MRCS Applied Basic Science and Clinical Topics

Urinary tract obstruction 387

persistent problem in about 5% men. Risk Clinical features

factors for post-prostatectomy incontinence Early low-grade disease is often
include: asymptomatic. About 60% of patients

• Preoperative incontinence present with symptoms of bladder outflow

• Neurological disease obstruction. Approximately 10% of cancers

• Previous pelvic or prostatic surgery are identified as an incidental findings at

• Large benign prostate TURP. The remainder present with bone pain,

About 75% of cases are due to sphincter cord compression or leuco-erythroblastic

damage and 15% due to detrusor anaemia as a result of metastatic disease.

abnormality. Conservative management Renal failure can occur due to bilateral
improves symptoms in 50% patients. ureteric obstruction. With locally advanced
tumours, the diagnosis can be confirmed by
.ir/Prostate carcinoma rectal examination. Features include a hard
nodule or loss of the central sulcus.
Prostate cancer is the most common cancer
in men accounting for nearly a quarter of all Investigation
new male cancers. There are about 35,000
Transrectal ultrasound is the most important
snew cases per year in the UK. Although diagnostic investigation. It can confirm
the diagnosis and an ultrasound-guided
there has been a rise in prostate cancer transrectal biopsy can be performed. Pelvic
CT or MRI is useful in the staging of the
sincidence over the last 20 years, this has disease. PSA is a kallikrein-like protein
nnot been reflected in mortality rates. It is produced by prostatic epithelial cells. A
serum level of 4 ng/mL is the upper limit
more common in northern Europe and of normal. A level greater than 10 ng/mL is
highly suggestive of prostatic carcinoma.
iaNorth America and rare in far east Asia. It isHowever, it can be also be raised in BPH.
Serum PSA is a useful marker for monitoring
uncommon before the age of 50 years. It is response to treatment. Bone scanning will
detect the presence of metastases. A bone
rsfound at post-mortem in 50% of men older scan is unlikely to be abnormal if the patient
is asymptomatic and the PSA level is less than
than 80 years. About 5–10% of operations for 10 ng/mL.
benign disease reveal unsuspected prostate
Management
ecancer. Much of the increased incidence can
.pbe attributed to the incidental discovery of More men die with than from prostate
cancer. Treatment depends on the stage of
prostate cancers following TURP and, more the disease, the patient’s age and his general
recently, the use of prostate specific antigen fitness. For local disease the options are
observation, radical radiotherapy or radical
ip(PSA) testing.
://vPathology

Prostate cancer is an adenocarcinoma usually
arising in the posterior part of the gland.
About 70%, 20% and 10% arise in peripheral,

ttptransition and central zone, respectively.

Spread occurs through the capsule into
perineural spaces, bladder neck, pelvic wall

hand rectum. Invasion into the seminal vesicles
is associated with distant spread. Lymphatic prostatectomy. For locally advanced disease

spread is common. Haematogenous spread the options are radical radiotherapy or

occurs to axial skeleton. hormonal therapy. Hormonal therapy is the

Tumours are graded by the Gleason mainstay of treatment for metastatic disease.

classification. It is based on the glandular and Radical prostatectomy

cellular pattern of the tumour. It combines Radical prostatectomy involves removal of
the two most common architectural patterns the entire prostate gland. The seminal vesicles
of cancer within the sampled specimen. Each are removed with the prostate gland. Care is
of the two most common patterns is assigned taken to preserve the peri-prostatic plexus
a grade from one to five. A Gleason sum score of nerves. The urethra is anastomosed to the
is reported as the two scores added together. base of the bladder. Radical prostatectomy

388 Chapter 23 Urology 

is associated with improvement in mean The gel should be massaged into the posterior

survival compared to simple observation urethra and a catheter not passed for at least

and a 50% reduction in risk of metastatic 5 minutes. A 12 to 16 Fr gauge Foley catheter

disease. However, erectile dysfunction occurs (usually with 10 mL balloon) is then inserted.

in 50% patients and about 3% develop stress The catheter should pass easily into bladder.

incontinence. The balloon should not be inflated until urine

Hormonal therapy is seen coming from the catheter. A drainage
bag should be attached and the volume of
About 80% of prostate cancers are androgen
urine drained recorded. Female catheters
dependent for their growth. Hormonal
should only be used in women. If the catheter
therapy involves androgen depletion and
it produces good palliation until tumours fails to drain a significant volume of urine,
‘escape’ from hormonal control. Androgen reconsider the diagnosis. An attempt at a ‘trial
without catheter’ can be made at 48 hours.
.ir/depletion can be achieved by: If difficulty is encountered in passing the
catheter:
• Bilateral subcapsular orchidectomy
• LHRH agonists – goseraline • Do not use force
• Anti-androgens – cyproterone acetate, • Do not inflate the catheter balloon until

sflutamide urine has been seen in the catheter
s• Oestrogens – stilbeostrol • Do not use a catheter introducer unless

• Complete androgen blockade adequately trained in its use

ianUrinary retention If unable to pass a urethral catheter the use
of a suprapubic puncture is desirable. If an
Retention of urine can be acute or chronic. appropriate technique of catheterisation
is used then complications are rare. False
rsChronic retention can be associated with passages and urethral strictures can occur if
there is significant trauma to the prostate or
either low or high intravesical pressure. urethra. Minor degrees of haematuria can
occur but usually clears spontaneously. Post
eAcute retention obstruction diuresis has been described but is
usually self-limiting. It occasionally requires
Acute retention usually presents with an intravenous crystalloid volume replacement.
There is no evidence to support gradual
.pinability to pass urine for several hours. decompression of the bladder.

It is usually associated with lower abdominalChronic retention

ippain. The bladder is visible and palpable Chronic retention is usually relatively
painless. High intravesical pressure can cause
and tender on palpation. Causes of acute hydronephrosis and renal impairment. It can
present as late-onset enuresis and may also
://vretention include: present with hypertension. Low pressure

• Bladder outflow obstruction
• Faecal impaction
• Urethral stricture

ttp• Acute or chronic prostatitis

• Blood clot in the bladder
• Retroverted gravid uterus

h• Post operation
• Spinal anaesthesia chronic retention presents with symptoms

• Spinal cord injury of bladder outflow obstruction. Patients with

• Urethral rupture chronic retention and renal impairment need

• Anal pain urgent urological assessment.

• Drug induced – anticholinergics,

antidepressants Pain and swelling in the

Management scrotum
Testicular tumours
The immediate management of acute retention
is urethral catheterisation. A catheter is

passed using a full aseptic technique. Urethral Testicular tumours are one of the commonest
analgesia can be achieved with lignocaine gel. malignancies seen in young men. There are

Pain and swelling in the scrotum 389

about 1500 new cases per year in the UK. The survival is more than 95%. Even in those with
incidence has doubled in the past 25 years. metastatic disease at presentation, cure rates
The two main type of tumour are teratomas of 80% have been reported.
and seminomas. They have a roughly equal
incidence and have a peak age of presentation Clinical features
of 25 and 35 years, respectively. The highest
incidence is seen in caucasians and is five Testicular tumours usually present with a
times higher than other ethnic groups. Risk testicular swelling or lump. The amount of pain
factors for the development of testicular is variable, but it is often minimal. Patients
tumours include: occasionally present with gynaecomastia.
Seminomas metastasise to para-aortic nodes.
• Cryptorchidism Teratomas metastasise to the liver, lung, bone
• Testicular maldescent and brain. Patients may present with symptoms
• Klinefelter’s syndrome of metastatic disease, usually abdominal or
• Family history back pain or respiratory symptoms.

The classification of testicular tumours is as Investigation
follows:
The diagnosis can often be confirmed
• Seminomas by testicular ultrasound. A pathological
• Teratoma differentiated diagnosis is made by performing an inguinal
• Malignant teratoma intermediate orchidectomy. There is no place for scrotal
• Malignant teratoma undifferentiated exploration and a testicular biopsy. The
• Malignant teratoma trophoblastic disease can be staged by thoraco-abdominal
• Yolk sac tumours CT scanning (Table 23.7). Tumour markers
are useful in staging and assessing response
Treatment for testicular cancer is very to treatment, a-fetoprotein (aFP) is produced
effective. Nearly all men are cured by surgery, by yolk sac elements and is not produced
chemotherapy and radiotherapy. In those by seminomas. Beta-human chorionic
with disease localised to testis, the 5-year

Royal Marsden staging of testicular tumours

Stage Definition
I
IM Disease confined to testis A – Less than 2 cm
II Rising post-orchidectomy tumour marker B – 2–5 cm
Abdominal lymphadenopathy C – More than 5 cm
III O – No abdominal disease
Supra-diaphragmatic disease A, B, C – Abdominal nodal disease
IV
L1 Extra-lymphatic metastases
L2 Less than three lung metastases
L3 More than three lung metastases
More than three lung metastases one or
H+ more greater than 2 cm
Liver involvement

Table 23.7  Royal Marsden staging of testicular tumours

390 Chapter 23 Urology

gonadotrophin (bHCG) is produced by Differential diagnosis of a scrotal swelling
trophoblastic elements and elevated levels
are seen in both teratomas and seminomas. Swelling not Swelling confined to

Management confined to scrotum scrotum

In most cases, initial surgical treatment Hernia Epididymo-orchitis
is by radical inguinal orchidectomy. The
spermatic cord is divided at the deep inguinal Infantile hydrocele Testicular tumour
ring before the testis is mobilised. Testis-
preserving surgery may be possible or may be Epididymal cysts
necessary in those with synchronous bilateral Vaginal hydrocele
tumours or a tumour in a solitary testes. Torsion testis

Seminomas are radiosensitive. Stage Table 23.8  Differential diagnosis of a scrotal swelling
I and II disease is managed by inguinal
orchidectomy plus radiotherapy to the • Can the testis and epididymis be identified
ipsilateral abdominal and pelvic nodes. separately?
Stage II disease and above should be
treated with chemotherapy. Teratomas • Does the swelling transilluminate?
are not radiosensitive. Stage I disease • Is the swelling tender?
treated by orchidectomy and surveillance.
Chemotherapy should be given to those with Testicular torsion
Stage II disease, those who relapse or have
metastatic disease at presentation. Testicular torsion is a common surgical
emergency in adolescent boys. The peak
Contralateral intra-tubular germ-cell incidence is in the second decade of life. A
neoplasia occurs in 5% of men presenting high insertion of the tunica vaginalis (‘Bell
with testicular cancers. As a result, it has been clapper testis’) predisposes to the condition.
recommended that patients with testicular The abnormality is usually bilateral and the
cancer should undergo contralateral contralateral testis usually has a horizontal
testicular biopsies. Contralateral intra- lie.
tubular germ-cell neoplasia has a high-risk of
progression to invasive cancer and irradiation Clinical features
of the testis should be considered. Patients Testicular torsion usually presents with
should be offered storage of semen. High-risk acute scrotal pain. However, it may present
patients include those with: with acute abdominal pain and no testicular
symptoms. Therefore, it is essential to
• Testicular maldescent examine the scrotum in all boys who
• Testicular atrophy present with acute abdominal pain. Urinary
• Age less than 30 years symptoms are uncommon. About 50% of
boys have had previous episode of pain.
Scrotal swellings Examination shows a tender high-riding
testis often with a small hydrocele.
Scrotal swellings can arise from above or from
within the scrotum. The exact nature of a Management
scrotal swelling can usually be determined by Investigation is usually not required.
obtaining an accurate history and performing Testicular torsion is a clinical diagnosis
a thorough clinical examination. Extensive requiring urgent surgical exploration. The
investigation is usually not required. The diagnosis is usually obvious. If the testis is
differential diagnosis of a scrotal swelling is infarcted then an orchidectomy should be
shown in Table 23.8. To determine the nature performed. If the viability of the testis is in
of a scrotal swelling four things need to be
assessed:

• Can you get above the swelling?

