Chapter 1: Evaluation of the Urologic Patient

Question 1

What are the components of the International Prostate Symptom Score (IPSS)?

Answer 1

1. Incomplete Emptying
   
   • 0: Not at all
   • 1: Less than 1 time in 5
   • 2: Less than half the time
   • 3: About half the time
   • 4: More than half the time
   • 5: Almost always
2. Frequency
   
   • 0: Not at all
   • 1: Less than 1 time in 5
   • 2: Less than half the time
   • 3: About half the time
   • 4: More than half the time
   • 5: Almost always
3. Intermittency
   
   • 0: Not at all
   • 1: Less than 1 time in 5
   • 2: Less than half the time
   • 3: About half the time
   • 4: More than half the time
   • 5: Almost always
4. Urgency
   
   • 0: Not at all
   • 1: Less than 1 time in 5
   • 2: Less than half the time
   • 3: About half the time
   • 4: More than half the time
   • 5: Almost always
5. Weak Stream
   
   • 0: Not at all
   • 1: Less than 1 time in 5
   • 2: Less than half the time
   • 3: About half the time
   • 4: More than half the time
   • 5: Almost always
6. Straining
   
   • 0: Not at all
   • 1: Less than 1 time in 5
   • 2: Less than half the time
   • 3: About half the time
   • 4: More than half the time
   • 5: Almost always
7. Nocturia
   
   • 0: None
   • 1: 1 time
   • 2: 2 times
   • 3: 3 times
   • 4: 4 times
   • 5: 5 or more times

Quality of Life Due to Urinary Symptoms:
- 0: Delighted
- 1: Pleased
- 2: Mostly satisfied
- 3: Mixed - about equally satisfied and dissatisfied
- 4: Mostly dissatisfied
- 5: Unhappy
- 6: Terrible

Mnemonic: “IF YOU WISSIN”
- Incomplete Emptying
- Frequency
- Your
- Urgency
- Weak Stream
- Intermittency
- Straining
- Satisfaction (Quality of Life)
- Is
- Nocturia

Story: Picture a patient saying to the doctor, “IF YOU WISSIN (like peeing), remember these symptoms and quality of life factors!” This helps them recall each component of the IPSS.

Question 2

1. Pain associated with a stone in the ureter is the result of:
   a. obstruction of urine flow with distention of the renal capsule.
   b. irritation of the ureteral mucosa by the stone.
   c. excessive ureteral peristalsis in response to the obstructing stone.
   d. irritation of the intramural ureter.
   e. urinary extravasation from a ruptured calyceal fornix.

Answer 2

1. a. Obstruction of urine flow with distention of the renal capsule. Pain is usually caused by acute distention of the renal capsule, usually from inflammation or obstruction.

Question 3

2. The most common cause of gross hematuria in a patient older than 50 years is:
   a. renal calculi.
   b. infection.
   c. bladder cancer.
   d. benign prostatic hyperplasia.
   e. trauma.

Answer 3

2. c. Bladder cancer. The most common cause of gross hematuria in a patient older than age 50 is bladder cancer.

Question 4

3. The most common cause of pain associated with gross hematuria is:
   a. simultaneous passage of a kidney stone.
   b. ureteral obstruction due to blood clots.
   c. urinary tract malignancy.
   d. prostatic inflammation.
   e. prostatic enlargement.

Answer 4

3. b. Ureteral obstruction due to blood clots. Pain in association with hematuria usually results from upper urinary tract hematuria with obstruction of the ureters with clots.

Question 5

4. All of the following are typical lower urinary tract symptoms associated with benign prostatic hyperplasia EXCEPT:
   a. urgency.
   b. frequency.
   c. nocturia.
   d. dysuria.
   e. weak urinary stream.

Answer 5

4. d. Dysuria. Dysuria is painful urination that is usually caused by inflammation.

Question 6

5. The most likely cause of continuous incontinence (loss of urine at all times and in all positions) is:
   a. enterovesical fistula.
   b. noncompliant bladder.
   c. detrusor hyperreflexia.
   d. vesicovaginal fistula.
   e. sphincteric incompetence.

Answer 6

5. d. Vesicovaginal fistula. Continuous incontinence is most commonly due to a urinary tract fistula that bypasses the urethral sphincter or an ectopic ureter.

