second edition
                        Julian A Smith
                            Jane G Fox
                       Alan C...
Hunt and Marshall’s
Clinical Problems
    in Surgery
   Second edition
Hunt and Marshall’s
    Clinical Problems
        in Surgery
                 Second edition

Churchill Livingstone
is an imprint of Elsevier

Elsevier Australia. ACN 001 002 357
(a division of Reed International Boo...

Foreword                                               ix    2.3 Facial weakness                                ...
vi   CO N T E N T S

3.4 Nipple discharge                             74    6.5   Pain in the upper limbs              ...
CO N T E N T S    vii

7.16 Haematemesis and melaena (upper                   10.9   Anaemia                           ...
viii   CO N T E N T S

     Investigations and procedures                      13.6 Facial injury                      ...

The seeds for a satisfactory and rewarding career as           each of the subjects is dealt with in a uniform a...
Breast problems
68     C L I N I C A L P R O B L E M S I N S U R G E RY

breast. Erythematous discoloration of skin may be             ...
3   BREAST PROBLEMS             69

tenderness, particularly in the spine, and auscultation             Positive signs ...
70      C L I N I C A L P R O B L E M S I N S U R G E RY

a                                                            ...
3    BREAST PROBLEMS             71

the breast, usually without a dominant lump. The              Confusion can be red...
72    C L I N I C A L P R O B L E M S I N S U R G E RY

History and physical examination                             po...
3   BREAST PROBLEMS             73

and firm. It may be possible to detect fluctuation. The       by skin or nipple ret...
74    C L I N I C A L P R O B L E M S I N S U R G E RY

can interpret mammograms correctly in about 90%               a...
3   BREAST PROBLEMS                  75

    An opaque milky discharge commonly appears a            Unilateral bloody ...
76    C L I N I C A L P R O B L E M S I N S U R G E RY

inflammatory cells. Ductal epithelial cells or red blood
cells ...
3   BREAST PROBLEMS           77

and is associated with signs of fixation or a bloodstained   because of their oestrog...
Urogenital problems
                  Caroline Dowling and Mark Fryde...
9   U R O G E N I TA L P R O B L E M S       329

    sign is classic of a mobile retroperitoneal renal        ●   ultr...
330      C L I N I C A L P R O B L E M S I N S U R G E RY

9   U R O G E N I TA L P R O B L E M S     331

and requiring repeated narcotic injections without           contrast a...
332     C L I N I C A L P R O B L E M S I N S U R G E RY

Hunt & Marshall’s Clinical Problems in General Surgery by Smith, Fox & Saunders
Hunt & Marshall’s Clinical Problems in General Surgery by Smith, Fox & Saunders
Hunt & Marshall’s Clinical Problems in General Surgery by Smith, Fox & Saunders
Hunt & Marshall’s Clinical Problems in General Surgery by Smith, Fox & Saunders
Hunt & Marshall’s Clinical Problems in General Surgery by Smith, Fox & Saunders
Hunt & Marshall’s Clinical Problems in General Surgery by Smith, Fox & Saunders
Hunt & Marshall’s Clinical Problems in General Surgery by Smith, Fox & Saunders
Hunt & Marshall’s Clinical Problems in General Surgery by Smith, Fox & Saunders
Hunt & Marshall’s Clinical Problems in General Surgery by Smith, Fox & Saunders
Hunt & Marshall’s Clinical Problems in General Surgery by Smith, Fox & Saunders
Hunt & Marshall’s Clinical Problems in General Surgery by Smith, Fox & Saunders
Hunt & Marshall’s Clinical Problems in General Surgery by Smith, Fox & Saunders
Hunt & Marshall’s Clinical Problems in General Surgery by Smith, Fox & Saunders
Hunt & Marshall’s Clinical Problems in General Surgery by Smith, Fox & Saunders
Hunt & Marshall’s Clinical Problems in General Surgery by Smith, Fox & Saunders
Hunt & Marshall’s Clinical Problems in General Surgery by Smith, Fox & Saunders
Hunt & Marshall’s Clinical Problems in General Surgery by Smith, Fox & Saunders
Hunt & Marshall’s Clinical Problems in General Surgery by Smith, Fox & Saunders
Hunt & Marshall’s Clinical Problems in General Surgery by Smith, Fox & Saunders
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Hunt & Marshall’s Clinical Problems in General Surgery by Smith, Fox & Saunders


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Hunt & Marshall’s Clinical Problems in Surgery discusses common problems encountered in the clinical practice of surgery and how to solve and treat them. The approach of the text will be to encourage diagnostic economy, and to this end students will be assisted to develop skills in pattern recognition, appreciation of the natural history and prognosis of individual problems and their causative diseases, and an ability to come to the core of the patient’s presenting problem, while maintaining an holistic approach to the unique requirements of the individual patient. The text is designed to help the student understand the questions raised at each level of the of the diagnostic, therapeutic and overall decision making tree and thereby to construct an appropriate pathway of management for each clinical problem.

