Chapter 1: Evaluation of the urologic patient: History, physical examination, laboratory tests, imaging, and hematuria workup

Question 1

Table 1.1
What are the 8 main components of the International Prostate Symptom Score (IPSS)?

Answer 1

1. Incomplete Emptying
2. Frequency
3. Intermittency
4. Urgency
5. Weak Stream
6. Straining
7. Nocturia
8. Quality of Life due to Urinary Symptoms

Question 2

Table 1.1
What are the columns of the IPSS in terms of quantity?

Answer 2

Not at all
< 1 time in 5
Less than half the time
About half the time
More than half the time
Almost always

Question 3

Table 1.1
How is nocturia graded on the IPSS?

Answer 3

None
1
2
3
4
=>5

Question 4

Table 1.1
How is quality of life graded on the IPSS?

Answer 4

Delighted
Pleased
Mostly satisfied
Mixed-about equally satisfied and dissatisfied
Mostly dissatisfied
Unhappy
Terrible

Question 5

Table 1.1
What is the question for Incomplete Emptying?

Answer 5

Over the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating?

Question 6

Table 1.1
What is the question for Frequency?

Answer 6

Over the past month, how often have you had to urinate again less than 2 hours after you finished urinating?

Question 7

Table 1.1
What is the question for Intermittency?

Answer 7

Over the past month, how often have you found you stopped and started again several times when you urinated?

Question 8

Table 1.1
What is the question for Urgency?

Answer 8

Over the past month, how often have you found it difficult to postpone urination?

Question 9

Table 1.1
What is the question for Weak Stream?

Answer 9

Over the past month, how often have you had a weak urinary stream?

Question 10

Table 1.1
What is the question for Straining?

Answer 10

Over the past month, how often have you had to push or strain to begin urination?

Question 11

Table 1.1
What is the question for nocturia?

Answer 11

Over the past month, how many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning?

Question 12

Table 1.1
What is the question for quality of life?

Answer 12

If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that?

Question 13

Memorize the 7 symptoms by creating a mnemonic sentence:

Incomplete Emptying (I)
Frequency (F)
Intermittency (I)
Urgency (U)
Weak Stream (W)
Straining (S)
Nocturia (N)

Answer 13

“I Feel It’s Urgent With Some Nocturnal trips.”

Question 14

For the symptom frequency categories, remember the sequence 0-5:

Answer 14

Not at all (0)
Less than 1 time in 5 (1)
Less than half the time (2)
About half the time (3)
More than half the time (4)
Almost always (5)

Question 15

For Nocturia, remember the sequence 0-5 with an additional category “None”:

Answer 15

None (0)
1 time (1)
2 times (2)
3 times (3)
4 times (4)
≥5 times (5)

Question 16

For the quality of life due to urinary symptoms, memorize the 7 categories:

Answer 16

Delighted (0)
Pleased (1)
Mostly satisfied (2)
Mixed (3)
Mostly dissatisfied (4)
Unhappy (5)
Terrible (6)

Question 17

Decreased libido
“Hippo Has Low Libido”

Answer 17

Antihypertensives: H
Hydrochlorothiazide: H

Question 18

Erectile dysfunction
Mnemonic: “Pandas Prefer Ben’s Dysfunction”

Answer 18

Psychotropic drugs: P
Propranolol: P
Benzodiazepines: B

Question 19

Ejaculatory dysfunction

Mnemonic: “Alligator Ponders Time Machine, Phenomenal Ants”

Answer 19

α-Adrenergic antagonists: A
Prazosin: P
Tamsulosin: T
α-Methyldopa: M
Psychotropic drugs: P
Phenothiazines: Ph
Antidepressants: A

Question 20

Priapism

Mnemonic: “Aphrodite Has Thunderous Permanent Happiness”

Answer 20

Antipsychotics: A
Phenothiazines: Ph
Antidepressants: A
Trazodone: T
Antihypertensives: A
Hydralazine: H
Prazosin: P

Question 21

Decreased spermatogenesis

Mnemonic: “Cats And Dogs Make Noisy Parties”

Answer 21

Chemotherapeutic agents: C
Alkylating agents: A
Drugs with abuse potential: D
Marijuana: M
Alcohol: A
Nicotine: N
Drugs affecting endocrine function: D
Antiandrogens: A
Prostaglandins: P

Question 22

Incontinence or impaired voiding

Mnemonic: “Dancing Hippos Visit Overflowing Sinks”

Answer 22

Direct smooth muscle stimulants: D
Histamine: H
Vasopressin: V
Others: O
Furosemide: F
Valproic acid: V
Smooth muscle relaxants: S
Diazepam: D
Striated muscle relaxants: S
Baclofen: B

Question 23

Urinary retention or obstructive voiding symptoms

Mnemonic: “An Odd Dolphin Flies, Catching Noisy Clouds, Laughing Alpha Llamas Dance”

Answer 23

Anticholinergic agents or musculotropic relaxants: A
Oxybutynin: O
Diazepam: D
Flavoxate: F
Calcium channel blockers: C
Nifedipine: N
Antiparkinsonian drugs: A
Carbidopa: C
Levodopa: L
α-Adrenergic agonists: α
Pseudoephedrine: P
Phenylephrine: Ph
Antihistamines: A
Loratadine: L
Diphenhydramine: D

Question 24

Acute renal failure

“A Penguin Climbs An Amphitheater, Crying Out Near Pharaohs”

Answer 24

Antimicrobials: A
Aminoglycosides: A
Penicillins: P
Cephalosporins: C
Amphotericin: A
Chemotherapeutic drugs: C
Cisplatin: C
Others: O
Nonsteroidal anti-inflammatory drugs: N
Phenytoin: P

Question 25

Gynecomastia

Mnemonic: “A Vivacious Camel Dances, Giggling Crows Mock Pheasants, Tricycles Aim Inward”

Answer 25

Antihypertensives: A
Verapamil: V
Cardiac drugs: C
Digoxin: D
Gastrointestinal drugs: G
Cimetidine: C
Metoclopramide: M
Psychotropic drugs: P
Phenothiazines: Ph
Tricyclic antidepressants: T
Amitriptyline: A
Imipramine: I

Question 26

Answer 26

FIG. 1.1 Bimanual examination of the kidney.

