1a Tumours of the testis, penis, urethra and scrotum 1b Neurogenic bladder Flashcards Preview

Urology > 1a Tumours of the testis, penis, urethra and scrotum 1b Neurogenic bladder > Flashcards

Flashcards in 1a Tumours of the testis, penis, urethra and scrotum 1b Neurogenic bladder Deck (24)
Loading flashcards...
1
Q

Testicular tumor types

A

Germ cell tumors (5)
95% of testicular tumors.
Usually are a mixed type of tumor and prognosis is based on the worst component.
Seen in men age 15-40.
Painless testicular mass that doesn’t transilluminate.

Seminoma – Highly Radiosensitive, very good prognosis. increased LDH and ALP

Non-seminomas – Not radiosensitive, poor prognosis.

  • Yolk sac tumors (increased AFP)
  • Choriocarcinoma (increased hCG, can cause gynecomastia or hyperthyroidism. hCG has same alpha subunit as LH, FSH, and TSH.)
  • Teratoma (mature teratoma in males is malignant)
  • Embryonal carcinoma (painful, hemorrhagic and necrotic mass, worst prognosis)

Non-Germ cell tumors (3)
5% of testicular tumors

  • Leydig cell tumor. Reinke crystals, gynecomastia in men, precocious puberty in boys. boys become men men become women. Benign
  • Sertoli cell tumors. Benign.
  • Testicular lymphoma, the most common testicular cancer in elderly men, malignant, formed as a metastasis from another primary lymphoma
2
Q

Testicular tumors metastasize to

A

Choriocarcinomas metastasize hematogenously to the Lung and Brain

Other testicular tumors spread lymphatically, to lumbar paraaortic nodes.

Lung and retroperitoneal nodes are most common sites.

Also: liver, brain, bones, kidney.

Retroperitoneal mets cause back pain
Pulmonary mets cough, dyspnea.

3
Q

Testicular cancer treatment

A

Radical orchiectomy, removing testis and spermatic cord, for ALL testicular tumors.

Chemotherapy for all cases with vascular or lymphatic spread.

For seminomas, radiotherapy to the paraaortic retroperitoneal regions.

For non-seminomatous germ cell tumors, radical retroperitoneal node dissection is needed.

4
Q

Staging of testicular cancer

A
TNM staging or clinical staging. 
Clinical: 
1 - lesion confined to testis
2 - retroperitoneal node involvement
3- supradiaphragmatic nodes or visceral metastases. 

TNM
Tis Intratubular germ cell neoplasia (carcinoma in situ, confinced to the seminiferous tubules)
T1 Tumor limited to testis
T2 Tumor extends outside tunic albuginea or shows vascular–lymphatic invasion
T3 Tumor invades spermatic cord
T4 Tumor invades scrotum

N1 Regional lymph nodes <2 cm and/or 5 or fewer nodes
N2 Regional lymph nodes of !5 cm or more than 5 nodes involved
N3 Lymph nodes >5 cm

M1a Nonregional lymph nodes or pulmonary metastases
M1b Other distant metastases

5
Q

Tumors of the Penis

A

95% are squamous cell carcinoma
Others: basal cell carcinoma, melanoma, kaposi sarcoma.

Risk factors are poor hygeine in elderly males that are uncircumcised.

About 50% occur on the glans

Are associated with HPV, 16, 18, 31, 33

6
Q

Precursor lesions to penile scc

A

Bowen disease - Leukoplakia on the shaft.

Erythroplasia of Queyrat - Erythroplakia on the glans

Bowenoid papulosis - carcinoma in situ presenting as red papules.

7
Q

Penile tumor metastases

A

Lymphatic spread

Glans - drains to the deep inguinal lymph nodes

Shaft and scrotum - superficial inguinal lymph nodes.

Corpus spongiosus , prostate, and lower bladder -> internal illiac.

8
Q

TNM staging of penile tumors

A
Classification (TNM):
• T1: Invades subepithelial connective tissue
• T2: Invades corpus cavernosum or spongiosum
• T3: Invades urethra or prostate
• T4: Invades other adjacent structures
• N1: Single inguinal lymph node
• N2: Multiple inguinal lymph nodes
• N3: Pelvic lymph nodes
• M: Distant metastasis
9
Q

Treatment of penile tumors

A

Excision with adequate margins

Chemo with MTX, 5FU, Bleomycin

10
Q

Urethra cancer

A

More common in women.
High risk in urethral diverticula

85% are distal and are squamous cell carcinomas, has a better prognosis.

15% are proximal and are transitional cell carcinoma

11
Q

Treatment of urethral cancer.

