4: Urologic evaluation of the child Flashcards
1
Q
When evaluating a child with a urologic condition, why is it important to approach family members with sensitivity and patience?
A. Because family members may be uncooperative during the encounter
B. Because the family members are often the source of the child’s anxiety
C. Because the family members may not be aware of the child’s symptoms
D. Because approaching the family members with sensitivity and patience helps establish a trustful relationship
A
D. When evaluating a child with a urologic condition, it is critical to approach family members with sensitivity and patience to establish a trustful relationship. Open expression of the provider’s awareness of their anxiety, along with respecting the privacy of older children, is important in establishing a good rapport with the family.
2
Q
When asking the historian to report their experience and observations, what is the best way to approach the questions?
A. Ask for a diagnosis or judgment of “normalcy.”
B. Ask about frequency and consistency of stool rather than if a child is “constipated.”
C. Ask the parent to describe the child’s symptoms in their own words.
D. Ask the parent to list all the possible causes of the child’s symptoms.
A
B. When asking the historian to report their experience and observations, it is best to ask about frequency and consistency of stool rather than if a child is “constipated.” Asking about specific symptoms, rather than using diagnostic terminology, can help avoid confusion and promote clarity in communication.
3
Q
How can engaging the child in a nonthreatening activity or discussion facilitate a successful evaluation?
A. By distracting the child from the discomfort of the examination
B. By making the child more anxious and uncooperative
C. By making the child more aware of their symptoms
D. By allowing the child to relax during the encounter
A
D. Engaging the child in a nonthreatening activity or discussion can help facilitate relaxation during the encounter, making it easier for the healthcare provider to perform a successful evaluation.
4
Q
When should the physical examination be performed when evaluating a child with a urologic condition?
A. At the beginning of the encounter
B. After the guardian has left the room
C. At the end of the encounter
D. Before taking a history
A
C. The physical examination should be performed at the end of the encounter to prevent the guardian from missing out on important clinical details if the child becomes upset.
5
Q
What is the purpose of examining the testicles during a pediatric urologic evaluation?
A. To assess the patient’s overall health
B. To establish the location and size of the gonads
C. To identify pathology of the bladder
D. To measure the patient’s blood pressure
A
B. The purpose of examining the testicles during a pediatric urologic evaluation is to establish the location, size, and texture of the gonads, as well as to identify pathology of the testicles and scrotum.
6
Q
What position may the patient be in during a testicular exam?
A. Standing
B. Lying on their back
C. Lying on their stomach
D. All of the above
A
D. During a testicular exam, the patient may be examined supine in frog leg position, with the legs spread apart, sitting, squatting, or standing. The examiner should stand on the contralateral side to the area of concern.
7
Q
What technique can be used to increase intraabdominal pressure to visualize a bulge during a pediatric urologic evaluation?
A. Jumping
B. Coughing
C. Laughing
D. All of the above
A
D. Techniques to increase intraabdominal pressure to visualize a bulge during a pediatric urologic evaluation include jumping, coughing, laughing, or blowing bubbles. This technique can help identify a hernia, which is a common condition in pediatric patients.
8
Q
How can a lubricated glove aid the examiner during a testicular exam?
A. By helping to identify pathology of the bladder
B. By increasing the patient’s comfort
C. By aiding in the visualization of a bulge
D. By allowing for a more gentle sweep of the testicle
A
D. A lubricated glove (with soap and water) may aid the examiner during a testicular exam by allowing for a more gentle sweep of the testicle toward the internal inguinal ring, sliding from the anterior superior iliac spine to the pubic tubercle.
9
Q
How can hydrocele fluid appear during a pediatric urologic evaluation?
A. Red
B. Yellow
C. Blue
D. Green
A
C. During a pediatric urologic evaluation, hydrocele fluid (and neonatal bowel) transilluminates and may appear blue through scrotal skin. This can be a useful diagnostic tool for identifying a hydrocele, which is a common condition in pediatric patients.
10
Q
Table 4.1 Useful Examination Tips
A
11
Q
What should be visualized during a female genital examination?
A. The bladder, ureters, and urethra
B. The kidneys and adrenal glands
C. The labia, introitus, urethral meatus, clitoris, and anus
D. The rectum and anal sphincter
A
C. During a female genital examination, the labia, introitus, urethral meatus, clitoris, and anus should be visualized.
12
Q
In what position should the patient be placed during a female genital examination?
A. Lying on her stomach
B. Lying on her back with legs straight
C. Sitting upright
D. In a frog leg position
A
D. The patient should be placed in a frog leg position during a female genital examination.
13
Q
What should be done to expose the introitus during a female genital examination?
A. The labia majora should be gently pulled laterally and caudally.
B. The patient should bear down or cough.
C. The examiner should insert a speculum into the vagina.
D. The patient should stand and bend forward at the waist.
A
A. To expose the introitus during a female genital examination, the labia majora should be gently pulled laterally and caudally.
14
Q
Why is a female genital examination an important part of a urologic evaluation?
A. Because it helps identify kidney stones
B. Because it can help diagnose urinary tract infections
C. Because it can help identify abnormalities in the urinary tract
D. Because it allows for a thorough examination of the entire genitourinary system
A
D. A female genital examination is an important part of a urologic evaluation because it allows for a thorough examination of the entire genitourinary system, including the urinary tract and genital structures. It can help identify a range of conditions, including urinary tract infections, vaginal infections, and abnormalities in the genital or urinary tract.
15
Q
What can a urinalysis identify?
A. Blood and protein in the stool
B. Blood, protein, urinary casts, and infectious markers in urine
C. Glucose and ketones in the blood
D. Electrolyte imbalances in the blood
A
B. A urinalysis can identify blood, protein, urinary casts, and infectious markers in urine. It includes gross examination for color, turbidity, and debris, as well as dipstick and microscopic analyses.
