GU

Question 1

A 28-year-old healthy female calls your clinic with a 2-day history of dysuria, urgency, and frequency. She has not had a fever, back pain, nausea, or hematuria, and has not noticed any vaginal discharge or itching. She was seen for similar symptoms 3 months ago and was treated with a 3-day course of antibiotics, with full resolution of symptoms.

Treatment for this patient should be based on (check one)
her reported symptoms
the presence or absence of suprapubic tenderness on examination
the presence or absence of leukocyte esterase on a urine dipstick
findings from a mid-stream urine culture
findings from urine microscopy

Answer 1

her reported symptoms

based on the patient’s symptoms rather than documented evidence of infection (SOR C). In healthy premenopausal women with no history of a urinary tract functional abnormality, current pregnancy, or another underlying condition that may increase the risk of treatment failure, infection can be presumed based on symptoms. Patients with acute uncomplicated cystitis are not febrile and have no vaginal symptoms. Men and children, as well as women who do not meet these criteria, require in-person evaluation.

A urine dipstick has relatively low sensitivity and specificity for urinary tract infection (SOR A). Negative dipstick results do not reliably rule out infection in a patient with strongly positive symptoms. A midstream culture is as good as or better than a urinary catheter–obtained specimen (SOR B). However, neither of these is required for the diagnosis or treatment of uncomplicated acute cystitis.

Question 2

A 55-year-old male with diabetes mellitus is found to have asymptomatic microscopic hematuria. The rest of his urinalysis is negative. He has no other medical problems and quit smoking 10 years ago. His only medication is metformin (Glucophage). A urine culture is negative and his renal function is normal. CT urography is also negative.

Which one of the following should be the next step in the evaluation of his microscopic hematuria? (check one)
Urine cytology
Cystoscopy
Nephrology referral
Stopping metformin and performing a repeat urinalysis
Antibiotic therapy

Answer 2

Cystoscopy

Patients with microscopic hematuria should initially be assessed for benign causes such as urinary tract infection, vigorous exercise, menstruation, and recent urologic procedures. If none of these is found, the next step would be assessing for renal disease using urine microscopy to look for casts or dysmorphic blood cells, and checking renal function. If the results are negative, CT urography and cystoscopy should be performed. CT evaluates the upper urinary tract for nephrolithiasis and renal cancer, while cystoscopy evaluates the bladder for bladder cancer, urethral strictures, and prostatic problems.

Urine cytology is less sensitive than cystoscopy for bladder cancer. This patient has normal renal function and no signs of renal disease on the urinalysis other than hematuria, so a nephrology consultation is not necessary at this time. Metformin use is not associated with microscopic hematuria. There is no role for antibiotics, given the negative urine culture.

Question 3

You are evaluating a couple for infertility. The semen analysis demonstrates oligozoospermia on two separate samples. The history and physical examination of the male partner are otherwise unremarkable.

Which one of the following would be the most appropriate next step in the evaluation of his oligozoospermia? (check one)
A CBC with differential and a basic metabolic panel
FSH and early morning total testosterone levels
Antisperm antibody testing
Scrotal ultrasonography
Referral for a testicular biopsy

Answer 3

FSH and early morning total testosterone levels

A semen analysis is the first step in the evaluation of male infertility. In males with oligozoospermia (especially if the sperm count is <10 million/mL), the American Urological Association recommends an endocrine evaluation with an FSH level and early morning total testosterone levels. The results of that testing can dictate next steps. A CBC and a basic metabolic panel have no role in the evaluation of male infertility. Antisperm antibody testing is rarely recommended and should only be considered in consultation with a fertility specialist. Scrotal ultrasonography is not recommended in individuals with a normal physical examination and should only be performed in individuals with palpable varicoceles on physical examination. A testicular biopsy is not usually required to help differentiate between obstructive and nonobstructive azoospermia.

Question 4

A 20-year-old offensive lineman who plays football for the small college in your town presents to your office at midseason with pain in his right groin. He describes it as a burning, aching sensation that gets worse when he coughs or strains during a bowel movement, and when he is required to block opponents or push against the blocking sled in practice.

As part of the physical examination, you have the patient stand, and you insert your finger into the inguinal canal and follow the spermatic cord to the internal inguinal ring. When you reach the internal ring the patient reports discomfort. When you ask him to cough and strain the pain increases and you feel an impulse or bulge at the tip of your finger. The remainder of his physical examination is normal.

This patient’s history and examination findings are most consistent with which one of the following diagnoses? (check one)
Athletic pubalgia (sports hernia)
Osteitis pubis
Adductor muscle tendinopathy
Ilioinguinal nerve entrapment
Inguinal hernia

Answer 4

Inguinal hernia

This patient’s history, along with the bulge/impulse detected on physical examination when he strained or coughed, is most consistent with the diagnosis of inguinal hernia. A “sports hernia” is not a true hernia, but rather a tearing of tissue fibers. The patient often presents with symptoms consistent with a hernia, but without evidence on physical examination. Pain along the symphysis pubis would suggest osteitis pubis, and pain along the adductor tendons would suggest adductor tendinopathy. Ilioinguinal nerve entrapment syndrome is an abdominal muscular pain syndrome characterized by the clinical triad of muscle-type iliac fossa pain with a characteristic radiation pattern, altered sensory perception in the ilioinguinal nerve cutaneous innervation area, and a well-circumscribed trigger point medial to and below the anterosuperior iliac spine.

Question 5

A 23-year-old male presents to your office with a 2-day history of dull, achy, right testicular
pain. He reports that the pain began gradually, reaching a peak last night. He does not recall any
trauma and denies any urethral complaints.
Your examination reveals an extremely tender right testis with some tenderness extending to the
epididymis. A preliminary report from a stat ultrasound examination shows an enlarged,
heterogeneous right testis with increased color flow.

Which one of the following is the preferred management? (check one)
Watchful waiting
Repeat ultrasonography in 24 hours
Antibiotic treatment
Emergent urology referral

Answer 5

Antibiotic treatment

Acute epididymitis is often the result of descending infection caused by urinary tract pathogens. When the
infection involves the epididymis and testis (epididymo-orchitis), sonography will frequently show an
enlarged heterogeneous testis with increased color flow.

In sexually active men under age 35, acute epididymitis is caused most frequently by Chlamydia
trachomatis and less commonly by Neisseria gonorrhoeae. Clinical features suggestive of urethritis may
be absent (subclinical urethritis). Epididymitis in men who have practiced unprotected insertive rectal
intercourse is often caused by Enterobacteriaceae. These men usually do not have urethritis but do have
bacteriuria. Treatment of acute epididymo-orchitis consists of administering appropriate antibiotics for the
treatment of both gonorrhea and Chlamydia infections. Additional antibiotic coverage may be indicated
based on the patient’s sexual history.

