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    By E. Asaru. Gettysburg College. 2018.

    It is not state which system causes the important buy aygestin 5 mg visa, however best 5 mg aygestin, to recognize outfow obstruction (sympathetic that patients with neurological or somatic) discount aygestin 5 mg fast delivery. These can, however, disease should be evaluated for be differentiated by proper lower urinary tract function. A distinction should patient with unexplained lower be made between detrusor-smooth urinary tract symptoms should be muscle sphincter dyssynergia evaluated for possible neurologic or detrusor-striated muscle abnormality. The evaluation of the patient Neurologic should include: Conditions • Detrusor function • Urethral function Supra-pontine lesions • Co-ordination between the two Supra pontine lesions e. Treatment decisions These conditions will lead to less must take into account the inhibition of bladder control. This might not directly be associated with pathology but Voiding dysfunction occurs in occur as part of the normal aging 35-75% of patients. High lesions will mostly consists of frequency, urgency, cause over activity of the bladder nocturia and urge incontinence. Dopamine defciency Multiple Sclerosis is a progressive in the substantia nigra accounts disease affecting young and for the classical motor features middle aged people with of the disease. This condition neural demyelination with axon will only cause lower urinary tract sparing and it is possibly immune dysfunction after many years and mediated. Detrusor and later not be able to self- overactivity with striated sphincter 82 dyssynergia is the most common sphincter control. Up to 15% of These patients will normally end patients might present with the up having treatment in a center urinary symptoms before the for neurologic rehabilitation. In this by central disc compression at the condition the lower urinary level of L5 or S1 where the cauda tract function will be affected equina is central in the spinal fairly soon after the start of the space before it exits through the disease. Cauda Equina syndrome rehabilitation for the urinary is characterized by perineal tract dysfunction is often not sensory loss, loss of both anal indicated and not very satisfactory. They unknown and it is a progressive have acontractile detrusor muscle neurodegenerative condition with and no bladder sensation. Spinal cord damage Complete spinal cord lesions below Spinal cord damage, as in spinal T6 will normally give detrusor over cord injuries, spina bifda patients activity with smooth sphincter and compression of the spinal cord synergia and striated sphincter due to disc compression, tumors dyssynergia. In obstructed labor, minor damage can happen Treatment of spinal cord injuries to the innervation of the lower should aim to create a low- urinary tract. This will normally pressure system and emptying with lead to atonic or hypoactive clean intermittent catheterization. Fortunately, A complication of the above T6 damage to the pelvic plexus is lesions is Autonomic Hyperrefexia. The condition sympathetic) causing headache, will stabilize and function will hypertension and fushing of the return spontaneously to the pelvic body above the lesion. Correction of the under of stimuli in susceptible patients lying neurologic damage is almost is important and sublingual never possible. The whole spectrum developing condition affecting of dysfunctions can be present in motor, sensory and sphincter these patients but seems to be in function. It will mostly stabilize in the more advanced stages of the 2-4 weeks and recovery is usually disease. Peripheral Nerve Damage Fowler Syndrome Peripheral nerve damage is This syndrome presenting in young normally associated with diseases women below 30 presenting like diabetes, herpes virus with acute retention and often infection, Guillain-Barre Syndrome 84 have polycystic ovarian disease. Special investigations Clinical Evaluation Ultrasound of the bladder, urine dipstick and serum creatinine is The evaluation of the neurologic indicated. If any abnormality is picked up with these screening patient includes the normal tests, the necessary workup must physical, biochemical and dynamic be done. The only difference Urodynamic evaluation is that special attention must be Standard Urodynamic testing gives information on bladder and taken to include the state of the urethral function. Urodynamic studies should be performed in a specialized unit examination will sometimes detect where good studies will be done a full bladder. There is detrusor pressures reaching more not a good correlation between than 40 cm of water, especially in anal sphincter activity and the presence of detrusor sphincter urethral function.