Question 7

6. All of the following are potential causes of anejaculation EXCEPT:
   a. sympathetic denervation.
   b. pharmacologic agents.
   c. bladder neck and prostatic surgery.
   d. androgen deficiency.
   e. cerebrovascular accidents.

Answer 7

6. e. Cerebrovascular accidents. Anejaculation may result from several causes: (1) androgen deficiency, (2) sympathetic denervation, (3) pharmacologic agents, and (4) bladder neck and prostatic surgery.

Question 8

7. What percentage of patients with multiple sclerosis will present with urinary symptoms as the first manifestation of the disease?
   a. 1%
   b. 5%
   c. 10%
   d. 15%
   e. 20%

Answer 8

7. b. 5%. In fact, 5% of patients with previously undiagnosed multiple sclerosis present with urinary symptoms as the first manifestation of the disease.

Question 9

8. What important information is gained from pelvic bimanual examination that cannot be obtained from radiologic evaluation?
   a. Presence of bladder mass
   b. Invasion of bladder cancer into perivesical fat
   c. Presence of bladder calculi
   d. Presence of associated pathologic lesion in female adnexal structures
   e. Mobility/fixation of pelvic organs

Answer 9

8. e. Mobility/fixation of pelvic organs. In addition to defining areas of induration, the bimanual examination allows the examiner to assess the mobility of the bladder; such information cannot be obtained by radiologic techniques such as computed tomography (CT) and magnetic resonance imaging (MRI), which convey static images.

Question 10

9. With which of the following diseases is priapism most commonly associated?
   a. Peyronie disease
   b. Sickle cell anemia
   c. Parkinson disease
   d. Organic depression
   e. Leukemia

Answer 10

9. b. Sickle cell anemia. Priapism occurs most commonly in patients with sickle cell disease but can also occur in those with advanced malignancy, coagulation disorders, and pulmonary disease, as well as in many patients without an obvious cause.

Question 11

10. What is the most common cause of cloudy urine?
    a. Bacterial cystitis
    b. Urine overgrowth with yeast
    c. Phosphaturia
    d. Alkaline urine
    e. Significant proteinuria

Answer 11

10. c. Phosphaturia. Cloudy urine is most commonly caused by phosphates in the urine.

Question 12

11. Conditions that decrease urine specific gravity include all of the following EXCEPT:
    a. increased fluid intake.
    b. use of diuretics.
    c. decreased renal concentrating ability.
    d. dehydration.
    e. diabetes insipidus.

Answer 12

11. d. Dehydration. Conditions that decrease specific gravity include (1) increased fluid intake, (2) diuretics, (3) decreased renal concentrating ability, and (4) diabetes insipidus.

Question 13

12. Urine osmolality usually varies between:
    a. 10 and 200 mOsm/L.
    b. 50 and 500 mOsm/L.
    c. 50 and 1200 mOsm/L.
    d. 100 and 1000 mOsm/L.
    e. 100 and 1500 mOsm/L.

Answer 13

12. c. 50 and 1200 mOsm/L. Osmolality is a measure of the amount of solutes dissolved in the urine and usually varies between 50 and 1200 mOsm/L.

Question 14

13. Elevated ascorbic acid levels in the urine may lead to false-negative results on a urine dipstick test for:
    a. glucose.
    b. hemoglobin.
    c. myoglobin.
    d. red blood cells.
    e. leukocytes.

Answer 14

13. a. Glucose. False-negative results for glucose and bilirubin may be seen in the presence of elevated ascorbic acid concentrations in the urine.

Question 15

14. Hematuria is distinguished from hemoglobinuria or myoglobinuria by:
    a. dipstick testing.
    b. the simultaneous presence of significant leukocytes.
    c. microscopic presence of erythrocytes.
    d. examination of serum.
    e. evaluation of hematocrit.

Answer 15

14. c. Microscopic presence of erythrocytes. Hematuria can be distinguished from hemoglobinuria and myoglobinuria by microscopic examination of the centrifuged urine; the presence of a large number of erythrocytes establishes the diagnosis of hematuria.

Question 16

15. The presence of one positive dipstick reading for hematuria is associated with significant urologic pathologic findings on subsequent testing in what percentage of patients?
    a. 2%
    b. 10%
    c. 25%
    d. 50%
    e. 75%

Answer 16

15. c. 25%. Investigators at the University of Wisconsin found that 26% of adults who had at least one positive dipstick reading for hematuria were subsequently found to have significant urologic pathologic findings.

