Medical notes (hypospadias)

Pic- en.wikipedia.org

Hypospadias

Due to improper development of urethra the opening is user the penis.

Types

Glandular- Milli meters away from the usual opening

Coronal - junction between the gland and body

Penile- shaft

Peno- Scrotal- between the two scrotum- urethra is not deve at all.

Clinical features

Micturition is normal but can we clothes especially in types 3 and 4.
Penis is bent (chordee)
Sexual intercourse is difficult.
Hooded prepuce

Treatment

One stage urethroplasty
Treatment of chordee
Urethra formation by tube

Two stage urethroplasty
-chordee is corrected in 6-12 months after birth. (Orthoplasty)
- reconstruction of urethra at 5-6 years (urethroplasty)

Medical notes (BPH)

Pic- urology.jhu.edu/prostate/bph.php
Urology

Benign prostatic hypertrophy

(Benign enlargement of prostate)

Etiology
Hormonal theory- decreased androgen and increased estrogen leads to hypertrophy.
Neoplatic theory- benign neoplasm of fibrous, muscular and grandular parts of prostate.

Pathogenesis
There is obstruction of urethra by the elongated prostate.
- Urethral changes- elongates, narrows.
- Bladder changes- hypertrophies with folds, I.e fasciculations and sacculation, the urine is caught up in them and may even cause diverticuli or stones due to stasis.
Kidney changes- hydronephrosis (enlargement due to stasis of urine).

Clinical features

Frequency- due to ineffective emptying of bladder.
Urgency
Hesitancy to pass urine because it is ineffective.
Acute and chronic retention of urine.
Hematuria.

Complications
Diverticuli
Stone
Hydronephrosis
UTI
Renal failure

Investigation

Urea, creatinine- rule out hydronephrosis and renal failure
Uroflowmetry- measures the flow of urine with a flow meter. If the flow is less than 10 ml/sec its peak obstruction.
Ultrasounds- prostate, bladder, kidney.
CT, MRI.

Staging
1- 1-2 cm on rectal exam
2- 2-3 exam on rectal exam
3- 3-4 cms on rectal exam
4- more than 4 cm mass.

Treatment.
If there is no obstruction and not much symptoms no medication, just advice them avoid alcohol.

Drugs-
Finastride acetate
Alpha adnenergic drugs.

Surgery

Indications- urinary retention
Frequency is unbearable, complication.

Transurethral resection a prostate

A resectoscope is sent via the ureter, constant irrigation is applied with water, prostate is cut into pieces.
Post op recovery is smooth, but water intoxication can happen.

Transvesical suprapubic prostectomy
If gland weighs more than 100 g
The prostate is accessed via the extra peritoneal approach, and ennucleated (removal of the entire organ without cutting) with fingers.
Malicot's catheter is used to drain the bladder.
Prostatic Urethra is dissected, but a new one develops along the foley's catheter by fibrosis.

Retro pubic prostectomy

Other method
YAG laser.

Medical notes (ca prostate)

Urology

Carcinoma prostate

Etiology
65 years or older
Second most common type in old males

Clinical features
Might occur after prostatectomy
As the outer layer is left behind
Mass felt in the anterior rectal wall during rectal exam
Bone pain (metastasis)
Sciatica (thorocolumbar metastasis)
Hematuria
Acute Urinary retention
Difficulty passing urine

Spread
Prostate metastasis are multiple and moth like, osteoblastic.

Hematogenous- bones via veins especially the vertebrae, then femur, pelvis.

Lymphatic- first in the illiac, then para aortic, medistinal finally in left supraclvicular.

Direct- urithra, bladder, seminal vesicles, rectum.

Investigation

Serum acidic phosphatase: present in prostate, usually not detected in serum, but its found during malignancy.

Serum alkaline phosphatase

PROSTATE SENSITIVE ANTIGEN
Very important indicator
4nmol/ml - malignancy possible
10nmol/ml- malignancy
35 nmol/ml - disseminated.

