 \212 \212 \212 Usually euthyroid but hyperthyroidism may develop. Tests US, to see if nodule is solid, cystic, calcified, or part of a group of nodules. Radi onucleotide scans may show malignant lesions as hypofunctioning or \200\234cold, \200\235 whereas a hyperfunctioning \200\234hot \200\235 lesion suggests adenoma. Fine-needle aspir ate (FNA) Can be done in the office or by US guid- ance (most common). 70 \200\22390% will be diagnostic. No clinical/lab test is good enough to tell without doubt if follicular neop lasms found on FNA are benign, so such patients are referred for surgery. Thyroid neoplasia Uncommon malignancy but the most common endocrine cancer. Affects women more than men, age s 25 \200\22365. Most common presentation is a cold nodule on US. Risk of cancer in nodule is 12 \200\22315%. Increased risk in those <40 yrs and with calcifications of the nodule no ted on US. Known risk factors (1) History of radiation (2) History of goiter. (3) Family hi story of thyroid disease (multiple endocrine neoplasia [MEN]-2a, -2b). (4) Female. (5) Asia n. Five types: 25%. Middle-aged; spreads early via blood (bone, lungs). \212 Follicular: W ell-differentiated. Treat by total thyroidectomy, T4 suppression, and radioiodine ( 131 I) ablation. Anaplastic: absence of unresectable disease, excision + radiotherapy may be tried . 5%. Sporadic (75%) or part of MEN syndrome (p. 304). May Medullary: produce calcitonin. T hey do not concentrate iodine. Do thyroidectomy + node clearance (do pheochromocytoma scree n preop). External beam radiotherapy should be considered to prevent regional recurrence. 6 0%. Often seen in the young; spread to nodes and lung. Total Papillary: thyroidectomy (to r emove nonobvious tumor) node excision + radio- iodine to ablate residual cells may all b e needed. Give T4 to suppress TSH. Prognosis is better if young and female. 5%. : \211\210 3:1. May present with stridor or dysphagia. Do Lymphoma: full staging pretreatment (chemoradiotherapy). Assess histology for mucosa-associated lymphoid tissue (MALT) origin (associated with a good prognosis). \212 Rare. : \211\210 3:1. Elderly; poor response to any treatment. In the \212 504 \212 \212 Thyroid surgery indications Pressure symptoms, hyperthyroidism, carcinoma, cosmetic reasons . Render euthyroid preop, by antithyroid drugs and/or propranolol. Check vocal cords by ind irect laryngoscopy pre- and postop. Early complications Recurrent laryngeal nerve palsy, he morrhage (if compresses airway, instantly remove sutures for evacuation of clot), hypoparathyroidism (check plasma Ca 2+ daily, usually transient), thyroid storm (symptoms of severe hyperthyr oidism; treat by propranolol PO or IV, antithyroid drugs, and iodine [p. 782]). Late compli cations Hypothyroidism. y r e g r u S Esophageal cancer Benign tumors make up 1%; most are common leiomyoma or GIST. The incidenc e of esophageal cancer is on the rise, especially in Western coun- tries. The types of esop hageal cancer include squamous cell, adenocarci- noma, and small cell cancer. The most comm on presenting symptoms are dysphagia and weight loss. Squamous cell cancer of the esophagus \212 \212 \212 Adenocarcinoma \212 \212 More common worldwide Associated with cigarette use and alcohol More common in the proximal one-third of the esophagus More common in the United States Associated with Plummer \200\223Vinson syndrome, obesity, reflux esophagitis Barrett \200\231s esophagus (there is a 44-fold increased risk of ade nocarcinoma if severe reflux for >10 yrs). Evaluation \212 \212 \212 \212 \212 Treatment Resection: \212 Barium swallow EGD with biopsy Endoscopic US CT scan Staging laparoscopy (see Table 13.31) Transthoracic (radical) resection with en-bloc lymphadenectomy; three incisions Transhiatal resection; easier to perform \212 Reconstruction: \212 \212 Adjuvant therapy: \212 Gastric pull-up with pyloroplasty based on the right gastric artery Colonic interposition Given preoperatively (neoadjuvant) or postoperatively for stage II or III tumors Cisplatin, 5-FU Radiation Palliation with metal stents for stage IV disease 505 \212 \212 \212 Table 13.31 Staging for esophageal cancer and 5-yr survival TNM TisN0M0 T1N0M0 T2N0M0, T3N0M0 T1N1M0, T2N1M0 T3-T4N1 \200\2232M0 Any T, Any N M1 Stage 0 I IIA IIB III IV 5-yr survival 100 85 45 20 10 <4 Gastric cancer The incidence of gastric cancer, unlike esophageal, has dropped dramati- cal ly in the past 70 yrs ( 70%). Risk factors include lower economic status; smoking; consumpt ion of salted, smoked foods; atrophic gastritis; genetic factors (HNPCC), H. pylori . Adeno carcinoma accounts for >90%; others include squamous cell, carci- noid, GIST, lymphoma. Pat hology The adenocarcinoma may be polypoid, ulcerating, or leather bottle-type (linitis plas tica). Some are confined to mucosa and submucosa, so-called early gastric