibrosis

350
Q

Dialysis-associated cysts

A

Characterized by the presence of multiple small cysts that are found throughout the cortex and medulla
Cysts often associated with oxalate crystals

351
Q

Uremic medullary cystic disease

A

Causes chronic renal failure in children and adolescents
There is usually a family history
Kidneys have numerous cysts at the cortico-medullary junction

352
Q

Medullary sponge kidney

A

Results from dilated collecting ducts in the medulla

Usually bilateral but may be unilateral

353
Q

viral infx of kidney

A

Hepatitis B- Associated with membranous or membranoproliferative glomerulonephritis
Hepatitis C- Associated with mesangiocapillary glomerulonephritis
HIV- Characterized by collapse of the glomerular capillaries, severe interstitial fibrosis and inflammation

354
Q

MORE viral infx of kidney

A

Polyomavirus-induced nephropathy- BK and JC viruses Causes disease in immunocompromised patients (HIV and renal transplants)
Diagnosis can be made on urinary cytology by identification of cells containing large basophilic intranuclear viral inclusions (decoy cells)
EBV- Induces B-cell proliferation and transformation with development of lymphoproliferative disorders

355
Q

Hyperacute rejection of kidney

A

Develops within minutes or hours (<48hrs)
Due to preformed antibodies in the blood of the recipient
Immune damage directed at the endothelial cells of the graft
The kidneys are flaccid, cyanosed and mottled
Thrombi and cortical infracts are seen microscopically

356
Q

Acute rejection of kidney

A

Develops within days, months or years

Mononuclear cell infiltrate, interstitial oedema, haemorrhage and tubulitis are seen microscopically

357
Q

Chronic rejection of kidney

A

Develops month or years following transplantation

Characterized by interstitial fibrosis and tubular atrophy

358
Q

urinary calculi s/s and s/x

A

renal colic, dull ache in the loins

recurrent and intractable UTI

359
Q

urinary calculi Classification

A

calcium oxalate (75-80% of all calculi)
struvite stones (composed of magnesium, ammonium phosphate). Stones are large with a staghorn appearance
uric acid stones
calculi in cystinuria and oxalosis

360
Q

Benign renal tumours

A

Renal fibroma

Benign cortical adenoma

361
Q

Malignant renal tumours

A

Renal cell carcinoma - most common type of kidney cancer in adults
Wilm’s tumour- most common cancer of the kidneys in children
Carcinoma of the renal pelvis

362
Q

Osteoporosis is a skeletal disease that is characterized by

A

Low bone mass
Microarchitectural disruption
Skeletal fragility
Increased fracture risk

363
Q

Most common fragility fractures occur in

A

vertebrae
hip
wrist

364
Q

risk facttors for osteopenia

A 
Advanced age
Cortisone therapy
Low body mass (<58kg)
Smoking and excess alcohol
Sarcopenia
rheumatoid arthritis
365
Q

osteoporosis mx lifestyle

A

Exercise – improves muscle strength and balance and reduces falls
Adequate calcium and Vit D intake

Excessive Ca intake does not reduce fractures and leads to increased risk of cardiovascular disease and renal calculi

366
Q

osteoporosis mx medical

A

Estrogen or estrogen/progesterone
Bisphosphonates – GI side-effects
Raloxifen – Selective estrogen receptor modulator
Teriparatide- parathyroid hormone analogue
Denosumab- Monoclonal antibodies

367
Q

Types of surgery

A

Standard surgery – Adnexectomy +/- hysterectomy + total omentectomy + washings + nodes + biopsies
Radical surgery – Pelvic clearance + nodes
Supra-radical surgery – Upper abdominal cytoreduction

368
Q

complete surgical cytoreduction

A

“Standard” surgery: • hysterectomy, bilateral adnexectomy • excision of the pelvic peritoneum, total omentectomy, appendectomy, bulky pelvic and lumbo-aortic nodes +/− simple peritonectomies.

“Radical” surgery:- removal of the uterus and ovaries and pelvic peritoneum with the and recto-sigmoid +/− simple peritonectomies.

369
Q

Cystic renal dysplasia

A

Abnormal persistence of undifferentiated mesenchyme: forming heterologous tissues - cartilage, primitive collecting ductules
gross or microscopic cysts
Ureteric obstruction
Large cysts lined by flattened cuboidal epithelium
Intervening parenchyma is fibrotic with islands of bluish cartilage

370
Q

Multicystic dysplastic kidney

A

Occurs only sporadically - No defined pattern of inheritance
The cysts are larger and more variably sized than those of ARPKD
Often unilateral. - If bilateral, it is often asymmetric and oligohydramnios and its complications can ensue, just as with ARPKD

371
Q

Childhood polycystic kidney disease

A

Autosomal recessive
Smooth external surface [mass of cysts of uniform sizes
Cyst lined by uniform cuboidal epithelium
Most of the cysts are elongated and radially arranged from the center of the kidney

372
Q

Nephronophthisis

A

Cysts in medulla/corticomedullary junction
tubular atrophy
Interstitial inflammation/fibrosis

373
Q

Hydronephrosis causes

A

Congenital eg Posterior urethral valves
Urinary calculi
BPH, pregnancy, uterine prolapse

374
Q

Renal cell carcinoma Clinical triad

A

Flank pain, mass effect, and hematuria

375
Q

Ureteritis follicularis

A

Aggregation of lymphocytes in the subepithelial region

Slight elevations of the mucosa and produce a fine granular mucosal surface

376
Q

Cystitis Glandularis and Cystitis Cystica

A

Nests of transitional epithelium (Brunn nests) grow downward into the lamina propria undergo transformation of their central epithelial cells into: Cuboidal or columnar epithelium lining [cystitis glandularis] Cystic spaces lined by urothelium [cystitis cystica]
The two processes often coexist [cystitis cystica et glandularis]
In cystitis glandularis, goblet cells are present, and the epithelium resembles intestinal mucosa (intestinal or colonic metaplasia

377
Q

Types of acute cystitis

A

Hemorrhagic cystitis - Radiation

  • Antitumor chemotherapy (cyclophosphamide in Px of leukemia)
  • Adenovirus infection

Suppurative cystitis - Ulceration of large areas of the mucosa

378
Q

Chronic Cystitis

A

Thickening of the epithelium
Fibrous thickening in the muscularis propria

Histologic variants
Follicular cystitis - Aggregation of lymphocytes into lymphoid follicles within the bladder mucosa
Eosinophilic cystitis - Infiltration with submucosal eosinophils together with fibrosis

379
Q

Interstitial Cystitis (Hunner Ulcer)

A

painful form of chronic cystitis in women and associated with inflammation and fibrosis of all layers of the bladder wall
cystoscopic findings of fissures and punctate hemorrhages (glomerulations)
mast cells are particularly prominent

