Week 2 Flashcards
(122 cards)
1
Q
What does cryptorchidism mean?
A
Undescended testis
2
Q
How do testes develop?
A
42 days post-conception, gonad develops down Y chromosome pathway. Sertoli cells develop and secrete AMH, and Leydig cells secrete DHT and T. AMH regresses mullarian structures, DHT develops male external genitalia and T develops Wolffian structures
3
Q
What are the coverings of the testis?
A
Skin, external spermatic fascia, cremaster muscle, internal spermatic fascia, parietal tunica vaginalis and visceral tunica vaginalis
4
Q
How do you differentiate between inguinal hernia and hydrocele in testes?
A
Shining a light, fluid glows, hernia doesn’t
5
Q
Where do the testis begin development?
A
Urogenital ridge, as an intra-abdominal organ
6
Q
Why do testis descend?
A
Normal body temperate is harmful to spermatogenesis
7
Q
What hormones control testicular descent?
A
Insulin like-3, AMH (gubernacular enlargement) and Testosterone (gubernacular migration)
8
Q
How do inguinal hernias form?
A
Bowel migrates down inguinal canal???
9
Q
What are the four walls of the inguinal canal?
A
MALT: 2M, 2A, 2L, 2T
Upper wall: 2 muscles
- internal oblique muscle
COME BACK TO THIS QUESTION
10
Q
How are hormonal secretions regulated?
A
Hypothalamic-pituitary-gonadal axis
11
Q
How to clinical examination of testis?
A
Wash hands, introduction, chaperone Full abdominal examination Standing then lie flat, ask about pain Palpation, warm hands Describe masses felt Lymph nodes
12
Q
What is testicular dysgenesis syndrome?
A
A male-reproduction relates disorder characterised by 4 conditions: hypospadias, cryptorchidism, testicular cancer and infertility
13
Q
What is cryptorchidism also known as?
A
Impalpable or undescended testes
14
Q
Describe cryptorchidism:
A
Can be bilateral or unilateral
Majority of cases have no discernible aetiology
Long term consequences: TSD
Retained testis are often smaller
Changes caused by position itself can add further damage
15
Q
How is cryptorchidism classified?
A
Position
Position over time
Aetiological factors
Retractile (bounce back up?)
16
Q
What should happen to patients with undescended testis after the age of 6 months?
A
Any undescended testis after the age of 6 months should be referred for orchidopexy
17
Q
What are the risk factors for cryptorchidism?
A
Birthweight <2.5kg
Small for gestational age
Prematurity
Maternal diabetes, including gestational diabetes
Environmental factors may also play a role for the risk of cryptorchidism
Can occur as part of an underlying disease
18
Q
What happens to semen quality in later life if babies have cryptorchidism?
A
Adult men with persistent bilateral cryptorchidism have azoospermia, whereas 28% after operation have normal sperm count 49% of men with persistent unilateral cryptorchidism have a normal sperm concentration as compared to 71% after orchidopexy Earlier surgery (between 10 months and 4 years) preferable in bilateral cryptorchidism
19
Q
What is the link between cryptorchidism and testicular cancer?
A
Cryptorchidism is a well established risk factor for testicular neoplasia. Bilateral carries a higher risk of malignancy
Early orchidopexy/spontaneous descent is not associated with increased risk
20
Q
How is cryptorchidism investigated?
A
Ultrasound is the gold standard. CT/MRI can be done, as well as laparoscopy
Consider karyotype Biochemical tests (T)
21
Q
How is cryptorchidism treated?
A
Operative treatment is the best treatment. Should be carried out at age 6-18 months.
Clinical examination 12 months post op, follow up at puberty if bilateral
22
Q
How else can cryptorchidism be treated?
A
Hormonal treatment:
hCG stimulation test
LHRH test
Overall efficacy of approx 20%
23
Q
What is hypospadias?
A
An ectopically placed urethral meatus lies proximal to the normal site on the ventral aspect of the penis, and in severe cases opens on to the scrotum
24
Q
What are the different classifications of hypospadias?
A
Coronal, mid-shaft, penoscrotal, scrotal and perineal OR distal, mid, proximal
25
What are the causes of hypospadias?
Advanced maternal age, assisted pregnancies (IVF), teratogenic drug, reduced sensitive to androgens and genetic factors
26
How is hypospadias treated?
Surgery, uses foreskin to recreate urethra.
Advise against circumcision
Hormonal treatment prior to surgery
27
What are disorders of sex development (DSD)?
Any congenital condition is which development of chromosomal, gonadal or anatomic sex is atypical
28
How are DSDs classified?
Primary root (karyotype), secondary root (classifications of development) and actual diagnosis
29
What is congenital adrenal hyperplasia?
