Brainscape's Knowledge GenomeTM


Top Flashcards (Certified)
All Flashcards

Definitions > Gynae > Flashcards

Gynae Flashcards

(570 cards)

Start Studying
1
Q

two processes that ensure only one sperm fertilizes eggs

A

zonal inhibiting proteins

membrane depolarisation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Zonal inhibiting proteins

A

cause the release of any other attached sperm and destroy the oocyte’s sperm receptors, thus preventing any more sperm from binding

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Functionsoftheplacenta

A

protection, echanger, endocrine fx

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

hcg function during the beginning of pregnancy

A

promotes the maintenance of the corpus luteum

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

epoophoron

A

remnant of the mesonephric tubules that can be found next to the ovary and fallopian tube

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

paroophoron

A

remnant of the lower part of the mesonephros in the broad ligament between the epoophoron and the uterus

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Gartner’s duct cyst

A

a benign vaginal cyst that originates from the Gartner’s duct, which is a vestigial remnant of the mesonephric duct (wolffian duct) in females

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

H-Y antigen

A

a male histocompatibility antigen that causes females to reject male skin grafts

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Primary amenorrhea

A

the failure of menses to occur by age 16 years, in the presence of normal growth and secondary sexual characteristics

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Secondary amenorrhea

A

defined as the cessation of menses sometime after menarche has occurred

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Müllerian agenesis

A

a congenital malformation characterized by a failure of the Müllerian duct to develop

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

other names for Müllerian agenesis

A

Mayer–Rokitansky–Küster–Hauser syndrome (MRKH)

vaginal agenesis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

menopause sx

A 
Vaginal dryness
Hot flashes
Weight gain and slowed metabolism
Thinning hair and dry skin
Sleep problems
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Asherman’s syndrome

A

an acquired uterine condition that occurs when scar tissue (adhesions) form inside the uterus and/or the cervix

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

what does oxytocin and prostaglandins do during parturition

A

cause uterine contractions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

lung changes in pregnancy

A

decr: expiratory reserve volume
residual volume
functional residual capacity
total lung capacity

same: vital capacity
insp reserve volum

incr: tidal volume
insp capacity
dead volume

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Polar bodies fx

A

to eliminate one half of the diploid chromosome set produced by meiotic division in the egg, leaving behind a haploid cell

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

sinual tubercle gives rise to (M & F)

A

M: seminal colliculus.
F: vaginal plate and hymen

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

granulosa cells

A

production of steroids and LH receptors

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

thecal cells

A

produce androgens

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

what are oestrogens are bound to

A

albumin and sex hormone-binding globulin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

what are progesterones are bound to

A

albumin & transcortin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

oestrogen fx

A

Stimulate proliferation of epithelial cells of uterine tubes, uterus & vagina
Reduce membrane potential of myometrial muscle fibres
Stimulate duct growth in mammary glands

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

progesterone fx

A

incr membrane potential of myometrial muscle fibres
Stimulates alveolar formation in breasts
Antagonises action of aldosterone on kidney

