GU COPY

Question 1

Urge Incontinence S/sxs & Dx

Answer 1

• most common in elderly and nursing home residents
• overactive detrusor muscle → increased frequency and involuntary loss of urine
• S/sxs:
  
  • suddent urge to urinate (pts often unable to make it to restroom)
  • loss of LARGE volumes of urine with SMALL postvoid residual
  • nocturnal wetting
• Dx:
  
  • urodynamic study → shows how well the bladder, urethra and sphincter hold and release urine
    
    • will have increased bladder contractions during the filling phase

Question 2

Urge Incontinence Tx

Answer 2

• bladder training exercises: goal is to increase the amount of time between voiding
• limit fluids <2-2.5L/day
• avoid bladder irritants: chocolate, caffeine, acidic fruits and juices, spicy foods, and aspirin
• anticholinergic: oxybutynin, tolterodine, darifenacin, solifenacin, trospium, fesoterodine)
  
  • → reduce bladder irritability and contractility
  • SEs = retention, dry mouth, constipation, nausea, blurred vision, tachycardia, confusion, delirium, contraindicated in narrow angle glaucoma
• 3rd line = botox
• 4th line = neuromodulation-electrical sim → percutaneous tibial nerve stimulation

Question 3

Stress Incontinence S/sxs & Dx

Answer 3

Most common in women (after having multiple children)

• weakness of the pelvic diaphragm (pelvic floor) leads to loss of bladder support with resulting hypermobility of the bladder neck
• S/sxs:
  
  • involuntary loss of urine (only in spurts) during activities that increase the pressure of the abdominal cavity
    
    • cough, sneezing, weight lifting
• Dx: clinical diagnosis → rule out infx with urinalysis
  
  • urinary stress test

Question 4

Stress Incontinence Tx

Answer 4

• kegel exercises: 3-6 weeks of daily exercises, 200/day
• vaginal estrogens
• pessary
  
  • SEs: vaginal irritation, foul-smelling discharge, UTIs
• surgery → mid-urethral sling
• weight loss

Question 5

Overflow Incontinence S/sxs, Dx, & Tx

Answer 5

Most commonly affects diabetic patients and pts with neurological disorders

• inadequate bladder contraction (due to impaired detrusor contractility) or a bladder outlet obstruction → urinary retention and eventual overdistention
• S/sxs:
  
  • nocturnal bed wetting
  • infrequent voiding (2-3x/24 hours)
  • difficulty starting urination
  • large post voiding residual volume
• Men: bladder outlet obstruction due to BPH
• Women: prolapse of bladder (Cystocele) or uterus; rarely urethral stricture or bladder neck contracture
• Tx:
  
  • intermittent self-catheterization
  • cholinergic agents: bethanechol to increase bladder contraction
  • alpha blockers: terazosin, doxazosin to decrease sphincter resistance

Question 6

Functional Incontinence S/sxs, Dx, & Tx

Answer 6

• occurs in pts who have normal voiding systems but who may have difficulty reaching a toilet due to physical/mental disabilities
• S/sxs: increased urinary volume and inability to urinate in a timely manner
• Dx: clinical
• Tx: scheduled voiding times

Question 7

Overactive Bladder Etiology, S/sxs, Dx, & Tx

Answer 7

• muscles of the bladder start to contract involuntarily even when the volume of the urine in the bladder is low
• Risk factors: age, current smoking, hyperlipidemia, DM, cardiovascular and renal disease
• S/sxs:
  
  • urgency (sudden need to urinate)
    
    • followed by occasional loss of urine
    • no leaking with coughing or sneezing
• Dx:
  
  • urinalysis
  • post-void residual volume
  • urinary stress test
  • U/S
  • Cystoscopy and urodynamic testing
  • detrusor overactivity (overactive bladder)can be diagnosed if there is urgency or leakage with a detrusor contraction that the pt cannot suppress
• Tx:
  
  • pelvic floor exercises
  • anticholinergic: oxybutynin and TCAs (Tricyclic antidepressants) imipramine

Question 8

Cystocele Etiology, S/sxs, Dx, and Tx

Answer 8

Bladder prolapse → occurs when the supportive connective tissue separating the bladder and vagina weaken

• Risk Factors:
  
  • obesity
  • chronic cough
  • can occur after childbirth or after lifting heavy objects
• S/sxs: preceived or discovered bulge in the vagina
  