carcinoma. Presen tation symptoms Often nonspecific. Dyspepsia (p. 208) lasting >1 month in patients aged 40 \200\22350 yrs demands GI investigation. Others: Weight loss, vomiting, dysphagia, anemia. Signs suggesting incurable disease: Epigastric mass, hepatomegaly, jaundice, ascites (p. 22 7), large left supraclavicular (Virchow \200\231s) node (Troisier \200\231s sign), acanthos is nigricans. Spread is local, lymphatic, blood-borne, and transcoelomic; e.g., to ovaries (Krukenberg tumor). Evaluation \212 \212 \212 Treatment \212 EGD with multiple biopsies; always biopsy ulcers Endoscopic US CT scan/MRI to evaluate for metastatic disease (see Table 13.32) Endoscopic mucosal resection may remove early cancers limited to the mucosa. Surgical resec tion with gross negative margins of 6 cm Need at least 15 lymph nodes harvested to determin e the nodal status of the disease Adjacent organs should be resected en-bloc only if involv ed with tumor and only one organ is involved. Stage II and IIIA may benefit from a more ext ensive nodal dissection D 2 (12 lymph node stations) versus D 1 (6 lymph node stations) wit h an improved 5-yr survival, 80% versus 55%, respectively. Reconstruction esophagojejunosto my. Adjuvant therapy includes radiation and 5-FU-based chemotherapy. \212 \212 \212 \212 \212 is performed with a Roux-en-Y end-to-side \212 Table 13.32 Staging for gastric cancer 506 TNM TisN0M0 T1N0M0 T1N1MO, T2N0M0 T1N2M0, T2N1M0, T3N0M0 T2N2M0, T3N1M0, T4N0M0 T3N2M0 T4N1 \200\2233M0, T1 \200\2233N3M0, or M1 Stage 0 IA IB II IIIA IIIB IV Cutaneous neoplasms Cutaneous neoplasms are the most commonly diagnosed tumor in the United States, with 600,000 new cases annually. The most common cutane- ous neoplasms include: \212 Basal cell cancer \212 Squamous cell cancer Melanoma: \212 \212 y r e g r u S Accounts for 5% of all skin cancers but leads to 65% of all skin cancer-related deaths The evaluation and treatment of cutaneous neoplasms is based on whether the lesion is melan oma or nonmelanoma skin cancer. Melanoma Risk factors: \212 \212 \212 \212 \212 \212 Types of melanoma: \212 \212 \212 \212 Fair complexion Sun exposure Previous history of melanoma Dysplastic nevi syndrome Large co ngenital nevi have a 5 \200\22320% lifetime risk of developing melanoma Xeroderma pigmentos um Lentigo maligna ( 10 \200\22315%), least aggressive Superficial spreading ( 70%) Nodular me lanoma ( 15 \200\22330%), most aggressive Acryl lentiginous melanoma ( 2 \200\2238%), seen in greater percentage of darker-skinned individuals (African Americans, Asians, Hispanics) Most common sites: \212 Women: Legs \212 Men: Back of body Depths of invasion <0.75 mm 0. 76 \200\2231.5 mm 1.5 \200\2234 mm >4 mm Any depth + 1 nodal station Any depth + >1 nodal s tation Or disseminated disease *Dependent on site as well Staging: JCC 5-yr survival* (%) 99 Stage IA 90 Stage IB 75 Stage IIA 65 Stage IIB 40 Stage III 0 Stage IV 507 Treatment Wide local excision is the primary method of local control of the lesion. The mar gin of excision is based on the thickness of the lesion (Table 13.33). For advanced stage ( III and IV), chemotherapy in the form of immunother- apy is currently offered in addition t o surgery, with a modest response. Sentinel lymph node dissection indications: (1) Primary melanoma \211 1 mm because >10% chance of lymph node spread, (2) clinically negative noda l basin, (3) no evidence of distant disease. Procedure: Should be performed concurrently wi th wide local excision because improves accuracy. An intradermal injection with technetium- sulfur-colloid is performed around the lesion. Table 13.33 Appropriate margins for wide local excision of primary melanoma Thickness of primary lesion Margin Melanoma in situ <1 mm 1 \200\2234 mm >4 mm 5 mm 1 cm 2 cm \211 2 cm The sentinel node is located by use of a -probe to identify the site of a hot focus ( \211 10 \227 background counts); the use of isosulfan blue dye will also allow for easier identification of the sentinel node. Lymphadenectomy: Indications and procedure: (1) Patie nts with known nodal disease determined clinically or on sentinel node dissection. Intermed iate thickness melanoma and sentinel node cannot be performed. (2) Nodal dissections should be complete. (3) The risk of upper or lower extremity lymphedema associated with an axilla ry or inguinal dissection is 10%. Sites of spread or recurrence: Local, distant cutaneous sites (in transit), dis- tant nodal sites, lung, liver, brain, bone, gastrointestinal tract , thyroid. Adjuvant therapy: Interferon, dacarbazine, temozolomide, immunotherapy, radiatio n for palliation. Nonmelanoma skin cancer Risk factors: \212 Chemical carcinogens \212 HP V Previous skin radiation \212 Basal cell carcinoma \212 Most common Little or no aggress ive potential \212 Squamous cell carcinoma (scc) \212 \212 \212 \212 Treatment \212 Contain