Pain and swelling in the scrotum 391

doubt, then the testis should be wrapped epigastric veins. A varicocele consists of
in a warm swab and observed. If the testis dilatation of the veins of the pampiniform
is viable, then both the ipsilateral and plexus.
contralateral side should be fixed within the
scrotum. Clinical features
Most varicoceles are detected in adolescence
Approximately 60% of testes are or early adult life. About 95% occur on the left
salvageable. However, if patients are re- side and are idiopathic. They are occasionally
examined at 6 months after surgery, 10% of associated with left renal tumours. Most are
testes are found to be atrophic. The outcome asymptomatic. If they do cause symptoms,
is best in those operated on less than 6 hours it is usually a vague or annoying discomfort.
since the onset of symptoms. Beyond 12 Examination shows the typical ‘bag of worms’
hours, salvage of the testis is less assured. which reduces in size in the supine position.
Occasionally, long-term sub-fertility is a Varicoceles are occasionally associated with
problem possibly due to an auto-immune infertility but there is no evidence that surgery
response affecting both testes. increased semen quality or conception rates.

Epididymitis Management
Varicoceles only need treatment if
Epididymitis is uncommon in adolescents symptomatic. The veins can be ligated via
and one should be wary about making the either a scrotal or inguinal approach. Recently
diagnosis at this age. Patients usually have a laparoscopic ligation has been reported.
more prolonged history, the pain may not be Recurrence can occur due to the collateral
severe and urinary symptoms may be present. supply via the cremasteric vein.
Examination shows tenderness which is
greatest over the epididymis. Treatment is Priapism
with antibiotics.
Priapism is a persistent erection of the penis.
Idiopathic scrotal oedema It is uncommon but early diagnosis and
treatment is essential. Delayed presentation
Idiopathic scrotal oedema usually occurs in or treatment results in corporal anoxia and
boys less than 10 years old. It presents with loss of erectile function.
scrotal redness and oedema. Pain is slight
and the testis feels normal. Management is Pathophysiology
conservative. Priapism can be either high or low flow. Low-
flow priapism is more common and is due
Torsion of a testicular appendix to venous stasis and ischaemia. Aetiological
factors include:
Torsion of a testicular appendix presents with
sudden testicular pain but often not severe. A • Intracavernosal injection
hydrocele with a tender appendage (hydatid • Pelvic malignancy
of Morgagni) is often apparent. If discovered • Blood disorders – sickle-cell disease,
during scrotal exploration, the appendage
should be excised. leukaemia
• Trauma – spinal cord injury
Varicocele • Prolonged sexual activity
• Urogenital tract inflammation
In the scrotum, the veins from the testis • Drugs
form the pampiniform plexus. This reduces
to one or two well-defined veins in the High-flow priapism is uncommon and is due
inguinal canal. One testicular vein is formed to the development of an arteriocavernosal
at the deep inguinal ring. The left testicular fistula. This can follow blunt or penetrating
vein drains into the left renal vein. The tight penile or perineal trauma. Anatomically, it
testicular vein drains into the inferior vena involves the corpora cavernosa only.
cava. Some venous drainage also occurs
via the cremasteric vein into the inferior

392 Chapter 23 Urology

Clinical features Postoperative semen samples are required at
8 and 12 weeks after surgery. Two negative
An adequate history and clinical features will specimens are necessary before other
allow differentiation of low-flow and high-flow forms of contraception can be abandoned.
priapism. Low-flow priapism presents with Failure can occur and pregnancy has been
painful persistent erection. The penile shaft is reported following 1 in 2000 vasectomies.
firm and glans penis is usually soft. High-flow Complications of vasectomy include:
priapism is often painless. There is invariably a
clear history of trauma. • Bruising or haematoma
• Wound infection
Management • Epididymo-orchitis
• Sperm granuloma
Aspiration of the corpora will distinguish the • Chronic testicular pain
two types. In high-flow priapism, the blood
is arterial. In low-flow priapism, the blood Reversal of vasectomy
is dark and viscous and is similar to venous
blood. Intracorporeal blood gas analysis can About 5% of men subsequently seek vasectomy
be useful to distinguish the two types. Early reversal. A vasectomy can be reversed by either
treatment is essential, preferably within a vasovasostomy or vasoepididymostomy.
12 hours of the onset of symptoms. Low- In experienced hands, vasovasostomy can
flow priapism requires urgent aspiration result in a tube patency rates of greater than
and instillation of a vasoconstrictor. 90% but pregnancy occurs in no more than
Aspiration alone is successful in only 30% 50%. Outcome depends on several factors.
cases. Phenylephrine can be used as the The time since the vasectomy is important.
vasoconstrictor. This should be followed by a Vasovasostomy is more likely to be successful
drainage procedure into: if it is performed within 3 years of vasectomy.
Greater success has been reported with
• The glans penis (Modified Winter/Ebbehoj microsurgical techniques.
shunt)
Aspects of pelvic surgery
• The corpora spongiosum (Quackel Gynaecological causes of
procedure) acute abdominal pain

• The long saphenous vein (Grayhack Ectopic pregnancy
procedure)
An ectopic pregnancy is defined as a
Detumescence can be achieved in 70% of gestation that occurs outside the uterine
patients and maintenance of erectile function cavity. It is seen in 1% of all pregnancies with
is present in about 40%. High-flow priapism 11,000 cases per year in UK. The incidence is
requires closure of the arteriocavernosal increasing. The mortality is less than 1%. Risk
fistula and can often be performed by an factors include:
interventional radiologist.
• Previous pelvic inflammation
Vasectomy • Infertility
• Tubal surgery
Vasectomy is one of the safest and • Intrauterine contraceptive devise
most effective means of contraception. • Previous ectopic pregnancy
Approximately 100,000 vasectomies
are performed in the UK each year. The commonest site for an ectopic pregnancy
Approximately 1 in 6 men over the age of is in the tubal ampulla. It usually presents
35 years have had a vasectomy. Most are with 6 to 8 weeks of amenorrhoea. The
performed under local anaesthetics. The vas patient has lower abdominal pain and slight
deferens is identified ligated and divided. vaginal bleeding. Cardiovascular collapse
Most surgeons excise a segment of the and shoulder tip pain suggest a large
vas. Fascial interposition is more effective intraperitoneal bleed. Examination will often
than ligation alone. Recovery is rapid and
complications are rare.

Aspects of pelvic surgery 393

shown abdominal and adnexal tenderness. Ovarian cysts
The patient invariably has a positive urinary
pregnancy test. Ultrasound will show an Ruptured ovarian cyst
empty uterus and may identify the ectopic
pregnancy. A intrauterine pregnancy on Ovarian cysts are either functional or
ultrasound almost invariably excludes an proliferative. They cause abdominal pain if
ectopic pregnancy. If the patient is shocked they rupture, tort or infarct. Patients present
immediate laparotomy is essential. If there is with sudden onset of severe lower abdominal
no evidence of cardiovascular compromise, pain. The differential diagnosis includes
laparoscopy is the investigation of choice. The PID or a ruptured ectopic pregnancy. Cysts
fetus can then be removed by laparoscopic may be palpable on bimanual examination.
salpingotomy or salpingectomy. The diagnosis can be confirmed by
transabdominal or transvaginal ultrasound
Pelvic inflammatory disease or laparoscopy. Treatment usually involves
ovarian cystectomy.
Pelvic inflammatory disease (PID) is usually
synonymous with acute salpingitis. It is an Functional cysts
ascending sexually transmitted disease due
to chlamydia (60%), Neisseria gonorrhoea Functional cysts are the commonest type
(30%) and anaerobes. Untreated it can of ovarian cyst (Figure 23.7). They present
progress to a pyosalpinx or a tubo-ovarian as follicular, corpus luteal or theca luteal
abscess. It presents with lower abdominal cysts. They are benign and usually resolve
pain and a vaginal discharge. Pelvic spontaneously. They may be an incidental
examination is uncomfortable. High vaginal finding on a clinical or radiological
and endocervical swabs are essential. If investigation. Symptoms result from pressure
doubt over the diagnosis exists, consideration or rupture. The differential diagnosis includes
should be given to a diagnostic laparoscopy. a tubo-ovarian abscess or ectopic pregnancy.
PID often improves with antibiotics Most regress in 6–10 weeks and surgery can
(tetracycline and metronidazole) and surgery often be avoided.
is rarely required. PID increases the risk
of infertility and there is a 40% chance of Mature cystic teratoma
tubal occlusion after three episodes. It also
increases the risk of ectopic pregnancy by Mature cystic teratoma accounts for 10%
a factor of six-fold. About 20% of patients of ovarian neoplasms. They develop from
develop chronic pelvic pain. totipotential cells and have well differentiated
mesodermal and ectodermal elements. About
Endometriosis
A functional ovarian cyst
Endometriosis is the presence of functional
endometrial tissue outside the uterine cavity. Figure 23.7  A functional ovarian cyst
It results from either retrograde menstruation
or celomic metaplasia. It usually affects
the ovaries, fallopian tubes and the serosal
surface of the bowel. It is most commonly
seen in women between 30 and 50 years. It
presents with premenstrual lower abdominal
pain. It may also cause back pain, intestinal
obstruction and urological symptoms. Large
‘chocolate’ cysts may rupture causing acute
abdominal pain. It is a cause of infertility. The
diagnosis can be confirmed at laparoscopy.
Hormonal therapy may improve symptoms
and danazol is the first line treatment of choice.