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Sertoli cell fx
Secrete H-Y antigen Synthesise oestradiol from androgens Secrete ABP
26
Seminal vesicle
``` Secretions are neutral/alkaline constitiutes 60% of semen Nutrition to sperms clotting of sperms enhances fertilization of ovum ```
27
prostate
``` Secretion is a thin, milky alkaline fluid constitutes 30% of semen a role in the activation of sperm Maintenace of sperm motility Clotting of semen Lysis of seminal coagulum ```
28
Bulbourethral Gland
Produce thick, clear mucus prior to ejaculation that neutralizes traces of acidic urine in the urethra
29
Theca externa
PGF2α induces the contraction of the smooth muscle cells of the theca externa, increasing intrafollicular pressure. This aids in rupture of the mature oocyte
30
Theca interna
receptors for LH to produce androstenedione
31
Barr body
inactive X chromosome in a female somatic cell, rendered inactive in a process called lyonization
32
effects of 5-alpha reductase mutation
hypospadias female external genitalia lack of prostate growth
33
Bicornuate uterus facts
``` No fertility issues Recurrent miscarriages Fetal malpresentation Prematur labour Rx with metroplasty ```
34
Unicornuate uterus facts
Second trimester miscarriage endometriosis is common when underdeveloped horn has cavity Associated with renal anomalies
35
Cervical cerclage
procedure used to reinforce cervix that shortens too quickly
36
activin
incr FSH binding and aromatization | incr action of LH
37
Hypothalamic–pituitary–adrenal axis fx
regulates many body processes, including digestion, the immune system, mood and emotions, sexuality, and energy storage and expenditure
38
Hypothalamic–pituitary–gonadal axis
controls development, reproduction, and aging in animals
39
Hypothalamic–pituitary–thyroid axis
regulation of metabolism, thyroid levels and also responds to stress
40
Primary Ovarian Insufficiency
Intermittent ovarian function HRT, Weight-bearing exercise and calcium essential Barrier contraception
41
Oxytocin and arginine vasopressin (AVP) are neuropeptides synthesized in which nuclei of the hypothalamus
paraventricular | supraoptic
42
Mayer-Rokitansky-Kuster-Hauser Syndrome (utero-vaginal agenesis)
Normal secondary development, external female genitalia & ovaries Absent uterus and upper vagina Ass w/ renal, skeletal and middle ear anomalies
43
Androgen Insensitivity
Normal looking female external genitalia breasts & No sexual hair Absent uterus and upper vagina
44
Gestational trophoblastic disease facts
Spectrum of diseases arising from fetal chorionic tissue. All the neoplasms have cytotrophoblasts and syncytiotrophoblasts Secreting B-HCG
45
cytotrophoblast fx
secretes proteolytic enzymes to break down the extracellular matrix between the endometrial cells to allow finger-like projections of trophoblast to penetrate through the myometrium
46
Syncytiotrophoblast fx
actively invades the uterine wall to facilitating passive exchange of material between the mother and the embryo
47
Complete hydatidiform mole facts
No foetal embryonic tissue develops Hydropic swelling villi and trophoblastic hyperplasia Chromosomes of the sperm duplicate
48
list 3 types of Gestational trophoblastic disease (GTD)
Complete Hydatidiform Mole (CHM) Choriocarcinoma (Cca) Placental site trophoblastic tumour
49
Invasive mole usually develops from
partial or complete mole
50
cause of a Partial hydatidiform mole
2 Sperm cells fertilize normal egg
51
Placental site trophoblastic tumour facts
Do not have villi BHCG levels low Epitheloid trophoblastic tumour (ETT) is a rare variant of PSTT (Placental site trophoblastic tumour)
52
Risk factors of GTD
Poor social economic conditions Lack of carotene < 20 years / > 40 years
53
list 2 s/s and 3 Symptoms of GTN
Uterus larger than expected BHCG higher than gestational age Vaginal bleeding during pregnancy Passage of grapelike villi from uterus Hyperemesis Gravidarum
54
GTN metastases sites
lung liver brain
55
Low risk disease management of GTN
Methotrexate or Actinomycin-D
56
High-risk GTN Mx- 1st line
EMA-CO | Etoposide, methotrexate, actinomycin-D, Cyclophosphamide, Vincristine (Oncovin)
57
what is done to remove the oocytes from the ovary for IVF
transvaginal oocyte aspiration (TVOA)
58
Areas identified within the IVF environment that may pose a threat to ART
``` infx power failure equipment natural disasters eg floods type/quality of medium ```
59
embryo transfer facts
* The embryo can be transferred into the uterus of the patient on day 2, 3 or 5 of culture * The patient is required to have a full bladder for easier visualization and position of the uterus
60
what are DHEA and DHEAS tests used for
to determine andrenal contribution to disease of androgen excess
61
triad of presesnting sx of ectopic
vaginal bleeding amenorrhea abd pain
62
Reasons for decline in fertility
Women delaying pregnancy for careers Increasing use of contraception Unfavourable economic conditions- rising cost of living
63
Subfertility
patients have a successful pregnancies after fertility Rx
64
Fecundity
the probability to achieve pregnancy in 1 menstrual cycle
65
Male infertility cx
primary pathologies of male reproductive system environmental lifestyle factors systemic dz
66
Ovarian hyperstimulation syndrome (OHSS)
is an excessive response to taking the fertility medication to stimulate egg growth. When OHSS is severe enough you can get blood clots, shortness of breath, abdominal pain
67
Antral follicle count
a transvaginal ultrasound study, performed in the early phase of your menstrual cycle, in which your physician visually counts the number of egg-containing follicles that are developing on both of your ovaries
68
how many follicles in an Antral follicle count indicate a poor ovarian reserve
less than 5
69
3 Basic test for infertile couple
Semen analysis Tests for ovulation Tests for tubal patency
70
in semen analysis what will we test for
Sperm count Motility morphology
71
we can test for ovulation using
endometrial biopsy Progesterone on day 21 Tests for ovarian reserve
72
give eg for Tests for ovarian reserve
Day 2/3 serum FSH,LH and estradiol levels Antral Follicle Count Anti-mullerian hormon
73
in Tests for tubal patency what are our first and second line options
1st line: Hysterosalpingography (HSG) Hysterosalpingo-contrast sonography 2nd line: (invasive)Laparoscopy chromopertubation
74
chromopertubation
a method for the study of patency of fallopian tube
75
prolactin facts
produced from lactotrophs & decidual cells Stimulated by TRH and VIP (vasoactive intestinal peptide) short half life cleared by the liver and kidneys suppress the secretion of GnRH from the hypothalamus
76
Physiological causes of hyperprolactinemia
Pain Vaginal examination Sleep
77
Pathological causes of hyperprolactinemia
Hypothalamic: craniopharyngioma Thyroid: Hypothyroidism Chronic renal disease
78
Drug induced causes of hyperprolactinemia
Dopamine antagonist - Sulpiride Dopamine depleting agents - aldomet Narcotics - Codeine
79
idiopathic causes of hyperprolactinemia
Ovulatory dysfunction Osteoporosis Visual field defects
80
how does prolactin cause amenorrhea
by suppress the secretion of GnRH from the hypothalamus
81
galactorrhea Rx
Bromocriptine 2,5 – 10 mg dly Lisuride 0.1-0.2 mg dly Carbergoline 0.25- 1 mg weekly
82
lung changes in pregnancy DECREASE
decr: expiratory reserve volume residual volume functional residual capacity total lung capacity
83
lung changes in pregnancy SAME
same: vital capacity | insp reserve volum
84
lung changes in pregnancy INCREASE
incr: tidal volume insp capacity dead volume
85
what does accumulation of mineralocorticoid precursors in 11 hydroxylase deficiency result in
hypernatremia hypokalemia HT excess andrgens
86
what dose HAIR-AN syndrome consist of
``` hyperandrogenism (HA) insulin resistance (IR) acanthosis nigricans (AN) ```
87
High-risk GTN Mx- 2nd line
EMA-EP | Etoposide, Methotrexate, Actinomycin D, Etoposide, Cisplatin
88
Hyperandrogenism in females
amenorrhea Hyperlipidemia virilization
89
Hyperandrogenism in males
Dehydration and shock due to decr Na & incr K Phallic enlargement without testicular enlargement Inhibition of GNRH secretion testis atrophy leading to: -low testosterone levels -low sperm count
90
what are the common effects of Hyperandrogenism in both sexes
Rapid skeletal maturation | Premature epiphyseal fusion
91
Non-tumour related causes of hyperandrogenism | Adrenal causes
CAH - 21 hydroxylase deficiency - 11 hydroxylase deficiency Cushing syndrome
92
Non-tumour related causes | ovarian causes
PCOS Hyperthecosis HAIR-AN syndrome
93
Medications that cause hyperandrogenism
Danazol- androgen Metoclopramide- stomach medication Resepine- HT medication
94
Tumour related causes of hyperandrogenism | Adrenal tumours
Adrenocortical tumour Adrenal adenoma Adrenal carcinoma
95
Tumour related causes of hyperandrogenism | Ovarian tumours
Arrhenoblastoma Hilar cell ovarian tumour Krukenberg tumour
96
non classical CAH
Milder enzyme deficiency | No genital ambiguity
97
classic CAH Rx
hydrocortisone prednisone dexamethasone
98
Gestational hyperandrogenism presesnts with
``` Luteoma theca lutean cysts Ovarian tumour Exogenous androgens/progestogens Placental aromatase deficiency ```
99
hirsutism Mx
COC Inhibit LH stimulate SHBG production Cosmetic therapy
100
what can you do if you find a child with Ambiguous genitalia
Physical exam Ultrasonography Karyotype
101
classic CAH facts
low aldosterone and cortisol high ACTH & 17-OH progestonolone can prenatal Dx using Amniocentesis and chorionic villi sampling
102
Pre-testicular cx of male infertility
General factors - Viral illness Endocrine - Hypothalamic (Kallman’s syndrome) Drugs - H2 receptor antagonists
103
testicular cx of male infertility
Varicocele Previous testicular torsion/ trauma Mumps orchitis
104
post-testicular cx of male infertility
Congenital bilateral absence of the vas deferens Retrograde ejaculation Sexual problems- erectile dysfunction
105
Semen analysis can be informative about
Sperm production Sperm transport and maturation Sperm transfer and function in the female tract
106
Standard instructions for semen collection
defined abstinence 3 days | evaluated within one hour of collection
107
Macroscopic evaluation of Semen analysis
``` Colour - greyish - white Viscosity - smooth and watery Liquefaction time- 15-60 mins Volume - 2-6ml pH - 7.2 or more ```
108
Microscopic evaluation of Semen analysis
``` Motility Vitality- measurement of all living sperm-whether they're moving or not Count Morphology MAR (antisperm antibodies) ```
109
cx of No ejaculate
Ductal obstruction Retrograde ejaculation Hypogonadism
110
cx of Low volume ejaculate
ductal Obstruction Absence of vas deferens or seminal vesicles Infectio
111
Asthenozoospermia cx
``` Immunological factors (ASABs) Defect in sperm structure Poor liquefaction ```
112
Azoospermia cx
Klinefelter’s syndrome Sertoli only syndrome Hypogonadotrophic hypogonadism
113
oligospermia cx
Genetic disorder Endocrinopathies Varicocele
114
Teratozoospermia cx
Varicocele Stress Infection
115
teratozoospermic index (TZI)
Ratio of the number of abnormalities/abnormal sperm | should be between 1 and 3
116
Aetiology of recurrent pregnancy loss
Unknown toxins immunologic anatomic
117
Contraindications to medical or expectant management of pregnancy losses
Haemodynamically or medically unstable patient Signs of pelvic infection/sepsis History of coagulopathy
118
Misoprostol Side effects include
diarrhoea N+V fever/rigors
119
Mifepristone
antiprogestin that result in weakening of the uterine attachment of a pregnancy. This results in capillary breakdown and synthesis of prostaglandins
120
antiphospholid syndrome pregnancy complications
fetal death pre eclampsia thrombocytopenia
121
Screening tests for recurrent pregnancy loss
``` Lupus anticoagulant anticardiolipid antibodies anti-ß2 glycoprotein1 antibodies diabetic screening - glucose tolerance test prolactin ```
122
Cervical insufficiency facts
Second trimester miscarriage losses Screening with transvaginal ultrasound cervical length from 16 weeks to <24wks If cervical length < 25mm then cerclage Vaginal Progesterone (200mg) at night
123
Cervical insufficiency Hx
painless dilatation of the cervix in the second trimester delivery of a live fetus Spontaneous rupture of membranes
124
Antiphospholipid syndrome Mx
Low dose Aspirin (75 -100mg) daily once fetal heart seen | can be combined with Unfractionated Heparin or LMWH until 36 wks
125
advantages of LMWH over heparin
less osteoporosis, haemorrhage and thrombocytopenia reduced protein binding longer half life
126
Complications of termination of pregnancy
Incomplete miscarriage Heamorrhage Infection
127
Rotterdam Criteria
irregular or absent ovulation, elevated levels of androgenic hormones, and/or enlarged ovaries containing at least 12 follicles each
128
PCOS presents clinically by
``` menstrual irregularity androgen excess (hirsutism) acne androgen-dependent alopecia infertility- anovulation ```
129
4 danger signs of cancer
Abnormal bleeding Abnormal masses Unexplained fever Weight loss
130
another 4 danger signs of cancer
Pain Pale Change in personality, gait, balance Red eye or absent red reflex
131
methods of epigenetic change
Changes in DNA methylation Histone modification Polycomb group proteins
132
Un-methylated gene promotor sections allow
transcription of genes | expression of protein product
133
Over- or undermethylation patterns allow
activation of usually silence genes | silencing of important genes
134
MicroRNA or miRNA
Very important during embryogenesis and early development Interacts by being incorporated into the RNA protein complex Degrades and/or block mRNA before transcription
135
epigenetic drugs
Demethylation agents or DNMT-I | Histone deacetylases H-DACS
136
Characteristic signs of hereditary breast/ovarian cancer syndrome
Early or pre-menopausal breast cancer Bilateral breast cancer Any single individual with both diseases
137
aetiology of intersex disorders
