Urogenital Flashcards
1
Q
What bacteria count is indicative of a UTI?
A
Pure growth of >10^5 organisms/ml of fresh mid-stream urine.
2
Q
What is a UTI in male children more suggestive of?
A
Structural abnormality.
3
Q
What differences in symptoms are there between men and women in a UTI?
A
Asymptomatic bacteriuria less common in men.
4
Q
What are the causes of a UTI?
A
Remember KEEPS: K lebsiella E. coli (most common) E enterococcus P roteus/pseudomonas S taphylococcus saprophyticus.
5
Q
What are the gram negative causes of UTI?
A
E.coli.
Proteus mirabilis.
Klebsiella pneumonia.
Pseudomonas aeruginosa.
6
Q
What type of gram negative bacteria is E.coli?
A
Lactose-fermenting.
7
Q
What does proteus mirabilis look like on culture?
A
Swarming.
8
Q
What is klesiella pneumonia UTI associated with?
A
Hospitals and catheters.
9
Q
What is pseudomonas aeruginosa UTI associated with?
A
Recurrent UTI/underlying pathology.
10
Q
What are the gram positive causes of UTI?
A
Staphylococcus saprophyticus.
Enterococcus.
11
Q
What type of gram positive bacteria is Staphylococcus saprophyticus?
A
Lactose fermenting. Catalase positive, coagulase negative.
Second most common cause.
12
Q
Who does Staphylococcus saprophyticus most commonly affect?
A
Young, sexually active females.
13
Q
What type of gram positive bacteria is enterococcus?
A
Short-chain, diplococci.
14
Q
What is a non-bacterial cause of UTI?
A
TB.
15
Q
How does catheterisation cause a UTI?
A
Insertion may carry organisms into the bladder.
Formation of biofilms which protect from the flow of urine, host defences and antibiotics.
16
Q
What are the risk factors for a UTI?
A
Female, sexual intercourse, menopause (less oestrogen so loss of protective flora), catheterisation, diabetes mellitus (hyperglycaemia stops diapedesis), pregnancy, urinary tract obstruction, malformations, immunosuppression.
17
Q
Why is a UTI more likely in women than men?
A
Shorter urethra.
18
Q
How does bacteria get into the urinal tract?
A
- Urethra (catheters push bugs into the bladder)
- Obstruction: stones, BPH or stasis of urine
- E.coli fimbriae helps them to adhere to bladder epithelium and ascend into urinary tract.
- Pregnancy: stasis of urine.
19
Q
What is an upper UTI?
A
Descending infection: pyelonephritis, urethritis.
20
Q
What is a lower UTI?
A
Ascending infection: cystitis, urethritis and prostatitis.
21
Q
What is suggestive of urethritis?
A
Pyuria but negative urine culture.
22
Q
What are the symptoms of an upper UTI?
A
Loin/abdominal pain, tenderness, nausea, vomiting, fever, costovertebral angle pain.
23
Q
What are the symptoms of a lower UTI?
A
Remember HD FUSS: H aematuria D ysuria F requency U rgency S uprapubic pain S melly urine.
24
Q
What type of urine sample do you take with a UTI?
A
Midstream urine. The first sample of urine has first shedding of epithelial cells.
25
What do you look for in a urine dipstick with a UTI?
Blood, protein, nitrites, leucocytes (sign of infection), pH, glucose, ketones (sign of DKA).
26
What does early morning urine sample look for?
TB. After a period of dehydration they are at their highest concentration.
27
What may clasts on urine microscopy be indicative of?
Infection and damage to the kidney epithelium (glomerulonephritis).
28
What do epithelial cells indicate on a urine microscopy?
A poorly taken sample.
29
What is an uncomplicated UTI?
Non-pregnant female.
30
What is a complicated UTI?
Pregnant females, males, catheterised patients, children, recurrent/persistent infection, immunocompromised, nosocomial infection, structural abnormality, urosepsis and associated urinary tract disease.
31
When is asymptomatic bacteriuria prevalent?
Over 65s.
32
When do you not treat a UTI?
Over 65s.
33
Do you need to send a sample in an uncomplicated UTI?
No, treat empirically with 3 days.
| If MSU is sent, adjust antibiotics accordingly.
34
What is adjunctive advice in a UTI?
Increase fluid intake, void pre-post intercourse and hygiene.
35
What antibiotics are used to treat a UTI?
Trimethoprim, nitrofurantoin.
36
When is Nitrofurantoin contraindicated?
In pregnancy third trimester, creatinine clearance <45ml/min.
37
What are the side effects of Nitrofurantoin?
Nausea, vomiting, liver problems and weakness.
38
When is trimethoprim contraindicated?
In pregnancy.