380
Q

Malacoplakia

A

Characterized macroscopically by soft, yellow, raised mucosal plaques 3 to 4 cm in diameter
histologically by infiltration with large, foamy macrophages with occasional multinucleate giant cells and interspersed lymphocytes
Laminated mineralized concretions resulting from deposition of calcium in enlarged lysosomes [Michaelis-Gutmann bodies]
Chronic bacterial infection [E. coli or Proteus species

381
Q

Polypoid Cystitis

A

Results from irritation to the bladder mucosa

Formation of broad, bulbous, polypoid projections as a result of marked submucosal edem

382
Q

Papillomas (Urothelial Tumors )

A

In younger patients
Small (0.5 to 2.0 cm), delicate, structures, superficially attached to the mucosa by a stalk
Finger-like papillae have a central core of loose fibrovascular tissue
Covered by transitional epithelial cells that are histologically identical to normal urothelium

383
Q

Papillary urothelial neoplasms of low malignant potential (PUNLMP)

A

Either thicker urothelium or diffuse nuclear enlargement
Limited proliferative activity
Usually larger than papillomas

384
Q

Low-grade papillary urothelial carcinomas

A

Minimal but definite evidence of nuclear atypia-
scattered hyperchromatic nuclei, infrequent mitotic figures predominantly towards the base
mild variation in nuclear size and shape

385
Q

High-grade papillary urothelial carcinoma

A

Dyscohesive and have large hyperchromatic nuclei
The tumor cells show frank anaplasia
Mitotic figures, including atypical ones, are frequent

386
Q

Condyloma Acuminatum of penis

A 
benign 
Papillomatosis
acanthosis
hyperkeratosis
koilocytosis
387
Q

Bowen disease

A

Genital region of both men and women, usually in those over the age of 35 years
Solitary, thickened plaque with shallow ulceration and crusting
On the glans and prepuce as single or multiple shiny red, sometimes velvety, plaques where it is clinically referred to as Erythroplasia of Queyrat

388
Q

Bowenoid papulosis

A

The younger age of patients and the presence of multiple (rather than solitary) pigmented (reddish brown) papular lesions is typical

389
Q

Invasive squamous cell carcinoma of penis

A

Circumcision confers protection

macroscopic patterns: - Papillary - Flat

390
Q

Verrucous carcinoma

A

well-differentiated variant of squamous cell carcinoma that has low malignant potential
These tumors are locally invasive, but they rarely metastasize

391
Q

Non-specific epididymoorchitis

A

Chlamydia trachomatis and Neisseria gonorrhea are the most frequent culprits
In men older than age 35, the common urinary tract pathogens, such as Escherichia coli

392
Q

Specific epididymoorchitis

A

Granulomatous (Autoimmune) Orchitis - nontuberculous granulomatous orchitis, granulomas are seen restricted within spermatic tubules.
Mumps - acute interstitial orchitis develops about 1 week after onset of swelling of the parotid glands.
Tuberculosis
Gonorrhea
Syphilis

393
Q

syphilis Specific epididymoorchitis

A

Almost invariably, the testis is involved first by the infection
In many cases, the orchitis is not accompanied by epididymitis
morphologic patterns- Gummas, diffuse interstitial inflammation
obliterative endarteritis with perivascular cuffing of lymphocytes and plasma cells

394
Q

Germ Cell Tumors

A

Multipotential germ cells
in 60% of the tumors, there is a mixture of two or more of the histologic patterns
Originate from intratubular germ cell neoplasia [ITGCN]
ITGCN is seen adjacent to all germ cell tumors in adults except for spermatocytic seminoma and epidermoid and dermoid cysts
It is also not seen in pediatric tumors (teratomas, yolk sac tumors)
treated by low-dose radiotherapy

395
Q

intratubular germ cell neoplasia [ITGCN]

A 
Cryptochidism
Prior germ cell tumour in adult patient
Family history of germ cell tumour
Androgen insensitivity syndrome
Gonadal dysgenesis syndrome
396
Q

Germ Cell Tumors Histogenesis

A

Gonadal cell line [seminoma – end-stage neoplasm]
Non-gonadal cell line [Embryonic and extra-embryonic]
Embryonic [embryonal carcinoma ; teratoma]
Extraembryonic [Yolk sac and choriocarcinoma

397
Q

Seminoma

A

Most common type of germinal tumor in adults [over 30years]
Identical tumor arises in the ovary [dysgerminoma]
Microscopically [sheets of uniform cells divided into poorly demarcated lobules by delicate septa of fibrous tissue]

Tumor cells are round to polyhedral and has a distinct cell membrane; a clear or watery-appearing cytoplasm; and a large, central nucleus with one or two prominent nucleoli
The cytoplasm contains varying amounts of glycogen
Classic seminoma cells do not contain α-fetoprotein (AFP) or human chorionic gonadotropin (HCG) [but stain for PLAP (Placental alkaline phosphatase)

398
Q

Seminoma - Variants

A

Anaplastic seminoma [cellular; nuclear irregularity ; tumor giant cells and many mitoses]
Spermatocyic seminoma - does not arise from an ITGCN - In much later age than for most testicular tumors [over 65 years] - Slow-growing tumor that rarely if ever produces metastases

399
Q

Spermatocytic seminomas [three cell populations]

A

smaller cells resembling secondary spermatocytes
medium-sized round nucleus and eosinophilic cytoplasm
scattered giant cells

400
Q

Embryonal carcinoma

A

More aggressive than seminomas
Foci of hemorrhage or necrosis [hemorrhagic mass]
Considerable variation in cell and nuclear size and shape
Mitotic figures and tumor giant cells are frequent
raised HCG & AFP

401
Q

Yolk Sac Tumor

A

Most common testicular tumor in children up to 3 years of age
In this age group, it has a very good prognosis
Elevated serum levels of AFP useful in diagnosis

402
Q

Yolk Sac Tumor Microscopically

A

Lacelike (reticular) network of cuboidal cells
Papillary structures
Solid cords of cells
Structures resembling endodermal sinuses (SchillerDuval bodies)
Eosinophilic hyaline globules AFP and α1-antitrypsin

403
Q

Choriocarcinoma

A

Highly malignant form of testicular tumor
Hemorrhage and necrosis are extremely common
Composed of cytotrophoblastic and syncytiotrophoblastic cells

Often, they cause no testicular enlargement and are detected only as a small palpable nodule
Rapidly growing, they may outgrow the blood supply, and sometimes the primary testicular focus is replaced by a small fibrous scar, leaving only widespread metastases

404
Q

Choriocarcinoma Microscopically

A

Syncytiotrophoblastic cell is large - abundant eosinophilic vacuolated cytoplasm
Cytotrophoblastic cells are more regular - polygonal with distinct cell borders and clear cytoplasm

