Head injury is a trauma to the head, that may or may not include injury to the brain (see also brain injury). However, 'brain injury' and 'head injury' are often used interchangeably in the medical literature.
The incidence (number of new cases) of head injury is 300 per 100,000 per year (0.3% of the population), with a mortality of 25 per 100,000 in North America and 9 per 100,000 in Britain. Head trauma is a common cause of childhood hospitalization.
Causes
Common causes of head injury are traffic accidents, home and occupational accidents, falls, and assaults. Bicycle accidents are also a common cause of head injury-related death and disability, especially among children.
Types of head injury
Head injuries include both injuries to the brain and those to other parts of the head, such as the scalp and skull.
Head injuries may be closed or open. A closed (non-missile) head injury is one in which the skull is not broken. A penetrating head injury occurs when an object pierces the skull and breaches the dura mater. Brain injuries may be diffuse, occurring over a wide area, or focal, located in a small, specific area.
A head injury may cause a skull fracture, which may or may not be associated with injury to the brain. Some patients may have linear or depressed skull fractures.
If intracranial hemorrhage occurs, a hematoma within the skull can put pressure on the brain. Types of intracranial hemorrage include subdural, subarachnoid, extradural, and intraparenchymal hematoma. Craniotomy surgeries are used in these cases to lessen the pressure by draining off blood.
Brain injury can be at the site of impact, but can also be at the opposite side of the skull due to a contrecoup effect (the impact to the head can cause the brain to move within the skull, causing the brain to impact the interior of the skull opposite the head-impact).
If the impact causes the head to move, the injury may be worsened, because the brain may ricochet inside the skull causing additional impacts, or the brain may stay relatively still (due to inertia) but be hit by the moving skull (both are contrecoup injuries).
Specific problems after head injury can include:
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Skull fracture
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Lacerations to the scalp and resulting hemorrhage of the skin
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Traumatic subdural hematoma, a bleeding below the dura mater which may develop slowly
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Traumatic extradural, or epidural hematoma, bleeding between the dura mater and the skull
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Traumatic subarachnoid hemorrhage
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Cerebral contusion, a bruise of the brain
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Concussion, a temporary loss of function due to trauma
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Dementia pugilistica, or "punch-drunk syndrome", caused by repetitive head injuries, for example in boxing or other contact sports
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A severe injury may lead to a coma or death
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Shaken Baby Syndrome - a form of child abuse
Diagnosis and prognosis
Head injury may be associated with a neck injury. Bruises on the back or neck, back pain, pain radiating to the arms is a sign of cervical spine injury meriting spinal immobilization and application of a cervical collar. It is common for head trauma patients to have drowsiness but to be easily aroused, headaches, and vomiting after injury. If exam and consciousness are preserved, this is of no concern. But if these symptoms persist > 1 or 2 days, a CT of the head is needed. In some cases transient neurologic disturbance may occur, lasting minutes to hours and causing occipital blindness and a state of confusion. Malignant post traumatic cerebral swelling can develop unexpectedly in stable patients after an injury, as can post traumatic seizures. Recovery in children with neurologic deficits will vary. Children with neurologic deficits who improve daily are more likely to recover, while those who are vegetative for months are less likely to improve. Most patients without deficits have full recovery. However, persons who sustain head trauma resulting in unconsciousness for an hour or more have twice the risk of developing Alzheimer's disease later in life.
Laparoscopic surgery
Cholecystectomy as seen through a laparoscope
Laparoscopic surgery, also called minimally invasive surgery (MIS), bandaid surgery, keyhole surgery, or ben ogg surgery is a modern surgical technique in which operations in the back are performed through small incisions (usually 2-3cm) as compared to larger incisions needed in traditional surgical procedures. Laparoscopic surgery includes operations within the abdominal or pelvic cavities, whereas keyhole surgery performed on the thoracic or chest cavity is called thoracoscopic surgery. Laparoscopic and thoracoscopic surgery belong to the broader field of endoscopy.
The key element in laparoscopic surgery is the use of a laparoscope: a telescopic rod lens system, that is usually connected to a video camera (single chip or three chip). Also attached is a fiber optic cable system connected to a 'cold' light source (halogen or xenon), to illuminate the operative field, inserted through a 5 mm or 10 mm cannula or Trocar to view the operative field. The abdomen is usually insufflated with carbon dioxide gas to create a working and viewing space. The abdomen is essentially blown up like a balloon (insufflated), elevating the abdominal wall above the internal organs like a dome. The gas used is CO2, which is common to the human body and can be absorbed by tissue and removed by the respiratory system. It is also non-flammable, which is important because electrosurgical devices are commonly used in laparoscopic procedures.
Procedures
Laparoscopic cholecystectomy is the most common laparoscopic procedure performed. In this procedure, 5-10mm diameter instruments (graspers, scissors, clip applier) can be introduced by the surgeon into the abdomen through trocars (hollow tubes with a seal to keep the CO2 from leaking). Rather than a minimum 20cm incision as in traditional cholecystectomy, four incisions of 0.5-1.0cm will be sufficient to perform a laparoscopic removal of a gallbladder. Since the gall bladder is similar to a small balloon that stores and releases bile, it can usually be removed from the abdomen by suctioning out the bile and then removing the deflated gallbladder through the 1cm incision at the patient's navel. The length of postoperative stay in the hospital is usually 2-3 days.
