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09. HPB (870) > BPH > Flashcards

BPH Flashcards

1
Q

Prostate is derivation of ____derm

A

endoderm

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2
Q

____ zone is site of BPH

A

Transitional (encircles urethra)

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3
Q

____ zone is site of prostate ca.

A

Peripheral (75% of gland)

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4
Q

BPH is cellular proliferation of ____ and ____ parts

A

stromal & epithelial

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5
Q

alpha-1 blockers inhibit prostate _____ and decrease prostatic urethral resistance

A

smooth muscle contraction

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6
Q

LUTS work-up

History
Exam
_____ symptom score
Lab test: ____

A

AUA-SS

UA

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7
Q

Prior to BPH surgery….

Size evaluation with ___, ____, or ___
Voiding studies - ____ & ____

A

U/S, cystoscopy, or cross-sectional imaging

PVR & Uroflow

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8
Q

1st Line BPH therapies

A
  • Fluid restriction prior to sleeping
  • Limiting alcohol and caffeine
  • Voiding diary with frequency-volume chart
  • Timed voiding
  • Double voiding
  • Bladder training
  • Avoiding constipation
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9
Q

Alpha-blocker side effects

A

Adverse effects
• Dizziness (orthostasis)
• Retrograde ejaculation (6%)
• Rhinitis (12%)
• Intraoperative floppy iris syndrome (IFIS)
• higher rates of iris trauma and posterior capsule rupture during cataract surgery with ANY use of Tamsulosin

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10
Q

____ has the least risk of ejaculatory dysfunction of all alpha-blockers

A

Alfuzosin (Uroxatral)

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11
Q

5-ARIs have maximal prostate size reduction after ___ with an average size reduction of ___ %

A

6 months… 15-30%

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12
Q

Finasteride also suppresses _____ which makes it useful in men with refractory hematuria 2/2 prostatic bleeding

A

VEGF

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13
Q

Risk reduction of retention or prostate surgery with Finasteride use is ___%

A

70%

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14
Q

____ medications work by relaxing detrusor muscle to increase bladder storage volumes and decrease sensation for micturition

A

Beta-3 agonists (Mirabegron)

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15
Q

Side effects of Mirabegron

A

HTN(7.3%), Nasopharyngitis (3.4%)

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16
Q

PDE-5i with FDA approval for daily use in men with BPH/LUTS

A

Tadalafil 5 mg (Cialis)

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17
Q

Side effcts of PDE-5i

A

Headache (15%)
Facial flushing (4-10%)
Dyspepsia (3-11%)

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18
Q

Mechanism of PDE-5i

A

block breakdown of cGMP to GMP by phosphodiesterase leading to vasodilation

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19
Q

MTOPS study

Compared ___, ____, ___, ____
Results: ____ AUR, BPH surgery, BPH progression

A

placebo vs doxazosin vs finasteride vs combo

REDUCED aur, bph sx, bph progression

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20
Q

COMBAT trial

Compared ____ vs ____ vs ____
Results: ___ Qmax, PSA, & prostate volume

A

Tamsulosin vs Dutasteride (Avodart) vs combo

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21
Q

TIMES Trial

Compared ____ vs _____
Results: ____ nocturia, frequency/urgency, ____ in Qmax, PVR

A

Tolteroderine (Detrol) vs Detrol + Flomax

Improved symptoms
No change in Qmax or PVR

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22
Q

PLUS trial

Compared ____ vs ____
Results: ____ mean volume voided per micturition, & urgency and frequency, ____ in Qmax or PVR, ____
retention rates in the tamsulosin plus mirabegron group

A

Flomax vs Flomax + Mirabegron

Improved volume & urgency & frequency
No change in Qmax or PVR
Higher retention rates in combo group

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23
Q

Indications for BPH Surgery

A 
Refractory to and/or unwilling to use other therapies  Renal insufficiency secondary to BPH
Urinary retention secondary to BPH
Recurrent UTI
Recurrent bladder stones
Gross hematuria secondary to BPH
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24
Q

Urolift contraindications

Size >___ cc
Prominent ____ lobe

A

> 80 cc

Prominent middle lobe

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25
Q

Water Vapor Therapy (Rezum) Mechanism

A

Water vapor energy leads to disruption of cell membranes and tissue necrosis

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26
Q

AUA Guideline: PAE is ___ recommended for the treatment of LUTS/BPH outside the context of a clinical trial

A

NOT

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27
Q

AUA Guideline: PAE is ___ recommended for the treatment of LUTS/BPH outside the context of a clinical trial

A

NOT

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28
Q

What challenges are involved in the medical management of BPH in elderly men?

A

Multiple comorbidities, polypharmacy, adverse effects, drug-drug interactions, limited data on medications for those over 80, and specific concerns regarding alpha blockers.

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29
Q

What is FORTA classification, and how is it used in treating BPH in elderly men?

A

FORTA (Fit fOR The Aged) classification categorizes the safety and efficacy of medications for BPH in men over 65. It helps in selecting the right medication, considering factors like side effects and interactions.

