Botulinum toxin A (Botox ) can be injected into the external sphincter in severe cases that are refractory to more conservative management options  generic trental 400 mg otc. A thorough history trusted trental 400mg, physical exam buy 400mg trental free shipping, and noninvasive evaluation are essential to ruling out organic causes 1692 and to establish an etiology . It is helpful for patients and their families to keep an elimination diary to ascertain the child’s specific toileting habits. For example, many parents are not aware that their child has constipation unless specifically queried as to the frequency and caliber of the stool. Voiding dysfunction may be treated by behavior modification or pharmacological agents and rarely requires surgical intervention. A rare consequence of dysfunctional elimination is phantom urinary incontinence —an entity whereby children sense wetness when they are, in fact, dry. This phenomenon is strongly associated with obsessive compulsive disorder and responds completely to effective treatment of constipation . A list of common pharmacotherapeutic agents for bladder dysfunction is provided in Table 114. Micturition into the vagina results in leakage when the child stands upright, allowing efflux of urine from the vaginal vault. Clinical findings consistent with vaginal voiding include postvoid dribbling, labial fusion, and leaning forward at an extreme angle during micturition . Simple maneuvers to direct the urinary stream more accurately by separating the legs further during voiding, and waiting a few minutes after micturition to allow efflux into the toilet, usually solve the problem (Figure 114. Imaging studies are essential to define the anatomic abnormalities causing the incontinence. Magnetic resonance urography and intravenous pyelogram are useful to identify ectopic ureters, duplication anomalies, and ureteroceles, as well as providing useful information regarding renal function. Urodynamic studies are often useful in detecting sphincteric, storage, and urinary flow abnormalities and are essential in all patients with neurogenic incontinence. The goals of treatment for congenital abnormalities of the female urogenital tract are restoration of physical appearance and function, preservation of renal function, and achievement of manageable urine storage and continence. It has an incidence between 1 in 10,000 and 50,000 live births and is less common in females than in males [15,16]. Why some children develop normal bladder capacities while others go on to develop small and poorly compliant bladders is incompletely understood. A range of surgical techniques (complete versus staged repairs) have been employed to achieve successful primary bladder closure with or without pelvic osteotomies. Early bladder closure within 72 1693 hours was advocated in the past; more recently, delayed primary closure has demonstrated comparable outcomes [17,18]. Bladder augmentation or diversion are surgical options later in life, although some patients require no such intervention . Bladder neck reconstruction may be performed at the time of bladder closure or afterward. Continence rates vary greatly depending upon the strictness of definition as well as length of follow-up. Stress incontinence has been managed successfully with injections of ® dextranomer/hyaluronic acid (Deflux ) into the bladder neck [20,21]. In a survey of women who underwent closure of bladder exstrophy as infants, most experienced normal menses, the majority were sexually active and satisfied with their social lives, and some had borne children (all via cesarean section). Unfortunately, almost half reported some degree of psychological distress resulting from their malformation . A voiding cystourethrogram 3 months later shows cure of reflux, but the presence of vaginal voiding. Management of cloacal exstrophy requires a multidisciplinary team–based approach, with the principal goals of treatment focusing on patient function, psychosocial development, and overall quality of life. The treatment of storage abnormalities of the bladder resulting from this anomaly usually involves bladder augmentation with intestinal segments. The goals of management of pediatric 1695 neurogenic bladder include achieving low-pressure urinary storage and providing urinary continence while preserving upper tract function. Bladder augmentation, with creation of a cutaneous continent catheterizable channel and/or bladder neck procedures, is a frequent component in attaining management goals in a substantial number of children who fail medical management. Abnormal Sphincter Anatomic abnormalities may impede normal development of the bladder neck. Incompetence of the bladder neck may result in primary urinary incontinence and is seen in conditions such as female epispadias, urogenital sinus, bilateral ureteral ectopia, and ectopic ureteroceles. Conservative measures to improve sphincteric function are limited and surgical intervention is warranted. Surgical options focus on the