Unilateral absent flow on color and spectral Doppler sonography is a highly sensitive and specific finding
in acute testicular torsion and emergent urology referral is indicated. Heterogeneous echotexture of the
testis is a common finding in sonograms performed to evaluate acute scrotal pain, regardless of the cause.
There is no role for repeat ultrasonography or watchful waiting in patients with acute epididymo-orchitis
(SOR C).

Question 6

A 61-year-old male is found to have a 2-cm right adrenal incidentaloma on CT. He has no history of hypertension, electrolyte abnormalities, headaches, flushing, or sweating.

Which one of the following studies should be performed in patients found to have an adrenal incidentaloma? (check one)
An ACTH stimulation test
A dexamethasone suppression test
Paired serum aldosterone and plasma renin activity
Serum or urine metanephrines
A PET Scan

Answer 6

A dexamethasone suppression test

Adrenal incidentalomas usually do not produce overt hormone excess, but mild autonomous cortisol secretion (MACS) is present in up to 30%–50% of cases. This mild secretion of cortisol may predispose patients to metabolic syndrome, osteoporosis, and cardiovascular events. MACS can be ruled out with an overnight 1-mg dexamethasone suppression test. The remainder of the evaluation can be based on CT findings and clinical symptoms.

An ACTH stimulation test is used to evaluate for adrenal insufficiency, which is not caused by an adenoma. If no hypertension or hypokalemia are present, the serum aldosterone and plasma renin activity paired values may not be necessary. Testing for metanephrines is indicated only if pheochromocytoma is suspected. If no clinical symptoms of pheochromocytoma (such as hypertension, sweating, or headaches) are present and the lesions are <10 Hounsfield units on CT, pheochromocytoma and malignancy are very unlikely. A PET scan would not be indicated in this scenario.

Question 7

A 27-year-old male with no significant medical history presents for evaluation of a new onset of blood in his semen occurring on three occasions over the past 10 days. He has not had any additional genitourinary, gastrointestinal, or constitutional symptoms. He has no personal history of tobacco use and he is sexually active with his wife only. A physical examination, including a genitourinary examination, is unremarkable. A CBC, comprehensive metabolic panel, prothrombin time/partial thromboplastin time, urinalysis and culture, and sexually transmitted infection screening are all normal.

Which one of the following is the most appropriate next step? (check one)
Reassurance and no additional testing
A PSA level
Ultrasonography of the scrotum and prostate
CT of the abdomen and pelvis
Referral to a urologist

Answer 7

Reassurance and no additional testing

In most cases, hematospermia (visible blood in the ejaculate) is benign and self-limiting, often caused by infection or inflammation of the genitourinary tract. Other potential etiologies include trauma or iatrogenic injury, systemic diseases including severe uncontrolled hypertension or a bleeding disorder, cysts, calculi, or prolonged abstinence. Hematospermia is rarely caused by genitourinary cancer, and underlying malignancy is particularly unlikely in men <40 years of age with new-onset hematospermia. Although acute-onset hematospermia may cause great distress to the patient, if the initial evaluation is unrevealing the most appropriate intervention for a man <40 years of age is reassurance that the problem will likely self-resolve, with the recommendation to return for follow-up if the problem persists or recurs. Further evaluation with PSA testing and referral to a urologist is indicated for men with symptoms persisting beyond 10 occasions or 1 month’s duration and for men over 40 years of age. After an unremarkable history, examination, and basic laboratory workup, the next step is to provide reassurance with appropriate return precautions. PSA testing, ultrasonography of the scrotum and prostate, CT of the abdomen and pelvis, and referral to a urologist are not warranted at this time.

Question 8

A 48-year-old male presents with a 4-week history of rectal pain associated with minimal rectal bleeding. On examination there is a small tear of the anorectal mucosa at the 6 o’clock position.

The most appropriate initial treatment would be topical? (check one)
Botulinum toxin
Clobetasol (Temovate)
Capsaicin (Capzasin-HP, Zostrix)
Nitroglycerin

Answer 8

Nitroglycerin

This patient has classic findings for acute rectal fissure. Although patients often require an internal sphincterotomy, nonsurgical measures that relax the sphincter have proven helpful. Botulinum toxin injected into the internal sphincter has proven most beneficial, but topical preparations are not yet available and have not been shown to be effective for this problem. Corticosteroid creams may decrease the pain temporarily, but potent fluorinated corticosteroid creams such as clobetasol are not indicated in the treatment of fissure. Capsaicin cream can be helpful for pruritus ani, but not for anal fissures. Drugs that dilate the internal sphincter, including diltiazem, nifedipine, and nitroglycerin ointment, have proven to be beneficial in healing acute fissures, but usually have to be compounded by a pharmacist.

Question 9

An 88-year-old male nursing-home patient is having problems with constant overflow incontinence. Intermittent catheterization has proven difficult due to urethral obstruction and his resistance to such procedures. He has dementia and generalized weakness as a result of multiple strokes and is bedbound, requiring total care for most activities of daily living. Examination shows a grade 3 coccygeal ulcer that has been present for several months, and a digital rectal examination demonstrates a large, irregular prostate.

Which one of the following is the best choice to quickly correct his incontinence? (check one)
Doxazosin (Cardura)
Finasteride (Proscar)
Tolterodine (Detrol)
Long-term indwelling Foley catheter placement
Referral for transurethral prostatectomy

Answer 9

Long-term indwelling Foley catheter placement

While it would increase the risk of urinary infection, indwelling catheter placement is most likely to provide immediate relief of this patient’s urinary retention. It will minimize or prevent further contamination of his decubitus ulcer with urine. Prostatectomy may relieve the urethral obstruction, but this patient is likely to remain incontinent due to his vascular dementia. Doxazosin or finasteride would likely be inadequate in this situation. Tolterodine is not indicated for overflow incontinence.

Question 10

A 72-year-old male is admitted to the hospital after a syncopal episode that led to a skull fracture. All of his blood tests are in the normal range. The following morning his sodium level is 132 mEq/L (N 135–145) and further testing confirms that he is suffering from the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). He is placed on a free-water restriction of <1 L/day. Later that evening he complains of a headache and vomits repeatedly. A recheck of his electrolytes shows that his sodium has dropped to 121 mEq/L.