39
What is pyelonephritis?
Infection of the renal parenchyma and soft tissues of renal pelvis and upper ureter.
40
Who is most commonly affected by pyelonephritis?
Predominantly females <35 (except in neonates) and associated with significant sepsis and systemic upset.
41
What are the causes of pyelonephritis?
```
Remember KEEPS:
K lebsiella
E. coli (most common cause)
E nterobacter
P roteua
S epticaemia and other haematogenous e.g. IE.
```
42
What is the triad of symptoms for pyelonephritis?
Loin/flank pain, fever and pyuria.
43
Are symptoms unilateral or bilateral in pyelonephritis?
Usually unilateral.
44
What is the gold standard investigation for UTI?
MSU with microscopy, culture and sensitivity.
45
When is an ultrasound used in a UTI?
To rule out obstruction in the upper tract.
46
What is the treatment for pyelonephritis?
• IV antibiotics: broad spectrum e.g. Co-amoxiclav/ciproflaxacin +/- Gentamicin. In pregnancy give cefalexin.
47
What are the complications of pyelonephritis?
Renal abscess, emphysematous pyelonephritis and septicaemia.
48
What is a urine dipstick positive for in cystitis?
Leukocytes, blood and nitrites (bacteria break nitrates down into nitrites).
49
What is the management for cystitis?
Often resolves without antibiotics with fluids.
Antibiotics:
First line: nitrofurantoin (1st trimester if pregnant), trimethoprim (3rd trimester if pregnant) or cefalexin
2nd line: ciprofloxacin or co-amoxiclav.
50
When does prostatitis usually present?
Over 35.
51
What causes acute prostatitis?
Strep. Faecalis.
E.coli.
Chlamydia.
Enterobacter serratia.
52
What causes chronic prostatitis?
Bacterial e.g. Strep. Faecalis, E.coli or chlamydia
| Non-bacterial e.g. elevated prostatic pressure, pelvic floor myalgia.
53
What are the symptoms of acute prostatitis?
Systemically unwell, fever, rigors, malaise, painful ejaculation, pelvic pain, haematuria, sharp pelvic/penile/anal pain.
Voiding LUTS: straining, poor stream, incomplete emptying, hesitancy, post-micturition dribbling, dysuria.
54
What are the symptoms of chronic prostatitis?
Acute symptoms > 3months, recurrent UTIs and pelvic pain.
55
What would show on a DRE for prostatitis?
Prostate is tender, hard from calcification, tender and hot.
56
What are the investigations for prostatitis?
DRE, urine dipstick (positive for leucocytes and nitrites), MSU microscopy, culture and sensitivity, blood cultures, STI screen (chlamydia in particular), trans-urethral ultrasound scan.
57
What is the treatment for acute prostatitis?
First line: IV gentamicin + IV co-amoxiclav.
Second line: trimethoprim.
TRUSS guided abscess drainage if necessary.
58
What is the treatment for chronic prostatitis?
4-6-week course of quinolone e.g. ciprofloxacin ± alpha blocker: Tamsulosin.
59
What are the 2 types of urethritis?
1. Gonococcal.
| 2. Non-gonococcal (more common).
60
What are the causes of non-gonococcal urethritis?
Chlamydia trachomatis (most common), mycoplasma genitalium and trichomonas vaginalis.
61
What is the gonococcal cause of urethritis?
Neisseria gonorrhoea.
62
What are the non-infective causes of urethritis?
Trauma, urethral stricture, irritation, urinary calculi (stones).
63
What are the symptoms of urethritis?
May be asymptomatic. Dysuria +/- discharge (more noticeable after holding urine overnight), blood or pus.
Urethral pain.
Penile discomfort.
Non-gonococcal is the same but with no discharge.
64
What are the investigations for urethritis?
```
Nucleic acid amplification test (NAAT).
Screen for STIs.
Microscopy of gram-stained smears of genital secretions.
Blood cultures.
Urine dipstick to exclude UTI.
Urethral smear.
```
65
What is the management for chlamydia?
Oral azithromycin or 1 week oral doxycycline.
| If pregnant: oral erythromycin (14 days) or oral azithromycin.
66
What is the management for gonorrhoea?
IM ceftriazone with oral azithromycin.
67
What is benign prostatic enlargement?
Benign proliferation of musculofibrous/glandular tissue of the transitional (inner) zone of the prostate.
Increase in epithelial and stromal cell numbers in periurethral area of prostate.
May be due to increase in cell number or due to decreased apoptosis, or a combination of both.
68
What is responsible for prostatic growth?
Dihydrotestosterone is responsible for prostatic growth.
69
What is protective of BPH?
