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m o c . t o p s g o l b . d a o l n w o d s q c m l a c i d e m ww.
Theme: Urinary tract trauma A. Urinary tract infection B. Bladder outlet obstruction C. Bulbar urethral rupture D. Membranous urethral rupture E. Bladder rupture F. Bladder contusion For the scenario given please select the most likely injury. Each option may be used once, more than once or not at all.

1.

A 56 year old man is involved in a road traffic accident. He is found to have a pelvic fracture. He reports that he has some lower abdominal pain. He has peritonism in the lower abdomen. The nursing staff report that he has not passed any urine. A CT scan shows evidence of free fluid. You answered Bulbar urethral rupture The correct answer is Bladder rupture A pelvic fracture and lower abdominal peritonism should raise suspicions of bladder rupture (especially as this man cannot pass urine).

2.

A 52 year old man falls off his bike. He is found to have a pelvic fracture. On examination he is found to have perineal oedema and on PR the prostate is not palpable. A urine dipstick shows blood. Membranous urethral rupture A pelvic fracture and highly displaced prostate should indicate a diagnosis of membranous urethral rupture.

3.

A 52 year old woman falls out of a tree while rescuing a cat. She has a pelvic fracture. She has suprapubic tenderness and complains of dysuria. Her abdomen is soft and non tender. A urine dipstick shows blood, nitrates and leucocytes. Urinary tract infection There is no indication of a more sinister diagnosis here. The patient's abdomen is normal and she is able to pass urine. Her dipstick confirms an infection. Also in women urethral injury is rare. Next question

Similar theme questions in September 2009 and April 2010

m o c . t o p s g o l b . d a o l n w o d s q c m l a c i d e m ww.
Lower genitourinary tract trauma

Most bladder injuries occur due to blunt trauma 85% associated with pelvic fractures

Easily overlooked during assessment in trauma

Up to 10% of male pelvic fractures are associated with urethral or bladder injuries

Types of injury
Urethral injury

Mainly in males Blood at the meatus (50% cases) There are 2 types:

i.Bulbar rupture - most common - straddle type injury e.g. bicycles - triad signs: urinary retention, perineal haematoma, blood at the meatus ii. Membranous rupture - can be extra or intraperitoneal - commonly due to pelvic fracture - Penile or perineal oedema/ hematoma - PR: prostate displaced upwards (beware co-existing retroperitoneal haematomas as they may make examination difficult) - Investigation: ascending urethrogram - Management: suprapubic catheter (surgical placement, not percutaneously) External genitalia injuries (i.e., the penis and the scrotum)

Secondary to injuries caused by penetration, blunt trauma, continence- or sexual pleasure-enhancing devices, and mutilation

Bladder injury

rupture is intra or extraperitoneal presents with haematuria or suprapubic pain history of pelvic fracture and inability to void: always suspect bladder or urethral injury inability to retrieve all fluid used to irrigate the bladder through a Foley catheter indicates bladder injury investigation- IVU or cystogram management: laparotomy if intraperitoneal, conservative if extraperitoneal

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Question 4 of 1800

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Which virus is implicated as a causative agent for anal cancer?

A. Human papillomavirus 7 B. Human immunodeficiency virus 1

m o c . t o p s g o l b . d a o l n w o d s q c m l a c i d e m ww.
C. Human immunodeficiency virus 2 D. Human papillomavirus 16 E. Human T-lymphotropic virus 1 Next question Oncoviruses

Viruses which cause cancer These may be detected on blood test and prevented by vaccine

These are the main types of oncoviruses and their diseases:

Oncovirus Epstein-Barr virus Cancer Burkitt's lymphoma Hodgkin's lymphoma Post transfusion lymphoma Nasopharyngeal carcinoma Cervical cancer Anal cancer Penile cancer Vulval cancer Oropharyneal cancer Kaposi's sarcoma Hepatocellular carcinoma Hepatocellular carcinoma

Human papillomavirus 16/18

Human herpes virus 8 Hepatitis B virus Hepatitis C virus

Human T-lymphotropic virus 1 Tropical spastic paraparesis Adult T cell leukaemia

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A 72 year old man presents with symptoms and signs of benign prostatic hyperplasia. Which of the following structures is most likely to be enlarged on digital rectal examination?

m o c . t o p s g o l b . d a o l n w o d s q c m l a c i d e m ww.
A. Posterior lobe of the prostate B. Median lobe of the prostate C. Right lateral lobe of the prostate D. Left lateral lobe of the prostate E. Anterior lobe of the prostate

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Carcinoma of the prostate typically occurs in the posterior lobe. The median lobe is usually enlarged in BPH. The anterior lobe has little in the way of glandular tissue and is seldom enlarged. Benign Prostatic Hyperplasia

Prostatic enlargement occurs in many elderly men >90% of men aged over 80 will have at least microscopic evidence of benign prostatic hyperplasia

Pathology As part of the hyperplastic process increase in both stromal and glandular components are seen. The changes are most notable in the central and periurethral region of the gland. Image showing enlarged prostate removed by transvesical prostatectomy with massive enlargement of the median lobe

A 58 year old man has been suffering from mechanical back pain for several years. One morning he awakes from sleep and feels a sudden onset of pain in his back radiating down his left leg. Which of the following events is most likely to account for his symptoms?