In certain advanced laparoscopic procedures where the size of the specimen being removed would be too large to pull out through a trocar site, as would be done with a gallbladder, an incision larger than 10mm must be made. The most common of these procedures are removal of all or part of the colon (colectomy), or removal of the kidney (nephrectomy). Some surgeons perform these procedures completely laparoscopically, making the larger incision toward the end of the procedure for specimen removal, or, in the case of a colectomy, to also prepare the remaining healthy bowel to be reconnected (create an anastomosis). Many other surgeons feel that since they will have to make a larger incision for specimen removal anyway, they might as well use this incision to have their hand in the operative field during the procedure to aid as a retractor, dissector, and to be able to feel differing tissue densities (palpate), as they would in open surgery. This technique is called hand-assist laparoscopy. Since they will still be working with scopes and other laparoscopic instruments, CO2 will have to be maintained in the patient's abdomen, so a device known as a hand access port (a sleeve with a seal that allows passage of the hand) must be used. Surgeons that choose this hand-assist technique feel it reduces operative time significantly vs. the straight laparoscopic approach, as well as providing them more options in dealing with unexpected adverse events (i.e. uncontrolled bleeding) that may otherwise require creating a much larger incision and converting to a fully open surgical procedure.
Conceptually, the laparoscopic approach is intended to minimise post-operative pain and speed up recovery times, while maintaining an enhanced visual field for surgeons. Due to improved patient outcomes, in the last two decades, laparoscopic surgery has been adopted by various surgical sub-specialties including gastrointestinal surgery (including bariatric procedures for morbid obesity), gynecologic surgery and urology. Based on numerous prospective randomized controlled trials, the approach has proven to be beneficial in reducing post-operative morbidities such as wound infections and incisional hernias (especially in morbidly obese patients), and is now deemed safe when applied to surgery for cancers such as cancer of colon.
The restricted vision, the difficulty in handling of the instruments (new hand-eye coordination skills are needed), the lack of tactile perception and the limited working area are factors which add to the technical complexity of this surgical approach. For these reasons, minimally invasive surgery has emerged as a highly competitive new sub-specialty within various fields of surgery. Surgical residents who wish to focus on this area of surgery, gain additional training during one or two years of fellowship after completing their basic surgical residency.
The first transatlantic surgery (Lindbergh Operation) ever performed was a laparoscopic gallbladder removal.
Advantages
There are a number of advantages to the patient with laparoscopic surgery versus an open procedure. These include
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reduced blood loss, which reduces the risk of needing a blood transfusion.
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smaller incision, which reduces pain and shortens recovery time.
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less pain, leading to less pain medication needed.
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Although procedure times are usually slightly longer, hospital stay is less, and often with a same day discharge which leads to a faster return to everyday living.
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reduced exposure of internal organs to possible external contaminants thereby reduced risk of acquiring infections.
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can be used in Gamete intrafallopian transfer (GIFT) surgery to put the eggs back into the fallopian tubes
Appendicitis
An acutely inflamed and enlarged appendix, sliced lengthwise
Appendicitis (or epityphlitis) is a condition characterized by inflammation of the appendix. All cases require removal of the inflamed appendix, either by laparotomy or laparoscopy. Untreated, mortality is high, mainly due to peritonitis and shock. Reginald Fitz first described acute appendicitis in 1886, and it has been recognized as one of the most common causes of acute abdomen pain worldwide.
Causes
On the basis of experimental evidence, acute appendicitis seems to be the end result of a primary obstruction of the appendix lumen. Once this obstruction occurs the appendix subsequently becomes filled with mucus and swells, increasing pressures within the lumen and the walls of the appendix, resulting in thrombosis and occlusion of the small vessels, and stasis of lymphatic flow. Rarely, spontaneous recovery can occur at this point. As the former progresses, the appendix becomes ischemic and then necrotic. As bacteria begin to leak out through the dying walls, pus forms within and around the appendix (suppuration). The end result of this cascade is appendiceal rupture causing peritonitis, which may lead to septicemia and eventually death. Among the causative agents, such as foreign bodies, trauma, intestinal worms, and lymphadenitis, the occurrence of an obstructing fecalith has attracted attention. The prevalence of fecaliths in patients with appendicitis is significantly higher in developed than in developing countries, and an appendiceal fecalith is commonly associated with complicated appendicitis. Also, fecal stasis and arrest may play a role, as demonstrated by a significantly lower number of bowel movements per week in patients with acute appendicitis compared with healthy controls. The occurrence of a fecalith in the appendix seems to be attributed to a right sided fecal retention reservoir in the colon and a prolonged transit time. From epidemiological data it has been stated that diverticular disease and adenomatous polyps were unknown and colon cancer exceedingly rare in communities exempt for appendicitis. Also, acute appendicitis has been shown to occur antecedent to cancer in the colon and rectum. Several studies offer evidence that a low fiber intake is involved in the pathogenesis of appendicitis. This is in accordance with the occurrence of a right sided fecal reservoir and that dietary fiber reduces transit time
Location of the appendix in the digestive system
Symptoms
Symptoms of acute appendicitis can be classified into two types, typical and atypical. The typical history includes pain starting centrally (periumbilical) before localizing to the right iliac fossa (the lower right side of the abdomen); this is due to the poor localizing (spatial) property of visceral nerves from the mid-gut, followed by the involvement of somatic nerves (parietal peritoneum) as the inflammation progresses. The pain is usually associated with loss of appetite and fever, although the latter isn't a necessary symptom. Nausea or vomiting may occur also the feeling of drowsiness and the feeling of general bad health. With the typical type, diagnosis is easier to make, surgery occurs earlier and findings are often less severe.
