Surgery

Question 1

Peptic ulcer disease:
-Which is most common ulcers?
-Describe the pain felt in duodenal ulcer vs gastric ulcer
-What other features may be seen?

Answer 1

Duodenal ulcers: more common than gastric ulcers, epigastric pain relieved by eating
Gastric ulcers: epigastric pain worsened by eating
Features of upper gastrointestinal haemorrhage may be seen (haematemesis, melena etc)

Question 2

Appendicitis
-Describe the pain
-Give 3 other features
-What is the clinical sign suggestive of appendicitis?

Answer 2

Pain initial in the central abdomen before localising to the right iliac fossa
Anorexia is common
Tachycardia, low-grade pyrexia, tenderness in RIF
Rovsing’s sign: more pain in RIF than LIF when palpating LIF

Question 3

Is acute appendicitis common? Who does this most commonly affect? what is the pathogenesis?

Answer 3

Acute appendicitis is the most common acute abdominal condition requiring surgery. It can occur at any age but is most common in young people aged 10-20 years.

Pathogenesis
lymphoid hyperplasia or a faecolith → obstruction of appendiceal lumen → gut organisms invading the appendix wall → oedema, ischaemia +/- perforation

Question 4

Features of appendicitis:
-Describe the pain?
-Is there vomiting or diarrhoea?
-Is the pyrexia?
-Will the patient be hungry

Answer 4

Abdominal pain is seen in the vast majority of patients:
peri-umbilical abdominal pain (visceral stretching of appendix lumen and appendix is midgut structure) radiating to the right iliac fossa (RIF) due to localised parietal peritoneal inflammation.
the migration of the pain from the centre to the RIF has been shown to be one of the strongest indicators of appendicitis
patients often report the pain being worse on coughing or going over speed bumps. Children typically can’t hop on the right leg due to the pain.

Other features:
-vomit once or twice but marked and persistent vomiting is unusual
diarrhoea is rare. However, pelvic appendicitis may cause localised rectal irritation of some loose stools. A pelvic abscess may also cause diarrhoea
-mild pyrexia is common - temperature is usually 37.5-38oC. Higher temperatures are more typical of conditions like mesenteric adenitis
-anorexia is very common. It is very unusual for patients with appendicitis to be hungry
-around 50% of patients have the typical symptoms of anorexia, peri-umbilical pain and nausea followed by more localised right lower quadrant pain

Question 5

Give 4 examination findings of acute appendicitis? what are 2 classical signs

Answer 5

Examination

-generalised peritonitis if perforation has occurred or localised peritonism
-rebound and percussion tenderness, guarding and rigidity
-retrocaecal appendicitis may have relatively few signs
-digital rectal examination may reveal boggy sensation if pelvic abscess is present, or even right-sided tenderness with a pelvic appendix

classical signs
-Rovsing’s sign (palpation in the LIF causes pain in the RIF) is now thought to be of limited value
-psoas sign: pain on extending hip if retrocaecal appendix

Question 6

Diagnosis of appendicitis
-What is seen on bloods?
-What is seen on urinalysis?
-What imaging can be used?

Answer 6

Diagnosis

-typically raised inflammatory markers coupled with compatible history and examination findings should be enough to justify appendicectomy
-a neutrophil-predominant leucocytosis is seen in 80-90%
-urine analysis: useful to exclude pregnancy in women, renal colic and urinary tract infection. In patients with appendicitis, urinalysis may show mild leucocytosis but no nitrites
-there are no definite rules on the use of imaging and its use is often determined by the patient’s gender, age, body habitus and the likelihood of appendicitis
-thin, male patients with a high likelihood of appendicitis may be diagnosed clinically
-ultrasound is useful in females where pelvic organ pathology is suspected. Although it is not always possible to visualise the appendix on ultrasound, the presence of free fluid (always pathological in males) should raise suspicion
-CT scans are widely used in patients with suspected appendicitis in the US but this practice has not currently reached the UK, due to the concerns regarding excessive ionising radiation and resource limitations

Question 7

Describe the management of appendicitis

Answer 7

Management

-appendicectomy
can be performed via either an open or laparoscopic approach
-laparoscopic appendicectomy is now the treatment of choice
-administration of prophylactic intravenous antibiotics reduces wound infection rates
-patients with perforated appendicitis (typical around 15-20%) require copious abdominal lavage.
-patients without peritonitis who have an appendix mass should receive broad-spectrum antibiotics and consideration given to performing an interval appendicectomy
-be wary in the older patients who may have either an underlying caecal malignancy or perforated sigmoid diverticular disease.
-trials have looked at the use of intravenous antibiotics alone in the treatment of appendicitis. The evidence currently suggests that whilst this is successful in the majority of patients, it is associated with a longer hospital stay and up to 20% of patients go on to have an appendicectomy within 12 months.

Question 8

Acute pancreatitis
-what is this usually due to
-What 2 symptoms does this cause
-What may be seen on examination?

Answer 8

Usually due to alcohol or gallstones
Severe epigastric pain
Vomiting is common
Examination may reveal tenderness, ileus and low-grade fever
Periumbilical discolouration (Cullen’s sign) and flank discolouration (Grey-Turner’s sign) is described but rare

Question 9

Give 10 causes of pancreatitis?

Answer 9

Popular mnemonic is GET SMASHED

Gallstones
Ethanol
Trauma
Steroids
Mumps (other viruses include Coxsackie B)
Autoimmune (e.g. polyarteritis nodosa), Ascaris infection
Scorpion venom
Hypertriglyceridaemia, Hyperchylomicronaemia, Hypercalcaemia, Hypothermia
ERCP
Drugs (azathioprine, mesalazine*, didanosine, bendroflumethiazide, furosemide, pentamidine, steroids, sodium valproate)

Question 10

Give 3 clinical features of biliary colic?

Answer 10

-Pain in the RUQ radiating to the back and interscapular region, may be following a fatty meal. Slight misnomer as the pain may persist for hours
-Obstructive jaundice may cause pale stools and dark urine
-It is sometimes taught that patients are female, forties, fat and fair although this is obviously a generalisation

Question 11

Acute cholecystitis - give 4 clinical features?

Answer 11

History of gallstones symptoms (see above)
Continuous RUQ pain
Fever, raised inflammatory markers and white cells
Murphy’s sign positive (arrest of inspiration on palpation of the RUQ)

Question 12

What is ascending cholangitis?

Answer 12

Ascending cholangitis is a bacterial infection (typically E. coli) of the biliary tree. The most common predisposing factor is gallstones.

Question 13

What is charcots triad of ascending cholangitis? What is seen on bloods?

Answer 13

Charcot’s triad of right upper quadrant (RUQ) pain, fever and jaundice occurs in about 20-50% of patients

fever is the most common feature, seen in 90% of patients
RUQ pain 70%
jaundice 60%
hypotension and confusion are also common (the additional 2 factors in addition to the 3 above make Reynolds' pentad)

Other features

raised inflammatory markers

Question 14

What is the imaging modality used first line for ascending cholangitis?

Answer 14

Investigation

ultrasound is generally used first-line in suspected cases to look for bile duct dilation and bile duct stones

Question 15

What is the management of ascending cholangitis?

Answer 15

Management

intravenous antibiotics
endoscopic retrograde cholangiopancreatography (ERCP) after 24-48 hours to relieve any obstruction

Question 16

Diverticulitis:
-describe the nature and the site of pain
-What is seen on blood tests? Is there a pyrexia

Answer 16

Colicky pain typically in the LLQ
Fever, raised inflammatory markers and white

Question 17

Describe the pain felt in abdominal aortic aneurysm? what may the presentation of this look like? what may be in the past medical history?

Answer 17

Severe central abdominal pain radiating to the back
Presentation may be catastrophic (e.g. Sudden collapse) or sub-acute (persistent severe central abdominal pain with developing shock)
Patients may have a history of cardiovascular disease

Question 18

What is an AAA? what is the normal diameter of the infrarenal aorta in females vs males? what is considered aneurysmal? what is the pathophysiology of AAA?

Answer 18

Abdominal aortic aneurysms occur primarily as a result of the failure of elastic proteins within the extracellular matrix. Aneurysms typically represent dilation of all layers of the arterial wall. Most aneurysms are caused by degenerative disease. After the age of 50 years the normal diameter of the infrarenal aorta is 1.5cm in females and 1.7cm in males. Diameters of 3cm and greater, are considered aneurysmal. The pathophysiology involved in the development of aneurysms is complex and the primary event is loss of the intima with loss of elastic fibres from the media. This process is associated with, and potentiated by, increased proteolytic activity and lymphocytic infiltration.

Question 19

Give 5 causes of AAA

Answer 19

Major risk factors for the development of aneurysms include smoking and hypertension. Rare but important causes include syphilis and connective tissues diseases such as Ehlers Danlos type 1 and Marfan’s syndrome.

Question 20

Give the interpetation and action for each aorta width:
<3cm
3-4.4cm
4.5-5.4cm
=>5.5

Answer 20

Aorta width Interpretation Action
< 3 cm Normal No further action
3 - 4.4 cm Small aneurysm Rescan every 12 months
4.5 - 5.4 cm Medium aneurysm Rescan every 3 months
≥ 5.5cm Large aneurysm Refer within 2 weeks to vascular surgery for probable intervention
Only found in 1 per 1,000 screened patients

Question 21

When should an AAA be referred urgently within 2 weeks to vascular surgery?

Answer 21

high rupture risk

symptomatic, aortic diameter >=5.5cm or rapidly enlarging (>1cm/year)
refer within 2 weeks to vascular surgery for probable intervention
treat with elective endovascular repair (EVAR) or open repair if unsuitable. In EVAR a stent is placed into the abdominal aorta via the femoral artery to prevent blood from collecting in the aneurysm. A complication of EVAR is an endo-leak, where the stent fails to exclude blood from the aneurysm, and usually presents without symptoms on routine follow-up.

Question 22

Intestinal obstruction:
-what may be in the past medical history
-What 2 symptoms will be complained of?
-What will be found oe

Answer 22

History of malignancy/previous operations
Vomiting
Not opened bowels recently
‘Tinkling’ bowel sounds

Question 23

What 2 factors point towards pregnancy in abdo swelling?

Answer 23

Young female
Amenorrhoea

Question 24

Give 2 risk factors which would point towards ascites as a cause of abdo swelling?

Answer 24

History of alcohol excess, cardiac failure

Question 25

What 2 features would be assoc with urinary retention as a cause of abdo swelling?

Answer 25

History of prostate problems Dullness to percussion around suprapubic area

Question 26

Give 6 clinical features which would point towards ovarian cancer as a cause of abdominal swelling?

Answer 26

Older female Pelvic pain Urinary symptoms e.g. urgency Raised CA125 Early satiety, bloating

Question 27

What is a hydatid cyst?

Answer 27

Hydatid cysts are endemic in Mediterranean and Middle Eastern countries. They are caused by the tapeworm parasite Echinococcus granulosus. An outer fibrous capsule is formed containing multiple small daughter cysts. These cysts are allergens which precipitate a type 1 hypersensitivity reaction.