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30
Q

What are the key considerations in using alpha blockers in the management of BPH in elderly patients?

A

Alpha blockers like alfuzosin, doxazosin, tamsulosin, and silodosin are commonly used. Considerations include FORTA classification, side effects like orthostatic hypotension, intraoperative floppy iris syndrome (IFIS), interaction with cataract surgery, and sexual side effects.

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31
Q

Figure. Treatment algorithm for the elderly male with BPH. OAB, overactive bladder. OSA, obstructive sleep apnea

A
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32
Q

What factors must be considered for an individualized approach to BPH in men over 80?

A

Comorbidities, operative risk, polypharmacy, living environment, resources, and mental acuity.

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33
Q

Why is understanding the living environment crucial in older patients with BPH?

A

To assess toileting abilities, fall risks, caregiver support, and choose the best treatment path.

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34
Q

What diagnostic tools are important in understanding BPH issues in older men?

A

Voiding diaries, urodynamics, cystoscopy.

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35
Q

What is the typical first-line therapy for BPH?

A

Medications, considering comorbidities, polypharmacy, and the FORTA classification.

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36
Q

What should be considered when prescribing alpha blockers for BPH in the elderly?

A

Side effects like orthostatic hypotension, IFIS, and QTc prolongation. Only silodosin and tamsulosin are acceptable in the FORTA classification.

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37
Q

What are the advantages and classification of 5ARIs in BPH treatment for the elderly?

A

Reduction of prostate volume, lack of adverse cognitive and cardiovascular effects, 3-4 months for symptom change, FORTA B classification.

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38
Q

What is the role of PDE-5s in BPH treatment?

A

Treats both LUTS and ED, tadalafil FDA-approved for daily use, FORTA-C classification.

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39
Q

What is the role and considerations of anticholinergics in BPH treatment for the elderly?

A

Reduces nerve impulses in bladder muscles, significant side effects in some types, fesoterodine preferred, FORTA classification varies.

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40
Q

Describe the role and effects of beta-3 agonists like mirabegron in BPH treatment.

A

Causes detrusor relaxation, well-tolerated with low adverse effects, hypertension, and urinary tract infection as common effects.

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41
Q

What are the combination therapies for BPH, and how effective are they?

A

Alpha Blocker and 5-ARI, Alpha Blocker and Anticholinergic; effective in reducing symptoms and progression.

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42
Q

What are the roles of testosterone replacement and antiandrogens in BPH treatment?

A

Testosterone improves quality of life but risks prostate growth (mitigated with 5ARIs); antiandrogens for rapid reduction in prostate size.

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43
Q

What are the special considerations for elderly patients undergoing BPH surgery?

A

Anesthetic risks, polypharmacy, anticoagulation, comorbidities, social factors, recovery components, frailty, and potential catheter use.

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44
Q

What are MISTs, and what makes them attractive for frail men?

A

Low-risk office-based procedures like prostatic urethral lift, water vapor thermotherapy; may require anesthesia or sedation. Advantages and disadvantages listed in table 3.

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45
Q

How is PAE used in BPH treatment, especially for frail older men?

A

Reasonable and safe treatment, beneficial for refractory/recurrent hematuria, concerns about contrast load and prolonged treatment times.

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46
Q

What are the key considerations regarding anesthesia in elderly BPH surgery?

A

Hemodynamic and cognitive risks, limiting duration, regional approaches, risk of neurotoxicity, pressure ulcers, limited mobility, and traumatic fractures.

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47
Q

What are the surgical approaches and potential modifications for elderly BPH patients?

A

: Avoiding monopolar TUR, laparoscopic, robotic, and open surgery; preferring laser procedures; modifying techniques like channel bipolar TUR; considering short-term hormonal therapy for untreated prostate cancer.

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48
Q

What are the critical postoperative considerations for elderly men after BPH surgery?

A

Managing fluid intake, constipation, voiding symptoms, recurrent hematuria, potential catheter or suprapubic tube trials, antibiotics, consideration of 5ARIs or antiandrogens.

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49
Q

What is the importance of assessing frailty in elderly patients undergoing BPH surgery?

A

Increased risk of complications, length of hospital stay, mortality; assessment tools like frailty phenotype and frailty index; lack of consensus on optimization; geriatric assessment advised.

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50
Q

What are the concluding thoughts on treating BPH in older men?

A

Requires full assessment and thoughtful approach, considering voiding issues, treatment risks, patient frailty, living environment; tailored treatment options with multiple choices.

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51
Q

What is the FORTA classification system for medical therapies used to treat BPH in men ≥65, and how are the medications classified?