Question 27

Answer 27

FIG. 1.2 Examination of the inguinal canal.

Question 28

Colorless: VOD

Imagine a glass of clear water.

Answer 28

(Very dilute urine, Overhydration)

Question 29

Cloudy/milky: PPC

Picture a glass of milk.

Answer 29

(Phosphaturia, Pyuria, Chyluria)

Question 30

Red: HHAAPP

Visualize a glass of red wine.

Answer 30

(Hematuria, Hemoglobinuria/myoglobinuria, Anthocyanin, Chronic lead and mercury poisoning, Phenolphthalein, Phenothiazines)

Question 31

Orange: DPS

Think of a glass of orange juice.

Answer 31

(Dehydration, Phenazopyridine, Sulfasalazine)

Question 32

Yellow: NRP

Envision a glass of lemonade.

Answer 32

(Normal, Phenacetin, Riboflavin)

Question 33

Green-blue: BIAAMMMPRT

Imagine a glass of green smoothie.

Answer 33

Biliverdin, Indicanuria, Amitriptyline, Indigo carmine, Methylene blue, Phenols, Resorcinol, Triamterene

Question 34

Brown: UPAACFMN

Picture a glass of iced coffee.

Answer 34

(Urobilinogen, Porphyria, Aloe, Chloroquine and primaquine, Furazolidone, Metronidazole, Nitrofurantoin)

Question 35

Brown-black: AHMTCCMMMS

Visualize a glass of dark soda.

Answer 35

(Alcaptonuria, Hemorrhage, Melanin, Tyrosinosis, Cascara, Methocarbamol, Methyldopa, Sorbitol)

Question 36

Glomerular Disorders in Patients With Glomerular Hematuria
DISORDER PATIENTS
IgA nephropathy (Berger disease)

Answer 36

30

Question 37

Glomerular Disorders in Patients With Glomerular Hematuria
DISORDER PATIENTS

Mesangioproliferative GN

Answer 37

14

Question 38

Glomerular Disorders in Patients With Glomerular Hematuria
DISORDER PATIENTS

Focal segmental proliferative GN

Answer 38

13

Question 39

Glomerular Disorders in Patients With Glomerular Hematuria
DISORDER PATIENTS

Familial nephritis (e.g., Alport syndrome)

Answer 39

11

Question 40

Glomerular Disorders in Patients With Glomerular Hematuria
DISORDER PATIENTS

Membranous GN

Answer 40

7

Question 41

Glomerular Disorders in Patients With Glomerular Hematuria
DISORDER PATIENTS

Mesangiocapillary GN

Answer 41

6

Question 42

Glomerular Disorders in Patients With Glomerular Hematuria
DISORDER PATIENTS

Focal segmental sclerosis

Answer 42

4

Question 43

Glomerular Disorders in Patients With Glomerular Hematuria
DISORDER PATIENTS

Unclassifiable

Answer 43

4

Question 44

Glomerular Disorders in Patients With Glomerular Hematuria
DISORDER PATIENTS

Systemic lupus erythematosus

Answer 44

3

Question 45

Glomerular Disorders in Patients With Glomerular Hematuria
DISORDER PATIENTS

Postinfectious GN

Answer 45

2

Question 46

Glomerular Disorders in Patients With Glomerular Hematuria
DISORDER PATIENTS

Subacute bacterial endocarditis

Answer 46

2

Question 47

Glomerular Disorders in Patients With Glomerular Hematuria
DISORDER PATIENTS

Others

Answer 47

4

Question 48

Glomerular Disorders in Patients With Glomerular Hematuria
DISORDER PATIENTS

Focal segmental disorders

Answer 48

Focal segmental proliferative GN (13 patients) and Focal segmental sclerosis (4 patients)

Question 49

Top 3 most common glomerular disorders in patients with glomerular hematuria

Answer 49

“1. IgA nephropathy (Berger disease) - 30 patients, 2. Mesangioproliferative GN - 14 patients, 3. Focal segmental proliferative GN - 13 patients”

Question 50

“Least common glomerular disorders in patients with glomerular hematuria”

Answer 50

“Systemic lupus erythematosus (3 patients), Postinfectious GN (2 patients), Subacute bacterial endocarditis (2 patients)”

Question 51

What is glomerular hematuria?

Answer 51

Glomerular hematuria refers to the presence of blood in the urine that originates from the glomeruli, which are tiny, specialized structures in the kidneys. The primary function of glomeruli is to filter blood and form the initial filtrate that eventually becomes urine. In glomerular hematuria, red blood cells are able to pass through the glomerular filtration barrier, leading to blood in the urine.

Question 52

Answer 52

FIG. 1.3 KUB demonstrating residual stone fragments (arrows) adjacent to a right ureteral stent 1 week after right extracorporeal shock wave lithotripsy.

Question 53

Answer 53

FIG. 1.4 (A) Right retrograde pyelogram performed using an 8-Fr cone-tipped ureteral catheter and dilute contrast material. The ureter and intrarenal collecting system are normal. (B) Left retrograde pyelogram using an 8-Fr cone-tipped ureteral catheter. A filling defect in the left distal ureter (arrow) is a low-grade transitional cell carcinoma. The ureter demonstrates dilation, elongation, and tortuosity, the hallmarks of chronic obstruction.

Question 54

Answer 54

FIG. 1.5 Loopogram in a patient with epispadius/exstrophy and ileal conduit urinary diversion. (A) Plain film prior to contrast administration. (B) After contrast administration via a catheter placed in the ileal conduit, free reflux of both ureterointestinal anastomoses is demonstrated. (C) A postdrain radiograph demonstrates persistent dilation of the proximal loop indicating mechanical obstruction of the conduit (arrows).

Question 55

Answer 55

FIG. 1.6 Normal retrograde urethrogram demonstrating (A) the balloon technique for retrograde urethrography, (B) Brodney clamp (arrowhead) technique; note the bulbar urethral stricture (arrow), and (C) normal structures of the male urethra.