Question 17

16. The most common cause of glomerular hematuria is:
    a. transitional cell carcinoma.
    b. nephritic syndrome.
    c. Berger disease (immunoglobulin A nephropathy).
    d. poststreptococcal glomerulonephritis.
    e. Goodpasture syndrome.

Answer 17

16. c. Berger disease (immunoglobulin A nephropathy). IgA nephropathy, or Berger disease, is the most common cause of glomerular hematuria, accounting for about 30% of cases.

Question 18

17. The most common cause of proteinuria is:
    a. Fanconi syndrome.
    b. excessive glomerular permeability due to primary glomerular disease.
    c. failure of adequate tubular reabsorption.
    d. overflow proteinuria due to increased plasma concentration of immunoglobulins.
    e. diabetes.

Answer 18

17. b. Excessive glomerular permeability due to primary glomerular disease. Glomerular proteinuria is the most common type of proteinuria and results from increased glomerular capillary permeability to protein, especially albumin. Glomerular proteinuria occurs in any of the primary glomerular diseases such as IgA nephropathy or in glomerulopathy associated with systemic illness such as diabetes mellitus.

Question 19

18. Transient proteinuria may be due to all of the following EXCEPT:
    a. exercise.
    b. fever.
    c. emotional stress.
    d. congestive heart failure (CHF).
    e. ureteroscopy.

Answer 19

18. e. Ureteroscopy. Transient proteinuria occurs commonly, especially in the pediatric population, and usually resolves spontaneously within a few days. It may result from fever, exercise, or emotional stress. In older patients, transient proteinuria may be due to CHF.

Question 20

19. Glucose will be detected in the urine when the serum level is above:
    a. 75 mg/dL.
    b. 100 mg/dL.
    c. 150 mg/dL.
    d. 180 mg/dL.
    e. 225 mg/dL.

Answer 20

19. d. 180 mg/dL. This so-called renal threshold corresponds to a serum glucose level of about 180 mg/dL; above this level, glucose will be detected in the urine.

Question 21

20. The specificity of dipstick nitrite testing for bacteriuria is:
    a. 20%.
    b. 40%.
    c. 60%.
    d. 80%.
    e. >90%.

Answer 21

20. e. >90%. The specificity of the nitrite dipstick test for detecting bacteriuria is greater than 90%.

Question 22

21. All of the following are microscopic features of squamous epithelial cells EXCEPT:
    a. large size.
    b. small central nucleus.
    c. irregular cytoplasm.
    d. presence in clumps.
    e. fine granularity in the cytoplasm.

Answer 22

21. d. Presence in clumps. Squamous epithelial cells are large, have a central small nucleus about the size of an erythrocyte, and have an irregular cytoplasm with fine granularity.

Question 23

22. The number of bacteria per high-power microscopic field that corresponds to colony counts of 100,000/mL is:
    a. 1.
    b. 3.
    c. 5.
    d. 10.
    e. 20.

Answer 23

22. c. 5. Therefore five bacteria per high-power field in a spun specimen reflect colony counts of about 100,000/mL.

Question 24

23. Pain in the flaccid penis is usually due to:
    a. Peyronie disease.
    b. bladder or urethral inflammation.
    c. priapism.
    d. calculi impacted in the distal ureter.
    e. hydrocele.

Answer 24

23. b. Bladder or urethral inflammation. Pain in the flaccid penis is usually secondary to inflammation in the bladder or urethra, with referred pain that is experienced maximally at the urethral meatus.

Question 25

24. Chronic scrotal pain is most often due to:
    a. testicular torsion.
    b. trauma.
    c. cryptorchidism.
    d. hydrocele.
    e. orchitis.

Answer 25

24. d. Hydrocele. Chronic scrotal pain is usually related to noninflammatory conditions such as a hydrocele or varicocele, and the pain is usually characterized as a dull, heavy sensation that does not radiate.

Question 26

25. Terminal hematuria (at the end of the urinary stream) is usually due to:
    a. bladder neck or prostatic inflammation.
    b. bladder cancer.
    c. kidney stones.
    d. bladder calculi.
    e. urethral stricture disease.

