2021 Flashcards
Stabilization of the myocardium during life-threatening hyperkalemia associated with loss of P waves and widening of the QRS complex on the EKG is best accomplished using:
A. I.V. calcium gluconate. B. I.V. sodium bicarbonate. C. 10% glucose with regular insulin. D. potassium exchange resin with sorbitol. E. hemodialysis.
A. I.V. calcium gluconate.
Severe hyperkalemic cardiotoxicity must be treated immediately, not by lowering serum potassium concentration alone, but by preventing cardiac excitability and antagonizing the cardiotoxic effects of hyperkalemia. Thus, I.V. calcium gluconate is the initial treatment of choice. This must be followed by measures to immediately lower serum potassium since the duration of calcium effects are brief. Bicarbonate and glucose should be given next, but they are short-acting and exchange resins or dialysis should be planned for more long-term treatment.
If the inferior mesenteric artery is ligated, the artery that maintains blood supply to the rectum is:
A. superior mesenteric. B. ileocolic. C. middle sacral. D. external iliac. E. hypogastric.
E. hypogastric.
Blood supply to the rectum arises proximally from the superior rectal artery, which branches from the inferior mesenteric artery, and distally from the middle and inferior rectal arteries. When the inferior mesenteric artery is ligated, blood supply to the rectum is maintained by the middle rectal artery, which is a branch of the anterior division of the internal iliac (hypogastric) artery, and the inferior rectal artery, a branch of the internal pudendal artery also arising from the anterior division of the hypogastric artery. The superior mesenteric, ileocolic, middle sacral, and external iliac arteries do not provide blood supply to the rectum.
Three years after placement of an artificial urinary sphincter with initial good results for post-prostatectomy incontinence, a 55-year-old man has recurrent incontinence. Examination of the device and cystoscopy suggests normal cycling and no cuff erosion. The next step is:
A. deactivate device for a two month trial period.
B. alpha-blocker therapy.
C. antimuscarinics.
D. urodynamics.
E. surgical exploration for repair or replacement.
D. urodynamics.
Urethral atrophy results from chronic compression of the corpus spongiosum by the cuff and is the leading cause of urinary incontinence in this setting. However, urodynamic evaluation may reveal detrusor overactivity or decreased bladder compliance. Deactivation will not permit improved sphincter function. Surgical exploration is not indicated if the cause of the incontinence is unrelated to the device (i.e., detrusor overactivity or impaired compliance). Alpha-blockers would not be expected to have any effect on urinary incontinence in this case regardless of the underlying cause. Antimuscarinics would not treat causes of incontinence related to device malfunction. Treatment options for this patient, if he indeed has recurrent stress incontinence, would include downsizing the cuff or moving the cuff to a more proximal or distal location.
A 59-year-old man on active surveillance for Gleason 3+3=6 prostate cancer with a stable PSA of 5.1 ng/mL has intraductal carcinoma on repeat biopsy. He prioritizes maintenance of sexual function. The next step is:
A. PSA in six months. B. MRI scan in one year. C. repeat biopsy in one year. D. whole gland cryosurgery. E. nerve-sparing radical prostatectomy.
E. nerve-sparing radical prostatectomy.
Intraductal carcinoma of the prostate is an aggressive lesion for which immediate treatment, rather than active surveillance, is recommended. Thus, obtaining PSA in six months or waiting one year for an MRI scan or repeat biopsy would not be advised as these approaches risk delay in definitive therapy. Further, while limited data exist regarding the optimal treatment modality for intraductal carcinoma, whole gland cryosurgery likely represents undertreatment, particularly given the young age of the patient. Moreover, whole gland cryosurgery may significantly impact erectile function, such that AUA Guidelines state, “clinicians should inform localized prostate cancer patients considering whole gland cryosurgery that erectile dysfunction is an expected outcome”. Among the management options listed, although nerve-sparing radical prostatectomy poses risk to erectile function, it represents the optimal approach. XRT would also be an acceptable treatment option. If XRT is given with androgen deprivation, the risk of early/intermediate sexual dysfunction increases.
The renal toxicity of I.V. iodinated contrast material is due to:
A. glomerular injury.
B. afferent arteriolar constriction.
C. efferent arteriolar constriction.
D. intrarenal vasoconstriction and tubular necrosis.
E. efferent arteriolar dilation and tubular necrosis.
D. intrarenal vasoconstriction and tubular necrosis.
Three key risk factors that may provoke iodinated contrast-induced renal injury include pre-existing renal dysfunction (serum creatinine > 1.6 mg/dL or estimated GFR < 60 mL/min/1.73m2), pre-existing diabetes, and reduced intravascular blood volume. Contrast agents evoke renal injury by two mechanisms: first, by acting as an intrarenal vasoconstricting agent resulting in decreased intrarenal blood flow and hypoxemia; second, by a direct toxic effect of the contrast agent on tubular epithelial cells. The combination of renal medullary ischemia and direct cellular toxicity leads to increased renal epithelial cell apoptosis and acute tubular necrosis. The osmolality of the contrast agent once believed to be of paramount importance in the induction of contrast-induced nephropathy has been shown to play a minimal role in contrast-induced nephropathy. Indeed, recent studies have found that viscosity of the contrast agent is more important than osmolality. These findings resulted in the recommendation that periprocedural hydration along with limiting the amount of contrast agent are the key to preventing contrast-induced renal damage. A recent meta-analysis to evaluate the various interventions employed for prevention of this complication (assessing sodium bicarbonate solutions, adenosine antagonists [theophylline], N-acetylcysteine, and ascorbic acid) noted mixed results with no definitive proof that these agents could prevent the complication. Randomized control studies have, however, shown that in patients with a creatinine of > 3.5 mg/dL, prophylactic hemodialysis prior to and following the study can reduce the risk of this complication.
A 19-year-old with a pelvic fracture-related urethral injury undergoes endoscopic realignment. Three months after catheter removal, he has a weak stream. Retrograde urethrogram and VCUG are shown. The next step is:
A. urethral dilation. B. internal urethrotomy. C. anastomotic urethroplasty. D. buccal mucosa graft urethroplasty. E. penile skin flap urethroplasty.
C. anastomotic urethroplasty.
The images demonstrate a posterior urethral stricture. Anastomotic urethroplasty offers high success rates for urethral stenosis that occurs after urethral disruption injury due to pelvic fracture. Dilation and urethrotomy are potential options for first time treatment of short anterior urethral strictures, but not for posterior disruption injuries. Substitution urethroplasties, whether with buccal mucosa or penile skin flaps, are not appropriate when there is no lumen to augment, as in pelvic fracture urethral disruption. AUA Guidelines recommend anastomotic urethroplasty given the high success rates and the very low success rates of endoscopic management.
Ten days after an abdominal hysterectomy for cervical cancer, a 64-year-old woman has leakage of urine and purulent material from the vagina. A cystogram is normal, but a retrograde pyelogram demonstrates a left ureterovaginal fistula and marked hydronephrosis. The right upper tract is normal. The next step is I.V. antibiotics and:
A. percutaneous nephrostomy tube. B. ureteral stent placement. C. vaginal cuff drain placement. D. ureteroneocystostomy. E. transureteroureterostomy.
B. ureteral stent placement.
In the present case, the ureteral obstruction is not complete, as retrograde injection of contrast outlines the proximal ureter. Placement of a ureteral stent may result in resolution of the fistula. If retrograde placement is not successful, an antegrade approach can be undertaken. A percutaneous nephrostomy tube can be considered if stent placement is unsuccessful from either approach. If the fistula does not resolve after stent drainage, surgical repair would be indicated. There is no consensus as to the timing of surgical repair, though many would consider waiting at least four to six weeks after the initial surgery in order to optimize local tissue quality for healing. If surgical repair is necessary and she has a distal ureteral injury, then ureteroneocystostomy would likely be sufficient. A transureteroureterostomy would not be the initial repair for ureterovaginal fistula. Placement of a vaginal drain would not address the primary issue of the fistula.
A 22-year-old woman is evaluated for microscopic hematuria. Abdominal films demonstrate bilateral nephrocalcinosis with fine flecks of calcium appearing in most papillae. Renal function is normal. The most likely diagnosis is:
A. distal RTA. B. idiopathic hypercalciuria. C. Fanconi syndrome. D. proximal RTA. E. hyperparathyroidism.
A. distal RTA.
Nephrocalcinosis occurs primarily in children and young adults with distal RTA. This is characterized by impaired hydrogen ion excretion in the distal collecting duct. It rarely occurs in proximal RTA which results from an impairment in proximal tubular bicarbonate reabsorption or in Fanconi syndrome where excessive amounts of amino acids are excreted along with organic anions, such as citrate, which tend to prevent calcium precipitation. Idiopathic hypercalciuria and primary hyperparathyroidism rarely cause nephrocalcinosis, but when present, the acidification defect found in distal RTA usually coexists.
A 48-year-old woman develops a vesicovaginal fistula one week after vaginal hysterectomy. Cystoscopy shows a 5 mm area of erythema just cephalad to the trigone. Bilateral retrograde pyelograms are normal. Although vaginal leakage of urine persists, the majority of urine is voided normally. The next step is:
A. fulgurate fistula. B. bilateral nephrostomy tubes. C. immediate fistula repair. D. urethral catheter drainage. E. suprapubic cystostomy.