Due to excessive androgens Arising in fetus → CAH Arising in mother – androgens secreting tumor. Ingested by mother, eg. Danazol
138
21 hydroxylase deficiency presentation:
Enlarged clitoris fused labioscratal folds and urogenital sinus. Internal genitalia development normal
139
eg of ovarian androgen secreting tumours
Luteoma Arrehenoblastooma Kruken berg tumors
140
True gonadal dysgenesis features
Streak gonads normal mullerian structures Normal external female genitalia
141
Urinary incontinence
involuntary loss of urine
142
Continent
ability to retain urine between voluntary episodes of micturition
143
Urge incontinence
a sudden and strong need to urinate
144
Urinary Incontinence s/x
Frequency Urgency Nocturia
145
Stress urinary incontinence
involuntary loss of urine on effort or physical exertion or on sneezing or coughing due to sudden pressure on the bladder and urethra
146
Overactive bladder
group of urinary symptoms such as urinary urgency, usually accompanied by frequency and nocturia, with or without urgency urinary incontinence, in the absence of UTI or other obvious pathology
147
Mixed urinary incontinence
involuntary leakage associated with Stress Urinary Incontinence and Urge Urinary Incontinence
148
diabetes sx
``` polyuria and polydipsia blurry vision (retinopathy) weight loss (type 1) or weight gain (type 2) neuropathy fatigue ```
149
Stress Urinary incontinence Rx
Conservative- Vaginal pessaries mild-Pelvic floor exercises with electrical stimulation moderate to severe- BURCH or Slings surgery
150
Overactive bladder Rx
``` Lifestyle modification Behavioural modification Pelvic Floor Muscle Training Anticholinergics Neuromodulation ```
151
eg of drugs to control urination
``` trospium oxybutynin propiverene darifenacin fesoterodine ```
152
Urinary Incontinence & Pelvic organ prolapse risk factors
Vaginal childbirth Connective tissue disorders Menopause
153
anti cholinergic S/E
Dry mouth Blurred vision Constipation
154
Artifactual asthenozoospermia
Abstinence period too long, too short Lubricants Incomplete ejaculate
155
Transdermal patch
avoids the first pass metabolism through the liver fewer oestrogen-related side effects Applied weekly
156
vaginal ring
in the vagina for 3 weeks followed by ring-free week Avoids 1st pass metabolism fewer oestrogen-related side effects
157
Oestrogen excess side effects
Bloating migraine headache breakthrough bleeding- refers to vaginal bleeding or spotting that occurs between menstrual periods or while pregnant
158
progestational side effects
Headaches breast tenderness mood changes
159
Major Side Effects of contraception
Thromboembolism Cardiovascular Risk Cancer Risk
160
vaginal fistula causes
Abdominal surgery (hysterectomy or C-section) Pelvic, cervical, or colon cancer Bowel disease like Crohn's or diverticulitis
161
urinary fistula cx
Hysterectomy congenital Radiation treatment
162
what does Oral estrogen increase
MMP and CRP levels | Macrophages release Matrix Metalloproteinase (MMP) that digest collagen
163
menopausal hormone therapy risks
``` thromboembolism gallbladder disease stroke myocardial infarction breast cancer ```
164
When to prescribe tibolone (Progestin)
Any symptomatic post menopausal woman an increase in breast pain despite HRT dose adjustment low libido
165
endometriosis theories
Retrograde menstruation (Sampson’s Theory) Lymphatic spread Coelomic metaplasia/induction theory
166
endometriosis Common sites
Kidney, lung, liver, diaphragm Ovaries Anterior and posterior cul-de-sac
167
endometriosis Clinical presentation
Dysmenorrhoea Subfertility Chronic pelvic pain
168
Mechanism of subfertility in endometriosis
Mechanical interference- adhesions Ovulatory dysfunction Peritoneal fluid- has macrophages which are spermicidal
169
Adenomyosis def and s/x
Presence of endometrial glands and stroma in the myometrium Uterus is enlarged and globular Menorrhagia – 50% Dysmenorrhoea – 30%
170
Adenomyosis dx and Rx
TVS- Resembles myoma MRI- Cystic spaces give a “honey-comb” appearance Laparoscopic resection L/S electrocoagulation Hysterectomy
171
Primary dysmenorrhea
common menstrual cramps that are recurrent and are not due to other diseases
172
Secondary dysmenorrhea
pain that is caused by a disorder in the woman's reproductive organs
173
Pharmacological dysmenorrhea Mx
NSAIDS Pharmacological dysmenorrhea Mx COC
174
non Pharmacological dysmenorrhea Mx
Transcutaneous Electrical Nerve Stimulation. Acupuncture heat Therapy
175
surgical dysmenorrhea Mx
Laparoscopic Uterosacral Nerve Ablation | Laparoscopic Presacral Neurectomy
176
gynaecological cx of Secondary dysmenorrhea
Extrauterine- Pelvic congestion syndrome Intramural- fibroids intrauterine- IUCD
177
non gynaecological cx of Secondary dysmenorrhea
GUT- Interstitial cystitis GIT- Irritable bowel syndrome Orthopaedic- Spondylosis
178
physical sx of PMS
abd bloating extreme fatigur breast tenderness
179
behavioural sx of PMS
Labile Mood Irritability Tensions
180
Phamarcological treatment of PMS
Hormonal- COC’s eg. Yasmin Antidepressants- Fluoxetinine 20mg daily Analgesia- NSAIDs
181
non Phamarcological treatment of PMS
Cognitive therapy Calcium 1200mg/day exercise
182
Premenstrual syndrome types
Premenstrual Molimina- No interference with everyday functioning Premenstrual syndrome- With some functional impairment Premenstrual dysphoric disorder (PMDD)- Mimic psychiatric disorders
183
Lichen sclerosus et atrophicus
a chronic skin disease characterized by white, flat papules with an erythematous halo and black, hard follicular plug
184
what kind of trauma is most seen in pre-adolescent girls
tears abrarasion ecchymosis haematomas
185
Labial agglutination
occurs when the labia minora become fused together | and can lead to UTIs or vulvulovaginitis
186
4 phenotypes of PCOS
Type A: hyperandrogenism, chronic anovulation and polycystic ovaries(O+H+P) Type B: hyperandrogenism and chronic anovulation (O+H) Type C: hyperandrogenism and polycystic ovaries (H+P) Type D: chronic anovulationand polycystic ovaries.(O+P)
187
possible diff dx when considering Hyperandrogenism
``` Cushing’s syndrome Thyroid dysfunction Hyperprolactinaemia Congenital Adrenal Hyperplasia Androgen secreting neoplasm HAIR-AN Syndrome ```
188
“SOCIETAL EFFECTS” of fertility control
Reduces teenage, unwanted and unplanned pregnancy Reduction in poverty Increase in female education and employment, income
189
“MEDICAL EFFECTS” of contraception
Prevents pregnancy related complications and deaths eg. miscarriage Direct benefits of barrier methods eg decr STI’s Direct benefits of hormonal methods- Reduces ovarian and endometrial cancer
190
Non infective cx of Vaginal discharges and Infections
Foreign body/non specific infection Fistulae malignancy
191
Normal physiological discharge clinical hallmarks
Non offensive noncopious no associated symptoms
192
Candida on vagina presents with
Itching and burning Copious white – varying consistency (cottage cheese discharge) Vulvar erythema ± perianal
193
Trichomonas presentation
Profuse frothy yellow green discharge. Strong odour Vulvar erythema and oedema Classic ‘strawberry’ cervix
194
Gonococcal infection Presentation
Typically invades the cervix resulting in pus like discharge/offensive/abdominal cramping/bleeding and painful urination Complications – PID/Bartholins gland abscess/disseminated gonococcal infections Rx cefixime 400mg PO or Ceftiaxone 125mg IM
195
Chlamydia infx presentation
Can cause bartholins gland abscess, vaginitis, cervicitis,acute salpingitis and PID Symptoms include mucopurulent discharge, abdominal pain,dysuria Treatment – azithromycin or doxycyline
196
Syphilitic lesions of the vagina Presentation
chancre Associated lypmphadenopathy If left untreated secondary syphilitic lesions – chondylomata lata, snail track ulcers and mucous paches
197
Genital Tuberculosis Presentation
``` Ages 20-40yrs old Pelvic pain (chronic) Inflammatory pelvic mass Menstrual irregularities and infertility amenorrhoea ```
198
INH
5mg/kg.max 300mg Hepatotoxicity N +V Peripheral neuropathy
199
Rifampicin
10mg/kg max 600mg Hepatotoxic fever rash
200
Ethambutol dosage and s/e
15mg/kg max 800-1000mg Optic neuritis hypersensitivity reaction fever and lymphadenopathy
201
pyrizinamide
15-30mg/kg max1.5-2g Hepatitis Hyperuricemia rash
202
Differential Diagnosis when you suspect PID
``` Appendicitis Ectopic pregnancy Endometritis Ovarian cyst Ovarian torsion ```
203
Indication for surgery in PID
Ruptured TOA or generalized peritonitis Septic Shock or multiorgan dysfunction TOA or pelvic abscess not responding to treatment
204
Chronic pelvic infection facts
Due to acute PID, recurrent lowgrade pyogenic infection or TB Occlusion of ostia – hydro/pyo salpinx Prone to secondary bacterial infection or simply persistent low grade infection
205
Chronic pelvic infection Symptoms and Mx
chronic pelvic pain Dyspareunia Menorrhagia Medication- Analgesia & Antibiotics Surgery- total abd hysterectomy
206
organs affected by Genital Tuberculosis
fallopian tube endometrium ovaries
207
Treatment methods for cervical neoplasia
Local destruction: cryotherapy, laser Local excision: LLETZ, cone biopsy Surgical options: hysterectomy
208
cervical CA s/s and s/x
intermenstrual bleeding dysparenia Pain is a LATE complaint
209
Treatment options in cervical CA
Stage IA: LLETZ or cone is sufficient Stage IB: RHLND: radical hysterectomy and pelvic node dissection Stage II, III: Radical radiotherapy to pelvis with added chemotherapy Stage IV: Chemotherapy plus pelvic irradiation
210
Postmenopausal atrophic vaginitis facts
Burning, itching, dyspareunia, bloodstained discharge Vaginal epithelium shiny, thin and transparent Vaginal moisturisers and lubrication 1st line (topical vaginal estrogen)
211
Emphysematous vaginitis
Gas-filled blisters in vagina PV discharge / “popping sound” Associated with bacterial or trichomonal vaginitis
212
Toxic shock syndrome of vagina
Symptoms may include fever, rash, skin peeling, and hypotension Risk factors: very absorbent tampons, and skin lesions in young children
213
Benign conditions of the vagina
Vaginitis Cystic swellings Solid tumors Vaginal adenosis
214
Epidermal inclusion cysts
Women of childbearing age Following obstetric or other trauma of vagina Posterior and lateral vaginal wall
215
Congenital cysts of vagina
Mesonephric system (Wolffian duct) Gartner duct cysts Anterolateral aspect of vaginal wall ``` Paramesonephric system (Müllerian duct) Rare & occur on Lower 3rd of vagina near hymen ```
216
Polyps in vagina of vagina
proliferation of vaginal lamina propria Usually asymptomatic / incidental finding Differentiate from sarcoma botryoides (esp. children) and pyogenic granulomas (after surgery)
217
Vaginal adenosis
benign, Abnormal presence of columnar epithelium in vagina | Mucoid discharge, postcoital bleeding, dyspareunia DES syndrome
218
most vaginal cancers are metastatic what are the sites
cervix or endometrium | Vulva • Ovaries • Choriocarcinoma
219
If vaginal biopsy shows adenocarcinoma where do you look for other primary lesion
Endometrial cancer • Colon • Rectum | Breast • Ovary
220
Melanoma of vagina
Malignant melanoma of the vagina is rare Present as pigmented masses, plaques or ulcerative lesions Most frequently on the distal one-third of the anterior vaginal wall
221
Sarcomas of vagina
Most common sarcoma botryoides Highly malignant tumor that occurs in the vagina during infancy and early childhood (mean age 3 years) Gross appearance of grape-like masses that are exophytic
222
Diseases caused by HPV besides cerrvicalCA include
Head and neck cancers Anogenital warts Recurrent respiratory papillomatosis
223
Pre-operative factors associated with post-operative cardiac complication
Jugular vein distention or S3 gallop Myocardial infarct within 6 months Arrhythmia
224
Pre-op risk factors for post-op pulmonary complications
Pre-op history of COPD Purulent productive cough Anesthesia time greater than 3 hours
225
Preventing prolonged post-operative ileus
Reducing use of opioids in favor of NSAIDs | Using stimulant laxatives (Dulcolax) in addition to stool softeners
226
Postoperative care procedures
Early removal of the foley catheter in uncomplicated patients prevents UTIs Early ambulation Reduces incidence of VTE Early feeding facilitating early discharge and reducing length of hospital stay
227
Wound Complications
Dehiscence- Separation of facial layers, Serosanguinous drainage, Evisceration Seroma- Benign, No erythema or tenderness Collection of liquefied fat, serum and lymphatic fluid under the incision Hematoma- Abnormal collection of blood that causes discoloration of the wound edges Infection Incisional Herni
228
Factors influencing post-op infection
``` Definite decrease in host resistance increasing age obesity/malnutrition diabetic ketoacidosis acute/chronic steroid use ``` possible decrease in host resistance some forms of cancer radiation therapy adrenocortical insufficiency
229
Wound Infection
Necrotizing fasciitis - Bacterial infection of underlying fascia Clostridial Myositis - Clostridial muscle infection
230
Hypothermia
Drop in body temperature of 2 degrees C halts coagulation cascade thus bleeding cont Platelet dysfunction Mild - 32 – 35C Mod – 28 – 32C Severe – 25 – 28C
231
Malignant Hyperthermia
Rare; autosomal dominant Fever, tachycardia, rigidity, cyanosis First sign is increased end tidal CO2 (Often within 30 minutes) Rx: Dantrolene, correct electrolytes, cooling blanket
232
Postoperative fever | The Six W’s
``` Wind: pneumonia Wound: infections Water: UTI Walking: DVT (possible PE) Waste: abscess Wonder Drug: medication ```
233
Postoperative fever facts
Noninfectious- Within the first 48-72 hours Infectious- Fevers on post op days 3-8 dx: Fever within 24 hours – atelectasis fever on 5th to 10th day – wound infection Rx: acetaminophen or ibuprofen
234
Pulmonary Complications of surgery
Atelectasis Aspiration Pneumonitis Pulmonary edema
235
Cardiac complications of surgery
Hypertension Ischemia/Infarction arrhythmias
236
