Week 7 Flashcards
how common are ureteral and renal pelvic cancers? more common at what age and in what gender?
rare - 4% of all uroethelial cancers
usu dx at ~65 yo, M:F 2-4:1
etiology of ureteral and renal pelvic cancers?
smoking contrast dyes industrial dyes and solvents excessive NSAIDs contrast dyes balkan nephropathy (exposure to heavy metals and/or aristocholic acid from native plants)
most ureteral and pelvic cancers are of what type? %ages? what other type is common?
TCC - renal pelvic 90%, ureteral 70%
SCC - 10% of renal pelvic cancers, rare in ureteral cancers
survival rates of low stage and low grade ureteral and renal pelvic cancers?
60-90% for low stage and grade vs 0-33% for those with higher grade or those with tumor invasion
ssxs of ureteral or pelvic cancer?
gross hematuria 70-90% mb flank pn dt ureter obstruction may have irritative voiding sxs anorexia, wt loss, lethargy flank mass w/hydronephrosis SCV or inguinal LA, hepatomegaly w/METS
labs of ureteral or pelvic cancer?
hematuria (mb intermittent)
increased LFTs
positive cytology
imagining for ureteral or pelvic cancer?
IVU - shows filling defects, dilated upper ureter, hydronephrosis
retrograde pyelography
ureteropyeloscopy - direct visualization of upper tract abns
tx for ureteral or pelvic cancers?
recurrence rate?
goals?
open or laparascopic nephroureterectomy
15-80% recurrence rate
goal: save partial fxn of at least 1 KD
consider chemo or immunotherapy
6 congenital anomalies of the ureter? MC one?
- obstruction of the ureteropelvic jnx (MC)
- ureteral atresia
- duplication of the ureter
- ectopic ureteral orifice
- vaginal wall prolapse
- obstructed megaureter
obstruction of the ureteropelvic jxn is MC in what gender? often dx how and when? can lead to what 5 things?
obstruction of ureteropelvic jxn is MC in boy (5:2)
often dx via prenatal U/S
can lead to hydronephrosis, stones, hematuria, UTI, HTN
what is ureteral atresia? associated with what? what is common to happen?
blind ureter –> absent or multi-cystic, dysplastic KD
associated with HTN
common to see C/L vesicoureteral reflux
duplication of the ureter is MC in what gender? more often B/L or U/L? common presenting ssxs? dx how?
MC in F
often B/L
usu asx but can see persistent or recurrent infxn
dx via IVU and voiding cystourethrography
ectopic ureteral orifice can also be seen w/what other congenital anomaly? in boys the ureter can drain to where which can lead to what? in girls where can the orifice be and what can it lead to? how to dx?
commonly seen with duplication of the ureter
in boys ureter can drains to the vas deferences which can lead to epididymitis
in girls the orifice can be in the urethra, vagina or perineum which can lead to incontinence and infxn
dx via U/S, voiding cystourethrography or MRI
what is a vaginal wall prolapse? how can it present?
it is the sacculation of terminal ureter, can be intravesical or ectopic
may present w/infxn, bladder outlet obstruction, incontinence, prolapse through female urethra
what is an obstructed megaureter? MC to see obstructed megaureter on what side? MC in boys or girls? can lead to what two things? dx via what and when? how to tx?
it is an obstruction at the ureterovesical jxn
L is more common than R, but can be B/L
more common in boys
leads to hydroureter and blunted calyces
dx via prenatal U/S
can be surgically re-implanted or there may be spontaneous resolution
two forms of acquired anomalies of the ureter?
- ureteral obstruction
2. retroperitoneal fibrosis
what causes ureteral obstruction?
intrinsically - stone, CA, chronic inflammation
extrinsic - endometriosis, kinks, pelvic LAD
what is retroperitoneal fibrosis? causes? ssxs? dx via?
retroperitoneal fibrosis is when one or both ureters are compressed by chronic inflammation process in the retroperitoneal tissues
causes: malignancy, medications, membranous GN, IBD, AA, idiopathic
ssxs: back pn, malaise, anorexia, wt loss, uremia (if severe)
dx via U/S, excretory urography
what is senile urethritis (in women)?
post-meno or low E causes retrogressive changes in vaginal muscosa - leads to pale, dry tissue
these changes extend into LUT with some eversion of mucosa around urethral orifice
what is senile urethritis commonly misdiagnosed as?
a caruncle!
ssxs of senile urethritis?
burning, frequency, urgency stress incontinence vaginal or vulvar itching dry, pale vaginal epithelium red, hypersensitive meatus, eversion of urethral tip
labs of senile urethritis?
no pyuria
staining of vaginal smear w/Lugol’s solution will be light as opposed to dark brown as it should be because hypoestrogenism results in poor iodine uptake
instrumental exam for senile urethritis?
