ICL 5.8: Common Urologic Cases

Question 1

A 68-year-old while male with history of smoking 30 pack year. He is referred to Urology clinic because of confirmed microscopic hematuria. He denies any fever or flank pain. He denies any history of gross hematuria. His physical examination and kidney function are normal. What are other evaluations needed for this patient?

A) No need for any further evaluation.

B) Abdominal X-ray is important to rule out the presence of stones.

C) CT scan Abdomen and pelvis with and without contrast

Answer 1

D) CT scan abdomen and pelvis with and without contrast and cystoscopy

cystoscopy is going through the urethra and go up to the bladder and observe up close

Question 2

what is the best timing for a urine sample?

Answer 2

1. FRESHLY voided
2. not immediately after eating
3. normal hydration

Question 3

what imaging do you do for kidney stones?

Answer 3

not an abdominal x-ray because small stones, constipation, or uric acid stones don’t show up well

if they have a calcified clot in the vessels it could look like a stone and you can’t really differentiate them

you only do a KUB if they’ve already had a CT

Question 4

what does a normal renal US look like?

Answer 4

medulla should be hyperechoic/white and if it looks black then it’s hydronephrosis!

you can’t identify the causes of the obstruction though so a CT scan is better

Question 5

what are the predisposing conditions to having adverse reactions to contrast?

Answer 5

1. iodine allergy
2. ashtma
3. severe cardiac disease
4. renal insufficiency
5. dehydration
6. sickle cell anemia
7. anxiety
8. hyperthyroidism
9. adrenal phaeochromocytoma

Question 6

which patients do you take extra precautions with when giving contract?

Answer 6

1. taking metformin can cause lactic acidosis which can be fatal in 50% of patients with renal insufficiency

patients predisposed to contrast induced nephropathy:
1. CKD

2. DM
3. dehydration

Question 7

what is nephrogenic systemic sclerosis?

Answer 7

MRI with contrast complication

effects people with renal insufficiency with GFR <30

leads to fibrosis of the skin, subcutaneous tissues, lungs, esophagus, heart, and skeletal muscles

initial symptoms can occur between 2 days to 90 days

starts by swelling of the distal extremities and then induration of the skin

death may result in some patients

Question 8

what have we learned so far?

Answer 8

1. hematuria is important to workup; confirm with microscopic exam to confirm 3+ RBC per high power field to confirm hematuria
2. good evaluation of kidney, ureter and bladder with CT with and without contract
3. look inside urethra and prostate and prostate with cystoscope

so always get a urine test, imagining and cystoscope

Question 9

A 42-year-old man presented to the emergency department with severe right flank pain and hematuria. He reports that pain has been intermittent with increasing intensity in past 3 days. He reports no fever but has nausea for the past 24 hours. Vital signs are stable. He has tenderness on the right costovertebral angle. You decided the best next step for evaluation should be

A) Reassurance and pain control

B) Obtain urinalysis and CT scan abdomen and pelvis

C) Control pain then obtain urinalysis and CT scan abdomen and pelvis

D) Call general surgery on call for evaluation

Answer 9

C) Control pain then obtain urinalysis and CT scan abdomen and pelvis

severe right flank pain is very general but hematuria is the urinary tract!

US if the CT doesn’t show a good image because a KUB and MRI wouldn’t do a good job of seeing the small stone

Question 10

A 28-year-old African American man has acute severe left flank pain. Urinalysis showed microscopic hematuria. He denies a history of trauma or stone disease. The best module for evaluation is:

A) non-contrast helical CT scan

B) abdominal ultrasonography.

C) IVP.

D) MRI Scan.

Answer 10

A) non-contrast helical CT scan

lower dose radiation exposure CT

Question 11

A 38-year-old woman has severe right flank pain. She is afebrile and urinalysis demonstrates pyuria and microhematuria. A helical CT scan demonstrates right perinephric fluid and right hydroureteronephrosis down to a 3 mm distal ureteral stone. Her pain has been controlled. The best treatment is:

A) ureteral stent.

B) percutaneous nephrostomy drainage.

C) percutaneous drainage of perinephric fluid.

