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Gynae 2 Flashcards

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1
Q

hydrocoele

A

Defined as a collection of fluid within the tunica vaginalis (between the visceral and parietal layers) of the testis

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2
Q

congenital hydrocele

A

Communicating (“vogbreuk”) Infantile/fluid hernia
Interstitial
Cord

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3
Q

acquired primary hydrocele

A

Idiopathic (aetiology not known)

Imbalance between the fluid secretion and absorption (decreased) of the tunica vaginalis

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4
Q

acquired secondary hydrocele

A 
Infection
Trauma
Tumor
Torsion
Abnormalities in inguinal lymph nodes
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5
Q

hydrocele Rx

A

Communicating- May close spontaneously
Tying off the patent processus vaginalis

Primary- Hydrocelectomy
Aspiration + injection of sclerosing agent
Secondary- Treat underlying pathology

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6
Q

differentiating btwn hydrocele and inguinal hernia

A

hydrocele- palpable cord above mass, transclucent, fluctuate, fluid thrill
inguinal hernia- testis palpable, cough impulse, reducible, bowel sounds

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7
Q

colour of fluid of supratesticular cystic masses

A

Cord hydrocele- Straw color

Spermatocele- Milky or Grey opaque (barleywater) Epididymis cyst- Clear

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8
Q

varicocele

A

Defined as an abnormal dilatation of the veins of the pampiniform plexus of the spermatic cord

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9
Q

varicocele aetiology

A

Abnormality/absence of the venous valves
Left spermatic vein joining the left renal vein directly at a 90° angle
Longer left spermatic vein with increased hydrostatic pressure
Pressure of superior mesenteric artery on the left renal vein (Nutcracker phenomenon)

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10
Q

varicocele sx and s/s

A

Complaints of a scrotal mass (“Bag of worms”)
Complaints of scrotal discomfort
Fertility problems
Smaller left testis (atrophy

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11
Q

varicocele classification

A

Primary- Abnormality of valves in the spermatic vein
Secondary- Tumor of the left kidney (Tumor thrombus from renal cell CA)
Retro-peritoneal masses
Trauma

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12
Q

varicocele Rx

A

Spermatic venography plus embolisation with heated contrast/resin/coils (Antegrade or retrograde procedure)
Surgery- Open (Ivanissevitch, Paloma)
Laparoscopic

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13
Q

risk factors of penis cancer

A

Smoking
UV radiation
Foreskin (Phimosis, poor hygiene, smegma)
HPV infection 16 & 18

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14
Q

penis cancer presentation

A

A sore that fails to heal
Induration
Phimosis – obscures it and grows undetected
Rarely – mass, ulceration , suppuration or haemorrhage from inguinal mets
Usual delay in presentation due to Embarrassment, fear

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15
Q

Natural history of penis cancer

A

Begins as small lesion, papillary & exophytic or flat & ulcerative
Pattern in lymphatic spread
Metastatic nodes cause erosion into vessels, skin necrosis, chronic infection
Distant metastasis uncommon
Death within 2 years for untreated patients

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16
Q

Condyloma Acuminatum facts

A

Genital warts related to HPV (16 & 18)
Associated with SCC
Soft, multiple lesion on glans, prepuce & shaft
Dx: Biopsy
Treatment: Podophyllin, fulgaration, cryotherapy

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17
Q

Erythroplasia of Queyrat – non keratinising

A

Occur on glans
Red velvety circumscribed painless lesion
May ulcerate and painful – 10X more likely to progress than Bowen’s disease

Treatment- Penile preserving – topical 5-FU or imiquimod
Laser
Mohs surgery

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18
Q

Balanitis Xerotica Obliterans

A

Lichen sclerosis et atrophicus
>10% - penile cancer
White patch on glans and prepuce. Also meatus Aetiology – chronic infection, phimosis
Treatment – Steroid cream, Surgical

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19
Q

Bowenoid papulosis

A 
Resembles carcinoma in situ
Multiple papules or flat glanular lesion
Dx – biopsy
sx- pruritis, burning, dysuria
Treatment - electrodesiccation, cryotherapy, laser, topical 5-fluorouracil cream, excision with skin grafting
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20
Q