Question 28

Give 4 clinical features of hydatid cysts?

Answer 28

Clinical features are as follows: Up to 90% of cysts occur in the liver and lungs Can be asymptomatic, or symptomatic if cysts > 5cm in diameter Morbidity caused by cyst bursting, infection and organ dysfunction (biliary, bronchial, renal and cerebrospinal fluid outflow obstruction) In biliary rupture, there may be the classical triad of; biliary colic, jaundice, and urticaria

Question 29

What investigations are used for hydatid cysts?

Answer 29

Investigation imaging ultrasound if often used first-line CT is the best investigation to differentiate hydatid cysts from amoebic and pyogenic cysts serology useful for primary diagnosis and for follow-up after treatment wide variety of different antibody/antigen tests available

Question 30

What is the management of a hydatid cyst?

Answer 30

Surgery is the mainstay of treatment (the cyst walls must not be ruptured during removal and the contents sterilised first).

Question 31

what is a hernia? Give 4 risk factors?

Answer 31

The classical surgical definition of a hernia is the protrusion of an organ or the fascia of an organ through the wall of the cavity that normally contains it. Risk factors for abdominal wall hernias include: obesity ascites increasing age surgical wounds

Question 32

Give 5 features of hernia

Answer 32

Features palpable lump cough impulse pain obstruction: more common in femoral hernias strangulation: may compromise the bowel blood supply leading to infarction

Question 33

inguinal hernia: -Are these common? -where are these located? -Is strangulation common?

Answer 33

Inguinal hernias account for 75% of abdominal wall hernias. Around 95% of patients are male; men have around a 25% lifetime risk of developing an inguinal hernia. Above and medial to pubic tubercle Strangulation is rare

Question 34

give 3 clinical features of inguinal hernia

Answer 34

Features groin lump superior and medial to the pubic tubercle disappears on pressure or when the patient lies down discomfort and ache: often worse with activity, severe pain is uncommon strangulation is rare

Question 35

Describe the management of inguinal hernia

Answer 35

Management the clinical consensus is currently to treat medically fit patients even if they are asymptomatic a hernia truss may be an option for patients not fit for surgery but probably has little role in other patients mesh repair is associated with the lowest recurrence rate -unilateral inguinal hernias are generally repaired with an open approach -bilateral and recurrent inguinal hernias are generally repaired laparoscopically

Question 36

When can a patient return to work after repair of inguinal hernia? what are early and late complications of repair of inguinal hernia?

Answer 36

The Department for Work and Pensions recommend that following an open repair patients return to non-manual work after 2-3 weeks and following laparoscopic repair after 1-2 weeks Complications early: bruising, wound infection late: chronic pain, recurrence

Question 37

Femoral hernia -Where is this located? -who is this most commonly found in? -what is the management and why?

Answer 37

-Below and lateral to the pubic tubercle -More common in women, particularly multiparous ones -High risk of obstruction and strangulation -Surgical repair is required

Question 38

What is the difference between umbilical and para-umbilical hernia?

Answer 38

Umbilical hernia Symmetrical bulge under the umbilicus Paraumbilical hernia Asymmetrical bulge - half the sac is covered by skin of the abdomen directly above or below the umbilicus

Question 39

Descibe where an epigstric hernia is found? what are 3 risk factors?

Answer 39

Lump in the midline between umbilicus and the xiphisternum Risk factors include extensive physical training or coughing (from lung diseases), obesity

Question 40

How common are incisional hernia?

Answer 40

May occur in up to 10% of abdominal operations

Question 41

Spigelian hernia -What is this AKA -What is this?

Answer 41

Also known as lateral ventral hernia Rare and seen in older patients A hernia through the spigelian fascia (the aponeurotic layer between the rectus abdominis muscle medially and the semilunar line laterally)

Question 42

What is an obturator hernia?

Answer 42

A hernia which passes through the obturator foramen. More common in females and typical presents with bowel obstruction

Question 43

What is a richter hernua?

Answer 43

A rare type of hernia where only the antimesenteric border of the bowel herniates through the fascial defect Richter's hernia can present with strangulation without symptoms of obstruction

Question 44

Congenital inguinal hernia -What is this caused by -How common is this? -what is the management?

Answer 44

Indirect hernias resulting from a patent processus vaginalis Occur in around 1% of term babies. More common in premature babies and boys 60% are right sided, 10% are bilaterally Should be surgically repaired soon after diagnosis as at risk of incarceration

Question 45

What is an infantile umbilical hernia? who is this most common in? what is the management?

Answer 45

Symmetrical bulge under the umbilicus More common in premature and Afro-Caribbean babies The vast majority resolve without intervention before the age of 4-5 years Complications are rare

Question 46

What screening exists for colorectal cancer in the UK?

Answer 46

Overview most cancers develop from adenomatous polyps. Screening for colorectal cancer has been shown to reduce mortality by 16% the NHS offers home-based, Faecal Immunochemical Test (FIT) screening to older adults the NHS now has a national screening programme offering screening every 2 years to all men and women aged 60 to 74 years in England, 50 to 74 years in Scotland. Patients aged over 74 years may request screening

Question 47

how does a FIT test work? Wjhat is the advantage over FOB?

Answer 47

eligible patients are sent Faecal Immunochemical Test (FIT) tests through the post a type of faecal occult blood (FOB) test which uses antibodies that specifically recognise human haemoglobin (Hb) used to detect, and can quantify, the amount of human blood in a single stool sample dvantages over conventional FOB tests is that it only detects human haemoglobin, as opposed to animal haemoglobin ingested through diet only one faecal sample is needed compared to the 2-3 for conventional FOB tests whilst a numerical value is generated, this is not reported to the patient or GP, who will instead be informed if the test is normal or abnormal patients with abnormal results are offered a colonoscopy

Question 48

What are the rates of cancer found at colonoscopy post a positive FIT test

Answer 48

At colonoscopy, approximately: 5 out of 10 patients will have a normal exam 4 out of 10 patients will be found to have polyps which may be removed due to their premalignant potential 1 out of 10 patients will be found to have cancer

Question 49

Stomas - give location / appearance / output of ileostomy

Answer 49

Location - RIF Appearance - spouted Output - liquid

Question 50

Stomas - give location / appearance / output of colostomy

Answer 50

Location - varies, more likely on left side Appearance - flushed Output - solid

Question 51

Stomas - give use and common sites of: gastrostomy

Answer 51

USE: -Gastric decompression or fixation -Feeding Common site: Epigastrium

Question 52

Stomas - give use and common sites of: loop jejunostomy

Answer 52

use: -Seldom used as very high output -May be used following emergency laparotomy with planned early closure Common site: any location according to need

Question 53

Stomas - give use and common sites of: percutaneous jejunostomy

Answer 53

USE: Usually performed for feeding purposes and site in the proximal bowel Common site: Usually left upper quadrant

Question 54

Stomas - give use and common sites of: Loop ileostomy

Answer 54

USE: Defunctioning of colon e.g. following rectal cancer surgery Does not decompress colon (if ileocaecal valve competent) Common site: Usually RIF

Question 55

Stomas - give use and common sites of: end ileostomy

Answer 55

USE: -Usually following complete excision of colon or where ileocolic anastomosis is not planned -May be used to defunction colon, but reversal is more difficult Common site: RIF

Question 56

Stomas - give use and common sites of: end colostomy

Answer 56

USE Where a colon is diverted or resected and anastomosis is not primarily achievable or desirable SITE Either left or right iliac fossa

Question 57

Stomas - give use and common sites of: loop colostomy

Answer 57

USE To defunction a distal segment of colon Since both lumens are present the distal lumen acts as a vent SITE May be located in any region of the abdomen, depending upon colonic segment used

Question 58

Stomas - give use and common sites of: Caecostomy

Answer 58

USE Stoma of last resort where loop colostomy is not possible SITE Right iliac fossa

Question 59

Stomas - give use and common sites of: Mucous fistula

Answer 59

USE To decompress a distal segment of bowel following colonic division or resection Where closure of a distal resection margin is not safe or achievable Common SITE May be located in any region of the abdomen according to clinical need

Question 60

Haemorrhoids -common location -treatment

Answer 60

Location: 3, 7, 11 o'clock position Internal or external Treatment: Conservative, Rubber band ligation, Haemorrhoidectomy

Question 61

What are haemorrhoids? Give 4 clinical features1

Answer 61

Haemorrhoidal tissue is part of the normal anatomy which contributes to anal continence. These mucosal vascular cushions are found in the left lateral, right posterior and right anterior portions of the anal canal (3 o'clock, 7'o'clock and 11 o'clock respectively). Haemorrhoids are said to exist when they become enlarged, congested and symptomatic Clinical features -painless rectal bleeding is the most common symptom -pruritus -pain: usually not significant unless piles are thrombosed -soiling may occur with third or forth degree piles

Question 62

What is internal vs external haemorrhoid

Answer 62

External originate below the dentate line prone to thrombosis, may be painful Internal originate above the dentate line do not generally cause pain

Question 63

Give the grading of internal haemorrhoids

Answer 63

Grading of internal haemorrhoids Grade I Do not prolapse out of the anal canal Grade II Prolapse on defecation but reduce spontaneously Grade III Can be manually reduced Grade IV Cannot be reduced

Question 64

Give 5 management points for haemorrhoids

Answer 64

Management -soften stools: increase dietary fibre and fluid intake -topical local anaesthetics and steroids may be used to help symptoms -outpatient treatments: rubber band ligation is superior to injection sclerotherapy -surgery is reserved for large symptomatic haemorrhoids which do not respond to outpatient treatments newer treatments: Doppler guided haemorrhoidal artery ligation, stapled haemorrhoidopexy

Question 65

Acutely thrombosed external haemorrhoids: -How do these usually present? -What is found on examination? -Describe the management

Answer 65

Acutely thrombosed external haemorrhoids typically present with significant pain examination reveals a purplish, oedematous, tender subcutaneous perianal mass if patient presents within 72 hours then referral should be considered for excision. Otherwise patients can usually be managed with stool softeners, ice packs and analgesia. Symptoms usually settle within 10 days

Question 66

Anal fissue -How does this commonly present -common site -what is a chronic fissure?

Answer 66

Typically presents with painful rectal bleeding Location: midline 6 (posterior midline 90%) & 12 o'clock position. Distal to the dentate line Chronic fissure > 6/52: triad: Ulcer, sentinel pile, enlarged anal papillae

Question 67

What are anal fissures? Give 3 risk factors

Answer 67

Anal fissures are longitudinal or elliptical tears of the squamous lining of the distal anal canal. If present for less than 6 weeks they are defined as acute, and chronic if present for more than 6 weeks. Risk factors constipation inflammatory bowel disease sexually transmitted infections e.g. HIV, syphilis, herpes

Question 68

Give 3 clinical features of rectal fissures?