405
Q

Teratoma

A

Complex tumors having various cellular or organoid components reminiscent of normal derivatives from more than one germ layer
Elements may be mature or immature tissue
Rarely, non-germ cell tumors (carcinoma/sarcoma) may arise in a teratoma [teratoma with malignant transformation]
When the non-germ cell component spreads outside of the testis it does not respond to chemotherapy

406
Q

Teratoma Microscopically

A

Endodermal derivatives - Gut epithelium; bronchial epithelium
Mesodermal derivatives - Muscle tissue; bone and cartilage
Ectodermal derivatives - Skin and brain tissue

407
Q

Prostate Glands lined by two layers

A

Basal layer of low cuboidal epithelium

A layer of columnar secretory cells

408
Q

Prostate carcinoma Rx Stage 1 and 2

A

Radical prostatectomy – Retropubic – Perineal – Laparoscopic

Radiotherapy

409
Q

Prostate carcinoma Rx T3

A

Radiotherapy
Surgery
Brachytherapy

410
Q

Prostate carcinoma Rx Stage 4

A

Medical- GnRh analogues, Anti androgens, Estrogens

Surgical • Bilateral orchidectomy\seminectomy

411
Q

Prostate carcinoma Complications

A 
Hot flushes
Weight gain
Depression
Gynecomastia
Osteoporosis
Cognitive abilities
412
Q

Prostate carcinoma Palliative care

A

Pain – morphine
Localised bone pain – Radiation(70%)
Bisphosphonates

413
Q

Chemoprevention of Prostate carcinoma

A

Dietary- Soy products, Tomato products, omega fatty acids

Medical/supplements – Vit E, Selenium, Zinc

414
Q

Benign prostatic hyperplasia Absolute indications for Surgery

A 
Repetitive episodes of acute urinary retention
Chronic urinary retention
Recurrent UTI
Macroscopic heamaturia
Upper tract dilatation
Bladder stones
Failed medical therapy
415
Q

Benign prostatic hyperplasia Watchful waiting

A

Restrict fluid nocturnally
Double voiding
Urethral milking
Caution with alpha adrenergic meds

416
Q

Etiology of Fournier gangrene

A

Infection of Anorectal or Urogenital area

Dermatological- Hidradenitis suppurativa, Pressure sore ulcers, Trauma, Ass poor hygiene

417
Q

organisms causing fournier gangrene

A

E.coli, Bacteroides

Others- Proteus, Staphylococcus, Enterococcus, Klebsiella, Clostridium

418
Q

Fournier gangrene clinical presentation

A 
Pain and tenderness in the genitals
Fever and lethargy
Increasing erythema of the skin
Purulent discharge
Urinary &amp;/or GIT symptoms
419
Q

Fournier gangrene Rx

A

Rehydration
Antibiotics
Surgical debridement- Skin graft

420
Q

nervous system and micturition

A

Higher centres/ cortical micturition centre: suppression of involuntary bladder contractions
Pontine micturition centre: co-ordination of urethral sphincter & detrusor
Parasympathetic supply: pelvic nerve for micturition
Sympathetic supply: sympathetic trunk & hypogastric nerve, to not void
Somatic supply: pudendal nerve (noxious stimulus e.g.. pain), as well as pelvic floor

421
Q

Lesions at various levels & Example of disease process

A

At or above brain stem- CVA, dementia, brain tumour
At spinal cord- acute transverse myelitis, pernicious anaemia, poliomyelitis
Distal to spinal cord- Disc disease/ laminectomy, spinal stenosis, Guillam Barre Syndrome
Miscellaneous conditions- AIDS, Schistosomal myelopathy, syringomyelia

422
Q

Management of neurogenic bladder

Lower storage pressure

A

Detrusor overactivity: anticholinergics (systemic, intravesical), Botox injection
Poor compliance: anticholinergics, bladder augmentation
Detrusor sphincter dyssynergia: sphincterotomy (chemical, surgical), catheter
Bladder outlet obstruction: urethral stricture repair, bladder neck incision, Transurethral resection of the prostate

423
Q

neurogenic bladder medical mx

A

Beta 3 adrenergic agonist
anticholinergics
Botox: “intravesical” injection

424
Q

neurogenic bladder surgical mx

A

Continent storage
Increase bladder outlet pressure - Urethral bulking agents, Midurethral sling (tape)
Artificial urinary sphincter
Continent urinary diversion (Mitrofanoff)

If can’t achieve continence
Discreet, hygienic external collection devices
Incontinent urinary diversion (ileal conduit

425
Q

Priapism Classification

A 
Ischaemic priapism (veno-occlusive, low flow)
Non-ischaemic priapism (arterial, high flow)
Recurrent priapism (stuttering) - a variant of ischaemic priapism
426
Q

ischaemic priapism facts

A

Most common priapism
Idiopathic in majority of cases
Sickle cell anaemia most common cause in childhood
Common after ICI of papaverine based combinations

Rare after ICI with prostaglandin E1 monotherapy
Rare in men who have taken PDE5Is
Compartment syndrome of the corpora cavernosa

427
Q

Aetiology: Ischaemic priapism

A

Idiopathic
Prescribed drugs- ICI (papaverine, phentolamine), Antihypertensives
Recreational/Illicit drugs- Alcohol, cocaine
Hematologic disease- Sickle cell disease, Thalassemia
Infectious disease- Malaria, Rabies
Toxins- Scorpion sting, Spider bite
Metabolic disorders- Amyloidosis, Fabry’s disease
Neurological conditions- Syphilis, Cauda equina syndrome
Malignancy- Prostate, urethra

428
Q

ischaemic priaprism Clinical findings

A

Usually -Corpora rigid and tender but glans soft
Penile pain
AbN penile blood gas (Dark blood – hypoxia, hypercapnia, acidosis )

Sometimes- Hematologic abnormalities, Recent intra-cavernous injection
Seldom- Perineal trauma

Non ischaemic priaprism has the opposite Clinical findings except for Recent intra-cavernous injection which is the same

429
Q

ischaemic priaprism Rx

A

Aspiration
Phenylephrine
Puncture techniques
Shunt procedures

430
Q

Phenylephrine

A 
Cardiovascular monitoring (BP and ECG)
Dilute in normal Saline to 100-500 μg/ml)
Inject 200 μg every 3-5 minutes (x5)
Total maximum dose 1 mg within 1 hour
10 mg (1 ml) in 1 L of Saline
431
Q

Complications of Priapism

A

ED, corporal fibrosis, cavernositis

432
Q

Non-ischaemic def

A

A persistent erection caused by unregulated cavernous arterial inflow
An erection that is not fully rigid