16
Q
What is the typical range for urinary specific gravity?
A. 0.001 to 0.035
B. 0.035 to 1.001
C. 1.001 to 1.035
D. 1.035 to 1.100
A
C. The typical range for urinary specific gravity is 1.001 to 1.035. This can be indicative of hydration status and concentrating ability.
17
Q
What can urinary pH indicate?
A. Blood sugar levels
B. Serum electrolyte levels
C. Serum pH
D. Concentrating ability
A
C. Urinary pH can vary from 4.5 to 8 and is reflective of the serum pH.
18
Q
How many erythrocytes per high-powered field (HPF) are diagnostic of hematuria?
A. One
B. Two
C. Three
D. Four
A
C. Microscopic identification of three erythrocytes per high-powered field (HPF) is diagnostic of hematuria.
19
Q
What does the presence of proteinuria, RBC casts, and brown-colored urine suggest?
A. A nephrogenic origin of hematuria
B. A urinary tract infection
C. An electrolyte imbalance
D. A blood clot in the urinary tract
A
A. The presence of proteinuria, RBC casts, and brown-colored urine suggest a nephrogenic origin of hematuria.
20
Q
Why are clean-catch urine cultures difficult to obtain in children?
A. Children often have difficulty producing a urine sample.
B. The collection method is uncomfortable for children.
C. Clean-catch urine cultures are more prone to contamination in children.
D. Children are often resistant to providing a urine sample.
A
C. Clean-catch urine cultures are notoriously difficult to obtain in children without contamination. The collection method is the same as for adults, but children may have difficulty following instructions or maintaining cleanliness during the collection process.
21
Q
What is the colony count necessary to define an infection with the clean-catch urine culture method?
A. ≥ 10,000 CFU/mL
B. ≥ 50,000 CFU/mL
C. ≥ 100,000 CFU/mL
D. ≥ 500,000 CFU/mL
A
C. A colony count of ≥100,000 CFU/mL of organism plated within 1 hour of collection is necessary to define an infection with the clean-catch method.
22
Q
What is the colony count necessary to constitute an infection in a catheterized or suprapubic aspirate specimen?
A. ≥ 10,000 CFU/mL
B. ≥ 50,000 CFU/mL
C. ≥ 100,000 CFU/mL
D. ≥ 500,000 CFU/mL
A
B. A catheterized or suprapubic aspirate specimen should have a colony count of ≥50,000 CFU/mL to constitute an infection.
23
Q
What is considered normal for postvoid residual (PVR)?
A. A flat curve with no PVR
B. A bell-shaped curve with minimal PVR
C. A spike-shaped curve with no PVR
D. A bell-shaped curve with high PVR
A
B. Bell-shaped curves with minimal PVR are considered normal. This indicates efficient bladder emptying.
24
Q
What information does uroflow with electromyography of the pelvic floor provide?
A. Information on bladder volume
B. Information on kidney function
C. Information on bladder pelvic floor coordination
D. Information on urine concentration
A
C. Uroflow with electromyography of the pelvic floor provides information on bladder pelvic floor coordination. It can help identify any coordination issues that may be affecting bladder function.
25
What does video urodynamics assess?
A. Blood flow to the kidneys
B. Bladder volume
C. Continence, bladder stability, capacity, compliance, and sphincteric coordination
D. Urinary flow rate
C. Video urodynamics assesses continence, bladder stability, capacity, compliance, and sphincteric coordination. It is an important study to characterize and trend storage and voiding dynamics in children with structural or neurologic conditions affecting bladder function.
26
What does fluoroscopy visualize during video urodynamics?
A. Kidney function
B. Bladder volume
C. Anatomy including the bladder outlet during voiding, bladder shape, and reflux into the upper tracts
D. Urinary flow rate
C. Fluoroscopy visualizes anatomy including the bladder outlet during voiding, bladder shape, and reflux into the upper tracts. It is an important study to characterize and trend storage and voiding dynamics in children with structural or neurologic conditions affecting bladder function.
27
Table 4.2 Comparison of Pediatric Urologic Imaging Modalities
28
What does prenatal sonography visualize in relation to the renal system?
A. The size and shape of the kidneys
B. The quality of the renal cortex and the laterality of any abnormalities
C. The urinary bladder and urethra
D. The size and location of the adrenal glands
B. Prenatal sonography visualizes the quality of the renal cortex and the laterality of any abnormalities. It can also visualize the umbilical cord and anterior abdominal wall anatomy, quantity of amniotic fluid, and urine within the fetal bladder.
29
What is the main advantage of postnatal sonography in evaluating newborn kidneys?
A. It is less invasive than other imaging modalities
B. It is more accurate than other imaging modalities
C. It is less expensive than other imaging modalities
D. It is more effective at visualizing renal masses
A. Postnatal sonography is less invasive than other imaging modalities, such as CT or MRI. This makes it a more attractive option for evaluating newborn kidneys.
30
What can be mistaken for hydronephrosis on postnatal sonography in newborns?
A. Darker medullary pyramids
B. Smaller kidney size
C. Hypoechoic cortex
D. Renal cysts
A. A newborn kidney's more pronounced corticomedullary differentiation with darker medullary pyramids may be mistaken for hydronephrosis on postnatal sonography.
31
What conditions can sonography evaluate for in the renal system?
A. Renal masses and cysts
B. Ureteral reflux and obstruction
C. Bladder diverticula and calculi
D. All of the above
D. Sonography can evaluate for hydronephrosis, cortical dysplasia, pelvic and renal cysts, renal, abdominal, and bladder masses, nephrolithiasis, infection, trauma, posterior urethral valves, ureteroceles, bladder diverticula, and bladder calculi.