Giant condyloma acuminata – BuscheLowenstein tumour

A

Displaces, invades ad destroys adjacent structures
No metastasis
Treat wide excision

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21
Q

other penile CA condition

A

Cutaneous horn – extreme hyperkeratosis
Psuedo-epitheliomatous micaceous & keratotic balanitis
Leukoplakia – whitish lanular plaque invove meatus

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22
Q

renal tumours presentation

A

Classic triad- hematuria, pain and a flank mass
Para-neoplastic syndrome
Varicocele

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23
Q

renal tumours Rx

A

Surgery
Renal tumors are notoriously radio-resistant
Novel therapies are at present only investigational- Cryotherapy, Radiofrequency ablation, HIFU

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24
Q

testicular CA

A

35 years old male
hemoptysis, abdominal discomfort
no child
Big R testis , normal Left testis

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25
testicular CA Risk Factors
``` Previous history of testicular tumour UDT Infertility Atrophic testis CIS (carcinoma in situ) ```
26
testicular CA aetiology
``` Gonadal dysgenesis Environmental factors Chemical carcinogens Infections 7-10% in undescended testis- dysgenesis, high temperature, abnormal blood supply, endocrine dysfunction ```
27
testicular CA classification
Germ cell- Seminoma -Non seminoma: Teratocarcinoma, Yolk sac tumour, Choriocarcinoma, Embryonal, Mixed variant Non Germ cell- Leydig cell, Sertoli cell, Sarcoma, Leukaemia, Lymphoma, Metastasis
28
Non-seminoma tumour facts
Choriocarcinoma- Can present with extensive metastasiss with paradoxically small primary Teratoma- mature and immature elements Yolk sac tumour- In infants and young children
29
Frequency of testicular CA types
Seminoma, Embryonal Carcinoma, Teratocarcinoma Teratoma, Mixed, Choriocarcinoma
30
secondary tumours
Lymphoma Leukaemic infiltration Metastasis- prostate, breast, kidney
31
testicular CA presentation
50% have metastasis at diagnosis- Neck mass, respiratory, GIT, bone pain, neurological, lower extremities Heavy feeling or painless swelling around testicular region acute testicular pain Gynaecomastia
32
Metastasis of testicular CA primary “landing zone”
left-sided tumours: para-aortic, left renal hilar lymph nodes right-sided: inter-aortocaval and paracaval nodes
33
testicular CA Treatment
``` Multimodal- Radical orchidectomy Radiotherapy Chemotherapy Retroperitoneal lymph node dissection Follow up (surgical approach is inguinal) ```
34
Risk of incontinence
``` Abdominoperineal resection Polio (almost always recovers) Diabetic neuropathy Lumbar disc disease Stroke Meningomyelocele ```
35
risk factors of bladder tumours
``` Smoking Chemical exposure – exposure to carcinogen – Dye, rubber, aluminium, leather Radiation - pelvic Chemotherapy cyclophosphamide Bladder.Parisitic infection ```
36
Clinical presentation of bladder & upper tract tumours
Haematuria – painless LUTS – Dysuria, urgency, Frequency Pelvic pain – advanced disease
37
urothelial tumours mx
Superficial low grade disease – Resection or fulgeration Superficial high grade disease – Resection or fulgeration – Intravesical immune therapy: BCG installations – Intravesical chemotherapy: Mitomycin C Installations
38
Management - TCC
Muscle invasive disease – Clinically resectable: pelvic lymph adenectomy + radical cystectomy + urinary diversion, Partial cystectomy – Clinically unresectable: Radiation therapy, Chemotherapy + re-assessment regarding salvage surgery Metastatic disease – Chemotherapy: Methotrexate,vinblastine,doxorubicin,cisplatin Newer agents = Taxoids,gemcitabine
39
Management - SquamousCa of bladder
Resectable – Pelvic lymphadenectomy + radical cystectomy + urinary diversion Unresectable – Radiation
40
upper tract tumours presentation and mx