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    The surface marking corresponds to a point where the lat- ally and the cartilages of the 11th and 12th ribs posteriorly purchase 5mg aygestin visa. The pubic • Pancreas: the pancreatic neck lies on the level of the transpyloric tubercle is an important landmark and is identifiable on the superior plane (L1) cheap 5mg aygestin visa. The lower pole of the right kidney usually extends 3 cm below the defect in the external oblique aponeurosis 5mg aygestin free shipping. It extends as a de- • Bladder: in adults the bladder is a pelvic organ and can be palpated pression in the midline from the xiphoid process to the symphysis pubis. Surface anatomy of the abdomen 53 23 The pelvis Icthe bony and ligamentous pelvis Iliac crest Anterior gluteal line Iliac fossa Inferior gluteal line Posterior superior Anterior superior iliac spine iliac spine Anterior inferior Posterior gluteal line Auricular iliac spine surface Acetabulum Greater sciatic notch Obturator foramen Iliopectineal Pubic tubercle Spine of ischium line Pubic crest Lesser sciatic notch Pubic tubercle Body of pubis Ischial tuberosity Pubic Ramus of ischium Inferior ramus symphysis Fig. Prostate Obturator fascia The blue line represents the origin Obturator internus of levator ani from the obturator Anterior edge Levator prostatae fascia of levator ani 54 Abdomen and pelvis The pelvis is bounded posteriorly by the sacrum and coccyx and antero- The pelvic cavity laterally by the innominate bones. The pelvic brim (also termed the pelvic inlet) separates the pelvis into the false pelvis (above) and the true pelvis (below). By adulthood the constituent bones have fused together at the behind, the ischial tuberosities laterally and the pubic arch anteriorly. Posteriorly each hip bone articulates with the sacrum at the The true pelvis (pelvic cavity) lies between the inlet and outlet. It runs back- wards from the anterior superior iliac spine to the posterior superior The ligaments of the pelvis (Fig. The outer surface of the ilium is termed the gluteal sur- • Sacrotuberous ligament: extends from the lateral part of the sacrum face as it is where the gluteal muscles are attached. The The above ligaments, together with the sacro-iliac ligaments, bind auricular surface of the ilium articulates with the sacrum at the sacro- the sacrum and coccyx to the os and prevent excessive movement at the iliac joints (synovial joints). In addition, these ligaments create the greater and iliac ligaments strengthen the sacro-iliac joints. The pelvic floor muscles: support the viscera; produce a sphincter • Ischium: comprises a spine on its posterior part which demarcates action on the rectum and vagina and help to produce increases in intra- the greater (above) and lesser sciatic (below) notches. The rectum, urethra and vagina tuberosity is a thickening on the lower part of the body of the ischium (in the female) traverse the pelvic floor to gain access to the exterior. The ischial ramus projects The levator ani and coccygeus muscles form the pelvic floor, while piri- forwards from the tuberosity to meet and fuse with the inferior pubic formis covers the front of the sacrum. It overlying obturator internus on the side wall of the pelvis and the articulates with the pubic bone of the other side at the symphysis pubis ischial spine. The superior surface of the body the midline as follows: bears the pubic crest and the pubic tubercle (Fig. The anterior and lateral anorectal junction and also insert into the deep part of the anal aspects of the sacrum are termed the central and lateral masses, respect- sphincter. Posteriorly, the fused pedicles and laminae form aspect of the coccyx and a median fibrous raphe (the anococcygeal the sacral canal representing a continuation of the vertebral canal. Sacral cornua • Coccygeus: arises from the ischial spine and inserts into the lower bound the hiatus inferiorly on either side. It comprises The female pelvis differs from that of the male for the purpose of child- between three and five fused rudimentary vertebrae. In the male the sacral promon- The obturator membrane tory is prominent, producing a heart-shaped inlet. The obturator membrane is a sheet of fibrous tissue which covers the 2 The pelvic outlet is wider in females as the ischial tuberosities are obturator foramen with the exception of a small area for the passage of everted. The latter branch The pelvic fascia is the term given to the connective tissue that lines the gains access to the rectus sheath, which it supplies, and eventually pelvis covering levator ani and obturator internus.

