FINAL GU/STIs Flashcards
(216 cards)
1
Q
Who is at risk of UTIs/
A
premature newborns
prepubertal children
sexually active and pregnant women
women treated with antibiotics that disrupt vaginal flora
spermicide users
estrogen-deficient postmenopausal women
individuals with in-dwelling catheters
persons with diabetes mellitus, neurogenic bladder, or urinary tract obstruction.
2
Q
Complicated vs uncomplicated UTI
A
Uncomplicated = UTI in a person with normal urinary tract, typically will be mild and without complications
A complicated UTI develops when there is an abnormality in the urinary system or a health problem that compromises host defences, such as human immunodeficiency virus (HIV), kidney transplant, diabetes mellitus, or spinal cord injury.
3
Q
For what 2 reasons are mean less likely to get UTIs?
A
1) longer urethra
2) presence of prostatic secretions
4
Q
What do you call inflammation of the bladder?
A
Cystitis
5
Q
2 most common organisms to cause UTI?
A
The most common infecting microorganisms are uropathic strains of Escherichia coli and the second most common is Staphylococcus saprophyticus.
6
Q
Bacterial contamination of the normally sterile urine usually occurs by retrograde movement of Gram ________ bacilli into the urethra and bladder and then to the ureter and kidney
A
NEGATIVE
7
Q
Why do we feel like we have to pee all of the time with a UTI even though there’s only a wee bit of wee in there?
A
The inflammatory edema in the bladder wall
stimulates discharge of stretch receptors, initiating symptoms of bladder fullness with small volumes of
urine and producing the urgency and frequency of urination associated with cystitis
8
Q
In urinalysis, in order to diagnose an uncomplicated UTI we need to see _____ and/or ______ on the dip stick
A
Leukocytes, nitrites
9
Q
Define acute pyelonephritis
A
is an infection of one or both upper urinary tracts (ureter, renal pelvis, and interstitium).
10
Q
Common Causes of pyelonephritis (not the bacteria but the conditions that led to pyelo)
A
1) kidney stones
2) vesicoureteral reflux (chronic reflux of urine up the ureter and into kidney during micturition)
3) Pregnancy
4) Neurogenic bladder
5) Instrumentation (introduction of organisms into urethra and bladder by catheter or scope)
6) Female sex trauma
11
Q
How does pregnancy make a person susceptible to pyelo?
A
- Causes dilation and relaxation of ureter with hydroureter and hydronephrosis
- Partly caused by obstruction from enlarged uterus and partly from ureteral relaxation caused by higher progesterone levels
12
Q
Define hydroureter
A
Abnormal enlargement of the ureter caused by any blockage that prevents urine from draining into the bladder.
(is it saying that this occurs in pregnancy due to obstruction from the enlarged uterus? Not sure)
13
Q
What is hydronephrosis
A
Hydronephrosis is the swelling of a kidney due to a build-up of urine
14
Q
What 3 organisms are most commonly associated with pyelo?
A
E. coli, Proteus, or Pseudomonas
** The latter two microorganisms are more commonly associated with infections after urethral instrumentation or urinary tract surgery
15
Q
Is urine acidic or alkaline?
A
Acidic
16
Q
Why is a person with infection of E.Coli, Proteus, or Pseudomonas in their urinary tract more likely to form stones?
A
These microorganisms also split urea into ammonia, making alkaline urine that increases the risk for stone formation
17
Q
T/F the only way a person gets pyelo is by uropathic organisms travelling up along the ureters
A
False - dissemination can also occur via bloodstream
18
Q
T/F acute pyelonephritis commonly causes kidney failure
A
False - it rarely does
19
Q
Patho of pyelo
A
1) Microorganisms get into kidneys (via urine or bloodstream)
2) Inflammation usually focal and irregular, primarily affecting pelvis, calyces, and medulla
3) WBCs invade medulla –> renal inflammation, renal edema, and purulent urine
4) If severe, localized abscesses form in medulla & cortex
5) Can cause necrosis of renal papillae
6) After acute phase, have healing with fibrosis & atrophy of affected tubules
20
Q
In pyelonephritis, the _______ is usually most affected and the _______ is spared
(choose from: glomeruli and tubules)
A
**Tubules usually affected, glomeruli usually spared
21
Q
S&S of acute pyelonephritis
A
Acute onset fever, chills, flank or groin pain
UTI symptoms (frequency, dysuria, costovertebral tenderness) may precede systemic symptoms
22
Q
How do older adults present with pyelo?
A
Older adults may have nonspecific symptoms, such as low-grade fever
and malaise
23
Q
Dx of pyelonephritis
A
- Differentiating symptoms of cystitis from those of pyelonephritis by clinical assessment alone is difficult.
- The specific diagnosis is established by urine culture, urinalysis, and clinical signs and symptoms.
- White blood cell casts indicate pyelonephritis, but they are not always present in the urine.
- Complicated pyelonephritis requires blood cultures and urinary tract imaging.
24
Q
Tx of uncomplicated pyelo? What would make a patient susceptible to re-infection and antibiotic resistant organisms?
A
Uncomplicated acute pyelonephritis
responds well to 2 to 3 weeks of microorganism-specific antibiotic therapy
Follow-up urine cultures are
obtained at 1 and 4 weeks after treatment if symptoms recur.
Antibiotic-resistant microorganisms or re-infection may occur in cases of urinary tract obstruction or reflux. Intravenous pyelography and voiding
cystourethrography identify surgically correctable lesions.
25
What is chronic pyelonephritis? What do we know about the cause of it?
= a persistent or recurrent infection of the kidney leading to scarring of one or both kidneys.