32
Table 4.3 When to perform imaging for Antenatally detected hydronephrosis
33
Table 4.4 Imaging Features of Renal Cysts
34
Fig. 4.1 (A and B) Postnatal sonograms demonstrating the high contrast cortico-medullary differentiation typical of a newborn kidney, which might be mistaken for dilated calyces. (C) For comparison, a renal sonogram in an older child.
35
What does prenatal sonography visualize in relation to the renal system?
A. The size and shape of the kidneys
B. The quality of the renal cortex and the laterality of any abnormalities
C. The urinary bladder and urethra
D. The size and location of the adrenal glands
B. Prenatal sonography visualizes the quality of the renal cortex and the laterality of any abnormalities. It can also visualize the umbilical cord and anterior abdominal wall anatomy, quantity of amniotic fluid, and urine within the fetal bladder.
36
When should ultrasound be performed for cryptorchidism?
A. Routinely for all cases of cryptorchidism
B. When there is a suspicion of a tumor
C. When the child is over 10 years old
D. It should not be performed for routine cryptorchidism due to poor sensitivity of detecting an undescended testicle.
D. Ultrasound should not be performed for routine cryptorchidism due to poor sensitivity of detecting an undescended testicle.
37
What is testicular microlithiasis, and when does it require further follow-up imaging?
A. Testicular microlithiasis is a condition where the testicles are enlarged and require further imaging for diagnosis.
B. Testicular microlithiasis is a condition where small calcium deposits are present in the testicles, and it only requires further follow-up imaging if additional risk factors such as infertility or testis cancer are present.
C. Testicular microlithiasis is a condition where there is torsion of the testicles, and it requires further follow-up imaging to assess for damage.
D. Testicular microlithiasis is a condition where there is inflammation of the testicles, and it requires further imaging for diagnosis.
B. Testicular microlithiasis is a condition where small calcium deposits are present in the testicles. It only requires further follow-up imaging if additional risk factors such as infertility with atrophic testis or testis cancer with contralateral microlithiasis exist.
38
Table 4.5 Imaging Findings for Scrotal Pathology
39
What can plain abdominal radiography and scout imagery demonstrate?
A. Bony anatomy of the spine and pelvis
B. Urinary tract anatomy
C. Respiratory system anatomy
D. Both A and B
D. Plain abdominal radiography and scout imagery can demonstrate bony anatomy of the spine and pelvis, radiopaque stones, and stool burden.
40
What can be evaluated with voiding cystourethrography (VCUG)?
A. Vesicoureteral reflux
B. Anatomic detail of bladder wall and urethral abnormalities
C. Both A and B
D. None of the above
C. VCUG can evaluate for vesicoureteral reflux and provide excellent anatomic detail of bladder wall and urethral abnormalities like trabeculations, ureteroceles, diverticula, posterior urethral valves, stricture disease, bladder rupture, and foreign bodies.
41
What is the advantage of direct radionuclide cystography over fluoroscopic VCUG?
A. Provides equivalent anatomic detail
B. Has lower sensitivity
C. Has lower radiation exposure
D. Cannot detect vesicoureteral reflux
C. Direct radionuclide cystography accurately detects vesicoureteral reflux (VUR) with greater sensitive and lower radiation exposure than fluoroscopic VCUG but cannot provide equivalent anatomic detail.
42
What does DMSA stand for, and how is it used in imaging?
A. Dual Medical-Surgical Analysis; used to visualize bony anatomy
B. Dimercapto-succinic acid; used to assess relative renal function and detect areas of decreased uptake due to scarring or infection
C. Diethylenetriamine pentaacetic acid; used to evaluate drainage of the collecting system
D. None of the above
B. DMSA stands for dimercapto-succinic acid and is used to assess relative renal function and detect areas of decreased uptake due to scarring or infection.
43
What is the purpose of MAG-3 diuretic renography?
A. To assess relative renal function and detect areas of decreased uptake due to scarring or infection
B. To visualize bony anatomy
C. To evaluate drainage of the collecting system
D. None of the above
C. MAG-3 diuretic renography is used to evaluate drainage of the collecting system and generate information about differential renal function, washout curves, and washout halftimes.
44
What should be considered when interpreting the results of MAG-3 diuretic renography?
A. The report is often misleading
B. The test should only be used in adults
C. Background subtraction is not necessary
D. None of the above
A. When interpreting the results of MAG-3 diuretic renography, patterns of uptake and drainage should be visually reviewed, as simply using the report is often misleading.
45
What does DTPA stand for, and how is it used in imaging?
A. Dual Technetium-Positive Analysis; used to detect areas of decreased uptake
B. Diethylenetriamine pentaacetic acid; used in diuretic renography to evaluate drainage of the collecting system
C. Dimercapto-succinic acid; used to assess bony anatomy
D. None of the above
B. DTPA stands for diethylenetriamine pentaacetic acid and is used in diuretic renography to evaluate drainage of the collecting system, although it is less commonly used than MAG3.
46
In what situations should computed tomography (CT) be used in children, according to the text?
A. Routinely for any urologic condition
B. To assess bladder function
C. To quantify stone burden and in cases of blunt abdominal trauma or pediatric renal tumor evaluation
D. To assess sexual differentiation disorders
C. According to the text, CT in children should be used judiciously to limit ionizing radiation in developing tissues, and indications when CT scan advantages outweigh risks include quantifying stone burden, blunt abdominal trauma, and pediatric renal tumor evaluation.
47
What is the main advantage of magnetic resonance urography (MRU) over other imaging techniques in the evaluation of the urinary tract?
