Week 7

Question 1

how common are ureteral and renal pelvic cancers? more common at what age and in what gender?

Answer 1

rare - 4% of all uroethelial cancers

usu dx at ~65 yo, M:F 2-4:1

Question 2

etiology of ureteral and renal pelvic cancers?

Answer 2

smoking
contrast dyes
industrial dyes and solvents
excessive NSAIDs
contrast dyes
balkan nephropathy (exposure to heavy metals and/or aristocholic acid from native plants)

Question 3

most ureteral and pelvic cancers are of what type? %ages? what other type is common?

Answer 3

TCC - renal pelvic 90%, ureteral 70%

SCC - 10% of renal pelvic cancers, rare in ureteral cancers

Question 4

survival rates of low stage and low grade ureteral and renal pelvic cancers?

Answer 4

60-90% for low stage and grade vs 0-33% for those with higher grade or those with tumor invasion

Question 5

ssxs of ureteral or pelvic cancer?

Answer 5

gross hematuria 70-90%
mb flank pn dt ureter obstruction
may have irritative voiding sxs
anorexia, wt loss, lethargy
flank mass w/hydronephrosis
SCV or inguinal LA, hepatomegaly w/METS

Question 6

labs of ureteral or pelvic cancer?

Answer 6

hematuria (mb intermittent)
increased LFTs
positive cytology

Question 7

imagining for ureteral or pelvic cancer?

Answer 7

IVU - shows filling defects, dilated upper ureter, hydronephrosis
retrograde pyelography
ureteropyeloscopy - direct visualization of upper tract abns

Question 8

tx for ureteral or pelvic cancers?
recurrence rate?
goals?

Answer 8

open or laparascopic nephroureterectomy
15-80% recurrence rate
goal: save partial fxn of at least 1 KD
consider chemo or immunotherapy

Question 9

6 congenital anomalies of the ureter? MC one?

Answer 9

1. obstruction of the ureteropelvic jnx (MC)
2. ureteral atresia
3. duplication of the ureter
4. ectopic ureteral orifice
5. vaginal wall prolapse
6. obstructed megaureter

Question 10

obstruction of the ureteropelvic jxn is MC in what gender? often dx how and when? can lead to what 5 things?

Answer 10

obstruction of ureteropelvic jxn is MC in boy (5:2)
often dx via prenatal U/S
can lead to hydronephrosis, stones, hematuria, UTI, HTN

Question 11

what is ureteral atresia? associated with what? what is common to happen?

Answer 11

blind ureter –> absent or multi-cystic, dysplastic KD
associated with HTN
common to see C/L vesicoureteral reflux

Question 12

duplication of the ureter is MC in what gender? more often B/L or U/L? common presenting ssxs? dx how?

Answer 12

MC in F
often B/L
usu asx but can see persistent or recurrent infxn
dx via IVU and voiding cystourethrography

Question 13

ectopic ureteral orifice can also be seen w/what other congenital anomaly? in boys the ureter can drain to where which can lead to what? in girls where can the orifice be and what can it lead to? how to dx?

Answer 13

commonly seen with duplication of the ureter
in boys ureter can drains to the vas deferences which can lead to epididymitis
in girls the orifice can be in the urethra, vagina or perineum which can lead to incontinence and infxn
dx via U/S, voiding cystourethrography or MRI

Question 14

what is a vaginal wall prolapse? how can it present?

Answer 14

it is the sacculation of terminal ureter, can be intravesical or ectopic
may present w/infxn, bladder outlet obstruction, incontinence, prolapse through female urethra

Question 15

what is an obstructed megaureter? MC to see obstructed megaureter on what side? MC in boys or girls? can lead to what two things? dx via what and when? how to tx?

Answer 15

it is an obstruction at the ureterovesical jxn
L is more common than R, but can be B/L
more common in boys
leads to hydroureter and blunted calyces
dx via prenatal U/S
can be surgically re-implanted or there may be spontaneous resolution

Question 16

two forms of acquired anomalies of the ureter?

Answer 16

1. ureteral obstruction

2. retroperitoneal fibrosis

Question 17

what causes ureteral obstruction?

Answer 17

intrinsically - stone, CA, chronic inflammation

extrinsic - endometriosis, kinks, pelvic LAD

Question 18

what is retroperitoneal fibrosis? causes? ssxs? dx via?

Answer 18

retroperitoneal fibrosis is when one or both ureters are compressed by chronic inflammation process in the retroperitoneal tissues
causes: malignancy, medications, membranous GN, IBD, AA, idiopathic
ssxs: back pn, malaise, anorexia, wt loss, uremia (if severe)
dx via U/S, excretory urography

Question 19

what is senile urethritis (in women)?

Answer 19

post-meno or low E causes retrogressive changes in vaginal muscosa - leads to pale, dry tissue
these changes extend into LUT with some eversion of mucosa around urethral orifice

Question 20

what is senile urethritis commonly misdiagnosed as?

Answer 20

a caruncle!

Question 21

ssxs of senile urethritis?

Answer 21

burning, frequency, urgency
stress incontinence
vaginal or vulvar itching
dry, pale vaginal epithelium
red, hypersensitive meatus, eversion of urethral tip

Question 22

labs of senile urethritis?

Answer 22

no pyuria
staining of vaginal smear w/Lugol’s solution will be light as opposed to dark brown as it should be because hypoestrogenism results in poor iodine uptake

Question 23

instrumental exam for senile urethritis?

Answer 23

panendoscopy will show red, granular urethral mucosa, mb stenosis

Question 24

tx of senile urethritis?

Answer 24

estrace vaginal cream 1 g vaginally 1-3x/wk
vagifem 1 table IV qd x 2 wks, maintenance of 2x/wk
estrogen urethral suppositories (difficult to insert)

Question 25

appearance of a carbuncle? when does it normally appear?

Answer 25

benign, red, raspberry-like, friable vascular tumor involving the posterior lip of external meatus normally appears after menopause

Question 26

ssxs of urethral carbuncle? ddx?

Answer 26

ssxs: dysuria, dyspareunia, bloody spotting from mild trauma ddx: carcinoma of the urethra, senile urethritis, thrombosis of urethral V

Question 27

tx and prognosis of urethral carbuncle?

Answer 27

usu cured by excision, but may recur

Question 28

Not common - usually only in children or in paraplegics w/ LMN lesions An angry, red mass may become gangrenous if not promptly reduced In a young girl must be differentiated from prolapse of anterior vaginal wall

Answer 28

prolapse of the urethra

Question 29

May occur after local injury secondary to fracture of the pelvis, or accidental trauma in repair of anterior vaginal wall prolapse or urethral diverticula Repair with vaginal urethroplasty

Answer 29

urethrovaginal fistula

Question 30

Not common; some times multiple Usually secondary to obstetric urethral trauma Some contain carcinoma

Answer 30

urethral diverticulum

Question 31

presentation of urethral diverticulum? dx? tx? prognosis?

Answer 31

presentation: recurrent attacks of cystitis, purulent urethral d/c, dyspareunia, st lg enough for pt to self-dx dx: palpate on vaginal exam, confirm w/endoscopy and excretory urogram tx: removal of sac through incision, repair defect prognosis: usu good unless sac is next to the external sphincter, may develop urethrovaginal fistula

Question 32

causes of urethral structure in F?

Answer 32

not common | congenital or acquired - trauma (intercourse), childbirth, surgery or acute or chronic urethritis

Question 33

presentation of urethral stricture? dx? ddx? tx? prognosis?

Answer 33

presentation: persistent hesitancy, slow urinary stream, burning, frequency, nocturia, urethral pn dt urethritis or cystitis dx: attempt to pass fairly lg catheter, cystoscopy may show bladder trabeculation ddx: chronic cystitis, cancer, bladder neck tumor tx: gradual urethral dilatation up to 36F, combat infxn prognosis: good with tx

Question 34

are male urethral strictures more commonly genetic or acquired? often dt what?

Answer 34

more commonly acquired | MC due to infxn (indwelling catheter use) or from external trauma

Question 35

ssxs of male urethral strictures?

Answer 35

decreased urinary stream, stream forking, post-void dribbling chronic urethral d/c acute cystitis, sxs of infxn, frequency, dysuria induration in area of stricture

Question 36

urinary flow rate of male urethral stricture? what do you need to do to check for infection?

Answer 36

can cause rates less than 10 ml/s | post prostatic massage to check for infxn

Question 37

tx considerations for urethral stricture?

Answer 37

dilation to break up scar tissue, not a permanent solution urethrotomy (lysis of urethral strictures using a sharp knife w/catheter left in place to prevent bleeding and pn) surgical reconstruction

Question 38

what can urinary obstruction lead to?

Answer 38

hydronephrosis, renal insufficiency, renal failure can occur anywhere in the tract can also lead to infxn

Question 39

causes of urinary obstruction?

Answer 39

congenital: meatal stenosis, distal urethra stenosis, narrowed posterior urethral valves, ectopic ureter, uterocele, damage to S2-4, vesicoutereral reflux acquired: stricture 2ndary to infxn or injury, BPH, CaP, impingement by vesical tumor or local extension of cancer, stones, PG, neurogenic dysfxn of the bladder, elongation and kinking of the ureter, severe constipation, drugs

Question 40

what can urinary obstruction from the lower tract lead to? mid-tract? upper tract? KD?

Answer 40

lower tract: can lead to diverticulum, infxn, abscess dt increased pressure w/in urethral walls mid-tract: stage of compensation where bladder wall will form trabeculations, cellulues and diverticular, leading to decompensation where detrusor muscle will decompensate and will get residual urine upper tract: back pressure leads to thickening of ureteral musculature, elongation and torsion KD: back P dilates renal pelvis and calyces leading to ischemic atrophy and hydronephrosis --> loss of fxn

Question 41

complications of urinary obstruction?

Answer 41

urine stagnation can lead to infxn urea-splitting organisms can cause alkalinization of the urine which can precipitate stones (struvites) B/L KD involvement will lead to renal insufficiency and reflux nephropathy if severely infected and obstructed KD then pyelonephrosis (functionless, filled w/pus)

Question 42

tx of urethral obstruction?

Answer 42

relief of obstruction through cath'ing, surgery, urinary diversion eradication any infxns

Question 43

what is hydronephrosis?

Answer 43

dilation of the renal pyelocalyceal system from obstruction

Question 44

ssxs of hydronephrosis?

Answer 44

``` pn in flank, lower abd, testes/labia pn in flank on micturation is suggestive of vesicoureteral reflux abn mass mb N/V urgency, frequency polyuria, nocturia w/incomlete emptying anuria is possible ```

Question 45

PE of hydronephrosis?

Answer 45

HTN will be present dt increased renin

Question 46

labs w/hydronephrosis?

Answer 46

BUN and Cr will incr w/loss of KD fxn hypernatremia, hyperkalemia, RTA normal urine sediment unless concurrent infxn, stones

Question 47

what imaging to dx hydronephrosis?

Answer 47

U/S - greater than 90% S/S | antegrade or retrograde ureterogram or voiding cysturethrogram

Question 48

tx of hydronephrosis?

Answer 48

urological referral to address cause IV fluid and electrolyte replacement if left untreated can cause irreversible KD damage to the affected KD!!

Question 49

three types of GU allergies?

Answer 49

contact derm - penis, scrotum, labia, vagina, perineum, dt tight underwear, inc perspiration, condoms, vaginal creams, etc LUT - urethra and bladder (and prostate in men) UUT - KD and ureter

Question 50

IgA for what? IgE for what?

Answer 50

IgA for bac | IgE for allergies

Question 51

if prolonged or frequent exposure to GU allergens what can happen? two examples?

Answer 51

pathological changes can occur and become permanent such as in IC or chronic urethritis

Question 52

causes of GU allergies?

Answer 52

foods and drugs (MC cz, either primarily though eating or secondarily through urine during elimination) inhalants drugs - abx, hypnotics, antihistamines, salvarsarin, salicylates, quinine derivatives, gold, insulin, IVU contrast media, disinfectants organisms - candida, tuberculosis, helminths, oxyuris, plasmodium, serums and vaccines foods and lectins - milk, cheese, eggs, meat, white flour, fish, lobster, mushroom, fruits, lettuce, asparagus, carrot, tomato, cucumber, chocolate, onion, lemon, melon, yeast, paprika, black pepper, EtOH contact allergens - rubber, spermicides, injectable materials

Question 53

ssxs of GU allergies? what does it look like but actually isn't?

Answer 53

edema, swelling, inflam, itching during acute attack LUTS - increased urinary frequency, urgency, dysuria, nocturia, dull suprapubic ache looks like UTI but it isn't! No fever, but flank pn, gross hematuria, urinary retention mb present nocturia/enuresis ureteral spasms

Question 54

cystoscopy will show what with chronic allergy/exposure? UA will show? CBC will show?

Answer 54

cystoscopy - pale, swollen bladder urethral mucosa w/areas of bulbous edema surrounded by areas of hyperemia and oozing blood - consider IC; mb reduced bladder capacity UA - wright's stain fo urinary sediment might show eosinophilia CBC - will show increased eosinophils

Question 55

peyronie's dz now known as what? what is it? caused by what?

Answer 55

CITA: chronic inflammation of the tunica albuginea it is scarring of the tunica albuginea in the corpora cavernosa that leads to painful erection and dorsal curvature caused by abberation of wound healing where there was an over-expression of TGF-beta1 and fibroblastic proliferation

Question 56

RFs for peyronie's dz/CITA?

Answer 56

``` penile trauma FMHx HLA-B7 or HLA-DQ5 (+) dupuytren's contracture plantar fascial contractures tympanosclerosis paget dz gout lipomas DM HTN vasulitis hyperlipidemia A+ blood type hx of pelvic surgery drugs: propanolol, methotrexate smoking ```

Question 57

pharm tx options for CITA? procedural options? surgial options? naturopathic?

Answer 57

pharm: pentoxyifyllin to block TGF, colchicine to inhibit collagen fibrosis, potassium para-aminobenzoate as an antifibrotic procedural: verapamil injection, PRP, iontophoresis w/corticosteroids or verapamil to relieve pn, extracorporeal shock wave therapy, GAINSwave, penile traction therapy, vacuum erection devices surgical: have to have sxs for 12+mos and greater than 65 deg curvature naturopathic: counseling, acetyl-L-carnitine 1 g BID, SSKI directly to plaques, bromelain btw meals, natural vit E 300 mg BID, L-argingine 1000 mg BID

Question 58

what is phimosis? what can develop? RFs?

Answer 58

phimosis: foreskin cannot be retracted away from glans penis physiologic: 50% of boys have normal retractability by age 10 pathologic: pn, constriction, meatus blockage dt adhesion calculi and SCC can develop RFs: frequent diaper rash, poor, hygiene, condom catheter, DM, balanitis xerotica obliterans (lichen sclerosis)

Question 59

tx for phimosis?

Answer 59

self-stretching of the foreskin (do not force!), topical corticosteroids, last resort is dorsal slit, french cut or full circumcision naturopathic: cream of calendula w/centella every pm x 1 mo oral bromelain, gotu kola

Question 60

what is paraphimosis?

Answer 60

foreskin gets stuck in the retracted position which becomes inflamed and leads to reduced blood flow to the penis - can cause gangrene or necrosis

Question 61

tx for paraphimosis?

Answer 61

ice apply firm pressure to foreskin x 5 min to force blood out of the area then gently try and replace/reduce over the glans penile block mb necessary dorsal slit

Question 62

what is balanitis? balanoposthitis? causes?

Answer 62

balanitis - inflammation of glans penis balanoposthitis - inflammation of glans and foreskin causes: infxn, derm (psoriasis, contact derm), pre/malignancy (erythroplasia of Queyrat, SCC), drug rxn

Question 63

RFs for balanitis? RFs for balanoposthitis?

Answer 63

``` abx use DM HIV (+) condom catheter use circumcision procedure STI contact zipper injury obesity conditions that cause edema (CHF, cirrhosis, nephrotic syndrome) for balanoposthisis all the ones above plus having foreskin and phimosis ```

Question 64

symptoms of balanitis/balanoposthitis?

Answer 64

pn during or after urination, D/C from inflamed tissue, local erythema and edema

Question 65

tx of balanitis/balanoposthitis?

Answer 65

``` wash affected area w/saline BID if candida then clotrimazole or miconazole if bac infxn then metronidazole for anaerobes, mupirocin for staph or strep topical corticosteroid gotu kola-vit E cream anti-inflams (curcumin, bromelain) immunomodulators probiotics warm compresses or sitz baths ```

Question 66

complications of balanitis/balanoposthitis

Answer 66

phimosis, paraphimosis meatal stenosis (leading to increased risk of UTIs, bladder urinary retention and possibly hydronephrosis) malignant transformation of premalignant lesions

Question 67

associated with RA serpiginous annular, grayish ulceration on glans penis screen for STI and HLA-B27

Answer 67

circinate balanitis

Question 68

male genital lichen sclerosis | glans and foreskin tissue atrophies and appears whitish

Answer 68

balanitis xerotica obliterans

Question 69

ssxs of balanitis xerotica obliterans? pe? complications?

Answer 69

sx: pn w/intercourse, itching, decreased urine stream PE: white atrophic plaques on glans and prepuce, enlarges into sclerotic mass complications: phimosis, meatal stenosis, benign but can co-exist w/or precede SCC

Question 70

benefits of circumcision?

Answer 70

easier hygiene reduction in UTI potential reduction in penile CA lower prevalence of HPV, lower cervical CA rates in partners reduction in penile inflammation and phimosis

Question 71

cons of circumcision?

Answer 71

only parents are able to consent could decrease sensation are cutting away healthy tissue

Question 72

appearance of HPV infxn (condylomata acuminata)?

Answer 72

bloody spotting from urethra | protruding papilloma or on genital surface

Question 73

tx considerations of condylomata acuminata?

Answer 73

local excision/fulguration, transurethral fulguration if deeper condylox gel application liquid nitrogen application examine and tx sexual partner plus condom use to help prevent recurrence

Question 74

what are pearly penile papules? appearance? tx?

Answer 74

1-2 mm fleshy or white, dome-shaped papules, angiofibromas arranged circumferentially at the corona, st densely packed and in multiple rows tx: local application of liquid nitrogen, laser or radiosurgery

Question 75

when do tumors of the penis generally appear? RFs?

Answer 75

usu appear in 6th decade | RFs: poor hygiene, mb dt HPV, uncircumcised, psoriasis, AIDS, lichen sclerosis

Question 76

precancerous dermatologic lesions on the penis?

Answer 76

leukoplakia - red, irritated, sore balanitis xerotica obliterans - white patching originating on glans or prepuce, MC in middle-aged DM giant condylomata acuminata - cauliflower-like lesion on prepuce, glans, shaft; thought to be dt HPV, difficult to distinguish from SCC

Question 77

two types of penile cancer seen?

Answer 77

carcinoma in situ (bowen dz and erythroplasia of Queyrat) | invasive carcinoma of the penis

Question 78

what is Bowen dz?

Answer 78

carcinoma in situ of the penis | typically involves penile shaft, red plaque w/encrustations

Question 79

what is the appearance of erythroplasia of Queyrat?

Answer 79

velvety, red lesion w/ulcerations, usu on the glans

Question 80

where does invasive carcinoma of the penis originate from? MC sites? typical appearance?

Answer 80

typically originates on the glans MC site is the prepuce and the shaft appear papillary or ulcerative

Question 81

how does invasive carcinoma start and then spread?

Answer 81

starts as ulcerative or papillary lesion that then gradually involves the entire glans or shaft primary dissemination via LN to femoral and iliac nodes

Question 82

tumor staging for penile cancer - each stage appearance where?

Answer 82

stage I = glans stage II = shaft stage III = penis and nodes stage IV = METS to other sites of the body

Question 83

classical ssxs of penile cancer?

Answer 83

penile lesion that is indurated or erythematous, ulcerated, nodular or exophytic, lesion necrosis, foul odor, bleeding suppuration, phimosis may obscure lesion mb pn, d/c, irritative voiding sxs inguinal LAD

Question 84

imaging for penile cancer?

Answer 84

CXR, bone scan, CT of ab and pelvis for METS

Question 85

ddx of penile cancer?

Answer 85

``` syphilitic chancre (painless) chancroid (H. ducreyi) (painful) condyloma acuminata ("grape cluster") ```

Question 86

tx of penile cancer? prognosis?

Answer 86

bx mandatory for dx carcinoma in situ: 5-FU cream, YAG laser invasive penile carcinoma: complete excision w/margina, may need circumcision if involves prepuce, may need partial or total penectomy if involves shaft if (+) LAD then LN dissection if inoperative then chemo and radiotherapy if systemic then chemo prognosis: survival correlates w/presence or absence of nodal dz; 5 yr w/no nodal involvement is 65-90%, 5 yr w/nodal involvement is 20-50%