Renal Complications of surgery
Urinary retention | Acute Renal Failure
237
Gastrointestinal Complications of surgery
Postoperative ileus GI Bleeding Pseudomembranous colitis
238
Neurologic Complications of surgery
Delirium, Dementia and Psychosis Seizure Disorders Stroke and Transient Ischemic Attacks
239
Contributing factors to paeds vulvovaginitis
Suboptimal handwashing Tight, non-absorbent or wet clothing Topical irritants- bubble baths, detergents
240
Non-Specific Vulvovaginitis
No infectious etiology found | Clinically, less discharge and erythema than in cases with infectious etiology
241
Non-Specific Vulvovaginitis Rx
Remove tight-fitting clothes and wet bathing suits immediately after use Avoid bubble baths and strong detergents Cotton underwear Desotin, A&D ointment, other emollients (preparation that softens the skin) Short course of a mild topical steroid to reduce itching
242
Specific Vulvovaginitis | Infectious Etiologies
``` Respiratory Pathogens Enteric Bacteria STD’s Candida Pinworms ```
243
sx of some infx and non infx cx of Vulvovaginitis
strep pyogenes: Dysuria, vulvar pain, pruriitis or burning candida: Pruritis, thick white d/c (Discharge pinworm: intense vulvar or perianal pruritis, esp at night non infx foreign body: Purulent, foul smelling, often brown/bloody vaginal discharge
244
Specific Vulvovaginitis | NON Infectious Etiologies
``` Foreign Body Systemic Illness Miscarriage Vulvar Skin Disease Trauma ```
245
Risk factors of vulvar cancer
HPV Lichen sclerosis Long history of puritis
246
Vulvar Intraepithelial Neoplasms s/s and sx
asymptomatic itching hyperpigmentation rough raisesd lesion
247
Melanoma of vulva
Usually arises from nevi Blue/black Ulcerated RX: wide excision with 2 cm free border
248
Pagets Disease of the Vulva
Hyperemic tissue Cake icing effect (red, velvety area with white islands of tissue on the vulva) Rx: wide local excision 30% will develop adenocarcinoma of the breast, colon, and rectum
249
treatments for infx cx of Vulvovaginitis
oral penicillin cephalosporin erythromycin amoxicillin
250
Sexuality
sexual orientation, sexual activity and the capacity for sexual feelings
251
Sexual response cycle phases
excitement plateau orgasm resolution
252
Types of Paraphilic disorders
``` Paedophilia Voyeurism Sadism Frotteurism Transvestism ```
253
viagra side effects
headaches indigestion vision problems for people with retinal eye conditions
254
eg of biological solutions in sexual problems
viagra transurethral alprostadil injectable phentolamine
255
mx of abn uterine bleeding
``` COC Tranexamic acid Mirena Hysterectomy endometrial ablation ```
256
non structural cx of abn uterine bleeding
``` Coagulopathy Ovulatory Endometrial Iatrogenic Not yet classified ```
257
structural cx of abn uterine bleeding
Polyps Adenomyosis Leiomyoma Malignancy
258
fibroids presentation
``` Asymptomatic Presence of a pelvic mass Abnormal uterine bleeding infertility Pain: Backache, dysmenorrhoea, dyspareunia ```
259
Complications of fibroids
Torsion of pedunculated myoma Bleeding and anaemia Degeneration: Red, Hyaline, Mucoid, Cystic, Fat
260
cx of sexual dysfunction
Psychiatric disorders – Depression Pharmacological Agents – Antidepressants; Medical conditions – Endocrine disorders Surgical procedures – Radiation therapy
261
Biological approach to sexual dysfunction is Contraindicated in people who
use nitrates have heart problems hypo/hypertensio
262
what are X-rays in gynae used for
hystero-salpingram and for diagnosis of perforations
263
endometrium and myometrium echogenicity
Early menstrual phase- anechoic- blood , Very thin 1-4 mm Proliferative; 4-8 mm, isoechoic or slightly hyperechoic relative to the outer Late proliferative (periovulatory)- A multilayered endometrium Secretory phase- echogenic, 8-16 mm Homogenous Low-medium echogenicity
264
echogenicity of gynae conditions
Ectopic pregnancy- Consist of central hypoechoic area surrounded by echogenic rim of trophoblastic tissue Molar pregnancy- Echogenic intrauterine tissue with cystic appearance Incomplete Miscarriage- thickened irregular endometrium with hyper and hypoechoic echoes
265
Rape trauma syndrome short and long term effects
Short term- Humiliation Helplessness Anxiety long term- Sexual dysfunction Increased number of gynaecological problems Frequent users of medical services
266
mx of rape/sexual abuse
Informed consent Thorough History & Examination complete necessary forms and collect evidence Pregnancy, RPR & HIV test. Emergency contraception Doxycycline 100mg bd PO x10d. Metronidazole 2g PO STAT. OR Zithromax 1g stat. PEP - AZT & 3TC anti-retroviral counsel and follow up
267
Functional benign cysts
Follicular cyst- Usually less than 5 cm Corpus luteal- Haemorrhagic corpus luteum Granulosa-theca lutein cyst- In molar pregnancy or part of ovarian hyperstimulation syndrome
268
non Functional benign cysts
Endometrioma- Filled with dark haemolysed blood | PCOS- Anovulation, Hyperandrogenism
269
Primary ovarian tumours
Benign- Epithelial | Malignant- Germ cells tumours, Sex cord
270
Epithelial tumours types
``` Serous- malignant type is the commonest of ALL ovarian cancer Mucinous- If ruptured pseudomyxoma peritonei Endometrioid- occurs primarily in women who are between 50 and 70 years of age Clear cell (mesonephroid)- Polypoid masses that protrude into the cyst Brenner- Usually benign, occur in reproductive life ```
271
Germ cell tumours
Dermoid cyst ( benign cystic teratoma) - Contain tissue derived from 2 or more germ cell layers Non- gestational choriocarcinoma- Secrete HCG. Malignant Germ cell tumour- Dysgerminoma which is highly malignant
272
Sex cord tumours
Granulosa cell tumour Fibromas Thecomas
273
complication of ovarian tumours
Torsion Haemorrhage Rupture
274
malignant vs benign
``` Benign- Thin cyst walls Smooth cyst walls Size less than 8 cm in diameter Unilaterality No ascitic fluid or blood flow ``` ``` malignant- Thick cyst walls Papillary growths on inner or outer surfaces Bilaterality Ascitic fluid present Very strong blood flow ```
275
Post Menopausal Bleeding
Uterine bleeding more than one year after last menstruation | Vaginal bleeding in the presence of raised FSH and LH values in perimenopausal age group
276
levonorgestrel additional benefits
Thickens cervical mucus Decidualizes endometrium Leads to glandular atrophy that further prevents implantatio
277
Disadvantages of IUCD
Cu IUCD’s can increase volume of blood loss during menses Only LNG IUCD protects against PID Can increase dysmenorrhea
278
advantages of IUCD
Doesnt require adherence fewer side effects Reduced risk of cervical and ovarian cancer
279
Contraindications of IUCD
Distortion of uterine cavity – congenital, fibroids Unexplained uterine bleeding Breast cancer – only for LNG IUCD Wilson’s disease for Cu IUCD
280
Tubal occlusion methods
``` Partial salpingectomy Salpingectomy Fimbriectomy Bipolar cauterization – not a good method Clips Ring ```
281
Leiomyosarcomas facts
Rare Aggressive tumours Usually large (> 10 cm) soft tumours in the myometrium of the uterus Leiomyomas NOT precursor to leiomyosarcomas variants Epithelioid & Myxoid
282
Leiomyosarcomas Clinical presentation
``` Asymptomatic Pre or Postmenopausal bleeding or both Abdominal pain Abdominal distension Urinary symptoms ```
283
Endometrial carcinoma Risk Factors
``` Obesity Hypertension tamoxifen Nulliparity Lynch syndrome (hereditary non-polyposis colorectal cancer) ```
284
BPH: Symptoms
Storage- Frequency Urgency (Urge incontinence) Nocturia Voiding -Weak stream Intermittency Straining Incomplete Emptying
285
Later signs/symptoms of BPH
Abdominal/flank pain with voiding Uremia (renal failure) →fatigue, anorexia, somnolence UTI’s
286
BPH: Clinical findings
Late signs of renal failure: anemia, hypertension Abdominal exam: hydronephrosis/pyelonephritis GU exam: hernia, stricture, phimosis DRE in BPH: smooth, enlarged (can’t get finger above it), nodular, with a loss of distinction between the lobes
287
BPH: Non-Surgical Option
``` Herbal Phytotherapy (e.g.. Saw Palmetto) Alpha-1-adrenergic antagonists (terazosin, doxazosin 5-Alpha-reductase inhibitors (finasteride, dutasteride) ```
288
BPH: Surgical Option
TransUrethral Resection of the Prostate(TURP) Transurethral Incision of Prostate (TUIP): less morbidity with similar efficacy indicated for smaller prostates Open Prostatectomy
289
BPH: New Modalities of Rx
Minimally invasive: (Prostatic Stents Laser prostatectomy ,HoLEP) Holmium laser enucleation of the prostate Electrovaporization (TUVP Transurethral Vaporization of Prostate
290
Acute prostatitis
acute infectious disease sudden onset fever, tenderness, urinary symptoms, constitutional symptoms
291
Chronic prostatitis
recurring infection with same organism few prostate related symptoms difficulty urinating, low back pain, perineal pressur
292
acute bacterial Prostatitis Etiology
Gram-negative enteric organisms most frequent pathogens- E. col K. pneumoniae P. mirabilis less frequently P. aeruginosa Enterobacter spp Serratia spp
293
chronic bacterial prostatitis Etiology
S. epidermidis S. aureus Other/ Unusual- CMV, TB, Candida
294
prostatitis Rx
trimethoprim-sulfamethoxazole fluoroquinolones (e.g., ciprofloxacin cephalosporins 4 weeks of antibiotic therapy to reduce chronic prostatitis risk
295
which antimicrobials can you use to sterilize urine prior to study in the case of significant bacteriuria
ampicillin, cephalexin, or nitrofurantoin for 2 to 3 days
296
long-term suppressive therapy for recurrent infections
ciprofloxacin three times weekly trimethoprim-sulfamethoxazole daily nitrofurantoin 100 mg daily
297
bilharzia Clinical manifestation
Acute: Penetration- Swimmers itch, Circulation- Katayama fever Intestinal- Abdominal pains, Hepatomegaly Ureter- Distal ureteric stricture, Ureteric calcifications Bladder- Mass (inflammatory), Calcified bladder Genitalia- Cervicitis, Epididymitis, Calcifications of genital organs
298
bilharzia Rx
Medical- Praziquantel, 40mg/kg | Surgical- For complications
299
enuresis
Nocturnal bedwetting in a child older than 6 years in the absence of any neurological condition
300
Epidemiology: Law of 15 eg
1% of 15 yr. old wet 15 % of enuretics have encopresis 15% of non-enuretics have nocturnal polyuria
301
enuresis Rx
Anticholinergics Desmopressin Imipramine Limit fluid intake in the evening (from 17:00) Child must help change sheets if wet
302
Voiding Dysfunction
Neuropathic- Myelodysplasia (Neural Tube Defect) | Non-neuropathic- Intravaginal reflux, Hinman Syndrome, Ochoa syndrom
303
Genitourinary TB Clinical manifestation
Kidney- Parenchymal masses, infindibular stenosis of collecting system Ureter- Stricture, Fibrosis of Vesico-ureteric junction Bladder- Granuloma, Contracted bladder Prostate- Inflamed, Abscess Epididymis- Infertility, Beaded Vas deferens Testicle- mass, abscess
304
besides RIPE what can be used to treat Genitourinary TB
Streptomycin Steroids Surgical intervention
305
Erection requirements
``` Stimulus (visual, fantasy, tactile) Intact nerve supply Normal penile vasculature Healthy cavernous tissue Normal hormonal environment ```
306
Treatment for Prostate Cancer and erectile dsyfunction
radical prostatectomy External beam radiotherapy brachytherapy PDE5Is (Phosphodiesterase-5 inhibitors) still the first-line management for ED post-RP
307
aetiology of erectile dsyfunction
Vasculogenic- CV disease, Lack of regular physical exercise Central Neurogenic causes- Degenerative disorder (MS, Parkinson’s), Stroke Peripheral Neurogenic- Polyneuropathy, Surgery (pelvic) Structural- Phimosis, Peyronie’s disease Hormonal- Diabetes Mellitus, Metabolic Syndrome Drug-induced- Antihypertensives, Antidepressants Psychogenic- Generalised (lack of arousability), Situational (partner-related) Trauma- Penile or Pelvic fractures
308
Medical management of ED
First-line Therapy- PDE5 inhibitors, Vacuum erection devices, Shockwave therapy (LI-SWT) Second-line therapy- Intra-cavernous injections Third-line therapy- Penile prostheses
309
PDE5 inhibitors side effects
``` Headache Facial flushing Nasal congestion Dyspepsia Back pain, myalgia : Tadalafil Abnormal vision: Sildenafil/Vardenafil ```
310
Safety issues with PDE5s
``` Nitrates are contra-indicated alpha Blocker interaction Dose adjustments (CYP34A): decr PDE5 dose- ketoconazole, ritinovir, erithromycin incr PDE5 dose- rifampicin, phenobarbital, carbamazipine ```
311
Other causes of anal incontinence
Colorectal disease: rectal prolapse/inflammatory bowel ds/fistulas Congenital atresia Surgical injury to the anal sphincters
312
anal incontinence facts
Urgency of defecation- decrease in warning time indicates injury to voluntary striated ext anal sphincter or its nerve supply Fecal incontinence with no warning- passive soiling suggests damage to the IAS New onset symptoms- colonoscopy and barium constrast studies
313
Management of Overactive bladder syndrome
Weight reduction Pelvic floor muscle exercise with electrical stimulation Anti-cholinergic medication- e.g. Oxybutynin B3 agonists-e.g. Mirabegron Sacral neuromodulation
314
Acute urethral syndrome
symptoms of dysuria, frequency and/or pyuria without evidence of significant bacteriuria, often in association with vaginitis or urethritis
315
Recurrent UTI
≥2 infections in six months or ≥3 infections in one year Referred to as relapse when infection of the same organism occurs within 2 weeks and is usually drug-resistant Reinfection is diagnosed when a second infection is found after effective antibiotic therapy with a subsequent negative urine culture
316
Risk factors for UTIs
Behavioural factors- soaps Instrumentation of the urinary tract- urethral catheterization Voiding dysfunction Chronic vesico-ureteric reflux
317
Risk factors for Recurrent UTIs
``` Lower urinary tract obstruction Chronic retention of urine Bladder stones Cystocele Vesicovaginal fistula ```
318
Clinical symptoms of UTIs
Upper UTIs- Fever Chills Flank pain ``` Lower UTIs- Frequency Urgency Dysuria Suprapubic pain Haematuria-rarely ```