A. It is less expensive
B. It provides higher resolution images
C. It does not require sedation in children
D. It can assess renal vasculature, parenchymal enhancement, and excretory function
D. According to the text, MRU can assess renal vasculature, parenchymal enhancement, and excretory function using postcontrast, T1-weighted images, in addition to localizing anatomic abnormalities and detailing ureteral anatomy in a three-phase study. MRU is less useful than sonography for the evaluation of stones, acute scrotum, scrotal masses, undescended testicles, and disorders of sexual development. MRU can take approximately an hour and may require sedation in children younger than 6 years.
48
Which of the following is a congenital malformation of the kidney that can be visualized on imaging?
A. Nephrolithiasis
B. Acute pyelonephritis
C. Horseshoe kidney
D. Ureteral stricture
C. According to the text, horseshoe kidneys can be visualized on imaging and appear as a solitary malrotated kidney due to the kidneys fusing and becoming entrapped by the inferior mesenteric artery. A solitary kidney can also be visualized on imaging if one kidney failed to develop. Nephrolithiasis and acute pyelonephritis are conditions that can affect the kidneys but are not congenital malformations. Ureteral stricture is a condition that affects the ureter, not the kidney.
49
Fig. 4.2 Normal and abnormal ascent of the kidneys. (A and B) The metanephros normally ascends from the sacral region to its definitive lumbar location between the sixth and ninth weeks. (C) Rarely, a kidney may fail to ascend, resulting in a pelvic kidney. (D) If the inferior poles of the kidneys fuse before ascent, the resulting horseshoe kidney does not ascend to a normal position because of entrapment by the inferior mesenteric artery.
50
How is hydronephrosis typically graded on ultrasound?
a) According to the Society for Fetal Urology classification
b) According to the American Urological Association classification
c) According to the International Classification of Diseases
d) None of the above
a) Hydronephrosis is typically graded on ultrasound according to the Society for Fetal Urology classification.
Explanation: The Society for Fetal Urology has developed a classification system to grade hydronephrosis on ultrasound. This classification system takes into account the degree of dilation of the renal pelvis and calyces, as well as the presence or absence of ureteral dilation.
51
a) After an initial ultrasound, VCUG and/or diuretic renography may be used to diagnose hydronephrosis.
: If an ultrasound shows hydronephrosis, further imaging may be needed to determine the cause and severity of the condition. VCUG (voiding cystourethrogram) is a test that can show if there is any reflux of urine from the bladder into the ureter. Diuretic renography is a test that can show how well the kidneys are functioning and how quickly urine is flowing through the urinary system. These tests may be used to help diagnose the cause of the hydronephrosis and determine the appropriate treatment.
52
Fig. 4.3 The Society for Fetal Urology (SFU) criteria as demonstrated in postnatal sonograms. Grade 0 shows no central renal dilation. In grade 1, the renal pelvis only is visible; in grade 2, major calices can be identified; in grade 3, major and minor calices can be identified; and grade 4 has features of grade 3 but with parenchymal thinning as well. Within grade 3, there are many different degrees of collecting system dilation that conform to the criteria.
53
What is dysuria?
a) A burning or stinging pain with urination
b) A condition that affects the kidneys
c) A type of bladder cancer
d) None of the above
a) Dysuria is a burning or stinging pain with urination.
Explanation: Dysuria is a symptom of discomfort or pain when urinating, typically described as a burning or stinging sensation. It is often caused by inflammation or irritation of the urethra or bladder.
54
What should be assessed during the history taking for a patient with dysuria?
a) Family medical history
b) Duration, consistency, and severity of dysuria
c) Patient's occupation
d) All of the above
b) Duration, consistency, and severity of dysuria should be assessed during the history taking for a patient with dysuria.
Explanation: When taking a history for a patient with dysuria, it is important to ask about the duration, consistency, and severity of the symptoms. Additionally, other factors such as the presence of concomitant hematuria, systemic symptoms like fever, preceding trauma, history of prior infections, weak or deviated urinary stream, voiding patterns, and the presence of constipation should be assessed.
55
What should be assessed during the examination of a patient with dysuria?
a) Visual assessment of meatal caliber
b) Palpation of the bladder to rule out urinary retention
c) Assessment of erythema in girls or boys
d) All of the above
d) Visual assessment of meatal caliber, palpation of the bladder to rule out urinary retention, and assessment of erythema in girls or boys should be assessed during the examination of a patient with dysuria.
Explanation: During the physical examination of a patient with dysuria, the meatal caliber should be visually assessed, and the presence of meatal stenosis, which can present with a ventral web of tissue below the meatus and usually results in a dorsally deflected urinary stream, should be noted. The presence of erythema in girls or boys suggests local inflammation, and the bladder should be palpated to rule out urinary retention. The abdomen can also be palpated for the presence of excessive stool.
56
What is the most common cause of dysuria?
a) Urinary infection
b) Nonbacterial viral cystitis
c) Foreign body or stone
d) Voiding dysfunction
a) Urinary infection is the most common cause of dysuria.
Explanation: The most common cause of dysuria is urinary infection, which can be identified through a urinalysis that shows leukocytes or nitrites on a dip stick. Hematuria without infection suggests a foreign body or stone, which can be visualized with imaging. Nonbacterial viral cystitis presents with significant dysuria and hematuria. Voiding dysfunction is another differential diagnosis to be considered.
57
What is the treatment for dysuria?
a) Treatment is directed at the cause
b) A therapeutic trial of azo-dye medication is useful if the cause is unclear
c) Directly treating voiding dysfunction often improves symptoms
d) All of the above
d) Treatment for dysuria involves identifying and treating the underlying cause. A therapeutic trial of azo-dye medication is useful if the cause is unclear, and directly treating voiding dysfunction often improves symptoms.