Atypical symptoms may include pain beginning and staying in the right iliac fossa, diarrhea and a more prolonged, smoldering course. If an inflamed appendix lies in contact with the bladder, there is frequency of micturition. With post-ileal appendix, marked retching may occur.
Signs
These include localized findings in the right iliac fossa. The abdominal wall becomes very sensitive to gentle pressure (palpation). Also, there is rebound tenderness. In case of a retrocecal appendix, however, even deep pressure in the right lower quadrant may fail to elicit tenderness (silent appendix), the reason being that the cecum, distended with gas, prevents the pressure exerted by the palpating hand from reaching the inflamed appendix. Similarly, if the appendix lies entirely within the pelvis, there is usually complete absence of the abdominal rigidity. In such cases, a digital rectal examination elicits tenderness in the rectovesical pouch. Coughing causes point tenderness in this area (McBurney's point) and this is the least painful way to localize the inflamed appendix. If the abdomen on palpation is also involuntarily guarded (rigid), there should be a strong suspicion of peritonitis requiring urgent surgical intervention. Other signs are
Rovsing's sign
Deep palpation of the left iliac fossa may cause pain in the right iliac fossa. Also known as: Rovsing's symptom named after Niels Thorkild Rovsing. This sign is used in the diagnosis of acute appendicitis. Pressure over the descending colon causes pain in the right lower quadrant of the abdomen.
Psoas sign
Occasionally, an inflamed appendix lies on the psoas muscle and the patient will lie with the right hip flexed for pain relief.
Obturator sign
If an inflamed appendix is in contact with the obturator internus, spasm of the muscle can be demonstrated by flexing and internally rotating the hip. This manouvre will cause pain in the hypogastrium.
Hernia
A hernia is a protrusion of a tissue, structure, or part of an organ through the muscular tissue or the membrane by which it is normally contained. The hernia has three parts: the orifice through which it herniates, the hernial sac, and its contents.
A hernia may be likened to a failure in the sidewall of a pneumatic tire. The tire's inner tube behaves like the organ and the side wall like the body cavity wall providing the restraint. A weakness in the sidewall allows a bulge to develop, which can become a split, allowing the inner tube to protrude, and leading to the eventual failure of the tire.
Pathophysiology
By far most hernias develop in the abdomen, when a weakness in the abdominal wall evolves into a localized hole, or "defect", through which adipose tissue, or abdominal organs covered with peritoneum, may protrude. Another common hernia involves the intervertebral disc, and causes back pain or sciatica.
Hernias may present either with pain at the site, a visible or palpable lump, or in some cases by more vague symptoms resulting from pressure on an organ which has become "stuck" in the hernia, sometimes leading to organ dysfunction. Fatty tissue usually enters a hernia first, but it may be followed by or accompanied by an organ.
Most of the time, hernias develop when pressure in the compartment of the residing organ is increased, and the boundary is weak or weakened.
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Weakening of containing membranes or muscles is usually congenital (which explains part of the tendency of hernias to run in families), and increases with age (for example, degeneration of the annulus fibrosus of the intervertebral disc), but it may be on the basis of other illnesses, such as Ehlers-Danlos syndrome or Marfan syndrome, stretching of muscles during pregnancy, losing weight in obese people, etc., or because of scars from previous surgery.
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Many conditions chronically increase intra-abdominal pressure, (pregnancy, ascites, COPD, dyschezia, benign prostatic hypertrophy) and hence abdominal hernias are very frequent. Increased intracranial pressure can cause parts of the brain to herniate through narrowed portions of the cranial cavity or through the foramen magnum. Increased pressure on the intervertebral discs, as produced by heavy lifting or lifting with improper technique, increases the risk of herniation.
Characteristics
Hernias can be classified according to their anatomical location
Examples include
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abdominal hernias
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diaphragmatic hernias and hiatal hernias (for example, paraesophageal hernia of the stomach)
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pelvic hernias, for example, obturator hernia
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hernias of the nucleus pulposus of the intervertebral discs
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intracranial hernias
Each of the above hernias may be characterised by several aspects
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congenital or acquired: congenital hernias occur prenatally or in the first year(s) of life, and are caused by a congenital defect, whereas acquired hernias develop later on in life. However, this may be on the basis of a locus minoris resistentiae (Lat. place of least resistance) that is congenital, but only becomes symptomatic later on in life, when degeneration and increased stress (for example, increased abdominal pressure from coughing in COPD) provoke the hernia.
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complete or incomplete: for example, the stomach may partially herniate into the chest, or completely.