Castration (removal of testicles). Androgens e.g. testosterone do not cause BPH but are a requirement for BPH. BPH is not seen in those with castration prior to puberty or genetic disease that inhibit androgen action/production.
70
What layer expands in peripheral prostate carcinoma?
Peripheral layer.
71
What is the pathophysiology of BPH?
Glandular epithelial cells and stromal cells undergo hyperplasia. Usually the median lobe is affected. After 30, men produce around 1% less testosterone each year but 5a-reductase increases with age and so there are increased dihydrotestosterone levels. Prostate cells respond by living longer and growing which causes hypertrophy
72
Why does a large prostate cause problems?
May squeeze or partly block:
1. The bladder so urine retention which causes bladder dilation and hypertrophy, urine stasis and bacterial growth so causes UTIs.
2. The urethra so urination problems.
73
What are the voiding symptoms in BPH?
```
Remember SHIPP:
S training
H esitancy
I ncomplete emptying
P oor/intermittent stream
P ost-micturition dribbling.
```
74
What are the storage symptoms in BPH?
Frequency increased.
Urgency: sudden compelling desire to void which is difficult to defer e.g. key in front door (latchkey incontinence).
Nocturia: >30% voided volume at night.
Urgency incontinence: type of urinary leakage which is preceded by urgency.
75
What are red flags in BPH?
Dysuria: painful or difficult urination.
Haematuria: blood in the urine.
Painless haematuria always suspected as malignancy until proven otherwise.
76
Is PSA raised in BPH?
It may be.
77
What is the treatment for BPH?
First line: selective alpha 1-adrenenergic receptor antagonists e.g. oral Tamsulosin which relaxes smooth muscle in bladder neck and prostate, producing an increase in urinary flow rate and an improvement in obstructive symptoms. Side effects of tamsulosin are postural hypotension so patient should take at night in bed, so they can’t faint and retrograde ejaculation where bladder neck relaxes so sperm travels back into bladder.
Second line: 5-a-reductase inhibitors e.g. oral Finasteride, Dutasteride. They inhibit conversion of testosterone to more active dihydrotestosterone. Side effects are fatigue, lethargy and degree of ED and libido loss.
78
What is the gold-standard surgery for BPH?
Trans-urethral resection of prostate but there is a risk of erectile dysfunction.
79
What are the indications for surgery in BPH?
Remember RUSHES:
R etention
U TIs
S tones
H aematuria (refractory to 5-alpha-reductas-inhibitors)
E levated creatinine due to bladder outflow obstruction
S ymptom deterioration.
80
What are the types of prostate cancer?
Adenocarcinomas: most common, arise from peripheral zone.
Transitional cell carcinomas: arise from transitional zone.
Small cell prostate cancer: arise from neuroendocrine cells.
81
What are the causes of prostate cancer?
```
Hormonal factors e.g. increased testosterone.
Family history (BRCA1 and BRCA2 mutations and HOXB13 is a predisposition gene).
```
82
Where might prostate cancer spread?
Local to seminal vessels, bladder and rectum.
Via lymph.
Haematogenously to bone (sclerotic bony lesions), brain, liver and lung.
83
Which lobes does prostate cancer most commonly affect?
Lateral lobes.
84
What is PSA elevated in?
BPE, UTI, prostatitis and prostate cancer.
85
What are the problems with PSA?
70% of men with an elevated PSA do not have cancer.
| 6% of men with prostate cancer do not have an elevated PSA.
86
What are the investigations for prostate cancer?
DRE, PSA, trans-rectal ultrasound scan, prostate biopsy with Gleason grading.
I-PSSS grading for bladder outflow obstruction.
87
What is the management of prostate cancer defined to the gland?
Prostatectomy or radiotherapy.
88
What is the management of prostate cancer which is disease progressing/advanced?
Localised radical treatment (radical prostatectomy and radical radiotherapy).
89
What medical treatment is given in prostate cancer?
Hormone therapy slows tumour growth (prostate cancer is most hormone-sensitive malignancy): GnRH agonists e.g. s/c Goserelin or s/c leuprorelin (testosterone flares use anti-androgen e.g. cyproterone acetate) and androgen receptor blockers e.g. Bicalutamide.
Treat hypercalcaemia with diuretics.
Give bisphosphonates (zoledronic acid).
90
What is the management for metastatic prostate cancer?
Androgen suppression, bilateral surgical orchidectomy (castration) and palliative care.
91
What are the 2 types of testicular cancer?
Seminoma: 96% arise from germ cells.
Teratomas: composed of tissue not normally present at the site (teeth).
92
When does testicular cancer present?
Seminomas: 25-40 and 60.
Teratomas: infancy.
Testicular cancer is the most common cancer in males aged 15-44.