creation of an increase in bladder outlet resistance or a new sphincter mechanism. In mild cases, the diagnosis may not be apparent until the child remains wet into childhood. In complete epispadias, incontinence results secondary to (1) a foreshortened and widened urethra, (2) a partially absent external urethral sphincter, and (3) a poorly developed bladder neck. Treatment is directed at the reconstruction of these deficient structures and ureteral reimplantation proximal to the reconstructed bladder neck [26,27]. Persistent incontinence may be treated with urethral bulking agent injection at the bladder neck. Urogenital Sinus Anomalies Persistence of a urogenital sinus may result in the urethra emptying into the vaginal vault. This may not be readily apparent unless the urethra is not visualized during attempt at catheterization. Infants may present with a dilated vagina, possibly resulting in an abdominal mass, if the posterior lip of the hymen causes partial obstruction at the orifice of the urogenital sinus (Figure 114. Retained urine in the vagina (urocolpos) and uterine canal may increase to enormous volumes. Drainage of urine with vaginal catheterization followed by a vaginogram showing contrast within the cervical canal and uterus, and possibly into the peritoneal cavity, is diagnostic. Further reconstructive surgery is often required (see discussion of congenital adrenal hyperplasia in the “Disorders of Sexual Differentiation” section). Duplicated Ectopic Ureters An ectopic upper pole ureter may join the lower end of the remnant mesonephric duct system comprising Gartner’s ducts. These ureters are associated with nonfunction of the associated renal moiety and may result in cystic dilation of Gartner’s duct with eventual rupture of the cyst and drainage into the vaginal opening. Renal and pelvic ultrasound may demonstrate a dilated or abnormal upper pole renal moiety, and a cystic structure may be seen in the pelvis or vaginal area. Computerized tomography scanning or magnetic resonance imaging are helpful in further delineating the anatomy, while retrograde fluoroscopic studies are diagnostic if the often-elusive ectopic orifice can be identified (Figure 114. Appropriate treatment of ureteral ectopia is dependent upon whether or not there is ureteral duplication and whether the ectopic ureter drains into the genital or urinary tract. Ectopic ureters to the genital tracts may be treated by simple upper pole nephrectomy; ectopia to the urinary tract usually involves ureterectomy in addition to heminephrectomy in order to prevent postoperative urinary reflux and infection (Figure 114. Bypass of Sphincter Mechanism In instances where the bladder neck and sphincter mechanism have developed normally, urinary incontinence may develop as a result of ureteral ectopia distal to the continence mechanism.
Cytohistology of Lymph Nodes and Spleen buy trental 400mg without a prescription, Cambridge University Press cheap trental 400mg with amex, Cambridge purchase trental 400mg on-line, United Kingdom, 2014. Wojcik General Background Malignant salivary gland tumors include a diverse group of primary neoplasms involving both the major and minor salivary glands [1–4]. Al-Abbadi Pathology and Cytopathology, Jordan University Hospital, Amman, Jordan Histopathology, Microbiology and Forensic Medicine, University of Jordan – College of Medicine, Amman, Jordan e-mail: alabbadima@yahoo. Vielh Department of Anatomic and Molecular Pathology, National Laboratory of Health, Dudelange, Luxembourg e-mail: philippe. Defnition Salivary gland aspirates classifed as “Malignant” contain a combination of cyto- morphologic features that, either alone or in combination with ancillary studies, is diagnostic of malignancy. When possible, an attempt should be made to provide the grade of the neoplasm as well as the specifc tumor type (e. In the pediatric age group, it constitutes about a third of salivary gland carcinomas [7, 8]. The tumors are usually asymptomatic and slow-growing; pain, fxation to the surrounding tissues, and facial nerve involvement are considered poor prognostic features and may indicate high grade transformation. Distant metastases are rare; however, they have been reported in the liver and lung. Cellular smear with loosely cohesive groups of fragile acinar cells adherent to a delicate capillary meshwork. Note the presence of stripped nuclei in the focculent background and the conspicuous absence of ductal cells (smear, Romanowsky stain) Fig. Dyshesive well-preserved tumor cells with delicate granular cytoplasm and stripped nuclei. Aspirate showing a sheet of cells with abundant delicate cytoplasm with scattered small coarse granules (smear, Papanicolaou stain) Fig. This acinic cell carcinoma has three-dimensional clusters of acinar cells with abundant delicate cytoplasm; low N:C ratio; uniform, round-to-oval nuclei, with distinct nucleoli (smear, Papanicolaou stain) Capillary meshwork with loosely adherent cells or well-developed papillary formations