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Phase 2- RNU > Week 2 > Flashcards

Week 2 Flashcards

1
Q

What does cryptorchidism mean?

A

Undescended testis

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2
Q

How do testes develop?

A

42 days post-conception, gonad develops down Y chromosome pathway. Sertoli cells develop and secrete AMH, and Leydig cells secrete DHT and T. AMH regresses mullarian structures, DHT develops male external genitalia and T develops Wolffian structures

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3
Q

What are the coverings of the testis?

A

Skin, external spermatic fascia, cremaster muscle, internal spermatic fascia, parietal tunica vaginalis and visceral tunica vaginalis

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4
Q

How do you differentiate between inguinal hernia and hydrocele in testes?

A

Shining a light, fluid glows, hernia doesn’t

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5
Q

Where do the testis begin development?

A

Urogenital ridge, as an intra-abdominal organ

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6
Q

Why do testis descend?

A

Normal body temperate is harmful to spermatogenesis

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7
Q

What hormones control testicular descent?

A

Insulin like-3, AMH (gubernacular enlargement) and Testosterone (gubernacular migration)

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8
Q

How do inguinal hernias form?

A

Bowel migrates down inguinal canal???

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9
Q

What are the four walls of the inguinal canal?

A

MALT: 2M, 2A, 2L, 2T

Upper wall: 2 muscles
- internal oblique muscle
COME BACK TO THIS QUESTION

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10
Q

How are hormonal secretions regulated?

A

Hypothalamic-pituitary-gonadal axis

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11
Q

How to clinical examination of testis?

A 
Wash hands, introduction, chaperone
Full abdominal examination
Standing then lie flat, ask about pain
Palpation, warm hands
Describe masses felt
Lymph nodes
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12
Q

What is testicular dysgenesis syndrome?

A

A male-reproduction relates disorder characterised by 4 conditions: hypospadias, cryptorchidism, testicular cancer and infertility

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13
Q

What is cryptorchidism also known as?

A

Impalpable or undescended testes

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14
Q

Describe cryptorchidism:

A

Can be bilateral or unilateral
Majority of cases have no discernible aetiology
Long term consequences: TSD
Retained testis are often smaller
Changes caused by position itself can add further damage

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15
Q

How is cryptorchidism classified?

A

Position
Position over time
Aetiological factors
Retractile (bounce back up?)

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16
Q

What should happen to patients with undescended testis after the age of 6 months?

A

Any undescended testis after the age of 6 months should be referred for orchidopexy

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17
Q

What are the risk factors for cryptorchidism?

A

Birthweight <2.5kg
Small for gestational age
Prematurity
Maternal diabetes, including gestational diabetes
Environmental factors may also play a role for the risk of cryptorchidism
Can occur as part of an underlying disease

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18
Q

What happens to semen quality in later life if babies have cryptorchidism?

A 
Adult men with persistent bilateral cryptorchidism have azoospermia, whereas 28% after operation have normal sperm count
49% of men with persistent unilateral cryptorchidism have a normal sperm concentration as compared to 71% after orchidopexy
Earlier surgery (between 10 months and 4 years) preferable in bilateral cryptorchidism
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19
Q

What is the link between cryptorchidism and testicular cancer?

A

Cryptorchidism is a well established risk factor for testicular neoplasia. Bilateral carries a higher risk of malignancy
Early orchidopexy/spontaneous descent is not associated with increased risk

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20
Q

How is cryptorchidism investigated?

A

Ultrasound is the gold standard. CT/MRI can be done, as well as laparoscopy

Consider karyotype
Biochemical tests (T)
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21
Q

How is cryptorchidism treated?

A

Operative treatment is the best treatment. Should be carried out at age 6-18 months.
Clinical examination 12 months post op, follow up at puberty if bilateral

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22
Q

How else can cryptorchidism be treated?

A

Hormonal treatment:
hCG stimulation test
LHRH test
Overall efficacy of approx 20%

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23
Q

What is hypospadias?