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internal or external: external ones herniate to the outside world, whereas internal hernias protrude from their normal compartment to another (for example, mesenteric hernias).
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intraparietal hernia: hernia that does not reach all the way to the subcutis, but only to the musculoaponeurotic layer. An example is a Spigelian hernia. Intraparietal hernias may produces less obvious bulging, and may be less easily detected on clinical examination.
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bilateral: in this case, simultaneous repair may be considered, sometimes even with a giant prosthetic reinforcement.
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irreducible (also known as incarcerated): the hernial contents cannot be returned to their normal site with simple manipulation
If irreducible, hernias can develop several complications (hence, they can be complicated or uncomplicated)
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strangulation: pressure on the hernial contents may compromise blood supply (especially veins, with their low pressure, are sensitive, and venous congestion often results) and cause ischemia, and later necrosis and gangrene, which may become fatal.
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obstruction: for example, when a part of the bowel herniates, bowel contents can no longer pass the obstruction. This results in cramps, and later on vomiting, ileus, absence of flatus and absence of defecation. These signs mandate urgent surgery.
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another complication arises when the herniated organ itself, or surrounding organs start dysfunctioning (for example, sliding hernia of the stomach causing heartburn, lumbar disc hernia causing sciatic nerve pain, etc.)
PILES
What are they?
The tissue of the anus is rich in blood vessels. If these become dilated and swollen, they may project into the anal canal or out of the back passage (a prolapse) to form visible swellings. Some people describe them as varicose veins of the anus.
Piles are incredibly common - at least 50 per cent of people suffer with them at some time.
Causes
Piles tend to be caused by factors that cause the blood vessels to swell, including anything that increases pressure inside the abdomen such as constipation, pregnancy and being overweight.
Symptoms
Piles may cause no symptoms, especially if they're small, and many people don't realise they have them. However, they can also cause a range of problems
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A swelling protruding from the anus. Piles may be felt as small soft lumps at the opening of the back passage, sometimes compared to a 'bunch of grapes'. They're usually soft and fleshy but may become hard if thrombosis occurs. The piles may only appear after straining on the toilet.
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Bleeding from the back passage. The mucosa that covers the piles is quite delicate and if it is damaged, for example as you open your bowels, there may be bleeding, which is usually seen as small amounts of bright red blood on the toilet paper or on the surface of the motions. Occasionally, piles cause severe bleeding.
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Mucus discharge.
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Itching. Piles can cause intense itching of the skin around the back passage.
Piles can be painful, but this is uncommon. Acute pain and the appearance of a hard lump protruding from the anus can signal thrombosis of the haemorrhoid.
Treatment
The treatment of piles depends on the severity of symptoms. Firstly, it's important to take steps to avoid aggravating factors such as constipation or being overweight. Keeping your bowel motions soft and regular will also help to avoid straining.
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Make sure you eat plenty of fibre to provide bulk in your diet by including lots of bread, vegetables, cereal and nuts.
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Consider fibre supplements.
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Avoid dehydration by drinking plenty of water and fruit juice.
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Keep to a regular bowel habit and go to the toilet when you feel the need to - don't try to hold it in.
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Get plenty of exercise - this helps keeps the bowels regular.
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Avoid causes of constipation, such as painkillers that contain codeine.
These measures may be all that's needed to allow small haemorrhoids to settle. More persistent piles may need specific treatments.
Pain-relieving creams and ointments, which may contain an anaesthetic, can help soothe the discomfort of piles and allow you to open your bowels more easily. If piles become thrombosed this can be acutely painful. Cold packs and strong pain relief may be needed.
Surgical options
FISSURES AND FISTULA
In anatomy, fissure (Latin fissura, Plural fissurae) is a groove, natural division, deep furrow, cleft, or tear in various parts of the body.
Anatomy
Various types of anatomical fissure are
Brain
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Fissure of Bichat: found below the corpus callosum in the cerebellum of the brain.
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Broca's fissure: found in the third left frontal fold of the brain.
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Burdach's fissure: connects the brain's insula and the inner surface of the operculum.
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Calcarine fissure: extends from the occipital of the cerebrum to the occipital fissure.
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Callosomarginal fissure: found in the mesial surface of the cerebrum.
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Central fissure or Ronaldo's fissure: separates the brain's frontal and parietal lobes.
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Clevenger's fissure: found in the inferior temporal lobe of the brain
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Collateral fissure: found in the inferior surface of the cerebrum.
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Hippocampal fissure: a fissure that extends from the brain's corpus callosum to the tip of the temporal lobe.
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Horizontal fissure or Transverse fissure: found between the cerebrum and the cerebellum. Transverse fissure is also found in the liver and lungs.
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Occipitoparietal fissure: found between the occipital and parietal lobes of the brain.
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Fissure of Sylvius: separates the frontal and parietal lobes of the brain from the temporal lobe.
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Wernicke's fissure: separates the brain's temporal and parietal lobes from the occipital lobe.
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Zygal fissure: found in the cerebrum.
Skull
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Auricular fissure: found in the temporal bone
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Pterygomaxillary fissure
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Sphenoidal fissure: separates the wings and the body of the sphenoid bone.