The specific cause of chronic pyelonephritis is difficult to determine. Recurrent infections from acute pyelonephritis may be associated with chronic pyelonephritis. Generally, chronic pyelonephritis is more likely to occur in individuals who have renal infections associated with some type
of obstructive pathological condition, such as renal stones and vesicoureteral reflux.
26
Outline how chronic urinary tract obstruction leads to CKD
prevents eliminiation of bacteria --> Progressive inflammation, alterations in renal pelvis and calyces, destruction of tubules, atrophy or dilation and diffuse scarring & impaired urine-concentrating ability --> leads to CKD
27
S&S of chronic pyelo?
The early symptoms of chronic pyelonephritis are often minimal and may include hypertension, frequency, dysuria, and flank pain.
Progression can lead to kidney failure, particularly in the presence of
obstructive uropathy or diabetes mellitus.
28
Diagnostics for chronic pyelo
Urinalysis, intravenous pyelography, and ultrasound are used diagnostically. Treatment is related to the underlying cause. Obstruction must be relieved
29
What demographic most often gets bladder cancer? (sex and age)
men older than 60 years
30
What is the most common type of bladder cancer? Are tumors typically superficial or deep?
Transitional cell (urothelial) carcinoma is the most common bladder malignancy, and tumours are usually superficial
(More advanced tumours are muscle invasive)
31
Risk factors for bladder CA
- smoking
- exposed to metabolites of aniline dyes
- high levels of arsenic in drinking water
- heavy consumption of phenacetin (pain/fever med that was discontinued in 1970s)
- have uroepithelial schistosomiasis infection (is a parasite that apparently is 2nd only to malaria in its impact worldwide!)
32
Where does bladder CA most commonly metastasize to?
lymph nodes, liver, bones, or lungs.
33
What is secondary bladder cancer
develops by invasion of cancer from bordering
organs, such as cervical carcinoma in women or prostatic carcinoma in men.
34
________ is the archetypal clinical manifestation of bladder cancer.
Gross painless hematuria
35
Other S&S for bladder CA?
- Episodes of hematuria tend to recur
- often accompanied by bothersome lower urinary tract symptoms including daytime voiding frequency, nocturia, urgency, and urge urinary incontinence (particularly for carcinoma in situ)
- Flank pain may occur if tumour growth obstructs one or both ureterovesical junctions.
36
Dx of bladder CA
- Cystoscopy with tissue biopsy confirms the diagnosis of bladder cancer. - Urine cytological study (pathological analysis of sloughed cells within the urine) is used for screening high-risk individuals.
37
Tx of bladder CA
Transurethral resection or laser ablation, combined with intravesical chemotherapy or biological therapy,
is effective for superficial tumours. Radical cystectomy with urinary diversion and adjuvant
chemotherapy is required for locally invasive tumours.
38
What is urethritis?
Urethritis is an inflammatory process that is usually, but not always, caused by a sexually transmitted microorganism.
39
Most likely causes of urethritis. How do we classify causes that are due to or not due to gonorrhea?
Infectious urethritis caused by Neisseria gonorrhoeae is often called gonococcal urethritis (GU); urethritis caused by other microorganisms is called nongonococcal urethritis (NGU).
Nonsexual origins of urethritis include inflammation or infection as a result of urological procedures, insertion of foreign bodies into the urethra, anatomical abnormalities, or trauma.
40
Non infectious urethritis is rare but does happen. What causes this?
Associated with the ingestion of wood or ethyl alcohol or turpentine. It is also seen with reactive arthritis
41
S&S or urethritis?
- urethral tingling or itching or a burning sensation
- frequency and urgency with urination
- may note a purulent or clear mucouslike discharge from the
urethra.
42
Dx of urethritis?
Nucleic acid detection amplification tests (NAAT) allow early detection of N. gonorrhoeae and Chlamydiatrachomatis in urine studies.
43
Tx of urethritis?
Treatment consists of appropriate antibiotic therapy for infectious urethritis and avoidance of future exposure or mechanical irritation.
44
True or false: Gonorrhea is the second more common reportable STI in Canada.
True. Chlamydia is first. Syphillis and HIV are other reportable STIs.
45
True or false: Gonorrhea cases continue to increase
True
46
Name risk factors for gonorrhea
Risk factors: sexual contact with new partner without barrier protection, sexual contact with someone who has gonorrhea, sexually active <25y, being born to person with gonorrhea, MSM, exchange of sex for money or drugs, street involvement, substance use
47
What is the incubation period for gonorrhea?
Usually 2-7 days. Can be 1-14
48
Stacey was diagnosed with gonorrhea and took all her antibiotic treatment as prescribed. She states she is glad that she will never have to deal with this again! What do you say to this statement?
Re- infection rates are high and regular testing is encouraged. Can teach about risk factors and how to decrease risk of infection.
49
True or false: Gonorrhea is viral in nature
False. Caused by bacteria Neisseria gonorrhea
50
How is gonorrhea transmitted?
Through contact with exudate from mucous membranes of person with gonorrhea. Passed through sexual contact (vaginal, oral, anal). Bacteria can be found in body fluids including semen, pre-ejaculate, vaginal, and anal fluids.
51
Where can gonorrhea infection occur?
Penis or external genitals, vagina or internal genitals, anus, pharynx, and eye
52
How does Neisseria gonorrhea actually infect?
Bacterial attaches to epithelial cells and invades; can also attach to sperm, leading to tranmissino from males to uninfected sexual partners. Results in localized infection at site of innoculation.
53
What are the symptoms of gonorrhea?