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  1. 1. second edition Julian A Smith Jane G Fox Alan C Saunder Ming Kon Yii Hunt & MarsHall’s CliniCal Problems in surgery
  2. 2. Hunt and Marshall’s Clinical Problems in Surgery Second edition
  3. 3. Hunt and Marshall’s Clinical Problems in Surgery Second edition Julian A Smith Jane G Fox Alan C Saunder Ming Kon Yii Sydney Edinburgh London New York Philadelphia St Louis Toronto
  4. 4. Churchill Livingstone is an imprint of Elsevier Elsevier Australia. ACN 001 002 357 (a division of Reed International Books Australia Pty Ltd) Tower 1, 475 Victoria Avenue, Chatswood, NSW 2067 © 2010 Elsevier Australia This publication is copyright. Except as expressly provided in the Copyright Act 1968 and the Copyright Amendment (Digital Agenda) Act 2000, no part of this publication may be reproduced, stored in any retrieval system or transmitted by any means (including electronic, mechanical, microcopying, photocopying, recording or otherwise) without prior written permission from the publisher. Every attempt has been made to trace and acknowledge copyright, but in some cases this may not have been possible. The publisher apologises for any accidental infringement and would welcome any information to redress the situation. This publication has been carefully reviewed and checked to ensure that the content is as accurate and current as possible at time of publication. We would recommend, however, that the reader verify any procedures, treatments, drug dosages or legal content described in this book. Neither the author, the contributors, nor the publisher assume any liability for injury and/or damage to persons or property arising from any error in or omission from this publication. National Library of Australia Cataloguing-in-Publication Data Hunt and Marshall’s clinical problems in surgery / editors, Julian A. Smith ... [et al.]. 2nd ed. ISBN: 9780729538268 (pbk.) Includes index. Surgery. Clinical medicine—Handbooks, manuals, etc. Smith, Julian A. 617 Publisher: Sophie Kaliniecki Developmental Editor: Sabrina Chew Publishing Services Manager: Helena Klijn Editorial Coordinator: Andreea Heriseanu and Eleanor Cant Edited by Matt Davies Proofread by Kerry Brown Design by Avril Makula Illustrations by Joseph Freidin and Alan Laver Index by Max McMaster Typeset by Pindar NZ Printed by China Translation and Printing Services
  5. 5. Contents Foreword ix 2.3 Facial weakness 42 Preface x 2.4 Nose and sinuses 42 Acknowledgements xi Anatomy/physiology 42 Contributors xii Blood supply 43 Reviewers xiii Nerve supply 43 Paranasal sinuses 43 Introduction xiv Epistaxis 43 The problem-oriented clinical approach xvii Nasal obstruction 44 1 Collect and record the database xviii Sinusitis/nasal polyps/allergy 45 2 Constructing a problem list xix 2.5 Throat 45 3 Assessment and plan xx Tonsils and adenoids 45 4 Progress notes xx Microbiology/pathology 46 5 Discharge summaries xxi Infectious mononucleosis 46 Student case presentations xxii 2.6 Airway emergencies and tracheostomy 47 2.7 Snoring and obstructive apnoea 48 1 Integument problems 1 2.8 Voice/dysphonia/hoarse voice 48 Jane Fox and David Speakman Nerve supply 49 1.1 Introduction 1 Dysphonia 49 The clinical history of a lump or ulcer 3 2.9 Dysphagia 51 The physical examination of a lump or ulcer 5 2.10 Congenital anomalies 51 1.2 Focal skin lesions 8 Vascular malformations 51 Clearly benign lesions 9 Nasolabial cyst/dermoids/cleft lip and palate 51 ‘Suspicious’ lesions 13 2.11 Foreign bodies 51 Pigmented skin lesions 17 Ear 51 1.3 Subcutaneous lumps 18 Nose 52 1.4 Cutaneous and subcutaneous Oropharyngeal/oesophageal 52 infections 23 Upper airway 52 Specific infections of skin and 2.12 Head and neck cancer 53 subcutaneous tissues 25 2.13 Larynx 53 1.5 Lymph node swellings 29 2.14 Parotid and salivary glands 53 2.15 Thyroid/parathyroid 55 2 Ear, nose and throat and head and Goitre 55 neck problems 31 2.16 Mouth ulcers and lesions 61 Sarin Wongprasartsuk, Andrew Danks and 2.17 Approach to a head and neck lump 63 Neil Vallance 2.18 Neck pain 63 2.1 Introduction 31 2.19 Cranial nerve evaluation 64 History 31 Examination of the head and neck 31 3 Breast problems 67 2.2 Ear 35 Jane Fox External ear 36 3.1 Introduction 67 Middle ear 37 3.2 Breast pain 69 Inner ear 38 3.3 Breast lump 71 v
  6. 6. vi CO N T E N T S 3.4 Nipple discharge 74 6.5 Pain in the upper limbs 133 3.5 Gynaecomastia 76 6.6 Subcutaneous hand lumps 134 6.7 Hand deformities 138 4 Chest and chest wall problems 78 6.8 Hand infections 145 Julian Smith 6.9 Nail disorders 149 4.1 Introduction 78 6.10 Painful hip 152 4.2 Acute chest pain 83 6.11 Painful knee 155 4.3 Pleural effusion 87 6.12 Painful foot 159 4.4 Chronic cough and haemoptysis 88 6.13 Swollen leg 163 4.5 Chest wall problems 93 6.14 Leg ulcer 167 6.15 Varicose veins 173 5 Back and related limb 6.16 Limb ischaemia 177 neurological problems 95 Functional ischaemia – intermittent Ming Kon Yii, Andrew Danks and Marinis claudication 177 Pirpiris Critical ischaemia – rest pain, gangrene 5.1 Introduction 95 or ulcer 180 5.2 Back pain 99 Acute limb ischaemia 184 Neurological system 102 Raynaud’s phenomenon 185 5.3 Limb weakness and numbness – peripheral neuropathies 105 7 Abdomen and gut problems 187 Clinical assessment of specific nerve Alan Saunder and Ken Farrell palsies 106 7.1 Introduction 187 Median nerve 107 History – analysis of abdominal pain 187 Ulnar nerve 108 Physical examination 189 Radial nerve and posterior interosseous 7.2 ‘Acute abdomen’ (acute abdominal nerve 110 surgical emergency) 193 Axillary (circumflex) nerve 110 7.3 Acute upper abdominal pain 203 Brachial plexus 111 7.4 Acute right iliac fossa pain 208 Spinal nerve root lesions (cervical) 111 7.5 Acute lower abdominal (pelvic) pain 213 Lower limb: common peroneal nerve 111 7.6 Chronic epigastric pain 217 Posterior tibial nerve 112 7.7 Chronic lower abdominal (pelvic) pain 223 Sciatic nerve 112 7.8 Bowel obstruction 227 Femoral nerve 112 Initial assessment: small or large bowel Lumbo-sacral plexus and roots 112 obstruction? 227 5.4 Limb weakness – other causes 113 Small bowel obstruction 227 Weakness with wasting 113 Large bowel obstruction 232 Weakness without wasting 114 7.9 Abdominal mass 235 CNS lesions – hemiplegia 114 Right upper quadrant mass 237 Spinal cord lesions – paraplegia or Hepatomegaly 240 quadriplegia 115 Left upper quadrant mass 241 Splenomegaly 241 6 Limb problems 117 Combined liver and spleen enlargement 242 Ming Kon Yii and Marinis Pirpiris Epigastric mass 243 6.1 Introduction 117 Right iliac fossa mass 244 Arterial circulation 117 Left iliac fossa mass 245 Venous circulation 118 Abdominal swellings arising from the Neurological system 119 pelvis 246 Musculoskeletal locomotor system 120 7.10 Abdominal distension 246 6.2 Bony lumps 120 7.11 Retrosternal pain and heartburn 249 6.3 Musculotendinous lumps 125 7.12 Dysphagia 253 Muscle swellings 126 7.13 Weight loss 259 Tendinous swellings 126 7.14 Vomiting 261 6.4 Painful shoulder 130 7.15 Jaundice 265
  7. 7. CO N T E N T S vii 7.16 Haematemesis and melaena (upper 10.9 Anaemia 367 gastrointestinal haemorrhage) 271 10.10 Diabetes mellitus 368 7.17 Acute lower gastrointestinal (colonic) 10.11 Mental health problems 369 haemorrhage 277 10.12 Additional preoperative preparation 372 7.18 Iron deficiency anaemia 279 7.19 Bleeding with defaecation (anorectal 11 Postoperative problems 375 bleeding) 282 Ming Kon Yii 7.20 Altered bowel habit (constipation) 287 11.1 Introduction 375 7.21 Diarrhoea 291 11.2 Pain 375 7.22 Acute anal pain 297 11.3 Nausea and vomiting 376 7.23 Anal pruritus 301 11.4 Tachycardia 378 7.24 Anorectal lump 302 11.5 Fever 378 7.25 Anal discharge and incontinence 305 11.6 Shortness of breath and tachypnoea 380 7.26 Pneumaturia 308 11.7 Confusion and altered mental state 382 7.27 Perianal fistula and sinus 308 11.8 Low urine output 382 11.9 Sudden collapse or rapid 8 Groin, scrotum and abdominal deterioration 383 wall problems 312 11.10 Wound care problems 385 Alan Saunder, Caroline Dowling, 11.11 Abnormal investigations 387 Ken Farrell and Mark Frydenberg Hypokalaemia 387 8.1 Introduction 312 Hyperkalaemia 387 8.2 Inguinoscrotal lumps 317 Hydrogen ion (acid-base) disorders 388 Scrotal lumps 317 Metabolic acidosis 388 Groin and inguinoscrotal lumps 320 Metabolic alkalosis 388 8.3 Abdominal wall problems 324 Respiratory acidosis and alkalosis 389 The umbilicus 324 Umbilical discharge 324 12 Problems in surgical intensive Umbilical swellings and defects 325 care 390 Swellings of the abdominal wall 326 Tim Crozier 12.1 Introduction: What is intensive care? 390 9 Urogenital problems 328 12.2 Patient selection 390 Caroline Dowling and Mark Frydenberg 12.3 Throughput and efficiency 391 9.1 Introduction: urinary tract 328 12.4 ICU versus high dependency unit care 391 9.2 Loin pain 329 12.5 Postoperative ICU care 391 9.3 Painless haematuria 334 12.6 Recovery and discharge from the ICU to 9.4 Lower urinary tract symptoms (LUTS) 337 the surgical ward 394 9.5 Poor urinary stream 340 12.7 General management of ICU patients 395 9.6 Urinary retention 344 12.8 Cardiopulmonary arrest 395 9.7 Urinary incontinence 346 12.9 Common problems in the ICU 395 9.8 Penile lesions 348 12.10 The dying patient 403 12.11 Limitation of treatment/not for 10 Preoperative medical escalation of care orders 403 problems in surgical patients 352 12.12 Withdrawal of treatment 403 Julian Smith and Ming Kon Yii 12.13 Brain death and organ donation 403 10.1 Introduction 352 10.2 Assessing patients for surgery 352 13 Problems in the injured 10.3 Cardiac disease 355 patient 404 10.4 Respiratory disease 358 James Lim, Bruce Waxman and 10.5 Cerebrovascular disease 359 Marcel Favilla 10.6 Alcoholic liver disease 359 13.1 Introduction 404 10.7 Chronic renal disease 362 13.2 Managing the injured patient 404 10.8 Haemostatic and haemopoietic Initial assessment 404 disorders 363 Primary survey and resuscitation 405