93
Where does testicular cancer metastasise to?
Lung.
94
What are the symptoms of testicular cancer>
Painless/painful lump in testicle.
Testicular and/or abdominal pain.
Haematospermia.
Cough and dyspnoea is indicative of lung metastases.
Back pain is indicative of para-aortic lymph node metastasis.
Hydrocele.
95
What are the investigations in testicular cancer?
Ultrasound to differentiate between masses.
Biopsy and histology: seminoma are “fried egg” like cells.
Serum tumour markers: alpha-fetoprotein (AFP) and/or beta subunit of human chorionic gonadotrophin (B-hCG). Beta-hCG is raised in seminoma. Normal AFP means seminoma and raised AFP and B-hCG in non-seminomas germ cell tumours (sometimes teratomas). Also Lactate dehydrogenase (LDH).
96
What is the staging in testicular cancer?
CXR and CT to assess tumour staging:
1. No metastases
2. Para-aortic: infradiaphragmatic
3. Supradiaphragmatic
4. Spread to lungs.
97
What is the management in testicular cancer?
Radical orchidectomy via inguinal approach (offer sperm banking).
Radiotherapy: seminomas with metastases.
Chemotherapy: more widespread tumours and teratomas.
98
Where does renal cell carcinoma arise from?
Renal tubule (proximal tubular epithelium).
99
Where does transitional cell carcinoma arise from?
Renal pelvis.
100
What are the common metastases of renal cell carcinoma?
Lymphoma, lung, breast, skin, bone.
| "Cannon ball metastases".
101
What do renal cell carcinomas secrete?
PTH: hypercalcaemia.
ACTH: Cushing's like syndrome.
EPO: polycythaemia.
Renin: hypertension.
102
What is renal cell carcinoma associated with?
Von Hippel-Lindau syndrome and Polycystic Kidney Disease.
103
What are the symptoms of renal cell carcinoma?
Classic triad: loin/flank pain, haematuria, abdominal mass.
| Cancer symptoms: weight loss, loss of appetite, night sweats.
104
What are the investigations for renal cell carcinoma?
Intravenous urogram: dye stains kidney and passes into ureter. Blurs the outline.
Ultrasound: differentiate benign cyst from complex cyst/solid tumour.
CT scan: more sensitive and will show involvement of renal vein or inferior vena cava. For preoperative staging.
MRI: better than CT for staging.
Bloods: FBC, U&Es, Calcium, ESR.
Urinalysis.
Biopsy.
Bone scan.
105
What are the differential diagnoses for renal cell carcinoma?
Transitional cell carcinoma.
Wilm’s tumour (common in children).
Renal oncocytoma.
Leiomyosarcoma.
106
What is the management for renal cell carcinoma?
```
Resistant to traditional chemotherapy and radiotherapy.
Localised (T1): radical nephrectomy +/- lymphadectomy. Partial nephrectomy used if there is bilateral involvement or contralateral kidney has poor function.
Ablative therapy (T1a) is used in patients with significant co-morbidities who would not tolerate surgery: cryoablation, radiofrequency.
Metastatic: biological therapies e.g. interleukin-2 and interferon alpha, mTOR inhibitors e.g. temsirolimus, tyrosine kinase inhibitors e.g. sunitinib and sorafenib and monoclonal antibodies e.g. bevacizumab.
```
107
What is schistosomiasis usually associated with?
Squamous cell carcinoma (bladder).
108
What are risk factors for bladder cancer?
```
Smoking.
Bladder stones.
Paraplegia: long term catheter use.
Occupation exposure.
Exposure to drugs e.g. phenacetin and cyclophosphamide.
Chronic inflammation of urinary tracts e.g. schistosomiasis (usually associated with squamous carcinoma), bladder stones or indwelling catheters.
Age >40.
M>F.
Pelvic irradiation.
Family history.
```
109
Where does bladder cancer spread?
Local to pelvic structure.
Lymphatic to iliac and para-aortic nodes.
Haematogenous to liver and lungs.
110
What are the types of bladder cancer?
>90% urothelial (transitional) cell carcinomas.
Squamous cell carcinoma can arise due to recurrent UTIs and kidney stones.
Adenocarcinoma frequently metastasises.
111
What are the symptoms of bladder cancer?
Painless haematuria: visible or non-visible.
Mucusuria.
Abdominal mass.
Cancer (B) symptoms: weight loss, night sweats, loss of appetite.
UTI symptoms: frequency, urgency and dysuria in absence of bacteriuria.
Voiding irritability and change in bladder habits.
Pain from clot retention or advanced/metastatic disease.
112
What is the diagnostic investigation for bladder cancer?