  • difficulty getting urine stream going
  • feeling of incomplete emptying
  • frequency or urgency
  • worsened with standing
• Dx:
  
  • pelvic exam and urodynamic studies
  • urinalysis
• Tx: minimal sxs = no tx
  
  • kegel exercises, pelvic floor training
  • pessaries
  • surgery → strengthen the support underneath the bladder

Question 9

Urethral Prolapse

Answer 9

S//sxs urethral mass and vaginal bleeding

often associated with constipation, painless

Question 10

Cryptorchidism

Answer 10

• when the testes do not descend aka undescended testicle
• Risk factors:
  
  • premature infants (30%) vs full term infants (5%)
  • most common in R testicle
• increases risk of cancer and infertility
• Dx:
  
  • referral made to urology if testicles have not descended by 3 months of age
    
    • surgery between 6months - 1 year of age (orchiopexy)
      *

Question 11

Peyronie Disease Etiology, S/sxs, Dx, & Tx

Answer 11

buildup of fibrous hardened tissue in the corpus cavernosum → often caused by repeated injury (sex, physical activity) and genetic susceptibility is involved

• S/sxs:
  
  • penile pain worsened with erection
  • curvature of penis on erection
  • interference with sexual function
  • thick circumferential plaque at the coronal sulcus
• Dx:
  
  • hx and penile exam
• Tx:
  
  • stable, mild curvature (≤ 30 degrees) with satisfactory sexual function:
    
    • observation = okay
  • worsening curvature or sexual dysfunction:
    
    • pentoxifylline (vasodilator & anti-inflammatory) = best if initial tx within 3 months of onset
    • > 3 months of deformity?
      
      • intralesional injection with collagenase
    • >12 months and wont respond to other txs?
      
      • surgical management
        *

Question 12

Bladder Trauma

Answer 12

blunt force bladder injuries usually seen with lower abdominal trauma and pelvic fractures often with MVAs

• ***always suspect bladder injury in pts with pelvic fracture and inability to void***
• S/sxs:
  
  • bruising/edema of lower abdomen, perineum, or genitalia
• Dx:
  
  • CBC, prothrombin time (PT) and activated partial thromboplastin time (aPTT) → coagulopathy
  • plain radiography of pelvis
  • retrograde cystogram → once urethral injury has been excluded and/or foley cath is place
• Tx:
  
  • Ruptures:
    
    • intraperitoneal or large bladder rupture = surgery to close
    • extraperitoneal bladder rupture = can be treated with bladder catheter and observation
  • Contusion
    
    • drainage of the bladder should allow for resolution of the injury within a few days → f/u with cystography to assess integrity of bladder wall

Question 13

Urethral Trauma

Answer 13

• classic sign = blood at the meatus
• anterior urethral injuries (bulbous and pendulous) = due to direct blows, straddle injuries, instrumentation
• posterior urethral (prostatic and membranous) injuries: usually coincide with major pelvic fracture
• Less common in women (shorter urethra and is more mobile)
• S/sxs: high riding ballotable (can be “bounced back and forth”) prostate on digital rectal exam (DRE)
  
  • penile or perineal edema and/or hematoma (common in anterior injuries)
  • scrotal or peritoneal ecchymosis
• Dx:
  
  • retrograde urography uses cystoscopy and ureteral catheterization to introduce a radiopaque contrast agent directly into the ureters and renal collecting system
• Tx:
  
  • surgical repair for urethral injuries

Question 14

External Genitalia Trauma

Answer 14

male external genitalia: penis, scrotum, testes and ejaculatory complex

Female: vulva, vagina, and labia majora/minora and clitoris

• Causes: blunt mechanisms, falls, straddle injury
  
  • penile fractures: most commonly during sexual intercourse or masturbation
    
    • → hear “popping” or “snapping” sound
• Tx:
  
  • Penile Injuries = close f/u care especially if skin was grafted
  • surgery = best tx for penile fractures
  • f/u hormonal studies and semen analysis with scrotal or testicular injuries

Question 15

Kidney and Ureter Trauma general info and dx

Answer 15

• ***significant force is needed in order to injure the kidneys***
  
  • → MVAs, Falls, Direct Blows, Lower Rib Fractures
  • Kids: most common cause of renal injury = bike accidents
  • adults: 75% of ureteral injuries are iatrogenic
• Dx:
  