D) conservative management with a trial to pass the stone

Answer 11

D) conservative management with a trial to pass the stone

perinephric fluid is the fluid leaking from the kidney but this isn’t an emergency; it means the kidneys are draining and it’s not great to have urine outside the kidney but they aren’t going to die and since she doesn’t have any pain then you should probably just give antibiotics to make sure she doesn’t give an infection then monitor

Question 12

A 38-year-old woman has severe right flank pain. She has a temperature of 103 °F. Urinalysis demonstrates pyuria and microhematuria. A helical CT scan demonstrates right hydroureteronephrosis with a 6 mm proximal ureteral stone. The best treatment is:

A) Antibiotics and send her home

B) Admit the patient, give proper antibiotics and proceed with drainage of her kidney with a stent or percutaneous access.

C) Admit the patient with IV antibiotics and proceed with stone removal.

D) conservative management with a trial to pass the stone

Answer 12

B) Admit the patient, give proper antibiotics and proceed with drainage of her kidney with a stent or percutaneous access

this is a renal emergency!

Question 13

what are the renal conditions considered an emergency?

Answer 13

emergency situations:
1. fever because could be sepsis

2. persistent pain
3. persistent nausea – patient isn’t eating or drinking there’s a risk of dehydration
4. if both kidneys are obstructed or if there’s only one kidney

Question 14

The best method to decrease the rate of catheter- associated UTI’s in hospitalized adults is

A) Antimicrobial prophylaxis.

B) One- way valves in drainage systems.

C) Addition of antimicrobials to drainage bag.

D) Removal of catheters as soon as they are not needed

Answer 14

D) Removal of catheters as soon as they are not needed

Question 15

A 64- year- old man with BPH presented with dysuria, frequency, and hematuria following removal of a urethral catheter after a hip replacement. He has severe pain on the right side of the scrotum. On examination, he has tenderness and swollen testicle on the right side.
What is your primary diagnosis?

A) Spermatocele

B) Testicular cancer

C) Hematocele

D) Epididymo-orchitis

Answer 15

D) Epididymo-orchitis

probably has an infection from the catheter

spermatocele isn’t an infection

confirm with urine culture to make sure, do US and give antibiotics

Question 16

A 56- year- old man with history of nasal allergy has increased urinary frequency, weak stream and urgency. He started to take Sudafed for allergy after which he started to have increased urinary symptoms. He presented to the ED with severe difficulty with voiding. The most common cause of urinary symptoms in this age group is

A) urethral stricture

B) prostate cancer

C) Enlarged prostate

D) cystitis

Answer 16

C) Enlarged prostate

sudafed is a an anticholindergic which weakens the bladder

when the bladder enlarges, it squeezes the bladder and compresses the prostatic urethra and you’ll have a problem emptying the bladder

Question 17

which conditions can cause storage symptoms?

Answer 17

1. cystitis
2. recessive fluid intake
3. bladder sotne
4. carcinoma in situ

Question 18

which conditions can cause voiding symptoms?

Answer 18

1. enlarged prostate
2. urethral stricture
3. large cystocele
4. neurogenic atonic bladder

Question 19

This is 48-year-old white male who is brought to the ED by his wife for urinary retention. He was working on fixing his fence and fell astride on the edge of the fence. He experienced severe perineal pain and bloody discharge from the urethra. The ED physician examined the patient and found that he has a butterfly swelling in the perineal area. Retrograde urethrogram is performed in the radiology department. Please review the pictures and answer the following question, what is the anatomical reason of this hematoma distribution?

A) Scarpa’s Fascia.

B) Superficial perineal membrane.

C) Colles’ Fascia

D) Rectus Fascia

Answer 19

C) Colles’ Fascia

they will present with butterfly hemorrhage and this is basically pathoneumonic for Colles fascia tear

if someone has blood on their urethra, do NOT put in a catheter because you could tear the opening in the urethra to the point of no return

Question 20

27 yo white woman present to the ED complaining of right abdominal pain. Pain initially was in the right upper quadrant and the flank area. Pain was sharp and severe (10/10). It was associated with nausea and gastric upset. She denies any fever. She had cough 3 days earlier with watery nose. Later during the day, Pain moved to the right groin area and was controlled by NSAID.
3 days later, she started to feel pain in the pelvic area and was associated with increased urinary frequency and urgency. She also had some blood in urine.

Answer 20

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