12 Urology

Question 1

A 14-year-old boy presents in the ER with very severe pain of sudden onset in his right testicle. There is no fever, pyuria, or history of recent mumps. The testis is swollen, exquisitely painful, “high riding,” and with a “horizontal lie.” The cord is not tender.

Answer 1

What is it? Testicular torsion, a urologic emergency.

Management. Emergency surgery to save the testicle. Do not waste time doing diagnostic studies.

Question 2

A 24-year-old man presents in the emergency room with very severe pain of recent onset in his right scrotal contents. There is a fever of 103°F and pyuria. The testis is in the normal position, and it appears to be swollen and exquisitely painful. The cord is also very tender.

Answer 2

What is it? Acute epididymitis.
Management. This is the condition that presents the differential diagnosis with testicular torsion. Torsion is a surgical emergency. Epididymitis is not. Don’t rush this guy to the OR, all he needs is antibiotic therapy. If by chance the diagnosis of testicular torsion is missed, the medicolegal implications are so bad that urologists routinely do a sonogram when they are sure the problem is epididymitis—just to completely, absolutely, unequivocally rule out torsion.

Question 3

A 72-year-old man is being observed with a ureteral stone that is expected to pass spontaneously. He develops chills, a temperature spike to 104°F, and flank pain.

Answer 3

What is it? Obstruction of the urinary tract alone is bad. Infection of the urinary tract alone is bad. But the combination of the two is horrible: a true urologic emergency. That’s what this fellow has.
Management. Massive IV antibiotic therapy, but the obstruction must also be relieved right now. In a septic patient stone extraction would be hazardous, thus the option in addition to antibiotics would be decompression by ureteral stent or percutaneous nephrostomy.

Question 4

An adult woman relates that 5 days ago she began to notice frequent, painful urination, with small volumes of cloudy and malodorous urine. For the first 3 days she had no fever, but for the past 2 days she has been having chills, high fever, nausea, and vomiting. Also in the past 2 days she has had pain in the right flank. She has had no treatment whatsoever up to this time.

Answer 4

What is it? Pyelonephritis.
Management. Urinary tract infections should not happen in men or in children, and thus they should trigger a workup looking for a cause. Women of reproductive age, on the other hand, get cystitis all the time, and they are treated with appropriate antibiotics without great fuss. However, when they get flank pain and septic signs it’s another story. This woman needs hospitalization, IV antibiotics, and at least a sonogram to make sure that there is no concomitant obstruction

Question 5

A 62-year-old man presents with chills, fever, dysuria, urinary frequency, diffuse low back pain, and an exquisitely tender prostate on rectal exam.

Answer 5

What is it? Acute bacterial prostatitis.
Management. This vignette is supposed to elicit from you what you would not do. The treatment for this man is intuitive: he needs IV antibiotics—but what should not be done is any more rectal exams or any vigorous prostatic massage. Doing so could lead to septic shock.

Question 6

A 33-year-old man has urgency, frequency, and burning pain with urination. The urine is cloudy and malodorous. He has mild fever. On physical examination the prostate is not warm, boggy, or tender.

Answer 6

The first part of this vignette sounds like prostatitis, which would be common and not particularly challenging; but if the prostate is normal on examination the ante is raised: The point of the vignette becomes that men (particularly young ones) are not supposed to get urinary tract infections. This infection needs to be treated, so ask for urinary cultures and start antibiotics— but also start a urologic workup. Do not start with cystoscopy (do not instrument an infected bladder, you could trigger septic shock). Start first with a sonogram.

Question 7

You are called to the nursery to see an otherwise healthy-looking newborn boy because he has not urinated in the first 24 hours of life. Physical examination shows a big distended urinary bladder.

Answer 7

What is it? Kids are not born alive if they have no kidneys (without kidneys, lungs do not develop). This represents some kind of obstruction. First look at the meatus: it could be simple meatal stenosis. If it is not, posterior urethral valves is the best bet.
Management. Drain the bladder with a catheter if it passes easily (it will pass through the valves). Voiding cystourethrogram for diagnosis, endoscopic fulguration or resection for treatment.

Question 8

A bunch of newborn boys are lined up in the nursery for you to do circumcisions. You notice that one of them has the urethral opening in the ventral side of the penis, about midway down the shaft.

Answer 8

What is it? Hypospadias.
The point of the vignette is that you don’t do the circumcision. The foreskin may be needed later for reconstruction when the hypospadias is surgically corrected.

Question 9

A newborn baby boy has one of his testicles down in the scrotum, but the other one is not. On physical examination the missing testicle is palpable in the groin. It can easily be pulled down to its normal location without tension, but it will not stay there; it goes back up.

Answer 9

What is it? This is a retractile testicle, due to an overactive cremasteric reflex.
Management. Nothing needs to be done now. Even truly undescended testicles may spontaneously descend during the first year of life. Those that do not require orchidopexy.

Question 10

A 9-year-old boy gives a history of 3 days of burning on urination, with frequency, low abdominal and perineal pain, left flank pain, and fever and chills.