394 Chapter 23 Urology

10% are bilateral. Cystic teratomas have a celomic epithelium. About 75% are serous
smooth capsule and may grow to 30 cm in and 20% are mucinous. Risk factors include:
diameter. They may contain mature elements
including bone, hair and teeth (Figure • Advancing age
23.8). Functioning thyroid tissue may cause • Nulliparity
thyrotoxicosis (struma ovarii). Malignant • Family history (BRCA1 and BRCA2)
transformation is rare. Treatment is by • Possibly fertility drugs
ovarian cystectomy.
Clinical features
Ovarian germ cell tumours The clinical features of ovarian carcinoma
are often non-specific. Early features include
In adolescents and young women, the urinary frequency and abdominal discomfort.
majority of ovarian neoplasms are germ Later features include distension, early satiety
cell tumours. Approximately 25% of and anorexia. An abdominal mass and ascites
these tumours are malignant. If they are may be present.
functioning they can present with precocious
puberty or early menarche. Tumour markers Investigation
such as CEA, a-fetoprotein or b-hCG may be The diagnosis of ovarian carcinoma can often
increased. CA125 is usually not raised in germ be confirmed by abdominal and pelvic CT.
cell tumours. Types of malignant tumour The serum CA125 may be raised. In patients
include dysgerminoma and embryonal presenting with ascites with no obvious
carcinomas. Treatment is usually by surgical cause, cytology may show characteristic
debulking and chemotherapy. malignant cells. Ovarian carcinoma spreads
by three routes – trans-celomic, lymphatic
Ovarian carcinoma and haematogenous. The staging of the
disease is surgical and 20–40% of patients
Approximately 6500 women are diagnosed are upstaged after surgical intervention. The
with ovarian cancer in the UK each year International Federation of Gynaecology and
making it the second most common Obstetrics staging of ovarian carcinoma is as
gynaecological cancer and the fifth most follows:
common cancer in women. Ovarian
carcinoma arises from either the ovarian or • Stage 1 – Tumour limited to ovaries

A plain abdominal x-ray showing an ovarian Figure 23.8  A plain abdominal
teratoma containing teeth x-ray showing an ovarian teratoma
containing teeth

Aspects of pelvic surgery 395

• Stage 2 – Involvement of one or both Urge incontinence
ovaries with pelvic extension
Urge incontinence is part of the overactive
• Stage 3 – Involvement of one or both bladder symptom syndrome. Patients
ovaries with extension beyond the pelvis experience frequency, urgency and
incontinence due to detrusor muscle
• Stage 4 – Involvement of one or both overactivity.
ovaries with distant metastases
Overflow incontinence
Management
Overflow incontinence occurs in both sexes.
Thorough surgical staging should be Symptoms are often relatively few. Patients
undertaken of all patients. For Stage 1 tend to dribble urine. Men often have a full
disease a unilateral salpingo-oophorectomy and palpable bladder. Women often have
should be performed if future fertility abnormal anatomy or a vesicovaginal fistula.
required. Otherwise Stage 1 disease
should be managed with a total abdominal Investigation
hysterectomy and bilateral salpingo- In the investigation of incontinence, the
oophorectomy +/– omentectomy and following investigations should be considered:
peritoneal biopsies. For Stage 2 and 3 disease
surgical debulking should be performed. • Mid stream urine specimen
This should be followed by chemotherapy. • Renal function
Platinum-based chemotherapy regimens • PSA in men
are the most effective. The role of a second- • Renal ultrasound
look laparotomy and further debulking is • Flexible cystoscopy
controversial.
Urodynamic assessment evaluates the
The role of screening for ovarian function of the bladder and results should
carcinoma is currently under investigation. be interpreted with the clinical presentation.
There is currently no evidence for CA-125 Assessment can involve:
or ultrasound screening of the general
population. • Frequency–volume chart
• Pad test
Urinary incontinence • Flow rates
• Residual volume by ultrasound
Incontinence can be defined as the • Conventional cystometry
involuntary loss of urine, causing social or • Videocysturethrography – filling and voiding
hygiene problems that can be objectively
demonstrated. It is a common and under Management
reported problem that affects at least 4 The manaagement of incontinence should
million people in UK. It affects women more start with general support. This involves
than men, particularly the elderly. It can be specialist nurses using appliances, pads and
classified as: catheters. Specific treatment will depend on
the underlying cause.
• Stress incontinence
• Urge incontinence Urge incontinence
• Overflow incontinence The overactive bladder syndrome can be
managed by behaviour change, drugs –
Stress incontinence anti-muscarinic agents, desmopressin and
surgery. The surgical options include:
Stress incontinence affects about 30% of
women over 30 years. It usually develops after • Injection of botulinum toxin
childbirth and symptoms worsen with age. • Neuromodulation
Incontinence occurs with effort or exertion • Clam cystoplasty
and is worse when upright. Urine loss is seen • Detrusor myectomy
immediately after a rise in intra-abdominal • Urinary diversion
pressure.

396 Chapter 23 Urology • Anterior colporrhaphy
• Marshall–Marchett–Kranz procedure
Stress incontinence • Needle suspension of bladder neck
Stress incontinence can be managed by • Pubovaginal slings
physiotherapy, biofeedback, electrical • Periurethral bulking agents
stimulation and drugs – duloxetine. The • Implantation of artificial sphincters
surgical options include:
• Burch colposuspension

Index

Note: Page numbers in bold or italic refer to tables or figures respectively.

0–9 Acute lung injury (ALI), 50 Anaesthesia, principles of, 15
Acute phase response, 87 first order kinetics, 15–16
2,3-Biphosphoglycerate (2,3-BPG), Acute physiology score, 54 general anaesthesia, 16–18
115 Acute renal failure, 53–54 multicompartment models, 16
Acute respiratory distress syndrome perioperative monitoring, 18–20
5-Aminosalicylic acid (5-ASA), 199 pharmacokinetics, 15
5-Hydroxytryptamine (5HT), 35, (ARDS), 49–51, 51 Anaesthetic agents
Acute seroconversion illness (ASI), adverse effects, 18
338–339, see also Serotonin ideal inhalational, 17
and CTZ, 38 85 local, 37
5HT antagonists, 16 Adenomas, 191 regional, 37
Adjuvant chemotherapy Anal carcinoma, 195–196
A breast cancer, 216–217 Anal fissures, 203, 297
colorectal cancer, 194 clinical features, 203
Abdominal aortic aneurysm, 243, 250 Adrenal incidentalomas, 223, 233, pilonidal sinus, 204, 204, 205
endovascular aneurysm repair, treatment, 203–204
250 234 Analgesia, simple, 35–36
Abdominal compartment syndrome Adrenergic receptors, 34 Anaphylaxis, 30
Adrenocorticotrophic hormones, Anastomoses, principles of, 56–57
95–96 Anatomical snuff-box’, 349
Abdominal masses, in children 224 Anderson–Hynes pyeloplasty, 383
nephroblastoma, 295 Advanced Trauma Life Support Aneurysms
neuroblastoma, 295–296 abdominal aortic aneurysm,
Abdominal stomas, 154 (ATLS), 89
Abdominal trauma Aerodigestive tract, foreign bodies 243
assessment of, 133 bronchus and lung, 273 Buerger’s disease, 243
damage control surgery, oesophagus, 273 Raynaud’s disease, 243
133–134 pharynx, 273 Angiodysplasia, 141
gastrointestinal injury, 134 stomach, 273 Angular dermoid, external, 320
Abdominal wall α-Fetoprotein (aFP), 389 Ankle fractures, 349
anatomy of, 147 Age points, 54 Anorchia, 213
hernias, see Hernias AIDS, see Acquired Anorectal anomalies 290–291
incisions, 148–149, 148–149 Anorectal sepsis, 201, 201–202, 202
inguinal canal, 147–148 immunodeficiency syndrome Antibiotic prophylaxis, 78
Aberrations of normal development (AIDS) Anticholinergics, 16
Air leak, 127 Antidiuretic hormone (ADH), 377
and involution Airway and cervical spine control, Antihistamines, 16
(ANDI), 209 89–90 Antisepsis, 83
ABO blood groups system, 29, 30 Airway management, 88 Anti-thyroid drugs, 226
Abscess Albendazole, 181 Anus, 190, 190
anorectal, 201 Albumin, 40 Aortic dissection, 121–123, 122
amoebic liver, 180–181 Aldosterone, 377 APACHE I, 15
appendix, 137 Alginates, 16, 59 APACHE II, 15, 54
breast, 211 Allografts, 347–348 APACHE III, 15
intra-abdominal, 135–136 Alternative hypothesis, 70 Apocrine sweat glands, 307
lung, 130 Amelanotic melanomas, 319 Apoptosis, 73
psoas, 75–76 America Society of Anesthesiologists Appendiceal carcinoid tumours, 237
pyogenic liver, 180 (ASA) grading, 7 Appendicectomy, 137
superficial and deep, 74–75 Amoebic liver abscess, 180–181 Appendicitis, 136–137
Acetylcholine (ACh), 34, 337–338 Amputations, 254 Appendix, 189
Achalasia, 162–163 Amyloid, 73 Appendix abscess, 137
Acid–base balance, 51 Anaemia, preoperative, 31–32 Appendix mass, 137
Acquired immunodeficiency Anaerobes, 44, 76 Aromatase inhibitors, 217
syndrome (AIDS) Anaerobic streptococci, 76 Arterial disease
immunology, 85 Anaesthesia, 62 invasive vascular assessment, 245
management, 86 recovery from, 20 non-invasive testing of arterial
natural history, 85–86, 86 body temperature, control of,
transmission, 85 21 patency, 243–245
Actin, 340 care of patient, 20
Activated partial thromboplastin time maintenance of, 17
(APPT) tests, 26 monitoring of, 18–19
thermoregulation, 20