Cystoscopy and biopsy to determine cell type.
| CT urogram is also diagnostic and provides staging.
113
What is the management for bladder cancer?
Non-Muscle invading: transurethral resection of bladder tumour (TURBT).
Muscle invasion: radical cystectomy and conduit/neobladder. Radical radiotherapy +/- chemotherapy (cisplatin).
114
What should be suspected if abdominal mass and haematuria in children?
Wilm's tumour (nephroblastoma).
115
How do you distinguish between the different non-malignant scrotal diseases?
If you cannot get above it, this is an inguinoscrotal hernia or proximally extending hydrocele.
A separate and cystic is epididymal cyst.
A separate and solid is epididymitis or varicocele.
Testicular and cystic is hydrocele.
Testicular and solid is tumour or haematocele.
116
What is the cause of an epidiymal cyst?
Probably obstruction of the epidisymis.
117
Where does an epidiymal cyst lie in relation to the tests?
Above and behind.
118
What fluid does an an epidiymal cyst contain?
Clear and milky (spermatocele).
119
What is the investigation for an epididymal cyst?
Scrotal ultrasound. It will transiluminate.
120
What are the differential diagnoses for an epididymal cyst?
Spermatocele: fluid and sperm filled cyst in epididymis. No way to clinically differentiate, can be differentiated by aspiration as sperm are present in milky fluid.
Hydrocele: collections of fluid surrounding entire testicle.
Varicocele: dilated veins that get larger with increases in abdominal pressure.
121
What is the management foe an epididymal cyst?
Usually not necessary, surgical excision if painful and symptomatic.
122
What is hydrocele?
Abnormal collection of fluid within the tunica vaginalis (fluid surrounding the testis).
123
What are the 3 types of hydrocele?
Simple: scrotal enlargement with a non-tender, smooth cystic swelling. Anterior to and below the testis transilluminate.
Communicating: as simple. Vacillates in size and is usually related to ambulation.
Non-communicating: imbalance between secretion and re-absorption of fluid.
124
What causes primary hydrocele?
Overproduction of fluid in tunica vaginalis.
| Associated with a patent processus vaginalis which typically resolves during first year of life
125
What causes secondary hydrocele?
Communicating hydrocele is when processus vaginalis fails to close, allowing peritoneal fluid to communicate freely with the scrotal portion.
126
What is secondary hydrocele secondary to?
```
Testis tumour.
Trauma.
Infection.
TB.
Testicular torsion.
Generalised oedema.
```
127
Where does hydrocele lie in relation to the testes?
Anterior to and below.
128
What is the investigation for hydrocele?
Scrotal ultrasound. Will transluminate.
129
What is the management for hydrocele?
Resolve spontaneously, many of infancy resolve by 2 years.
| Therapeutic aspiration or surgical removal.
130
What is varicocele?
Abnormal distribution of testicular veins in the pampiniform venomous plexus, caused be venous reflux.
131
Which side is more common in varicocele?
Left side more common due to angle of the left testicular vein entering the left renal vein.
132
When does the incidence of varicocele increase?
After puberty.
133
What are the 3 causes of varicocele?
1. Angle at which the left testicular vein enters the left renal vein.
2. Increased reflux from compression of renal vein (can be due to problems with valves causing backflow).
3. Lack of effective valves between the testicular and renal veins.
134
What is the pathophysiology of varicocele?
Impaired venous drainage so increased venous pressure and so vein dilation.
Excessive pressure causes swelling.
135
What are the symptoms of varicocele?
Dull ache.
Scrotal heaviness.
"Bag of worms".
The side affected hangs lower.
136
What are the investigations for varicocele?
Venography.
| Colour doppler ultrasound to see blood flow.
137
When do you intervene in varicocele?
Surgery if there is pain, infertility or testicular atrophy.
138
What is haematoceles?
Blood in tunica vaginalis.
139
What causes haematoceles?
Trauma.
140
What is the management for varicoceles?
Aspiration or surgery.
141
What is testicular torsion?
Twisting of the spermatic cord.
142
When does testicular torsion typically occur?
In neonates or post-pubertal boys (most common 11-30) but can occur any time.
143
What side is most commonly affected in testicular torsion?
Left side.
144
What is the cause of testicular torsion in adolescents and neonates?
Bell-clapper deformity where the testis is inadequately affixed to the scrotum allowing it to move more freely on axis and more susceptible to twisting.
145
What is the cause of testicular torsion?
Testiuclar malignancy or trauma.
146
What are the risk factors for testicular torsion?
Genetic factor, high insertion of the tunica vaginalis.
147
What are the symptoms of testicular torsion?
Sudden onset testicular pain which makes walking difficult and often comes on during sport of physical activity.
Inflamed and tender testicle.