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    Stage T1 tumours originate from the urothelium but penetrate the basement membrane which separates the urothelium from the deeper layers purchase 5 mg aygestin with amex. T1 tumours invade into the lamina propria buy aygestin 5 mg mastercard, but are not so deep that they reach the detrusor muscle generic 5mg aygestin free shipping. Carcinoma in situ (Tis) is a high-grade (anaplastic) carcinoma confined to the urothelium, but with a flat non-papillary configuration. Unlike a papillary tumour, Tis appears as reddened and velvety mucosa and is slightly elevated but sometimes not visible. Three types of Tis are distinguishable;  Primary Tis (no previous or concurrent papillary tumours);  Secondary Tis (with a history of papillary tumours);  Concurrent Tis (in the presence of papillary tumours). Predicting recurrence and progression of tumours [15,16]: TaT1 tumours The pattern of recurrence and progression depends on the following clinical and pathological factors: 1. Larger tumours should be resected in fractions, which include the exophytic part, the underlying bladder wall and the edges of resection area. An immediate single post-operative instillation with a chemotherapeutic agent (drug optional – Mitomycin C preferred). Maintenance therapy for at least 1 year (monthly once) is necessary [22,23] although the optimal maintenance scheme has not yet been determined. The major issue in the management of intermediate risk tumours is to prevent recurrence and progression, of which recurrence is clinically the most frequent. Adjuvant intravesical chemotherapy (drug optional), schedule: optional although the duration of treatment should not exceed 1 year. Maintenance therapy for at least 1 year (monthly once) is necessary although the optimal maintenance schedule has not yet been determined. Early radical cystectomy at the time of diagnosis provides excellent disease-free survival, but over-treatment occurs in up to 50% of patients. Muscle invasive bladder cancer: Neo-adjuvant chemotherapy: Neo-adjuvant cisplatin-containing combination chemotherapy improves overall survival by 5-7% at 5 years. Radical Surgery and Urinary Diversion Cystectomy is the preferred curative treatment for localized muscle invasive bladder cancer. Radical cystectomy includes removal of regional lymph nodes, the extent of which has not been sufficiently defined. A delay in cystectomy increases the risk of progression and cancer-specific death. Radical cystectomy in both sexes must not include the removal of the entire urethra in all cases, which may then serve as outlet for an orthotopic bladder substitution. Terminal ileum and colon are the intestinal segments of choice for urinary diversion. Positive margins anywhere on the bladder specimen (in both sexes), if the primary tumour is located at the bladder neck or in the urethra (in women), or if tumour extensively infiltrates the prostate. Before cystectomy, the patient should be counselled adequately regarding all possible alternatives, and the final decision should be based on a consensus between patient and surgeon. For patients with inoperable locally advanced tumours (T4b), primary radical cystectomy is a palliative option and not recommended as a curative treatment. External beam radiotherapy [35, 36] External beam radiotherapy alone should only be considered as a therapeutic option when the patient is unfit for cystectomy or a multimodality bladder-preserving approach Radiotherapy can also be used to stop bleeding from the tumour when local control cannot be achieved by transurethral manipulation because of extensive local tumour growth. Chemotherapy [37,38] Although cisplatin-based chemotherapy, as primary therapy for locally advanced tumours in highly selected patients, has led to complete and partial local responses, the long-term success rate is low. Multimodality treatment [39,40] There are comparable long-term survival rates in cases of multimodality treatment success. Adjuvant Chemotherapy Adjuvant chemotherapy is advised within clinical trials, but not for routine use. Post-chemotherapy surgery after a partial or complete response may contribute to long-term disease-free survival. Second-line treatment: In patients progressing after platinum-based combination chemotherapy for metastatic disease vinflunine should be offered, which has the highest level of evidence to date, or clinical trials of other treatments. Follow-up for non-muscle invasive bladder tumours [48, 49] Patients with non-muscle invasive bladder tumours need to be regularly followed up because of the risk of recurrence and progression; however, the frequency and duration of cystoscopies should reflect the individual patient’s degree of risk.