Often asymptomatic (Screening is critical for case finding) but can include
* Penis/ external genitals: abnormal discharge, painful or itchy sensation, dysuria or difficult urination, pain or mild swelling in testicles
* Vagina/ internal genitals: abnormal discharge, abnormal bleeding (after intercourse or between menstrual periods), lower abdominal pain, pelvic pain, pain during sex. Infection of Bartholin’s glands can lead to labial swelling, abscess formation, and pain.
* Anus: abnormal discharge, generalized pain
* Throat: rare to have symptoms, may have sore throat
* Eye: swelling or abnormal discharge (acute redness, purulent discharge and crusting, conjunctivitis)
54
Complications of untreated gonorrhea include
PID, increase risk of co-infection with other STIs (including HIV), PID, epididymitis, infertility, ectopic pregnancy, chronic pelvic pain, reactive arthritis, disseminated infection
55
Who is screening for gonorrhea recommended for?
for asymptomatic sexually active people under 25y, all pregnant people, neonates born to mothers with gonorrhea, and other people with risk factors for STI and blood borne infections *critical for case finding as infection is frequently asympomatic
56
What is used to confirm clinical suspicion of gonorrhea?
Swabs (NAAT/ nucleic acid ampligication test- high specificity) (C&S)
-vaginal, cervical, urethral, conjunctival
First catch urine
57
True or false: in order to collect the best possible swab to test for gonorrhea, the swab must be inserted at least 0.5 inches into the urethra
False false false false. Do not insert the swab into the urethra, collect swab from discharge of meatus.
58
Describe the treatment of gonorrhea
-Administer on initial visit based on historical factors/ clinical exam suspicion after collecting swabs (do not wait for test results)
-Combination therapy abx (i.e., cefixime and azithro or ceftriaxone and azithro)- due to high potential for antibiotic resistance and co-infection with chalmydia (treatment covers both infections)
59
You have diagnosed a patient with gonorrhea, collected the appropriate swabs, and administered appropriate antibiotic treatment. What discharge teaching should you provide before they go?
-Do not have sex (even with a condom) for 7 days after start of treatment
-All sexual partners in the last 2 months should be tested and treated for gonorrhea (or, if no sexual contact in last 2 months, follow up should occur for last sexual contact)
-Use of condoms decreases chances of getting/ transmitting gonorrhea
-Regular testing encouraged
60
What is pelvic inflammatory disease?
Acute inflammatory process caused by infection of female reproductive organs
61
Risk factors for PIC?
Infection by a previous STI that was not treated (delaying treatment increases complications from PID); having multiple sex partners or a sex partner who has had multiple sex partners or a previous PID; being sexually active at age 25 or younger; using douches; and using an IUD for birth control.
-Other causes of infection include spontaneous or induced abortions, normal or abnormal deliveries (called puerperal infections), or other surgical procedures; these infections are often polymicrobial.
62
True or false: PID only involves the fallopian tubes and ovaries
False! May involve any organ, or combination of organs, in the upper genital tract: uterus, fallopian tubes, or ovaries
63
True or false: normal vaginal flora can contribute to PID
Kind of true-
Many infectious disorders that affect the vulva and vagina are sexually transmitted, such as chlamydia and gonorrhoea that migrate from the vagina to the uterus, fallopian tubes, and ovaries.
However, microorganisms that comprise the vaginal flora (e.g., anaerobes, Gardnerella vaginalis, Haemophilus influenzae, enteric Gram-negative rods, and Streptococcus agalactiae) also are implicated with PID. The anerobic bacteria can increase risk for PID through altering pH and integrity of mucous blocking the cervical canal.
Additionally, cytomegalovirus (CMV), Mycoplasma hominis, Ureaplasma urealyticum, and Mycoplasma genitalium may be associated with PID.
64
Describe the pathophysiology of PID
Pathological microbes ascend from infected cervix to affect the uterus and adeneaxe (uterine appendages). Initial infection usually involves endocervical mucosa, but can start in the Bartholins glands or other flands.
It then moves up to the fallopian tubes and ovarian region.
65
Main infectious causes of PID?
Chlamydia and gonorrhea
66
S&S of PID?
Variable and vague.
Asymptomatic to sudden, severe abdo pain with fever.
Usually, the first symptom is gradual onset low bilat abdo pain. Symptoms are more likely to develop during or immediately after menstruation and worse with movement or intercourse.
Other symptoms include dysruia and irregular bleeding
67
Diagnosis of PID
Vague symptoms make it difficult. Consider in sexually active person with female reproductive organs if they have abdominal or pelvic tenderness and one of the following: cervical motion tenderness, uterine tenderness, or adnexal tenderness.
Minimum Criteria (One or More Needed for Diagnosis)
* Cervical motion tenderness, or
* Uterine tenderness, or
* Adnexal tenderness
Additional Criteria That Increase Specificity of Diagnosis
* Body temperature >38.3°C (>101°F)
* Mucopurulent cervical or vaginal discharge
* Numerous white blood cells on saline wet prep
* Elevated C-reactive protein
* Elevated erythrocyte sedimentation rate
* Documented infection with Chlamydia trachomatis or Neisseria gonorrhoeae
Definitive Criteria (Not Needed for Treatment)
* Transvaginal ultrasound, magnetic resonance imaging, or
* Doppler studies showing thickened and fluid-filled tubes
* Laparoscopic visualization of PID-related abnormalities
68
What is the causative organism in Trichomonas? What type of organism is it?
Trichomonas vaginalis (anaerobic flagellated protozoan)= extracellular parasite
69
True or false – males and females are equally affected by Trichomonas?
False – females affected more often than males
Females can acquire the disease from both females and males, while males typically acquire the infection from females and do not usually transmit the infection to other males
70
How does a person get Trichomonas? Outline the patho
Trichomoniasis is virtually always sexually transmitted
Localized infection where the organism attaches to the squamous epithelium of the vaginal and urethral mucosa and to Bartholin glands, causing inflammation and itching of mucosa
71
Signs and symptoms of Trichomonas. Do they differ in men and women?