Lack of enzyme causes negative feedback to produce more testosterone than usual (causes masculinisation of females (enlargement of clitoris to resemble phallus and fusion of labia to resemble scrotum))
30
How does DSD present in the newborn?
Overt genital ambiguity: apparent female genitalia with enlarged clitoris, posterior labial fusion and inguinal/labial mass or apparent male genitalia with bilateral undescended testes, micropenis and hypospadias
Family history of DSD such as CAIS
Discordance between genital appearance and prenatal karyoptype
31
How can DSDs be managed in newborns?
All newborn infants should receive a male or female sex assignment, where there is doubt. hasty decisions should be avoided
Need for multidisciplinary team
Strict confidence and open communication
Surgical management, sex steroid replacement and psychosocial management
32
How common is infertility?
1 in 7 heterosexual couples suffer from infertility
33
What is the definition of transsexualism?
A desire to live and be accepted as a member of the opposite sex, usually accompanied by a sense of discomfort with, or inappropriateness of one's anatomic sex, and a wish to have surgery and hormonal treatment to make one's body as congruent as possible with one's preferred sex
34
What is dual-role transvestism?
The wearing of clothes of the opposite sex for parts of the individual's existence in order to enjoy the temporary experience of membership of the opposite sex, but without any desire for a more permanent sex change or associated surgical reassignment, and without sexual excitement accompanying the cross-dressing
35
How are patients assessed for hormonal treatment?
Medical history (migraine history red flag), family history, blood pressure, weight/BMI <35, baseline bloods (U+E, LFT, lipids, glucose, thyroid function, FBC, FSH, LH, prolactin, estradiol, testosterone, SHBG)
36
How is the fertility of FTM patients preserved?
Collection of oocytes, storage of oocytes and storage of embryo
37
How is the fertility of MTF patients preserved?
Collection and storage of semen
38
What are the (WPATH) criteria for hormone therapy?
1. Persistent, well-documented gender dysphoria
2. Capacity to make a fully informed decision and to consent for treatment
3. Age of majority in a given country
4. If significant medicinal or mental health concerns are present, they must be reasonably well-controlled
39
How is HRT delivered in transmen?
Sustanon 125mg intramuscular injection/ Testim gel 1/2 tube daily
Increase to sustanon 250mg 3 weekly/ Testim gel 1 tube daily
Nebido 1000mg 12 weekly
40
How is menstruation suppressed in transmen?
Sometimes testosterone alone
Can use depo provera, GnRH analogues
Contraception (testosterone alone is not sufficient (progesterone))
41
What are the effects of testosterone in transmen?
Lower voice, fail and body hair growth, increased muscle bulk, amenorrhoea, clitoromegaly, increase libido, tendency to be more aggressive
42
What are the risks of testosterone therapy?
Polycythaemia (bone marrow produces more RBCs), liver dysfunction, increased risk for CVS disease, increased weight, diabetes, mental health disturbance
43
How is HRT delivered in transwomen?
Oestrogen supplements and anti-androgen drugs
44
What are the effects of HRT in transwomen?
Breast growth, softer skin, less facial and body hair, fat redistribution to hips, more emotional
45
What are the risks of oestrogen supplements?
Increases risk for VTE (venous thromboembolism), increases weight, increased BP, increases risk for breast cancer
46
What surgery can be done for transmen?
Bilateral mastectomy and male chest reconstruction. Hysterectomy and oophorectomy. Metoidioplasty (hypertrophied clitoris is released and urethra redirected through)
Phalloplasty (radial artery flap (non-hairy skin from forearm with radial artery and nerves, nerves and artery are attached to existing genital structures), pubic, thigh (disadvantage as no sensation from constructed phallus), erectile tubes are implanted into phallus, with reservoir of fluid in abdomen and pump in scrotum
47
What surgery can be done for transwomen?
```
Thyroid chondroplasty (Adam's apple). Penectomy, orchidectomy, clitoroplasty, vulvoplasty and penile inversion vaginoplasty (scrotal skin moulded into labia). Colovaginoplasty.
Breast augmentation
```
48
What urinary tract problems can occur after gender reassignment surgery in FTM patients?
Neo-urethral stenosis and urethral fistula
49
What urinary tract problems can occur after gender reassignment surgery in MTF patients?
Urinary spraying, and increases risk of UTI due to shortened urethra
50
What are post GRS problems in FTM patients?
Dislodgement and infection of erectile cylinders. Mechanical failure of erectile mechanism. Hysterectomy and oophorectomy usually with one of phalloplasty procedures, as well as vaginal ablation
51
What are post GRS problems in MTF patients?