398 Index

Arterial opoxxayyteggneecnnyts, eanntousnrioa-itnniov(PanasO(iSv2ae)O,t2e)4s, 9ti4n9g Baroreceptors, 113 Blood products, 29
Arterial Barrett oesophagus, 160 Blood supply
Arterial Basal cell carcinoma, 319, 319 heart, conducting system of, 109
of Bell clapper testis, 390 left coronary artery, 109, 110
duplex ultrasound, 244–245 Bell’s palsy, 275 of duodenum, 158
hand-held Doppler, 243–244, Bence–Jones proteins, 371 of oesophagus, 156
245 Benzodiazepines, 16 of stomach, 157, 157
magnetic resonance angiography, Berry aneurysms, 331 right coronary artery, 109
245 β-blockers, 16 Blood transfusion, 29
pulse generated run off, 245 Beta-human chorionic complications, 29–31, 30
Arteries Blow-out fracture, 96–97
axillary artery, 239 gonadotrophin (β-HCG), 390 Blunt ophthalmic trauma, 96
blood supply of stomach, 157, Bilateral cryptorchidism, 213 Body temperature, control of, 21
157 Bile acids, 172, 174 Boerhaave’s syndrome, 162
brachial artery, 239 Bile duct Bone grafting, principles of, 347
common carotid artery, 239 common, 170, 170 allografts, 347–348
external carotid artery, 239– injury, 176 autografts, 347
240 stones, common, 174, 176, bone substitutes, 348
femoral artery, 239 Bone healing, stages of, 344
internal carotid artery, 240 176 Bone substitutes, 348
popliteal artery, 239 Biliary colic, 174–175 Bone tumours, primary, 368–369, 369
Arteriosclerosis, 240 Biological therapy, breast cancer, Bones, 335
aetiology, 241 compact bone, 335
complicated plaques, 241 217 microstructure of, 335–336
fatty streaks, 241 Bipolar diathermy, 60–61, 61, 61 of hand, 342–343
fibrous plaques, 241 Bismuth iodoform paraffin paste of wrist and hand, 343
pathology, 241 ossification, 336
risk factors, 241 (BIPP), 274 trabecular bone, 335
Artificial sphincters, 396 Bladder calculi, 381–382 Brachial plexus, 341
Artificial ventilation, 50 Bladder carcinoma, 384–385 Bradykinin, 35
Ascites, 187–188 Bladder outflow obstruction, causes Brainstem death, 332
Asepsis, 83 abnormal brainstem reflexes,
Aspiration pneumonitis, 44, 45 of, 385
Atelectasis, 44, 127 Blast wounds, 92–93 332
Atheroma, 240–241 Bleeding and coagulation disorders, clinical tests, 332
ATLS, see Advanced Trauma Life exclusions, 332
Support (ATLS) 26 persistent apnoea, confirmation,
ATLS, principles in burn assessment, prothrombin time, 26
310 Bleeding diatheses, 26–27 332
Atresias, 289 Bleeding disorders, classification of, preconditions, 332
Atrial septal defect, 285 Branchial remnants, 298
Atrophy, 73 26–27, 28 Breast anatomy, 207, 207
Atticoantral CSOM, 271 Bleeding peptic ulcer, 140 Breast cancer, 214
Audit loop, 4 Bleeding time, 26 axillary surgery, 214–216
Autoclaves, 83 Blood, function and components, biological therapy, 217
Autografts, 347 chemotherapy, 216–217
Autologous blood transfusion, 31 22–23 genetics, 100
intraoperative acute Blood gas analysis, 51 hormonal treatment, 105
normovolaemic haemodilution, variables from, 52 in male, 218
31 Blood groups invasive, 214
intraoperative cell salvage, 31 ABO blood groups system, 29 locally advanced, 217–218,
predeposit transfusion, 31 cross matching, 29
Autonomic nervous system (ANS), Rhesus antibodies, 29 217
33 Blood loss, acute, 53 prognostic factors, 216
functions of, 33 Blood-patch’, 38 recurrence of, 218
Autonomic receptors, 34 Blood pressure surgery, 214
Avascular necrosis, 346 and age, 282 Breast cysts, 210–211
Axillary nerve, 341 and anaesthesia, 19 Breast disease,
Axillary surgery, 214–216 and catecholamines, 113 assessment, 207–208
and compartment syndrome, 94 benign, 209, 209
B and fluid resuscitation, 89 Breast imaging, 208
and head injuries, 325, 327 mammography, 208
Bacillus Calmette–Guerin, 384 and hormones, 113 MRI, 208
Bacteraemia, definition of, 48 and myocardial ischaemia, 53 ultrasound, 208
Bacterial haemolysis, 29–30 and renal artery stenosis, 238 Breast infections
Bacteroides, 211 and spinal cord injury, 331 lactational sepsis, 211
Bankart lesion, 357 and tourniquets, 63 non-lactational sepsis, 211
cardiac function measurement, Breast pain, 209
cyclical mastalgia, 209–210
19, 112 non-cyclical mastalgia, 210
early warning system, 46
mean pressure, 47
regulation of, 113
secondary hypertension, 237
systolic, 47, 53
vascular resistance, 20

Index 399

Breast reconstruction, 218 Cardiac risk index, revised, 11 Chest x-ray, 122, 123, 124, 129, 129,
free flaps, 219 Cardiac stab wounds, 123–124 138, 138
nipples reconstruction, 219 Cardiogenic support, 53
pedicled myocutaneous flaps, Cardiopulmonary bypass, 116, 116 Child protection, 282
Cardiovascular complications Chlorhexidine, 83
219 obesity, 12 Cholangiocarcinoma, 182–183
tissue expander, 218 postoperative, 44 Cholangitis, acute, 175
Breathing, 90 Cardiovascular disease, 11 Cholecystitis, acute, 174–175
Breslow depth, 316 Eagle index, 11 Choledochal cysts, 296–297
Bronchial carcinoma, 213 hypertension, 11–12 Cholinergic receptors, 34
Bronchiectasis, 130–131 myocardial infarction, 11 Chondromas, 369
Bronchodilators, 16 revised cardiac risk index, 11 Chondrosarcoma, 370
Bronchopleural fistula, 127–128 Cardiovascular support, 53 Christmas disease, see Haemophilia B
Brown–Sequard syndrome, 329 Carotid artery disease, 252 Chronic health points, 54
Buerger’s disease, 243 carotid endarterectomy, 252–253 Cimetidine, 213
Bulbar urethra rupture, 378 carotid stenting, 253 Circumcision, 298
urethrogram, 378 Carotid endarterectomy, 252–253 Cirrhosis, 186, 187, 213
Bupivacaine, 37 Carotid stenting, 253 Civil Procedure Rules 1998, 6
Burch colposuspension, 396 Carpal tunnel, 359 Claw toes, 363
Burn unit, referral criteria, 311 anatomy of, 361 Cleft lip and palate, 283
Burns Carpal tunnel syndrome, 359–360 aetiology, 283–284
assessment, 310–311 clinical features, 360 clinical features, 284
full-thickness burns, 310 management, 360 embryology, 284
partial-thickness burns, 310 Cartilage, 336 management, 284
pathophysiology, 309–310 Case-control studies, 68 Clinical governance 2–4, 4
superficial burns, 310 Catecholamines, 113, 338 Clinical trials, 67–68
Catheter Clostridium difficile, 79
C over needle, 41 Clostridium welchii, 79
through needle, 41 Clotting cascade, 26, 27
Caecal volvulus, 144–145 Catheterisation, suprapubic, 65 Clubfoot, 304–305
Caecum, 189 Cauda equina, anatomy of, 368 Coagulase-negative staphylococci,
Calcific tendonitis, 359 Cell cycle, 104, 104
Calcification, 73 Cell proliferation, see also Cancer 81, 354
Cancer Co-analgesia, 107
colorectal, 191–192 genes Coarctation of aorta, 285
development of, 99 carcinogenesis, 99 Codman’s triangle, 370
epidemiology of, 100–101 neoplastic, 99 Coeliac disease, 168
gastric, see Gastric cancer non-neoplastic, 99 Cohort studies, 68
genes, 99–100 Cellulitis, 76 Colles fracture, 349
genetics, 100 Central cord lesion, 329 Colloids, 40
lung, 126–127 Central nervous system (CNS), 33 Colon, see Large intestine
neoplastic proliferation, 99 infections, 332–334 Colonic infection, see
NHS screening programmes, Cerebral palsy 300–301
Cerebrospinal fluid (CSF), 324 Pseudomembranous colitis
101–102 Ceruminous glands, 307 Colonic polyps, benign, 191
non-neoplastic proliferation, 99 Chalazion, 97 Colonic pseudo-obstruction, 145
oesophageal, 160–161 Chemical burns, 311 Colorectal cancer
staging of, 102–103 Chemoreceptor trigger zone (CTZ), 38 hereditary non-polyposis,
treatment of, 103–107 afferent and efferent connections
tumour markers, 100 192–194, 193
Candida, 41 to, 39 incidence, 191
Carbon dioxide equilibrium curve, Chemotherapeutic liver metastases, 194–195
Chemotherapy risk factors, 191–192
115–116 agents, 81 Colporrhaphy, anterior, 396
Carbon monoxide, 115 aim of, 104 Communication skills, 1–2
Carcinogenesis, 99 mechanism of action, 104, 104 Compact bone, 335
Carcinoid tumours, 237 toxicity, 104–105 structure of, 335
appendiceal carcinoid tumours, use of, 105 Compartment syndromes, 94–95
Chest drains pressure monitoring, 95
237 complications of, 124–125, 125 Compound fractures, 346
clinical features, 237 components, 124 Confusion, postoperative, 45–46
diagnosis of, 237 indications, 124 Congenital diaphragmatic hernia,
Carcinoma in situ, 384 occurrence, 124
Cardiac cycle, 111–112, 112 principles of, 124, 125 287
Cardiac function, 9–10 removal, 125 Congenital heart disease
chest x-rays, 10 Chest injuries atrial septal defect, 285
ECG, 10–11 occult, in children, 282 classification of, 284–285
echocardiography, 11 primary, 123 coarctation of the aorta, 286
nuclear medicine, 11 secondary, 123 tetralogy of Fallot, 285–286
Cardiac output, 49 transposition of the great vessels,
and left-sided pressures, 20
286
ventricular septal defect, 285