433
Q

ischaemic priapism def

A

A persistent erection of the penis marked by rigidity of the corpora cavernosa and by little or no cavernous arterial inflow

434
Q

Aetiology: Non ischaemic priapism

A 
penile or perineal trauma
Non penetrating (blunt) or Penetrating
435
Q

NON ischaemic priaprism Clinical findings

A

Penile blood gas analysis- Bright red blood

Colour Penile Doppler Ultrasound- Turbulent flow at fistula

436
Q

NON ischaemic priaprism Rx

A

Diagnostic corporeal aspiration
Observation and systemic support- Spontaneous resolution (62%)
Selective embolization

437
Q

Stuttering Priapism

A

Sickle cell disease the most common course
Idiopathic and neurological causes have been reported
Men who had an acute ischaemic priapism are at risk to develop a stuttering priapism

438
Q

Stuttering Priapism Rx (same as Rx for ischaemic priaprism)

A

Aspiration
Phenylephrine
Puncture techniques
Shunt procedures

439
Q

Prevention of future episodes of Stuttering Priapism

A 
Alpha-adrenergic agonists(oral) 
Hormonal manipulation of circulating testosterone
Digoxin
Terbutaline
Gabapentin
440
Q

eg of shunts

A

distal- winter and ebbehoj

proximal- quackels or grayhack

441
Q

Pyronies disease

A

Superficial fibrosing disorder of penis which causes Plaque formation & Penile deformity
Risk factors- Heredity, Connective tissue disease, Age (median age is 55-57)

442
Q

Pyronies disease

Clinical manifestation

A 
Penile  Pain (Sometimes painless)
Curvature of penis 
Palpable plaque 
Erectile dysfunction
Stress ass with sexual function
443
Q

Pyronies disease phases

A

Acute phase
Progressive penile deformity
Pain with erection or flaccid state
Duration varies between 6-18 months

Chronic phase
Stability of deformity for 3-6 months
Reduced pain

444
Q

Pyronies disease Rx

A

Non pharmacological
Penile traction therapy
extracorporeal shock wave therapy

Medical treatment
Oral- Procarbazine, Vitamin E
Transdermal- Verapamil, Dexamethasone
Intra-lesional- Interferon, Collagenase clausdridium hystoliticum

Surgical treatment
inflatable penile prosthesis
Tunical plication

445
Q

catheter Uses

A

Diagnostic- VCUG
Therapeutic- Urinary retention
Treatment- Intravesical chemotherapy

446
Q

catheter Types

A

Kidney- Nephrostomy tubes, JJ stents (double

Bladder- Transurethral, Suprapubic catheter

447
Q

2 way urethral catheter Indication

A

Urine (diagnostic), Urinary retention, Pyuria

448
Q

3 way urethral catheter Indication

A

Irrigate bladder

Gross haematuri, Bladder tumour, Post TURP or TURBT (Transurethral Resection of a Bladder tumur)

449
Q

Malecot catheter

A

Used as a Nephrostomy tube or Suprapubic catheter

450
Q

Suprapubic catheter

A

Bladder outlet obstruction- BPH, Urethral stricture, Bladder stenosis
Neurogenic bladder, Long term catheter

451
Q

Nelaton

A

Intermittent catheterization
Neurogenic bladder
Decompensated bladder- Posterior urethral valves, BPH

452
Q

Condom catheter

A

Used in males with incontince, Less risk for infection

453
Q

jj stents

A

Bypass obstruction - Supra vesical obstruction

Ureteric dilatations

454
Q

Urinary retention Causes

A 
Bladder outlet obstruction: BPH 
Any neuropathic bladder 
Pain 
Gynaecological &amp; Surgical 
Medications inc. anaesthetic drugs
Hypothyroidism
455
Q

Chronic Urinary retention Mx

A

Conservative
Look out for obstructive uropathy & Post obstructive diuresis
Observe in the Casualty: Urine output stat and then over the next 2 hours

456
Q

Pelvic-Ureteric Junction Obstruction types

A

intrinsic- narrowing with interruption in development of circular musculature of UPJ or an alteration in collagen fibers in and around the muscular cells
extrinsic- more often symptomatic

457
Q

Pelvic-Ureteric Junction Obstruction aetiology

A

congenital (extrinsic)-
crossing renal vessesl
external bands or adhesions
persistent fetal ureter convolutions

acquired - stone disease
post-op iatrogenic scarring/ischemia
inflammatory stricture

idiopathic
lower pole UPJO - occurs in kidneys with an associated incomplete renal duplication
hydronephrosis of Lower Pole - due to short/long bifurcated ureteral segment

458
Q

Pelvic-Ureteric Junction Obstruction aetiology

congential intrinsic

A

aperistaltic segment of ureter - N spiral smooth muscle replaced by abN longitudinal muscle bundles or fibrous tissue
true congenital stricture - excess collagen deposition

congenital kinks or valvular mucosal folds - mucosa & smooth muscle
Ostling’s folds (valvular mucosal folds) are due to differential growth rates of ureter and body of child (not obstructive … disappear w/ linear growth)

459
Q

anomalies associated with UPJO

A

associated GU anomalies found in ~50% of infants - contralateral UPJO (10-40%) } most common contralateral anomaly thus contralateral renal dysplasia (ie B/L UPJO)
contralateral MCDK (Multicystic-dysplastic kidney)
duplicated collecting system
horseshoe kidney
VUR found in 20-40% } usually low grade

460
Q

UPJO clinical presentation

A

infants - usually asymptomatic
can present w/ FTT, feeding difficulties, sepsis from infection

adolescents - usually symptomatic
UTI
episodic flank or upper abdo pain +/- N/V often exacerbated by diuresis (Dietl’s crisis)
hematuria (25%) from rupture of mucosal vessels in dilated collecting system

461
Q

indications for intervention in UPJO

A 
Bilateral disease
Renal function impairment
UTIs
Solitary kidney 
Stones
HT
462
Q

minimally invasive approaches to UPJO repair

A

endoscopic - antegrade vs retrograde
Acucise endopyelotomy vs balloon dilation
endopyelotomy - cold knife, electrocautery, laser
~80% success rate

laparoscopic - transperitoneal vs retroperitoneal (retroperitoneal approach slightly more difficult due to confined space for suturing)
success rate >95%

robot-assisted - transperitoneal vs retroperitoneal

463
Q

Vesico-Ureteric Reflux aetiology

A

primary - fundamental deficiency in UVJ anti-reflux mechanism with N bladder & ureter
lack of 5:1 ratio of ureteral length:width

secondary - normal UVJ function that is overwhelmed - usually due to bladder dysfunction