Granulation tissue (silver nitrate cautery), neovaginal hair growth (hairballs), vascular occlusion of arterial supply to neo-clitoris, neovaginal stricture and ongoing need for dilation
52
When are smear tests recommended in patients who have had gender reassignment surgery?
FTM still recommended if cervix is still present (removed from SCCRS after hysterectomy)
MTF ensure not on SCCRS recall system
53
What are the implications for cancer screenings after GRS?
Prostate:
MTF less risk due to oestrogen and anti-androgen. Screen as non-trans males
Breast:
FTM- still some breast tissue, self examination, refer breast lumps as usual
MTF- offer breast screening
54
What does seminal fluid contain?
Alkaline fluid (helps neutralise acid in the female tract), fructose (used as ATP source by sperm), prostaglandins (aid spermatic motility), and proteolytic enzymes (liquefy semen)
55
Why are the many blood vessels necessary in the theca interna?
The theca interna has an endocrine function; transport of secretions to site of action
56
What hormones does the theca interna synthesise?
Androgens
57
What do the granulosa cells of the follicle do?
Convert androgens to oestrogen
58
What type is vaginal epithelium?
Stratifies squamous epithelium
59
How does the vagina protect against microbial growth?
Degradation of glycogen in vaginal mucosa produces organic acids, which creates a low pH environment retarding microbial growth
60
Where does vaginal mucus come from?
Mainly from glands in the uterine cervix (greater vestibular glands of Bartholin at entry to the vagina do produce some mucus, but not in significant amounts)
61
What kind of tissue is the endometrial stroma?
Connective tissue
62
What happens to the endometrial wall at menstruation?
The stratum functionalis shrinks as a result of the death of the corpus luteum, whose hormones maintain it. The spiral arteries become even more coiled, resulting in vascular stasis, eventually resulting in tissue death. Active vasoconstriction follows, and a final relaxation of the arteries results in a flow of blood which carries away the dying tissue
63
What is the widest part of the uterine tube?
The ampulla
64
What is the epithelium of the uterine tube?
Ciliated columnar, cilia help beat fertilised egg along the tube
65
Which part of the uterine tube is the most lateral?
Infundibulum, which is fringed by fimbrae (fingerlike processes that help capture the egg)
66
What does the spermatic cord contain?
Ductus deferens, arteries (deferential, cremasteric and testicular), the pampiniform venous plexus, lymphatic vessels, nerves and the tunica vaginalis
67
Where do Sertoli cells lie?
On the inside of the basement membrane of the seminiferous tubules; they are responsible for the blood-testis barrier
68
What does the blood-testis barrier prevent?
Autoimmune destruction of developing gametes
69
How does spermatogenesis occur?
In waves across the tubule. Primary spermatocytes lie slightly further in and divide via meiosis I to produce secondary spermatocytes which divide in meiosis II to produce spermatids
70
What do Leydig cells secrete, and what are they closely associated with?
Testosterone, blood vessels
71
What surrounds the 2 corpora cavernosa of erectile tissue?
The tunica albuginea
72
How does the lining of the urethra vary along its length in males?
Initially it is urothelium, but changes to pseudostratified columnar and again to stratified squamous towards the external urethral meatus
73
What are the 3 muscular layers of the ductus deferens?
Inner longitudinal, middle circular and outer longitudinal
74
What lines the ductus deferens?
Psueodstratified columnar epithelium with stereocilia
75
Why is the inguinal canal of clinical importance?
A patient may develop an inguinal hernia in the canal
76
What does the inguinal canal transmit?
Spermatic cord in males, and round ligament of the uterus in females, as well as the ilioinguinal nerve in both sexes
77
What is the superficial inguinal ring?
A triangular shaped region in the aponeurosis of the external oblique where the spermatic cord or round ligament emerges from the canal, just above or lateral to the pubic crest
78
What makes up the roof of the inguinal canal?
Arched fibres of the internal oblique and transversus abdominis muscles (M for muscles)
79
What makes up the anterior wall of the inguinal canal?
2 aponeurosis: of internal and external oblique
80
What makes up the floor (L for lower border) of the inguinal canal?
2 ligaments: inguinal ligament and lacunar ligament
81
What makes up the posterior wall of the inguinal canal?
2 Ts: transversalis fascia, and conjoint tendon medially
82
Where is the deep inguinal ring found?
Midway between the anterior superior iliac spine and symphysis pubis, about 1.25cm above the inguinal ligament
83
How long is the inguinal canal?
About 4cm
84
What is a direct inguinal hernia?
A protrusion medial to the inferior epigastric vessels, aa a result of weakness in the floor of the inguinal canal
85
What is an indirect inguinal hernia?