D. urethral catheter drainage.
In this patient, a trial of conservative management using urethral catheter drainage is indicated because of the small size of the fistula and the brief interval after the surgery. Given that the patient has no prior history of XRT or pelvic surgery, tissues should be adequately vascularized and capable of healing. Bilateral nephrostomy tubes to divert the urine drainage is more invasive and would not provide additional benefit over bladder drainage alone for a vesicovaginal fistula (VVF). Similarly, a suprapubic cystostomy does not offer benefit over a urethral catheter. There is little data to support fulguration of a VVF. Should catheter drainage fail, early repair may be done using a vaginal approach.
In a man with low-risk prostate cancer, the genomic test which provides an estimate of adverse pathologic features is:
A. Oncotype Dx®. B. Decipher®. C. Prolaris®. D. Confirm MDx®. E. Mitomic®.
A. Oncotype Dx®.
A variety of commercially available biopsy-based genomic tests are available in prostate cancer. Oncotype Dx® (mRNA expression in 17 genes) was developed to predict the likelihood of Gleason 4+3=7 or extracapsular extension at prostatectomy. Decipher® (mRNA expression of 22 genes) and Prolaris® (mRNA expression of cell cycle progression genes) predict the likelihood of metastasis or cancer-specific mortality. Confirm MDx® (epigenetic evaluation of hypermethylation in three genes) and Mitomic® (mitochondrial DNA) evaluate prostate tissue from a negative biopsy to predict the likelihood of cancer on a subsequent biopsy.
A two-month-old girl with a lumbar myelomeningocele had a febrile UTI. After therapy, videourodynamics show bilateral grade 5 VUR, a trabeculated bladder, leakage around the 7 Fr urodynamics catheter at a volume of 40 mL, and a detrusor pressure of 50 cm H2O. The next step is:
A. vesicostomy.
B. incontinent ileovesicostomy.
C. antibiotics and oxybutynin.
D. augmentation and bilateral ureteral reimplants.
E. bilateral ureteral reimplants and CIC.
A. vesicostomy.
This patient has high-grade VUR and a small trabeculated bladder with reduced capacity and poor compliance. This is combined with high urethral resistance. Antibiotics alone, with or without ureteral reimplantations, would be inadequate therapy. With grade 5 VUR, a bladder volume of only 40 mL (which would predominantly be made up of the volume of the upper tracts) and poor compliance with adequate urethral outlet, ureteral reimplantation without correction of the poor bladder compliance would be inadequate with a high risk of VUR recurrence. CIC may be helpful for the short-term; however, very poor compliance would make catheterization alone inadequate. Augmentation with ureteral reimplants and CIC or ileovesicostomy may ultimately be the therapy of choice but is not the best therapy for a two-month-old. Vesicostomy would provide temporary effective therapy.
A 15-year-old sexually active boy has urethritis, confluent red papules with a yellowish scale on the glans penis, arthritis of the knees, and uveitis. The best initial treatment of the skin lesions is:
A. intramuscular penicillin G. B. systemic retinoids. C. topical steroids. D. topical podophyllin. E. oral doxycycline.
C. topical steroids.
This boy has reactive arthritis (formerly Reiter’s Syndrome) which includes urethritis, genital skin lesions similar to those of psoriasis, arthritis, and inflammatory disease of the eye (uveitis). The skin lesions alone are difficult to distinguish from psoriasis, but the complex of symptoms is specific for reactive arthritis. The etiology is unknown but may be triggered by infection and is likely genetic as almost all affected patients have the HLA-B27 haplotype. Initial treatment is usually with topical steroids. If symptoms persist, systemic retinoids or even methotrexate may be needed. Oral or I.V. antibiotics are not indicated for this patient. Podophyllin is useful in treating genital warts but would not be beneficial in this patient.
A 53-year-old man with a history of cyclophosphamide chemotherapy has clot urinary retention. He continues to require daily blood transfusions despite cystoscopic fulguration and catheter clot evacuation. Alum irrigations and percutaneous nephrostomy drainage have been unsuccessful. A cystogram shows no VUR. The next step is:
A. 2-Mercaptoethane sulfonate (mesna). B. 10% formalin bladder irrigations. C. 10% formaldehyde bladder irrigations. D. cystectomy. E. 1% formalin bladder irrigations.
E. 1% formalin bladder irrigations.
Formaldehyde is a gas that can be dissolved in water. The maximum dissolution is 37% formaldehyde in an aqueous solution. In other words, 100% formalin equals 37% formaldehyde solution. This solution is then diluted to give an appropriate concentration of formalin. Since formaldehyde is a gas, it is not instilled into the bladder until it is dissolved in water yielding formalin. Typically, one starts with a low concentration (1%) of formalin bladder irrigations. If this fails, subsequent irrigations can be increased to higher concentrations. However, prior a cystogram should be performed to exclude VUR, and if reflux is found, ureteral occlusion balloons should be placed. Patients should be aware of potential postoperative pain, decreased bladder volume, and marked urinary urgency and frequency. Cystectomy should be reserved for situations that do not respond to less aggressive measures. Mesna has been utilized for prophylaxis of cyclophosphamide-induced hemorrhagic cystitis but is not therapeutic once cystitis has developed.
A 35-year-old man with C5 quadriplegia is managed with a condom catheter. He has recurrent febrile UTIs and episodes of autonomic dysreflexia. CMG reveals a detrusor LPP of 60 cm H2O at 150 mL, detrusor-external sphincter dyssynergia, and a residual of 75 mL after reflex bladder contraction. The next step is:
A. observation. B. CIC. C. antimuscarinic medication. D. external sphincterotomy. E. male sling.
D. external sphincterotomy.
Suprasacral spinal cord injury is often a management dilemma, as it may present with both storage and emptying failure. If bladder pressures are suitably low, or can be safely lowered by various means, the issue can be treated as an emptying failure and CIC may be used. This man, on the other hand, has several issues that require intervention including a high detrusor LPP which puts his upper urinary tracts at risk, recurrent UTIs and autonomic dysreflexia (AD). Observation may result in upper tract compromise and do not address his recurrent UTIs or AD; thus, is not a viable option at this time. Since he is a high quadriplegic, CIC is typically not feasible for these patients unless there is a caregiver or family member who are able to perform regular CIC. Additionally, his functional bladder capacity is only 150 mL, therefore, CIC alone would be inadequate. Antimuscarinic medication alone would also not be helpful since it would not address the dyssynergia or issues with incomplete emptying. A male sling would increase his outlet resistance and do nothing to reduce the impact of his bladder on the upper urinary tract. An external sphincterotomy can be used in these men to decrease the outlet resistance and lower the detrusor LPP. This would also likely address his issues with AD and recurrent UTI and he can continue to manage his bladder with the condom catheter; thus, avoiding the need for CIC in a patient who does not have the manual dexterity to perform that task.
A 76-year-old asymptomatic woman has a urine culture showing > 105 Klebsiella CFU/mL. Treatment with amoxicillin may:
A. reduce mortality. B. reduce morbidity. C. increase mortality. D. increase morbidity. E. increase risk of stone formation.
D. increase morbidity.
Prospective randomized trials comparing antimicrobial versus no therapy in elderly male and female nursing home residents with asymptomatic bacteriuria consistently document no benefit of antimicrobial therapy. There was no decrease in symptomatic episodes and no change in survival. In fact, treatment with antimicrobial therapy was associated with increased morbidity including increased occurrence of adverse drug effects, reinfection with resistant organisms, and increased cost of treatment. Therefore, asymptomatic bacteriuria in elderly patients should not be treated with antimicrobial agents. There is no increased risk of stone formation when treating with amoxicillin.
A seven-year-old boy with prostatic alveolar rhabdomyosarcoma undergoes chemotherapy per the Children’s Oncology Group protocol, but has residual mass on a post-treatment CT scan. Biopsy confirms mature rhabdomyoblasts. The next step is:
A. observation. B. salvage chemotherapy. C. XRT. D. radical prostatectomy. E. pelvic exenteration.
A. observation.
Residual mass, as in this case, does not imply viable tumor and does not correlate with outcome. Mature rhabdomyoblasts or stroma on biopsy may be safely observed with repeat imaging. Tumor cells may differentiate and mature into rhabdomyoblasts as in this case. Neither salvage chemotherapy nor XRT is required. Excision of the mass or pelvic exenteration are not required when only rhabdomyoblasts are present.
Seven years after cystectomy and ileal conduit for bladder cancer, a 66-year-old woman has bilateral hydroureteronephrosis. CT scan has no evidence of cancer recurrence and urine cytology is negative. Serum creatinine is 1.8 mg/dL. Loopogram and renogram are shown. The next step is:
A. looposcopy. B. bilateral percutaneous nephrostomy. C. stomal revision. D. revision of left ureteroileal anastomosis. E. left nephroureterectomy.