Answer 10

What is it? Little boys are not supposed to get urinary tract infections. There is more than meets the eye here. A congenital anomaly has to be ruled out.
Management. Treat the infection of course, but do IVP and voiding cystogram looking for reflux. If found, long-term antibiotics while the child “grows out of the problem.”

Question 11

A mother brings her 6-year-old girl to you because “she has failed miserably to get proper toilet training.” On questioning you find out that the little girl perceives normally the sensation of having to void and voids normally and at appropriate intervals, but also happens to be wet with urine all the time.

Answer 11

What is it? A classic vignette: low implantation of one ureter. In little boys there would be no symptoms, because low implantation in boys is still above the sphincter, but in little girls the low ureter empties into the vagina and has no sphincter. The other ureter is normally implanted and accounts for her normal voiding pattern.
Management. If the vignette did not include physical exam, that would be the next step, which might show the abnormal ureteral opening. Often physical examination does not reveal the anomaly, and imaging studies would be required (start with IVP). Surgery will follow.

Question 12

A 16-year-old boy goes on a beer-drinking binge for the first time in his life. Shortly thereafter he develops colicky flank pain.

Answer 12

What is it? Another classic. Ureteropelvic junction obstruction.
Management. Start with ultrasound (sonogram). Repair will follow.

Question 13

A 62-year-old man reports an episode of gross, painless hematuria. Further questioning determines that the patient has total hematuria rather than initial or terminal hematuria.

Answer 13

What is it? The blood is coming anywhere from the kidneys to the bladder, rather than the prostate or the urethra. Either infection or tumor can produce hematuria. In older patients without signs of infection, cancer is the main concern, and it could be either renal cell carcinoma or transitional cell cancer of the bladder or ureter.
Management. Do a CT scan and cytoscopy.

Question 14

A 70-year-old man is referred for evaluation because of a triad of hematuria, flank pain, and a flank mass. He also has hypercalcemia, erythrocytosis, and elevated liver enzymes.

Answer 14

What is it? Full-blown picture of renal cell carcinoma (very rarely seen nowadays).
Management. Do a CT scan.

Question 15

A 55-year-old chronic smoker reports three instances in the past 2 weeks when he has had painless, gross, total hematuria. In the past 2 months he has been treated twice for irritative voiding symptoms, but has not been febrile, and urinary cultures have been negative.

Answer 15

What is it? Most likely bladder cancer but must exclude renal etiology.
Management. Do a CT scan and cytoscopy.

Question 16

I. A 59-year-old black man has a rock-hard, discrete, 1.5-cm nodule felt in his prostate during a routine physical examination.
II. A 59-year-old black man is told by his primary care physician that his prostatic specific antigen (PSA) has gone up significantly since his last visit. He has no
palpable abnormalities in his prostate by rectal exam.

Answer 16

What are they? The two classic presentations for early cancer of the prostate.
Management. Transrectal needle biopsy, guided by the examining finger in the first case, and guided by sonogram in the second. Eventually surgical resection or radiotherapy after the extent of the disease has been established.

Question 17

A 62-year-old man had a radical prostatectomy for cancer of the prostate 3 years ago. He now presents with widespread bony pain. Bone scans show metastases throughout the entire skeleton, including several that are very large and very impressive.

Answer 17

Management. The point of the vignette is that significant, often dramatic palliation can be obtained with orchiectomy, although it will not be long-lasting (1 or 2 years only). An expensive alternative is luteinizing hormone-releasing hormone agonists, and another option is antiandrogens (flutamide).

Question 18

A 78-year-old man comes in for a routine medical checkup. He is asymptomatic. When a physician had seen him 5 years earlier, a PSA had been ordered, but he notices as he leaves the office this time that the study has not been requested. He asks if he should get it.

Answer 18

Management. For many years PSA was not done after age 75. Improved longevity and better treatments for early prostatic cancer have led to a more flexible approach. Also, with the advent of robotic prostatectomy, the surgery is so much safer and with better outcomes that PSA is now being offered selectively.

Question 19

A 25-year-old man presents with a painless, hard testicular mass. It is clear in the physical examination that the mass arises from the testicle rather than the epididymus. To be sure, a sonogram was done. The mass was indeed testicular.

Answer 19

What is it? Testicular cancer.
Management. This will sound horrible, but here is a disease where we shoot to kill first—and ask questions later. The diagnosis is made by performing a radical orchiectomy by the inguinal route. That irreversible, drastic step is justified because testicular tumors are almost never benign. Beware of the option to do a trans-scrotal biopsy: that is a definite no-no. Further treatment will include lymph node dissection in some cases (too complicated a decision for you to know about) and platinum-based chemotherapy. Serum markers are useful for follow-up: a-fetoprotein and b-human chorionic gonadotropin (b-HCG), and they have to be drawn before the orchiectomy (but they do not determine the need for the diagnostic orchiectomy—that still needs to be done).

Question 20

A 25-year-old man is found on a pre-employment chest x-ray to have what appears to be a pulmonary metastasis from an unknown primary tumor. Subsequent physical examination discloses a hard testicular mass, and the patient indicates that for the past 6 months he has been losing weight for no obvious reason.