keratin pearls Bowen \200\231s disease: Queyrat erythroplasia: Marjolin \200\231s u lcer: In situ cancer that occurs around the anus In situ cancer that occurs around the penis Aggressive SCC in old scar For basal cell and SCC in certain hard-to-reconstruct areas; 508 Mohs surgery: layered excision of tumor to limit the amount of tissue removed SCC requires 1 cm margin Adjuvant therapy \212 \212 \212 \212 Chemotherapy: Mitomycin, 5-FU, cisplatin (anal) Radiation Common urological disorders Torsion of the testis The aim is to recognize this condition ea rly on so that prompt surgical intervention can be undertaken to preserve both the fertilit y and hormonal function of the involved testis. If in any clinical doubt, and timely color Doppler US is not available, surgical exploration is mandatory. A missed torsion is one of the most common reasons for medical malpractice claims! Symptoms Sudden onset of pain in one testis, which makes walking uncomfortable. (Pain in th e abdomen, nausea, and vomiting are common.) Signs Inflammation of one testis: It is tender , hot, and swollen. The testis may lie high and transversely. Torsion may occur at any age but is most common at 11 \200\22330 yrs. Tests Doppler US (may demonstrate lack of blood fl ow to testis). Isotope scanning was used but its use has declined with the widespread avail ability of color Doppler US. Treatment Ask consent for possible orchiectomy + bilateral fix ation (orchiopexy). At surgery, a scrotal incision is made to expose and untwist the sperma tic cord. If the color of the testis returns and it pinks up, return it to the scrotum and fix both testes to the scrotum. If you are unsure of the status of the testis, incise the t unica albuginea; if you see bright red blood then the blood supply has been reconstituted. Differential diagnosis Primarily, epididymitis but here the patient tends to be older and t here may be symptoms of urinary infection, and more gradual onset of pain. Also consider te stis tumor, trauma, and an acute hydrocele. NB: Torsion of the hydatid of Morgagni: Remnant s of the M llerian ducts; occurs a little earlier and causes less pain (the patient can often walk with no pain, unlike in testicular torsion) and its tiny blue nodule may be disc ernible through the scrotal skin. It is thought to be due to the surge in gonadotrophins th at signal the onset of puberty. Idiopathic scrotal edema is a benign condition and is diffe rentiated from torsion by the absence of pain and tenderness. Urinary retention and benign prostatic hyperplasia Retention means not emptying the bladder ( obstruction or decreased d etru- sor power ). Acute retention The bladder is usually tender, containing 600 mL of uri ne. The cause in men is usually prostatic obstruction; e.g., precipitated by anticholinergi cs, \200\234holding it, \200\235 constipation, pain, anesthetics, alcohol, infection (p. 2 57). Examine: Abdomen, PR, perineal sensation (cauda equina compression). Investigations: p rostate-specific antigen (PSA) (p. 681). Renal US and bladder US. Tricks to aid voiding: An algesia, privacy on hospital wards, ambulation, stand- ing to void, voiding to the sound of running taps \200\224or in a hot bath. If the tricks fail: Catheterize (p. 720) and drain bladder. After about 7 d, trial without catheter may work (esp. if <75 yrs old and <1 L dra ined or reten- tion was triggered by a passing event [e.g., general anesthesia]). Preventio n: Finasteride reduces prostate size and retention risk. Chronic retention is more insidiou s. Bladder capacity may be >1.5 L. Presentation: Overflow incontinence, acute on chronic re tention, a lower abdominal mass, UTI, or renal failure. Prostatic enlargement is the com- m on cause. Others: Pelvic malignancy, rectal surgery; DM; CNS disease [e.g., transverse myel itis/MS]; zoster (S2 \200\223S4). Only catheterize the patient if there is pain, urinary in fection, or renal impairment (e.g., urea >12 mmol/L). Institute definitive treatment prompt ly. Intermittent self-catheterization is sometimes required. Both bladder and renal US may be informative. Catheters and catheterization (p. 720). Prostate cancer (p. 511). Benign pr ostatic hypertrophy (BPH) is common (24% if aged 40 \200\22364; if older, 40%). Decreased u rine flow (e.g., <15 mL/s) is associated with frequency, urgency, and voiding difficulty. y r e g r u S Midstream urine, analysis and culture, CBC, and 509 Managing BPH : \212 \212 \212 \212 \212 History: Severity of symptoms and impact on life. Rectal examination. Effect on bladder/kid neys: US (residual volume Electrolytes: Renal function. MSU: R/O infection. R/O cancer: PSA , transrectal US biopsy. Then consider: \212Transurethral resection of the prostate (TU RP, a common operation; 14% become impotent). Cross-match 2 U. Consider perioperative antib iot- ics (e.g., cefuroxime 1.5 g/8 h IV, 3 doses). Beware excessive bleeding postop and clo t retention. 