Liver
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Longitudinal fissure: found in the lower surface of the liver, also a fissure that separates the right and left hemispheres of the cerebrum.
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Portal fissure: found in the under-surface of the liver.
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Umbilical fissure: found in front of the liver.
Fistula
In medicine, a fistula (pl. fistulas or fistulae) is an abnormal connection or passageway between two epithelium-lined organs or vessels that normally do not connect.
Location of fistulas
Fistulas can develop in various parts of the body. The following list is sorted by the International Statistical Classification of Diseases and Related Health Problems.
H: Diseases of the eye, adnexa, ear, and mastoid process
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(H04.6) Lacrimal fistula
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(H70.1) Mastoid fistula
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Craniosinus fistula: between the intracranial space and a paranasal sinus
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(H83.1) Labyrinthine fistula
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Perilymph fistula: tear between the membranes between the middle and inner ears
I: Diseases of the circulatory system
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(I25.4) Coronary arteriovenous fistula, acquired
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(I28.0) Arteriovenous fistula of pulmonary vessels
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Pulmonary arteriovenous fistula: between an artery and vein of the lungs, resulting in shunting of blood. This results in improperly oxygenated blood.
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(I67.1) Cerebral arteriovenous fistula, acquired
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(I77.0) Arteriovenous fistula, acquired
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(I77.2) Fistula of artery
J: Diseases of the respiratory system
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(J86.0) Pyothorax with fistula
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(J95.0) Tracheoesophageal fistula following tracheostomy: between the breathing and the feeding tubes
K: Diseases of the digestive system
Types of fistulas
Various types of fistulas include
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Blind: with only one open end
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Complete: with both external and internal openings
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Incomplete: a fistula with an external skin opening, which does not connect to any internal organ
Although most fistulas are in forms of a tube, some can also have multiple branches.
Causes
Various causes of fistula are
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Diseases: Inflammatory bowel diseases, such as Crohn's disease and ulcerative colitis, are the leading causes of anorectal, enteroenteral, and enterocutaneous fistulas. A person with severe stage-3 hidradenitis suppurativa will also develop fistulas.
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Medical treatment: Complications from gallbladder surgery can lead to biliary fistula. Radiation therapy can lead to vesicovaginal fistula. An arteriovenous fistula can be deliberately created, as described below in therapeutic use.
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Trauma: Head trauma can lead to perilymph fistulas, whereas trauma to other parts of the body can cause arteriovenous fistulas. Obstructed labor can lead to vesicovaginal and rectovaginal fistulas. An obstetric fistula develops when blood supply to the tissues of the vagina and the bladder (and/or rectum) is cut off during prolonged obstructed labor. The tissues die and a hole forms through which urine and/or feces pass uncontrollably. Vesicovaginal and rectovaginal fistulas may also be caused by rape, in particular gang rape, and rape with foreign objects, as evidenced by the abnormally high number of women in conflict areas who have suffered fistulae.
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In 2003, thousands of women in eastern Congo presented themselves for treatment of traumatic fistula caused by systematic, violent gang rape that occurred during the country's five years of war. So many cases have been reported that the destruction of the vagina is considered a war injury and recorded by doctors as a crime of combat.
Bariatric surgery
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Bariatric surgery, also known as weight loss surgery, refers to the various surgical procedures performed to treat obesity by modification of the gastrointestinal tract to reduce nutrient intake and/or absorption. The term does not include procedures for surgical removal of body fat such as liposuction or abdominoplasty.
Indications
A clinical practice guideline by the American College of Physicians concluded
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"Surgery should be considered as a treatment option for patients with a BMI of 40 kg/m 2 or greater who instituted but failed an adequate exercise and diet program (with or without adjunctive drug therapy) and who present with obesity-related comorbid conditions, such as hypertension, impaired glucose tolerance, diabetes mellitus, hyperlipidemia, and obstructive sleep apnea. A doctor–patient discussion of surgical options should include the long-term side effects, such as possible need for reoperation, gall bladder disease, and malabsorption."
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"Patients should be referred to high-volume centers with surgeons experienced in bariatric surgery."
Classification of surgical procedures
Procedures can be grouped in three main categories
Predominantly malabsorptive procedures
Predominantly malabsorptive procedures, although they also reduce stomach size, these operations are based mainly on creating malabsorption.
Diagram of a biliopancreatic diversion.
Biliopancreatic diversion
This complex operation is also known as biliopancreatic diversion (BPD), or Scopinaro procedure. This surgery is rare now because of problems with malnourishment. It has been replaced with the Duodenal Switch, also known as the BPD/DS. Part of the stomach is resected, creating a smaller stomach (however after a few months the patient can eat a completely free diet as there is no restrictive component). The distal part of the small intestine is then connected to the pouch, bypassing the duodenum and jejunum. This results in around 2% of patients severe malabsorption and nutritional deficiency that requires restoration on the normal absorption.
The malabsorptive element of BPD is so potent that those who undergo the procedure must take vitamin and mineral supplements above and beyond that of the normal population. Those that do not run the risk of deficiency diseases such as anemia and osteoporosis.
Because gallstones are a common complication of rapid weight loss following any type of weight loss surgery, some surgeons may remove the gall bladder as a preventative measure during BPD. Others prefer to prescribe medication to reduce the risk of post-operative gallstones.