E. left nephroureterectomy.
This patient has developed upper tract deterioration following cystectomy and ileal conduit diversion. This has been reported in some series to occur in over 50% of patients with long-term follow-up. The renogram in this instance demonstrates no obstruction to the right renal unit with hydronephrosis likely the result of chronic reflux. The renogram also demonstrates no significant function of the left renal unit. Because there is no reflux into the left system, it cannot be monitored as to the possible development of upper tract urothelial carcinoma. In this setting, nephroureterectomy is recommended. Looposcopy will not add to the evaluation, as it will not provide access to the left system. Bilateral percutaneous nephrostomy is not indicated because there is no evidence of obstruction of the right side. Similarly, there is no evidence of stomal stenosis, as the conduit is not dilated or elongated. Revision of the left ureteroileal anastomosis should not be undertaken for a non-functioning kidney. Another option would be left nephrostomy tube placement, antegrade studies, and selective cytology to further risk stratify the patient prior to making a final decision.
Three months following an abdominoperineal resection, a 62-year-old man has persistent urinary retention managed with CIC. Cystoscopy reveals trilobar prostatic enlargement. Creatinine and PSA are normal. CMG reveals no detrusor overactivity, Pdet of 15 cm H2O at a maximal cystometric capacity of 350 mL, and no increase in detrusor pressure noted when given permission to void. The next step is:
A. continue CIC. B. finasteride. C. tamsulosin. D. Rezum™. E. TURP.
A. continue CIC.
Patients who have undergone an abdominoperineal resection are at risk for developing denervation of not only their bladder but also the urethral sphincter mechanisms. This patient has a mild loss of compliance with an end fill pressure of 15 cm H2O at a capacity of 350 mL. A loss of compliance can be a concern in regards to renal damage, but at that pressure his upper urinary tracts are not at risk. In addition, the lack of a detrusor contraction suggests that is the cause of his urinary retention and not bladder outlet obstruction. Additionally, denervation of the smooth muscle in the area of the bladder neck and membranous urethra places these patients at considerable risk for incontinence following transurethral resection of the prostate. Because of the possibility of urinary incontinence following TURP or RezumTM, the preferred management of this patient is continued CIC. Neither finasteride nor tamsulosin will be effective in the absence of effective detrusor contractions.
A 72-year-old man with recurrent nephrolithiasis has a positive voided cytology nine months after ureteroscopic laser ablation of a 7 mm right upper tract urothelial carcinoma. Retrograde pyelograms are normal and bladder and prostatic urethral biopsies are negative. Ureteroscopic biopsies demonstrate CIS in the right proximal and midureter. GFR is 44 mL/min/1.73 m2. The next step is:
A. ureteroscopic laser ablation.
B. ureteral stent insertion and intravesical BCG.
C. percutaneous nephrostomy tube insertion and antegrade BCG.
D. ureterectomy with Boari flap reimplantation.
E. nephroureterectomy.
C. percutaneous nephrostomy tube insertion and antegrade BCG.
Given the patient’s history of both chronic kidney disease as well as recurrent nephrolithiasis, efforts for nephron preservation would be advised in this setting. Nephroureterectomy would not represent the best option, particularly in the absence of high-grade papillary disease. At the same time, ureteroscopic laser ablation is not likely to be successful here, given the often-multifocal nature of CIS and the difficulty in accurately identifying CIS ureteroscopically. Instead, initial treatment with topical therapy would offer an opportunity for nephron preservation and would treat the entire urothelium of the ipsilateral upper tract. In particular, percutaneous (antegrade) instillation through a nephrostomy tube has been associated with relatively high rates of renal preservation, particularly for patients with CIS of the upper tract. On the other hand, attempting to establish VUR with stent insertion has been noted to be an unreliable method to achieve exposure of the upper urinary tract to intravesical instillation. Meanwhile, although Boari flap reconstruction may be able to reach even the proximal ureter and thereby facilitate reconstruction after proximal ureterectomy, this approach risks disease recurrence in the remaining upper tract urothelium given the often-multifocal nature of CIS.
A 32-week-gestation neonate in the NICU for respiratory difficulties is found to have Candida albicans on two successive catheterized urine cultures. He is voiding spontaneously and his renal and bladder ultrasound is normal. The next step is:
A. repeat urine culture in one week. B. circumcision. C. intravesical amphotericin. D. parenteral fluconazole. E. parenteral amphotericin.
D. parenteral fluconazole.
The incidence of nosocomial candidal UTIs occurring within neonatal intensive care units is common and directly related to the use of parenteral antibiotics. In this select patient population, aggressive treatment of asymptomatic candiduria is required due to a high incidence of subsequent candidemia. Indeed, in some published series, failure to treat asymptomatic candiduria in premature neonates resulted in systemic candidemia in up to 80% of patients, therefore, observation is not the correct option. Isolating treatment to the bladder with topical irrigation will not effectively minimize the risk of candidemia, and thus parenteral treatment is required. Fluconazole is the treatment of choice in a premature infant when compared to amphotericin because of significantly diminished systemic side effects. Circumcision will not decrease the risk of candidemia.
A 53-year-old diabetic man sustains a minor proximal crural perforation during primary implantation of a three-piece inflatable penile prosthesis via a penoscrotal approach. The best management is:
A. abort the procedure.
B. secure exit tubing of the ipsilateral cylinder.
C. extend corporotomy for primary repair.
D. place a malleable implant.
E. direct closure via perineal approach.
A common intraoperative complication with penile prosthesis surgery is crural perforation. If this occurs with insertion of an inflatable device with attached tubing, placing a tunica albuginea closure suture on either side of the exit tubing to keep the cylinder in place works well and does not require a more extensive repair. The “suture sling” involves placement of a nonabsorbable polypropylene stitch with a needle attached to both ends. The needle can be carefully placed in the very proximal end of the cylinder or through the rear tip extender. After placement of the cylinder in the appropriate corporal space and applying traction on the distal insertion string for proper placement, the suture is brought out through each side of the tunica just distal to the input tube exit and the sling suture is tied firmly over the corporotomy closure. A more significant perforation injury, including damage to the urethra, would require termination of the procedure. Placement of a malleable prosthesis is not advised as it is more likely to erode.
A 27-year-old pregnant woman in her third trimester has urinary frequency and dysuria. Physical examination demonstrates suprapubic tenderness but no flank discomfort. Urine culture is positive for pan-sensitive E. coli. She should be treated with:
A. tetracycline. B. trimethoprim/sulfamethoxazole. C. amoxicillin. D. ciprofloxacin. E. nitrofurantoin.
C. amoxicillin.
Penicillin and penicillin derivatives have been proven to be the safest antibiotics for use during pregnancy. Aside from allergy, there are no other known contraindications. Nitrofurantoin is usually safe but there is a risk of maternal neuropathy and hemolysis in a fetus with relative G6PD deficiency. Nitrofurantoin should only be used during the first two trimesters of pregnancy due to the risks of hemolytic anemia in the neonate. Trimethoprim/sulfamethoxazole should be avoided during pregnancy, as folic acid antagonists are known teratogens. Tetracycline is contraindicated due to adverse effect on the fetus (tooth discoloration and dysplasia). Ciprofloxacin should not be used during pregnancy due to its effects on developing cartilage.
A 48-year-old man has a two-week history of low back pain and difficulty voiding. Physical examination reveals an absent bulbocavernosus reflex and loss of perineal sensation. Imaging reveals a L4-L5 disc protrusion. The most likely distribution of his neural injury is:
A. parasympathetic alone. B. sympathetic alone. C. pudendal alone. D. parasympathetic and pudendal. E. sympathetic and pudendal.
D. parasympathetic and pudendal.
The clinical picture is consistent with cauda equina syndrome, which is associated with disc disease (severe central posterior disc protrusion) and other spinal canal pathologies that involve the L4-S2 region. Additional features of the presentation include loss of voluntary control of both anal and urethral sphincters and of sexual responsiveness. The most consistent urodynamic finding is that of a normally compliant, areflexic bladder with either normal innervation or incomplete denervation of the perineal floor musculature. Disc protrusions of the lumbar spine interfere with the parasympathetic and somatic innervation of the lower urinary tract, striated sphincter and other pelvic floor musculature, and afferent activity from the bladder and affected somatic segments to the spinal cord. With loss of parasympathetic innervation, patients will report difficulty voiding or have urinary retention. They may report a decreased sensation of bladder fullness and stress urinary incontinence when the disk protrusion affects the afferent signaling from the bladder and the somatic innervation to the pelvic floor, respectively.
A 48-year-old woman with ESRD has a history of low-grade Ta urothelial carcinoma treated by TURBT one year ago. Since then all cystoscopies have been normal. The recommended cancer free waiting time period from her last negative cystoscopy before proceeding with renal transplantation is:
A. no delay necessary. B. one year. C. two years. D. five years. E. none, transplant is contraindicated.
A. no delay necessary.
The cancer-free waiting time for renal transplant recipients is generally measured from the time of last treatment and depends primarily upon the risk of cancer recurrence. The presence of a low-grade, non-invasive urothelial carcinoma of the bladder should not delay transplantation.