Abdominal pain.
Nausea and vomiting.
148
What are the investigations in testicular torsion?
Doppler ultrasound shows decreased blood flow.
| Urinalysis to exclude infection and epididymis.
149
What is the management in testicular torsion?
Surgery within 6 hours has 90-100% salvage rate.
| Orchidectomy and bilateral fixation.
150
When is epidiymo-orchitis most common?
15-30 and >60.
151
What are the causes of epididymis-orchitis?
STIs: under 35 is chlamydia and gonorrhoea. Over 35 is UTI KEEPS.
Also mumps and trauma.
152
What are the symptoms of epididymis-orchitis.
Subacute onset of unilateral scrotal pain and swelling.
STI Epididymo-orchitis: urethritis, urethral discharge.
Mumps: headache, fever, unilateral/bilateral parotid swelling.
Tenderness.
Sweats/fever.
153
What is the sign for epididymis-orchitis?
Palpable swelling of testicles and epididymis.
154
What are the investigations for epididymis-orchitis?
```
Nucleic acid amplification test (NAAT): Female self-collected vaginal swab, endo-cervical swab, first void urine. Male: first void urine. High specificity and sensitivity.
MSU dipstick.
Ultrasound to rule out abscesses.
Blood cultures.
STI screening.
Urethral smear and swab.
```
155
What is the management for epidiymis-orchitis?
Chlamydia: Oral azithromycin or 1 week oral doxycycline. If pregnant oral erythromycin (14 days) or oral azithromycin.
Gonorrhoea: IM ceftriaxone with oral azithromycin.
UTI: Oral ciprofloxacin.
Analgesia: NSAIDs e.g. ibuprofen.
Partner notification and testing.
Abstinence.
156
What are the most common causes of epididymitis?
E.coli and chlamydia. Also trauma.
157
How do organisms spread into the epididymitis?
By retrograde spread from prostatic urethra and seminal vesicles or through blood stream.
158
What type of bacteria is Chlamydia trachomatis?
Gram negative.
159
What type of bacteria is Neisseria gonorrhoea?
Gram negative.
160
Where are the site of infections of chlamydia and gonorrhoea in an adult?
```
Both infect non-squamous epithelia:
• Urethra
• Endocervical canal
• Rectum
• Pharynx
• Conjuctiva.
```
161
Where are the site of infections of chlamydia and gonorrhoea in a neonate?
Conjuctiva.
| Atypical pneumonia also in neonatal chlamydia.
162
Where is the main site of infection of chlamydia and gonorrhoea in males?
Urethra.
163
Where is the main site of infection of chlamydia and gonorrhoea in females?
Endocervical canal.
164
What are complications of chlamydia and gonorrhoea in males?
Epididymo-orchitis and reactive arthritis.
165
What are complications of chlamydia and gonorrhoea in females?
Pelvic inflammatory disease (infection spreads from endocervical canal up to fallopian tubes and cause scarring which can lead to tubular factor infertility, ectopic pregnancy and chronic pelvic pain). Neonatal transmission can cause ophthalmic neonatorum and atypical pneumonia with CT. Fits Hugh Curtis syndrome (peri-hepatitis) is inflammation around the liver.
166
What is the investigation for chlamydia?
Nucleic Acid Amplification Tests (NAAT) :
• High specificity and sensitivity
• Sensitivity not 100%
• Negative test does not mean not infected
• Female: self-collected vaginal swab, endocervical swab, first void urine (lower sensitivity, sometimes used in community based asymptomatic screening)
• Male: first void urine.
167
What are the investigations for gonorrhoea?
```
Near patient test:
• Microscopy of gram stained smears of genital secretions looking for gram negative diplococci within cytoplasm of polymorphs
• Male: urethra
• Female: endocervix
• Rectum.
Culture on selective medium to confirm diagnosis.
Sensitivity testing.
NAAT.
```
168
What is the treatment for chlamydia?
Doxycycline 100mg twice a day for 7 days or azithromycin (1 dose).
Erythromycin 500mg twice a day for 14 days OR azithromycin in pregnancy as doxycycline in pregnancy can cause tooth staining.
169
What is the treatment for gonorrhoea?
Ceftriaxone IM injection with azithromycin.
170
What is syphilis?
Treponema pallidum sub-species pallidum.
171
What are the types of syphilis?
```
Early infectious syphilis (within 2 years of infection): Primary, Secondary and Early Latent
Late syphilis (over 2 years since infection): Late latent, CNS, gummatous.
```
172
How is syphilis highly transmissible?
Through oral sex.
173
What type of transmission is syphilis?
Vertical.
Primary and secondary >90% transmission, 50% fetal loss or still birth, 50% congenital syphilis.