Answer 68

Features -painful, bright red, rectal bleeding -around 90% of anal fissures occur on the posterior midline. -if the fissures are found in alternative locations then other underlying causes should be considered e.g. Crohn's disease

Question 69

Give 4 management points of acute anal fissure

Answer 69

Management of an acute anal fissure (< 1 week) soften stool dietary advice: high-fibre diet with high fluid intake bulk-forming laxatives are first-line - if not tolerated then lactulose should be tried lubricants such as petroleum jelly may be tried before defecation topical anaesthetics analgesia

Question 70

Give 3 management points for chronic anal fissures

Answer 70

Management of a chronic anal fissure Continue management as per acute fissure topical glyceryl trinitrate (GTN) is first-line treatment for a chronic anal fissure if topical GTN is not effective after 8 weeks then secondary care referral should be considered for surgery (sphincterotomy) or botulinum toxin

Question 71

Ano rectal abscess -Common organisms 2 -Give 4 positions

Answer 71

E.coli, staph aureus Positions: Perianal, Ischiorectal, Pelvirectal, Intersphincteric

Question 72

Anal fistula -What is this usually due to? -give 4 locations

Answer 72

Usually due to previous ano-rectal abscess Intersphincteric, transsphincteric, suprasphincteric, and extrasphincteric. Goodsalls rule determines location

Question 73

Rectal prolapse: -What two things is this assoc with?

Answer 73

Associated with childbirth and rectal intussceception. May be internal or external

Question 74

Pruritus ani -What is this most commonly caused by in adults vs children?

Answer 74

Extremely common. In children is often related to worms, in adults may be idiopathic or related to other causes such as haemorrhoids.

Question 75

What is the commonest anal neoplasm?

Answer 75

Squamous cell carcinoma commonest unlike adenocarcinoma in rectum

Question 76

solitary rectal ulcer: -What is this assoc with? -What is seen on histology?

Answer 76

Associated with chronic straining and constipation. Histology shows mucosal thickening, lamina propria replaced with collagen and smooth muscle (fibromuscular obliteration)

Question 77

Scrotal swelling: what are 3 features of inguinal hernia?

Answer 77

If inguinoscrotal swelling; cannot 'get above it' on examination Cough impulse may be present May be reducible

Question 78

Scotal swelling - testicular tumours -what does this feel like? -what other symptoms may be present? -What 3 investigations are necessary?

Answer 78

Often discrete testicular nodule (may have associated hydrocele) Symptoms of metastatic disease may be present USS scrotum and serum AFP and β HCG required Acute epididymo-orchitis

Question 79

Scrotal swellings, epididymal cysts -What are these? -When do these occur? -Is this painful? -What site do these occur in and what is found on examination?

Answer 79

-Single or multiple cysts -May contain clear or opalescent fluid (spermatoceles) -Usually occur over 40 years of age -Painless -Lie above and behind testis -It is usually possible to 'get above the lump' on examination

Question 80

Epididymal cysts: -Are these common? -Give 3 associated conditions -How may this be diagnosed? -what is the management?

Answer 80

Epididymal cysts are the most common cause of scrotal swellings seen in primary care. Features separate from the body of the testicle found posterior to the testicle Associated conditions polycystic kidney disease cystic fibrosis von Hippel-Lindau syndrome Diagnosis may be confirmed by ultrasound. Management is usually supportive but surgical removal or sclerotherapy may be attempted for larger or symptomatic cysts.

Question 81

Scrotal swellings, hydrocele -What does this feel like on examination? -What other tests can be done at the bedside? -what may this indicate in young men?

Answer 81

-Non painful, soft fluctuant swelling -Often possible to 'get above it' on examination -Usually contain clear fluid -Will often transilluminate -May be presenting feature of testicular cancer in young men

Question 82

What is a hydrocele? what is communicating vs non-communicating? What may hydroceles develop secondary to?

Answer 82

A hydrocele describes the accumulation of fluid within the tunica vaginalis. They can be divided into communicating and non-communicating: communicating: caused by patency of the processus vaginalis allowing peritoneal fluid to drain down into the scrotum. Communicating hydroceles are common in newborn males (clinically apparent in 5-10%) and usually resolve within the first few months of life non-communicating: caused by excessive fluid production within the tunica vaginalis Hydroceles may develop secondary to: epididymo-orchitis testicular torsion testicular tumours

Question 83

Give 4 features of hydrocele? How is this diagnosed?

Answer 83

Features -soft, non-tender swelling of the hemi-scrotum. Usually anterior to and below the testicle -the swelling is confined to the scrotum, you can get 'above' the mass on examination -transilluminates with a pen torch -the testis may be difficult to palpate if the hydrocele is large Diagnosis may be clinical but ultrasound is required if there is any doubt about the diagnosis or if the underlying testis cannot be palpated.

Question 84

Testicular torsion -How does this present? -Who does this typically affect? -what is found on examination? -What is the management?

Answer 84

-Severe, sudden onset testicular pain -Risk factors include abnormal testicular lie -Typically affects adolescents and young males -On examination testis is tender and pain not eased by elevation -Urgent surgery is indicated, the contra lateral testis should also be fixed

Question 85

What is a varicocele? Where do these most commonly occur? what may this indicate?

Answer 85

-Varicosities of the pampiniform plexus -Typically occur on left (because testicular vein drains into renal vein) -May be presenting feature of renal cell carcinoma -Affected testis may be smaller and bilateral varicoceles may affect fertility

Question 86

What are varicoceles classically described as?

Answer 86

A varicocele is an abnormal enlargement of the testicular veins. They are usually asymptomatic but may be important as they are associated with infertility. Varicoceles are much more common on the left side (> 80%). Features: classically described as a 'bag of worms' subfertility

Question 87

What is the diagnosis and management of varicocele?

Answer 87

Diagnosis ultrasound with Doppler studies Management usually conservative occasionally surgery is required if the patient is troubled by pain. There is ongoing debate regarding the effectiveness of surgery to treat infertility -A solitary right-sided varicocele requires urgent referral to a urologist

Question 88

Describe the management of testicular malignancy?

Answer 88

Testicular malignancy is always treated with orchidectomy via an inguinal approach. This allows high ligation of the testicular vessels and avoids exposure of another lymphatic field to the tumour.

Question 89

Describe the management of epididymal cysts

Answer 89

Epididymal cysts can be excised using a scrotal approach

Question 90

Describe the management of hydrocele

Answer 90

Management -infantile hydroceles are generally repaired if they do not resolve spontaneously by the age of 1-2 years -in adults a conservative approach may be taken depending on the severity of the presentation. Further investigation (e.g. ultrasound) is usually warranted however to exclude any underlying cause such as a tumour Hydroceles are managed differently in children where the underlying pathology is a patent processus vaginalis and therefore an inguinal approach is used in children so that the processus can be ligated. In adults a scrotal approach is preferred and the hydrocele sac excised or plicated

Question 91

Testicular cancer: -is this common? -How are these categorised?

Answer 91

Testicular cancer is the most common malignancy in men aged 20-30 years. Around 95% of cases of testicular cancer are germ-cell tumours. Germ cell tumours may essentially be divided into: seminomas non-seminomas: including embryonal, yolk sac, teratoma and choriocarcinoma Non-germ cell tumours include Leydig cell tumours and sarcomas.

Question 92

When is the peak incidence of teratomas / seminomas? give 5 risk factors

Answer 92

The peak incidence for teratomas is 25 years and seminomas is 35 years. Risk factors include: infertility (increases risk by a factor of 3) cryptorchidism family history Klinefelter's syndrome mumps orchitis

Question 93

Give 4 features of testicular cancer

Answer 93

Features a painless lump is the most common presenting symptom pain may also be present in a minority of men hydrocele gynaecomastia -this occurs due to an increased oestrogen:androgen ratio -germ-cell tumours → hCG → Leydig cell dysfunction → increases in both oestradiol and testosterone production, but rise in oestradiol is relatively greater than testosterone - leydig cell tumours → directly secrete more oestradiol and convert additional androgen precursors to oestrogens

Question 94

What are the tumour markers found in germ cell tumours?

Answer 94

Tumour markers in germ cell tumours seminomas: hCG may be elevated in around 20% non-seminomas: AFP and/or beta-hCG are elevated in 80-85% LDH is elevated in around 40% of germ cell tumours

Question 95

what is the diagnosis and management of testicular cancer?

Answer 95

Diagnosis ultrasound is first-line Management -treatment depends on whether the tumour is a seminoma or a non-seminoma -orchidectomy -chemotherapy and radiotherapy may be given depending on staging and tumour type

Question 96

Describe the prognosis of seminomas and teratomas in testicular cancer

Answer 96

Prognosis is generally excellent 5 year survival for seminomas is around 95% if Stage I 5 year survival for teratomas is around 85% if Stage I

Question 97

Acute bacterial prostatitis - what is this typically caused by? give 4 risk factors?

Answer 97

Acute bacterial prostatitis is typically caused by gram-negative bacteria entering the prostate gland via the urethra. Escherichia coli is the most commonly isolated pathogen. Risk factors for acute bacterial prostatitis include recent urinary tract infection, urogenital instrumentation, intermittent bladder catheterisation and recent prostate biopsy.

Question 98

Give 3 features of acute bacterial prostatisis? what is found on DRE?

Answer 98

Features -the pain of prostatitis may be referred to a variety of areas including the perineum, penis, rectum or back -obstructive voiding symptoms may be present -fever and rigors may be present -digital rectal examination: tender, boggy prostate gland

Question 99

What is the management of acute bacterial prostatitis?

Answer 99

Management Clinical Knowledge Summaries currently recommend a 14-day course of a quinolone consider screening for sexually transmitted infections

Question 100

What is the management of chronic prostatitis?

Answer 100

A prolonged course of a quinolone is often recommended. There has been some debate as to whether prostatic massage has improved outcomes, though no conclusive data published to date.

Question 101

What are 2 risk factors of BPH?

Answer 101

Benign prostatic hyperplasia (BPH) is a common condition seen in older men. Risk factors -age around 50% of 50-year-old men will have evidence of BPH and 30% will have symptoms around 80% of 80-year-old men have evidence of BPH -ethnicity: black > white > Asian

Question 102

BPH LUTS: -Give 5 voiding symptoms

Answer 102

Voiding symptoms (obstructive): weak or intermittent urinary flow straining hesitancy terminal dribbling incomplete emptying

Question 103

BPH LUTS: -Give 4 storage symptoms -Give 1 post-micturition symptom

Answer 103

storage symptoms (irritative) urgency frequency urgency incontinence nocturia Post-micturition dribbling

Question 104

Give 3 complications of BPH

Answer 104

complications urinary tract infection retention obstructive uropathy

Question 105

What are 5 components of assessment of BPH?