A 30-year-old man with fever of 39.2° C undergoes incision and drainage of a perineal abscess and administration of broad-spectrum I.V. antibiotics. The next morning, urine starts to drain from the wound with voiding. The next step is:
A. CT urogram. B. cystoscopy. C. urethral catheter. D. suprapubic cystostomy. E. surgical repair.
D. suprapubic cystostomy.
Urethrocutaneous fistulae associated with periurethral and/or perineal abscess is most commonly due to underlying inflammatory urethral stricture and secondary UTI. At the time of presentation, multiple periurethral sinuses and pockets might be found resulting in a dense local inflammatory phlegmon. Urethral instrumentation in the face of active infection and a likely stricture is ill-advised due to the risk of bacteremia, sepsis, and potential worsening of the inflammatory process. Suprapubic cystostomy with aggressive incision and drainage should be performed in order to relieve the local infection. This can be followed by urethral reconstruction at a delayed interval. A CT urogram would not be helpful unless there was indication of upper tract issues.
When using an omental flap for repair of a vesicovaginal fistula, the artery on which the vascular pedicle of the omentum is based is the:
A. right gastroepiploic. B. left gastroepiploic. C. superior mesenteric. D. gastric E. splenic.
A. right gastroepiploic.
The right and left gastroepiploic arteries provide the sole blood supply to the omentum. An omental flap should be preferentially based on the right gastroepiploic artery. The pedicle is mobilized off the stomach from the left. This will result in a well-vascularized and sufficiently long flap. The right gastroepiploic is a larger vessel than the left gastroepiploic, and its origin is somewhat caudal as compared to the left, allowing a shorter course into the deep pelvis. The superior mesenteric, gastric, and splenic arteries do not supply the omentum.
A 30-year-old calcium stone former reports fatigue one month after starting hydrochlorothiazide for hypercalciuria secondary to renal calcium leak. The next step is:
A. check serum calcium and phosphorous. B. check serum sodium and potassium. C. liberalize intake of sodium chloride. D. increase fluid intake. E. switch from hydrochlorothiazide to indapamide.
B. check serum sodium and potassium.
Weakness, muscle cramps and fatigue are common side effects of thiazide therapy, and often can be avoided simply by starting at a low dose and gradually increasing it. These symptoms may be due to diuretic-induced hypokalemia or hyponatremia. In this clinical scenario, potassium and sodium levels should always be checked. If there is hypokalemia, treatment may be with potassium supplements or switching to a combined thiazide - potassium sparing diuretic preparation. If there is hyponatremia, treatment includes cessation of thiazide use, cation repletion, and oral fluid restriction. If severely symptomatic hyponatremia occurs, 3% I.V. saline solution may be indicated. It is unlikely that serum calcium and phosphorous will reveal new information in the setting of previously diagnosed renal calcium leak. Liberalization of sodium chloride and increasing fluid intake will reduce the effectiveness of the thiazide diuretic. Indapamide is not an improvement over hydrochlorothiazide in terms of hypokalemia risk.
One month after endovascular aortic repair (EVAR) for an aortic aneurysm, a 62-year-old man has the CT scan shown. Serum creatinine is 0.8 mg/dL. The next step is:
A. surveillance. B. MRI scan of the abdomen and pelvis. C. percutaneous biopsy of periureteral fibrosis. D. corticosteroids and tamoxifen. E. bilateral ureterolysis.
A. surveillance.
The case illustrates the ureteral involvement in patients with chronic peri-aortitis. There is a time-dependent regression of peri-aortic fibrosis after aneurysm exclusion, usually requiring at least four to six months, and the regression rate may be slow but persistent. To what extent the use of corticosteroids in some patients contributed to outcomes of interest is unclear. Tamoxifen has been used with some success as an alternative to steroids for peri-ureteral fibrosis but is not indicated here. A systematic review of the literature indicates that in terms of regression of peri-aortic fibrosis, surgical aneurysm repair is superior to EVAR. Persistent peri-aortic fibrosis occurs in 14% of patients treated with open surgical aneurysm repair. After EVAR, up to 40% of patients will not have resolution of peri-aortic fibrosis. In this case, diagnostic testing (MRI scan or biopsy) to exclude malignancy is not indicated because of the presence of the aneurysm. Bilateral ureterolysis is not indicated this early in the disease course.
Despite six months of behavioral modification and pelvic floor physiotherapy, a 52-year-old woman has persistent urinary frequency, urgency, and urgency incontinence. Physical examination demonstrates urine leakage with cough and a POP-Q of: Aa:-1, Ba:-1, C:-6, D:-7, Ap:-2, and Bp:-2. The next step is:
A. antimuscarinic medication. B. incontinence pessary. C. periurethral bulking. D. midurethral sling. E. autologous fascial sling.
A. antimuscarinic medication.
This patient has mixed urinary incontinence. Although stress incontinence is demonstrated on physical examination, this is not her primary complaint. Therefore, it is more appropriate to start with a treatment to address urgency urinary incontinence (antimuscarinic) and not stress incontinence (bulking agent, slings). An incontinence pessary is not indicated as it is meant to address stress incontinence via urethral compression. Additionally, she does not have prolapse symptoms and only mild anterior wall descent on exam. If she does not improve with pharmacotherapy, urodynamics would be helpful to better clarify bladder and urethral function as well as the etiology of leakage before proceeding to more invasive treatments.
A 54-year-old woman who underwent intestinal bypass surgery 15 years ago for obesity has passed 15 calcium oxalate stones. A 24-hour urine collection reveals a volume of 850 mL, pH 5.2, decreased calcium, sodium, citrate, and magnesium, and markedly elevated oxalate levels. Medical management should consist of increased fluid intake and:
A. calcium citrate.
B. magnesium citrate.
C. potassium citrate and calcium citrate.
D. calcium carbonate and magnesium citrate.
E. sodium bicarbonate and magnesium citrate.
C. potassium citrate and calcium citrate.
Intestinal bypass surgery results in a urine profile similar to that of chronic diarrheal syndrome, characterized by low urine volume, acidic urine, hypocitraturia, hyperoxaluria and low serum sodium, magnesium and calcium levels. Correction of the acidosis with potassium citrate will additionally correct the hypocitraturia since calcium citrate alone is typically not enough to correct the hypocitraturia and acidosis. A liquid formulation of potassium citrate may be needed if tablet formulation is poorly absorbed due to rapid intestinal transit. Calcium supplementation will not only raise urine calcium but will also complex intestinal oxalate that is typically over absorbed in states of bowel disease or intestinal resection. Although magnesium is poorly absorbed (similarly to calcium and sodium), magnesium supplementation is generally not advised because of the tendency of magnesium compounds to cause diarrhea. Any formulation of calcium supplementation is acceptable, although calcium citrate has been shown to have superior gastrointestinal absorption.
A contraindication to cytoreductive nephrectomy for metastatic RCC is:
A. progression of disease during initial systemic therapy.
B. vena caval thrombus.
C. involvement of the contralateral adrenal gland.
D. gross hematuria.
E. pulmonary metastases.
A. progression of disease during initial systemic therapy.
Cytoreductive nephrectomy as part of a multidisciplinary approach to metastatic RCC has been shown to prolong survival in two historic randomized clinical trials among patients treated with interferon. However, its use in the current era of significantly more effective systemic therapies has been debated. What has emerged regarding use of cytoreductive nephrectomy is that proper patient selection is crucial. One particularly adverse prognostic factor for disease-related mortality after cytoreductive nephrectomy is progression of disease during initial systemic therapy. As such, patients initially treated with systemic therapy who experience disease progression should be considered for an alternative systemic therapy rather than surgical resection. Meanwhile, neither pulmonary metastases nor contralateral adrenal involvement are contraindications to cytoreductive nephrectomy. In fact, isolated adrenal metastases may be amenable to local treatment (resection, ablation) while patients with pulmonary-only metastases often have a prolonged indolent clinical course, such that in both scenarios, durable survival after cytoreductive nephrectomy is possible. Gross hematuria also does not represent a contraindication to cytoreductive nephrectomy, and, in fact, significant local symptoms from the primary tumor (i.e., severe flank pain, persistent gross hematuria) represent one indication to perform cytoreductive nephrectomy, considering as well a patient’s age and performance status. Likewise, the presence of a tumor thrombus is not a contraindication to cytoreductive nephrectomy and may be a deciding factor for surgery in select patients. Indeed, tumor thrombus may cause significant patient morbidity (i.e., lower extremity edema) and may with continued growth be an imminent source of mortality. Responses of tumor thrombus to systemic tyrosine kinase inhibitors have been found to be minimal, while the response to newer, checkpoint inhibitor therapies remains to be determined.
A 72-year-old man with castration-resistant prostate cancer and bony metastases is placed on abiraterone 1000 mg QD and prednisone 5 mg twice daily. After one month of therapy, he experiences fatigue, nausea, and anorexia, despite objective clinical improvement in his bone metastases. The next step is:
A. histamine-2 blocker. B. magnesium supplementation. C. megestrol acetate. D. increase dose of prednisone. E. switch to enzalutamide.
D. increase dose of prednisone
Abiraterone is a CYP-17 inhibitor indicated for men with newly diagnosed metastatic castration-sensitive or metastatic castration-resistant prostate cancer. Due to CYP-17 blockade of glucocorticoid and androgen production, adrenal precursors such as ACTH are preferentially shunted to produce excess mineralocorticoids, which can lead to hypokalemia, hypertension, and lower extremity edema. Hypokalemia can lead to weakness, nausea and vomiting, and anorexia. Abiraterone is typically administered with prednisone 5 mg twice daily to counteract the potential mineralocorticoid excess. ACTH excess and related symptoms can occur even with administration of low-dose prednisone with abiraterone. Megestrol acetate is a progestin that, in addition to suppressing gonadotropins, also inhibits ACTH secretion and can be used as an appetite stimulant. Hypomagnesemia is not a common side effect of abiraterone. Switching therapy to enzalutamide would not be indicated as he is otherwise responding to the abiraterone other than the side effects. A histamine (H2) blocker would not be indicated as the symptoms are unlikely due to GERD or gastritis.