panendoscopy will show red, granular urethral mucosa, mb stenosis
tx of senile urethritis?
estrace vaginal cream 1 g vaginally 1-3x/wk
vagifem 1 table IV qd x 2 wks, maintenance of 2x/wk
estrogen urethral suppositories (difficult to insert)
appearance of a carbuncle? when does it normally appear?
benign, red, raspberry-like, friable vascular tumor involving the posterior lip of external meatus
normally appears after menopause
ssxs of urethral carbuncle? ddx?
ssxs: dysuria, dyspareunia, bloody spotting from mild trauma
ddx: carcinoma of the urethra, senile urethritis, thrombosis of urethral V
tx and prognosis of urethral carbuncle?
usu cured by excision, but may recur
Not common - usually only in children or in paraplegics w/ LMN lesions
An angry, red mass may become gangrenous if not promptly reduced
In a young girl must be differentiated from prolapse of anterior vaginal wall
prolapse of the urethra
May occur after local injury secondary to fracture of the pelvis, or accidental trauma in repair of anterior vaginal wall prolapse or urethral diverticula
Repair with vaginal urethroplasty
urethrovaginal fistula
Not common; some times multiple
Usually secondary to obstetric urethral trauma
Some contain carcinoma
urethral diverticulum
presentation of urethral diverticulum? dx? tx? prognosis?
presentation: recurrent attacks of cystitis, purulent urethral d/c, dyspareunia, st lg enough for pt to self-dx
dx: palpate on vaginal exam, confirm w/endoscopy and excretory urogram
tx: removal of sac through incision, repair defect
prognosis: usu good unless sac is next to the external sphincter, may develop urethrovaginal fistula
causes of urethral structure in F?
not common
congenital or acquired - trauma (intercourse), childbirth, surgery or acute or chronic urethritis
presentation of urethral stricture? dx? ddx? tx? prognosis?
presentation: persistent hesitancy, slow urinary stream, burning, frequency, nocturia, urethral pn dt urethritis or cystitis
dx: attempt to pass fairly lg catheter, cystoscopy may show bladder trabeculation
ddx: chronic cystitis, cancer, bladder neck tumor
tx: gradual urethral dilatation up to 36F, combat infxn
prognosis: good with tx
are male urethral strictures more commonly genetic or acquired? often dt what?
more commonly acquired
MC due to infxn (indwelling catheter use) or from external trauma
ssxs of male urethral strictures?
decreased urinary stream, stream forking, post-void dribbling
chronic urethral d/c
acute cystitis, sxs of infxn, frequency, dysuria
induration in area of stricture
urinary flow rate of male urethral stricture? what do you need to do to check for infection?
can cause rates less than 10 ml/s
post prostatic massage to check for infxn
tx considerations for urethral stricture?
dilation to break up scar tissue, not a permanent solution
urethrotomy (lysis of urethral strictures using a sharp knife w/catheter left in place to prevent bleeding and pn)
surgical reconstruction
what can urinary obstruction lead to?
hydronephrosis, renal insufficiency, renal failure
can occur anywhere in the tract
can also lead to infxn
causes of urinary obstruction?
congenital: meatal stenosis, distal urethra stenosis, narrowed posterior urethral valves, ectopic ureter, uterocele, damage to S2-4, vesicoutereral reflux
acquired: stricture 2ndary to infxn or injury, BPH, CaP, impingement by vesical tumor or local extension of cancer, stones, PG, neurogenic dysfxn of the bladder, elongation and kinking of the ureter, severe constipation, drugs
what can urinary obstruction from the lower tract lead to? mid-tract? upper tract? KD?
lower tract: can lead to diverticulum, infxn, abscess dt increased pressure w/in urethral walls
mid-tract: stage of compensation where bladder wall will form trabeculations, cellulues and diverticular, leading to decompensation where detrusor muscle will decompensate and will get residual urine
upper tract: back pressure leads to thickening of ureteral musculature, elongation and torsion
KD: back P dilates renal pelvis and calyces leading to ischemic atrophy and hydronephrosis –> loss of fxn
complications of urinary obstruction?
urine stagnation can lead to infxn
urea-splitting organisms can cause alkalinization of the urine which can precipitate stones (struvites)
B/L KD involvement will lead to renal insufficiency and reflux nephropathy
if severely infected and obstructed KD then pyelonephrosis (functionless, filled w/pus)
tx of urethral obstruction?
relief of obstruction through cath’ing, surgery, urinary diversion
eradication any infxns
what is hydronephrosis?
dilation of the renal pyelocalyceal system from obstruction
ssxs of hydronephrosis?
pn in flank, lower abd, testes/labia pn in flank on micturation is suggestive of vesicoureteral reflux abn mass mb N/V urgency, frequency polyuria, nocturia w/incomlete emptying anuria is possible
PE of hydronephrosis?