319
Common Uropathogens
``` E Coli Proteus Klebsiella Enterobacter P. aeruginosa ```
320
UTI Rx
at least three-day treatment of 1st Gen Cephalosporins Fluoroquinolones nitrofurantoin
321
UTI Rx facts
``` Resistance rate ranges are based on patient’s age: younger women record higher rates of resistance of E. coli toward ampicillin and trimethoprim– sulfamethoxazole than the elderly, a resistance rate higher than 15–20% requires the choice of a different antibiotic class Fosfomycin tromethamine can be used in a single dose, while nitrofurantoin monohydrate macrocrystals are given at seven-day treatment, twice daily In postmenopausal women a 3-day regimen has been suggested, as well as a local hormone supplementation ```
322
recurrent UTIs prophylaxis
nitrofurantoin norfloxacin trimethoprim–sulfamethoxazole Cranberry and lingonberry
323
postcoital prophylaxis for UTI
single dose of an effective antimicrobial nitrofurantoin 50 mg trimethoprim-sulfamethoxazole 40/200 mg cephalexin 500 mg
324
hormones kideny produces
renin prostaglandins erythropoietin
325
Azotemia
elevation of blood urea nitrogen and creatinine levels result of a decreased glomerular filtration rate
326
Uremia
azotemia + a constellation of clinical signs and symptoms (e.g. peripheral oedema, fatigue, restless legs)
327
angiotensin II funtion
Stimulates sodium transport (reabsorption) at several renal tubular sites Stimulates thirst centers within the brain Releas ADH
328
nephritic syndrome signs and sx
``` HT proteinuria blurred vision haematuria azotaemia oliguria ```
329
Nephrotic syndrome
``` characterized by very heavy proteinuria (> 3.5g/day) hypoalbuminemia severe oedema hyperlipidemia lipiduria ```
330
Acute kidney injury
characterized by rapid decline in GFR (hours to days) concurrent dysregulation of fluid and electrolyte balance retention of metabolic waste products oliguria and anuria may develop
331
Chronic kidney disease
diminished GFR that is persistently <60ml/minute/1.73m2 for at least 3 months and/or persistent albuminuria
332
Renal tubular defects
dominated by polyuria, nocturia and electrolyte disorders
333
nephrolithiasis
spasms of severe pain on flanks, back and below ribs haematuria pain on urination
334
Acute tubular necrosis
Ischaemic or toxic patients present with extreme oliguria (<100 ml of urine in 24 hours) oliguric phase often followed by a diuretic phase oliguric phase complicated by development of hyperkalaemia with the risk of cardiac arrhythmias
335
Interstitial nephritis
heterogenous group of conditions which have common morphological (inflammatory reaction composed mainly of T-cells) and clinical features Etiology- toxins, immunological, metabolic s/s and sx- fever and/or rash, incr urine output, haematuria or dark urine
336
Analgesic nephropathy
Results from chronic ingestion of large quantities of asprin Asprin induces papillary ischaemia by inhibiting the synthesis of vasodilatory prostaglandins Patients may develop transitional cell carcinoma of the renal pelvis and/or ureter
337
kidney Lesions associated with metabolic disorders
hypokalemia- causes coarse vacuolation of the tubular epithelial cells urate- precipitated crystals cause obstruction and tubular dilatation hypercalcemia- stones within the pelvicalyceal system oxalosis- tubular crystalline deposits
338
kidney Lesions due to physical agents
Radiation nephritis- present with hypertension and renal insufficiency Obstructive uropathy- pelvis and calyceal system become dilated due to back pressure (hydronephrosis)
339
acute pyelonephritis
presents with malaise, fever, pain and tenderness in the loins urine examination reveals presence of pus cells and white cell casts abscesses and wedge-shaped foci of suppurative inflammation are seen in the renal cortex and medulla at microscopic examination
340
Chronic pyelonephritis
develops when there is reflux of urine into the kidney during micturition raising the intrapelvic and intracalyceal pressure deep irregular scars are seen towards the poles of the kidneys interstitial fibrosis and tubular atrophy are seen microscopically
341
Xanthoganulomatous pyelonephritis
develops in patients with chronic pyelonephritis associated with Proteus and E.coli infections presents as a renal mass mimicking a neoplasm the kidney cut surface shows a yellow mass surrounded by distorted calyces and small abscesses
342
Potter’s syndrome
Bilateral agenesis thus oligohydramnios thus hypoplastic lungs presents - low set ears receding chin wide-set eyes ‘parrot beak’ nose associated abnormalities: spinal cord defects
343
Congenital renal diseases
most of the diseases are prone to infx and/or stones Unilateral agenesis- affected children do not survive long because of associated multiple developmental abnormalities, prone to infections and trauma Renal hypoplasia- prone to infection and stone formation Renal dysplasia- presents as cystic kidneys Ectopic kidneys- may be associated with intestinal malrotation Horseshoe kidney- results from fusion of the two nephrogenic blastemas during fetal life, renal function usually normal
344
MORE Congenital renal diseases
Cystinuria- autosomal recessive, cysteine crystals are found in the urine and calculi may develop Renal tubular acidosis- autosomal dominant, loss of bicarbonate and failure to acidify and concentrate the urine, tendency to form stones and develop infections
345
Congenital nephrotic syndrome
autosomal recessive nephrotic syndrome develops due to excessive proteinuria patients vulnerable to pneumococcal infection the kidneys have a microcystic appearance which results from dilatation of the proximal tubules and Bowman’s capsule high levels of alpha-fetoprotein in the amniotic fluid and maternal blood
346
Alport’s disease
Mode of inheritance variable but is X-linked in 50% of families triad of: nephritis, deafness and ocular lesions presents with haematuria usually in the 1st decade of life Renal failure in males develops in the 2nd decade Renal function in females preserved until the 5th decade
347
Simple renal cysts
Do not affect renal function | May present with pain if bleeding occurs
348
Autosomal dominant polycystic kidney disease
Mutations in the ADPKD1 and ADPKD2 genes Always bilateral The cysts vary in size from a few millimeters to several centimeters and are separated by thin bands of renal parenchyma Eventually results in renal failure Patients may develop cysts in other organs including liver, pancreas and lungs and berry aneurysm
349
Autosomal recessive polycystic kidney disease
Perinatal subgroup- affected babies are stillborn or die of renal failure and respiratory distress soon after birth Neonatal, infantile and juvenile subgroups- characterized by less severe disease and longer survival associated with liver abnormalities including proliferation of the bile ducts and hepatic fibrosis
350
Dialysis-associated cysts
Characterized by the presence of multiple small cysts that are found throughout the cortex and medulla Cysts often associated with oxalate crystals
351
Uremic medullary cystic disease
Causes chronic renal failure in children and adolescents There is usually a family history Kidneys have numerous cysts at the cortico-medullary junction
352
Medullary sponge kidney
Results from dilated collecting ducts in the medulla | Usually bilateral but may be unilateral
353
viral infx of kidney
Hepatitis B- Associated with membranous or membranoproliferative glomerulonephritis Hepatitis C- Associated with mesangiocapillary glomerulonephritis HIV- Characterized by collapse of the glomerular capillaries, severe interstitial fibrosis and inflammation
354
MORE viral infx of kidney
Polyomavirus-induced nephropathy- BK and JC viruses Causes disease in immunocompromised patients (HIV and renal transplants) Diagnosis can be made on urinary cytology by identification of cells containing large basophilic intranuclear viral inclusions (decoy cells) EBV- Induces B-cell proliferation and transformation with development of lymphoproliferative disorders
355
Hyperacute rejection of kidney
Develops within minutes or hours (<48hrs) Due to preformed antibodies in the blood of the recipient Immune damage directed at the endothelial cells of the graft The kidneys are flaccid, cyanosed and mottled Thrombi and cortical infracts are seen microscopically
356
Acute rejection of kidney
Develops within days, months or years | Mononuclear cell infiltrate, interstitial oedema, haemorrhage and tubulitis are seen microscopically
357
Chronic rejection of kidney
Develops month or years following transplantation | Characterized by interstitial fibrosis and tubular atrophy
358
urinary calculi s/s and s/x
renal colic, dull ache in the loins | recurrent and intractable UTI
359
urinary calculi Classification
calcium oxalate (75-80% of all calculi) struvite stones (composed of magnesium, ammonium phosphate). Stones are large with a staghorn appearance uric acid stones calculi in cystinuria and oxalosis
360
Benign renal tumours
Renal fibroma | Benign cortical adenoma
361
Malignant renal tumours
Renal cell carcinoma - most common type of kidney cancer in adults Wilm’s tumour- most common cancer of the kidneys in children Carcinoma of the renal pelvis
362
Osteoporosis is a skeletal disease that is characterized by
Low bone mass Microarchitectural disruption Skeletal fragility Increased fracture risk
363
Most common fragility fractures occur in
vertebrae hip wrist
364
risk facttors for osteopenia
``` Advanced age Cortisone therapy Low body mass (<58kg) Smoking and excess alcohol Sarcopenia rheumatoid arthritis ```
365
osteoporosis mx lifestyle
Exercise – improves muscle strength and balance and reduces falls Adequate calcium and Vit D intake Excessive Ca intake does not reduce fractures and leads to increased risk of cardiovascular disease and renal calculi
366
osteoporosis mx medical
Estrogen or estrogen/progesterone Bisphosphonates – GI side-effects Raloxifen – Selective estrogen receptor modulator Teriparatide- parathyroid hormone analogue Denosumab- Monoclonal antibodies
367
Types of surgery
Standard surgery – Adnexectomy +/- hysterectomy + total omentectomy + washings + nodes + biopsies Radical surgery – Pelvic clearance + nodes Supra-radical surgery – Upper abdominal cytoreduction
368
complete surgical cytoreduction
“Standard” surgery: • hysterectomy, bilateral adnexectomy • excision of the pelvic peritoneum, total omentectomy, appendectomy, bulky pelvic and lumbo-aortic nodes +/− simple peritonectomies. “Radical” surgery:- removal of the uterus and ovaries and pelvic peritoneum with the and recto-sigmoid +/− simple peritonectomies.
369
Cystic renal dysplasia
Abnormal persistence of undifferentiated mesenchyme: forming heterologous tissues - cartilage, primitive collecting ductules gross or microscopic cysts Ureteric obstruction Large cysts lined by flattened cuboidal epithelium Intervening parenchyma is fibrotic with islands of bluish cartilage
370
Multicystic dysplastic kidney
Occurs only sporadically - No defined pattern of inheritance The cysts are larger and more variably sized than those of ARPKD Often unilateral. - If bilateral, it is often asymmetric and oligohydramnios and its complications can ensue, just as with ARPKD
371
Childhood polycystic kidney disease
Autosomal recessive Smooth external surface [mass of cysts of uniform sizes Cyst lined by uniform cuboidal epithelium Most of the cysts are elongated and radially arranged from the center of the kidney
372
Nephronophthisis
Cysts in medulla/corticomedullary junction tubular atrophy Interstitial inflammation/fibrosis
373
Hydronephrosis causes
Congenital eg Posterior urethral valves Urinary calculi BPH, pregnancy, uterine prolapse
374
Renal cell carcinoma Clinical triad
Flank pain, mass effect, and hematuria
375
Ureteritis follicularis
Aggregation of lymphocytes in the subepithelial region | Slight elevations of the mucosa and produce a fine granular mucosal surface
376
Cystitis Glandularis and Cystitis Cystica
Nests of transitional epithelium (Brunn nests) grow downward into the lamina propria undergo transformation of their central epithelial cells into: Cuboidal or columnar epithelium lining [cystitis glandularis] Cystic spaces lined by urothelium [cystitis cystica] The two processes often coexist [cystitis cystica et glandularis] In cystitis glandularis, goblet cells are present, and the epithelium resembles intestinal mucosa (intestinal or colonic metaplasia
377
Types of acute cystitis
Hemorrhagic cystitis - Radiation - Antitumor chemotherapy (cyclophosphamide in Px of leukemia) - Adenovirus infection Suppurative cystitis - Ulceration of large areas of the mucosa
378
Chronic Cystitis
Thickening of the epithelium Fibrous thickening in the muscularis propria Histologic variants Follicular cystitis - Aggregation of lymphocytes into lymphoid follicles within the bladder mucosa Eosinophilic cystitis - Infiltration with submucosal eosinophils together with fibrosis
379
Interstitial Cystitis (Hunner Ulcer)
painful form of chronic cystitis in women and associated with inflammation and fibrosis of all layers of the bladder wall cystoscopic findings of fissures and punctate hemorrhages (glomerulations) mast cells are particularly prominent
380
Malacoplakia
Characterized macroscopically by soft, yellow, raised mucosal plaques 3 to 4 cm in diameter histologically by infiltration with large, foamy macrophages with occasional multinucleate giant cells and interspersed lymphocytes Laminated mineralized concretions resulting from deposition of calcium in enlarged lysosomes [Michaelis-Gutmann bodies] Chronic bacterial infection [E. coli or Proteus species
381
Polypoid Cystitis
Results from irritation to the bladder mucosa | Formation of broad, bulbous, polypoid projections as a result of marked submucosal edem
382
Papillomas (Urothelial Tumors )
In younger patients Small (0.5 to 2.0 cm), delicate, structures, superficially attached to the mucosa by a stalk Finger-like papillae have a central core of loose fibrovascular tissue Covered by transitional epithelial cells that are histologically identical to normal urothelium