When performing fluoroscopy, the action that will most effectively lower the patient’s radiation exposure is to:
A. move the image intensifier closer to the patient.
B. move the x-ray tube closer to the patient.
C. use electronic magnification.
D. use tight collimation.
E. increase kVp.
A. move the image intensifier closer to the patient.
The source of the radiation exposure is the x-ray tube. The closer the patient is to the x-ray tube, the higher the rate of exposure to radiation. The image intensifier should be kept as close to the patient as practical to limit radiation dose. Tight collimation will not change the entrance dose rate but does limit the scatter of x-ray (limits exposure for others in the room besides the patient). Electronic magnification has no effect on entrance dose rate. Increased kVp will increase both the penetrability and intensity of radiation at the skin entrance, thus increasing patient exposure.
A 25-year-old man hears a snap during intercourse, without loss of erection. He awakens the next morning with penile pain and on examination has penile shaft and scrotal ecchymosis. He has a normal stream and no hematuria. The next step is:
A. observation. B. penile MRI scan. C. penile duplex Doppler ultrasound. D. urethrography. E. penile exploration.
A. observation.
A genuine penile fracture involves a tear in the tunica albuginea. The injury will invariably result in acute loss of erection due to blood rapidly exiting the affected corpus cavernosum. This will in turn lead to the classically described eggplant deformity as well as frequently observed deviation of the phallus to the side opposite the tunical tear because of the resultant hematoma and mass effect. The fact that he was able to complete intercourse suggests that the clinical scenario in this case is not a penile fracture. The described ecchymosis indicates blood trapped beneath Colles’ fascia, again suggesting that no penile fracture has occurred. It is likely that the patient tore a subcutaneous penile vein from excessive torquing of his penis while erect. There was no evidence of hematuria or LUTS; therefore, there is no indication for urethral evaluation with urethrography or cystoscopy. MRI scan and penile exploration are unnecessary as the described clinical scenario will resolve spontaneously.
A 53-year-old woman has a 3.5 cm right adrenal mass. Her medications include lisinopril and amitriptyline. Her blood pressure is 142/93 mmHg. Fasting plasma metanephrine is 1.2 nmol/L (normal < 0.3 nmol/L). The next step is:
A. 24-hour urine for metanephrines.
B. stop lisinopril and repeat plasma metanephrines.
C. stop amitriptyline and repeat plasma metanephrines.
D. start labetalol.
E. start phenoxybenzamine.
C. stop amitriptyline and repeat plasma metanephrines.
The patient has an adrenal mass and a metabolic evaluation that shows a mildly elevated plasma metanephrine. In this setting, the presence of a falsely elevated fasting metanephrine should be excluded. Common reasons for a false positive metanephrine testing include taking stimulants, such as caffeine and nicotine, as well as medications that interfere with epinephrine metabolism, such as tricyclic antidepressants and drugs that interfere with the assay such as acetaminophen. Thus, repeating the testing once the patient has been off amitriptyline, a tricyclic antidepressant, for one to two weeks would be recommended. Of note, ACE-inhibitors do not interfere with assays for metanephrine. Performing a 24-hour urine while the patient remains on a tricyclic antidepressant is also likely to give a false-positive result. Phenoxybenzamine, an alpha-blocker medication, would be indicated for treatment after a diagnosis of pheochromocytoma has been confirmed, while labetalol, a beta-blocker, would not be indicated if the patient had a pheochromocytoma prior to initiating alpha blockade.
A 63-year-old man previously treated with pelvic XRT for colon cancer undergoes radical prostatectomy. Four weeks after surgery, a 3 cm rectourethral fistula is noted. The next step is catheter drainage and:
A. bowel rest.
B. fecal diversion and bilateral percutaneous nephrostomy tubes.
C. transrectal fistula repair.
D. transabdominal fistula repair.
E. fecal diversion and staged fistula repair.
E. fecal diversion and staged fistula repair.
The incidence of rectourethral fistula after radical retropubic prostatectomy is 1-2%. The risk of a fistula increases with a prior history of pelvic XRT, rectal surgery, or TURP. Fistulas generally occur at the vesicourethral anastomosis and are often due to unrecognized rectal injury at the time of surgery. Although single and staged repairs have been described, staged repairs are recommended in cases of large fistulae and those associated with XRT, uncontrolled local or systemic infection, immunocompromised states, or inadequate bowel preparation at the time of definitive repair. Conservative treatment with urethral catheterization is unlikely to be successful for large fistulae in the setting of prior XRT.
A 22-year-old man has erectile dysfunction following penile trauma. His examination is unremarkable and Doppler ultrasound reveals a peak systolic velocity of 42.27 cm/s and an end-diastolic velocity of -7.72 cm/s. The most likely cause of his erectile dysfunction is:
A. arterial insufficiency. B. venous leak. C. psychogenic. D. Peyronie's disease. E. arteriovenous fistula.
C. psychogenic.
This patient’s ultrasound findings are normal; he does not have arterial insufficiency or venous leak. Arterial insufficiency is suggested when the peak systolic velocity is < 25 cm/s. Venous leak is suggested when the end-diastolic velocity is > 5 cm/s. His examination does not suggest a plaque consistent with Peyronie’s disease. Many young men have psychogenic erectile dysfunction after penile trauma and temporary support using a PDE-5 inhibitor will often allow confidence restoration with normalization of erectile function without medication use in the long-term. Patients with arteriovenous fistula will not have a negative end-diastolic velocity.
Prolapse of a vesicostomy is best avoided by:
A. limiting the stoma size to no larger than 24 Fr.
B. resecting excess bladder wall tissue.
C. placing the stoma at the bladder dome.
D. circumferential suturing of bladder to rectus fascia.
E. placing the stoma midway between the symphysis pubis and the umbilicus.
C. placing the stoma at the bladder dome.
When the bladder dome is brought out for the vesicostomy, it effectively immobilizes the posterior wall of the bladder, preventing its prolapse out the vesicostomy stoma. The bladder dome can be reliably identified by seeing and dividing the urachal remnant. Resecting bladder tissue is contraindicated to facilitate future undiversion. Size of stoma, excess bladder tissue, and suturing the bladder to the rectus fascia will not prevent prolapse. Placement of the stoma is predicated on the position of the dome of the bladder rather than location on the abdominal wall.
Despite tamsulosin and solifenacin, a 27-year-old man has progressive severe urgency and frequency. Videourodynamics with fluoroscopic images are shown. The arrow shown in the image points to the bladder neck during voiding phase. The next step is:
A. cervical and cranial MRI scan. B. retrograde urethrogram. C. pelvic floor muscle training. D. TUIP. E. neuromodulation.
D. TUIP.
The patient has primary bladder neck obstruction, noted by a closed bladder neck during attempt to void and elevated voiding pressures with low flow rate. Further neurological evaluation is not warranted in this setting but might be if the obstruction were more distal at the level of the sphincter (suggesting detrusor external sphincter dyssynergia). Pelvic floor muscle training (PFMT) will not be helpful in this setting as pelvic floor dysfunction is not noted (fluoroscopically, the obstruction would be at the level of the pelvic floor, much more distally). Neuromodulation would not be indicated in the setting of obstruction. TUIP is generally favored over TURP in a young man due to a lower incidence of retrograde ejaculation.
Alpha-mercaptopropionylglycine prevents cystine stones by:
A. promoting a diuresis. B. alkalinizing the urine. C. decreasing cystine excretion. D. forming drug-cystine complexes. E. increasing available urinary citrate.
D. forming drug-cystine complexes.
Alpha-mercaptopropionylglycine (Thiola®) is a second-line therapy for prevention of cystine stones after starting alkalinization therapy. This drug can increase cystine solubility in urine by formation of a more soluble mixed-disulfide bond (i.e., drug to cystine complex rather than cystine to cystine complex). It does not promote diuresis, alkalinize the urine, decrease cystine excretion or increase available urine citrate.
A 26-year-old woman has a 2 cm, circumferentially calcified saccular aneurysm on renal arteriography. Her blood pressure is 126/82 mmHg and her creatinine is 1.1 mg/dL. She is considering pregnancy. The next step is:
A. observation. B. serial imaging. C. lisinopril. D. endovascular stent. E. surgical repair.
E. surgical repair.
Pregnancy is a risk factor for renal artery aneurysm rupture, regardless of size or calcification, therefore, observation and serial imaging are not recommended. If this were not a woman of child-bearing age, the aneurysm could be followed, as it is not large and is completely calcified. Lisinopril will not reduce the likelihood of rupture or ischemic damage. An endovascular stent is not recommended for someone in this age group, due to the risk of lifelong anticoagulation therapy. She should be counseled to undergo surgical treatment of her aneurysm prior to becoming pregnant.