20% of TURPs need redoing within 10 yrs. See Table 13.34. \206\221 , hydronephrosis). \212Transurethral incision of the prostate (TUIP) involves less destruction than TURP and less risk to sexual function while achieving similar clini- cal improvement in symptoms. It achieves its effect by relieving pressure on the urethra. It is perhaps the best surgical option for those with small glands (<30 g; i.e., 50% of those operated on in some areas). \212Retropubic prostatectomy is an open operation. \212Transurethral laser-induced prosta tectomy (TULIP). \212Drugs may be useful in mild disease, and while awaiting TURP: \212 -Blockers: Tamsulosin 400 mcg/24 h PO. Alternatives: Alfuzosin, dox- azosin, terazosin. Th ese decrease smooth muscle tone (prostate and bladder). SE : Drowsiness, depression, dizzin ess, BP \206\223 , dry mouth, ejacu- latory failure, extrapyramidal signs, nasal congestio n, weight \206\221 . They are the drugs of choice. Table 13.34 Advice for patients concerning transurethral prostatectomy Preop consent issues may center on risks of the procedure: \212 \212 \212 \212 \212 \212 \212 \212 \212 \212 Postoperative advice: \212 \212 Hematuria/hemorrhage Infection; prostatitis Hematospermia Impotence ( 10%) Hypothermia Inco ntinence (10%) Urethral trauma/stricture Clot retention near strictures Post TURP syndrome (T \206\223 ; Na + \206\223 ) Retrograde ejaculation (common) 510 Avoid driving for 2 wks after the operation. Avoid sex for 2 wks after surgery. Then get ba ck to normal. The amount ejaculated may be reduced (as it flows backward into the bladder \200\224harmless, but may cloud the urine). It means you may be infertile. Impotence may be a problem after TURP, but do not expect this: In some men, erections improve. Rarely, orga smic sensations are reduced. Expect to pass blood in the urine for the first 2 wks. A small amount of blood colors the urine bright red. Do not be alarmed. At first, you may need to urinate more frequently than before. In 6 wks, things should be much better, but the operat ion cannot be guaranteed to work (8% fail, and lasting incontinence is problem in 6%; 12% m ay need repeat TURPs within 8 yrs, compared with 1.8% of men undergo- ing open prostatectom y). If feverish, or if urination hurts, take a sample of urine to your doctor. \212 \212 \212 5 \212 -reductase inhibitors: Finasteride (5 mg/d PO \206\223 testosterone \200\231s c on- version to dihydrotestosterone). It is excreted in semen, so warn to use condoms. Women should avoid handling crushed pills. SE : Impotence; libido \206\223 . Effects on prostat e size are limited and slow so, if -blockers fail, many try surgery next. y r e g r u S \212Wait and see is an option, but risks incontinence, retention, and renal failure. Urinary tract malignancies Renal cell carcinoma (hypernephroma, Grawitz tumor) Arises from the proximal renal tubular epithelium. Epidemiology: 90% of renal cancers; mean age 55 yrs; : = 2:1. Clinical features: 50% are incidental findings during abdominal imaging for other symptoms. Hematuria, flank pain, abdominal mass, anorexia, malaise, weight loss, PUO may occur. Rarely, invasion of left renal vein compresses the left testicular vein causing a left varicocele. Spread may be direct (renal vein), via lymph nodes, or hematogenous (bo ne, liver, lung). Tests: Blood: CBC (polycythemia from erythropoietin secretion); ESR; elec - trolytes, alk phos. Urine: RBCs; cytology. Imaging: US; CT/MRI; renal angiography (if par tial nephrectomy or palliative embolization are being considered; angiography can be done b y CT); IVP (filling defect in kidney calcification); CXR ( \200\234cannon ball \200\235 metastases). Treatment : Nephron sparing versus radical nephrectomy either open or laparosc opic, depending on the size of tumor. Metastatic disease is reason to consider immunotherap y with interferon- or interleukin-2. Prognosis: 5-yr survival: 45%. Transitional cell ca rcinoma (TCC) may arise in the bladder (50%), ureter, or renal pelvis. Epidemiology: Age >4 0 yrs; : = 4. Risk factors: Smoking, drugs (cyclophosphamide, phenacetin), industrial carcinogens (azo-dyes, \222 -naphthalene). Schistosomiasis is a risk factor for squamous cell carcinoma of the bladder. Presentation: Painless hematuria; frequency, urgency, dysuri a, or urinary tract obstruction. Diagnosis: Urine cytology, IVP, cystoscopy + biopsy, CT/MR I scan. Treatment: See bladder tumors (p. 514). Prognosis: Varies with clinical stage/histo logical grade: 10 \200\22380% 5-yr survival. Wilms \200\231 tumor (nephroblastoma) is a chi ldhood tumor of primitive renal tubules and mesenchymal cells. It presents most commonly wi th an abdominal mass and hematuria. Investigations: US with careful examination of the rena l vein; CT/MRI scan. May biopsy only if tumor is