A

An ectopically placed urethral meatus lies proximal to the normal site on the ventral aspect of the penis, and in severe cases opens on to the scrotum

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24
Q

What are the different classifications of hypospadias?

A

Coronal, mid-shaft, penoscrotal, scrotal and perineal OR distal, mid, proximal

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25
Q

What are the causes of hypospadias?

A

Advanced maternal age, assisted pregnancies (IVF), teratogenic drug, reduced sensitive to androgens and genetic factors

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26
Q

How is hypospadias treated?

A

Surgery, uses foreskin to recreate urethra.
Advise against circumcision
Hormonal treatment prior to surgery

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27
Q

What are disorders of sex development (DSD)?

A

Any congenital condition is which development of chromosomal, gonadal or anatomic sex is atypical

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28
Q

How are DSDs classified?

A

Primary root (karyotype), secondary root (classifications of development) and actual diagnosis

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29
Q

What is congenital adrenal hyperplasia?

A

Lack of enzyme causes negative feedback to produce more testosterone than usual (causes masculinisation of females (enlargement of clitoris to resemble phallus and fusion of labia to resemble scrotum))

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30
Q

How does DSD present in the newborn?

A

Overt genital ambiguity: apparent female genitalia with enlarged clitoris, posterior labial fusion and inguinal/labial mass or apparent male genitalia with bilateral undescended testes, micropenis and hypospadias
Family history of DSD such as CAIS
Discordance between genital appearance and prenatal karyoptype

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31
Q

How can DSDs be managed in newborns?

A

All newborn infants should receive a male or female sex assignment, where there is doubt. hasty decisions should be avoided
Need for multidisciplinary team
Strict confidence and open communication

Surgical management, sex steroid replacement and psychosocial management

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32
Q

How common is infertility?

A

1 in 7 heterosexual couples suffer from infertility

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33
Q

What is the definition of transsexualism?

A

A desire to live and be accepted as a member of the opposite sex, usually accompanied by a sense of discomfort with, or inappropriateness of one’s anatomic sex, and a wish to have surgery and hormonal treatment to make one’s body as congruent as possible with one’s preferred sex

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34
Q

What is dual-role transvestism?

A

The wearing of clothes of the opposite sex for parts of the individual’s existence in order to enjoy the temporary experience of membership of the opposite sex, but without any desire for a more permanent sex change or associated surgical reassignment, and without sexual excitement accompanying the cross-dressing

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35
Q

How are patients assessed for hormonal treatment?

A

Medical history (migraine history red flag), family history, blood pressure, weight/BMI <35, baseline bloods (U+E, LFT, lipids, glucose, thyroid function, FBC, FSH, LH, prolactin, estradiol, testosterone, SHBG)

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36
Q

How is the fertility of FTM patients preserved?

A

Collection of oocytes, storage of oocytes and storage of embryo

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37
Q

How is the fertility of MTF patients preserved?

A

Collection and storage of semen

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38
Q

What are the (WPATH) criteria for hormone therapy?

A
  1. Persistent, well-documented gender dysphoria
  2. Capacity to make a fully informed decision and to consent for treatment
  3. Age of majority in a given country
  4. If significant medicinal or mental health concerns are present, they must be reasonably well-controlled
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39
Q

How is HRT delivered in transmen?

A

Sustanon 125mg intramuscular injection/ Testim gel 1/2 tube daily
Increase to sustanon 250mg 3 weekly/ Testim gel 1 tube daily
Nebido 1000mg 12 weekly

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40
Q

How is menstruation suppressed in transmen?

A

Sometimes testosterone alone
Can use depo provera, GnRH analogues
Contraception (testosterone alone is not sufficient (progesterone))

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41
Q

What are the effects of testosterone in transmen?

A

Lower voice, fail and body hair growth, increased muscle bulk, amenorrhoea, clitoromegaly, increase libido, tendency to be more aggressive

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42
Q

What are the risks of testosterone therapy?

A

Polycythaemia (bone marrow produces more RBCs), liver dysfunction, increased risk for CVS disease, increased weight, diabetes, mental health disturbance

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43
Q

How is HRT delivered in transwomen?