A random urine culture in a 70-year-old asymptomatic woman after cystectomy and ileal conduit diversion reveals > 100,000 Proteus species. The next step is:
A. observation. B. repeat urine culture. C. antibiotic therapy. D. loopogram. E. non-contrast CT scan.
C. antibiotic therapy.
Approximately three quarters of urine specimens from ileal conduits are culture positive; nevertheless, most adults show no ill effects when exposed to chronic bacteriuria. Deterioration of the upper tracts is more likely when the culture becomes dominant for Proteus or Pseudomonas, and thus, these patients should receive antibiotic therapy to reduce the incidence of stone formation. Those patients with mixed cultures may generally be observed, provided they are not symptomatic. Another urine culture would not provide additional information nor alter the treatment plan. Further imaging in this asymptomatic patient, with either loopogram or CT scan, is not indicated.
The most likely neurologic deficit following nerve injury at the time of laparoscopic varicocelectomy is:
A. numbness on the base of the penis and anterior scrotum. B. numbness on the anterior thigh. C. numbness on the lateral thigh. D. inability to extend the knee. E. inability to adduct the thigh.
B. numbness on the anterior thigh.
Laparoscopic varicocelectomy is a minimally invasive option for management of varicoceles. The genitofemoral nerve lies directly atop the psoas muscle in close proximity to where the gonadal vessels are ligated during this procedure. Approximately 4-5% of patients undergoing laparoscopic varicocelectomy will complain of either temporary or permanent alterations in the sensory innervation of the anterior thigh consistent with injury to the genitofemoral nerve. The genitofemoral nerve arises from L1-L2, emerges from the psoas, passes posterior to the ureter, and divides into the genital and femoral branches above the inguinal ligament. The femoral branch then passes behind the inguinal ligament and enters the femoral sheath. The genital branch enters the inguinal canal close to the internal inguinal ring to supply the cremaster muscle and the scrotal skin. The ilioinguinal nerve (numbness on the base of the penis and anterior scrotum) and lateral femoral cutaneous nerve (numbness on the lateral thigh) run at least 3 cm lateral to the internal ring and, therefore, should be at little risk during routine laparoscopic varicocelectomy. The obturator nerve (inability to adduct the thigh) is medial and caudal to the iliac vessels and should not be injured during varicocelectomy. The femoral nerve (inability to extend the knee) is deep in the psoas muscle. It can be injured during open surgery with retraction, but injury is unlikely during laparoscopic surgery.
An 80-year-old woman with a history of estrogen receptor-negative breast cancer has dysuria and urinary frequency. Urine cultures and cytology are negative. Physical examination demonstrates normal pelvic organ support and vaginal atrophy. The next step is:
A. estradiol vaginal ring. B. oral estrogen. C. betamethasone cream. D. solifenacin. E. amitriptyline.
A. estradiol vaginal ring.
While the efficacy and safety of systemic estrogen administration has been hotly contested by results of the Women’s Health Initiative and the HERS study, local vaginal estrogen administration can improve both urgency and dysuria in women with genitourinary symptoms of menopause (GSM). Systemic estrogens are contraindicated in women with a history of breast cancer. One approach is to use low dose vaginal estrogen cream or tablets two to three times per week or insert a ring containing estradiol as there are minimal increases in systemic estrogen concentrations. Amitriptyline and antimuscarinics, such as solifenacin, should be used with caution in the elderly due to possible cognitive side effects. Little or no data is available on the efficacy or safety of corticosteroids in the treatment of dysuria and urgency in women with atrophic vaginitis.
One year after radical cystectomy, a 62-year-old man undergoes urethrectomy for poorly-differentiated squamous cell carcinoma of the urethra with invasion of the corpus spongiosum. Surgical margins are negative. Physical examination of the inguinal regions is normal. The next step is:
A. surveillance. B. XRT. C. chemotherapy. D. sentinel lymph node biopsy. E. bilateral inguinal lymphadenectomy.
A. surveillance.
Most urethral recurrences are diagnosed within two years following radical cystectomy. After cystectomy, periodic surveillance of the male urethra with urethral wash cytology can identify tumors at an earlier stage than simply awaiting patient symptoms. Lymphatics from the anterior urethra drain into the superficial and deep inguinal lymph nodes and occasionally into the external iliac nodes. Ilioinguinal lymphadenectomy is indicated in the presence of palpable inguinal lymph nodes without evidence of metastatic disease. This patient has high-grade pT2 disease and is at risk for recurrence. However, unlike penile cancer, benefit from prophylactic inguinal node dissection, XRT, or chemotherapy has not been demonstrated in squamous cell carcinoma of the urethra. The current role of sentinel biopsy in this context is not defined.
A 25-year-old woman has recurrent pan-sensitive E. coli UTIs with urgency and frequency but no fever. The next step is:
A. post-coital voiding. B. cranberry supplement. C. daily ciprofloxacin. D. abdominal ultrasound. E. cystoscopy.
B. cranberry supplement.
In women with recurrent uncomplicated symptomatic UTIs, prophylactic options include cranberry supplements or antibiotic prophylaxis. If the recurrent UTIs are related to intercourse, post-coital antibiotics are indicated. Appropriate antibiotics include trimethoprim/sulfamethoxazole, nitrofurantoin, and cephalexin. Fluoroquinolones should be reserved for instances of bacterial resistance or allergy and should be avoided if possible due to the black box warning. Strategies such as post-coital voiding, changing to cotton underwear, wiping away from the urethra, and avoidance of hot tubs have not been shown to decrease the rate of infections. Cystoscopy and imaging (i.e., abdominal ultrasound) should not be routinely obtained in women with uncomplicated recurrent UTIs.
A 38-year-old woman with a history of stones is taking topiramate for migraine headaches. A 24-hour urine collection will most likely demonstrate:
A. hypercalciuria. B. hyperuricosuria. C. hypocitraturia. D. hyperoxaluria. E. hypomagnesuria.
C. hypocitraturia.
Patients started on topiramate (used for migraines, seizure disorder, weight loss and many other indications) develop hypocitraturia and should be counseled on the inherent risks of stone formation, particularly prior stone formers. Treatment options include potassium citrate or stopping topiramate and finding an alternative treatment. Hypercalciuria, hyperuricosuria, hyperoxaluria, and hypomagnesuria are not specific to topiramate therapy.
A 40-year-old woman with spina bifida has an ileal conduit and ESRD. She is scheduled for a living-related donor transplant. A retrograde loopogram shows mid-loop stenosis and an aperistaltic loop that is significantly shortened. The transplant ureter should be anastomosed to the:
A. native bladder.
B. original ileal conduit.
C. original ileal conduit revised at the time of transplantation.
D. new ileal conduit created prior to transplantation.
E. new ileal conduit created at the time of transplantation.
D. new ileal conduit created prior to transplantation.
The purpose of the preoperative transplant evaluation is to determine the suitability of the urinary bladder or its substitute. A retrograde loopogram is necessary to assess the urinary conduit for areas of stenosis and to ensure that it empties appropriately. Renal transplantation into intestinal conduits have been successful. Since the loopogram shows that her present conduit does not function well, she will need a new conduit. This should be done prior to transplantation to ensure that the conduit loop is adequate. The native bladder has been defunctionalized and is unlikely to have a reasonable low-pressure capacity in this patient with neurogenic bladder dysfunction. If a conduit is created at time of transplant, there is an increased risk of bowel spillage or anastomotic leak that would increase post-transplant complications.
A 53-year-old woman has urine leakage with sneezing and exercise despite pelvic floor muscle training. On physical examination, after voiding, she has no significant prolapse and no leakage with cough or Valsalva. The next step is:
A. full bladder stress test. B. urodynamics. C. antimuscarinic therapy. D. periurethral injection. E. midurethral sling.
A. full bladder stress test.
This patient has symptomatic stress urinary incontinence (SUI), though none is noted on examination. She should not be treated invasively without documentation of SUI on examination. She should return for a full bladder stress test done supine and repeated standing if necessary. If that remains negative, urodynamics could be offered to try to better delineate her leakage. Antimuscarinics should not be offered in the presence of primarily SUI symptoms.
A six-month-old boy has proximal hypospadias, a right nonpalpable testis, and a normal sized left scrotal testis. Karyotype is 46,XY. Laparoscopic view of the right internal inguinal ring is shown. The most likely finding at inguinal exploration is:
A. testicular agenesis. B. testicular nubbin. C. undescended testis. D. streak gonad. E. ovotestis.
C. undescended testis.
When a testis is not palpable, the most common finding at exploration is an abdominal testis or a “peeping” testis at the internal inguinal ring (shown in the laparoscopic picture with vas deferens and testicular vessels entering an open internal ring). It is likely that the increased intra-abdominal pressure forced the abdominal testis into the inguinal canal through the open internal ring. Less common is a vanishing testis, nubbin, or an extra-abdominal location not palpated due to body habitus. There is no evidence for mixed gonadal dysgenesis (streak gonad) or ovotesticular disorder of sex development in this patient and both are far less common than simple cryptorchidism.