Uniform, round eccentric nuclei with distinct nucleoli (Fig. The tumor cells are large and polygonal to oval with indistinct cell borders, and abun- dant delicate vacuolated cytoplasm, which has a subtle basophilic quality. Cytoplasmic zymogen granules, which are indicative of serous acinar 7 Malignant 101 Fig. This acinic cell carcinoma has loosely cohesive groups of cells with a somewhat higher N:C ratio imparting more of a non-specifc glandular appearance (smear, Papanicolaou stain) differentiation, are usually coarse, stain basophilic in Papanicolaou-stained prepara- tions, but are best seen in Romanowsky-type stains where they appear red or magenta. Unfortunately, zymogen granules are often sparse and/or diffcult to detect on routinely stained cytologic preparations. In addition to serous acinar cells, aspi- rates can also show clear cells, intercalated duct-like cells, and non-specifc glandu- lar cells. Intercalated duct-like cells are smaller, cuboidal, have a higher N:C ratio with centrally placed nuclei, and lack the classic cytoplasmic zymogen granules. Non-specifc glandular cells are frequently seen; they resemble the intercalated duct-like cells but are larger and rounder (Fig. Numerous naked nuclei may be present in the aspirate and may be diffcult to distinguish from lym- phocytes. The tumor is found most commonly in the parotid gland, followed by the intraoral minor salivary glands and submandibular gland. Most tumors occur in adults and show an equal gender distribution; the mean age is 47 years (range 14–78 years) . Cells have low-grade vesicu- lar nuclei with fnely granular chromatin and distinctive centrally located nucleoli (Fig. Moderate to abundant pale to pink vacuolated or granular cytoplasm is present (Fig. These aspirates (a–c) show different architectural patterns of microcystic, tubular, microfollicular, and solid sheets of glandular cells with eosinophilic colloid-like secretory material (smear, Papanicolaou and Romanowsky stains) Fig. This aspirate of secretory carcinoma consists of cells with low-grade vesicular nuclei with fnely granular chromatin and distinct nucleoli (smear, Papanicolaou stain) 7 Malignant 105 Fig. The aspirate shows a biphasic tumor with inner cuboidal ductal cells and prominent outer myoepithelial cells (smear, Papanicolaou stain) 7 Malignant 107 Fig. Aspirate of epithelial- myoepithelial carcinoma showing biphasic cells organized in pseudopapillary tubules and sheets (smear, Papanicoloau stain) Fig. This aspirate of epithelial- myoepithelial carcinoma has a prominent biphasic pattern of ductal cells and abundant pale myoepithelial cells as well as focal proteinaceous material (smear, Papanicolaou stain) Laminated, acellular stromal cores (Fig. This epithelial-myoepithelial carcinoma has prominent concentrically laminated proteinaceous secretions that should be distinguished from the matrix material of adenoid cystic carcinoma (smear, Papanicolaou stain) ductal component is sometimes more diffcult to identify. Concentrically laminated acellular stromal spheres stain pink with Diff-Quik and blue-green with Papanicolaou stains. Material should be collected for ancillary studies to highlight the biphasic nature of the tumor. Tumors are usually large and have an infltra- tive growth pattern with foci of necrosis. Regional or distant metastases may already be present at the time of diagnosis, contributing to the poor prognosis of this tumor. The standard management for resectable tumors is radical surgery with ipsilateral neck dissection, followed by postoperative adjuvant radiotherapy. The aspirate is cellular with three-dimensional groups of epithelial cells with moderate amounts of cytoplasm and hyperchromatic nuclei in a background of blood and necrosis (smear, Romanowsky stain) 110 S. This aspirate of salivary duct carcinoma contains groups of high-grade malignant cells with abundant cytoplasm, nuclear pleomorphism, prominent nucleoli, and glandular features (smear, Romanowsky stain) Fig. Immunohistochemistry can be very helpful for addressing the differential diagnostic considerations. Metastatic carcinoma from breast or prostate can sometimes enter the differential diagnosis, particularly in a patient with a known history of these cancers. Clinical correlation and interpretation of the cytologic fndings in the appropriate clinical context is essential for the diagnosis of high-grade primary and secondary salivary gland cancers . A focused panel of immunochemical markers can usually resolve any diffcult cases where the cytomorphology is not defnitive (Table 7. There is a known predilection for Inuits in the Arctic region and Southern China and Japan. Patients usually present with an enlarging mass of the parotid or submandibular gland with associated cervical lymphadenopathy. Tumors usually range in size from 1–10 cm and often infltrate the surrounding parenchyma. It is cytologically and histologically similar in appearance to nasopharyngeal carci- noma. The cytomorphol- ogy is fairly unique, and