  8. 8. viii CO N T E N T S Investigations and procedures 13.6 Facial injury 438 following the primary survey and Initial assessment 438 resuscitation 410 Definitive care 439 Secondary survey 410 13.7 Eye and orbital injury 439 Investigations and procedures Corneal flash burns 441 following the secondary survey 412 Perforating globe injuries 442 Re-evaluation 412 Superficial foreign body injury 443 Definitive care and transfer 412 Closed globe injury 444 Medical records and documentation 413 Injury to the orbit 444 Shock 413 Injury to the eyelids 446 13.3 Soft tissue injury and wound care 415 13.8 Chest injury 446 Classification of wounds 415 Life-threatening chest injuries 447 Principles of wound healing 415 13.9 Abdominal injury 450 Factors adversely affecting wound healing 415 13.10 Nerve injury 455 Definitive care 417 13.11 Vascular injury 458 13.4 Burns 421 13.12 Urinary tract injury 464 Pathophysiology of burns 421 Renal injury 464 First aid 422 Ureteral injury 466 Initial assessment 422 Bladder and urethral injury 466 Subsequent assessment and definitive 13.13 Spinal injury 467 care 424 Classification of spinal cord injury 468 13.5 Head injury 428 13.14 Major fractures and joint injury 470 Classification and definitions 428 13.15 Hand injury 474 Initial assessment 430 Investigations 433 Picture credits 477 Definitive care 433 Index 478
  9. 9. Foreword The seeds for a satisfactory and rewarding career as each of the subjects is dealt with in a uniform and a medical practitioner are planted in medical school logical fashion supported by clear and informative where students begin to develop professional habits diagrams, figures, tables, images and summaries. that can last for a lifetime. It is here that the important Details of surgical procedures are provided where building blocks required to become a competent and necessary for understanding but kept to a minimum. caring clinician must first be learned. This occurs A unique and welcome approach is the focus on through a step-wise process that recognises the impor- a problem-orientated clinical record and the art of tance of each patient as an individual with their own clinical conversation. Clarity in communicating the particular set of circumstances. patient’s problem(s) to another health professional The integrated curricula of many medical schools and the proper recording of these facts in the patient’s place an increasing emphasis on internal medicine yet record is a learned skill that is fundamental to the the generality of surgery may be equally important provision of acute and continuing care. in considering the timely management of a patient’s This easily readable textbook should appeal to a illness. For the student or trainee the clinical approach broad spectrum of undergraduate and postgraduate must be the same. This involves obtaining a thorough readers. It will be especially helpful for those preparing history, completing a physical examination, developing for examinations where the candidate is required to a differential diagnosis and deciding on a series of demonstrate robust skills in clinical reasoning as well investigations and a plan of management. Fundamental as in surgical knowledge. to this process is the development of the skill of clinical reasoning in order that judgement and decision making John P Collins, MD, MCH, FRCS, FRCSEd, FRACS, can take place. FAcad Med, FRCSI (Hon) The authors of this textbook are to be congratulated Immediate Past Dean of Education, Royal for creating a valuable and learner-friendly educational Australasian College of Surgeons, Melbourne resource that will provide students, trainees and those Visiting Professor, Nuffield Department of Surgery, beyond with the knowledge and clinical approach they University of Oxford, UK require to ensure the delivery of satisfactory health Visiting Research Fellow, Green Templeton College care. Using a problem-orientated clinical approach, Oxford, UK ix
  10. 10. Breast problems 3 Jane Fox 3.1 INTRODUCTION BOX 3.1 CAUSES OF UNILATERAL History ENLARGEMENT OF THE BREAST OR Discovering a lump is the complaint of most concern BREAST ASYMMETRY in patients presenting with breast disease. The clinician ■ Benign hypertrophy must answer the questions: Is a discrete (dominant) ■ Giant fibro-adenoma lump really present? Then, if the answer is yes: Is it ■ Sarcoma a carcinoma? Most carcinomas present as painless lumps. The other common forms of presentation of ■ Filariasis breast problems are painful breasts (often with general lumpiness), nipple discharge and skin changes. Also important is a history of: past breast pathology; Localised skin retraction and dimpling is an cyclical changes in the breast, particularly premenstrual important sign of infiltration by carcinoma. The breast tenderness and lumpiness; times of menarche and stroma is traversed by fine fibrous bands that support menopause; pregnancy, contraception and lactation the breast and have attachments to the dermis and to details including the number and dates of pregnancies the fascia over the pectoralis major muscle. Invasive and complications of lactation such as milk retention, and sclerosing lesions within the breast, by involving breast abscess, nipple soreness and retracted nipple; these ligaments, can produce tethering and dimpling and any family history of breast disease. of the overlying skin. The patient, while sitting, is asked successively to Physical examination raise the hands fully above the head, to clasp hands The fully exposed breasts are examined initially in the behind the neck, to place hands on hips, to press the seated and then the supine position. hands against the hips and to lean forwards. Asymmetry On inspection any asymmetry or alteration and distortion by a mass or skin tethering (Fig 3.1) and in contour of the breasts is noted (Box 3.1). Most retraction, are often only detected by movements such differences in size of the breasts are developmental. as arm elevation or leaning forward, or by tension of Accessory nipples may be observed along the milk the underlying chest muscles. Dermal oedema due line between axillae and groins. The most common to lymphatic obstruction causes a skin appearance site is just below the normal breast. Accessory breast resembling orange peel or pig skin (peau d’orange). tissue is most commonly seen between the true breast This sign is a feature of a locally advanced cancer or a and the axilla and may increase in size initially with local inflammatory lesion such as an abscess or may lactation but is rarely connected to the mammary follow treatment for breast cancer, particularly when ducts, although a rudimentary nipple may appear as the axillary lymph nodes have been dissected and when a pore on the skin. the patient has received radiotherapy to the conserved 67
  11. 11. 68 C L I N I C A L P R O B L E M S I N S U R G E RY breast. Erythematous discoloration of skin may be of a copious milky discharge and some psychoactive due to underlying infection, duct obstruction during medications may precipitate nipple discharge due to lactation or, occasionally, inflammatory malignancy. endocrine interactions. Cytological examination of the In the areola the nodules of Montgomery’s follicles are fluid may aid diagnosis. seen. These can sometimes become infected. Bilateral Palpation is initially performed with the patient nipple retraction may be a developmental anomaly. A supine. A pillow is placed beneath the shoulder on recent history of unilateral nipple retraction suggests the side being examined and the arm on that side underlying breast disease, particularly malignancy or is abducted with the hand placed behind the head periductal inflammation. (Fig 3.2). This spreads the breast over a larger area, Nipple discharge should be induced, if possible, reducing the depth of the breast tissue and thus by segmental compression around the areola, or facilitating palpation. The whole breast is palpated, assessed by examining the stain on underclothing. including the axillary tail, using the palmar surfaces of Spontaneous nipple discharge that is bloodstained or the fingers with the hand flat. This avoids mistaking a clear sticky yellow fluid is most commonly due to normal fat or glandular tissue for discrete lumps, a duct papilloma, but occasionally indicative of serious mistake that is common if the tips of the fingers are used. intraduct pathology, particularly ductal carcinoma The detection of a discrete or dominant lump requires in situ. Physiological discharge may been seen in experience in palpating the normal texture of the breast young women and during lactation. A thick creamy and recognising the normal and cyclical variation. If or green discharge suggests mammary duct ectasia and a lump is discovered or the patient’s suspicion of a is rarely spontaneous. Hyperprolactinaemia due to a lump is confirmed, its physical characteristics are microadenoma of the pituitary gland is a rare cause fully assessed. Many dominant lumps in the breast are cystic so that assessment for fluctuation is important; however, fluctuation will not be elicitable with deep cysts. The important physical characteristics of cancer are discreteness and induration. Fixity is usually a late sign except where a cancer is unusually superficial or in the infra-mammary fold of the breast. Finally the patient is brought back to the seated position to complete the examination. Any lumps are assessed by palpation with one hand, then by both hands compressing the breast between them. Fixation of the lump to the underlying muscle is tested by assessing for change in mobility upon contraction of the pectoralis major muscle. The patient is asked to press her hand against the hip in order to contract the muscle. The axilla is palpated while resting the patient’s forearm on the examiner’s forearm. Palpable nodes are common in the normal axilla; firm nodes of 1 cm or more suggest involvement by metastatic tumour. Enlarged and tender nodes may indicate an inflammatory or infective process. The examination is completed by looking for signs of metastatic disease, palpation for supraclavicular nodes and for hepatomegaly and bone Figure 3.1 Skin tethering due to cancer only demonstrable when the patient raises her arms Figure 3.2 Breast examination