A 59-year-old man with a history of liver transplantation has a 1 cm raised, tender, penile lesion at the coronal sulcus dorsally. Incisional biopsy reveals Kaposi’s sarcoma. The next step is:
A. decrease immunosuppression. B. topical 5-FU. C. local excision. D. CO2 laser ablation. E. partial penectomy.
A. decrease immunosuppression.
Kaposi’s sarcoma is the 2nd most common malignancy of the penis (after squamous cell carcinoma) due to the prevalence of HIV infection. It also occurs in patients on immunosuppression for organ transplantation or other indications. In this setting, Kaposi’s sarcoma often regresses with modification of the immunosuppressive regimen and this should be the initial approach. If the tumor fails to respond to these efforts, local excision, laser ablation, or XRT should be considered. Partial penectomy is not indicated for this tumor type. 5-FU is typically utilized in squamous cell carcinoma of the penis.
A 57-year-old woman has urine leakage with exercise and a vaginal bulge. On examination, she leaks with cough and POP-Q reveals: Aa:-2, Ba:-2, Ap:+2, Bp:+2, and C:0. The next step is a midurethral sling:
A. only.
B. with anterior repair.
C. with posterior repair.
D. with anterior and apical vault repair.
E. with posterior and apical vault repair.
E. with posterior and apical vault repair.
Her POP-Q examination reveals both posterior wall prolapse (Bp:+2 indicates the most distal portion of the posterior vaginal wall is 2 cm beyond the hymen) and apical prolapse (C at 0 indicates the vaginal cuff at the level of hymen). Therefore, a posterior and apical vault repair should be performed concomitantly at the time of midurethral sling. A sling alone will only address her incontinence and not her prolapse. An anterior repair is not indicated as her anterior wall is well-supported. A posterior repair alone would not address her apical prolapse.
A 55-year-old woman with breast cancer has a 3.5 cm right adrenal nodule. The nodule has an attenuation of 25 Hounsfield units on non-contrast CT scan, with 80% washout on contrast-enhanced CT scan. The lesion is most likely a:
A. lipid rich adenoma. B. lipid poor adenoma. C. myelolipoma. D. breast cancer metastasis. E. primary adrenal cancer.
B. lipid poor adenoma.
The majority (approximately 70%) of adrenal adenomas contain high intracellular lipid content (lipid rich adenomas) and as such are characterized on non-contrast CT scan by Hounsfield units < 10. Similarly, myelolipomas contain macroscopic fat and are, thereby, associated with low, and even negative, Hounsfield units. Approximately 30% of adenomas have a lower lipid content, and are known as lipid poor, or atypical adenomas. Consistent with the low lipid content, the Hounsfield units of these lesions on non-contrast CT scan is > 10. However, lipid poor adenomas can usually be distinguished from malignant lesions (i.e., primary adrenal cancers, adrenal metastases) on imaging by assessing the washout of contrast on CT scan with delayed imaging. In particular, an absolute percent washout (enhanced-delayed/enhanced-unenhanced) of > 60% - as in the case here - is indicative of an adenoma. On the other hand, the majority of malignant lesions, including most primary adrenal and metastases, typically have a < 60% washout on CT scan.
In the setting of high risk penile cancer, the indication to perform deep inguinal lymph node dissection at the time of surgery is based upon the presence of:
A. high-grade primary tumor.
B. corporal invasion.
C. palpable inguinal nodes.
D. superficial nodal metastases confirmed by frozen section.
E. lymphovascular invasion in the primary tumor.
D. superficial nodal metastases confirmed by frozen section.
Both superficial inguinal and modified complete dissections have been proposed as staging tools for patients with penile cancer without palpable inguinal lymphadenopathy. Superficial node dissection involves removal of those nodes superficial to the fascia lata. A deep dissection includes removal of those nodes deep to the fascia lata contained within the femoral triangle. The deep dissection is performed if the superficial nodes have confirmed nodal metastases at surgery by frozen-section analysis. The rationale for superficial dissection is that positive nodes deep to the fascia lata have not been reported unless superficial nodes were also positive. The presence of lymphovascular invasion, tumor grade, and tumor stage are all prognostic indicators of nodal invasion and thus help to determine which patients should undergo superficial inguinal node dissection. However, they do not directly impact the extent of the dissection. The presence of palpable nodes is indicative of the presence of cancer approximately 40% of the time (5-65% depending on risk); thus, the decision to perform a deep dissection should depend on histological confirmation of the presence of tumor by frozen section.
A 54-year-old man suffers a complete spinal cord injury at vertebral level L2. Once the spinal shock phase has ended, videourodynamics would most likely show:
A. normal detrusor contractility.
B. volitional control of the external urethral sphincter.
C. detrusor external sphincter dyssynergia.
D. a competent bladder neck.
E. detrusor overactivity.
D. a competent bladder neck.
An injury below vertebral level L1 would result in a sacral spinal cord injury. At this level, injury would be expected to leave the patient with detrusor hypocontractility related to loss of parasympathetic innervation of the detrusor smooth muscle, lack of volitional control of the external sphincter, and potential development of stress urinary incontinence or overflow incontinence related to sphincteric weakness. However, the bladder neck would be expected to remain competent. Complete lesions above the sacral cord usually result in detrusor overactivity, smooth sphincter synergy, and striated sphincter dyssynergia.
A three-week-old circumcised boy has a normal renal ultrasound and VCUG after a febrile UTI. Six months later, he develops another febrile UTI. A repeat renal ultrasound is normal. The next step is:
A. observation. B. diuretic MAG-3 renal scan. C. nuclear VCUG. D. prophylactic antibiotics. E. cystoscopy.
C. nuclear VCUG.
For the initial evaluation of febrile UTIs in infants, a fluoroscopic VCUG should be performed, especially in boys. This will not only reveal VUR but also may delineate any bladder or urethral pathology. Upper tract imaging (most commonly using a renal and bladder ultrasound) can define any obstructive etiology causing hydronephrosis. A normal renal ultrasound, however, does not rule out VUR. Up to 30% of initial VCUGs can miss VUR. If an infant has another febrile UTI after the first negative evaluation, a repeat VCUG is warranted. A nuclear VCUG is associated with less radiation and may be more sensitive in detecting low-grade VUR. It is controversial whether prophylactic antibiotics in the absence of an anatomically defined problem is beneficial or harmful. An aggressive evaluation of infants with recurrent febrile UTIs is important to minimize the risk of renal scarring, thus observation is not recommended. Given two normal renal ultrasound studies, diuretic MAG-3 scan is unlikely to reveal any useful information. Cystoscopy is unwarranted.
A 12-year-old boy with a history of CAH has painful bilateral testicular masses confirmed on ultrasound. The next step is:
A. antibiotics. B. increase corticosteroids. C. fine needle aspiration of testis. D. bilateral partial orchiectomy. E. abdominal pelvic CT scan.
B. increase corticosteroids.
The association between testicular tumors/nodules and CAH has been recognized for many years and are defined as testicular adrenal rest tumors (TART). Tumors are considered to be aberrant adrenal tissue that has descended with the testes and has become hyperplastic due to ACTH stimulation. The recommended treatment of TART consists of increasing the glucocorticoid dose to suppress ACTH secretions. Biopsy and or removal is not indicated unless increasing medical therapy fails. Antibiotics and abdominal pelvic CT scan are not indicated.
A 22-year-old man with NSGCT completed chemotherapy that included ifosfamide two weeks ago. He has weakness and lethargy, but appears euvolemic. Serum labs reveal Na 137 mEq/L, Cl 135 mEq/L, CO2 12 mEq/L, K 2.7 mEq/L, and creatinine 0.9 mg/dL. Blood gas reveals serum pH 7.3. Urinalysis reveals pH 7.6. The next step is:
A. I.V. Ringer's lactate. B. I.V. D5W with 20 mEq/L KCl. C. I.V. hydrocortisone. D. oral spironolactone. E. oral potassium citrate.
E. oral potassium citrate.
The clinical presentation is that of weakness and lethargy following the course of chemotherapy accompanied by significant hypokalemia and hyperchloremic metabolic acidosis. Despite the acidosis, his urinary pH is alkaline, indicating inability to acidify urine. The most likely diagnosis is a drug-induced renal tubular acidosis (RTA) type 1 (distal), in which there is a failure of ammonium secretion in the distal tubule. Type 2 (proximal) RTA represents a defective reabsorption of bicarbonate in the proximal tubule. Although distal RTA can be genetic, this most likely represents an acquired condition due to ifosfamide chemotherapy. The treatment is oral potassium and bicarbonate supplementation. I.V. fluid hydration is unnecessary with no evidence of dehydration and normal creatinine with no evidence of contraction alkalosis. The use of steroids or diuretics would be detrimental to this patient.
A ten-year-old boy has a 1 cm ureteral stricture distal to the iliac vessels that was identified three months after a complex ureteroscopic stone extraction. The next step is:
A. stent placement. B. balloon dilation and stent placement. C. endoureterotomy and stent placement. D. ureteral reimplantation. E. ureteroureterostomy.
D. ureteral reimplantation.
A distal ureteral stricture in a ten-year-old boy should be managed with a definitive therapy that has a nearly 100% long-term success rate. Passive dilation with a stent, balloon dilation, and endoscopic incision have variable results and do not give durable life-long success. A distal stricture can be managed with a reimplantation with or without bladder mobilization. A ureteroureterostomy is not indicated given the proximity of the stricture to the bladder.