massive and preoperative chemotherapy will be given. Treatment: Nephrectomy, with adjunctive radiotherapy and chemotherapy depending on pathological stage. Prognosis: 90% 5-yr survival. Prostate cancer is the second most com mon malignancy of men. Incidence: Rises with age: 80% in men >80 yrs (in autopsy studies). Associations: \206\221 testosterone, +ve family history. Most are adenocarcinomas arising in the peripheral pro-state. Spread may be local (seminal vesicles, bladder, rectum) via no des or hematogenous (sclerotic bony lesions). Symptoms: May be asymptomatic or nocturia, he sitancy, poor stream, terminal dribbling, or urinary obstruction. Weight \206\223 bone pain suggests metastases. Digital rectal exam: May show a hard, irregular prostate. Diagnos is: \206\221 PSA (p. 681; 511 normal in 30% of small cancers); transrectal US and biopsy; bone scan; CT/ MRI. See Tables 13.35 and 13.36. Treatment Local disease: Which is better: Radical prostatectomy, radiother apy or watchful waiting with serial PSA monitoring? One trial ( N = 695) found radical pros tatectomy improved disease-specific mortality, but not overall survival when compared with watchful waiting. Radical surgery does risk erectile dysfunction and incontinence. Some cen ters recommend brachytherapy for local disease. Metastatic disease: Hormonal drugs may give benefit for 1 \200\2232 yrs. Gonadotrophin-releasing analogs; e.g., 12-weekly goserelin (1 0.8 mg SC as Zoladex LA ) first stimulate, then inhibit pituitary flutamide, gonadotrophin output. diethylstilboestrol. Symptomatic treatment: Analgesia; treat hypercalcemia; radiot herapy for bone metastases or spinal cord compression. Prognosis 10% die in 6 months, but 1 0% live >10 yrs. Screening: Rectal examination; PSA; transrectal US. There are problems wit h all (p. 681). Alternatives: Cyproterone acetate, Table 13.35 Advice to asymptomatic men asking for a PSA test The prostate lies below the bladder and surrounds the tube taking urine out. Prostate cance r is common in older men. Many men >50 (to whom this advice applies) consider a PSA test on their blood to detect prostatic cancer. Is this a good idea? The test itself has no side e ffects, provided you don \200\231t mind giving blood and time. There is indirect evidence o f benefit of screening from the United States, where fewer radical prostatectomies reveal c ancer-affected lymph nodes than do those done before widespread PSA-based screen- ing. Inte nsive screening and treatment for prostate cancer does not, however, appear to be associate d with lower prostate-specific mortality in retrospective studies. Table 13.36 Prognostic factors in prostate cancer A number of prognostic factors are used to help determine whether watchful waiting or aggre ssive therapy should be undertaken in pros- tate cancer. These include age, overall general health and risk factors, pretreatment PSA level, tumor stage (as measured by the TNM syste m), and tumor grade (as measured by its Gleason score). Gleason grading is from 1 \200\2231 0, with 10 being the highest grade and carrying the poorest prognosis. A pathologist determ ines the Gleason grade by analyzing his- tology from two separate areas of tumor specimen, then adds them to get the total Gleason score for the tumor. Scores from 8 \200\22310 sugge st an aggressive tumor; 5 \200\2237 suggest intermediate grade; whereas from 2 \200\2234 su g- gest indolent tumor. Patients with high Gleason scores (6 \200\2237) are more likely to be treated aggressively, especially if they are young and/or have higher stage disease. 512 Urinary incontinence Think twice before inserting a urinary catheter. Carry out rectal exam ination to exclude fecal impaction. Is the bladder palpable after voiding (retention with o verflow)? Do not think of people as either dry or incontinent but as incontinent in certain cir- cumstances (i.e., stress-cough, laughing). Attending to these circumstances is as imp ortant as focusing on the physiology. Incontinence in men Enlargement of the prostate is th e major cause of incontinence: Urge incontinence (see below) or dribbling may result from t he partial retention of urine. TURP may weaken the bladder sphincter and cause incontinence . Troublesome incontinence needs specialist assessment. Incontinence in women occurs when p hysiological factors are relatively \212 Functional incontinence unimportant. The patient is \200\234caught short \200\235 and too slow in finding the toilet because of immobility or unfamiliar surroundings. Leakage of urine due to incompetent sphincter. Stress incontine nce: Leakage typically occurs when intra-abdominal pressure rises (e.g., cough- ing, laughi ng). The key to diagnosis is the loss of small (but often fre- quent) amounts of urine when coughing, etc. Examine for pelvic floor prolapse. Look for cough leak with the patient sta nding and