Transrectal trucut biopsy

Xray (bones), CT, MRI, ultrasound, bone scan.

Staging
T0- nil. T1- T1a(<5%), T1b(>5%), T1c (all found only on histology, non symptomatic, not palpable)
T2- T2a (single lobe, within capsule), T2b (both lobes, within capsule).
T3- outside the capsule
T4- metastasis

Treatment-
Early malignancy (T1,T2)
PSA (prostate specific antigen) <20 nmol/ml
Radical prostectomy
Radical radiotherapy

Late malignancy
1.Androgen ablation-
Low orchidetomy
Oral Stillbestrol (estrogen)
(Disuria, pain disappears in 48 hrs)
Phosphorylated diethyl stilbestrol.

2.Radiotherapy-
Localized radiotherapy
Hemobody irradiation (one half of body radiation)

3.Chemotherapy-Mitomycin, nytrogen mustard.

Medical notes (ca penis)

Urology

Carcinoma of penis

It is most commonly a squamous cell ca, can also be melanoma, adenocarcinoma etc..

Premalignant lesions

Genital warts (warts are benign lesions that are caused after an infection) eg Buschke- Lowensteine lesion, a cauliflower like tumor.
Paget's disease of penis: a reddish raw lesion (erythroplasia)
Leukoplakia (white lesion)
Bowen's disease: a small eczematous plaque

Etiology: Phymosis- common in uncircumcised.

Clinical features
Common after 60 yrs
Foul smelling discharge
Hematuria
Phymosis
Ulceroproliferative growth with induration.
A fungating lesion which may make the external meatus (opening) disappear.

Spread:
Direct- prepuce (skin over the glans penis)- glans penis (the terminal part of penis)- shaft- corpora cavernosa.
Lymphatic- Inguinal ligament.

Investigation:
Wedge biopsy of growth
FNAC of nodes
CT, MRI
CT guided FNAC

Staging
1- tumor only in glans penis
2- tumor in shaft
3- lymphatic spread
4- metastatic, fixed nodes.

Treatment
Stage 1-
Only in prepuce- circumcision
In glans- partial amputation

Stage 2- partial amputation (at least 2.5 cms after lesion)
Or total penectomy and perineal urithrostomy (making a permanent urithral opening in perineum)
Or Radiotherapy

Stage 3
Total penectomy, or partial penectomy depending on the extent of lesion.

Lymph enlargement
Give antibiotics- enlargement persists- nodal dissection.
Or Radiotherapy

Stage four
Radiotherapy (external radiotherapy, intestesial radiotherapy)
+ chemotherapy (cisplatin, methotrexate, bleomycin)

Medical notes (surgery)

Urology

Phymosis and paraphymosis

Phymosis.           Paraphymosis.
Inability to            Inability to pull
Retract the           Retracted
Prepuce                prepuce    
(Foreskin).            forward.

Phymosis

Etiology-
Congenital
Chronic balanophosthitis (inflammation of glans penis and prepuse)
Chancre (painless ulcer due to infection)
Carcinoma

Clinical features
Ballooning of penis
Can't retract the skin over penis (prepuce)
Might in turn lead to balanophosthitis

Complications
Ca penis
Paraphymosis

Treatment- circumcision.

Paraphymosis

Pathogenesis

The non retractable skin forms a ring and compresses veins (venous congestion), causing glans penis to swell.

Causes - after urinary catheterization, after sexual inter course.

Clinic features- pain, swelling and edema of prepuce and glans penis.

Treatment
Injection hydrluronidase (250 units) on the ring then after swelling subsides physical manipulation.
Circumcision later.

Complication - ulcer and gangrene.