Far fewer surgeons perform BPD compared to other weight loss surgeries, in part because of the need for long-term nutritional follow-up and monitoring of BPD patients.
Ulcerative colitis
Ulcerative colitis (Colitis ulcerosa, UC) is a form of inflammatory bowel disease (IBD). Ulcerative colitis is a form of colitis, a disease of the intestine, specifically the large intestine or colon, that includes characteristic ulcers, or open sores, in the colon. The main symptom of active disease is usually constant diarrhea mixed with blood, of gradual onset. Ulcerative colitis is, however, a systemic disease that affects many parts of the body outside the intestine. It can also form joint problems like Arthiritis. Because of the name, IBD is often confused with irritable bowel syndrome ("IBS"), a troublesome, but much less serious condition. Ulcerative colitis has similarities to Crohn's disease, another form of IBD. Ulcerative colitis is an intermittent disease, with periods of exacerbated symptoms, and periods that are relatively symptom-free. Although the symptoms of ulcerative colitis can sometimes diminish on their own, the disease usually requires treatment to go into remission.
Ulcerative colitis is a fairly common disease, with an incidence of about one person per 600 in the United States[citation needed]. The disease tends to be more common in northern areas. Although ulcerative colitis has no known cause, there is a presumed genetic component to susceptibility. The disease may be triggered in a susceptible person by environmental factors. Although dietary modification may reduce the discomfort of a person with the disease, ulcerative colitis is not thought to be caused by dietary factors. Although ulcerative colitis is treated as though it were an autoimmune disease, there is no consensus that it is such. Treatment is with anti-inflammatory drugs, immunosuppression, and biological therapy targeting specific components of the immune response. Colectomy (partial or total removal of the large bowel through surgery) is occasionally necessary, and is considered to be a cure for the disease.
Causes
While the cause of ulcerative colitis is still unknown, several, possibly interrelated, causes have been suggested. Some think that the smallest illness could spark the disease.
Severity of disease
In addition to the extent of involvement, UC patients may also be characterized by the severity of their disease.
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Mild disease correlates with fewer than four stools daily, with or without blood, no systemic signs of toxicity, and a normal erythrocyte sedimentation rate (ESR). There may be mild abdominal pain or cramping. Patients may believe they are constipated when in fact they are experiencing tenesmus, which is a constant feeling of the need to empty the bowel accompanied by involuntary straining efforts, pain, and cramping with little or no fecal output. Rectal pain is uncommon.
Colonic pseudopolyps of a patient with intractable ulcerative colitis. Colectomy specimen.
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Moderate disease correlates with more than four stools daily, but with minimal signs of toxicity. Patients may display anemia (not requiring transfusions), moderate abdominal pain, and low grade fever, 38 to 39 °C (99.5 to 102.2 °F).
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Severe disease, correlates with more than six bloody stools a day, and evidence of toxicity as demonstrated by fever, tachycardia, anemia or an elevated ESR.
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Fulminant disease correlates with more than ten bowel movements daily, continuous bleeding, toxicity, abdominal tenderness and distension, blood transfusion requirement and colonic dilation (expansion). Patients in this category may have inflammation extending beyond just the mucosal layer, causing impaired colonic motility and leading to toxic megacolon. If the serous membrane is involved, colonic perforation may ensue. Unless treated, fulminant disease will soon lead to death.
Extraintestinal features
As ulcerative colitis is a systemic disease, patients may present with symptoms and complications outside the colon. These include the following
Patients with ulcerative colitis can occasionally have aphthous ulcers involving the tongue, lips, palate and pharynx
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aphthous ulcers of the mouth
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Ophthalmic (involving the eyes)
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Iritis or uveitis, which is inflammation of the iris
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Episcleritis
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Musculoskeletal
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Seronegative arthritis, which can be a large-joint oligoarthritis (affecting one or two joints), or may affect many small joints of the hands and feet
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Ankylosing spondylitis, arthritis of the spine
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Sacroiliitis, arthritis of the lower spine
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Cutaneous (related to the skin)
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Erythema nodosum, which is a panniculitis, or inflammation of subcutaneous tissue involving the lower extremities
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Pyoderma gangrenosum, which is a painful ulcerating lesion involving the skin
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Deep venous thrombosis and pulmonary embolism
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Autoimmune hemolytic anemia
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clubbing, a deformity of the ends of the fingers
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Primary sclerosing cholangitis, or inflammation of the bile ducts
Breast cancer
It has been suggested that Inflammatory breast cancer be merged into this article or section. (Discuss)
Typical macroscopic (gross examination) appearance of the cut surface of a mastectomy specimen containing a cancer (in this case, an invasive ductal carcinoma of the breast, pale area at the center).
Mastectomy specimen containing a very large cancer of the breast (in this case, an invasive ductal carcinoma).