Haematuria, Flank pain, Colic pain, Flank mass, Weight loss Mx- Gold standard: Nephro-ureteroctomy and cuff of bladder
41
Causes of abnormal SHBG in males & females
decr- obesity, hypothyroidism, PCOS, high doses of glucocorticoids, androgens icr- anorexia nervosa, hyperthyroidism, liver dz, anit convulsants, oestrogens
42
Symptoms and signs of male hypogonadism
physical- gynocomastia, decr muscle mass aand/or BMD psychological- depression, lack of energy sexual- erectile dysfunction, decr libido
43
countries with highest rates of femicide
``` hondura jamaica lesotho RSA guinea bissau ```
44
Intimate Partner Violence
IPV includes physical violence, sexual violence, stalking and psychological aggression by a current or former intimate partner (spouse, boyfriend/girlfriend, dating partner or ongoing sexual partner)
45
risk factors for IPV
Individual risk factors- younger age, intellectual disability Relationship risk factors- separated relationship status, marital disagreements Community risk factors- high levels of crime, poverty and unemploymen Social risk factors- gender inequality, devaluation of women
46
protocol for IPV assessment
Screen in a safe setting with the woman alon Use professional language interpreters Incorporate screening for IPV into routine medical history Keep printed take home resources such as hotline numbers
47
Documentation
encounters may become forensic evidence of the abuse Direct quotations and photos should be included after informed consent is given by patient Complete documentation should include the history, timeline, examination, symptoms, witnesses and results of imaging and laboratory studies as well as referrals and law enforcement notification
48
Belmont report 3 core principles
respect for persons Beneficence Justice
49
virtue
A dispositional trait of character that is socially valuable and reliably present in a person, and a moral virtue is a dispositional trait of character that is morally valuable and reliably present
50
The cardinal virtues
courage, prudence, temperance, and justice
51
B&C five virtues
applicable to the medical practitioner: trustworthiness, integrity, discernment, compassion, and conscientiousness
52
Conservative management of female sexual dysfunction
Lifestyle changes such as weight loss, decreasing fatigue, stress management, and smoking/alcohol cessation Manage contributary co morbidities. Physical therapy and pelvic floor rehabilitation Psychological intervention: Couples and individual counselling, sex therapy, psychiatry
53
medical management of female sexual dysfunction
``` Hormone therapy Serotinergic/dopaminergic agents Apomorphine Bremelanotide Phosphodiesterase inhibitors ```
54
medical management of female sexual dysfunction GPPD
``` Topical anaesthetics, hormones Ospemifine Antidepressants Oral neuropathic pain meds i.e Gabapentin Botox Injectable steroids Vaginal laser therapy Vestibulectomy ```
55
acute pelvic pain Also seen with disorders of
gastrointestinal Urinary Musculoskeletal systems
56
most probable causes of acute pelvic pain 0-21yrs
``` dysmenorrhea PID ovarian cysts rupture haemorrage ```
57
most probable causes of acute pelvic pain 21-35yrs
``` ovarian cystes endometriosis pregnancy spontaneous abortion ectopic pregnancy ```
58
most probable causes of acute pelvic pain 35yrs to menopause
``` uterine fibroids endometriosis ovarian cancer/tumour pregnancy abortion ```
59
progesterone in leiomyomas
``` Results in increased cell proliferation and survival and enhancement of extracellular matrix formation ```
60
Renal colic
* Acute flank pain * On and off character (traditional definition) * Loin to groin radiation * Associated n+v
61
referred pain of renal colic
``` gastric liver and biliary colonic ureteral and kidney diaphragmatic irritation ```
62
renal colic causes