Medical notes (hydrocoele)

Pic- www.studyblue.com

Urology

Hydrocoele

Collection of fluid in the tunica Vaginalis

Types
Congenital

Due to patent processes vaginalis

Sub types
Vaginal hydrocoele- only around the scrotum (sac)
Infantile hydrocoele- till the external ring
True congenital hydrocoele- connection with peritoneum
Encysted-Appears like a small cyst at the root.
Hydrocoele en bissac- has connection with an abdominal sac.

Acquired.
Primary vaginal hydrocoele
Young or middle age
1.Due to increased secretion
2.Due to defective lymphatic drainage

Clinical features
Localized to scrotum, Cystic, transillumination positive, get above the swelling present.

Fluid- serous - albumin fibrinogen.

Secondary vaginal hydrocoele
Epididymo orchitis
1.Tuberculosis
2.Filariasis - recurrent, liquid fat
Tumor
Pyocoele- infection on an pre existing hydrocoele.
Hematocoele

Feature -transillumination negative
Also negative in thick tunical vaginalis

Treatment
1.Plication (making folds)- "Lords plication" done for small hydrocoele, tunica vaginalis is cut and plicated to tunica albugenia fluid is drained by lymphatics.
2.Partial excision and eversion, it is sutured to the back of testis.
3.Aspiration

Complication
Hematocoele
Pyocoele
Calcification
Rupture
Hernia of the sac

MGNREGA

MGNREGA

It is a rural employment program started by the government of India.

It was started in 2005, covered 200 districts in 2006, and by 2008 it covered all villages.

It was initially named as National Rural Employment Guarantee Act, then it was changed to Mahatma Gandhi National Rural Employment Guarantee Act.

It is hailed as the largest social security and public works program in the world.

Its objective is to provide at least 100 days of paid employment to a rural adult in each household.

And it is completely implemented by gram panchayaths, no contractors are used.

Every applicant who volunteers for the program should be given a job within 5 km of his house.

The applicant will work on creating durable assets such as roads, canals, ponds...

If work is not provided within 15 days of applying then he/she is entitled to an unemployment allowance.

Maharashtra under former Chief Minister Vasantrao Naik was the first to start such a scheme in 1970.

It was later taken up by the planning commission and made a national wide program.

The present Act is an integration of several such programs like the Employment Assurance Scheme from the 1970s'.

But corruption and politics have have dimmed it's magnificence, in 2014-15, only 28% of the payments were made on time. 

But its largely a success story, that has raised minimal wages, started 12 crore jobs, and completed 14.6 million projects.

Apart from providing economic security and creating rural assets, it has helped in protecting the environment and empowering women.

World Bank called MGNREGA a "stellar example of rural development", and we agree wholeheartedly.

Medical notes (surgery)

Urology

Pic- www.drtimnathan-urology.com.au

Varicocoele

Dilatation of testicular veins.

Right testicular vein drains in to Inferior vena cava
Left in to renal vein.
Left sided varicocoele is more common since its lower.

Etiology
Young, thin.
Old- Renal cell carcinoma

Clinical features
Dragging pain
On standing swelling enlarges.
Cough produces impulse in the veins
Valsalva's maneuver produces pulse - blow test- (blowing air via the ears)
Varices Reduces on lying down.

Types
1.Small (palpable on Valsalva's)
2.Medium (palpable without it)
3.Large (visible)

Complications
1. Oligospermia (temperature, hormones)
2. Hydrocele

Treatment-
Surgery
1. Inguinal approach - ligation of
Pampariform plexus
2. Retroperitoneal approach - ligation of one testicular vein.
3. Sub inguinal microscopic varicocelectomy.

Medical notes (surgery)

Pic- coreem.net

Urology

Torsion testis

Predisposing factors

1. Long redundant spermatic chord
2. Invertion of testis
3. Sudden contraction of cremastric muscle
4. Epididymis separated from testis.

Types of testicular torsion

1. Extravaginal
2. Intravaginal

Clinical features
10- 25 (age)
Sudden agonizing Pain.
Empty scrotum on the affected side also edematous.