400 Index

Conn’s syndrome, 233, 235 Digoxin, 213 Endometriosis, 393
pathophysiology, 235 Dimercaptosuccinic acid (DMSA) Endoscopic surgery, 62–63
Consciousness level, 47 Endotracheal intubation, 16–17
Constipation, 107 scanning, 379 Entamoeba histolytica, 180
Contractures, 56 Dinner fork deformity, of wrist, 349 Enteral nutrition, 42
Cord lesion Disc rupture, acute, 366 Enterobacter, 44
anterior, 329 neurological signs of, 366 Enterococcus species, 82
posterior, 329 Disinfection, 84 Enterocutaneous fistulas, 153–154
Core biopsy, 209 Disseminated intravascular Epicondylitis, lateral, 359
Corneal abrasion, 96 Epicondylitis, medial, 359
Corneal foreign body, 96 coagulation (DIC), 29 Epidermal growth factor (EGF), 55
Coronary artery bypass surgery Distal interphalangeal (DIP), 314 Epididymitis, 391
Diverticular disease Epidural anaesthesia, complications
(CABG), 117–118, 118 clinical features, 197
Coronary artery disease, 116–118 complications of, 196 of, 37
Coroner, 5 diagnosis, 197 Epidural analgesia, postoperative,
referral to, 5 incidence, 196
role of, 5 pathology, 196–197 38
Coroner’s Act 1988, 5 treatment, 197 hypotension, 38
Correctable congenital abnormalities, Diverticulectomy, 278–279 post spinal headache, 38
Doctors, duties of, 1 Epigastric hernia, 152
282 Documentation and record keeping, Epiglottitis, acute, 271
Corticosteroids, 199 Epistaxis, 274
Cranial nerves, 34 2 Escharotomies, 311
Crohn’s disease Dohlman’s procedure, 279 Escherichia coli, 74, 76, 379
clinical features, 198 Dopamine, and CTZ, 38 Ethics and law
diagnosis, 199 Drains, types of, 63–64 coroner’s role, 5
epidemiology, 197 Duct ectasia nipple retraction, 209 death referral, 5
inflammatory bowel disease, 197 Ductal carcinoma in situ (DCIS), Ethylene oxide, 84
pathophysiology, 197–198, Euroscore, 117
214 risk changes, 118
198 Duke’s classification, 194 Evidence-based medicine 67–71,
surgery for, 200–201 Duke’s clinical criteria, 121
treatment, 199 Duloxetine, 396 67, 69, 71
Cruciate injuries Duodenal atresia Excitatory postsynaptic potential
acute anterior, 362 and Down’s syndrome, 288
posterior, 362 management, 288–289 (EPSP), 337
Cryptorchidism, 299, 389 x-ray, abdominal, 289 Exomphalos, management, 286–287
Crystalloids, 40 Duodenum, 157–158 Extensor tendon injuries, 315
composition, 40 Dupuytren’s contracture, 360–362, Extracapsular fractures, 349
properties, 41 Extracorporeal shock wave lithotripsy
Cushing’s syndrome, 233–235, 235 361
Cyclical mastalgia, 209–210 Dysphagia, 162 (ESWL), 381
Cyproterone acetate, 213 Dysplasia, 99 Exudation, 308
Cystic duct, anatomical variations Dyspnoea, 107
F
of, 170 E
Cystic hygroma, 298 Facet joint dysfunction, 367
Cystic teratoma, mature, 393–394 Eagle index, 11 Facial nerve palsy
Cysts, hydatid liver, 181 Ecchinococcus granulosa, 181 anatomy, 274, 275
Cytokines, 87 Eccrine sweat glands, 307 causes of, 275
Ectopic pregnancy, 392–393 clinical features, 274
D Elbow, 341 Bell’s palsy, 275
Elective surgery grades, 7 function, 275
Day care surgery, 61–62 Electrical burns, 311 management, 276
de Quervain’s disease, 360 Embolism, 242 Ramsay Hunt syndrome, 275–
clinical features, 360 Embryology, of gastrointestinal tract,
management, 360 276
de Quervain’s thyroiditis, 231 155 Factor VIII deficiency, see
Debriding agents, 59 Emergency burr holes, position of,
Deep inferior epigastric perforator Haemophilia A
327 Factor IX deficiency, see Haemophilia
(DIEP) flap, 219 Emergency embolectomy, 248
Deep tension’ sutures, 43 Empyema, 130 B
Dermatofibromas, 320 Endocrine response, 87 Familial adenomatous polyposis
Dextrans, 40 Endocrine surgery, 221
Diabetes mellitus, 12 endocrine physiology, 221 (FAP), 192
Diabetic foot, 248–249 parathyroid gland, 222–223 Fat embolism, 95
Diamorphine, 36 pituitary gland, 223–224 Femoral hernia, 151, 151–152
Diathermy, 60 thyroid gland, 221–222 Fentanyl, 37
bipolar, 60–61, 61, 61 Endocrine therapy, breast cancer, Fibroadenomas, 209, 210
monopolar, 60, 60 giant, 210
217 simple, 210
aromatase inhibitors, 217 Fibroplasia, 55
tamoxifen, 217 Fibrous thyroiditis, acute, 231
Field change’ disease, 384

Index 401

Fine needle aspiration (FNA), Gastrointestinal tract Halothane, 17
208–209 anatomical layers of, 155, Hand tendon injuries, 313
anatomy, 313–314
Fine needle aspiration cytology, 228 155–156 injury zones, 314
First pain, 34 embryology of, 155 Hartmann solution, 40
Flail chest, 124 injuries to, 134 Head and neck, arteries of
Flexor tendon injuries, 314–315 Gastro-oesophageal reflux disease common carotid artery, 239
management, 315 external carotid artery, 239–240
postoperative management, 315 (GORD), 159–160, 160 internal carotid artery, 240
Flexor zones, of hand, 314, 314 Gastroschisis, management, 287 Head injuries, complications
Fluid replacement, in burn treatment, Gate control theory, 35, 36 acute subdural haematoma,
Gelatins, 40
310 General anaesthesia, 16 327–328
Fluid replacement therapy, 40 premedication, 16 chronic subdural haematoma,
crystalloids, 40 induction of, 16–17
colloids, 40 Generalised hypopituitarism, 213 328–329
Foam dressings, 59 Giant-cell tumours, 369–370 Heart
Focused assessment for the Glasgow Coma Scale (GCS), 90 anatomy, 109–111, 110
Gleason classification, 387 blood flow through, 111–112,
sonographic assessment of trauma Glomus tumour, 321
(FAST), 133 Glucagonomas, 185–186 112
Fracture Glutaraldehyde, 84 blood pressure, regulation of,
complications of, 345 Glycosylated haemoglobin (HbA1c),
paediatric, see Paediatric fractures 113
Frank–Starling curve, 113 9 blood supply, 109, 110
Free flaps, 219 Goitre, 226 conduction system, 110
Frozen shoulder, 358–359 Goldman Cardiac Risk Index, 15 myocyte action potential, 111
Functional cysts, 393 Golfer’s elbow, 359, see also Medial nerve supply, 109–110
pericardium, 110–111
G epicondylitis sounds, 112
Gonadotrophins, 213, 224 stroke volume, determination
Galactorrhoea, 212 Goodsall’s Rule, 201, 202
causes of, 212 Gram-negative bacteria, 44, 354 of, 112–113, 113
Gallbladder, 170, 170 Granulomatous, 231 Heart rate
Gallstones Grayhack procedure, 392 and autonomic nervous system
acute cholangitis, 175 Growth hormone, 224
acute cholecystitis, 174–175 GTN ointment, 204 (ANS), 33, 33, 87
biliary colic, 174–175 Gunshot wounds, 92–93 during anaesthesia, 19
common bile duct stones, 176 Gynaecomastia, 212–214, 213, 213 early warning systems, 46, 47
incidence, 173–174 electrocardiogram (ECG), 19
Mirizzi’s syndrome, 175 H in neonates, 281
pathophysiology, 174, 174 Swan–Ganz catheter, 20
treatment of, 175–176 Haematuria, 382 Helicobacter pylori, 165, 166
γ-Aminobutyric acid (GABA), 339 glomerular causes, 383 Henderson–Hasselbach equation,
Ganglions, 362 investigation, 382–383
clinical features, 362 non-glomerular causes, 383 51
management, 362 surgical causes, 383 Hepatitis B virus, 84–85
Garden classification, 348 Haemochromatosis, 213 Hepatitis C virus (HCV), 85
Gas gangrene, 79, 79 Haemoglobin, 49, 53 Hepatocellular carcinoma (HCC),
Gastric acid carbon dioxide transport, 115
control of, 158–159 oxygen transport to, 114 181–182
secretion of, 158 Haemolysis, acute, 29–30 Hereditary non-polyposis colorectal
Gastric cancer Haemolytic transfusion reaction,
Birmingham staging, 164, 164 cancer (HNPCC), 192–194, 193
clinical features, 163–164 delayed, 31 Hernia, 390
incidence, 163 Haemophilia, 27–28 epigastric, 152
macroscopic appearance of, Haemophilia A, 27 femoral, 151, 151–152
Haemophilia B, 27 incisional, 152–153
163, 164 Haemophilus influenza, 44, 262, 354 inguinal, 149–151, 150, 151
management, 164–165 Haemorrhage obturator, 153
risk factors, 163 lower gastrointestinal, 141–142 paediatric, see Paediatric hernias
surgery, 166 upper gastrointestinal, 139–141 spigelian, 153
Gastric lymphoma, 165 Haemorrhoidectomy, 203 types of, 152, 152
Gastric physiology, 158 Haemorrhoids, 202–203 umbilical, 152
Gastric volvulus, 167–168, 167 Haemostasis, 25, 308 High output state, 53
Gastrin, 158–159 clotting cascade, 26 Hip disorders
Gastrinomas, 185 platelet aggregation, 26 clinical features, 301–302
Gastrointestinal anastomoses, 56–57 vasoconstriction, 26 development dysplasia, 301
Gastrointestinal stomas, 154 Haemothorax, 123 diagnostic calendar, 301
Gastrointestinal stromal tumours Haldane effect, 116 investigation, 302
Hallux rigidus, 363 irritable hip, 302
(GIST), 165 Hallux valgus, 363 management, 302
pathophysiology, 301
Perthe’s disease, 302
slipped upper femoral epiphysis,