Answer 105

Assessment dipstick urine U&Es: particularly if chronic retention is suspected PSA: should be done if there are any obstructive symptoms, of if the patient is worried about prostate cancer urinary frequency-volume chart should be done for at least 3 days International Prostate Symptom Score (IPSS) tool for classifying the severity of lower urinary tract symptoms (LUTS) and assessing the impact of LUTS on quality of life Score 20–35: severely symptomatic Score 8–19: moderately symptomatic Score 0–7: mildly symptomatic

Question 106

Give 6 management options of BPH

Answer 106

Management options -watchful waiting -alpha-1 antagonists e.g. tamsulosin, alfuzosin -5 alpha-reductase inhibitors e.g. finasteride -the use of combination therapy (alpha-1 antagonist + 5 alpha-reductase inhibitor) was supported by the Medical Therapy Of Prostatic Symptoms (MTOPS) trial and is also supported by NICE: 'If the man has bothersome moderate-to-severe voiding symptoms and prostatic enlargement' -if there is a mixture of storage symptoms and voiding symptoms that persist after treatment with an alpha-blocker alone, then an antimuscarinic (anticholinergic) drug such as tolterodine or darifenacin may be tried -surgery transurethral resection of prostate (TURP)

Question 107

BPH - Alpha-1-antagonists: -How do these work? -When are these used? -What are 4 adverse effects?

Answer 107

alpha-1 antagonists e.g. tamsulosin, alfuzosin decrease smooth muscle tone of the prostate and bladder considered first-line: NICE recommend if moderate-to-severe voiding symptoms (IPSS ≥ 8) improve symptoms in around 70% of men adverse effects: dizziness, postural hypotension, dry mouth, depression

Question 108

5-alpha-reductase inhibitors: -How do these work? -What blood test can this affect? -what are 4 adverse effects?

Answer 108

-block the conversion of testosterone to dihydrotestosterone (DHT), which is known to induce BPH -indicated if the patient has a significantly enlarged prostate and is considered to be at high risk of progression -unlike alpha-1 antagonists causes a reduction in prostate volume and hence may slow disease progression. This however takes time and symptoms may not improve for 6 months -may also decrease PSA concentrations by up to 50% -adverse effects: erectile dysfunction, reduced libido, ejaculation problems, gynaecomastia

Question 109

Describe the cut-off for PSA?

Answer 109

Age-adjusted upper limits for PSA were recommended by the PCRMP: Age PSA level (ng/ml) 50-59 years 3.0 60-69 years 4.0 > 70 years 5.0 However, NICE Clinical Knowledge Summaries currently suggest a different cut-off: men aged 50-69 years should be referred if the PSA is >= 3.0 ng/ml OR there is an abnormal DRE note this is a lower threshold than the PCRMP 60-69 years limits recommended above

Question 110

Give 5 factors that may increase PSA?

Answer 110

PSA levels may also be raised by*: -benign prostatic hyperplasia (BPH) -prostatitis and urinary tract infection (NICE recommend to postpone the PSA test for at least 1 month after treatment) -ejaculation (ideally not in the previous 48 hours) -vigorous exercise (ideally not in the previous 48 hours) -urinary retention -instrumentation of the urinary tract

Question 111

Is PSA a good test?

Answer 111

Poor specificity and sensitivity around 33% of men with a PSA of 4-10 ng/ml will be found to have prostate cancer. With a PSA of 10-20 ng/ml this rises to 60% of men around 20% with prostate cancer have a normal PSA various methods are used to try and add greater meaning to a PSA level including age-adjusted upper limits and monitoring change in PSA level with time (PSA velocity or PSA doubling time)

Question 112

Give 4 risk factors for prostate cancer?

Answer 112

Prostate cancer is now the most common cancer in adult males in the UK and is the second most common cause of death due to cancer in men after lung cancer. Risk factors increasing age obesity Afro-Caribbean ethnicity family history: around 5-10% of cases have a strong family history

Question 113

Give 4 possible features of prostate cancer

Answer 113

Localised prostate cancer is often asymptomatic. This is partly because cancers tend to develop in the periphery of the prostate and hence don't cause obstructive symptoms early on. Possible features include: -bladder outlet obstruction: hesitancy, urinary retention -haematuria, haematospermia -pain: back, perineal or testicular -digital rectal examination: asymmetrical, hard, nodular enlargement with loss of median sulcus

Question 114

What is the first line investigation for prostate cancer?

Answer 114

The traditional investigation for suspected prostate cancer was a transrectal ultrasound-guided (TRUS) biopsy. However, recent guidelines from NICE have now advocated the increasing use of multiparametric MRI as a first-line investigation.

Question 115

Give 4 complications of TRUS biopsy?

Answer 115

Complications of TRUS biopsy: -sepsis: 1% of cases -pain: lasting >= 2 weeks in 15% and severe in 7% -fever: 5% -haematuria and rectal bleeding

Question 116

How are the results of multiparametric MRI interpreted for those with suspected clinically localised prostate ca

Answer 116

Multiparametric MRI is now the first-line investigation for people with suspected clinically localised prostate cancer. the results are reported using a 5‑point Likert scale If the Likert scale is >=3 a multiparametric MRI-influenced prostate biopsy is offered If the Likert scale is 1-2 then NICE recommend discussing with the patient the pros and cons of having a biopsy.

Question 117

Describe the management of localised prostate cancer? T1/T2

Answer 117

Localised prostate cancer (T1/T2) Treatment depends on life expectancy and patient choice. Options include: -conservative: active monitoring & watchful waiting -radical prostatectomy -radiotherapy: external beam and brachytherapy

Question 118

Descibe the management of localised advanced prostate cancer? T3/T4

Answer 118

Localised advanced prostate cancer (T3/T4) Options include: -hormonal therapy -radical prostatectomy: erectile dysfunction is a common complication radiotherapy -external beam and brachytherapy -patients may develop proctitis and are also at increased risk of bladder, colon, and rectal cancer following radiotherapy for prostate cancer

Question 119

Management of metastatic prostate cancer: -Give 6 anti-androgen therapies -What else can be used?

Answer 119

One of the key aims of treating advanced prostate cancer is reducing androgen levels. A combination of approaches if often used. Anti-androgen therapy -synthetic GnRH agonist or antagonists -interestingly, GnRH antagonists such as degarelix are being evaluated to suppress testosterone while avoiding the flare phenomenon -bicalutamide -cyproterone acetate -abiraterone -bilateral orchidectomy (used to rapidly reduce testosterone levels) Chemotherapy with docetaxel

Question 120

synthetic GnRH agonist or antagonists use in prostate Ca: -How does this work? -What is given additionally?

Answer 120

-GnRH agonists: e.g. Goserelin (Zoladex) -paradoxically result in lower LH levels longer term by causing overstimulation, resulting in disruption of endogenous hormonal feedback systems. The testosterone level will therefore rise initially for around 2-3 weeks before falling to castration leves -initially therapy is often covered with an anti-androgen to prevent a rise in testosterone - 'tumour flare'. The resultant stimulation of prostate cancer growth may result in bone pain, bladder obstruction and other symptoms

Question 121

Bicalutamide in prostate ca treatment: what is this and how does this work?

Answer 121

non-steroidal anti-androgen blocks the androgen receptor

Question 122

Cyproterone acetate in Prostate Ca treatment - what is this and how does this work?

Answer 122

Cyproterone acetate -steroidal anti-androgen -prevents DHT binding from intracytoplasmic protein complexes -used less commonly since introduction of non-steroidal anti-androgens

Question 123

Abiraterone in Prostate Ca treatment -How does this work? -Who is this an option for?

Answer 123

abiraterone -androgen synthesis inhibitor -option for the treatment of hormone-relapsed metastatic prostate cancer in patients who have no or mild symptoms after androgen deprivation therapy has failed, and before chemotherapy is indicated

Question 124

How is prognosis predicted in patients with prostate ca?

Answer 124

The Gleason score is used to predict prognosis in patients with prostatic cancer. The grading system is based on the glandular architecture seen on histology following hollow needle biopsy The most prevalent and the second most prevalent pattern seen are added to obtain a Gleason score. The Gleason grade ranges from 1 to 5 meaning the Gleason score ranges from 2 to 10 (i.e. two values added) The higher the Gleason score the worse the prognosis

Question 125

What is balanitis?

Answer 125

Balanitis is inflammation of the glans penis and sometimes extends to the underside of the foreskin which is known as balanoposthitis. There are a number of causes of balanitis and the most common causes are infective (both bacterial and candidal) although there are a number of other autoimmune causes that are important to know. Simple hygiene is a key part of the treatment of balanitis and both improper washing under the foreskin and the presence of a tight foreskin can make balanitis worse. The presentation can either be acute or more chronic and children and adults are affected by the causes differently.

Question 126

Balanitis due to candida -Frequency -Acute or chronic -Features on assessment -Occurring in children or adults? -Management

Answer 126

Very common Acute Usually occurs after intercourse and associated with itching and white non-urethral discharge Both In the case of candidiasis the treatment is with topical clotrimazole which has to be applied for two weeks to fully treat the infection.

Question 127

Balanitis due to dermatitis (contact or allergic) -Frequency -Acute or chronic -Features on assessment -Occurring in children or adults? -Treatmnet

Answer 127

Very common Acute Itchy, sometimes painful and occasionally associated with a clear non-urethral discharge. Often there is no other body area affected Both Dermatitis and circinate balanitis are managed with mild potency topical corticosteroids (e.g. hydrocortisone)

Question 128

Balanitis due to dermatitis (eczema or psoriasis) -Frequency -Acute or chronic -Features on assessment -Occurring in children or adults? -Treatmnet

Answer 128

Very common Both Very itchy but not associated with any discharge and there will be a medical history of an inflammatory skin condition with active areas elsewhere on the body Both Dermatitis and circinate balanitis are managed with mild potency topical corticosteroids (e.g. hydrocortisone)

Question 129

Balanitis due to bacterial infections -Frequency -Acute or chronic -Features on assessment -Occurring in children or adults? -Treatment

Answer 129

Common Acute Painful and can be itchy with yellow non-urethral discharge and most often due to Staphylococcus spp. Both Bacterial balanitis is most often due to Staphylococcus spp. or Group B Streptococcus spp. and can be treated with oral flucloxacillin or clarithromycin if penicillin allergic.

Question 130

Balanitis due to anaerobic infection -Frequency -Acute or chronic -Features on assessment -Occurring in children or adults? -Treatment?

Answer 130

Common Acute May be itchy but is most associated with a very offensive yellow non-urethral discharge Both Anaerobic balanitis is managed with saline washing and can also be managed with topical or oral metronidazole if not settling.

Question 131

Balanitis due to lichen planus -Frequency -Acute or chronic -Features on assessment -Occurring in children or adults?

Answer 131

Uncommon Both May be itchy, the main diagnostic feature is the presence of Wickham's striae and violaceous papules More commonly adults

Question 132

Balanitis due to lichen sclerosus -Frequency -Acute or chronic -Features on assessment -Occurring in children or adults? Treatment?

Answer 132

balanitis xerotica obliterans Rare Chronic May be itchy, associated with white plaques and can cause significant scarring Both Lichen sclerosus and plasma cell balanitis of Zoon are managed with high potency topical steroids (e.g. clobetasol). Circumcision can help in the case of lichen sclerosus.

Question 133

Zoons Balanitis -Frequency -Acute or chronic -Features on assessment -Occurring in children or adults? -Treatmnet?

