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Reproduction, Nephrology and Urology > Week 2 > Flashcards

Week 2 Flashcards

1
Q

What are the layers of the covering of the testes?

A 
Skin
Dartos 
External spermatic fascia
Cremaster
Internal spermatic fascia
Tunica vaginalis (parietal and visceral)
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2
Q

How would you distinguish between a hernia and hydrocele in the testes?

A

Pass a light through; fluid will trans-illuminate

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3
Q

At what time point does the gubernaculum begin to enlarge and pull the testes down?

A

Weeks 28-35

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4
Q

Which hormones control testicular descent?

A

INSL-3, anti-Mullerian hormone and testosterone

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5
Q

What are the 4 walls of the inguinal canal?

A

MALT
M - superior 2 muscles; internal oblique and transverse abdominus
A - anterior 2 aponeuroses; external and internal oblique
L - inferior 2 ligaments; inguinal and lacunar
T - posterior 2 T’s; transverse fascia and conjoint tendon

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6
Q

What is the cause and consequence of testicular dysgenesis syndrome?

A

Impaired foetal testes development → decreased Leydig and Sertoli function → hypospadias/cryptochidism and infertility/testicular cancer respectively

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7
Q

What is cryptorchidism?

A

Impalpable or undescended testes which are usually smaller if present, can be bilateral or unilateral and has an uncertain aetiology

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8
Q

What are the classifications of cryptorchidism?

A

Abdominal (impalpable)
Inguinal (palpable)
Pre-scrotal

Retractile (sit in scrotum but retract over time)

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9
Q

At what age would undescended testes be concerning?

A

6 months - refer for orchidopexy (up to 18 months)

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10
Q

What are the major risk factors for cryptorchidism?

A 
Low birthweight (<2.5kg)
Small for gestational age
Premature 
Maternal/gestational diabetes 
Environmental (phthalates, smoking)
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11
Q

How can cryptorchidism affect sperm quality?

A

No sperm production in bilateral (normal in 30% after surgery)
50% normal sperm in unilateral (70% after surgery)

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12
Q

What percentage of testicular cancer arises from cryptorchidism?

A

5%

Higher risk in bilateral and abdominal

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13
Q

What investigations can be carried out for cryptorchidism?

A

Ultrasound, CT/MRI, laparoscopy, karyotyping (genetic sex disorders), biochemical (testosterone)

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14
Q

What are the possible complications of surgical treatment of cryptorchidism?

A

Testicular shrinkage, high recurrence, haematoma, pain

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15
Q

What hormonal treatment is available for cryptorchidism?

A

hCG stimulation - mimic LH to cause testosterone surge (20% effective, high recurrence)
LHRH test - puberty
Complications - pain, behavioural problems, inflammation, shrinkage

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16
Q

What is hypospadias?

A

Common congenital abnormality of the penis in which the urethral opening is not in its normal position at the head of the penis but somewhere along the ventral aspect

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17
Q

What are the classifications of hypospadias?

A

Glanular, coronal, mid-shaft, penoscrotal, scrotal, perineal

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18
Q

What problems/features are associated with hypospadias?

A

Chordee (bend in penis), hooded foreskin, cryptorchidism, inguinal hernia, urethral strictures, problems urinating

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19
Q

What causes hypospadias?

A

Unclear
Hormonal fluctuations of testosterone and progesterone, advanced maternal age, IVF pregnancies, endocrine disruptors, reduced androgen sensitivity, genetics

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20
Q

How is hypospadias treated?

A

Surgically
Very complex, multiple procedures, foreskin used to repair, hormonal treatment given prior
Complications - scarring, curvature, strictures, fistula

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21
Q

Describe how congenital adrenal hyperplasia causes masculinisation of females

A

Lack of 21-α-hydroxylase → aldosterone/cortisol etc cannot be produced → overproduction of
testosterone in utero → masculinisation of female

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22
Q

What does the enzyme 5-α-reductase do?

A

Converts testosterone to DHT

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23
Q

What is DHT important for?

A

External masculinisation

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24
Q

How might disorders of sex development appear in the newborn?

A

Apparent female - enlarged clitoris, posterior labial fusion, inguinal mass
Apparent male - cryptorchidism, micropenis, hypospadias
Discordance between genital appearance and prenatal karyotype

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25
Q

How are disorders of sex development managed?

A

All newborns receive gender assignment within 21 days
Multidisciplinary team involved in decision making
Surgical management, sex steroid replacement and psychosocial management options

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26
Q

What lifestyle factors are important in fertility?

A

Smoking, alcohol, recreational drugs, STIs, radiation, toxins, tight clothing

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27
Q

What drugs can have an adverse effect on male fertility?