Explanation: Treatment for dysuria is directed at the underlying cause. If the cause is unclear, a therapeutic trial of azo-dye medication can be useful. Directly treating voiding dysfunction often improves symptoms, and reassurance is important to ensure compliance with voiding improvement programs.
58
What should be assessed during the history taking for a patient with hematuria?
a) Bleeding patterns
b) Difficulty voiding
c) History of preceding trauma or infections
d) All of the above
d) Bleeding patterns, difficulty voiding, history of preceding trauma or infections, and other relevant comorbidities should be assessed during the history taking for a patient with hematuria.
Explanation: When taking a history for a patient with hematuria, it is important to ask about the bleeding patterns, duration, clot formation or severity of bleeding, difficulty voiding, history of preceding trauma, prior infections, family history of progressive renal disease, and excessive bleeding with prior surgeries. Identifying relevant comorbidities, such as BK virus, provides insight in an immunocompromised child.
59
What should be assessed during the examination of a patient with hematuria?
a) Blood at the urethral meatus
b) Perineal irritation
c) Flank tenderness
d) All of the above
d) Blood at the urethral meatus, perineal irritation, flank tenderness, and palpable abdominal masses should be assessed during the examination of a patient with hematuria.
Explanation: During the physical examination of a patient with hematuria, key findings include blood at the urethral meatus, perineal irritation, flank tenderness, and palpable abdominal masses.
60
What is the most common cause of hematuria?
a) Perineal irritation
b) Trauma
c) Urinary tract infection (UTI)
d) Nephrolithiasis
c) Urinary tract infection (UTI) is the most common cause of hematuria.
Explanation: The most common cause of hematuria is urinary tract infection (UTI), which can be identified through a urinalysis that shows leukocytes or nitrites on a dip stick. Other possible causes of hematuria include perineal irritation, trauma, meatal stenosis with ulceration, coagulation abnormalities, and nephrolithiasis.
61
What is the treatment for hematuria?
a) Treatment is severity and etiology specific
b) Microhematuria can be observed and retested in 6–12 months if urinary crystals, casts, proteinuria, hypertension, and family history of progressive renal disease are absent
c) Benign idiopathic urethrorrhagia with normal imaging is managed with watchful waiting
d) All of the above
d) Treatment for hematuria is severity and etiology specific. Microhematuria can be observed and retested in 6–12 months if urinary crystals, casts, proteinuria, hypertension, and family history of progressive renal disease are absent. Benign idiopathic urethrorrhagia with normal imaging is managed with watchful waiting.
Explanation: Treatment for hematuria is severity and etiology specific. Microhematuria can be observed and retested in
62
At what age should daytime urinary continence typically occur?
a) By 2 years of age
b) By 4 years of age
c) By 6 years of age
d) By 8 years of age
b) Daytime urinary continence typically occurs by 4 years of age.
Explanation: Daytime urinary continence typically occurs by 4 years of age, followed by night continence, generally achieved by 5-6 years of age.
63
What should be assessed during the history taking for a patient with incontinence?
a) Voiding habits
b) Drinking and bowel habits
c) Neurologic history
d) All of the above
d) Voiding habits, drinking and bowel habits, neurologic history, and spinal cord injury or surgery should be assessed during the history taking for a patient with incontinence.
Explanation: When taking a history for a patient with incontinence, it is important to ask about voiding habits cautiously, so as not to elicit blanket statements such as "she is always wet." Ask about periods of dryness, worsening with activity, voiding postponement, posturing, drinking habits, bowel habits, neurologic history, and spinal cord injury or surgery.
64
What should be assessed during the examination of a patient with incontinence?
a) Genitalia for signs of irritation or abnormal configuration
b) Abdomen for stool burden
c) Lower extremities for normal gait and feet
d) All of the above
d) The examination of a patient with incontinence should target the genitalia for signs of irritation or abnormal configuration, the abdomen for stool burden, and the lower extremities for normal gait and feet.
Explanation: During the physical examination of a patient with incontinence, the genitalia should be examined for signs of irritation or abnormal configuration, the abdomen should be examined for stool burden, and the lower extremities should be examined for normal gait and feet.
65
What is the most common diagnosis for incontinence?
a) Neurogenic bladder
b) Ectopic ureter
c) Bowel and bladder dysfunction
d) Epispadias
c) Bowel and bladder dysfunction is the most common diagnosis for incontinence.
Explanation: The most common diagnosis for incontinence is bowel and bladder dysfunction, which typically requires behavioral modification that includes improved hydration, timed voiding every 2-3 hours, and a vigorous bowel regimen. Other etiologies, including ectopic ureter and neurogenic bladder, necessitate further workup.
66
What should be assessed during the history taking for a patient with scrotal pain?
a) Preceding trauma
b) Associated symptoms
c) Testicular size
d) Both a and b
d) Preceding trauma and associated symptoms should be assessed during the history taking for a patient with scrotal pain.
Explanation: When taking a history for a patient with scrotal pain, it is important to define the duration and onset of pain, preceding trauma, and associated symptoms such as erythema, nausea or vomiting, fevers or chills, or abdominal pain.
67
What should be assessed during the physical examination of a patient with scrotal pain?
a) Testicular lie or position in the scrotum
b) Masses, tenderness, fluctuance, and erythema on examination
c) Turgor compared with the contralateral side
d) All of the above
d) The physical examination of a patient with scrotal pain should assess the testicular lie or position in the scrotum, masses, tenderness, fluctuance, and erythema on examination, and turgor compared with the contralateral side.