A 25-year-old man has persistent left flank pain after a left ureteral reimplant with a Boari flap. CT scan demonstrates a dilated left renal pelvis. A MAG-3 diuretic renogram with a urethral catheter demonstrates a left T1/2 of 20 minutes with a differential function of 40%. The next step is:
A. VCUG. B. ureteral stent. C. ureteroscopy. D. percutaneous nephrostomy tube. E. Whitaker test.
A. VCUG.
Hydronephrosis may be due to obstruction or VUR. Ureteral reimplants with a Boari flap are often not tunneled, and VUR must be considered in symptomatic patients. VUR may result in an equivocal T1/2 on a diuretic renogram, as in this case. A urethral catheter should be placed in those at risk for VUR prior to the study. Ureteroscopy would not define whether physiologic obstruction is present. A Whitaker test may determine if obstruction is present but is more invasive and should be reserved for difficult cases in which diuretic renography does not define obstruction or cannot be utilized because of impaired renal function. The placement of a nephrostomy tube alone will not define functional obstruction. Similarly, placement of a ureteral stent will not help with the diagnosis.
A 65-year-old woman with stress-predominant mixed urinary incontinence has worsening of her OAB symptoms three months following midurethral sling. Urinalysis is normal. Urodynamics are shown. The likely cause of her symptoms is:
A. natural progression of OAB. B. outlet obstruction. C. mesh erosion into her bladder. D. mesh erosion into her urethra. E. voiding dysfunction.
B. outlet obstruction.
This patient’s symptoms are likely secondary to an obstructing midurethral sling. The argument for the sling causing bladder outlet obstruction include the temporal relationship of her symptoms worsening after sling placement as well as evidence of obstructed voiding on the pressure-flow study (high pressure/low flow). The pressure-flow nomogram places this patient in the “equivocal” category; however, it is important to realize that these nomograms are meant for male patients. Women void with lower pressures; therefore, these types of nomograms will underestimate female bladder outlet obstruction. There are various definitions of female bladder outlet obstruction with many using Qmax at 12 mL/sec or less and voiding pressure > 25 cm H2O. Though voiding dysfunction caused by the failure of pelvic floor muscles to relax appropriately is another potential cause for bladder outlet obstruction, the timing suggests that this patient’s symptoms are likely related to an obstructing sling. In addition, without concomitant EMG measurements or fluoroscopic views during the voiding phase, voiding dysfunction cannot be diagnosed. Mesh erosion into her bladder or urethra is unlikely given her normal urinalysis; however, any patient undergoing sling incision in a situation such as this should undergo cystoscopy prior to surgical intervention to evaluate for such an occurrence.
A 26-year-old woman has a one year history of weight gain, hypertension, and abdominal striations. CT scan is shown. The next step is:
A. 24-hour urinary 17-ketosteroids. B. low dose dexamethasone suppression test. C. MRI scan of the abdomen. D. MRI scan of the brain. E. biopsy.
B. low dose dexamethasone suppression test.
The CT scan demonstrates a small left adrenal lesion. Weight gain, hypertension, and skin changes secondary to disturbed collagen synthesis are all hallmarks of Cushing’s syndrome, but are not specific features of the diagnosis. Current guidelines for the evaluation of suspected Cushing’s syndrome recommend an overnight low dose dexamethasone suppression test. Twenty four-hour urine for 17-ketosteroids is not recommended as a screen for Cushing’s syndrome. MRI scan of the abdomen may demonstrate high signal intensity on T2 sequences in cases of pheochromocytoma and adrenocortical carcinoma but will not distinguish functional from non-functional adrenal masses and would not be indicated as the next step. An adrenal biopsy cannot differentiate adrenal adenomas from adrenal carcinomas and would not be indicated prior to obtaining a metabolic work-up. MRI scan of the brain to assess for a pituitary adenoma would be appropriate after functional work-up indicated a probable diagnosis of ACTH-dependent Cushing’s disease, but would not be used as a screening diagnostic procedure prior to establishing the presence of hypercortisolism.
After XRT for prostate cancer and a channel TURP, a 74-year-old man has urinary incontinence. Urinalysis is normal, voided volume is 200 mL, and PVR is 40 mL. His urodynamic study is shown. The next step is:
A. tamsulosin. B. solifenacin. C. onabotulinumtoxinA injection. D. male sling. E. artificial sphincter.
B. solifenacin.
This urodynamics shows detrusor overactivity (DO) and no evidence of stress incontinence. Therapies should be geared accordingly for urgency urinary incontinence (UUI). Though behavioral modification and pelvic floor training are recommended for first line therapy for UUI, given the frequent episodes of DO at low volumes, an antimuscarinic (or beta agonist), such as solifenacin, may provide more immediate improvement. Botulinum toxin injection could be considered for refractory symptoms as third line therapy. A sling and an artificial urinary sphincter would not be considered as these therapies are meant to address stress urinary incontinence. Tamsulosin is used for obstructive LUTS.
A 68-year-old diabetic man has nocturia. DRE reveals a benign 40 gram prostate, urinalysis is unremarkable, and PVR is 55 mL. He completes a 24-hour frequency-volume chart as shown. The next step is:
A. decrease nightly fluid intake. B. decrease caffeine consumption. C. tamsulosin. D. oxybutynin. E. sleep study.
E. sleep study.
This patient has nocturia (awakens two times to void). The cause of his nocturia is nocturnal polyuria (NP) as his nocturnal volume is > 20-33% of his total 24 hour urine production. His total 24 hour urine (from 7:00 am to 7:00 am) production is normal (2,400 mL). The nocturnal volume voided is 900 mL, this is 37.5% of his total 24-hour urine production. It is important to know that the first morning void is included in the nocturnal volume voided since that urine is made overnight. Common underlying causes of NP include excessive nighttime fluid intake, peripheral edema, obstructive sleep apnea (OSA), diabetes mellitus, and congestive heart failure. Behavioral modifications are appropriate, but in this patient, decreasing fluids prior to bedtime is incorrect because he does not consume fluids four hours prior to bedtime. Decreasing caffeine consumption is incorrect as well because he consumes minimal caffeine, and only in the morning. Even though he has an enlarged prostate, his PVR is negligible and he does not have obstructive symptoms; therefore, tamsulosin would be unlikely to impact his nocturnal frequency. Oxybutynin would not be indicated as he does not have symptoms of OAB such as urinary frequency or urgency. In this patient, suggesting that his primary care physician order a sleep study would be the next step as it could uncover OSA as a potential cause of his nocturnal polyuria. In addition, treatment of OSA with continuous positive airway pressure (CPAP) often results in an improvement in his NP and a decrease in nocturnal voids. Another option to treat NP would be desmopressin which also requires monitoring of serum sodium as hyponatremia is a risk of this medication.
A 12-year-old ambulatory boy with a history of imperforate anus repair has significant urinary incontinence despite maximal anticholinergics and onabotulinumtoxinA injection. He performs CIC every two to three hours during the day. Urodynamics is shown. End filling maximum bladder capacity is 150 mL and Valsalva LPP is 70 cm H2O. The next step is:
A. CIC. B. onabotulinumtoxinA injection to urethral sphincter. C. overnight bladder drainage. D. bladder neck reconstruction. E. augmentation cystoplasty.
E. augmentation cystoplasty.
This boy has disabling urinary incontinence and has failed anticholinergic treatment as well as previous onabotulinumtoxinA injections. The urodynamics shows severe detrusor overactivity, low bladder capacity, and LPP that should be adequate for urinary continence once the detrusor overactivity is corrected. OnabotulinumtoxinA to the external sphincter is likely to worsen, rather than improve incontinence in this situation, and there is no evidence of sphincter dyssynergy in the urodynamics tracing. Overnight bladder drainage is an option, but not preferred in a 12-year-old child who is ambulatory and will not address the daytime incontinence. Bladder neck reconstruction is not required since the Valsalva LPP is high enough to be consistent with continence once the bladder capacity is increased. Augmentation cystoplasty is the best option in this case to relieve the severe overactivity and reduced bladder capacity, and the 12-year-old age range improves the likelihood of compliance with care of the augmented bladder.
A 58-year-old man receives neoadjuvant chemotherapy for muscle invasive plasmacytoid variant bladder cancer. Follow-up CT scan is shown. Metastatic evaluation is negative. The next step is:
A. ultrasound guided biopsies. B. cystoscopy and exam under anesthesia. C. chemotherapy and XRT. D. diagnostic laparoscopy. E. radical cystoprostatectomy.
B. cystoscopy and exam under anesthesia.
Plasmacytoid variant bladder cancer is strongly associated with adverse clinicopathological features, including locally advanced T3-T4 disease. The image in this patient suggests an extravesical component of the cancer and possible circumferential tumor involvement of the rectum. Cystoscopy and examination under anesthesia are the best initial steps to determine whether this patient’s cancer is resectable and the extent of the operation required (i.e., radical cystectomy vs. pelvic exenteration). Ultrasound-guided biopsies could reveal viable tumor; yet, if positive would not alter management. Combination chemotherapy and XRT is an option for symptom palliation if surgery is not feasible but would not be the next step. Diagnostic laparoscopy can help identify peritoneal implants but is not the best initial step and unnecessary if the patient’s cancer is unresectable.