A

Alcohol, antipsychotics, arsenic, aspirin, caffeine, calcium channel blockers, pesticides, lead, antidepressants

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28
Q

What investigations are carried out in primary care for fertility?

A

Rubella status, STI screen, BMI, cervical smear

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29
Q

What is the WHO classification of anovulation?

A

Group 1 - HP failure (10%)
Group 2 - HPO dysfunction (85%)
Group 3 - ovarian failure (5%)

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30
Q

How can HP failure, HPO dysfunction and ovarian failure be treated?

A

HP - lifestyle, GnRH, gonadotrophins
HPO - metformin, gonadotrophins
Ovarian - oocyte donation

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31
Q

What should the pH of semen be?

A

7.2

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32
Q

What is a normal sperm concentration and count?

A

15 million per ml

39 million per ejaculate

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33
Q

What features of sperm are considered in fertility?

A

Motility, viability and morphology

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34
Q

What is HyCoSy?

A

Hysterosalpingo-contrast-sonography
Simple and well-tolerated outpatient ultrasound procedure used to assess the patency of the fallopian tubes and detect abnormalities of the uterus and endometrium

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35
Q

What is a HSG?

A

Hysterosalpingogram

Used to check for uterine tube blockage

36
Q

What tests may be carried out for fertility?

A

Cystic fibrosis screening, karyotyping, FSH levels, surgical sperm retrieval

37
Q

What are the main areas which can be the cause of infertility?

A

Semen
Uterine tubes
Uterus and peritoneum
Unexplained

38
Q

What tests/treatments are invalid for infertility?

A 
Post coital cervical mucous assessment
Inhibin levels
Ovarian volume
Ovarian blood supply
Gamete intrafallopian transfer
39
Q

What is the holy triad of fertility?

A

Ovary, uterine tube and sperm

Uterus and peritoneum also important

40
Q

What needs to be done before IVF/ICSI can take place?

A

Hep B/C and HIV tests
HFEA paperwork
Counselling of realistic expectations
Pregnancy rate calculation

41
Q

Define transgender, transsexual, genderqueer/non-binary and agender

A

Transgender - a person whose gender identity differs from the sex the person had or was identified as having at birth
Transsexual - a person having a strong desire to assume the physical characteristics and gender role of the opposite sex
Genderqueer/non-binary - a person who does not subscribe to conventional gender distinctions but identifies with neither, both, or a combination of male and female genders
Agender - lacking gender

42
Q

What non-binary pronouns are there?

A 
They, them, their, theirs, theirself
Ze, zey, zem, zeir, zeirs, zeirself
Zie, zim, zir, zirs, zirself
Ey, em, eir, eirs, eirself
One
43
Q

What is WPATH?

A

World Professional Association for Transgender Health

Worldwide association of multi-disciplinary practitioners working with trans patients

44
Q

What is dual-role transvestism?

A

Wearing clothes of the opposite sex to

enjoy the temporary experience without any desire for a sex change or sexual excitement

45
Q

What is gender identity disorder of childhood?

A

Manifests during early childhood and is
characterised by a persistent and intense distress about assigned sex and desire to be (or insistence that one is) of the other sex; requires a profound disturbance of the normal gender identity

46
Q

How can fertility be preserved in transgender people?

A

FTM - collect and store oocytes

MTF - collect and store semen

47
Q

What are the WPATH standards of care criteria for hormone therapy for transgender people?

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 (if younger, follow the Standards of Care outlined in section VI)
  4. If significant medical or mental health concerns are present, they must be reasonably well controlled
48
Q

What hormonal therapy can transmen receive and what changes occur?

A

Testosterone - sustanon injection, testim gel, nebido injection

Effects - lower voice, facial and body hair growth, increased muscle bulk, amenorrhoea, clitoromegaly, aggression

49
Q

What are the risks of testosterone therapy?

A

Polycythaemia, liver dysfunction, CVD, weight gain, diabetes, mental health problems

50
Q

How can menstruation be suppressed in transmen?

A

Testosterone, contraceptive injection (depo provera), GnRH analogues, contraceptive implant

51
Q

What hormonal therapy can transwomen receive and what changes occur?

A

Oestrogen - oestradiol valerate injection, oestradiol transdermal patch
Anti-androgen - GnRH analogues, cyproterone acetate, finasteride, spironolactone

Effects - breast growth, softer skin, less facial and body hair, fat redistribution to hips, more emotional

52
Q

What are the risks of oestrogen therapy?

A

Venous thromboembolism, weight gain, increased BP, breast cancer

53
Q

What is the GMC guidance for prescribing for transgender people?