Answer 26

25. a. Bladder neck or prostatic inflammation. Terminal hematuria occurs at the end of micturition and is usually secondary to inflammation in the area of the bladder neck or prostatic urethra.

Question 27

26. Enuresis is present in what percentage of children at age 5 years?
    a. 5%
    b. 15%
    c. 25%
    d. 50%
    e. 75%

Answer 27

26. b. 15%. Enuresis refers to urinary incontinence that occurs during sleep. It occurs normally in children as old as 3 years but persists in about 15% of children at age 5 and about 1% of children at age 15.

Question 28

27. All of the following in the medical history suggest that erectile dysfunction is more likely due to organic rather than psychogenic causes EXCEPT:
    a. sudden onset.
    b. peripheral vascular disease.
    c. absence of nocturnal erections.
    d. diabetes mellitus.
    e. inability to achieve adequate erections in a variety of circumstances.

Answer 28

27. a. Sudden onset. A careful history will often determine whether the problem is primarily psychogenic or organic. In men with psychogenic impotence, the condition frequently develops rather quickly, secondary to a precipitating event such as marital stress or change or loss of a sexual partner.

Question 29

28. All of the following should be routinely performed in men with hematospermia EXCEPT:
    a. cystoscopy.
    b. digital rectal examination.
    c. serum prostate-specific antigen (PSA) level.
    d. genital examination.
    e. urinalysis.

Answer 29

28. a. Cystoscopy. A genital and rectal examination should be done to exclude the presence of tuberculosis, a PSA assessment and digital rectal examination should be done to exclude prostatic carcinoma, and a urinary cytologic assessment should be done to exclude the possibility of transitional cell carcinoma of the prostate.

Question 30

29. Pneumaturia may be due to all of the following EXCEPT:
    a. diverticulitis.
    b. colon cancer.
    c. recent urinary tract instrumentation.
    d. inflammatory bowel disease.
    e. ectopic ureter.

Answer 30

29. e. Ectopic ureter. Pneumaturia is the passage of gas in the urine. In patients who have not recently had urinary tract instrumentation or a urethral catheter placed, this is almost always due to a fistula between the intestine and bladder. Common causes include diverticulitis, carcinoma of the sigmoid colon, and regional enteritis (Crohn disease).

Question 31

30. Which of the following disorders may commonly lead to irritative voiding symptoms?
    a. Parkinson disease
    b. Renal cell carcinoma
    c. Bladder diverticula
    d. Prostate cancer
    e. Testicular torsion

Answer 31

30. a. Parkinson disease. The second important example of nonspecific lower urinary tract symptoms that may occur secondary to a variety of neurologic conditions is irritative symptoms resulting from neurologic disease such as cerebrovascular accident, diabetes mellitus, or Parkinson disease.

Question 32

What drug class is associated with decreased libido and give a specific example?

Answer 32

• Antihypertensives: Hydrochlorothiazide

Mnemonic: “Decreased Libido – Hydro (short for Hydrochlorothiazide)”

Story: Picture someone feeling sluggish and less interested in romantic activities after drinking water from a bottle labeled “Hydro.”

Question 33

What drug classes are associated with erectile dysfunction and give specific examples?

Answer 33

Remember the mnemonic “Erectile Dysfunction: Problematic Drugs”:
- P: Psychotropic drugs (Propranolol, Benzodiazepines)

Classes of drugs associated with erectile dysfunction:
- Psychotropic drugs
- Specific examples: Propranolol, Benzodiazepines

Question 34

What drug classes are associated with ejaculatory dysfunction and give specific examples?

Answer 34

• α-Adrenergic antagonists: Prazosin, Tamsulosin, α-Methyldopa
• Psychotropic drugs: Phenothiazines, Antidepressants

Mnemonic: “Ejaculatory Dysfunction – PAT” (Prazosin, Antidepressants, Tamsulosin)

Story: Picture a man named Pat who is having trouble with ejaculatory dysfunction, holding a sign with the drugs Prazosin, Antidepressants, and Tamsulosin.

Question 35

What drug classes are associated with priapism and give specific examples?