383
Papillary urothelial neoplasms of low malignant potential (PUNLMP)
Either thicker urothelium or diffuse nuclear enlargement Limited proliferative activity Usually larger than papillomas
384
Low-grade papillary urothelial carcinomas
Minimal but definite evidence of nuclear atypia- scattered hyperchromatic nuclei, infrequent mitotic figures predominantly towards the base mild variation in nuclear size and shape
385
High-grade papillary urothelial carcinoma
Dyscohesive and have large hyperchromatic nuclei The tumor cells show frank anaplasia Mitotic figures, including atypical ones, are frequent
386
Condyloma Acuminatum of penis
``` benign Papillomatosis acanthosis hyperkeratosis koilocytosis ```
387
Bowen disease
Genital region of both men and women, usually in those over the age of 35 years Solitary, thickened plaque with shallow ulceration and crusting On the glans and prepuce as single or multiple shiny red, sometimes velvety, plaques where it is clinically referred to as Erythroplasia of Queyrat
388
Bowenoid papulosis
The younger age of patients and the presence of multiple (rather than solitary) pigmented (reddish brown) papular lesions is typical
389
Invasive squamous cell carcinoma of penis
Circumcision confers protection | macroscopic patterns: - Papillary - Flat
390
Verrucous carcinoma
well-differentiated variant of squamous cell carcinoma that has low malignant potential These tumors are locally invasive, but they rarely metastasize
391
Non-specific epididymoorchitis
Chlamydia trachomatis and Neisseria gonorrhea are the most frequent culprits In men older than age 35, the common urinary tract pathogens, such as Escherichia coli
392
Specific epididymoorchitis
Granulomatous (Autoimmune) Orchitis - nontuberculous granulomatous orchitis, granulomas are seen restricted within spermatic tubules. Mumps - acute interstitial orchitis develops about 1 week after onset of swelling of the parotid glands. Tuberculosis Gonorrhea Syphilis
393
syphilis Specific epididymoorchitis
Almost invariably, the testis is involved first by the infection In many cases, the orchitis is not accompanied by epididymitis morphologic patterns- Gummas, diffuse interstitial inflammation obliterative endarteritis with perivascular cuffing of lymphocytes and plasma cells
394
Germ Cell Tumors
Multipotential germ cells in 60% of the tumors, there is a mixture of two or more of the histologic patterns Originate from intratubular germ cell neoplasia [ITGCN] ITGCN is seen adjacent to all germ cell tumors in adults except for spermatocytic seminoma and epidermoid and dermoid cysts It is also not seen in pediatric tumors (teratomas, yolk sac tumors) treated by low-dose radiotherapy
395
intratubular germ cell neoplasia [ITGCN]
``` Cryptochidism Prior germ cell tumour in adult patient Family history of germ cell tumour Androgen insensitivity syndrome Gonadal dysgenesis syndrome ```
396
Germ Cell Tumors Histogenesis
Gonadal cell line [seminoma – end-stage neoplasm] Non-gonadal cell line [Embryonic and extra-embryonic] Embryonic [embryonal carcinoma ; teratoma] Extraembryonic [Yolk sac and choriocarcinoma
397
Seminoma
Most common type of germinal tumor in adults [over 30years] Identical tumor arises in the ovary [dysgerminoma] Microscopically [sheets of uniform cells divided into poorly demarcated lobules by delicate septa of fibrous tissue] Tumor cells are round to polyhedral and has a distinct cell membrane; a clear or watery-appearing cytoplasm; and a large, central nucleus with one or two prominent nucleoli The cytoplasm contains varying amounts of glycogen Classic seminoma cells do not contain α-fetoprotein (AFP) or human chorionic gonadotropin (HCG) [but stain for PLAP (Placental alkaline phosphatase)
398
Seminoma - Variants
Anaplastic seminoma [cellular; nuclear irregularity ; tumor giant cells and many mitoses] Spermatocyic seminoma - does not arise from an ITGCN - In much later age than for most testicular tumors [over 65 years] - Slow-growing tumor that rarely if ever produces metastases
399
Spermatocytic seminomas [three cell populations]
smaller cells resembling secondary spermatocytes medium-sized round nucleus and eosinophilic cytoplasm scattered giant cells
400
Embryonal carcinoma
More aggressive than seminomas Foci of hemorrhage or necrosis [hemorrhagic mass] Considerable variation in cell and nuclear size and shape Mitotic figures and tumor giant cells are frequent raised HCG & AFP
401
Yolk Sac Tumor
Most common testicular tumor in children up to 3 years of age In this age group, it has a very good prognosis Elevated serum levels of AFP useful in diagnosis
402
Yolk Sac Tumor Microscopically
Lacelike (reticular) network of cuboidal cells Papillary structures Solid cords of cells Structures resembling endodermal sinuses (SchillerDuval bodies) Eosinophilic hyaline globules AFP and α1-antitrypsin
403
Choriocarcinoma
Highly malignant form of testicular tumor Hemorrhage and necrosis are extremely common Composed of cytotrophoblastic and syncytiotrophoblastic cells Often, they cause no testicular enlargement and are detected only as a small palpable nodule Rapidly growing, they may outgrow the blood supply, and sometimes the primary testicular focus is replaced by a small fibrous scar, leaving only widespread metastases
404
Choriocarcinoma Microscopically
Syncytiotrophoblastic cell is large - abundant eosinophilic vacuolated cytoplasm Cytotrophoblastic cells are more regular - polygonal with distinct cell borders and clear cytoplasm
405
Teratoma
Complex tumors having various cellular or organoid components reminiscent of normal derivatives from more than one germ layer Elements may be mature or immature tissue Rarely, non-germ cell tumors (carcinoma/sarcoma) may arise in a teratoma [teratoma with malignant transformation] When the non-germ cell component spreads outside of the testis it does not respond to chemotherapy
406
Teratoma Microscopically
Endodermal derivatives - Gut epithelium; bronchial epithelium Mesodermal derivatives - Muscle tissue; bone and cartilage Ectodermal derivatives - Skin and brain tissue
407
Prostate Glands lined by two layers
Basal layer of low cuboidal epithelium | A layer of columnar secretory cells
408
Prostate carcinoma Rx Stage 1 and 2
Radical prostatectomy – Retropubic – Perineal – Laparoscopic | Radiotherapy
409
Prostate carcinoma Rx T3
Radiotherapy Surgery Brachytherapy
410
Prostate carcinoma Rx Stage 4
Medical- GnRh analogues, Anti androgens, Estrogens | Surgical • Bilateral orchidectomy\seminectomy
411
Prostate carcinoma Complications
``` Hot flushes Weight gain Depression Gynecomastia Osteoporosis Cognitive abilities ```
412
Prostate carcinoma Palliative care
Pain – morphine Localised bone pain – Radiation(70%) Bisphosphonates
413
Chemoprevention of Prostate carcinoma
Dietary- Soy products, Tomato products, omega fatty acids | Medical/supplements – Vit E, Selenium, Zinc
414
Benign prostatic hyperplasia Absolute indications for Surgery
``` Repetitive episodes of acute urinary retention Chronic urinary retention Recurrent UTI Macroscopic heamaturia Upper tract dilatation Bladder stones Failed medical therapy ```
415
Benign prostatic hyperplasia Watchful waiting
Restrict fluid nocturnally Double voiding Urethral milking Caution with alpha adrenergic meds
416
Etiology of Fournier gangrene
Infection of Anorectal or Urogenital area | Dermatological- Hidradenitis suppurativa, Pressure sore ulcers, Trauma, Ass poor hygiene
417
organisms causing fournier gangrene
E.coli, Bacteroides | Others- Proteus, Staphylococcus, Enterococcus, Klebsiella, Clostridium
418
Fournier gangrene clinical presentation
``` Pain and tenderness in the genitals Fever and lethargy Increasing erythema of the skin Purulent discharge Urinary &/or GIT symptoms ```
419
Fournier gangrene Rx
Rehydration Antibiotics Surgical debridement- Skin graft
420
nervous system and micturition
Higher centres/ cortical micturition centre: suppression of involuntary bladder contractions Pontine micturition centre: co-ordination of urethral sphincter & detrusor Parasympathetic supply: pelvic nerve for micturition Sympathetic supply: sympathetic trunk & hypogastric nerve, to not void Somatic supply: pudendal nerve (noxious stimulus e.g.. pain), as well as pelvic floor
421
Lesions at various levels & Example of disease process
At or above brain stem- CVA, dementia, brain tumour At spinal cord- acute transverse myelitis, pernicious anaemia, poliomyelitis Distal to spinal cord- Disc disease/ laminectomy, spinal stenosis, Guillam Barre Syndrome Miscellaneous conditions- AIDS, Schistosomal myelopathy, syringomyelia
422
Management of neurogenic bladder | Lower storage pressure
Detrusor overactivity: anticholinergics (systemic, intravesical), Botox injection Poor compliance: anticholinergics, bladder augmentation Detrusor sphincter dyssynergia: sphincterotomy (chemical, surgical), catheter Bladder outlet obstruction: urethral stricture repair, bladder neck incision, Transurethral resection of the prostate
423
neurogenic bladder medical mx
Beta 3 adrenergic agonist anticholinergics Botox: “intravesical” injection
424
neurogenic bladder surgical mx
Continent storage Increase bladder outlet pressure - Urethral bulking agents, Midurethral sling (tape) Artificial urinary sphincter Continent urinary diversion (Mitrofanoff) If can’t achieve continence Discreet, hygienic external collection devices Incontinent urinary diversion (ileal conduit
425
Priapism Classification
``` Ischaemic priapism (veno-occlusive, low flow) Non-ischaemic priapism (arterial, high flow) Recurrent priapism (stuttering) - a variant of ischaemic priapism ```
426
ischaemic priapism facts
Most common priapism Idiopathic in majority of cases Sickle cell anaemia most common cause in childhood Common after ICI of papaverine based combinations Rare after ICI with prostaglandin E1 monotherapy Rare in men who have taken PDE5Is Compartment syndrome of the corpora cavernosa
427
Aetiology: Ischaemic priapism
Idiopathic Prescribed drugs- ICI (papaverine, phentolamine), Antihypertensives Recreational/Illicit drugs- Alcohol, cocaine Hematologic disease- Sickle cell disease, Thalassemia Infectious disease- Malaria, Rabies Toxins- Scorpion sting, Spider bite Metabolic disorders- Amyloidosis, Fabry’s disease Neurological conditions- Syphilis, Cauda equina syndrome Malignancy- Prostate, urethra
428
ischaemic priaprism Clinical findings
Usually -Corpora rigid and tender but glans soft Penile pain AbN penile blood gas (Dark blood – hypoxia, hypercapnia, acidosis ) Sometimes- Hematologic abnormalities, Recent intra-cavernous injection Seldom- Perineal trauma Non ischaemic priaprism has the opposite Clinical findings except for Recent intra-cavernous injection which is the same
429
ischaemic priaprism Rx
Aspiration Phenylephrine Puncture techniques Shunt procedures
430
Phenylephrine
``` Cardiovascular monitoring (BP and ECG) Dilute in normal Saline to 100-500 μg/ml) Inject 200 μg every 3-5 minutes (x5) Total maximum dose 1 mg within 1 hour 10 mg (1 ml) in 1 L of Saline ```
431
Complications of Priapism
ED, corporal fibrosis, cavernositis
432
Non-ischaemic def
A persistent erection caused by unregulated cavernous arterial inflow An erection that is not fully rigid
433
ischaemic priapism def
A persistent erection of the penis marked by rigidity of the corpora cavernosa and by little or no cavernous arterial inflow
434
Aetiology: Non ischaemic priapism
``` penile or perineal trauma Non penetrating (blunt) or Penetrating ```
435
NON ischaemic priaprism Clinical findings
Penile blood gas analysis- Bright red blood | Colour Penile Doppler Ultrasound- Turbulent flow at fistula
436
NON ischaemic priaprism Rx
Diagnostic corporeal aspiration Observation and systemic support- Spontaneous resolution (62%) Selective embolization
437
Stuttering Priapism
Sickle cell disease the most common course Idiopathic and neurological causes have been reported Men who had an acute ischaemic priapism are at risk to develop a stuttering priapism
438
Stuttering Priapism Rx (same as Rx for ischaemic priaprism)
Aspiration Phenylephrine Puncture techniques Shunt procedures
439
Prevention of future episodes of Stuttering Priapism
``` Alpha-adrenergic agonists(oral) Hormonal manipulation of circulating testosterone Digoxin Terbutaline Gabapentin ```
440
eg of shunts
distal- winter and ebbehoj | proximal- quackels or grayhack
441
Pyronies disease
Superficial fibrosing disorder of penis which causes Plaque formation & Penile deformity Risk factors- Heredity, Connective tissue disease, Age (median age is 55-57)
442
Pyronies disease | Clinical manifestation
``` Penile Pain (Sometimes painless) Curvature of penis Palpable plaque Erectile dysfunction Stress ass with sexual function ```
443
Pyronies disease phases
Acute phase Progressive penile deformity Pain with erection or flaccid state Duration varies between 6-18 months Chronic phase Stability of deformity for 3-6 months Reduced pain
444
Pyronies disease Rx
Non pharmacological Penile traction therapy extracorporeal shock wave therapy Medical treatment Oral- Procarbazine, Vitamin E Transdermal- Verapamil, Dexamethasone Intra-lesional- Interferon, Collagenase clausdridium hystoliticum Surgical treatment inflatable penile prosthesis Tunical plication
445
catheter Uses
Diagnostic- VCUG Therapeutic- Urinary retention Treatment- Intravesical chemotherapy
446
catheter Types
Kidney- Nephrostomy tubes, JJ stents (double | Bladder- Transurethral, Suprapubic catheter
447
2 way urethral catheter Indication
Urine (diagnostic), Urinary retention, Pyuria
448
3 way urethral catheter Indication
Irrigate bladder | Gross haematuri, Bladder tumour, Post TURP or TURBT (Transurethral Resection of a Bladder tumur)
449
Malecot catheter
Used as a Nephrostomy tube or Suprapubic catheter
450
Suprapubic catheter
Bladder outlet obstruction- BPH, Urethral stricture, Bladder stenosis Neurogenic bladder, Long term catheter