A. Prolapse of inner annulus fibrosus B. Prolapse of outer annulus fibrosus C. Prolapse of nucleus pulposus D. Rupture of the ligamentum flavum E. None of the above Next question

m o c . t o p s g o l b . d a o l n w o d s q c m l a c i d e m ww.
Theme from 2009 Exam The symptoms would be most likely the result of intervertebral disk prolapse. In disk prolapse the nucleus pulposus is the structure which usually herniates. Intervertebral discs

Consist of an outer annulus fibrosus and an inner nucleus pulposus.

The anulus fibrosus consists of several layers of fibrocartilage.

The nucleus pulposus contains loose fibres suspended in a mucoprotein gel with the consistency of jelly.
The nucleus of the disc acts as a shock absorber.

Pressure on the disc causes posterior protrusion of the nucleus pulposus. Most commonly in the
lumbrosacral and lower cervical areas.

The discs are separated by hyaline cartilage.

There is one disc between each pair of vertebrae, except for C1/2 and the sacrococcygeal vertebrae.

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Questions 7 to 9 of 1800

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Theme: Paediatric neck masses A. Cystic hygroma

m o c . t o p s g o l b . d a o l n w o d s q c m l a c i d e m ww.
B. Thyroglossal cyst C. Rhabdomyosarcoma D. Branchial cyst E. Dermoid cyst Please select the most likely underlying diagnosis for the situation that is described. Each option may be used once, more than once, or not at all. 7. A 2 year old boy is brought to the clinic by his mother who has noticed that he has developed a small mass. On examination a small smooth cyst is identified which is located above the hyoid bone. On ultrasound the lesion appears to be a heterogenous and multiloculated mass. You answered Branchial cyst The correct answer is Dermoid cyst Dermoid cysts are usually multiloculated and heterogeneous. Most are located above the hyoid and their appearances on imaging differentiate them from thyroglossal cysts.

8.

A 22 month old baby is brought to the clinic by her mother who is concerned that she has developed a swelling in her neck. On examination she has a soft, lesion located in the posterior triangle that transilluminates. Cystic hygroma Cystic hygromas are soft and transilluminate. Most are located in the posterior triangle.

9.

A 3 year old boy is brought to the clinic by his mother who has noticed a mass in his neck. On examination he has a smooth mass located on the lateral aspect of his anterior triangle, near to the angle of the mandible. On ultrasound it has a fluid filled, anechoic, appearance. You answered Dermoid cyst The correct answer is Branchial cyst Branchial cysts are usually located laterally and derived from the second branchial cleft. Unless infection has occurred they will usually have an anechoic appearance on ultrasound. Next question

Neck Masses in Children

Thyroglossal cyst

Located in the anterior triangle, usually in the midline and below the hyoid (65% cases) Derived from remnants of the thyroglossal duct

m o c . t o p s g o l b . d a o l n w o d s q c m l a c i d e m ww.

Thin walled and anechoic on USS (echogenicity suggests infection of cyst) Branchial cyst Six branchial arches separated by branchial clefts Incomplete obliteration of the branchial apparatus may result in cysts, sinuses or fistulae 75% of branchial cysts originate from the second branchial cleft Usually located anterior to the sternocleidomastoid near the angle of the mandible Unless infected the fluid of the cyst has a similar consistency to water and is anechoic on USS Dermoids Derived from pleuripotent stem cells and are located in the midline Most commonly in a suprahyoid location They have heterogeneous appearances on imaging and contain variable amounts of calcium and fat

Thyroid gland

True thyroid lesions are rare in children and usually represent thyroglossal cysts or tumours like lymphoma

Lymphatic malformations

Usually located posterior to the sternocleidomastoid Cystic hygroma result from occlusion of lymphatic channels The painless, fluid filled, lesions usually present prior to the age of 2 They are often closely linked to surrounding structures and surgical removal is difficult They are typically hypoechoic on USS

Infantile haemangioma

May present in either triangle of the neck Grow rapidly initially and then will often spontaneously regress Plain x-rays will show a mass lesion, usually containing calcified phleboliths As involution occurs the fat content of the lesions increases

Lymphadenopathy

Located in either triangle of the neck May be reactive or neoplastic Generalised lymphadenopathy usually secondary to infection in children (very common)

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