Active infection (for women): purulent, malodorous, thin vaginal discharge associated with burning, pruritus, dysuria, frequency, lower abdominal pain, dyspareunia
Men are usually asymptomatic, occasionally report mild urethritis
72
What should be done for diagnostic testing for Trichomonas?
Preferred diagnostic tests include nucleic acid amplification tests (NAATs) can be used for all patients or used selectively, such as for those with concerning symptoms and/or vaginal discharge but negative microscopy results.
Testing of vaginal pH and wet mount microscopy. Only performed on vaginal discharge and is not applicable to urethral or anal specimens.
73
True or false, only symptomatic individuals need treatment for Trichomonas
True or false, only symptomatic individuals need treatment for Trichomonas
74
What is the treatment for Trichomonas?
PO Metronidazole (Flagyl)
75
What is the most common cause of scrotal swelling?
Hydrocele
76
What is a hydrocele?
A collection of fluid between the layers of the tunica vaginalis in the scrotum
77
What are the two types of Hydrocele?
Communicating (fluid collection = peritoneal fluid)
Non-communicating (fluid comes from mesothelial lining of tunica vaginalis)
78
Who most often gets communicating hydrocele?
Occurs in male newborns (6%)
Due to failure of processus vaginalis closure during development
Malformation often resolves spontaneously in first year of life
79
What are causes of non-communicating hydrocele?
Idiopathic or due to infections (Epididymitis, orchitis)
Can also be caused by trauma, torsion or scrotal surgery
Major cause worldwide: filariasis (tropical disease, roundworms that cause impaired lymphatic drainage) *check for travel to tropical countries
80
True or False – Hydrocele is not associated with infertility
True
81
A man presents with hydrocele in his third or fourth decade of life – what should he be evaluated for?
Testicular Cancer
82
What are signs and symptoms of hydrocele?
Tense, smooth scrotal mass that transilluminates easily
83
Is Chlamydia viral or bacterial? What is the name of the microorganism?
Bacterial, caused by Chlamydia trachomatis (CT)
84
T/F Chlamydia is usually asymptomatic
True
90% of women asymptomatic
70% of men asymptomatic
85
If symptomatic, S&S of chlamydia
(will present very similar to Gonorrhea)
* conjunctivitis
* sore throat (throat infection is most often asymptomatic)
* urethral symptoms such as, discharge, itch or awareness
* painful (dysuria) or difficult urination
* testicular pain and/or swelling (symptoms of epididymitis)
* abnormal change in vaginal discharge
* abnormal vaginal bleeding: after intercourse or between menstrual period
* lower abdominal pain (PID)
* dyspareunia
* inflammation of the rectum, rectal pain and anal discharge (symptoms of proctitis)
86
When testing for chlamydia & gonorrohea, what body parts should you be swabbing?
Anywhere that you have sex:
vagina, anus, throat
87
How does a CT.GC infection lead to infertility or risk for ectopic pregnancy?
result in scarring of the Fallopian tubes, ovaries, endometrial lining, and occasionally, the adjacent perineum
88
Risk factors for CT
- young age (<25)
- new sexual partners, having multiple sexual partners
- history of CT (reinfection very common)
- inconsistent use of condoms
- Any other reason that would decrease your change of having protected sex (such as low socioeconomic status, low education) and more sex (sex work)
- generally higher rates in women
-MSM
- History of other STI including HIV
89
T/F you can get chlamydia from touching an infected toilet seat
FALSE!
It is not possible to become infected with chlamydia by touching an object like a toilet seat.
90
T/F having a CT infection while pregnant is dangerous
True. Untreated infection can cause serious problems in pregnancy, including miscarriage and premature birth.
- If baby is born with CT, can have conjunctivitis that affects vision over time, or develop pneumonia
91
1st line treatment for CT?
Doxycycline BID x 7 days or Azithromycin 1g PO in single dose
92
Potential complications of untreated CT
epididymitis
* sexually-acquired reactive arthritis
* pelvic inflammatory disease (PID)
* infertility
* ectopic pregnancy
* chronic pelvic pain
93
What is a bartholin cyst?
Acute inflammation of one or both ducts that lead from the introitus (vaginal opening) to the Bartholin glands. Most lesions are cysts or abscesses.
94
Cause of Bartholin's cyst/ abscess?
Usually due to micro-organisms infecting the lower female reproductive tract, i.e., strep, staph, and sexually transmitted pathogens. May be preceded by infection.
95
Patho of Bartholin's cyst/ abscess?
Infection or trauma to duct causes inflammatory changes that narrow the distal duct. Narrowing may lead to obstruction and stasis of glandular secretions.
96
Clinical manifestations of Batholin's cyst/ abscess?
Obstruction can be 1-8cm in diameter, and is located in posterolateral vulva. Usually red, painful. Pus may be visible at opening. May have fever and malaise. *Symptoms only occur if exacerbation of infection causes abscess to form in gland.
Can be acute or chronic (small cyst that is tender by asymptomatic- requires no treatment)
97
Dx and tx Bartholin's cyst/ abscess?
Dx based on clinical manifestations and identification of infectious organism. Culture any exudate. Leave small cysts alone. Abscessed= broad spectrum Abx. Some clinicians may try I&D. No single treatment effective for relief/ preventing recurrence. Analgesia and sitz bath.
98
Define balanitis
Inflammation of the glans penis
99
What condition does balanitis commonly co- occur with?
Posthitis- inflammation of the prepuce (foreskin). Together, they are called Balanoposthitis.