A

FORTA A (Absolutely): None
FORTA B (Beneficial): Dutasteride, Finasteride (5ARI); Fesoterodine, Oxybutynin extended release, Solifenacin, Tolterodine, Trospium (Anticholinergic); Tadalafil (Phosphodiesterase inhibitor)
FORTA C (Careful/Caution): Darifenacin, Mirabegron (Anticholinergic); Alfuzosin, Doxazosin, Silodosin, Tamsulosin, Terazosin (Alpha blocker)
FORTA D (Do Not Recommend): Oxybutynin immediate release (Anticholinergic); Propiverine (Anticholinergic)

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52
Q

What are the advantages and disadvantages of MIST procedures in treating BPH?

A

Advantages:
Office setting performance
Sedation options for those intolerant to local anesthesia
Fast procedures in experienced hands (e.g., prostatic urethral lift, water vapor thermotherapy)
No tissue removal (prevents sloughing or delayed complications)
No sexual side effects
Some therapies repeatable (e.g., water vapor thermotherapy, transurethral microwave therapy)

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53
Q

What are the advantages and disadvantages of MIST procedures in treating BPH?

A

May not sufficiently improve symptoms
Prolonged treatment time for awake patients (e.g., transurethral microwave therapy)
Delayed symptom resolution due to lack of tissue removal
Utility in large prostates unproven for most methods
Potential post-procedure hematuria
Prostatic edema may require prolonged catheterization
May not be suitable or efficacious with middle lobes
Uncertain long-term durability in large prostates or those with a middle lobe

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54
Q

What are the side effects and risks of Alpha Blockers in the treatment of BPH in elderly patients?

A

Orthostatic hypotension
Retrograde ejaculation
Rhinitis
Risk for IFIS
QTc prolongation
CHF exacerbation in selective patients

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55
Q

What are the side effects and risks of Beta 3 Agonists in the treatment of BPH in elderly patients?

A

Hypertension
Cardiac arrhythmias
Dizziness
Headache
Constipation
Infections (e.g., cystitis, pharyngitis)

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56
Q

What are the side effects and risks of PDE-5 Inhibitors in the treatment of BPH in elderly patients?

A

Headache
Dyspepsia
Nasopharyngitis
Back pain
Cardiovascular effects
Dizziness
Hypotension

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57
Q

What are the side effects and risks of 5ARIs in the treatment of BPH in elderly patients?

A

Altered sexual function
Reduction of sexual libido
ED
Gynecomastia (no association with male breast cancer)

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58
Q

What are the side effects and risks of Anticholinergics in the treatment of BPH in elderly patients?

A

Dry eyes and mouth
Blurred vision
Constipation
Fever
Flushing
Tachycardia
QT prolongation
Urinary retention
Psychosis/confusion

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59
Q
A
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60
Q

Sex accessory tissues include the :(4)

They are believed to play a major, but unknown, role in the reproductive process

A

Sex accessory tissues include the prostate gland, seminal vesicles, ampullae, and bulbourethral glands. They are believed to play a major, but unknown, role in the reproductive process

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61
Q

The wolffian ducts develop into the seminal vesicles, epididymis, vas deferens, ampulla, and ejaculatory duct; the developmental growth of this group of glands is stimulated by: ___

A

fetal testosterone

62
Q

The prostate first appears and starts its development from the urogenital sinus during the __month of fetal growth, and development is directed primarily by __

A

third

DHT

63
Q

for prostate development to proceed, __ receptor is required to be functional in the mesenchyme.

A

ANDROGEN

64
Q

α1A. Research work has demonstrated three subtypes of the α1 -adrenergic receptor (α1A, α1B, and α1D), of which the α1A receptor appears to be linked to ___

A

α1A is linked to contraction .

65
Q

Testosterone is synthesized in the Leydig cells of the testes from ___ by a series of __ reactions; however, once testosterone is reduced by __into DHT or to estrogens by aromatase, the process is irreversible.

A

PREGNENOLONE

REVERSIBLE

5a-reductase

66
Q

Less than __ of the total testosterone in the plasma is derived from DHEA.

A

1%

67
Q

The majority of testosterone bound to plasma protein is associated with __.

A

Sex hormone-binding globulin (SHBG).

68
Q

___ ISOFORM is mutated in 5α-reductase deficiency and is the dominant isoform present in the prostate gland.

A

TYPE 2 ISOFORM

69
Q

The source of fructose in human seminal plasma is the ___

A

SEMINAL VESICLES

70
Q

The __ the length, the more actively the androgen receptor is thought to function.

A

SHORTER the POLY CAG repeats

71
Q
  1. There are two major cellular components in the prostate:
A

epithelial and stromal.

72
Q
  1. Because of the diurnal variation of serum testosterone, to avoid inconsistency it should be ___
A

measured in the morning.

73
Q

the plasma half-life of testosterone is

A

10 to 20 minutes,

74
Q
  1. The source of prostaglandins, fructose, and semenogelin, and contribution of most volume to seminal fluid is the ___
A

SEMINAL VESICLES

75
Q

he source of citrate, zinc, spermine, and choline is:

A

the prostate

76
Q

__ is a serine protease and degrades semenogelin.

Semenogelin gives rise to the __ of semen.