HTN will be present dt increased renin
labs w/hydronephrosis?
BUN and Cr will incr w/loss of KD fxn
hypernatremia, hyperkalemia, RTA
normal urine sediment unless concurrent infxn, stones
what imaging to dx hydronephrosis?
U/S - greater than 90% S/S
antegrade or retrograde ureterogram or voiding cysturethrogram
tx of hydronephrosis?
urological referral to address cause
IV fluid and electrolyte replacement
if left untreated can cause irreversible KD damage to the affected KD!!
three types of GU allergies?
contact derm - penis, scrotum, labia, vagina, perineum, dt tight underwear, inc perspiration, condoms, vaginal creams, etc
LUT - urethra and bladder (and prostate in men)
UUT - KD and ureter
IgA for what? IgE for what?
IgA for bac
IgE for allergies
if prolonged or frequent exposure to GU allergens what can happen? two examples?
pathological changes can occur and become permanent such as in IC or chronic urethritis
causes of GU allergies?
foods and drugs (MC cz, either primarily though eating or secondarily through urine during elimination)
inhalants
drugs - abx, hypnotics, antihistamines, salvarsarin, salicylates, quinine derivatives, gold, insulin, IVU contrast media, disinfectants
organisms - candida, tuberculosis, helminths, oxyuris, plasmodium, serums and vaccines
foods and lectins - milk, cheese, eggs, meat, white flour, fish, lobster, mushroom, fruits, lettuce, asparagus, carrot, tomato, cucumber, chocolate, onion, lemon, melon, yeast, paprika, black pepper, EtOH
contact allergens - rubber, spermicides, injectable materials
ssxs of GU allergies? what does it look like but actually isn’t?
edema, swelling, inflam, itching during acute attack
LUTS - increased urinary frequency, urgency, dysuria, nocturia, dull suprapubic ache
looks like UTI but it isn’t! No fever, but flank pn, gross hematuria, urinary retention mb present
nocturia/enuresis
ureteral spasms
cystoscopy will show what with chronic allergy/exposure? UA will show? CBC will show?
cystoscopy - pale, swollen bladder urethral mucosa w/areas of bulbous edema surrounded by areas of hyperemia and oozing blood - consider IC; mb reduced bladder capacity
UA - wright’s stain fo urinary sediment might show eosinophilia
CBC - will show increased eosinophils
peyronie’s dz now known as what? what is it? caused by what?
CITA: chronic inflammation of the tunica albuginea
it is scarring of the tunica albuginea in the corpora cavernosa that leads to painful erection and dorsal curvature
caused by abberation of wound healing where there was an over-expression of TGF-beta1 and fibroblastic proliferation
RFs for peyronie’s dz/CITA?
penile trauma FMHx HLA-B7 or HLA-DQ5 (+) dupuytren's contracture plantar fascial contractures tympanosclerosis paget dz gout lipomas DM HTN vasulitis hyperlipidemia A+ blood type hx of pelvic surgery drugs: propanolol, methotrexate smoking
pharm tx options for CITA? procedural options? surgial options? naturopathic?
pharm: pentoxyifyllin to block TGF, colchicine to inhibit collagen fibrosis, potassium para-aminobenzoate as an antifibrotic
procedural: verapamil injection, PRP, iontophoresis w/corticosteroids or verapamil to relieve pn, extracorporeal shock wave therapy, GAINSwave, penile traction therapy, vacuum erection devices
surgical: have to have sxs for 12+mos and greater than 65 deg curvature
naturopathic: counseling, acetyl-L-carnitine 1 g BID, SSKI directly to plaques, bromelain btw meals, natural vit E 300 mg BID, L-argingine 1000 mg BID
what is phimosis? what can develop? RFs?
phimosis: foreskin cannot be retracted away from glans penis
physiologic: 50% of boys have normal retractability by age 10
pathologic: pn, constriction, meatus blockage dt adhesion
calculi and SCC can develop
RFs: frequent diaper rash, poor, hygiene, condom catheter, DM, balanitis xerotica obliterans (lichen sclerosis)
tx for phimosis?
self-stretching of the foreskin (do not force!), topical corticosteroids, last resort is dorsal slit, french cut or full circumcision
naturopathic: cream of calendula w/centella every pm x 1 mo
oral bromelain, gotu kola
what is paraphimosis?
foreskin gets stuck in the retracted position which becomes inflamed and leads to reduced blood flow to the penis - can cause gangrene or necrosis
tx for paraphimosis?
ice
apply firm pressure to foreskin x 5 min to force blood out of the area then gently try and replace/reduce over the glans
penile block mb necessary
dorsal slit
what is balanitis? balanoposthitis? causes?