Answer 35

• Antipsychotics: Phenothiazines
• Antidepressants: Trazodone
• Antihypertensives: Hydralazine, Prazosin

Mnemonic: “Priapism – PATTH (Pronounced ‘Path’)”
Story: Picture a winding path (PATTH) in a forest where each tree represents a drug class (Phenothiazines, Antidepressants, Trazodone, Hydralazine, Prazosin), leading to a man with priapism.

Question 36

What drug classes are associated with decreased spermatogenesis and give specific examples?

Answer 36

Remember the mnemonic “CAN Drugs” and visualize a story:

• C: Chemotherapeutic agents (Alkylating agents)
• A: Abuse potential drugs (Marijuana, Alcohol, Nicotine)
• N: Endocrine function drugs (Antiandrogens, Prostaglandins)

Story/Mental Image:

Imagine a CAN (like a soda can) filled with different types of drugs. When you open the CAN, it contains:

• C for Chemotherapy drugs represented by a small model of a cancer cell (Alkylating agents).
• A for Abuse potential drugs like a tiny marijuana leaf, a miniature bottle of alcohol, and a nicotine patch.
• N for Endocrine function drugs with a mini symbol for hormones like a test tube and syringe (Antiandrogens, Prostaglandins).

Whenever you see someone with decreased spermatogenesis, think of this CAN filled with these specific drugs.

Question 37

What drug classes are associated with incontinence or impaired voiding and give specific examples?

Answer 37

Use the mnemonic “Helping Vessels For Very Different Bladders”:
- Helping: Histamine (Direct smooth muscle stimulants)
- Vessels: Vasopressin (Direct smooth muscle stimulants)
- For: Furosemide (Others)
- Very: Valproic acid (Others)
- Different: Diazepam (Smooth muscle relaxants)
- Bladders: Baclofen (Striated muscle relaxants)

Incontinence or impaired voiding is associated with the following classes of drugs and specific examples:
- Direct smooth muscle stimulants
- Specific examples: Histamine, Vasopressin
- Others
- Specific examples: Furosemide, Valproic acid
- Smooth muscle relaxants
- Specific example: Diazepam
- Striated muscle relaxants
- Specific example: Baclofen

Question 38

What drug classes are associated with urinary retention or obstructive voiding symptoms and give specific examples?

Answer 38

Urinary retention or obstructive voiding symptoms are associated with the following classes of drugs and specific examples:
- Anticholinergic agents or musculotropic relaxants
- Specific examples: Oxybutynin, Diazepam, Flavoxate
- Calcium channel blockers
- Specific example: Nifedipine
- Antiparkinsonian drugs
- Specific examples: Carbidopa, Levodopa
- α-Adrenergic agonists
- Specific examples: Pseudoephedrine, Phenylephrine
- Antihistamines
- Specific examples: Loratadine, Diphenhydramine

Question 39

What drug classes are associated with acute renal failure and give specific examples?

Answer 39

• Antimicrobials: Aminoglycosides, Penicillins, Cephalosporins, Amphotericin
• Chemotherapeutic drugs: Cisplatin
• Others: Nonsteroidal anti-inflammatory drugs, Phenytoin

Mnemonic: “Acute Renal Failure – ACAP CAP”
Story: Imagine a cap (ACAP CAP) that is tightly closed, causing acute renal failure. Each letter represents a drug: Aminoglycosides, Cephalosporins, Amphotericin, Penicillins, Cisplatin, Anti-inflammatory drugs, Phenytoin.

Question 40

What drug classes are associated with gynecomastia and give specific examples?

Answer 40

Use the mnemonic “Very Diligent Cat Mice Prefer Training”:
- Very: Verapamil (Antihypertensives)
- Diligent: Digoxin (Cardiac drugs)
- Cat: Cimetidine (Gastrointestinal drugs)
- Mice: Metoclopramide (Gastrointestinal drugs)
- Prefer: Phenothiazines (Psychotropic drugs)
- Training: Tricyclic antidepressants (Amitriptyline, Imipramine)

Gynecomastia is associated with the following classes of drugs and specific examples:
- Antihypertensives
- Specific example: Verapamil
- Cardiac drugs
- Specific example: Digoxin
- Gastrointestinal drugs
- Specific examples: Cimetidine, Metoclopramide
- Psychotropic drugs
- Specific examples: Phenothiazines, Tricyclic antidepressants (Amitriptyline, Imipramine)