  • CT scanning with contrast

Question 16

Vesicoureteral Reflux Etiology, S/sxs, Dx, & Tx

Answer 16

urine flow retrograde or backward from the bladder up the ureters and into the kidney

• Two Types:
  
  • primary vesicoureteral reflux: most common type → when child is born with defect at the ureterovesical junction
  • secondary vesicoureteral reflux:
    
    • obstruction that causes increased pressure and backflow; most commonly caused by recurrent UTIs
  • At risk:
    
    • young females with hx of pyelonephritis or recurrent cystitis → evaluate for VUR
  • S/sxs:
    
    • fever
    • urine cx with E.coli
  • Dx:
    
    • VCUG (voiding cystourethrography) and serial U/S
  • Tx:
    
    • mild to moderate VUR = usually resolves on its own
    • more serious = surgery
    • recently diagnosed: give prophylactic abx that are administered nightly at ½ the normal dosage

Question 17

Cystitis S/sxs, PE, Dx, & Tx

Answer 17

infx of bladder

• Most common organisms: E.coli, Klebsiella, proteus, enterobacter, citrobacter
• S/sxs:
  
  • hematuria, dysuria, increased urinary frequency, nocturia
  • no fever, chills or back pain
• PE: NO CVA TENDERNESS
• Dx:
  
  • urine dipstick: nitrites, leukocyte esterase
  • urinalysis: pyuria (WBCs in urine), bacteriuria, +/- blood, +/- nitrites
  • Urine Cx = GOLD STANDARD
    
    • → but do not need for uncomplicated cystitis
      
      • (non-pregnant woman)
• Tx:
  
  • uncomplicated UTIs:
    
    • trimethoprim -sulfamethoxazole (BACTRIM) x 3 days
    • Nitrofurantoin x 5 days
    • fluoroquinolones x 3 days
  • Lower UTI in pregnancy:
    
    • nitrofurantoin x 7 days
    • Cephalexin (Keflex) x 7 days
  • Pediatric Cystitis:
    
    • 1st gen ceph (Keflex) for low risk of renal involvement
    • 2nd gen ceph (cefuroxime) or 3rd gen ceph (cefixime, cefdinir, ceftibuten) for those with high likelihood of renal involvement

Question 18

Epididymitis S/sxs, PE, Dx, and Tx

Answer 18

• Pathogens:
  
  • Men < 35 = chlamydia and gonorrhea
  • Men ≥ 35 = E.coli
• S/sxs:
  
  • dull, aching scrotal pain that gradually increases
  • dysuria, unilateral scrotal pain & swelling
• PE:
  
  • (+) Phren’s sign → relief of sxs with elevation = Classic Sign
  • tender scrotum on posterior
• Dx:
  
  • important to r/o testicular torsion → Rapid onset, higher testis → u/s with doppler
  • urinalysis & cx + GCCT → pyuria (WBCs in urine) and bacteriuria
• Tx:
  
  • <35 or suspected STD: ceftriaxone IM + doxycycline
  • ≥ 35 with suspected enteric organism:
    
    • levofloxacin or double strength Trimethoprim-Sulfamethoxazole (Bactrim)

Question 19

Orchitis s/sxs, PE, Dx, & Tx

Answer 19

• Mumps = most common cuase in kids
• orchitis without epididymitis = very uncommon in adults
• S/sxs: unilateral scrotal pain
• PE:
  
  • tender, swollen testicle
    
    • shininess of the overlying skin
    • scrotal edema with erythema
• Dx:
  
  • r/o testicular torsion with u/s with doppler
  • urinalysis with cxs: pyuria and bacteriuria with cxs positive for suspected organisms
• Tx:
  
  • rest, NSAIDS, scrotal support, ice, and abx (if bacterial)
  • Age <35 or sexuallya ctive post-pubertal males → tx like epididymitis
    
    • → ceftriaxone IM + doxycycline
  • Age ≥ 35 (STI not suspected) →levofloxacin

Question 20

Acute Bacterial Prostatitis S/sxs, PE, Dx, & Tx

Answer 20

• Men < 35: chlamydia & gonorrhea
• Men ≥ 35: E.coli
• most common in younger men and more serious
• S/sxs:
  
  • fever, chills, malaise
  • dysuria (pain with urination), urgency, frequency
  • perineal and low back pain
• PE:
  
  • DRE (digital rectal exam):
    