Signs
Deming's sign - tender lump at external ring
Prehns' sign- rising the scrotum increases pain.
Angells' sign- opposite scrotum is horizontal.

Management

Preferred detortioned in first 4 hours
First hour- manual detorsion
If it doesn't work explore the scrotum and detorsion is dome and its fixed to scrotum.
If the testis is necrosed  then remove it.
The other testis should be fixed to scrotum as soon as possible to prevent damage as its at risk.

Medical notes (surgery)

Urology
Pic- doctorsgates.blogspot.com

Fournier's gangrene

Gangrene of the scrotum.

Etiology-
Low social economic factors and poor hygiene.

Pathogenesis
A trauma usually a scratch- infection - rapid inflammation of scrotum - fever and toxic symptoms - gangrene of the scrotum- exposed testis- spread to abdomen thigh even penis.

Organisms
Hemolytic Streptococcus
Staphylococcus
E coli
Anaerobes

Clinical features
Inflammation,
Scrotal gangrene
Fever
Toxic features
Spread

Treatment
Broad spectrum antibiotics
Ampicillin- gram +
Gentamycin- gram -
Metronidazole - anaerobes
Surgical excision of gangrene.
Implation in to thigh in case of exposed testis till
Skin graft is done.

Medial notes (surgery)

Pic - http://www.drugs.com/health-guide/hematuria.html

Hematuria

Hematuria is defined as blood in urine.

The blood can be microscopic and macroscopic.

It can also be early (at the start of urination)(urethra),  terminal (at the end) (bladder neck, prostrate), diffuse (throughout) (kidney, upper UTI).
Pseudo hematuria is pigmentation of urine by food.

Causes
Infection -
1.acute glomurulonephritis
2. TB
Infarction
1.Emboli in sub acute endocarditis to renal infact
2.Mismatched Blood transfusion
Injury
1.Stab or burn
Tumors
1.Wilms' tumor
2.Transitional cell carcinoma
Stones
Polycyclic kidney
Bleeding disorders- stickle cell.
BPH

Most common problems

Stone (ureter, urethra,  bladder)
Tumor (carcinoma bladder, prostrate)

Investigation
History
Age, Occupation

Color of urine (bright red, altered), Amount (small.rcc, profuse.papilloma)

Painless or painful

Early, terminal or diffuse

General exam- pallor, BP
Abdominal exam- kidneys palpable, bladder,

Rectal exam- prostrate.
Plain X- ray KUB
Urine exam- microscopy, culture, biochemistry (albumin, creatinine, urea)
Ultrasounds
IVP, IVUgraphy
CT
Urethroscope, cystoscope

Management- treat anemia, maintain blood volume and electrolytes, antibiotics, treat the cause.

Tuberculosis

The white old man tuberculosis, a "myco" bacteria clearly a racist by the way he sticks to the tropics.

Occupies your lungs without an invitation.

He rides mucus the sputum,  from noses to noses or mouths to mouths for recreation.

He converts them tissues in to curdy white cheese, by a process called calcification.

And he is bound to take a very long if not an indefinite lease, irregularly or in continuation. (Chronic)

He puts at least 5 lakhs (India) to external sleep, still the biggest killer since his coronation.

The old white man will make you cough your eyes out, burn with high fever.

Make you spit blood from your mouth (hemoptysis), loose weight and quiver.

You can try crying a river, but once he is set, he will not stop until everything he gets.

He can reach your gut, your brain, your spine, even your liver, he casts a wide net.

HIV and Smoke are two of his special hope, each pulls him in with a tight rope.

The white old man is certainly dope, but even he has enemies that will melt him like pears soap.

Rifampisin, Streptomycin, to name a few, can eat him up without a clue.

DOTS is a regimen that makes sure Rifampisin and his buddies are taken without fail, so TB gets cut off in its tail.

Remember the old white man may be gruesome and deadly, but he can be warted off or thrown out abruptly.