Question 56

Answer 56

FIG. 1.7 A voiding cystourethrogram performed for the evaluation of recurrent urinary tract infection in this female patient. (A) An oblique film during voiding demonstrates thickening of the midureteral profile (arrows). (B) After interruption of voiding, a ureteral diverticulum is clearly visible extending posteriorly and to the left of the midline (arrows).

Question 57

Answer 57

FIG. 1.8 (A) Technetium 99m-mercaptoacetyltriglycine ( 99mTc-MAG3) perfusion images demonstrate normal, prompt, symmetric blood flow to both kidneys. (B) Perfusion time-activity curves demonstrating essentially symmetric flow to both kidneys. Note the rising curve typical of 99mTc-MAG3 flow studies. Dynamic function images demonstrate good uptake of tracer by both kidneys and prompt visualization of the collecting systems. This renogram demonstrates prompt peaking of activity in both kidneys. The downslope represents prompt drainage of activity from the kidneys. Printout of quantitative data shows the differential renal function to be 47% on the left, 53% on the right. The normal half-life for drainage is less than 20 minutes when 99mTc-MAG3 is used. The half-life is 5 minutes on the left and 7 minutes on the right, consistent with both kidneys being unobstructed.

Question 58

Answer 58

FIG. 1.9 Normal Technetium 99m-mercaptoacetyltriglycine ( 99mTc-MAG3) renogram of a patient with history of hydronephrosis being evaluated for obstruction. In the upper portion of the figure, a series of 2-second–per–frame flow images demonstrate the movement of radiotracer from the site of injection, to the heart, aorta/renal arteries, and kidneys. A corresponding time-activity curve is shown. The white curve reflects activity in the aorta, and the purple and teal curves reflect radiotracer activity in the kidneys. Note the sharp upstroke of all three lines and that activity in the aorta precedes activity in the kidneys by several seconds. In the lower half of the figure, a series of 2-minute–per–frame images depicts radiotracer activity within the kidneys as it transitions bilaterally into the collecting systems and then drains down the ureters. In the corresponding time-activity curve, activity within the kidneys peaks at approximately 3 to 4 minutes and then washes out, reaching half-peak approximately 6 to 9 minutes later. The split function of the kidneys is within normal limits, measuring 46% on the left and 54% on the right (red rectangle). No evidence of obstruction is present, and no furosemide is administered.

Question 59

Answer 59

FIG. 1.10 99mTc-MAG3 renogram of a patient with right-sided renal obstruction. (A) In the 2-second–per–frame flow images at the top of the panel, the left kidney appears much better perfused than the right kidney. This is borne out in the time-activity curve in the upper half of the panel in which the teal curve representing the left kidney has a significantly sharper upstroke relative to the purple curve of the right kidney. The white curve of the aorta is irregular and unreliable because of the abnormal course of the aorta caused by the patient’s scoliosis. In the bottom half of the panel, the 2-minute–per–frame images demonstrate normal transit of radiotracer through the left kidney parenchyma and into the collecting system, with drainage to the bladder. This is shown by the teal curve of the left kidney on the time-activity curve. The right kidney, which appears smaller and has a central photopenic area corresponding to a dilated renal pelvis, demonstrates increasing uptake throughout the study with very slow transit into the collecting system. This is shown by the purple curve of the right kidney in the time-activity curve. A markedly abnormal split function is present, measuring 79% on the left and 21% on the right (red rectangle). (B) Given the obstructive pattern of the right kidney, 40 mg of intravenous furosemide was administered. The 1-minute–per–frame images in the upper portion of the panel demonstrate no significant clearing of radiotracer from the left renal collecting system after furosemide administration. This is also seen in the time-activity curve, where the teal curve representing the left kidney is nearly horizontal. The lack of response to furosemide is diagnostic of an obstructed collecting system.

Question 60

Answer 60

FIG. 1.11 In this simplified schematic diagram of ultrasound imaging, the ultrasound wave is produced by a pulse generator controlled by a master clock. The reflected waves received by the transducer are analyzed for amplitude and transit time within the body. The scan converter produces the familiar picture seen on the monitor. The actual image is a series of vertical lines that are continuously refreshed to produce the familiar real-time, gray-scale image.

Question 61

Answer 61

FIG. 1.12 Midsagittal plane of the kidney. Note the relative hypoechogenicity of the renal pyramids (P) compared with the cortex (C). The central band of echoes (B) is hyperechoic compared with the cortex. The midsagittal plane will have the greatest length measurement pole to pole. A perfectly sagittal plane will result in a horizontal long axis of the kidney.

Question 62

Answer 62

FIG. 1.13 (A) Transverse view of the bladder (BL) in this female patient demonstrates the uterus (U). (B) Sagittal view of the bladder shows the uterus posterior to the bladder.

Question 63

Answer 63

FIG. 1.14 Demonstration of normal bilateral intratesticular blood flow by color Doppler.

Question 64

Answer 64

FIG. 1.15 (A) In the transverse plane scanning from the dorsal surface of the midshaft of the penis, the corpora cavernosa (CC) are paired structures seen dorsally, whereas the corpus spongiosum (CS) is seen ventrally in the midline. A calcification (Ca ++) is seen between the two CC with posterior shadowing. (B) In the parasagittal plane, the CC is dorsal with the relatively hypoechoic CS seen ventrally. Within the CC, the cavernosal artery is shown with a Ca ++ in the wall of the artery and posterior shadowing.

Question 65

Answer 65

FIG. 1.16 Normal transperineal ultrasound of the female pelvis in the midsagittal plane. The anterior compartment comprises the bladder (BL) and urethra, apical compartment comprises the vagina and uterus (UT), posterior compartment is the rectum. Source: (Image courtesy Lewis Chan, MD.)