    • boggy, warm, tender, enlarged prostate
  • if you suspect prostatitis DO NOT MASSAGE THE PROSTATE → can lead to SEPSIS
• Dx:
  
  • urinalysis: pyuria +/- hematuria
  • urine cx: positive
  • prostatic fluid/secretions: may show leukocytosis with a cx → typically positive for E.coli
  • U/S CT scan Cystoscopy for men with significant voiding issues
  • Blood Tests: CBC, blood cx if clinical findings suggestive of bacteremia → BUN, creatinine levels for pts with urinary retention/obstruction
    
    • → serum PSA may be elevated
• Tx:
  
  • Men < 35: ceftriaxone + doxy
  • Men ≥ 35: fluoroquinolones or Bactrim for 3-6 weels
  • URETHRAL CATHETERIZATION IS CONTRAINDICATED IN THESE PATIENTS

Question 21

Chronic Prostatitis S/sxs, PE, Dx, & Tx

Answer 21

• usually men age 40-70
• can be bacterial/abacterial; chronic bacterial = most common form of prostatitis
• S/sxs:
  
  • can be asymptomatic
  • hx of recurrent UTIs
  • perineal/low back pain; suprapubic discomfrot
• PE: DRE → enlarged, non-tender prostate
• Tx: fluoroquinolones or Bactrim x 6-12 weeks

Question 22

Pyelonephritis S/sxs, PE, Dx, & Tx

Answer 22

infx of the kidneys usually by E. coli

• S/sxs:
  
  • dysuria + fever + flank pain +/- nausea/vomting
• PE: flank pain
• Dx: urinalysis: bacteria and WBC casts
• Tx:
  
  • outpatient: cipro/levo +/- ceftriaxone IM
  • inpatient: cipro/levo or imipenem for more severe disease
  • admit all pregnant patients with pyelo!

Question 23

Urethritis Etiology, S/sxs, Dx, & Tx

Answer 23

infx of the urethra

• Etiology: STIs: chlamydia, N. gonorrhoeae, trichomonas vaginalis & HSV = common cause in both sexes
• Sxs: dysuria
  
  • in men: urethral discharge → can be purulent, whitish, or mucoid
• Dx; first void or first-catch urine sometimes with cx
  
  • positive leukocyte esterase on urine dipstick
    
    • or ≥ 10WBCs/HPF
  • nucleic acid amplification test = allows for identification of N. gonorrhoeae, C. trachomatis
• Tx: should treat empirically for STDs in sexually active pts pending test results
• →ceftriaxone 500mg IM + doxycycline 100mg PO BID x7 days
  
  • → can consider replacing doxy with azithromycin 1g PO if compliance in question or pregnancy

Question 24

Bladder Cancer Etiology, S/sxs, Dx, &Tx

Answer 24

• transitional cell carcinoma = most common type
• 4:1 men to women
• risk factor: SMOKING
• S/sxs:
  
  • painless hematuria
• Dx: cystoscopy with biopsy = GOLD STANDARD
  
  • persistent hematuria > 3RBC/HPF on ⅔ urinalysis → bladder cancer until proven otherwise!!
• Tx:
  
  • endoscopic resection with cystoscopy Q 3 months thereafter
  • → high recurrence rate
  • recurrent or multiple lesions can be treated with intravesical BCG vaccine injection

Question 25

Penile Cancer Etiology, Risks PE, Dx, Tx & Prevention

Answer 25

**squamous cell carcinoma = most common type** * mean age of diagnosis = **60 years old** * **_Etiology_**: **HSV** & **HPV 18** * _Risk factors:_ uncircumcised, poor hygiene * _PE_: mass or blister that can become **wart-like** growth that **discharges blood** or **foul-smelling fluid** * **penile mass** or **ulcer**, especially those who have not been circumcised * _Dx_: biopsy * _Tx:_ **surgery = most common** * radiation & chemo = also options * _Prevention:_ * condom use and **HPV vaccine**