  12. 12. 3 BREAST PROBLEMS 69 tenderness, particularly in the spine, and auscultation Positive signs of malignancy on mammography of the chest. A diagramatic record can then be made include an irregular infiltrating mass and focal of the findings (Fig 3.3). pleomorphic microcalcification. Differentiation of mass lesions and calcified lesions uses a combination Diagnostic tests of mammographic workup including magnification, Percutaneous aspiration of a breast lump is often part ultrasound and image-guided biopsy (Fig 3.4). of the routine physical examination, both to obtain a cytological specimen for diagnosis and to definitively Cytology and histology treat breast cysts. Simple aspiration of breast cysts is both Fine needle aspiration cytology (FNAC) is a very useful diagnostic and therapeutic. Cytological examination diagnostic test in solid lumps. Diagnostic accuracy can of the greenish-yellow fluid is not worthwhile, but be over 90–95%; however, the technique is often not cytology should be done if the aspirate is bloodstained diagnostic and core biopsy for histology is preferred or if the cyst is recurrent or if an ultrasound shows a in many centres. complex lesion. A negative report should never override clinical suspicion. Imaging techniques: mammography, Histology is more reliable than cytology, provided ultrasound the site of sampling is accurate – so false negatives Imaging of breast tissue commonly utilises mam- for cancer are rare. Open biopsy is the most reliable mography and ultrasound. Mammography provides examination, although it is uncommon for a patient the most sensitive and specific method of screening to not have a preoperative diagnosis. It is no longer an asymptomatic woman for signs of breast cancer. routine for the extent of a patient’s surgery to be Examination of a symptomatic patient generally determined by intraoperative frozen section. involves both mammography and ultra sound Specific markers can be indentified by immuno- and ultrasound should be regarded as a focused histochemistry including oestrogen and progesterone investigation rather than a screening strategy. High- receptors and tyrosine kinase receptors, which are resolution ultrasound is useful in providing diagnostic useful in predicting susceptibility to targeted therapies information about solid and cystic masses and is and in predicting prognosis. The development of gene increasingly used as a clinical tool to differentiate array techniques and proteomics are expected to refine between ‘lumpy normal’ and breast pathology. these tests. Mammography is least useful in breasts with dense glandular tissue in women aged under 30 years. Imaging 3.2 BREAST PAIN of dense breast tissue, particularly in women identified Breast pain (mastalgia) is a very common problem and at high risk of developing breast cancer, is challenging. is not often due to malignant disease. At present MRI (magnetic resonance imaging) has promising sensitivity and improving specificity and is of particular use in young women at high risk of breast Common causes cancer because of a genetic predisposition. 1 Cyclical mastalgia 2 Focal lesions – inflammation, neoplasia Clinical features and diagnosis In most instances breast pain is cyclical. This condition is very common. Sometimes the pain is continuous, severe and disabling. There is often a premenstrual increase in pain and lumpiness. The condition is most common between the ages of 30 and 50 years and is unusual after menopause. Breast pain may be cyclical or noncyclical – the former is much more common. The severity of pain varies widely and cyclical pain may be regarded as a minor variation to normal swelling, tenderness and tenseness before or with the period. Severe symptoms may be associated with increased Figure 3.3 Scheme for recording the characteristics of breast circulating prolactin. lesions On examination, tender lumpiness is felt in
  13. 13. 70 C L I N I C A L P R O B L E M S I N S U R G E RY a b c d Figure 3.4 Mammographic and sonographic images of the breast Mammographic and sonographic images of the breast often demonstrate the features of benign and malignant breast lesions. (a) Breast cancer typically appears on a mammogram as a focal density with spiculate edges. (b) Microcalcification can be associated with benign and malignant breast pathology and is graded according to its morphology. Typically malignant calcification is variable in size and shape and may cast the branching pattern of the milk ducts. (c) Simple cysts may show as a discrete density on mammography, but ultrasound best demonstrates the smooth cyst wall and anechoic cyst fluid. (d) Fibroadenomas may also appear as a discrete density on mammography and on ultrasound. A benign solid lesion should have more breadth than height. Courtesy of Dr Manish Jain, MIA
  14. 14. 3 BREAST PROBLEMS 71 the breast, usually without a dominant lump. The Confusion can be reduced by the correct method association of a lump will require appropriate imaging of palpation, which is to palpate gently with the and percutaneous cytological aspiration cytology or pulps of the fingers with a flat hand. Prodding and biopsy; management of the lump in such instances squeezing should be avoided in order to better detect is the main problem. The diagnosis of pain can the truly dominant lump. Breast examination requires be established by regular review without recourse experience before the clinician can be reasonably sure to radiological examination or biopsy. Patients are whether a lump is present or not. Greater sensitivity frequently reassured simply to have an explanation can be achieved by palpation with the breast and for their pain and may not require specific treatment. fingers lubricated by a thin soap film. Perhaps for Appropriate diagnostic and screening tests should be this reason, many lumps are first noted by the patient undertaken on the basis of clinical signs and estimated while showering. risk of cancer (particularly age). If the clinician feels that a lump is not present, the patient can be reassured, but it is important to Treatment plan determine what the patient has identified as a lump, Managing breast pain is often difficult. The principles and to consider whether imaging is indicated. of treatment are: The clinician also may be unsure whether a discrete ● Nonspecific measures including analgesia, lump is present or not. When a degree of lumpiness avoiding trauma and wearing at all times a is present, it may be difficult to be sure on the first brassiere that gives good support and protection. examination whether there is a dominant swelling A low-fat diet may assist in management and in a lumpy breast. In these cases the usual practice is does no harm. regular review, often timing the next visit at a different ● For patients with severe cyclical pain, many time during the menstrual cycle, as lumpiness of dietary modifications and methods of treatment breast tissue is commonly a cyclical phenomenon. have been used with variable success. Vitamins The natural lumpiness of the breast is least in the B1 (riboflavin) and B6 (pyridoxine) and a early part of the menstrual cycle. Bilateral mammog- diuretic taken for one week prior to the period raphy and ultrasound are also very helpful in these are commonly used, but their value is difficult to patients. assess and not supported by controlled clinical If the clinician identifies a dominant lump, age is trials. often helpful in suggesting an appropriate differential Bromocriptine (which reduces the circulating diagnosis. A variety of common breast changes can level of prolactin), danazol (an androgen), tamoxifen be defined by the acronym ‘ANDI’ (abnormalities (a selective oestrogen receptor modulator (SERM) of normal development and involution). Fibro- antagonist) and evening primrose oil (a source of adenomas are a developmental abnormality and most essential fatty acid) have all been used with some commonly present in women in their late teens and 20s success. The side effects of prolactin antagonists, and respond to normal growth stimuli. Benign breast SERMs and androgens can be severe and are usually cysts are a phenomenon of involution and commonly unacceptable in a benign condition unless symptoms present between 30 years and menopause. Carcinoma are severe. Evening primrose oil has been assessed by should be considered the most likely cause of a new RCT and approximately 80% of women with cyclical palpable abnormality in a post-menopausal woman breast pain respond to treatment, although the effect but occurs in young women as well. Thickenings in the is not immediate. Danazol is used as a short course of region of scars from previous benign breast biopsies treatment. can also cause difficulties in diagnosis. Similarly, a variety of discrete nonpalpable lesions 3.3 BREAST LUMP may be detected by screening mammography, although In most instances a lump in the breast is incidentally a lump may not be palpable. found by a woman or her general practitioner and may not be a discrete lesion. The breast consists of Causes fat and glandular tissue arranged between fibrous 1 Carcinoma tissue septa. It can be easy to sense a localised area 2 Fibro-adenosis of resistance that is incorrectly considered to be a 3 Fibrocystic change (breast cyst) lump. Squeezing the breast tissue between finger and 4 Fibro-adenoma thumb accentuates the tendency to produce ‘pseudo- 5 Mammary duct ectasia lumps’. 6 Less common causes