essentially the same as nonkeratinizing nasopharyngeal carcinoma. The presence of a polymorphous lymphoid background and pleomor- phic cells with vesicular nuclei and prominent nucleoli can raise a differential diag- nosis of a high-grade lymphoproliferative lesion, especially Hodgkin lymphoma. Cell block of lymphoepithelial carcinoma showing undifferentiated-appearing epithelial cells in a lymphoid background (H&E stain) 114 S. Carcinoma with High-Grade Transformation “Dedifferentiation,” or the more widely accepted term “high-grade transformation,” is defned as the transformation of a well-differentiated tumor into a high-grade malignancy that lacks the distinct histologic characteristics of the original neoplasm [9, 13, 14]. Primary salivary gland carcinomas with high-grade transformation follow an especially aggressive clinical course.
Such raw data have meaning only if a detailed specification of the type of flowmeter used is given 400mg trental sale. The interpretation of any dynamic variation (signal patterns) in free flow will rely on personal experience cheap trental 400mg fast delivery, can be only descriptive order 400mg trental with mastercard, and in general will remain speculative. For the documentation of the results of uroflowmetry, the following recommendations are made: Maximum (smoothed) urine flow rate should be rounded to the nearest whole number (a recording of 10. The results from uroflowmetry should be reported in the standard format: Qmax/Vvoid/Vres. The adoption of these standards will aid the interpretation of uroflowmetry results. This process will usually be aided by the a priori completion of a frequency volume chart and free uroflowmetry. There are certain key recommendations that will lead to the performance of a successful urodynamic study: First, a good urodynamic investigation should be performed interactively with the patient. It should be established by discussion with the patient that the patient’s symptoms have been reproduced during the test. Second, there should be continuous and careful observation of the signals as they are collected, and the continuous assessment of the qualitative and quantitative plausibility of all signals. Third, artifacts should be avoided, and any artifacts that occur should be corrected immediately. It is always difficult and is often impossible to correct artifacts during a retrospective analysis. Furthermore, it is more time-consuming than if the signals are continuously observed and tested at regular intervals and artifacts recognized during the urodynamic study and corrected. At present, ambulatory urodynamic monitoring has to rely on retrospective quality control and artifact corrections. However, in principle, the same quality criteria apply for ambulatory urodynamic monitoring as for standard urodynamics . This makes a consensus on quality even more important, because only when such criteria are precisely defined can they be implemented in an “automated intelligent” ambulatory system. Quality control relies on pattern recognition and a knowledge of normal values as well as prior identification of useful information obtained from noninvasive urodynamics and all other sources relevant for the urodynamic question. Useful information obtained from noninvasive testing includes typical voided volumes and postvoid residual volumes as well as the expected values for Qmax. Only by good preparation can it be ensured that (1) the proper answers to the urodynamic questions will be obtained before the study is terminated and (2) essential modifications, additions, or repetitions of measurements will have been performed in order to derive the necessary information. The effective practice of urodynamics requires (1) a theoretical understanding of the underlying physics of the measurement, (2) practical experience with urodynamic equipment and procedures, (3) an understanding of how to ensure quality control of urodynamic signals, and (4) the ability to analyze critically the results of the measurements. Because urodynamics deals largely with mechanical measurements such as pressure and volume and their related changes in time, and because many 1836 analytical models use mechanical concepts such as resistance to flow or contraction power, it is essential that the nature of these measurements and concepts, in particular for pressure and flow rate, are understood. Therefore, in addition to a comprehensive understanding of anatomy and physiology, some basic knowledge of biomechanics and physics is required. The quality control of urodynamic measurements must be approached on a holistic basis. Different types and levels of data quality and plausibility control should be used (1) on a physical and technical level, (2) on a biomechanical level, and (3) on a pathophysiological clinical level. A common problem in urodynamics is that clinicians often proceed immediately to a clinical interpretation, that is, to level 3, without a critical analysis of the potential pathophysiologic information content, without