with full bladder. Stress incontinence is common during pregnancy and following c hildbirth. It occurs to some degree in about 50% of postmenopausal women. In elderly women, pelvic floor weakness (e.g., with uterine pro- lapse or urethrocele) is the most common ca use. is the most common type seen in hospital practice. Urge incontinence The urge to pass urine is quickly followed by uncontrollable complete emptying of the bladder as the detruso r muscle contracts. Large amounts of urine flow down the patient \200\231s legs. In the eld erly, it is usually related to detrusor instability (a urodynamic diagnosis) or organic bra in damage. Look for evidence of stroke, Parkinson \200\231s, dementia. Other causes: Urinar y infection, diabetes, diuretics, senile vaginitis, urethritis. y r e g r u S \212 \212 In both sexes, incontinence may result from diminished awareness due to confusion or sedati on. Occasionally, incontinence may be purposeful (e.g., preventing admission to an old peop le \200\231s home) or due to anger. Management Check for: UTI, diabetes mellitus, diuretic use, fecal impaction. Do urine analysis and culture. Stress incontinence: Pelvic floor exer cises may help. Intravaginal electrical stimulation may also be effective, but is not accep table to many women. A ring pessary may help uterine prolapse while awaiting surgical repai r (this must be preceded by cystometry and urine flow rate measurement to exclude detrusor instability or sphincter dyssynergia). Surgical options for stress incontinence include Bur ch colposuspension and sling procedures; a variety of minimal-access techniques (e.g., invo lving tension-free vaginal tape) have also been tried but remain unproven. If urge incontin ence: Examine for spinal cord and CNS signs (including cog- nitive test) and for vaginitis \200\224treat with estriol 0.1% cream (e.g., Ovestin , one applicator dose twice weekly fo r a few months) \200\224consider cyclical pro- gesterone if prolonged use, if no hysterecto my, to avoid risk of uterine cancer. The patient (or caregiver) should complete an incontin ence chart for 3 d to obtain the pattern of incontinence. Maximize access to toilet; advise on toileting regimen (e.g., every 4 h). The aim is to keep bladder vol- ume below that whi ch triggers emptying. Drugs may help reduce nighttime incontinence but are generally disapp ointing. Consider aids (absorbent pad; bedside commode). Do urodynamic assessment before an y surgical intervention. 513 Bladder tumors What appear as benign papillomata rarely behave in a purely benign way. They are almost certainly indolent transitional cell (urothelial) malignancies. Adenocarcinomas and squamous cell carcinomas are rare in the West (the latter may follow schistosomiasis). Histology is important for prognosis: Grade 1, differentiated; grade 2, intermediate; grad e 3, poorly differenti- ated. 80% are confined to bladder mucosa and only 20% penetrate mu scle (increases mortality to 50% at 5 yrs). Presentation Painless hematuria (see Table 13.3 7), recurrent UTIs, voiding irritability. Associations Smoking, aromatic amines (rubber ind ustry), chronic cystitis, schistosomiasis ( \206\221 risk of squamous cell carcinoma), pel vic irradiation, and history of Cytoxan exposure. Tests Urine: Microscopy/cytology (cancers may cause sterile pyuria). \212 \212 \212 \212 Staging Complex and changing (EUA, exam ination under anesthesia) IVP may show filling defects ureteric involvement. Cystoscopy with biopsy is diagnostic. Bimanual examination under anesthesia (EUA) helps assess spread. CT/MRI or lymphangiograph y may show involved pelvic nodes. Tis Ta T1 T2 T3 T4 Not felt at EUA Not felt at EUA Not felt at EUA Rubbery thickening at EUA EUA: Mobile mass EUA: Fixed mass Carcinoma in situ Tumor confined to epithelium Tumor in mucosa or submucosa Superficial mus cle involved Deep muscle involved Invasion beyond bladder Treatment of transitional cell carcinoma (tcc) Tis/Ta/T 1 : 80% of all patients. Electrocau tery via cystoscope. Consider intravesical chemotherapeutic agents (e.g., mitomycin C) for multiple small tumors or high-grade tumors. Immunotherapy with intravesical BCG is use- ful in high-grade tumors and carcinoma in situ . T 2 \200\2233 : Radical cystectomy is the gol d standard. Radiotherapy gives worse 5-yr survival rates than surgery, but preserves the bl adder. Salvage cys- tectomy can be performed if radiotherapy fails, but yields worse result s than primary surgery. Postop chemotherapy (e.g., M-VAC: Methotrexate, vinblastine, Adriam ycin, and cisplatin) is toxic but effective. Methods to preserve the bladder with transuret hral resection/partial cystectomy + sys- temic chemotherapy have been tried, but long-term results are disappoint- ing. The patient should have all these options explained by a urolo gist and an oncologist. T 4 : Usually palliative