What would be the most appropriate way to address his hyponatremia at this time? (check one)
Start oral tolvaptan (Samsca)
Start oral sodium tablets
Start an intravenous infusion of hypertonic saline
Further restrict fluid intake

Answer 10

Start an intravenous infusion of hypertonic saline

Head trauma is a known cause of the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). This patient’s course has been very acute, with hyponatremia developing within 48 hours. Such a precipitous drop in serum sodium may lead to cerebral and pulmonary edema. If left untreated the patient can have seizures, become obtunded, and die from brain herniation. These dangers require immediate treatment with hypertonic saline to correct the falling levels of sodium. This must be done cautiously so as to not overcorrect the sodium level too quickly, which could lead to osmotic demyelination syndrome. An increase in serum sodium levels of about 6 mEq/L should be enough to reduce symptoms and prevent progressive cerebral edema.

Question 11

Misleadingly low serum sodium can be caused by?
(check one)
Hyperglycemia
Diuretic use
Heart Failure
Renal Disease

Answer 11

Hyperglycemia

A decrease in serum sodium concentration does not always indicate a decrease in osmolality of body fluids. In cases of hyperglycemia, the main cause of the hyponatremia is the glucose-related increase in osmolality of extracellular fluid, followed by the movement of water from intracellular to extracellular fluid compartments and a subsequent loss of excessive extracellular fluid and electrolytes. The serum sodium concentration is also diminished in patients with hyperlipidemia or hyperproteinuria because of the volume occupied by the lipids or proteins. If the lipids or proteins are removed, the sodium concentration in the remaining plasma is found to be normal. No treatment is needed for these conditions.

Question 12

A 25-year-old white male truck driver presents with a 1-day history of throbbing rectal pain. Your examination shows a large thrombosed external hemorrhoid.

Which one of the following is the preferred initial treatment for this patient?

(check one)
Infrared coagulation
Rubber band ligation of the hemorrhoid
Elliptical excision of the thrombosed hemorrhoid
Stool softeners and a topical analgesic/hydrocortisone cream

Answer 12

Elliptical excision of the thrombosed hemorrhoid

The appropriate management of a thrombosed hemorrhoid presenting within 72 hours of the onset of symptoms is elliptical excision of the hemorrhoid and overlying skin under local anesthesia, such as 0.5% bupivacaine hydrochloride in 1:200,000 epinephrine, infiltrated slowly with a 27-gauge needle.

Incision and clot removal may provide inadequate drainage, resulting in rehemorrhage and clot reaccumulation. Most thrombosed hemorrhoids contain multilocular clots that may not be accessible through a simple incision. Rubber band ligation is an excellent technique for management of internal hemorrhoids, and infrared coagulation is also used for this purpose. Banding an external hemorrhoid would cause exquisite pain.

If the pain is already subsiding or more time has elapsed, and if there is no necrosis or ulceration, measures such as sitz baths, bulk laxatives, stool softeners, and local analgesia may be helpful. Some local anesthetics carry the risk of sensitization. Counseling to avoid precipitating factors such as prolonged standing/sitting, constipation, and delay of defecation is also appropriate.

Question 13

For which type of renal calculus is acidification of the urine indicated?

(check one)
Cystine
Uric acid C
Calcium oxalate
Calcium phosphate

Answer 13

Calcium phosphate

Urine pH is an important factor in the production of kidney stones. Uric acid, cystine, and calcium oxalate stones tend to form in acidic urine, whereas struvite (magnesium ammonium phosphate) and calcium phosphate stones form in alkaline urine. Urine should be acidified for prevention of calcium phosphate and struvite stones. Cranberry juice or betaine can lower urine pH.

Question 14

A 68-year-old female presents with recent poor oral intake, fatigue, and confusion. Osmotic demyelination syndrome (central pontine myelinolysis) and permanent neurologic deficits could result from overly rapid correction of which one of the following abnormalities?

(check one)
Hyperglycemia
Hyperkalemia
Hypokalemia
Hypernatremia
Hyponatremia

Answer 14

Hyponatremia

Overly rapid correction of hyponatremia may cause osmotic demyelination syndrome, or central pontine myelinolysis, sometimes resulting in permanent neurologic deficits after a brief improvement in neurologic status. Signs and symptoms may include dysarthria, dysphagia, paresis, coma, and seizures. It is believed that brain volume shrinks because it cannot assimilate the new electrolytes fast enough and water is lost from the cells. Rapid correction of hypernatremia that has been present for a short time is relatively safe. Hyperkalemia is a life-threatening condition that should be corrected promptly. Rapid correction of hypoglycemia is not an issue. Overly rapid correction of hyperglycemia and subsequent cerebral edema is unusual and is primarily seen in children.

Question 15

A 67-year-old male presents with a 12-hour history of the inability to urinate. He also reports mild symptoms of benign prostatic hyperplasia that he has tolerated for the last couple of years. Today he has significant discomfort in his suprapubic area, and his bladder is palpable. He has not had any fever or recent painful urination. Ultrasonography shows 300 cc of retained urine in the bladder.

Which one of the following would be the initial treatment for this patient’s acute urinary retention? (check one)
An oral α-blocker followed by urethral catheter placement if he is unable to void within 24 hours
Urethral catheter placement with immediate removal after draining the bladder
Urethral catheter placement followed by continuous drainage for 3 days
Suprapubic catheter placement
Transurethral resection of the prostate

Answer 15

Urethral catheter placement followed by continuous drainage for 3 days

Acute symptomatic urinary retention should be treated with immediate urethral catheterization. The
catheter should be left in place for 3 days, followed by a voiding trial. During this time the patient should
be evaluated for underlying causes of the retention, such as infection, and prescribed or over-the-counter
medications. Starting an -blocker while the catheter is in place should be considered, but initial treatment
with an -blocker without catheterization is not indicated. Suprapubic catheter placement should only be
used when urethral catheterization is unsuccessful. Transurethral resection of the prostate may be necessary
later but is not the initial treatment.

Question 16

Which one of the following fluoroquinolones should NOT be used in the treatment of urinary tract infections? (check one)
Ciprofloxacin (Cipro)
Gatifloxacin (Tequin)
Levofloxacin (Levaquin)
Moxifloxacin (Avelox)
Norfloxacin (Noroxin)

Answer 16

Moxifloxacin (Avelox)

When trimethoprim/sulfamethoxazole is contraindicated, a 3-day course of ciprofloxacin, levofloxacin, norfloxacin, lomefloxacin, or gatifloxacin is a reasonable alternative. Moxifloxacin attains inadequate urinary concentrations and should not be used in the management of urinary tract infections.