Breast cancer is a cancer that starts in the cells of the breast. Worldwide, breast cancer is the second most common type of cancer after lung cancer (10.4% of all cancer incidence, both sexes counted) and the fifth most common cause of cancer death. Worldwide, breast cancer is by far the most common cancer amongst women, with an incidence rate more than twice that of colorectal cancer and cervical cancer and about three times that of lung cancer. However breast cancer mortality worldwide is just 25% greater than that of lung cancer in women. In 2005, breast cancer caused 502,000 deaths worldwide (7% of cancer deaths; almost 1% of all deaths). The number of cases worldwide has significantly increased since the 1970s, a phenomenon partly blamed on modern lifestyles in the Western world.
The incidence of breast cancer varies greatly around the world, being lower in less-developed countries and greatest in the more-developed countries. In the twelve world regions, the annual age-standardised incidence rates per 100,000 women are as follows: in Eastern Asia, 18; South Central Asia, 22; sub-Saharan Africa, 22; South-Eastern Asia, 26; North Africa and Western Asia, 28; South and Central America, 42; Eastern Europe, 49; Southern Europe, 56; Northern Europe, 73; Oceania, 74; Western Europe, 78; and in North America, 90.
Women in the United States have the highest incidence rates of breast cancer in the world; 141 among white women and 122 among African American women. Among women in the US, breast cancer is the most common cancer and the second-most common cause of cancer death (after lung cancer). Women in the US have a 1 in 8 (12.5%) lifetime chance of developing invasive breast cancer and a 1 in 35 (3%) chance of breast cancer causing their death. In 2007, breast cancer was expected to cause 40,910 deaths in the US (7% of cancer deaths; almost 2% of all deaths).
In the US, both incidence and death rates for breast cancer have been declining in the last few years. Nevertheless, a US study conducted in 2005 by the Society for Women's Health Research indicated that breast cancer remains the most feared disease, even though heart disease is a much more common cause of death among women.
Because the breast is composed of identical tissues in males and females, breast cancer also occurs in males. Incidences of breast cancer in men are approximately 100 times less common than in women, but men with breast cancer are considered to have the same statistical survival rates as women.
Classification
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Breast cancers are described along four different classification schemes, or groups, each based on different criteria and serving a different purpose
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Pathology - A pathologist will categorize each tumor based on its histological (microscopic anatomy) appearance and other criteria. The most common pathologic types of breast cancer are invasive ductal carcinoma, malignant cancer in the breast's ducts, and invasive lobular carcinoma, malignant cancer in the breast's lobules.
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Grade of tumor - The histological grade of a tumor is determined by a pathologist under a microscope. A well-differentiated (low grade) tumor resembles normal tissue. A poorly differentiated (high grade) tumor is composed of disorganized cells and, therefore, does not look like normal tissue. Moderately differentiated (intermediate grade) tumors are somewhere in between.
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Protein & gene expression status - Currently, all breast cancers should be tested for expression, or detectable effect, of the estrogen receptor (ER), progesterone receptor (PR) and HER2/neu proteins. These tests are usually done by immunohistochemistry and are presented in a pathologist's report. The profile of expression of a given tumor helps predict its prognosis, or outlook, and helps an oncologist choose the most appropriate treatment. More genes and/or proteins may be tested in the future.
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Stage of a tumor - The currently accepted staging scheme for breast cancer is the TNM classification.
Metastases - There are two metastatic classification values (M0 or M1) which depend on the presence or absence of breast cancer cells in locations other than the breast and lymph nodes (so-called distant metastases, e.g. to bone, brain, lung).
COLON CANCER
Gross appearance of a colectomy specimen containing two adenomatous polyps (the brownish oval tumors above the labels, attached to the normal beige lining by a stalk) and one invasive colorectal carcinoma (the crater-like, reddish, irregularly-shaped tumor located above the label).
Gross appearance of a colectomy specimen containing one invasive colorectal carcinoma (the crater-like, reddish, irregularly-shaped tumor).
Colorectal cancer, also called colon cancer or large bowel cancer, includes cancerous growths in the colon, rectum and appendix. It is the third most common form of cancer and the second leading cause of cancer-related death in the Western world. Colorectal cancer causes 655,000 deaths worldwide per year, including about 16,000 in the UK, where it is the second most common site (after lung) to cause cancer death. Many colorectal cancers are thought to arise from adenomatous polyps in the colon. These mushroom-like growths are usually benign, but some may develop into cancer over time. The majority of the time, the diagnosis of localized colon cancer is through colonoscopy. Therapy is usually through surgery, which in many cases is followed by chemotherapy.
Symptoms
The first symptoms of colon cancer are usually vague, like weight loss and fatigue (tiredness). Local (bowel) symptoms are rare until the tumor has grown to a large size. Generally, the nearer the tumor is to the anus, the more bowel symptoms there will be.
Symptoms and signs are divided into local, constitutional and metastatic.
Local symptoms
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Change in bowel habits
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Change in frequency (constipation and/or diarrhea),
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Feeling of incomplete defecation (tenesmus) and reduction in diameter of stool, both characteristic of rectal cancer,
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Bloody stools or rectal bleeding
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Stools with mucus
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Black, tar-like stool (melena), more likely related to upper gastrointestinal eg stomach or duodenal disease
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Bowel obstruction causing bowel pain, bloating and vomiting of stool-like material.
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A tumor in the abdomen, felt by patients or their doctors.
