History and Physical Examination

Question 1

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 1

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 2

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 2

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

Question 3

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 3

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 4

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 4

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

Question 5

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 5

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 6

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 6

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 7

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 7

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 8

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 8

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 9

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 9

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 10

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 10

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

Question 11

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 11

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 12

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 12

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 13

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 13

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 14

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 14

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 15

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 15

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 16

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 16

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 17

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 17

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 18

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 18

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 19

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 19

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 20

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

Answer 20

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

Question 21

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 21

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 22

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 22

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

Question 23

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 23

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 24

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

Answer 24

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 25

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 25

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 26

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

Answer 26

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 27

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 27

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 28

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 28

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 29

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 29

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 30

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 30

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