Question 66

Answer 66

FIG. 1.17 Computed tomography (CT) of the abdomen and pelvis demonstrating normal genitourinary anatomy. (A) The adrenal glands are indicated with arrows. The upper pole of the right and left kidneys is indicated with rk and lk, respectively. a, Aorta; li, liver; p, pancreas; s, spleen; v, inferior vena cava. (B) Scan through the upper pole of the kidneys. The left adrenal gland is indicated with an arrow. a, Aorta; c, colon; d, duodenum; li, liver; lk, left kidney; p, pancreas; rk, right kidney; v, inferior vena cava. (C) Scan through the hilum of the kidneys. The main renal veins are indicated with solid arrows, and the right main renal artery is indicated with an open arrow. a, Aorta; c, colon; d, duodenum; li, liver; lk, left kidney; p, pancreas; rk, right kidney; v, inferior vena cava. (D) Scan through the hilum of the kidneys slightly caudal to C. The left main renal vein is indicated with a solid straight arrow, and the left main renal artery is indicated with an open arrow. The hepatic flexure of the colon is indicated with a curved arrow. a, Aorta; c, colon; d, duodenum; li, liver; lk, left kidney; p, pancreas; rk, right kidney; v, inferior vena cava. (E) Scan through the mid to lower polar region of the kidneys. a, Aorta; ac, ascending colon; d, duodenum; dc, descending colon; lk, left kidney; p, pancreas; rk, right kidney; rp, renal pelvis; v, inferior vena cava. (F) CT scan obtained below the kidneys reveals filling of the upper ureters (arrows). The wall of the normal ureter is usually paper thin or not visible on CT. a, Aorta; ac, ascending colon; dc, descending colon; v, inferior vena cava. (G) Contrast filling of the midureters (arrows) on a scan obtained at the level of the iliac crest and below the aortic bifurcation. ac, Ascending colon; dc, descending colon; la, left common iliac artery; ra, right common iliac artery; v, inferior vena cava. (H) The distal ureters (arrows) course medial to the iliac vessels on a scan obtained below the promontory of the sacrum. b, Urinary bladder; la, left external iliac artery; lv, left external iliac vein; ra, right external iliac artery; rv, right external iliac vein. (I) Scan through the roof of the acetabulum reveals distal ureters (solid arrows) near the ureterovesical junction. The bladder (b) is filled with urine and partially opacified with contrast material. The normal seminal vesicle (open arrows) usually has a paired bow-tie structure with slightly lobulated contour. a, Right external iliac artery; r, rectum; v, right external iliac vein. (J) Scan at the level of the pubic symphysis (open arrow) reveals the prostate gland (solid arrow). a, Right external iliac artery; m, obturator internus muscle; r, rectum; v, right external iliac vein.

Question 67

Answer 67

FIG. 1.18 Computed tomography of the abdomen and pelvis in patient with an obstructing ureteral stone at the level of the ureterovesicle junction. (A) Level of the left upper pole. Mild renal enlargement, caliectasis, and perinephric stranding are apparent. (B) Level of the left renal hilum. Left pyelectasis with a dependent stone, mild peripelvic and perinephric stranding, and a retroaortic left renal vein. (C) Level of the left lower pole. Left caliectasis, proximal ureterectasis, and mild periureteral stranding are present. (D) Level of the aortic bifurcation. The dilated left ureter (arrow) has lower attenuation than do nearby vessels. (E) Level of the upper portion of the sacrum. A dilated left ureter (arrow) crosses anteromedial to the common iliac artery. (F) Level of the midsacrum. A dilated left ureter (arrow) is accompanied by periureteral stranding. (G) Level of the top of the acetabulum showing a dilated pelvic portion of the left ureter (arrow). (H) Level of the ureterovesical junction. The impacted stone with a “cuff” or “tissue rim” sign that represents the edematous wall of the ureter. Source: (Reprinted from Talner LB, O’Reilly PH, Wasserman NF. Specific causes of obstruction. In: Pollack HM, et al., eds: Clinical urography, 2nd ed. Philadelphia: Saunders, 2000.)

Question 68

Answer 68

FIG. 1.19 A 50-year-old man with a left side pheochromocytoma and select images from a 1.5T magnetic resonance imaging. (A) Heavily weighted T2 single-shot fast spin echo with an isointense signal (not bright). (B) Moderately weighted T2 fat-suppressed fast recovery fast spin echo with hyperintense signal (bright). (C) T1-weighted precontrast images. (D) T1-weighted postcontrast images with marked early enhancement.

Question 69

Q: What are the morphologic and imaging characteristics of incidental adrenal lesions (IAL)?

Answer 69

A: Size, shape, texture, unenhanced CT attenuation (HU), 15-minute CT washout (%), MRI signal characteristics, and nuclear medicine characteristics.

Question 70

Q: What are the characteristics of adrenal metastasis IAL?

Answer 70

A: Size: Variable
Shape: Variable
Texture: Heterogeneous when larger
Unenhanced CT attenuation (HU): >10
15-Minute CT washout (%): RPW <40
MRI signal characteristics: High T2 signal
Nuclear medicine characteristics: Positive on PET images

Question 71

Q: What are the characteristics of adrenal cortical carcinoma IAL?

Answer 71

A: Size: >4 cm
Shape: Variable
Texture: Variable
Unenhanced CT attenuation (HU): >10
15-Minute CT washout (%): RPW <40
MRI signal characteristics: Intermediate to high T2 signal
Nuclear medicine characteristics: Positive on PET images

Question 72

Q: What are the characteristics of pheochromocytoma IAL?

Answer 72

A: Size: Variable
Shape: Variable
Texture: Variable
Unenhanced CT attenuation (HU): >10, rarely <10
15-Minute CT washout (%): RPW <40
MRI signal characteristics: High T2 signal
Nuclear medicine characteristics: Positive on MIbG

Question 73

Q: What are the characteristics of cyst IAL?

Answer 73

A: Size: Variable
Shape: Smooth, round
Texture: Smooth
Unenhanced CT attenuation (HU): <10
15-Minute CT washout (%): Does not enhance
MRI signal characteristics: High T2 signal
Nuclear medicine characteristics: Negative

Question 74

Q: What are the characteristics of adenoma IAL?

Answer 74

A: Size: 1–4 cm
Shape: Smooth, round
Texture: Homogeneous
Unenhanced CT attenuation (HU): <10 in 70%
15-Minute CT washout (%): RPW >40; APW >60
MRI signal characteristics: SI dropoff on OP images
Nuclear medicine characteristics: Variable on PET images

Question 75

Q: What are the characteristics of myelolipoma IAL?