Explanation: During the physical examination of a patient with scrotal pain, the testicular lie or position in the scrotum should be noted, as well as masses, tenderness, fluctuance, and erythema on examination, and turgor compared with the contralateral side.
68
What imaging modality is useful in assessing testicular contour and Doppler flow in a patient with scrotal pain?
a) CT scan
b) MRI
c) X-ray
d) Testicular ultrasound
d) Testicular ultrasound is useful in assessing testicular contour and Doppler flow in a patient with scrotal pain.
Explanation: Testicular ultrasound is a useful imaging modality in assessing testicular contour, Doppler flow, and to define poorly palpable masses in a patient with scrotal pain.
69
What are some differential diagnoses for scrotal pain?
a) Testicular torsion
b) Varicocele
c) Epididymo-orchitis
d) All of the above
d) Testicular torsion, varicocele, and epididymo-orchitis are some of the differential diagnoses for scrotal pain.
Explanation: The differential diagnoses for scrotal pain include testicular torsion, testicular or epididymal appendix torsion, testicular or paratesticular tumor, varicocele, hernia and hydrocele, testicular trauma, epididymo-orchitis, scrotal abscess, cellulitis, and constipation.
70
Table 4.6 Diagnosis and Treatment Options for Various Scrotal Pathology
71
What should be evaluated in the patient's history when urinary retention is suspected?
a) Time since last void, prior episodes, bowel history, and neurologic disorders.
b) Family history, social history, and religious affiliation.
c) Allergies, medication use, and vaccination history.
a) Time since last void, prior episodes, bowel history, and neurologic disorders.
Explanation: In the patient's history, the clinician should inquire about time since the last void, prior episodes of urinary retention, bowel history, and neurologic disorders that may contribute to retention.
72
Why should a neurologic exam be performed when urinary retention is suspected?
a) To evaluate for sacral dimpling or tufts and lower extremity motor or sensory deficits.
b) To evaluate for ear infections and hearing loss.
c) To evaluate for skin rashes and allergies.
a) To evaluate for sacral dimpling or tufts and lower extremity motor or sensory deficits.
Explanation: A neurologic exam is indicated to evaluate for sacral dimpling or tufts and lower extremity motor or sensory deficits that may indicate a neurologic disorder or injury that could contribute to urinary retention.
73
What should be considered in a neonate with urinary retention?
a) Posterior urethral valves.
b) Constipation.
c) Neurologic disorders.
a) Posterior urethral valves.
Explanation: In a neonate with urinary retention, posterior urethral valves should be considered.
74
What is the management for urinary retention if constipation or dysfunctional voiding is suspected?
a) Catheterization.
b) Antibiotics.
c) Enema.
c) Enema.
Explanation: If constipation or dysfunctional voiding is suspected as the cause of urinary retention, an enema can be administered.
75
What should be evaluated in the patient's history when penile pain is suspected?
a) Family history, social history, and religious affiliation.
b) Duration, severity, inciting events, erythema, fever, and difficulties with urination and constipation.
c) Allergies, medication use, and vaccination history.
b) Duration, severity, inciting events, erythema, fever, and difficulties with urination and constipation.
Explanation: In the patient's history, the clinician should ask about duration, severity, inciting events, erythema, fever, and difficulties with urination and constipation.
76
What are the causes of penile pain?
a) Eye infections, ear infections, and sinusitis.
b) Tonsillitis, strep throat, and mononucleosis.
c) Priapism, paraphimosis, balanitis, urinary retention, constipation, voiding dysfunction, and idiopathic penile edema.
c) Priapism, paraphimosis, balanitis, urinary retention, constipation, voiding dysfunction, and idiopathic penile edema.
Explanation: Causes of penile pain include priapism, paraphimosis, balanitis, urinary retention, constipation, voiding dysfunction, and idiopathic penile edema.
77
Why is careful examination of the penis important when evaluating penile pain?
a) To evaluate the testicles.
b) To evaluate the prostate gland.
c) To note foreskin, urethral meatus position and size, penile shaft curvature or torsion, erythema, pubescence, and lesions on the penis.
c) To note foreskin, urethral meatus position and size, penile shaft curvature or torsion, erythema, pubescence, and lesions on the penis.
Explanation: Careful examination of the penis is important to note foreskin, urethral meatus position and size, penile shaft curvature or torsion, erythema, pubescence, and lesions on the penis, as sexually transmitted diseases are prevalent among adolescent boys.
78
Table 4.7 Treatment of Common Penile Conditions
79
What should be evaluated in the patient's history when flank pain or colic is suspected?
a) Family history, social history, and religious affiliation.
b) Duration, onset, inciting events, trauma, and associated symptoms.
c) Allergies, medication use, and vaccination history.
b) Duration, onset, inciting events, trauma, and associated symptoms.
Explanation: In the patient's history, the clinician should ask about duration, onset, inciting events, trauma, and associated symptoms such as gross hematuria, dysuria, fevers, and chills.
80
What is the first-line medical expulsion therapy in children, especially with small, distal stones?
a) Surgery.
b) Analgesia.
c) Alpha-blockers.
c) Alpha-blockers.
Explanation: Alpha-blockers are recommended as first-line medical expulsion therapy in children, especially with small, distal stones.
81
How can paraphimosis be distinguished on examination?
a) By noting a tight band of tissue in front of the glans.
b) By noting a tight band of tissue behind the glans.
c) By noting a tight band of tissue around the testicles.
b) By noting a tight band of tissue behind the glans.
Explanation: Paraphimosis can be distinguished on examination by noting a tight band of tissue behind the erythematous, edematous glans indicating the foreskin was not reduced after retraction.