302–303

402 Index

Hip fractures, 348 I Intracranial pressure (ICP), 324
Hip replacement surgery, 353 and volume, 325
acetabular component, 353 Iatrogenic injuries, 22 Intrahepatic biliary apparatus, 171–172
femoral component, 353 ICU, principles of Intraocular foreign body, 97
joint resurfacing, 353–354 high-risk surgical patients, 46 Intraoperative acute normovolaemic
polymethylmethacrylate cement, outreach services, 46–47
Idiopathic scoliosis haemodilution, 31
353 adolescent, 304 Intraoperative cell salvage, 31
surgery, 353 infantile, 304 Intraosseous infusion, 92, 93
Hirschsprung’s disease, 290 juvenile, 304 Intraperitoneal chemotherapy, 195
Histamine, 35, 158 myopathic scoliosis, 304 Intrathoracic bleeding, 127
Histology neuropathic scoliosis, 304 Intussusception, 294
of small intestine, 158 osteopathic scoliosis, 304 Iron deficiency anaemia, 24
of stomach, 157 Idiopathic scrotal oedema, 391 Iron metabolism, 23
tuberculosis, 80–81 Immunosuppressive agents, 199 dietary iron, 23
HIV infection, see Acquired Implant-based reconstruction, 218, ferritin, 23
haemosiderin, 23
immunodeficiency syndrome see also Tissue expander iron absorption, 23
(AIDS) Incisional hernia, 152–153 iron transport, 24
Hodgkin’s lymphoma, 263 Incisions, 57, 148–149, 148–149 transferrin, 23
Hormones, 113 Infantile hydrocele, 390 Irradiation, 213
Hot air ovens, 83–84 Infantile hypertrophic pyloric Irreducible hernias, 299
Human experiments, see Clinical Irritable hip, 302
trials stenosis, 293 Ischaemia and infarction, 242–243
Hydatid disease, 181 Infantile idiopathic scoliosis, 304 Isoflurane, 17–18
Hydrocolloids, 58–59 Infected joint replacements, 354 Isolated gonadotrophin deficiency,
Hydrogels, 59 Infective endocarditis, 120–121, 121
Hydroxyethyl starch, 40 Infective enteritis, 297 213
Hyperaemia, 308 Inflammation, 307 Isolated limb perfusion (ILP), 318
Hypernephroma, 213 acute, 308 complications of, 318–319
Hyperparathyroidism causes of, 307–308 Isopropyl alcohol, 83
causes of, 231 chronic, 308
clinical features, 231 in wound healing, 308–309 J
preoperative parathyroid Inflammatory bowel disease, see
localisation, 232 Jenkin’s rule’, 57
radiology, 232 Crohn’s disease; ulcerative colitis Juxtaglomerular apparatus, 375
scintigraphy, 232 Informed consent, 13–14
selective venous Ingrowing toenails, 321 K
catheterisation, 232 bilateral, 321
Hyperplasia, 99, 209 management, 321 Kaposi’s sarcoma, 321
Hypersensitivity reactions, types of, Inguinal canal, 147–148 Keloid scars, 56, 309, 309
73–74 Inguinal hernias, 298–299 Keratinocytes, 307
Hypertension, 11–12 direct, 149 Keratoacanthomas, 319, 320
Hypertonic solutions, 92 embryology, 299 Kidneys, 373, 374
Hypertrophic scars, 56, 309 indirect, 150, 150–151, 151 Klinefelter’s syndrome, 213, 389
Hypertrophy, 99 Inherited syndromes, 192–194, 193 Knee injuries, 362
adolescent, 209 Injury
epidermal, 321 metabolic response to, 87–88 L
infantile pyloric stenosis, 293 penetrating, 88, 94
left ventricular, 286 prevention of, 22 Lactic acidosis, 51–52
right ventricular, 285, 286 Injury Severity Score, 15 Lactational breast sepsis, 211
spinal stenosis, 367 Insensible losses, 40 Langerhans’ cells, 307
tonsillar, 227 Inspiratory reserve volume (IRV), 9, Laparoscopic appendicectomy, 137
Hyphaema, 96 Laparoscopic cholecystectomy,
Hypospadias 10
management, 291–292 Insulin like growth factor (IGF-1), 55 175–176
types of, 291 Insulinomas, 185 Laparoscopic surgery, 62–63
Hypotension, 38 Intensive care unit (ICU), 134 Large bowel obstruction, 143–144
Hypothermia, perioperative, 21 Intermediate salivary tumours, 276 Large bowel polyps, 191, 290
care for, 21 Intermittent claudication, 246 Large intestine
phases of, 21–22 Intestinal fistulas anatomy of, 189, 189–191, 190
Hypovolaemic shock enterocutaneous fistulas, in Hirschsprung’s disease, 290
clinical features, 91 Laryngeal mask airway (LMA), 17
fluid resuscitation, 91–92 153–154 Lasers, 60, 61
grading of, 91 gastrointestinal stomas, 154 Lauge–Hansen classification, 349
intraosseous infusion, 92, 93 Intra-abdominal abscesses, 135–136 Leg ulceration, 256
Hypoxaemia, 44 Intra-aortic balloon pump, 120 Leukotrienes B4, 35
Hypoxaemic failure, 49 Intra-arterial thrombolysis, 248 Leukotrienes D4, 35
Hypoxia, postoperative, 44 Intracapsular fractures, 348 Ligament injuries, medial collateral,
Intracompartmental pressure (ICP),
362–363
95
Intracranial abscess, 332–333

Index 403

Lignocaine, 37 Mammography, 208 Multiple-gated acquisition (MUGA),
Limb compartment syndromes, 94, Marjolin ulceration, 257 117
Marshall–Marchett–Kranz procedure,
94 Multiple myeloma, 371
Limb ischaemia, 246–248 396 Multiple organ dysfunction syndrome
Lipid soluble opiates, 37 Mastalgia and nodularity, 209
Lithotripsy, 381 Mastectomy (MODS), 47, 87
Liver local recurrence following, 218 Mumps, 213, 277
anatomy of, 169, 169–170 simple, 214 Muscarinic receptors, 34
blood flow, 171 Mebendazole, 181 Muscle contraction, 339
blood supply to, 169 Mechanical ventilation, 50 physiology of, 339–340
function tests, 174, 182 complications, 50 Muscle relaxants, 18
sinusoids, anatomy of, 171, Meckel’s diverticulum, 297 Mycobacterium bovis, 384
Meconium ileus, 289 Mycobacterium tuberculosis, 80
172 management, 289 Myelomeningocele, 292
Liver injury, 135 Median nerve, 342 Myocardial infarction, 11
Liverpool Care Pathway, 106 Medical litigation 5–6 Myopathic scoliosis, 304
Lobular carcinoma in situ (LCIS), Melanocytes, 307 Myosin, 340
Melanoma Myositis ossificans, 346
214 acral lentiginous, 317
Lower gastrointestinal haemorrhage, juvenile, 320–321 N
141–142 nodular, 317
Lower limb, subungual, 317 Nasogastric tubes, 64
arteries of, 239 superficial spreading, 316 National Confidential Enquiry into
joints of, 343–344 Meleney’s synergistic gangrene, 76
veins of, 240 Meninges, 323–324 Patient Outcome and Death
Lower renal tract layers of, 323 (NCEPOD), 4
bladder, 374–375 Meningocele, 292 National Health Service breast
male urethra, 375 Mensical injuries, 362 screening programme, 102
prostate, 375 Mental Capacity Act, 14 National Health Service cervical
ureter, anatomical relations of, purpose of, 14 screening programme, 102
Merkel cells, 307 Nausea, 107
374 Mesenteric ischaemia, acute, 139 Neck lumps, in children
Lumbar back pain, 365–366 Metabolic acidosis, 51–52 branchial remnants, 298
Lumbo-sacral meningocele, 293 Metabolic and nutritional support, Neck swellings, common, 278
Lung pharyngeal pouch, 278
abscess, 130 fluid and electrolyte management, Necrosis, 73
anatomy of, 113–114 39 Necrotising enterocolitis, 294
cancer, 126–127 Metacarpophalangeal (MCP) joints, Necrotising fascitis, 76
Lung function tests, 9, see also 314, 352 Necrotising soft tissue infections, 76
Metaplasia, 99 Needle cricothyroidotomy, 91
Respiratory function tests Metaplastic polyps, 191 Negative pressure topical dressings,
Lymphadenectomy, regional, Metastatic bone tumours, 370–371 59–60
Methicillin resistant Staphylococcus Neisseria meningitidis, 262
317–318 aureus (MRSA), 82 (Neoadjuvant) chemotherapy, breast
Lymphadenopathy, 262, 263 Methyldopa, 213 cancer, 216
Lymphoedema, 260–261 Metronidazole, 181 Neonatal intestinal obstruction, 288
Lymphoedema, secondary, 260 Micropapillomatosis, 209 Neoplastic salivary gland disease
Lymphoma, 213 Migration of leukocytes, 308 clinical features, 276
Lymphomatous thyroiditis, 231 Military wounds, 92 intermediate salivary tumours,
Lynch syndrome, 192–194, 193 Minimal access surgery, 62 276
Mirizzi’s syndrome, 175 investigation, 276
M Modified Winter/Ebbehoj shunt, 392 malignant salivary tumours, 276
MODS, see Multiple organ pathology, 276
Macrophages, 55 dysfunction syndrome (MODS) pleomorphic adenoma, 276
Malignant melanoma Monopolar diathermy, 60, 60 Warthin’s tumour, 276
Clark level versus Breslow depth, Morphine, 36, 107 Nephroblastoma, 295
Morton’s neuroma, 364 Nephrolithotomy, percutaneous,
318 MRSA, see Methicillin resistant 381
clinical features, 316 Staphylococcus aureus (MRSA) Nephron, 375–377
epidemiology, 315 μ receptors, 36 Neural tube defects, 292–293
isolated limb perfusion (ILP), Mucosa, 155 Neuroanatomy 323–324
Muir and Barclay formula, 310 Neuroblastoma, 295–296
318–319 Multiple endocrine neoplasia (MEN) Neurological disease
major and minor signs of, 318 syndromes, 236–237 in bladder outflow obstruction,
management, 316 MEN 1 gene, 236 385
pathology, 315–316 MEN 1 syndrome, 185, 236 post-prostatectomy incontinence,
systemic adjuvant therapy, MEN 2a syndrome, 236 387
MEN 2b syndrome, 236 Neurological disorders, and coeliac
318 disease, 198
tumour thickness, 316
Malignant salivary tumours, 276
Malnutrition, 42
Malrotation, 289
clinical features, 289–290
management, 290

404 Index

Neuromuscular junction, 339 Ogilvie’s syndrome, see Colonic Paediatric umbilical hernia, 299
excitation-contraction coupling, pseudo-obstruction Paget’s disease, 214, 215, 365
Paget’s sarcomas, 365
339 Olecranon bursa, 360 Pain, 34
muscle contraction, 339 Olecranon bursitis, 359 bone, 107
Neurones Oncogenes, 99–100 co-analgesia, 107
and action potential, 336–337 Opiate analgesia, 43 dyspnoea, 107
biochemical changes, 337 Opiate sparing’ effects, 36 liver capsule, 107
structure of, 336, 336 Opiates, 16, 36 morphine, 107
Neuropathic scoliosis, 304 Ossification, 336 neuropathic, 107
Neurosurgical disorders Osteitis deformans, 365, see also somatic pain, 34
brainstem death, 332 WHO analgesia ladder, 106, 106
central nervous system infections, Paget’s disease Pain control, postoperative, 35
Osteoarthritis, 351 Palliative care, 106, 106 -107
332–333 Osteochondromas, 369 Pancreas
spinal abscess, 333–334 Osteoclastoma, 369–370, see also anatomy of, 170–171, 171
subarachnoid haemorrhage, chronic inflammation of, 185
Giant-cell tumours gastrinomas, 185
331–332 Osteoid osteomas, 369 Pancreatic carcinoma 183–184, 184
Neurosurgical trauma Osteomalacia, 364–365 Pancreatic neuroendocrine tumours,
head injuries, 325–327 Osteomyelitis, acute, 354–355
Nicotinic receptors, 34 Osteopathic scoliosis, 304 184–185
Nipple discharge, 211–212 Osteoporosis, 364 Pancreatic pseudocyst, 179, 179–180
Nipple inversion, 209 Osteosarcomas, 370 Pancreatitis,
Nipples reconstruction, 219 Otitis externa, 270 acute, 176–179, 177, 178
Nitrous oxide, 18 Otorhinolaryngology, 269 chronic, 185–186
Nodes of Ranvier, 337 Ovarian carcinoma, 394–395 Paralytic ileus, 142–143
Non-absorbable sutures, 43 Ovarian cysts Parasympathetic nerve system, 34
Non-cyclical mastalgia, 210 functional cysts, 393, 393 Parathyroid disease
Non-haemolytic transfusion febrile mature cystic teratoma, 393– familial hypocalciuric