A

Radical cystectomy in women and radical cystoprosatectomy in men.

Removal of the bladder, prostate, tumor, and distal ureter with acceptable margins, and lymph nodes.

12
Q

Tumors of the scrotum

A

Malignant: SCC

Benign: sebaceous cysts.

13
Q

Neurogenic bladder

- what are the two phases of the bladder’s function

A

• Storage phase: The bladder passively fills with urine. Bladder compliance allows the bladder accommodate the increased urine volume by 2 main factors:
o Neuronal reflexes that control bladder tension
o Passive elastic properties

• Voiding phase: Occurs by contracting the detrusor muscle in the bladder and simultaneously relaxing the urethral sphincter and pelvic floor muscles.

Motor (efferent) control:
• Storage phase is under sympathetic control (hypogastric n.): Relaxation of detrusor muscle and contraction of sphincter and pelvic floor (+ pudendal
nerve)

• Voiding phase is under parasympathetic control (pelvic n.): Contraction of detrusor muscle and relaxation of sphincter and pelvic floor.

14
Q

Neurogenic bladder

- involuntary storage reflex

A

As the bladder fills the reflexive activity of the sympathetic system will increase and inhibit the parasympathetic.

15
Q

What drives the urge to urinate

A

Stretch receptors activate parasympathetic afferents.
Ascend via the spinal cord in the PAG.

Activate the Pontine Micturition Center. in the Suprapontine region of the midbrain.

Concious inputs to the PMC will then switch it to favoring the parasympathetic innervation of the bladder, switching to the voiding phase.

Once voiding begins, feed-forward reflexes increase and maintain the contraction until it is empty.

16
Q

Neurogenic bladder is

A

Dysfunction of voiding due to lesions of the bladders innervation.

17
Q

The 4 sites of neurogenic bladder lesions.

A
  1. Suprapontine: Typically due to stroke, tumor, trauma. Will cause neurogenic detrusor over activity due to reduced inhibitory control of the pontine
    micturition center.
  2. Pontine: Typically due to Parkinson’s or multiple sclerosis. Can cause any type
    of dysfunction.
  3. Suprasacral spinal cord: Typically due to spinal cord injury. Will cause NDO + overactive urethra –> detrusor sphincter dyssynergia.
  4. Sacral and subsacral: Typically due to myelomeningocele, spina bifida, DM and
    iatrogenic from surgical injury. Lesisons can be complete or incomplete (most
    common):
    o Injury to pudendal nerve: Incompetent urethra
    o Injury to pelvic nerve: Underactive detrusor muscle
    o Injury to afferent pathway: Diminished bladder sensation
18
Q

The Wein classification of voiding disorders

A
• Failure to store 
Urinary incontinence
   o Because of the bladder (neurogenic 
      detrusor over activity (NDO))
   o Because of outlet (urethral sphincter 
    incompetence)
• Failure to empty 
Raised post void residual volume (PVR)
    o Because of the bladder (detrusor 
    under activity)
    o Because of outlet (urethral over 
    activity)
19
Q

Diagnosing Neurogenic Bladder.

A

Assess voiding pattern over a period of 2-4 days. Rule out infection and hematuria with urinalysis.

With ultrasound you can assess kidneys and ureters for hydronephrosis, and assess post void residual volumes (PVR).

Uroflowmetry:
• An electronic flowmeter measures the urinary flow and plots the flow pattern in a graphic representation of flow rate vs. voiding time.
• Decreased peak urinary flow rate is highly suggestive of outflow obstruction
(2SD below the mean)

20
Q

Treatment for Neurogenic Detrusor Overactivity

A

Bladder training, anticholinergics, botulinum injections, catheterization, augmentatition enterocystoplasty or implanted neuromodulation devices.

21
Q

Treatment for Incompotent sphincter

A

Physiotherapy, mid-urethral sling, artificial urinary

sphinter, catheterization or peri-urethral bulking injections.

22
Q

Treatment for detrusor underactivity

A

Clean intermittent self-catheterization

23
Q

Treatment for Overactive sphincter

A

Spasmolytics, botulinum, sphincterotomy, stents and pedundal nerve block.

24
Q

Autonomic dysreflexia

A

Exaggerated sympathetic response that occurs du to noxious stimulus below the level of
injury in patients who have spinal cord injury above T6. Presents with HTN,
bradycardia, sweating and headache. Caused by:
• High detrusor pressure
• Blocked catheter
• Bladder stone
• UTI
• Pressure-flow udodynamics
Give sublingual nifedipine 10mg to lower BP rapidly.