Question 26

Prostate Cancer Etiology, S/sxs, PE, Dx, Tx

Answer 26

* most are **adenocarcinomas** * associated with the **BRCA1 gene** * _Risk factors_: african american, old age, family hx * _S/sxs_: **urinary retention** (more likely sign of BPH), **decrease in urine stream strength** * **back pain (**metastatic disease) * **painful ejaculation** * _PE_: DRE: hard, nodular, enlarged, and asymmetrical prostate * _Dx_: * indications for transrectal biopsy with normal rectal exam → **PSA \> 10** or **abnormal transrectal U/S** * _PSA \> 4_: **U/s with needle biopsy** * _PSA \>10_: bone scan to r/o metastases * _Tx_; * **radical prostatectomy → complication = erectile dysfunction & urinary incontinence** * with metastases: need androgen deprivation therapy (**leuprolide)** → type of medical castration, but can be reversible *

Question 27

Testicular Cancer Etiology, PE, Dx, & Tx

Answer 27

* Most common **solid tumor** in young men **ages 15-40** (avg 42 yo) * 5 year survival =90% * most common type =**germ cell tumor** * 2 types: **seminomas** * **nonseminomatous germ cell tumor (NSGCT)** * Seminomas: * classic seminoma (95%) * spermatocytic seminoma * NSGCTs * emrbyonal carcinoma * yolk sac carcinoma * choriocarcinoma * _PE_: * **firm, painless, nontender, fixed mass** on testicle * _Dx_: **Scrotal U/x** * radiologic studies to search for metastases → most commonly in brain, belly, lungs * **tumor markers**: **alpha-fetoprotein** (AFP) → + in NSGCT, not seminomas * **human chorionic gonadotropin** + in both NSGCT and seminomas * **lactate dehydrogenase** (LDH) * _Tx_: * **orchiectomy** +/- chemo and radiation depending on cell type * **NSGCT = radioresistant** * **Se**minomatous tumors = *radio**se**nsitive* and can be treated with _radiation therapy_

Question 28

Renal Cell Carcinoma Etiology, S/sxs, Dx, &Tx

Answer 28

* transitional epithelium of the renal pelvis or ureter * Male to female ration 2:1 (vs bladder cancer 4:1) * age of occurrence 40-70 years * 5 year survival = 75% (vs 50% in bladder cancer) * _etiology_: * **cigarette smoke** * acquired: * **Polycystic kidney disease** * **tuberous sclerosis, spontaneous mutations** * genetic: **Von Hippel-Lindau Syndrome** * _Pathology:_ * 60% are **clear cell carcinoma** * if it involves epithelial cells of the proximal tubule → VERY LIKELY TO METASTASIZE (80%) * _S/sxs_: * **classic triad**: 1. hematuria, 2. abdominal mass, 3. abdominal pain or CVA tenderness * fever, weight-loss * anemia * _Dx_: * **CT of abdomen/pelvis and CXR** * UA and urine cytology * **Staging**: \<7cm = favorable, **\>10cm or local invasion→ metastasis is a concern** * _Tx_: * radial or partial nephrectomy for localized disease * **no chemo** * advanced? surgery is an option

Question 29

Wilms Tumor Etiology, PE, Dx, and Tx

Answer 29

* **Most common solid renal tumor of childhood** * arises from otherwise healthy kid's kidneys \< **4 years old** * _Risk factors_: family hx, horseshoe kidney * _Associated Conditions_: **WAGR syndrome** * Wilms Tumor * Aniridia (no iris) * GU abnormalities * Retardation * _PE_: **palpable, nontender mass on the lateral abdomen** * mass feels smooth and firm and does NOT cross the midline * _Dx_: **U/S** and **CT of the abdomen** followed by biopsy or resection. * CXR to look for metastases * **should _NEVER PALPATE_ the abdomen of a child with Wilms tumor** → increases risk of rupturing the encapsulated tumor → metastasis * _Tx_: **surgical resection and chemo** * → most cases are curable \*\*\*\*

Question 30

Calcium Nephrolithiasis Risk factors and Prevention

Answer 30

* calcium oxalate = most common * **_Radiopaque_** * _Risk factors_: **decreased fluid intake**, high urinary calcium or pH, high animal protein intake, hypercalcemia, males, medications (loop diuretics, acetazolamide, antacids) * _Prevention_: **increased fluid intake, thiazide diuretics**, citrate, low sodium diet, decreased animal protein diet

Question 31

Uric Acid Nephrolithiasis Risk Factors and Prevention

Answer 31

* 5-8% * **_Radiolucent_** (cannot see on Xray) * _Risk Factors_: **excess meat, alcohol, gout**, chemo (tumor lysis) * _Prevention_: * increased fluids, allopurinol or potassium citrate, urine alkalinization, adequate hydration prior to chemo