Answer 133

Plasma cell balanitis of Zoon Rare Chronic Not itchy with clearly circumscribed areas of inflammation Both Lichen sclerosus and plasma cell balanitis of Zoon are managed with high potency topical steroids (e.g. clobetasol).

Question 134

Circinate balanitis -Frequency -Acute or chronic -Features on assessment -Occurring in children or adults? -Treatment?

Answer 134

Uncommon Both Not itchy and not associated with any discharge. The key feature is painless erosions and it can be associated with reactive arthritis Adults Dermatitis and circinate balanitis are managed with mild potency topical corticosteroids (e.g. hydrocortisone)

Question 135

What are the investigations for balanitis?

Answer 135

-The majority of conditions are diagnosed clinically based on the history and physical appearance of the glans penis. -In the cases of suspected infective causes a swab can be taken for microscopy and culture which may demonstrate bacteria or Candida albicans. -When there is a doubt about the cause and there is extensive skin change, then a biopsy can be helpful in confirming the diagnosis.

Question 136

What is the general management of balanitis?

Answer 136

General treatment: There are three things which form the basis of management of all causes of balanitis; gentle saline washes, ensuring to wash properly under the foreskin, and in the case of more severe irritation and discomfort then 1% hydrocortisone can be used for a short period. When the cause is not clear, these measures can often resolve the condition alone.

Question 137

Can you get circumcision for religious/cultural reasons with the NHS?

Answer 137

Circumcision has been performed in a variety of cultures for thousands of years. Today it is mainly people of the Jewish and Islamic faith who undergo circumcision for religious/cultural reasons. Circumcision for religious or cultural reasons is not available on the NHS.

Question 138

Give 3 benefits of circumcision

Answer 138

he medical benefits of routine circumcision remain controversial although some evidence has emerged that it: reduces the risk of penile cancer reduces the risk of UTI reduces the risk of acquiring sexually transmitted infections including HIV

Question 139

Give 4 medical indications for circumcision

Answer 139

Medical indications for circumcision phimosis recurrent balanitis balanitis xerotica obliterans paraphimosis It is important to exclude hypospadias prior to circumcision as the foreskin may be used in surgical repair. Circumcision may be performed under a local or general anaesthetic.

Question 140

Give 3 factors of erectile dysfunction that favour an organic cause?

Answer 140

Gradual onset of symptoms Lack of tumescence Normal libido

Question 141

Give 7 factors in erectile dysfunctions that favour a psychogenic cause?

Answer 141

-Sudden onset of symptoms -Decreased libido -Good quality spontaneous or self-stimulated erections -Major life events -Problems or changes in a relationship -Previous psychological problems -History of premature ejaculation

Question 142

Give 3 risk factors for erectile dysfunction?

Answer 142

Other than increasing age, risk factors include: cardiovascular disease risk factors: obesity, diabetes mellitus, dyslipidaemia, metabolic syndrome, hypertension, smoking alcohol use drugs: SSRIs, beta-blockers

Question 143

what investigations should be done for patients who present with erectile dysfunction?

Answer 143

As part of the assessment for erectile dysfunction Clinical Knowledge Summaries (CKS) recommend that all men have their 10-year cardiovascular risk calculated by measuring lipid and fasting glucose serum levels. Free testosterone should also be measured in the morning between 9 and 11am. If free testosterone is low or borderline, it should be repeated along with follicle-stimulating hormone, luteinizing hormone and prolactin levels. If any of these are abnormal refer to endocrinology for further assessment. Opinion on testosterone measurement differs between some experts but CKS advises universal measurement of testosterone in men with erectile dysfunction as recommended by the British Society for Sexual Medicine and the European Association of Urology.

Question 144

Describe the management of erectile dysfunction

Answer 144

PDE-5 inhibitors (such as sildenafil, 'Viagra') have revolutionised the management of ED they should be prescribed (in the absence of contraindications) to all patients regardless of aetiology sildenafil can be purchased over-the-counter without a prescription. Vacuum erection devices are recommended as first-line treatment in those who can't/won't take a PDE-5 inhibitor. Other points for a young man who has always had difficulty achieving an erection, referral to urology is appropriate people with erectile dysfunction who cycle for more than three hours per week should be advised to stop

Question 145

What is priapism?

Answer 145

Priapism is a persistent penile erection, typically defined as lasting longer than 4 hours and is not associated with sexual stimulation. Priapism can be described as either ischaemic or non-ischaemic with both categories having a different pathophysiology. Ischaemic priapism is typically due to impaired vasorelaxation and therefore reduced vascular outflow resulting in congestion and trapping of de-oxygenated blood within the corpus cavernosa. Non-ischaemic priapism is due to high arterial inflow, typically due to fistula formation often either as the result of congenital or traumatic mechanisms.

Question 146

Who does priapism most commonly affect?

Answer 146

Epidemiology Age at presentation has a bimodal distribution, with peaks between 5-10 years and 20-50 years of age incidence has been estimated at up to 5.34 per 100,000 patient-years

Question 147

Give 5 causes of priapism?

Answer 147

Causes -Idiopathic -Sickle cell disease or other -haemoglobinopathies -Erectile dysfunction medication (e.g. Sildenafil and other PDE-5 inhibitors), this also includes intracavernosal injected therapies. -Other drugs both prescribed (anti-hypertensives, anticoagulants, antidepressants etc) and recreational (specifically cocaine, cannabis and ecstasy). -Trauma

Question 148

Describe the presentation of priapism? 5

Answer 148

Patients typically present acutely with: -A persistent erection lasting over 4 hours -Pain localised to the penis -Often a history of either known haemoglobinopathy or use of medications listed above -Patients may, more rarely, present with either a non-painful erection or an erection that is not fully rigid: these are both suggestive of non-ischaemic priapism. -History of trauma to the genital or perineal region: also suggestive of non-ischaemic priapism.

Question 149

Give 4 investigations for priapism

Answer 149

Investigations: -Cavernosal blood gas analysis to differentiate between ischaemic and non-ischaemic: in ischaemic priapism pO2 and pH would be reduced whilst pCO2 would be increased. -Doppler or duplex ultrasonography: this can be used as an alternative to blood gas analysis to assess for blood flow within the penis. -A full blood count and toxicology screen can be used to assess for an underlying cause of the priapism. -Diagnosis of priapism is largely clinical, with investigations helping to categorise into ischaemic and non-ischaemic as well as assessing for the underlying cause.

Question 150

Describe the management of priapism

Answer 150

Ischaemic priapism is a medical emergency and delayed treatment can lead to permanent tissue damage and long-term erectile dysfunction. -If the priapism has lasted longer than 4 hours, the first-line treatment is aspiration of blood from the cavernosa, this is often combined with injection of a saline flush to help clear viscous blood that has pooled. -If aspiration and injection fails, then intracavernosal injection of a vasoconstrictive agent such as phenylephrine is used and repeated at 5 minute intervals. -If medical therapy fails then surgical options can be considered. Non-ischaemic priapism is not a medical emergency and is normally suitable for observation as a first-line option.

Question 151

Male sterilisation -What is the failure rate? What needs to be done before the patient can have UPSI

Answer 151

Male sterilisation - vasectomy -failure rate: 1 per 2,000 - male sterilisation is a more effective method of contraception than female sterilisation -simple operation, can be done under LA (some GA), go home after a couple of hours -doesn't work immediately -semen analysis needs to be performed twice following a vasectomy before a man can have unprotected sex (usually at 12 weeks)

Question 152

What are 5 complications of vasectomy? what is the reversal success rate?

Answer 152

complications: bruising, haematoma, infection, sperm granuloma, chronic testicular pain (affects between 5-30% men) the success rate of vasectomy reversal is up to 55%, if done within 10 years, and approximately 25% after more than 10 years

Question 153

what is a fibroadenoma of breast? give 5 features? What is the management

Answer 153

-Develop from a whole lobule -Mobile, firm breast lumps -12% of all breast masses -Over a 2 year period up to 30% will get smaller -No increase in risk of malignancy Management: If >3cm surgical excision is usual, Phyllodes tumours should be widely excised (mastectomy if the lesion is large) Common in women under the age of 30 years Often described as 'breast mice' due as they are discrete, non-tender, highly mobile lumps

Question 154

give 3 clinical features of breast cysts? what is the management?

Answer 154

-7% of all Western females will present with a breast cyst -Usually presents as a smooth discrete lump (may be fluctuant) -Small increased risk of breast cancer (especially if younger) Cysts should be aspirated, those which are blood stained or persistently refill should be biopsied or excised

Question 155

Give 4 clinical features of sclerosing adenosis of breast? (radial scars and complex sclerosing lesions) What is the management?

Answer 155

-Usually presents as a breast lump or breast pain -Causes mammographic changes which may mimic carcinoma -Cause distortion of the distal lobular unit, without hyperplasia (complex lesions will show hyperplasia) -Considered a disorder of involution, no increase in malignancy risk -Lesions should be biopsied, excision is not mandatory

Question 156

Give 3 clinical features of epithelial hyperplasia of breast? what is the management of this?

Answer 156

-Variable clinical presentation ranging from generalised lumpiness through to discrete lump -Disorder consists of increased cellularity of terminal lobular unit, atypical features may be present -Atypical features and family history of breast cancer confers greatly increased risk of malignancy -If no atypical features then conservative, those with atypical features require either close monitoring or surgical resection

Question 157

Give 3 clinical features of fat necrosis breast? what is the management?

Answer 157

-Up to 40% cases usually have a traumatic aetiology -Physical features usually mimic carcinoma -Mass may increase in size initially Imaging and core biopsy More common in obese women with large breasts May follow trivial or unnoticed trauma Initial inflammatory response, the lesion is typical firm and round but may develop into a hard, irregular breast lump Rare and may mimic breast cancer so further investigation is always warranted

Question 158

Give 4 clinical features of duct papilloma of breast? what is the manageemnt?

Answer 158

-Usually present with nipple discharge -Large papillomas may present with a mass -The discharge usually originates from a single duct -No increase risk of malignancy Microdochectomy Local areas of epithelial proliferation in large mammary ducts Hyperplastic lesions rather than malignant or premalignant May present with blood stained discharge

Question 159

What is Fibroadenosis (fibrocystic disease, benign mammary dysplasia) of breast?

Answer 159

Most common in middle-aged women 'Lumpy' breasts which may be painful. Symptoms may worsen prior to menstruation

Question 160

What is mammary duct ectasia?

Answer 160

Dilatation of the large breast ducts Most common around the menopause May present with a tender lump around the areola +/- a green nipple discharge If ruptures may cause local inflammation, sometimes referred to as 'plasma cell mastitis'

Question 161

What is benign cyclical mastalgia and give 3 clinical features

Answer 161

Benign cyclical mastalgia is a common cause of breast pain in younger females. Clinical features It varies in intensity according to the phase of the menstrual cycle Cyclical mastalgia is not usually associated with point tenderness of the chest wall (more likely to be Tietze's syndrome). The underlying cause is difficult to pinpoint, examination should focus on identifying focal lesions (such as cysts) that may be treated to provide symptomatic benefit.