A

PSA

COAGULATION

77
Q
  1. Increases in human kallikrein 2, pro-PSA, and bound PSA are associated with __ cancer.
A

prostate ca

78
Q

{___ produced in the prostate may be elevated in prostate cancer; it is also produced in the bone and may be elevated in diseases that affect the bone such as Paget disease, osteoporosis, and bone metastases.

A

Acid phosphatase

79
Q

The ____ develop into the seminal vesicles, epididymis, vas deferens, ampulla, and ejaculatory duct; the developmental growth of this group of glands is stimulated by fetal testosterone and not DHT.

A

WOLFFIAN DUCTS

80
Q
A
81
Q

What is a major contraindication for the implantation of an artificial urinary sphincter for post radical prostatectomy urinary incontinence?

A. Previous radiation therapy
B. Significant detrusor overactivity
C. Previously treated anastomotic stricture
D recurrent elevated prostate-specific antigen

A

B. Significant detrusor overactivity

82
Q

Which result suggests a diagnosis of bladder outflow obstruction most?

A. Qmax 6ml/s, voided volume 50ml, post-micturition residual 150ml
B. Qmax 12ml/s, voided volume 140ml, post-micturition residual 130ml
C. Qmax 12ml/s, voided volume 340ml, post-micturition residual 95ml
D. Qmax 18ml/s, voided volume 150ml, post-micturition residual 200

A

C. Qmax 12ml/s, voided volume 340ml, post-micturition residual 95ml

83
Q

In normal male patients undergoing uroflowmetry, which parameter is independent of the voided volume (Vcomp)?

A. Qmax/(krumelur”check”)Vcomp
B. Qave/(krumelur”check”) Qmax
C. Qmax/Qcomp
D. Vcomp/(krumelur”check”)T100

A

A. Qmax/(krumelur”check”)Vcomp

84
Q

Bladder wall thickness increases:

  1. With age
  2. In patients with bladder outlet obstruction
  3. After TurP

A. All 3 options are correct
B. Only option 2 is correct
C. Only option 1 is correct
D. Options 1 and 2 are both correct

A

D. Options 1 and 2 are both correct

85
Q

Bladder wall mechanical stretch stress alters the expression of several growth factors. In particular it decreases the expression of which of the following?

A. bFGF
B. EGF
C. HB-EGF
D. TGF

A

D. TGF

86
Q

Bladder voiding efficiency is defined as:
A. Voided volume: pre-void bladder volume x 100%
B. Voided volume: cystometric bladder capacity x 100%
C. (Voided volume+residual urine): total bladder capacity x 100%
D. (Voided volume + residual urine): cystomeric bladder capacity x 100%

A

A. Voided volume: pre-void bladder volume x 100%

87
Q

The MTOPS study and the CombAT have evaluated the combination of:

A. Alfa-blockers and desmopressin
B. Alfa-blockers and antimuscarins
C. 5alfa-reductase inhibitors and alfa-blockers
D. 5alfa-reductase inhibitors and antimuscarinics

A

C. 5alfa-reductase inhibitors and alfa-blockers

88
Q

The most appropriate procedure for the correction of genuine Stress Urine incontinence (SIU) due to bladder neck hypermobility is:

A. Colposuspention
B. Sling procedure
C. Mid-urethral tape
D. Urethral bulking agents

A

C. Mid-urethral tape

89
Q

High doses of capsaicin and resiniferatoxin:

A. Have no effect on the A6-fibres
B. Cause cell death of the C-fibres
C. Cause activation of the A6-fibres, leading to detrusor areflexia
D. Cause depletion of the afferent nerve cell’s supply of substance P and neurokinin A

A

D. Cause depletion of the afferent nerve cell’s supply of substance P and neurokinin A

90
Q

Following a CVA a fixed deficit may become apparent. Which dysfunctional symptom is usually associated with this?

A. Urgency
B. Hesitancy
C. Frequency
D. Post-micturition dribbling

A

A. Urgency

91
Q

During urodynamic studies which parameter is not directly measured but calculated?

A. Urethral pressure
B. Detrusor pressure
C. Intravesical pressure
D. Intra-abdominal pressure

A

B. Detrusor pressure

92
Q

Which are the key baseline parameters allowing a stratification of BPH patients according to the risk of progression?

  1. Serum PSA
  2. Prostate size
  3. Serum creatinine
  4. Age and symptom severity

A. Only 1 and 2
B. All exept 1
C. All exept 3
D. All

A

C. All exept 3

93
Q

What is the preferred method for diagnosing a ureteropelvic junction obstruction?

A. Ultrasonography and excretory urography
B. Ultrasonography and CT
C. Diuretic renography and excretory urography
D. Retrograde pyelography and excretory urography

A

C. Diuretic renography and excretory urography

94
Q

Which statement is correct regarding pelvic organ prolapse after incontinence surgery?