Question 17

A 45-year-old white male presents with severe intermittent right flank pain that radiates into his right groin area. You suspect a ureteral stone. Which one of the following would most reliably confirm your suspected diagnosis? (check one)
A helical CT scan of the abdomen and pelvis without contrast
Intravenous pyelography
Abdominal ultrasonography
A KUB plain film of the abdomen
A urinalysis

Answer 17

A helical CT scan of the abdomen and pelvis without contrast

An unenhanced helical CT scan of the abdomen and pelvis is the best study for confirming the diagnosis of a urinary tract stone in a patient with acute flank pain, supplanting the former gold standard, intravenous pyelography. A CT scan may also reveal other pathology, such as appendicitis, diverticulitis, or abdominal aortic aneurysm. Although abdominal ultrasonography has a very high specificity, it is still not better than CT, and its sensitivity is much lower; thus, its use is usually confined to pregnant patients with a suspected stone. Plain abdominal radiographs may show the stone if it is radiopaque, and are useful for following patients with radiopaque stones. CT will reveal a radiopaque stone. While most patients with stones will have hematuria, its absence does not rule out a stone.

Question 18

A 72-year-old white female who is otherwise healthy complains of occasional incontinence. She reports that this occurs mainly at night when she awakens with an intense desire to void, and by the time she is able to get to the bathroom she has “wet herself.” The most likely diagnosis is: (check one)
Sphincter incompetence
Detrusor instability
Detrusor hypotonia
Uninhibited neurogenic bladder

Answer 18

Detrusor instability

Urinary incontinence is very common in the elderly female. Treatment depends entirely on a careful history to ascertain the exact circumstances when the patient wets herself. One of the most common types of incontinence results from uninhibited contractions of the detrusor muscle. This detrusor instability causes an intense urge to void, which overcomes the patient’s voluntary attempt to hold the sphincter closed; hence, the common term urge incontinence. Other common causes of incontinence include a weak sphincter (sphincter incompetence), which leads to leakage associated with ordinary activities such as coughing or lifting (stress incontinence). Another common cause is overflow of urine from an abnormally distended, hypotonic, poorly contractile bladder (detrusor hypotonia). This is probably more common in males with longstanding obstruction due to prostatic hypertrophy. A rare type of incontinence is caused by spinal cord damage. This reflex incontinence is due to the patient being unable to sense the need to void.

Question 19

A 72-year-old female with longstanding diabetes mellitus presents to your office. During the review of systems, she complains of difficulty voiding and frequent “dribbling.” A urinalysis is negative for infection and her post-void residual volume is 250 mL. Which one of the following is the most likely cause of this patient’s urinary incontinence? (check one)
Excess urine output due to hyperglycemia
Atrophic vaginitis
A grade II cystocele
Asymptomatic bacteriuria
Autonomic neuropathy

Answer 19

Autonomic neuropathy

Dribbling and increased post-void residual volume (>100 mL) are signs of overflow incontinence. Overflow incontinence can be caused by outflow obstruction (e.g., prostate hypertrophy, urethral constriction, fecal impaction) or, as in this case, by detrusor muscle denervation caused by diabetic or other neuropathies. Excess urine output from hyperglycemia would result in frequent urination, but not urinary retention. Atrophic vaginitis and cystoceles are usually associated with stress incontinence. Asymptomatic bacteriuria is unlikely because the patient does not have any evidence of infection.

Question 20

A 48-year-old female presents to your office for follow-up of painful rectal bleeding with bowel movements. She has increased her fiber consumption and is using a stool softener as you recommended at her last visit 2 weeks ago. She reports that her pain has worsened since yesterday and she is very uncomfortable. An examination reveals a firm and tender right posterior hemorrhoid below the dentate line.

Which one of the following would be the most appropriate next step in providing relief for this thrombosed hemorrhoid? (check one)
Topical corticosteroids
Bioflavonoid supplements
Oral antibiotics
Rubber band ligation
Excision

Answer 20

Excision

This patient has tried first-line treatment for hemorrhoids with increased fiber intake but has returned with
symptoms of a thrombosed external hemorrhoid. Office-based surgical excision of the thrombosed external
hemorrhoid within 2–3 days of symptom onset may provide significant symptomatic relief (SOR B) and
result in a lower risk of recurrence. While conservative treatment with topical therapies such as
corticosteroids may be helpful, symptomatic relief is prolonged with excision of the thrombosed
hemorrhoid.
Bioflavonoids are used outside the United States for symptomatic treatment of hemorrhoids but evidence
is lacking and they are not approved by the FDA for this use. Oral antibiotic therapy has no role in the
treatment of thrombosed external hemorrhoids but may be beneficial in treating an abscess, which would
present with a gradual onset of pain and a fluctuant rectal mass. Rubber band ligation is an appropriate
treatment for grades I–III internal hemorrhoids (SOR A).

Question 21

A 65-year-old male presents with a 1-month history of problems passing urine. He says that his bladder will feel full when he needs to urinate, but the urine stream is weak and his bladder does not feel as if it has emptied completely. The symptoms have become increasingly severe over the past week. Other symptoms include upper respiratory congestion for 3 days which he has treated with an over-the-counter decongestant with some relief, constipation with no passage of stool in the past 9 days, and increasing low back pain incompletely relieved with ibuprofen, with associated weakness in both legs. Examination shows a healthy-appearing male who is moderately overweight. He is afebrile and vital signs are normal. There is no abdominal tenderness and no masses are detected. A rectal examination reveals a large amount of hard stool in the rectum; a markedly enlarged (4+), boggy, tender prostate gland; laxity of the anal sphincter; and numbness in the perianal area. Urinalysis shows trace protein and 10-20 WBCs/hpf. Ultrasonography shows a post-void residual volume of 250 mL (normal for age <100). Which one of the following must be done urgently in this complicated patient? (check one)
Foley catheterization
Hospitalization for intravenous antibiotics
Digital disimpaction of the rectum, and Fleet enemas until clear
MRI of the lumbosacral spine

Answer 21

MRI of the lumbosacral spine

The differential diagnosis of urinary retention in the elderly is broad. While most causes are benign and readily treated, the physician must be vigilant in looking for conditions that require urgent intervention.This patient presents with many possible causes of urinary retention, with the most common being benign prostatic hyperplasia. Acute prostatitis, especially in a male with an enlarged prostate, is another relatively common reason for obstructive symptoms. This patients physical examination and abnormal urinalysis support this diagnosis, but his normal vital signs and lack of fever suggest he can be treated with an oral fluroquinolone and does not require hospital admission for intravenous therapy. Medications such as oral decongestants can contribute to urinary retention in men with enlarged prostate glands, and should be used with caution and discontinued if obstructive symptoms occur. Obstipation with stool impaction is another relatively common reason for urinary retention in the elderly and can be treated with manual disimpaction and enemas. In this patient, the presence of increasing low back pain and leg weakness, and the findings of anal sphincter laxity and numbness in the perianal area on examination, suggest the presence of a serious neurologic etiology such as cauda equina syndrome. Urgent diagnosis and treatment are necessary to reduce morbidity, and MRI should be performed immediately. The presence of a mildly elevated post-void residual is not an indication for urgent decompression with a Foley catheter.