100
Epidemiology of balanitis
Common conditions affecting children and adults
Pediatric patients most commonly present around 2-5 years old
In adults, uncircumcised males with diabetes are at highest risk
Circumcision can decrease prevalence of inflammatory conditions of glans penis by 68%
101
Patho of balanitis
Associated with poor hygiene and phimosis (inability to retract foreskin). Glandular secretions (smegma) and sloughed epithelium cells accumulate under the foreskin, and bacteria (mycobacterium smegmatis) can irritate the glans directly or lead to infection.
*Need to differentiate from skin disorders like psoriasis, eczema and candidiasis.
102
Signs and symptoms of balanitis?
Penile pain, pruritus, discharge, erythema, rash, inconsalable crying. Can occur with phimosis, inability to void, ulcers, and rashes.
103
What may medical condition can balanitis be the first sign of in adults? (esp if candida is present)
Diabetes
104
Treatment of balanitis
Hygiene, antimicrobials, consider circumcision to prevent recurrence
105
What is testicular torsion?
When the testis rotates on its vascular pedicle, interrupting its blood supply.
106
What should you do if a patient presents with suspected testicular torsion?
This is a surgical emergency- requires surgery within 6 hours if it cannot be reduced manually
107
What is an acute scrotum?
Testicular pain and swelling
108
What age is testicular torsion most common in?
Neonates and adolescents, particularly at puberty
109
Patho of testicular torsion?
Onset may be spontaneous or follow physical exertion/ trauma. Torsion twists the arteries and veins in the spermatic cord, reducing or stopping circulation to the testes. Vascular engorgement and ischemia develop.
110
Signs and symptoms testicular torsion?
Scrotal swelling and pain not relieved by rest or scrotal support. Possible erythema. Pain is not positional. May have low abdo and inguinal pain. Testicle may be swollen or in a high position. Testis may be hard. May have nausea and vomitting.
111
Dx of testicular torsion?
Ultrasound
112
2 fx's of the testes
1) production of games (sperm)
2) production of androgens & testosterone (sex hormones)
113
What is cryptorchidism
Failure of the testes to descend through the inguinal canal
114
What is the tunica vaginalis?
= the serous covering of the testis. It is a pouch of serous membrane, derived from the saccus vaginalis of the peritoneum, which in the fetus preceded the descent of the testis from the abdomen into the scrotum.
* separates the testis from the scrotal wall (along with the tunica albuginea)
115
What is the tunica albuginea
a layer of connective tissue covering the testicles
- inward extension of the tunica albuginea separate the testis into ~250 compartments or lobules (containing the seminiferous tubules)
116
Fx of the seminiferous tubules
Sperm production!
117
Tissue surrounding the seminiferous tubules contain __________ cells, which occur in clusters and produce androgens (chiefly testerone)
Leydig cells
118
The two ends of the seminiferous tubules join & leave the lobule through the tubulus rectus, which leads to the central portion of the testis. What do we call this central portion?
The rete testis
(figure 32-14 is very helpful to understand this anatomy)
119
Once sperm pass through the seminiferous tubules and rete testis, they mature in the __________
Epididymis
120
Arterial blood from the internal spermatic and differential arteries flows over the surface of the testes before entering the parenchyma. This surface flow serves to cool off the blood to promote spermatogenesis, approximately ______ to _______ degrees celcius below body core temperature
1 to 7 degrees
(one paragraph later the book says that 1-2 degrees below body temp celcius is ideal for spermatogenesis....this seems more reasonable?)
Overall, sounds like around 34 degrees is the sweet spot for sperm production
121
In addition to bloodflow, what anatomical characteristic of the testes allows them to stay cool?
They dangle! (are suspended outside of pelvic cavity to facilitate cooling)
122
Which scrotal structure is described as " a comma-shaped structure that covers over the posterior portion of the testis, consisting of single, densely packed and markedly coiled duct"
Epididymis
123
When sperm leaves the epididymis, where does it go?
Vas deferens
124
Physiologic functions of the epididymis?
Sperm maturation, mobility, and fertility
125
How long does it take sperm to travel through the epididymis?
12 days! DUring this time, they receive nutrients and testosterone & their capacity for fertilization is enhanced
126
Where is sperm stored?
The epidiymal tail & vas deferens
127
Describe the vas deferens
= a duct with muscular layers capable of powerful peristalsis that transports sperm toward the urethra
128
The vas deferens enters the pelvic cavity through the _________
Spermatic cord
129
What male structure is considered homologous to the female labia majora?
Scrotum
130
Why is the scrotum wrinkled?
Allows it to enlarge or relax away from the body
131
What happens to the scrotum skin at puberty?
Becomes darkened, develops sebaceous glands, and becomes sparsely covered with hair
132
Just under the scrotum lies a layer of connective tissue (fascia) and smooth muscle. What is this layer called? What is its function?
Tunica dartos
Contracts to pull testes close to warm body when its cold out :) (or relaxes in warm weather to keep them cool)
**This layer also forms the septum that separates the two testes
133
The tip of the penis is called the _______
glans
134
Fancy word for foreskin
Prepuce
135
Overview: what is the pathway that sperm follow from the seminiferous tubules to the urethra?
1) Spermatogenesis occurs in the seminiferous tubules
2) Rete testis
3) Efferent tubules
2) To epididymis (to mature)
3) To vas deferens (for storage and transport), which enters pelvic cavity through spermatic cord, loops up and over bladder and ends at prostate gland
4) Urethra
136
Overall functions of the scrotum
Encloses and protects the tests, epididymides and spermatic cord
Sensitivity to touch, pressure, temperature and pain protects testes from potential harm
During sexual excitement, scrotal skin and tunica thicken and the scrotum tightens and lifts and the spermatic cords shorten, partially elevating testes toward the body
137
What are the seminal vesicles? Function?