Answer 75

A: Size: 1–5 cm
Shape: Smooth, round
Texture: Variable with macroscopic fat
Unenhanced CT attenuation (HU): <0, often <-50
15-Minute CT washout (%): No data
MRI signal characteristics: High T1 signal, India ink, variable SI dropoff on OP images
Nuclear medicine characteristics: Negative on PET images

Question 76

Q: What are the characteristics of lymphoma IAL?

Answer 76

A: Size: Variable
Shape: Variable
Texture: Variable
Unenhanced CT attenuation (HU): >10
15-Minute CT washout (%): RPW <40
MRI signal characteristics: Intermediate SI
Nuclear medicine characteristics: Variable positivity on PET images

Question 77

Q: What are the characteristics of hematoma IAL?

Answer 77

A: Size: Variable
Shape: Smooth
Texture: Variable
Unenhanced CT attenuation (HU): >10, sometimes >50
15-Minute CT washout (%): No data
MRI signal characteristics: Variable signal
Nuclear medicine characteristics: Negative

Question 78

Q: What are the characteristics of neuroblastoma IAL?

Answer 78

Size: Variable
Shape: Variable
Texture: Smooth, round
Unenhanced CT attenuation (HU): >10
15-Minute CT washout (%): RPW <40
MRI signal characteristics: Variable if necrotic
Nuclear medicine characteristics: Positive

Question 79

Q: What are the characteristics of ganglioneuroma IAL?

Answer 79

A: Size: Variable
Shape: Variable
Texture: Variable
Unenhanced CT attenuation (HU): >10
15-Minute CT washout (%): No data
MRI signal characteristics: Usually intermediate SI
Nuclear medicine characteristics: Usually negative

Question 80

Q: What are the characteristics of hemangioma IAL?

Answer 80

A: Size: Variable
Shape: Variable
Texture: Variable
Unenhanced CT attenuation (HU): >10
15-Minute CT washout (%): No data
MRI signal characteristics: Usually intermediate SI
Nuclear medicine characteristics: Usually negative

Question 81

Q: What are the characteristics of granulomatous IAL?

Answer 81

A: Size: 1–5 cm
Shape: Smooth
Texture: Usually homogeneous
Unenhanced CT attenuation (HU): >10
15-Minute CT washout (%): No data
MRI signal characteristics: Usually intermediate SI
Nuclear medicine characteristics: Positive on PET images if active

Question 82

Urologic Side Effect: Decreased libido

Answer 82

Class of Drugs: Antihypertensives
Specific Examples: Hydrochlorothiazide

Question 83

Urologic Side Effect: Erectile dysfunction

Answer 83

Class of Drugs: Psychotropic drugs
Specific Examples: Propranolol, Benzodiazepines

Question 84

Urologic Side Effect: Ejaculatory dysfunction

Answer 84

Class of Drugs: alpha-Adrenergic antagonists
Specific Examples: Prazosin, Tamsulosin, alpha-Methyldopa, Psychotropic drugs, Phenothiazines,
Antidepressants

Question 85

Urologic Side Effect: Priapism

Answer 85

Class of Drugs: Antipsychotics
Specific Examples: Phenothiazines, Antidepressants, Trazodone, Antihypertensives, Hydralazine,
Prazosi

Question 86

Urologic Side Effect: Decreased spermatogenesis

Answer 86

Class of Drugs: Chemotherapeutic agents
Specific Examples: Alkylating agents, Drugs with abuse potential, Marijuana, Alcohol, Nicotine,
Drugs affecting endocrine function, Antiandrogens, Prostaglandins

Question 87

Urologic Side Effect: Incontinence or impaired voiding

Answer 87

Class of Drugs: Direct smooth muscle stimulants
Specific Examples: Histamine, Vasopressin, Others, Furosemide, Valproic acid, Smooth muscle
relaxants, Diazepam, Striated muscle relaxants, Baclofen

Question 88

Urologic Side Effect: Urinary retention or obstructive voiding symptoms

Answer 88

Class of Drugs: Anticholinergic agents or musculotropic relaxants
Specific Examples: Oxybutynin, Diazepam, Flavoxate, Calcium channel blockers, Nifedipine,
Antiparkinsonian drugs, Carbidopa, Levodopa, alpha-Adrenergic agonists, Pseudoephedrine,
Phenylephrine, Antihistamines, Loratadine, Diphenhydramine

Question 89

Urologic Side Effect: Acute renal failure

Answer 89

Class of Drugs: Antimicrobials
Specific Examples: Aminoglycosides, Penicillins, Cephalosporins, Amphotericin, Chemotherapeutic
drugs, Cisplatin, Others, Nonsteroidal anti-inflammatory drugs, Phenytoin

Question 90

Urologic Side Effect: Gynecomastia

Answer 90

Class of Drugs: Antihypertensives
Specific Examples: Verapamil, Cardiac drugs, Digoxin, Gastrointestinal drugs, Cimetidine,
Metoclopramide, Psychotropic drugs, Phenothiazines, Tricyclic antidepressants, Amitriptyline,
Imipramine

Question 92

What is the definition of microhematuria?

Answer 92

Guideline 1: 3 or more RBC/HPF on a single, properly collected urine specimen (Note: This has to be RBC seen on a microscopic exam- macroscopic blood does not count- see guideline 2 below)

Guideline 2: Clinicians should not define microhematuria by positive dipstick testing alone. A positive urine dipstick of trace blood or greater should prompt formal microscopic examination of the urine.

Question 93

What should you pay particular attention to in the initial evaluation in a person with microhematuria?

Answer 93

Guideline 3:
Perform a history and physical examination to assess risk factors for GU malignancy, medical renal disease, and non-malignant GU causes of microhemturia
-Age
-Gender
-Smoking
-LUTs
-Prior pelvic radiation
-Prior cyclophosphamide/ifosfamide chemo
-Exposure to dyes/chemicals
-Indwelling foley
-Family history of UC or lynch syndrome

Guideline 5: In persons with findings suggestive of a non-malignant or gynecology etiology, these persons should be evaluated with appropriate physical examination techniques and tests to identify the etiology. (IE: do a pelvic exam in women)

Question 94

How do you evaluate a person on anticoagulants or anti platelet drugs with microhematuria?