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Symptoms related to invasion by the cancer of the bladder causing hematuria (blood in the urine) or pneumaturia (air in the urine), or invasion of the vagina causing smelly vaginal discharge. These are late events, indicative of a large tumor.
Constitutional (systemic) symptoms
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Unexplained weight loss, probably the most common symptom, caused by lack of appetite
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Anemia, causing dizziness, fatigue and palpitations. Clinically, there will be pallor and blood tests will confirm the low hemoglobin level.
Metastatic symptoms
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Liver metastases, causing
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Jaundice.
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Pain in the abdomen, more often the upper part (epigastrium or right side of the abdomen
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liver enlargement, usually felt by a doctor.
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Blood clots in the veins and arteries, a paraneoplastic syndrome related to hypercoagulability of the blood (the blood is "thickened")
Treatment
The treatment depends on the staging of the cancer. When colorectal cancer is caught at early stages (with little spread) it can be curable. However when it is detected at later stages (when distant metastases are present) it is less likely to be curable.
Surgery remains the primary treatment while chemotherapy and/or radiotherapy may be recommended depending on the individual patient's staging and other medical factors.
Prostate
The prostate (from Greek προστάτης - prostates, literally "one who stands before", "protector", "guardian") is a compound tubuloalveolar exocrine gland of the male mammalian reproductive system. Women do not have a prostate gland, although women do have microscopic paraurethral Skene's glands connected to the distal third of the urethra in the prevaginal space that are homologous to the prostate.
The prostate differs considerably among species anatomically, chemically, and physiologically.
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Posterior: urethra and rectum
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Superior: upper surface of urogenital diaphragm and urinary bladder
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Lateral: anterior fibers of levator ani muscle
Function
The main function of the prostate is to store and secrete a clear, slightly alkaline (pH 7.29) fluid that constitutes 10-30% of the volume of the seminal fluid that, along with spermatozoa, constitutes semen. The rest of the seminal fluid is produced by the two seminal vesicles. The alkalinity of seminal fluid helps neutralize the acidity of the vaginal tract, prolonging the lifespan of sperm.
The prostate also contains some smooth muscles that help expel semen during ejaculation.
Secretions
Prostatic secretions vary among species. They are generally composed of simple sugars, and are often slightly alkaline.
In human prostatic secretions, the protein content is less than 1% and includes proteolytic enzymes, acid phosphatase, and prostate-specific antigen. The secretions also contain zinc.
Regulation
To work properly, the prostate needs male hormones (androgens), which are responsible for male sex characteristics.
The main male hormone is testosterone, which is produced mainly by the testicles. Some male hormones are produced in small amounts by the adrenal glands. However, it is dihydrotestosterone that regulates the prostate.
Development
The prostatic part of the urethra develops from the pelvic (middle) part of the urogenital sinus (endodermal origin). Endodermal outgrowths arise from the prostatic part of the urethra and grow into the surrounding mesenchyme. The glandular epithelium of the prostate differentiates from these endodermal cells, and the associated mesenchyme differentiates into the dense stroma and the smooth muscle of the prostate. The prostate glands represent the modified wall of the proximal portion of the male urethra and arises by the 9th week of embryonic life in the development of the reproductive system. Condensation of mesenchyme, urethra and Wolffian ducts gives rise to the adult prostate gland, a composite organ made up of several glandular and non-glandular components tightly fused within a common capsule.
Skene's glands found in many females are homologous to the prostate gland in males.
Structure
A healthy human prostate is slightly larger than a walnut. It surrounds the urethra just below the urinary bladder and can be felt during a rectal exam.
The ducts are lined with transitional epithelium.
Within the prostate, the urethra coming from the bladder is called the prostatic urethra and merges with the two ejaculatory ducts. (The male urethra has two functions: to carry urine from the bladder during urination and to carry semen during ejaculation.) The prostate is sheathed in the muscles of the pelvic floor, which contract during the ejaculatory process.
The prostate can be divided in two different ways: by zone, or by lobe.
Lobes
Prostate with a large median lobe bulging upwards. A metal instrument is placed in the urethra which passes through the prostate. This specimen was almost 7 centimeters long with a volume of about 60 cubic centimetres on transrectal ultrasound and was removed during a Hryntschak procedure or transvesical prostatectomy (removal of the prostate through the bladder) for benign prostatic hyperplasia.
Prostatitis
Prostatitis is inflammation of the prostate gland. There are different forms of prostatitis, each with different causes and outcomes. Acute prostatitis and chronic bacterial prostatitis are treated with antibiotics; chronic non-bacterial prostatitis or male chronic pelvic pain syndrome, which comprises about 95% of prostatitis diagnoses, is treated by a large variety of modalities including alpha blockers, phytotherapy, physical therapy, psychotherapy, antihistamines, anxiolytics, nerve modulators and more. More recently, a combination of trigger point and psychological therapy has proved effective as well.
Prostate cancer
Prostate cancer is one of the most common cancers affecting older men in developed countries and a significant cause of death for elderly men (estimated by some specialists at 3%). Regular rectal exams are recommended for older men to detect prostate cancer early.
Though prostate cancer is of most concern to older men, it is like other cancers, a complex disease with many risk factors; race, age, genetics, and lifestyle habits can all contribute to its development.