chemo-/radiotherapy. Chronic catheterizati on and uri- nary diversions may help to relieve pain. Cystectomy complications include sexu al and urinary malfunction. To avoid a urostomy, a continent urinary reservoir may be made from the patient \200\231s ileum. Follow-up History, examination, and regular cystoscopy. H igh-risk tumors: Every 3 months for 2 yrs, then every 6 months. Low-risk tumors: First foll ow-up cystoscopy after 9 months, then yearly. Tumor spread Local, to pelvic structures; lym phatic, to iliac and para-aortic nodes; hematogenous, to liver and lungs. Survival This dep ends on age at surgery. For example, the 3-yr survival after cystectomy for T2 and T3 tumor s is 60% if 65 \200\22375 yrs old, falling to 40% if 75 \200\22382 yrs old (in whom the ope rative mortality is 4%). With unilateral 514 y r e g r u S Table 13.37 Is asymptomatic microscopic hematuria significant? Dipstick tests are often done routinely as part of a new admission. If microscopic hematuri a is found, but the patient has no related symp- toms, what does this mean? Before rushing into a barrage of investiga- tions, consider: \212 A meta-analysis found incidence of urogenital disease (e.g., bladder cancer) was no higher in those with asymptomatic microhematuria than in those without. 1 Asymptomatic microscopic hematuria is the sole presenting feature in only 4% of bladder cancers, and there is no ev idence that these are less advanced than malignancies presenting with macroscopic hematuria . When monitoring those with treated bladder cancer for recurrence, microscopic hematuria t ests have a sensitivity of only 31% in those with superficial bladder malignancy, in whom d etection would be most useful. Although 80% of those with flank pain due to a renal stone h ave microscopic hematuria, so will >50% of those with flank pain but no stone. \212 \212 \212 The conclusion is not that urine dipstick testing is useless, but that results should not b e interpreted in isolation . Smokers and those with a +ve family history for urothelial mal ignancy may be investigated dif- ferently from those with no risk factors (e.g., US, cystos copy referral to a renal physician in some patients), but in a young fit athlete, the di agnosis is more likely to be exercise-induced hematuria. pelvic node involvement, only 6% of patients survive 5 yrs. The 3-yr survival with bilatera l or para-aortic node involvement is nil. Massive bladder hemorrhage may complicate treatme nt; consider alum solu- tion bladder irrigation (safer than formalin): It is an in-patient procedure. Gynecology Disorders of the vulva The vulva is the area surrounding the vagina that is loos ely covered by skin and is affected by pathologic processes that affect squamous epithelium . Benign disorders: Bartholin \200\231s gland cyst or abscess: Obstruction of the mucus-sec reting gland surrounding the vagina leads to superinfection; polymicrobial, needs marsupial ization and antibiotics. Undrained abscess of either Bartholin \200\231s gland or perianal glands may lead to necrotizing fas- ciitis. More common in diabetics, immuno-compromised, a nd a history of atherosclerotic disease. Premalignant and malignant conditions: Vulvar intr aepithelial neoplasia (VIN): Presents either asymptomatically or with pruritus. Appearance is white and red papular or macular rash. 5% acetic acid may help visualize. Document lesio ns and biopsy. Often associated with human papilloma virus (HPV). Look for perianal lesions as well. Histological grade : VIN I (mild dysplasia), VIN II (moderate), VIN III (severe d ysplasia or carcinoma in situ). Treatment : Local excision, CO 2 laser 515 1 JAMA 1989, Sep 1;262(9):1214 \200\2231219. Vulvar cancer: 5% of female genital malignancies; look for vaginal and ano- rectal involvem ent. VIN is usually a precursor lesion. 90% squamous cell, also melanoma. Inguinal and pelv ic lymph nodes involved in 20% of cases if lesion is <2 cm, 40% of cases if lesion is >2 cm . Treatment : Unilateral lesions <2 cm can be treated with WLE. All others are treated with WLE and bilateral inguinal/femoral lymphadenectomy. If node-negative, 5-yr survival approa ches 90%; inguinal node metastases, 40%; pelvic nodes, 20%. Disorders of the vagina Benig n disorders: Pelvic organ prolapse: Secondary to weakness in pel- vic support. Risk factors include pregnancy and childbirth, increased in intra-abdominal pressure (respiratory disea se, obesity), postmenopausal atrophy, and connective tissue disorder. Presentation: Pelvic pressure, coital difficulty, backache, protrusion from the vagina, vaginal spotting, urinar y incontinence, fecal incontinence or obstructed defecation. Evaluation: Clinical exam, uro dynamics, radiographic studies include cysto- colpoproctography, dynamic pelvic MRI. Treatm ent: Pessary if unfit for surgery. Abdominal suspension procedures including