Answer 94

Guideline 4: They should have the same evaluation as someone not on these drugs.

Question 95

If a person is identified as having an UTI or a gynecology or non-malignant GU cause of having microhematuria, are you done with evaluation?

Answer 95

Guideline 6/7: You must obtain a urinalysis with microscopic examination to ensure resolution of the hematuria. If it persists or you can’t identify the etiology, you should perform a risk-based assessment of the microhematuria.

*** The panel acknowledges that there are some non-malignant causes such as BPH, nephrolithiasis, vaginal atrophy or prolapse, in which the MH won’t completely resolve even with appropriate management. In these cases you must use judgement and careful shared decision making to decide to pursue MH evaluation.

Question 96

If a person is thought to have microhematuria secondary to medical renal disease are you done with evaluation?

Answer 96

Guideline 8: Refer these patients to nephrology. but still do a risk based urological evaluation.

Question 97

What are the low, intermediate and high risk categories of microhematuria?

Answer 97

Low risk (must meet all criteria): women age < 50, men age < 40, never smoker or < 10 pack years, 3-10 RBC/HPF on a single UA, no risk factors for GU malignancy

Intermediate risk (meet any one criteria): women age 50-59, men age 40-59, 10-30 pack years, 11-25 RBC/HPF on a single UA, repeat UA in a low risk patient with repeat 3-10 RBC/HPF, additional risk factors for UC.

High risk (meet any one criteria): Women or men >59 years, > 30 pack years, > 25 RBC/HPF, any gross hematuria

Question 98

How should you treat a low risk person with microhematuria?

Answer 98

Guideline 10: Clinicians should engage in shared decision making to decide between repeating UA within 6 months or proceeding with cystoscopy and renal bladder ultrasound.

Question 99

How should you treat a low risk patient who has a repeat microhematuria who elected not to undergo initial evaluation?

Answer 99

Guideline 11: You should reclassify these patients as intermediate or high risk and perform cystoscopy with upper tract imaging

Question 100

How should you work up an intermediate risk patient with microhematuria?

Answer 100

Guideline 12: Clinicians should perform cystoscopy and renal ultrasound

Question 101

How should you work up a high risk hematuria patient?

Answer 101

Guideline 13: Cystoscopy and upper tract imaging:
1st preference is multiphasic CT urography (if GFR >30 and no iodine allergy)
2nd preference is MR urography
3rd preference is retrograde pyelography with non-contrast axial imaging or renal ultrasound

Special exception: pregnant women get RUS with axial imaging after delivery

Question 102

What type of cystoscopy should you perform in a person with microhematuria?

Answer 102

Guideline 14: Clinicians should perform white light cystoscopy as part of the workup (blue light costs more money, time and has not been studied in this setting and may lead to unnecessary biopsies- it is NOT currently recommended)

Question 103

What may you do in someone with persistent microhematuria previously worked up by renal ultrasound?

Answer 103

Guideline 15: Perform additional imaging of the upper urinary tract

Question 104

What should you do in a intermediate risk patient with a family history of RCC or a known genetic renal tumor syndrome?

Answer 104

Guideline 16: You should get upper tract imaging

(known genetic renal tumor syndromes are: VHL, BHD, hereditary papillary RCC, hereditary leiomyomatosis RCC, and tuberous sclerosis)

Question 105

What is the role of urinary markers in the workup of microhematuria?

Answer 105

Guidelien 17: Do not use urine cytology or makers in the initial evaluation of microhematuria

Guideline 18: You may obtain urine cytology for patients with persistent microhematuria after a negative work up who have irritative voiding symptoms or risk factors for CIS

Question 106

After a negative microhematuria workup, how often should you repeat a urinalysis?

Answer 106

Guideline 19: Within 12 months

Question 107

After a negative microhematuria evaluation and negative subsequent urinalysis, what should you do?

Answer 107

Guideline 20: the UA should be repeated in 12 months after an initial negative evaluation. However, if the subsequent UA is negative, you can stop any further workup

Question 108

For persons with a prior negative microhematuria workup and persistent microhematuria, what is recommended?

Answer 108

Guideline 21: Shared decision making regarding need for additional workup

Question 109

For persons with a prior negative microhematuria workup and worsening microhematuria or gross hematuria or new symptoms, what is recommended?

Answer 109

Guideline 22: It is recommended that you have further workup though what this workup entails is not specified and it ultimately says this should be shared decision making based on patient preferences and physician judgement…..

Question 110

Characterization of gross hematuria depending on the phase and explain indication

Answer 110

1. Initial–> urethral source 2. Terminal –> Trigone,neck prostate 3. Total hematuria –> Bladder and above

Question 111

causes of pigmenturia mimicking GH:

Answer 111

1. Endogenous sources (Bilirubin, myoglobin, porphyrins) 2. Food (Beets, rhubarb) 3. Drugs (phenazopyridine) 4. simple dehydration

Question 112

AUA definition of microscopic hematuria

Answer 112

3 or more / HPF

Question 113

causes of false positives for MH, cause of false negative

Answer 113

first void urine and post sexual activity might cause false positive Dilute urine (<308 osm) -> might cause false negative

Question 114

The likelihood of identifying a malignancy has been found to be greater among patients with higher levels of MH _ RBC/HPF, GH, or risk factors for malignancy

Answer 114

>25 rbc/hpf

Question 115

Common Risk Factors for Urinary Tract Malignancy in Patients With Microscopic Hematuria

Answer 115

Question 116

Patients who develop hematuria who are taking anticoagulaton or antiplatelet medications should undergo _____.