82
What is the physical finding of balanitis?
a) Swelling and erythema of the penis.
b) Irritated, erythematous glans.
c) Tight band of tissue behind the glans.
b) Irritated, erythematous glans.
Explanation: Balanitis presents with an irritated, erythematous glans.
83
What is summer penile syndrome?
a) Swelling and erythema of the penis caused by summer allergies.
b) Swelling and erythema of the penis caused by insect bites or outdoor exposure.
c) Swelling and erythema of the penis caused by sexually transmitted infections.
b) Swelling and erythema of the penis caused by insect bites or outdoor exposure.
Explanation: Summer penile syndrome is swelling and erythema of the penis caused by insect bites or outdoor exposure. It is typically self-limited and managed conservatively.
84
What is the recommended management for summer penile syndrome?
a) Observation with analgesia.
b) Manual reduction.
c) Conservative management.
c) Conservative management.
Explanation: Summer penile syndrome is typically self-limited and managed conservatively.
85
What is priapism?
a) A persistent penile erection related to sexual stimulation.
b) A persistent penile erection unrelated to sexual stimulation lasting >4 hours.
c) A temporary penile erection lasting <4 hours.
b) A persistent penile erection unrelated to sexual stimulation lasting >4 hours.
Explanation: Priapism is a persistent penile erection, typically affecting only the corpora cavernosa, unrelated to sexual stimulation sustained for >4 hours.
86
What are the types of priapism?
a) Ischemic (venoocclusive, low flow), nonischemic (arterial, high flow), and acute.
b) Ischemic (venoocclusive, low flow), nonischemic (arterial, high flow), and stuttering (intermittent).
c) Ischemic (venoocclusive, low flow), chronic, and acute.
b) Ischemic (venoocclusive, low flow), nonischemic (arterial, high flow), and stuttering (intermittent).
Explanation: The types of priapism are ischemic (venoocclusive, low flow), nonischemic (arterial, high flow), and stuttering (intermittent).
87
What is the recommended treatment for low-flow priapism resulting from sickle cell disease?
a) Observation with analgesia.
b) Concurrent treatment of the underlying disease with transfusion, alkalization, hydration, and oxygen as well as intracavernous treatment with aspiration or intracavernous injection of sympathomimetics.
c) Surgery.
b) Concurrent treatment of the underlying disease with transfusion, alkalization, hydration, and oxygen as well as intracavernous treatment with aspiration or intracavernous injection of sympathomimetics.
Explanation: Treatment of low-flow priapism resulting from sickle cell disease includes concurrent treatment of the underlying disease with transfusion, alkalization, hydration, and oxygen as well as intracavernous treatment with aspiration (with or without irrigation) or intracavernous injection of sympathomimetics as indicated.
88
What is high-flow priapism?
a) A type of priapism that involves a completely rigid corpora cavernosa.
b) A type of priapism that results from sickle cell disease.
c) A type of priapism that is caused by trauma to the penis.
c) A type of priapism that is caused by trauma to the penis.
Explanation: High-flow priapism is a type of priapism that is caused by trauma to the penis.
89
What is the recommended treatment for high-flow priapism?
a) Surgery.
b) Intracavernous treatment with aspiration or intracavernous injection of sympathomimetics.
c) Observation with analgesia.
b) Intracavernous treatment with aspiration or intracavernous injection of sympathomimetics.
Explanation: Treatment for high-flow priapism is controversial because it may not produce long-term fibrosis. However, intracavernous treatment with aspiration or intracavernous injection of sympathomimetics may be indicated.
90
How can a fluid-filled scrotum be differentiated from a hard mass?
a) Palpation of the affected side.
b) Transillumination.
c) Both a and b.
c) Both a and b.
Explanation: Palpation of the affected side helps differentiate a fluid-filled scrotum from a hard mass. Transillumination may also help differentiate fluid from solid mass.
91
What is the significance of the "fountain sign" in scrotal ultrasound?
a) It indicates the presence of a hydrocele.
b) It indicates the presence of a testicular tumor.
c) It indicates the presence of scrotal erythema.
a) It indicates the presence of a hydrocele.
Explanation: Scrotal ultrasound aids in diagnosis and will show the “fountain sign” or swirling edematous scrotal wall tissues, indicating the presence of a hydrocele.
92
What is acute idiopathic scrotitis?
a) A testicular torsion.
b) An inflammatory process of probable allergic origin causing significant swelling, erythema and itching.
c) A type of hernia.
b) An inflammatory process of probable allergic origin causing significant swelling, erythema and itching.
Explanation: Acute idiopathic scrotitis is an inflammatory process of probable allergic origin that causes significant swelling, erythema, and itching.
93
What is acute idiopathic scrotitis?
a) A testicular torsion.
b) An inflammatory process of probable allergic origin causing significant swelling, erythema and itching.
c) A type of hernia.
b) An inflammatory process of probable allergic origin causing significant swelling, erythema and itching.
Explanation: Acute idiopathic scrotitis is an inflammatory process of probable allergic origin that causes significant swelling, erythema, and itching.
94
What is the appearance of an interlabial mass in the case of urethral prolapse?
a) Smooth, congested, mucosa-covered mass protruding from the urethra.
b) Erythematous, friable appearing mucosa on vaginal exam.
c) Thin-walled golden or whitish cyst anterior to the vagina.
b) Erythematous, friable appearing mucosa on vaginal exam.
Explanation: Urethral prolapse will demonstrate an erythematous, friable appearing mucosa on vaginal exam.
95
How can ureteroceles be differentiated from urethral prolapse?
a) Ureteroceles are circumferential, while urethral prolapse is not.
b) Ureteroceles are not circumferential, while urethral prolapse is.
c) Both a and b.