reactions, 30–31 394 hypercalcaemia, 233
Non-lactational breast sepsis, 211, ovarian germ cell tumours, hyperparathyroidism, 231
normocalcaemic hypercalciuria,
211 394
Non-neoplastic salivary gland Ovarian teratoma, abdominal x-ray, 233
persistent hyperparathyroidism,
enlargement 394
acute sialadenitis, 277 Overactive bladder symptom 232
sialolithiasis, 277 recurrent hyperparathyroidism,
Sjögren’s syndrome, 277 syndrome, 395 232
Non-steroidal anti-inflammatory Overflow incontinence, 395 Parathyroid gland 222–223, 223
Overwhelming post-splenectomy Parenteral nutrition, 42
agents, 36 central, 42
Non-steroids anti-inflammatories, infection (OPSI), 134, 262 metabolic complications of, 43
Oxygen dissociation curve, 114–115, monitoring, 42–43
16 Parkland formula, 310
Normal distribution, 69, 70 115 Parotid gland, 269–270
Nosocomial pneumonia, 44 Oxygen therapeutic agents, 92 Parsonnet score, 15, 117
Nottingham Prognostic Index, 216 risk changes, 118
Null hypothesis, 70 P Pathologic fractures, 346–347
Nutritional assessment, 42 causes of, 347
Nutritional support, 42 Packed cell volume (PCV), 53 Pathophysiology
enteral nutrition, 42 Packed red blood cells, 92 trauma, 87–88
parenteral nutrition, 42 Paediatric fractures, 350 wound healing, 55, 55–56
management, 350 Patient-controlled analgesia (PCA),
O Paediatric hernias
inguinal hernia, 298–299 36–37
Obesity, 12 irreducible hernia, 299 Peak flow measurements, 10
complications associated, 12 umbilical hernia, 299 Pedicled myocutaneous flaps, 219
Obstruction Paediatric stridor, acute, 271 latissimus dorsi (LD) flap, 219
colonic pseudo, 145 Paediatric surgery pedicle transverse rectus
large bowel, 143–144 cardiovascular system, 281
small bowel, 142–143 renal system, 281 abdominis (TRAM) flap
Obstructive jaundice, 172–173, 173 respiratory system, 281 Pelvic inflammatory disease (PID), 393
management, 173 thermoregulation, 281 Pelviureteric junction (PUJ)
Obturator hernia, 153 Paediatric surgical disorders,
Oesophageal atresia obstruction, 382
clinical features, 287–288 common Peptic ulcer disease, 165–166, 167
management, 288 hypertrophic pyloric stenosis, Percutaneous coronary intervention
Oesophageal cancer, 160–161
Oesophageal perforation, 162 293 (PCI), 117
Oesophagus intussusception, 294 Percutaneous tracheostomy, 272
anatomy of, 156 necrotising enterocolitis, 294 Perforated peptic ulcer 137–139, 138
disease, 159–163 Paediatric trauma, 281 Pericardial tamponade, 123
airway and breathing, 282
assessment, 282
circulation, 282

Index 405

Perioperative arrhythmias, 44–45 Post spinal headache, 38 R
Peripheral vascular disease Postoperative complications, timing
critical limb ischaemia, 246–247 Radial nerve, 341–342
intermittent claudication, 246 of, 43 Radical prostatectomy, 387–388
Peritoneal dialysis, 265 Postoperative nausea and vomiting Radioactive iodine, 226
Peritonitis, 135 Radiotherapy
Periurethral bulking agents, 396 (PONV), 38 DNA damage, 103
Persistent generalised Pott’s disease, 356–357 electromagnetic, 103
Povidone–iodine, 83 fractionation, 103
lymphadenopathy (PGI), 85 Praziquantel, 181 use of, 103
Perthe’s disease, 302 Predeposit transfusion, 31 Ramsay Hunt syndrome, 275–276
Peutz–Jeghers syndrome, 191, Pre-existing and ongoing losses, 39–40 Randomised controlled trials (RCTs),
Preoperative assessment, 7
319–320 surgery fitness, 7–8 68
Phaeochromocytomas, 235–236 Preoperative investigations, 8 Rapid-sequence induction, 16
Pharyngeal pouch chest x-rays, 8 Raynaud’s disease, 243, 263–264
clinical features, 278 coagulation screening, 9 Recombinant factor VIIa, 28
diverticulectomy, 278–279 ECG, 8 Rectal bleeding, in children
Dohlman’s procedure, 279 echocardiography, 8 anal fissures, 297
investigation, 278 full blood count, 8 causes of, 297
Phenothiazines, 16, 213 glycosylated haemoglobin infective enteritis, 297
Phyllodes tumours, 210 large bowel polyps, 297
Physiological scoring systems, 54 (HbA1c), 9 Meckel’s diverticulum, 297
APACHE II score, 54 liver function, 9 Rectal prolapse, 204–205
POSSUM system, 54 lung function, 9 Rectum, see Large intestine
Physiology renal function, 8 Red eye, acute, 97
of liver, 171–172, 172 Priapism, 391–392 Red fibres, 340
respiratory system, 114 Prostate cancer, 387 Renal cell carcinoma, 383
Pigmented skin lesions, 320 hormonal treatment, 105–106, 388 clinical features, 383
blue naevus, 320 Prostate specific antigen (PSA) investigation, 383–384
compound naevus, 320 management, 384
halo naevus, 320 testing, 387 Renal dialysis, 264
intradermal naevus, 320 Prostatic hyperplasia, benign, 385 peritoneal dialysis, 265
junctional naevus, 320 clinical features, 385 Renal failure
Pilonidal sinus investigation, 385 acute, 45
Karydakis procedure, 205 management, 385–387 chronic, 12–13, 264–265
in natal cleft, 204 Proteus mirabilis, 77, 379 peritoneal dialysis, 264
Pituitary and adrenal disease Prothrombin time (PT) tests, 26 postoperative, 46
adrenal incidentalomas, 233 Proton pump inhibitors, 16 renal dialysis, 264
carcinoid tumours, 233 Proximal interphalangeal (PIP) joint, Renal function, 11
Cushing’s syndrome, 233 Renal function, control of
multiple endocrine neoplasia 314, 352 aldosterone, 377
Pseudo gynaecomastia, 212 antidiuretic hormone, 377
syndromes, 233 Pseudocysts, 179, 179–180 filtration, 376
phaeochromocytomas, 233 Pseudomembranous colitis resorption, 376
secondary hypertension, 233 clinical features, 80 urine concentration regulation,
Pituitary gland pathophysiology, 79
anterior pituitary physiology, 224 treatment, 80 377
hypothalamus, 224 Pseudomonas aeruginosa, 44, 379 urine volume regulation, 377
posterior pituitary physiology, Pseudomyxoma peritonei, 195 Renal physiology
Psoas abscess, 75–76 kidney functions, 375
224 Pubovaginal slings, 396 nephron, 375
thyroid stimulating hormone, Pulmonary embolism, 259, 260 Renal transplantation
Pulse oximetry, 49 immunosuppression, 266–267
224 Purified protein derivative (PPD), 81 rejection, 267
Plantar fasciitis, 363–364 Pyelonephritis, acute, 379 Renal trauma, 377
Plastic surgery trauma Pyloric stenosis, 166 Respiration rate, 47
burns, 309–310 Pylorus-preserving proximal Respiratory burns, 311
full-thickness burns, 310 Respiratory complications, obesity,
partial-thickness burns, 310 pancreaticoduodenectomy, 184
superficial burns, 310 Pyogenic granulomas, 320 12
Platelet aggregation, 26 Pyogenic liver abscess, 180 Respiratory disease, 12
Platelet derived growth factors Pyrexia smoking, 12
assessment, 43 Respiratory failure, 49–50
(PDGF), 55, 308 mechanisms of, 21 Respiratory function tests, 9
Pleomorphic adenoma, 276 postoperative, 43 gas transfer, 9
Pneumoperitoneum, 62–63 peak flow rates, 9, 10
Pneumothorax, 128, 128–130, 129 Q spirometry, 9
Polycythaemia, 32 Respiratory rate (RR), 9
Polyps, juvenile, 191 Quackel procedure, 392 Respiratory support, 49
Popliteal artery aneurysms, 251 Quality of life (QoL) Respiratory volumes, 10
Portal hypertension, 186, 186–187, assessments, 70–71
characteristics of, 70
187 Quinsy, 271
POSSUM, 7, 15, 54