A

Oestrogen supplements and anti-androgen drugs

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44
Q

What are the effects of HRT in transwomen?

A

Breast growth, softer skin, less facial and body hair, fat redistribution to hips, more emotional

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45
Q

What are the risks of oestrogen supplements?

A

Increases risk for VTE (venous thromboembolism), increases weight, increased BP, increases risk for breast cancer

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46
Q

What surgery can be done for transmen?

A

Bilateral mastectomy and male chest reconstruction. Hysterectomy and oophorectomy. Metoidioplasty (hypertrophied clitoris is released and urethra redirected through)
Phalloplasty (radial artery flap (non-hairy skin from forearm with radial artery and nerves, nerves and artery are attached to existing genital structures), pubic, thigh (disadvantage as no sensation from constructed phallus), erectile tubes are implanted into phallus, with reservoir of fluid in abdomen and pump in scrotum

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47
Q

What surgery can be done for transwomen?

A 
Thyroid chondroplasty (Adam's apple). Penectomy, orchidectomy, clitoroplasty, vulvoplasty and penile inversion vaginoplasty (scrotal skin moulded into labia). Colovaginoplasty.
Breast augmentation
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48
Q

What urinary tract problems can occur after gender reassignment surgery in FTM patients?

A

Neo-urethral stenosis and urethral fistula

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49
Q

What urinary tract problems can occur after gender reassignment surgery in MTF patients?

A

Urinary spraying, and increases risk of UTI due to shortened urethra

50
Q

What are post GRS problems in FTM patients?

A

Dislodgement and infection of erectile cylinders. Mechanical failure of erectile mechanism. Hysterectomy and oophorectomy usually with one of phalloplasty procedures, as well as vaginal ablation

51
Q

What are post GRS problems in MTF patients?

A

Granulation tissue (silver nitrate cautery), neovaginal hair growth (hairballs), vascular occlusion of arterial supply to neo-clitoris, neovaginal stricture and ongoing need for dilation

52
Q

When are smear tests recommended in patients who have had gender reassignment surgery?

A

FTM still recommended if cervix is still present (removed from SCCRS after hysterectomy)
MTF ensure not on SCCRS recall system

53
Q

What are the implications for cancer screenings after GRS?

A

Prostate:
MTF less risk due to oestrogen and anti-androgen. Screen as non-trans males
Breast:
FTM- still some breast tissue, self examination, refer breast lumps as usual
MTF- offer breast screening

54
Q

What does seminal fluid contain?

A

Alkaline fluid (helps neutralise acid in the female tract), fructose (used as ATP source by sperm), prostaglandins (aid spermatic motility), and proteolytic enzymes (liquefy semen)

55
Q

Why are the many blood vessels necessary in the theca interna?

A

The theca interna has an endocrine function; transport of secretions to site of action

56
Q

What hormones does the theca interna synthesise?

A

Androgens

57
Q

What do the granulosa cells of the follicle do?

A

Convert androgens to oestrogen

58
Q

What type is vaginal epithelium?

A

Stratifies squamous epithelium

59
Q

How does the vagina protect against microbial growth?

A

Degradation of glycogen in vaginal mucosa produces organic acids, which creates a low pH environment retarding microbial growth

60
Q

Where does vaginal mucus come from?

A

Mainly from glands in the uterine cervix (greater vestibular glands of Bartholin at entry to the vagina do produce some mucus, but not in significant amounts)

61
Q

What kind of tissue is the endometrial stroma?

A

Connective tissue

62
Q

What happens to the endometrial wall at menstruation?

A

The stratum functionalis shrinks as a result of the death of the corpus luteum, whose hormones maintain it. The spiral arteries become even more coiled, resulting in vascular stasis, eventually resulting in tissue death. Active vasoconstriction follows, and a final relaxation of the arteries results in a flow of blood which carries away the dying tissue

63
Q

What is the widest part of the uterine tube?

A

The ampulla

64
Q

What is the epithelium of the uterine tube?