4-6 cm long gland that lie behind the bladder and in front of the rectum
Ducts of seminal vesicles join the ampulla of the ductus/vas deferens to become the ejaculatory duct
Secrete nutritive, glucose-rich fluid into semen
**Note: this is considered an internal organ while all the other things (parts of the testes) are actually considered "external"
138
Is PCOS (polycystic ovarian syndrome) the same as benign ovarian cysts?
No! Different so don't get them confused
139
When do benign ovarian cysts occur in the lifespan?
Can occur at any time during the lifespan, but most common during reproductive years (in particular, in extremes of those years)
An increase in benign ovarian cysts occurs when hormonal imbalances are more common, around puberty & menopause
140
How common are ovarian cysts?
Quite common! Comprise 1/3 of gynecological hospital admissions
141
What are the 2 kinds of "functional cysts" of the ovaries and why are they called this?
1) Follicular cysts
2) Corpus luteum cysts
"functional" because they are caused by variations in normal physiological events
142
Are functional cysts unilateral or bilateral? Symptomatic or asymptomatic?
Follicular and corpus luteum cysts are unilateral. They are typically 5 to 6 cm in
diameter but can grow as large as 8 to 10 cm. Most women are asymptomatic.
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How does a follicular cyst form?
- Produced when follicle or number of follicles are stimulated but no dominant follicle develops & completes maturation
- Follicular cysts (also called ovarian cysts or functional cysts) are filled with fluid and can be caused by a transient condition in which the dominant follicle fails to rupture or one or more of the nondominant follicles fails to regress.
- This is due to abnormal hormonal cycle
- Normally about 120 follicles are stimulated and one becomes dominant and reaches ovulation
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S&S of follicular cysts. How do they resolve?
- Although individuals may experience no symptoms, some have pelvic pain, a sensation of feeling bloated, tender breasts, and heavy or irregular menses.
- After several subsequent cycles in which hormone levels once again follow a regular cycle and progesterone levels are restored, cysts usually will be absorbed or will regress. Follicular cysts can be random or recurrent events.
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What kind of ovarian cysts can lead to hemorrhage? Describe why
- Corpus luteum cyst
- may normally form by the granulosa cells left behind after ovulation.
- This cyst is highly vascularized but usually limited in size, and with the normal menstrual cycle it spontaneously regresses.
- With an imbalance in hormones, low LH and progesterone levels may cause an abnormal or hemorrhagic cyst. In some cases, large cysts can rupture and cause hemorrhage.
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Are corpus luteum cysts common? What kind of symptoms do they cause?
- less common than follicular cysts, but luteal cysts typically cause more symptoms, particularly if they rupture.
- Manifestations include dull pelvic pain and amenorrhea or delayed menstruation, followed by irregular or heavier-than-normal bleeding.
- Rupture occasionally occurs and can cause massive bleeding with excruciating pain; immediate surgery may be required.
- Corpus luteum cysts usually regress spontaneously in nonpregnant women
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What kind of ovarian cyst have malignant potential? Describe these.
- Dermoid cysts are ovarian teratomas that contain elements of all three germ layers; they are common ovarian neoplasms.
- These growths may contain mature tissue including skin, hair, sebaceous and sweat glands, muscle fibres, cartilage, and bone.
- Dermoid cysts are usually asymptomatic and are found incidentally on pelvic examination. Dermoid cysts have malignant potential and should be removed
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How do ovarian cysts, tumors, or enlargement of the ovary lead to ovarian torsion? Is this an emergency?
Torsion of the ovary is a rare complication of ovarian cysts or tumours or enlargement of the ovary
If a cyst is sufficiently large, it can cause the ovary to twist on its ligaments, decreasing blood supply to the ovary and causing extreme pain.
Ovarian torsion is rare but is a gynecological emergency when present. It usually presents with acute, severe unilateral abdominal or pelvic pain and is treated surgically.
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What is a varicocele?
A varicocele is an abnormal dilation of the testicular veins within the spermatic cord caused either by congenital absence of valves in the internal spermatic vein or by acquired valvular incompetence.
= a bag of worms
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In which testicle do 90% of varicoceles occur?
Left
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T/F Varicocele is always nontender
False. It can be painful or tender
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What age group do we see varicocele most often in?
Varicocele occurs in 10 to 15% of males and is seen most often after puberty.
- Because most develop in adolescence, physiological changes in testosterone level may contribute to increasing blood flow to the testicle, causing venous dilation
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Unilateral right-sided varicoceles are rare and result from ______________.
compression or obstruction of the inferior vena cava by a tumour or thrombus.
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What population might it be difficult to diagnose varicocele in (think body habitus)
Men with obesity
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What is happening in a varicocele with blood flow? What are the dangers of this?
The cause of varicocele is poorly understood. Blood pools in the veins rather than flowing into the venous system.
Varicocele decreases blood flow through the testis
This interferes with spermatogenesis and causes infertility.
Varicoceles can alter testosterone and follicle-stimulating hormone (FSH) levels, cause oxidative stress, decrease sperm count, and affect sperm quality
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What do we do about a varicocele? Is surgery needed?
Varicocele surgical repair is generally done when the male has a grade II or III varicocele and an abnormal semen analysis and the female has no known cause of infertility.
If varicocele is mild and fertility is not an issue, a scrotal support is usually sufficient to relieve symptoms of scrotal heaviness or “dragging.” Colour doppler ultrasonography is used to confirm diagnosis.
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5 types of viral hepatitis?
Hep A, B, C, D, E
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What kind of hepatitis commonly occurs in children (20-50% of reported cases of this virus)
Where do we see outbreaks?