A. The rate of cystocele is similar after colposuspension and with TVT
B. The rate of cervical prolapse is similar after colposuspension and with TVT
C. The rate of enterocele is similar after colposuspension and with TVT
D. The rate of rectocele is similar after colposuspension and with TVT

A

A. The rate of cystocele is similar after colposuspension and with TVT

95
Q

The failure rates for urinary incontinence after open colposuspension after 5 years are approximately:

A. 5%
B. 20%
C. 40%
D. 60%

A

B. 20%

96
Q

What is the approximate incidence of pelvic organ prolapse in parous women?

A. 15%
B. 25%
C. 35%
D. 50%

A

D. 50%

97
Q

Which of the many botulinum neurotoxin serotypes is most widely used in urology?

A. Neurotoxin A
B. Neurotoxin B
C. Neurotoxin C
D. Neurotoxin D

A

A. Neurotoxin A

98
Q

What is the recommended dose of onabotulinum toxin in idiopathic detrussor overactivity?

A. 100 IU
B. 200 IU
C. 300 IU
D. 400 IU

A

A. 100 IU

99
Q

In elderly women with potential risk of cognitive dysfunction, which therapy should be avoided in treatment of incontinence?

A. Mirabegron
B. Oxybutinin
C. Electrostimulation
D. Oesteogens

A

B. Oxybutinin

100
Q

Which ejaculation problem might be observed with alfa1-adrenoceptor anragonists?

A. Anejaculation
B. Retrograde ejaculation
C. Haematospermia
D. Premature ejaculation

A

A. Anejaculation

101
Q

Regarding the efficacy of TurP

A. The probability of requiring a second prostate operation is reported at 1 and 2% per year
B. The complication rate does not increase with prostate size
C. Short-term and long-term mortality rates are higher after open prostatectomy than after TurP
D. Long-term complications include only urethral stricture and retrograde ejaculation

A

A. The probability of requiring a second prostate operation is reported at 1 and 2% per year

102
Q

What is correct regarding Detrusor Overactivity (DO) and Bladder Outlet Obstruction (BOO)?

A. In pressure-flow studies the amplitude of DO is not correlated with the grade of BOO
B. All men with urinary urgency and BOO have DO
C. The prevalence of DO becomes higher as BOO increases
D. As patients gets older, prevalence of DO ranges from 10% in men without BOO to 32% in men with the most severe BOO

A

C. The prevalence of DO becomes higher as BOO increases

103
Q

Which condition will NOT have direct impact on the reduction of symptoms of urinary incontinence in women?

A. Smoking cessasion
B. Reduction of caffein intake
C. Body mass reduction
D. Pelvic floor muscle training

A

B. Reduction of caffein intake

104
Q

A fit 63-year-old man with a 1,5 cm bulbar stricture after TUR of the prostate has had several optical urethrotomies which failed. Which is the most appropriate treatment?

A. A scrotal flap
B. A free skin graft
C. A pedicled penile skin flap
D. An end-to-end anastomosis

A

D. An end-to-end anastomosis

105
Q

Of the following options, which is the best indication for transurethral incision of the prostate?

A. Presence of a median lobe
B. BPH of <30g
C. BPH under the age of 65
D. Prostatic cancer with obstruction

A

B. BPH of <30g

106
Q

The spinal cord micturition centre is anatomically located at the level of which vertebral body approximately?

A. L1
B. L3
C. Th6
D. TH 10

A

A. L1

107
Q

The treatment of the female patient with mixed urinary incontinence should start with the management of:

A. Stress incontinence
B. Urgency incontinence
C. The most bothersome symptome
D. The less bothersome symptome with the least invasive treatment

A

C. The most bothersome symptome

108
Q

What is the definition of bladder pain syndrome in women?

A. Cyclic pain, accompanied with dyspareunia and infertility
B. Non-cyclic pain, mainly exacerbated by diet, located in the flanks
C. Cyclic pain, usually non exacerbated by voiding, located in the pelvis
D. Non-Cyclic pain, usually exacerbated by voiding, located in the pelvis

A

D. Non-Cyclic pain, usually exacerbated by voiding, located in the pelvis

109
Q

Pressure flow study simultaneous measures:

A. Uroflowmetry and intravesical pressure
B. Uroflowmetry and intraabdominal pressure
C. Uroflowmetry, intravesical and intraurethral pressure
D. Uroflowmetry, intravesical and intraabdominal pressures

A

D. Uroflowmetry, intravesical and intraabdominal pressures

110
Q

Alfa1-blockers can cause:

A. Headache
B. Decreased libido
C. Erectile dysfunction
D. Floppy iris syndrome

A

D. Floppy iris syndrome

111
Q

Antimuscarine drugs can cause:

A. Diarrhea
B. Insomnia
C. Headache
D. Dry mouth

A

D. Dry mouth

112
Q

In studies, the odds-ratio of Intraoperative Floppy Iris Syndrome was much higher for:

A. Alfuzosin
B. Doxazosin
C. Tamsulosin
D. Terazosin

A

C. Tamsulosin

113
Q

Which statement is correct regarding single incision urethral slings (mini-slings)?