Question 22

Which one of the following is associated with testosterone supplementation in men with hypogonadism? (check one)
Muscle wasting
Polycythemia
Osteoporosis
An increased risk of benign prostatic hypertrophy

Answer 22

Polycythemia

Testosterone increases hematocrit and can cause polycythemia. In patients receiving testosterone supplementation, hematocrit should be monitored every 6 months for the first 18 months, then annually. Testosterone should be discontinued if there is more than a 50% rise in hematocrit. Testosterone also causes an increase in lean body mass, and may increase bone density.

Question 23

A 45-year-old white male is admitted to the intensive-care unit after being pinned in a car wreck for 2 hours. He has sustained several broken bones and crush injuries to both thighs. On admission his urine is clear but the next morning it is burgundy colored. Some fresh urine is drawn from his Foley catheter and sent for analysis, with the following results:

Specific gravity…………1.020
pH…………6.0
Protein…………30 mg/dL (N 1-14)
Glucose…………negative
Hemoglobin…………4+
Urobilinogen…………0.1 Ehrlich Units (N 0.1-1.0)
Bile…………negative
RBCs…………1-2/hpf
WBCs…………0-2/hpf
Occasional hyaline casts

You immediately order a CBC which shows his hematocrit to have dropped 4 percentage points overnight. Visual inspection of the serum shows it is light yellow. The color of his urine is most likely due to

(check one)
myoglobinuria
hematuria from trauma to the urinary tract
a transfusion reaction with hemolysis of RBCs and free hemoglobin into the urine
hemoglobinuria resulting from reabsorption of hemoglobin from hematomas
acute porphyria provoked by trauma

Answer 23

myoglobinuria

A positive dipstick for hemoglobin without any RBCs noted in the urine sediment indicates either free hemoglobin or myoglobin in the urine. Since the specimen in this case was a fresh sample, significant RBC hemolysis within the urine would not be expected. If a transfusion reaction occurs, haptoglobin binds enough free hemoglobin in the serum to give it a pink coloration. Only when haptoglobin is saturated will the free hemoglobin be excreted in the urine. Myoglobin is released when skeletal muscle is destroyed by trauma, infarction, or intrinsic muscle disease. If the hematuria were due to trauma there would be many RBCs visible on microscopic examination of the urine. Free hemoglobin resorption from hematomas does not occur. Porphyria may cause urine to be burgundy colored, but it is not associated with a positive urine test for hemoglobin.

Question 24

A 45-year-old male sees you to review the results of a male hormone imbalance test that he took online. On the list of symptoms, he marked decreased sex drive and excessive sweating as severe; fatigue, mood changes, sleep problems, and muscle strength as moderate; and hair loss, decreased mental ability, weight gain, and muscle and joint pain as mild. The patient has no known chronic diseases and takes a daily multivitamin. His medical history and a physical examination are unremarkable. He would like to start testosterone therapy as soon as possible.

After discussing the limited indications for testosterone replacement, which one of the following would be the most appropriate next step to address this patient’s concerns? (check one)
Reassurance only
FSH and LH levels
A total testosterone level at the end of this visit
Two separate fasting morning total testosterone levels
A clinical trial of testosterone replacement

Answer 24

Two separate fasting morning total testosterone levels

A diagnosis of hypogonadism in men with symptoms and signs of testosterone deficiency should be confirmed by unequivocally and consistently low serum total testosterone and/or free testosterone concentrations. Significant diurnal and day-to-day variations affect testosterone concentration measurements. Testosterone levels are also affected by food intake and blood glucose levels. The 2018 Endocrine Society guidelines recommend that measurements of total testosterone concentrations should be obtained on two separate fasting morning specimens, using an accurate, reliable, and certified laboratory assay method. Because acute illness can also affect testosterone levels, testing should be postponed until after full recovery. Testing for testosterone deficiency in men on short-term treatment with medications such as opioids or cimetidine, which can suppress testosterone concentrations, should also be delayed until after the treatment ends. LH and FSH levels should be obtained once low testosterone has been confirmed, in order to help differentiate between primary or secondary hypogonadism. According to the 2020 evidence-based guidelines from the American College of Physicians, testosterone replacement is recommended for men with age-related testosterone deficiency and sexual dysfunction, and is not recommended to help with physical function, cognition, or energy.

Question 25

A 46-year-old female presents with a 2-week history of polyuria. She has not had any discomfort with urination or visible change in her urine. Her past medical history includes hysterectomy for fibroids. Further history reveals no concerning environmental exposures other than a 5-pack-year history of smoking in her twenties. A physical examination, including a pelvic examination, is unremarkable. A urine dipstick reveals only 1+ RBCs. A microscopic urinalysis is negative with the exception of 7 RBCs/hpf, and a urine culture is negative.

Which one of the following would you recommend at this point? (check one)
Repeat urinalysis in 6 months
Renal ultrasonography only
Urine cytology and renal ultrasonography
Urine cytology and CT urography
Cystoscopy and CT urography

Answer 25

Repeat urinalysis in 6 months

This patient presents with microscopic hematuria without a clear cause. Past guidelines from the American Urologic Association recommended cystoscopy and CT urography for all patients over the age of 35 with microscopic hematuria. However, current guidelines recommend risk stratification and emphasize the use of imaging that has less radiation exposure. Because she is female and younger than 50 years of age, this patient is at low risk of urologic malignancy. Her smoking history and RBC count of <10 RBCs/hpf are also considered low risk. The guidelines recommend the option of repeating urinalysis in 6 months before proceeding with imaging or procedures, given her low risk (SOR C). Renal ultrasonography may be used in intermediate-risk patients, while CT urography is reserved for high-risk patients. Urine cytology is not a recommended test in this setting.

Question 26

A 47-year-old male presents with a 3-day history of fever, chills, low back pain, and urinary frequency. He does not have any nausea, vomiting, or abdominal pain. There is no significant past medical history.

The patient’s vital signs include a temperature of 38.1°C (100.6°F), a pulse rate of 88 beats/min, and a respiratory rate of 14/min. The examination reveals a mildly tender lower abdomen with no guarding or rebound tenderness; no costovertebral angle tenderness; and an enlarged, homogeneous, exquisitely tender prostate.