Hepatitis A virus (HAV)
Outbreaks tend to occur in day care centres with large numbers of children who are not toilet trained and staff members who practice poor handwashing techniques.
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Can Hep A be transmitted from mother to newborn or via a blood transfusion?
Possibly, but Vertical transmission from mother to newborn or from a transfusion is rare
160
Is there a Hep A vaccine?
Yes! And incidence has gone down considerably since using it
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S&S of hep A in children?
HAV in children is usually mild and asymptomatic, but it may involve nausea, vomiting, and diarrhea.
162
Does Hep A in children lead to lasting liver damage?
Almost all children recover from hepatitis A without residual liver damage. Relapse HAV occurs in 3 to 20% of individuals
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Are hepatitis viruses RNA or DNA viruses?
Hep B is DNA, the rest are RNA
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Hep A – what is the route of transmission?
Fecal-oral route (most common), parenteral, sexual
165
Hep B mode of transmission
Parenteral, sexual, across placenta
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Which 2 types of hepatitis have acute onset?
A and E (the rest are insidious)
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Is hep B slow or fast onset?
Insidious
168
Can hep A be chronic?
No is typically acute issue
169
T/F Hep B is a reportable disease
True
170
Incubation period of hep A vs hep B vs Hep C
A = 30 days
B = 60-180 days
C = 35-60 days
(just wanted to make the point that the incubation periods are pretty long!)
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Which is considered more severe, hep A or Hep B?
Hep A is considered mild
Hep B is severe and may be prolonged/chronic
172
T/F Any age group may be affected by Hep B
True
173
T/F All 5 types of viral hepatitis can cause acute illness
True
174
Modes of transmission for Hep C
Parenteral, sexual, across placenta
175
Which 2 types of viral hepatitis increase risk for HCC (I assume this means hepatocellular carcinoma?)
B and C
176
How is Hep E transmitted?
Fecal-oral
177
In what population is Hep E considered severe?
Pregnant women
178
The clinical manifestations of the various types of hepatitis are similar. Following the incubation period, there are 3 phases to the infection, what are they?
Prodromal
Icteric phase
Recovery phase
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Outline the prodromal phase of viral hepatitis. What S&S do you see here?
Begins about 2 weeks after exposure and ends with the appearance of jaundice; marked by fatigue, anorexia, malaise, nausea, vomiting, headache, hyperalgia, cough, and low-grade fever; infection is highly transmissible during this phase
180
Icteric phase of viral hepatitis. What do you see here?
Begins 1 to 2 weeks after the prodromal phase and lasts 2 to 6 weeks; jaundice, dark urine, and clay-coloured stools are common; the liver is enlarged, smooth, and tender, and percussion or palpation of the liver causes pain; GI and respiratory symptoms subside, but fatigue and abdominal pain may persist or become more severe. This is the actual phase of illness.
Individuals who develop chronic HBV, HDV, or HCV infection do not become jaundiced and may not be diagnosed.
181
Outline the recovery phase of viral hepatitis. Does the liver
Begins with resolution of jaundice, about 6 to 8 weeks after exposure; symptoms diminish, but the liver remains enlarged and tender; liver function returns to normal 2 to 12 weeks after the onset of jaundice
182
What causes syphilis?
Treponema pallidum, a gram-negative bacteria
183
Can T pallidum live outside the human body?
No, it's an obligate parasite
184
How is syphilis transmitted?
Can be acquired or congenital
1) Acquired:
- sexual contact (oral, anal, vaginal) or cuts/breaks in mucuous membranes of external genitalia or mouth
- Sharing contaminated needles
- Direct contact with skin lesion
2) If mother has syphilis
- Can occur in utero or as baby exits during birth
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What is primary syphilis? What sign can you see in this stage?
- Formation of PAINLESS syphilitic chancre
- Is localized infection
- occurs 1-3 weeks after T pallidum lands on skin or mucous membranes
186
Where does the primary chancre develop?
If acquired through sexual contact, will see on external genitalia (or lips/mouth)
If acquired through touching another person with syphilis, may see on hands or other parts of the body
187
T/F syphilis can only be contracted during the priamry and secondary phases, and not during the latent or tertiary phase
False - Can be contracted in any stage and with or without symptoms.
188
Time course of primary, secondary and latent/tertiary syphilis
Primary: 3 – 90 days after sexual contact
Secondary: 14 – 90 days after sexual contact
Latent or Tertiary: Up to 30 years
189
How long does the primary chancre stick around in primary syphilis?
Usually gone within a few weeks
190
What occurs in secondary syphilis?
- Bacteria have spread from site of chancre
- Non-itchy, non-painful rash can develop (Syphilitic dermatitis)
Rash is most often found on the chest, belly, genitals, palms of the hands, and soles of the feet but can occur anywhere (often starts on trunk and moves distally)
- Usually self-limiting but can come back months later.
- Rashes highly variable (can be pustular, scaly and hard, or have condyloma lata)
Condyloma lata are hypertrophic, flattened, dull white, pink or gray papules at mucocutaneous junctions and in moist areas of the skin. They are extremely infectious. (look like worts)
Other symptoms:
Headache
Fever
hair loss
swollen lymph nodes
bumps or patches inside the mouth, anus, penis or vagina
191
What is latent syphilis?
Is dormant, usually asymptomatic
Early latent syphilis: occurs within year of infection, still see bacteria present in blood so many still have symptoms of secondary
Late latent phase: generally after year; spirochete bacteria usually stay within tissues and organs
192
WHat is tertiary syphilis?
Have type IV hypersentitivty reaction
See organ damage:
Cardiovascular damage
Neurosyphilis
Damage to liver, joints, testes
Formation of gumma (granulomatous lesions of collection of immune cells)
193
What occurs in cardiovascular syphilis
Manifests 10 – 25 years after initial infection.