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    Differences in the levels of caries performed by application of multivariate regression were explained by differences in oral hygiene practice and analysis buy aygestin 5 mg cheap. There was little difference in the frequency of sugars intake between the Longitudinal studies of diet and caries incidence different regions best 5mg aygestin. A large cross-sectional study of 2514 When investigating the association between diet and the Americans aged 9–29 years conducted between 1968 and development of dental caries it is more appropriate to use 1970 found that the dental caries experience of adolescents a longitudinal design in which sugars consumption habits eating the highest amounts of sugars (upper 15% of the over time are related to changes in dental caries sample) was twice that of those eating the lowest amounts experience buy cheap aygestin 5 mg on-line. Different fluoride children were divided into high, medium, or low bands of exposure should also be considered in this respect. However, in the 15–18-year-old age group, the children with caries development over a 20-month period. A significant was positively related to the level of dental caries at age relationship between the markers of frequent consump- 88 3 years and Stecksen-Blinks and Holm showed that tion of sugary items and sugars-containing beverages and snacking frequency was positively associated with dental caries increment was found. Despite the short period of found after control of confounders related to oral hygiene observation, a significant relationship between caries practices and socio-economic status. In a comprehensive that when social factors were controlled for, an association study of dental caries increment and diet of over 400 was found between frequency of consumption of 95 English adolescents (aged 11–12 years) a small but confectionery and soft drinks, high intake of confectionery significant relationship was found between intake of total 50 and soft drinks and dental caries. It studied the relationship between sugars Diet, nutrition and prevention of dental diseases 211 intake and dental caries increment over 3 years in children sugars in the diet should result in a reduction in the total 96 initially aged 10–15 years. Children who consumed a higher of frequency of sugars intake in the development of dental 99 proportion of their total dietary energy as sugars had a caries. Konig¨ showed that dental caries experience higher caries increment for approximal caries, though increases with increasing frequency of intake of sugars there was no significant association between sugars intake even when the absolute intake of sugars eaten by all 100 and pit and fissure caries. Some human studies show that the frequency of sugars When the children were divided into those who had a high intake is an important aetiological factor for caries 53,101 compared with a low caries increment, a tendency development. The primary evidence for the belief towards more frequent snacking was seen in the high that the prevalence of dental caries is directly related to the caries children. However, intake of sugars was generally frequency with which sugar is eaten comes from the 78 high for all subjects in this study with only 20 out of 499 Vipeholm study. This study showed caries development children consuming less than 75 g/d, and the average was low when sugars were consumed up to four times a 102 intake of the lowest quartile of consumption being 109 g/d day at mealtimes. Burt and Szpunar recognised old children in Iceland, also found a threshold effect for that, in the Michigan Study, the reason for the low relative the frequency of sugars consumption on caries develop- risk of caries development in the high sugars consumers ment of four times a day. In children reporting four or was that small variances were found both for caries more intakes of sugars per day or three or more between- increment and intake of sugars. In was concluded that data from longitudinal studies in an earlier cross-sectional study of 4-year-old children in 103 modern societies that make use of prevention still show a Iceland, Holbrook showed that caries levels markedly relationship between sugars consumption and caries increased at frequency of intake of sugars above 30 times a 104 activity. Holt ,ina failed to show a relationship between sugars intake and longitudinal study of English preschool children, found development of dental caries because many of these were that dmft was higher (dmft 1. Additionally, the influence of frequency of consumption In this study, the relationship between total amount of was generally ignored. The sugars consumption and dental caries increments may be studies above suggest that if free sugars intake is limited to weak due to the limited range of sugars intake in the study a maximum of four times a day, caries levels will be population, i. If Some studies have investigated the association between all people within a population are exposed to the disease frequency of consumption of sugars-rich foods and caries risk factor the relationship between the risk factor and the development. There is more between- quency of consumption of confectionery and caries country variation in intake of sugars which explains the development was found in a study conducted on 900 stronger association between sugar availability and dental 14-year-old Caucasian, Hawaiian and Japanese school- 105 106 caries levels found from analysis of worldwide data children in Hawaii. A higher caries consumed incidence was associated with consumption of sweets and The importance of frequency versus the total amount of cakes at mealtimes and with frequency of confectionery sugars is difficult to evaluate as the two variables are hard consumption. The findings of Kalsbeek and Vereeps , between meals and amount consumed in American confirmed the association between the frequency of con- children (r ¼þ0. There is also evidence to show that Animal studies have also been used to investigate the these two variables are strongly associated. In addition, relationship between amount of sugars consumed and the oral hygiene standard, socio-economic status and fluoride 110,111 110 exposure all influence the sugars-caries relationship.

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