A

Prescribing medicines recommended by a gender specialist
Following recommendations for safety and treatment monitoring
Making referrals to NHS
services that have been recommended by a specialist

54
Q

What is a bridging prescription and when is it acceptable to issue?

A

Prescribing hormonal therapy before approval from the gender identity clinic
Patient is already self-prescribing from an unregulated source, mitigation of suicide/self-harm, advice sought from specialist to provide lowest dose

55
Q

What surgical options are there for transmen?

A

Bilateral mastectomy, male chest reconstruction, hysterectomy, oophorectomy, metoidioplasty, phalloplasty

56
Q

What surgical options are there for transwomen?

A

Thyroid chondroplasty, penectomy/orchidectomy/clitoroplasty/vulvoplasty/penile inversion vaginoplasty/colovaginoplasty, breast augmentation

57
Q

What are the complications for FTM surgery?

A

Dislodgement of erectile cylinders, mechanical failure of erectile mechanism
Neo-urethral stenosis, urethral fistula

58
Q

What are the complications for MTF surgery?

A

Granulation tissue, hairballs, vascular occlusion of arterial supply to neo-clitoris, neovaginal stricture
Urinary spraying, increased risk of UTI due to shortened urethra

59
Q

What screening would transgender people undergo?

A

Smear test - if FTM and cervix is still present (no hysterectomy)
Prostate - MTF
Breast - FTM (and offer to MTF)

60
Q

Which structure opens into the prostatic urethra?

A

Ejaculatory ducts

61
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

62
Q

Why is the inguinal canal of clinical importance?

A

Patient may develop an inguinal hernia

63
Q

What does the inguinal canal transmit in the male and female?

A

Male - spermatic cord and ilioinguinal nerve

Female - round ligament of the uterus and ilioinguinal nerve

64
Q

Where is the deep inguinal ring located?

A

Inguinal canal; transversalis fascia

65
Q

Where is the superficial inguinal ring located?

A

Inguinal canal; aponeurosis of external oblique

66
Q

What feature strengthens the aponeurosis of the external oblique to prevent splitting?

A

Intercrural fibres

67
Q

What is the length of the inguinal canal?

A

4cm

68
Q

What is the difference between a direct and indirect inguinal hernia?

A

Direct - protrusion medial to inferior epigastric vessels

Indirect - passes through the deep ring, lateral to epigastric vessels

69
Q

Where does the spermatic cord begin and end?

A

Inferior abdomen to scrotum

70
Q

Where does the round ligament of the uterus begin and end?

A

Uterine horns to the labia majora

71
Q

What is the covering of the round ligament of the uterus?

A

Transversalis fascia

72
Q

What are the coverings of the spermatic cord?

A

External spermatic fascia, cremaster muscle and internal spermatic fascia

73
Q

What do the urethral folds become in the male and female?

A

Male - scrotal raphe, spongy urethra, ventral aspect of penis
Female - labia minora

74
Q

What do the genital swellings become in the male and female?

A

Male - scrotum

Female - labia majora

75
Q

What does the mesonephric duct become in the male?

A

Epididymis, vas deferens and seminal vesicle

76
Q

What is the embryonic layer origin of the cloaca?

A

Endoderm

77
Q

What is the proctodeum?

A

Surface depression in which the cloacal membrane sits

78
Q

What do the cloacal folds join to form?

A

Genital tubercle

79
Q

Why is it inappropriate to use genital tubercle length to identify foetal sex via ultrasound?

A

Tubercle is larger in the female than the male during early development

80
Q

What are the boundaries of the femoral triangle?

A

Base - inguinal ligament
Medial - adductor magnus
Lateral - sartorius
Apex - where sartorius crosses medial

81
Q

What are the contents of the femoral triangle?

A

Femoral nerve, artery, vein

Inguinal lymph nodes and vessels

82
Q

What is the femoral sheath and what is its importance?

A

Tube of fascia enclosing vessels in the femoral triangle, creating a femoral canal medially
Allows the vessels to glide deep to the inguinal ligament during movement of the hip

83
Q

What is the function of the femoral canal?

A

Allows expansion of the femoral vein if there is an increase in venous return from the lower limb

84
Q

What is the femoral ring?

A

Wide upper end of the femoral canal; weakness which can be enlarged by stretching of the inguinal ligament (e.g. in pregnancy)

85
Q

What are the boundaries of the femoral ring?

A

Anterior - inguinal ligament
Medial - lacunar ligament
Posterior - pubic bone
Lateral - femoral vein

Reproduction, Nephrology and Urology (4 decks)

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