Early latency: 40% transmission.
After 4 years: 2% transmission.
174
What are the symptoms of primary syphilis?
Primary chancre: 95% genital skin, also nipples, mouth.
Dusky macule, papule, hard clean based non-tender ulcer, 50% solitary.
Regional nodes 1-2 weeks after chancre.
Untreated: heals without scarring 4-8 weeks.
175
What are the symptoms of secondary syphilis?
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Onset 6-8 after infection: primary chance may be present concurrently (30%), may have no history of primary chancre.
70% present with skin rash on:
• Limbs
• Palms and soles
• Chest
• Neck
• Face.
Other manifestations: mucous membrane lesions (30%), generalised lymphadenopathy (50-60%), alopecia (moth-eaten), hoarseness, bone pain, hepatitis, nephrotic syndrome, deafness, iritis, meningitis, cranial nerve palsies, constitutional.
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176
What is the mainstay of diagnosis for syphilis?
Serology. Genital ulcer serology usually positive if ulcer present for 2 or more weeks. If serology negative, repeat at 6 and 12 weeks to exclude diagnosis
177
What is the management for syphilis?
IM penicillin.
178
What is the prognosis for untreated syphilis?
65% : no clinical sequelae.
15%: late benign gummatous 2-40 years after exposure.
10%: neurosyphilis 2-30 years after exposure, GPI 10-15 years, Tabes 15-35 years.
10%: CV 20-30 years after exposure.
179
What does the spermatic cord pass through?
The lingual canal.
180
Dilation of which veins is called varicocele?
Pampiniform plexus of testicular veins.
| They drain venous blood from the testes into the testicular vein.
181
Where does the left testicular vein drain into?
Left renal vein.
182
Where does the right testicular vein drain into?
Inferior vena cava.
183
What is the name of the duct that transports sperm from the epididymis to the ejaculatory ducts, ready for ejaculation?
Vas deferens.
184
Where do the lymph vessels in the spermatic cord drain into?
Para-aortic nodes, located in the lumbar region.
185
What forms the pathway of descent for the testes during embryonic development
The processus vaginalis (a projection of the peritoneum). In an adult it is fused shut.
186
What is a hernia?
A protrusion of an organ or fascia through the wall of a cavity that normally contains it.
187
What are the 7 layers of the testicle?
1. Scrotum/skin
2. Dartos muscle
3. External spermatic fascia
4. Cremaster
5. Internal spermatic fascia
6. Tunica vaginalis (parietal and visceral)
7. Tunica albuginea.
188
Where is the epididymis in relation to the testicle?
Posterolateral.
189
Where are sperm produced?
Testicle.
190
Where are sperm stored?
Epididymis.
191
What are the two coverings of the testicles?
1. Tunica vaginalis is external, covering anterior surface of each testicle. It is derived from abdominal peritoneum. Fluid in here is called a hydrocele.
2. Tunica albuginea is a fibrous capsule enclosing the testes, penetrating the testes and dividing it into lobules.
192
Fluid in where is called hydrocele?
Tunica vaginalis.
193
How does sperm get to the urethra for ejaculation?
Tail of the epididymis is connected to vas deferens which transports sperm to the urethra for ejaculation.
194
Where do the scrotal veins drain into?
The external pudendal veins.
195
Where is the referred pain in the scrotum felt?
T11/T12.
196
What muscle is immediately underneath the scrotal skin and regulates temperature?
Dartos.
197
Where would you palpate to assess the spread of testicular cancer?
The lymph nodes in the epigastrium.
198
Where is blood pumped to help maintain an erection?
Corpus cavernosa.
199
What forms the corpus cavernous?
The two crura from the body.
200
What forms the corpus spongiosum?
The bulb of the penis.
201
What are the cavernous spaces of the penis drained by?
Deep dorsal vein of the penis?
202
What is the innervation of the penis?
S2-S4.
203
What is the role of prostate?
Secretes proteolytic enzymes into the semen to break down clotting factors in the ejaculate so it remains in a mostly fluid state in the female reproductive tract.
204
What is posterior to the prostate?
Ampulla of the rectum, hence DRE can examine prostate.
205
What are the lateral lobes of the prostate prone to?
Malignancy.
206
What does the prostatic venous plexus drain into?
The internal iliac vein.
207
Where does the sympathetic, parasympathetic and sensory innervation of the prostate come from?
Inferior hypogastric plexus.
| This comes of sympathetic chain at T10-L2.
208
What prevents semen entering the bladder during ejaculation?
The internal urethral sphincter closes.
209
What does ejaculate contain?
Alkaline fluid (neutralises acidity of male urethra and vagina).
Fructose to provide energy to spermatozoa.