406 Index

Resuscitation, adequacy of, 40 Sialolithiasis, 277 Spleen, 261
Revised Trauma score, 15 Sickle cell anaemia, 24–25 Splenectomy
Rhesus antibodies, 29 Sigmoid volvulus, 144 causes, 261
Rheumatoid arthritis, 351–353, 352 Sipple’s syndrome, 236 indications for, 261
Rheumatoid hand, 352 SIRS, see Systemic inflammatory physiological effects of,
Rickets, 364–365
Riedel’s thyroiditis, 231 response syndrome (SIRS) 261–262
Risk assessment models and tools, Sister Mary Joseph’s nodule, 165 ruptured spleen, 262
Sjögren’s syndrome, 277 Splenic injury, 134–135
15 Skeletal contraction, 339 Spondylolisthesis, 367
Risk management, preoperative, 15 Skeletal fractures, 344–346 Spontaneous pneumothorax, 129,
Rotator cuff Skeletal muscle, 339
impingement, 358 Skewed distribution, 69, 70 129
tears, 358 Skin Sputum retention, 127
Royal Marsden staging, of testicular anatomy of, 307 Squamous cell carcinoma, 319, 319
functions of, 307–308 Staghorn calculus, 381
tumours, 389 of abdominal wall, 147 Staging
Ruptured ovarian cysts, 393 preoperative preparation, 83 of cancer, 102–103
Ruptured spleen, 262 preparation, 83 of gastric cancer, 164, 164
shaving, 83 of lung cancers, 126
S tests, 81 Staphylococcal infections, 81
Skin adnexal tumours, 319 Staphylococcus aureus, 41, 44, 74, 75,
Saliva, 270 Skin flaps, 312
Salivary gland advancement flaps, 313 76, 81, 211
anatomy, 269 axial pattern grafts, 312 Staphylococcus epidermidis, 81
parotid gland, 269–270 free myocutaneous flaps, 313 Staphylococcus saprophyticus, 81
physiology, 270 myocutaneous flaps, 312 Statistical hypothesis, 69–70
submandibular gland, 270 random pattern grafts, 312 Statistical test, 70, 71
Salivary gland disease rotation flap, 313 Stenosing tenovaginitis, 360, see also
management of, 277 tissue expanders, 313
neoplastic salivary gland disease, tube pedicle grafts, 312 de Quervain’s disease
Skin grafts, 311 Sterilisation
276–277 full-thickness skin grafts, 311–312 autoclaves, 83
Salmonella infections, 354 partial-thickness skin grafts, ethylene oxide, 84
Sarcomere, 340 hot air ovens, 83–84
Scaphoid fractures, 349 311, 312 irradiation, 84
Scars, 56 Slater and Harris fractures, 350, 350 sporicidal chemicals, 84
Schistosoma haematobium infection, Slipped upper femoral epiphysis Sternomastoid tumours, 298
clinical features, 302 Steroids, 16
384 investigation, 302–303 Stomach, anatomical structure, 156,
Schwann cells, 337 treatment, 302
Scintigraphy, 232 Small bowel obstruction, 142–143 156–157, 157
Sclerotherapy, 255 Small intestine, anatomy of, 157–158 Stomas, 272, 290
Scoline rash, 18 Smoking, 12, 126 gastrointestinal, 154
Scoliosis, 303 Sodium, 39 gastrointestinal injuries, 134
sciatic, 366 Solitary thyroid nodules, 226 pre-existing and ongoing losses,
Scoring systems, 137 biochemical assessment, 227
Scrotal swellings, 390 clinical features, 227 39
differential diagnosis of, 390 diagnosis of, 227 Streptococcal species, 354
Secondary hypertension, 237 fine needle aspiration cytology, Streptococcus pneumoniae, 81–82,
causes of, 238 228
renal artery stenosis, 237–238 isotope scanning, 228 262
Secondary pain, 34 ultrasound, 227–228 Streptococcus pyogenes, 74, 81, 354
Seldinger technique, 41 Somatic pain, 34 Stress incontinence, 395
Sepsis, 47 Sphincter of Oddi, 170 Subacute thyroiditis, 231
anorectal sepsis, 201, 201 Sphincterotomy, 204 Subarachnoid haemorrhage,
definition of, 48 Spigelian hernia, 153
lactational sepsis, 211 Spina bifida, 292 331–332
non-lactational sepsis, 211, Spina bifida occulta, 292 Subdural haematoma
Spinal abscess, 333–334 acute, 327–328
211 Spinal anaesthesia, complications chronic, 328–329, 328
‘Sepsis six’, 49 Submandibular gland, 270
Septic arthritis, 355–356, 355 of, 37 Subtarsal foreign body, 96
Septic shock, definition of, 48 Spinal cord compression, 367–368 Subungual haematoma, 321
Serotonin, 338–339 Spinal cord injuries, 329–331, 330 Superficial and deep abscesses,
Shock, 52–53 partial cord lesions, 329
Shock, hypovolaemic, see Spinal stenosis, 367 74–75
Spironolactone, 213 Superficial fascia, 147
Hypovolaemic shock Spitz naevus, 320–321, see also Superior radioulnar joint, 341
Shoulder, 341 Suppurative otitis media, acute, 270
Shoulder dislocation, 357–358, 358 Juvenile melanoma Suppurative otitis media, chronic
Shoulder pain, 358–359
Sialadenitis, acute, 277 (CSOM)
atticoantral CSOM, 271
tubotympanic CSOM, 270–271
Suppurative thyroiditis, acute, 231
Suprapubic catheterisation, 65

Index 407

Surgery, Thrombosis, 241–242 Transjugular intrahepatic portosystemic
haematological problems, 22–23 Thymectomy, 131 shunting (TIPPS), 141, 187
preparation for, 13–14 Thymoma, 131
Surgical airway, 91 Thyroglossal cysts, 224–225 Transposition of the great vessels,
Surgical cricothyroidotomy, 91 Thyroid disease 285
Surgical cutdown, 41 solitary thyroid nodules, 226–228
Surgical drains, 63–64 thyroglossal cysts, 224–225 Transurethral prostatectomy (TURP),
Surgical preparation, 83 thyroid neoplasms, 228–230 386
Surgical techniques thyroiditis, 230–231
blades, 57 thyrotoxicosis, 225–226 complications of, 386
diathermy, 60–61, 60–61 Thyroid gland, 221 Trastuzumab (herceptin), 217
incisions, 57 anatomy, 221 Trauma
suture materials and needles, embryology, 221, 222 abdominal, see Abdominal
histology, 221–222
58, 59 physiology, 222 trauma
wound closure, 57–58 Thyroid neoplasms, 228 airway and ventilation, 90–91
wound dressings, 58–59 anaplastic carcinoma, 229 clinical assessment, 89–90
Suture, materials and needles, 58, 59 benign thyroid tumours, 228 eye and common infection,
Swan–Ganz catheter, 20 diagnosis, 230
Sweat glands, 307 follicular adenoma, 228 96–97
Sympathetic nervous system, 33–34, follicular tumours, 229 hypovolaemic shock, 91–95
malignant thyroid tumours, pathophysiology of, 87–88
87 prehospital trauma care, 88–89,
Symptomatic breast cancer, 214 228–229
Synapse, structure and function medullary carcinoma, 229–230 89
papillary tumours, 229 resuscitation, 89–90
of, 338 recurrent laryngeal nerve palsy, Traumatic pneumothorax, 128–130
Synapses and neuromuscular Traumatic wounds
230 abdominal stab, 93–94
junctions thyroid lymphoma, 229 gunshot and blast, 92–93
synapses, 337 toxic adenoma, 228 Tricholemmal cysts, 320
synapse, function of, 337 Thyroid stimulating hormone, 224 Tru-cut needle biopsy, 209, see also
Systemic inflammatory response Thyroiditis
acute suppurative thyroiditis, Core biopsy
syndrome (SIRS), 47, 87 Tuberculosis, 80–81
definition of, 48 231 Tubotympanic CSOM, 271
de Quervain’s thyroiditis, 230–231 Tumour markers, 100
T Hashimoto’s thyroiditis, 231 Tumour suppressor genes, 100
Riedel’s thyroiditis, 231 Tumours markers, 195
Tamoxifen, 217 Thyrotoxicosis, 225 Type 1 fibres, 340, see also Red fibres
Temperature, 47 anti-thyroid drugs, 226 Type 2 fibres, 340, see also White
Tendons, 305 clinical features, 225
Tennis elbow, 359, see also Lateral diagnosis, 226 fibres
Grave’s disease, 225–226 Type I errors, 70
epicondylitis radioactive iodine, 226 Type II errors, 70
Tension pneumothorax, 129 surgery, 226
Teratogenesis, 283 thyroid storm, 226 U
Testicular maldescent, 389 Tidal volume (TV), 9
Testicular torsion, 390 Tissue expanders, 218, 313 Ulcerative colitis, 197–200, 198, 200
clinical features, 390 Tonsillitis, acute, 271 Ulnar nerve, 342
management, 390–391 Torsion of a testicular appendix, 391 Ulnar nerve entrapment, at elbow,
Testicular tumours, 388–389 Touch receptors, 307, see also Merkel
clinical features, 389 359
investigation, 389 cells Ultrasound, 133
management, 389–390 Tourniquets, 63 Umbilical hernia, 152
Tetanus, 78 Trabecular bone, 335 Undescended testes, 299
Tetralogy of Fallot Trachea, 113 management, 300
clinical features, 285 Tracheostomy Upper gastrointestinal haemorrhage
investigation, 286 complications of, 273 bleeding peptic ulcer, 140
management, 286 percutaneous tracheostomy, clinical features, 139–140
Therapeutic regulated accurate care initial management, 140
272 variceal, 140–141
(TRAC), 59 postoperative care, 272 Upper limb
Thoracic trauma techniques, 272 arteries of, 239
cardiac stab wounds, 123–124 Tracheostomy care, postoperative, disorders of, 357
flail chest, 124 joints of, 341
great vessels, injuries to, 124 272 Upper renal tract
haemothorax, 123 Transcutaneous electrical nerve anatomy of, 374
mortality, 123 kidneys, 373
pericardial tamponade, 123 stimulation (TENS), 35 structure of, 373
unstable patient, management Transformation growth factor β ureter, 373–374
Ureteric colic, differential diagnosis
of, 123 (TGF-β), 55, 308
Thoracotomy, 127–128 Transfusion related acute lung injury, of, 380
Thrombin time tests, 26 Ureteroscopy (USC), 381
Thromboprophylaxis, 257–259 31 Urge incontinence, 395
Transitional cell tumours (TCCs), 384 Urinary catheters, 64–65
Urinary incontinence, 395

408 Index

Urinary retention, 388 peripheral, 41 Wound dehiscence, 43
Urinary tract techniques, 41–42 Wound healing, 308
calculi, 380–381 venous cutdown, 42 aberrations, 309, 309
infections (UTIs), 45, 379–380 Venous disease haemostasis, 308
obstruction, 385 leg ulceration, 256–257 inflammation, 308
trauma, 378 pulmonary embolism, regeneration and repair, 309
Uroflowmetry results, 386 timeline, 309
259–260 Wound infection
V thromboprophylaxis, 257–259 aerobic pathogens, 77
varicose veins, 254–256 antibiotic prophylaxis, 78
Valvular heart disease, 118–119 venous hypertension, 256–257 definition, 77
Vancomycin, 82 venous thrombosis, 257–259 occurrence, 76–77
Variceal upper gastrointestinal Venous hypertension, 256–257 predisposing factors, 77
Venous physiology, 240 prevention, 77
haemorrhage, 140–141 Venous thrombosis, 257–259, 257 risk of, 77–78
Varicocele, 391 Ventilation, 91 Wounds
Varicose veins Ventilatory failure, 49–50 cardiac stab, 123–124
clinical features, 254–255 Ventricular septal defect, 285 closure, 57–58
endovascular laser treatment, Vesicoureteric reflux (VUR), 379 dressings, 58–61, 60–61, 61
Viridans streptococci, 82 healing, 55, 55–56
255 Visceral pain, 35 traumatic, see Traumatic wounds
investigation, 255 peripheral activation, 35
management, 255 spinal level activation, 35 X
radiofrequency ablation, 255 supraspinal level activation, 35
recurrent varicose veins, 256 Vitamin K, 172 Xenogarft 347
sclerotherapy, 255 Vomit, 107 X-ray
surgery, 255–256 Vomiting centre, afferent and efferent abdominal, 139, 142, 197, 289,
Vascular assessment, invasive
angiography, 245 connections to, 39 394
CT angiography, 245–246 von Hippel–Lindau syndrome, 383 cervical spine, 32
Vascular disease, 239 von Willebrand’s disease, 28 chest, 8, 10, 45,
Vascular endothelium, 87 clinical uses, 28–29 hip, 302
Vascular pathology, 240–243 recombinant factor VIIa, 28 skeletal, 365
Vascular trauma, 253 von Willebrand factor (vWF), 28 skull, 326
clinical features, 253
complications, 254 W Y
investigation, 253–254
Vasectomy, 392 Wallace ‘Rule of Nines’, 310 Y connector, 91
reversal of, 392 Warthin’s tumour, 276 Yolk sac tumours, 389
Vasoconstriction, 26 Weber classification, 349
Vecuronium, 18 Wermer’s syndrome, 236 Z
Venous access Whipple’s procedure, 183, 184
anatomy of, 41 White fibres, 340 Zollinger–Ellison syndrome, 185
central, 41 WHO safe surgery checklist, 15