464
Q

Mx of Vesico-Ureteric Reflux

A

watchful waiting- sterile urine + good bladder emptying is essential (eg prophylactic ABx behavioural Rx probiotics

endoscopic surgery - many different injectables } eg DEFLUX suburetrerally

open repair - classified according to approach to ureter (intravesical, extravesical, combined) also classified based on position of submucosal tunnel in relation to original hiatus suprahiatal, infrahiatal

465
Q

surgical techniques for VUR

A 
pre-op cystoscopy 
Pfannenstiel incision (abdominal surgical incision that allows access to the abdomen) made 2cm above symphysis pubis

intravesical - Politano-Leadbetter (suprahiatal tunnel)
Glenn-Anderson (infrahiatal tunnel)
Cohen Cross-trigonal - most commonly used intra-vesical reimplantation

extravesical - Lich-Gregoire (contraindicated if presence of Hutch diverticulum & not recommended for bilateral VUR)

combined - Paquin technique - extravesical approach to ureter + Politano-Leadbetter intravesical

466
Q

Cryptochidism risk factors

A

patient- low birth weight/Small-for-gestational age/pre-term, twin neonate, Family Hx +ve

maternal- Pre-eclampsia, Breech presentation, C/S delivery

467
Q

Cryptochidism classification

A

non-palpable (20%) - intra-abdominal - usually just inside the internal ring
peeping

Palpable (80%) - intra-canalicular
extra-canalicular - suprapubic or infrapubic
ectopic - majority make it out external ring

468
Q

consequences of Undescended testis

A 
infertility
testicular malignancy
hernia
torsion
trauma
hypergonadotropic hypogonadism
469
Q

Mx of Undescended testis

A

hormonal therapy

open or laparascopic surgery- Non-palpable (imaging alone is inaccurate

470
Q

Methods to gain extra length of spermatic cord during orchidopexy (surgery to move an undescended (cryptorchid) testicle into the scrotum and permanently fix it there)

A

complete mobilization of cremasterics off spermatic cord
high ligation of hernia sac
Prentiss maneuver
Jones incision (retroperitoneal dissection)
Fowler-Stephens procedure

471
Q

hypospadia characteristics

A

abN ventral opening of urethral meatus
abN ventral chordee (penis usually curves downward)
abN distribution of foreskin with a dorsal “hood” and deficient ventral foreskin

472
Q

hypospadia facts

A

A variant of hypospadias is the megameatus intact prepuce form (MIP), in which the foreskin is completely formed
boys w/ hypospadias +/or UDT +/or NON-ambiguous genitalia +/or cryptorochidism are more likely to have chromosomal abN and or intersex

473
Q

basic principles important in hypospadias repair

A 
correction of penile curvature (orthoplasty)
urethroplasty
meatoplasty
glanuloplasty
adequate skin coverage
474
Q

hypospadias repair notes

A

Orthoplasty- assess penile curvature
dermal graft (harvested from non-hirsute donor site) - ideal for short phallus with severe ventral chordee
porcine SIS (small intestinal submucosa) interposition graft - for severe ventral chordee
single-layer SIS better than multi-layer

475
Q

management options for hypospadias

A

Distal - Advancements techniques eg MAGPI
Tubularization techniques eg Tubularized incised plate (TIP), Thiersch-Duplay
Flaps eg Mathieu

Middle - Tubularization techniques eg TIP
Flaps eg Mathieu, Onlay flaps (onlay island flap (OIF), split-prepuce OIF)

Proximal- Single stage urethroplasty

Flaps eg OIF, onlay-tube-onlay
Tubularization techniques eg Duckett TPIF (transverse preputial island flap), Koyangi
2-Stage urethroplasty

476
Q

general principles of re-do hypospadias repair

A

minimum wait time is 6 months after previous failed repair
no attempts at repair until all edema, infection, and/or inflammation has resolved
Retrograde urethrography (RUG) +/or voiding cystourethrography (VCUG) may be needed in complex re-do hypospadias repairs
assess adequacy of local tissue vs the need for extragenital tissue graft

477
Q

Infections of the lower genital tract

Herpes simplex

A

Vulva, vagina,cervix
STD
usually HSV-2
Papules →vesicles → ulcers → heal 1-3 weeks

478
Q

Infections of the lower genital tract

Candida

A

Associated with DM, OC,pregnancy

Leukorrhea and pruritis

479
Q

Infections of the lower genital tract

Trichomonas vaginalis

A

STD
Flagellated protozoan
Purulent discharge and discomfort
Strawberrycervix

480
Q

Infections of the lower genitaltract

Mycoplasma

A

Vaginitis / cervicitis

Spontaneousabortions

481
Q

enteric bacteria eg

A

Staphylococcus, Salmonella, Klebsiella, Enterobacter, Proteus

482
Q

Acute Kidney Injury definition

A

reversible increase in serum creatinine and nitrogenous waste products and the inability of the kidney to regulate fluid and electrolyte homeostasis

483
Q

Acute Kidney Injury facts

A

accumulation of metabolic waste products with incr S-urea and creatinine,
development of hyperkalaemia, metabolic acidosis, hyperphosphatemia and hypocalcaemia
decr in urine output in most cases
development of oedema

484
Q

formula for creatinine clearinace

A

(eCCL)=40 x height (cm) /s-creatinine (μmol/L)

Normal creatinine clearance is 88–128 mL/min for healthy women and 97–137 mL/min for healthy men

485
Q

risk factors for Acute Kidney Injury

A

Age (> risk in neonates and young children)
Hypovolaemia, sepsis, surgery
Pre-existing kidney, liver or heart disease
Exposure to nephrotoxins (eg cyclosporine, aminoglycoside, cisplatin)

486
Q

AKI is seen in 3 scenarios

A

Pre renal
Intra-renal or intrinsic renal disease
Post renal or obstructive uropathies

487
Q

Pre renal AKI include

A

True loss of intravascular fluid as with vomiting and diarrhoea or
No external fluid loss, but the fluid is lost in the 3rd space and the circulating blood volume is ineffective e.g. in heart failure

488
Q

Pre renal AKI causes

A

Hypovolaemia: due to blood loss
Circulatory failure: CCF
Hepato-renal syndrome: Liver disease associated with
splanchnic vasoconstriction
Drugs: diuretics
Third space losses including septic shock

489
Q

Intrinsic Renal Failure causes

A

Glomerular- Acute Glomerulonephritis
Arterial- hemolytic-uremic syndrome, embolic, arteritis
Venous- Renal venous thrombosis
Acute tubular necrosis
Drugs and toxins e.g. NSAIDS, vancomycin, haemoglobin

490
Q

Post renal AKI causes

A

Morphological obstruction
Obstruction of the urinary tract e.g. bladder outlet obstruction
Obstruction of urine drainage in a solitary kidney
Supra-vesical obstruction e.g. pelvo-ureteric obstruction