451
Nelaton
Intermittent catheterization Neurogenic bladder Decompensated bladder- Posterior urethral valves, BPH
452
Condom catheter
Used in males with incontince, Less risk for infection
453
jj stents
Bypass obstruction - Supra vesical obstruction | Ureteric dilatations
454
Urinary retention Causes
``` Bladder outlet obstruction: BPH Any neuropathic bladder Pain Gynaecological & Surgical Medications inc. anaesthetic drugs Hypothyroidism ```
455
Chronic Urinary retention Mx
Conservative Look out for obstructive uropathy & Post obstructive diuresis Observe in the Casualty: Urine output stat and then over the next 2 hours
456
Pelvic-Ureteric Junction Obstruction types
intrinsic- narrowing with interruption in development of circular musculature of UPJ or an alteration in collagen fibers in and around the muscular cells extrinsic- more often symptomatic
457
Pelvic-Ureteric Junction Obstruction aetiology
congenital (extrinsic)- crossing renal vessesl external bands or adhesions persistent fetal ureter convolutions acquired - stone disease post-op iatrogenic scarring/ischemia inflammatory stricture idiopathic lower pole UPJO - occurs in kidneys with an associated incomplete renal duplication hydronephrosis of Lower Pole - due to short/long bifurcated ureteral segment
458
Pelvic-Ureteric Junction Obstruction aetiology | congential intrinsic
aperistaltic segment of ureter - N spiral smooth muscle replaced by abN longitudinal muscle bundles or fibrous tissue true congenital stricture - excess collagen deposition congenital kinks or valvular mucosal folds - mucosa & smooth muscle Ostling’s folds (valvular mucosal folds) are due to differential growth rates of ureter and body of child (not obstructive … disappear w/ linear growth)
459
anomalies associated with UPJO
associated GU anomalies found in ~50% of infants - contralateral UPJO (10-40%) } most common contralateral anomaly thus contralateral renal dysplasia (ie B/L UPJO) contralateral MCDK (Multicystic-dysplastic kidney) duplicated collecting system horseshoe kidney VUR found in 20-40% } usually low grade
460
UPJO clinical presentation
infants - usually asymptomatic can present w/ FTT, feeding difficulties, sepsis from infection adolescents - usually symptomatic UTI episodic flank or upper abdo pain +/- N/V often exacerbated by diuresis (Dietl’s crisis) hematuria (25%) from rupture of mucosal vessels in dilated collecting system
461
indications for intervention in UPJO
``` Bilateral disease Renal function impairment UTIs Solitary kidney Stones HT ```
462
minimally invasive approaches to UPJO repair
endoscopic - antegrade vs retrograde Acucise endopyelotomy vs balloon dilation endopyelotomy - cold knife, electrocautery, laser ~80% success rate laparoscopic - transperitoneal vs retroperitoneal (retroperitoneal approach slightly more difficult due to confined space for suturing) success rate >95% robot-assisted - transperitoneal vs retroperitoneal
463
Vesico-Ureteric Reflux aetiology
primary - fundamental deficiency in UVJ anti-reflux mechanism with N bladder & ureter lack of 5:1 ratio of ureteral length:width secondary - normal UVJ function that is overwhelmed - usually due to bladder dysfunction
464
Mx of Vesico-Ureteric Reflux
watchful waiting- sterile urine + good bladder emptying is essential (eg prophylactic ABx behavioural Rx probiotics endoscopic surgery - many different injectables } eg DEFLUX suburetrerally open repair - classified according to approach to ureter (intravesical, extravesical, combined) also classified based on position of submucosal tunnel in relation to original hiatus suprahiatal, infrahiatal
465
surgical techniques for VUR
``` pre-op cystoscopy Pfannenstiel incision (abdominal surgical incision that allows access to the abdomen) made 2cm above symphysis pubis ``` intravesical - Politano-Leadbetter (suprahiatal tunnel) Glenn-Anderson (infrahiatal tunnel) Cohen Cross-trigonal - most commonly used intra-vesical reimplantation extravesical - Lich-Gregoire (contraindicated if presence of Hutch diverticulum & not recommended for bilateral VUR) combined - Paquin technique - extravesical approach to ureter + Politano-Leadbetter intravesical
466
Cryptochidism risk factors
patient- low birth weight/Small-for-gestational age/pre-term, twin neonate, Family Hx +ve maternal- Pre-eclampsia, Breech presentation, C/S delivery
467
Cryptochidism classification
non-palpable (20%) - intra-abdominal - usually just inside the internal ring peeping Palpable (80%) - intra-canalicular extra-canalicular - suprapubic or infrapubic ectopic - majority make it out external ring
468
consequences of Undescended testis
``` infertility testicular malignancy hernia torsion trauma hypergonadotropic hypogonadism ```
469
Mx of Undescended testis
hormonal therapy | open or laparascopic surgery- Non-palpable (imaging alone is inaccurate
470
Methods to gain extra length of spermatic cord during orchidopexy (surgery to move an undescended (cryptorchid) testicle into the scrotum and permanently fix it there)
complete mobilization of cremasterics off spermatic cord high ligation of hernia sac Prentiss maneuver Jones incision (retroperitoneal dissection) Fowler-Stephens procedure
471
hypospadia characteristics
abN ventral opening of urethral meatus abN ventral chordee (penis usually curves downward) abN distribution of foreskin with a dorsal “hood” and deficient ventral foreskin
472
hypospadia facts
A variant of hypospadias is the megameatus intact prepuce form (MIP), in which the foreskin is completely formed boys w/ hypospadias +/or UDT +/or NON-ambiguous genitalia +/or cryptorochidism are more likely to have chromosomal abN and or intersex
473
basic principles important in hypospadias repair
``` correction of penile curvature (orthoplasty) urethroplasty meatoplasty glanuloplasty adequate skin coverage ```
474
hypospadias repair notes
Orthoplasty- assess penile curvature dermal graft (harvested from non-hirsute donor site) - ideal for short phallus with severe ventral chordee porcine SIS (small intestinal submucosa) interposition graft - for severe ventral chordee single-layer SIS better than multi-layer
475
management options for hypospadias
Distal - Advancements techniques eg MAGPI Tubularization techniques eg Tubularized incised plate (TIP), Thiersch-Duplay Flaps eg Mathieu Middle - Tubularization techniques eg TIP Flaps eg Mathieu, Onlay flaps (onlay island flap (OIF), split-prepuce OIF) Proximal- Single stage urethroplasty Flaps eg OIF, onlay-tube-onlay Tubularization techniques eg Duckett TPIF (transverse preputial island flap), Koyangi 2-Stage urethroplasty
476
general principles of re-do hypospadias repair
minimum wait time is 6 months after previous failed repair no attempts at repair until all edema, infection, and/or inflammation has resolved Retrograde urethrography (RUG) +/or voiding cystourethrography (VCUG) may be needed in complex re-do hypospadias repairs assess adequacy of local tissue vs the need for extragenital tissue graft
477
Infections of the lower genital tract | Herpes simplex
Vulva, vagina,cervix STD usually HSV-2 Papules →vesicles → ulcers → heal 1-3 weeks
478
Infections of the lower genital tract | Candida
Associated with DM, OC,pregnancy | Leukorrhea and pruritis
479
Infections of the lower genital tract | Trichomonas vaginalis
STD Flagellated protozoan Purulent discharge and discomfort Strawberrycervix
480
Infections of the lower genitaltract | Mycoplasma
Vaginitis / cervicitis | Spontaneousabortions
481
enteric bacteria eg
Staphylococcus, Salmonella, Klebsiella, Enterobacter, Proteus
482
Acute Kidney Injury definition
reversible increase in serum creatinine and nitrogenous waste products and the inability of the kidney to regulate fluid and electrolyte homeostasis
483
Acute Kidney Injury facts
accumulation of metabolic waste products with incr S-urea and creatinine, development of hyperkalaemia, metabolic acidosis, hyperphosphatemia and hypocalcaemia decr in urine output in most cases development of oedema
484
formula for creatinine clearinace
(eCCL)=40 x height (cm) /s-creatinine (μmol/L) | Normal creatinine clearance is 88–128 mL/min for healthy women and 97–137 mL/min for healthy men
485
risk factors for Acute Kidney Injury
Age (> risk in neonates and young children) Hypovolaemia, sepsis, surgery Pre-existing kidney, liver or heart disease Exposure to nephrotoxins (eg cyclosporine, aminoglycoside, cisplatin)
486
AKI is seen in 3 scenarios
Pre renal Intra-renal or intrinsic renal disease Post renal or obstructive uropathies
487
Pre renal AKI include
True loss of intravascular fluid as with vomiting and diarrhoea or No external fluid loss, but the fluid is lost in the 3rd space and the circulating blood volume is ineffective e.g. in heart failure
488
Pre renal AKI causes
Hypovolaemia: due to blood loss Circulatory failure: CCF Hepato-renal syndrome: Liver disease associated with splanchnic vasoconstriction Drugs: diuretics Third space losses including septic shock
489
Intrinsic Renal Failure causes
Glomerular- Acute Glomerulonephritis Arterial- hemolytic-uremic syndrome, embolic, arteritis Venous- Renal venous thrombosis Acute tubular necrosis Drugs and toxins e.g. NSAIDS, vancomycin, haemoglobin
490
Post renal AKI causes
Morphological obstruction Obstruction of the urinary tract e.g. bladder outlet obstruction Obstruction of urine drainage in a solitary kidney Supra-vesical obstruction e.g. pelvo-ureteric obstruction Functional obstruction Neuropathic bladder
491
Acute Kidney Injury Clinical manifestations
Anaemia, jaundice Oedema Hypertension - With warm peripheries –sepsis/volume overload - With cold peripheries – intravascular depletion Flank masses/enlarged kidneys
492
Oliguria definintions
urine output <1 ml/kg/hour in neonates < 0.5 ml/kg/hour in older children Anuria – less than above despite adequate rehydration
493
Acute Kidney Injury Mx
Manage life threatening conditions according to ABC principles Dehydrated patients require resuscitation with IV 0.9% NaCl and frequent re assessment The patient must be weighed 12 hourly If the patient is anuric 5% Dextrose water (electrolyte free solution) is used IV furosemide may be used in volume replete patient to assess urine output when Treat hypertension avoid ACE inhibitors during acute phase
494
management of hyperkalaemia
Stop all K+ containing IV fluids Avoid drugs that cause hyperkalaemia e.g. ACE-I, ARBs, NSAIDS Follow guidelines to shift K+ intracellularly temporary to stablise cardiac muscle and attempt K elimination with Sodium polystyrene sulfonate (Kexelate) Dialysis is the only alternative if these measures fail
495
Absolute indications for dialysis
``` Anuria > 24 hours Fluid overload - pulmonary oedema Central nervous system signs e.g. convulsions or coma Bleeding diathesis Uraemic pericarditis ```
496
Relative indications for dialysis
incr Serum-K / decr Na not responding to conservative treatment Persistent metabolic acidosis- pH < 7.1 or S-HCO3 < 10 mmol / L Uncontrollable HT Severe incr S-phosphate / and incr S-calcium
497
Haematuria in Children | Red urine
In children haematuria is usually a medical and not a urologic/surgical problem Red urine without red blood cells ie heme-positive urine will give a False positive test
498
Causes of heme positive urine
Haemoglobinuria Myoglobinuria Food dyes, beetroot, berry juices Drugs e.g. Rifampicin
499
Haematuria sx origin
``` Symptomatic haematuria with dysuria, loin pain or renal colic usually originates from nonnephrological conditions Asymptomatic haematuria (with or without proteinuria) –usually originates in the kidney ```
500
Haematuria from the glomeruli and tubules characteristics
``` Brown, cola or black tea coloured Often associated with proteinuria Microscopy: red cell casts and dysmorphic RBC May be accompanied by leucocytes Epithelial cell casts ```
501
Dysmorphic RBC’s
Originate in glomerulus Crenated (notched edges) Size vary
502
Haematuria from the lower urinary tract
``` Gross haematuria, blood clots Bright red or pink Terminal haematuria (passage of clear urine with blood or blood-stained urine right at the end of the urine stream) Microscopy: normal red cell morphology Minimal proteinuria ```
503
Non glomerular (non-dysmorphic) rbc’s
Round / biconcave smooth-walled Similar size Originate extra-glomerular UTI / hypercalciuria / stones
504
History clues of haematuria
Terminal haematuria - ?Schistosomiasis Recurrent haematuria- Symptomatic /colicky pain: stones Family history of renal disease or deafness – ?Alport syndrome / thin basement membrane disease Skin rash (impetigo, purpuric) Joint pains Anaemia, oedema Vasculitis: SLE or HSP (Henoch Schoenlein purpura )
505
Acute Post-Streptococcal GN s/s and sx
``` Acute onset of macroscopic haematuria Oliguria Oedema Hypertension Puffy eyes ```
506
relative energy deficient syndrome components
Eating disorder Amenorrhea Osteoporosis/ Osteopenia Nutritional deficiency + low eostrogen = osteopenia
507
relative energy deficient syndrome sx and s/s
``` S/s- Depression Orthostatic hypotension Bradycardia Yellow skin discoloration Vaginal atrophy/dyspareunia ``` ``` Sx- Fatigue Hair loss Cold hands and feet Dry skin Weight loss ```
508
relative energy deficient syndrome severe cases sx and s/s
``` Constipation and Abdominal Pain Hypothermia lanugo type hair back and buttocks Petechiae-hypoplastic bone marrow Cardiac murmers ```
509
relative energy deficient syndrome Mx
Mainly based of corrected energy deficiency by decreasing energy expenditure (train less by 10-12%) and increasing intake (eat more) Drugs: calcium and vitamin D, anaemia treatment
510
Oral contraceptiv use in atheletes
Pregnancy prevention cycle manipulation acne dysmenorrhea or menorragia
511
Detection of CKD
Main manifestation : development of proteinuria and hypertension S-creatinine poor marker of renal function S-creatinine correlates with muscle bulk, age, gender → falsely low in children with malnutrition
512
CKD definition