Which one of the following is indicated to help guide this patient’s treatment? (check one)
A serum prostate-specific antigen level
A culture of prostate secretions after massage of the prostate
A culture of midstream voided urine
CT of the abdomen and pelvis with intravenous and oral contrast
An ultrasound-guided prostate biopsy

Answer 26

A culture of midstream voided urine

This patient has clinically diagnosable acute bacterial prostatitis, and no further testing, including imaging, is required to establish the diagnosis. Culture of a midstream voided urine may aid in identifying the pathogen, but prostate massage should be avoided because it may increase the risk of bacteremia. A prostate biopsy is not indicated in the presence of acute infection, and a prostate-specific antigen level is not indicated because it is likely to be elevated in the presence of infection.

Question 27

A 49-year-old male is concerned about lesions on his penis that he has noticed over the past 6 months. He was circumcised as a child and has had the same female sexual partner for 5 years. He does not have any pain, itching, or dysuria. On examination you note multiple reddish-blue papules on the scrotum and a few similar lesions on the shaft of the penis.

The most likely diagnosis is (check one)
pearly penile papules
lichen nitidus
lichen sclerosus
angiokeratomas
squamous cell carcinoma in situ (Bowen’s disease)

Answer 27

angiokeratomas

Penile lesions are usually easily diagnosed from clinical findings. Pearly penile papules are common and benign, and present as small, skin-colored, dome-shaped papules in a circular pattern around the coronal sulcus.

Lichen nitidus is benign but uncommon. It presents as discrete, pinhead-sized hypopigmented papules that are asymptomatic. Papules are often found scattered all over the penis, as well as on the abdomen and upper extremities.

Lichen sclerosus is more common and appears as hypopigmented lesions with the texture of cellophane. The lesions are usually located on the glans or prepuce. Atrophy, erosions, and bullae are common, and patients often present with itching, pain, bleeding, and possibly phimosis or obstructed voiding. Lichen sclerosus is associated with squamous cell cancer in a small percentage of cases.

Carcinoma in situ is a premalignant condition that is more common in uncircumcised males over age 60. Lesions are typically beefy red, raised, irregular plaques and can be found on the glans, meatus, frenulum, coronal sulcus, and prepuce. Lesions can be ulcerated or crusted. Pruritus and pain are common. A biopsy is important for making the diagnosis.

Angiokeratomas are lesions that are usually asymptomatic, circumscribed, red or bluish papules. They may appear solely on the glans of the penis, but are also found on the scrotum, abdomen, thighs, groin, and extremities. They may be misdiagnosed as pearly papules or carcinoma. Treatment is not necessary unless the lesions are bleeding or extensive. It is important to realize that angiokeratomas on the shaft of the penis, the suprapubic region, or the sacral region can be associated with Fabry disease. Patients with this finding should be promptly referred.

Question 28

A 40-year-old male presents to your office for follow-up of an abnormal clean-catch urine test performed at his employee health clinic during a preemployment screening examination. He had a positive urine dipstick for hemoglobin and 5 RBCs/hpf on microscopy. The urine was negative for protein, WBCs, and casts. A basic metabolic panel was notable for a creatinine level of 0.8 mg/dL (N 0.6–1.2) and a BUN of 15 mg/dL (N 8–23). He reports that he has been healthy and has not sought medical care in the last 5 years. He quit smoking 6 months ago and walks the dog daily for 30 minutes. A physical examination today is normal.

According to the guidelines of the American Urological Association, which one of the following would be the most appropriate next step in the workup? (check one)
Repeat urine microscopy
Urine cytology
Cystoscopy
Renal ultrasonography
Retrograde pyelography

Answer 28

Cystoscopy

Asymptomatic microhematuria is defined as 3 or more RBCs/hpf on a properly collected urine specimen in the absence of an obvious benign cause. Vigorous exercise, viral illness, trauma, and infection have been ruled out as a cause of hematuria in this patient. His renal function is normal. The most appropriate next step in evaluating a patient 35 years of age is to perform a urologic evaluation with cystoscopy. Cystoscopy is also recommended for patients of any age who have risk factors for urinary tract malignancy.

The initial examination should also include CT urography with and without contrast. When CT with contrast is contraindicated, an alternative is retrograde pyelography in conjunction with noncontrast CT, MR urography, or ultrasonography. Obtaining urine cytology and urine markers is not recommended as part of the routine evaluation of asymptomatic microhematuria. A repeat urinalysis with microscopy is not needed to confirm asymptomatic microhematuria. According to the American Urological Association, one positive urine sample is sufficient to prompt an evaluation.

Question 29

A 54-year-old male is concerned about testosterone deficiency. He has erectile dysfunction with impaired erections and decreased libido. He has also noted hair loss on his legs, breast tenderness, and fatigue. He has chronic renal disease and compensated heart failure, and he takes opioids for chronic pain. Five years ago he had a non–ST-elevation myocardial infarction and has done well with medical management.

The patient’s morning testosterone level is low on two separate readings and you want to initiate testosterone replacement.

Laboratory Findings

Estimated glomerular filtration rate 58 mL/min/1.73 m2
Creatinine 2.0 mg/dL (N 0.7–1.3)
Hematocrit 55% (N 42–52)
Prostate-specific antigen 3.9 ng/dL (N 0.0–4.0)

Which one of the following is an ABSOLUTE contraindication to starting treatment with testosterone in this patient?
(check one)
The history of coronary artery disease
Benign prostatic hyperplasia
Chronic renal disease
Compensated heart failure
Polycythemia

Answer 29

Polycythemia

Testosterone replacement has significant risks and contraindications. Absolute contraindications include breast cancer, prostate cancer, a prostate-specific antigen (PSA) level >4 ng/dL, an abnormal rectal examination with nodules, and polycythemia with a hematocrit >54%. Relative contraindications include a baseline hematocrit >50%, a desire for fertility, uncontrolled heart failure, untreated sleep apnea, and severe lower tract symptoms. This patient has polycythemia with a hematocrit >54% and should not be started on testosterone. Testosterone stimulates erythropoiesis and increases the risk of thrombosis. Although there may be an association between testosterone deficiency and coronary artery disease, a history of coronary artery disease is not a contraindication to testosterone replacement. Patients with chronic renal disease who are on chronic opioid therapy are at higher risk of developing secondary testosterone deficiency. Testosterone replacement may increase PSA levels and should not be used in patients with known or suspected prostate cancer.

Question 30

A staff member at a local assisted living facility calls you about an 88-year-old female who has chronic urinary incontinence and well controlled hypertension. A urinalysis was obtained after the patient reported some dizziness and malaise. She does not have dysuria and has had no change to her incontinence. The patient is afebrile and other vital signs are normal. The urine culture reveals >100,000 colony-forming units of Escherichia coli, with sensitivities pending.