Question 162

Describe the management of cyclical mastalgia

Answer 162

Management -Women should be advised to wear a supportive bra -Conservative treatments include standard oral and topical analgesia -flaxseed oil and evening primrose oil are sometimes used but neither are recommended by NICE Clinical Knowledge Summaries -If the pain has not responded to conservative measures after 3 months, and is affecting the quality of life or sleep, then referral should be considered -Hormonal agents such as bromocriptine and danazol may be more effective. However, many women discontinue these therapies due to adverse effects.

Question 163

What does breast cancer characteristically present as? what is pagets disease of breast?

Answer 163

Characteristically a hard, irregular lump. There may be associated nipple inversion or skin tethering Paget's disease of the breast - intraductal carcinoma associated with a reddening and thickening (may resemble eczematous changes) of the nipple/areola

Question 164

How does pagets disease of breast differ from eczema of breast? how is this diagnosed? what is the treatment?

Answer 164

Paget's disease differs from eczema of the nipple in that it involves the nipple primarily and only latterly spreads to the areolar (the opposite occurs in eczema). Diagnosis is made by punch biopsy, mammography and ultrasound of the breast. Treatment will depend on the underlying lesion.

Question 165

Who is offered screening in breast cancer?

Answer 165

he NHS Breast Screening Programme is offered to women between the ages of 50-70 years. Women are offered a mammogram every 3 years. After the age of 70 years women may still have mammograms but are 'encouraged to make their own appointments'. The effectiveness of breast screening is regularly debated although it is currently thought that the NHS Breast Screening Programme may save around 1,400 lives per year.

Question 166

Referrals for patients with a family history breast cancer - who gets referred if they have 1 first-degree or second-degree relative diagnosed with breast ca?

Answer 166

If the person concerned only has one first-degree or second-degree relative diagnosed with breast cancer they do NOT need to be referred unless any of the following are present in the family history: age of diagnosis < 40 years bilateral breast cancer male breast cancer ovarian cancer Jewish ancestry sarcoma in a relative younger than age 45 years glioma or childhood adrenal cortical carcinomas complicated patterns of multiple cancers at a young age paternal history of breast cancer (two or more relatives on the father's side of the family)

Question 167

Which women are offered breast ca screening from a younger age?

Answer 167

Women who are at an increased risk of breast cancer due to their family history may be offered screening from a younger age. The following patients should be referred to the breast clinic for further assessment: one first-degree female relative diagnosed with breast cancer at younger than age 40 years, or one first-degree male relative diagnosed with breast cancer at any age, or one first-degree relative with bilateral breast cancer where the first primary was diagnosed at younger than age 50 years, or two first-degree relatives, or one first-degree and one second-degree relative, diagnosed with breast cancer at any age, or one first-degree or second-degree relative diagnosed with breast cancer at any age and one first-degree or second-degree relative diagnosed with ovarian cancer at any age (one of these should be a first-degree relative), or three first-degree or second-degree relatives diagnosed with breast cancer at any age

Question 168

Give 11 risk factors for breast ca?

Answer 168

Predisposing factors -BRCA1, BRCA2 genes - 40% lifetime risk of breast/ovarian cancer -1st degree relative premenopausal relative with breast cancer (e.g. mother) -nulliparity, 1st pregnancy > 30 yrs (twice risk of women having 1st child < 25 yrs) -early menarche, late menopause -combined hormone replacement therapy (relative risk increase * 1.023/year of use), -combined oral contraceptive use -past breast cancer -not breastfeeding -ionising radiation -p53 gene mutations -obesity -previous surgery for benign disease (?more follow-up, scar hides lump)

Question 169

What are 4 common types of breast ca?

Answer 169

Most breast cancers arise from duct tissue followed by lobular tissue, described as ductal or lobular carcinoma respectively. These can be further subdivided as to whether the cancer hasn't spread beyond the local tissue (described as carcinoma-in-situ) or has spread (described as invasive). Therefore, common breast cancer types include: -Invasive ductal carcinoma. This is the most common type of breast cancer. To complicate matters further this has recently been renamed 'No Special Type (NST)'. In contrast, lobular carcinoma and other rarer types of breast cancer are classified as 'Special Type' -Invasive lobular carcinoma -Ductal carcinoma-in-situ (DCIS) -Lobular carcinoma-in-situ (LCIS)

Question 170

What is pagets disease of the nipple? what is the likelihood of underlying malignancy?

Answer 170

Paget's disease of the nipple is an eczematoid change of the nipple associated with an underlying breast malignancy and it is present in 1-2% of patients with breast cancer. In half of these patients, it is associated with an underlying mass lesion and 90% of such patients will have an invasive carcinoma. 30% of patients without a mass lesion will still be found to have an underlying carcinoma. The remainder will have carcinoma in situ.

Question 171

what is inflammatory breast cancer?

Answer 171

Inflammatory breast cancer where cancerous cells block the lymph drainage resulting in an inflamed appearance of the breast. This accounts for around 1 in 10,000 cases of breast cancer.

Question 172

Describe who warrants USOC breast referral, who should be considered for USOC breast referral and who should be referred non-urgently

Answer 172

Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer if they are: aged 30 and over and have an unexplained breast lump with or without pain or aged 50 and over with any of the following symptoms in one nipple only: discharge, retraction or other changes of concern Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer in people: with skin changes that suggest breast cancer or aged 30 and over with an unexplained lump in the axilla Consider non-urgent referral in people aged under 30 with an unexplained breast lump with or without pain.

Question 173

Surgery for breast cancer -What is the management if there are no palpable lymph nodes at presentation? -What is the management if there are palpable lumph nodes?

Answer 173

Prior to surgery, the presence/absence of axillary lymphadenopathy determines management: women with no palpable axillary lymphadenopathy at presentation should have a pre-operative axillary ultrasound before their primary surgery if negative then they should have a sentinel node biopsy to assess the nodal burden in patients with breast cancer who present with clinically palpable lymphadenopathy, axillary node clearance is indicated at primary surgery this may lead to arm lymphedema and functional arm impairment

Question 174

Give 4 factors of breast cancer that would indicate mastectomy?

Answer 174

-Multifocal tumour -Central tumour -Large lesion in small breast -DCIS >4cm

Question 175

Give 4 factors of breast cancer that would indicate wide local excision?

Answer 175

-Solitary lesion -Peripheral tumour -Small lesion in large breast -DCIS <4cm

Question 176

Who is offered radiotherapy after surgical management of breast ca?

Answer 176

Whole breast radiotherapy is recommended after a woman has had a wide-local excision as this may reduce the risk of recurrence by around two-thirds. For women who've had a mastectomy radiotherapy is offered for T3-T4 tumours and for those with four or more positive axillary nodes

Question 177

What hormonal therapy is used in breast cancer and who is given what?

Answer 177

Adjuvant hormonal therapy is offered if tumours are positive for hormone receptors. For many years this was done using tamoxifen for 5 years after diagnosis. Tamoxifen is still used in pre- and peri-menopausal women. In post-menopausal women, aromatase inhibitors such as anastrozole are used for this purpose*. This is important as aromatisation accounts for the majority of oestrogen production in post-menopausal women and therefore anastrozole is used for ER +ve breast cancer in this group. Important side effects of tamoxifen include an increased risk of endometrial cancer, venous thromboembolism and menopausal symptoms.

Question 178

What is tamoxifen? Give 4 adverse effects?

Answer 178

Selective oEstrogen Receptor Modulators (SERM) Tamoxifen is a SERM which acts as an oestrogen receptor antagonist and partial agonist. It is used in the management of oestrogen receptor-positive breast cancer. Adverse effects menstrual disturbance: vaginal bleeding, amenorrhoea hot flushes - 3% of patients stop taking tamoxifen due to climacteric side-effects venous thromboembolism endometrial cancer

Question 179

What biological therapy is used in patient with breast ca?

Answer 179

The most common type of biological therapy used for breast cancer is trastuzumab (Herceptin). It is only useful in the 20-25% of tumours that are HER2 positive. Trastuzumab cannot be used in patients with a history of heart disorders.

Question 180

Describe what aromatase inhibitors are used in breast ca and who is this used in? what are 4 side effect?

Answer 180

Anastrozole and letrozole are aromatase inhibitors that reduces peripheral oestrogen synthesis. This is important as aromatisation accounts for the majority of oestrogen production in postmenopausal women and therefore anastrozole is used for ER +ve breast cancer in this group. Adverse effects osteoporosis NICE recommends a DEXA scan when initiating a patient on aromatase inhibitors for breast cancer hot flushes arthralgia, myalgia insomnia

Question 181

What cytotoxic therapy is used in patients with breats ca?

Answer 181

Cytotoxic therapy may be used either prior to surgery ('neoadjuvanant' chemotherapy) to downstage a primary lesion or after surgery depending on the stage of the tumour, for example, if there is axillary node disease - FEC-D is used in this situation.

Question 182

Nipple discharge: what features point to galactorrhoea?

Answer 182

Commonest cause may be response to emotional events, drugs such as histamine receptor antagonists are also implicated

Question 183

Nipple discharge due to hyperprolactinaemia -Give 4 features

Answer 183

Commonest type of pituitary tumour Microadenomas <1cm in diameter Macroadenomas >1cm in diameter Pressure on optic chiasm may cause bitemporal hemianopia

Question 184

Give 4 features of mammary duct ectasia

Answer 184

Dilatation breast ducts. Most common in menopausal women Discharge typically thick and green in colour Most common in smokers

Question 185

What would point towards carcinoma causing nipple discharge?

Answer 185

Often blood stained May be underlying mass or axillary lymphadenopath

Question 186

Nipple dischareg - give 3 features of intraductal papilloma

Answer 186

Commoner in younger patients May cause blood stained discharge There is usually no palpable lump

Question 187

Describe the reporting of investigations for nipple dischagre and a mass lesion is suspected

Answer 187

Where a mass lesion is suspected or investigations are requested these are prefixed using a system that denotes the investigation type e.g. M for mammography, followed by a numerical code as shown below: 1 No abnormality 2 Abnormality with benign features 3 Indeterminate probably benign 4 Indeterminate probably malignant 5 Malignant

Question 188

Give 4 management points for benign nipple discharge

Answer 188

Exclude endocrine disease Nipple cytology unhelpful Smoking cessation advice for duct ectasia For duct ectasia with severe symptoms, total duct excision may be warranted.

Question 189

What is mastitis and give 2 clinical features

Answer 189

Mastitis refers to inflammation of the breast tissue and is typically associated with breastfeeding, where it develops in around 1 in 10 women. Features painful, tender, red hot breast fever, and general malaise may be present

Question 190

Describe the management of mastitis?

Answer 190

Management the first-line management of mastitis is to continue breastfeeding. simple measures analgesia warm compresses the BNF advises treating 'if systemically unwell, if nipple fissure present, if symptoms do not improve after 12-24 hours of effective milk removal of if culture indicates infection' the first-line antibiotic is oral flucloxacillin for 10-14 day reflects the fact that the most common organism causing infective mastitis is Staphylococcus aureus breastfeeding or expressing should continue during antibiotic treatment. If left untreated, mastitis may develop into a breast abscess. This generally requires incision and drainage.