evidence of structural or functional kidney abnormalities that persist for at least 3 months, with implications for health, with or without a decreased GFR <60 ml/min/1.73 m2
513
Markers of kidney damage
``` Proteinuria Urine sediment abnormalities Electrolyte and other abnormalities due to tubular disorders Abnormality detected by histology Structural abnormality History of kidney transplant Decreased GFR <60 ml/min ```
514
Non specific ss and sx of CKD
Poor growth from infancy throughout childhood Gastrointestinal complaints – vomiting / constipation Swelling / pruritis - treated for allergy Pale - investigated for anaemia Shortness of breath “pneumonia” Bone pain and deformities Cardiomegaly convulsion / coma
515
Aspects of Treatment of CKD in Children
Diet and nutritional aspects- Restrict: meat, dairy, egg, beans, grains and rising agents & have Phosphate binders (calcium carbonate Anaemia- Supplement iron and folic acid as indicated, For persistent anaemia add erythropoietin stimulating agent Hypertension- ACE-I or ARBs Proteinuria CKD Bone and mineral disorder- phosphate binders, Active Vitamin D Metabolic acidosis- oral NaHCO3 solution Dislipidaemia- Restrict saturated fats in diet Cardiovascular disease- in CKD stage IV or V cardiac arrest is the main cause of death
516
embryology of kidney
Ureteric bud: Abnormal development affects the –Renal collection system, Calyces, Pelvis & ureter Metanephros: Abnormal development affects the renal parenchyma – nephrons
517
Unilateral Renal Hypoplasia
Patients usually remain asymptomatic | occasional HT and proteinuria
518
Bilateral Renal Hypoplasia
Degree of renal functional impairment varies Clinical problems: polyuria, polydypsia, dehydration Tubulopathy: “salt-losing nephropathy” → poor growth
519
Bilateral Renal Agenesis
Occurs in 1/4000 pregnancies Mother has oligohydramnios Baby has Potter Sequence Baby dies shortly after birth due to respiratory distress / hypoplastic lungs
520
Cystic Renal Diseases
I: Early abnormal embriological development e.g. Multicystic Dysplastic Kidney II: Early steps in embriolgical development is normal but terminal differentiation of tubules is abnormal eg Polycystic Kidneys, Autosomal recessive, Autosomal dominant, Medullary cystic kidneys
521
Multicystic Kidney
Unilateral non-functional kidney Morphology: Large irregular mass – undifferentiated dysplastic elements and cysts of different sizes 30-50% associated with an abnormality in the contralateral kidney Isolated MCDK is usually is asymptomatic
522
Posterior Urethral Valves (PUV) facts
95 % cases are boys | Associated with oligohydramnios- If oligohydramnios develops before 16th week of gestation →very poor prognosis
523
Posterior Urethral Valves (PUV) clinical presentation
``` Potter sequence Respiratory distress at birth Bilateral palpable kidneys Bladder palpable above pubis Dribbling of urine or total bladder outlet obstruction Occasionally urinary ascites in neonates ```
524
Prune Belly Syndrome triad
Non obstructive megacystis, megaureter and hydronephrosis Absence of abdominal wall muscles Undescended testes
525
Genito urinary fistulas aetiology
Congenital: very rare traumatic fistula- Obstetric trauma (Necrotic /Traumatic) -Surgical trauma -Direct trauma Inflammatory disease- eg bilharzia or TB Malignant neoplasms Radium necrosis -Sloughing of the bladde
526
Necrotic Obstetric Fistula
Prolonged compression of soft tissues between head & brim of a narrow pelvis. → ischaemia, pressure necrosis & sloughing of base of the bladder. Urethra is also often involved Incontinence develops 5-7 days after labour Such fistulae are often surrounded by dense fibrosis
527
Traumatic Obstetric Fistula
Direct injury to bladder wall by sharp instrument during a difficult labour Incontinence appears immediately after labour
528
Genito urinary fistulas sx
Incontinence of urine Symptoms of vulvitis- Pruritus, burning pain Cystitis
529
Preoperative Preparation of Genito urinary fistulas
Treat vulvitis: Cover skin of the vulva, and inner thighs by a thick layer of Vaseline, zinc oxide ointment or any bland ointment, to prevent maceration of the skin by the continuous discharge of urine Renal function tests Culture of urine
530
Genito urinary fistulas Mx with regards to injury
If injury to the bladder is discovered during a difficult labour-Don’t suture the tear due to tissue oedema and friability, fix rubber catheter for 10 days If the injury is detected some time after labour, as in cases of necrotic fistulas, operations done except at least 3 months after delivery to allow for maximum involution of the tissues.
531
Sim’s operation Indications
If tissues are too adherent and fibrosed to do flap splitting After failure of the flap splitting.
532
Postoperative Care
Recumbent position The bladder should be constantly empty Fluids (3 litres/day) Urinary antiseptics & antibiotics Vaginal pack is removed 24 hours after operation Catheter is removed after 10 days After its removal the patient is instructed to void urine every two hours by day & every four hours by night to avoid over-distension of bladder & disruption of suture line.
533
Subsequent Management of genitourinary fistula
Patient is instructed to avoid sexual intercourse for 3 months & avoid pregnancy for 1 year
534
uretero vaginal fistula facts
cause- Injury to ureter during a gynaecological operation as hysterectomy, may develop following a difficult labour leads to incomplete incontinence It is always small & high up in vagina lateral to cervix
535
uretero vaginal fistula Rx
Abdominal re-implantation of ureter into bladder If not possible, ureter is transplanted into sigmoid colon If kidney function is very poor on the affected side → kidney can be sacrificed.
536
sx experienced in gyaneCA pts undergoing palliative care
pain anorexia fatigue insomnia
537
sx experinced in gyaneCA pts caregivers
``` Considerable stress Depression Depression induced fatigue Insomnia Difficulty in concentration/decision making ```
538
Tests and procedures to avoid in terminal disease gynaeCA
pap smears imaging Bricker's palliative surgery to be performed only if life expectancy more than 6 months.
539
vaginal bleeding of cervical CA Rx
Tight aseptic vaginal packing + catheter insertion+ broad spectrum antibiotics Hemostatic RT Embolization of uterine arteries Tranexemic acid
540
narcotics side effects
constipation, pruritus, nausea, drowsiness, skin rash
541
pain mx of gynae CA
Narcotics Diffuse bone pain – bifosfonates and narcotic NSAIDS and antidepressants provide a synergistic effect when proscribed with opioids Anticonvulsant agent use can help in pain of neuropathic origin
542
gynae CA pulm complications
dypsnoea | Lymphangitis ca – is ca spread into lymphactics of the lung.- Rx: O2/Morphine/Cortison
543
in advanced or recurrent cx ca | sx and Rx
sx- N+V, confusion, somnolence, seizures, uremic halitosis | Rx with Nehprostomies or ureteral stents
544
palliative pelvic excenteration
Highest morbidity and mortality in GynOnc Consists in removal of all pelvic organs with creation of urinary conduit, colostomy for stool and reconstruction of pelvic floor Complications: Heamorrhage, Wound sepsis, Fistulas, leakage
545
paraneoplastic hypercalcaemic syndrome
Rx: Hydration, Lasix, steroids, calcium binding agents, bifosfornates. Terminal hypercalcaemia – phenothiazines and butyrophenones / haloperidol, antihistamines, steroids, 5HT-3 antagosnists
546
Rx of nausea
Start with dopamine receptor antagonist (haloperidol, metoclopropamide → can be titrated to maximum benefit) If nausea still persists – an anticolinergic (scopolamine), followed by addition of antihistamine or cannabioid Benzodiazepine is added for anxiety component of nausea
547
palliative bowel obstruction
Localized obstruction of recto-sigmoid → loop colostomy Multiple sites of obstruction → no surgery tumour implant on bowel surface and mesentery → adhesions and peristalsis impediment - Rx: → palliation with NG tube/percutaneous gastrostomy Intraluminal stenting under endoscopy
548
ascites in palliative care of gynaeCA
Impairs reabsorption of peritoneal fluid Can become very troublesome in refractory disease with pts c/o of pain, SOB, early satiety, vomiting and fatigue Best relief → repeated paracentesis
549
anorexia in palliative care of gynaeCA
Anorexia without bowel obstruction → anabolic steroids or megesterol acetate can be used Parenteral nutrition can be of value but for limited periods (post-op) as it causes fluid overload, infection and diarrhoea At terminal stages pts are neither hungry or thirsty; caregivers often interpret it that doctors let the pt starve
550
constipaitons in palliative care of gynaeCA
predsol enemas Addition of fibre, colonic stimulants, laxatives Rx- Docusate sodium (Stool softeners), Senna (laxative) Dose should be incr with a goal of soft bowel movement every 1-2 days If constipation persists add Bisacodyle, Lactulose, Sorbitol, MG hydroxide or Metroclorpropamide
551
bone metastasis of endometrial CA
Diffuse bone pain without evidence of fractures Rx: Biphosfornates or RANKL inhibitors (Denosumab) - These agents reduce incident of fractures, spinal cord compression and need for bone surgery and RT Corticosteroid or systemic administration of radio isotopes (strontium) Local RT nerve block or RT ablation all provide relief.
552
hypercalcaemia due to endometrial CA
Symptoms: Malaise, fatigue, confusion, pain, heart dysrithmias → heart arrest Untreated hyper Ca → coma and death Rx: Rehydration ↑ Ca excretion, inhibition of osteoclastic Ca release Loop diuretics Palliative terminal setting – Biphosphonates, gallium nitrate to inhibit osteoclasts
553
liver mets due to endometrial CA
Usually asymptomatic but becomes symptomatic only late | Rx: analgesia , regional nerve block, liver mets ablation with Adriamycin is occasionally used
554
brain mets due to endometrial CA
Cause cognitive and behaviour abnormalities Rx: systemic steroids and RT Neurological resection followed by post operative RT can be selectively performed in cases with solitary brain mets
555
vulvar and vaginal CA
Because of more superficial site of origin, disease causes external septic ulcers and spread to perineum and inguinofemoral lymphnode chains Rx: activated charcoal dressings/Drawtex/zinc oxide Rectal fistulas and anal sphincter involvement rx with diverting colostomy skin ulceration rx at least twice with radiotherapy
556
things to look out for when a fistula is suspected
pyelonephritis± uremia manifestations Abdominal: scar, renal mass, tenderness Ammonia smell
557
prevention of fistul
obstetrics- adequate ANC, continuous bladder drainage for 5-7days ureteric- ureteral catheter, direct visualization/paplation
558
Various surgical approach to fistula
vagina- Flap splitting operation, Sauccerization, Latizko (partial colpoclesis), Repair and graft abd- Transperitoneal ,trans/intravesical with graft
559
fistula facts
most common fistula in developing countries vesicovaginal (obstetric) & in developed id uretericvaginal Urethrovaginal fistula causes double stream urine Vesicouterine fistula causes yousef syndrome (cyclical hematuria, amenorrhea and urinary incontinence)
560
Rectovaginal Fistula sx
Large fistula: incontinence to flatus, liquid stool and hard faeces Small fistula: incontinence to flatus and liquid stool Foul smelling vaginal discharge Vulvitis &vaginitis
561
Rectovaginal Fistula mx
``` pre and post operative preparation rectal enema low residule fluid diet 5 days before surgery intestinal antiseptics- neomycin vaginal douche ```
562
Rectovaginal Fistula surgical mx
RVF IN lower 1/3 of vagina- Lawson Tait‘s operation RVF IN middle 1/3 of vagina- Flap splitting ,Start as rectocele repair and extend dissection above the fistula. RVF IN upper 1/3 of vagina- Abdominal approach/Latzko operation
563
Postoperative care of Rectovaginal Fistula
Early- Rest Diet- Low residue diet, Excess fluids local care- vaginal pack remove after 24h, Antiseptics wash of the vulva after every micturition Drugs- Antibiotics, analgesics, laxatives, Intestinal antiseptics Late : elective CS in subsequent delivery
564
5 infective causative organisms of adult male urethritis
``` neisseria chlamydia mycoplasma genitalum trichomonas ureaplasma ```
565
male urethritis syndrome Rx
First-line treatment: Ceftriaxone 250mg IM stat AND Azithromycin 1g PO stat If sexual partner has vaginal discharge, add l Metronidazole 2g stat PO as a single dose Suspected ceftriaxone 250mg treatment failure: Ceftriaxone 1g IM stat AND Azithromycin 2g PO stat AND Metronidazole 2g stat PO as a single dose (if not already given)
566
Main causes of vaginal discharge syndrome
``` Bacterial vaginosis (BV) Candidiasis Neisseria gonorrhoeae Chlamydia trachomatis Trichomonas vaginalis ```
567
vaginal discharge syndrome Rx
First-line treatment: < 35 years OR Partner has NO MUS- Metronidazole, oral ,2g as single dose AND Clotrimazole vaginal pessary 500mg stat or vaginal cream 12 hourly for 7 days Partner has MUS Ceftriaxone 250mg IM stat as a single dose AND Azithromycin oral ,1g, as a single dose AND Metronidazole oral 2g as a single dose
568
epidemiology of genital ulcer disease
``` syphilis chancroid- Haemophilus ducreyi herpes LGV granuloma inguinale- Klebsiella granulomatis ```
569
genital ulcer syndrome Rx
If not sexually active in the last 3 months- Acyclovir 400mg 3 x daily for 7 days If sexually active in the last 3 month- ADD Benzathine penicillin 2.4 million units IM stat as a single dose Acyclovir oral 400mg tdsfor 7 days If no improvement in 1 week- Azithromycin 1g oral as a single dose Aspirate fluctuant buboes at each visit
570
when an extended-spectrum cephalosporins resistant gonorrhea is encountered
All cefixime treatment failure should get high dose ceftriaxone 1g stat IM and ideally microbiology work-up Refer all ceftriaxone treatment failures within 7 days for microbiology work-up and gentamicin 240mg stat IM

Definitions (11 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions