Week 9 Flashcards

Question

Reciprocal induction

Answer 1

Day 32- ureteric bud (metanephric duct) sprouts into intermediate mesoderm- metanephric blastema The ureteric bud bifurcates repeatedly- each bifurcation capped with mesoderm which eventually give foetal kidney its lobulated appearance The ureteric bud and kidney rely on signals from each other to keep developing (an example of reciprocal induction) ie in the absence of one the other will regress The metanephric duct gives rise to collecting ducts and the metanephric bastema the rest of the nephron Urine production begins at about week 10 when all tubules have finally canalised and joined together Ureteric bud division ceases about week 15 where a nephrons continue to develop to week 36

Answer 2

Small walnut sized gland found in men Produces and secretes fluid which nourishes sperm -proteolytic enzymes, prostatic acid and phosphatase, fibrinolysin, zinc, PSA (prostate-specific antigen)

Answer 3

Anterior lobe Median lobe Lateral lobes Posterior lobe

Answer 4

“McNeal” zone Peripheral zone: < 70% glandular tissue, origin 70-80% prostate cancers Central zone: 25% glandular tissue, origin <5% of prostate cancers surrounds ejaculatory ducts Transition zone: 10% glandular tissue, origin of benign prostatic hyperplasia Anterior fibromuscular stroma: ~5%, no glandular components

Answer 5

Surgical sieve Vascular Infection/inflammation Traumatic Autoimmune Metabolic Idiopathic/iatrogenic Neoplastic Degenerative Most common prostate diseases: -prostatitis -benign prostatic enlargement —lower urinary tract symptoms —urinary retention -prostate cancer

Answer 6

By age 65, 50% men will experience BPE -at age of 90, 90% of men will have BPE Benign increase in the number of epithelial and stroma cells in the transition zone BPE is a clinical diagnosis -LUTS, DRE, uroflowmetry, imaging Benign prostatic hyperplasia is a histological diagnosis, has to be proven at biopsy Symptoms not always proportional to degree of BPE May present with urinary retention

Answer 7

Storage symptoms: -frequency -urgency -urge incontinence -nocturia -nocturnal enuresis (bedwetting) -incomplete emptying Voiding symptoms: -haematuria- red flag symptom -dysuria -hesitancy -poor flow -intermittent stream -spraying/splitting of stream -terminal dribbling

Answer 8

Uroflowmetry (“flow studies”) Post-void residual PSA and renal function Urine dipstick testing +/- urine MC&S Bladder diary Urodynamics, USS KUB may be necessary

Answer 9

Alpha 1 adrenoceptor antagonist: -tamsulosin -inhibits effect of noradrenaline on smooth muscle in the prostate and bladder neck, relaxing smooth muscle and relieving obstructive symptoms -Hours/days full effect within weeks -retrograde ejaculation, dizziness, postural hypotension (take medications before bed), floppy iris syndrome during cataract surgery 5alpha reductase inhibitor: -finasteride, dutasteride -inhibits conversion of testosterone to dihydrotestosterone- more potent form drive hyperplasia works to shrink gland -6weeks-6months -erectile dysfunction, reduced libido, gynaecomastia (1-2%) doesn’t resolve with stopping medication, ejaculation disorders

Answer 10

Watchful waiting- not all men require treatment Combination therapy (tamsulosin and finasteride) more effective than monotherapy

Answer 11

Transurethral resection of prostate (TURP) Holmium laser enucleation of the prostate (HoLEP) Greenlight laser prostatectomy Prostatic urethral lift Open prostatectomy Aquablation (Rezum )

Answer 12

Acute urinary retention: the acute and painful inability to pass urine which is relived by insertion of catheter -immediate management: 2 way 14-16Fr urethral catheter -document residual volume, colour of urine, easy or difficult passage Chronic urinary retention: adapting to distal obstruction, low pressure, high pressure HPCR -over time the bladder stretches and capacity increases -often painless -large residual volume >800ml -renal impairment/hydronephrosis -decompression haematuria -post obstructive diuresis

Answer 13

Inflammatory: UTI, prostatitis Obstructive: BPE, stricture, bladder neck stenosis, constipation, pelvic mass, clot retention Drugs: alcohol, diuretics, spinal/epidural anaesthesia, opioids Neurogenic: cauda equina syndrome CES, spinal cord injury, MS, Parkinson’s disease, pelvic injury/trauma, pelvic surgery

Answer 14

Red flag symptoms: -low back pain, lower limb neurology, saddle anaesthesia-> think cauda equina syndrome- full neuro exam -weight loss, bony pain, haematuria -> think malignancy -nocturnal bedwetting indicative of HPCR Examination: -abdomen- has pain and abdominal swelling resolved -DRE- is prostate enlarged, smooth, craggy, hard, nodules, tender, blood, faecal loading, anal tone, saddle anaesthesia Investigations: - urine MC&S, FBC, UE (urea and electrolytes), CRP (if infection) Management: treat the cause -hourly UO monitoring —post obstructive diuresis indicates HPCR —if UO >150ml/hr over 2 consecutive hours —Normal saline (0.9% NaCl) replacement of half that volume over the following hour -tamsulosin 400mg trial without catheter If HPCR do not remove catheter -options: long term catheter, intermittent self-catheterisation, surgery ie TURP

Answer 15

Causative pathogen detected in only 10% -acute bacterial prostatitis -E.coli -chronic prostatitis (>3 months symptoms)- wider spectrum -immunosuppressed states- TB, candida Risk factors: UTI/epididymitis , transurethral surgery, indwelling catheter, immunosuppression History: fevers, rigors, general malaise, perineal pain, LUTS May present as AUR or recurrent UTIs Examination: suprapubic tenderness, palpable bladder -DRE: tender, “boggy” prostate, fluctuance suggests abscess Investigations: urine dip, FBC, UE, CRP, lactate -post void bladder scan to assess residual urine -mid stream urine for culture -blood culture if febrile Management: -may be septic-> resuscitation with A to E -Sepsis 6 Antibiotic choice guided by local protocols and previous sensitivities -often broad spectrum penicillin +/or quinolone (ciprofloxacin) -consider extended oral course on discharge