Prostaglandins to suppress female immune response.
Clotting factors help form a seal/plug after the ejaculate has entered the vagina, so the sperm travel in one way.
210
What nerve system maintains an erection?
Parasympathetic.
211
What nerve system causes ejaculation?
Sympathetic.
212
What is semen made of?
60% seminal vesicle fluid, 30% prostatic & 10% sperm and trace of bulbourethral fluid.
213
What is a normal sperm count?
Normal sperm count is 50-120 million/mL (< 25 million/mL is associated with infertility).
214
What is the route of sperm travel?
Route of sperm travel : seminiferous tubules -> epididymis -> vas deferens -> ampulla (seminal vesicles added) -> prostate -> urethra.
215
What nerve innervation does detrusor muscle have?
Both parasympathetic and sympathetic innervation.
216
What is the function of the internal sphincter in females?
it is a functional sphincter (i.e. no sphincter muscles) formed from bladder neck and proximal urethra.
217
What does relaxation of the external urethral sphincter cause?
Urine flow. This is under voluntary control.
218
What vessels supply the bladder?
Internal iliac vessels.
219
What is the sympathetic innervation of the bladder?
Hypogastric nerve (T12-L2) causing relaxation of detrusor muscle allowing urine retention.
220
What is the parasympathetic innervation of the bladder?
Pelvic nerve (S2-S4). Increased signal impulse leads to contraction of detrusor muscle causing micturition.
221
What controls motor innervation of the external urethral sphincter?
Pudendal nerve (S2-S4), causing it to constrict (and store urine) or relax (causing micturition).
222
What does bladder stretch lead to?
Micturition.
| This is overwritten in children and adults but not in infants.
223
What is the reflex arc of the bladder in adults and children (not infants)?
1. Bladder stretches and sensory fibres transmit this to spinal cord
2. Interneurones signal to parasympathetic efferent nerves (pelvic nerve)
3. This contracts detrusor muscle and stimulates micturition.
224
What is the sensory innervation of the vulva?
Anterior portion is the Ilioinguinal nerve, genital branch (of genitofemoral).
Posterior portion is the pudendal nerve, posterior cutaneous nerve of thigh. This is a branch off the sacral plexus.
225
What is the nerve innervation of the clitoris and vestibule?
Parasympathetic innervation from uterovaginal plexus (which is part of inferior hypogastric plexus).
226
What is the vasculature in the vulva?
Pudendal arteries/veins.
227
What is the innervation of the vagina?
Uterovaginal plexus:
• Inferior fibres is the superior part of vagina
• Pudendal nerve is the inferior part of vagina.
228
What is the vasculature of the vagina?
Uterine and vaginal arteries.
229
What is the ectocervix lined by?
Non-keratinising stratified squamous epithelium.
230
What is the endocervical canal lined by?
Mucus-secreting simple columnar epithelium.
231
What is the innervation of the cervix?
* Sympathetic is uterovaginal plexus
| * Parasympathetic is pelvic splanchnic nerves.
232
What is the vasculature of the cervix?
Uterine artery and uterine veins.
233
What are the fallopian tubes lined by?
Ciliated columnar epithelial cells and non-ciliated secretory cells.
234
What is the innervation of the fallopian tubes?
• Sympathetic and parasympathetic from ovarian and pelvic plexuses.
235
What is the vasculature of the fallopian tubes?
Uterine and ovarian arteries/veins.
236
Where are oestrogen and progesterone produced?
Ovaries.
237
What are the ovaries lined by?
Simple cuboidal epithelium, known as germinal epithelium
238
What are the 3 types of ligament in the female genitalia?
Broad, ovarian and uterine.
239
What lifts the anus on contraction to stop defecation?
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Puborectalis muscle (and pubococcygeus muscle which are part of the levator ani.
The contraction of the puborectalis muscle changes the angle of the rectum and anus to make passage of faeces harder.
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240
What makes up the anal triangle?
* Anal aperture: opening of anus
* External anal sphincter muscles (voluntary)
* Two ischioanal fossae (spaces located laterally to anus, contain connective tissue).
241
What happens to the detrusor muscle during storage?
Relaxes.
242
What happens to the detrusor muscle during voiding?
Contracts.
243
What happens to the external sphincter during storage?
Contracts.
244
What happens to the external sphincter during voiding?
Relaxes.
245
What is the parasympathetic neural control of LUT?
Pelvic nerve. Cholinergic S2-S4 so drives detrusor muscle contraction. So we pee when we are relaxed.
246
What is the sympathetic neural control of LUT?
Hypogastric nerve. Noradrenergic T10-L2
| Sphincter/urethral contraction. Inhibits detrusor contraction.