Functional obstruction
Neuropathic bladder

491
Q

Acute Kidney Injury Clinical manifestations

A

Anaemia, jaundice
Oedema
Hypertension
- With warm peripheries –sepsis/volume overload
- With cold peripheries – intravascular depletion
Flank masses/enlarged kidneys

492
Q

Oliguria definintions

A

urine output <1 ml/kg/hour in neonates
< 0.5 ml/kg/hour in older children

Anuria – less than above despite adequate rehydration

493
Q

Acute Kidney Injury Mx

A

Manage life threatening conditions according to ABC principles
Dehydrated patients require resuscitation with IV 0.9% NaCl and frequent re assessment
The patient must be weighed 12 hourly
If the patient is anuric 5% Dextrose water (electrolyte free solution) is used
IV furosemide may be used in volume replete patient to assess urine output
when Treat hypertension avoid ACE inhibitors during acute phase

494
Q

management of hyperkalaemia

A

Stop all K+ containing IV fluids
Avoid drugs that cause hyperkalaemia e.g. ACE-I, ARBs, NSAIDS
Follow guidelines to shift K+ intracellularly temporary to stablise cardiac muscle and attempt K elimination with Sodium polystyrene sulfonate (Kexelate)
Dialysis is the only alternative if these measures fail

495
Q

Absolute indications for dialysis

A 
Anuria > 24 hours
Fluid overload  - pulmonary oedema
Central nervous system signs e.g. convulsions or coma
Bleeding diathesis 
Uraemic pericarditis
496
Q

Relative indications for dialysis

A

incr Serum-K / decr Na not responding to conservative treatment
Persistent metabolic acidosis- pH < 7.1 or S-HCO3 < 10 mmol / L
Uncontrollable HT
Severe incr S-phosphate / and incr S-calcium

497
Q

Haematuria in Children

Red urine

A

In children haematuria is usually a medical and not a urologic/surgical problem

Red urine without red blood cells ie heme-positive urine will give a False positive test

498
Q

Causes of heme positive urine

A

Haemoglobinuria
Myoglobinuria
Food dyes, beetroot, berry juices
Drugs e.g. Rifampicin

499
Q

Haematuria sx origin

A 
Symptomatic haematuria with dysuria, loin pain or renal colic usually originates from nonnephrological conditions
Asymptomatic haematuria (with or without proteinuria) –usually originates in the kidney
500
Q

Haematuria from the glomeruli and tubules characteristics

A 
Brown, cola or black tea coloured
Often associated with proteinuria
Microscopy: red cell casts and dysmorphic RBC
May be accompanied by leucocytes
Epithelial cell casts
501
Q

Dysmorphic RBC’s

A

Originate in glomerulus
Crenated (notched edges)
Size vary

502
Q

Haematuria from the lower urinary tract

A 
Gross haematuria, blood clots
Bright red or pink
Terminal haematuria (passage of clear urine with blood or blood-stained urine right at the end of the urine stream)
Microscopy: normal red cell morphology
Minimal proteinuria
503
Q

Non glomerular (non-dysmorphic) rbc’s

A

Round / biconcave smooth-walled
Similar size
Originate extra-glomerular
UTI / hypercalciuria / stones

504
Q

History clues of haematuria

A

Terminal haematuria - ?Schistosomiasis
Recurrent haematuria- Symptomatic /colicky pain: stones
Family history of renal disease or deafness – ?Alport syndrome / thin basement membrane disease
Skin rash (impetigo, purpuric)
Joint pains
Anaemia, oedema
Vasculitis: SLE or HSP (Henoch Schoenlein purpura )

505
Q

Acute Post-Streptococcal GN s/s and sx

A 
Acute onset of macroscopic haematuria
Oliguria
Oedema
Hypertension
Puffy eyes
506
Q

relative energy deficient syndrome components

A

Eating disorder
Amenorrhea
Osteoporosis/ Osteopenia
Nutritional deficiency + low eostrogen = osteopenia

507
Q

relative energy deficient syndrome sx and s/s

A 
S/s- Depression
Orthostatic hypotension
Bradycardia
Yellow skin discoloration
Vaginal atrophy/dyspareunia 
Sx- Fatigue
Hair loss
Cold hands and feet
Dry skin
Weight loss
508
Q

relative energy deficient syndrome severe cases sx and s/s

A 
Constipation and Abdominal Pain
Hypothermia
lanugo type hair back and buttocks
Petechiae-hypoplastic bone marrow
Cardiac murmers
509
Q

relative energy deficient syndrome Mx

A

Mainly based of corrected energy deficiency by decreasing energy expenditure (train less by 10-12%) and increasing intake (eat more)
Drugs: calcium and vitamin D, anaemia treatment

510
Q

Oral contraceptiv use in atheletes

A

Pregnancy prevention
cycle manipulation
acne
dysmenorrhea or menorragia

511
Q

Detection of CKD

A

Main manifestation : development of proteinuria and hypertension
S-creatinine poor marker of renal function
S-creatinine correlates with muscle bulk, age, gender → falsely low in children with malnutrition

512
Q

CKD definition

A

evidence of structural or functional kidney abnormalities that persist for at least 3 months, with implications for health, with or without a decreased GFR <60 ml/min/1.73 m2

513
Q

Markers of kidney damage

A 
Proteinuria 
Urine sediment abnormalities
Electrolyte and other abnormalities due to tubular disorders 
Abnormality detected by histology
Structural abnormality
History of kidney transplant
Decreased GFR <60 ml/min
514
Q

Non specific ss and sx of CKD

A

Poor growth from infancy throughout childhood
Gastrointestinal complaints – vomiting / constipation
Swelling / pruritis - treated for allergy
Pale - investigated for anaemia
Shortness of breath “pneumonia”
Bone pain and deformities
Cardiomegaly
convulsion / coma

515
Q

Aspects of Treatment of CKD in Children

A

Diet and nutritional aspects- Restrict: meat, dairy, egg, beans, grains and rising agents & have Phosphate binders (calcium carbonate
Anaemia- Supplement iron and folic acid as indicated, For persistent anaemia add erythropoietin stimulating agent
Hypertension- ACE-I or ARBs

Proteinuria
CKD Bone and mineral disorder- phosphate binders, Active Vitamin D
Metabolic acidosis- oral NaHCO3 solution
Dislipidaemia- Restrict saturated fats in diet
Cardiovascular disease- in CKD stage IV or V cardiac arrest is the main cause of death

516
Q

embryology of kidney

A

Ureteric bud: Abnormal development affects the –Renal collection system, Calyces, Pelvis & ureter
Metanephros: Abnormal development affects the renal parenchyma – nephrons