Answer 20

What is it? Obviously same as above—but with metastasis. The point of this vignette is that testicular cancer responds so well to chemotherapy that treatment is undertaken regardless of the extent of the disease when first diagnosed. Manage exactly as the previous case.

Question 21

A 60-year-old man shows up in the ER because he has not been able to void for the past 12 hours. He wants to, but cannot. On physical examination his bladder is palpable halfway up between the pubis and the umbilicus, and he has a big, boggy prostate gland without nodules. He gives a history that for several years now he has been getting up four or five times a night to urinate. Because of a cold, 2 days ago he began taking antihistaminics, using “nasal drops,” and drinking plenty of fluids.

Answer 21

What is it? Acute urinary retention, with underlying benign prostatic hypertrophy.
Management. Indwelling bladder catheter, to be left in for at least 3 days. Further management will be based on the use of alpha-blockers. Other options include 5-alpha reductase inhibitors for large glands, or newly developed noninvasive interventions. The traditional TURP is rarely done now.

Question 22

On the second postoperative day after surgery for repair of bilateral inguinal hernias, the patient reports that he “cannot hold his urine.” Further questioning reveals that every few minutes he urinates a few milliliters of urine. On physical examination there is a large palpable mass arising from the pelvis and reaching almost to the umbilicus.

Answer 22

What is it? Acute urinary retention with overflow incontinence.
Management. Indwelling bladder catheter.

Question 23

A 42-year-old woman consults you for urinary incontinence. She is the mother of 5 children and ever since the birth of the last one, 7 years ago, she leaks a
small amount of urine whenever she sneezes, laughs, gets out of a chair, or lifts any heavy objects. She relates that she can hold her urine all through the night without any leaking whatsoever.

Answer 23

What is it? Stress incontinence.
Management. If she has no physical findings, she can be taught exercises that strengthen the pelvic floor. If she has a large cystocele, she will need surgical reconstruction.

Question 24

A 72-year-old man who in previous years has passed 3 urinary stones is now again having symptoms of ureteral colic. He has relatively mild pain that began 6 hours ago and does not have much in the way of nausea and vomiting. CT scan shows a 3-mm ureteral stone just proximal to the ureterovesical junction.

Answer 24

Management. Urologists have a bewildering array of options nowadays to treat stones, including laser beams, shock waves, ultrasonic probes, baskets for extraction, etc.—but there is still a role for watching and waiting. This man is a good example: small stone, almost at the bladder. Give him time, medication for pain, and plenty of fluids, and he will probably pass it.

Question 25

A 54-year-old woman has a severe ureteral colic. CT scan shows a 7-mm ureteral stone at the ureteropelvic junction.

Answer 25

Management. Whereas a 3-mm stone has a 70% chance of passing, a 7-mm stone only has a 5% probability of doing so. This one will have to be smashed and retrieved. Best option among answers offered would be shock-wave lithotripsy (SWL). (Contraindications to SWL include pregnancy, bleeding diathesis, and stones that are several centimeters big.)

Question 26

A 72-year-old man consults you with a history that for the past several days he has noticed that bubbles of air come out along with the urine when he urinates. He also gives symptoms suggestive of mild cystitis.

Answer 26

What is it? Pneumaturia caused by a fistula between the bowel and the bladder. Most commonly from sigmoid colon to dome of the bladder, caused by diverticulitis. Cancer (also originating in the sigmoid) is the second possibility.
Management. Intuitively you would think that either cystoscopy or sigmoidoscopy would verify the diagnosis, but real life does not work that way: they seldom show anything. Contrast studies (cystogram or barium enema) are also typically unrewarding. The test to get is CT scan. Because ruling out cancer of the sigmoid is important, the sigmoidoscopic examination would be done at some point, but not as the first test. Eventually surgery will be needed.

Question 27

A 32-year-old man has sudden onset of impotence. One month ago he was unexpectedly unable to perform with his wife after an evening of heavy eating and heavier drinking. Ever since then he has not been able to achieve an erection when attempting to have intercourse with his wife, but he still gets nocturnal erections and can masturbate normally.

Answer 27

What is it? Classic psychogenic impotence: young man, sudden onset, partner-specific.
Management. Curable with psychotherapy if promptly done.

Question 28

I. Ever since he had a motorcycle accident where he crushed his perineum, a young man has been impotent.
II. Ever since he had an abdominoperineal resection for cancer of the rectum, a 52-year-old man has been impotent.

Answer 28

Organic impotence has sudden onset only when it is related to trauma. Vascular injury explains the first of these two, and vascular reconstruction may help. Nerve injury accounts for the second, and only prosthetic devices can help there.

Question 29

A 66-year-old diabetic man with generalized arteriosclerotic occlusive disease notices gradual loss of erectile function. At first he could get erections, but they did not last long; later the quality of the erection was poor; and eventually he developed complete impotence. He does not get nocturnal erections.

Answer 29

This is the classic pattern of organic impotence (not related to trauma). A wide range of therapeutic options exists, but probably the first choice now is sildenafil, tadalafil, and vardenafil.