sacrocolpopexy or sacrocolpoperineopexy. Premalignant or malignant conditions: Vaginal cancer: Rare, most are extensions from either vulvar or cervical can- cers. Usually squamous cell (90%), aden ocarcinoma, sarcoma (DES expo- sure), melanoma in 10%. Surgery has a limited role. Radiatio n therapy is the mainstay. Poor survival rates. Disorders of the uterus Benign disorders: H yperplasia or uterine polyps: Presentation is abnormal uterine bleeding. Laser or cauteriza tion of the endometrium is the method of treatment. Leiomyoma (fibroids): 25% of women in r eproductive years have fibroids. Risk of malignant degeneration is <0.5%. GnRH analogs, myo mectomy, embolization, hysterectomy are all methods of treatment. Cervicitis: Common organi sms include Trichomonas vaginalis, Chlamydia trachomatis, N. gonorrhoeae, Herpes simplex vi rus. Presentation : Vaginal dis- charge, pruritus. Clinical finding s: Yellow discharge and erythematous cervix on inspection. Cervical motion tenderness on bimanual exam. Treatment is antibiotics and education. Pelvic inflammatory disease (PID): Spread of organisms in the endocervix through the endometrium to the fallopian tubes and beyond. Common organisms inc lude Chlamydia trachomatis, N. gonorrhoeae, Haemophilus influenzae. Criteria for diagnosis include lower abdominal pain, mucopu- rulent cervical discharge on exam, bilateral adnexal tenderness. Associated findings include fever, leukocytosis. Treatment : For questionable d iagnosis, laparoscopy is helpful. There are usually erythematous tubes, with a sticky exuda te. Antibiotics are the mainstay treatment. Outpatient treatment is ceftriaxone 250 mg intr amuscular and doxycycline 100 mg bid for 10 \200\22314 d. Reexamine outpatients within 48 h . A tubo-ovarian abscess is the most severe form of PID. Inpatient antibiotics will resolve abscess in 75%; drain- age is necessary either operatively or via interventional radiology in 25%. Malignant disorders Cervical cancer 20% of female genital cancers. Adenocarcinoma (90%) or squamous cell cancer (10%). Spreads primarily through direct extension and into t he regional pelvic lymph nodes. Treatment is either radiotherapy or surgery 516 with similar 5-yr survival rates. Localized disease has a 5-yr survival rate of 80 \200\223 90%; metastatic disease to the lymph nodes, 40% 5-yr survival. Endometrial cancer: Most co mmon female genital cancer. Risk factors include nulliparity, obesity, delayed menopause, c hronic anovulation, and unopposed postmenopausal estrogens. Presenting symptom is bleeding. Types include adenocarcinoma (90%). Evaluation includes transvaginal US and endometrial sa mpling. Treatment of localized disease is surgical and includes extrafascial abdominal hyst er- ectomy and bilateral salpingo-oophorectomy. Poorly differentiated endo- metrial cancer and extension into the cervix or beyond the superficial myometrium should undergo selective pelvic and periaortic lymph node sampling. Additional radiotherapy is commonly employed in these patients. 5-yr survival for superficial stage I disease is 80%; stage II disease is 60%; 30% for advanced disease. Disorders of the ovary Benign disorders: Benign follicular, corpus luteal, and theca lutein cysts are the most common. Usually disappear with new menst rual cycle or oral contraception. Cysts >10 cm are unlikely to disappear. Teratoma: Commonl y seen in women of reproductive age. Often bilateral. Ovarian cystectomy is recommended tre atment. Serous or mucinous cystadenoma: Benign epithelial tumors. Treated with cys- tectomy or oophorectomy. Intraoperative frozen section may be important to determine whether these cysts contain malignant cells. If so, and the patient is postmenopausal, bilateral oophore ctomy and hysterectomy is recommended. Ectopic pregnancy: Risk factors include history of P ID, use of infertility drugs, intrauterine contraceptive device. Any women of childbearing age with lower abdominal pain should have a \222 -HCG drawn. Small ectopic pregnancies may be treated with methotrexate. Laparoscopy or laparotomy is otherwise performed. Malignant disorders: Ovarian cancer: 25% of all female genital cancers. Risk factors include \206 \221 age, \206\223 fertility, family history, Peutz \200\223Jeghers \200\231 syndrome, Tur ner \200\231s syndrome. Presentation is often late and consists of abdominal pain and swell ing, GI symptoms, adnexal mass. Evaluation: CBC, chemistry, CA-125, -fetoprotein, CT, IV P. Treatment: Abdominal hysterectomy with bilaterally salpingo-oophorectomy, lymphadenectom y, and tumor cytoreduction. Adjuvant chemotherapy (Taxol) and/or radiation are given for ad vanced disease. 5-yr survival from epithelial ovarian cancer is 70% for stage I, 30% for st age II, and <15% for stage III and IV. y r e g r u S 517 Infectious diseases (ID ) Shmuel Shoham , M.D. s e s a e s i d Contents