517
Q

Unilateral Renal Hypoplasia

A

Patients usually remain asymptomatic

occasional HT and proteinuria

518
Q

Bilateral Renal Hypoplasia

A

Degree of renal functional impairment varies
Clinical problems: polyuria, polydypsia, dehydration
Tubulopathy: “salt-losing nephropathy” → poor growth

519
Q

Bilateral Renal Agenesis

A

Occurs in 1/4000 pregnancies
Mother has oligohydramnios
Baby has Potter Sequence
Baby dies shortly after birth due to respiratory distress / hypoplastic lungs

520
Q

Cystic Renal Diseases

A

I: Early abnormal embriological development e.g. Multicystic Dysplastic Kidney

II: Early steps in embriolgical development is normal but terminal differentiation of tubules is abnormal eg
Polycystic Kidneys, Autosomal recessive, Autosomal dominant, Medullary cystic kidneys

521
Q

Multicystic Kidney

A

Unilateral non-functional kidney
Morphology: Large irregular mass – undifferentiated
dysplastic elements and cysts of different sizes
30-50% associated with an abnormality in the
contralateral kidney
Isolated MCDK is usually is asymptomatic

522
Q

Posterior Urethral Valves (PUV) facts

A

95 % cases are boys

Associated with oligohydramnios- If oligohydramnios develops before 16th week of gestation →very poor prognosis

523
Q

Posterior Urethral Valves (PUV) clinical presentation

A 
Potter sequence
Respiratory distress at birth
Bilateral palpable kidneys
Bladder palpable above pubis
Dribbling of urine or total bladder outlet obstruction
Occasionally urinary ascites in neonates
524
Q

Prune Belly Syndrome triad

A

Non obstructive megacystis, megaureter and hydronephrosis
Absence of abdominal wall muscles
Undescended testes

525
Q

Genito urinary fistulas aetiology

A

Congenital: very rare
traumatic fistula- Obstetric trauma (Necrotic /Traumatic)
-Surgical trauma
-Direct trauma
Inflammatory disease- eg bilharzia or TB
Malignant neoplasms
Radium necrosis -Sloughing of the bladde

526
Q

Necrotic Obstetric Fistula

A

Prolonged compression of soft tissues between head & brim of a narrow pelvis. → ischaemia, pressure necrosis & sloughing of base of the bladder.
Urethra is also often involved
Incontinence develops 5-7 days after labour
Such fistulae are often surrounded by dense fibrosis

527
Q

Traumatic Obstetric Fistula

A

Direct injury to bladder wall by sharp instrument during a difficult labour
Incontinence appears immediately after labour

528
Q

Genito urinary fistulas sx

A

Incontinence of urine
Symptoms of vulvitis- Pruritus, burning pain
Cystitis

529
Q

Preoperative Preparation of Genito urinary fistulas

A

Treat vulvitis: Cover skin of the vulva, and inner thighs by a thick layer of Vaseline, zinc oxide ointment or any bland ointment, to prevent maceration of the skin by the continuous discharge of urine
Renal function tests
Culture of urine

530
Q

Genito urinary fistulas Mx with regards to injury

A

If injury to the bladder is discovered during a difficult labour-Don’t suture the tear due to tissue oedema and friability, fix rubber catheter for 10 days

If the injury is detected some time after labour, as in cases of necrotic fistulas, operations done except at least 3 months after delivery to allow for maximum involution of the tissues.

531
Q

Sim’s operation Indications

A

If tissues are too adherent and fibrosed to do flap splitting
After failure of the flap splitting.

532
Q

Postoperative Care

A

Recumbent position
The bladder should be constantly empty
Fluids (3 litres/day)
Urinary antiseptics & antibiotics
Vaginal pack is removed 24 hours after operation
Catheter is removed after 10 days
After its removal the patient is instructed to void urine
every two hours by day & every four hours by night
to avoid over-distension of bladder & disruption of suture line.

533
Q

Subsequent Management of genitourinary fistula

A

Patient is instructed to avoid sexual intercourse for 3 months & avoid pregnancy for 1 year

534
Q

uretero vaginal fistula facts

A

cause- Injury to ureter during a gynaecological operation as hysterectomy, may develop following a difficult labour
leads to incomplete incontinence
It is always small & high up in vagina lateral to cervix

535
Q

uretero vaginal fistula Rx

A

Abdominal re-implantation of ureter into bladder
If not possible, ureter is transplanted into sigmoid colon
If kidney function is very poor on the affected side → kidney can be sacrificed.

536
Q

sx experienced in gyaneCA pts undergoing palliative care

A

pain
anorexia
fatigue
insomnia

537
Q

sx experinced in gyaneCA pts caregivers

A 
Considerable stress
Depression
Depression induced fatigue 
Insomnia
Difficulty in concentration/decision making
538
Q

Tests and procedures to avoid in terminal disease gynaeCA

A

pap smears
imaging
Bricker’s palliative surgery to be performed only if life expectancy more than 6 months.

539
Q

vaginal bleeding of cervical CA Rx

A

Tight aseptic vaginal packing + catheter insertion+ broad spectrum antibiotics
Hemostatic RT
Embolization of uterine arteries
Tranexemic acid

540
Q

narcotics side effects

A

constipation, pruritus, nausea, drowsiness, skin rash

541
Q

pain mx of gynae CA

A

Narcotics
Diffuse bone pain – bifosfonates and narcotic
NSAIDS and antidepressants provide a synergistic effect when proscribed with opioids
Anticonvulsant agent use can help in pain of neuropathic origin

542
Q

gynae CA pulm complications

A

dypsnoea

Lymphangitis ca – is ca spread into lymphactics of the lung.- Rx: O2/Morphine/Cortison

543
Q

in advanced or recurrent cx ca

sx and Rx

A

sx- N+V, confusion, somnolence, seizures, uremic halitosis

Rx with Nehprostomies or ureteral stents

544
Q

palliative pelvic excenteration

A

Highest morbidity and mortality in GynOnc
Consists in removal of all pelvic organs with creation of urinary conduit, colostomy for stool and reconstruction of pelvic floor
Complications: Heamorrhage, Wound sepsis, Fistulas, leakage

545
Q

paraneoplastic hypercalcaemic syndrome

A

Rx: Hydration, Lasix, steroids, calcium binding agents, bifosfornates.
Terminal hypercalcaemia – phenothiazines and butyrophenones / haloperidol, antihistamines, steroids, 5HT-3 antagosnists

546
Q

Rx of nausea

A

Start with dopamine receptor antagonist (haloperidol, metoclopropamide → can be titrated to maximum benefit)
If nausea still persists – an anticolinergic (scopolamine), followed by addition of antihistamine or cannabioid
Benzodiazepine is added for anxiety component of nausea

547
Q

palliative bowel obstruction

A

Localized obstruction of recto-sigmoid → loop colostomy
Multiple sites of obstruction → no surgery
tumour implant on bowel surface and mesentery → adhesions and peristalsis impediment - Rx: → palliation with NG tube/percutaneous gastrostomy
Intraluminal stenting under endoscopy