``` Renal • Benign -infective- pyelonephritis perinephric abscess • Malignant -renal cell carcinoma ``` ``` Non-renal • Bowel related- -appendicitis (rt sided pain) -diverticulitis Gynae related- -p.i.d -ectopic pregnancy ```
63
renal colic mx
``` • Conservative management Medical Expulsive Therapy (MET) • Intervention - Minimally invasive- ESWL - Endoscopic- stenting- retrograde stent insertion - Ureterorenoscopy + lithotripsy ```
64
Indications for surgical intervention in renal colic
* Obstructive calculus with Infection * Solitary kidney with calculus * Bilateral ureteric calculus obstruction * Renal insufficiency with calculi * Intractable pain * Failed conservative management
65
Relative indications for surgical intervention in renal colic
• Occupational- high risk duty like pilots • Abberant anatomy- ureterocele, ectopic kidneys, post-reimplantation ureters.
66
what composition of stones is suited to which procedure
- ESWL- wedelite- CaOx Dihydrate | - URS- brushite (colorless to pale yellow monoclinic prismatic crystals), cysteine, whewelite -hydrated calcium oxalate
67
most common renal stones formed
calcium struvite uric acid cysteine
68
ureterorenoscopic complications
Early: mucosal injury • ureteral perforation • bleeding • avulsion Late: stricturing sepsis • reflux hematuria • persistence of colic
69
Renal colic in pregnancy
* Be as conservative as possible * Severe colic: u/s * if fails, * limited Intravenous pyelogram (control,x2films) * Mx- URS (ESWL is c/i) * holmium YAG preferable (smaller penetr)
70
Renal colic in children
• Amenable to ESWL, URS • Small calibre ureter, urethra, ESWL bias Stone types- ?cysteine; ?brushite calcium oxalate stones and calcium phosphate stones, are the most common types of kidney stones in children
71
viral STI
``` Common – HIV-1 & 2 – HSV 1 & 2* – HPV* – HBV ``` • Less common – HCV – Molluscum contagiosum* – CMV (in immunosuppressed individuals)*
72
HIV TRANSMISSION (through genital mucosa)
direct penetration transcytosis infx of Langerhans cells
73
Factors influencing sexual transmission of HIV
* High HIV viral load * Other STIs - ↑ CD4 lymphocytes, genital ulcers * Female gender – at ↑ risk than males * Circumcision status - ↑ risk in uncircumcised men * Vaginal tears – during sexual intercourse
74
HIV transmission routes high to low
``` blood products IV drugs penile anal needle stick penile vaginal ```
75
genital herpes Complications
``` – recurrency – aseptic meningitis – meningo-encephalitis – urinary retention – transmission to the foetus/neonate ```
76
HSV Treatment & prophylaxis
• Acyclovir, Valacyclovir*, Famcyclovir for 7 days – Early antiviral treatment alleviates symptoms & prevents serious complications • Resistant infections: Foscarnet, Cidofovir
77
pathophysiology of stricture
``` Noxious stimulus (bacterial, chemical, physical) Denuded epithelium Squamous metaplasia Fissures develop in epithelium Urine extravasation Fibrosis develops in the corpus spongiosum Fibrotic plaques coalesce Stricture ```
78
Aetiology of strictures
Congenital Acquired • Infections • Trauma
79
Clinical presentation of strictures
``` • Obstructive /Irritative LUTS • Urinary tract infections • Acute urinary retention • Overflow incontinence • Renal failure • Haematuria Asymptomatic ```
80
Non invasive tests for stricture
Uroflow SONAR- Useful for bulbar strictures? limited
81
invasive tests for stricture
``` Catheterisation • Radiology – Contrast studies- retrograde urethrogram, voiding cystogram. • VCUG • Urethrocystoscopy – urethral – suprapubic – Does not show length ```
82
Rx of stricutures
``` • Optical urethrotomy • Dilatation • Laser urethrotomy (holmium:YAG laser) • Urethroplasty – One stage – Two stage ```
83
complications of penile fracture
```  Sepsis/ abscess  Urine leak  Venogenic e.d  Acquired lateral curvature  Recurrence of fracture ```
84
Rx of penile fracture