Presents as any of the following:
- Aneurysmal dilation of the ascending aorta
- Insufficiency of the aortic valve
- Narrowing of the coronary arteries.
- Pulsations of the dilated aorta may cause symptoms by compressing or eroding adjacent structures in the chest.
Symptoms include:
- Brassy cough
- Obstruction of breathing due to pressure on the trachea
- Hoarseness due to vocal cord paralysis resulting from compression of the left laryngeal nerve
- Painful erosion of the sternum and ribs or spine.
194
What is gummatous syphilis
Formation of gummas
Can involve the skin, bones, and internal organs.
Gummas are soft, destructive, inflammatory masses. It most often contains a mass of dead and swollen fiber-like tissue.
Typically localized but may diffusely infiltrate an organ or tissue.
Grow and heal slowly and leave scars.
195
What is neurosyphilis
infection of the CNS.
Damages spinal cord, leading to loss of proprioception, loss of senation, weakness, and even paralysis (usually in legs)
Symptoms include headache, dizziness, personality changes, balance problems, dementia, vision changes, hearing loss, numbness, or weakness in the legs
Stroke
196
What other organs does syphilis affect?
Eyes - loss of light reflex
Ears: Otosyphilis (cochleovestibular system with T. pallidum and typically presents with sensorineural hearing loss, tinnitus, or vertigo. Hearing loss can be unilateral or bilateral, have a sudden onset, and progress rapidly. Otosyphilis can result in permanent hearing loss)
Trophic lesions: may penetrate as deeply as the underlying bone.
Neurogenic arthropathy (Charcot joints)
Infertility
197
Complications of syphilis in pregnancy
Prematurity
low birthweight
stillbirth
neonatal demise
chronic eye, ear, teeth, bone, organ, blood, and joint problems.
198
T/F If treated early, syphilis often resolves without other health complications
True
199
T/F Syphilis increases your risk for contracting HIV
True
200
How do we diagnosis syphilis
Blood tests (most accurate 90 days or more after exposure)
Always order HIV serology with a Syphilis blood test
Treponemal tests – detect syphilis-specific antibodies. Will typically remain positive for life once someone is infected with syphilis
Non-treponemal tests – detect antibodies to cellular components released during tissue damage caused by syphilis (are less specific and can be increased with other conditions). Reported as titres and will decline overtime.
Having Syphilis antibodies does not prevent reinfection. Patients should continue to take precautions with partners.
Swab (accurate once symptoms are present)
Lumbar Puncture – All patients diagnosed with tertiary syphilis to rule out neurosyphilis
201
Once started on antibiotics (usually Pen G) for syphilis, the patient should abstain from sex for ___ days
14
202
With syphilis, all sexual partners within the last____months should be tested and treated (this can be done anonymously)
3 - 12
203
Is BV considered an STI?
No
204
What is BV?
Bacterial vaginosis (BV) is an infection of the vagina caused by an alteration in the normal flora of the vagina, with an increase in anaerobes and Gram-negative bacilli as well as a decrease in the Lactobacillus flora.
205
BV is characterized by 3 alterations in the vaginal environment. What are these?
1) A shift in vaginal microbiota from Lactobacillus species to one of high bacterial diversity, including facultative anaerobes.
2) Production of volatile amines by the new bacterial microbiota and reduced lactic acid production → sometimes produces “fishy smell”
3) Resultant rise in vaginal pH to >4.5 (normal vaginal pH of estrogenized females typically ranges from 4.0 to 4.5)
206
Riskpredisposing factors for BV?
* sexual contact with at least one partner
* new/multiple sexual partners
* other STI
* intrauterine device (IUD)
* cigarette smoking
* douching
207
Is BV typically due to overgrowth of one kind of bacteria?
No, usually polymicrobial
208
Is BV recurrence common?
Yes
209
T/F The majority of time, BV will present with symptoms
False. 50-70% have no symptoms
210
S&S of bacterial vaginosis
- change in normal patterns of discharge
* odour (fishy)
* irritation (itching, burning0
BV alone typically does not cause dysuria, dyspareunia, pruritus, burning, or vaginal inflammation (erythema, edema).
The presence of these symptoms suggests mixed vaginitis (symptoms due to 2 pathogens)
211
BV predisposes the patient to other infections. What are these (3)?
HIV → increased risk of getting or transmitting
STIs → increased risk of getting
Pelvic inflammatory disease → BV is more common among those with PID.
212
Risk of BV during pregnancy
Preterm birth
Postpartum fever
213
BV can be diagnosed by use of clinical criteria: 3 of 4 are needed to make clinical diagnosis (Amsel’s diagnostic criteria). What are the Amsel's criteria?
1) Vaginal pH: >4.5 with BV; normal vaginal pH range is 4 to 4.5.
2) Clue cells on microscopic examination.
3) Homogeneous, thick white discharge that coats the vaginal walls.
4) A fishy odour of the vaginal discharge before or after the addition of 10% KOH (wet prep with 10% KOH and normal saline prep); microscopic examination of vaginal secretions should always be done.
*In my practice, we just use a swab to collect a specimen and place it on a slide, then send the slide in
214
Tx of BV
Bacterial vaginosis is treated with antibiotics. The medicines most often used are:
Metronidazole → oral or vaginal cream
Clindamycin → oral or vaginal cream
215
What is the difference between vaginosis and vaginitis?
The absence of clinical signs of inflammation is the basis for the term "vaginosis" rather than "vaginitis”, thus vaginosis = no WBC count
216
WHat is considered the gold standard test for BC
Gram stain