548
Q

ascites in palliative care of gynaeCA

A

Impairs reabsorption of peritoneal fluid
Can become very troublesome in refractory disease with pts c/o of pain, SOB, early satiety, vomiting and fatigue
Best relief → repeated paracentesis

549
Q

anorexia in palliative care of gynaeCA

A

Anorexia without bowel obstruction → anabolic steroids or megesterol acetate can be used
Parenteral nutrition can be of value but for limited periods (post-op) as it causes fluid overload, infection and diarrhoea
At terminal stages pts are neither hungry or thirsty; caregivers often interpret it that doctors let the pt starve

550
Q

constipaitons in palliative care of gynaeCA

A

predsol enemas
Addition of fibre, colonic stimulants, laxatives
Rx- Docusate sodium (Stool softeners), Senna (laxative)
Dose should be incr with a goal of soft bowel movement every 1-2 days
If constipation persists add Bisacodyle, Lactulose, Sorbitol, MG hydroxide or Metroclorpropamide

551
Q

bone metastasis of endometrial CA

A

Diffuse bone pain without evidence of fractures
Rx: Biphosfornates or RANKL inhibitors (Denosumab) - These agents reduce incident of fractures, spinal cord compression and need for bone surgery and RT
Corticosteroid or systemic administration of radio isotopes (strontium)
Local RT nerve block or RT ablation all provide relief.

552
Q

hypercalcaemia due to endometrial CA

A

Symptoms: Malaise, fatigue, confusion, pain, heart dysrithmias → heart arrest
Untreated hyper Ca → coma and death

Rx: Rehydration ↑ Ca excretion, inhibition of osteoclastic Ca release
Loop diuretics

Palliative terminal setting – Biphosphonates, gallium nitrate to inhibit osteoclasts

553
Q

liver mets due to endometrial CA

A

Usually asymptomatic but becomes symptomatic only late

Rx: analgesia , regional nerve block, liver mets ablation with Adriamycin is occasionally used

554
Q

brain mets due to endometrial CA

A

Cause cognitive and behaviour abnormalities
Rx: systemic steroids and RT
Neurological resection followed by post operative RT can be selectively performed in cases with solitary brain mets

555
Q

vulvar and vaginal CA

A

Because of more superficial site of origin, disease causes external septic ulcers and spread to perineum and inguinofemoral lymphnode chains
Rx: activated charcoal dressings/Drawtex/zinc oxide
Rectal fistulas and anal sphincter involvement rx with diverting colostomy
skin ulceration rx at least twice with radiotherapy

556
Q

things to look out for when a fistula is suspected

A

pyelonephritis± uremia manifestations
Abdominal: scar, renal mass, tenderness
Ammonia smell

557
Q

prevention of fistul

A

obstetrics- adequate ANC, continuous bladder drainage for 5-7days
ureteric- ureteral catheter, direct visualization/paplation

558
Q

Various surgical approach to fistula

A

vagina- Flap splitting operation, Sauccerization, Latizko (partial colpoclesis), Repair and graft

abd- Transperitoneal ,trans/intravesical with graft

559
Q

fistula facts

A

most common fistula in developing countries vesicovaginal (obstetric) & in developed id uretericvaginal
Urethrovaginal fistula causes double stream urine
Vesicouterine fistula causes yousef syndrome (cyclical hematuria, amenorrhea and urinary incontinence)

560
Q

Rectovaginal Fistula sx

A

Large fistula: incontinence to flatus, liquid stool and hard faeces
Small fistula: incontinence to flatus and liquid stool
Foul smelling vaginal discharge
Vulvitis &vaginitis

561
Q

Rectovaginal Fistula mx

A 
pre and post operative preparation 
rectal enema
low residule fluid diet 5 days before surgery
intestinal antiseptics- neomycin
vaginal douche
562
Q

Rectovaginal Fistula surgical mx

A

RVF IN lower 1/3 of vagina- Lawson Tait‘s operation
RVF IN middle 1/3 of vagina- Flap splitting ,Start as rectocele repair and extend dissection above the fistula.
RVF IN upper 1/3 of vagina- Abdominal approach/Latzko operation

563
Q

Postoperative care of Rectovaginal Fistula

A

Early- Rest
Diet- Low residue diet, Excess fluids
local care- vaginal pack remove after 24h, Antiseptics wash of the vulva after every micturition
Drugs- Antibiotics, analgesics, laxatives, Intestinal antiseptics
Late : elective CS in subsequent delivery

564
Q

5 infective causative organisms of adult male urethritis

A 
neisseria
chlamydia
mycoplasma genitalum
trichomonas
ureaplasma
565
Q

male urethritis syndrome Rx

A

First-line treatment: Ceftriaxone 250mg IM stat AND Azithromycin 1g PO stat
If sexual partner has vaginal discharge, add l Metronidazole 2g stat PO as a single dose

Suspected ceftriaxone 250mg treatment failure: Ceftriaxone 1g IM stat AND Azithromycin 2g PO stat AND Metronidazole 2g stat PO as a single dose (if not already given)

566
Q

Main causes of vaginal discharge syndrome

A 
Bacterial vaginosis (BV)
Candidiasis
Neisseria gonorrhoeae
Chlamydia trachomatis
Trichomonas vaginalis
567
Q

vaginal discharge syndrome Rx

A

First-line treatment: < 35 years OR Partner has NO MUS- Metronidazole, oral ,2g as single dose AND Clotrimazole vaginal pessary 500mg stat or vaginal cream 12 hourly for 7 days

Partner has MUS
Ceftriaxone 250mg IM stat as a single dose AND
Azithromycin oral ,1g, as a single dose AND
Metronidazole oral 2g as a single dose

568
Q

epidemiology of genital ulcer disease

A 
syphilis
chancroid- Haemophilus ducreyi
herpes
LGV
granuloma inguinale- Klebsiella granulomatis
569
Q

genital ulcer syndrome Rx

A

If not sexually active in the last 3 months- Acyclovir 400mg 3 x daily for 7 days

If sexually active in the last 3 month- ADD Benzathine penicillin 2.4 million units IM stat as a single dose
Acyclovir oral 400mg tdsfor 7 days

If no improvement in 1 week- Azithromycin 1g oral as a single dose
Aspirate fluctuant buboes at each visit

570
Q

when an extended-spectrum cephalosporins resistant gonorrhea is encountered

A

All cefixime treatment failure should get high dose ceftriaxone 1g stat IM and ideally microbiology work-up
Refer all ceftriaxone treatment failures within 7 days for microbiology work-up and gentamicin 240mg stat IM

Definitions (11 decks)

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