Answer 116

patients who develop hematuria (microscopic or gross) who are taking anticoagulation or antiplatelet medications (e.g., warfarin, enoxaparin, heparin, aspirin, clopidogrel, nonsteroidal anti-inflammatory agents) should undergo a complete evaluation in the same manner as patients not taking such medications

Question 117

In women, the ACOGAU society recommend/does not recommend evaluation for asymptomatic MH for patients that has never smoked aged 33-50 who have <25 hpc. What is the rate of Urinary tract for this malignancy for this patients

Answer 117

does not recomment, <0.5%

Question 118

Blue light cystoscopy uses _____ or ____ instillation

AUA recommends for/against using blue-light cystoscopy for evaluation of MH

Answer 118

5-aminolevulinic acid ALA or Hexyl aminolevulinate (HAL)

Against

Question 119

the imaging of choice by the AUA for evaluation of asymptomatic MH

Answer 119

Multiphasic ct urogram

Question 120

36/F patient consulted for Asymptomatic MH,noted no infection, no menstruation,no urologic procedures, what is the next step for workup

Answer 120

Renal function testing, cystoscopy imaging CTU. COncurrent workup for proteinuria and red cell morphology to see if there is nephrological cause.

If negative for the following, the patient may follow-up at least one UA/Micro yearly for at least 2 years. If still with persistent MH, annual must be done. Repeat anatomic evaluation within 3-5 years if clinically indicated

Question 121

patients presenting with GH in the absence of antecedent ___ or____ should be evaluated with a ____ examination, ___ and ____

Answer 121

patients presenting with GH in the absence of antecedent trauma or culture-documented UTI should be evaluated with a urine cytologic examination, cystoscopy, and upper tract imaging, preferably CT urogram.

Question 122

_____________, a member of the ____ family, is the most common virus associated with hemorrhagic cystitis

Answer 122

BK virus, polyomavirus

Question 123

treatment for viral hemorrhagic cystitis is:___

Answer 123

primarily supportive, with hydration, diuresis, and bladder irrigation, although case reports of success with antiviral therapy exist

Question 124

Chemotherapeutic drugs that cause Hemorrhagic cystitis

Bladder toxicity results from renal excretion of the metabolite ___, which is produced by the liver and stimulates bladder mucosal sloughing and subsequent tissue edema/fibrosis

____, which binds to ___ and renders it inert, has been suggested for prophylaxis against cyclophosphamide-induced hemorrhagic cystitis

Answer 124

cyclophosphomide and iphosphamide

Bladder toxicity results from renal excretion of the metabolite acrolein, which is produced by the liver and stimulates bladder mucosal sloughing and subsequent tissue edema/fibrosis

2-Mercaptoethane sulfonate (mesna), which binds to acrolein and renders it inert, has been suggested for prophylaxis against cyclophosphamide-induced hemorrhagic cystitis

Question 125

what is the initial management for HC? next step if initial management for hemorrhagic cystitis is not effective:

Answer 125

Hyperbaric oxygen therapy

Question 126

this agent may be considered for first-line intravesical therapy among patients with hemorrhagic cystitis failing initial supportive measures, particularly among those without renal insufficiency.

Answer 126

Alum, aluminum ammonium sulfate or aluminum potassium sulfate) may be dissolved in sterile water (50 g alum in a 5-L bag of sterile water [1% alum solution]) and then used to irrigate the bladder at a rate of 200 to 300 mL/h.

Question 127

A lysine analogue, aminocaproic acid is a competitive inhibitor of activators of plasminogen, including urokinase, and thus interrupts fibrinolysis and the cascade that perpetuates hemorrhage

Answer 127

aminocaproic acid

Continuous bladder irrigation with 200 mg aminocaproic acid/L of 0.9% normal saline has been described, with irrigation continued for 24 hours after hematuria resolves.

Question 128

mechanism of HBOT

Answer 128

local tissue oxygen tension increases and thus oxygen extraction by tissues increases, thereby diminishing edema and promoting neovascularization, all of which are critical steps in the wound healing process

Question 129

BPH/Prostate Cancer represents the most common cause of prostate-related bleeding and has been cited as the most common cause of GH in men older than ___

Answer 129

BPH represents the most common cause of prostate-related bleeding and has been cited as the most common cause of GH in men older than 60

Question 130

The cause for BPH-related hematuria has been thought to be increased prostatic vascularity resulting from ____ in hyperplastic prostate tissue This noted increase in microvessel density has in turn been linked to higher levels of _____

Answer 130

The cause for BPH-related hematuria has been thought to be increased prostatic vascularity resulting from higher microvessel density in hyperplastic prostate tissue This noted increase in microvessel density has in turn been linked to higher levels of vascular endothelial growth factor (VEGF)

Question 131

Treatment with finasteride is associated with decreased ___, prostate ___ and __

Answer 131

Treatment with finasteride is associated with decreased VEGF expression (Pareek et al., 2003), prostate microvessel density (Pareek et al., 2003), and prostatic blood flow

Question 132

“Nutcracker syndrome” (i.e., renal vein entrapment syndrome) is defined as the compression of the left/right renal vein between the __ and the superior ___

tx for nutcracker syndrome

Answer 132

“Nutcracker syndrome” (i.e., renal vein entrapment syndrome) is defined as the compression of the left renal vein between the abdominal aorta posteriorly and the superior mesenteric artery anteriorly.

Left renal vein transposition, superior mesenteric artery transposition, and nephrectomy have been described as surgical approaches for management of this condition

Question 133

According to AUA guidelines, microhematuria sufficient to trigger a diagnostic evaluation is defined as:

a. a positive chemical test (urine dipstick) showing small, moderate, or large blood on one properly collected specimen.
b. a positive chemical test (urine dipstick) showing small, moderate, or large blood on at least two of three properly collected specimens.
c. a positive chemical test (urine dipstick) showing large blood on one properly collected specimen.
d. urine microscopy showing three or more red blood cells per high-powered field on one properly collected urine specimen.
e. urine microscopy showing three or more RBC/HPF on at least two of three properly collected urine specimens

Answer 133

. d. Urine microscopy showing three or more red blood cells per high-powered field on one properly collected urine specimen. The presence of three of more RBCs/HPF on a single urine microscopy is associated with malignancy in 2.3-5.5% of patients. Chemical tests for hematuria detect the peroxidase activity of erythrocytes using benzidine, and can render false results in the presence of dehydration, myoglobinuria, high doses of vitamin C, improper technique, and other factors. While higher levels of microhematuria (>25 RBCs/HPF) are known to be associated with higher rates of malignancy on evaluation, setting the threshold higher than three RBCs/HPF or requiring more than one positive urinalysis would lead to an unknown number of missed opportunities for diagnosis

Question 134

The likelihood of finding a malignancy in a patient with microhematuria is influenced by all of the following EXCEPT: a. age. b. gender. c. use of anticoagulants. d. tobacco use. e. degree of hematuria.