A. Long-term results are similar to conventional mod-urethral slings.
B. Short-term results (except TVT-secure)are similar to conventional mid-urethral slings.
C. There is no comparison for mini-slings and conventional mid-urethral slings
D. The complication rate is higher in single-incision slings compared with conventional mod-urethral slings.

A

B. Short-term results (except TVT-secure)are similar to conventional mid-urethral slings.

114
Q

Bladder contactility index (BCI) is calculated during urodynamics based on the following two parameters:

A. Maximal closing pressure and maximal flow value
B. Average flow value and maximal detrusor pressure
C. Maximal detrusor pressure and urethral closing pressure
D. Maximal detrusor pressure at maximal flow and maximal flow value

A

D. Maximal detrusor pressure at maximal flow and maximal flow value

115
Q

Which advice has best evidence of helping patients to relieve urinary stress incontinence?

A. Reduce fluid intake
B. Lose weight
C. Reduce caffeine intake
D. Stop smoking

A

B. Lose weight

116
Q

Which option is most appropriate for the management of urinary incontinence following radical prostatectomy at 3 months?

A. Artificial urinary sphincter
B. Male sling
C. Pelvic floor physiotheraphy
D. Anticholinergic medication

A

C. Pelvic floor physiotheraphy

117
Q

A 79-year-old man has medication (alpha-blocket and 5 alpha-resuctase inhibitors) for 5 years. He attends for annual review. His nocturia has increased from two times to three times but otherwise he is unchanged and overall he is not bothered by his symptoms. His urine flow rate is similar to the year before: Qmax 9 mL/S, voided volume 225mL. His residual urine volume has increased last year from 195mL to 330mL. Which statement is correct?

A. Watchful waiting is still an option
B. Medical management should be abandoned because of increasing residual urine volume
C. Bladder outflow surgery is mandatory as there is evidence of deteriorating bladder outflow obstruction
D. It would have been better if he had had a transurethral resection of the prostate a year ago

A

A. Watchful waiting is still an option

118
Q

The greater and lesser sciatic foramina are separated by the:

a
sacrotuberous ligament.

b
Cooper (pectineal) ligament.

c
arcuate line.

d
sacrospinous ligament.

e
piriformis muscle.

A

D sacrospinous lig

119
Q

During inguinal incisions, the vessels invariably encountered in Camper fascia are the:

a
superficial inferior epigastric artery and vein.

b
superficial circumflex iliac artery and vein.

c
external pudendal artery and vein.

d
gonadal artery and veins.

e
accessory obturator vein.

A

a

120
Q

Rupture of the penile urethra at the junction of the penis and scrotum can result in urinary extravasation into all of the following structures EXCEPT the:

a
anterior abdominal wall up to the clavicles.

b
scrotum.

c
penis, deep to the dartos fascia.

d
perineum in a “butterfly” pattern.

e
buttock

A

e- Blood and urine can accumulate in the scrotum and penis deep to the dartos fascia after an anterior urethral injury. In the perineum, their spread is limited bu the fusions of colles fascia to the ischiopubic rami laterally, and to the posterior edge of the perineal membrane, the resulting hematoma is therefore butterfly shaped. these processess will not extend down the leg or into the buttock, but they can freely travel up the anterior abdominal wall deep to Scarpa fascia to the clavicles and around the flank on the bank

121
Q

During inguinal hernia repair in a male patient, injury of the ilioinguinal nerve in the canal will most likely produce:

a

anesthesia over the dorsum of the penis.

b

anesthesia over the pubis and scrotum and loss of cremasteric contraction.

c

anesthesia over the pubis and anterior scrotum only.

d

anesthesia over the anterior and medial thigh.

e

anesthesia over the pubis only.

A

C

122
Q

A child has dense scarring after failed extravesical reimplantation. The landmark that can assist in locating the ureter in the pelvis is the:

a

obturator nerve; the ureter will be medial to it.

b

obliterated umbilical artery; the ureter will be found lateral to it.

c

obliterated umbilical artery; the ureter will be found medial to it.

d

external iliac artery; the ureter crosses it to reach the pelvis.

e

vas deferens; the ureter will pass anterior to it.

A

c. obliterated umibilical artery, the obliterated umbilical artery in the medial umbilical fold serves as an important landmark for the surgeon. It can be traced from the origin from the internal iliac artery to locate the ureter, which lies on its medial side

123
Q

The levator ani attaches to all of the following EXCEPT the:

a

perineal body.

b

pubis.

c

coccyx.

d

vagina.

e

arcus tendineus fascia pelvis.

A

E.

124
Q

Accessory obturator veins (from the external iliac artery) and accessory obturator arteries (from the inferior epigastric artery) are encountered in:

a

50% and 25% of patients, respectively.

b

5% and 50% of patients, respectively.

c

50% and 75% of patients, respectively.

d

25% and 50% of patients, respectively.

e

25% and 5% of patients, respectively.

