Question

Personal Information

Name: Mrs. Maggie Meriwether

Age: 56 years old

Gender: Female

Description

Mrs. Meriwether is a 56-year-old woman, who was apparently in good health until six months ago, at which point she started noticing an uncontrollable urge to urinate when she was exercising, lifting weights, sneezing, or coughing. The embarrassing part for her is that, although she has tried to suppress the urge, she has voided in her underwear very often. The problem has become more frequent, and she has to wear a sanitary pad constantly. The patient also shares that she has something protruding through her vagina. She is anxious because she thinks she has a tumor. After conducting a thorough medical interview and physical examination, the doctor diagnoses stress urinary incontinence and cystocele.

Our patient is a mother of four children with vaginal deliveries complicated by shoulder dystocia. During her last pregnancy, she had a whitish and cottage cheese-like vaginal discharge. A year ago, Mrs. Meriwether had an episode of gastroenteritis accompanied by profuse vomiting and diarrhea, which produced moderate dehydration and electrolyte and acid-base imbalances. Our patient also indicates she has had two episodes of right renal colic produced a renal lithiasis. Patient has no history of smoking or alcohol intake.

• Urinary system: Leakage of urine through the urethra during Valsalva maneuver
• Reproductive system: Soft mass protruding through the vagina, mostly when the patient is pushing

1. According to history, our patient was very concerned about having a tumor. What are some tumors of the female reproductive system that we should rule out in this case?
2. Mrs. Meriwether had two episodes of renal colic produced by renal lithiasis. Describe this diagnosis and the prognosis. Is this condition related to a chronic kidney disease? Why or why not?

Answer 1

Q)1) what are the some tumors of the Female Reproductive system that we should rule out in this case?

Ans) In Gyanecology, tumors of the female Reproductive system deals by one subtopic namely : Gynecological Oncology which mainly related to the Ovarian Tumors.

Ovarian Tumors : 1. Benign Ovarian Tumors,

2. Malignant Ovarian Tumours and

2. Miscellaneous Ovarian Tumors.

1. Benign Ovarian Tumors : They are further classified into

A) Benign epithelial Tumors : 80% are most common benign Ovarian Tumors, they are further classified into

a) serous cyst adenoma : Most common benign epithelial tumor of Ovary,

- thin walled , unilocular cyst filled with serous fluid and lined by cells similar to those lining the fallopian tube,

- Bilateral in 20% of cases ,

- Chances of malignancy is 40%,

- Psammoma bodies seen.

b) Mucinous Cystadenoma : 2nd most common benign epithelial tumor of Ovary,

- Thick walled , mucoid material containg tumor which may be unilocular or multilocular lined by single columnar epithelium,

- chances of malignancy 10%,

- Pseudomyxoma perotonei is a rare complication,

C) Brenner Tm/ transitional tumor: rare solid tumor, resembling fibroma of Ovary, mostly benign,

- most common age is peei and post menopausal females,

- Walthard cell nests are seen and cells have coffee bean nuclei.

B) Benign Sex cord Tumors : they are further divided into

a) Theca Cell Tumor : almost always benign,

- presents after menopause,

- Unilateral,

- Tumor secrets estrogen which can lead to postmenopausal bleeding, Endo metrial hyperplasia and endometrial cancer.

b) Fibroma : arises from stromal cells,

- hard in consistency,

- Microscopy shows spindle shaped cells,

- when fibroma is accompanied with ascites and hydrothorax ( usually right side) it is called as Meigs Syndrome.

C) Benign Germ Cell Tumor : is further divided into

a) Dermoid cyst ( mature cystic teratoma )

- mature teratoma,

- immature teratoma,

- mono dermal teratomas.

D) Gonadoblastoma : this is a benign neoplasm in the presence of Androgen Insentivity Syndrome and Swyer's Syndrome.

- Pseudomyxoma peritonei,

2) Malignant Ovarian Tumors : they are mainly

- Low malignant potential tumors,

- neoplastic Ovarian Tumours.

Characteristic features: increases frequency of ovulation,

- risk of Ovarian cancer increases.

RISK FACTORS: advanced age,

- early menarche and late menopause,

- family Hx of Ovarian cancer, breast, endometrial and colorectal cancer,

3. Miscellaneous tumors : A) Uulva : Vulval intraepithelial Neoplasia,

- Paget's disease of Vulva,

- Vulval cancer,

B) Vaginal carcinomas.

This case is not related any Tumors, usually in case of tumors pt experiences pain, loss of weight and appetite.

Q)2) Diagnosis and prognosis of Renal lithiasis ?

Ans) Diagnosis : Clinical presentation: clinical presentation is with costovertebral angle or flankpain which can radiate to the scortum or labia. Hematuria with non dysmorphic RBCs may be noted, Oliguria and AKI are uncommon, but can result of there is bilateral obstruction or if a solitary functioning kidney is affected,

DIAGNOSTIC TESTING: LABORATORIES: Metabolic Evaluation includes Urine culture,PH and microscopy.

IMAGING: plain abdominal film may reveal radioopaque stones composed of calcium salts, struvite or cyssteine,

Non corast CT,

Treatment: Hydration to increase urine output and with anagesia,

- prevent if recurrent stone formation,

- for calcium stones , a low calcium diet, pt should avoid oxalate rich foods,

Uric acid stones : redused size by allopurinol,

Struvite calculi - surgical intervention for their removal.

Cystine stones : urinary alkalization to induce solubility,

  The renal calculi usually not related to chronic diseases, why not means the urinary stones easily push out from the urinary system whether conservative or surgical management.

The risk factors for Chronic kidney disease are :

- NSAIDS,

- Uncontrolled Hypertension,

- nephrotoxic agents

- UTI or obstruction ( renal artery stenosis),

- Renal vein thrombosis.

Stress incontinence: it has three definitions, 1,

. Symptom : complaint of involuntary leakage of urine,

sign : leakage on exertion,

Urodynamic finding: increased abdominal pressure, with no detrusor contraction, sudden loss coughing, sneezing, laughing,excercise,having sex and lifting heavy objects.

a) urge incontinence: sudden strong desire to void with involuntary leakage : Acute cystitis in women, neuropathic bladder, bladder outlet obstruction,

b) false incontinence : in enlarged prostate in men,

Clinical evaluation of Urinary Incontinence:

History:

Onset, duration, pattern,

type- stress,urge,total,overflow,

voiding pattern: normal,frequency, urgency,straining,

Drugs: anticholinergic,alphadrenergic blockers, diuretics,sedatives,hypnotics,opiates,

Surgery: Hysterectomy,prostactomy,orthotopic neobladder,anti incontinence procedures,

Obsterics: parity,deliveries,trauma,

Physical examination:

General: obesity,

abdominal : chronic retention,

vaginal examination : masses, prolapse,cystocele,rectocele

Management : Duloxyteine hydrochloride