Question 191

Is bladder cancer common? Give 2 risk factors

Answer 191

Bladder cancer is the second most common urological cancer. It most commonly affects males aged between 50 and 80 years of age. Those who are current, or previous (within 20 years), smokers have a 2-5 fold increased risk of the disease. Exposure to hydrocarbons such as 2-Naphthylamine increases the risk. Although rare in the UK, chronic bladder inflammation arising from Schistosomiasis infection remains a common cause of squamous cell carcinomas, in those countries where the disease is endemic

Question 192

What are 3 types of bladder malignancies?

Answer 192

Bladder malignancies Urothelial (transitional cell) carcinoma (>90% of cases) Squamous cell carcinoma ( 1-7% -except in regions affected by schistosomiasis) Adenocarcinoma (2%) Urothelial carcinomas may arise as solitary lesions, or may be multifocal, owing to the effect of 'field change' within the urothelium. Up to 70% of TCC's will have a papillary growth pattern. These tumours are usually superficial in location and accordingly have a better prognosis. The remaining tumours show either mixed papillary and solid growth or pure solid growths. These tumours are typically more prone to local invasion and may be of higher grade, the prognosis is therefore worse. Those with T3 disease or worse have a 30% (or higher) risk of regional or distant lymph node metastasis.

Question 193

how is bladder cancer staged?

Answer 193

TNM Most will undergo a cystoscopy and biopsies or TURBT, this provides histological diagnosis and information relating to depth of invasion. Locoregional spread is best determined using pelvic MRI and distant disease CT scanning. Nodes of uncertain significance may be investigated using PET CT.

Question 194

What is the most common presentations of bladder cancer?

Answer 194

Most patients (85%) will present with painless, macroscopic haematuria. In those patients with incidental microscopic haematuria, up to 10% of females aged over 50 will be found to have a malignancy (once infection excluded).

Question 195

What is the management of bladder ca?

Answer 195

Those with superficial lesions may be managed using TURBT in isolation. Those with recurrences or higher grade/ risk on histology may be offered intravesical chemotherapy. Those with T2 disease are usually offered either surgery (radical cystectomy and ileal conduit) or radical radiotherapy.

Question 196

What is the prognosis of bladder ca? T1/2/3/4a/any

Answer 196

T1 90% T2 60% T3 35% T4a 10-25% Any T, N1-N2 30%

Question 197

Renal cell cancer: -Is this common -what is the most common type?

Answer 197

Renal cell cancer is also known as hypernephroma and accounts for 85% of primary renal neoplasms. It arises from proximal renal tubular epithelium. The most common histological subtype is clear cell (75 to 85 percent of tumours).

Question 198

Give 5 associations of renal cell cancer?

Answer 198

Associations -more common in middle-aged men -smoking -von Hippel-Lindau syndrome -tuberous sclerosis -incidence of renal cell cancer is only slightly increased in patients with autosomal dominant polycystic kidney disease

Question 199

What is the classical triad of renal cell cancer? give 5 other clinical features?

Answer 199

Classical triad: haematuria loin pain abdominal mass -pyrexia of unknown origin endocrine effects -may secrete erythropoietin (polycythaemia) -parathyroid hormone-related protein (hypercalcaemia), renin -ACTH -25% have metastases at presentation -paraneoplastic hepatic dysfunction syndrome varicocele majority are left-sided caused by the tumour compressing veins

Question 200

What is stauffer syndrome in renal cell cancer?

Answer 200

Stauffer syndrome a paraneoplastic disorder associated with renal cell cancer typically presents as cholestasis/hepatosplenomegaly it is thought to be secondary to increased levels of IL-6

Question 201

Describe the T categories of renal cell carcinoma?

Answer 201

T category Criteria T1 Tumour ≤ 7 cm and confined to the kidney T2 Tumour > 7 cm and confined to the kidney T3 Tumour extends into major veins or perinephric tissues, but not into the ipsilateral adrenal gland and not beyond Gerota's fascia T4 Tumor invades beyond Gerota's fascia (including contiguous extension into the ipsilateral adrenal gland)

Question 202

Give 3 management points of renal cell cancer

Answer 202

Management -for confined disease a partial or total nephrectomy depending on the tumour size -patients with a T1 tumour (i.e. < 7cm in size) are typically offered a partial nephrectomy -alpha-interferon and interleukin-2 have been used to reduce tumour size and also treat patients with metatases -receptor tyrosine kinase inhibitors (e.g. sorafenib, sunitinib) have been shown to have superior efficacy compared to interferon-alpha

Question 203

Describe the medical and acute management of renal colic

Answer 203

Pain management and medical therapy both BAUS and NICE recommend an NSAID as the analgesia of choice for renal colic NICE whilst diclofenac has been traditionally used the increased risk of cardiovascular events with certain NSAIDs (e.g. diclofenac, ibuprofen) should be considered when prescribing if NSAIDs are contraindicated or not giving sufficient pain relief NICE recommend IV paracetamol the CKS guidelines suggest for patients who require admission: 'Administer a parenteral analgesic (such as intramuscular diclofenac) for rapid relief of severe pain' alpha blockers NICE promote smooth muscle relaxation and dilation of the ureter. potentially easing stone passage NICE recommend these are considered for distal ureteric stones less than 10 mm in size BAUS don't formally recommend but do however acknowledge a recently published meta-analysis advocates the use of α-blockers for patients amenable to conservative management, with the greatest benefit amongst those with larger stones

Question 204

Give 6 initial investigations for renal colic?

Answer 204

Initial investigations -urine dipstick and culture -serum creatinine and electrolytes: check renal function -FBC / CRP: look for associated infection -calcium/urate: look for underlying causes -stone analysis should be considered once the stone has passed -also: clotting if percutaneous intervention planned and blood cultures if pyrexial or other signs of sepsis

Question 205

what imaging is used in renal colic?

Answer 205

Imaging non-contrast CT KUB should be performed on all patients, within 24 hours of admission NICE if a patient has a fever, a solitary kidney or when the diagnosis is uncertain an immediate CT KUB should be performed. In the case of an uncertain diagnosis, this is to exclude other diagnoses such as ruptured abdominal aortic aneurysm CT KUB has a sensitivity of 97% for ureteric stones and a specificity of 95% ultrasound should be used for pregnant women and children the sensitivity of ultrasound for stones is around 45% and specificity is around 90%

Question 206

What is the management of renal stone?

Answer 206

Renal stones -watchful waiting if <5mm and asymptomatic - 5-10mm shockwave lithotripsy -10-20 mm shockwave lithotripsy OR ureteroscopy -> 20 mm percutaneous nephrolithotomy

Question 207

what is the management of ureteric stones?

Answer 207

Uretic stones -<10mm shockwave lithotripsy +/- alpha blockers -10-20 mm ureteroscopy

Question 208

How can calcium renal stones be prevented?

Answer 208

Calcium stones may be due to hypercalciuria, which is found in up to 5-10% of the general population. high fluid intake add lemon juice to drinking water avoid carbonated drinks limit salt intake potassium citrate may be beneficial NICE thiazides diuretics (increase distal tubular calcium resorption)

Question 209

How can oxalate renal stones be prevented?

Answer 209

Oxalate stones cholestyramine reduces urinary oxalate secretion pyridoxine reduces urinary oxalate secretion

Question 210

How can uric acid renal stones be prevented?

Answer 210

Uric acid stones allopurinol urinary alkalinization e.g. oral bicarbonate

Question 211

Give 5 voiding LUTS

Answer 211

Hesitancy Poor or intermittent stream Straining Incomplete emptying Terminal dribbling

Question 212

Give 4 storage LUTS

Answer 212

Urgency Frequency Nocturia Urinary incontinence

Question 213

Give 2 post-micturition LUTS

Answer 213

Post-micturition dribbling Sensation of incomplete emptying

Question 214

What is examination and the assessment of a patient presenting with LUTS

Answer 214

Examination urinalysis: exclude infection, check for haematuria digital rectal examination: size and consistency of prostate a PSA test may be indicated, but the patient should be properly counselled first It is useful to get the patient to complete the following to guide management: urinary frequency-volume chart: distinguish between urinary frequency, polyuria, nocturia, and nocturnal polyuria. International Prostate Symptom Score (IPSS): assess the impact on the patient's life. This classifies the symptoms as mild, moderate or severe

Question 215

Give 5 management points for predominately voiding LUTS

Answer 215

Predominately voiding symptoms -conservative measures include: pelvic floor muscle training, bladder training, prudent fluid intake and containment products -if 'moderate' or 'severe' symptoms offer an alpha-blocker -if the prostate is enlarged and the patient is 'considered at high risk of progression' then a 5-alpha reductase inhibitor should be offered -if the patient has an enlarged prostate and 'moderate' or 'severe' symptoms offer both an alpha-blocker and 5-alpha reductase inhibitor -if there are mixed symptoms of voiding and storage not responding to an alpha blocker then a antimuscarinic (anticholinergic) drug may be added

Question 216

Give 4 management points for predominately overactive bladder

Answer 216

Predominately overactive bladder conservative measures include moderating fluid intake bladder retraining should be offered antimuscarinic drugs should be offered if symptoms persist. NICE recommend oxybutynin (immediate release), tolterodine (immediate release), or darifenacin (once daily preparation) mirabegron may be considered if first-line drugs fail

Question 217

What is the management of nocturia

Answer 217

Nocturia advise about moderating fluid intake at night furosemide 40mg in late afternoon may be considered desmopressin may also be helpful

Question 218

Describe the interpretation of ABPI

Answer 218

Interpretation of ABPI > 1.2: may indicate calcified, stiff arteries. This may be seen with advanced age or PAD 1.0 - 1.2: normal 0.9 - 1.0: acceptable < 0.9: likely PAD. Values < 0.5 indicate severe disease which should be referred urgently The ABPI is a good test, values less than 0.90 have been shown to have a sensitivity of 90% and a specificity of 98%* for PAD. Compression bandaging is generally considered acceptable if the ABPI >= 0.8.

Question 219

What is the management of PAD that is not severe/critical limb ischaemia?

Answer 219

Peripheral arterial disease (PAD) is strongly linked to smoking. Patients who still smoke should be given help to quit smoking. Comorbidities should be treated, including hypertension diabetes mellitus obesity As with any patient who has established cardiovascular disease, all patients should be taking a statin. Atorvastatin 80 mg is currently recommended. In 2010 NICE published guidance suggesting that clopidogrel should be used first-line in patients with peripheral arterial disease in preference to aspirin. Exercise training has been shown to have significant benefits. NICE recommend a supervised exercise programme for all patients with peripheral arterial disease prior to other interventions.

Question 220

What is the manageemnt of severe PAD or critical limb ischaemia? What drugs are licensed of PAD?