Answer 134

c. Use of anticoagulants. Increasing age, male gender, and tobacco use are risk factors for urologic cancers and specifically for urothelial carcinoma. In addition, while there is little data to distinguish among thresholds of two, three, four, or five RBCs/HPF, it is clear that a high level of microhematuria (>25 RBCs/HPF) is associated with a greater likelihood of malignancy. By contrast, patients using anticoagulant medications or antiplatelet medications have a similar risk of malignancy compared to those who do not use these medications. Therefore such patients should be evaluated comparably to those who do not use anticoagulants or anti-platelet agents

Question 135

According to AUA guidelines, the proper initial assessment of a 50- year-old patient with asymptomatic microhematuria includes:

a. blood pressure measurement, serum creatinine level, cystoscopy, and computed tomography (CT) urogram.
b. urine cytology, cystoscopy, and CT urogram. c. urine cytology, blue-light cystoscopy, and any upper tract imaging. d. urine cytology and renal/bladder ultrasound. e. no evaluation is necessary unless microhematuria is persistent/recurrent or hematuria is visible

Answer 135

a. Blood pressure measurement, serum creatinine level, cystoscopy, and computed tomography (CT) urogram. The AUA suggests that adult patients presenting with asymptomatic microhematuria should undergo evaluation to determine the cause. Blood pressure measurement and serum creatinine level may help identify patients who require concurrent nephrologic workup, and creatinine level also helps determine patient eligibility for contrast imaging. The evaluation of asymptomatic hematuria includes imaging (preferably with CT urogram), and cystoscopy in patients 35 and older and those under 35 with risk factors for malignancy

Question 136

In the evaluation of patients with microhematuria, cystoscopy may be safely avoided if: a. there are no associated symptoms in a patient of any age. b. the patient is under 35 years of age and without symptoms or risk factors for malignancy. c. the patient is taking aspirin or warfarin. d. the cytology is negative. e. the patient has a history of urinary tract infection and hematuria is still present after treatment

Answer 136

b. The patient is under 35 years of age and without symptoms or risk factors for malignancy. The AUA guidelines ( Fig. 16.1 ) call for use of cystoscopy for evaluation of hematuria in all patients 35 years of age and older (Recommendation). The risk of malignancy is very low in persons under 35 years of age, such that the potential benefits of cystoscopy may be outweighed by the very small risks associated with the procedure. Therefore it is an option to omit cystoscopy in patients under the age of 35, provided that the patient does not have risk factors for a urologic malignancy.

Question 137

Patients presenting with gross hematuria in the absence of recent trauma or concurrent infection who are on anticoagulation medications should be evaluated with: a. urinalysis, urine cytology, and cystoscopy only. b. CT urogram, with cystoscopy only if symptomatic. c. no evaluation necessary. d. assessment of anticoagulation status, and evaluation only if supra-therapeutic. e. urine cytology, cystoscopy, CT urogram.

Answer 137

e. Urine cytology, cystoscopy, CT urogram. Given the increased frequency with which clinically significant findings are associated with gross hematuria, the recommended evaluation in this setting is relatively uniform. That is, patients presenting with gross hematuria in the absence of antecedent trauma or culture-documented urinary tract infection should be evaluated with a urine cytology, cystoscopy, and upper tract imaging, preferably CT urogram. Importantly, patients who develop hematuria who are on anticoagulation medications should undergo a complete evaluation in the same manner as patients not taking such medications, as the prevalence of hematuria, as well as the likelihood of finding genitourinary cancers, among patients with hematuria on anticoagulation has been reported to be no different from patients not taking such medications.

Question 138

The metabolite of oxazaphosphorine chemotherapeutic agents which is responsible for hemorrhagic cystitis is: a. Mesna. b. Acrolein. c. Formalin. d. Gemcitabine. e. Methotrexate.

Answer 138

b

Question 139

Use of intravesical alum for hemorrhagic cystitis should be avoided in patients with: a. a history of malignancy. b. a history of detrusor instability. c. active gross hematuria. d. renal insufficiency. e. vesicoureteral reflux

Answer 139

d. Renal insufficiency. Alum may be considered for first-line intravesical therapy among patients with hemorrhagic cystitis ( Fig. 16.2 ) failing initial supportive measures. However, while cell penetration and therefore overall toxicity of this agent are low, systemic absorption may nevertheless occur and may result in aluminum toxicity, with consequent mental status changes, particularly among patients with renal insufficiency. Meanwhile, prior to intravesical administration of silver nitrate or of formalin, a cystogram should be obtained to evaluate for the presence of vesicoureteral reflux.

Question 140

A 35-year-old man presents with complaint of penile pain and immediate detumescence during intercourse. Physical examination notes blood at the urethral meatus. The next step should be: a. immediate operative exploration. b. CT scan of pelvis. c. retrograde urethrography. d. obtain serum coagulation parameters. e. conservative management with serial examinations.

Answer 140

Retrograde urethrography. The clinical scenario is consistent with an acute penile fracture. Blood at the meatus raises suspicion for concomitant urethral injury that requires investigation by retrograde urethrography prior to planned operative repair. Conservative management poses the risk of untreated urethral and corporal injury that can result in urethral stricture disease and erectile dysfunction. 11. b. Renal angiography.

Question 141

Alum may be used as a first-line intravesical therapy for hemorrhagic cystitis in patients ___ . Formalin is a highly effective form of intravesical therapy for hemorrhagic cystitis. A ____ should be obtained before therapy to ensure no ____

Answer 141

10. Alum may be used as a first-line intravesical therapy for hemorrhagic cystitis in patients without renal dysfunction. 11. Formalin is a highly effective form of intravesical therapy for hemorrhagic cystitis. A cystogram should be obtained before therapy to ensure no vesicoureteral reflux.