considering the plausibility of the signals (level 1), without considering the biomechanical context of the measurements (level 2), and without taking into account the physical properties of the parameters, technical limitations, and accuracy of the signals. Therefore, it is recommended that invasive urodynamics should not be performed without precise indications and well-defined “urodynamic questions” that are to be answered by the results of the urodynamic study. However, a significant delay is to be expected for the typical urodynamic flow rate recorded extracorporeally. This delay will vary with anatomy, pathology, flow rate, and the setup for measurement. Our understanding of the actual dynamics of flow rate changes is limited, and the relatively slow response of most flowmeters may not be sufficient to match the dynamics of the much faster pressure signal. Therefore, we recommend the use of more descriptive terminology for synchronizing pressure and flow values, such as pdet. The time delay correction needs to be considered when analyzing pressure–flow studies . This, however, is not due simply to a mechanical increase of outflow resistance by the intraurethral catheter, because such a difference is also found in suprapubic pressure– flow studies. This indicates more complex causes, possibly psychogenic, but also physiologic, for example, that a difference in detrusor contraction strength may be involved, and that the fast filling rate used in clinical studies may lead to reduced contractility. This could also explain the difference in results between conventional and ambulatory studies. Zero pressure and reference height are concepts that are often confused in urodynamics, for example, by use of the misleading term “zero reference height. Zero pressure is the value recorded when a transducer is open to the environment when disconnected from any tubes or catheters, or when the open end of a connected, fluid-filled tube is at the same vertical level as the transducer. The reference height is the level at which the transducers must be placed so that all urodynamic pressures have the same hydrostatic component. It is often argued that it does not make a difference for the most relevant parameter, pdet, if the same error is introduced to pves and pabd, as they tend to cancel each other out. The hydrostatic pressure is real and important, and 1837 inevitably plays a role in any intracorporeal pressure recording. Also, it is only meaningful to subtract one pressure from the other— for example, (pves ‒ pabd = pdet)—when both are recorded to the same reference level. Pressure Transducers Urodynamic techniques are developed using external pressure transducers connected to the patient with fluid-filled lines, allowing easier compliance with the standards of correct zero and reference height. Catheter-mounted pressure transducers, so-called microtip transducer catheters, have become popular due to their apparent higher accuracy, better dynamic resolution, and their apparent independence from hydrostatic pressure. A catheter-mounted pressure transducer is an advantage for dynamic recordings of urethral pressures during coughing (stress profiles) as well as for ambulatory urodynamics in mobile patients. Here, only the application of catheter-mounted pressure transducers for intravesical and pabd recordings will be discussed as urethral pressures are dealt with in a separate report . All aspects of urodynamic pressure recording outlined in the preceding section are valid and independent of transducer type. It is impossible to define the precise position of an intravesical and a rectal catheter-mounted pressure transducer as to place them at any common level, and impossible to position them at the standard level of the upper border of the symphysis pubis. It has become popular to circumvent this problem by setting the catheter-mounted pressure transducer to zero pressure when inside the body at the start of pressure recording. This, however, means that both the standard zero pressure as well the reference level are ignored, so that such recorded pressure cannot be compared between patients or centers. The fact is that the initial intravesical and abdominal resting pressures are real, are different between patients, and depend significantly on the patient’s position. Thus, there are significant potential errors: By ignoring the correct atmospheric zero pressure, an error of up to 50 cmH O can occur, and as the reference height of catheter-mounted pressure transducers is usually2 undetermined, another potential error of 10 cmH O is possible for a full bladder. In addition, when a2 study starts with zero pabd, then the commonly observed pabd decrease at pelvic floor relaxation during voiding will result in negative pabd values, and thus in pdet being higher than pves. The same problem of apparent independence from the existing hydrostatic pressure also applies to air-filled catheters and/or connection tubings.
T. Deckard. University of Tennessee, Knoxville.