A

Ciliated columnar, cilia help beat fertilised egg along the tube

65
Q

Which part of the uterine tube is the most lateral?

A

Infundibulum, which is fringed by fimbrae (fingerlike processes that help capture the egg)

66
Q

What does the spermatic cord contain?

A

Ductus deferens, arteries (deferential, cremasteric and testicular), the pampiniform venous plexus, lymphatic vessels, nerves and the tunica vaginalis

67
Q

Where do Sertoli cells lie?

A

On the inside of the basement membrane of the seminiferous tubules; they are responsible for the blood-testis barrier

68
Q

What does the blood-testis barrier prevent?

A

Autoimmune destruction of developing gametes

69
Q

How does spermatogenesis occur?

A

In waves across the tubule. Primary spermatocytes lie slightly further in and divide via meiosis I to produce secondary spermatocytes which divide in meiosis II to produce spermatids

70
Q

What do Leydig cells secrete, and what are they closely associated with?

A

Testosterone, blood vessels

71
Q

What surrounds the 2 corpora cavernosa of erectile tissue?

A

The tunica albuginea

72
Q

How does the lining of the urethra vary along its length in males?

A

Initially it is urothelium, but changes to pseudostratified columnar and again to stratified squamous towards the external urethral meatus

73
Q

What are the 3 muscular layers of the ductus deferens?

A

Inner longitudinal, middle circular and outer longitudinal

74
Q

What lines the ductus deferens?

A

Psueodstratified columnar epithelium with stereocilia

75
Q

Why is the inguinal canal of clinical importance?

A

A patient may develop an inguinal hernia in the canal

76
Q

What does the inguinal canal transmit?

A

Spermatic cord in males, and round ligament of the uterus in females, as well as the ilioinguinal nerve in both sexes

77
Q

What is the superficial inguinal ring?

A

A triangular shaped region in the aponeurosis of the external oblique where the spermatic cord or round ligament emerges from the canal, just above or lateral to the pubic crest

78
Q

What makes up the roof of the inguinal canal?

A

Arched fibres of the internal oblique and transversus abdominis muscles (M for muscles)

79
Q

What makes up the anterior wall of the inguinal canal?

A

2 aponeurosis: of internal and external oblique

80
Q

What makes up the floor (L for lower border) of the inguinal canal?

A

2 ligaments: inguinal ligament and lacunar ligament

81
Q

What makes up the posterior wall of the inguinal canal?

A

2 Ts: transversalis fascia, and conjoint tendon medially

82
Q

Where is the deep inguinal ring found?

A

Midway between the anterior superior iliac spine and symphysis pubis, about 1.25cm above the inguinal ligament

83
Q

How long is the inguinal canal?

A

About 4cm

84
Q

What is a direct inguinal hernia?

A

A protrusion medial to the inferior epigastric vessels, aa a result of weakness in the floor of the inguinal canal

85
Q

What is an indirect inguinal hernia?

A

A protrusion due to weakness of the deep inguinal ring

86
Q

What covers the spermatic cord?

A

External spermatic fascia, derived from aponeurosis of the external oblique; cremaster muscle and fascia, derived from the internal oblique and its fascial coverings; internal spermatic fascia, derived from the transversalis fascia

87
Q

Where does the round ligament begin?

A

At the uterine horns, where the uterine tubes enter the uterus

88
Q

What covers the round ligament?

A

Transversalis fascia

89
Q

What nerve is the ilio-inguinal nerve a branch of?

A

L1

90
Q

What does the ilio-inguinal nerve supply?

A

The skin of the scrotum, or labia majora; and the adjacent thigh

91
Q

What normally protects the inguinal canal from herniation?

A

The oblique direction of the canal, offsetting the deep and superficial rings. When intra-abdominal pressure is raised, the posterior and anterior walls are pressed together .

92
Q

What is the embryological origin of the gut?

A

Endoderm

93
Q

What does the hindgut end in?

A

The cloaca

94
Q

What develops around the cloacal membrane in the 3rd week after fertilisation?