Question 32

Struvite Nephrolithiasis Risk Factors and Prevention

Answer 32

**magnesium ammonium phosphate** → can form **staghorn calculi** * formed in the renal pelvis due to urea-splitting organisms * **_Radiopaque_** (visible on Xray) * _Risk factors_: **chronic UTI** with klebsiella and proteus species * _Prevention:_ control source of infx

Question 33

Cysteine Nephrolithiasis Risk Factors and Prevention

Answer 33

Rare 1-3% * _Congenital defect_ in the reabsorption of the amino acid cysteine * _Prevention:_ * dietary modification, low sodium, **urine alkalinization , chelating agents in rare cases**

Question 34

Nephrolithiasis Etiology, S/sxs, PE, Dx, & Tx

Answer 34

* Types: Calcium, Uric Acid, Struvite, Cysteine * _S/sxs_: **renal colic**: sharp, severe, colicky flank pain at the CVA→ can radiate to groin * difficult to find comfortable position * N/V * discolored urine, hematuria, frequency, urgency * _PE_: **CVA tenderness**, usually afebrile * _Dx_: * **acidic urin (pH \<5)** → uric acid and cystine stones * **alkaline urine (pH \>7.2)** → struvite stones * **IMAGING TEST OF CHOICE = Non-contrast CT of abdomen & pelvis** * _Tx_: * \<5mm? : 80% chance of spontaneous passage → **IV fluids & analgesics** * **tamsulosin** (alpha blocker to help facilitate passage) * \>1cm? 20% → spontaneous passage * if uric acid stones → alkalinization of urine to pH \>6.5 is helpful * **extracorporeal shock wave lithotripsy**: can break up stones * **ureteroscopy +/- stent** * **percutaneous nephrolithotomy** * used for large stones \>10cm , struvite, or if less invasive options fail

Question 35

Hypospadias/Epispadias Dx and Tx

Answer 35

* **_Hypospadias_**: when the urethral meatus open onto the **ventral** (bottom/underside) of the **penile shaft** * genetic heritability * **IVF** has been associated with increased risk of **hypospadias** * **_Epispadias_**: when the urethral meatus opens onto the **dorsal (topside)** of the penile shaft * _Dx_: usually made during the newborn exam but **imaging studies (excretory urogram)** can be helpful * _Tx_: **surgical repair** before 1-2 years of age * **DO NOT CIRCUMCISE** → may use foreskin in surgical repair

Question 36

Paraphimosis Dx & Tx

Answer 36

* entrapment of the foreskin in the retracted position → **Medical Emergency** * **Para**phimosis needs a **Para**medic * \*\*\*always remember to reduce the foreskin after urethral catheterization\*\*\* * _Dx_: clinical * _Tx_: firm circumferential compression of the glans with the hand may reduce the edema enough to allow the foreskin back to its normal position * → if not successful, **dorsal slit using local anesthetic** temporarily relieves the problem → **CIRCUMCISION** after edema is resolved

Question 37

Phimosis Dx and Tx

Answer 37

* foreskin in normal position and **cannot be retracted** * adult phimosis often caused from scarring **after trauma, infx** (such as balanitis) or **prolonged irritation** * _Dx_: clinical * _Tx_: in children, will normally resolve by age 5 * tx not usually required in absence of other issues such as balanitis, UTIs, urinary obstruction * **betamethasone cream 0.05% BID-TID** * gently stretch the foreskin

Question 38

When to screen for PSA

Answer 38

DISCUSS WITH PATIENT * men age 55-69 yo * 50 years old if first degree family hx * 45-50 if african american

Question 39

BPH S/sxs, PE, Dx, & Tx

Answer 39

Benign Prostatic Hyperplasia * 50% of men have BPH by age 60, \>90% by age 85 * _S/sxs_: difficulty starting stream, post-void dribbling, hesitancy (**start and stop**) * nocturia * weak urinary stream * _PE_: **digital rectal exam** → uniformly enlarged firm and rubber prostate * _Dx_: * DRE +PSA * PSA \< 4 = normal * PSA \> 4 → BPH, prostate cancer, prostatitis * **UA** to r/o other causes * _Tx_: * if mild → watchful waiting * **alpha blockers** can provide the most rapid relief (smooth muscle relaxation of porstate and bladder neck * **tamsulosin, prazosin, terazosin** (shrink size of prostate) * **finasteride** & **dutasteride** * **TURP** (transurethral resection of the prostate) if unresponsive to meds * **5-alpha reductase inhibitors**