  15. 15. 72 C L I N I C A L P R O B L E M S I N S U R G E RY History and physical examination possible metastatic spread and staging the disease by 1. Carcinoma clinical examination (Box 3.2). Carcinoma of the breast is uncommon under the age of 30 years. Thereafter the prevalence of the disease steadily increases to a maximum at the age of about BOX 3.2 BREAST CANCER STAGING 60 years. Cancer staging systems based on the features of Most patients with carcinoma present with a pain- the primary tumour, the regional lymph nodes less lump in the breast. Symptoms of breast pain, nipple and distant metastases have been developed discharge, nipple retraction, generalised enlargement by the National Cancer Institute in the US. The of the breast and axillary swelling are less common staging system is regularly updated, particularly forms of presentation. as more detailed pathological testing such as Symptoms of metastatic disease may be present immunohistochemistry and PCR becomes available at diagnosis, although the majority of cancers are and impacts on the accuracy of predicting prognosis and on the evidence informing best practice. detected at an early stage (locoregional disease alone). Primary tumour (T) About half the cancers of the breast occur in the T0 No detectable primary tumour upper outer quadrant. A little less than a quarter are Tis In situ tumour (DCIS, LCIS, Paget’s disease of found in the region of the areola. the nipple) On initial inspection in the seated position the T1 Tumour less than 2 cm features sought include a mass or deformity, nipple T2 Tumour 2 cm and less than 5 cm retraction and dimpling of the skin (often produced by raising the arms above the head). With advanced T3 Tumour 5 cm and greater disease, skin discoloration, nodularity, erythema, T4 Tumour directly involving skin or chest wall oedema of the skin (peau d’orange) and ulceration and inflammatory cancer may be seen. Regional lymph node involvement (N) In the supine position with the shoulder on the N0 No lymph node involvement pillow, a breast cancer is commonly palpated as a N1 Mobile ipsilateral axillary nodes localised, nontender, firm or hard lump with a poorly N2 Fixed or matted axillary nodes or internal defined margin. Occasionally the lump is tender. mammary nodes Sometimes there may be evidence of inflammation. Rarely an inflammatory carcinoma presenting with N3 Infraclavicular or supraclavicular nodes warmth and extensive hyperaemia and oedema can Metastatic involvement (M) be mistaken for a breast abscess. Such inflammatory M0 No distant metastases carcinomas can exhibit redness involving most of the M1 Any distant metastases skin over the breast. The lump is examined for tethering to the fascia of pectoralis major muscle and the axilla is examined for involvement of nodes. Microscopic 2. Fibro-adenosis metastases are present in about one-third of clinically Fibro-adenosis is a condition leading to coexisting negative nodes. hyperplasia (adenosis and epitheliosis) and involution Although the patient’s complaint of a breast (fibrosis and cyst formation). Fibro-adenosis is most lump may be mistaken, some lumps are so small they common in women between 30 and 50 years of age cannot easily be felt by the clinician and yet have and is much less common after menopause. Dominant been discovered by the alert patient. These lesions are lumps indistinguishable from carcinoma may develop. generally less than 1 cm in diameter and need to be The lumps are often tender and a past history of painful very carefully sought with the patient’s aid. premenstrual lumpiness in the breast is common. Although rare, breast cancer may occur during Biopsy is necessary to be sure of the diagnosis of any pregnancy or lactation, when the changes in the dominant lump. breast obscure the true nature of the lesion and lead to a delay in diagnosis. A galactocele may persist as a 3. Fibrocystic change (breast cyst) localised collection of milk after lactation. Diagnosis Macrocystic change is a form of fibrocystic change is made clinically and on ultrasound, but biopsy may where cyst formation is marked. Cysts often present as be necessary. dominant lumps. Pain and tenderness are not common. Examination is completed by assessing the areas of A solitary cyst is smooth, spherical or domed, tense
  16. 16. 3 BREAST PROBLEMS 73 and firm. It may be possible to detect fluctuation. The by skin or nipple retraction and can be clinically clinical distinction is important because these lesions indistinguishable from carcinoma. In most, but not can be diagnosed and treated by aspiration at the all, cases there is a history of injury to the breast but initial consultation and the patient can be reassured. the trauma may have been unnoticed at the time. If aspiration does not provide complete resolution of the Breast abscess is usually (but by no means always) lump, if the aspirate is bloodstained, if the mass persists a complication of lactation. A common sequence after aspiration or if there is early re-accumulation of of events is for painful duct obstruction to occur. fluid, biopsy is indicated. Lactation is suppressed by the clinician and antibiotic treatment is often given. The inflammatory response 4. Fibro-adenoma that follows duct obstruction is not initially due to Fibro-adenoma is a common benign neoplasm of bacterial infection and should have been treated by the breast that mainly occurs before the age of 30. expression of milk and continued lactation. In most It is an abnormality of normal development and is cases the problem resolves with these measures. In thought to arise from a single breast lobule. Typically many instances the incorrect use of antibiotics for a fibro-adenoma is a round, firm, discrete, mobile, too long a period has been a causal factor in the nontender lesion about 1–2 cm in diameter (‘breast development of the abscess (‘antibioma’). mouse’) and found in a young woman in her late Causes of breast abscess in nonlactating breasts teens or early 20s. Impalpable fibro-adenomas may include mammary duct ectasia. be detected at routine breast imaging and multiple Mondor’s disease is a condition of subcutaneous fibro-adenomas are not uncommon. An uncommon lymphangitis presenting as a subcutaneous palpable form of fibro-adenoma occurs in this age group, with a discrete cord just lateral to the breast. It can occur in very cellular structure (‘cystosarcoma phyllodes’). This other areas such as the cubital fossa. It may accompany lesion is rarely malignant but may enlarge rapidly and other breast pathologies, including carcinoma, but recur locally after excision. usually occurs in a normal breast and is benign and self-resolving. It is now most commonly seen following 5. Mammary duct ectasia breast surgery. Mammary duct ectasia (‘plasma cell’ mastitis) is a common inflammatory condition of the breast. The Diagnostic plans condition is associated with duct stagnation and is 1. Fine needle aspiration cytology (FNAC) more common in the years just before menopause. A Radical surgery for breast cancer should never be lump develops when there is extravasation of the duct undertaken without an unequivocal histological contents and a localised foreign body inflammatory diagnosis of cancer. However, FNAC can provide useful response with variable degrees of fibrosis. The lump diagnostic information, particularly in confirming is a firm or hard, tender, poorly defined swelling. The benign conditions. When facilities are available, the lump is usually found near the margin of the areola, first diagnostic step is percutaneous aspiration of often with surrounding inflammation. Many cases the lump and cytological examination of the aspirate settle down, but often exploration is necessary to make (FNAC). The needle is inserted into the mass and the a diagnosis. A localised acute abscess may require plunger of the syringe is maximally retracted. The drainage. Presentation of later disease with developed needle is then moved back and forth in the mass four fibrosis can mimic the signs of cancer very closely. or five times. Throughout this manoeuvre negative After exploration, there is danger of a subsequent pressure is maintained by keeping the plunger of persistent mamillary fistula if the mass and obstructed the syringe retracted. Before removal of the needle ducts are not adequately excised. the suction is released; the needle is then withdrawn from the lesion. A small drop of aspirated material is 6. Less common causes placed on to a labelled slide and air dried. An ordinary Lipomas are usually easy to diagnose but, because of disposable syringe with a fine needle can be used or a their situation, biopsy is often necessary to be sure syringe holder that facilitates one-handed aspiration, of the diagnosis. A lipoma is a soft lobulated lesion leaving the other hand free to fix the lump. usually lying near the periphery of the breast in the subcutaneous fat. On compression it tends to slip away 2. Mammography from beneath the fingers. Mammography is the only reliable widely available Fat necrosis is of considerable clinical importance means of detecting breast cancer before a mass can because the mass that results is often accompanied be palpated in the breast. Experienced radiologists