A

A. 50 and 25

125
Q

A retractor blade has rested on the psoas muscle during a prolonged procedure, resulting in a femoral nerve palsy. Postoperatively, the patient will experience:

a

inability to flex the hip and numbness over the anterior thigh.

b

inability to flex the knee and numbness over the thigh.

c

numbness over the anterior thigh only.

d

inability to extend the knee and numbness over the anterior thigh.

e

inability to flex the knee only.

A

D.

126
Q

Autonomic nerves contributing to the pelvic plexus include the:

a

superior hypogastric nerves from the para-aortic plexuses.

b

pelvic sympathetic trunks.

c

pelvic parasympathetic neurons from the sacral spinal cord.

d

a and c only.

e

a, b, and c.

A

E. the presynaptic sympathetic cell bodies reach the pelvic plexus by two pathways. (1) the superior hypogastric plexus (2) pelvic continuation of the sympathetic trunks., presynaptic parasympathetic innervation arises from the intermediolateral cell column of the sacral cord

127
Q

To preserve the vascular supply to the ureter, incisions in the peritoneum should be made:

a

medially in the abdomen and laterally in the pelvis.

b

laterally in the abdomen and medially in the pelvis.

c

always medial to the ureter.

d

always lateral to the ureter.

e

directly over the ureter.

A

B. blood supply in the abdomen and medially in the pelvis

128
Q

Relative to the ureter, the uterine vessels are found:

a

laterally.

b

posteriorly.

c

anteriorly.

d

medially.

e

running together in a common sheath.

A

C. Anteriorly, the ureter first runs posterior to the ovary then turns medially to run deep to the base of the broad ligament before entering a loose connective tissue tunnel through the substance of the cardinal ligament

129
Q

All of the following features of the ureterovesical junction cooperate to prevent vesicoureteral reflux EXCEPT:

a

fixation of the ureter to the superficial trigone.

b

sphincteric closure of the ureteral orifice.

c

detrusor backing.

d

telescoping of the bladder outward over the ureter.

e

passive closure of the intramural ureter caused by bladder filling.

A

A. the intravesical portion of the ureter lies immediately beneath the bladder urothelium and is therefore quite pliant, it is backed by a strong plate of the detrusor muscle. With bladder filling, this arrangement is thought to result in passive occlusion of the ureter like a valve flap

130
Q

n contrast to that of the male, the female bladder neck:

a

has extensive adrenergic innervation.

b

has a thickened middle smooth muscle layer.

c

is largely responsible for urinary continence.

d

is surrounded by type I (slow-twitch) fibers.

e

has longitudinal smooth muscle fibers that extend to the external meatus.

A

E. At the female bladder neck, the inner longitudinal fibers converge radially to pass downward as the inner longitudinal circular of the urethra. The middle circular layer does not appear to be as robust as that of the male. The female bladder neck differs strikingly from the male in possessing little adrenergic innervation

131
Q

Which of the following statements about the trigone is TRUE?

a

Epithelium is thicker than the rest of the bladder and densely adherent.

b

Superficial smooth muscle is a continuation of Waldeyer sheath.

c

Smooth muscle enlarges to form thick fascicles.

d

Smooth muscle of the ureter forms the interureteric ridge (Mercier bar).

e

When the bladder empties, the trigone is thrown into thick folds.

A

D.Fibers from each of the ureter form a triangular sheet of muscle that extends from the two ureteral orifices at the internal urethra meatus. The edges of this muscular sheet are thickened between the ureteral orifices (the interureteric crest or mercier bar_ and between the ureters and the internal urethral meatus (BELL MUSCLE)

132
Q

During a perineal prostatectomy, the muscle that must be divided to gain access to the apex of the prostate is the:

a

rectourethralis.

b

internal anal sphincter.

c

perineal body.

d

external anal sphincter.

e

puboanalis.

A

a. The prostate may be accessed anterior to the sphincter, by dividing the central tendon and sphincteric attachments to the perineum (Young procedure) or by following the anterior rectal wall beneath the external anal sphincter (Belt procedure).

133
Q

Arterial supply to the bladder includes:

a

the superior vesical artery.

b

the inferior vesical artery.

c

the obturator artery

d

the uterine artery.

e

all of the above.

A

e.

134
Q

The ducts of which of the following prostatic zones drain into the preprostatic urethra?

a

Periurethral glands

b

Central zone

c

Transition zone

d

Peripheral zone

e

a and c

A

A. periurethral glands

135
Q

Benign prostatic hyperplasia (BPH) may arise from the:

a

periurethral glands.

b

central zone.

c

transition zone.

d

peripheral zone.

e

a and c.

A

E.

136
Q

In BPH, blood supply to the adenoma arises from the:

a

superior vesical artery.

b

urethral arteries extending down the urethra from the bladder neck.

c

capsular arteries that arise laterally.

d

dorsal venous complex.

e

neurovascular bundle.

A

b.