Answer 16

Prostate adenocarcinoma is the most common cancer in men in uk Signs and symptoms: -may be asymptomatic opportunistic PSA testing -LUTS -haematuria, haematospermia -abnormal DRE (hard, nodular, craggy prostate, asymmetry) Advanced disease: -leg swelling, anorexia, weight loss, bony pain, coagulopathy, neurological defects Risk factors: -age, ethnicity, family history, BRCA2 gene mutations

Answer 17

PSA- prostate specific antigen -enzyme produced by the prostate to liquefy semen - raised serum PSA in UTI, prostatitis, urinary retention, urethral instrumentation incl, catheterisation, ejaculation, BPE and cancer -age specific “normal” ranges -must be corroborated with history, examination and DRE MRI of prostate- diagnosis and local staging TRUS biopsy (transrectal ultrasound guided prostate biopsy) Or transperineal prostate biopsy Gleason grading system: -cells are graded 1-5 (5 most abnormal) -the most common and second most common grades are noted and added together -Gleason 4+3 is more abnormal than 3+4

Answer 18

T1: non palpable disease T2: palpable confined prostate T3: spreads outside prostate T4: adjacent organs involved N: lymph node spread M: non regional lymph node spread MRI: T, N Nuclear medicine bone scan- M CT TAP (thorax, abdo, pelvis)- N, M

Answer 19

All patients should be discussed in urology MDT Active surveillance: -aim is to avoid treating indolent cancers by only treating if sign of progression -suitable if medically fit, life expectancy> 10-15 years, localised disease -regular monitoring PSA +DRE look for evidence progression Watchful waiting: not fit for curative treatment -suitable if life expectancy<10-15 years, significant comorbidities therefore not fit for radical treatment -avoiding treatment unless patient develops symptoms -disease control rather than cure

Answer 20

Radiotherapy: is suitable for local and locally advanced cancer, symptomatic relief of painful bony metastases Surgery: radical prostatectomy (open, laparoscopic, robotic) with or without lymphadenopathy Hormone treatment: can be used for locally advanced or metastatic disease Chemotherapy: used in metastatic disease, especially those who become resistant to hormone treatment Role of cancer nurse specialist is vital

Answer 21

“Failure of the circulation to deliver oxygenated blood to meet tissue requirements”

Answer 22

A reduction in blood flow to tissues depriving them of oxygen (ischaemia) Organs of vital importance, brain, heart, and kidneys can suffer irreversible damage, eventually leading to death Inadequate cellular oxygen delivery-> anaerobic metabolism—> inadequate energy production and lactic acid production—> metabolic failure and metabolic acidosis—> cell death

Answer 23

Lactate levels Measure in arterial blood gas Urinary catheter- 0.5mls/kg. 30-40mls/hr

Answer 24

Amount of oxygen in the blood -ie (oxygen content of blood both dissolved and carried by Hb) -the flow of blood around the circulation ie (CO)

Answer 25

DO2= CO x (Hbx SPO2 x1.34) + (PaO2 x 0.2)

Answer 26

Increase fraction of inspired oxygen they breathe in will optimise oxygen delivery Hb- direct measure: reduced with haemorrhage, increased with blood transfusion O2- oxygen saturation (direct measure), dissolved oxygen. All patients in shock should get high flow oxygen

Answer 27

Is the volume of blood ejected from left ventricle in a minute CO= stroke volume x heart rate = 5L/min SV (is the volume ejected each heart beat): -preload (EDV) -myocardial contractility -afterload- (pressure the heart must work against to eject blood during systole) systemic vascular resistance

Answer 28

Preload- Hypovolaemic: haemorrhage Inotropy- cardiogenic: CHF, ACS, dysrhythmia, valve, cardiac tamponade Afterload- distributive: sepsis, thryotoxicosis, anaphylaxis, neurogenic MAP= (SV xHR) xSVR

Answer 29

Reduced venous return Impaired cardiac function Reduced vascular tone- unable to vasoconstrict Body has compensatory mechanisms to maintain oxygen delivery to essential organs

Answer 30

Reduced delivery of oxygen Increased anaerobic metabolism Increased lactic acid production Fall in arterial pH Stimulation of peripheral chemoreceptors: carotid bodies (Glossopharyngeal nerve), aortic bodies (vagus nerve) Respiratory centre (medulla) Respiratory muscles: increased depth and increased rate of

Answer 31

High heart rate Clammy skin Cold peripheries Pale skin Poor capillary refill Reduced urine output

Answer 32

Renin-angiotensin- aldosterone pathway Juxtaglomerular cells in the kidney respond to a reduction in blood volume Renin released into blood Angiotensinogen-> angiotensin I—ACE—> angiotensin II Vasoconstriction, thirst, adrenal cortex (releasing aldosterone) Vasoconstriction— increase blood pressure, Thirst increases blood volume Aldosterone make kidneys increase Na+ reabsorption from filtrate increase blood volume Increase in blood volume increases blood pressure

Answer 33

Reduced blood flow to pituitary Secretes ADH Capillary ADH secreted into nephron water moves into capillary ADH increases amount water reabsorbed from filtrate into blood Urine output is reduced as more water is returned to the blood

Answer 34

Therefore to: -recognise shock -treats underlying cause -support the body in maintaining oxygen delivery to tissues

Week 9 Flashcards

(58 cards)