  17. 17. 74 C L I N I C A L P R O B L E M S I N S U R G E RY can interpret mammograms correctly in about 90% axillary lymph nodes is indicated. Since 2004 sentinel of cases. lymph node sampling, using a radioactive tracer Indications for mammography are: or patent blue dye, is the usual practice in clinical ● to screen a selected group of women who are at stage 1 disease, with axillary dissection reserved for high risk of developing breast cancer, including those patients with pre- or postoperative evidence of those who have had a previous breast cancer axillary node involvement. Those patients requiring or treated electing to have a mastectomy may consider immediate ● to evaluate a questionable or ill-defined mass or or delayed breast reconstruction with implant or other suspicious change in the breast autologous tissue. ● to assist in the localisation of the lesion prior to Once the complete pathological report is available, biopsy or surgery. further treatment to reduce the risk of systemic recurrence should be considered. This is generally within Treatment plan the context of a multidisciplinary service involving the Dominant lumps require a tissue diagnosis. When the surgeon, medical oncologist and radiation oncologist, presence of breast cancer is established by core needle breast care nurse and other health professionals. The histology the treatment plan is as follows. treatment may involve chemotherapy, endocrine therapy including SERMs and aromatase inhibitors 1. Clinical staging and targeted therapies such as trastuzumab. In locally Before surgery the patient’s clinical stage should be advanced breast cancer systemic treatment may be assessed. Liver function tests should be performed; used first in recognition of a high risk of early systemic liver metastases may only be evident by the presence of relapse and to reduce the extent of locoregional disease an elevated serum alkaline phosphatase. Chest X-rays preoperatively. may show pulmonary metastases but are not a routine staging strategy 4. Stage IV disease and advanced local Further preoperative investigations such as bone disease scanning and a CT scan of the chest, liver and brain are The management of locally advanced and metastatic indicated only if metastases at these sites are clinically breast cancer depends on the extent of disease, the suspected or if the tumour is locally advanced as patient’s symptoms and the biological characteristics evidenced by a mass over 5cm or if the axillary nodes are of the tumour. Curative treatment may be appropriate palpable and abnormal. Bone scanning has not proved for locally advanced disease but stage 4 disease with dis- to be of reliable clinical value as a routine preoperative tant metastases is currently not curable and treatment test because of a high incidence of false positive results. focuses on symptom relief and slowing progression. It The diagnosis and treatment plan are fully discussed is recommended that management again be planned with the patient, emphasising treatment options and in a multidisciplinary context. sufficient time between diagnosis and treatment to consider and clarify these options. 3.4 NIPPLE DISCHARGE In most instances nipple discharge is due to benign 2. Curative surgical treatment for early breast disease; potentially concerning discharge disease will be spontaneous rather than expressed. It is not This is potentially possible for patients with stage 1 or uncommon for some fluid to be expressed either by an 2 disease. Those with stage 4 disease can only receive individual woman or during mammography, but it is palliative treatment. Surgery is unlikely to be curative not a recommended part of breast examination. for those with stage 3 disease. In the majority of The patient can usually describe the nature of patients with potentially curable disease the treatment the discharge or its appearance on the brassiere. is initially surgical, aiming to control local disease Spontaneous bloodstained or serous nipple discharge for the life of the patient. The majority of patients is usually due to a duct papilloma. Brownish-green can choose between breast conserving treatment, or creamy discharge, which can be expressed from which is a complete local excision of the cancer with multiple ducts and is often bilateral, is suggestive of histologically clear margins and radiotherapy, or a duct ectasia. It is important to know whether the total mastectomy. A small number of patients require discharge is unilateral or bilateral, whether there may a total mastectomy because of the size of the tumour be a physiological discharge and whether the patient or because the tumour is multifocal. When the cancer is able to locate the segment of breast from which is invasive some form of histological examination of pressure will produce the discharge.
  18. 18. 3 BREAST PROBLEMS 75 An opaque milky discharge commonly appears a Unilateral bloody discharge from a single few days before parturition. A thin transparent white duct discharge may continue after lactation. In both these This is usually caused by an intraduct papilloma. situations nipple discharge is not a diagnostic problem. Carcinoma is a rare cause and usually presents with Milky discharge from multiple ducts in a nonlactating an associated lump or mammographically identifiable breast may occur in rare syndromes associated lesion but is occasionally due to imaging occult ductal with hyperprolactinaemia. Occasionally, drugs and cancer in situ. With intraduct papilloma a mass is only contraceptive agents may cause milky discharge that occasionally palpable or visible sonographically. It is stops when these agents are ceased. useful for the clinician to define, if possible, the involved Paget’s disease of the nipple is a rare cause of a duct by pressure on different segments of the breast minor degree of nipple discharge that may also be around the nipple at the margin of the areola as this confused with eczema (Table 3.1). This condition is may facilitate focused imaging and surgery (Fig 3.5). an areolar intra-epithelial carcinoma spreading from a deeper intraduct carcinoma. Mamillary fistula This produces a purulent discharge from a point Common causes away from the nipple. Such a fistula usually results 1 Duct papilloma from periductal inflammation and abscess formation, 2 Intraduct carcinoma sometimes in association with a specific infection, and 3 Mammary duct ectasia occurs in the skin close to the areola. A long history of discharge often dates from a peri-areolar abscess Diagnostic plans that has been incised or has pointed to discharge Discharge from many duct orifices (often spontaneously on to the skin. The nipple is usually bilateral) inverted and it is generally possible to pass a probe The most likely diagnoses are benign mammary along the tract to a communicating major duct and dysplasia and mammary duct ectasia. A very rare out through the nipple. cause is hyperprolactinaemia. Mammary duct ectasia Purulent discharge may originate in a subareolar characteristically gives a creamy-white or toothpaste- abscess of Montgomery’s gland. This produces a like discharge and often shows associated retro-areolar purulent discharge from a point away from the nipple inflammation or swelling with nipple retraction. but within the areola. Mammary dysplasia associated with a serous or greenish discharge is more common in premenopausal women. Diagnostic plan The discharge is often bilateral, arises from many In the majority of cases the clinical diagnosis is obvious. ducts and is most marked just before menstruation. Cytology of the discharge is indicated, together with Associated breast lumpiness is common, but a dominant breast imaging. Fine needle aspiration cytology or lump needing biopsy is not usually found. Mammary core biopsy for histology of an associated mass may duct ectasia can present as a lump alone, discharge with be required. Cytology in duct ectasia will show only an associated lump or discharge alone. TABLE 3.1 Differences between Paget’s disease and eczema of the nipple Paget’s disease Eczema Unilateral Bilateral Older patients Younger Not itchy Itchy No vesicles or pustules Vesicles and pustules Nipple destruction Nipple normal with areolar changes Palpable lump often present No lump Figure 3.5 Nipple discharge A spot of fluid is seen to appear from a single duct with pressure Mammographic changes Normal mammogram on the related breast segment.
  19. 19. 76 C L I N I C A L P R O B L E M S I N S U R G E RY inflammatory cells. Ductal epithelial cells or red blood cells suggest the presence of an intraduct papilloma. Rarely, atypical cells or malignant cells are seen with more serious intraduct pathology. Treatment plan When a defined unilateral mass is present, treatment of A B the discharge is secondary to treatment of the mass. With a bloodstained nipple discharge the segment of breast from which the discharge arises should be defined. At operation the responsible duct is probed and excised with an adequate margin (microdochectomy) through a circumareolar incision. Histology will almost always confirm a benign lesion (Fig 3.6). Figure 3.6 Microdochectomy Bilateral and diffuse nipple discharge with normal A: identifiction of affected duct by local pressure and insertion of mammograms often needs no treatment other than lacrimal probe; B: excision of a segment containing the duct and reassurance. Rarely, prolonged nipple discharge in papilloma through a circumareolar incision association with mammary duct ectasia may require subareolar disconnection of the ducts. Mamillary fistula and Montgomery’s sinus are clinical examination the condition is present bilaterally treated by formal excision of the fistula and related in up to one-third of normal adult men. Most of these duct segment. men do not have pain or tenderness and are unaware of breast enlargement. 