Question 40

Hydrocele PE, Dx, & Tx

Answer 40

* mass of fluid-filled congenital remnants of the tunica vaginalis * infants: will usually close within the 1st year of life * _PE_: * **painless scrotal swelling** (most common cause of this) * **+ transillumination** vs tumor or varicocele which both do not transilluminate * _Dx_: **Scrotal U/S** * _Tx_: in infants → will usually close in the 1st year of life, but may require surgery if clinically indicated * **have parents practice watchful waiting for 1 year**

Question 41

Varicocele PE, Dx & Tx

Answer 41

venous varicosity within the spermatic vein * _PE_: feels like a "**bag of worms**' superior to the testicles * **dilation worse when the pt is upright or with valsalva** → decrease in size with elevation of the scrotum or supine position * negative transillumination → chronic non-tender mass that does not transilluminate * _Dx_: **Scrotal U/s** * _Tx_: **surgical repair** if varicocele is painful or appears to be cause of **infertility**

Question 42

Testicular Torsion S/sxs, PE, Dx, & Tx

Answer 42

* _Risk Factors_: **after vigorous activity** or minor trauma * usually **post-pubertal boys** (65% in boys age 10-20) * more common in pts with a hx of **cryptorchidism** * _S/sxs_: * *severe, acute onset lower abdominal pain***,** sharp pain that may radiate into thigh * vomiting * _PE_: **negative phren's sign** * loss of **cremasteric reflex** ( elevation of the testes in response to stroking of the inner thigh) * **Blue dot sign**: tender nodule 2-3mm in diameter of the upper pole of the testicle * _Dx_: **U/s with doppler** = best initial test * **Radionuclide scan** demonstrates decreased uptake in the affected testes **→ GOLD STANDARD** * _Tx_: * need to de-torse the testicles in **_\< 6 hours_** (90% salvage rate) * \>24 hours? \<10% salvage * **orchiopexy** (permanent fixation of the testicle)

Question 43

Urethral Prolapse S/sxs, PE, Dx, & Tx

Answer 43

* most commonly affects **prepubertal girls** and **post-menopausal women** * _S/sxs_: * vaginal bleeding = most common presenting symptom * _PE_: doughnut-shaped protrusion * _Dx_: **clinical** and is often found during a routine exam * _Tx_: **estrogen creams**, vaseline, and sitz baths * **surgical excision** for young patients with symptomatic urethral prolapse or with recurrent urethral prolapse

Question 44

Urinary Stricture S/sxs, Dx, & Tx

Answer 44

* narrowing of the urethra caused by: * injury, instrumentation (TURP), infx etc * _S/sxs_: **weak urine flow**, sudden, frequent urges to urinate, **UTI** * **_hesitancy_** (stopping and starting) * _Dx_: cystourethroscopy, retrograde urethrogram (RUG), voiding cystourethrogram (VCUG) * **RUG** → helps to find **location** and **length of stricture** to guide tx * _Tx_: **urethral dilation** or **stent placement**

Question 45

Nephrolithiasis vs Urolithiasis

Answer 45

* Nephrolithiasis: * is the disease of having kidney stones * Urolithiasis: * presence of stones in the urinary tract

Question 46

UTI prevention

Answer 46

* drink adequate amount of water * avoid delay in voiding * personal hygiene * cranberry juice/tablets * abx prophylaxis for 3 UTIs/12 months * Bactrim/Cipro

Question 47

Pediatric Enuresis

Answer 47

generally applied to kids ≥ 5 years of age, **meds for kids \>6 years only** * often hereditary * 3 main causes: * nocturnal polyuria * detrusor overactivity * increased arousal thresholds * _Minor Enuresis:_ **_we can tx_** * daytime frequency * giggle incontinence * stress incontinence * post void-dribbling * nocturnal enuresis * _moderate enuresis:_ **_referral to uro_** * underactive bladder * overactive bladder * dysfunctional elimination syndrome

Question 48

Nonmonosymptomatic enuresis

Answer 48

* most often associated with **Constipation** * occurs in children with enuresis who also have other LUTS * primary enuresis = 85% of all cases of childhood enuresis

Question 49

Imipramine

Answer 49

**anticholinergic** used for _overactive bladder_ in children \> 6years