In addition to supportive care and hydration, which one of the following would be indicated at this time? (check one)
Ciprofloxacin (Cipro)
Fosfomycin (Monurol)
Nitrofurantoin (Macrodantin)
Trimethoprim/sulfamethoxazole (Bactrim)
No antibiotics

Answer 30

No antibiotics

This patient has asymptomatic bacteriuria and does not require antibiotic therapy at this time. In women age 70 and older the incidence of asymptomatic bacteriuria is 16%–18%, and in chronically incontinent and disabled older adults rates may reach 43%. Symptoms that raise concern for a urinary tract infection (UTI) include acute dysuria, new or worsening urinary urgency or frequency, new incontinence, gross hematuria, and suprapubic or costovertebral angle tenderness. General malaise in the absence of these symptoms is unlikely to represent a UTI and unlikely to improve with antibiotic therapy.

When antibiotic therapy is indicated for a UTI, trimethoprim/sulfamethoxazole remains the first-line agent. Nitrofurantoin may be used for those with a creatinine clearance >40 mL/min/1.73 m2. Ciprofloxacin is recommended as a first-line agent only in communities with trimethoprim/sulfamethoxazole resistance rates above 10%–20%. Fosfomycin may be used for more highly resistant organisms. The choice of antibiotic should be guided by bacterial pathogens if they are known.

Question 31

A 60-year-old male with symptomatic low testosterone is started on a testosterone patch. You should order specific periodic monitoring of his PSA level and (check one)
no other laboratory studies
ALT and AST levels
BUN and creatinine levels
C-reactive protein level
hematocrit

Answer 31

hematocrit

When testosterone therapy is started, baseline and periodic measurements of PSA and hematocrit should be performed. If the hematocrit increases to >54% the testosterone dosage should be stopped or decreased to avoid hemoconcentration. Liver and renal function tests should be monitored routinely with many drugs but not specifically with testosterone. The C-reactive protein level is not monitored during testosterone therapy.

Question 32

A 23-year-old male presents with a lump in his left testicle that he found while showering last week. He has a history of orchiopexy for cryptorchidism at age 17. He is otherwise healthy. Testicular ultrasonography reveals a hypoechoic mass in his left testicle.

Which one of the following would be most appropriate at this time? (check one)
Watchful waiting
Serum β-hCG, α-fetoprotein, and LDH levels
CT of the abdomen and pelvis
Referral to a urologist

Answer 32

Referral to a urologist

Patients with a history of cryptorchidism are at high risk for the development of testicular cancer, especially if orchiopexy is performed after puberty. If sonography shows a hypoechoic mass, a testicular biopsy is contraindicated, since it may contaminate the scrotum or alter the lymphatic drainage. Radical inguinal orchiectomy is both diagnostic and therapeutic. Watchful waiting would not be an option in this high-risk patient. CT of the chest, abdomen, and pelvis, and measurement of the tumor markers are useful for staging and as an indication of tumor burden, but they are not diagnostic.

Question 33

A 36-year-old female calls your office because of a 2-day history of dysuria, urinary urgency, and urinary frequency. She has not had any fever, nausea, or vaginal discharge. She tells you her symptoms are similar to a previous urinary tract infection. She uses subdermal etonogestrel (Nexplanon) for contraception, takes no oral medications, and has no drug allergies.

Which one of the following would be most appropriate at this point? (check one)
Prescribe ciprofloxacin (Cipro)
Prescribe nitrofurantoin (Macrobid, Macrodantin)
Prescribe a urinary analgesic such as phenazopyridine (Pyridium)
Ask the patient to come in today for evaluation
Ask the patient to submit a urine specimen before you prescribe antibiotics

Answer 33

Prescribe nitrofurantoin (Macrobid, Macrodantin)

Urinary tract infection (UTI) is the most common bacterial infection in women. The annual incidence of UTI in women is 12%. Women who have had a UTI in the past are usually quite adept at diagnosing their own subsequent UTIs. Prospective studies have shown that women who suspect they have a UTI are more than 85% accurate based on culture results (SOR B). This is more accurate than dipstick testing, which has a sensitivity of 75% and a specificity of 82%. Nonpregnant female patients who have typical UTI symptoms without signs of pyelonephritis (i.e., fever and nausea) or vaginitis can be treated safely and effectively by phone.

Urine culture testing is not indicated for uncomplicated UTIs. It has been found that the traditional criterion for infection (100,000 colony-forming units/mL) is not sensitive for women with a UTI. Urine testing should be reserved for patients suspected of having pyelonephritis.

There are three first-line antibiotics for uncomplicated UTI. These include nitrofurantoin for 5 days, trimethoprim/sulfamethoxazole for 3 days, and fosfomycin as a single dose (SOR A). Fluoroquinolones are second-line agents and are best reserved for more serious infections such as pyelonephritis.

Urinary analgesics can be helpful with UTI symptoms but are not the preferred method of treatment, as antibiotics rapidly reduce the symptoms of infection.

Question 34

A home health nurse calls you about a 62-year-old male who is recovering at home several days after spinal surgery. His recovery was going well until he became unable to urinate despite the sensation of needing to do so. His last normal void was about 12 hours ago and felt incomplete. Catheterization produced 900 mL of clear-appearing urine that she will send for urinalysis. His bowel movements have been normal and his need for pain medications has been decreasing.

In addition to stopping medications that may be promoting his urinary retention, which one of the following management strategies would be most appropriate? (check one)
Leaving the indwelling catheter in place for 48–72 hours
Starting finasteride (Proscar), 5 mg daily
Starting oxybutynin, 10 mg daily
Sending the patient to the emergency department

Answer 34

Leaving the indwelling catheter in place for 48–72 hours

This patient is suffering from acute urinary retention, likely due to mild benign prostatic hyperplasia exacerbated by pain medication and a lack of activity. Acute urinary retention could also possibly be due to irritation of sympathetic and/or parasympathetic nerves near the spine. Placing an indwelling bladder catheter is appropriate. It would also be reasonable, although impractical in the short term, to teach the patient or his caretakers to intermittently catheterize him.

The likelihood of a successful return to voiding spontaneously will increase over time. However, the risk of catheter-associated urinary tract infection is estimated to be about 5% per day. Therefore, catheter removal and a trial of spontaneous voiding should be attempted after 48–72 hours. There is good evidence that starting an α-blocking medication such as tamsulosin during the time the catheter is in place will nearly double the success of the trial of spontaneous voiding. Finasteride in isolation is not recommended and oxybutynin would be contraindicated.

Question 35

A 41-year-old male presents to the emergency department with severe left-sided back pain. He is afebrile and a urinalysis shows red blood cells. Imaging reveals a 6-mm stone in the lower ureter and no hydronephrosis.

In addition to NSAIDs and narcotics for pain control, which one of the following would be most effective for hastening passage of the stone? (check one)
An α1-blocker such as tamsulosin (Flomax)
A 5-α-reductase inhibitor such as finasteride (Proscar)
A nonselective β-blocker such as propranolol
A phosphodiesterase inhibitor such as sildenafil (Viagra)
A thiazide diuretic such as hydrochlorothiazide

Answer 35

An α1-blocker such as tamsulosin (Flomax)

α1-Blockers such as doxazosin, prazosin, and tamsulosin have been shown to hasten the passage of ureteral stones (level 2 evidence). They are probably more effective than calcium channel blockers (level 2 evidence). β-Blockers, phosphodiesterase inhibitors such as sildenafil, 5-α-reductase inhibitors such as finasteride, and thiazide diuretics have not been shown to hasten stone passage. However, thiazide diuretics have been shown to decrease stone formation in patients with hypercalciuria.

Question 36

A 29-year-old male presents to your office with a 2-week history of anal pain and bright red blood on his stool with bowel movements. He says he typically has bowel movements every 3–5 days and his stool is usually hard. He has not noted any purulent drainage or perianal masses.

Which one of the following is the most likely diagnosis? (check one)
Anal fistula
Anal fissure
Internal hemorrhoids
External hemorrhoids
Perirectal abscess

Answer 36

Anal fissure

Posterior midline fissures cause pain during and after defecation. Most are caused by the passage of hard stool and when stretched cause bleeding. Conservative therapy consisting of bulk agents and stool softeners usually allows these to heal.

Internal hemorrhoids can cause bleeding with the passage of stool but are typically painless. External hemorrhoids can bleed with trauma but typically cause pain with thrombosis, independent of bowel movements. Anal fistulas and perirectal abscesses may intermittently drain purulent material. Abscesses can cause continuous pain, and a perianal mass may be noted on examination.

Question 37

A 46-year-old female has a 3-day history of dysuria with burning, frequency, and urgency. She reports no fever, weakness, or hematuria. Her chronic health problems include obesity and prediabetes. She has no known allergies.

Which one of the following would be the most appropriate treatment regimen for this patient? (check one)
Ibuprofen for 3 days
Trimethoprim/sulfamethoxazole (Bactrim) for 3 days
Ciprofloxacin (Cipro) for 3 days
Levofloxacin (Levaquin) for 7 days
Azithromycin (Zithromax) for 7 days

Answer 37

Trimethoprim/sulfamethoxazole (Bactrim) for 3 days

Acute uncomplicated cystitis responds well to 3 days of trimethoprim/sulfamethoxazole, 160/800 mg twice daily. Increasing resistance to fluoroquinolones has been seen and they are therefore less likely to be successful. Because of the association with tendon rupture they are also not considered first-line treatment. β-Lactam agents have similar resistance issues. Azithromycin is not indicated for urinary tract infections.

Ibuprofen alone has produced good symptom relief, but antibiotics are frequently needed
for a definitive cure. The presence of diabetes or prediabetes should not change treatment (SOR A, SOR C).

Question 38

A 15-year-old male presents with a 2-day history of dark-colored urine, lower extremity edema, and fatigue. Approximately 2 weeks ago he said he had a “bad sore throat” that was treated empirically with amoxicillin. On examination his blood pressure is 144/92 mm Hg, his pulse rate is 76 beats/min, and his other vital signs are normal. Other than mild dependent edema there are no additional significant physical examination findings. A urinalysis dipstick shows 3+ hematuria.

Which one of the following findings on microscopic evaluation of the urine sediment would help to confirm the diagnosis in this patient? (check one)
Gram-positive cocci in chains
RBC casts
WBC casts
Eosinophils
Oxalate crystals

Answer 38

RBC casts

This is a classic presentation for acute poststreptococcal glomerulonephritis (APSGN), with the onset of
gross hematuria associated with hypertension and systemic edema. This is most commonly seen in
school-age children, usually 1–2 weeks after an episode of pharyngitis or 3–4 weeks after an episode of
impetigo, caused by so-called nephritogenic strains of Group A -hemolytic Streptococcus. The hematuria
is caused by immune complex–mediated glomerular injury.

Bacteriuria may be seen in both upper and lower urinary tract infections, but may also be a spurious
finding, especially with the combined presence of epithelial cells. The classic finding on microscopic
urinalysis for acute glomerulonephritis is the presence of RBC casts. WBC casts are seen with acute
pyelonephritis. The presence of urinary eosinophils indicates acute interstitial nephritis. Calcium oxalate
makes up the most common type of kidney stones.
Antibiotics prescribed for antecedent pharyngitis do not prevent APSGN. Treatment is supportive,
controlling blood pressure and edema with a thiazide or a loop diuretic. The prognosis for resolution and
full recovery of the vast majority of patients with APSGN is excellent, especially in the pediatric age
group.

Question 39

For urinary stones 5–10 mm in diameter, which one of the following has been proven effective in facilitating expulsion from the distal ureter? (check one)
Ciprofloxacin (Cipro)
Naproxen
Nitrofurantoin (Macrodantin)
Promethazine
Tamsulosin (Flomax)

Answer 39

Tamsulosin (Flomax)

Tamsulosin promotes passage of ureter stones that are 5–10 mm in diameter. The number needed to treat
is five patients to cause the expulsion of one stone (SOR B). There was no difference in the percentage of
patients passing stones smaller than 5 mm when comparing tamsulosin to placebo, as these stones have a
high rate of spontaneous passage without any intervention. Naproxen and promethazine are sometimes used
for the management of pain and nausea associated with stones, but they have not been shown to facilitate
stone expulsion. Ciprofloxacin and nitrofurantoin are used to treat urinary tract infections but have not
been shown to facilitate stone expulsion.

Question 40

A 58-year-old female presents to your office after being seen in the emergency department last weekend for her first episode of renal colic. After undergoing CT urography she passed a calcium phosphate kidney stone.

Which one of the following medications in her current regimen places her at higher risk for kidney stone formation? (check one)
Escitalopram (Lexapro)
Levothyroxine (Synthroid)
Lisinopril (Prinivil, Zestril)
Metformin (Glucophage)
Topiramate (Topamax)

Answer 40

Topiramate (Topamax)

Topiramate increases the risk of kidney stones. It is a carbonic anhydrase inhibitor, which induces a
metabolic acidosis that leads to hypercalciuria and the formation of calcium phosphate stones. The risk of
kidney stones is not increased by escitalopram, levothyroxine, lisinopril, or metformin.