3.5 GYNAECOMASTIA Gynaecomastia is a common disorder. It can take the 2. Systemic disease form of either a discrete, palpable subareolar plate of Gynaecomastia is commonly seen with alcoholic liver tissue easily distinguished from surrounding fat or a disease and may be due to oestrogen retention. Up to more diffuse mass only slightly different on palpa- 30% of males with thyrotoxicosis have gynaecomastia. tion from the surrounding fat. Early histological Tender gynaecomastia may occur during the recovery examination reveals duct dilatation and epitheliosis. phase after severe illness or injury, when this has been Later the ductules become sparse and embedded in a associated with marked catabolism and weight loss. diffuse fibrous stroma. This condition was called refeeding gynaecomastia Unilateral gynaecomastia is more suggestive of local when originally noticed in former prisoners of pathology but may also be due to systemic causes. war. It is probably due to hormonal imbalance associated with a sudden return of gonadal function. Common causes Refeeding gynaecomastia may also be a factor in 1 Gynaecomastia of puberty and old age the gynaecomastia of patients with renal failure, as 2 Systemic diseases: alcoholic liver disease, renal it commonly occurs soon after commencement of injury, thyrotoxicosis, previous malnutrition dialysis or transplantation. 3 Carcinoma of the lung and other neoplasms 4 Drug-induced gynaecomastia 3. Carcinoma of the lung and other tumours Clinical features Carcinoma of the lung is uncommonly associated 1. Puberty and old age with gynaecomastia but should always be considered Gynaecomastia can result from an imbalance between as a possible cause in high-risk patients who develop circulating oestrogens and androgens, a state most gynaecomastia in mid-adult life. common at the time of puberty. Many normal pubertal Other tumours, such as hepatoma, adrenal or boys therefore develop gynaecomastia. In most testicular tumours, are rare causes of gynaecomastia. instances the condition is asymptomatic. Regression Carcinoma of the male breast should be considered in usually occurs within one or two years. The prevalence patients with unilateral gynaecomastia, but carcinoma of gynaecomastia also increases slowly in normal is a rare cause of breast enlargement in men. The adult men and into old age (senile gynaecomastia). diagnosis of carcinoma is suggested by a hard painless Gynaecomastia of minor degree is common. On lump, which is asymmetrical or eccentric in location
  20. 20. 3 BREAST PROBLEMS 77 and is associated with signs of fixation or a bloodstained because of their oestrogen-like properties and nipple discharge. Axillary nodes may be enlarged. sometimes because of ‘refeeding’ after control of congestive cardiac failure. 4. Drug-induced gynaecomastia Cytotoxic agents can produce secondary hypo- gonadism because of testicular damage. A secondary hypogonadal state can also be induced by drugs that act BOX 3.3 COMMON DRUGS ASSOCIATED on the central nervous system to raise serum prolactin. WITH GYNAECOMASTIA Such drugs include phenothiazines, amphetamines, ■ Oestrogens tricyclic antidepressants and marihuana. ■ Androgens Diagnostic plan ■ Methyldopa It is not necessary to perform a biopsy on all ■ Spironolactone patients with gynaecomastia. Clinical examination ■ Cimetidine including ultrasound is usually a reliable method of ■ Marihuana diagnosis. Biopsy is indicated if the lump is firm or ■ Digoxin hard and in some cases of asymmetrical or unilateral ■ Cytotoxic agents gynaecomastia. ■ Phenothiazines The recent onset of symptomatic gynaecomastia in adult life suggests the need for further investigation. ■ Amphetamines Of greatest importance is a careful drug history. The ■ Tricyclic antidepressants testis should be examined for neoplasms; chest X-ray ■ Reserpine and thyroid function tests should be performed. Screening tests of serum hormone levels are rarely necessary. A careful drug history is necessary. Drugs are an increasingly common cause of gynaecomastia. A Treatment plan commonly implicated drug is oestrogen, when used In many instances (gynaecomastia of puberty,) the either to induce feminisation (often concealed) or as condition is transient and reassurance is all that is treatment for carcinoma of the prostate. Testosterone required. Withdrawal of a potentially offending drug administration can also cause gynaecomastia, as can may lead to regression of the lesion. Senile gynae- anabolic steroid abuse. Methyldopa, used for the comastia is treated by reassurance. treatment of hypertension, is a common cause of If pain or tenderness is severe and persistent, gynaecomastia. despite analgesia and pyridoxine treatment, or if the Spironolactone and cimetidine can produce appearance is psychologically disturbing, excision gynaecomastia by competitive displacement of should be considered. Anti-oestrogens should not testosterone from its intracellular receptor. be used, especially for the benign gynaecomastia of Digitalis preparations can also cause gynaecomastia puberty.
  21. 21. Urogenital problems 9 Caroline Dowling and Mark Frydenberg 9.1 INTRODUCTION: URINARY include nocturnal polyuria and a constellation of TRACT nonspecific symptoms: anorexia, nausea and vomiting, headache, visual disturbances, lethargy, sallow skin, History oedema and general malaise. Urinary disease presents with a relatively small number of defined symptoms as presenting problems. Patients Physical examination may present with lower urinary tract symptoms Physical examination is often normal in patients with (LUTS) that are subcategorised as storage or irritative urinary tract disease. Detection of abnormalities symptoms (urinary frequency, urgency, nocturia, involves identification of renal or bladder masses, dysuria), voiding or obstructive symptoms (change together with examination of the lower urinary tract in strength of the urinary stream) and incontinence. in both sexes. Imaging is often then required. Ongoing obstructive LUTS may eventually present Renal masses are usually found to be due to as retention of urine. Haematuria may be due to simple renal cysts, tumours or obstruction causing benign or malignant disease; renal pain (colic) results hydronephrosis. Abdominal examination may reveal from obstruction, most often with ureteric calculi. a unilateral renal mass or the bilateral masses of Occasionally there may be recognition of a renal mass. polycystic kidneys. However, the majority of renal masses are now detected A renal swelling has the following characteristics: as incidental findings on abdominal imaging per- ● It fills out the flank and loin as it enlarges laterally formed for investigation of often unrelated symptoms. and downwards. One may be able to get above Prostate cancer is increasingly detected in the context a focal renal mass, but the upper margin of an of overall health assessments or as a case finding during enlarged kidney is often indistinct or disappears assessment of LUTS. A careful assessment of the history under the costal margin. In contradistinction to often suggests the diagnosis, which is usually supported spleen or liver, a kidney swelling’s inner margin by an imaging modality. rarely crosses the midline (apart from congenital Common pathologies are congenital anomalies, anomalies such as horseshoe kidneys). functional disorders and specific malignancies, ● It has a smooth, rounded lower pole. including those affecting children. Other malignancies ● It moves up and down with respiration but not of the urinary tract and prostate increase in frequency usually markedly as liver or splenic with age. Urinary tract trauma and infections are enlargements. common to all ages. Bladder neck obstruction from ● It has a band of colonic resonance over it prostatic disease is the most common problem in the anteriorly. elderly male. ● It is bimanually palpable and ballottable – a hand Patients should be assessed for evidence of renal from behind can displace the mass forwards failure (Ch 10.7). Symptoms of chronic renal failure where it is palpated by the hand in front. The 328
  22. 22. 9 U R O G E N I TA L P R O B L E M S 329 sign is classic of a mobile retroperitoneal renal ● ultrasound, plain X-ray and computed swelling but can be shared by any large flank tomography, angiography and MRI. swelling such as a very large liver or spleen (Fig 9.1). 9.2 LOIN PAIN Digital rectal examination (DRE) may reveal the The most common cause of loin pain is acute or changes of benign prostatic hypertrophy, prostatitis or chronic renal pain. Acute obstruction with dilatation carcinoma of the prostate. The external genitalia should of the urinary tract above the bladder causes acute also be examined. As with all physical examination, renal pain (renal or ureteric ‘colic’) that has a wide appropriate consent is obtained and privacy should distribution. Pain often radiates from the flank on be provided. the affected side to the anterior abdomen and groin and may extend into the penis or scrotum, or labia in Diagnostic tests females, or into the upper thigh (Fig 9.3). It is severe Several special investigations are of critical importance. and prostrating in character and although described They range from simple examination of the urine as ‘colic’ is usually continuously and unremittingly (which must never be omitted) to sophisticated severe until relieved. Renal ‘colic’ is due to ureteric functional and imaging tests. Those most commonly obstruction by stone, crystal, blood clot, necrotic employed are: papilla or infective debris, or back pressure due to a ● urinary examination and its chemical, cytological neuropathic bladder. Chronic renal pain gives a dull and bacteriological analyses loin ache and can be due to a variety of renal and ● serum biochemistry including estimation perirenal causes. of creatinine, urea and electrolytes and PSA (prostate specific antigen) where appropriate ● functional tests determining total renal function and that of individual kidneys and the adequacy of urine flow and its dynamics; nuclear medicine C has facilitated assessment of renal function, using radionucleides such as technetium 99-MDTPA D and MAG3 (mercaptoacetyl triglycerine) to measure glomerular filtration rate ● intravenous urography, retrograde and antegrade pyelo-ureterography, cystography and B urethrography; nonionic radiological contract agents have significantly increased the safety of these investigations ● cysto-urethroscopy (Figs 9.2a, b and c) A Figure 9.2a Cystoscopy and ureteric catheterisation A: tip of cystoscope with elevating bridge; B: trigone of bladder; C: ureteric oriface; D: interureteric bar Figure 9.1 Palpation of right kidney Figure 9.2b Normal right ureteric orifice as seen on cystoscopy