A protrusion due to weakness of the deep inguinal ring
86
What covers the spermatic cord?
External spermatic fascia, derived from aponeurosis of the external oblique; cremaster muscle and fascia, derived from the internal oblique and its fascial coverings; internal spermatic fascia, derived from the transversalis fascia
87
Where does the round ligament begin?
At the uterine horns, where the uterine tubes enter the uterus
88
What covers the round ligament?
Transversalis fascia
89
What nerve is the ilio-inguinal nerve a branch of?
L1
90
What does the ilio-inguinal nerve supply?
The skin of the scrotum, or labia majora; and the adjacent thigh
91
What normally protects the inguinal canal from herniation?
The oblique direction of the canal, offsetting the deep and superficial rings. When intra-abdominal pressure is raised, the posterior and anterior walls are pressed together .
92
What is the embryological origin of the gut?
Endoderm
93
What does the hindgut end in?
The cloaca
94
What develops around the cloacal membrane in the 3rd week after fertilisation?
A pair of cloacal folds develop and join to form the genital tubercle at the cranial end of the embryo
95
What happens to the cloaca caudally?
The cloacal folds are subdivided into urethral folds in front and anal folds behind. Genital swellings then appear on either side of the urethral folds
96
What happens during the 6th and 7th weeks of development, with respect to the cloaca?
A block of mesoderm, the urorectal septum, grows down towards the cloacal membrane, eventually fusing with it. This divided the common cloaca into the rectum behind and the urogenital sinus in front
97
What happens to the cloacal membrane in the 8th week?
It breaks down
98
What stimulates elongation of the genital tubercle to form the phallus?
Androgens (testosterone) from the foetal testis
99
How does the phallus form?
As it elongates (under stimulation by testosterone), the phallus pulls the urethral folds forwards and they form the lateral walls of the urethral groove. By the end of the 3rd month the 2 folds close over the urethral plate enclosing the penile urethra
100
How does the scrotum form?
Scrotal swellings grow towards each other, and fuse to form the scrotum. The line of fusion is marked by the scrotal raphe
101
What happens to the genital tubercle in female development?
In the absence of androgens, though the phallus elongates rapidly initially, it slows and remains as the small clitoris
102
What do urethral folds form in the female?
The labia minora
103
What forms the labia majora?
The unfused genital swellings enlarge and form two folds of skin- labia majora
104
Where is the mesonephros seen?
At the lateral edge of the mesonephric duct, just below the posterior cardinal vein
105
What is the epithelial lining of the mesonephric tubules?
Columnar epithelium
106
What is the epithelial lining of the mesonephric duct?
Cuboidal epithelium
107
What does the mesonephric duct develop into in the male?
A system of connected organs between the efferent ducts of the testis and the prostate, namely the epididymis, the vas deferens and the seminal vesicles
108
What does congenital adrenal hyperplasia cause in developing babies?
Masculinisation of the external genitalia- clitoral hypertrophy and partial fusion of the labia majora
109
What does the femoral triangle contain?
Femoral nerve and its terminal branches
| Femoral sheath and its contents
110
What are the contents of the femoral sheath?
Femoral artery and several of its branches, femoral vein and its proximal tributaries and the deep inguinal lymph nodes and lymphatic vessels
111
What are the borders of the femoral triangle?
Base: inguinal ligament
Medial border: lateral border of adductor magnus muscle
Lateral border: sartorius muscle
Apex: where sartorial crosses medial border
112
What does the femoral sheath allow?
The vessels to glide deep to the inguinal ligament during hip movements
113
What does the femoral canal allow?
Expansion of the femoral vein if there is increased venous return from the lower limb
114
What are the boundaries of the femoral ring?
Anterior: the inguinal ligament
Medial: the sharp edge of the lacunar ligament
Posterior: the pectin of the pubic bone
Lateral: the femoral vein
115
Where are spermatogonia found throughout life?
Seminiferous tubules
116
Which hormones peak at day 14 of the menstrual cycle?
LH (biggest peak) and FSH. Oestrogen peaks just before day 14
117
Which structures open into the prostatic urethra?
Ejaculatory ducts
118
What is a spermatid?
Haploid cell that undergoes physical modification and cytoplasmic reduction to produce residual bodies and the final product of spermatogenesis
119
The uterine tube can be recognised by what feature?
It is about 10 cm long
120
What does the vas deferens develop from?
The embryonic mesonephric duct
121
Prior to ovulation, which hormone do the granulosa cells secrete?
Oestrogen, granulosa cells express aromatase, which converts androgens to oestrogens which then get secreted
122
How does the uterine tube develop?
From the paramesonephric duct