A

A pair of cloacal folds develop and join to form the genital tubercle at the cranial end of the embryo

95
Q

What happens to the cloaca caudally?

A

The cloacal folds are subdivided into urethral folds in front and anal folds behind. Genital swellings then appear on either side of the urethral folds

96
Q

What happens during the 6th and 7th weeks of development, with respect to the cloaca?

A

A block of mesoderm, the urorectal septum, grows down towards the cloacal membrane, eventually fusing with it. This divided the common cloaca into the rectum behind and the urogenital sinus in front

97
Q

What happens to the cloacal membrane in the 8th week?

A

It breaks down

98
Q

What stimulates elongation of the genital tubercle to form the phallus?

A

Androgens (testosterone) from the foetal testis

99
Q

How does the phallus form?

A

As it elongates (under stimulation by testosterone), the phallus pulls the urethral folds forwards and they form the lateral walls of the urethral groove. By the end of the 3rd month the 2 folds close over the urethral plate enclosing the penile urethra

100
Q

How does the scrotum form?

A

Scrotal swellings grow towards each other, and fuse to form the scrotum. The line of fusion is marked by the scrotal raphe

101
Q

What happens to the genital tubercle in female development?

A

In the absence of androgens, though the phallus elongates rapidly initially, it slows and remains as the small clitoris

102
Q

What do urethral folds form in the female?

A

The labia minora

103
Q

What forms the labia majora?

A

The unfused genital swellings enlarge and form two folds of skin- labia majora

104
Q

Where is the mesonephros seen?

A

At the lateral edge of the mesonephric duct, just below the posterior cardinal vein

105
Q

What is the epithelial lining of the mesonephric tubules?

A

Columnar epithelium

106
Q

What is the epithelial lining of the mesonephric duct?

A

Cuboidal epithelium

107
Q

What does the mesonephric duct develop into in the male?

A

A system of connected organs between the efferent ducts of the testis and the prostate, namely the epididymis, the vas deferens and the seminal vesicles

108
Q

What does congenital adrenal hyperplasia cause in developing babies?

A

Masculinisation of the external genitalia- clitoral hypertrophy and partial fusion of the labia majora

109
Q

What does the femoral triangle contain?

A

Femoral nerve and its terminal branches

Femoral sheath and its contents

110
Q

What are the contents of the femoral sheath?

A

Femoral artery and several of its branches, femoral vein and its proximal tributaries and the deep inguinal lymph nodes and lymphatic vessels

111
Q

What are the borders of the femoral triangle?

A

Base: inguinal ligament
Medial border: lateral border of adductor magnus muscle
Lateral border: sartorius muscle
Apex: where sartorial crosses medial border

112
Q

What does the femoral sheath allow?

A

The vessels to glide deep to the inguinal ligament during hip movements

113
Q

What does the femoral canal allow?

A

Expansion of the femoral vein if there is increased venous return from the lower limb

114
Q

What are the boundaries of the femoral ring?

A

Anterior: the inguinal ligament
Medial: the sharp edge of the lacunar ligament
Posterior: the pectin of the pubic bone
Lateral: the femoral vein

115
Q

Where are spermatogonia found throughout life?

A

Seminiferous tubules

116
Q

Which hormones peak at day 14 of the menstrual cycle?

A

LH (biggest peak) and FSH. Oestrogen peaks just before day 14

117
Q

Which structures open into the prostatic urethra?

A

Ejaculatory ducts

118
Q

What is a spermatid?

A

Haploid cell that undergoes physical modification and cytoplasmic reduction to produce residual bodies and the final product of spermatogenesis

119
Q

The uterine tube can be recognised by what feature?

A

It is about 10 cm long

120
Q

What does the vas deferens develop from?

A

The embryonic mesonephric duct

121
Q

Prior to ovulation, which hormone do the granulosa cells secrete?

A

Oestrogen, granulosa cells express aromatase, which converts androgens to oestrogens which then get secreted

122
Q

How does the uterine tube develop?

A

From the paramesonephric duct

Phase 2- RNU (4 decks)

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