Lecture 22: Pelvic clinical Flashcards
Presentation of uterus fibroid tumours
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
How would surgery be performed to address uterine fibroids?
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
Presentation of extra-uterine pregnancy
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
Why does contrast matter injected into vagina show up in peritoneal cavity?
Travels through the fallopian tubes, through the fimbriae and into the peritoneal cavity
See figure
Why is the uterus so triangular when contrast is injected into the vagina?
Only the interior lumen of the uterus is dyed, not the entire organ
What would it mean if the fallopian tubes did not show up with contrast?
Possible blockage somewhere
Position of the uterus during normal pregnancy
See figure
What happens to respiratory function during pregnancy?
Lung volumes undergo changes: ERV decreases, FRC decreases and inspiratory capacity increases to maintain TLC.
FVC and FEV1 do not change
Pain innvervation of vaginal and uterus
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.
What type of anaesthesia takes advantage of the pelvic pain line?
Caudal epidural
What types of anesthesia are available during child birth?
Caudal epidural block
Epidural block
Pudendal nerve block
Where is anesthetic administered in caudal epidural block?
Anaesthetic administered by catheter in sacral canal
Easy readministration
What nerves are blocked in caudal epidural block?
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!)
Where is anesthesia administered for an epidural block?
L3-L4 and L4-L5 interspaces
Where is anesthesia administered for a pudendal nerve block?
near ischial spine as peripheral nerve block
What are the effects of pudendal nerve block?
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
When is pudendal nerve block useful?
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
Clinical presentation of hydrocele
Testicular swelling
Non tender
Swelling transilluminates, with a shadow indicating position of actual testicle
What causes hydrocele?
Fluid accumulation between visceral and parietal layer of tunica vaginalis testis
Clinical presentation of enlarged prostate
Inability to urinate
IV pyelogram (intravenous urogram) reveals bilateral dilation of ureters
See figure
How is a digital rectal examination of the prostate performed?
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
Which part of the prostate is affected in BPH?
Transition/central zone
Marks the poster-medial glandular tissue located between the two ejaculatory ducts
See figure
Clinical presentation of kidney stones
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
Why does a patient with kidney stones feel pain in groin?
Kidney is close to lumbar plexus
What are the indications for a suprapubic catheter?
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
Insertion of suprapubic catheter
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
Clinical presentation of prostate cancer
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
What would DRE reveal in prostate cancer
Might reveal a rock solid posterior surface of the prostate
Not secure examination, masses in this area are not always cancer
Progression of prostate cancer
Locally invasive growth, lymphogenic metastasis pathway
Haematogen metastasizing growth
See figure
How can PSA serum levels be used in prostate cancer?
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
Therapeutic reduction of AR stimulation
Use 5 alpha reductase blocker
Androgen receptor antagonist
Castration
See figure