137
Q

Which of the following statements concerning the striated urethral sphincter is TRUE?

a

It is composed of type I (slow-twitch) and type II (fast-twitch) fibers.

b

It is bounded above by the superior fascia.

c

It receives motor blanches from the dorsal nerve of the penis.

d

It is shaped like a signet ring and is 2 to 2.5 cm in length.

e

It is densely supplied with proprioceptive muscle spindles.

A

d

138
Q

The seminal vesicle:

a

is normally palpable in a rectal examination.

b

is a lateral outpouching of the prostate (central zone).

c

contracts in response to excitatory efferents from the sacral parasympathetic nerves.

d

is medial to the vas deferens.

e

stores sperm.

A

c. innervation arises from the pelvic plexus, with major excitatory efferents contributed by the hypogastric nerves (sympathetic)

139
Q

When the endopelvic fascia lateral to the prostate and puboprostatic ligaments is opened, vessels are commonly encountered that pierce the levator ani to join the periprostatic plexus laterally. These vessels are communicating branches from the:

a

pampiniform plexus of veins.

b

dorsal vein of the penis.

c

internal pudendal veins.

d

external pudendal veins.

e

accessory obturator veins.

A

C.

140
Q

Lymphatic drainage from the prostate flows to the:

a

external iliac and common iliac nodes.

b

internal iliac and obturator nodes.

c

para-aortic nodes.

d

internal iliac and inguinal nodes.

e

perirectal and common iliac nodes.

A

B. Internal and obturator nodes

141
Q

The first branch of the pudendal nerve in the perineum is the:

a

dorsal nerve of the penis.

b

inferior rectal nerve(s).

c

perineal nerve.

d

posterior femoral cutaneous branches.

e

posterior scrotal branches.

A

a

142
Q

After fracture of the penis (disruption of the tunica albuginea), if Buck fascia remains intact, the hematoma will be visible in the:

a

perineum in a butterfly pattern.

b

penis and scrotum only.

c

penis, scrotum, and perineum and tracking up the anterior abdominal wall.

d

shaft of the penis only.

e

shaft and glans of the penis.

A

d

143
Q

The skin of the penile shaft and foreskin can be elevated as a rotational flap supplied by the:

a

dorsal artery of the penis.

b

superficial inferior epigastric vessels.

c

gonadal vessels.

d

external pudendal vessels.

e

several branches of the perineal vessels.

A

D. the blood supply of the skin of the penile shaft is independent of the erectily bodies and is derived from the external pudendal branches of the femoral vessels

144
Q

The dartos layer of smooth muscle and fascia in the scrotum is continuous with:

a

the dartos layer of the penis.

b

Colles fascia.

c

Scarpa fascia.

d

Buck fascia.

e

a, b, and c.

A

e

145
Q

The cremaster muscle is supplied by the:

a

ilioinguinal nerve.

b

genital branch of the genitofemoral nerve.

c

femoral branch of the genitofemoral nerve.

d

terminal branches of the subcostal nerve (T12).

e

iliohypogastric nerve.

A

b

146
Q

Lymphatic drainage from the bulbar urethra travels:

a

through perianal nodes to reach the pelvis.

b

directly to the deep pelvic lymph nodes.

c

through the superficial and deep inguinal lymph nodes.

d

to prepubic nodes.

A

c

147
Q

In their course from the seminiferous tubule to the epididymis, sperm pass through, in order:

a

straight tubules, efferent ductules, rete testis.

b

rete testis, straight tubules, efferent ductules.

c

efferent ductules, rete testis, straight tubules.

d

straight tubules, rete testis, efferent ductules.

e

rete testis, efferent ductules, straight tubules.

A

d

148
Q

The testicular artery may be ligated without sacrificing the testis because of collateral circulation from:

a

vasal and cremasteric arteries.

b

external pudendal and vasal arteries.

c

external pudendal, vasal, and cremasteric arteries.

d

numerous anastomotic branches from the scrotal arteries.

e

cremasteric and external pudendal arteries.

A

a.

149
Q

To avoid damage to subtunical testicular vessels, biopsy of the testis should be performed at the:

a

lower pole of the testis.

b

anterior upper pole directly opposite the testicular mesentery.

c

medial surface of the lower pole.

d

lateral surface of the lower pole.

e

lateral or medial surface of the upper pole.

A

e

150
Q

Which layers of the scrotum and testicular tunics usually need to be débrided in patients with Fournier gangrene?

a

The scrotal skin only

b

The scrotal skin and dartos layer

c

The scrotal skin, dartos layer, and external spermatic fascia

d

The scrotal skin, dartos layer, and external cremasteric and internal spermatic fasciae, leaving the tunica vaginalis intact

e

All tissues including the tunica vaginalis

A

b

151
Q

Lymphatic drainage from the bladder passes through the:

a

external iliac lymph nodes.

b

obturator and internal iliac lymph nodes.

c

internal and common iliac lymph nodes.

d

common iliac, periureteral, and para-aortic lymph nodes.

e

a, b, and c.

A

e

09. HPB (870) (8 decks)

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