  23. 23. 330 C L I N I C A L P R O B L E M S I N S U R G E RY abdomen and groin; its acutely severe and unremitting character (despite its description as colic, it is frequently constant); an associated urge to void (usually indicating stone in the lower or intramural ureter); microscopic or macroscopic haematuria; and the response to the pain by the patient, who usually walks, bends or rolls about in an effort to obtain relief. The patient looks pale, sweats and may vomit. The pain is often characterised as the worst pain ever experienced. Examination may reveal tenderness in the renal angle or a tender renal swelling. The urine usually shows blood macroscopically or on chemical testing (dipstick), with numerous red cells on microscopic examination. Figure 9.2c Right ureteric orifice with guidewire in situ 2. Pain referred from the ovary or other abdominal viscera It is important to distinguish renal colic from other causes of abdominal pain, particularly those that may be imminently life-threatening such as leaking abdomi- nal aortic aneurysm or ectopic pregnancy. Ovarian pain, as from a twisted ovarian cyst, can sometimes be confused with renal pain because of its similarly wide distribution, but associated gynaecological symptoms, pelvic tenderness and an ovarian mass will usually enable the two to be easily distinguished. Pain referred from other sources, such as dissecting or leaking aortic aneurysm or thoracolumbar nerve root pain, is usually distinguishable by associated signs of vascular occlusion or locomotor abnormality. Renal pain with a predominantly abdominal component may occasionally be confused with acute cholecystitis, diverticulitis or appendicitis when those organs are sited in a lumbar position. These and other causes of severe abdominal pain, such as perforated ulcer, are usually distinguishable because of associated clinical features and signs of peritonitis and because such patients lie still with the pain. Figure 9.3 Renal ‘colic’ Typically, a continuous severe pain that radiates from the renal angle 3. Musculoskeletal pain and flank to the abdomen, parallel to the inguinal ligament, to the Pain from the lower thoracic spine can be felt in the base of the penis and into the scrotum. lumbar region. The onset of musculoskeletal pain (unless traumatic) is less acute than renal colic and Causes is exacerbated by standing, heavy lifting and twisting 1 Renal pain (colic) movements. The acute pain of lower thoracic intraspinal 2 Referred pain from the ovary or other abdominal disease is also made worse by coughing and sneezing viscera and often relieved by rest. Examination will usually 3 Musculoskeletal pain reveal local tenderness and deformity of the spine. 4 Less common causes Muscular injury or strain in the lumbar region can be confused with renal colic but the history of injury is Clinical assessment usually diagnostic. 1. Renal pain (colic) Acute renal colic is usually unmistakable because of: 4. Less common causes the location of the pain and its radiation from flank to Renal ‘colic’, without objective evidence of obstruction
  24. 24. 9 U R O G E N I TA L P R O B L E M S 331 and requiring repeated narcotic injections without contrast administration and ability to detect other relief, should raise suspicion of narcotic addiction intra-abdominal pathologies, intravenous urography but this should always be a diagnosis of exclusion. (IVP) was used to confirm the diagnosis of urinary Such patients may discolour their urine with blood obstruction, with demonstration of the causative obtained from finger-prick to make the clinical picture calculus, either as a radio-opaque shadow in line with more convincing. Occasionally herpes zoster (shingles) the ureter or as a radiolucent filling defect (Figs 9.4a– may present with loin pain. c), or showing a dilated upper urinary tract as the aftermath of a stone that has passed. IVP is now rarely Diagnostic plan performed in most emergency departments but is a On presentation to hospital, the diagnosis is usually useful adjunct if the diagnosis is equivocal. Ultrasound made after clinical history, examination and then can be helpful in excluding other intra-abdominal and urine dipstick with a commercial kit with positive for pelvic lesions or to demonstrate and serially monitor red blood cells is demonstrated and infection largely upper urinary tract dilatation due to obstruction. excluded by the absence of nitrites. The imaging Ultrasound is thus of particular value in children, in modality to confirm the diagnosis will then usually be whom repeated X-rays should be avoided. Renal colic a non-contrast spiral computed tomography (CT) scan with symptoms and signs of pyelonephritis (fever, of the abdomen and pelvis. An accompanying plain systemic toxicity) always requires urgent imaging. An abdominal X-ray is helpful in planning treatment and obstructed and infected kidney requires urgent relief, elucidating if the stone is radio-opaque or radiolucent. whereas obstruction in the absence of infection can be The X-ray may demonstrate an opaque calculus observed over the course of a week or more without (85% of urinary calculi are radio-opaque – Box 9.1), likelihood of renal parenchymal damage. which needs to be distinguished from phleboliths and other opacities. The CT findings consistent Treatment plan with an obstructing stone include perinephric fat Renal colic stranding, dilatation of the renal pelvis and/or ureter Parenteral narcotic injection is required for pain relief. and identification of the stone itself. The presence of Intravenous pethidine or morphine relieves pain the contralateral kidney should be sought and the within a short time and a protocol of administration is size and position of other calculi that appear bright white should be noted. Urine should then be sent for formal microscopy and culture to definitively exclude infection and quantitate the haematuria, and to look for crystals (oxalate). At the time of presentation, blood should be drawn for full examination, creatinine, urea and electrolytes to ascertain renal function and screen for metabolic abnormalities and serum uric acid; calcium and phosphate estimations are also useful screening tests for major metabolic abnormalities. Stone analysis is done if the stone is recovered. The patient is instructed to strain the urine to check for stone passage and obtain the stone for analysis. BOX 9.1 TYPES OF URINARY CALCULI ■ 70% are calcium oxalate and phosphate in acid urine (radio-opaque) ■ 15% are urate calculi in acid urine (radiolucent) ■ 10% are magnesium ammonium phosphate in alkaline, usually infected urine (radio-opaque) ■ 1% are cystine (partly radio-opaque) Prior to the popularity of CT for diagnosis, which Figure 9.4a Ureteric stone has the advantages of high sensitivity, speed, lack of Right-sided obstruction from stone causing hydronephrosis.
  25. 25. 332 C L I N I C A L P R O B L E M S I N S U R G E RY usually followed in the emergency department. In most instances the pain settles after adequate administration of initial narcotic and a period of observation in the emergency or short-stay ward. Adequate antiemetic should be given with the narcotic. Oral nonsteroidal anti-inflammatory drugs (NSAIDS) should be given with the initial narcotic (e.g. indomethcin 100 mg) and these can be given as suppositories if the patient is not tolerating oral medication. Precautions should be taken in those with a history of peptic ulcer disease. NSAIDS are a very effective form of pain relief in renal colic and can be continued as an outpatient. The patient can also be given oral narcotics such as paracetomol. Management of urinary calculi Most urinary calculi pass spontaneously, especially if they are small or less than 5 mm. Treatment is therefore initially expectant. The patient is treated with euvolemia, as pushing fluids will exacerbate pain, and observed at regular intervals by repeat imaging; a plain film if the stone was initially visualised this way will suffice. Additional CT, ultrasound or IVP may be necessary to confirm if the stone has passed. If Figure 9.4b CT stone coronal view of VUJ stone the stone enters the bladder its spontaneous passage Reproduced with permission from John Kourambas is usually assured; occasionally a stone subsequently impacts in the urethra causing acute stoppage of the urinary stream. Conservative management may be supported by agents that aid stone passage by ureteric relaxation such as an alpha-blocker (e.g. tamsulosin) or calcium channel antagonists (verapamil) alone or in combination. Indications for stone removal (Box 9.2). Removal is indicated only when parenchymal damage is a concern, for example, with unresolved urinary infection or the stone seems very unlikely to pass spontaneously, as with large calculi (> 1 cm diameter) or persisting pain without progress. It is also mandatory in the case of a solitary kidney, where anuria may ensue. BOX 9.2 INDICATIONS FOR REMOVAL/ DISRUPTION OF SYMPTOMATIC RENAL OR URETERIC STONE ■ Solitary kidney ■ Persistent symptomatic obstruction with urinary infection and danger of renal parenchymal damage ■ Large calculus (> 1 cm) that is unlikely to pass spontaneously ■ Persistent symptomatic obstruction without improvement or onward passage over one or two Figure 9.4c IVP demonstrating proximal ureteric stone weeks Reproduced with permission from John Kourambas