Lecture 22: Pelvic clinical

Question 1

Presentation of uterus fibroid tumours

Answer 1

Irregular and painful messes

Unexplained abdominal mass

Palpate large mass in lower abdomen

No pain on deep palpation, bowel sounds normal

Exploratory laparotomy reveals enlarged uterus covered in large, fibroid tumours

Question 2

How would surgery be performed to address uterine fibroids?

Answer 2

Open abdominal surgery

Leave ovaries in for hormone production (Need to make sure that ovarian vessels stay attached)

Need to ligate ovarian ligament

Remove uterine tube (Ovarian cancer is derived from cells in fallopian tube that cause ovarian cancer)

Ligate uterine artery, avoid ureter

Remove broad ligament

See figure

Question 3

Presentation of extra-uterine pregnancy

Answer 3

Sudden onset of pain in lower left abdomen

Missed last menstrual bleeding

Reports vaginal bleeding has just started and believes this is the next expected menstrual bleeding, just more painful

Laproscopic finding shows enraptured extrauterine pregnancy in the ampulla

Question 4

Why does contrast matter injected into vagina show up in peritoneal cavity?

Answer 4

Travels through the fallopian tubes, through the fimbriae and into the peritoneal cavity

See figure

Question 5

Why is the uterus so triangular when contrast is injected into the vagina?

Answer 5

Only the interior lumen of the uterus is dyed, not the entire organ

Question 6

What would it mean if the fallopian tubes did not show up with contrast?

Answer 6

Possible blockage somewhere

Question 7

Position of the uterus during normal pregnancy

Answer 7

See figure

Question 8

What happens to respiratory function during pregnancy?

Answer 8

Lung volumes undergo changes: ERV decreases, FRC decreases and inspiratory capacity increases to maintain TLC.

FVC and FEV1 do not change

Question 9

Pain innvervation of vaginal and uterus

Answer 9

Pain sensation from the fundus and body of the uterus travels along sympathetic nerve fibres to the lower thoracic and upper lumbar (Th10-L1) spinal cord.

Pain sensation of the vagina and the cervix uteri travels along the parasympathetic pathway (S2-S4).

The inferior part (lowest 5th) of the vagina receives somatic innervation through the pudendal nerve.

Question 10

What type of anaesthesia takes advantage of the pelvic pain line?

Answer 10

Caudal epidural

Question 11

What types of anesthesia are available during child birth?

Answer 11

Caudal epidural block

Epidural block

Pudendal nerve block

Question 12

Where is anesthetic administered in caudal epidural block?

Answer 12

Anaesthetic administered by catheter in sacral canal

Easy readministration

Question 13

What nerves are blocked in caudal epidural block?

Answer 13

S2 – S4 nerve roots are blocked resulting in anaesthesia of the complete birth canal including pain afferences from cervix and upper vagina and perineal pain afferences travelling with pudendal nerve

Lower limbs usually not affected

Mother is aware of uterine contractions (pelvic pain line!)

Question 14

Where is anesthesia administered for an epidural block?

Answer 14

L3-L4 and L4-L5 interspaces

Question 15

Where is anesthesia administered for a pudendal nerve block?

Answer 15

near ischial spine as peripheral nerve block

Question 16

What are the effects of pudendal nerve block?

Answer 16

Anaesthesia effective for S2-S4 dermatomes (perineal skin) and lower third of vagina

Not effective for cervix and upper part of vagina

Mother is aware of uterine contractions

Readministration is problematic during prolonged birth phase

Question 17

When is pudendal nerve block useful?

Answer 17

Pudendal nerve block is useful to relax perineal muscles and reduce the perineal pain associated with the second stage of labour or with episiotomy or the repair thereof

Pudendal nerve anesthesia alone may not eliminate all perineal pain

Question 18

Clinical presentation of hydrocele

Answer 18

Testicular swelling

Non tender

Swelling transilluminates, with a shadow indicating position of actual testicle

Question 19

What causes hydrocele?

Answer 19

Fluid accumulation between visceral and parietal layer of tunica vaginalis testis

Question 20

Clinical presentation of enlarged prostate

Answer 20

Inability to urinate

IV pyelogram (intravenous urogram) reveals bilateral dilation of ureters

See figure

Question 21

How is a digital rectal examination of the prostate performed?

Answer 21

Palpation of prostate at 4 cm above the anus

BPH: Prostate will be enlarged and bulky (not usual chestnut size) and will have firm-elastic texture

See figure

Question 22

Which part of the prostate is affected in BPH?

Answer 22

Transition/central zone

Marks the poster-medial glandular tissue located between the two ejaculatory ducts

See figure

Question 23

Clinical presentation of kidney stones

Answer 23

Sudden onset of pain, originating from flank and radiating into groin and scrotum

Patient has vomited and reports nausea, sweating

Catheter urine shows microhematuria (irritation of mucosa of urinary system)

See figures

Question 24

Why does a patient with kidney stones feel pain in groin?

Answer 24

Kidney is close to lumbar plexus

Question 25

What are the indications for a suprapubic catheter?

Answer 25

long-term urinary catheter (e.g. neurological diseases, injury of the spinal cord)

Urinary incontinence (e.g. following a cerebrovascular insult, brain tumor)

Pre- and post-surgical catheter in case of surgery on the urethra

Urethral injury or obstruction (e.g. trauma, BPH-benign prostate hypertrophy,
locally invasive prostate cancer, bladder stones with obstruction of urethra)

Recurrent lower urinary tract (LUTS) infections with a transurethral catheter

Question 26

Insertion of suprapubic catheter

Answer 26

A filled bladder extends and rises up to 10 cm above the pubic symphysis pushing it‘s peritoneal lining cranially
further towards the umbilicus

The bladder then is adjacent to the abdominal wall and surgical access superior to the pubic symphysis is possible without opening the peritoneal cavity

Question 27

Clinical presentation of prostate cancer

Answer 27

No early symptoms, no pain (originates from peripheral lobe that does not surround urethra)

No enlargement of the prostate gland (invasive growth; early metastasis)

Metastasis to bone, causes fractures with minor impact due to disrupted stability of bone

Question 28

What would DRE reveal in prostate cancer

Answer 28

Might reveal a rock solid posterior surface of the prostate

Not secure examination, masses in this area are not always cancer

Question 29

Progression of prostate cancer

Answer 29

Locally invasive growth, lymphogenic metastasis pathway

Haematogen metastasizing growth

See figure

Question 30

How can PSA serum levels be used in prostate cancer?

Answer 30

Increased PSA serum levels are not specific for prostate cancer!

PSA may also be elevated in BPH and prostatitis !

PSA can be used in patients who are being treated for prostate cancer, to follow up on the success of treatment

Question 31

Therapeutic reduction of AR stimulation

Answer 31

Use 5 alpha reductase blocker

Androgen receptor antagonist

Castration

See figure