``` Optimize the surgical exposure. Evacuate the hematom Identify the site of injury. Correct the defect in the tunica albuginea. Repair the urethral injury ```
85
Mx- penile amputation
```  Sterile saline-soaked gauze  Salvage 18 hours  Microvascular repair- artery, nerve  Tunical repair- interrupted sutures  Urethra, if involved: 2 layer repair over catheter ```
86
Botched circumcision
Penile stumps Perineal urethrostomies Psychological morbidity, body-image issues among previously fit young men
87
Technicalities of transplant
 1,5mm cavernosal artery reanastomosis  Full sensation not yet achieved (may take up to 2yrs)  Indefinite immunosuppressive medication  Ethical, social concerns
88
Testicular and scrotal injuries
 Blunt (85%)  Penetrating (10-15%; gsw and stabs)  Avulsion (work-related)  Causes: sport-related  self-mutilation  animal-bites
89
mx of bites to testicules
``` Mx- dog bites- irrigate, debride primary closure a/b- prev- Pen V + cephalexin ATT antirabies vaccine  Human bites- n.b- do not close primarily ```
90
Scrotal trauma
 <50% surface area- primary closure  If extensive- delay closure- thigh pouch  Reconstruction – local skin flaps- medial thigh rectus
91
Mechanisms of injury in urter
• Traumatic- blunt vs penetrating • Iatrogenic- more common cause of injury- gynaecologic urologic- endoscopic, open general surg radiation related
92
imaging in ureteral injuries
- non-invasive IVP- ? obsolete CT ivp – gold standard - Invasive Retrograde pyelogram Antegrade pyelogram (where nephrostomy present)
93
Management of ureteric injury
- Stent insertion - Primary Anastomosis- ureteroureterostomy - Transureteroureterostomy - Ureteric reimplantation - Urinary diversion; percutaneous or ureterostomy
94
Jj stent insertion
• Incomplete/partial ureteric stenosis • Post ureteric repair- ureteroneocystostomy uretero-ureterostomy
95
complications of transureteroureterostomy/ Ileal interposition
``` • Early: Urinomas Retroperitoneal abscesses • Late: Ureteric strictures - renal damage fistulae ```
96
Mechanisms of injury to bladder
``` • Traumatic - blunt; *MVA most common cause- pelvic fracture blow/kick to full bladder fall from height - Penetrating; GSW stab - Iatrogenic; gynae- hysterectomy, c/s uro- open endoscopic- e.g turbt laparoscopic ```
97
Principles of intraperitoneal repair
* Avoid pelvic hematoma; stay midline * Visualise u.o’s * Post-op drainage * Catheter 7 to 10 days; then cystogram
98
Indications for open repair
* Intraperitoneal rupture * Laparatomy for other reasons- ortho- open pelvic # needing orif * Penetrating injury * Bladder neck injury * Rectal or vaginal injury * Spicules in bladder * Relative- unresolving gross hematuria
99
Surgical options for urethral stricture | disease
• Urethral dilation • Internal urethrotomy- cold knife, laser • Permanent urethral stents • Open reconstruction- primary repair tissue transfer repair technics- buccal, preputial, bladder, t.vaginalis
100
Surgical options for delayed repair
• Endoscopic- ‘cutting to the light’ • Open- perineal approach • transpubic approach
101
Risk Factorsfor POP
Aging Menopause Pregnancy & parity ( esp. associated prolonged labour, instrumental delivery, big baby, episiotomy) Obesity Chronic constipation Genetic factors ( connective tissue disorders; Ehlers Danlos, Marfan)
102
metabolic acidosis causes
Diarrhea (loss of HCO3) – Diabetic ketoacidosis – Renal failure
103
High anion gap metabolic acidosis
* M = methanol * U = uraemia * D = diabetic ketoacidosis * P = propylene glycol (in diazepam inj) * I = isoniazid * L = lactic acidosis * E = ethylene glycol / ethonol * S = salicylates • CUTE DIMPLES (includes cyanide & Touline)
104
Imaging modalities for the urinary tract
``` • Radiography • Ultrasound • Computed Tomography (CT) • Magnetic Resonance Imaging (MRI) • Angiography/Intervention • Nuclear Medicine ```

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