balanitis - inflammation of glans penis
balanoposthitis - inflammation of glans and foreskin
causes: infxn, derm (psoriasis, contact derm), pre/malignancy (erythroplasia of Queyrat, SCC), drug rxn
RFs for balanitis? RFs for balanoposthitis?
abx use DM HIV (+) condom catheter use circumcision procedure STI contact zipper injury obesity conditions that cause edema (CHF, cirrhosis, nephrotic syndrome) for balanoposthisis all the ones above plus having foreskin and phimosis
symptoms of balanitis/balanoposthitis?
pn during or after urination, D/C from inflamed tissue, local erythema and edema
tx of balanitis/balanoposthitis?
wash affected area w/saline BID if candida then clotrimazole or miconazole if bac infxn then metronidazole for anaerobes, mupirocin for staph or strep topical corticosteroid gotu kola-vit E cream anti-inflams (curcumin, bromelain) immunomodulators probiotics warm compresses or sitz baths
complications of balanitis/balanoposthitis
phimosis, paraphimosis
meatal stenosis (leading to increased risk of UTIs, bladder urinary retention and possibly hydronephrosis)
malignant transformation of premalignant lesions
associated with RA
serpiginous annular, grayish ulceration on glans penis
screen for STI and HLA-B27
circinate balanitis
male genital lichen sclerosis
glans and foreskin tissue atrophies and appears whitish
balanitis xerotica obliterans
ssxs of balanitis xerotica obliterans? pe? complications?
sx: pn w/intercourse, itching, decreased urine stream
PE: white atrophic plaques on glans and prepuce, enlarges into sclerotic mass
complications: phimosis, meatal stenosis, benign but can co-exist w/or precede SCC
benefits of circumcision?
easier hygiene
reduction in UTI
potential reduction in penile CA
lower prevalence of HPV, lower cervical CA rates in partners
reduction in penile inflammation and phimosis
cons of circumcision?
only parents are able to consent
could decrease sensation
are cutting away healthy tissue
appearance of HPV infxn (condylomata acuminata)?
bloody spotting from urethra
protruding papilloma or on genital surface
tx considerations of condylomata acuminata?
local excision/fulguration, transurethral fulguration if deeper
condylox gel application
liquid nitrogen application
examine and tx sexual partner plus condom use to help prevent recurrence
what are pearly penile papules? appearance? tx?
1-2 mm fleshy or white, dome-shaped papules, angiofibromas
arranged circumferentially at the corona, st densely packed and in multiple rows
tx: local application of liquid nitrogen, laser or radiosurgery
when do tumors of the penis generally appear? RFs?
usu appear in 6th decade
RFs: poor hygiene, mb dt HPV, uncircumcised, psoriasis, AIDS, lichen sclerosis
precancerous dermatologic lesions on the penis?
leukoplakia - red, irritated, sore
balanitis xerotica obliterans - white patching originating on glans or prepuce, MC in middle-aged DM
giant condylomata acuminata - cauliflower-like lesion on prepuce, glans, shaft; thought to be dt HPV, difficult to distinguish from SCC
two types of penile cancer seen?
carcinoma in situ (bowen dz and erythroplasia of Queyrat)
invasive carcinoma of the penis
what is Bowen dz?
carcinoma in situ of the penis
typically involves penile shaft, red plaque w/encrustations
what is the appearance of erythroplasia of Queyrat?
velvety, red lesion w/ulcerations, usu on the glans
where does invasive carcinoma of the penis originate from? MC sites? typical appearance?
typically originates on the glans
MC site is the prepuce and the shaft
appear papillary or ulcerative
how does invasive carcinoma start and then spread?
starts as ulcerative or papillary lesion that then gradually involves the entire glans or shaft
primary dissemination via LN to femoral and iliac nodes
tumor staging for penile cancer - each stage appearance where?
stage I = glans
stage II = shaft
stage III = penis and nodes
stage IV = METS to other sites of the body
classical ssxs of penile cancer?
penile lesion that is indurated or erythematous, ulcerated, nodular or exophytic, lesion necrosis, foul odor, bleeding suppuration, phimosis may obscure lesion
mb pn, d/c, irritative voiding sxs
inguinal LAD
imaging for penile cancer?
CXR, bone scan, CT of ab and pelvis for METS
ddx of penile cancer?
syphilitic chancre (painless)
chancroid (H. ducreyi) (painful)
condyloma acuminata ("grape cluster")tx of penile cancer? prognosis?
bx mandatory for dx
carcinoma in situ: 5-FU cream, YAG laser
invasive penile carcinoma: complete excision w/margina, may need circumcision if involves prepuce, may need partial or total penectomy if involves shaft
if (+) LAD then LN dissection
if inoperative then chemo and radiotherapy
if systemic then chemo
prognosis: survival correlates w/presence or absence of nodal dz; 5 yr w/no nodal involvement is 65-90%, 5 yr w/nodal involvement is 20-50%