) Ureteroceles are circumferential, while urethral prolapse is not.
Explanation: A prolapsed ureterocele will be a smooth, congested, mucosa-covered interlabial mass protruding from the urethra and distinct from the vagina. This can be differentiated from urethral prolapse because the ureterocele is circumferential.
96
What is the appearance of a skene's cyst?
a) Smooth, congested, mucosa-covered mass protruding from the urethra.
b) Erythematous, friable appearing mucosa on vaginal exam.
c) Thin-walled golden or whitish cyst anterior to the vagina.
c) Thin-walled golden or whitish cyst anterior to the vagina.
Explanation: A thin-walled golden or whitish cyst anterior to the vagina is typical for a Skene’s cyst, which are commonly self-resolving.
97
What is the appearance of a botryoid rhabdomyosarcoma in the vagina?
a) A "cluster of grapes".
b) A smooth, congested, mucosa-covered mass protruding from the urethra.
c) A thin-walled golden or whitish cyst anterior to the vagina.
a) A "cluster of grapes".
Explanation: Botryoid rhabdomyosarcoma is evident in the vagina as a "cluster of grapes".
98
What is the appearance of urethral diverticula?
a) Smooth, congested, mucosa-covered mass protruding from the urethra.
b) Erythematous, friable appearing mucosa on vaginal exam.
c) Variably sized, urine-filled periurethral cystic structure protruding through the vaginal opening.
c) Variably sized, urine-filled periurethral cystic structure protruding through the vaginal opening.
Explanation: Urethral diverticula can present as variably sized, urine-filled periurethral cystic structure protruding through the vaginal opening.
99
Table 4.8 Diagnosing and Managing Interlabial Masses
100
What is the Skene's gland?
The Skene's gland, also known as the female prostate, is a gland located on the front wall of the vagina and surrounding the urethra in females. It is named after Alexander Skene, the American gynecologist who first described it in 1880. The Skene's gland is believed to produce and secrete fluids that help lubricate and support the urethra during sexual activity. The gland is also associated with female ejaculation and may play a role in female sexual function and orgasm.
101
What is the condition characterized by the fusion of the labia minora in the midline, concealing the vaginal opening?
a. Imperforate hymen
b. Cloacal anomaly
c. Labial adhesions
d. Vaginal agenesis
c. Labial adhesions
Explanation: Labial adhesions are a common condition in young girls where the labia minora are fused in the midline, concealing the vaginal opening. Symptomatic cases can be treated with topical estrogen or steroids to separate the edges, but continued moisturizing ointment will be needed to prevent refusion.
102
What is the condition characterized by a bulging white or yellow membrane in the introitus of an infant or potentially amenorrhea with painful episodes in the older child?
a. Imperforate hymen
b. Cloacal anomaly
c. Labial adhesions
d. Vaginal agenesis
a. Imperforate hymen
Explanation: Imperforate hymen is usually characterized by a bulging white or yellow membrane in the introitus of an infant or potentially amenorrhea with painful episodes in the older child. It can be treated with incision for drainage, which is usually sufficient and dilation is not required.
103
What is the condition characterized by a single perineal opening in a phenotypic female where the urethra, vagina, and colon converge?
a. Imperforate hymen
b. Cloacal anomaly
c. Labial adhesions
d. Vaginal agenesis
b. Cloacal anomaly
Explanation: Cloacal anomaly is a rare condition characterized by a single perineal opening in a phenotypic female where the urethra, vagina, and colon converge. The external appearance is flat with no obvious introitus, but the bladder may be distended, and the presence of the anomaly may be indicated prenatally. The initial goal is to provide gastrointestinal and urinary drainage.
104
What is the characteristic feature of female epispadias?
A. Abnormal vaginal position
B. Flattened labia majora
C. Bifid clitoris
D. Narrow urethra
C. Bifid clitoris
Explanation: Female epispadias is a congenital anomaly that involves the abnormal positioning of the urethral opening in the female genitalia. One of the characteristic features of female epispadias is a bifid clitoris, which means the clitoris is split in two. Additionally, the mons pubis may appear flattened, and the urethra may be wide open, resulting in urinary incontinence. Surgery is often required to correct this condition.
105
What is the most important initial evaluation in a newborn with ambiguous genitalia?
a. Determining the sex of the baby
b. Palpating the gonads
c. Measuring the size of the clitoris
d. Examining the urethra
b. Palpating the gonads is the most important initial evaluation in a newborn with ambiguous genitalia. This can help to rule out certain conditions such as 46, XX congenital adrenal hyperplasia.
106
What is the significance of nonpalpable gonads with virilization in a newborn with ambiguous genitalia?
a. It is a normal finding
b. It suggests mixed gonadal dysgenesis
c. It rules out 46, XX congenital adrenal hyperplasia
d. It requires urgent evaluation for salt wasting
d. Nonpalpable gonads with virilization in a newborn with ambiguous genitalia require urgent evaluation for salt wasting. This finding is concerning for 46, XX congenital adrenal hyperplasia, which requires immediate attention.
107
What is the spectrum of conditions included in epispadias-exstrophy complex?
Epispadias-exstrophy complex is a spectrum of conditions ranging from epispadias to classic exstrophy to the extreme end of cloacal exstrophy, with failure of urethral and bladder closure.
Explanation:
Epispadias-exstrophy complex is a congenital anomaly that affects the genitourinary system. It involves abnormal development of the bladder, urethra, and genitalia. The condition includes a range of defects, from minor abnormalities such as epispadias to severe malformations such as cloacal exstrophy. The condition can affect both boys and girls, and the severity of the malformation can vary widely. The most severe form, cloacal exstrophy, is a rare and life-threatening condition that requires immediate surgical intervention.