Answer 220

Severe PAD or critical limb ischaemia may be treated by: endovascular revascularization percutaenous transluminal angioplasty +/- stent placement endovascular techniques are typically used for short segment stenosis (e.g. < 10 cm), aortic iliac disease and high-risk patients surgical revascularization surgical bypass with an autologous vein or prosthetic material endarterectomy open surgical techniques are typically used for long segment lesions (> 10 cm), multifocal lesions, lesions of the common femoral artery and purely infrapopliteal disease Amputation should be reserved for patients with critical limb ischaemia who are not suitable for other interventions such as angioplasty of bypass surgery. Drugs licensed for use in peripheral arterial disease (PAD) include: naftidrofuryl oxalate: vasodilator, sometimes used for patients with a poor quality of life cilostazol: phosphodiesterase III inhibitor with both antiplatelet and vasodilator effects - not recommended by NICE

Question 221

Give 4 risk factors for varicose veins?

Answer 221

Risk factors increasing age female gender pregnancy the uterus causes compression of the pelvic veins obesity

Question 222

Why may patients present with varicose veins?

Answer 222

For many patients, the cosmetic appearance may prompt presentation. However other patients may complain of symptoms: aching, throbbing itching Other patients may present with complications of varicose veins: a variety of skin changes may be seen: -varicose eczema (also known as venous stasis) -haemosiderin deposition → hyperpigmentation -lipodermatosclerosis → hard/tight skin -atrophie blanche → hypopigmentation bleeding superficial thrombophlebitis venous ulceration deep vein thrombosis

Question 223

What is the investigations of varicose veins?

Answer 223

Investigation venous duplex ultrasound: this will demonstrate retrograde venous flow

Question 224

Give 4 conservative treatments for varicose veins?

Answer 224

Management the majority of patients with varicose veins do not require surgery. Conservative treatments include: leg elevation weight loss regular exercise graduated compression stockings

Question 225

Give 5 reasons for referral of patients for varicose veins?

Answer 225

reasons for referral to secondary care include: significant/troublesome lower limb symptoms e.g. pain, discomfort or swelling previous bleeding from varicose veins skin changes secondary to chronic venous insufficiency (e.g. pigmentation and eczema) superficial thrombophlebitis an active or healed venous leg ulcer

Question 226

Give 3 possible treatments for varicose veins?

Answer 226

possible treatments: endothermal ablation: using either radiofrequency ablation or endovenous laser treatment foam sclerotherapy: irritant foam → inflammatory response → closure of the vein surgery: either ligation or stripping

Question 227

What is scheuermann's disease? -Who does this affect? -give 2 symptoms -What is seen on xray -What is a clinical feature? -What is the management?

Answer 227

Epiphysitis of the vertebral joints is the main pathological process Predominantly affects adolescents Symptoms include back pain and stiffness X-ray changes include epiphyseal plate disturbance and anterior wedging Clinical features include progressive kyphosis (at least 3 vertebrae must be involved) Minor cases may be managed with physiotherapy and analgesia, more severe cases may require bracing or surgical stabilisation

Question 228

What is scoliosis? what are the two different types and how can you differentiate? how is this managed?

Answer 228

Consists of curvature of the spine in the coronal plane Divisible into structural and non structural, the latter being commonest in adolescent females who develop minor postural changes only. Postural scoliosis will typically disappear on manoeuvres such as bending forwards Structural scoliosis affects > 1 vertebral body and is divisible into idiopathic, congential and neuromuscular in origin. It is not correctable by alterations in posture Within structural scoliosis, idiopathic is the most common type Severe, or progressive structural disease is often managed surgically with bilateral rod stabilisation of the spine

Question 229

What is spina bifida? -What are 3 categories -What is the most severe type? -What is used during pregnancy to reduce the incidence of this?

Answer 229

Non fusion of the vertebral arches during embryonic development Three categories; myelomeningocele, spina bifida occulta and meningocele Myelomeningocele is the most severe type with associated neurological defects that may persist in spite of anatomical closure of the defect Up to 10% of the population may have spina bifida occulta, in this condition the skin and tissues (but not not bones) may develop over the distal cord. The site may be identifiable by a birth mark or hair patch The incidence of the condition is reduced by use of folic acid supplements during pregnancy

Question 230

What is spondylolysis? Where does this usually affect?

Answer 230

Congenital or acquired deficiency of the pars interarticularis of the neural arch of a particular vertebral body, usually affects L4/ L5 May be asymptomatic and affects up to 5% of the population Spondylolysis is the commonest cause of spondylolisthesis in children Asymptomatic cases do not require treatment

Question 231

Spondylolisthesis - what is this? what may be seen on plain films?

Answer 231

This occurs when one vertebra is displaced relative to its immediate inferior vertebral body May occur as a result of stress fracture or spondylolysis Traumatic cases may show the classic 'Scotty Dog' appearance on plain films Treatment depends upon the extent of deformity and associated neurological symptoms, minor cases may be actively monitored. Individuals with radicular symptoms or signs will usually require spinal decompression and stabilisation

Question 232

Extradural haematoma: -What is this and what does this often result from? -Give 2 clinical features

Answer 232

Bleeding into the space between the dura mater and the skull. Often results from acceleration-deceleration trauma or a blow to the side of the head. The majority of epidural haematomas occur in the temporal region where skull fractures cause a rupture of the middle meningeal artery. Features features of raised intracranial pressure some patients may exhibit a lucid interval

Question 233

Subdural haematoma: -What is this and where does this most commonly occur? -Give 3 risk factors -Give the clinical features

Answer 233

Bleeding into the outermost meningeal layer. Most commonly occur around the frontal and parietal lobes. Risk factors include old age, alcoholism and anticoagulation. Slower onset of symptoms than a epidural haematoma. There may be fluctuating confusion/consciousness

Question 234

Subarachnoid haemorrhage: -What is the classic symptom? -What does this usually occur from?

Answer 234

Classically causes a sudden occipital headache. Usually occurs spontaneously in the context of a ruptured cerebral aneurysm but may be seen in association with other injuries when a patient has sustained a traumatic brain injury

Question 235

Intracerebral haematoma: -give causes/risk factors -How do patients present? -What is seen on CT -What is the treatment

Answer 235

n intracerebral (or intraparenchymal) haemorrhage is a collection of blood within the substance of the brain. Causes / risk factors include: hypertension, vascular lesion (e.g. aneurysm or arteriovenous malformation), cerebral amyloid angiopathy, trauma, brain tumour or infarct (particularly in stroke patients undergoing thrombolysis). Patients will present similarly to an ischaemic stroke (which is why it is crucial to obtain a CT in head in all stroke patients prior to thrombolysis) or with a decrease in consciousness. CT imaging will show a hyperdensity (bright lesion) within the substance of the brain. Treatment is often conservative under the care of stroke physicians, but large clots in patients with impaired consciousness may warrant surgical evacuation.

Question 236

Who gets a CT head within 1 hr post head injury according to NICE?

Answer 236

CT head within 1 hour GCS < 13 on initial assessment GCS < 15 at 2 hours post-injury suspected open or depressed skull fracture any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid leakage from the ear or nose, Battle's sign). post-traumatic seizure. focal neurological deficit. more than 1 episode of vomiting

Question 237

Who gets a CT head within 8 hours post head injury?

Answer 237

CT head scan within 8 hours of the head injury - for adults with any of the following risk factors who have experienced some loss of consciousness or amnesia since the injury: age 65 years or older any history of bleeding or clotting disorders including anticogulants dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall from a height of greater than 1 metre or 5 stairs) more than 30 minutes' retrograde amnesia of events immediately before the head injury

Question 238

What is the max safe dose of lidocaine?

Answer 238

Lidocaine is the most widely used LA. It has a rapid onset of action and anaesthesia lasts for around 1 hour. the maximum safe dose is 3mg/kg. The BNF states 200mg (or 500mg if given in solutions containing adrenaline), which equates to 3mg/kg for a 66kg patient. This is the equivalent of 20ml of 1% solution or 10ml of 2% solution lidocaine is available pre-mixed with adrenaline. This increases the duration of action of lidocaine and reduces blood loss secondary to vasoconstriction. It must never be used near extremities due to the risk of ischaemia

Question 239

Suture material - absorbable or non-absorbable? Silk Novafil Prolene Ethilon

Answer 239

non-absorbable

Question 240

Suture material - absorbable or non-absorbable? Vicryl Dexon PDS

Answer 240

Absorbable

Question 241

How long does it take for sutures to disappear?

Answer 241

Non-absorbable sutures are normally removed after 7-14 days, depending on the location. Absorbable sutures normally disappear after 7-10 days.

Question 242

What is removal time for sutures on: Face Scalp/limbs/chest Hand/foot/back

Answer 242

Area Removal time (days) Face 3 - 5 Scalp, limbs, chest 7 - 10 Hand, foot, back 10 - 14

Question 243

When are patients referred to bariatric surgery?

Answer 243

Obesity - NICE bariatric referral cut-offs with risk factors (T2DM, BP etc): > 35 kg/m^2 no risk factors: > 40 kg/m^2

Question 244

What are 3 primarily restrictive types of bariatric surgery?

Answer 244

Primarily restrictive operations laparoscopic-adjustable gastric banding (LAGB) it is normally the first-line intervention in patients with a BMI of 30-39kg/m^2 produces less weight loss than malabsorptive or mixed procedures but as it has fewer complications sleeve gastrectomy stomach is reduced to about 15% of its original size intragastric balloon the balloon can be left in the stomach for a maximum of 6 months

Question 245

What is the primarily malabsorptive bariatric operation?

Answer 245

Primarily malabsorptive operations biliopancreatic diversion with duodenal switch usually reserved for very obese patients (e.g. BMI > 60 kg/m^2)

Question 246

Which bariatric operation is mixed both malabsorptive and restrictive?

Answer 246

Mixed operations Roux-en-Y gastric bypass surgery is both restrictive and malabsorptive in action

Question 247

VTE prophylaxis: -How long after elective hip replacement is this advised?

Answer 247

LMWH for 10 days followed by aspirin (75 or 150 mg) for a further 28 days or LMWH for 28 days combined with anti-embolism stockings until discharge or Rivaroxaban

Question 248

VTE prophylaxis: -How long after elective knee replacement is this advised?

Answer 248

Aspirin (75 or 150 mg) for 14 days or LMWH for 14 days combined with anti-embolism stockings until discharge or Rivaroxaban

Question 249

VTE prophylaxis: -How long after fragility fracture of pelvis/hip/proximal femur is this advised?

Answer 249

The NICE guidance states the following (our bolding): Offer VTE prophylaxis for a month to people with fragility fractures of the pelvis, hip or proximal femur if the risk of VTE outweighs the risk of bleeding. Choose either: LMWH , starting 6–12 hours after surgery or fondaparinux sodium, starting 6 hours after surgery, providing there is low risk of bleeding.

Question 250

VTE prophylaxis: what advice is given to women prior to surgery and to all patients after surgeyr?

Answer 250

Pre-surgical interventions: Advise women to stop taking their combined oral contraceptive pill/hormone replacement therapy 4 weeks before surgery Post-surgical interventions: Try to mobilise patients as soon as possible after surgery Ensure the patient is hydrated